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Farhat M, Cox H, Ghanem M, Denkinger CM, Rodrigues C, Abd El Aziz MS, Enkh-Amgalan H, Vambe D, Ugarte-Gil C, Furin J, Pai M. Drug-resistant tuberculosis: a persistent global health concern. Nat Rev Microbiol 2024; 22:617-635. [PMID: 38519618 DOI: 10.1038/s41579-024-01025-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 03/25/2024]
Abstract
Drug-resistant tuberculosis (TB) is estimated to cause 13% of all antimicrobial resistance-attributable deaths worldwide and is driven by both ongoing resistance acquisition and person-to-person transmission. Poor outcomes are exacerbated by late diagnosis and inadequate access to effective treatment. Advances in rapid molecular testing have recently improved the diagnosis of TB and drug resistance. Next-generation sequencing of Mycobacterium tuberculosis has increased our understanding of genetic resistance mechanisms and can now detect mutations associated with resistance phenotypes. All-oral, shorter drug regimens that can achieve high cure rates of drug-resistant TB within 6-9 months are now available and recommended but have yet to be scaled to global clinical use. Promising regimens for the prevention of drug-resistant TB among high-risk contacts are supported by early clinical trial data but final results are pending. A person-centred approach is crucial in managing drug-resistant TB to reduce the risk of poor treatment outcomes, side effects, stigma and mental health burden associated with the diagnosis. In this Review, we describe current surveillance of drug-resistant TB and the causes, risk factors and determinants of drug resistance as well as the stigma and mental health considerations associated with it. We discuss recent advances in diagnostics and drug-susceptibility testing and outline the progress in developing better treatment and preventive therapies.
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Affiliation(s)
- Maha Farhat
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Helen Cox
- Institute of Infectious Disease and Molecular Medicine, Wellcome Centre for Infectious Disease Research and Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Marwan Ghanem
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Claudia M Denkinger
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Infection Research (DZIF), partner site Heidelberg University Hospital, Heidelberg, Germany
| | | | - Mirna S Abd El Aziz
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Debrah Vambe
- National TB Control Programme, Manzini, Eswatini
| | - Cesar Ugarte-Gil
- School of Public and Population Health, University of Texas Medical Branch, Galveston, TX, USA
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada.
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Vasiliu A, Martinez L, Gupta RK, Hamada Y, Ness T, Kay A, Bonnet M, Sester M, Kaufmann SHE, Lange C, Mandalakas AM. Tuberculosis prevention: current strategies and future directions. Clin Microbiol Infect 2024; 30:1123-1130. [PMID: 37918510 DOI: 10.1016/j.cmi.2023.10.023] [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: 06/13/2023] [Revised: 10/20/2023] [Accepted: 10/22/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND An estimated one fourth of the world's population is infected with Mycobacterium tuberculosis, and 5-10% of those infected develop tuberculosis in their lifetime. Preventing tuberculosis is one of the most underutilized but essential components of curtailing the tuberculosis epidemic. Moreover, current evidence illustrates that tuberculosis manifestations occur along a dynamic spectrum from infection to disease rather than a binary state as historically conceptualized. Elucidating determinants of transition between these states is crucial to decreasing the tuberculosis burden and reaching the END-TB Strategy goals as defined by the WHO. Vaccination, detection of infection, and provision of preventive treatment are key elements of tuberculosis prevention. OBJECTIVES This review provides a comprehensive summary of recent evidence and state-of-the-art updates on advancements to prevent tuberculosis in various settings and high-risk populations. SOURCES We identified relevant studies in the literature and synthesized the findings to provide an overview of the current state of tuberculosis prevention strategies and latest research developments. CONTENT We present the current knowledge and recommendations regarding tuberculosis prevention, with a focus on M. bovis Bacille-Calmette-Guérin vaccination and novel vaccine candidates, tests for latent infection with M. tuberculosis, regimens available for tuberculosis preventive treatment and recommendations in low- and high-burden settings. IMPLICATIONS Effective tuberculosis prevention worldwide requires a multipronged approach that addresses social determinants, and improves access to tuberculosis detection and to new short tuberculosis preventive treatment regimens. Robust collaboration and innovative research are needed to reduce the global burden of tuberculosis and develop new detection tools, vaccines, and preventive treatments that serve all populations and ages.
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Affiliation(s)
- Anca Vasiliu
- Department of Pediatrics, Baylor College of Medicine, Global TB Program, Houston, TX, USA.
| | - Leonardo Martinez
- Department of Epidemiology, School of Public Health, Boston University, Boston, MA, USA
| | - Rishi K Gupta
- Institute of Health Informatics, University College London, London, United Kingdom
| | - Yohhei Hamada
- Institute for Global Health, University College London, London, United Kingdom
| | - Tara Ness
- Department of Pediatrics, Baylor College of Medicine, Global TB Program, Houston, TX, USA
| | - Alexander Kay
- Department of Pediatrics, Baylor College of Medicine, Global TB Program, Houston, TX, USA
| | - Maryline Bonnet
- University of Montpellier, TransVIHMI, IRD, INSERM, Montpellier, France
| | - Martina Sester
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
| | - Stefan H E Kaufmann
- Department of Immunology, Max Planck Institute for Infection Biology, Berlin, Germany; Systems Immunology (Emeritus Group), Max Planck Institute for Multidisciplinary Sciences, Göttingen, Germany; Hagler Institute for Advanced Study, Texas A&M University, College Station, TX, USA
| | - Christoph Lange
- Department of Pediatrics, Baylor College of Medicine, Global TB Program, Houston, TX, USA; Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany; Respiratory Medicine and International Health, University of Lübeck, Lübeck, Germany
| | - Anna M Mandalakas
- Department of Pediatrics, Baylor College of Medicine, Global TB Program, Houston, TX, USA; Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany
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White YN, Solans BP, Denti P, van der Laan LE, Schaaf HS, Vonasek B, Malik AA, Draper HR, Hussain H, Hesseling AC, Garcia-Prats AJ, Savic RM. Pharmacokinetics and Optimal Dosing of Levofloxacin in Children for Drug-Resistant Tuberculosis: An Individual Patient Data Meta-Analysis. Clin Infect Dis 2024; 78:756-764. [PMID: 38340060 PMCID: PMC10954342 DOI: 10.1093/cid/ciae024] [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: 09/13/2023] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Each year 25 000-32 000 children develop rifampicin- or multidrug-resistant tuberculosis (RR/MDR-TB), and many more require preventive treatment. Levofloxacin is a key component of RR/MDR-TB treatment and prevention, but the existing pharmacokinetic data in children have not yet been comprehensively summarized. We aimed to characterize levofloxacin pharmacokinetics through an individual patient data meta-analysis of available studies and to determine optimal dosing in children. METHODS Levofloxacin concentration and demographic data were pooled from 5 studies and analyzed using nonlinear mixed effects modeling. Simulations were performed using current World Health Organization (WHO)-recommended and model-informed optimized doses. Optimal levofloxacin doses were identified to target median adult area under the time-concentration curve (AUC)24 of 101 mg·h/L given current standard adult doses. RESULTS Data from 242 children (2.8 years [0.2-16.8] was used). Apparent clearance was 3.16 L/h for a 13-kg child. Age affected clearance, reaching 50% maturation at birth and 90% maturation at 8 months. Nondispersible tablets had 29% lower apparent oral bioavailability compared to dispersible tablets. Median exposures at current WHO-recommended doses were below the AUC target for children weighing <24 kg and under <10 years, resulting in approximately half of the exposure in adults. Model-informed doses of 16-33 mg/kg for dispersible tablets or 16-50 mg/kg for nondispersible tablets were required to meet the AUC target without significantly exceeding the median adult Cmax. CONCLUSIONS Revised weight-band dosing guidelines with doses of >20 mg/kg are required to ensure adequate exposure. Further studies are needed to determine safety and tolerability of these higher doses.
