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Martinez L, Seddon JA, Horsburgh CR, Lange C, Mandalakas AM. Effectiveness of preventive treatment among different age groups and Mycobacterium tuberculosis infection status: a systematic review and individual-participant data meta-analysis of contact tracing studies. THE LANCET. RESPIRATORY MEDICINE 2024; 12:633-641. [PMID: 38734022 DOI: 10.1016/s2213-2600(24)00083-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/27/2024] [Accepted: 03/12/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Tuberculosis is a preventable disease. However, there is debate regarding which individuals would benefit most from tuberculosis preventive treatment and whether these benefits vary in settings with a high burden and low burden of tuberculosis. We aimed to compare the effectiveness of tuberculosis preventive treatment in exposed individuals of differing ages and Mycobacterium tuberculosis infection status while considering tuberculosis burden of the settings. METHODS In this systematic review and individual-participant meta-analysis, we investigated the development of incident tuberculosis in people closely exposed to individuals with tuberculosis. We searched for studies published between Jan 1, 1998, and April 6, 2018, in MEDLINE, Web of Science, BIOSIS, and Embase. We restricted our search to cohort studies; case-control studies and outbreak reports were excluded. Two reviewers evaluated titles, abstracts, and full text articles for eligibility. At each stage, two reviewers discussed discrepancies and re-evaluated articles until a consensus was reached. Individual-participant data and a pre-specified list of variables, including characteristics of the exposed contact, the index patient, and environmental characteristics, were requested from authors of all eligible studies; contacts exposed to a drug-resistant tuberculosis index patient were excluded. The primary study outcome was incident tuberculosis. We estimated adjusted hazard ratios (aHRs) for incident tuberculosis with mixed-effects Cox regression models with a study-level random effect. We estimated the number-needed-to-treat (NNT) to prevent one person developing tuberculosis. Propensity score matching procedures were used in all analyses. This study is registered with PROSPERO (CRD42018087022). FINDINGS After screening 25 358 records for eligibility, 439 644 participants from 32 cohort studies were included in the individual-participant data meta-analysis. Participants were followed for 1 396 413 person-years (median of 2·7 years [IQR 1·3-4.4]), during which 2496 people were diagnosed with incident tuberculosis. Overall, effectiveness of preventive treatment was 49% (aHR 0·51 [95% CI 0·44-0·60]). Participants with a positive tuberculin-skin-test (TST) or IFNγ release assay (IGRA) result at baseline benefitted from greater protection, regardless of age (0·09 [0·05-0·17] in children younger than 5 years, 0·20 [0·15-0·28] in individuals aged 5-17 years, and 0·17 [0·13-0·22] in adults aged 18 years and older). The effectiveness of preventive treatment was greater in high-burden (0·31 [0·23-0·40]) versus low-burden (0·58 [0·47-0·72]) settings. The NNT ranged from 9 to 34 depending on age among participants with a positive TST or IGRA in both high-burden and low-burden settings; among all contacts (regardless of TST or IGRA test result), the NNT ranged from 29 to 43 in high-burden settings and 213 to 455 in low-burden settings. INTERPRETATION Our findings suggest that a risk-targeted strategy prioritising contacts with evidence of M tuberculosis infection might be indicated in low-burden settings, and a broad approach including all contacts should be considered in high-burden settings. Preventive treatment was similarly effective among contacts of all ages. FUNDING None.
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Affiliation(s)
- Leonardo Martinez
- Boston University School of Public Health, Department of Epidemiology, Boston, MA, USA.
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa; Department of Infectious Disease, Imperial College London, London, UK
| | - C Robert Horsburgh
- Boston University School of Public Health, Department of Epidemiology, Boston, MA, USA
| | - Christoph Lange
- German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany; Global TB and Immigrant Health Program, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA; Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany; Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany
| | - Anna M Mandalakas
- German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany; Global TB and Immigrant Health Program, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA; Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
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Girma D, Abita Z, Guteta M, Abebe A, Adugna A, Alie MS, Abebe GF. Incidence density mortality rate among HIV-positive children on antiretroviral therapy in Ethiopia: a systematic review and meta-analysis. BMC Public Health 2024; 24:2061. [PMID: 39085806 PMCID: PMC11290179 DOI: 10.1186/s12889-024-19579-3] [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: 11/08/2023] [Accepted: 07/24/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND Human Immunodeficiency Virus (HIV) continues to be the major cause of childhood deaths, particularly in the sub-Saharan African region. In Ethiopia, though several primary studies have been conducted on the incidence of HIV-related child mortality, the pooled incidence density mortality rate among HIV-positive children is unknown. Therefore, this systematic review and meta-analysis aimed to estimate the pooled incidence density mortality rate among HIV-positive children and identify its associated factors in Ethiopia. METHODS We browsed PubMed, HINARI, Science Direct, Google Scholar, African Journals Online, and cross-references using different search terms to identify articles. Quality appraisal was done using the Joanna Briggs Institute checklist. Meta-package was used to estimate the pooled incidence of mortality and hazard ratio (HR) of predictors. Heterogeneity was tested using the I-square statistics. Publication bias was tested using a funnel plot visual inspection and Egger's test. Data was presented using forest plots and tables. The random effect model was used to compute the pooled estimate. RESULTS The overall pooled incidence density mortality rate among HIV-positive children was 2.52 (95% CI: 1.82, 3.47) per 100 child years. Advanced HIV disease (hazard ratio (HR): 3.45, 95% CI (Confidence Interval): 2.64, 4.51), tuberculosis co-infection (HR: 3.19, 95% CI: 2.08, 4.88), stunting (3.22, 95% CI: 2.46, 4.22), underweight (HR: 2.71, 95% CI: 1.72, 4.26), wasting (HR: 4.14, 95% CI: 2.27, 7.58), didn't receive Isoniazid preventive therapy (HR: 3.33, 95% CI: 2.22, 4.99), anemia (HR: 3.03, 95% CI: 2.52, 3.64), fair or poor antiretroviral therapy adherence (HR: 4.14, 95% CI: 3.28, 5.28) and didn't receive cotrimoxazole preventive therapy (HR: 3.82, 95% CI: 2.49, 5.86) were factors associated with a higher hazard of HIV related child mortality. CONCLUSIONS The overall pooled incidence density mortality rate among HIV-positive children was high in Ethiopia as compared to the national strategy target. Therefore, counseling on antiretroviral therapy adherence should be strengthened. Regular monitoring of hemoglobin levels and assessment of nutritional status should be done for all children living with HIV. Moreover, healthcare professionals should follow the national HIV treatment guidelines and provide cotrimoxazole preventive therapy and Isoniazid preventive therapy up on the guidelines for children living with HIV. REGISTRATION Registered in PROSPERO with ID: CRD42023486902.
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Affiliation(s)
- Desalegn Girma
- College of Health Science, Department of Midwifery, Mizan-Tepi University, Mizan-Teferi, Ethiopia.
| | - Zinie Abita
- College of Health Science, department of public health, Mizan-Tepi University, Mizan-Teferi, Ethiopia
| | - Mirresa Guteta
- College of Health Science, Department of Nursing, Mizan Tepi University, Mizan-Teferi, Ethiopia
| | - Abinet Abebe
- College of Health Science, school of pharmacy, department of clinical pharmacy, Mizan Tepi University, Mizan-Teferi, Ethiopia
| | - Amanuel Adugna
- College of Health Science, Department of Midwifery, Mizan-Tepi University, Mizan-Teferi, Ethiopia
| | - Melsew Setegn Alie
- College of Health Science, department of public health, Mizan-Tepi University, Mizan-Teferi, Ethiopia
| | - Gossa Fetene Abebe
- College of Health Science, Department of Midwifery, Mizan-Tepi University, Mizan-Teferi, Ethiopia
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Girma D, Abita Z, Shifera N, Arage MW, Abate BB, Alie MS, Abebe GF. Incidence rate of tuberculosis among HIV infected children in Ethiopia: systematic review and meta-analysis. BMC Pediatr 2024; 24:363. [PMID: 38790006 PMCID: PMC11127285 DOI: 10.1186/s12887-024-04819-7] [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] [Received: 10/10/2023] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Tuberculosis is one the leading causes of death from a single infectious disease, caused by the bacillus mycobacterium tuberculosis. In Ethiopia, even though several primary studies have been conducted on the incidence of tuberculosis among HIV-infected children, the pooled incidence rate of tuberculosis among HIV-infected children (aged 0-14 years) is unknown. Therefore, the main objectives of this systematic review and meta-analysis are to estimate the pooled incidence rate of tuberculosis among HIV-infected children and its predictors in Ethiopia. METHOD International electronic databases such as PubMed, HINARI, Science Direct, Google Scholar, and African Journals Online were searched using different search engines. Quality of primary studies was checked using the Joanna Briggs Institute checklist. The heterogeneity of studies was tested using I-square statistics. Publication bias was tested using a funnel plot and Egger's test. Forest plots and tables were used to present the results. The random effect model was used to estimate the pooled incidence of tuberculosis among children living with HIV. RESULT A total of 13 studies were included in this systematic review and meta-analysis. The pooled incidence of tuberculosis among HIV-infected children was 3.77 (95% CI: 2.83, 5.02) per 100-person-year observations. Advanced HIV disease (HR: 2.72, 95% CI: 1.9; 3.88), didn't receive complete vaccination (HR: 4.40, 95% CI: 2.16; 8.82), stunting (HR: 2.34, 95% CI: 1.64, 3.33), underweight (HR: 2.30, 95% CI: 1.61; 3.22), didn't receive Isoniazid preventive therapy (HR: 3.64, 95% CI: 2.22, 5.96), anemia (HR: 3.04, 95% CI: 2.34; 3.98), fair or poor antiretroviral therapy adherence (HR: 2.50, 95% CI: 1.84; 3.40) and didn't receive cotrimoxazole preventive therapy (HR: 3.20, 95% CI: 2.26; 4.40) were predictors of tuberculosis coinfection among HIV infected children. CONCLUSION This systematic review and meta-analysis concluded that the overall pooled incidence rate of tuberculosis among HIV-infected children was high in Ethiopia as compared to the END TB strategy targets. Therefore, emphasis has to be given to drug adherence (ART and Isoniazid) and nutritional counseling. Moreover, early diagnosis and treatment of malnutrition and anemia are critical to reduce the risk of TB coinfection. REGISTRATION Registered in PROSPERO with ID: CRD42023474956.
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Affiliation(s)
- Desalegn Girma
- Department of Midwifery, College of Health Science, Mizan-Tepi University, Mizan-Teferi, Ethiopia.
| | - Zinie Abita
- Department of Public Health, College of Health Science, Mizan-Tepi University, Mizan-Teferi, Ethiopia
| | - Nigusie Shifera
- Department of Public Health, College of Health Science, Mizan-Tepi University, Mizan-Teferi, Ethiopia
| | - Mulugeta Wodaje Arage
- Department of Midwifery, School of Midwifery, College of Health Science, Woldiya University, Woldiya, Ethiopia
| | - Biruk Beletew Abate
- Department of Nursing, School of Nursing, College of Health Science, Woldiya University, Woldiya, Ethiopia
| | - Melsew Setegn Alie
- Department of Public Health, College of Health Science, Mizan-Tepi University, Mizan-Teferi, Ethiopia
| | - Gossa Fetene Abebe
- Department of Midwifery, College of Health Science, Mizan-Tepi University, Mizan-Teferi, Ethiopia
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Cherkos AS, Cranmer LM, Njuguna I, LaCourse SM, Mugo C, Moraa H, Maleche-Obimbo E, Enquobahrie DA, Richardson BA, Wamalwa D, John-Stewart G. Effect of tuberculosis-HIV co-treatment on clinical and growth outcomes among hospitalized children newly initiating antiretroviral therapy. AIDS 2024; 38:579-588. [PMID: 38016160 PMCID: PMC10922257 DOI: 10.1097/qad.0000000000003797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
OBJECTIVE Evaluate effects of tuberculosis (TB)-HIV co-treatment on clinical and growth outcomes in children with HIV (CHIV). DESIGN Longitudinal study among Kenyan hospitalized ART-naive CHIV in the PUSH trial (NCT02063880). METHODS CHIV started ART within 2 weeks of enrollment; Anti-TB therapy was initiated based on clinical and TB diagnostics. Children were followed for 6 months with serial viral load, CD4%, and growth assessments [weight-for-age z -score (WAZ), height-for-age z -score (HAZ), and weight-for-height z -score (WHZ)]. TB-ART treated and ART-only groups were compared at 6 months post-ART for undetectable viral load (<40 c/ml), CD4% change, and growth using generalized linear models, linear regression, and linear mixed-effects models, respectively. RESULT Among 152 CHIV, 40.8% (62) were TB-ART treated. Pre-ART, median age was 2.0 years and growth was significantly lower, and viral load significantly higher in the TB-ART versus ART-only group. After 6 months on ART, 37.2% of CHIV had undetectable viral load and median CD4% increased by 7.2% (IQR 2.0-11.6%) with no difference between groups. The TB-ART group had lower WAZ and HAZ over 6 month follow-up [WAZ -0.81 (95% CI: -1.23 to -0.38], P < 0.001; HAZ -0.15 (95% CI: -0.29 to -0.01), P = 0.030] and greater rate of WAZ increase in analyses unadjusted and adjusted for baseline WAZ [unadjusted 0.62 (95% CI: 0.18-1.07, P = 0.006) or adjusted 0.58 (95% CI: 0.12-1.03, P = 0.013)]. CONCLUSION TB-HIV co-treatment did not adversely affect early viral suppression and CD4 + recovery post-ART. TB-ART-treated CHIV had more rapid growth reconstitution, but growth deficits persisted, suggesting need for continued growth monitoring.
