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Zhou Y, Wang F, Huang L, Liu K, Zhang Y, Luo D, Ling Y, Li Y, Wang F, Chen B. Factors associated with tuberculosis care-seeking and diagnostic delays among childhood pulmonary tuberculosis in Zhejiang Province, China: a 10-year retrospective study. Sci Rep 2024; 14:17086. [PMID: 39048697 PMCID: PMC11269686 DOI: 10.1038/s41598-024-68173-5] [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: 05/27/2024] [Accepted: 07/22/2024] [Indexed: 07/27/2024] Open
Abstract
We conducted a retrospective study to investigate risk factors for tuberculosis care-seeking delay and diagnostic delays among pediatric pulmonary tuberculosis cases in Zhejiang Province from 2013 to 2022. Among 1274 cases, 49.61% experienced tuberculosis care-seeking delays (> 14 days from symptom onset to first hospital visit) and 14.91% faced diagnostic delays (> 14 days from initial consultation to diagnosis). The proportion of care-seeking delays ranged from 37.42 to 64.89%, while diagnostic delay fluctuated from 6.11 to 21.02%. Urban residence (OR = 0.78, 95% CI 0.62-0.98, P = 0.030), first visiting a municipal-level hospital (OR = 0.57, 95% CI 0.45-0.72, P < 0.001), and diagnostic method (OR = 0.66, 95%CI 0.52-0.84, P < 0.001) were associated with tuberculosis care-seeking delay, whereas first visiting a municipal-level hospital (OR = 2.05, 95% CI 1.49-2.80, P < 0.001) was linked to diagnostic delay. Further analysis using a 28-day cutoff point revealed that children aged 0-4 years, those from migrant populations, laboratory-confirmed patients, and those who first visited a county-level hospital were more likely to experience delays in seeking tuberculosis care. Thus, society should pay more attention to the health of rural, migrant, and 0-4-year-old children, as they are at higher risk of experiencing tuberculosis care-seeking delays.
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Affiliation(s)
- Yiqing Zhou
- School of Public Health, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Fengying Wang
- Department of Tuberculosis and AIDS Control and Prevention, Jinhua Municipal Center for Disease Control and Prevention, Jinhua, Zhejiang, China
| | - Lisu Huang
- Department of Infectious Diseases, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Kui Liu
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang, China
| | - Yu Zhang
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang, China
| | - Dan Luo
- School of Public Health, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yuxiao Ling
- School of Public Health, Health Science Center, Ningbo University, Ningbo, Zhejiang, China
| | - Yang Li
- School of Public Health, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Fei Wang
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang, China.
| | - Bin Chen
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang, China.
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Kakinda M, Olum R, Baluku JB, Bongomin F. Diagnostic accuracy of clinical diagnostic scoring systems for childhood tuberculosis: a systematic review and meta-analysis protocol. BMJ Open 2023; 13:e069448. [PMID: 37085315 PMCID: PMC10124241 DOI: 10.1136/bmjopen-2022-069448] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
Abstract
INTRODUCTION Diagnosis of childhood tuberculosis (TB) poses several challenges. Therefore, clinical signs and symptoms, radiological studies, laboratory examinations, point-based scoring systems or diagnostic algorithms have been developed to improve diagnostic yields in this population. However, there are limited data on the diagnostic test accuracy of paediatric TB scoring systems. Therefore, this systematic review and meta-analysis aims to synthesise the available evidence on the diagnostic accuracy of childhood TB diagnostic scoring systems. METHODS AND ANALYSIS This protocol describes a systematic review, developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses of Diagnostic Test Accuracy. We will conduct a comprehensive literature search for relevant articles in the following databases: PubMed, CINAHL, Embase, Scopus and Cochrane Databases. The eligibility criteria for studies will be formulated based on the Participants (Population), Index Test, Comparator Test and Target Condition criteria for the review question. The index test will be defined as any attempt to diagnose childhood TB using either a scoring system or a diagnostic algorithm, whereas a composite reference standard will be used as a reference standard. This will include any attempt to confirm diagnosis of TB. Where bacteriological confirmation is not obtained and there are at least two of the following features: chest radiograph consistent with TB, immunological evidence of Mycobacterium tuberculosis infection and/or positive response to TB treatment will also be considered. The QUADAS-2 Tool will be used to assess the quality of the studies. The diagnostic accuracy measures (ie, sensitivity, specificity, negative predictive and positive predictive values) will be pooled with the random-effects or fixed-effects models, as appropriate. All statistical analyses will be performed using the Review Manager V.5.4. ETHICS AND DISSEMINATION This research is exempt from ethics approval given that this is a protocol for a systematic review, which uses published data. The findings from this review will be disseminated through peer-reviewed publications and scientific conferences. PROSPERO REGISTRATION NUMBER CRD42022367049.
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Affiliation(s)
- Michael Kakinda
- Clinical Directorate, Joint Clinical Research Center, Wakiso, Uganda
- Lifebox Foundation, New York, New York, USA
| | - Ronald Olum
- Department of Medicine, St Francis Hospital Nsambya, Kampala, Uganda
| | - Joseph Baruch Baluku
- Division of Pulmonology, Kiruddu National Referral Hospital, Kampala, Uganda
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Felix Bongomin
- Department of Medical Microbiology & Immunology, Gulu University, Gulu, Uganda
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3
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Malik AA, Gandhi NR, Marcy O, Walters E, Tejiokem M, Chau GD, Omer SB, Lash TL, Becerra MC, Njuguna IN, LaCourse SM, Maleche-Obimbo E, Wamalwa D, John-Stewart GC, Cranmer LM. Development of a Clinical Prediction Score Including Monocyte-to-Lymphocyte Ratio to Inform Tuberculosis Treatment Among Children With HIV: A Multicountry Study. Open Forum Infect Dis 2022; 9:ofac548. [PMID: 36381621 PMCID: PMC9645646 DOI: 10.1093/ofid/ofac548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 10/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background Clinical pediatric tuberculosis (TB) diagnosis may lead to overdiagnosis particularly among children with human immunodeficiency virus (CHIV). We assessed the performance of monocyte-lymphocyte ratio (MLR) as a diagnostic biomarker and constructed a clinical prediction score to improve specificity of TB diagnosis in CHIV with limited access to microbiologic testing. Methods We pooled data from cohorts of children aged ≤13 years from Vietnam, Cameroon, and South Africa to validate the use of MLR ≥0.378, previously found as a TB diagnostic marker among CHIV. Using multivariable logistic regression, we created an internally validated prediction score for diagnosis of TB disease in CHIV. Results The combined cohort had 601 children (median age, 1.9 [interquartile range, 0.9-5.3] years); 300 (50%) children were male, and 283 (47%) had HIV. Elevated MLR ≥0.378 had sensitivity of 36% (95% confidence interval [CI], 23%-51%) and specificity of 79% (95% CI, 71%-86%) among CHIV in the validation cohort. A model using MLR ≥0.28, age ≥4 years, tuberculin skin testing ≥5 mm, TB contact history, fever >2 weeks, and chest radiograph suggestive of TB predicted active TB disease in CHIV with an area under the receiver operating characteristic curve of 0.85. A prediction score of ≥5 points had a sensitivity of 94% and specificity of 48% to identify confirmed TB, and a sensitivity of 82% and specificity of 48% to identify confirmed and unconfirmed TB groups combined. Conclusions Our score has comparable sensitivity and specificity to algorithms including microbiological testing and should enable clinicians to rapidly initiate TB treatment among CHIV when microbiological testing is unavailable.
