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Amofa-Sekyi M, Schaap A, Mureithi L, Kosloff B, Cheeba M, Kangololo B, Vermaak R, Paulsen R, Ruperez M, Floyd S, de Haas P, Fidler S, Hayes R, Ayles H, Shanaube K. Comparing patterns of recent and remote Mycobacterium tuberculosis infection determined using the QuantiFERON-TB Gold Plus assay in a high TB burden setting. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003182. [PMID: 38768253 PMCID: PMC11104639 DOI: 10.1371/journal.pgph.0003182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/11/2024] [Indexed: 05/22/2024]
Abstract
One quarter of the world's population is estimated to be infected with Mycobacterium tuberculosis. Identifying recent TB infection (TBI) offers an avenue to targeted TB preventative therapy provision, and prevention to disease progression. However, detecting recent TBI remains challenging. The QuantiFERON-TB Gold Plus assay (QFT-Plus) claims to have improved sensitivity in detecting recent TBI, by the addition of the TB2 antigen tube to the TB1 tube used in previous tests. TB2 detects CD8-mediated interferon gamma response, a potential marker of recent infection. We compared QFT-Plus TB1 and TB2 responses in individuals with recent and remote infection in high-burden settings. The Tuberculosis Reduction through Expanded Antiretroviral Treatment and TB Screening (TREATS) Project followed a cohort of adolescents and young people (AYP) aged 15-24 years in Zambia and South Africa to determine TBI incidence measured by QFT-Plus over 24 months. We categorised individuals with QTF-Plus positive result into recent and remote infection. We compared their TB1 and TB2 responses and the antigen tube differential [TB2-TB1], an indicator of CD8-activity, using logistic regression. At baseline, 3876 AYP, 1852/3876 (47.8%) were QFT-Plus positive whilst 2024/3876 (52.2%) QFT-Plus negative. Of the QFT-Plus baseline positives, 1069/1852 (57.7%) tested positive at both 12 and 24 months-remote infection. Of the QFT-Plus baseline negatives, 274/2024(13.3%) converted within a 12-month period- recent infection. TB1 and TB2 responses were higher in remote than recent infection. In recent infection, TB2 responses were greater than TB1 responses. The mean differential was 0.01 IU/ml in recent and -0.22 IU/ml in remote infection, (p = 0.145). The quantitative QFT-Plus results did not appear to reflect a marked distinction between recent and remote infection. Further analysis of the responses of infected individuals who developed disease is required to determine whether any signal in QFT-Plus results may predict progression to disease.
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Affiliation(s)
- Modupe Amofa-Sekyi
- Zambart, Lusaka, Zambia
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Ab Schaap
- Zambart, Lusaka, Zambia
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Linda Mureithi
- Health Systems Trust, Cape Town, South Africa
- School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Barry Kosloff
- Zambart, Lusaka, Zambia
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | | | | | - Maria Ruperez
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sian Floyd
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Petra de Haas
- KNCV Tuberculosis Foundation, The Hague, Netherlands
| | - Sarah Fidler
- HIV Trials Unit, Imperial College London, London, United Kingdom
| | - Richard Hayes
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Helen Ayles
- Zambart, Lusaka, Zambia
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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Sung J, Nantale M, Nalutaaya A, Biché P, Mukiibi J, Kamoga CE, Akampurira J, Kayondo F, Kiyonga R, Mukiibi M, Nakasolya O, McGeehan M, Dowdy DW, Katamba A, Kendall EA. Evidence for Tuberculosis in Individuals With Xpert Ultra "Trace" Sputum During Screening of High-Burden Communities. Clin Infect Dis 2024; 78:723-729. [PMID: 37787077 PMCID: PMC10954329 DOI: 10.1093/cid/ciad595] [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: 06/22/2023] [Revised: 09/12/2023] [Accepted: 09/27/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND "Trace" results on Xpert MTB/RIF Ultra ("Ultra"; Cepheid) -a molecular diagnostic test for tuberculosis (TB)-are often interpreted as an indication for TB treatment, but may also represent detection of nonviable bacilli or analytical error. In community-screening settings where individual TB risk is low, there is limited guidance on how to interpret Ultra-trace results. METHODS We conducted systematic Ultra TB screening of adults and adolescents (≥15 years) in Kampala, Uganda, through door-to-door and event-based sputum collection. We enrolled individuals with trace-positive sputum for detailed clinical, radiographic, and microbiological (including 2 sputum cultures, repeat Ultra, and for people with HIV, urine lipoarabinomannan) evaluation, and compared those findings with similar evaluations in controls with Ultra-negative and Ultra-positive (non-trace) sputum. RESULTS Of 21 957 people screened with Ultra, 211 (1.0%) tested positive, including 96 (46% of positives) with trace results. Of 92 people enrolled with trace-positive sputum; 12% (11/92) were HIV-positive and 14% (13/92) had prior TB. The prevalence of TB among participants with trace-positive sputum results was 14% (13/92) by culture, 24% (22/92) using broader microbiological criteria, and 26% (24/92) after accounting for clinical diagnosis. The prevalence of cough and of abnormal chest computed tomography (CT) findings were 32% and 26%, respectively, if Ultra-negative; 34% and 54% if trace-positive/non-microbiologically confirmed; 72% and 95% if trace-positive/microbiologically confirmed; and 71% and 93% if Ultra-positive (more than trace). CONCLUSIONS Most individuals with trace-positive sputum in Ugandan communities did not have microbiologically confirmed TB but had more symptoms and chest CT abnormalities than people with Ultra-negative sputum.