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Affiliation(s)
- Yasmine N White
- Department of Bioengineering and Therapeutics, Schools of Pharmacy and Medicine, University of California–San Francisco, San Francisco, California, USA
| | - Belen P Solans
- Department of Bioengineering and Therapeutics, Schools of Pharmacy and Medicine, University of California–San Francisco, San Francisco, California, USA
- Center for Tuberculosis, University of California–San Francisco, San Francisco, California, USA
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Louvina E van der Laan
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Bryan Vonasek
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin–Madison, Madison, Wisconsin, USA
| | - Amyn A Malik
- TB Programs, Interactive Research Development (IRD) Global, Singapore, Singapore
- Epidemiology department, Peter O'Donnell Jr. School of Public Health, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Heather R Draper
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Hamidah Hussain
- TB Programs, Interactive Research Development (IRD) Global, Singapore, Singapore
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anthony J Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin–Madison, Madison, Wisconsin, USA
| | - Radojka M Savic
- Department of Bioengineering and Therapeutics, Schools of Pharmacy and Medicine, University of California–San Francisco, San Francisco, California, USA
- Center for Tuberculosis, University of California–San Francisco, San Francisco, California, USA
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Zhou G, Luo S, He J, Chen N, Zhang Y, Cai S, Guo X, Chen H, Song C. Effectiveness and safety of tuberculosis preventive treatment for contacts of patients with multidrug-resistant tuberculosis: a systematic review and meta-analysis. Clin Microbiol Infect 2024; 30:189-196. [PMID: 37741621 DOI: 10.1016/j.cmi.2023.09.015] [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: 05/17/2023] [Revised: 09/12/2023] [Accepted: 09/16/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Contacts of patients with multidrug-resistant tuberculosis (MDR-TB) are at risk of developing TB disease. Tuberculosis preventive treatment (TPT) is an intervention that can potentially reduce this risk. OBJECTIVES To evaluate the effectiveness and safety of TPT for contacts of patients with MDR-TB. DATA SOURCES EMBASE, PubMed, Web of Science, and the Cochrane Library were searched for eligible studies on 24 July 2023, without start date restrictions. STUDY ELIGIBILITY CRITERIA We included studies that compared TPT with no treatment in contacts of patients with MDR-TB and reported outcomes of progression to TB disease. PARTICIPANTS Contacts of patients with MDR-TB. INTERVENTIONS TPT. ASSESSMENT OF RISK OF BIAS A modified version of the Newcastle-Ottawa Scale was used. METHODS OF DATA SYNTHESIS Random-effects meta-analysis was utilized to calculate the relative risk for disease progression to TB in contacts of patients with MDR-TB who received TPT compared to those who did not. Additionally, completion, adverse effect, and discontinued rates were assessed. RESULTS Involving 1105 individuals from 11 studies, the pooled relative risk for disease progression in contacts receiving TPT versus those without treatment was 0.34 (95% CI: 0.16-0.72). Subgroup analysis indicated a lower pooled relative risk for regimens based on the drug-resistance profile of the index patients with TB compared to uniform treatment regimens (0.22 [95% CI: 0.06-0.84] vs. 0.49 [95% CI: 0.17-1.35]), although not statistically significant. The pooled completed rate was 83.8%, adverse effect rate was 22.9%, and discontinued rate was 6.5%. After excluding the levofloxacin and pyrazinamide regimen study, the completed rate increased to 88.0%, and adverse effects and discontinued rates decreased to 8.0% and 4.0%, respectively. DISCUSSION TPT reduces TB disease progression risk in contacts of patients with MDR-TB. Tailored TPT regimens based on drug-resistance profiles may offer additional benefits. Furthermore, efforts to improve completed rates and manage adverse effects are essential for optimizing effectiveness and safety.
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Affiliation(s)
- Guozhong Zhou
- Department of Science and Research, The Affiliated Anning First People's Hospital of Kunming University of Science and Technology, Kunming, Yunnan Province, China
| | - Shiqi Luo
- Department of Immunology, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, China
| | - Jian He
- Department of Pulmonary and Critical Care Medicine, The Affiliated Anning First People's Hospital of Kunming University of Science and Technology, Kunming, Yunnan Province, China
| | - Nan Chen
- Department of Endocrinology, The Affiliated Anning First People's Hospital of Kunming University of Science and Technology, Kunming, Yunnan Province, China
| | - Yu Zhang
- Department of Endocrinology, The Affiliated Anning First People's Hospital of Kunming University of Science and Technology, Kunming, Yunnan Province, China
| | - Shunli Cai
- School of Basic Medical Sciences, Kunming Medical University, Kunming, Yunnan Province, China
| | - Xin Guo
- School of Basic Medical Sciences, Kunming Medical University, Kunming, Yunnan Province, China
| | - Hongbo Chen
- Department of Pulmonary and Critical Care Medicine, The Affiliated Anning First People's Hospital of Kunming University of Science and Technology, Kunming, Yunnan Province, China
| | - Chao Song
- Department of Medical Imaging, The Affiliated Anning First People's Hospital of Kunming University of Science and Technology, Kunming, Yunnan Province, China.
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5
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Kasaie P, Pennington J, Gupta A, Dowdy DW, Kendall EA. The Impact of Preventive Treatment for Multidrug- and Rifampin-Resistant Tuberculosis Exceeds Trial-Based Estimates. Clin Infect Dis 2024; 78:133-143. [PMID: 37724763 PMCID: PMC10810707 DOI: 10.1093/cid/ciad557] [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: 06/20/2023] [Revised: 08/18/2023] [Accepted: 09/18/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Several clinical trials of tuberculosis preventive treatment (TPT) for household contacts of patients with multidrug- or rifampin-resistant tuberculosis (MDR/RR-TB) are nearing completion. The potential benefits of delivering TPT to MDR/RR-TB contacts extend beyond the outcomes that clinical trials can measure. METHODS We developed an agent-based, household-structured TB and MDR/RR-TB transmission model, calibrated to an illustrative setting in India. We simulated contact investigation in households of patients with MDR/RR-TB, comparing an MDR/RR-TPT regimen (assuming 6-month duration, 70% efficacy) and associated active case finding against alternatives of contact investigation without TPT or no household intervention. We simulated the TB and MDR/RR-TB incidence averted relative to placebo over 2 years, as measurable by a typical trial, as well as the incidence averted over a longer time horizon, in the broader population, and relative to no contact investigation. RESULTS Observing TPT and placebo recipients for 2 years as in a typical trial, MDR/RR-TPT was measured to prevent 72% (interquartile range, 45%-100%) of incident MDR/RR-TB among recipients; the median number needed to treat (NNT) to prevent 1 MDR/RR-TB case was 73, compared to placebo. This NNT decreased to 54 with 13-18 years of observation, to 27 when downstream transmission effects were also considered, and to 12 when the effects of active TB screening were included by comparing to a no-household-contact-intervention scenario. CONCLUSIONS If forthcoming trial results demonstrate efficacy, the long-term population impact of TPT for MDR/RR-TB-including the large effect of increased active TB detection among MDR/RR-TB contacts-could be much greater than suggested by trial outcomes alone.
