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Leukes VN, Hella J, Sabi I, Cossa M, Khosa C, Erkosar B, Mangu C, Siyame E, Mtafya B, Lwilla A, Viegas S, Madeira C, Machiana A, Ribeiro J, Garcia-Basteiro AL, Riess F, Elísio D, Sasamalo M, Mhalu G, Denkinger CM, Castro MDM, Bashir S, Schumacher SG, Tagliani E, Malhotra A, Dowdy D, Schacht C, Buech J, Nguenha D, Ntinginya N, Ruhwald M, Penn-Nicholson A, Kranzer K. Study protocol: a pragmatic, cluster-randomized controlled trial to evaluate the effect of implementation of the Truenat platform/MTB assays at primary health care clinics in Mozambique and Tanzania (TB-CAPT CORE). BMC Infect Dis 2024; 24:107. [PMID: 38243223 PMCID: PMC10797907 DOI: 10.1186/s12879-023-08876-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/05/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND In 2020, the WHO-approved Molbio Truenat platform and MTB assays to detect Mycobacterium tuberculosis complex (MTB) and resistance to rifampicin directly on sputum specimens. This primary health care center-based trial in Mozambique and Tanzania investigates the effect of Truenat platform/MTB assays (intervention arm) combined with rapid communication of results compared to standard of care on TB diagnosis and treatment initiation for microbiologically confirmed TB at 7 days from enrolment. METHODS The Tuberculosis Close the Gap, Increase Access, and Provide Adequate Therapy (TB-CAPT) CORE trial employs a pragmatic cluster randomized controlled design to evaluate the impact of a streamlined strategy for delivery of Truenat platform/MTB assays testing at primary health centers. Twenty-nine centers equipped with TB microscopy units were selected to participate in the trial. Among them, fifteen health centers were randomized to the intervention arm (which involves onsite molecular testing using Truenat platform/MTB assays, process process optimization to enable same-day TB diagnosis and treatment initiation, and feedback on Molbio platform performance) or the control arm (which follows routine care, including on-site sputum smear microscopy and the referral of sputum samples to off-site Xpert testing sites). The primary outcome of the study is the absolute number and proportion of participants with TB microbiological confirmation starting TB treatment within 7 days of their first visit. Secondary outcomes include time to bacteriological confirmation, health outcomes up to 60 days from first visit, as well as user preferences, direct cost, and productivity analyses. ETHICS AND DISSEMINATION TB-CAPT CORE trial has been approved by regulatory and ethical committees in Mozambique and Tanzania, as well as by each partner organization. Consent is informed and voluntary, and confidentiality of participants is maintained throughout. Study findings will be presented at scientific conferences and published in peer-reviewed international journals. TRIAL REGISTRATION US National Institutes of Health's ClinicalTrials.gov, NCT04568954. Registered 23 September 2020.
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Affiliation(s)
| | - J Hella
- Ifakara Health Institute, Dar Es Salaam, Tanzania
| | - I Sabi
- Mbeya Medical Research Centre, National Institute for Medical Research (NIMR), Mbeya, Tanzania
| | - M Cossa
- Centro de Investigação Em Saúde de Manhiça (CISM), Manhica, Mozambique
| | - C Khosa
- Instituto Nacional de Saúde (INS), Marracuene, Mozambique
| | | | - C Mangu
- Mbeya Medical Research Centre, National Institute for Medical Research (NIMR), Mbeya, Tanzania
| | - E Siyame
- Mbeya Medical Research Centre, National Institute for Medical Research (NIMR), Mbeya, Tanzania
| | - B Mtafya
- Mbeya Medical Research Centre, National Institute for Medical Research (NIMR), Mbeya, Tanzania
| | - A Lwilla
- Mbeya Medical Research Centre, National Institute for Medical Research (NIMR), Mbeya, Tanzania
| | - S Viegas
- Instituto Nacional de Saúde (INS), Marracuene, Mozambique
| | - C Madeira
- Instituto Nacional de Saúde (INS), Marracuene, Mozambique
| | - A Machiana
- Instituto Nacional de Saúde (INS), Marracuene, Mozambique
| | - J Ribeiro
- Instituto Nacional de Saúde (INS), Marracuene, Mozambique
| | - A L Garcia-Basteiro
- Centro de Investigação Em Saúde de Manhiça (CISM), Manhica, Mozambique
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - F Riess
- Division of Infectious Diseases and Tropical Medicine, Ludwig Maximilian University Hospital, Munich, Germany
| | - D Elísio
- Centro de Investigação Em Saúde de Manhiça (CISM), Manhica, Mozambique
| | - M Sasamalo
- Ifakara Health Institute, Dar Es Salaam, Tanzania
| | - G Mhalu
- Ifakara Health Institute, Dar Es Salaam, Tanzania
| | - C M Denkinger
- Division of Infectious Disease and Tropical Medicine and German Centre for Infection Research, Heidelberg University Hospital, Heidelberg, Germany
| | - M D M Castro
- Division of Infectious Disease and Tropical Medicine and German Centre for Infection Research, Heidelberg University Hospital, Heidelberg, Germany
| | - S Bashir
- Division of Infectious Disease and Tropical Medicine and German Centre for Infection Research, Heidelberg University Hospital, Heidelberg, Germany
| | | | - E Tagliani
- Emerging Bacterial Pathogens Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - A Malhotra
- Johns Hopkins University (JHU), Baltimore, MD, USA
| | - D Dowdy
- Johns Hopkins University (JHU), Baltimore, MD, USA
| | | | - J Buech
- LINQ Management, Berlin, Germany
| | - D Nguenha
- Centro de Investigação Em Saúde de Manhiça (CISM), Manhica, Mozambique
| | - N Ntinginya
- Mbeya Medical Research Centre, National Institute for Medical Research (NIMR), Mbeya, Tanzania
| | | | | | - K Kranzer
- Division of Infectious Diseases and Tropical Medicine, Ludwig Maximilian University Hospital, Munich, Germany.
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK.
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Abuzerr S, Zinszer K. Computer-aided diagnostic accuracy of pulmonary tuberculosis on chest radiography among lower respiratory tract symptoms patients. Front Public Health 2023; 11:1254658. [PMID: 37965525 PMCID: PMC10641698 DOI: 10.3389/fpubh.2023.1254658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/09/2023] [Indexed: 11/16/2023] Open
Abstract
Even though the Gaza Strip is a low pulmonary tuberculosis (TB) burden region, it is well-known that TB is primarily a socioeconomic problem associated with overcrowding, poor hygiene, a lack of fresh water, and limited access to healthcare, which is the typical case in the Gaza Strip. Therefore, this study aimed at assessing the accuracy of the automatic software computer-aided detection for tuberculosis (CAD4TB) in diagnosing pulmonary TB on chest radiography and compare the CAD4TB software reading with the results of geneXpert. Using a census sampling method, the study was conducted in radiology departments in the Gaza Strip hospitals between 1 December 2022 and 31 March 2023. A digital X-ray, printer, and online X-ray system backed by CAD4TBv6 software were used to screen patients with lower respiratory tract symptoms. GeneXpert analysis was performed for all patients having a score > 40. A total of 1,237 patients presenting with lower respiratory tract symptoms participated in this current study. Chest X-ray readings showed that 7.8% (n = 96) were presumptive for TB. The CAD4TBv6 scores showed that 11.8% (n = 146) of recruited patients were presumptive for TB. GeneXpert testing on sputum samples showed that 6.2% (n = 77) of those with a score > 40 on CAD4TB were positive for pulmonary TB. Significant differences were found in chest X-ray readings, CAD4TBv6 scores, and GeneXpert results among sociodemographic and health status variables (P-value < 0.05). The study showed that the incidence rate of TB in the Gaza Strip is 3.5 per 100,000 population in the Gaza strip. The sensitivity of the CAD4TBv6 score and the symptomatic review for tuberculosis with a threshold score of >40 is 80.2%, and the specificity is 94.0%. The positive Likelihood Ratio is 13.3%, Negative Likelihood Ratio is 0.2 with 7.8% prevalence. Positive Predictive Value is 52.7%, Negative Predictive Value is 98.3%, and accuracy is 92.9%. In a resource-limited country with a high burden of neglected disease, combining chest X-ray readings by CAD4TB and symptomatology is extremely valuable for screening a population at risk. CAD4TB is noticeably more efficient than other methods for TB screening and early diagnosis in people who would otherwise go undetected.
