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Njagi LN, Nduba V, Mureithi MW, Mecha JO. Prevalence and predictors of tuberculosis infection among people living with HIV in a high tuberculosis burden context. BMJ Open Respir Res 2023; 10:10/1/e001581. [PMID: 37197794 DOI: 10.1136/bmjresp-2022-001581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 04/28/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) disease is the leading cause of mortality among people living with HIV (PLHIV). Interferon-gamma release assays (IGRAs) are approved for TB infection ascertainment. However, current IGRA data on the prevalence of TB infection in the context of near-universal access to antiretroviral therapy (ART) and TB preventive therapy (TPT) are lacking. We estimated the prevalence and determinants of TB infection among PLHIV within a high TB and HIV burden context. METHODS This cross-sectional study included data from adult PLHIV age ≥18 years in whom QuantiFERON-TB Gold Plus (QFT-Plus) assay, an IGRA, was performed. TB infection was defined as a positive or indeterminate QFT-Plus test. Participants with TB and those who had previously used TPT were excluded. Regression analysis was performed to identify independent predictors of TB infection. RESULTS Of 121 PLHIV with QFT-Plus test results, females were 74.4% (90/121), and the mean age was 38.4 (SD 10.8) years. Overall, 47.9% (58/121) were classified as TB infection (QFT-Plus test positive and indeterminate results were 39.7% (48/121) and 8.3% (10/121), respectively). Being obese/overweight (body mass index ≥25 kg/m2; p=0.013, adjusted OR (aOR) 2.90, 95% CI 1.25 to 6.74) and ART usage for >3 years (p=0.013, aOR 3.99, 95% CI 1.55 to 10.28) were independently associated with TB infection. CONCLUSION There was a high TB infection prevalence among PLHIV. A longer period of ART and obesity were independently associated with TB infection. The relationship between obesity/overweight and TB infection may be related to ART use and immune reconstitution and requires further investigation. Given the known benefit of test-directed TPT among PLHIV never exposed to TPT, its clinical and cost implications for low and middle-income countries should be explored further.
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Affiliation(s)
- Lilian Nkirote Njagi
- Center for Respiratory Disease Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Medical Microbiology & Immunology, University of Nairobi Faculty of Health Sciences, Nairobi, Kenya
| | - Videlis Nduba
- Center for Respiratory Disease Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Marianne Wanjiru Mureithi
- Department of Medical Microbiology & Immunology, University of Nairobi Faculty of Health Sciences, Nairobi, Kenya
| | - Jared Ongechi Mecha
- Department of Clinical Medicine and Therapeutics, University of Nairobi Faculty of Health Sciences, Nairobi, Kenya
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White HA, Baggaley RF, Okhai H, Patel H, Stephenson I, Bodimeade C, Wiselka MJ, Pareek M. The impact, effectiveness and outcomes of targeted screening thresholds for programmatic latent tuberculosis infection testing in HIV. AIDS 2022; 36:2035-2044. [PMID: 35983827 PMCID: PMC9612707 DOI: 10.1097/qad.0000000000003364] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 06/02/2022] [Accepted: 06/16/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Screening and treatment for latent tuberculosis infection (LTBI) are key for TB control. In the UK, the National Institute for Health and Care Excellence (NICE) and the British HIV Association (BHIVA) give conflicting guidance on which groups of people with HIV (PWH) should be screened, and previous national analysis demonstrated heterogeneity in how guidance is applied. There is an urgent need for a firmer clinical effectiveness evidence base on which to build screening policy. METHODS We conducted a systematic, programmatic LTBI-screening intervention for all PWH receiving care in Leicester, UK. We compared yields (percentage IGRA positive) and number of tests required when applying the NICE and BHIVA testing strategies, as well as strategies targeting screening by TB incidence in patients' countries of birth. RESULTS Of 1053 PWH tested, 118 were IGRA-positive (11.2%). Positivity was associated with higher TB incidence in country-of-birth [adjusted odds ratio, 50-149 cases compared with <50 cases/100 000: 11.6; 95% confidence interval (CI) 4.79-28.10)]. There was high testing uptake (1053/1069, 98.5%). Appropriate chemoprophylaxis was commenced in 100 of 117 (85.5%) patients diagnosed with LTBI, of whom 96 of 100 (96.0%) completed treatment. Delivering targeted testing to PWH from countries with TB incidence greater than 150 per 100 000 population or any sub-Saharan African country, would have correctly identified 89.8% of all LTBI cases while cutting tests required by 46.1% compared with NICE guidance, performing as well as BHIVA 2018 guidance. CONCLUSION Targeting screening to higher risk PWH increases yield and reduces the number requiring testing. Our proposed 'PWH-LTBI streamlined guidance' offers a simplified approach, with the potential to improve national LTBI-screening implementation.