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Affiliation(s)
- Parastu Kasaie
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jeff Pennington
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Amita Gupta
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Emily A Kendall
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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6
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Pham TAM, Forse R, Codlin AJ, Phan THY, Nguyen TT, Nguyen N, Vo LNQ, Dat PT, Minh HDT, Nguyen LH, Nguyen HB, Nguyen NV, Bodfish M, Lönnroth K, Wingfield T, Annerstedt KS. Determinants of catastrophic costs among households affected by multi-drug resistant tuberculosis in Ho Chi Minh City, Viet Nam: a prospective cohort study. BMC Public Health 2023; 23:2372. [PMID: 38042797 PMCID: PMC10693707 DOI: 10.1186/s12889-023-17078-5] [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: 01/23/2023] [Accepted: 10/26/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND Globally, most people with multidrug-resistant tuberculosis (MDR-TB) and their households experience catastrophic costs of illness, diagnosis, and care. However, the factors associated with experiencing catastrophic costs are poorly understood. This study aimed to identify risk factors associated with catastrophic costs incurrence among MDR-TB-affected households in Ho Chi Minh City (HCMC), Viet Nam. METHODS Between October 2020 and April 2022, data were collected using a locally-adapted, longitudinal WHO TB Patient Cost Survey in ten districts of HCMC. Ninety-four people with MDR-TB being treated with a nine-month TB regimen were surveyed at three time points: after two weeks of treatment initiation, completion of the intensive phase and the end of the treatment (approximately five and 10 months post-treatment initiation respectively). The catastrophic costs threshold was defined as total TB-related costs exceeding 20% of annual pre-TB household income. Logistic regression was used to identify variables associated with experiencing catastrophic costs. A sensitivity analysis examined the prevalence of catastrophic costs using alternative thresholds and cost estimation approaches. RESULTS Most participants (81/93 [87%]) experienced catastrophic costs despite the majority 86/93 (93%) receiving economic support through existing social protection schemes. Among participant households experiencing and not experiencing catastrophic costs, median household income was similar before MDR-TB treatment. However, by the end of MDR-TB treatment, median household income was lower (258 [IQR: 0-516] USD vs. 656 [IQR: 462-989] USD; p = 0.003), and median income loss was higher (2838 [IQR: 1548-5418] USD vs. 301 [IQR: 0-824] USD; p < 0.001) amongst the participant households who experienced catastrophic costs. Being the household's primary income earner before MDR-TB treatment (aOR = 11.2 [95% CI: 1.6-80.5]), having a lower educational level (aOR = 22.3 [95% CI: 1.5-344.1]) and becoming unemployed at the beginning of MDR-TB treatment (aOR = 35.6 [95% CI: 2.7-470.3]) were associated with experiencing catastrophic costs. CONCLUSION Despite good social protection coverage, most people with MDR-TB in HCMC experienced catastrophic costs. Incurrence of catastrophic costs was independently associated with being the household's primary income earner or being unemployed. Revision and expansion of strategies to mitigate TB-related catastrophic costs, in particular avoiding unemployment and income loss, are urgently required.
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Affiliation(s)
- Thi Anh Mai Pham
- WHO Collaborating Centre for Social Medicine and Tuberculosis, Department of Global Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | - Rachel Forse
- WHO Collaborating Centre for Social Medicine and Tuberculosis, Department of Global Public Health Sciences, Karolinska Institute, Stockholm, Sweden.
- Friends for International TB Relief, 1/21 Le Van Luong, Nhan Chinh, Thanh Xuan, Ha Noi, Viet Nam.
| | - Andrew J Codlin
- WHO Collaborating Centre for Social Medicine and Tuberculosis, Department of Global Public Health Sciences, Karolinska Institute, Stockholm, Sweden
- Friends for International TB Relief, 1/21 Le Van Luong, Nhan Chinh, Thanh Xuan, Ha Noi, Viet Nam
| | - Thi Hoang Yen Phan
- Centre for Development of Community Health Initiatives, 1/21 Le Van Luong, Nhan Chinh, Thanh Xuan, Ha Noi, Viet Nam
| | - Thanh Thi Nguyen
- Centre for Development of Community Health Initiatives, 1/21 Le Van Luong, Nhan Chinh, Thanh Xuan, Ha Noi, Viet Nam
| | - Nga Nguyen
- Friends for International TB Relief, 1/21 Le Van Luong, Nhan Chinh, Thanh Xuan, Ha Noi, Viet Nam
| | - Luan Nguyen Quang Vo
- Centre for Development of Community Health Initiatives, 1/21 Le Van Luong, Nhan Chinh, Thanh Xuan, Ha Noi, Viet Nam
| | - Phan Thuong Dat
- Pham Ngoc Thach Hospital, 120 Hong Bang, Ward12, District 5, Ho Chi Minh City, Viet Nam
| | - Ha Dang Thi Minh
- Pham Ngoc Thach Hospital, 120 Hong Bang, Ward12, District 5, Ho Chi Minh City, Viet Nam
| | - Lan Huu Nguyen
- Pham Ngoc Thach Hospital, 120 Hong Bang, Ward12, District 5, Ho Chi Minh City, Viet Nam
| | - Hoa Binh Nguyen
- National Lung Hospital/National TB Control Programme, 463 Hoang Hoa Tham, Vinh Phu, Ba Dinh, Ha Noi, Viet Nam
| | - Nhung Viet Nguyen
- National Lung Hospital/National TB Control Programme, 463 Hoang Hoa Tham, Vinh Phu, Ba Dinh, Ha Noi, Viet Nam
- University of Medicine and Pharmacy, Vietnam National University, Ha Noi, Viet Nam
| | - Miranda Bodfish
- CDC Foundation, 600 Peachtree Street NE, Suite 1000, Atlanta, USA
| | - Knut Lönnroth
- WHO Collaborating Centre for Social Medicine and Tuberculosis, Department of Global Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | - Tom Wingfield
- WHO Collaborating Centre for Social Medicine and Tuberculosis, Department of Global Public Health Sciences, Karolinska Institute, Stockholm, Sweden
- Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, Merseyside, UK
- Tropical and Infectious Disease Unit, Liverpool University Hospital NHS Foundation Trust, Liverpool, L7 8XP, Merseyside, UK
| | - Kristi Sidney Annerstedt
- WHO Collaborating Centre for Social Medicine and Tuberculosis, Department of Global Public Health Sciences, Karolinska Institute, Stockholm, Sweden
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7
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Schäfer HL, Barker M, Follmann P, Günther A, Hörning A, Kaiser-Labusch P, Kerzel S, Maier C, Roth S, Schmidt C, Schütz K, Stehling F, Struffert M, Timmesfeld N, Vöhringer P, Brinkmann F. Pediatric multi-drug-resistant tuberculosis in Germany - diagnostic and therapeutic challenges of an "orphan disease". Eur J Pediatr 2023; 182:5167-5179. [PMID: 37707590 PMCID: PMC10640426 DOI: 10.1007/s00431-023-05167-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/08/2023] [Accepted: 08/16/2023] [Indexed: 09/15/2023]
Abstract
Delay in diagnosing multidrug-resistant tuberculosis (MDR-pTB) in children prolongs time to effective treatment. Data on risk factors for pediatric MDR from low-incidence countries are scarce. Retrospective nationwide case-control study to analyze MDR-pTB cases in Germany between 2010 and 2020 in comparison to a drug-susceptible (DS)-pTB group. We included 52 MDR cases (24 tuberculosis (TB), 28 TB infection (TBI); mean age 7.3 years) and 56 DS cases (31 TB, 26 TBI; mean age 7.9 years). Groups were similar for sex, household size, and migration background. Compared to the DS group, more children with MDR were born in the Commonwealth of Independent States (CIS) (22% MDR-pTB vs. 13% DS-pTB, n.s.) and had more MDR index cases (94% MDR-pTB, 5% DS-pTB, p < 0.001). The interval between first healthcare contact and initiation of effective therapy was significantly longer in MDR-pTB (47 days) than in DS-pTB (11 days, p < 0.001), correlating with disease progression. Treatment for MDR-pTB was successful in 74%, but 22% experienced long-term adverse effects (e.g., hepatopathy, hearing loss). CONCLUSIONS Close contact to MDR cases or birth in MDR-TB-high-incidence countries are risk factors for MDR-pTB. Early identification of potential MDR index cases by contact investigation, and susceptibility testing in children from high-burden MDR-TB countries are essential for timely diagnosis and treatment, reducing the severity of disease and treatment side effects. TRIAL REGISTRATION Deutsches Register Klinischer Studien ( https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00023817 ), DRKS00023817, 2020-09-08. WHAT IS KNOWN •Management of children with MDR-TB remains challenging due to difficulties in diagnosing MDR-TB (lack of information on MDR index case, lack of microbiological confirmation in paucibacillary disease). •Choice of treatment regimen and monitoring of side effects. WHAT IS NEW •Children with an MDR-TB index or born in a MDR-TB-high-incidence country are at higher risk of developing MDR-TB in a low incidence country. •The time lag to initiate treatment in MDR-TB is longer than in DS-TB and MDR-TB treatment involves a higher risk of adverse effects in longer treatment regimens especially with injectables.