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Affiliation(s)
- Amyn A Malik
- Correspondence: Amyn A. Malik, PhD, Yale Institute for Global Health, 1 Church St, Suite 340, New Haven, CT 06510 ()
| | - Neel R Gandhi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Olivier Marcy
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
- Centre INSERM U1219, Bordeaux Population Health, University of Bordeaux, Bordeaux, France
| | - Elisabetta Walters
- Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- John Walton Muscular Dystrophy Research Centre, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | | | | | - Saad B Omer
- Yale Institute for Global Health, New Haven, Connecticut, USA
- Yale School of Medicine, New Haven, Connecticut, USA
- Yale School of Public Health, New Haven, Connecticut, USA
| | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Mercedes C Becerra
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Partners In Health, Boston, Massachusetts, USA
| | - Irene N Njuguna
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Sylvia M LaCourse
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | | | - Dalton Wamalwa
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Gunasekera KS, Vonasek B, Oliwa J, Triasih R, Lancioni C, Graham SM, Seddon JA, Marais BJ. Diagnostic Challenges in Childhood Pulmonary Tuberculosis-Optimizing the Clinical Approach. Pathogens 2022; 11:pathogens11040382. [PMID: 35456057 PMCID: PMC9032883 DOI: 10.3390/pathogens11040382] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/08/2022] [Accepted: 03/14/2022] [Indexed: 12/25/2022] Open
Abstract
The management of childhood tuberculosis (TB) is hampered by the low sensitivity and limited accessibility of microbiological testing. Optimizing clinical approaches is therefore critical to close the persistent gaps in TB case detection and prevention necessary to realize the child mortality targets of the End TB Strategy. In this review, we provide practical guidance summarizing the evidence and guidelines describing the use of symptoms and signs in decision making for children being evaluated for either TB preventive treatment (TPT) or TB disease treatment in high-TB incidence settings. Among at-risk children being evaluated for TPT, a symptom screen may be used to differentiate children who require further investigation for TB disease before receiving TPT. For symptomatic children being investigated for TB disease, an algorithmic approach can inform which children should receive TB treatment, even in the absence of imaging or microbiological confirmation. Though clinical approaches have limitations in accuracy, they are readily available and can provide valuable guidance for decision making in resource-limited settings to increase treatment access. We discuss the trade-offs in using them to make TB treatment decisions.
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Affiliation(s)
- Kenneth S. Gunasekera
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT 06510, USA
- Correspondence:
| | - Bryan Vonasek
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI 53726, USA;
| | - Jacquie Oliwa
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi P.O. Box 43640-00100, Kenya;
- Department of Paediatrics and Child Health, School of Medicine, University of Nairobi, Nairobi P.O. Box 30197-00100, Kenya
| | - Rina Triasih
- Department of Pediatrics, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta 55284, Indonesia;
| | - Christina Lancioni
- Department of Pediatrics, School of Medicine, Oregon Health and Science University, Portland, OR 97239, USA;
| | - Stephen M. Graham
- Centre for International Child Health, University of Melbourne and Murdoch Children’s Research Institute, Royal Children’s Hospital, Melbourne, VIC 3052, Australia;
- Burnet Institute, Melbourne, VIC 3004, Australia
| | - James A. Seddon
- Department of Infectious Diseases, Imperial College London, London W2 1PG, UK;
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town 8000, South Africa
| | - Ben J. Marais
- University of Sydney and The Children’s Hospital at Westmead, Sydney, NSW 2145, Australia;
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5
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Gunasekera KS, Walters E, van der Zalm MM, Palmer M, Warren JL, Hesseling AC, Cohen T, Seddon JA. Development of a Treatment-decision Algorithm for Human Immunodeficiency Virus-uninfected Children Evaluated for Pulmonary Tuberculosis. Clin Infect Dis 2021; 73:e904-e912. [PMID: 33449999 PMCID: PMC8366829 DOI: 10.1093/cid/ciab018] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Limitations in the sensitivity and accessibility of diagnostic tools for childhood tuberculosis contribute to the substantial gap between estimated cases and cases notified to national tuberculosis programs. Thus, tools to make accurate and rapid clinical diagnoses are necessary to initiate antituberculosis treatment in more children. METHODS We analyzed data from a prospective cohort of children <13 years old being routinely evaluated for pulmonary tuberculosis in Cape Town, South Africa, from March 2012 to November 2017. We developed a regression model to describe the contributions of baseline clinical evaluation to the diagnosis of tuberculosis using standardized, retrospective case definitions. We included baseline chest radiographic and Xpert MTB/RIF assay results to the model to develop an algorithm with ≥90% sensitivity in predicting tuberculosis. RESULTS Data from 478 children being evaluated for pulmonary tuberculosis were analyzed (median age, 16.2 months; interquartile range, 9.8-30.9 months); 242 (50.6%) were retrospectively classified with tuberculosis, bacteriologically confirmed in 104 (43.0%). The area under the receiver operating characteristic curve for the final model was 0.87. Clinical evidence identified 71.4% of all tuberculosis cases in this cohort, and inclusion of baseline chest radiographic results increased the proportion to 89.3%. The algorithm was 90.1% sensitive and 52.1% specific, and maintained a sensitivity of >90% among children <2 years old or with low weight for age. CONCLUSIONS Clinical evidence alone was sufficient to make most clinical antituberculosis treatment decisions. The use of evidence-based algorithms may improve decentralized, rapid treatment initiation, reducing the global burden of childhood mortality.
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Affiliation(s)
- Kenneth S Gunasekera
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Elisabetta Walters
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Marieke M van der Zalm
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Megan Palmer
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Joshua L Warren
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Anneke C Hesseling
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - James A Seddon
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
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6
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Ainan S, Furia FF, Mhimbira F, Mnyambwa NP, Mgina N, Zumla A, Mfinanga SG, Ngadaya E. Xpert® MTB/RIF assay testing on stool for the diagnosis of paediatric pulmonary TB in Tanzania. Public Health Action 2021; 11:75-79. [PMID: 34159066 DOI: 10.5588/pha.20.0062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/03/2021] [Indexed: 11/10/2022] Open
Abstract
SETTING Six health facilities in Dar es Salaam, Tanzania. OBJECTIVE To evaluate the use of stool specimens in the diagnostic workup of paediatric TB using the Xpert® MTB/RIF assay. DESIGN Between December 2018 and May 2019, we performed a cross-sectional diagnostic study of children aged between 1 month and 14 years with presumptive TB. A single stool specimen was tested using Xpert. The result was compared with the reference microbiological standard for respiratory or gastric specimens tested using Xpert and/or solid culture. The sensitivity, specificity and predictive values of stool Xpert assay were assessed. RESULTS A total of 225 children with a median age of 2.17 years (IQR 1.16-5.19) were enrolled; 165/225 (73.3%) were aged <5 years. Of 225 children, 8 (3.6%) were diagnosed with TB as they were culture- or Xpert-positive on sputum/gastric aspirate. The stool Xpert assay showed a sensitivity of 62.5% (95% CI 25-92) and specificity of 100% (95% CI 98-100) against the reference standard. CONCLUSION Use of the Xpert assay on stool specimens had a moderate sensitivity and high specificity in the diagnosis of pulmonary TB in children. Our data adds to the body of evidence for the use of Xpert assay on stool as a non-respiratory specimen to complement conventional methods used to diagnose the disease.