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Affiliation(s)
- Samer Abuzerr
- Department of Medical Sciences, University College of Science and Technology, Gaza, Palestine
| | - Kate Zinszer
- School of Public Health, Department of Social and Preventive Medicine, University of Montreal, Montréal, QC, Canada
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Shah HD, Nazli Khatib M, Syed ZQ, Gaidhane AM, Yasobant S, Narkhede K, Bhavsar P, Patel J, Sinha A, Puwar T, Saha S, Saxena D. Gaps and Interventions across the Diagnostic Care Cascade of TB Patients at the Level of Patient, Community and Health System: A Qualitative Review of the Literature. Trop Med Infect Dis 2022; 7:tropicalmed7070136. [PMID: 35878147 PMCID: PMC9315562 DOI: 10.3390/tropicalmed7070136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/03/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022] Open
Abstract
Tuberculosis (TB) continues to be one of the important public health concerns globally, and India is among the seven countries with the largest burden of TB. There has been a consistent increase in the notifications of TB cases across the globe. However, the 2018 estimates envisage a gap of about 30% between the incident and notified cases of TB, indicating a significant number of patients who remain undiagnosed or ‘missed’. It is important to understand who is ‘missed’, find this population, and provide quality care. Given these complexities, we reviewed the diagnostic gaps in the care cascade for TB. We searched Medline via PubMed and CENTRAL databases via the Cochrane Library. The search strategy for PubMed was tailored to individual databases and was as: ((((((tuberculosis[Title/Abstract]) OR (TB[Title/Abstract])) OR (koch *[Title/Abstract])) OR (“tuberculosis”[MeSH Terms]))) AND (((diagnos *) AND (“diagnosis”[MeSH Terms])))). Furthermore, we screened the references list of the potentially relevant studies to seek additional studies. Studies retrieved from these electronic searches and relevant references included in the bibliography of those studies were reviewed. Original studies in English that assessed the causes of diagnostic gaps and interventions used to address them were included. Delays in diagnosis were found to be attributable to both the individuals’ and the health system’s capacity to diagnose and promptly commence treatment. This review provides insights into the diagnostic gaps in a cascade of care for TB and different interventions adopted in studies to close this gap. The major diagnostic gaps identified in this review are as follows: people may not have access to TB diagnostic tests, individuals are at a higher risk of missed diagnosis, services are available but people may not seek care with a diagnostic facility, and patients are not diagnosed despite reaching health facilities. Therefore, reaching the goal to End TB requires putting in place models and methods to provide prompt and quality assured diagnosis to populations at par.
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Affiliation(s)
- Harsh D Shah
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar 382042, India; (S.Y.); (K.N.); (P.B.); (J.P.); (A.S.); (T.P.); (S.S.); (D.S.)
- Correspondence:
| | - Mahalaqua Nazli Khatib
- Global Evidence Synthesis Initiative, School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha 442004, India; (M.N.K.); (Z.Q.S.); (A.M.G.)
| | - Zahiruddin Quazi Syed
- Global Evidence Synthesis Initiative, School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha 442004, India; (M.N.K.); (Z.Q.S.); (A.M.G.)
| | - Abhay M. Gaidhane
- Global Evidence Synthesis Initiative, School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha 442004, India; (M.N.K.); (Z.Q.S.); (A.M.G.)
| | - Sandul Yasobant
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar 382042, India; (S.Y.); (K.N.); (P.B.); (J.P.); (A.S.); (T.P.); (S.S.); (D.S.)
- Global Evidence Synthesis Initiative, School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha 442004, India; (M.N.K.); (Z.Q.S.); (A.M.G.)
| | - Kiran Narkhede
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar 382042, India; (S.Y.); (K.N.); (P.B.); (J.P.); (A.S.); (T.P.); (S.S.); (D.S.)
| | - Priya Bhavsar
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar 382042, India; (S.Y.); (K.N.); (P.B.); (J.P.); (A.S.); (T.P.); (S.S.); (D.S.)
| | - Jay Patel
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar 382042, India; (S.Y.); (K.N.); (P.B.); (J.P.); (A.S.); (T.P.); (S.S.); (D.S.)
| | - Anish Sinha
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar 382042, India; (S.Y.); (K.N.); (P.B.); (J.P.); (A.S.); (T.P.); (S.S.); (D.S.)
| | - Tapasvi Puwar
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar 382042, India; (S.Y.); (K.N.); (P.B.); (J.P.); (A.S.); (T.P.); (S.S.); (D.S.)
| | - Somen Saha
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar 382042, India; (S.Y.); (K.N.); (P.B.); (J.P.); (A.S.); (T.P.); (S.S.); (D.S.)
- Global Evidence Synthesis Initiative, School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha 442004, India; (M.N.K.); (Z.Q.S.); (A.M.G.)
| | - Deepak Saxena
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar 382042, India; (S.Y.); (K.N.); (P.B.); (J.P.); (A.S.); (T.P.); (S.S.); (D.S.)
- Global Evidence Synthesis Initiative, School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha 442004, India; (M.N.K.); (Z.Q.S.); (A.M.G.)
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Mohammed H, Oljira L, Teji Roba K, Ngadaya E, Mehari R, Manyazewal T, Yimer G. Who to Involve and Where to Start Integrating Tuberculosis Screening into Routine Healthcare Services: Positive Cough of Any Duration as the First Step for Screening Tuberculosis in Ethiopia. Risk Manag Healthc Policy 2021; 14:4749-4756. [PMID: 34858070 PMCID: PMC8630431 DOI: 10.2147/rmhp.s337392] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 11/02/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Recent country surveys have shown an unacceptably high prevalence of confirmed tuberculosis (TB) even among those with a low duration of cough, and more than 50% of those with bacteriologically confirmed pulmonary tuberculosis (PTB) do not report symptoms that correspond to presumptive TB. Furthermore, there has been an increase in the incidence of smear-negative PTB patients who can serve as a source of infection. We investigated whether screening people who sought healthcare for cough of any duration can increase TB case detection in Ethiopia, and compiled the lessons learned and recommendations. METHODS We carried out a facility-based study in Ethiopia. All consenting participants who sought any healthcare at the outpatients department, and healthcare facilities for reproductive and child health, anti-retroviral therapy, and diabetes were screened for cough of any duration, and those with cough underwent further investigations using chest radiography (CXR) (except for pregnant women, patients on anti-retroviral therapy, and diabetic patients) and microbiological tests. Confirmed cases were linked to TB treatment following the country's standard guidelines. RESULTS We screened 195,713 people who sought healthcare for cough of any duration. Of these, 2647 reported cough symptom of any duration, of whom 1853 underwent further diagnostic tests as they fulfilled the criteria for presumptive TB. Overall, 309/1853 (16.7%) were diagnosed with PTB and linked to TB treatment. Screening by cough of any duration and/or CXR improved TB case finding, and engaging all health teams (administrative and supportive staff, as well as healthcare providers) in the TB screening and diagnosis significantly improved the process. CONCLUSION Screening for TB using cough of any duration and/or CXR for any patient who sought healthcare has the potential to increase both the number of presumptive TB cases and the number of patients diagnosed with and treated for TB in Ethiopia. Such initiatives require strong engagement of facility staff, regular maintenance and calibration of TB diagnostic equipment, and uninterrupted reagent supplies.
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Affiliation(s)
- Hussen Mohammed
- Department of Public Health, College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Lemessa Oljira
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Kedir Teji Roba
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Esther Ngadaya
- National Institute for Medical Research, Muhimbili Research Centre, Dares Saalem, Tanzania
| | - Roman Mehari
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tsegahun Manyazewal
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Getnet Yimer
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Ohio State Global One Health Initiative, Office of International Affairs, The Ohio State University, Addis Ababa, Ethiopia
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Creswell J, Khan A, Bakker MI, Brouwer M, Kamineni VV, Mergenthaler C, Smelyanskaya M, Qin ZZ, Ramis O, Stevens R, Reddy KS, Blok L. The TB REACH Initiative: Supporting TB Elimination Efforts in the Asia-Pacific. Trop Med Infect Dis 2020; 5:E164. [PMID: 33114749 PMCID: PMC7709586 DOI: 10.3390/tropicalmed5040164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 10/09/2020] [Accepted: 10/16/2020] [Indexed: 12/19/2022] Open
Abstract
After many years of TB 'control' and incremental progress, the TB community is talking about ending the disease, yet this will only be possible with a shift in the way we approach the TB response. While the Asia-Pacific region has the highest TB burden worldwide, it also has the opportunity to lead the quest to end TB by embracing the four areas laid out in this series: using data to target hotspots, initiating active case finding, provisioning preventive TB treatment, and employing a biosocial approach. The Stop TB Partnership's TB REACH initiative provides a platform to support partners in the development, evaluation and scale-up of new and innovative technologies and approaches to advance TB programs. We present several approaches TB REACH is taking to support its partners in the Asia-Pacific and globally to advance our collective response to end TB.
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Affiliation(s)
- Jacob Creswell
- Stop TB Partnership, 1218 Geneva, Switzerland; (A.K.); (M.S.); (Z.Z.Q.)
| | - Amera Khan
- Stop TB Partnership, 1218 Geneva, Switzerland; (A.K.); (M.S.); (Z.Z.Q.)
| | - Mirjam I Bakker
- KIT Royal Tropical Institute, 1092 Amsterdam, The Netherlands; (M.I.B.); (C.M.); (L.B.)
| | | | | | | | | | - Zhi Zhen Qin
- Stop TB Partnership, 1218 Geneva, Switzerland; (A.K.); (M.S.); (Z.Z.Q.)
| | | | | | - K Srikanth Reddy
- Global Affairs Canada, Global Health and Nutrition Bureau, Ottawa K1A 0G2, ON, Canada;
| | - Lucie Blok
- KIT Royal Tropical Institute, 1092 Amsterdam, The Netherlands; (M.I.B.); (C.M.); (L.B.)