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Affiliation(s)
- Hannah-Lena Schäfer
- Department of Pediatric Pulmonology, Ruhr University Bochum, St. Josef Hospital, University Hospital of Pediatrics and Adolescent Medicine, Alexandrinenstraße 5, Bochum, 44791, Germany.
| | - Michael Barker
- Department of Pediatrics, Heckeshorn Lung Unit, Helios Klinikum Emil von Behring, Berlin, Germany
| | - Peter Follmann
- Klinik für Kinder- und Jugendmedizin, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - Annette Günther
- Department of Pediatrics, Heckeshorn Lung Unit, Helios Klinikum Emil von Behring, Berlin, Germany
| | | | | | - Sebastian Kerzel
- Department of Pediatric Pneumology and Allergy, University Children's Hospital Regensburg, Campus St. Hedwig, Regensburg, Germany
| | - Christoph Maier
- Department of Pediatric Pulmonology, Ruhr University Bochum, St. Josef Hospital, University Hospital of Pediatrics and Adolescent Medicine, Alexandrinenstraße 5, Bochum, 44791, Germany
| | - Samra Roth
- Department of Pediatric Pneumology and Allergy, University Children's Hospital Regensburg, Campus St. Hedwig, Regensburg, Germany
| | - Christian Schmidt
- Klinik für Kinder- und Jugendmedizin, St. Vinzenz-Hospital, Dinslaken, Germany
| | - Katharina Schütz
- Klinik für Pädiatrische Pneumologie, Allergologie und Neonatologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Florian Stehling
- Centre for Pediatrics, University Hospital Essen, Essen, Germany
| | - Marie Struffert
- Department of Pediatric Pulmonology, Ruhr University Bochum, St. Josef Hospital, University Hospital of Pediatrics and Adolescent Medicine, Alexandrinenstraße 5, Bochum, 44791, Germany
| | - Nina Timmesfeld
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University, Bochum, Germany
| | - Paul Vöhringer
- Franz-Lust-Klinik für Kinder- und Jugendmedizin Städtisches Klinikum, Karlsruhe, Germany
| | - Folke Brinkmann
- Department of Pediatric Pulmonology, Ruhr University Bochum, St. Josef Hospital, University Hospital of Pediatrics and Adolescent Medicine, Alexandrinenstraße 5, Bochum, 44791, Germany
- Division of Pediatric Pulmonology and Allergology, German Center for Lung Research (ARCN, DZL), University Children's Hospital, Luebeck, Germany
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Shleider Carnero Canales C, Marquez Cazorla J, Furtado Torres AH, Monteiro Filardi ET, Di Filippo LD, Costa PI, Roque-Borda CA, Pavan FR. Advances in Diagnostics and Drug Discovery against Resistant and Latent Tuberculosis Infection. Pharmaceutics 2023; 15:2409. [PMID: 37896169 PMCID: PMC10610444 DOI: 10.3390/pharmaceutics15102409] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/23/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
Latent tuberculosis infection (LTBI) represents a subclinical, asymptomatic mycobacterial state affecting approximately 25% of the global population. The substantial prevalence of LTBI, combined with the risk of progressing to active tuberculosis, underscores its central role in the increasing incidence of tuberculosis (TB). Accurate identification and timely treatment are vital to contain and reduce the spread of the disease, forming a critical component of the global strategy known as "End TB." This review aims to examine and highlight the most recent scientific evidence related to new diagnostic approaches and emerging therapeutic treatments for LTBI. While prevalent diagnostic methods include the tuberculin skin test (TST) and interferon gamma release assay (IGRA), WHO's approval of two specific IGRAs for Mycobacterium tuberculosis (MTB) marked a significant advancement. However, the need for a specific test with global application viability has propelled research into diagnostic tests based on molecular diagnostics, pulmonary immunity, epigenetics, metabolomics, and a current focus on next-generation MTB antigen-based skin test (TBST). It is within these emerging methods that the potential for accurate distinction between LTBI and active TB has been demonstrated. Therapeutically, in addition to traditional first-line therapies, anti-LTBI drugs, anti-resistant TB drugs, and innovative candidates in preclinical and clinical stages are being explored. Although the advancements are promising, it is crucial to recognize that further research and clinical evidence are needed to solidify the effectiveness and safety of these new approaches, in addition to ensuring access to new drugs and diagnostic methods across all health centers. The fight against TB is evolving with the development of more precise diagnostic tools that differentiate the various stages of the infection and with more effective and targeted treatments. Once consolidated, current advancements have the potential to transform the prevention and treatment landscape of TB, reinforcing the global mission to eradicate this disease.
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Affiliation(s)
- Christian Shleider Carnero Canales
- Facultad de Ciencias Farmacéuticas Bioquímicas y Biotecnológicas, Vicerrectorado de Investigación, Universidad Católica de Santa María, Arequipa 04000, Peru; (C.S.C.C.)
| | - Jessica Marquez Cazorla
- Facultad de Ciencias Farmacéuticas Bioquímicas y Biotecnológicas, Vicerrectorado de Investigación, Universidad Católica de Santa María, Arequipa 04000, Peru; (C.S.C.C.)