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Affiliation(s)
- S Ainan
- Department of Paediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - F F Furia
- Department of Paediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - F Mhimbira
- Department of Intervention and Clinical Trials, Ifakara Health Institute, Dar es Salaam, Tanzania.,Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - N P Mnyambwa
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - N Mgina
- Central Tuberculosis Reference Laboratory, Dar es salaam, Tanzania
| | - A Zumla
- Department of Infection, Division of Infection and Immunity, University College London, and NIHR Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - S G Mfinanga
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania.,Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania
| | - E Ngadaya
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
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7
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Herman B, Sirichokchatchawan W, Pongpanich S, Nantasenamat C. Development and performance of CUHAS-ROBUST application for pulmonary rifampicin-resistance tuberculosis screening in Indonesia. PLoS One 2021; 16:e0249243. [PMID: 33765092 PMCID: PMC7993842 DOI: 10.1371/journal.pone.0249243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/13/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Diagnosis of Pulmonary Rifampicin Resistant Tuberculosis (RR-TB) with the Drug-Susceptibility Test (DST) is costly and time-consuming. Furthermore, GeneXpert for rapid diagnosis is not widely available in Indonesia. This study aims to develop and evaluate the CUHAS-ROBUST model performance, an artificial-intelligence-based RR-TB screening tool. METHODS A cross-sectional study involved suspected all type of RR-TB patients with complete sputum Lowenstein Jensen DST (reference) and 19 clinical, laboratory, and radiology parameter results, retrieved from medical records in hospitals under the Faculty of Medicine, Hasanuddin University Indonesia, from January 2015-December 2019. The Artificial Neural Network (ANN) models were built along with other classifiers. The model was tested on participants recruited from January 2020-October 2020 and deployed into CUHAS-ROBUST (index test) application. Sensitivity, specificity, and accuracy were obtained for assessment. RESULTS A total of 487 participants (32 Multidrug-Resistant/MDR 57 RR-TB, 398 drug-sensitive) were recruited for model building and 157 participants (23 MDR and 21 RR) in prospective testing. The ANN full model yields the highest values of accuracy (88% (95% CI 85-91)), and sensitivity (84% (95% CI 76-89)) compare to other models that show sensitivity below 80% (Logistic Regression 32%, Decision Tree 44%, Random Forest 25%, Extreme Gradient Boost 25%). However, this ANN has lower specificity among other models (90% (95% CI 86-93)) where Logistic Regression demonstrates the highest (99% (95% CI 97-99)). This ANN model was selected for the CUHAS-ROBUST application, although still lower than the sensitivity of global GeneXpert results (87.5%). CONCLUSION The ANN-CUHAS ROBUST outperforms other AI classifiers model in detecting all type of RR-TB, and by deploying into the application, the health staff can utilize the tool for screening purposes particularly at the primary care level where the GeneXpert examination is not available. TRIAL REGISTRATION NCT04208789.
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Affiliation(s)
- Bumi Herman
- College of Public Health Science, Chulalongkorn University, Bangkok, Thailand
- * E-mail: (SP); , (BH)
| | | | - Sathirakorn Pongpanich
- College of Public Health Science, Chulalongkorn University, Bangkok, Thailand
- * E-mail: (SP); , (BH)
| | - Chanin Nantasenamat
- Faculty of Medical Technology, Mahidol University, Salaya, Nakhon Pathom, Thailand
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8
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Nicol MP, Zar HJ. Advances in the diagnosis of pulmonary tuberculosis in children. Paediatr Respir Rev 2020; 36:52-56. [PMID: 32624357 PMCID: PMC7686111 DOI: 10.1016/j.prrv.2020.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/19/2020] [Indexed: 10/24/2022]
Abstract
Major challenges still exist in the accurate diagnosis of tuberculosis in children. Algorithms based on clinical and radiological features remain in widespread use despite poor performance. Newer molecular diagnostics allow for rapid identification of TB and detection of drug-resistance in a subset of children, but lack sensitivity. Molecular testing of multiple specimens, including non-traditional specimen types, such as nasopharyngeal aspirates and stool and urine, may improve sensitivity, but the optimal combination of specimens requires further research. Novel tests under development or evaluation include a urine lipoarabinomannan test with improved sensitivity and a range of biomarkers measured from stimulated or unstimulated peripheral blood.
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Affiliation(s)
- Mark P Nicol
- Division of Infection and Immunity, School of Biomedical Sciences, University of Western Australia, Perth, Australia.
| | - Heather J Zar
- Department of Paediatrics and Child Health, and SA-MRC Unit on Child & Adolescent Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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9
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Carvalho RF, Carvalho ACC, Velarde LGC, Rossoni AMDO, Aurilio RB, Sias SMDA, Schmidt CM, Moreira ADSR, Martins PDS, Gonçalves LI, Martire TM, Barbosa APF, dos Santos APQ, Romanelli RMDC, de Oliveira MDGR, Diniz LMO, de Carvalho AL, Lucena SC, Cruz MLS, Saavedra MC, Tahan TT, Rodrigues CDO, Kritski AL, Sant’Anna CC, Cardoso CAA, Sant’Anna MDFBP. Diagnosis of pulmonary tuberculosis in children and adolescents: comparison of two versions of the Brazilian Ministry of Health scoring system. Rev Inst Med Trop Sao Paulo 2020; 62:e81. [PMID: 33146310 PMCID: PMC7608063 DOI: 10.1590/s1678-9946202062081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/01/2020] [Indexed: 11/22/2022] Open
Abstract
The aim of this study was to evaluate the concordance between two versions of the scoring system (2011 and 2019), recommended by the Brazilian Ministry of Health, for the diagnosis of pulmonary tuberculosis (PTB) in children and adolescents. A retrospective descriptive study was performed to assess the medical records of children and adolescents with PTB, in TB units from Brazilian cities located in Rio de Janeiro, Minas Gerais, and Parana States, from January 1 st , 2004, to December 1 st , 2018. Patients aged 0 to 18 years old with a diagnosis of PTB were included. The comparison between the two scoring systems showed a moderate concordance according to the κ coefficient value = 0.625. Fourteen patients showed a reduction in the TB score, going from 30 points in the 2011, to 25 points or less in the 2019 one. Seventy one percent of these 14 patients had radiological changes suggestive of PTB and 86% had tuberculin skin tests greater than 10 mm. The study concluded that a moderate agreement was observed between the 2011 and 2019 scoring systems, with an increase in the number of patients scoring 25 points or less in 2019, which can eventually hinder the diagnosis of PTB.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Pedro da Silva Martins
- Instituto Oswaldo Cruz , Fundação Oswaldo Cruz , Rio de Janeiro , Rio de Janeiro , Brazil
| | | | | | | | | | | | | | | | | | - Sheila Cunha Lucena
- Hospital Municipal Raphael de Paula Souza , Rio de Janeiro , Rio de Janeiro , Brazil
| | | | - Mariza Curto Saavedra
- Hospital Federal dos Servidores do Estado , Rio de Janeiro , Rio de Janeiro , Brazil
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10
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Rossoni AMO, Lovero KL, Tahan TT, Netto AR, Rossoni MD, Almeida IN, Lizzi EAS, Kritski A, Rodrigues CO. Evaluation of pulmonary tuberculosis diagnostic tests in children and adolescents at a pediatric reference center. Pulmonology 2020; 28:83-89. [PMID: 32014421 PMCID: PMC7392787 DOI: 10.1016/j.pulmoe.2020.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 01/07/2020] [Accepted: 01/12/2020] [Indexed: 11/26/2022] Open
Abstract
Introduction This study evaluates the performance of individual and combinations tests used for pediatric tuberculosis diagnosis at a reference center. Materials and Methods Diagnostic test outcomes from children with presumed pulmonary tuberculosis evaluated from January 2005 - July 2010 were compared to a standard diagnosis made by an expert panel of physicians. Results Presence of at least one sign/symptom, history of contact, or abnormal chest X-ray (aCXR) individually showed the highest sensitivity (85.7%). While the combination of history of contact, at least one sign/symptom, positive tuberculin skin test, and aCXR had low sensitivity of 20%, but the specificity and a positive predictive value were 100%, respectively. The combination of tests used in the International Union Against Tuberculosis and Lung Disease and the Brazilian Ministry of Health systems showed sensitivity of 28.6% and 71.4% and specificity of 95.8% and 97.0%, respectively. Conclusions In the absence of a gold standard, the combination of clinical history, tuberculin skin test, and aCXR, as well as the Brazilian scoring system serve as simple, low-cost approach that can be used for pediatric TB diagnosis by first-contact care providers.