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Shanmugakani RK, Srinivasan B, Glesby MJ, Westblade LF, Cárdenas WB, Raj T, Erickson D, Mehta S. Current state of the art in rapid diagnostics for antimicrobial resistance. LAB ON A CHIP 2020; 20:2607-2625. [PMID: 32644060 PMCID: PMC7428068 DOI: 10.1039/d0lc00034e] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Antimicrobial resistance (AMR) is a fundamental global concern analogous to climate change threatening both public health and global development progress. Infections caused by antimicrobial-resistant pathogens pose serious threats to healthcare and human capital. If the increasing rate of AMR is left uncontrolled, it is estimated that it will lead to 10 million deaths annually by 2050. This global epidemic of AMR necessitates radical interdisciplinary solutions to better detect antimicrobial susceptibility and manage infections. Rapid diagnostics that can identify antimicrobial-resistant pathogens to assist clinicians and health workers in initiating appropriate treatment are critical for antimicrobial stewardship. In this review, we summarize different technologies applied for the development of rapid diagnostics for AMR and antimicrobial susceptibility testing (AST). We briefly describe the single-cell technologies that were developed to hasten the AST of infectious pathogens. Then, the different types of genotypic and phenotypic techniques and the commercially available rapid diagnostics for AMR are discussed in detail. We conclude by addressing the potential of current rapid diagnostic systems being developed as point-of-care (POC) diagnostic tools and the challenges to adapt them at the POC level. Overall, this review provides an insight into the current status of rapid and POC diagnostic systems for AMR.
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Affiliation(s)
- Rathina Kumar Shanmugakani
- Institute for Nutritional Sciences, Global Health, and Technology, Cornell University, Ithaca, New York, USA
- Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Balaji Srinivasan
- Institute for Nutritional Sciences, Global Health, and Technology, Cornell University, Ithaca, New York, USA
- Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Marshall J. Glesby
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Lars F. Westblade
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Washington B. Cárdenas
- Laboratorio para Investigaciones Biomédicas, Escuela Superior Politécnica del Litoral, Guayaquil, Guayas, Ecuador
| | - Tony Raj
- St. John’s Research Institute, Bangalore, Karnataka, India
| | - David Erickson
- Institute for Nutritional Sciences, Global Health, and Technology, Cornell University, Ithaca, New York, USA
- Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
- Sibley School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, New York, USA
| | - Saurabh Mehta
- Institute for Nutritional Sciences, Global Health, and Technology, Cornell University, Ithaca, New York, USA
- Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
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Scott L, David A, Govender L, Furrer J, Rakgokong M, Waja Z, Martinson N, Eisenberg G, Marlowe E, Stevens W. Performance of the Roche cobas MTB Assay for the Molecular Diagnosis of Pulmonary Tuberculosis in a High HIV Burden Setting. J Mol Diagn 2020; 22:1225-1237. [PMID: 32745613 DOI: 10.1016/j.jmoldx.2020.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 05/25/2020] [Accepted: 06/26/2020] [Indexed: 12/21/2022] Open
Abstract
Increased access to and improved sensitivities of methods for diagnosing Mycobacterium tuberculosis infection and detecting rifampicin and isoniazid resistance are needed. Herein, the performance of the new cobas MTB assay for use on cobas 6800/8800 Systems (Roche) was assessed and compared with two other commercial assays: RealTime MTB (Abbott), and Xpert MTB/RIF (Cepheid). Molecular PCR-based assays were conducted on sputum specimens from individuals with presumptive and confirmed tuberculosis (n = 294) from two clinical facilities in South Africa between December 2016 and October 2017. Liquid mycobacterial culture was the reference. Test sensitivities were 94.7% (95% CI, 88%-98%), 92.6% (95% CI, 85%-97%), and 91.6% (95% CI, 84%-96%) for cobas MTB, RealTime MTB, and Xpert MTB/RIF assays, respectively. cobas MTB sensitivity was unaffected by HIV coinfection (95.7%; 95% CI, 88%-99%; n = 176) and sediment testing (94.7%; 95% CI, 88%-98%). Sensitivities were 81.8% (95% CI, 60%-95%), 72.7% (95% CI, 50%-89%), and 72.7% (95% CI, 50%-89%) among smear-negative, culture-positive individuals (n = 221) for cobas MTB, RealTime MTB, and Xpert MTB/RIF assays, respectively. cobas MTB specificity was 95.7% (95% CI, 89%-99%) and 99% (95% CI, 94%-100%) among HIV coinfected and uninfected individuals, respectively. The cobas 6800/8800 system is already implemented in South Africa for high-throughput HIV viral load testing, making it suitable for integrated HIV/tuberculosis diagnostics.
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Affiliation(s)
- Lesley Scott
- Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Science, University of the Witwatersrand, Johannesburg, South Africa.
| | - Anura David
- Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Science, University of the Witwatersrand, Johannesburg, South Africa
| | - Lyndel Govender
- Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Science, University of the Witwatersrand, Johannesburg, South Africa
| | - Jan Furrer
- Division of Clinical Operations, Roche Molecular Diagnostics, Rotkreuz, Switzerland
| | - Modiehi Rakgokong
- Perinatal HIV Research Unit, Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
| | - Ziyaad Waja
- Perinatal HIV Research Unit, Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
| | - Neil Martinson
- Perinatal HIV Research Unit, Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa; Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland
| | - Gabriel Eisenberg
- Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Science, University of the Witwatersrand, Johannesburg, South Africa
| | - Elizabeth Marlowe
- Medical and Scientific Affairs, Roche Molecular Diagnostics, Pleasanton, California
| | - Wendy Stevens
- Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Science, University of the Witwatersrand, Johannesburg, South Africa; National Priority Programme of the National Health Laboratory Service, Johannesburg, South Africa
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Subbaraman R, Jhaveri T, Nathavitharana RR. Closing gaps in the tuberculosis care cascade: an action-oriented research agenda. J Clin Tuberc Other Mycobact Dis 2020; 19:100144. [PMID: 32072022 PMCID: PMC7015982 DOI: 10.1016/j.jctube.2020.100144] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The care cascade-which evaluates outcomes across stages of patient engagement in a health system-is an important framework for assessing quality of tuberculosis (TB) care. In recent years, there has been progress in measuring care cascades in high TB burden countries; however, there are still shortcomings in our knowledge of how to reduce poor patient outcomes. In this paper, we outline a research agenda for understanding why patients fall through the cracks in the care cascade. The pathway for evidence generation will require new systematic reviews, observational cohort studies, intervention development and testing, and continuous quality improvement initiatives embedded within national TB programs. Certain gaps, such as pretreatment loss to follow-up and post-treatment disease recurrence, should be a priority given a relative paucity of high-quality research to understand and address poor outcomes. Research on interventions to reduce death and loss to follow-up during treatment should move beyond a focus on monitoring (or observation) strategies, to address patient needs including psychosocial and nutritional support. While key research questions vary for each gap, some patient populations may experience disparities across multiple stages of care and should be a priority for research, including men, individuals with a prior treatment history, and individuals with drug-resistant TB. Closing gaps in the care cascade will require investments in a bold and innovative action-oriented research agenda.
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Affiliation(s)
- Ramnath Subbaraman
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, USA
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, USA
| | - Tulip Jhaveri
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, USA
| | - Ruvandhi R. Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
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9
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Extrapulmonary tuberculosis in Pakistan- A nation-wide multicenter retrospective study. PLoS One 2020; 15:e0232134. [PMID: 32343714 PMCID: PMC7188211 DOI: 10.1371/journal.pone.0232134] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/07/2020] [Indexed: 11/21/2022] Open
Abstract
Background Pakistan is fifth among high burden countries for tuberculosis. A steady increase is seen in extrapulmonary tuberculosis (EPTB), which now accounts for 20% of all notified TB cases. There is very limited information on the epidemiology of EPTB. This study was performed with the aim to describe the demographic characteristics, clinical manifestations and treatment outcomes of EPTB patients in Pakistan. Method We performed descriptive analysis on routinely collected data for cohorts of TB patients registered nationwide in 2016 at health facilities selected using stratified convenient sampling. Findings Altogether 54092 TB including 15790 (29.2%) EPTB cases were registered in 2016 at 50 study sites. The median age was 24 years for EPTB and 30 years for PTB patients. The crude prevalence of EPTB in females was 30.5% (95%CI; 29.9–31.0) compared to 27.9% (95%CI; 27.3–28.4) in males. The likelihood of having EPTB (OR), was 1.1 times greater for females, 2.0 times for children, and 3.3 times for residents of provinces in the North-West. The most common forms of EPTB were pleural (29.6%), lymphatic (22.7%) and abdominal TB (21.0%). Pleural TB was the most common clinical manifestation in adults (34.2%) and abdominal TB in children (38.4%). An increase in the prevalence of pleural and osteoarticular and decline in lymphatic and abdominal TB was observed with advancing age. Diversity in demography and clinical manifestations were noted between provinces. The treatment success rate for all type EPTB was significantly high compared to bacteriology confirmed PTB with the exception of EPTB affecting CNS with a high mortality rate. Conclusions The study provides an insight into demography, clinical manifestations and treatment outcomes of EPTB. Further studies are needed to explain significant diversities observed between provinces, specific risk factors and challenges concerning EPTB management.