| | | | | | | | - Paulo Inácio Costa
- School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara 14801-970, SP, Brazil
| | - Cesar Augusto Roque-Borda
- School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara 14801-970, SP, Brazil
- Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, 2300 Copenhagen, Denmark
| | - Fernando Rogério Pavan
- School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara 14801-970, SP, Brazil
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9
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Udwadia ZF, Tripathi AR, Patel JM. Treating household contacts of MDR-TB patients: Are we being too hasty? Lung India 2023; 40:404-405. [PMID: 37787351 PMCID: PMC10553770 DOI: 10.4103/lungindia.lungindia_377_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 07/27/2023] [Accepted: 07/29/2023] [Indexed: 10/04/2023] Open
Affiliation(s)
- Zarir F Udwadia
- Consultant Pulmonologist, Department of Respiratory Medicine, P.D. Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Awatansh R Tripathi
- Consultant Pulmonologist, Department of Respiratory Medicine, Cardinal Garcious Memorial Hospital Vasai West Thane, Maharashtra, India
| | - Jigneshkumar M Patel
- Senior Clinical Associate, Department of Respiratory Medicine, P.D. Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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Baker JJ, Nahar R, Petroelje BK, Goswami ND, Lardizabal AA. Fluoroquinolone-resistant latent tuberculosis infection: A literature review and case series of 5 patients treated with linezolid monotherapy. J Clin Tuberc Other Mycobact Dis 2023; 32:100376. [PMID: 37252368 PMCID: PMC10209533 DOI: 10.1016/j.jctube.2023.100376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
Latent tuberculosis infection (LTBI) constitutes an important public health problem because of risk of progression to TB disease. Effective treatment of multi-drug resistant (MDR) LTBI would prevent progression to MDR TB disease, which would improve patient and public health outcomes. The majority of MDR LTBI treatment studies have focused on the use of fluoroquinolone-based antibiotic regimens. Options for and experience in the treatment of fluoroquinolone-resistant MDR LTBI are limited in the published literature and not comprehensively addressed in current guidelines. In this review, we share our experience with the treatment of fluoroquinolone-resistant MDR LTBI with linezolid. We discuss treatment options for MDR TB that provide context for predicting effective MDR LTBI treatment, with a focus on the microbiologic and pharmacokinetic properties of linezolid that support its use. We then summarize the evidence for treatment of MDR LTBI. Finally, we present our experiences treating fluoroquinolone-resistant MDR LTBI with linezolid with an emphasis on dosing considerations to optimize efficacy and minimize potential toxicities.
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Affiliation(s)
- Jacob J. Baker
- Corewell Health, Michigan State University, Grand Rapids, MI, United States
| | - Richa Nahar
- Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Brian K. Petroelje
- Corewell Health, Michigan State University, Grand Rapids, MI, United States
| | - Neela D. Goswami
- Centers for Disease Control and Prevention, Atlanta, GA, United States
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11
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Graciaa DS, Schechter MC, Fetalvero KB, Cranmer LM, Kempker RR, Castro KG. Updated considerations in the diagnosis and management of tuberculosis infection and disease: integrating the latest evidence-based strategies. Expert Rev Anti Infect Ther 2023; 21:595-616. [PMID: 37128947 PMCID: PMC10227769 DOI: 10.1080/14787210.2023.2207820] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/24/2023] [Indexed: 05/03/2023]
Abstract
INTRODUCTION Tuberculosis (TB) is a leading infectious cause of global morbidity and mortality, affecting nearly a quarter of the human population and accounting for over 10 million deaths each year. Over the past several decades, TB incidence and mortality have gradually declined, but 2021 marked a threatening reversal of this trend highlighting the importance of accurate diagnosis and effective treatment of all forms of TB. AREAS COVERED This review summarizes advances in TB diagnostics, addresses the treatment of people with TB infection and TB disease including recent evidence for treatment regimens for drug-susceptible and drug-resistant TB, and draws attention to special considerations in children and during pregnancy. EXPERT OPINION Improvements in diagnosis and management of TB have expanded the available options for TB control. Molecular testing has enhanced the detection of TB disease, but better diagnostics are still needed, particularly for certain populations such as children. Novel treatment regimens have shortened treatment and improved outcomes for people with TB. However, important questions remain regarding the optimal management of TB. Work must continue to ensure the potential of the latest developments is realized for all people affected by TB.
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Affiliation(s)
- Daniel S. Graciaa
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marcos Coutinho Schechter
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Krystle B. Fetalvero
- Angelo King Medical Research Center-De La Salle Medical and Health Science Institute, Cavite, Philippines
- Department of Family and Community Medicine, Calamba Medical Center, Laguna, Philippines
| | - Lisa Marie Cranmer
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Russell R. Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kenneth G. Castro
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Abstract
PURPOSE OF REVIEW The current review identifies recent advances in the prevention, diagnosis, and treatment of childhood tuberculosis (TB) with a focus on the WHO's updated TB management guidelines released in 2022. RECENT FINDINGS The COVID-19 pandemic negatively affected global TB control due to the diversion of healthcare resources and decreased patient care-seeking behaviour. Despite this, key advances in childhood TB management have continued. The WHO now recommends shorter rifamycin-based regimens for TB preventive treatment as well as shorter regimens for the treatment of both drug-susceptible and drug-resistant TB. The Xpert Ultra assay is now recommended as the initial diagnostic test for TB in children with presumed TB and can also be used on stool samples. Point-of-care urinary lipoarabinomannan assays are promising as 'rule-in' tests for children with presumed TB living with HIV. Treatment decision algorithms can be used to diagnose TB in symptomatic children in settings with and without access to chest X-rays; bacteriological confirmation should always be attempted. SUMMARY Recent guideline updates are a key milestone in the management of childhood TB, and the paediatric TB community should now prioritize their efficient implementation in high TB burden countries while generating evidence to close current evidence gaps.
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Affiliation(s)
- Heather Finlayson
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences
| | - Juanita Lishman
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences
| | - Megan Palmer
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
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13
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Apolisi I, Cox H, Tyeku N, Daniels J, Mathee S, Cariem R, Douglas-Jones B, Ngambu N, Mudaly V, Mohr-Holland E, Isaakidis P, Pfaff C, Furin J, Reuter A. Tuberculosis Diagnosis and Preventive Monotherapy Among Children and Adolescents Exposed to Rifampicin-Resistant Tuberculosis in the Household. Open Forum Infect Dis 2023; 10:ofad087. [PMID: 36910692 PMCID: PMC10003730 DOI: 10.1093/ofid/ofad087] [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: 01/05/2023] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
Background Children and adolescents with household exposure to multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB) are at high risk of developing TB disease. Tuberculosis preventive therapy (TPT) is recommended, but programmatic experience is limited, particularly for adolescents. Methods We conducted a prospective cohort study to describe MDR/RR-TB diagnosis and TPT provision for individuals aged <18 years with MDR/RR-TB exposure. Participants were assessed for TB either in homes or health facilities, with referral for chest x-ray or specimen collection at clinician discretion. The TPT regimens included levofloxacin, isoniazid, or delamanid monotherapy for 6 months, based on source patient drug-resistance profile. Results Between March 1, 2020 and July 31, 2021, 112 participants were enrolled; median age was 8.5 years, 57 (51%) were female, and 6 (5%) had human immunodeficiency virus. On screening, 11 (10%) were diagnosed with TB: 10 presumptive MDR/RR-TB and 1 drug-susceptible TB. Overall, 95 (94% of 101) participants started TPT: 79 with levofloxacin, 9 with isoniazid, and 7 with delamanid. Seventy-six (80%) completed TPT, 12 (13%) were lost to follow up, and 7 (7%) stopped TPT early due to adverse events. Potential adverse events were reported for 12 (13%) participants; none were serious. There were no further TB diagnoses (200 days median follow up). Conclusions Post-MDR/RR-TB exposure management for children and adolescents resulted in significant MDR/RR-TB detection and both high TPT initiation and completion. Tuberculosis preventive monotherapy was well tolerated and there were no further TB diagnoses after initial assessment. Key factors supporting these outcomes included use of pediatric formulations for young children, monotherapy, and community-based options for assessment and follow up.