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Affiliation(s)
- Ashenafi S Cherkos
- Department of Population and Community Health, School of Public Health, University of North Texas Health Science Center, Fort Worth, TX
| | - Lisa M Cranmer
- Department of Pediatrics, Emory School of Medicine
- Department of Epidemiology, Emory Rollins School of Public Health
- Children's Healthcare of Atlanta, Atlanta, GA
| | - Irene Njuguna
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
- Medical Research Department, Kenyatta National Hospital, Nairobi, Kenya
| | - Sylvia M LaCourse
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Cyrus Mugo
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
| | - Hellen Moraa
- Department of Pediatrics and Child Health, University of Nairobi, Kenya
| | | | - Daniel A Enquobahrie
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
| | - Barbra A Richardson
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
- Department of Biostatistics, School of Public Health
| | - Dalton Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Kenya
| | - Grace John-Stewart
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
- Medical Research Department, Kenyatta National Hospital, Nairobi, Kenya
- Department of Pediatrics, University of Washington, Seattle, WA, USA
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Owachi D, Akatukunda P, Nanyanzi DS, Katwesigye R, Wanyina S, Muddu M, Kawuma S, Kalema N, Kabugo C, Semitala FC. Mortality and associated factors among people living with HIV admitted at a tertiary-care hospital in Uganda: a cross-sectional study. BMC Infect Dis 2024; 24:239. [PMID: 38388345 PMCID: PMC10885437 DOI: 10.1186/s12879-024-09112-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 02/07/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Hospital admission outcomes for people living with HIV (PLHIV) in resource-limited settings are understudied. We describe in-hospital mortality and associated clinical-demographic factors among PLHIV admitted at a tertiary-level public hospital in Uganda. METHODS We performed a cross-sectional analysis of routinely collected data for PLHIV admitted at Kiruddu National Referral Hospital between March 2020 and March 2023. We estimated the proportion of PLHIV who had died during hospitalization and performed logistic regression modelling to identify predictors of mortality. RESULTS Of the 5,827 hospitalized PLHIV, the median age was 39 years (interquartile range [IQR] 31-49) and 3,293 (56.51%) were female. The median CD4 + cell count was 109 cells/µL (IQR 25-343). At admission, 3,710 (63.67%) were active on antiretroviral therapy (ART); 1,144 (19.63%) had interrupted ART > 3 months and 973 (16.70%) were ART naïve. In-hospital mortality was 26% (1,524) with a median time-to-death of 3 days (IQR 1-7). Factors associated with mortality (with adjusted odds ratios) included ART interruption, 1.33, 95% confidence intervals (CI) 1.13-1.57, p 0.001; CD4 + counts ≤ 200 cells/µL 1.59, 95%CI 1.33-1.91, p < 0.001; undocumented CD4 + cell count status 2.08, 95%CI 1.73-2.50, p < 0.001; impaired function status 7.35, 95%CI 6.42-8.41, p < 0.001; COVID-19 1.70, 95%CI 1.22-2.37, p 0.002; liver disease 1.77, 95%CI 1.36-2.30, p < 0.001; co-infections 1.53, 95%CI 1.32-1.78, p < 0.001; home address > 20 km from hospital 1.23, 95%CI 1.04-1.46, p 0.014; hospital readmission 0.7, 95%CI 0.56-0.88, p 0.002; chronic lung disease 0.62, 95%CI 0.41-0.92, p 0.019; and neurologic disease 0.46, 95%CI 0.32-0.68, p < 0.001. CONCLUSION One in four admitted PLHIV die during hospitalization. Identification of risk factors (such as ART interruption, function impairment, low/undocumented CD4 + cell count), early diagnosis and treatment of co-infections and liver disease could improve outcomes.
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Affiliation(s)
- Darius Owachi
- Kiruddu National Referral Hospital, Kampala, P.O. BOX 6588, Uganda.
| | | | | | | | | | - Martin Muddu
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - Samuel Kawuma
- Makerere University Joint AIDS Program, Kampala, Uganda
| | | | - Charles Kabugo
- Kiruddu National Referral Hospital, Kampala, P.O. BOX 6588, Uganda
| | - Fred C Semitala
- Makerere University Joint AIDS Program, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
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Onwah O, Nwanja E, Akpan U, Toyo O, Nwangeneh C, Oyawola B, Idemudia A, Olatunbosun K, Igboelina O, Ogundehin D, James E, Onyedinachi O, Adegboye A, Eyo A. Prevalence and predictors of persistent low-level HIV viraemia: a retrospective cohort study among people receiving dolutegravir-based antiretroviral therapy in Southern Nigeria. Ther Adv Infect Dis 2024; 11:20499361241242240. [PMID: 38572299 PMCID: PMC10989043 DOI: 10.1177/20499361241242240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 03/11/2024] [Indexed: 04/05/2024] Open
Abstract
Background Persistent low-level viraemia (PLLV) is a risk factor for virologic failure among people receiving antiretroviral therapy (ART). Objectives We assessed the prevalence and predictors of PLLV among individuals receiving Dolutegravir-based ART in southern Nigeria. Design This retrospective cohort study used routine program data from electronic medical records of persons receiving Dolutegravir-based first-line ART in 154 PEPFAR/USAID-supported health facilities in Akwa Ibom and Cross Rivers states, Nigeria. Methods Clients on first-line Dolutegravir-based ART ⩾6 months, who had a viral load result in the 12 months preceding October 2021 (baseline), and a second viral load result by September 2022 were included. Persons with low-level viraemia (LLV) (viral load 51-999 copies/ml) received additional adherence support. The outcome analysed was PLLV (two consecutive LLV results). Indices were summarized using descriptive statistics, and predictors of PLLV were determined using multivariate logistic regression. Results In total, 141,208 persons on ART were included, of which 63.3% (n = 89,944) were females. The median age was 36 [29-44] years, median ART duration was 19 [11-42] months. At the end of the study, 10.5% (14,759/141,208) had initial LLV, 90.1% (13,304/14,759) of which attained undetectable viral load (⩽50 copies/ml), and 1.1% (163/14,759) transitioned to virologic failure (⩾1000 copies/ml) by the end of the study. PLLV prevalence was 0.9% (1292/141,208). Increasing ART duration [adjusted odds ratio (aOR) = 1.0; 95% confidence interval (CI): 1.005-1.008; p < 0.001] and viral suppression (<1000 copies/ml) before initial LLV (aOR = 1.7; 95% CI: 1.50-2.00; p < 0.001) were positively associated with PLLV, while receipt of tuberculosis preventive therapy reduced the likelihood of PLLV (aOR = 0.3; 95% CI: 0.10-0.94; p = 0.039). Conclusion PLLV was uncommon among individuals receiving dolutegravir-based ART and was associated with longer ART duration, prior viral suppression, and non-receipt of tuberculosis preventive therapy. This strengthens recommendations for continuous adherence support and comprehensive health services with ART, to prevent treatment failure.
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Affiliation(s)
- Ogheneuzuazo Onwah
- Excellence Community Education Welfare Scheme, 14 Ubium Street, Ewet Housing Estate, Uyo, Akwa Ibom, Nigeria
| | - Esther Nwanja
- Excellence Community Education Welfare Scheme, Uyo, Nigeria
| | - Uduak Akpan
- Excellence Community Education Welfare Scheme, Uyo, Nigeria
| | - Otoyo Toyo
- Excellence Community Education Welfare Scheme, Uyo, Nigeria
| | | | | | | | | | | | | | | | | | | | - Andy Eyo
- Excellence Community Education Welfare Scheme, Uyo, Nigeria
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Cherkos AS, LaCourse SM, Enquobahrie DA, Escudero JN, Mecha J, Matemo D, Kinuthia J, John-Stewart G. Isoniazid preventive therapy during infancy does not adversely effect growth among HIV-exposed uninfected children: secondary analysis of data from a randomized controlled trial. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.10.19.23297259. [PMID: 37905041 PMCID: PMC10614991 DOI: 10.1101/2023.10.19.23297259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Background Isoniazid preventive therapy (IPT) decreases risk of tuberculosis (TB) disease; impact on long-term infant growth is unknown. In a recent randomized trial (RCT), we assessed IPT effects on infant growth without known TB exposure. Methods The infant TB Infection Prevention Study (iTIPS) trial was a non-blinded RCT among HIV-exposed uninfected (HEU) infants in Kenya. Inclusion criteria included age 6-10 weeks, birthweight ≥2.5 kg, and gestation ≥37 weeks. Infants in the IPT arm received 10 mg/kg isoniazid daily for 12 months, while the control trial received no intervention; post-trial observational follow-up continued through 24 months of age. We used intent-to-treat linear mixed-effects models to compare growth rates (weight-for-age z-score [WAZ] and height-for-age z-score [HAZ]) between trial arms. Results Among 298 infants, 150 were randomized to IPT, 47.6% were females, median birthweight was 3.4 kg (interquartile range [IQR] 3.0-3.7), and 98.3% were breastfed. During the 12-month intervention period and 12-month post-RCT follow-up, WAZ and HAZ declined significantly in all children, with more HAZ decline in male infants. There were no growth differences between trial arms, including in sex-stratified analyses. In longitudinal linear analysis, mean WAZ (β=0.04 [95% CI:-0.14, 0.22]), HAZ (β=0.14 [95% CI:-0.06, 0.34]), and WHZ [β=-0.07 [95% CI: -0.26, 0.11]) z-scores were similar between arms as were WAZ and HAZ growth trajectories. Infants randomized to IPT had higher monthly WHZ increase (β to 24 months 0.02 [95% CI:0.01, 0.04]) than the no-IPT arm. Conclusion IPT administered to HEU infants did not significantly impact growth outcomes in the first two years of life.
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Affiliation(s)
- Ashenafi S Cherkos
- Biostatistics and Epidemiology Department, School of Public Health, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Sylvia M LaCourse
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, USA
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- Department of Global Health, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Daniel A Enquobahrie
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Jaclyn N Escudero
- Department of Global Health, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Jerphason Mecha
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Daniel Matemo
- Medical Research Department, Kenyatta National Hospital, Nairobi, Kenya
| | - John Kinuthia
- Medical Research Department, Kenyatta National Hospital, Nairobi, Kenya
- Department of Obstetrics and Gynaecology, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, USA
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- Department of Global Health, School of Public Health, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
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Assefa DG, Bedru A, Zeleke ED, Negash SE, Debela DT, Molla W, Mengistu N, Woldesenbet TT, Bedane NF, Kajogoo VD, Atim MG, Manyazewal T. Efficacy and safety of different regimens in the treatment of patients with latent tuberculosis infection: a systematic review and network meta-analysis of randomized controlled trials. Arch Public Health 2023; 81:82. [PMID: 37143101 PMCID: PMC10161529 DOI: 10.1186/s13690-023-01098-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 04/28/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Treatment of latent tuberculosis infection (LTBI) is effective in preventing progression to TB disease. This study aimed to synthesize available evidence on the efficacy, adherence, and safety of LTBI treatment in order to assist policymakers to design appropriate national treatment policies and treatment protocols. METHOD The PRISMA-NMA was used to review and report this research. Randomized controlled trials which compared the efficacy and safety of LTBI treatments were included. A systematic literature search was done to identify relevant articles from online databases PubMed/ MEDLINE, Embase, and Cochrane Center for Clinical Trial database (CENTRAL). The network meta-analysis was done using R- studio Version 1.4.1103. RESULT In this review, 42 studies were included, which enrolled 46,022 people who had recent contact with patients with active tuberculosis, evidence radiological of previous tuberculosis, tuberculin test equal or greater than 5 mm, radiographs that indicated inactive fibrotic or calcified parenchymal and/or lymph node lesions, had conversion to positive results on a tuberculin skin test, participants living with HIV, chronic Silicosis, immigrants, prisoners, old people, and pregnant women who were at risk for latent TB were included. The incidence of TB among people living with HIV who have taken 3RH as TPT was lower, followed by 48%,followed by 6H (41%). However, 3HP has also the potential to reduce the incidence of TB by 36% among HIV negative patients who had TB contact history. Patients' adherence to TPT was higher among patients who have taken 4R (RR 1.38 95% CI 1.0,1.89) followed by 3RH (34%). The proportion of subjects who permanently discontinued a study drug because of an adverse event were three times higher in the 3RH treatment group. Furthermore, the risk of grade 3 and 4 liver toxicity was significantly higher in 9H followed by 1HP, and 6H. CONCLUSION From this review, it can be concluded 3RH and 6H has a significant impact on the reduction of TB incidence among PLWH and 3HP among HIV negative people who had TB contact history. However, combinations of rifampicin either with isoniazid were significantly associated with adverse events which resulted in permanent discontinuation among adult patients. Furthermore, grade 3 and 4 liver toxicity was more common in patents who have taken 9H, 1HP, and 6H. This may support the current recommended TPT regimen of 3HP, 3RH, and 6H.
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Affiliation(s)
| | - Ahmed Bedru
- KNCV Tuberculosis Foundation, Country Office, Addis Ababa, Ethiopia
| | | | - Solomon Emiru Negash
- Department of Emeregency, Nashville Veterans Affairs Medical Center, Nashville, USA
| | - Dejene Tolossa Debela
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa, Ethiopia
| | | | | | | | | | | | - Mary Gorret Atim
- Department of Public Health, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - Tsegahun Manyazewal
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa, Ethiopia
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Efficacy, safety, and tolerability of isoniazid preventive therapy for tuberculosis in people living with HIV. AIDS 2023; 37:455-465. [PMID: 36412204 DOI: 10.1097/qad.0000000000003436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aim of this study was to systematically assess the efficacy, safety, and tolerability of isoniazid preventive therapy (IPT) for tuberculosis (TB) in people with HIV (PWH). DESIGN A systematic review and meta-analysis. METHODS A thorough literature search was performed using PubMed, Cochrane CENTRAL, and Google Scholar from their inception to June 30, 2021. All randomized controlled trials (RCTs) investigating the efficacy, safety, or tolerability of IPT on PWH compared with placebo or active comparators were included in the study. The heterogeneity among the studies was identified by using the I2 statistic and Cochran's Q test. RESULTS Out of the 924 nonduplicate RCTs identified through database searching and other sources, 26 studies comprising 38 005 patients were included. The overall effect estimate identified the reduction of active TB incidence [odds ratio (OR) 0.69; 95% confidence interval (95% CI) 0.57-0.84; P < 0.001], but not all-cause mortality (OR 0.91; 95% CI 0.82, 1.02; P = 0.10) with IPT compared with the control. In addition, no significant association was identified between the use of IPT and the risk of peripheral neuropathy (OR 1.50; 95% CI 0.96-2.36; P = 0.08) and hepatotoxicity (OR 1.21; 95% CI 0.97-1.52; P = 0.09). CONCLUSION This systematic review and meta-analysis identified a significant reduction in the incidence of active TB, but not all-cause mortality, among PWH who received IPT compared with the control. Lesser number of outcomes may be the reason for nonsignificant results in terms of safety outcomes of IPT. Therefore, there is a need for extensive and long-term studies to address these issues further, especially in TB/HIV endemic areas.
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Assefa DG, Zeleke ED, Bekele D, Ejigu DA, Molla W, Woldesenbet TT, Aynalem A, Abebe M, Mebratu A, Manyazewal T. Isoniazid Preventive Therapy for Prevention of Tuberculosis among People Living with HIV in Ethiopia: A Systematic Review of Implementation and Impacts. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:621. [PMID: 36612942 PMCID: PMC9819739 DOI: 10.3390/ijerph20010621] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Tuberculosis (TB) is a major cause of morbidity and mortality in people living with HIV (PLWHIV). Isoniazid preventive therapy (IPT) prevents TB in PLWHIV, but estimates of its effects and actual implementation vary across countries. We reviewed studies that examined the impact of IPT on PLHIV and the factors influencing its implementation in Ethiopia. METHODS We searched PubMed/MEDLINE, Embase, and the Cochrane Central Register of Clinical Controlled Trials from their inception to 1 April 2021 for studies of any design that examined the impact of IPT on PLHIV and the factors influencing its implementation. The protocol was registered in PROSPERO, ID: CRD42021256579. RESULT Of the initial 546 studies identified, 13 of which enrolled 12,426 participants, 15,640 PLHIV and 62 HIV clinical care providers were included. PLHIV who were on IPT, independently or simultaneously with ART, were less likely to develop TB than those without IPT. IPT interventions had a significant association with improved CD4 count and reduced all-cause mortality. IPT was less effective in people with advanced HIV infection. The major factors influencing IPT implementation and uptake were stock-outs, fear of developing isoniazid-resistant TB, patient's refusal and non-adherence, and improper counseling and low commitment of HIV clinical care providers. CONCLUSION IPT alone or in combination with ART significantly reduces the incidence of TB and mortality in PLHIV in Ethiopia than those without IPT. More research on safety is needed, especially on women with HIV who receive a combination of IPT and ART. Additionally, studies need to be conducted to investigate the efficacy and safety of the new TPT (3 months combination of isoniazid and rifapentine) in children and people living with HIV.