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Affiliation(s)
- Joowhan Sung
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Mariam Nantale
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Annet Nalutaaya
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Patrick Biché
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - James Mukiibi
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Caleb E Kamoga
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Joab Akampurira
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Francis Kayondo
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Rogers Kiyonga
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Michael Mukiibi
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Olga Nakasolya
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Molly McGeehan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - David W Dowdy
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
- Department of Internal Medicine Clinical Epidemiology Unit, Makerere University College of Health Science, Kampala, Uganda
| | - Emily A Kendall
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
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Vanobberghen F, Keter AK, Jacobs BK, Glass TR, Lynen L, Law I, Murphy K, van Ginneken B, Ayakaka I, van Heerden A, Maama L, Reither K. Computer-aided detection thresholds for digital chest radiography interpretation in tuberculosis diagnostic algorithms. ERJ Open Res 2024; 10:00508-2023. [PMID: 38196890 PMCID: PMC10772898 DOI: 10.1183/23120541.00508-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/25/2023] [Indexed: 01/11/2024] Open
Abstract
Objectives Use of computer-aided detection (CAD) software is recommended to improve tuberculosis screening and triage, but threshold determination is challenging if reference testing has not been performed in all individuals. We aimed to determine such thresholds through secondary analysis of the 2019 Lesotho national tuberculosis prevalence survey. Methods Symptom screening and chest radiographs were performed in participants aged ≥15 years; those symptomatic or with abnormal chest radiographs provided samples for Xpert MTB/RIF and culture testing. Chest radiographs were processed using CAD4TB version 7. We used six methodological approaches to deal with participants who did not have bacteriological test results to estimate pulmonary tuberculosis prevalence and assess diagnostic accuracy. Results Among 17 070 participants, 5214 (31%) had their tuberculosis status determined; 142 had tuberculosis. Prevalence estimates varied between methodological approaches (0.83-2.72%). Using multiple imputation to estimate tuberculosis status for those eligible but not tested, and assuming those not eligible for testing were negative, a CAD4TBv7 threshold of 13 had a sensitivity of 89.7% (95% CI 84.6-94.8) and a specificity of 74.2% (73.6-74.9), close to World Health Organization (WHO) target product profile criteria. Assuming all those not tested were negative produced similar results. Conclusions This is the first study to evaluate CAD4TB in a community screening context employing a range of approaches to account for unknown tuberculosis status. The assumption that those not tested are negative - regardless of testing eligibility status - was robust. As threshold determination must be context specific, our analytically straightforward approach should be adopted to leverage prevalence surveys for CAD threshold determination in other settings with a comparable proportion of eligible but not tested participants.