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Affiliation(s)
- Ivy Apolisi
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa
| | - Helen Cox
- Institute of Infectious Disease and Molecular Medicine and Wellcome Centre for Infectious Disease Research, Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Nolitha Tyeku
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa
| | - Johnny Daniels
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa
| | - Shaheed Mathee
- Western Cape Province Department of Health, Cape Town, South Africa
| | - Rabia Cariem
- City of Cape Town Department of Health, Cape Town, South Africa
| | | | - Noluvo Ngambu
- Western Cape Province Department of Health, Cape Town, South Africa
| | - Vanessa Mudaly
- Western Cape Province Department of Health, Cape Town, South Africa
| | | | - Petros Isaakidis
- Médecins Sans Frontières, Southern Africa Medical Unit, Cape Town, South Africa
| | - Colin Pfaff
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa
| | - Jennifer Furin
- Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Anja Reuter
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa
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Kasaie P, Pennington J, Gupta A, Dowdy DW, Kendall EA. Trials underestimate the impact of preventive treatment for household contacts exposed to multidrug-resistant tuberculosis: a simulation study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.02.06.23285528. [PMID: 36798407 PMCID: PMC9934809 DOI: 10.1101/2023.02.06.23285528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Background Several clinical trials of tuberculosis preventive treatment (TPT) for household contacts of patients with multidrug-resistant tuberculosis (MDR-TB) are nearing completion. The potential benefits of TPT for MDR-TB contacts extend beyond the outcomes that clinical trials can measure. Methods We developed an agent-based, household-structured TB and MDR-TB transmission model, calibrated to an illustrative setting in India, the country accounting for 26% of global MDR-TB burden. We simulated household contact investigation for contacts of patients with MDR-TB, comparing an MDR-TPT regimen against alternatives of isoniazid preventive treatment, household contact investigation without TPT, or no household contact intervention. We simulated outcomes of a clinical trial and estimated the patient-level and population-level effects over a longer time horizon. Findings During two years of follow-up per recipient, a simulated 6-month MDR-TPT regimen with 70% efficacy against both DS- and MDR-TB infection could prevent 72% [Interquartile range (IQR): 45 - 100%] of incident MDR-TB among TPT recipients (number needed to treat (NNT) 73 [44 - 176] to prevent one MDR-TB case), compared to household contact investigation without TPT. This NNT decreased to 54 [30 - 183] when median follow-up was increased from two to 16 years, to 27 [11 - Inf] when downstream transmission effects were also considered, and to 12 [8 - 22] when these effects were compared to a scenario of no household contact intervention. Interpretation If forthcoming trial results demonstrate efficacy, the long-term population impact of MDR-TPT implementation could be much greater than suggested by trial outcomes alone. Funding NIH K01AI138853 and K08AI127908; Johns Hopkins Catalyst Award.
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15
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Gomes I, Garg T, Churchyard G, Gupta A, Hesseling AC, Swindells S, Gurupira W, Martel B, Mbata L, Patil S, Riviere C, Tonquin M, Dowdy D, Sohn H. The cascade of care for household contacts of people with drug-resistant TB. Int J Tuberc Lung Dis 2023; 27:154-156. [PMID: 36853100 PMCID: PMC10115168 DOI: 10.5588/ijtld.22.0473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- I Gomes
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - T Garg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - G Churchyard
- Aurum Institute, Johannesburg, South Africa, School of Public Health, University of Witwatersrand, Johannesburg, South Africa, Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - A Gupta
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - A C Hesseling
- Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - S Swindells
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NB, USA
| | - W Gurupira
- Clinical Trials Research Centre (UZ-CTRC), University of Zimbabwe, Harare, Zimbabwe
| | - B Martel
- Socios En Salud Sucursal Peru, Lima, Peru
| | - L Mbata
- Aurum Institute, Rustenburg, South Africa
| | - S Patil
- Byramjee Jeejeebhoy Government Medical College CRS, Johns Hopkins University Baltimore-Washington-India Clinical Trials Unit, Pune, India
| | - C Riviere
- Les Centres GHESKIO, Port-au-Prince, Haiti
| | - M Tonquin
- Research Division, De La Salle Medical and Health Sciences Institute, Dasmarinas City, Cavite, The Philippines
| | - D Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - H Sohn
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
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16
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Chin KL, Anibarro L, Sarmiento ME, Acosta A. Challenges and the Way forward in Diagnosis and Treatment of Tuberculosis Infection. Trop Med Infect Dis 2023; 8:tropicalmed8020089. [PMID: 36828505 PMCID: PMC9960903 DOI: 10.3390/tropicalmed8020089] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 02/03/2023] Open
Abstract
Globally, it is estimated that one-quarter of the world's population is latently infected with Mycobacterium tuberculosis (Mtb), also known as latent tuberculosis infection (LTBI). Recently, this condition has been referred to as tuberculosis infection (TBI), considering the dynamic spectrum of the infection, as 5-10% of the latently infected population will develop active TB (ATB). The chances of TBI development increase due to close contact with index TB patients. The emergence of multidrug-resistant TB (MDR-TB) and the risk of development of latent MDR-TB has further complicated the situation. Detection of TBI is challenging as the infected individual does not present symptoms. Currently, there is no gold standard for TBI diagnosis, and the only screening tests are tuberculin skin test (TST) and interferon gamma release assays (IGRAs). However, these tests have several limitations, including the inability to differentiate between ATB and TBI, false-positive results in BCG-vaccinated individuals (only for TST), false-negative results in children, elderly, and immunocompromised patients, and the inability to predict the progression to ATB, among others. Thus, new host markers and Mtb-specific antigens are being tested to develop new diagnostic methods. Besides screening, TBI therapy is a key intervention for TB control. However, the long-course treatment and associated side effects result in non-adherence to the treatment. Additionally, the latent MDR strains are not susceptible to the current TBI treatments, which add an additional challenge. This review discusses the current situation of TBI, as well as the challenges and efforts involved in its control.
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Affiliation(s)
- Kai Ling Chin
- Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu 88400, Malaysia
- Borneo Medical and Health Research Centre, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu 88400, Malaysia
- Correspondence: (K.L.C.); (L.A.); (A.A.)
| | - Luis Anibarro
- Tuberculosis Unit, Infectious Diseases and Internal Medicine Department, Complexo Hospitalario Universitario de Pontevedra, 36071 Pontevedra, Spain
- Immunology Research Group, Galicia Sur Health Research Institute (IIS-GS), 36312 Vigo, Spain
- Correspondence: (K.L.C.); (L.A.); (A.A.)
| | - Maria E. Sarmiento
- School of Health Sciences, Universiti Sains Malaysia, Health Campus, Kubang Kerian 16150, Malaysia
| | - Armando Acosta
- School of Health Sciences, Universiti Sains Malaysia, Health Campus, Kubang Kerian 16150, Malaysia
- Correspondence: (K.L.C.); (L.A.); (A.A.)
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Majumdar SS, Islam S, Huang GKL, Morris L, Bauri M, Chan G, Kama G, Keam T, Peacock-Smith A, Finch S, Marukutira T, Bhatt S, Drewett G, Wratten M, Murray A, Pank N, Masah C, Bala R, Umali S, Kalon S, Greig J, Chani K, Kal M, Graham SM. Contact screening and management in a high-transmission MDR-TB setting in Papua New Guinea: Progress, challenges and future directions. FRONTIERS IN TROPICAL DISEASES 2023. [DOI: 10.3389/fitd.2022.1085401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Daru, South Fly District, Papua New Guinea is a high transmission setting for multidrug-resistant tuberculosis (MDR-TB). An emergency response by the Government in 2014 established a high-quality model for treatment and care. Household contact screening and management commenced in 2016 with TB preventive treatment (TPT) for well young child (<5 years) contacts of people with drug-susceptible TB and later expanded to young child contacts of MDR-TB. The model of care is community-based and led by non-specialist health workers, under supervision. An electronic medical record system supports care, reporting and operational research. Community engagement and education has been central, with a concerted focus on peer-led counselling and patient-centred services to improve TPT uptake and completion. Challenges include the application of households as the unit of intervention for detection of active TB and TPT provision. Our implementation experience in Daru has highlighted significant population mixing dynamics with most transmission likely occurring outside the household. We propose a community-wide screening approach with the provision of TPT based on testing to include older children, adolescents, and young adults. As there is the possibility of MDR-TB infection irrespective of the drug susceptibility of the household index case, a novel option is a combination TPT regimen of 6 months of daily isoniazid and levofloxacin (6HLfx). A sensitive aged-related algorithm to detect and exclude active TB is being developed. Ongoing community engagement, quality data systems with operational research to evaluate approaches are critical in high transmission MDR-TB settings.