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Affiliation(s)
- Andrea M O Rossoni
- Universidade Federal do Paraná (UFPR) the Graduate Program in Child and Adolescent Health, Curitiba, PR, Brasil
| | - Kathryn L Lovero
- University of California Berkeley, School of Public Health, Division of Infectious Diseases and Vaccinology and Division of Epidemiology, Berkeley, CA, United States
| | - Tonny T Tahan
- Universidade Federal do Paraná (UFPR) the Graduate Program in Child and Adolescent Health, Curitiba, PR, Brasil
| | - Antônio R Netto
- Universidade de São Paulo (USP), Escola de Medicina de Ribeirão Preto, Departamento de Medicina Social, Ribeirão Preto, SP, Brazil
| | - Marssoni D Rossoni
- Universidade Federal do Paraná (UFPR), Departamento de Medicina, Hospital das Clínicas, Curitiba, PR, Brasil
| | - Isabela N Almeida
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Laboratório de Pesquisa em Micobactérias, Belo Horizonte, MG, Brazil.
| | - Elisangela A S Lizzi
- Universidade Tecnológica Federal do Paraná (UTFPR), Departamento de Matemática, Curitiba, PR, Brazil
| | - Afranio Kritski
- Universidade Federal do Rio de Janeiro (UFRJ), Faculdade de Medicina, Programa Acadêmico de Tuberculose, Rio de Janeiro, RJ, Brazil
| | - Cristina O Rodrigues
- Universidade Federal do Paraná (UFPR) the Graduate Program in Child and Adolescent Health, Curitiba, PR, Brasil
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Chiappini E, Storelli F, Tersigni C, Venturini E, de Martino M, Galli L. QuantiFERON-TB Gold In-Tube test performance in a large pediatric population investigated for suspected tuberculosis infection. Paediatr Respir Rev 2019; 32:36-47. [PMID: 31155511 DOI: 10.1016/j.prrv.2019.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 01/30/2019] [Accepted: 03/18/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND The performance of QuantiFERON-TB Gold In-Tube (QTF-IT) in children is under debate, especially in those under 5 years of age. Moreover, interpretation of discordant QFT-IT/Tuberculin-Skin-Test (TST) results remains controversial. This study aims at studying the sensitivity of QFT-IT and TST in children with active TB cases and exploring risk factors associated with discordant TST+/QFT-IT-. METHODS Children consecutively referred to one single pediatric center between 2010 and 2017 for suspected tuberculosis infection (TB) were enrolled. All children underwent clinical evaluation, TST and QFT-IT. Sensitivity of QFT-IT and TST in active TB cases and risk factors associated with discordant TST+/QFT-IT- results were assessed. Uni- and multi-variate logistic regression analyses were performed. RESULTS Overall, 4631 children (median age 5.67 years) were enrolled, and 205 active TB cases were diagnosed (83 microbiologically confirmed). A high QFT-IT sensitivity was observed in children between 2 and 4 years of age (95.0%; 95%CI: 85.4-100) and in those between 5 and 18 years (89.1%; 95%CI:79.2-99.2) with microbiologically confirmed active TB. However, sensitivity was suboptimal in children younger than 2 years (84.6%; 95%CI: 65.0-100). Independent risk factors associated with discordant TST+/QFT-IT- results in children with latent tuberculosis infection (LTBI) were previous BCG vaccination (aOR:2.18; 95%CI:1.33-3.58; p = 0.002), age <2 years vs. 5-18 years (aOR:7.54; 95%CI:2.52-22.59; p < 0.0001), age 2-4 years vs. 5-18 years (aOR:4.63; 95%CI:2.66-8.06; p < 0.0001), and investigation for screening rather than for contact with a suspected or confirmed case (aOR:3.58; 95%CI:2.30-5.59; p < 0.0001). CONCLUSION Our data suggest that QFT-IT might be used as unique assay in children over 2 years of age investigated for recent immigration/adoption screening and in cases of recent low risk TB contact. This approach could considerably reduce the number of children undergoing pharmacological treatment. Conversely, both tests are recommended in cases of strong clinical suspicion or high risk TB contact in children less than 5 years of age, in order to avoid misdiagnosis.
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Affiliation(s)
- Elena Chiappini
- Paediatric Infectious Disease Unit, Meyer Children's University Hospital, Department of Health Sciences, University of Florence, Florence, Italy.
| | - Flavio Storelli
- Paediatric Infectious Disease Unit, Meyer Children's University Hospital, Department of Health Sciences, University of Florence, Florence, Italy.
| | - Chiara Tersigni
- Paediatric Infectious Disease Unit, Meyer Children's University Hospital, Department of Health Sciences, University of Florence, Florence, Italy
| | - Elisabetta Venturini
- Paediatric Infectious Disease Unit, Meyer Children's University Hospital, Department of Health Sciences, University of Florence, Florence, Italy.
| | - Maurizio de Martino
- Paediatric Infectious Disease Unit, Meyer Children's University Hospital, Department of Health Sciences, University of Florence, Florence, Italy.
| | - Luisa Galli
- Paediatric Infectious Disease Unit, Meyer Children's University Hospital, Department of Health Sciences, University of Florence, Florence, Italy.
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Kizito S, Katamba A, Marquez C, Turimumahoro P, Ayakaka I, Davis JL, Cattamanchi A. Quality of care in childhood tuberculosis diagnosis at primary care clinics in Kampala, Uganda. Int J Tuberc Lung Dis 2019; 22:1196-1202. [PMID: 30236188 DOI: 10.5588/ijtld.18.0043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To assess the quality of routine childhood tuberculosis (TB) evaluation in Kampala, Uganda. SETTING AND DESIGN This was a cross-sectional study of children aged <15 years attending six government-run clinics from November 2015 to December 2016. Clinicians completed a standardized patient record form for all child visits. We assessed the following performance indicators of TB evaluation developed based on the Desk Guide of the International Union Against Tuberculosis and Lung Disease, an evidence-based decision aid on childhood TB diagnosis and management for clinicians: proportion screened for TB symptoms or contact history, proportion referred for laboratory evaluation if screen-positive, and proportion treated for TB if test-positive or meeting clinical criteria. RESULTS Of 24 566 consecutive children enrolled, 11 614 (47%) were fully screened for TB symptoms. Of 1747 (15%) children who screened positive, 360 (21%) had sputum examined, including 159 (44%) using smear microscopy, 244 (67%) using Xpert® MTB/RIF, and 52 (14%) using both techniques. Treatment was initiated in 18/20 (80%) children who tested positive. An additional 65 screen-positive children met the clinical criteria for TB; none were initiated on treatment. CONCLUSIONS Large gaps exist along the pathway to diagnosis and treatment of childhood TB. There is an urgent need for enhanced implementation of evidence-based approaches to TB diagnosis to improve outcomes in childhood TB.