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Affiliation(s)
- Fiona Vanobberghen
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Alfred Kipyegon Keter
- Institute of Tropical Medicine, Antwerp, Belgium
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
- Ghent University, Ghent, Belgium
| | | | - Tracy R. Glass
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Irwin Law
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Keelin Murphy
- Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Irene Ayakaka
- SolidarMed, Partnerships for Health, Maseru, Lesotho
| | - Alastair van Heerden
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
- SAMRC/Wits Developmental Pathways for Health Research Unit (DPHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Llang Maama
- Disease Control Directorate, National Tuberculosis Program, Ministry of Health, Maseru, Lesotho
| | - Klaus Reither
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
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Klinkenberg E, Floyd S, Shanaube K, Mureithi L, Gachie T, de Haas P, Kosloff B, Dodd PJ, Ruperez M, Wapamesa C, Burnett JM, Kalisvaart N, Kasese N, Vermaak R, Schaap A, Fidler S, Hayes R, Ayles H. Tuberculosis prevalence after 4 years of population-wide systematic TB symptom screening and universal testing and treatment for HIV in the HPTN 071 (PopART) community-randomised trial in Zambia and South Africa: A cross-sectional survey (TREATS). PLoS Med 2023; 20:e1004278. [PMID: 37682971 PMCID: PMC10490889 DOI: 10.1371/journal.pmed.1004278] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 07/27/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) prevalence remains persistently high in many settings, with new or expanded interventions required to achieve substantial reductions. The HIV Prevention Trials Network (HPTN) 071 (PopART) community-randomised trial randomised 14 communities to receive the "PopART" intervention during 2014 to 2017 (7 arm A and 7 arm B communities) and 7 communities to receive standard-of-care (arm C). The intervention was delivered door-to-door by community HIV care providers (CHiPs) and included universal HIV testing, facilitated linkage to HIV care at government health clinics, and systematic TB symptom screening. The Tuberculosis Reduction through Expanded Anti-retroviral Treatment and Screening (TREATS) study aimed to measure the impact of delivering the PopART intervention on TB outcomes, in communities with high HIV and TB prevalence. METHODS AND FINDINGS The study population of the HPTN 071 (PopART) trial included individuals aged ≥15 years living in 21 urban and peri-urban communities in Zambia and South Africa, with a total population of approximately 1 million and an adult HIV prevalence of around 15% at the time of the trial. Two sputum samples for TB testing were provided to CHiPs by individuals who reported ≥1 TB suggestive symptom (a cough for ≥2 weeks, unintentional weight loss ≥1.5 kg in the last month, or current night sweats) or that a household member was currently on TB treatment. Antiretroviral therapy (ART) was offered universally at clinics in arm A and according to local guidelines in arms B and C. The TREATS study was conducted in the same 21 communities as the HPTN 071 (PopART) trial between 2017 and 2022, and TB prevalence was a co-primary endpoint of the TREATS study. The primary comparison was between the PopART intervention (arms A and B combined) and the standard-of-care (arm C). During 2019 to 2021, a TB prevalence survey was conducted among randomly selected individuals aged ≥15 years (approximately 1,750 per community in arms A and B, approximately 3,500 in arm C). Participants were screened on TB symptoms and chest X-ray, with diagnostic testing using Xpert-Ultra followed by culture for individuals who screened positive. Sputum eligibility was determined by the presence of a cough for ≥2 weeks, or ≥2 of 5 "TB suggestive" symptoms (cough, weight loss for ≥4 weeks, night sweats, chest pain, and fever for ≥2 weeks), or chest X-ray CAD4TBv5 score ≥50, or no available X-ray results. TB prevalence was compared between trial arms using standard methods for cluster-randomised trials, with adjustment for age, sex, and HIV status, and multiple imputation was used for missing data on prevalent TB. Among 83,092 individuals who were eligible for the survey, 49,556 (59.6%) participated, 8,083 (16.3%) screened positive, 90.8% (7,336/8,083) provided 2 sputum samples for Xpert-Ultra testing, and 308 (4.2%) required culture confirmation. Overall, estimated TB prevalence was 0.92% (457/49,556). The geometric means of 7 community-level prevalence estimates were 0.91%, 0.70%, and 0.69% in arms A, B, and C, respectively, with no evidence of a difference comparing arms A and B combined with arm C (adjusted prevalence ratio 1.14, 95% confidence interval, CI [0.67, 1.95], p = 0.60). TB prevalence was higher among people living with HIV than HIV-negative individuals, with an age-sex-community adjusted odds ratio of 2.29 [95% CI 1.54, 3.41] in Zambian communities and 1.61 [95% CI 1.13, 2.30] in South African communities. The primary limitations are that the study was powered to detect only large reductions in TB prevalence in the intervention arm compared with standard-of-care, and the between-community variation in TB prevalence was larger than anticipated. CONCLUSIONS There was no evidence that the PopART intervention reduced TB prevalence. Systematic screening for TB that is based on symptom screening alone may not be sufficient to achieve a large reduction in TB prevalence over a period of several years. Including chest X-ray screening alongside TB symptom screening could substantially increase the sensitivity of systematic screening for TB. TRIAL REGISTRATION The TREATS study was registered with ClinicalTrials.gov Identifier: NCT03739736 on November 14, 2018. The HPTN 071 (PopART) trial was registered at ClinicalTrials.gov under number NCT01900977 on July 17, 2013.