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18
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Dartois VA, Rubin EJ. Anti-tuberculosis treatment strategies and drug development: challenges and priorities. Nat Rev Microbiol 2022; 20:685-701. [PMID: 35478222 PMCID: PMC9045034 DOI: 10.1038/s41579-022-00731-y] [Citation(s) in RCA: 132] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 12/12/2022]
Abstract
Despite two decades of intensified research to understand and cure tuberculosis disease, biological uncertainties remain and hamper progress. However, owing to collaborative initiatives including academia, the pharmaceutical industry and non-for-profit organizations, the drug candidate pipeline is promising. This exceptional success comes with the inherent challenge of prioritizing multidrug regimens for clinical trials and revamping trial designs to accelerate regimen development and capitalize on drug discovery breakthroughs. Most wanted are markers of progression from latent infection to active pulmonary disease, markers of drug response and predictors of relapse, in vitro tools to uncover synergies that translate clinically and animal models to reliably assess the treatment shortening potential of new regimens. In this Review, we highlight the benefits and challenges of 'one-size-fits-all' regimens and treatment duration versus individualized therapy based on disease severity and host and pathogen characteristics, considering scientific and operational perspectives.
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Affiliation(s)
- Véronique A Dartois
- Center for Discovery and Innovation, and Hackensack Meridian School of Medicine, Department of Medical Sciences, Hackensack Meridian Health, Nutley, NJ, USA.
| | - Eric J Rubin
- Harvard T.H. Chan School of Public Health, Department of Immunology and Infectious Diseases, Boston, MA, USA
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19
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Ortiz-Brizuela E, Menzies D, Behr MA. Testing and Treating Mycobacterium tuberculosis Infection. Med Clin North Am 2022; 106:929-947. [PMID: 36280337 DOI: 10.1016/j.mcna.2022.08.001] [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] [Indexed: 11/25/2022]
Abstract
After infection with Mycobacterium tuberculosis, a minority of individuals will progress to tuberculosis disease (TB). The risk is higher among persons with well-established risk factors and within the first year after infection. Testing and treating individuals at high risk of progression maximizes the benefits of TB preventive therapy; avoiding testing of low-risk persons will limit potential harms. Several treatment options are available; rifamycin-based regimens offer the best efficacy-safety balance. In this review, we present an overview of the diagnosis and treatment of TB infection, and summarize common clinical scenarios.
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Affiliation(s)
- Edgar Ortiz-Brizuela
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, 1020 Pine Avenue, West Montreal, H3A 1A2, Canada; McGill International TB Centre, Research Institute of the McGill University Health Centre, 5252 boul.de Maisonneuve, West Montreal, Quebec, H4A 3S5, Canada; Department of Medicine, Insituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Vasco de Quiroga 15, Belisario Domínguez Secc 16, Tlalpan, Mexico City, 14000, Mexico
| | - Dick Menzies
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, 1020 Pine Avenue, West Montreal, H3A 1A2, Canada; McGill International TB Centre, Research Institute of the McGill University Health Centre, 5252 boul.de Maisonneuve, West Montreal, Quebec, H4A 3S5, Canada; Department of Medicine, McGill University, 1001 Decarie Boulevard, Montreal, Quebec, H4A 3J1, Canada
| | - Marcel A Behr
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, 1020 Pine Avenue, West Montreal, H3A 1A2, Canada; McGill International TB Centre, Research Institute of the McGill University Health Centre, 5252 boul.de Maisonneuve, West Montreal, Quebec, H4A 3S5, Canada; Department of Medicine, McGill University, 1001 Decarie Boulevard, Montreal, Quebec, H4A 3J1, Canada.
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20
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Preventive Treatment for Household Contacts of Drug-Susceptible Tuberculosis Patients. Pathogens 2022; 11:pathogens11111258. [DOI: 10.3390/pathogens11111258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/16/2022] Open
Abstract
People who live in the household of someone with infectious pulmonary tuberculosis are at a high risk of tuberculosis infection and subsequent progression to tuberculosis disease. These individuals are prioritized for contact investigation and tuberculosis preventive treatment (TPT). The treatment of TB infection is critical to prevent the progression of infection to disease and is prioritized in household contacts. Despite the availability of TPT, uptake in household contacts is poor. Multiple barriers prevent the optimal implementation of these policies. This manuscript lays out potential next steps for closing the policy-to-implementation gap in household contacts of all ages.
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21
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Preventive Therapy for Contacts of Drug-Resistant Tuberculosis. Pathogens 2022; 11:pathogens11101189. [PMID: 36297246 PMCID: PMC9609446 DOI: 10.3390/pathogens11101189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/12/2022] [Accepted: 10/14/2022] [Indexed: 11/07/2022] Open
Abstract
Preventing the progression of a drug-resistant tuberculosis (DR-TB) infection to disease is an important pillar of the DR-TB elimination strategy. International guidelines have recently proposed fluoroquinolones for tuberculosis preventive therapy (TPT) in DR-TB contacts, although the available evidence is low quality. The pooled data from small observational studies suggest that a fluoroquinolone-based TPT is safe, effective and cost-effective as a preventive treatment in DR-TB contacts. Three clinical trials are currently ongoing to generate higher quality evidence on the efficacy of levofloxacin and delamanid as a DR-TB preventive therapy. Additional evidence is also needed, regarding TPT treatment in fluoroquinolone-resistant-TB contacts, patient and health care worker perceptions on DR-TB preventive therapy for contacts, and the service delivery models to increase DR-TPT access. This state-of-the-art review presents the current literature on TPT for contacts of DR-TB cases, focusing on the available evidence and international guidelines.
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Matteelli A, Alffenaar JWC. Diagnosis and treatment of tuberculosis infection: can it contribute to achieving tuberculosis elimination? Eur Respir J 2022; 60:60/1/2200540. [PMID: 35798372 DOI: 10.1183/13993003.00540-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/05/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Alberto Matteelli
- Institute of Infectious and Tropical diseases, WHO Collaborating Centre for Tuberculosis/HIV coinfection and for the Tuberculosis Elimination Strategy, University of Brescia, Brescia, Italy
| | - Jan-Willem C Alffenaar
- Sydney Institute for Infectious Diseases, The University of Sydney School of Pharmacy Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Westmead Hospital, Sydney, Australia
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The global impact of household contact management for children on multidrug-resistant and rifampicin-resistant tuberculosis cases, deaths, and health-system costs in 2019: a modelling study. THE LANCET GLOBAL HEALTH 2022; 10:e1034-e1044. [PMID: 35597248 PMCID: PMC9197775 DOI: 10.1016/s2214-109x(22)00113-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/21/2022] [Accepted: 03/09/2022] [Indexed: 12/26/2022] Open
Abstract
Background Methods Findings Interpretation Funding
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Treatment of Rifampicin-Resistant Tuberculosis Disease and Infection in Children: Key Updates, Challenges and Opportunities. Pathogens 2022; 11:pathogens11040381. [PMID: 35456056 PMCID: PMC9024964 DOI: 10.3390/pathogens11040381] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/09/2022] [Accepted: 02/21/2022] [Indexed: 01/27/2023] Open
Abstract
Children affected by rifampicin-resistant tuberculosis (RR-TB; TB resistant to at least rifampicin) are a neglected group. Each year an estimated 25,000–30,000 children develop RR-TB disease globally. Improving case detection and treatment initiation is a priority since RR-TB disease is underdiagnosed and undertreated. Untreated paediatric TB has particularly high morbidity and mortality. However, children receiving TB treatment, including for RR-TB, respond well. RR-TB treatment remains a challenge for children, their caregivers and TB programmes, requiring treatment regimens of up to 18 months in duration, often associated with severe and long-term adverse effects. Shorter, safer, effective child-friendly regimens for RR-TB are needed. Preventing progression to disease following Mycobacterium tuberculosis infection is another key component of TB control. The last few years have seen exciting advances. In this article, we highlight key elements of paediatric RR-TB case detection and recent updates, ongoing challenges and forthcoming advances in the treatment of RR-TB disease and infection in children and adolescents. The global TB community must continue to advocate for more and faster research in children on novel and repurposed TB drugs and regimens and increase investments in scaling-up effective approaches, to ensure an equitable response that prioritises the needs of this vulnerable population.