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10
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Cattamanchi A, Berger CA, Shete PB, Turyahabwe S, Joloba M, Moore DAJ, Davis LJ, Katamba A. Implementation science to improve the quality of tuberculosis diagnostic services in Uganda. J Clin Tuberc Other Mycobact Dis 2020; 18:100136. [PMID: 31879703 PMCID: PMC6920311 DOI: 10.1016/j.jctube.2019.100136] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Nucleic acid amplification tests such as Xpert MTB/RIF (Xpert) have the potential to revolutionize tuberculosis (TB) diagnostics and improve case finding in resource-poor settings. However, since its introduction over a decade ago in Uganda, there remain significant gaps along the cascade of care for patients undergoing TB diagnostic evaluation at peripheral health centers. We utilized a systematic, implementation science-based approach to identify key reasons at multiple levels for attrition along the TB diagnostic evaluation cascade of care. Provider- and health system-level barriers fit into four key thematic areas: human resources, material resources, service implementation, and service coordination. Patient-level barriers included the considerable costs and time required to complete health center visits. We developed a theory-informed strategy using the PRECEDE framework to target key barriers by streamlining TB diagnostic evaluation and facilitating continuous quality improvement. The resulting SIMPLE TB strategy involve four key components: 1) Single-sample LED fluorescence microscopy; 2) Daily sputum transport to Xpert testing sites; 3) Text message communication of Xpert results to health centers and patients; and 4) Performance feedback to health centers using a quality improvement framework. This combination of interventions was feasible to implement and significantly improved the provision of high-quality care for patients undergoing TB diagnostic evaluation. We conclude that achieving high coverage of Xpert testing services is not enough. Xpert scale-up should be accompanied by health system co-interventions to facilitate effective implementation and ensure that high quality care is delivered to patients.
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Affiliation(s)
- Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco, United States
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Christopher A. Berger
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco, United States
| | - Priya B. Shete
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco, United States
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Stavia Turyahabwe
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Uganda National Tuberculosis and Leprosy Program, Kampala, Uganda
| | - Moses Joloba
- School of Biomedical Sciences, Makerere University College of Health Sciences, Kampala, Uganda
- Uganda National Tuberculosis Reference Laboratory, Kampala, Uganda
| | - David AJ Moore
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lucian J. Davis
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Epidemiology of Microbial Diseases and Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health; Pulmonary, Critical Care, and Sleep Medicine and Yale Center for Implementation Science, Yale School of Medicine, New Haven, United States
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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11
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Piatek AS, Wells WA, Shen KC, Colvin CE. Realizing the "40 by 2022" Commitment from the United Nations High-Level Meeting on the Fight to End Tuberculosis: What Will It Take to Meet Rapid Diagnostic Testing Needs? GLOBAL HEALTH, SCIENCE AND PRACTICE 2019; 7:551-563. [PMID: 31818871 PMCID: PMC6927833 DOI: 10.9745/ghsp-d-19-00244] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 09/17/2019] [Indexed: 11/23/2022]
Abstract
Existing rapid diagnostics offer faster and more sensitive diagnosis of tuberculosis (TB) and simultaneous detection of multidrug-resistant TB. A 5-fold increase in investment in these tools is needed to meet the needs of the TB community and the United Nations’ ambitious 40 million by 2022 diagnosis and treatment target. The potential gains from full adoption of World Health Organization (WHO)-recommended rapid diagnostics (WRDs) for tuberculosis (TB) are significant, but there is no current analysis of the additional investment needed to reach this goal. We sought to estimate the necessary investment in instruments, tests, and money, using Xpert MTB/RIF (Xpert), which detects Mycobacterium tuberculosis (MTB) and tests for resistance to rifampicin (RIF), as an example. An existing calculator for TB diagnostic needs was adapted to estimate the Xpert needs for a group of 24 countries with high TB burdens. This analysis assumed that countries will achieve the case-finding commitments agreed to at the recent United Nations High-Level Meeting on the Fight to End Tuberculosis, and that countries would adopt the WHO-recommended algorithm in which all people with signs and symptoms of TB receive an Xpert test. When compared to the current investments in these countries, this baseline model revealed that countries would require a 4-fold increase in the number of Xpert modules and a 6-fold increase in the number of Xpert test cartridges per year to meet their full testing needs. The incremental cost of the additional instruments for these countries would total approximately US$474 million, plus an incremental cost each year of cartridges of approximately $586 million, or a 5-fold increase over current investments. A sensitivity analysis revealed a variety of possible changes under alternative scenarios, but most of these changes either do not meet the global goals, are unrealistic, or would result in even greater investment needs. These findings suggest that a major investment is needed in WRD capacity to implement the recommended diagnostic algorithm for TB and reach the case-finding commitments by 2022.
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Affiliation(s)
- Amy S Piatek
- United States Agency for International Development, Washington, DC, USA
| | - William A Wells
- United States Agency for International Development, Washington, DC, USA.
| | - Kaiser C Shen
- United States Agency for International Development, Washington, DC, USA
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12
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Mason PH, Lyttleton C, Marks GB, Fox GJ. The technological imperative in tuberculosis care and prevention in Vietnam. Glob Public Health 2019; 15:307-320. [PMID: 31422743 DOI: 10.1080/17441692.2019.1650950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
A monocausal bacteriological understanding of infectious disease orients tuberculosis control efforts towards antimicrobial interventions. A bias towards technological solutions can leave multistranded public health and social interventions largely neglected. In the context of globalising biomedical approaches to infectious disease control, this ethnography-inspired review article reflects upon the implementation of rapid diagnostic technology in low- and middle-income countries. Fieldwork observations in Vietnam provided a stimulus for a critical review of the global rollout of tuberculosis diagnostic technology. To address local needs in tuberculosis control, health managers in resource-poor settings are readily cooperating with international donors to deploy novel diagnostic technologies throughout national tuberculosis programme facilities. Increasing investment in new diagnostic technologies is predicated on the supposition that these interventions will ameliorate disease outcomes. However, suboptimal treatment control persists even when accurate diagnostic technologies are available, suggesting that promotion of singular technological solutions can distract from addressing systemic change, without which disease susceptibility, propagation of infection, detection gaps, diagnostic delays, and treatment shortfalls persist.
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Affiliation(s)
- Paul H Mason
- NHMRC Tuberculosis Centre of Research Excellence, Australia.,Department of Anthropology, Macquarie University, Sydney, Australia.,School of Social Sciences, Monash University, Clayton, Australia.,Woolcock Institute of Medical Research, University of Sydney, Glebe, Australia
| | - Chris Lyttleton
- Department of Anthropology, Macquarie University, Sydney, Australia
| | - Guy B Marks
- NHMRC Tuberculosis Centre of Research Excellence, Australia.,Woolcock Institute of Medical Research, University of Sydney, Glebe, Australia.,University of New South Wales, Sydney, Australia
| | - Greg J Fox
- NHMRC Tuberculosis Centre of Research Excellence, Australia.,Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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13
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Alagna R, Sawadogo TL, Combary A, Diandé S, Cirillo DM. ASAP-GxNet project in Burkina Faso: fulfil country capacity gaps to ensure efficient utilisation of GeneXpert instruments in tuberculosis care and cascade. ERJ Open Res 2019; 5:00150-2018. [PMID: 30723729 PMCID: PMC6355978 DOI: 10.1183/23120541.00150-2018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 10/11/2018] [Indexed: 11/05/2022] Open
Abstract
Improving availability, accessibility and quality of national GeneXpert networks through ASAP-GxNet http://ow.ly/umaZ30mGRpE.
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Affiliation(s)
| | | | - Adjima Combary
- National Tuberculosis Program, Ouagadougou, Burkina Faso
| | - Souba Diandé
- National Tuberculosis Program, Ouagadougou, Burkina Faso
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14
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Padayatchi N, Daftary A, Naidu N, Naidoo K, Pai M. Tuberculosis: treatment failure, or failure to treat? Lessons from India and South Africa. BMJ Glob Health 2019; 4:e001097. [PMID: 30805207 PMCID: PMC6357918 DOI: 10.1136/bmjgh-2018-001097] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 01/02/2019] [Accepted: 01/04/2019] [Indexed: 11/06/2022] Open
Abstract
Tuberculosis (TB) remains an enormous public health concern globally. India and South Africa rank among the top 10 high TB burden countries with the highest absolute burden of TB, and the second highest rate of TB incidence, respectively. Although the primary drivers of TB transmission vary considerably between these two countries, they do indeed share common themes. In 2017, only 64% of the global estimated incident cases of TB were reported, the remaining 36% of ‘missing’ cases were either undiagnosed, untreated or unreported. These ‘missing TB cases’ have generated much hype for the challenges they present in achieving the End TB Strategy. Although India and South Africa have indeed made significant strides in TB control, analysis of the patient cascade of care clearly suggests that these ‘missed’ patients are not really missing—most are actively engaging the health system—the system, however, is failing to appropriately manage them. In short, quality of TB care is suboptimal and must urgently be addressed, merely focusing on coverage of TB services is no longer sufficient. While the world awaits revolutionary vaccines, drugs and diagnostics, programmatic data indicate that much can be done to accelerate the decline of TB. In this perspective, we compare and contrast these two national epidemics, and explore barriers, with a particular focus on the role of health systems in finding the missing millions.