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Affiliation(s)
- Eveline Klinkenberg
- London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom
- Department of Global Health and Amsterdam Institute for Global Health and Development, Amsterdam University Medical Center, Amsterdam, the Netherlands
- KNCV Tuberculosis Foundation, Hague, the Netherlands
| | - Sian Floyd
- London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom
| | - Kwame Shanaube
- Zambart, University of Zambia School of Public Health, Lusaka, Zambia
| | | | - Thomas Gachie
- London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom
- Zambart, University of Zambia School of Public Health, Lusaka, Zambia
| | - Petra de Haas
- KNCV Tuberculosis Foundation, Hague, the Netherlands
| | - Barry Kosloff
- London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom
- Zambart, University of Zambia School of Public Health, Lusaka, Zambia
| | - Peter J. Dodd
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Maria Ruperez
- London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom
| | - Chali Wapamesa
- Zambart, University of Zambia School of Public Health, Lusaka, Zambia
| | | | | | - Nkatya Kasese
- Zambart, University of Zambia School of Public Health, Lusaka, Zambia
| | | | - Albertus Schaap
- London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom
- Zambart, University of Zambia School of Public Health, Lusaka, Zambia
| | - Sarah Fidler
- HIV Clinical Trials Unit, Imperial College London, London, United Kingdom
| | - Richard Hayes
- London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom
| | - Helen Ayles
- London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom
- Zambart, University of Zambia School of Public Health, Lusaka, Zambia
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He S, Wei J, Feng J, Liu D, Wang N, Chen L, Xiong Y. The application of metagenomic next-generation sequencing in pathogen diagnosis: a bibliometric analysis based on Web of Science. Front Cell Infect Microbiol 2023; 13:1112229. [PMID: 37600953 PMCID: PMC10434771 DOI: 10.3389/fcimb.2023.1112229] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 07/18/2023] [Indexed: 08/22/2023] Open
Abstract
Background Infectious disease is a large burden on public health globally. Metagenomic next-generation sequencing (mNGS) has become popular as a new tool for pathogen diagnosis with numerous advantages compared to conventional methods. Recently, research on mNGS increases yearly. However, no bibliometric analysis has systematically presented the full spectrum of this research field. Therefore, we reviewed all the publications associated with this topic and performed this study to analyze the comprehensive status and future hotspots of mNGS for infectious disease diagnosis. Methods The literature was searched in the Web of Science Core Collection and screened without year or language restrictions, and the characteristics of the studies were also identified. The outcomes included publication years, study types, journals, countries, authorship, institutions, frontiers, and hotspots with trends. Statistical analysis and visualization were conducted using VOSviewer (version 1.6.16) and CiteSpace (version 6.1. R3). Results In total, 325 studies were included in the analysis after screening. Studies were published between 2009 and 2022 with a significantly increasing number from 1 to 118. Most of the studies were original articles and case reports. Frontiers in Cellular and Infection Microbiology and Clinical Infectious Disease were the most commonly cited and co-cited journals. Institutions and researchers from China contributed the most to this field, followed by those from the USA. The hotspots and frontiers of these studies are pneumonia, tuberculosis, and central nervous system infections. Conclusion This study determined that mNGS is a hot topic in the diagnosis of infectious diseases with development trends and provides insights into researchers, institutions, hotspots and frontiers in mNGS, which can offer references to related researchers and future research.