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Affiliation(s)
- Dawit Getachew Assefa
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa P.O. Box 3880, Ethiopia
- Department of Nursing, College of Medicine and Health Sciences, Dilla University, Dilla P.O. Box 419, Ethiopia
| | - Eden Dagnachew Zeleke
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa P.O. Box 3880, Ethiopia
- Department of Midwifery, College of Health Science, Bule-Hora University, Bule-Hora P.O. Box 144, Ethiopia
| | - Delayehu Bekele
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa P.O. Box 3880, Ethiopia
- Department of Obstetrics and Gynecology, Saint Paul’s Hospital Millennium Medical College, Addis Ababa P.O. Box 3880, Ethiopia
| | - Dawit A. Ejigu
- Department of Pharmacology, Saint Paul’s Hospital Millennium Medical College, Addis Ababa P.O. Box 3880, Ethiopia
| | - Wondwosen Molla
- Department of Midwifery, College of Medicine and Health Sciences, Dilla University, Dilla P.O. Box 419, Ethiopia
| | - Tigist Tekle Woldesenbet
- Department of Public Health, School of Graduate Studies, Pharma College, Hawassa P.O. Box 5, Ethiopia
| | - Amdehiwot Aynalem
- School of Nursing, College of Medicine and Health Sciences, Hawassa University, Hawassa P.O. Box 1560, Ethiopia
| | - Mesfin Abebe
- Department of Midwifery, College of Medicine and Health Sciences, Dilla University, Dilla P.O. Box 419, Ethiopia
| | - Andualem Mebratu
- Department of Midwifery, College of Medicine and Health Sciences, Dilla University, Dilla P.O. Box 419, Ethiopia
| | - Tsegahun Manyazewal
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa P.O. Box 3880, Ethiopia
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11
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Landscape of TB Infection and Prevention among People Living with HIV. Pathogens 2022; 11:pathogens11121552. [PMID: 36558886 PMCID: PMC9786705 DOI: 10.3390/pathogens11121552] [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: 11/05/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022] Open
Abstract
Tuberculosis (TB) is one of the leading causes of mortality in people living with HIV (PLHIV) and contributes to up to a third of deaths in this population. The World Health Organization guidelines aim to target early detection and treatment of TB among PLHIV, particularly in high-prevalence and low-resource settings. Prevention plays a key role in the fight against TB among PLHIV. This review explores TB screening tools available for PLHIV, including symptom-based screening, chest radiography, tuberculin skin tests, interferon gamma release assays, and serum biomarkers. We then review TB Preventive Treatment (TPT), shown to reduce the progression to active TB and mortality among PLHIV, and available TPT regimens. Last, we highlight policy-practice gaps and barriers to implementation as well as ongoing research needs to lower the burden of TB and HIV coinfection through preventive activities, innovative diagnostic tests, and cost-effectiveness studies.
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12
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Santos JM, Fachi MM, Beraldi-Magalhães F, Böger B, Junker AM, Domingos EL, Imazu P, Fernandez-Llimos F, Tonin FS, Pontarolo R. Systematic review with network meta-analysis on the treatments for latent tuberculosis infection in children and adolescents. J Infect Chemother 2022; 28:1645-1653. [PMID: 36075488 DOI: 10.1016/j.jiac.2022.08.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 06/15/2022] [Accepted: 08/26/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND We aimed to synthesize the evidence on the efficacy and safety of different treatment regimens for latent tuberculosis infection (LTBI) in children and adolescents. METHODS A systematic review with network meta-analysis was performed (CRD142933). Searches were conducted in Pubmed and Scopus (Nov-2021). Randomized controlled trials comparing treatments for LTBI (patients up to 15 years), and reporting data on the incidence of the disease, death or adverse events were included. Networks using the Bayesian framework were built for each outcome of interest. Results were reported as odds ratio (OR) with 95% credibility intervals (CrI). Rank probabilities were calculated via the surface under the cumulative ranking analysis (SUCRA) (Addis-v.1.16.8). GRADE approach was used to rate evidence's certainty. RESULTS Seven trials (n = 8696 patients) were included. Placebo was significantly associated with a higher incidence of tuberculosis compared to all active therapies. Combinations of isoniazid (15-25 mg/kg/week) plus rifapentine (300-900 mg/week), followed by isoniazid plus rifampicin (10 mg/kg/day) were ranked as best approaches with lower probabilities of disease incidence (10% and 19.5%, respectively in SUCRA) and death (20%). Higher doses of isoniazid monotherapy were significantly associated to more deaths (OR 18.28, 95% ICr [1.02, 48.60] of 4-6 mg/kg/day vs. 10 mg/kg/3x per week). CONCLUSIONS Combined therapies of isoniazid plus rifapentine or rifampicin for short-term periods should be used as the first-line approach for treating LTBI in children and adolescents. The use of long-term isoniazid as monotherapy and at higher doses should be avoided for this population.
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Affiliation(s)
- Josiane M Santos
- Pharmaceutical Sciences Postgraduate Research Program, Federal University of Paraná, Curitiba, Brazil.
| | - Mariana M Fachi
- Pharmaceutical Sciences Postgraduate Research Program, Federal University of Paraná, Curitiba, Brazil.
| | | | - Beatriz Böger
- Pharmaceutical Sciences Postgraduate Research Program, Federal University of Paraná, Curitiba, Brazil.
| | - Allan M Junker
- Pharmaceutical Sciences Postgraduate Research Program, Federal University of Paraná, Curitiba, Brazil.
| | - Eric L Domingos
- Pharmaceutical Sciences Postgraduate Research Program, Federal University of Paraná, Curitiba, Brazil.
| | - Priscila Imazu
- Pharmaceutical Sciences Postgraduate Research Program, Federal University of Paraná, Curitiba, Brazil.
| | - Fernando Fernandez-Llimos
- Laboratory of Pharmacology, Department of Drug Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal.
| | - Fernanda S Tonin
- Pharmaceutical Sciences Postgraduate Research Program, Federal University of Paraná, Curitiba, Brazil; H&TRC- Health & Technology Research Center, ESTeSL- Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal.
| | - Roberto Pontarolo
- Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil.
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13
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Cranmer LM, Cotton MF, Day CL, Nemes E. What's Old and New in Tuberculosis Vaccines for Children. J Pediatric Infect Dis Soc 2022; 11:S110-S116. [PMID: 36314550 PMCID: PMC9620432 DOI: 10.1093/jpids/piac078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Tuberculosis (TB) is a leading cause of global child mortality. Until the turn of the 21st century, Mycobacterium bovis bacille Calmette-Guerin (BCG) was the only vaccine to prevent TB. The pediatric TB vaccine pipeline has advanced in the past decade to include the evaluation of novel whole cell vaccines to replace infant BCG and investigation of subunit and whole cell vaccines to boost TB immunity during adolescence. We describe the history of BCG, current TB vaccine candidates in clinical trials, and the challenges and opportunities for future TB vaccine research in children. Children are a critical target population for TB vaccines, and expansion of the pediatric TB vaccine pipeline is urgently needed to end the TB pandemic.
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Affiliation(s)
- Lisa M Cranmer
- Department of Pediatrics, Division of Pediatric Infectious Disease, Emory School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, Georgia, USA
- Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Mark F Cotton
- Department of Pediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - Cheryl L Day
- Department of Microbiology & Immunology, Emory School of Medicine, Atlanta, Georgia, USA
- Emory Vaccine Center, Atlanta, Georgia, USA
| | - Elisa Nemes
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
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14
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Akamike IC, Okedo-Alex IN, Uneke CJ, Madubueze UC, Agbo UN, Okeke IM, Ogbonnaya LU. Health workers' knowledge and practice of Isoniazid preventive treatment guidelines in health facilities in Ebonyi State, Nigeria. Malawi Med J 2022; 34:184-191. [PMID: 36406103 PMCID: PMC9641607 DOI: 10.4314/mmj.v34i3.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Isoniazid preventive therapy is recommended as part of a comprehensive HIV and AIDS care strategy. IPT is used as prophylaxis to reduce the incidence of TB in HIV-infected persons. However, its implementation has been very slow and has been influenced by several factors. This study assessed health workers' knowledge and adherence to Isoniazid Preventive Therapy guidelines. Methods This was a cross-sectional study in six health facilities providing HIV care in Ebonyi State using a semi-structured, self-administered questionnaire. Data were collected from 85 health workers working in the HIV clinics. Data were also extracted from 200 patient treatment cards. Data analysis was carried out using SPSS version 20 software. Chi-square statistics and logistic regression were carried out to determine the association between socio-demographic characteristics and knowledge as well as self-reported practice of the guideline. Result Slightly over half of the respondents (58.8%) had good knowledge of the guideline, and the majority (75.3%) self-reported that they practiced the guideline. Only 17% of the treatment cards had isoniazid prescribed and only 11% of these had patient adherence assessed. The most common challenges to implementation of the guideline cited by health workers were unavailability of isoniazid, poor awareness, patient non-adherence, poor resources, high pill burden, and lack of training. Being a doctor and more than 3 years duration of work in the clinic were predictors of good knowledge. There was no predictor of practice. Conclusion There was good knowledge and practice of the guideline from health worker self-reports, however, review of treatment card showed prescription was low. Further studies to explore and understand why there is such low prescription of INH/IPT to HIV patients despite good knowledge of healthcare professionals are recommended.
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Affiliation(s)
- Ifeyinwa Chizoba Akamike
- Department of Community Medicine, Alex Ekwueme Federal University Teaching, Hospital, Abakaliki, Ebonyi State, Nigeria, African Institute for Health Policy and Health Systems, Ebonyi State University, Nigeria
| | - Ijeoma Nkem Okedo-Alex
- Department of Community Medicine, Alex Ekwueme Federal University Teaching, Hospital, Abakaliki, Ebonyi State, Nigeria, African Institute for Health Policy and Health Systems, Ebonyi State University, Nigeria
| | - Chigozie Jesse Uneke
- African Institute for Health Policy and Health Systems, Ebonyi State University, Nigeria
| | - Ugochukwu Chinyem Madubueze
- Department of Community Medicine, Alex Ekwueme Federal University Teaching, Hospital, Abakaliki, Ebonyi State, Nigeria, Alex Ekwueme Federal University, Ndufu Alike Ikwo, Ebonyi State, Nigeria
| | - Urudinachi Nnenne Agbo
- Department of Community Medicine, Alex Ekwueme Federal University Teaching, Hospital, Abakaliki, Ebonyi State, Nigeria, African Institute for Health Policy and Health Systems, Ebonyi State University, Nigeria
| | - Ifeyinwa Maureen Okeke
- Department of Community Medicine, Alex Ekwueme Federal University Teaching, Hospital, Abakaliki, Ebonyi State, Nigeria, African Institute for Health Policy and Health Systems, Ebonyi State University, Nigeria
| | - Lawrence Ulu Ogbonnaya
- Department of Community Medicine, Alex Ekwueme Federal University Teaching, Hospital, Abakaliki, Ebonyi State, Nigeria, African Institute for Health Policy and Health Systems, Ebonyi State University, Nigeria, Alex Ekwueme Federal University, Ndufu Alike Ikwo, Ebonyi State, Nigeria
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15
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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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16
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Fehily SR, Al‐Ani AH, Abdelmalak J, Rentch C, Zhang E, Denholm JT, Johnson D, Ng SC, Sharma V, Rubin DT, Gibson PR, Christensen B. Review article: latent tuberculosis in patients with inflammatory bowel diseases receiving immunosuppression-risks, screening, diagnosis and management. Aliment Pharmacol Ther 2022; 56:6-27. [PMID: 35596242 PMCID: PMC9325436 DOI: 10.1111/apt.16952] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 04/14/2022] [Accepted: 04/18/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND One quarter of the world's population has latent tuberculosis infection (LTBI). Systemic immunosuppression is a risk factor for LTBI reactivation and the development of active tuberculosis. Such reactivation carries a risk of significant morbidity and mortality. Despite the increasing global incidence of inflammatory bowel disease (IBD) and the use of immune-based therapies, current guidelines on the testing and treatment of LTBI in patients with IBD are haphazard with a paucity of evidence. AIM To review the screening, diagnostic practices and medical management of LTBI in patients with IBD. METHODS Published literature was reviewed, and recommendations for testing and treatment were synthesised by experts in both infectious diseases and IBD. RESULTS Screening for LTBI should be performed proactively and includes assessment of risk factors, an interferon-gamma releasing assay or tuberculin skin test and chest X-ray. LTBI treatment in patients with IBD is scenario-dependent, related to geographical endemicity, travel and other factors. Ideally, LTBI therapy should be used prior to immune suppression but can be applied concurrently where urgent IBD medical treatment is required. Management is best directed by a multidisciplinary team involving gastroenterologists, infectious diseases specialists and pharmacists. Ongoing surveillance is recommended during therapy. Newer LTBI therapies show promise, but medication interactions need to be considered. There are major gaps in evidence, particularly with specific newer therapeutic approaches to IBD. CONCLUSIONS Proactive screening for LTBI is essential in patients with IBD undergoing immune-suppressing therapy and several therapeutic strategies are available. Reporting of real-world experience is essential to refining current management recommendations.