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Affiliation(s)
- S Kizito
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - A Katamba
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - C Marquez
- Division of HIV, Infectious Diseases, and Global Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - P Turimumahoro
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - I Ayakaka
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - J L Davis
- Pulmonary, Critical Care, & Sleep Medicine Section, School of Medicine and Department of Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, Connecticut
| | - A Cattamanchi
- Division of Pulmonary and Critical Care Medicine and Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, and Curry International Tuberculosis Center, University of California San Francisco, San Francisco, California, USA
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13
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Oliwa JN, Gathara D, Ogero M, van Hensbroek MB, English M, van’t Hoog A. Diagnostic practices and estimated burden of tuberculosis among children admitted to 13 government hospitals in Kenya: An analysis of two years' routine clinical data. PLoS One 2019; 14:e0221145. [PMID: 31483793 PMCID: PMC6726144 DOI: 10.1371/journal.pone.0221145] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 07/31/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND True burden of tuberculosis (TB) in children is unknown. Hospitalised children are low-hanging fruit for TB case detection as they are within the system. We aimed to explore the process of recognition and investigation for childhood TB using a guideline-linked cascade of care. METHODS This was an observational study of 42,107 children admitted to 13 county hospitals in Kenya from 01Nov 15-31Oct 16, and 01Nov 17-31Oct 18. We estimated those that met each step of the cascade, those with an apparent (or "Working") TB diagnosis and modelled associations with TB tests amongst guideline-eligible children. RESULTS 23,741/42,107 (56.4%) met step 1 of the cascade (≥2 signs and symptoms suggestive of TB). Step 2(further screening of history of TB contact/full respiratory exam) was documented in 14,873/23,741 (62.6%) who met Step 1. Step 3(chest x-ray or Mantoux test) was requested in 2,451/14,873 (16.5%) who met Step 2. Step 4(≥1 bacteriological test) was requested in 392/2,451 (15.9%) who met Step 3. Step 5("Working TB" diagnosis) was documented in 175/392 (44.6%) who met Step 4. Factors associated with request of TB tests in patients who met Step 1 included: i) older children [AOR 1.19(CI 1.09-1.31)]; ii) co-morbidities of HIV, malnutrition or pneumonia [AOR 3.81(CI 3.05-4.75), 2.98(CI 2.69-3.31) and 2.98(CI 2.60-3.40) respectively]; iii) sicker children, readmitted/referred [AOR 1.24(CI 1.08-1.42) and 1.15(CI 1.04-1.28) respectively]. "Working TB" diagnosis was made in 2.9%(1,202/42,107) of all admissions and 0.2%(89/42,107) were bacteriologically-confirmed. CONCLUSIONS More than half of all paediatric admissions had symptoms associated with TB and nearly two-thirds had more specific history documented. Only a few amongst them got TB tests requested. TB was diagnosed in 2.9% of all admissions but most were inadequately investigated. Major challenges remain in identifying and investigating TB in children in hospitals with access to Xpert MTB/RIF and a review is needed of existing guidelines.
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Affiliation(s)
- Jacquie Narotso Oliwa
- KEMRI-Wellcome Trust Research Programme, Health Services Research Group, Nairobi, Kenya
- University of Nairobi, Department of Paediatrics and Child Health, Nairobi, Kenya
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - David Gathara
- KEMRI-Wellcome Trust Research Programme, Health Services Research Group, Nairobi, Kenya
| | - Morris Ogero
- KEMRI-Wellcome Trust Research Programme, Health Services Research Group, Nairobi, Kenya
| | - Michaël Boele van Hensbroek
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- The Academic Medical Centre, University of Amsterdam, Department of Global Health, Amsterdam, The Netherlands
| | - Mike English
- KEMRI-Wellcome Trust Research Programme, Health Services Research Group, Nairobi, Kenya
- Oxford University, Nuffield Department of Medicine, Oxford, England, United Kingdom
| | - Anja van’t Hoog
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- The Academic Medical Centre, University of Amsterdam, Department of Global Health, Amsterdam, The Netherlands
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Carvalho ACC, Cardoso CAA, Martire TM, Migliori GB, Sant'Anna CC. Epidemiological aspects, clinical manifestations, and prevention of pediatric tuberculosis from the perspective of the End TB Strategy. ACTA ACUST UNITED AC 2019; 44:134-144. [PMID: 29791553 PMCID: PMC6044667 DOI: 10.1590/s1806-37562017000000461] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 02/11/2018] [Indexed: 02/01/2023]
Abstract
Tuberculosis continues to be a public health priority in many countries. In 2015, tuberculosis killed 1.4 million people, including 210,000 children. Despite the recent progress made in the control of tuberculosis in Brazil, it is still one of the countries with the highest tuberculosis burdens. In 2015, there were 69,000 reported cases of tuberculosis in Brazil and tuberculosis was the cause of 4,500 deaths in the country. In 2014, the World Health Organization approved the End TB Strategy, which set a target date of 2035 for meeting its goals of reducing the tuberculosis incidence by 90% and reducing the number of tuberculosis deaths by 95%. However, to achieve those goals in Brazil, there is a need for collaboration among the various sectors involved in tuberculosis control and for the prioritization of activities, including control measures targeting the most vulnerable populations. Children are highly vulnerable to tuberculosis, and there are particularities specific to pediatric patients regarding tuberculosis development (rapid progression from infection to active disease), prevention (low effectiveness of vaccination against the pulmonary forms and limited availability of preventive treatment of latent tuberculosis infection), diagnosis (a low rate of bacteriologically confirmed diagnosis), and treatment (poor availability of child-friendly anti-tuberculosis drugs). In this review, we discuss the epidemiology, clinical manifestations, and prevention of tuberculosis in childhood and adolescence, highlighting the peculiarities of active and latent tuberculosis in those age groups, in order to prompt reflection on new approaches to the management of pediatric tuberculosis within the framework of the End TB Strategy.
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Affiliation(s)
- Anna Cristina Calçada Carvalho
- Laboratório de Inovações em Terapias, Ensino e Bioprodutos, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brazil
| | | | - Terezinha Miceli Martire
- Faculdade de Medicina, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Clemax Couto Sant'Anna
- Departamento de Pediatria, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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15
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A comparison of tuberculosis diagnostic systems in a retrospective cohort of HIV-infected children in Rio de Janeiro, Brazil. Int J Infect Dis 2017; 59:150-155. [PMID: 28455104 PMCID: PMC7978502 DOI: 10.1016/j.ijid.2017.01.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 01/16/2017] [Accepted: 01/27/2017] [Indexed: 11/30/2022] Open
Abstract
Objectives: The diagnosis of pediatric tuberculosis (TB) presents many challenges, and is further complicated in HIV-infected patients. While many diagnostic systems have been proposed, there is no pediatric TB diagnosis gold standard. The outcomes of four TB diagnostic systems in HIV-infected children were compared in this study. Methods: A retrospective cohort study was conducted at a TB/HIV reference hospital in Rio de Janeiro. HIV-infected pediatric patients evaluated for TB from 1998 to 2010 were reassessed using four diagnostic systems: Kenneth Jones, 1969; Tidjani, 1986; Ben Marais, 2006; Brazilian Ministry of Health, 2010. Results were compared to standardized diagnoses made by an expert panel of physicians. Results: Of the 121 patients in the study cohort, the expert panel diagnosed 64 as TB and 57 as not TB cases. The Tidjani system showed the highest diagnostic accuracy, with and without the inclusion of microbiological data. The Tidjani and Kenneth Jones systems produced fewer false-positives, and the Ben Marais and Ministry of Health fewer false-negatives. Across systems, there was little agreement between TB diagnoses. Conclusions: In HIV-infected pediatric patients, the Ben Marais and Ministry of Health systems are useful for TB diagnostic screening, whereas the Tidjani and Kenneth Jones systems are best used in a reference center setting.