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Affiliation(s)
- Sike He
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Jingwen Wei
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Jiaming Feng
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Dan Liu
- Department of Periodical Press, West China Hospital, Sichuan University, Chengdu, China
| | - Neng Wang
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, China
| | - Liyu Chen
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, China
| | - Ying Xiong
- Department of Periodical Press, West China Hospital, Sichuan University, Chengdu, China
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Ruperez M, Shanaube K, Mureithi L, Wapamesa C, Burnett MJ, Kosloff B, de Haas P, Hayes R, Fidler S, Gachie T, Schaap A, Floyd S, Klinkenberg E, Ayles H. Use of point-of-care C-reactive protein testing for screening of tuberculosis in the community in high-burden settings: a prospective, cross-sectional study in Zambia and South Africa. Lancet Glob Health 2023; 11:e704-e714. [PMID: 37061309 DOI: 10.1016/s2214-109x(23)00113-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 02/07/2023] [Accepted: 02/13/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND WHO recommends community-wide, systematic tuberculosis screening in high-prevalence settings. C-reactive protein has been proposed as a tuberculosis screening tool for people living with HIV. We aimed to assess the performance of a point-of-care C-reactive protein test for tuberculosis screening in the community in two countries with a high tuberculosis burden. METHODS We conducted a prospective, cross-sectional study in four communities in Zambia and South Africa, nested in a tuberculosis prevalence survey. We included adults (aged ≥15 years) who were sputum-eligible (tuberculosis-suggestive symptoms or computer-aided-detection score ≥40 on chest x-ray) and whose sputum was tested with Xpert Ultra and liquid culture. A 5% random sample of individuals who were non-sputum-eligible was also included. We calculated sensitivity and specificity of point-of-care C-reactive protein testing, alone and combined with symptom screening, to detect tuberculosis in participants who were sputum-eligible, compared with a microbiological reference standard (positive result in Xpert Ultra, culture, or both). FINDINGS Between Feb 19 and Aug 11, 2019, 9588 participants were enrolled in the tuberculosis prevalence study, 1588 of whom had C-reactive protein testing and received results (875 [55·1%] were women and girls, 713 [44·9%] were men and boys, 1317 [82·9%] were sputum-eligible, and 271 [17·1%] were non-sputum-eligible). Among participants who were sputum-eligible, we identified 76 individuals with tuberculosis, of whom 25 were living with HIV. Sensitivity of point-of-care C-reactive protein testing with a cutoff point of 5 mg/L or more was 50·0% (38/76, 95% CI 38·3-61·7) and specificity was 72·3% (890/1231, 69·7-74·8). Point-of-care C-reactive protein combined in parallel with symptom screening had higher sensitivity than symptom screening alone (60·5% [46/76, 95% CI 48·6-71·6] vs 34·2% [26/76, 23·7-46·0]). Specificity of point-of-care C-reactive protein combined in parallel with symptom screening was 51·7% (636/1231, 95% CI 48·8-54·5) versus 70·5% (868/1231, 67·9-73·0) with symptom screening alone. Similarly, in people living with HIV, sensitivity of point-of-care C-reactive protein combined with symptom screening was 72·0% (18/25, 95% CI 50·6-87·9) and that of symptom screening alone was 36·0% (9/25, 18·0-57·5). Specificity of point-of-care C-reactive protein testing combined in parallel with symptom screening in people living with HIV was 47·0% (118/251, 95% CI 40·7-53·4) versus 72·1% (181/251, 66·1-77·6) with symptom screening alone. INTERPRETATION Point-of-care C-reactive protein testing alone does not meet the 90% sensitivity stipulated by WHO's target product profile for desirable characteristics for screening tests for detecting tuberculosis. However, combined with symptom screening, it might improve identification of individuals with tuberculosis in communities with high prevalence, and might be particularly useful where other recommended tools, such as chest x-ray, might not be readily available. FUNDING European and Developing Countries Clinical Trials Partnership.
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Affiliation(s)
- Maria Ruperez
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK.
| | | | | | | | | | - Barry Kosloff
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK; Zambart, Lusaka, Zambia
| | - Petra de Haas
- KNCV Tuberculosis Foundation, The Hague, Netherlands
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Sarah Fidler
- Faculty of Medicine, Department of Infectious Disease, Imperial College London, London, UK
| | - Thomas Gachie
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK; Zambart, Lusaka, Zambia
| | - Albertus Schaap
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK; Zambart, Lusaka, Zambia
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Eveline Klinkenberg
- KNCV Tuberculosis Foundation, The Hague, Netherlands; Department of Global Health, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Helen Ayles
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK; Zambart, Lusaka, Zambia
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Keter AK, Lynen L, Van Heerden A, Wong E, Reither K, Goetghebeur E, Jacobs BKM. Evaluation of tuberculosis diagnostic test accuracy using Bayesian latent class analysis in the presence of conditional dependence between the diagnostic tests used in a community-based tuberculosis screening study. PLoS One 2023; 18:e0282417. [PMID: 36862729 PMCID: PMC9980779 DOI: 10.1371/journal.pone.0282417] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 01/15/2023] [Indexed: 03/03/2023] Open
Abstract