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Affiliation(s)
- Sasha R. Fehily
- Gastroenterology DepartmentSt Vincent's HospitalMelbourneVictoriaAustralia
- Department of MedicineUniversity of MelbourneParkvilleVictoriaAustralia
| | - Aysha H. Al‐Ani
- Department of MedicineUniversity of MelbourneParkvilleVictoriaAustralia
- Gastroenterology DepartmentRoyal Melbourne HospitalParkvilleVictoriaAustralia
| | | | - Clarissa Rentch
- Gastroenterology DepartmentRoyal Melbourne HospitalParkvilleVictoriaAustralia
| | - Eva Zhang
- Gastroenterology DepartmentRoyal Melbourne HospitalParkvilleVictoriaAustralia
| | - Justin T. Denholm
- Department of MedicineUniversity of MelbourneParkvilleVictoriaAustralia
- Infectious Diseases DepartmentRoyal Melbourne HospitalParkvilleVictoriaAustralia
- Victorian Tuberculosis ProgramMelbourneVictoriaAustralia
- Department of Infectious DiseasesDoherty InstituteParkvilleVictoriaAustralia
| | - Douglas Johnson
- Department of MedicineUniversity of MelbourneParkvilleVictoriaAustralia
- Infectious Diseases DepartmentRoyal Melbourne HospitalParkvilleVictoriaAustralia
| | - Siew C. Ng
- Department of Medicine and TherapeuticsInstitute of Digestive Disease, The Chinese University of Hong KongHong Kong SARChina
| | - Vishal Sharma
- Department of GastroenterologyPostgraduate Institute of Medical Education and ResearchChandigarhIndia
| | - David T. Rubin
- University of Chicago Medicine Inflammatory Bowel Disease CenterUniversity of Chicago MedicineChicagoIllinoisUSA
| | - Peter R. Gibson
- Department of GastroenterologyMonash University and Alfred HealthMelbourneVictoriaAustralia
| | - Britt Christensen
- Department of MedicineUniversity of MelbourneParkvilleVictoriaAustralia
- Gastroenterology DepartmentRoyal Melbourne HospitalParkvilleVictoriaAustralia
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17
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Rojo P, Moraleda C, Tagarro A, Domínguez-Rodríguez S, Castillo LM, Tato LMP, López AS, Manukyan L, Marcy O, Leroy V, Nardone A, Burger D, Bassat Q, Bates M, Moh R, Iroh Tam PY, Mvalo T, Magallhaes J, Buck WC, Sacarlal J, Musiime V, Chabala C, Mujuru HA. Empirical treatment against cytomegalovirus and tuberculosis in HIV-infected infants with severe pneumonia: study protocol for a multicenter, open-label randomized controlled clinical trial. Trials 2022; 23:531. [PMID: 35761406 PMCID: PMC9235074 DOI: 10.1186/s13063-022-06203-1] [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] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 03/26/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Pneumonia is the primary cause of death among HIV-infected children in Africa, with mortality rates as high as 35-40% in infants hospitalized with severe pneumonia. Bacterial pathogens and Pneumocystis jirovecii are well known causes of pneumonia-related death, but other important causes such as cytomegalovirus (CMV) and tuberculosis (TB) remain under-recognized and undertreated. The immune response elicited by CMV may be associated with the risk of developing TB and TB disease progression, and CMV may accelerate disease caused both by HIV and TB. Minimally invasive autopsies confirm that CMV and TB are unrecognized causes of death in children with HIV. CMV and TB may also co-infect the same child. The aim of this study is to compare the impact on 15-day and 1-year mortality of empirical treatment against TB and CMV plus standard of care (SoC) versus SoC in HIV-infected infants with severe pneumonia. METHODS This is a Phase II-III, open-label randomized factorial (2 × 2) clinical trial, conducted in six African countries. The trial has four arms. Infants from 28 to 365 days of age HIV-infected and hospitalized with severe pneumonia will be randomized (1:1:1:1) to (i) SoC, (ii) valganciclovir, (iii) TB-T, and (iv) TB-T plus valganciclovir. The primary endpoint of the study is all-cause mortality, focusing on the short-term (up to 15 days) and long-term (up to 1 year) mortality. Secondary endpoints include repeat hospitalization, duration of oxygen therapy during initial admission, severe and notable adverse events, adverse reactions, CMV and TB prevalence at enrolment, TB incidence, CMV viral load reduction, and evaluation of diagnostic tests such as GeneXpert Ultra on fecal and nasopharyngeal aspirate samples and urine TB-LAM. DISCUSSION Given the challenges in diagnosing CMV and TB in children and results from previous autopsy studies that show high rates of poly-infection in HIV-infected infants with respiratory disease, this study aims to evaluate a new approach including empirical treatment of CMV and TB for this patient population. The potential downsides of empirical treatment of these conditions include toxicity and medication interactions, which will be evaluated with pharmacokinetics sub-studies. TRIAL REGISTRATION ClinicalTrials.gov , NCT03915366, Universal Trial Number U111-1231-4736, Pan African Clinical Trial Registry PACTR201994797961340.
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Affiliation(s)
- Pablo Rojo
- Servicio de Pediatria. Hospital Universitario 12 de Octubre, Servicio Madrileño de Salud (SERMAS), Madrid, Spain
- Unidad Pediátrica de Investigación y Ensayos Clínicos (UPIC). Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Fundación Biomedica del Hospital Universitario 12 de Octubre (FIB-H12O), Madrid, Spain
| | - Cinta Moraleda
- Servicio de Pediatria. Hospital Universitario 12 de Octubre, Servicio Madrileño de Salud (SERMAS), Madrid, Spain
- Unidad Pediátrica de Investigación y Ensayos Clínicos (UPIC). Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Fundación Biomedica del Hospital Universitario 12 de Octubre (FIB-H12O), Madrid, Spain
| | - Alfredo Tagarro
- Unidad Pediátrica de Investigación y Ensayos Clínicos (UPIC). Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Fundación Biomedica del Hospital Universitario 12 de Octubre (FIB-H12O), Madrid, Spain
- Servicio de Pediatria. Hospital Universitario Infanta Sofia, Servicio Madrileño de Salud (SERMAS), Madrid, Spain
- Facultad de Ciencias Biomédicas, Universidad Europea de Madrid., Madrid, Spain
| | - Sara Domínguez-Rodríguez
- Unidad Pediátrica de Investigación y Ensayos Clínicos (UPIC). Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Fundación Biomedica del Hospital Universitario 12 de Octubre (FIB-H12O), Madrid, Spain
| | - Lola Madrid Castillo
- Unidad Pediátrica de Investigación y Ensayos Clínicos (UPIC). Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Fundación Biomedica del Hospital Universitario 12 de Octubre (FIB-H12O), Madrid, Spain
- London School of Hygiene & Tropical Medicine (LMC), London, UK
| | - Luis Manuel Prieto Tato
- Servicio de Pediatria. Hospital Universitario 12 de Octubre, Servicio Madrileño de Salud (SERMAS), Madrid, Spain
- Unidad Pediátrica de Investigación y Ensayos Clínicos (UPIC). Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Fundación Biomedica del Hospital Universitario 12 de Octubre (FIB-H12O), Madrid, Spain
| | - Aranzazu Sancho López
- Pharmacology Unit, Hospital Puerta de Hierro, Servicio, Madrileño de Salud (SERMAS), Madrid, Spain
| | - Lilit Manukyan
- Unidad Pediátrica de Investigación y Ensayos Clínicos (UPIC). Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Fundación Biomedica del Hospital Universitario 12 de Octubre (FIB-H12O), Madrid, Spain
| | - Olivier Marcy
- Université de Bordeaux, Inserm U1219, IRD EMR271, Bordeaux Population Health, GHiGS, Bordeaux, France
| | - Valeriane Leroy
- Institut National de la Santé et de la Recherche Médicale (Inserm), University Toulouse 3,CERPOP, Toulouse, France
| | | | - David Burger
- Stichting Katholieke Universiteit- Radboudumc (RUMC), Nijmegen, The Netherlands
| | - Quique Bassat
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain, Barcelona, Spain
- Pediatrics Department, Hospital Sant Joan de Déu, I, Universitat de Barcelona, Barcelona, Spain
- ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
- University of Lincoln, Lincoln, United Kingdom
| | | | - Raoul Moh
- Unité Pédagogique de Dermatologie et Infectiologie, UFR Sciences Médicales, Programme PAC-CI, Ivory Coast, Abidjan, Côte d’Ivoire
| | - Pui-Ying Iroh Tam
- Kamuzu University Health Sciences, Blantyre, Malawi
- Malawi-Liverpool Wellcome Programme (MLW), Liverpool School of Tropical Medicine (LSTM), Blantyre, Malawi
| | - Tisungane Mvalo
- Lilongwe Medical Relief Trust (LMRFT), UNC Project Malawi, Lilongwe, Malawi
| | | | - W. Chris Buck
- University of California Los Angeles David Geffen School of Medicine, Los Angeles, USA
- Universidade Eduardo Mondlane (UEM), Maputo, Mozambique
| | - Jahit Sacarlal
- Department of Microbiology, Faculty of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Victor Musiime
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
- Joint Clinical Research Centre, Kampala, Uganda
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18
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Yanes-Lane M, Ortiz-Brizuela E, Campbell JR, Benedetti A, Churchyard G, Oxlade O, Menzies D. Tuberculosis preventive therapy for people living with HIV: A systematic review and network meta-analysis. PLoS Med 2021; 18:e1003738. [PMID: 34520459 PMCID: PMC8439495 DOI: 10.1371/journal.pmed.1003738] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 07/18/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) preventive therapy (TPT) is an essential component of care for people living with HIV (PLHIV). We compared efficacy, safety, completion, and drug-resistant TB risk for currently recommended TPT regimens through a systematic review and network meta-analysis (NMA) of randomized trials. METHODS AND FINDINGS We searched MEDLINE, Embase, and the Cochrane Library from inception through June 9, 2020 for randomized controlled trials (RCTs) comparing 2 or more TPT regimens (or placebo/no treatment) in PLHIV. Two independent reviewers evaluated eligibility, extracted data, and assessed the risk of bias. We grouped TPT strategies as follows: placebo/no treatment, 6 to 12 months of isoniazid, 24 to 72 months of isoniazid, and rifamycin-containing regimens. A frequentist NMA (using graph theory) was carried out for the outcomes of development of TB disease, all-cause mortality, and grade 3 or worse hepatotoxicity. For other outcomes, graphical descriptions or traditional pairwise meta-analyses were carried out as appropriate. The potential role of confounding variables for TB disease and all-cause mortality was assessed through stratified analyses. A total of 6,466 unique studies were screened, and 157 full texts were assessed for eligibility. Of these, 20 studies (reporting 16 randomized trials) were included. The median sample size was 616 (interquartile range [IQR], 317 to 1,892). Eight were conducted in Africa, 3 in Europe, 3 in the Americas, and 2 included sites in multiple continents. According to the NMA, 6 to 12 months of isoniazid were no more efficacious in preventing microbiologically confirmed TB than rifamycin-containing regimens (incidence rate ratio [IRR] 1.0, 95% CI 0.8 to 1.4, p = 0.8); however, 6 to 12 months of isoniazid were associated with a higher incidence of all-cause mortality (IRR 1.6, 95% CI 1.2 to 2.0, p = 0.02) and a higher risk of grade 3 or higher hepatotoxicity (risk difference [RD] 8.9, 95% CI 2.8 to 14.9, p = 0.004). Finally, shorter regimens were associated with higher completion rates relative to longer regimens, and we did not find statistically significant differences in the risk of drug-resistant TB between regimens. Study limitations include potential confounding due to differences in posttreatment follow-up time and TB incidence in the study setting on the estimates of incidence of TB or all-cause mortality, as well as an underrepresentation of pregnant women and children. CONCLUSIONS Rifamycin-containing regimens appear safer and at least as effective as isoniazid regimens in preventing TB and death and should be considered part of routine care in PLHIV. Knowledge gaps remain as to which specific rifamycin-containing regimen provides the optimal balance of efficacy, completion, and safety.
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Affiliation(s)
- Mercedes Yanes-Lane
- Respiratory Epidemiology and Clinical Research Unit, McGill International TB Centre, McGill University, Montréal, Québec, Canada
| | - Edgar Ortiz-Brizuela
- Respiratory Epidemiology and Clinical Research Unit, McGill International TB Centre, McGill University, Montréal, Québec, Canada
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Jonathon R. Campbell
- Respiratory Epidemiology and Clinical Research Unit, McGill International TB Centre, McGill University, Montréal, Québec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Andrea Benedetti
- Respiratory Epidemiology and Clinical Research Unit, McGill International TB Centre, McGill University, Montréal, Québec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
- Department of Medicine, McGill University, Montreal, Canada
| | - Gavin Churchyard
- The Aurum Institute, Parktown, South Africa
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Olivia Oxlade
- Respiratory Epidemiology and Clinical Research Unit, McGill International TB Centre, McGill University, Montréal, Québec, Canada
| | - Dick Menzies
- Respiratory Epidemiology and Clinical Research Unit, McGill International TB Centre, McGill University, Montréal, Québec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
- * E-mail:
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19
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LaCourse SM, Richardson BA, Kinuthia J, Warr AJ, Maleche-Obimbo E, Matemo D, Cranmer LM, Mecha J, Escudero JN, Hawn TR, John-Stewart G. A Randomized Controlled Trial of Isoniazid to Prevent Mycobacterium tuberculosis Infection in Kenyan Human Immunodeficiency Virus-Exposed Uninfected Infants. Clin Infect Dis 2021; 73:e337-e344. [PMID: 32564076 PMCID: PMC8282257 DOI: 10.1093/cid/ciaa827] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/15/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-exposed uninfected (HEU) infants in endemic settings are at high risk of tuberculosis (TB). For infants, progression from primary Mycobacterium tuberculosis (Mtb) infection to TB disease can be rapid. We assessed whether isoniazid (INH) prevents primary Mtb infection. METHODS We conducted a randomized nonblinded controlled trial enrolling HEU infants 6 weeks of age without known TB exposure in Kenya. Participants were randomized (1:1) to 12 months of daily INH (10 mg/kg) vs no INH. Primary endpoint was Mtb infection at end of 12 months, assessed by interferon-γ release assay (QuantiFERON-TB Gold Plus) and/or tuberculin skin test (TST, added 6 months after first participant exit). RESULTS Between 15 August 2016 and 6 June 2018, 416 infants were screened, with 300 (72%) randomized to INH or no INH (150 per arm); 2 were excluded due to HIV infection. Among 298 randomized HEU infants, 12-month retention was 96.3% (287/298), and 88.9% (265/298) had primary outcome data. Mtb infection prevalence at 12-month follow-up was 10.6% (28/265); 7.6% (10/132) in the INH arm and 13.5% (18/133) in the no INH arm (7.0 vs 13.4 per 100 person-years; hazard ratio, 0.53 [95% confidence interval {CI}, .24-1.14]; P = .11]), and driven primarily by TST positivity (8.6% [8/93] in INH and 18.1% [17/94] in no INH; relative risk, 0.48 [95% CI, .22-1.05]; P = .07). Frequency of severe adverse events was similar between arms (INH, 14.0% [21/150] vs no INH, 10.7% [16/150]; P = .38), with no INH-related adverse events. CONCLUSIONS Further studies evaluating TB preventive therapy to prevent or delay primary Mtb infection in HEU and other high-risk infants are warranted. CLINICAL TRIALS REGISTRATION NCT02613169.