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Affiliation(s)
- Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.,Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Amrita Daftary
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | - Naressa Naidu
- Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.,Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.,Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
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15
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Kyu HH, Maddison ER, Henry NJ, Ledesma JR, Wiens KE, Reiner R, Biehl MH, Shields C, Osgood-Zimmerman A, Ross JM, Carter A, Frank TD, Wang H, Srinivasan V, Agarwal SK, Alahdab F, Alene KA, Ali BA, Alvis-Guzman N, Andrews JR, Antonio CAT, Atique S, Atre SR, Awasthi A, Ayele HT, Badali H, Badawi A, Barac A, Bedi N, Behzadifar M, Behzadifar M, Bekele BB, Belay SA, Bensenor IM, Butt ZA, Carvalho F, Cercy K, Christopher DJ, Daba AK, Dandona L, Dandona R, Daryani A, Demeke FM, Deribe K, Dharmaratne SD, Doku DT, Dubey M, Edessa D, El-Khatib Z, Enany S, Fernandes E, Fischer F, Garcia-Basteiro AL, Gebre AK, Gebregergs GB, Gebremichael TG, Gelano TF, Geremew D, Gona PN, Goodridge A, Gupta R, Haghparast Bidgoli H, Hailu GB, Hassen HY, Hedayati MTT, Henok A, Hostiuc S, Hussen MA, Ilesanmi OS, Irvani SSN, Jacobsen KH, Johnson SC, Jonas JB, Kahsay A, Kant S, Kasaeian A, Kassa TD, Khader YS, Khafaie MA, Khalil I, Khan EA, Khang YH, Kim YJ, Kochhar S, Koyanagi A, Krohn KJ, Kumar GA, Lakew AM, Leshargie CT, Lodha R, Macarayan ERK, Majdzadeh R, Martins-Melo FR, Melese A, Memish ZA, Mendoza W, Mengistu DT, Mengistu G, Mestrovic T, Moazen B, Mohammad KA, Mohammed S, Mokdad AH, Moosazadeh M, Mousavi SM, Mustafa G, Nachega JB, Nguyen LH, Nguyen SH, Nguyen TH, Ningrum DNA, Nirayo YL, Nong VM, Ofori-Asenso R, Ogbo FA, Oh IH, Oladimeji O, Olagunju AT, Oren E, Pereira DM, Prakash S, Qorbani M, Rafay A, Rai RK, Ram U, Rubino S, Safiri S, Salomon JA, Samy AM, Sartorius B, Satpathy M, Seyedmousavi S, Sharif M, Silva JP, Silveira DGA, Singh JA, Sreeramareddy CT, Tran BX, Tsadik AG, Ukwaja KN, Ullah I, Uthman OA, Vlassov V, Vollset SE, Vu G, Weldegebreal F, Werdecker A, Yimer EM, Yonemoto N, Yotebieng M, Naghavi M, Vos T, Hay SI, Murray CJL. Global, regional, and national burden of tuberculosis, 1990-2016: results from the Global Burden of Diseases, Injuries, and Risk Factors 2016 Study. THE LANCET. INFECTIOUS DISEASES 2018; 18:1329-1349. [PMID: 30507459 PMCID: PMC6250050 DOI: 10.1016/s1473-3099(18)30625-x] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 10/09/2018] [Accepted: 10/10/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although a preventable and treatable disease, tuberculosis causes more than a million deaths each year. As countries work towards achieving the Sustainable Development Goal (SDG) target to end the tuberculosis epidemic by 2030, robust assessments of the levels and trends of the burden of tuberculosis are crucial to inform policy and programme decision making. We assessed the levels and trends in the fatal and non-fatal burden of tuberculosis by drug resistance and HIV status for 195 countries and territories from 1990 to 2016. METHODS We analysed 15 943 site-years of vital registration data, 1710 site-years of verbal autopsy data, 764 site-years of sample-based vital registration data, and 361 site-years of mortality surveillance data to estimate mortality due to tuberculosis using the Cause of Death Ensemble model. We analysed all available data sources, including annual case notifications, prevalence surveys, population-based tuberculin surveys, and estimated tuberculosis cause-specific mortality to generate internally consistent estimates of incidence, prevalence, and mortality using DisMod-MR 2.1, a Bayesian meta-regression tool. We assessed how the burden of tuberculosis differed from the burden predicted by the Socio-demographic Index (SDI), a composite indicator of income per capita, average years of schooling, and total fertility rate. FINDINGS Globally in 2016, among HIV-negative individuals, the number of incident cases of tuberculosis was 9·02 million (95% uncertainty interval [UI] 8·05-10·16) and the number of tuberculosis deaths was 1·21 million (1·16-1·27). Among HIV-positive individuals, the number of incident cases was 1·40 million (1·01-1·89) and the number of tuberculosis deaths was 0·24 million (0·16-0·31). Globally, among HIV-negative individuals the age-standardised incidence of tuberculosis decreased annually at a slower rate (-1·3% [-1·5 to -1·2]) than mortality did (-4·5% [-5·0 to -4·1]) from 2006 to 2016. Among HIV-positive individuals during the same period, the rate of change in annualised age-standardised incidence was -4·0% (-4·5 to -3·7) and mortality was -8·9% (-9·5 to -8·4). Several regions had higher rates of age-standardised incidence and mortality than expected on the basis of their SDI levels in 2016. For drug-susceptible tuberculosis, the highest observed-to-expected ratios were in southern sub-Saharan Africa (13·7 for incidence and 14·9 for mortality), and the lowest ratios were in high-income North America (0·4 for incidence) and Oceania (0·3 for mortality). For multidrug-resistant tuberculosis, eastern Europe had the highest observed-to-expected ratios (67·3 for incidence and 73·0 for mortality), and high-income North America had the lowest ratios (0·4 for incidence and 0·5 for mortality). INTERPRETATION If current trends in tuberculosis incidence continue, few countries are likely to meet the SDG target to end the tuberculosis epidemic by 2030. Progress needs to be accelerated by improving the quality of and access to tuberculosis diagnosis and care, by developing new tools, scaling up interventions to prevent risk factors for tuberculosis, and integrating control programmes for tuberculosis and HIV. FUNDING Bill & Melinda Gates Foundation.
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16
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Cazabon D, Pande T, Kik S, Van Gemert W, Sohn H, Denkinger C, Qin ZZ, Waning B, Pai M. Market penetration of Xpert MTB/RIF in high tuberculosis burden countries: A trend analysis from 2014 - 2016. Gates Open Res 2018; 2:35. [PMID: 30234198 PMCID: PMC6139378 DOI: 10.12688/gatesopenres.12842.2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2018] [Indexed: 11/20/2022] Open
Abstract
Background: Xpert® MTB/RIF, a rapid tuberculosis (TB) molecular test, was endorsed by the World Health Organization in 2010. Since then, 34.4 million cartridges have been procured under concessional pricing. Although the roll out of this diagnostic is promising, previous studies showed low market penetration. Methods: To assess 3-year trends of market penetration of Xpert MTB/RIF in the public sector, smear and Xpert MTB/RIF volumes for the year 2016 were evaluated and policies from 2014-2016 within 22 high-burden countries (HBCs) were studied. A structured questionnaire was sent to representatives of 22 HBCs. The questionnaires assessed the total smear and Xpert MTB/RIF volumes, number of modules and days of operation of GeneXpert machines in National TB Programs (NTPs). Data regarding the use of NTP GeneXpert machines for other diseases and GeneXpert procurement by other disease control programs were collected. Market penetration was estimated by the ratio of total sputum smear volume for initial diagnosis divided by the number of Xpert MTB/RIF tests procured in the public sector. Results: The survey response rate was 21/22 (95%). Smear/Xpert ratios decreased in 17/21 countries and increased in four countries, since 2014. The median ratio decreased from 32.6 (IQR: 44.6) in 2014 to 6.0 (IQR: 15.4) in 2016. In 2016, the median GeneXpert utilization was 20%, however seven countries (7/19; 37%) were running tests for other diseases on their NTP-procured GeneXpert systems in 2017, such as HIV, hepatitis-C virus (HCV),
Chlamydia trachomatis, and
Neisseria gonorrhoeae. Five (5/15; 33%) countries reported GeneXpert procurement by HIV or HCV programs in 2016 and/or 2017. Conclusions: Our results show a positive trend for Xpert MTB/RIF market penetration in 21 HBC public sectors. However, GeneXpert machines were under-utilized for TB, and inadequately exploited as a multi disease technology.