Diagnostic accuracy studies in pulmonary tuberculosis (PTB) are complicated by the lack of a perfect reference standard. This limitation can be handled using latent class analysis (LCA), assuming independence between diagnostic test results conditional on the true unobserved PTB status. Test results could remain dependent, however, e.g. with diagnostic tests based on a similar biological basis. If ignored, this gives misleading inferences. Our secondary analysis of data collected during the first year (May 2018 -May 2019) of a community-based multi-morbidity screening program conducted in the rural uMkhanyakude district of KwaZulu Natal, South Africa, used Bayesian LCA. Residents of the catchment area, aged ≥15 years and eligible for microbiological testing, were analyzed. Probit regression methods for dependent binary data sequentially regressed each binary test outcome on other observed test results, measured covariates and the true unobserved PTB status. Unknown model parameters were assigned Gaussian priors to evaluate overall PTB prevalence and diagnostic accuracy of 6 tests used to screen for PTB: any TB symptom, radiologist conclusion, Computer Aided Detection for TB version 5 (CAD4TBv5≥53), CAD4TBv6≥53, Xpert Ultra (excluding trace) and culture. Before the application of our proposed model, we evaluated its performance using a previously published childhood pulmonary TB (CPTB) dataset. Standard LCA assuming conditional independence yielded an unrealistic prevalence estimate of 18.6% which was not resolved by accounting for conditional dependence among the true PTB cases only. Allowing, also, for conditional dependence among the true non-PTB cases produced a 1.1% plausible prevalence. After incorporating age, sex, and HIV status in the analysis, we obtained 0.9% (95% CrI: 0.6, 1.3) overall prevalence. Males had higher PTB prevalence compared to females (1.2% vs. 0.8%). Similarly, HIV+ had a higher PTB prevalence compared to HIV- (1.3% vs. 0.8%). The overall sensitivity for Xpert Ultra (excluding trace) and culture were 62.2% (95% CrI: 48.7, 74.4) and 75.9% (95% CrI: 61.9, 89.2), respectively. Any chest X-ray abnormality, CAD4TBv5≥53 and CAD4TBv6≥53 had similar overall sensitivity. Up to 73.3% (95% CrI: 61.4, 83.4) of all true PTB cases did not report TB symptoms. Our flexible modelling approach yields plausible, easy-to-interpret estimates of sensitivity, specificity and PTB prevalence under more realistic assumptions. Failure to fully account for diagnostic test dependence can yield misleading inferences.
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Affiliation(s)
- Alfred Kipyegon Keter
- Department of Clinical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
- Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Ghent, Belgium
- * E-mail:
| | - Lutgarde Lynen
- Department of Clinical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
| | - Alastair Van Heerden
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
- MRC/WITS Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Science, University of the Witwatersrand, Johannesburg, South Africa
| | - Emily Wong
- Africa Health Research Institute, Durban, South Africa
- Division of Infectious Diseases, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Klaus Reither
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Els Goetghebeur
- Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Ghent, Belgium
| | - Bart K. M. Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
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Wang Y, Tan J, Lei L, Yuan Y, Li W, Zhao Y, Wang Y, Niu X, Li Z, Wei L, Han Y, Cheng M, Guo X, Han X, Wang W. The value of Xpert MTB/RIF assay of urine samples in the early diagnosis of smear-negative urinary tuberculosis. Eur J Med Res 2022; 27:300. [PMID: 36539899 PMCID: PMC9764486 DOI: 10.1186/s40001-022-00947-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND According to reports, between 30 and 40 percent of extrapulmonary tuberculosis (EPTB) cases are caused by urinary tract tuberculosis (UTB). It is critical to identify UTB quickly since it frequently precedes delayed medical attention, which can have detrimental effects. This study examined the use of Xpert MTB/RIF, a PCR test that can detect MTB as well as resistance to an important drug, rifampicin (RIF), in UTB particularly, for the early identification of UTB. METHODS 180 participants with clinically presumptive UTB whose urine samples were chosen for urine sediment smear, culture, Xpert MTB/RIF, and TB-DNA testing at Henan Chest Hospital between January 2019 and July 2022. Evaluation of test performance using Composite Reference Standards (CRSs). We studied and compared the positivity rate for various tests using the t-test. The effectiveness of smear, culture, Xpert MTB/RIF, and TB-DNA was assessed using McNemar test. RESULTS In this subject, a total of 108 participants were diagnosed with UTB, and the positivity rate was 67.1%. Compared with CRS, the positivity rate of Xpert MTB/RIF, smear, culture, and TB-DNA was 29.69% (19/64, P < 0.001), 7.56% (9/119, P < 0.1), 12.12% (4/33, P > 0.05), and 18.75% (6/32, P < 0.1), respectively. The sensitivity of Xpert MTB/RIF assay was significantly better than that of smear and culture tests (78.9% vs. 77.8%, P < 0.05; 78.9% vs. 75%, P < 0.05). Under CRS, the positivity rate for Xpert, culture, and TB-DNA was 31.6% (6/19, P < 0.1), 6.2% (1/16, P > 0.05), and 26.7% (4/15, P > 0.05) for TB-DNA, respectively, compared to smear negative. Xpert MTB/RIF assay specificity was significant for culture and TB-DNA (53.6% vs. 25%, P < 0.01; 53.6% vs. 38.9%, P < 0.05), and Xpert MTB/RIF assay FPV was significant for culture and TB-DNA (53.6% vs. 0%, P < 0.001; 53.6% vs. 0%, P < 0.001). CONCLUSION Xpert MTB/RIF outperforms smear, cultures, and TB-DNA in detecting UTB, plus Xpert MTB/RIF is better suited for early diagnosis in smear-negative UTB.