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Affiliation(s)
- Sylvia M LaCourse
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - John Kinuthia
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Obstetrics and Gynaecology, Kenyatta National Hospital, Nairobi, Kenya
| | - A J Warr
- Department of Pediatrics, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - Daniel Matemo
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Lisa M Cranmer
- Department of Pediatrics, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
- Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Jerphason Mecha
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Jaclyn N Escudero
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Thomas R Hawn
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Grace John-Stewart
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
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20
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Dawit Z, Abebe S, Dessu S, Mesele M, Sahile S, Ajema D. Incidence and predictors of mortality among children co-infected with tuberculosis and human immunodeficiency virus at public hospitals in Southern Ethiopia. PLoS One 2021; 16:e0253449. [PMID: 34191846 PMCID: PMC8244885 DOI: 10.1371/journal.pone.0253449] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 06/04/2021] [Indexed: 01/27/2023] Open
Abstract
Background Tuberculosis and human immune deficiency virus co-infections remained the most common cause of child mortality for the last ten years. Globally, 1.2 million cases of tuberculosis occurred in patients living with HIV/AIDS, of which 1.0 million cases occurred in children. The public health impact of tuberculosis and human immune deficiency virus co-infection among children is high in developing countries and Sub-Saharan Africa accompanied three fourth of the global burden. However, there are limited studies that assess the incidence and predictors of mortality among tuberculosis and human immune deficiency virus co-infected children in Ethiopia. Methods A facility-based retrospective cohort study was conducted at Public hospitals in Southern Ethiopia with a total of 286 randomly selected records of ART enrolled children from 1st January 2009 to 31stDecember 2018. Data were entered into Epi Data version 3.1 and exported to STATA version 14 for analysis. Bivariate and multivariable Cox proportional hazards model was fitted to identify the predictors of mortality. Variables that had a p-value<0.05 at 95%CI in the multivariable cox proportional hazard model were considered as statistically significant. Results A total of 274 tuberculosis and human immunodeficiency virus co-infected children’s records were reviewed. The incidence of mortality among tuberculosis and human immunodeficiency virus co-infected children was 17.15 per 100 children. The overall incidence density rate of mortality was 2.97(95%CI: 2.2, 3.9) per 100 child year of observation and being anemic (AHR: 2.6; 95%CI: 1.28, 5.21), not initiating isoniazid prophylaxis therapy (AHR: 2.8; 95%CI: 1.44, 5.48), developing extrapulmonary tuberculosis (AHR: 5.7; 95%CI: 2.67, 12.56) and non-adherence (AHR: 5.2; 95%CI: 2.19, 12.39) were independent predictors of mortality. Conclusion Mortality rate was high among TB/HIV co-infected children at the public hospitals in Southern Ethiopia. Extra-pulmonary tuberculosis, anemia, non-adherence, and isoniazid preventive therapy use were statistically significant predictors of mortality among TB/HIV co-infected children. Therefore, extra pulmonary tuberculosis, and anemia should be closely monitored to increase their adherence as well as they should be provided with isoniazid preventive therapy.
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Affiliation(s)
- Zinabu Dawit
- Department of Nursing, Arba Minch College of Health Sciences, Arba Minch, Southern Ethiopia
- * E-mail:
| | - Sintayehu Abebe
- School of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Southern Ethiopia
| | - Samuel Dessu
- Department of Public Health, College of Medicine and Health Sciences, Wolkite University, Wolkite, Southern Ethiopia
| | - Molalegn Mesele
- Department of Midwifery, College of Health Sciences and Medicine, Wolaita Sodo University, Wolaita, Southern Ethiopia
| | - Serekebirhan Sahile
- Department of Nursing, Arba Minch College of Health Sciences, Arba Minch, Southern Ethiopia
| | - Desalegn Ajema
- School of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Southern Ethiopia
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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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22
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Riccardi N, Villa S, Canetti D, Giacomelli A, Taramasso L, Martini M, Di Biagio A, Bragazzi NL, Brigo F, Sotgiu G, Besozzi G, Codecasa L. Missed opportunities in tb clinical practice: How to bend the curve? A medical, social, economic and ethical point of view. Tuberculosis (Edinb) 2020; 126:102041. [PMID: 33385833 DOI: 10.1016/j.tube.2020.102041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/10/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Niccolò Riccardi
- StopTB Italia Onlus, Milan, Italy; Department of Infectious - Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Simone Villa
- StopTB Italia Onlus, Milan, Italy; Centre for Multidisciplinary Research in Health Science, University of Milan, Milan, Italy
| | - Diana Canetti
- StopTB Italia Onlus, Milan, Italy; Department of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Giacomelli
- StopTB Italia Onlus, Milan, Italy; Department of Biomedical and Clinical Sciences DIBIC L. Sacco, University of Milan, Milan, Italy
| | - Lucia Taramasso
- Infectious Diseases Clinic, Ospedale Policlinico San Martino - IRCCS, Genoa, Italy
| | | | - Antonio Di Biagio
- StopTB Italia Onlus, Milan, Italy; Infectious Diseases Clinic, Ospedale Policlinico San Martino - IRCCS, Genoa, Italy
| | | | - Francesco Brigo
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy
| | - Giovanni Sotgiu
- StopTB Italia Onlus, Milan, Italy; Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | | | - Luigi Codecasa
- StopTB Italia Onlus, Milan, Italy; Regional TB Reference Centre, Istituto Villa Marelli, Niguarda Hospital, Milan, Italy
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Reuter A, Seddon JA, Marais BJ, Furin J. Preventing tuberculosis in children: A global health emergency. Paediatr Respir Rev 2020; 36:44-51. [PMID: 32253128 DOI: 10.1016/j.prrv.2020.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/26/2020] [Indexed: 12/13/2022]
Abstract
It is estimated that 20 million children are exposed to tuberculosis (TB) each year, making TB a global paediatric health emergency. TB preventative efforts have long been overlooked. With the view of achieving "TB elimination" in "our lifetime", this paper explores challenges and potential solutions in the TB prevention cascade, including identifying children who have been exposed to TB; detecting TB infection in these children; identifying those at highest risk of progressing to disease; implementing treatment of TB infection; and mobilizing multiple stakeholders support to successfully prevent TB.
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Affiliation(s)
- Anja Reuter
- Medecins Sans Frontieres, Khayelitsha, South Africa.
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa; Department of Infectious Diseases, Imperial College London, United Kingdom
| | - Ben J Marais
- The University of Sydney and the Children's Hospital at Westmead, Sydney, Australia
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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24
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Zar HJ, Moore DP, Andronikou S, Argent AC, Avenant T, Cohen C, Green RJ, Itzikowitz G, Jeena P, Masekela R, Nicol MP, Pillay A, Reubenson G, Madhi SA. Diagnosis and management of community-acquired pneumonia in children: South African Thoracic Society guidelines. Afr J Thorac Crit Care Med 2020; 26:10.7196/AJTCCM.2020.v26i3.104. [PMID: 34471872 PMCID: PMC7433705 DOI: 10.7196/ajtccm.2020.v26i3.104] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Pneumonia remains a major cause of morbidity and mortality amongst South African children. More comprehensive immunisation regimens, strengthening of HIV programmes, improvement in socioeconomic conditions and new preventive strategies have impacted on the epidemiology of pneumonia. Furthermore, sensitive diagnostic tests and better sampling methods in young children improve aetiological diagnosis. OBJECTIVES To produce revised guidelines for pneumonia in South African children under 5 years of age. METHODS The Paediatric Assembly of the South African Thoracic Society and the National Institute for Communicable Diseases established seven expert subgroups to revise existing South African guidelines focusing on: (i) epidemiology; (ii) aetiology; (iii) diagnosis; (iv) antibiotic management and supportive therapy; (v) management in intensive care; (vi) prevention; and (vii) considerations in HIV-infected or HIVexposed, uninfected (HEU) children. Each subgroup reviewed the published evidence in their area; in the absence of evidence, expert opinion was accepted. Evidence was graded using the British Thoracic Society (BTS) grading system. Sections were synthesized into an overall guideline which underwent peer review and revision. RECOMMENDATIONS Recommendations include a diagnostic approach, investigations, management and preventive strategies. Specific recommendations for HIV infected and HEU children are provided. VALIDATION The guideline is based on available published evidence supplemented by the consensus opinion of SA paediatric experts. Recommendations are consistent with those in published international guidelines.
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Affiliation(s)
- H J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
- South African Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, South Africa
| | - D P Moore
- Department of Paediatrics and Child Health, Chris Hani Baragwanath Academic Hospital, and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - S Andronikou
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
- Department of Pediatric Radiology, Perelman School of Medicine, University of Philadephia, USA
| | - A C Argent
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
| | - T Avenant
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Pretoria, South Africa
| | - C Cohen
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - R J Green
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Pretoria, South Africa
| | - G Itzikowitz
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
| | - P Jeena
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - R Masekela
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - M P Nicol
- Division of Medical Microbiology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, South Africa; and Division of Infection and Immunity, School of Biomedical Sciences, University of Western Australia, Perth, Australia
| | - A Pillay
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - G Reubenson
- Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - S A Madhi
- South African Medical Research Council Vaccine and Infectious Diseases Analytics Unit, University of the Witwatersrand, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: South African Research Chair in Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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25
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Hunter OF, Kyesi F, Ahluwalia AK, Daffé ZN, Munseri P, von Reyn CF, Adams LV. Successful implementation of isoniazid preventive therapy at a pediatric HIV clinic in Tanzania. BMC Infect Dis 2020; 20:738. [PMID: 33028260 PMCID: PMC7542689 DOI: 10.1186/s12879-020-05471-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 10/02/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND In accordance with international guidance for tuberculosis (TB) prevention, the Tanzanian Ministry of Health recommends isoniazid preventive therapy (IPT) for children aged 12 months and older who are living with HIV. Concerns about tolerability, adherence, and potential mistreatment of undiagnosed TB with monotherapy have limited uptake of IPT globally, especially among children, in whom diagnostic confirmation is challenging. We assessed IPT implementation and adherence at a pediatric HIV clinic in Tanzania. METHODS In this prospective cohort study, eligible children living with HIV aged 1-15 years receiving care at the DarDar Pediatric Program in Dar es Salaam who screened negative for TB disease were offered a 6-month regimen of daily isoniazid. Patients could choose to receive IPT via facility- or community-based care. Parents/caregivers and children provided informed consent and verbal assent respectively. Isoniazid was dispensed with the child's antiretroviral therapy every 1-3 months. IPT adherence and treatment completion was determined by pill counts, appointment attendance, and self-report. Patients underwent TB symptom screening at every visit. RESULTS We enrolled 66 children between July and December 2017. No patients/caregivers declined IPT. Most participants were female (n = 43, 65.1%) and the median age was 11 years (interquartile range [IQR] 8, 13). 63 (95.5%) participants chose the facility-based model; due to the small number of participants who chose the community-based model, valid comparisons between the two groups could not be made. Forty-nine participants (74.2%) completed IPT within 10 months. Among the remaining 17, 11 had IPT discontinued by their provider due to adverse drug reactions, 5 lacked documentation of completion, and 1 had unknown outcomes due to missing paperwork. Of those who completed IPT, the average monthly adherence was 98.0%. None of the participants were diagnosed with TB while taking IPT or during a median of 4 months of follow-up. CONCLUSIONS High adherence and treatment completion rates can be achieved when IPT is integrated into routine, self-selected facility-based pediatric HIV care. Improved record-keeping may yield even higher completion rates. IPT was well tolerated and no cases of TB were detected. IPT for children living with HIV is feasible and should be implemented throughout Tanzania.
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Affiliation(s)
- Olivia F Hunter
- Dartmouth College, Hanover, NH, 03755, USA. .,, New York, USA.
| | - Furaha Kyesi
- Ministry of Health, Community Development, Gender, Elderly, and Children, Dodoma, Tanzania
| | | | | | - Patricia Munseri
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Lisa V Adams
- Geisel School of Medicine at Dartmouth, Hanover, NH, 03755, USA
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Sterling TR, Njie G, Zenner D, Cohn DL, Reves R, Ahmed A, Menzies D, Horsburgh CR, Crane CM, Burgos M, LoBue P, Winston CA, Belknap R. Guidelines for the treatment of latent tuberculosis infection: Recommendations from the National Tuberculosis Controllers Association and CDC, 2020. Am J Transplant 2020. [DOI: 10.1111/ajt.15841] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | - Gibril Njie
- National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of Tuberculosis Elimination CDC Atlanta Georgia USA
| | - Dominik Zenner
- Institute for Global Health University College London London England
| | - David L. Cohn
- Denver Health and Hospital Authority Denver Colorado USA
| | - Randall Reves
- Denver Health and Hospital Authority Denver Colorado USA
| | - Amina Ahmed
- Levine Children’s Hospital Charlotte North Carolina USA
| | - Dick Menzies
- Montreal Chest Institute and McGill International TB Centre Montreal Canada USA
| | - C. Robert Horsburgh
- Boston University Schools of Public Health and Medicine Boston Massachusetts USA
| | - Charles M. Crane
- National Tuberculosis Controllers Association Smyrna Georgia USA
| | - Marcos Burgos
- National Tuberculosis Controllers Association Smyrna Georgia USA
- New Mexico Department of Health University of New Mexico Health Science Center Albuquerque New Mexico USA
| | - Philip LoBue
- National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of Tuberculosis Elimination CDC Atlanta Georgia USA
| | - Carla A. Winston
- National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of Tuberculosis Elimination CDC Atlanta Georgia USA
| | - Robert Belknap
- Denver Health and Hospital Authority Denver Colorado USA
- National Tuberculosis Controllers Association Smyrna Georgia USA
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Martinez L, Cords O, Horsburgh CR, Andrews JR. The risk of tuberculosis in children after close exposure: a systematic review and individual-participant meta-analysis. Lancet 2020; 395:973-984. [PMID: 32199484 PMCID: PMC7289654 DOI: 10.1016/s0140-6736(20)30166-5] [Citation(s) in RCA: 145] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Tens of millions of children are exposed to Mycobacterium tuberculosis globally every year; however, there are no contemporary estimates of the risk of developing tuberculosis in exposed children. The effectiveness of contact investigations and preventive therapy remains poorly understood. METHODS In this systematic review and meta-analysis, we investigated the development of tuberculosis in children closely exposed to a tuberculosis case and followed for incident disease. We restricted our search to cohort studies published between Jan 1, 1998, and April 6, 2018, in MEDLINE, Web of Science, BIOSIS, and Embase electronic databases. Individual-participant data and a pre-specified list of variables were requested from authors of all eligible studies. These included characteristics of the exposed child, the index case, and environmental characteristics. To be eligible for inclusion in the final analysis, a dataset needed to include: (1) individuals below 19 years of age; (2) follow-up for tuberculosis for a minimum of 6 months; (3) individuals with household or close exposure to an individual with tuberculosis; (4) information on the age and sex of the child; and (5) start and end follow-up dates. Studies assessing incident tuberculosis but without dates or time of follow-up were excluded. Our analysis had two primary aims: (1) estimating the risk of developing tuberculosis by time-period of follow-up, demographics (age, region), and clinical attributes (HIV, tuberculosis infection status, previous tuberculosis); and (2) estimating the effectiveness of preventive therapy and BCG vaccination on the risk of developing tuberculosis. We estimated the odds of prevalent tuberculosis with mixed-effects logistic models and estimated adjusted hazard ratios (HRs) for incident tuberculosis with mixed-effects Poisson regression models. The effectiveness of preventive therapy against incident tuberculosis was estimated through propensity score matching. The study protocol is registered with PROSPERO (CRD42018087022). FINDINGS In total, study groups from 46 cohort studies in 34 countries-29 (63%) prospective studies and 17 (37%) retrospective-agreed to share their data and were included in the final analysis. 137 647 tuberculosis-exposed children were evaluated at baseline and 130 512 children were followed for 429 538 person-years, during which 1299 prevalent and 999 incident tuberculosis cases were diagnosed. Children not receiving preventive therapy with a positive result for tuberculosis infection had significantly higher 2-year cumulative tuberculosis incidence than children with a negative result for tuberculosis infection, and this incidence was greatest among children below 5 years of age (19·0% [95% CI 8·4-37·4]). The effectiveness of preventive therapy was 63% (adjusted HR 0·37 [95% CI 0·30-0·47]) among all exposed children, and 91% (adjusted HR 0·09 [0·05-0·15]) among those with a positive result for tuberculosis infection. Among all children <5 years of age who developed tuberculosis, 83% were diagnosed within 90 days of the baseline visit. INTERPRETATION The risk of developing tuberculosis among exposed infants and young children is very high. Most cases occurred within weeks of contact investigation initiation and might not be preventable through prophylaxis. This suggests that alternative strategies for prevention are needed, such as earlier initiation of preventive therapy through rapid diagnosis of adult cases or community-wide screening approaches. FUNDING National Institutes of Health.