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Affiliation(s)
- Helena A. White
- Department of Infection and HIV Medicine, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester
- Department of Respiratory Sciences, University of Leicester, Leicester
| | | | - Hajra Okhai
- Institute for Global Health, University College London, London
| | - Hemu Patel
- Department of Microbiology, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester, UK
| | - Iain Stephenson
- Department of Infection and HIV Medicine, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester
| | - Chris Bodimeade
- Department of Infection and HIV Medicine, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester
| | - Martin J. Wiselka
- Department of Infection and HIV Medicine, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester
| | - Manish Pareek
- Department of Infection and HIV Medicine, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester
- Department of Respiratory Sciences, University of Leicester, Leicester
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White HA, Okhai H, Sahota A, Maltby J, Stephenson I, Patel H, Hefford PM, Wiselka MJ, Pareek M. Latent tuberculosis screening and treatment in HIV: highly acceptable in a prospective cohort study. ERJ Open Res 2022; 8:00442-2021. [PMID: 35479297 PMCID: PMC9035605 DOI: 10.1183/23120541.00442-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 11/08/2021] [Indexed: 11/08/2022] Open
Abstract
Background People living with HIV (PLWH) are at increased risk of re-activation of latent tuberculosis infection (LTBI). Although UK and international guidelines identify this group as a priority for LTBI screening and treatment, data on attitudes of PLWH to this policy recommendation are lacking. Methods A five-point, Likert-style questionnaire was administered to PLWH to assess views and intentions towards accepting LTBI screening and treatment. Subsequent interferon-γ release assay (IGRA) testing was offered, and chemoprophylaxis if required. Influencing demographic and psychological associations with planned, and actual, testing and treatment uptake were assessed using multivariable logistic regression. Results 444 out of 716 (62%) patients responded. 417 out of 437 (95.4%) expressed intention to accept LTBI testing. The only significant association was the perceived importance of testing to the individual (adjusted odds ratio (aOR) 8.98, 95% CI 2.55–31.67). 390 out of 393 (99.2%) accepted appropriate IGRA screening; 41 out of 390 (10.5%) were positive. 397 out of 431 (92.1%) expressed intention to accept chemoprophylaxis, associated with perceived importance of treatment (aOR 3.52, 95% CI 1.46–8.51), a desire to have treatment for LTBI (aOR 1.77, 95% CI 0.99–3.15) and confidence in taking treatment (aOR 3.77, 95% CI 1.84–7.72). Of those offered chemoprophylaxis, 36 out of 37 (97.3%) accepted and 34 out of 36 (94.4%) completed treatment. There were no correlates with actual screening acceptance. Conclusions LTBI is common amongst PLWH, highlighting the importance of robust screening and treatment programmes. This study shows that screening and treatment for LTBI is highly acceptable to PLWH and provides strong, objective evidence for policy-makers developing guidelines in this cohort. This detailed exploration of the views of people living with HIV in the UK through a prospective questionnaire cohort study is the first of its kind in the published literature, and shows that latent TB screening and treatment is overwhelmingly supportedhttps://bit.ly/3HmhmRy
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Affiliation(s)
- Helena A White
- Dept of Respiratory Sciences, University of Leicester, Leicester, UK.,Dept of Infection and HIV Medicine, University Hospitals Leicester NHS Trust, Leicester, UK
| | - Hajra Okhai
- Institute for Global Health, University College London, London, UK
| | - Amandip Sahota
- Dept of Infection and HIV Medicine, University Hospitals Leicester NHS Trust, Leicester, UK
| | - John Maltby
- Dept of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, UK
| | - Iain Stephenson
- Dept of Infection and HIV Medicine, University Hospitals Leicester NHS Trust, Leicester, UK
| | - Hemu Patel
- Dept of Clinical Microbiology, University Hospitals Leicester NHS Trust, Leicester, UK
| | - Philip M Hefford
- Dept of Infection and HIV Medicine, University Hospitals Leicester NHS Trust, Leicester, UK
| | - Martin J Wiselka
- Dept of Infection and HIV Medicine, University Hospitals Leicester NHS Trust, Leicester, UK
| | - Manish Pareek
- Dept of Respiratory Sciences, University of Leicester, Leicester, UK.,Dept of Infection and HIV Medicine, University Hospitals Leicester NHS Trust, Leicester, UK