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Trawinski H, Lübbert C. Tuberkulose. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022. [DOI: 10.1055/a-1670-2085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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26
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Velen K, Shingde RV, Ho J, Fox GJ. The effectiveness of contact investigation among contacts of tuberculosis patients: a systematic review and meta-analysis. Eur Respir J 2021; 58:13993003.00266-2021. [PMID: 34016621 DOI: 10.1183/13993003.00266-2021] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/29/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND We aimed to evaluate the effectiveness of contact investigation in comparison to passive case-detection alone and estimated the yield of co-prevalent and incident tuberculosis (TB), and latent tuberculosis infection (LTBI) among contacts of patients with TB. METHODS A systematic search was undertaken of studies published between January 1, 2011 and October 1, 2019 in the English language. The proportion of contacts diagnosed with co-prevalent TB, incident TB and/or LTBI was estimated. Evaluation of the effectiveness of contact investigation included randomised trials, while the yield of contact investigation (co-prevalent and incident TB and LTBI) was assessed in non-randomised studies. RESULTS Data were extracted from 244 studies, of which 187 studies measured the proportion of contacts diagnosed with TB disease and 135 studies measured LTBI prevalence. Individual randomised trials demonstrated that contact investigation increased TB case notification (RR 2.5 [95% CI: 2.0-3.2]), TB case detection (OR 1.34 [95% CI: 0.43-4.24]) and decreased mortality (RR 0.6 [95% CI: 0.4-0.8]) and population TB prevalence (risk ratio 0.82 [95% CI: 0.64-1.04]).The overall pooled prevalence of TB was 3.6% (95% CI: 3.3-4.0%; I2=98.9%, 181 studies). The pooled prevalence of microbiologically-confirmed TB was 3.2% (95% CI: 2.6-3.7%; I2=99.5%, 106 studies). The pooled incidence of TB was highest in the first year after exposure to index patients (2.0%, 95% CI: 1.1-3.3%; I2=96.2%, 14 studies) and substantially lower five years after exposure to index patient (0.5%, 95% CI: 0.3-0.9%; 1 study). The pooled prevalence of LTBI among contacts was 42.4% (95% CI: 38.5-46.4%; I2=99.8%, 135 studies). CONCLUSIONS AND RELEVANCE This systematic review and meta-analysis found that contact investigation was effective in high-burden settings. The higher pooled prevalence estimates of microbiologically-confirmed TB compared to previous reviews suggests newer rapid molecular diagnostics contribute to increased case detection.
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Affiliation(s)
- Kavindhran Velen
- Sydney Medical School, The University of Sydney, Sydney, Australia.,The Aurum Institute, Parktown, South Africa
| | | | - Jennifer Ho
- Woolcock Institute of Medical Research, Sydney, Australia
| | - Greg James Fox
- Sydney Medical School, The University of Sydney, Sydney, Australia.,Woolcock Institute of Medical Research, Sydney, Australia
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Shah S, Ghetiya R, Soniwala M, Chavda J. Development and Optimization of Inhalable Levofloxacin Nanoparticles for The Treatment of Tuberculosis. Curr Drug Deliv 2020; 18:779-793. [PMID: 33155907 DOI: 10.2174/1567201817999201103194626] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/08/2020] [Accepted: 09/24/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Levofloxacin has been recommended by the WHO for the treatment of pulmonary tuberculosis and inhalable delivery of levofloxacin can be advantageous over conventional delivery. OBJECTIVE This study aimed to develop and optimize inhalable levofloxacin Loaded Chitosan Nanoparticles (LCN). The objective was to achieve the mean particle size of LCN less than 300nm, sustain the drug release up to 24 h, and achieve MMAD of LCN of less than 5μm. METHODS LCN were prepared by ionic gelation of chitosan with sodium tripolyphosphate (STPP) and subsequent lyophilization. A Plackett Burman screening design, 32 full factorial design, and overlay plots were sequentially employed to optimize the formulation. The mean particle size, % entrapment efficiency, in vitro drug release, and minimum inhibitory concentration were all evaluated. RESULTS The Pareto chart from the Placket Burman screening design revealed that the concentrations of chitosan and STPP was found to be significant (p < 0.05). Further analysis by 32 full factorial design revealed that F-ratio for each model generated was found to be greater than the theoretical value (p < 0.05), confirming the significance of each model. CONCLUSION The optimized formulation showed a mean particle size of 171.5 nm, sustained the drug release up to 24 h in simulated lung fluid, and revealed MMAD of 3.18 μm, which can confirm delivery of the drug to the deep lung region. However, further in vivo studies are required to design a suitable dosage regimen and establish the fate of nanoparticles for safe and efficacious delivery of the drug.
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Affiliation(s)
- Sunny Shah
- Bhagvanlal Kapoorchand Mody Government Pharmacy College, Rajkot, India
| | - Rohit Ghetiya
- Bhagvanlal Kapoorchand Mody Government Pharmacy College, Rajkot, India
| | | | - Jayant Chavda
- Bhagvanlal Kapoorchand Mody Government Pharmacy College, Rajkot, India
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Schluger NW. Prevention of Multidrug-Resistant Tuberculosis in Close Contacts. Back to the Future? Am J Respir Crit Care Med 2020; 202:1077-1078. [PMID: 32716633 PMCID: PMC7560810 DOI: 10.1164/rccm.202006-2488ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Neil W Schluger
- Department of Medicine New York Medical College Valhalla, New York
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29
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Marais BJ, Chakaya J, Swaminathan S, Fox GJ, Ehtesham NZ, Ntoumi F, Zijenah L, Maurer M, Zumla A. Tackling long-term morbidity and mortality after successful tuberculosis treatment. THE LANCET. INFECTIOUS DISEASES 2020; 20:641-642. [PMID: 32213333 DOI: 10.1016/s1473-3099(20)30167-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 03/02/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Ben J Marais
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Jeremiah Chakaya
- Department of Medicine, Therapeutics, Dermatology and Psychiatry, Kenyatta University, Nairobi, Kenya
| | | | - Greg J Fox
- The University of Sydney Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | | | - Francine Ntoumi
- Université Marien Gouabi, Fondation Congolaise pour la Recherche Médicale, Brazzaville, Congo; Institute for Tropical Diseases, University of Tübingen, Germany
| | - Lynn Zijenah
- Department of Immunology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Markus Maurer
- Immunosurgery Unit, Champalimaud Centre for the Unknown, Lisbon, Portugal; Department of Oncology and Haematology, Krankenhaus Nordwest, Frankfurt, Germany
| | - Alimuddin Zumla
- Department of Infection, Division of Infection and Immunity, University College London, and NIHR Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
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