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Affiliation(s)
- Leonardo Martinez
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Olivia Cords
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - C Robert Horsburgh
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA; Departments of Epidemiology, Biostatistics and Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Sterling TR, Njie G, Zenner D, Cohn DL, Reves R, Ahmed A, Menzies D, Horsburgh CR, Crane CM, Burgos M, LoBue P, Winston CA, Belknap R. Guidelines for the Treatment of Latent Tuberculosis Infection: Recommendations from the National Tuberculosis Controllers Association and CDC, 2020. MMWR Recomm Rep 2020; 69:1-11. [PMID: 32053584 PMCID: PMC7041302 DOI: 10.15585/mmwr.rr6901a1] [Citation(s) in RCA: 229] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Comprehensive guidelines for treatment of latent tuberculosis infection (LTBI) among persons living in the United States were last published in 2000 (American Thoracic Society. CDC targeted tuberculin testing and treatment of latent tuberculosis infection. Am J Respir Crit Care Med 2000;161:S221–47). Since then, several new regimens have been evaluated in clinical trials. To update previous guidelines, the National Tuberculosis Controllers Association (NTCA) and CDC convened a committee to conduct a systematic literature review and make new recommendations for the most effective and least toxic regimens for treatment of LTBI among persons who live in the United States. The systematic literature review included clinical trials of regimens to treat LTBI. Quality of evidence (high, moderate, low, or very low) from clinical trial comparisons was appraised using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. In addition, a network meta-analysis evaluated regimens that had not been compared directly in clinical trials. The effectiveness outcome was tuberculosis disease; the toxicity outcome was hepatotoxicity. Strong GRADE recommendations required at least moderate evidence of effectiveness and that the desirable consequences outweighed the undesirable consequences in the majority of patients. Conditional GRADE recommendations were made when determination of whether desirable consequences outweighed undesirable consequences was uncertain (e.g., with low-quality evidence). These updated 2020 LTBI treatment guidelines include the NTCA- and CDC-recommended treatment regimens that comprise three preferred rifamycin-based regimens and two alternative monotherapy regimens with daily isoniazid. All recommended treatment regimens are intended for persons infected with Mycobacterium tuberculosis that is presumed to be susceptible to isoniazid or rifampin. These updated guidelines do not apply when evidence is available that the infecting M. tuberculosis strain is resistant to both isoniazid and rifampin; recommendations for treating contacts exposed to multidrug-resistant tuberculosis were published in 2019 (Nahid P, Mase SR Migliori GB, et al. Treatment of drug-resistant tuberculosis. An official ATS/CDC/ERS/IDSA clinical practice guideline. Am J Respir Crit Care Med 2019;200:e93–e142). The three rifamycin-based preferred regimens are 3 months of once-weekly isoniazid plus rifapentine, 4 months of daily rifampin, or 3 months of daily isoniazid plus rifampin. Prescribing providers or pharmacists who are unfamiliar with rifampin and rifapentine might confuse the two drugs. They are not interchangeable, and caution should be taken to ensure that patients receive the correct medication for the intended regimen. Preference for these rifamycin-based regimens was made on the basis of effectiveness, safety, and high treatment completion rates. The two alternative treatment regimens are daily isoniazid for 6 or 9 months; isoniazid monotherapy is efficacious but has higher toxicity risk and lower treatment completion rates than shorter rifamycin-based regimens. In summary, short-course (3- to 4-month) rifamycin-based treatment regimens are preferred over longer-course (6–9 month) isoniazid monotherapy for treatment of LTBI. These updated guidelines can be used by clinicians, public health officials, policymakers, health care organizations, and other state and local stakeholders who might need to adapt them to fit individual clinical circumstances.
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LaCourse SM, Richardson BA, Kinuthia J, Warr AJ, Maleche-Obimbo E, Matemo D, Cranmer LM, Escudero JN, Hawn TR, John-Stewart GC. Infant TB Infection Prevention Study (iTIPS): a randomised trial protocol evaluating isoniazid to prevent M. tuberculosis infection in HIV-exposed uninfected children. BMJ Open 2020; 10:e034308. [PMID: 31969368 PMCID: PMC7045242 DOI: 10.1136/bmjopen-2019-034308] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 12/05/2019] [Accepted: 01/07/2020] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION HIV-exposed uninfected (HEU) infants in tuberculosis (TB) endemic settings are at high risk of Mycobacterium tuberculosis (Mtb) infection and TB disease, even in the absence of known Mtb exposure. Because infancy is a time of rapid progression from primary infection to active TB disease, it is important to define when and how TB preventive interventions exert their effect in order to develop effective prevention strategies in this high-risk population. METHODS AND ANALYSIS We designed a non-blinded randomised controlled trial to determine efficacy of isoniazid (INH) to prevent primary Mtb infection among HEU children. Target sample size is 300 (150 infants in each arm). Children are enrolled at 6 weeks of age from maternal and child health clinics in Kenya and are randomised to receive 12 months of daily INH ~10 mg/kg plus pyridoxine or no INH. The primary endpoint is Mtb infection, assessed by interferon-gamma release assay QuantiFERON-TB Gold Plus (QFT-Plus) or tuberculin skin test after 12 months post-enrolment. Secondary outcomes include severe adverse events, expanded Mtb infection definition using additional QFT-Plus supernatant markers and determining correlates of Mtb infection. Exploratory analyses include a combined outcome of TB infection, disease and mortality, and sensitivity analyses excluding infants with baseline TB-specific responses on flow cytometry. ETHICS AND DISSEMINATION An external and independent Data and Safety Monitoring Board monitors adverse events. Results will be disseminated through peer-reviewed journals, presentations at local and international conferences to national and global policy-makers, the local community and participants. TRIAL REGISTRATION NUMBER NCT02613169; Pre-results.
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Affiliation(s)
- Sylvia M LaCourse
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Barbra A Richardson
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - John Kinuthia
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Reproductive Health, Kenyatta National Hospital, Nairobi, Kenya
| | - A J Warr
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - Daniel Matemo
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Lisa M Cranmer
- Department of Pediatrics, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta Inc, Atlanta, Georgia, USA
| | - Jaclyn N Escudero
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Thomas R Hawn
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Grace C John-Stewart
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
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Does Isoniazid Preventive Therapy Provide Better Treatment Outcomes in HIV-Infected Individuals in Northern Ethiopia? A Retrospective Cohort Study. AIDS Res Treat 2020; 2020:7025738. [PMID: 32411454 PMCID: PMC7204289 DOI: 10.1155/2020/7025738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 09/26/2019] [Accepted: 12/09/2019] [Indexed: 11/17/2022] Open
Abstract
Objectives Early antiretroviral therapy (ART), isoniazid preventive therapy (IPT), and isoniazid-rifapentine (3HP) are effective strategies for preventing tuberculosis (TB) among people living with HIV (PLHIV). The study aimed to determine the effect of IPT on the TB incidence, follow-up CD4+ T cells, and all-cause mortality rate. Participants. Eligible patients on ART (n = 1, 863) were categorized into one-to-two ratios of exposed groups to IPT (n = 621) and nonexposed groups to IPT (n = 1, 242). Exposed groups entered the cohort at their first prescription of IPT, and unexposed groups entered into the study at the first prescription of ART and then followed until the occurrence of the outcome or date of administrative censoring (June 30, 2017). The outcome endpoints were TB incidence, follow-up CD4+ T cells, and all-cause mortality rate. Results The follow-up CD4+ T cells for the exposed and nonexposed groups were 405.74 and 366.95 cells/mm (World Health Organization (WHO), 2017), respectively, a statistically significant finding (t 1861 = -3.770, p < 0.0001; Cohen's d = 0.186). Nine percent of the exposed patients (620 incidence of TB per 100,000 person-years (PYs)) and 21.9% of the nonexposed patients (3160 incidence of TB per 100,000 PYs) developed TB. Mortality rate (per 100,000 PYs) was 440 for the exposed and 1490 for the unexposed patients. Statistically significant determinants of the all-cause mortality were unscheduled follow-up (AHR = 1.601; 95% CI: 1.154-2.222) and unable to work properly (AHR = 2.324; 95% CI: 1.643-3.288). Conclusion This study demonstrates the effect of IPT in reducing incidence of TB and all-cause mortality rate and improving follow-up CD4+ T cells. Promoting IPT use can help to achieve the TB eradicating national agenda in Ethiopia.
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Chauhan N, Poddar R. In silico pharmacophore modeling and simulation studies for searching potent antileishmanials targeted against Leishmania donovani nicotinamidase. Comput Biol Chem 2019; 83:107150. [DOI: 10.1016/j.compbiolchem.2019.107150] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 05/23/2019] [Accepted: 10/15/2019] [Indexed: 11/26/2022]
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Harries AD, Kumar AMV, Satyanarayana S, Takarinda KC, Timire C, Dlodlo RA. Treatment for latent tuberculosis infection in low- and middle-income countries: progress and challenges with implementation and scale-up. Expert Rev Respir Med 2019; 14:195-208. [PMID: 31760848 DOI: 10.1080/17476348.2020.1694907] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Treatment of latent tuberculosis infection (LTBI) is a crucial but neglected component of global tuberculosis control. The 2018 United Nations High-Level Meeting committed world leaders to provide LTBI treatment to at least 30 million people, including 4 million children<5 years, 20 million other household contacts and 6 million HIV-infected people by 2022.Areas covered: This review searched MEDLINE between 1990 and 2019 and discussed: i) high-risk groups to be prioritized for diagnosis and treatment of LTBI; ii) challenges with diagnosing LTBI in programmatic settings; iii) LTBI treatment options including isoniazid monotherapy, shorter regimens (rifampicin-monotherapy, rifampicin-isoniazid and rifapentine-isoniazid) and treatments for contacts of drug-resistant patients; iv) issues with programmatic scale-up of treatment including policy considerations, ruling out active TB, time to start treatment, safety, uninterrupted drug supplies and treatment adherence; and v) recording and reporting.Expert opinion: In 2017, <1.5 million persons were reported to be treated for LTBI. This must rapidly increase to 6 million persons annually. If HIV programs focus on HIV-infected people already accessing or about to start antiretroviral therapy and TB programs focus on household contacts, these targets could be achieved. Isoniazid remains the current treatment of choice although shorter courses of rifapentine-isoniazid are possible alternatives.
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Affiliation(s)
- Anthony D Harries
- The Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, Paris, France.,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Ajay M V Kumar
- The Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, Paris, France.,South-East Asia Office, International Union Against Tuberculosis and Lung Disease, New Delhi, India.,Yenepoya Medical College, Yenepoya (Deemed to be University), Mangalore, India
| | - Srinath Satyanarayana
- The Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, Paris, France.,South-East Asia Office, International Union Against Tuberculosis and Lung Disease, New Delhi, India
| | - Kudakwashe C Takarinda
- The Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, Paris, France.,AIDS and TB Department, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Collins Timire
- The Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, Paris, France.,AIDS and TB Department, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Riitta A Dlodlo
- TB Department, International Union Against Tuberculosis and Lung Disease, Paris, France
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Adeniyi OV, Selanto-Chairman N, Owolabi EO, Ajayi AI, Kayembe DK, Ter Goon D, Gordana A, Lambert J. Inequality in uptake of isoniazid prevention therapy and Mantoux test among pregnant women with HIV in the Eastern Cape, South Africa. BMC Public Health 2019; 19:1407. [PMID: 31664978 PMCID: PMC6819455 DOI: 10.1186/s12889-019-7769-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 10/11/2019] [Indexed: 11/23/2022] Open
Abstract
Background HIV-associated tuberculosis (TB) is a major cause of death among pregnant women in South Africa. Isoniazid prevention therapy (IPT) strategy was implemented in South Africa concurrently with life-long antiretroviral therapy (ART) to reduce the TB-associated morbidity and mortality in individuals living with HIV. This study assessed the extent of the implementation of IPT and the performance of the Mantoux test by geographic settings of health facilities and residences of pregnant women living with HIV in the Eastern Cape, South Africa. Methods We conducted a data analysis of 1709 pregnant women enrolled in the new electronic database of the prevention of mother-to-child transmission programme of the East London Prospective Cohort Study. Relevant data on place of residence and antenatal care, performance of the Mantoux test and subsequent initiation of IPT were obtained. Descriptive and inferential statistics were employed to analyse the geographical variations and accessibility to Mantoux test and IPT. Results The analysis shows that Mantoux test was performed on 803 pregnant women (47%) with significant geographical variation. After controlling for relevant covariates, pregnant women who resided in rural areas (AOR:0.63; CI: 0.47–0.84) compared to those who resided in urban areas were significantly less likely to receive Mantoux test. The rate of uptake of IPT was 79% with significant geographic variations. In the unadjusted model, rural place of residence (UOR:0.68; CI: 0.49–0.96) was independently associated with lower likelihood of uptake of INH prophylaxis; however, the effect was not significant after controlling for important covariates. Conclusions The high uptake rate of isoniazid prevention therapy in pregnant women living with HIV at the study sites is commendable; however, concerted efforts are needed to address the inequality gaps in the roll-out of IPT. Poor performance of Mantoux test is a serious concern and requires the attention of TB programme managers and other relevant authorities.