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Auguste PE, Mistry H, McCarthy ND, Sutcliffe PA, Clarke AE. Cost-effectiveness of testing for latent tuberculosis infection in people with HIV. AIDS 2022; 36:1-9. [PMID: 34873091 DOI: 10.1097/qad.0000000000003060] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE The aim of this study was to estimate the cost-effectiveness of screening strategies for predicting LTBI that progresses to active tuberculosis (TB) in people with HIV. DESIGN We developed a decision-analytical model that constituted a decision tree covering diagnosis of LTBI and a Markov model covering progression to active TB. The model represents the lifetime experience following testing for LTBI, and discounting costs, and benefits at 3.5% per annum in line with UK standards. We undertook probabilistic and one-way sensitivity analyses. SETTING UK National Health Service and Personal Social Service perspective in a primary care setting. PARTICIPANTS Hypothetical cohort of adults recently diagnosed with HIV. INTERVENTIONS Interferon-gamma release assays and tuberculin skin test. MAIN OUTCOME MEASURE Cost per quality-adjusted life year (QALY). RESULTS All strategies except T-SPOT.TB were cost-effective at identifying LTBI, with the QFT-GIT-negative followed by TST5mm strategy being the most costly and effective. Results indicated that there was little preference between strategies at a willingness-to-pay threshold of £20 000. At thresholds above £40 000 per QALY, there was a clear preference for the QFT-GIT-negative followed by TST5mm, with a probability of 0.41 of being cost-effective. Results showed that specificity for QFT-GIT and TST5mm were the main drivers of the economic model. CONCLUSION Screening for LTBI has important public health and clinical benefits. Most of the strategies are cost-effective. These results should be interpreted with caution because of the paucity of studies included in the meta-analysis of test accuracy studies. Additional high-quality primary studies are needed to have a definitive answer about, which strategy is the most effective.
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Affiliation(s)
| | | | - Noel D McCarthy
- Evidence in Communicable Disease Epidemiology and Control, Warwick Medical School, University of Warwick, Coventry, UK
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Kanabalan RD, Lee LJ, Lee TY, Chong PP, Hassan L, Ismail R, Chin VK. Human tuberculosis and Mycobacterium tuberculosis complex: A review on genetic diversity, pathogenesis and omics approaches in host biomarkers discovery. Microbiol Res 2021; 246:126674. [PMID: 33549960 DOI: 10.1016/j.micres.2020.126674] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 12/09/2020] [Accepted: 12/16/2020] [Indexed: 12/16/2022]
Abstract
Mycobacterium tuberculosis complex (MTBC) refers to a group of mycobacteria encompassing nine members of closely related species that causes tuberculosis in animals and humans. Among the nine members, Mycobacterium tuberculosis (M. tuberculosis) remains the main causative agent for human tuberculosis that results in high mortality and morbidity globally. In general, MTBC species are low in diversity but exhibit distinctive biological differences and phenotypes among different MTBC lineages. MTBC species are likely to have evolved from a common ancestor through insertions/deletions processes resulting in species speciation with different degrees of pathogenicity. The pathogenesis of human tuberculosis is complex and remains poorly understood. It involves multi-interactions or evolutionary co-options between host factors and bacterial determinants for survival of the MTBC. Granuloma formation as a protection or survival mechanism in hosts by MTBC remains controversial. Additionally, MTBC species are capable of modulating host immune response and have adopted several mechanisms to evade from host immune attack in order to survive in humans. On the other hand, current diagnostic tools for human tuberculosis are inadequate and have several shortcomings. Numerous studies have suggested the potential of host biomarkers in early diagnosis of tuberculosis, in disease differentiation and in treatment monitoring. "Multi-omics" approaches provide holistic views to dissect the association of MTBC species with humans and offer great advantages in host biomarkers discovery. Thus, in this review, we seek to understand how the genetic variations in MTBC lead to species speciation with different pathogenicity. Furthermore, we also discuss how the host and bacterial players contribute to the pathogenesis of human tuberculosis. Lastly, we provide an overview of the journey of "omics" approaches in host biomarkers discovery in human tuberculosis and provide some interesting insights on the challenges and directions of "omics" approaches in host biomarkers innovation and clinical implementation.