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Iskandar A, Nursiloningrum E, Arthamin MZ, Olivianto E, Chandrakusuma MS. The Diagnostic Value of Urine Lipoarabinomannan (LAM) Antigen in Childhood Tuberculosis. J Clin Diagn Res 2017; 11:EC32-EC35. [PMID: 28511392 PMCID: PMC5427318 DOI: 10.7860/jcdr/2017/20909.9542] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 12/06/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Diagnosis of Tuberculosis (TB) in children is difficult because the clinical presentation is not specific, the chest X-ray interpretation has low accuracy and sputum sample is difficult to obtain. Antigen detection test such as rapid urine LAM is a non-invasive alternative for diagnosing TB . Lipoarabinomannan (LAM) is the main component of M.tuberculosis cell wall. AIM To determine the diagnostic value of urinary LAM antigen for diagnosis of childhood TB. MATERIALS AND METHODS In the present cross-sectional study, subjects were included using consecutive sampling method. All the children aged 0-14 years Suspected of pulmonary or extra pulmonary TB suffering from cough more than two weeks, fever without clear aetiology, loss of body weight or poor weight gain, fatigue, malaise, chronic lymph node enlargement, spine angulation, joint swelling and had history of contact with positive sputum smear adult TB patient were enrolled in the study. Pulmonary and extra pulmonary diagnosis was based on clinical presentation, Tuberculin Skin Test (TST), chest X-ray, Acid Fast Bacillus (AFB) staining and or sputum culture. Urinary LAM level was measured by using Enzyme-Linked Immunosorbent Assay (ELISA). Cut off value and Area Under the Curve (AUC) were determined using ROC statistical analysis (SPSS 21.0). Sensitivity and specificity was measured from 2x2 cross table. RESULTS Out of 61 subjects suspected as TB, 49 (80.3%) were eventually diagnosed with TB. Of those diagnosed with TB, 21 (42.9%) were microbiologically confirmed cases either by sputum microscopy (34.7%) or culture (8.2%), whereas 28 subjects were unconfirmed cases (57.1%). The urinary LAM level was higher in subjects with TB (1.80+1.02) mg/l compared to non-TB group (0.46+0.3) mg/l; p<0.001(independent t-test). Urine LAM had 83% sensitivity and 85% specificity with cut off value 0.98 mg/l using microbiological and clinical confirmation as standard reference and 33% sensitivity and 60% specificity with cut off value 1.69 mg/l using microbiological confirmation only. CONCLUSION Urinary LAM has good diagnostic value for childhood TB diagnosis.
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Affiliation(s)
- Agustin Iskandar
- Consultant, Department of Clinical Pathology, Universitas Brawijaya, Malang, East Java, Indonesia
| | - Erlin Nursiloningrum
- Consultant, Department of Clinical Pathology, Universitas Brawijaya, Malang, East Java, Indonesia
| | | | - Ery Olivianto
- Consultant, Department of Child Health, Universitas Brawijaya, Malang, East Java, Indonesia
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17
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Chiappini E, Lo Vecchio A, Garazzino S, Marseglia GL, Bernardi F, Castagnola E, Tomà P, Cirillo D, Russo C, Gabiano C, Ciofi D, Losurdo G, Bocchino M, Tortoli E, Tadolini M, Villani A, Guarino A, Esposito S. Recommendations for the diagnosis of pediatric tuberculosis. Eur J Clin Microbiol Infect Dis 2016; 35:1-18. [PMID: 26476550 DOI: 10.1007/s10096-015-2507-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 10/07/2015] [Indexed: 01/10/2023]
Abstract
Tuberculosis (TB) is still the world's second most frequent cause of death due to infectious diseases after HIV infection, and this has aroused greater interest in identifying and managing exposed subjects, whether they are simply infected or have developed one of the clinical variants of the disease. Unfortunately, not even the latest laboratory techniques are always successful in identifying affected children because they are more likely to have negative cultures and tuberculin skin test results, equivocal chest X-ray findings, and atypical clinical manifestations than adults. Furthermore, they are at greater risk of progressing from infection to active disease, particularly if they are very young. Consequently, pediatricians have to use different diagnostic strategies that specifically address the needs of children. This document describes the recommendations of a group of scientific societies concerning the signs and symptoms suggesting pediatric TB, and the diagnostic approach towards children with suspected disease.
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18
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Olofin IO, Liu E, Manji KP, Danaei G, Duggan C, Aboud S, Spiegelman D, Fawzi WW. Active Tuberculosis in HIV-Exposed Tanzanian Children up to 2 years of Age: Early-Life Nutrition, Multivitamin Supplementation and Other Potential Risk Factors. J Trop Pediatr 2016; 62:29-37. [PMID: 26494727 PMCID: PMC4900129 DOI: 10.1093/tropej/fmv073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Over half a million children worldwide develop active tuberculosis (TB) each year. Early-life nutritional exposures have rarely been examined in relation to pediatric TB among HIV-exposed children. We therefore investigated independent associations of early-life nutritional exposures with active TB among HIV-exposed children up to 2 years of age. METHODS Participants were children from a randomized controlled multivitamin supplementation trial conducted in Dar es Salaam, Tanzania, from August 2004 to May 2008, who received daily multivitamin supplements or placebo for 24 months. RESULTS Lower mean corpuscular volumes [relative risks (RR): 0.48, 95% confidence interval (CI): 0.27, 0.87] and higher birth weights (RR: 0.61, 95% CI: 0.37, 0.99) were protective against active TB, whereas multivitamin supplementation was not associated with TB risk (RR: 0.87, 95% CI: 0.65, 1.16). CONCLUSIONS Knowledge of nutrition-related risk and protective factors for TB in HIV-exposed children could enhance preventive and case-finding activities in this population, contributing to efforts to reduce the global TB burden.
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Affiliation(s)
| | - Enju Liu
- Harvard T.H. Chan School of Public Health, Boston, MA 02115, U.S.A
| | - Karim P. Manji
- Muhimbili University of Health and Allied Sciences, United Nations Rd, Dar es Salaam, Tanzania
| | - Goodarz Danaei
- Harvard T.H. Chan School of Public Health, Boston, MA 02115, U.S.A
| | - Christopher Duggan
- Harvard T.H. Chan School of Public Health, Boston, MA 02115, U.S.A.,Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115, U.S.A
| | - Said Aboud
- Muhimbili University of Health and Allied Sciences, United Nations Rd, Dar es Salaam, Tanzania
| | - Donna Spiegelman
- Harvard T.H. Chan School of Public Health, Boston, MA 02115, U.S.A
| | - Wafaie W. Fawzi
- Harvard T.H. Chan School of Public Health, Boston, MA 02115, U.S.A
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Beneri C, Aaron L, Kim S, Jean-Philippe P, Madhi S, Violari A, Cotton MF, Mitchell C, Nachman S. Understanding NIH clinical case definitions for pediatric intrathoracic TB by applying them to a clinical trial. Int J Tuberc Lung Dis 2016; 20:93-100. [PMID: 26688534 PMCID: PMC4928853 DOI: 10.5588/ijtld.14.0848] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Standardized clinical case definitions represent the best option for pediatric tuberculosis (TB) disease diagnosis and classification. OBJECTIVE To apply published guidelines for intrathoracic TB classification for use in reporting diagnostic studies with passive case finding to presumed TB patients from International Maternal Pediatric Adolescent AIDS Clinical Trials P1041, a trial of isoniazid prophylaxis in healthy human immunodeficiency virus exposed, bacille Calmette-Guérin vaccinated infants which employed active surveillance to assess a novel application of these guidelines in this setting. METHODS P1041 presumed TB patients were retrospectively cross-classified by protocol-defined and National Institutes of Health (NIH) classifications, and agreement was assessed. RESULTS Of 219 TB suspects, 166 had signs/symptoms, with 158 considered TB (21 confirmed, 92 probable, 45 possible) and 8 not TB (6 TB unlikely, 2 alternative diagnoses). Weight loss and failure to thrive represented the majority of the observed signs/symptoms. Among those with signs/symptoms, agreement between definitions was poor. Furthermore, 53 TB presumptives were without signs/symptoms, including 33 classified by the P1041 protocol as TB. CONCLUSION Poor agreement between P1041 and NIH classifications reflects cases identified through active vs. passive surveillance, the latter reflecting the intended use of NIH definitions. Given the interest in standardized definitions for broader application, future efforts could focus on expanding TB disease classification to presumed TB patients identified through active surveillance.