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Affiliation(s)
- Yachun Wang
- grid.207374.50000 0001 2189 3846Medical Laboratory, Henan Provincial Chest Hospital, Zhengzhou University, Zhengzhou, 450003 China ,Henan Provincial Key Laboratory of Tuberculosis Diagnostic Medicine, Zhengzhou, 450003 China ,Henan Provincial Infectious Diseases (Tuberculosis) Clinical Medical Research Center, Zhengzhou, 450003 China
| | - Jiao Tan
- grid.207374.50000 0001 2189 3846Medical Laboratory, Henan Provincial Chest Hospital, Zhengzhou University, Zhengzhou, 450003 China ,Henan Provincial Key Laboratory of Tuberculosis Diagnostic Medicine, Zhengzhou, 450003 China ,Henan Provincial Infectious Diseases (Tuberculosis) Clinical Medical Research Center, Zhengzhou, 450003 China
| | - Lei Lei
- Henan Provincial Key Laboratory of Tuberculosis Diagnostic Medicine, Zhengzhou, 450003 China ,Henan Provincial Infectious Diseases (Tuberculosis) Clinical Medical Research Center, Zhengzhou, 450003 China ,grid.459614.bDepartment of Family Medicine, Henan Provincial Chest Hospital, Zhengzhou, 450003 China
| | - Yingying Yuan
- grid.207374.50000 0001 2189 3846Medical Laboratory, Henan Provincial Chest Hospital, Zhengzhou University, Zhengzhou, 450003 China ,Henan Provincial Key Laboratory of Tuberculosis Diagnostic Medicine, Zhengzhou, 450003 China ,Henan Provincial Infectious Diseases (Tuberculosis) Clinical Medical Research Center, Zhengzhou, 450003 China
| | - Wenbo Li
- grid.207374.50000 0001 2189 3846Medical Laboratory, Henan Provincial Chest Hospital, Zhengzhou University, Zhengzhou, 450003 China ,Henan Provincial Key Laboratory of Tuberculosis Diagnostic Medicine, Zhengzhou, 450003 China ,Henan Provincial Infectious Diseases (Tuberculosis) Clinical Medical Research Center, Zhengzhou, 450003 China
| | - Yue Zhao
- grid.207374.50000 0001 2189 3846Medical Laboratory, Henan Provincial Chest Hospital, Zhengzhou University, Zhengzhou, 450003 China ,Henan Provincial Key Laboratory of Tuberculosis Diagnostic Medicine, Zhengzhou, 450003 China ,Henan Provincial Infectious Diseases (Tuberculosis) Clinical Medical Research Center, Zhengzhou, 450003 China
| | - Yali Wang
- grid.207374.50000 0001 2189 3846Medical Laboratory, Henan Provincial Chest Hospital, Zhengzhou University, Zhengzhou, 450003 China ,Henan Provincial Key Laboratory of Tuberculosis Diagnostic Medicine, Zhengzhou, 450003 China ,Henan Provincial Infectious Diseases (Tuberculosis) Clinical Medical Research Center, Zhengzhou, 450003 China
| | - Xiaodong Niu
- grid.207374.50000 0001 2189 3846Medical Laboratory, Henan Provincial Chest Hospital, Zhengzhou University, Zhengzhou, 450003 China ,Henan Provincial Key Laboratory of Tuberculosis Diagnostic Medicine, Zhengzhou, 450003 China ,Henan Provincial Infectious Diseases (Tuberculosis) Clinical Medical Research Center, Zhengzhou, 450003 China
| | - Zheng Li
- grid.207374.50000 0001 2189 3846Medical Laboratory, Henan Provincial Chest Hospital, Zhengzhou University, Zhengzhou, 450003 China ,Henan Provincial Key Laboratory of Tuberculosis Diagnostic Medicine, Zhengzhou, 450003 China ,Henan Provincial Infectious Diseases (Tuberculosis) Clinical Medical Research Center, Zhengzhou, 450003 China
| | - Lukuan Wei
- grid.207374.50000 0001 2189 3846Medical Laboratory, Henan Provincial Chest Hospital, Zhengzhou University, Zhengzhou, 450003 China ,Henan Provincial Key Laboratory of Tuberculosis Diagnostic Medicine, Zhengzhou, 450003 China ,Henan Provincial Infectious Diseases (Tuberculosis) Clinical Medical Research Center, Zhengzhou, 450003 China
| | - Yungang Han
- grid.207374.50000 0001 2189 3846Medical Laboratory, Henan Provincial Chest Hospital, Zhengzhou University, Zhengzhou, 450003 China ,Henan Provincial Key Laboratory of Tuberculosis Diagnostic Medicine, Zhengzhou, 450003 China ,Henan Provincial Infectious Diseases (Tuberculosis) Clinical Medical Research Center, Zhengzhou, 450003 China
| | - Meijing Cheng