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Affiliation(s)
- Renuga Devi Kanabalan
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latiff, Bandar Tun Razak, Kuala Lumpur, 56000, Malaysia
| | - Le Jie Lee
- Prima Nexus Sdn. Bhd., Menara CIMB, Jalan Stesen Sentral 2, Kuala Lumpur, Malaysia
| | - Tze Yan Lee
- Perdana University School of Liberal Arts, Science and Technology (PUScLST), Suite 9.2, 9th Floor, Wisma Chase Perdana, Changkat Semantan Damansara Heights, Kuala Lumpur, 50490, Malaysia
| | - Pei Pei Chong
- School of Biosciences, Faculty of Health and Medical Sciences, Taylor's University Lakeside Campus, Subang Jaya, 47500, Malaysia
| | - Latiffah Hassan
- Department of Veterinary Laboratory Diagnostics, Faculty of Veterinary Medicine, Universiti Putra Malaysia, Serdang, Selangor, 43400 UPM, Malaysia
| | - Rosnah Ismail
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latiff, Bandar Tun Razak, Kuala Lumpur, 56000, Malaysia.
| | - Voon Kin Chin
- Department of Medical Microbiology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, 43400 UPM, Malaysia; Integrative Pharmacogenomics Institute (iPROMISE), Universiti Teknologi MARA, Puncak Alam Campus, Bandar Puncak Alam, Selangor, 42300, Malaysia.
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6
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[Interferon gamma release assay tests and HIV infection]. Rev Mal Respir 2018; 35:883-886. [PMID: 30224209 DOI: 10.1016/j.rmr.2018.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 03/21/2018] [Indexed: 11/21/2022]
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7
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Sambarey A, Devaprasad A, Mohan A, Ahmed A, Nayak S, Swaminathan S, D'Souza G, Jesuraj A, Dhar C, Babu S, Vyakarnam A, Chandra N. Unbiased Identification of Blood-based Biomarkers for Pulmonary Tuberculosis by Modeling and Mining Molecular Interaction Networks. EBioMedicine 2016; 15:112-126. [PMID: 28065665 PMCID: PMC5233809 DOI: 10.1016/j.ebiom.2016.12.009] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 12/16/2016] [Accepted: 12/16/2016] [Indexed: 02/06/2023] Open
Abstract
Efficient diagnosis of tuberculosis (TB) is met with multiple challenges, calling for a shift of focus from pathogen-centric diagnostics towards identification of host-based multi-marker signatures. Transcriptomics offer a list of differentially expressed genes, but cannot by itself identify the most influential contributors to the disease phenotype. Here, we describe a computational pipeline that adopts an unbiased approach to identify a biomarker signature. Data from RNA sequencing from whole blood samples of TB patients were integrated with a curated genome-wide molecular interaction network, from which we obtain a comprehensive perspective of variations that occur in the host due to TB. We then implement a sensitive network mining method to shortlist gene candidates that are most central to the disease alterations. We then apply a series of filters that include applicability to multiple publicly available datasets as well as additional validation on independent patient samples, and identify a signature comprising 10 genes - FCGR1A, HK3, RAB13, RBBP8, IFI44L, TIMM10, BCL6, SMARCD3, CYP4F3 and SLPI, that can discriminate between TB and healthy controls as well as distinguish TB from latent tuberculosis and HIV in most cases. The signature has the potential to serve as a diagnostic marker of TB.