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Affiliation(s)
- Christy Beneri
- Department of Pediatrics, Stony Brook School of Medicine, Stony Brook, NY, US
| | - Lisa Aaron
- Harvard School of Public Heath, Boston MA, US
| | - Soyeon Kim
- Rutgers New Jersey Medical School, The State University of New Jersey, Newark, NJ, US
| | - Patrick Jean-Philippe
- HJF-DAIDS, a Division of The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Contractor to NIAID, NIH, DHHS, Bethesda MD, US
| | - Shabir Madhi
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa
| | - Avy Violari
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark F. Cotton
- Department of Pediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | | | - Sharon Nachman
- Department of Pediatrics, Stony Brook School of Medicine, Stony Brook, NY, US
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Patching the gaps towards the 90-90-90 targets: outcomes of Nigerian children receiving antiretroviral treatment who are co-infected with tuberculosis. J Int AIDS Soc 2015; 18:20251. [PMID: 26639112 PMCID: PMC4670833 DOI: 10.7448/ias.18.7.20251] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 09/08/2015] [Accepted: 09/25/2015] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Nigeria has a high burden of children living with HIV and tuberculosis (TB). This article examines the magnitude of TB among children receiving antiretroviral treatment (ART), compares their ART outcomes with their non-TB counterparts and argues that addressing TB among children on ART is critical for achieving the 90-90-90 targets. METHODS This was a facility-based, retrospective analysis of medical records of children aged <15 years who were newly initiated on ART between 2011 and 2012. Structured tools were used to collect data. STATA software was used to perform descriptive, survival and multivariate analyses. RESULTS A total of 1142 children with a median age of 3.5 years from 20 selected facilities were followed for 24 months. Of these, 95.8% were assessed for TB at ART initiation and 14.7% had TB. Children on ART were more likely to have TB if they were aged 5 years or older (p<0.01) and had delayed ART initiation (p<0.05). The cotrimoxazole and isoniazid prophylaxes were provided to 87.9 and 0.8% of children, respectively. The rate of new TB cases was 3 (2.2-4.0) per 100 person-years at six months and declined to 0.2 (0.06-1.4) per 100 person-years at 24 months. TB infection [adjusted hazard ratio (aHR): 4.3; 2.3-7.9], malnutrition (aHR: 5.1; 2.6-9.8), delayed ART initiation (aHR: 3.2; 1.5-6.7) and age less than 1 year at ART initiation (aHR: 4.0; 1.4-12.0) were associated with death. Additionally, patients with TB (aHR: 1.3; 1.1-1.6) and children below the age of 1 at ART initiation (aHR: 2.9; 1.7-5.2) were more likely to be lost to follow-up (LFU). CONCLUSIONS Children on ART with TB are less likely to survive and more likely to be LFU. These risks, along with low isoniazid uptake and delayed ART initiation, present a serious challenge to achieving the 90-90-90 targets and underscore an urgent need for inclusion of childhood TB/HIV in global plans and reporting mechanisms.
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Incidence and Predictors of Tuberculosis among HIV Positive Children at University of Gondar Referral Hospital, Northwest Ethiopia: A Retrospective Follow-Up Study. INTERNATIONAL SCHOLARLY RESEARCH NOTICES 2015; 2015:307810. [PMID: 27347516 PMCID: PMC4897326 DOI: 10.1155/2015/307810] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 04/09/2015] [Accepted: 04/21/2015] [Indexed: 02/05/2023]
Abstract
Background. The aim of this study was to determine the incidence of tuberculosis and its predictors among HIV positive children. Methods. A six-year retrospective follow-up study was conducted among HIV infected children aged less than 15 years. Life table was used to estimate the cumulative probability of tuberculosis free survival. Cox proportional hazards model was used to identify predictors of tuberculosis. Results. A total of 271 HIV positive children were followed for six years and produced 1100.50 person-years of observation. During the follow-up period 52 new TB cases occurred. The overall incidence density of TB was 4.9 per 100 PY. Inappropriate vaccination [AHR: 8.03 (95% CI; 4.61–13.97)], ambulatory functional status [AHR: 1.99 (95% CI; 1.04–3.81)], and having baseline anemia [AHR: 2.23 (95% CI; 1.19–4.15)] were important predictors of time to TB occurrence. Conclusion. TB incidence rate was high. Early diagnosis and treatment of anemia and strengthening immunization program would reduce the risk of TB occurrence.
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Abstract
Severe acute malnutrition (SAM) is associated with increased severity of common infectious diseases, and death amongst children with SAM is almost always as a result of infection. The diagnosis and management of infection are often different in malnourished versus well-nourished children. The objectives of this brief are to outline the evidence underpinning important practical questions relating to the management of infectious diseases in children with SAM and to highlight research gaps. Overall, the evidence base for many aspects covered in this brief is very poor. The brief addresses antimicrobials; antipyretics; tuberculosis; HIV; malaria; pneumonia; diarrhoea; sepsis; measles; urinary tract infection; nosocomial Infections; soil transmitted helminths; skin infections and pharmacology in the context of SAM. The brief is structured into sets of clinical questions, which we hope will maximise the relevance to contemporary practice.
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Key Words
- Antibiotics,
- Children,
- Diarrhoea,
- HIV,
- Infection,
- Malaria
- Malnutrition,
- Measles,
- Pneumonia,
- Sepsis,
- Tuberculosis,
- Urinary tract infection,
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23
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Abuogi LL, Mwachari C, Leslie HH, Shade SB, Otieno J, Yienya N, Sanguli L, Amukoye E, Cohen CR. Impact of expanded antiretroviral use on incidence and prevalence of tuberculosis in children with HIV in Kenya. Int J Tuberc Lung Dis 2014; 17:1291-7. [PMID: 24025380 DOI: 10.5588/ijtld.12.0740] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Antiretroviral therapy (ART) reduces pulmonary tuberculosis (PTB) in human immunodeficiency virus (HIV) infected children. Recent ART recommendations have increased the number of children on ART. OBJECTIVE To determine the prevalence and incidence of TB in HIV-infected children after the implementation of expanded ART guidelines. DESIGN A prospective cohort study including HIV-infected children aged 6 weeks to 14 years was conducted in Kenya. The primary outcome measure was clinically diagnosed TB. Study participants were screened for prevalent TB at enrollment using Kenya's national guidelines and followed at monthly intervals to detect incident TB. Predictors of TB were assessed using logistic regression and Cox proportional hazards regression. RESULTS Of 689 participants (median age 6.4 years), 509 (73.9%) were on ART at baseline. There were 51 cases of prevalent TB (7.4%) and 10 incident cases, with over 720.3 child-years of observation (incidence 1.4 per 100 child-years). Months on ART (adjusted hazard ratio [aHR] 0.91, P = 0.003; aOR 0.91, P< 0.001) and months in care before ART (aHR 0.87, P= 0.001; aOR 0.92, P < 0.001) were protective against incident and prevalent TB. CONCLUSIONS ART was protective against TB in this cohort of HIV-infected children with high levels of ART use. Optimal TB prevention strategies should emphasize early ART in children.