- grid.207374.50000 0001 2189 3846Medical Laboratory, Henan Provincial Chest Hospital, Zhengzhou University, Zhengzhou, 450003 China ,Henan Provincial Key Laboratory of Tuberculosis Diagnostic Medicine, Zhengzhou, 450003 China ,Henan Provincial Infectious Diseases (Tuberculosis) Clinical Medical Research Center, Zhengzhou, 450003 China
| | - Xu Guo
- grid.207374.50000 0001 2189 3846Medical Laboratory, Henan Provincial Chest Hospital, Zhengzhou University, Zhengzhou, 450003 China ,Henan Provincial Key Laboratory of Tuberculosis Diagnostic Medicine, Zhengzhou, 450003 China ,Henan Provincial Infectious Diseases (Tuberculosis) Clinical Medical Research Center, Zhengzhou, 450003 China
| | - Xue Han
- grid.207374.50000 0001 2189 3846Medical Laboratory, Henan Provincial Chest Hospital, Zhengzhou University, Zhengzhou, 450003 China ,Henan Provincial Key Laboratory of Tuberculosis Diagnostic Medicine, Zhengzhou, 450003 China ,Henan Provincial Infectious Diseases (Tuberculosis) Clinical Medical Research Center, Zhengzhou, 450003 China
| | - Wei Wang
- grid.207374.50000 0001 2189 3846Medical Laboratory, Henan Provincial Chest Hospital, Zhengzhou University, Zhengzhou, 450003 China ,Henan Provincial Key Laboratory of Tuberculosis Diagnostic Medicine, Zhengzhou, 450003 China ,Henan Provincial Infectious Diseases (Tuberculosis) Clinical Medical Research Center, Zhengzhou, 450003 China
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9
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Tuberculosis control at a South African correctional centre: Diagnosis, treatment and strain characterisation. PLoS One 2022; 17:e0277459. [DOI: 10.1371/journal.pone.0277459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 10/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background
Correctional centres provide ideal conditions for tuberculosis (TB) transmission and disease progression. Despite the high TB incidence and incarceration rate in South Africa, data from South African correctional centres are scarce. Thus, the study evaluated TB diagnosis, treatment initiation and completion, and identified prevalent Mycobacterium tuberculosis strains among detainees entering a South African correctional centre.
Methods
This study was a prospective observational study that enrolled participants between February and September 2017 from a correctional centre located in the Western Cape, South Africa. All adult male detainees who tested positive for TB during admission screening were eligible to participate in the study. Sputum samples from enrolled participants underwent smear microscopy and culture. Strain typing was performed on culture-positive samples. The time between specimen collection and diagnosis, the time between diagnosis and treatment initiation, and the proportion of detainees completing TB treatment at the correctional centre were calculated.
Results
During the study period, 130 TB cases were detected through routine admission screening (126 male, 2 female, 2 juvenile). Out of the 126 eligible male detainees, 102 were enrolled in the study (81%, 102/126). All TB cases were detected within 30 hrs of admission screening. The majority (78%, 80/102) of participants started treatment within 48 hrs of TB diagnosis. However, only 8% (9/102) of participants completed treatment at the correction centre. Sputa from 90 of the 102 participants were available for smear and culture. There was a high smear positivity, with 49% (44/90) of isolates being smear positive. The Beijing family was the most frequent lineage (55.2%) in the study.
Conclusion
The strengths of the current TB control efforts at the correctional centre include rapid detection of cases through admission screening and prompt treatment initiation. However, a high number of detainees exiting before treatment completion highlights the need to strengthen links between correctional TB services and community TB services to ensure detainees complete TB treatment after release and prevent TB transmission.
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