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Affiliation(s)
| | | | - Abhilash Mohan
- Department of Biochemistry, IISc, Bangalore 560012, India
| | - Asma Ahmed
- Centre for Infectious Disease Research (CIDR), IISc, Bangalore 560012, India
| | - Soumya Nayak
- Centre for Infectious Disease Research (CIDR), IISc, Bangalore 560012, India
| | - Soumya Swaminathan
- National Institute for Research in Tuberculosis, Mayor Sathiyamoorthy Road, Chetpet, Chennai 600031, India
| | - George D'Souza
- St John's Research Institute, St. John's National Academy of Health Sciences, 560034 Bangalore, India
| | - Anto Jesuraj
- St John's Research Institute, St. John's National Academy of Health Sciences, 560034 Bangalore, India
| | - Chirag Dhar
- St John's Research Institute, St. John's National Academy of Health Sciences, 560034 Bangalore, India
| | - Subash Babu
- NIH-NIRT-ICER, Mayor Sathiyamoorthy Road, Chetpet, Chennai 600031, India
| | - Annapurna Vyakarnam
- Centre for Infectious Disease Research (CIDR), IISc, Bangalore 560012, India; Department of Infectious Diseases, King's College London School of Medicine, Guy's Hospital, Great Maze Pond, London, UK
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Lin AWC, Lau SKP, Woo PCY. Screening and treatment of latent tuberculosis infection among HIV-infected patients in resource-rich settings. Expert Rev Anti Infect Ther 2016; 14:489-500. [PMID: 26999724 DOI: 10.1586/14787210.2016.1168693] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Current international guidelines recommend screening and treatment of latent tuberculosis (TB) infection in HIV-infected patients in all settings. The main factors affecting the risk of TB in HIV-infected patients include the level of immunosuppression, coverage of antiretroviral therapy and local TB burden. In resource-rich settings where antiretroviral therapy is more accessible and HIV-infected patients are expected to be diagnosed at an earlier stage, local TB burden remains a key factor on their risk of TB. This article reviewed the epidemiology of latent TB infection among the adult HIV-infected patients, and the use and benefit of screening and treatment of latent TB infection in resource-rich settings in the past decade. While such practice should be continued in countries with medium or high TB burden, targeted screening and treatment only for HIV-infected patients with additional risk factors for TB might be a more practical option in resource-rich countries with low TB burden.
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Affiliation(s)
- Ada W C Lin
- a Department of Microbiology , The University of Hong Kong , Hong Kong , China
| | - Susanna K P Lau
- a Department of Microbiology , The University of Hong Kong , Hong Kong , China.,b State Key Laboratory of Emerging Infectious Diseases , The University of Hong Kong , Hong Kong , China.,c Research Centre of Infection and Immunology , The University of Hong Kong , Hong Kong , China.,d Carol Yu Centre for Infection , The University of Hong Kong , Hong Kong , China
| | - Patrick C Y Woo
- a Department of Microbiology , The University of Hong Kong , Hong Kong , China.,b State Key Laboratory of Emerging Infectious Diseases , The University of Hong Kong , Hong Kong , China.,c Research Centre of Infection and Immunology , The University of Hong Kong , Hong Kong , China.,d Carol Yu Centre for Infection , The University of Hong Kong , Hong Kong , China
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Dai Q, Lu W, Hou W. QFT-IT for diagnosing and screening TB infection in HIV patients: CD4 cells count as an important influential factor. Int J STD AIDS 2016; 27:701. [PMID: 27278449 DOI: 10.1177/0956462415606253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Qinghai Dai
- Tianjin Second People's Hospital and Tianjin Institute of Hepatology, Tianjin, People's Republic of China
| | - Wei Lu
- Tianjin Second People's Hospital and Tianjin Institute of Hepatology, Tianjin, People's Republic of China
| | - Wei Hou
- Tianjin Second People's Hospital and Tianjin Institute of Hepatology, Tianjin, People's Republic of China
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Abstract
PURPOSE OF REVIEW The detection of latent tuberculosis infection (LTBI) in different categories of compromised patients is reviewed with focus on the role of strategies incorporating immunodiagnostic tests and analysis of epidemiological and clinical risk factors. RECENT FINDINGS The development of active tuberculosis (TB) is increased in compromised patients and is closely related to determinants for disease reactivation or newly acquired TB infection. A targeted detection of LTBI in these high-risk groups should be performed especially if preventive treatment is planned. The performance of immunodiagnostic tests is highly variable among different groups of immunocompromised individuals. Findings of cross-sectional studies indicate a better diagnostic accuracy of interferon-γ release assays over the tuberculin skin test. The critical issue is that in low-incidence countries, the positive and negative predictive values of any of immunodiagnostic tests were very poor. A targeted testing process involving analysis of TB risk factors increases the predictive positive values of immunodiagnostic tests and may improve LTBI detection. SUMMARY The LTBI detection in immunocompromised patients is a challenge. The development of new immunological biomarkers and integrated clinical and epidemiological strategies are needed to identify LTBI in compromised individuals and to plan preventive chemotherapies in those at risk of developing active TB.