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Affiliation(s)
- Danielle Cazabon
- McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Tripti Pande
- McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Sandra Kik
- Foundation for Innovative New Diagnostics, FIND, Geneva, Switzerland
| | | | - Hojoon Sohn
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Claudia Denkinger
- Foundation for Innovative New Diagnostics, FIND, Geneva, Switzerland
| | | | | | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal, QC, Canada.,Epidemiology & Biostatistics, McGill University, Montreal, QC, Canada
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17
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Cazabon D, Pande T, Kik S, Van Gemert W, Sohn H, Denkinger C, Qin ZZ, Waning B, Pai M. Market penetration of Xpert MTB/RIF in high tuberculosis burden countries: A trend analysis from 2014 - 2016. Gates Open Res 2018; 2:35. [PMID: 30234198 DOI: 10.12688/gatesopenres.12842.1] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2018] [Indexed: 01/18/2023] Open
Abstract
Background: Xpert® MTB/RIF, a rapid tuberculosis (TB) molecular test, was endorsed by the World Health Organization in 2010. Since then, 34.4 million cartridges have been procured under concessional pricing. Although the roll out of this diagnostic is promising, previous studies showed low market penetration. Methods: To assess 3-year trends of market penetration of Xpert MTB/RIF in the public sector, smear and Xpert MTB/RIF volumes for the year 2016 were evaluated and policies from 2014-2016 within 22 high-burden countries (HBCs) were studied. A structured questionnaire was sent to representatives of 22 HBCs. The questionnaires assessed the total smear and Xpert MTB/RIF volumes, number of modules and days of operation of GeneXpert machines in National TB Programs (NTPs). Data regarding the use of NTP GeneXpert machines for other diseases and GeneXpert procurement by other disease control programs were collected. Market penetration was estimated by the ratio of total sputum smear volume for initial diagnosis divided by the number of Xpert MTB/RIF tests procured in the public sector. Results: The survey response rate was 21/22 (95%). Smear/Xpert ratios decreased in 17/21 countries and increased in four countries, since 2014. The median ratio decreased from 32.6 (IQR: 44.6) in 2014 to 6.0 (IQR: 15.4) in 2016. In 2016, the median GeneXpert utilization was 20%, however seven countries (7/19; 37%) were running tests for other diseases on their NTP-procured GeneXpert systems in 2017, such as HIV, hepatitis-C virus (HCV), Chlamydia trachomatis, and Neisseria gonorrhoeae. Five (5/15; 33%) countries reported GeneXpert procurement by HIV or HCV programs in 2016 and/or 2017. Conclusions: Our results show a positive trend for Xpert MTB/RIF market penetration in 21 HBC public sectors. However, GeneXpert machines were under-utilized for TB, and inadequately exploited as a multi disease technology.
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Affiliation(s)
- Danielle Cazabon
- McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Tripti Pande
- McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Sandra Kik
- Foundation for Innovative New Diagnostics, FIND, Geneva, Switzerland
| | | | - Hojoon Sohn
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Claudia Denkinger
- Foundation for Innovative New Diagnostics, FIND, Geneva, Switzerland
| | | | | | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal, QC, Canada.,Epidemiology & Biostatistics, McGill University, Montreal, QC, Canada
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18
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Zaidi SMA, Habib SS, Van Ginneken B, Ferrand RA, Creswell J, Khowaja S, Khan A. Evaluation of the diagnostic accuracy of Computer-Aided Detection of tuberculosis on Chest radiography among private sector patients in Pakistan. Sci Rep 2018; 8:12339. [PMID: 30120345 PMCID: PMC6098114 DOI: 10.1038/s41598-018-30810-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 07/31/2018] [Indexed: 11/09/2022] Open
Abstract
The introduction of digital CXR with automated computer-aided interpretation, has given impetus to the role of CXR in TB screening, particularly in low resource, high-burden settings. The aim of this study was to evaluate the diagnostic accuracy of CAD4TB as a screening tool, implemented in the private sector in Karachi, Pakistan. This study analyzed retrospective data from CAD4TB and Xpert MTB/RIF testing carried out at two private TB treatment and diagnostic centers in Karachi. Sensitivity, specificity, potential Xperts saved, were computed and the receiver operator characteristic curves were constructed for four different models of CAD4TB. A total of 6,845 individuals with presumptive TB were enrolled in the study, 15.2% of which had MTB + ve result on Xpert. A high sensitivity (range 65.8-97.3%) and NPV (range 93.1-98.4%) were recorded for CAD4TB. The Area under the ROC curve (AUC) for CAD4TB was 0.79. CAD4TB with patient demographics (age and gender) gave an AUC of 0.83. CAD4TB offered high diagnostic accuracy. In low resource settings, CAD4TB, as a triage tool could minimize use of Xpert. Using CAD4TB in combination with age and gender data enhanced the performance of the software. Variations in demographic information generate different individual risk probabilities for the same CAD4TB scores.
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Affiliation(s)
| | | | | | | | - Jacob Creswell
- StopTB Partnership, 1214 Geneva, 1214, Vernier, Switzerland
| | - Saira Khowaja
- Interactive Research & Development, Karachi, 75190, Pakistan
| | - Aamir Khan
- Interactive Research & Development, Karachi, 75190, Pakistan
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Baron EJ, Tenover FC, Gnanashanmugam D. Direct Detection of Mycobacterium tuberculosis in Clinical Specimens Using Nucleic Acid Amplification Tests. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.clinmicnews.2018.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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20
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Boudarene L, James R, Coker R, Khan MS. Are scientific research outputs aligned with national policy makers' priorities? A case study of tuberculosis in Cambodia. Health Policy Plan 2018; 32:i3-i11. [PMID: 29028223 DOI: 10.1093/heapol/czx041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2017] [Indexed: 11/13/2022] Open
Abstract
With funding for tuberculosis (TB) research decreasing, and the high global disease burden persisting, there are calls for increased investment in TB research. However, justification of such investments is questionable, when translation of research outputs into policy and health care improvements remains a challenge for TB and other diseases. Using TB in Cambodia as a case study, we investigate how evidence needs of national policy makers are addressed by topics covered in research publications. We first conducted a systematic review to compile all studies on TB in Cambodia published since 2000. We then identified priority areas in which evidence for policy and programme planning are required from the perspective of key national TB control stakeholders. Finally, results from the literature review were analysed in relation to the priority research areas for national policy makers to assess overlap and highlight gaps in evidence. Priority research areas were: TB-HIV co-infection; childhood TB; multidrug resistant TB (MDR-TB); and universal and equitable access to quality diagnosis and treatment. On screening 1687 unique papers retrieved from our literature search, 253 were eligible publications focusing on TB in Cambodia. Of these, only 73 (29%) addressed one of the four priority research areas. Overall, 30 (11%), five (2%), seven (2%) and 37 (14%) studies reported findings relevant to TB-HIV, childhood TB, MDR-TB and access to quality diagnosis and treatment respectively. Our analysis shows that a small proportion of the research outputs in Cambodia address priority areas for informing policy and programme planning. This case study illustrates that there is substantial room for improvement in alignment between research outputs and evidence gaps that national policy makers would like to see addressed; better coordination between researchers, funders and policy makers' on identifying priority research topics may increase the relevance of research findings to health policies and programmes.
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Affiliation(s)
- Lydia Boudarene
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore 117549, Singapore.,University of Health Science, 73 Preah Monivong Blvd (93), Phnom Penh, Cambodia
| | - Richard James
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore 117549, Singapore.,University of Health Science, 73 Preah Monivong Blvd (93), Phnom Penh, Cambodia
| | - Richard Coker
- Communicable Diseases Research and Policy Group, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK.,Mahidol University, 420/1 Ratchawithi RD, Ratchathewi District, Bangkok, Thailand
| | - Mishal S Khan
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore 117549, Singapore.,Communicable Diseases Research and Policy Group, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK
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21
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Goenka A, Jeena PM, Mlisana K, Solomon T, Spicer K, Stephenson R, Verma A, Dhada B, Griffiths MJ. Rapid Accurate Identification of Tuberculous Meningitis Among South African Children Using a Novel Clinical Decision Tool. Pediatr Infect Dis J 2018; 37:229-234. [PMID: 28777205 PMCID: PMC5747355 DOI: 10.1097/inf.0000000000001726] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early diagnosis of tuberculous meningitis (TBM) is crucial to achieve optimum outcomes. There is no effective rapid diagnostic test for use in children. We aimed to develop a clinical decision tool to facilitate the early diagnosis of childhood TBM. METHODS Retrospective case-control study was performed across 7 hospitals in KwaZulu-Natal, South Africa (2010-2014). We identified the variables most predictive of microbiologically confirmed TBM in children (3 months to 15 years) by univariate analysis. These variables were modelled into a clinical decision tool and performance tested on an independent sample group. RESULTS Of 865 children with suspected TBM, 3% (25) were identified with microbiologically confirmed TBM. Clinical information was retrieved for 22 microbiologically confirmed cases of TBM and compared with 66 controls matched for age, ethnicity, sex and geographical origin. The 9 most predictive variables among the confirmed cases were used to develop a clinical decision tool (CHILD TB LP): altered Consciousness; caregiver HIV infected; Illness length >7 days; Lethargy; focal neurologic Deficit; failure to Thrive; Blood/serum sodium <132 mmol/L; CSF >10 Lymphocytes ×10/L; CSF Protein >0.65 g/L. This tool successfully classified an independent sample of 7 cases and 21 controls with a sensitivity of 100% and specificity of 90%. CONCLUSIONS The CHILD TB LP decision tool accurately classified microbiologically confirmed TBM. We propose that CHILD TB LP is prospectively evaluated as a novel rapid diagnostic tool for use in the initial evaluation of children with suspected neurologic infection presenting to hospitals in similar settings.