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Affiliation(s)
- Oladele Vincent Adeniyi
- Department of Family Medicine & Rural Health, Faculty of Health Sciences, Walter Sisulu University, Mthatha/East London Hospital Complex, Cecilia Makiwane Hospital, East London, South Africa.
| | - Nonkosi Selanto-Chairman
- Department of Public Health, Faculty of Health Sciences, University of Fort Hare, East London, South Africa
| | - Eyitayo Omolara Owolabi
- Department of Nursing Sciences, Faculty of Health Sciences, University of Fort Hare, East London, South Africa
| | - Anthony Idowu Ajayi
- Department of Sociology, Faculty of Social Sciences & Humanities, University of Fort Hare, East London, South Africa. .,Population Dynamics and Sexual and Reproductive Health Unit, African Population and Health Research Center, Nairobi, Kenya.
| | - Dominique Kabengele Kayembe
- Department of Family Medicine & Rural Health, Faculty of Health Sciences, Walter Sisulu University, Mthatha/East London Hospital Complex, Cecilia Makiwane Hospital, East London, South Africa
| | - Daniel Ter Goon
- Department of Nursing Sciences, Faculty of Health Sciences, University of Fort Hare, East London, South Africa
| | - Avramovic Gordana
- Department of Infectious Diseases, Medicine and Sexual Health. Mater, Rotunda and University College, Dublin, Ireland
| | - John Lambert
- Department of Infectious Diseases, Medicine and Sexual Health. Mater, Rotunda and University College, Dublin, Ireland
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Frigati L, Archary M, Rabie H, Penazzato M, Ford N. Priorities for Decreasing Morbidity and Mortality in Children With Advanced HIV Disease. Clin Infect Dis 2019. [PMID: 29514237 PMCID: PMC5850631 DOI: 10.1093/cid/ciy013] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Early mortality and morbidity remain high in children initiating antiretroviral therapy (ART), especially in sub-Saharan Africa. Many children still present with advanced human immunodeficiency virus (HIV) disease. Tuberculosis, pneumonia, and severe bacterial infections are the main causes of hospital admission in HIV-infected children. In contrast to adults with advanced HIV disease, cryptococcal disease is not common in childhood, although there is a peak in infancy and adolescence. Interventions such as TB screening in symptomatic children, and isoniazid and cotrimoxazole prophylaxis should be implemented. There is evidence suggesting that rapid initiation (within 1 week) of ART in children with severe malnutrition or those with advanced HIV disease admitted to hospital is not beneficial and should be delayed until their condition has been stabilized. Research informing the prevention of severe bacterial infections, the management of pediatric immune reconstitution inflammatory syndrome, and other potential strategies to decrease morbidity and mortality in HIV-infected children are urgently needed.
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Affiliation(s)
- Lisa Frigati
- Department of Paediatrics and Child Health, Tygerberg Hospital and Stellenbosch University, Cape Town
| | - Moherdran Archary
- University of KwaZulu Natal, Nelson R Mandela School of Medicine, Berea, South Africa
| | - Helena Rabie
- Department of Paediatrics and Child Health, Tygerberg Hospital and Stellenbosch University, Cape Town
| | | | - Nathan Ford
- HIV Department, World Health Organization, Geneva, Switzerland
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Martinez L, le Roux DM, Barnett W, Stadler A, Nicol MP, Zar HJ. Tuberculin skin test conversion and primary progressive tuberculosis disease in the first 5 years of life: a birth cohort study from Cape Town, South Africa. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 2:46-55. [PMID: 29457055 PMCID: PMC5810304 DOI: 10.1016/s2352-4642(17)30149-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Tuberculosis is a leading cause of global childhood mortality. However, the epidemiology and burden of tuberculosis in infancy is not well understood. We aimed to investigate tuberculin skin test conversion and tuberculosis in the Drakenstein Child Health study, a South African birth cohort in a community in which tuberculosis incidence is hyperendemic. Methods In this prospective birth cohort study, we enrolled pregnant women older than 18 years who were between 20 and 28 weeks' gestation and who were attending antenatal care in a peri-urban, impoverished South African setting. We followed up their children for tuberculosis from birth until April 1, 2017, or age 5 years. All children received BCG vaccination at birth. Tuberculin skin tests were administered to children at 6, 12, 24, 36, 48, and 60 months of age, and at the time of a lower respiratory tract infection. An induration reaction of 10 mm or more was considered to be a tuberculin skin test conversion. To prevent boosting, we censored children with a reactive, negative tuberculin skin test. Findings Among 915 mother-child pairs (201 [22%] HIV-positive mothers and two [<1%] HIV-positive children), 147 (16%) children had tuberculin skin test conversion, with increasing cumulative hazard with age (0·08 at 6 months, 0·17 at 12 months, 0·22 at 24 months, and 0·37 at age 36 months). For every 100 child-years, the incidence was 11·8 (95% CI 10·0-13·8) for tuberculin skin test conversion, 2·9 (2·4-3·7) for all diagnosed tuberculosis, and 0·7 (0·4-1·0) for microbiologically confirmed tuberculosis. Isoniazid preventive therapy was effective in averting disease progression (adjusted hazard ratio 0·22, 95% CI 0·08-0·63; p<0·0001). Children with a lower respiratory tract infection were significantly more likely to also have tuberculosis than were those without one (2·27, 1·42-3·62; p<0·0001). Interpretation Greater focus should be placed on the first years of life as a period of high burden of transmission and clinical expression of tuberculosis infection and disease. Multifaceted interventions, such as isoniazid preventive therapy and tuberculosis screening of infants with LRTIs, beginning early in life, are needed in high-burden settings. Funding Bill & Melinda Gates Foundation, Medical Research Council South Africa, and National Research Foundation South Africa.
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Affiliation(s)
- Leonardo Martinez
- Division of Infectious Diseases and Geographic Medicine, School of Medicine, Stanford University, Stanford, CA, USA; Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | - David M le Roux
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Whitney Barnett
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Attie Stadler
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Mark P Nicol
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa.
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Pathmanathan I, Ahmedov S, Pevzner E, Anyalechi G, Modi S, Kirking H, Cavanaugh JS. TB preventive therapy for people living with HIV: key considerations for scale-up in resource-limited settings. Int J Tuberc Lung Dis 2019; 22:596-605. [PMID: 29862942 DOI: 10.5588/ijtld.17.0758] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Tuberculosis (TB) is the leading cause of death for persons living with the human immunodeficiency virus (PLHIV). TB preventive therapy (TPT) works synergistically with, and independently of, antiretroviral therapy to reduce TB morbidity, mortality and incidence among PLHIV. However, although TPT is a crucial and cost-effective component of HIV care for adults and children and has been recommended as an international standard of care for over a decade, it remains highly underutilized. If we are to end the global TB epidemic, we must address the significant reservoir of tuberculous infection, especially in those, such as PLHIV, who are most likely to progress to TB disease. To do so, we must confront the pervasive perception that barriers to TPT scale-up are insurmountable in resource-limited settings. Here we review available evidence to address several commonly stated obstacles to TPT scale-up, including the need for the tuberculin skin test, limited diagnostic capacity to reliably exclude TB disease, concerns about creating drug resistance, suboptimal patient adherence to therapy, inability to monitor for and prevent adverse events, a 'one size fits all' option for TPT regimen and duration, and uncertainty about TPT use in children, adolescents, and pregnant women. We also discuss TPT delivery in the era of differentiated care for PLHIV, how best to tackle advanced planning for drug procurement and supply chain management, and how to create an enabling environment for TPT scale-up success.
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Affiliation(s)
- I Pathmanathan
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - S Ahmedov
- Bureau for Global Health, United States Agency for International Development, Washington, DC
| | - E Pevzner
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - G Anyalechi
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - S Modi
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - H Kirking
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - J S Cavanaugh
- Office of the Global AIDS Coordinator, Washington, DC, USA
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The protective effect of isoniazid preventive therapy on tuberculosis incidence among HIV positive patients receiving ART in Ethiopian settings: a meta-analysis. BMC Infect Dis 2019; 19:405. [PMID: 31077133 PMCID: PMC6511123 DOI: 10.1186/s12879-019-4031-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 04/26/2019] [Indexed: 02/07/2023] Open
Abstract
Background Tuberculosis (TB) and HIV makeup a deadly synergy of infectious disease, and the combined effect is apparent in resource limited countries like Ethiopia. Previous studies have demonstrated inconsistent results about the protective effect of isoniazid preventive therapy (IPT) on active TB incidence among HIV positive patients receiving ART. Therefore, the aim of this meta-analysis was, first, to determine the protective effect of IPT on active tuberculosis incidence, and second, to assess the pooled incidence of active TB among HIV positive patients taking ART with and without IPT intervention in Ethiopia. Methods PubMed, Google scholar and Cochran library databases were searched from April 1 to 30, 2018. Two independent authors explored and assessed studies for eligibility, and extracted data based on predefined criteria. Studies that reported TB incidence among HIV positive patients taking ART in Ethiopia with and without IPT concomitant intervention, and with a clear stratified data on the incidence of TB based on the duration of IPT intervention were selected. A random effects model was used to estimate risk ratios and the pooled incident TB with the respective 95% confidence intervals. Results We identified 7 suitable studies in this analysis. Accordingly, IPT reduced the risk of TB incidence by 74%, risk ratio (RR) 0.26 (95% CI; 0.16–0.43%), compared to no IPT group. Moreover, IPT for 12 months reduced incident TB by 91% (RR: 0.09, 95% CI: 0.04 to 0.21), whereas 6 months IPT averted TB incidence by 63% (RR: 0.37, 95% CI: 0.26 to 0.52). The overall pooled incident TB among HIV infected patients receiving ART was 10.30% (95% CI; 7.57–13.02%). Specifically, incident TB among study cohorts with and without IPT was 3.79% (95% CI; 2.03–5.55%) and 16.32% (95% CI; 11.57–21.06%) respectively. Conclusion IPT reduced the risk of incident TB among HIV positive patients receiving ART in Ethiopian settings. Moreover, the duration of IPT intervention has effect on its protective role. Thus, scaling up the isoniazid preventive therapy program and its strict compliance is necessary to avert HIV fueled tuberculosis. Study protocol registration CRD42018090804. Electronic supplementary material The online version of this article (10.1186/s12879-019-4031-2) contains supplementary material, which is available to authorized users.
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Basu Roy R, Whittaker E, Seddon JA, Kampmann B. Tuberculosis susceptibility and protection in children. THE LANCET. INFECTIOUS DISEASES 2019; 19:e96-e108. [PMID: 30322790 PMCID: PMC6464092 DOI: 10.1016/s1473-3099(18)30157-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 01/27/2018] [Accepted: 02/09/2018] [Indexed: 12/14/2022]
Abstract
Children represent both a clinically important population susceptible to tuberculosis and a key group in whom to study intrinsic and vaccine-induced mechanisms of protection. After exposure to Mycobacterium tuberculosis, children aged under 5 years are at high risk of progressing first to tuberculosis infection, then to tuberculosis disease and possibly disseminated forms of tuberculosis, with accompanying high risks of morbidity and mortality. Children aged 5-10 years are somewhat protected, until risk increases again in adolescence. Furthermore, neonatal BCG programmes show the clearest proven benefit of vaccination against tuberculosis. Case-control comparisons from key cohorts, which recruited more than 15 000 children and adolescents in total, have identified that the ratio of monocytes to lymphocytes, activated CD4 T cell count, and a blood RNA signature could be correlates of risk for developing tuberculosis. Further studies of protected and susceptible populations are necessary to guide development of novel tuberculosis vaccines that could facilitate the achievement of WHO's goal to eliminate deaths from tuberculosis in childhood.
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Affiliation(s)
- Robindra Basu Roy
- Centre for International Child Health, Department of Paediatrics, Imperial College London, London, UK; Vaccines and Immunity Theme MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Elizabeth Whittaker
- Centre for International Child Health, Department of Paediatrics, Imperial College London, London, UK
| | - James A Seddon
- Centre for International Child Health, Department of Paediatrics, Imperial College London, London, UK
| | - Beate Kampmann
- Centre for International Child Health, Department of Paediatrics, Imperial College London, London, UK; Vaccines and Immunity Theme MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia.
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Tolerability of Isoniazid Preventive Therapy in an HIV-Infected Cohort of Paediatric and Adolescent Patients on Antiretroviral Therapy from a Resource-Limited Setting: A Retrospective Cohort Study. Drugs Real World Outcomes 2019; 6:37-42. [PMID: 30758779 PMCID: PMC6422975 DOI: 10.1007/s40801-019-0147-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Treating patients with latent tuberculosis infection (LTBI) to prevent development of active disease is an essential strategy for eliminating TB. There are concerns regarding the use of isoniazid due to the potential for hepatotoxicity. This study was conducted to determine the incidence of adverse hepatic events after isoniazid preventive therapy (IPT) commencement in a cohort of HIV-infected paediatric and adolescent patients on antiretroviral therapy (ART). METHODS This was a retrospective records review, using data from HIV-infected paediatric and adolescent patients collected during routine clinical visits at Newlands Clinic, Harare, Zimbabwe. Patients included in the analysis had commenced IPT between January 2014 and June 2015 (inclusive) whilst receiving ART. A survival analysis was conducted for the period that participants were receiving IPT with end-points defined by grade 3 or grade 4 elevations in alanine aminotransferase (ALT) levels. RESULTS Data from 438 patients commenced on IPT were analysed; 202 (46.1%) of them were female. The median age at IPT commencement was 10 (IQR = 7-12) years. Twenty-eight patients developed grade 3 or 4 elevations in ALT. Concomitant use of nevirapine as part of an ART regimen was the only factor that showed a statistically significant association with ALT elevation [relative risk (RR): 2.7; confidence interval (CI): 1.2-6.3, p = 0.012] compared with those not receiving nevirapine. The incidence of grade 3 or 4 elevations in ALT was 31.5/100 person-years (CI 20.9-45.5). CONCLUSION The incidence of IPT-associated ALT elevations was high in this population. We recommend vigilant monitoring of liver enzymes for patients receiving IPT, especially in patients concomitantly receiving nevirapine.
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Abstract
Mycobacterium tuberculosis is the leading cause of death worldwide from a single bacterial pathogen. The World Health Organization estimates that annually 1 million children have tuberculosis (TB) disease and many more harbor a latent form. Accurate estimates are hindered by under-recognition and challenges in diagnosis. To date, an accurate diagnostic test to confirm TB in children does not exist. Treatment is lengthy but outcomes are generally favorable with timely initiation. With the End TB Strategy, there is an urgent need for improved diagnostics and treatment to prevent the unnecessary morbidity and mortality from TB in children.
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Affiliation(s)
- Tania A Thomas
- Division of Infectious Diseases and International Health, University of Virginia, PO Box 801340, Charlottesville, VA 22908-1340, USA.
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Seddon JA, Garcia-Prats AJ, Purchase SE, Osman M, Demers AM, Hoddinott G, Crook AM, Owen-Powell E, Thomason MJ, Turkova A, Gibb DM, Fairlie L, Martinson N, Schaaf HS, Hesseling AC. Levofloxacin versus placebo for the prevention of tuberculosis disease in child contacts of multidrug-resistant tuberculosis: study protocol for a phase III cluster randomised controlled trial (TB-CHAMP). Trials 2018; 19:693. [PMID: 30572905 PMCID: PMC6302301 DOI: 10.1186/s13063-018-3070-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 11/21/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multidrug-resistant (MDR) tuberculosis (TB) presents a challenge for global TB control. Treating individuals with MDR-TB infection to prevent progression to disease could be an effective public health strategy. Young children are at high risk of developing TB disease following infection and are commonly infected by an adult in their household. Identifying young children with household exposure to MDR-TB and providing them with MDR-TB preventive therapy could reduce the risk of disease progression. To date, no trials of MDR-TB preventive therapy have been completed and World Health Organization guidelines suggest close observation with no active treatment. METHODS The tuberculosis child multidrug-resistant preventive therapy (TB-CHAMP) trial is a phase III cluster randomised placebo-controlled trial to assess the efficacy of levofloxacin in young child contacts of MDR-TB cases. The trial is taking place at three sites in South Africa where adults with MDR-TB are identified. If a child aged < 5 years lives in their household, we assess the adult index case, screen all household members for TB disease and evaluate any child aged < 5 years for trial eligibility. Eligible children are randomised by household to receive daily levofloxacin (15-20 mg/kg) or matching placebo for six months. Children are closely monitored for disease development, drug tolerability and adverse events. The primary endpoint is incident TB disease or TB death by one year after recruitment. We will enrol 1556 children from approximately 778 households with an average of two eligible children per household. Recruitment will run for 18-24 months with all children followed for 18 months after treatment. Qualitative and health economic evaluations are embedded in the trial. DISCUSSION If the TB-CHAMP trial demonstrates that levofloxacin is effective in preventing TB disease in young children who have been exposed to MDR-TB and that it is safe, well tolerated, acceptable and cost-effective, we would expect that that this intervention would rapidly transfer into policy. TRIAL REGISTRATION ISRCTN Registry, ISRCTN92634082 . Registered on 31 March 2016.