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Lee SSJ, Lin HH, Tsai HC, Su IJ, Yang CH, Sun HY, Hung CC, Sy CL, Wu KS, Chen JK, Chen YS, Fang CT. A Clinical Algorithm to Identify HIV Patients at High Risk for Incident Active Tuberculosis: A Prospective 5-Year Cohort Study. PLoS One 2015; 10:e0135801. [PMID: 26280669 PMCID: PMC4539234 DOI: 10.1371/journal.pone.0135801] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 07/27/2015] [Indexed: 02/07/2023] Open
Abstract
Background Predicting the risk of tuberculosis (TB) in people living with HIV (PLHIV) using a single test is currently not possible. We aimed to develop and validate a clinical algorithm, using baseline CD4 cell counts, HIV viral load (pVL), and interferon-gamma release assay (IGRA), to identify PLHIV who are at high risk for incident active TB in low-to-moderate TB burden settings where highly active antiretroviral therapy (HAART) is routinely provided. Materials and Methods A prospective, 5-year, cohort study of adult PLHIV was conducted from 2006 to 2012 in two hospitals in Taiwan. HAART was initiated based on contemporary guidelines (CD4 count < = 350/μL). Cox regression was used to identify the predictors of active TB and to construct the algorithm. The validation cohorts included 1455 HIV-infected individuals from previous published studies. Area under the receiver operating characteristic (ROC) curve was calculated. Results Seventeen of 772 participants developed active TB during a median follow-up period of 5.21 years. Baseline CD4 < 350/μL or pVL ≥ 100,000/mL was a predictor of active TB (adjusted HR 4.87, 95% CI 1.49–15.90, P = 0.009). A positive baseline IGRA predicted TB in patients with baseline CD4 ≥ 350/μL and pVL < 100,000/mL (adjusted HR 6.09, 95% CI 1.52–24.40, P = 0.01). Compared with an IGRA-alone strategy, the algorithm improved the sensitivity from 37.5% to 76.5%, the negative predictive value from 98.5% to 99.2%. Compared with an untargeted strategy, the algorithm spared 468 (60.6%) from unnecessary TB preventive treatment. Area under the ROC curve was 0.692 (95% CI: 0.587–0.798) for the study cohort and 0.792 (95% CI: 0.776–0.808) and 0.766 in the 2 validation cohorts. Conclusions A validated algorithm incorporating the baseline CD4 cell count, HIV viral load, and IGRA status can be used to guide targeted TB preventive treatment in PLHIV in low-to-moderate TB burden settings where HAART is routinely provided to all PLHIV. The implementation of this algorithm will avoid unnecessary exposure of low-risk patients to drug toxicity and simultaneously, reduce the burden of universal treatment on the healthcare system.