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Affiliation(s)
- Anu Goenka
- Manchester Collaborative Centre for Inflammation Research, University of Manchester, UK
- Manchester Academic Health Sciences Centre, University of Manchester, UK
- Department of Paediatrics and Child Health, Pietermaritzburg Metropolitan Hospitals Complex, South Africa
| | - Prakash M. Jeena
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, South Africa
| | - Koleka Mlisana
- Department of Microbiology, National Health Laboratory Service, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, South Africa
| | - Tom Solomon
- Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection and Global Health, University of Liverpool, UK
- Walton Centre NHS Foundation Trust, UK
| | - Kevin Spicer
- Department of Paediatrics and Child Health, Pietermaritzburg Metropolitan Hospitals Complex, South Africa
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, South Africa
| | - Rebecca Stephenson
- Department of Paediatrics and Child Health, Pietermaritzburg Metropolitan Hospitals Complex, South Africa
| | - Arpana Verma
- Manchester Academic Health Sciences Centre, University of Manchester, UK
- Centre for Epidemiology, Institute of Population Health, University of Manchester, UK
| | - Barnesh Dhada
- Department of Paediatrics and Child Health, Pietermaritzburg Metropolitan Hospitals Complex, South Africa
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, South Africa
| | - Michael J. Griffiths
- Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection and Global Health, University of Liverpool, UK
- Department of Neurology, Alder Hey Children’s NHS Trust, UK
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22
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Naidoo P, Theron G, Rangaka MX, Chihota VN, Vaughan L, Brey ZO, Pillay Y. The South African Tuberculosis Care Cascade: Estimated Losses and Methodological Challenges. J Infect Dis 2017; 216:S702-S713. [PMID: 29117342 PMCID: PMC5853316 DOI: 10.1093/infdis/jix335] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background While tuberculosis incidence and mortality are declining in South Africa, meeting the goals of the End TB Strategy requires an invigorated programmatic response informed by accurate data. Enumerating the losses at each step in the care cascade enables appropriate targeting of interventions and resources. Methods We estimated the tuberculosis burden; the number and proportion of individuals with tuberculosis who accessed tests, had tuberculosis diagnosed, initiated treatment, and successfully completed treatment for all tuberculosis cases, for those with drug-susceptible tuberculosis (including human immunodeficiency virus (HIV)–coinfected cases) and rifampicin-resistant tuberculosis. Estimates were derived from national electronic tuberculosis register data, laboratory data, and published studies. Results The overall tuberculosis burden was estimated to be 532005 cases (range, 333760–764480 cases), with successful completion of treatment in 53% of cases. Losses occurred at multiple steps: 5% at test access, 13% at diagnosis, 12% at treatment initiation, and 17% at successful treatment completion. Overall losses were similar among all drug-susceptible cases and those with HIV coinfection (54% and 52%, respectively, successfully completed treatment). Losses were substantially higher among rifampicin- resistant cases, with only 22% successfully completing treatment. Conclusion Although the vast majority of individuals with tuberculosis engaged the public health system, just over half were successfully treated. Urgent efforts are required to improve implementation of existing policies and protocols to close gaps in tuberculosis diagnosis, treatment initiation, and successful treatment completion.
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Affiliation(s)
- Pren Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Bill and Melinda Gates Foundation, Seattle, Washington
| | - Grant Theron
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research.,MRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Molebogeng X Rangaka
- Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Institute of Global Health, University College London, London, United Kingdom
| | - Violet N Chihota
- Implementation Research Division, Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Louise Vaughan
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research.,MRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Zameer O Brey
- Bill and Melinda Gates Foundation, Seattle, Washington
| | - Yogan Pillay
- HIV/AIDS, TB, and Maternal and Child Health Branch, National Department of Health, Pretoria, South Africa
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23
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Cazabon D, Suresh A, Oghor C, Qin ZZ, Kik SV, Denkinger CM, Pai M. Implementation of Xpert MTB/RIF in 22 high tuberculosis burden countries: are we making progress? Eur Respir J 2017; 50:50/2/1700918. [PMID: 28860268 DOI: 10.1183/13993003.00918-2017] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 05/31/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Danielle Cazabon
- McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Anita Suresh
- McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Collins Oghor
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | | | - Sandra V Kik
- KNCV Tuberculosis Foundation, The Hague, Netherlands
| | | | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal, QC, Canada .,Dept of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
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24
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Gjøen JE, Jenum S, Sivakumaran D, Mukherjee A, Macaden R, Kabra SK, Lodha R, Ottenhoff THM, Haks MC, Doherty TM, Ritz C, Grewal HMS. Novel transcriptional signatures for sputum-independent diagnostics of tuberculosis in children. Sci Rep 2017; 7:5839. [PMID: 28724962 PMCID: PMC5517635 DOI: 10.1038/s41598-017-05057-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 05/24/2017] [Indexed: 11/20/2022] Open
Abstract
Pediatric tuberculosis (TB) is challenging to diagnose, confirmed by growth of Mycobacterium tuberculosis at best in 40% of cases. The WHO has assigned high priority to the development of non-sputum diagnostic tools. We therefore sought to identify transcriptional signatures in whole blood of Indian children, capable of discriminating intra-thoracic TB disease from other symptomatic illnesses. We investigated the expression of 198 genes in a training set, comprising 47 TB cases (19 definite/28 probable) and 36 asymptomatic household controls, and identified a 7- and a 10-transcript signature, both including NOD2, GBP5, IFITM1/3, KIF1B and TNIP1. The discriminatory abilities of the signatures were evaluated in a test set comprising 24 TB cases (17 definite/7 probable) and 26 symptomatic non-TB cases. In separating TB-cases from symptomatic non-TB cases, both signatures provided an AUC of 0.94 (95%CI, 0.88–1.00), a sensitivity of 91.7% (95%CI, 71.5–98.5) regardless of culture status, and 100% sensitivity for definite TB. The 7-transcript signature provided a specificity of 80.8% (95%CI, 60.0–92.7), and the 10-transcript signature a specificity of 88.5% (95%CI, 68.7–96.9%). Although warranting exploration and validation in other populations, our findings are promising and potentially relevant for future non-sputum based POC diagnostic tools for pediatric TB.
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Affiliation(s)
- John Espen Gjøen
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Synne Jenum
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway.,Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway
| | | | - Aparna Mukherjee
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Ragini Macaden
- Division of Infectious Diseases, St. John's Research Institute, Koramangala, Bangalore, India
| | - Sushil K Kabra
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Tom H M Ottenhoff
- Department of Infectious Diseases Group, Immunology and Immunogenetics of Bacterial Infectious Disease, Leiden University Medical Center, Leiden, The Netherlands
| | - Marielle C Haks
- Department of Infectious Diseases Group, Immunology and Immunogenetics of Bacterial Infectious Disease, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark.
| | - Harleen M S Grewal
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway. .,Department of Microbiology, Haukeland University Hospital, University of Bergen, Bergen, Norway.
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25
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Evaluation of the MTBDRplus 2.0 assay for the detection of multidrug resistance among persons with presumptive pulmonary TB in China. Sci Rep 2017; 7:3364. [PMID: 28611407 PMCID: PMC5469733 DOI: 10.1038/s41598-017-03473-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 04/28/2017] [Indexed: 11/08/2022] Open
Abstract
We have conducted a multicenter study of the diagnostic accuracy of the MTBDRplus 2.0 assay in compared with conventional and molecular reference standard in four tuberculosis (TB)-specialized hospitals of China. A total of 5038 patients were enrolled in this study. The overall sensitivity of the assay for the diagnosis of TB was 92.7% [1723/1858, 95% confidence interval (95% CI): 91.5-93.9]. In smear-positive/culture-positive cases the sensitivity was 97.7% (995/1018, 95% CI: 96.6-98.6), whereas in smear-negative/culture-positive cases it was 86.7% (728/840, 95% CI: 84.2-88.9). The agreement rate between MTBDRplus 2.0 and Xpert MTB/RIF was 97.7% (1015/1039, 95% CI: 96.6-98.5) for smear-positive cases and 97.0% (3682/3794, 95% CI: 96.5-97.6) for smear-negative cases. As compared with phenotypic drug susceptibility testing, the MTBDRplus 2.0 correctly identified 298 of 315 patients (94.6%, 95% CI: 91.5-96.8) with rifampicin-resistance. As noted previously, isoniazid resistance is associated with many different mutations and consequently the sensitivity compared to phenotypic testing was lower (81.0%, 95% CI: 76.8-84.7). In conclusion, this assay is a rapid, accurate test in terms of increased sensitivity for detecting smear-negative TB patients, as well as an alternative for detecting both RIF and INH resistance in persons with presumptive TB, whereas the absence of a mutation in the specimens must be interpreted cautiously.