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Affiliation(s)
- James A. Seddon
- Centre for International Child Health, Department of Paediatrics, Imperial College London, Norfolk Place, London, W2 1PG UK
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Anthony J. Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Susan E. Purchase
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Anne-Marie Demers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Angela M. Crook
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit at University College London, London, UK
| | - Ellen Owen-Powell
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit at University College London, London, UK
| | - Margaret J. Thomason
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit at University College London, London, UK
| | - Anna Turkova
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit at University College London, London, UK
| | - Diana M. Gibb
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit at University College London, London, UK
| | - Lee Fairlie
- Wits Reproductive Health & HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Neil Martinson
- Perinatal HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa
| | - H. Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Anneke C. Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
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Rendon A, Goletti D, Matteelli A. Diagnosis and treatment of latent tuberculosis infection. Tuberculosis (Edinb) 2018. [DOI: 10.1183/2312508x.10022617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Endalamaw A, Engeda EH, Tezera N. Incidence of tuberculosis in children on antiretroviral therapy: a retrospective cohort study. BMC Res Notes 2018; 11:745. [PMID: 30342550 PMCID: PMC6195951 DOI: 10.1186/s13104-018-3846-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 10/11/2018] [Indexed: 12/25/2022] Open
Abstract
Objectives Be aware of the burden of tuberculosis among high-risk population is important. Three hundred fifty-two children were participated in this study. Survival analysis was conducted. We assessed the incidence of tuberculosis and its predictors in children on ART. Results Tuberculosis incidence rate in children on ART was 2.63 per 100 person-years. Those children who were on baseline World Health Organization clinical stages 3 and 4 (AHR (adjusted hazard ratio) = 3.0; 95% CI 1.2–7.7), “fair” and “poor” ART adherence (AHR = 4.0; 95% CI 1.5–10.8), late initiation of ART (AHR = 4.0; 95% CI 1.5–10.6), and less than 6 months duration on ART (AHR = 5.5; 95% CI 1.5–20.6) were more likely to develop tuberculosis infection. The incidence rate of TB in children on ART was high. This study suggests a need to give attention to advanced AIDS stages and improve timely initiation of ART and level of adherence to ART.
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Affiliation(s)
- Aklilu Endalamaw
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, P.O.BOX 196, Gondar, Ethiopia.
| | - Eshetu Hailesilassie Engeda
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, P.O.BOX 196, Gondar, Ethiopia
| | - Nega Tezera
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, P.O.BOX 196, Gondar, Ethiopia
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Charan J, Goyal JP, Reljic T, Emmanuel P, Patel A, Kumar A. Isoniazid for the Prevention of Tuberculosis in HIV-Infected Children: A Systematic Review and Meta-Analysis. Pediatr Infect Dis J 2018; 37:773-780. [PMID: 29280783 PMCID: PMC6019572 DOI: 10.1097/inf.0000000000001879] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Isoniazid is recommended for prevention of tuberculosis (TB) in HIV-infected adults, but its efficacy in children living with HIV (CLHIV) is not known. We performed a systematic review to assess the efficacy of isoniazid for the prevention of TB in CLHIV. METHODS We searched PubMed, Cochrane Clinical Trial Registry and Google Scholar from inception to December 2016. Any randomized controlled trial assessing the role of isoniazid for the prevention of TB in CLHIV was eligible for inclusion. The primary endpoint was TB incidence; secondary end points were mortality, overall survival and severe adverse events. Dual independent extraction of all data was performed. Data were pooled under a random effects model and summarized either as risk ratio (RR) or hazard ratio along with 95% confidence intervals (CIs). RESULTS Of 931 references, 3 randomized controlled trials enrolling 977 patients met the inclusion criteria. Pooled results showed a statistically nonsignificant reduction in TB incidence (RR: 0.70; 95% CI: 0.47-1.04; P = 0.07) and mortality (RR: 0.94; 95% CI: 0.39-2.23; P = 0.88) with the use of isoniazid compared with placebo. One study was stopped early because of excess deaths in the placebo arm. However, results from subgroup analysis restricted to only completed trials did not change the overall findings. CONCLUSIONS Isoniazid did not reduce the incidence of TB in CLHIV. All included studies were performed in regions with high prevalence of TB making the overall generalizability limited.
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Affiliation(s)
- Jaykaran Charan
- Department of Pharmacology. All Indian Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Jagdish Prasad Goyal
- Department of Pediatrics, All Indian Institute of Medical Science, Rishikesh, Uttrakhand, India
| | - Tea Reljic
- USF Health Program for Comparative Effectiveness Research, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Patricia Emmanuel
- Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Atul Patel
- Vedanta Institute of Medical Sciences, Ahmedabad, Gujarat, India
| | - Ambuj Kumar
- USF Health Program for Comparative Effectiveness Research, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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Survival and predictors of mortality among children co-infected with tuberculosis and human immunodeficiency virus at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia. A retrospective follow-up study. PLoS One 2018; 13:e0197145. [PMID: 29787596 PMCID: PMC5963769 DOI: 10.1371/journal.pone.0197145] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 04/28/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) is the leading cause of death in Human immunodeficiency virus (HIV) infected children globally. The aims of this study were to determine the mortality rate and to identify the predictors of mortality among TB/HIV co-infected children at University of Gondar Comprehensive Specialized Hospital. METHOD A retrospective follow-up study was conducted among TB/HIV co-infected children from February 2005 to March 2017. A Kaplan-Meier curve was used to estimate the median survival time. Bivariate and multivariable Cox proportional hazards models were fitted to identify the predictors of mortality. RESULTS A total of 271 TB/HIV co-infected children were included in the analysis. Of these, 38(14.02%) children were died during the follow-up period. This gives a total of 1167.67 child-years of observations. The overall mortality rate was 3.27(95%CI: 2.3-4.5) per 100 child-years. The independent predictors of time to death were age 1-5 years (as compared to age <1 year) (AHR = 0.3; 95%CI:0.09-0.98)), being anemic (AHR = 2.6; 95%CI:1.24-5.3), cotrimoxazole preventive therapy(CPT) non-users (AHR = 4.1; 95%CI:1.4-16.75), isoniazid preventive therapy(IPT) non-users (AHR = 2.95; 95%CI:1.16-7.5), having extra pulmonary tuberculosis(EPTB) (AHR = 2.43; 95%CI:1.1-5.3)) and fair or poor adherence to Anti-Retroviral Therapy (ART)(AHR = 3.5; 95%CI:1.7-7.5). CONCLUSION Mortality rate among TB/HIV co-infected children was high at University of Gondar Comprehensive Specialized Hospital. Age, extra-pulmonary tuberculosis, anemia, adherence, CPT and IPT were the independent predictors of mortality.
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Sekadde MP, Kay AW. Tuberculosis Prevention: an Under Prioritized yet Critical Intervention to Reduce Child Tuberculosis Morbidity and Mortality. CURRENT TROPICAL MEDICINE REPORTS 2018. [DOI: 10.1007/s40475-018-0139-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Okwara FN, Oyore JP, Were FN, Gwer S. Correlates of isoniazid preventive therapy failure in child household contacts with infectious tuberculosis in high burden settings in Nairobi, Kenya - a cohort study. BMC Infect Dis 2017; 17:623. [PMID: 28915796 PMCID: PMC5602922 DOI: 10.1186/s12879-017-2719-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 09/08/2017] [Indexed: 12/14/2022] Open
Abstract
Background Sub-Saharan Africa continues to document high pediatric tuberculosis (TB) burden, especially among the urban poor. One recommended preventive strategy involves tracking and isoniazid preventive therapy (IPT) for children under 5 years in close contact with infectious TB. However, sub-optimal effectiveness has been documented in diverse settings. We conducted a study to elucidate correlates to IPT strategy failure in children below 5 years in high burden settings. Methods A prospective longitudinal cohort study was done in informal settlings in Nairobi, where children under 5 years in household contact with recently diagnosed smear positive TB adults were enrolled. Consent was sought. Structured questionnaires administered sought information on index case treatment, socio-demographics and TB knowledge. Contacts underwent baseline clinical screening exclude TB and/or pre-existing chronic conditions. Contacts were then put on daily isoniazid for 6 months and monitored for new TB disease, compliance and side effects. Follow-up continued for another 6 months. Results At baseline, 428 contacts were screened, and 14(3.2%) had evidence of TB disease, hence excluded. Of 414 contacts put on IPT, 368 (88.8%) completed the 1 year follow-up. Operational challenges were reported by 258(70%) households, while 82(22%) reported side effects. Good compliance was documented in 89% (CI:80.2–96.2). By endpoint, 6(1.6%) contacts developed evidence of new TB disease and required definitive anti-tuberculosis therapy. The main factor associated with IPT failure was under-nutrition of contacts (p = 0.023). Conclusion Under-nutrition was associated with IPT failure for child contacts below 5 years in high burden, resource limited settings. IPT effectiveness could be optimized through nutrition support of contacts. Electronic supplementary material The online version of this article (10.1186/s12879-017-2719-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Florence Nafula Okwara
- Department of Pediatrics and Child Health, School of Medicine, Kenyatta University, 1609, Thika road campus, Nairobi, 0232, Kenya.
| | - John Paul Oyore
- Department of Community Health, Kenyatta University, School of Public Health, Nairobi, Kenya
| | - Fred Nabwire Were
- Department of Paediatrics and Child Health, University of Nairobi, School of Medicine, Nairobi, Kenya
| | - Samson Gwer
- Department of Medical physiology, Kenyatta University, Sechool of Medicin, Nairobi, Kenya.,Research and Evidence Program, Afya Research Africa, Nairobi, Kenya
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Stakeholder perspectives for optimization of tuberculosis contact investigation in a high-burden setting. PLoS One 2017; 12:e0183749. [PMID: 28886072 PMCID: PMC5590832 DOI: 10.1371/journal.pone.0183749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/10/2017] [Indexed: 11/19/2022] Open
Abstract
Introduction Optimal tuberculosis contact investigation impacts TB prevention, timely case finding and linkage to care, however data on routine implementation in high burden contexts is limited. Materials and methods In a multi-method qualitative study based on individual interviews with TB patients, facility observations and focus group discussions with health workers (HWs) in 13 public health facilities, and key informant interviews with governmental and non-governmental experts, we describe TB contact investigation in the context of an urban setting in Kenya and identify opportunities for optimization. Results Invitation of TB patients to bring close contacts by HWs was key for all patient decisions that led to contact screening in addition to patients’ understanding of TB transmission and desire to avoid contacts suffering from TB. Sub-optimal HW enquiry of TB patients and contacts presenting at the facility were missed opportunities which stemmed from lack of standardized operational procedures, documentation tools and HW training. Stakeholders proposed provision of fast tracked and holistic health packages for contacts seeking TB screening, and sustainable government led funding for the requisite infrastructure and workforce. Conclusion TB contact invitation by HWs leading to contact screening occurs in this context. Stakeholder perspectives inform the design of an operational framework for optimized delivery.
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Abstract
BACKGROUND Tuberculosis (TB) is an important cause of illness and death in HIV-positive children living in areas of high TB prevalence. We know that isoniazid prophylaxis prevents TB in HIV-negative children following TB exposure, but there is uncertainty related to its role in TB preventive treatment in HIV-positive children. OBJECTIVES To summarise the effects of TB preventive treatment versus placebo in HIV-positive children with no known TB contact on active TB, death, and reported adverse events. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE/PubMed, Embase and two trial registers up to February 2017. SELECTION CRITERIA We included trials of HIV-positive children with and without known TB exposure, randomized to receive TB preventive treatment or placebo. DATA COLLECTION AND ANALYSIS Two review authors independently used the study selection criteria, assessed risk of bias, and extracted data. We assessed effects using risk, incidence rate and hazard ratios and assessed the certainty of evidence using GRADE. MAIN RESULTS We included three trials, involving 991 participants, below the age of 13 years, from South Africa and Botswana. Children were randomized to isoniazid prophylaxis or placebo, given daily or three times weekly. The median length of follow-up ranged from 5.7 to 34 months; some were on antiretroviral therapy (ART).In HIV-positive children not on ART, isoniazid prophylaxis may reduce the risk of active TB (hazard ratio (HR) 0.31, 95% confidence interval (CI) 0.11 to 0.87; 1 trial, 240 participants, low certainty evidence), and death (HR 0.46, 95% CI 0.22 to 0.95; 1 trial, 240 participants, low certainty evidence). One trial (182 participants) reported number of children with laboratory adverse events, which was similar between the isoniazid prophylaxis and placebo groups. No clinical adverse events were reported.In HIV-positive children on ART, we do not know if isoniazid prophylaxis reduces the risk of active TB (risk ratio (RR) 0.76, 95% CI 0.50 to 1.14; 3 trials, 737 participants, very low certainty evidence) or death (RR 1.45, 95% CI 0.78 to 2.72; 3 trials, 737 participants, very low certainty evidence). Two trials (714 participants) reported number of clinical adverse events and three trials (795 participants) reported number of laboratory adverse events; for both categories, the number of adverse events were similar between the isoniazid prophylaxis and placebo groups. AUTHORS' CONCLUSIONS Isoniazid prophylaxis given to all children diagnosed with HIV may reduce the risk of active TB and death in HIV-positive children not on ART in studies from Africa. For children on ART, no clear benefit was detected. .
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Affiliation(s)
- Moleen Zunza
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Diane M Gray
- Red Cross War Memorial Children's Hospital and University of Cape TownDepartment of Paediatrics and Child HealthKlipfontein RoadRondeboschCape TownWestern CapeSouth Africa7700
| | - Taryn Young
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health SciencesPO Box 241Cape TownSouth Africa8000
- South African Medical Research CouncilCochrane South AfricaPO Box 19070TygerbergCape TownSouth Africa7505
| | - Mark Cotton
- Tygerberg Children's HospitalChildren's Infectious Diseases Clinical ResearchJ8 Tygerberg Children's HospitalFrancie van Zijl DriveTygerbergCape ProviceSouth Africa7505
| | - Heather J Zar
- Red Cross Children's Hospital and MRC Unit on Child and Adolescent Health, University of Cape TownDepartment of Paediatrics and Child HealthCape TownSouth Africa7700
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