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Affiliation(s)
- Susan Shin-Jung Lee
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Section of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Hsi-Hsun Lin
- Department of Infection Control and Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hung-Chin Tsai
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Section of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Ih-Jen Su
- National Health Research Institute, Zhu-nan, Taiwan
| | - Chin-Hui Yang
- Centers for Disease Control, Ministry of Health and Welfare, Taipei, Taiwan
- Division of Infectious Diseases, Department of Internal Medicine, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
| | - Hsin-Yun Sun
- Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Chin Hung
- Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Cheng-Len Sy
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Section of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Kuan-Sheng Wu
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Section of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Jui-Kuang Chen
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Section of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yao-Shen Chen
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Section of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chi-Tai Fang
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
- * E-mail:
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Zhu C, Liu Z, Li Z, Mei S, Hu Z. The performance and limitation of T-SPOT.TB for the diagnosis of TB in a high prevalence setting. J Thorac Dis 2014; 6:713-9. [PMID: 24976994 DOI: 10.3978/j.issn.2072-1439.2014.04.38] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 04/15/2014] [Indexed: 01/20/2023]
Abstract
BACKGROUND Tuberculosis (TB) diagnosis remains difficulty. The previous reports have shown that the T-SPOT.TB assay may be a more promising diagnostic tool for TB, however, it needs a further study to evaluate the diagnostic value of T-SPOT.TB for the specific populations in a high prevalence setting. METHODS In this present study, we conducted stratified and comparable analyses to explore the clinical value and the limitation of T-SPOT.TB assay in TB diagnosis in a high TB prevalence setting, Southern China. A total of 413 subjects including 163 pulmonary TB (PTB), 39 extrapulmonary TB (EPTB), 106 non-TB pulmonary diseases (NTBPDs), 20 medical staff and 85 healthy controls were included in the study. RESULTS According to T-SPOT.TB, there had a high incidence of latent TB infection (LTBI) in general population in Southern China, especially in the NTBPDS and medical staff. The T-SPOT.TB had a high performance in the diagnosis of active TB (ATB) in a lower risk of TB infection population such as the general population, however, the T-SPOT.TB for the diagnosis of ATB in the high risk of TB infection populations involving close contacts such as the patients with pulmonary diseases (PD) or medical staff isn't reliable due to the interference by LTBI. Under this condition, the value of rule-out of the assay was seemed to be better than that of rule-in. We believed that the T-SPOT.TB is suitable for screening both the EPTB and the ATB combined with diabetes mellitus (DM). However, we found that the sensitivity of T-SPOT.TB in sputum smear-negative population wasn't as high as that in smear-positive population. CONCLUSIONS The T-SPOT.TB testing results should be interpreted with caution combined with subject's characteristics in a high prevalence setting.
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Affiliation(s)
- Changtai Zhu
- 1 Department of Transfusion, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China ; 2 Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China ; 3 Department of Laboratory Medicine, Changzhou Tumor Hospital Soochow University, Changzhou 213001, China ; 4 Department of Emergency Medicine, Changzhou Tumor Hospital Soochow University, Changzhou 213001, China
| | - Zhonghua Liu
- 1 Department of Transfusion, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China ; 2 Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China ; 3 Department of Laboratory Medicine, Changzhou Tumor Hospital Soochow University, Changzhou 213001, China ; 4 Department of Emergency Medicine, Changzhou Tumor Hospital Soochow University, Changzhou 213001, China
| | - Zhiqiang Li
- 1 Department of Transfusion, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China ; 2 Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China ; 3 Department of Laboratory Medicine, Changzhou Tumor Hospital Soochow University, Changzhou 213001, China ; 4 Department of Emergency Medicine, Changzhou Tumor Hospital Soochow University, Changzhou 213001, China
| | - Shencong Mei
- 1 Department of Transfusion, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China ; 2 Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China ; 3 Department of Laboratory Medicine, Changzhou Tumor Hospital Soochow University, Changzhou 213001, China ; 4 Department of Emergency Medicine, Changzhou Tumor Hospital Soochow University, Changzhou 213001, China
| | - Zhongyi Hu
- 1 Department of Transfusion, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China ; 2 Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China ; 3 Department of Laboratory Medicine, Changzhou Tumor Hospital Soochow University, Changzhou 213001, China ; 4 Department of Emergency Medicine, Changzhou Tumor Hospital Soochow University, Changzhou 213001, China
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