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Affiliation(s)
- L L Abuogi
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA; Family AIDS Care and Education Services, Nairobi, Kenya
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24
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Anderson ST, Kaforou M, Brent AJ, Wright VJ, Banwell CM, Chagaluka G, Crampin AC, Dockrell HM, French N, Hamilton MS, Hibberd ML, Kern F, Langford PR, Ling L, Mlotha R, Ottenhoff THM, Pienaar S, Pillay V, Scott JAG, Twahir H, Wilkinson RJ, Coin LJ, Heyderman RS, Levin M, Eley B. Diagnosis of childhood tuberculosis and host RNA expression in Africa. N Engl J Med 2014; 370:1712-1723. [PMID: 24785206 PMCID: PMC4069985 DOI: 10.1056/nejmoa1303657] [Citation(s) in RCA: 264] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Improved diagnostic tests for tuberculosis in children are needed. We hypothesized that transcriptional signatures of host blood could be used to distinguish tuberculosis from other diseases in African children who either were or were not infected with the human immunodeficiency virus (HIV). METHODS The study population comprised prospective cohorts of children who were undergoing evaluation for suspected tuberculosis in South Africa (655 children), Malawi (701 children), and Kenya (1599 children). Patients were assigned to groups according to whether the diagnosis was culture-confirmed tuberculosis, culture-negative tuberculosis, diseases other than tuberculosis, or latent tuberculosis infection. Diagnostic signatures distinguishing tuberculosis from other diseases and from latent tuberculosis infection were identified from genomewide analysis of RNA expression in host blood. RESULTS We identified a 51-transcript signature distinguishing tuberculosis from other diseases in the South African and Malawian children (the discovery cohort). In the Kenyan children (the validation cohort), a risk score based on the signature for tuberculosis and for diseases other than tuberculosis showed a sensitivity of 82.9% (95% confidence interval [CI], 68.6 to 94.3) and a specificity of 83.6% (95% CI, 74.6 to 92.7) for the diagnosis of culture-confirmed tuberculosis. Among patients with cultures negative for Mycobacterium tuberculosis who were treated for tuberculosis (those with highly probable, probable, or possible cases of tuberculosis), the estimated sensitivity was 62.5 to 82.3%, 42.1 to 80.8%, and 35.3 to 79.6%, respectively, for different estimates of actual tuberculosis in the groups. In comparison, the sensitivity of the Xpert MTB/RIF assay for molecular detection of M. tuberculosis DNA in cases of culture-confirmed tuberculosis was 54.3% (95% CI, 37.1 to 68.6), and the sensitivity in highly probable, probable, or possible cases was an estimated 25.0 to 35.7%, 5.3 to 13.3%, and 0%, respectively; the specificity of the assay was 100%. CONCLUSIONS RNA expression signatures provided data that helped distinguish tuberculosis from other diseases in African children with and those without HIV infection. (Funded by the European Union Action for Diseases of Poverty Program and others).
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25
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Miotto P, Mwangoka G, Valente IC, Norbis L, Sotgiu G, Bosu R, Ambrosi A, Codecasa LR, Goletti D, Matteelli A, Ntinginya EN, Aloi F, Heinrich N, Reither K, Cirillo DM. miRNA signatures in sera of patients with active pulmonary tuberculosis. PLoS One 2013; 8:e80149. [PMID: 24278252 PMCID: PMC3836984 DOI: 10.1371/journal.pone.0080149] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 09/30/2013] [Indexed: 12/31/2022] Open
Abstract
Several studies showed that assessing levels of specific circulating microRNAs (miRNAs) is a non-invasive, rapid, and accurate method for diagnosing diseases or detecting alterations in physiological conditions. We aimed to identify a serum miRNA signature to be used for the diagnosis of tuberculosis (TB). To account for variations due to the genetic makeup, we enrolled adults from two study settings in Europe and Africa. The following categories of subjects were considered: healthy (H), active pulmonary TB (PTB), active pulmonary TB, HIV co-infected (PTB/HIV), latent TB infection (LTBI), other pulmonary infections (OPI), and active extra-pulmonary TB (EPTB). Sera from 10 subjects of the same category were pooled and, after total RNA extraction, screened for miRNA levels by TaqMan low-density arrays. After identification of “relevant miRNAs”, we refined the serum miRNA signature discriminating between H and PTB on individual subjects. Signatures were analyzed for their diagnostic performances using a multivariate logistic model and a Relevance Vector Machine (RVM) model. A leave-one-out-cross-validation (LOOCV) approach was adopted for assessing how both models could perform in practice. The analysis on pooled specimens identified selected miRNAs as discriminatory for the categories analyzed. On individual serum samples, we showed that 15 miRNAs serve as signature for H and PTB categories with a diagnostic accuracy of 82% (CI 70.2–90.0), and 77% (CI 64.2–85.9) in a RVM and a logistic classification model, respectively. Considering the different ethnicity, by selecting the specific signature for the European group (10 miRNAs) the diagnostic accuracy increased up to 83% (CI 68.1–92.1), and 81% (65.0–90.3), respectively. The African-specific signature (12 miRNAs) increased the diagnostic accuracy up to 95% (CI 76.4–99.1), and 100% (83.9–100.0), respectively. Serum miRNA signatures represent an interesting source of biomarkers for TB disease with the potential to discriminate between PTB and LTBI, but also among the other categories.
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Affiliation(s)
- Paolo Miotto
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Grace Mwangoka
- Ifakara Health Institute-Bagamoyo Research and Training Centre, Bagamoyo, United Republic of Tanzania
| | - Ilaria C. Valente
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Luca Norbis
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari; Research, Medical Education and Professional Development Unit, AOU Sassari, Sassari, Italy
| | - Roberta Bosu
- Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari; Research, Medical Education and Professional Development Unit, AOU Sassari, Sassari, Italy
| | | | - Luigi R. Codecasa
- Regional Reference Center for TB “Villa Marelli”, Niguarda Ca’ Granda Hospital, Milan, Italy
| | - Delia Goletti
- Translational research Unit, National Institute for Infectious Diseases “L. Spallanzani”, Rome, Italy
| | - Alberto Matteelli
- Institute of Infectious and Tropical Diseases, World Health Organization Collaborating Centre for TB/HIV co-infection, Brescia University, Brescia, Italy
| | - Elias N. Ntinginya
- National Institute of Medical Research-Mbeya Medical Research Centre, Mbeya, United Republic of Tanzania
| | - Francesco Aloi
- St. Francis Nsambya Hospital/AISPO, Kampala, Uganda
- Italian Association for Solidarity Among People (AISPO NGO), Kampala, Uganda
| | - Norbert Heinrich
- Division for Infectious Diseases and Tropical Medicine, Ludwig Maxmillian University, Munich, Germany
| | - Klaus Reither
- Ifakara Health Institute-Bagamoyo Research and Training Centre, Bagamoyo, United Republic of Tanzania
- Swiss Tropical and Public Health Institute and University of Basel, Basel, Switzerland
| | - Daniela M. Cirillo
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, San Raffaele Scientific Institute, Milan, Italy
- * E-mail:
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