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26
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Pai M, Furin J. Tuberculosis innovations mean little if they cannot save lives. eLife 2017; 6. [PMID: 28460659 PMCID: PMC5413344 DOI: 10.7554/elife.25956] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 04/10/2017] [Indexed: 12/18/2022] Open
Abstract
The past decade has seen the emergence of new diagnostics and drugs for tuberculosis, a disease that kills over 1.8 million people each year. However, these new tools are yet to reach scale, and access remains a major challenge for patients in low and middle income countries. Urgent action is needed if we are committed to ending the TB epidemic. This means raising the level of ambition, embracing innovation, increasing financial investments, addressing implementation gaps, and ensuring that new technologies reach those who need them to survive. Otherwise, the promise of innovative technologies will never be realized.
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Affiliation(s)
- Madhukar Pai
- McGill Global Health Programs and McGill International Tuberculosis Centre, McGill University, Montreal, Canada.,Manipal McGill Centre for Infectious Diseases, Manipal University, Manipal, India
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, United States
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27
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Rahman MT, Codlin AJ, Rahman MM, Nahar A, Reja M, Islam T, Qin ZZ, Khan MAS, Banu S, Creswell J. An evaluation of automated chest radiography reading software for tuberculosis screening among public- and private-sector patients. Eur Respir J 2017; 49:1602159. [PMID: 28529202 PMCID: PMC5460641 DOI: 10.1183/13993003.02159-2016] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 01/09/2017] [Indexed: 11/22/2022]
Abstract
Computer-aided reading (CAR) of medical images is becoming increasingly common, but few studies exist for CAR in tuberculosis (TB). We designed a prospective study evaluating CAR for chest radiography (CXR) as a triage tool before Xpert MTB/RIF (Xpert).Consecutively enrolled adults in Dhaka, Bangladesh, with TB symptoms received CXR and Xpert. Each image was scored by CAR and graded by a radiologist. We compared CAR with the radiologist for sensitivity and specificity, area under the receiver operating characteristic curve (AUC), and calculated the potential Xpert tests saved.A total of 18 036 individuals were enrolled. TB prevalence by Xpert was 15%. The radiologist graded 49% of CXRs as abnormal, resulting in 91% sensitivity and 58% specificity. At a similar sensitivity, CAR had a lower specificity (41%), saving fewer (36%) Xpert tests. The AUC for CAR was 0.74 (95% CI 0.73-0.75). CAR performance declined with increasing age. The radiologist grading was superior across all sub-analyses.Using CAR can save Xpert tests, but the radiologist's specificity was superior. Differentiated CAR thresholds may be required for different populations. Access to, and costs of, human readers must be considered when deciding to use CAR software. More studies are needed to evaluate CAR using different screening approaches.
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Affiliation(s)
- Md Toufiq Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | - Md Mahfuzur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Ayenun Nahar
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mehdi Reja
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tariqul Islam
- National Institute of Neurosciences and Hospital, Dhaka, Bangladesh
| | | | | | - Sayera Banu
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Scott L, da Silva P, Boehme CC, Stevens W, Gilpin CM. Diagnosis of opportunistic infections: HIV co-infections - tuberculosis. Curr Opin HIV AIDS 2017; 12:129-138. [PMID: 28059955 PMCID: PMC6024079 DOI: 10.1097/coh.0000000000000345] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Tuberculosis (TB) incidence has declined ∼1.5% annually since 2000, but continued to affect 10.4 million individuals in 2015, with 1/3 remaining undiagnosed or underreported. The diagnosis of TB among those co-infected with HIV is challenging as TB remains the leading cause of death in such individuals. Accurate and rapid diagnosis of active TB will avert mortality in both adults and children, reduce transmission, and assist in timeous decisions for antiretroviral therapy initiation. This review describes advances in diagnosing TB, especially among HIV co-infected individuals, highlights national program's uptake, and impact on patient care. RECENT FINDINGS The TB diagnostic landscape has been transformed over the last 5 years. Molecular diagnostics such as Xpert MTB/RIF, which simultaneously detects Mycobacterium tuberculosis (MTB) resistance to rifampicin, has revolutionized TB control programs. WHO endorsed the use of Xpert MTB/RIF in 2010 for use in HIV/TB co-infected patients, and later in 2013 for use as the initial diagnostic test for all adults and children with signs and symptoms of pulmonary TB. Line probe assays (LPAs) are recommended for the detection of rifampicin and isoniazid resistance in sputum smear-positive specimens and mycobacterial cultures. A second-line line probe assay has been recommended for the diagnosis of extensively drug-resistant (XDR)-TB Assays such as the urine lateral flow (LF)-lipoarabinomannan (LAM), can be used at the point of care (POC) and have a niche role to supplement the diagnosis of TB in seriously ill HIV-infected, hospitalized patients with low CD4 cell counts of less than 100 cells/μl. Polyvalent platforms such as the m2000 (Abbott Molecular) and GeneXpert (Cepheid) offer potential for integration of HIV and TB testing services. While the Research and Development (R&D) pipeline appears to be rich at first glance, there are actually few leads for true POC tests that would allow for earlier TB diagnosis or rapid, comprehensive drug susceptibility testing, especially when considering the very high attrition rates observed between biomarker discovery and product market entry. SUMMARY In this review, we describe diagnostic strategies specifically for HIV and TB co-infected individuals. Molecular diagnostics in particular within the past 5 years have revolutionized and 'disrupted' this field. They lend themselves to integration of services with platforms capable of polyvalent testing. Impact on patient care is, however, still debatable. What has been highlighted is the need for health system strengthening and for true POC testing that can be used in active case finding.
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Affiliation(s)
- Lesley Scott
- aDepartment of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa bNational Priority Programs, National Health Laboratory Service, Johannesburg, Gauteng, South Africa cFoundation for Innovative New Diagnostics, Geneva dGlobal TB Program, WHO, Geneva, Switzerland
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29
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Clouse K, Blevins M, Lindegren ML, Yotebieng M, Nguyen DT, Omondi A, Michael D, Zannou DM, Carriquiry G, Pettit A. Low implementation of Xpert MTB/RIF among HIV/TB co-infected adults in the International epidemiologic Databases to Evaluate AIDS (IeDEA) program. PLoS One 2017; 12:e0171384. [PMID: 28182705 PMCID: PMC5300213 DOI: 10.1371/journal.pone.0171384] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 01/18/2017] [Indexed: 11/29/2022] Open
Abstract
Objective Xpert MTB/RIF is recommended by the World Health Organization (WHO) as the initial tuberculosis (TB) diagnostic test in individuals suspected of HIV-associated TB. We sought to evaluate field implementation of Xpert among a cohort of HIV/TB co-infected individuals, including availability, utilization and outcomes. Design Observational cohort study (patient-level data) and cross-sectional study (site-level Xpert availability data). Methods Data were collected at 30 participating International epidemiologic Databases to Evaluate AIDS (IeDEA) sites in 18 countries from January 2012-January 2016. All patients were HIV-infected and diagnosed with TB, either bacteriologically or clinically, and followed until a determination of TB treatment outcome. We used multivariable modified Poisson regression to estimate adjusted relative risk (RR) and 95% confidence intervals for unfavorable TB treatment outcomes. Results Most sites (63%) had access to Xpert, either in the clinic (13%), in the same facility (20%) or offsite (30%). Among 2722 HIV/TB patients included, median age was 35.4 years and 41% were female; BMI and CD4 count were low. Overall, most patients (76%) received at least one TB test; 45% were positive. Only 4% of all patients were tested using Xpert: 64% were Xpert-positive, 13% showed rifampicin (RIF) resistance and 30% were extrapulmonary (EPTB) or both pulmonary-EPTB. Treatment outcomes were mostly favorable (77%) and we found little association between Xpert use and an unfavorable TB treatment outcome (RR 1.25, 95%CI: 0.83, 1.90). Conclusions In this cohort, Xpert utilization was low even though the majority of sites had access to the test. Our findings show the need for expanded implementation and further research exploring barriers to use in low-resource settings.
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Affiliation(s)
- Kate Clouse
- Vanderbilt Institute for Global Health, Nashville, Tennessee, United States of America
- Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Tuberculosis Center, Nashville, Tennessee, United States of American
| | - Meridith Blevins
- Vanderbilt Institute for Global Health, Nashville, Tennessee, United States of America
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Mary Lou Lindegren
- Vanderbilt Institute for Global Health, Nashville, Tennessee, United States of America
- Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Marcel Yotebieng
- College of Public Health, The Ohio State University, Columbus, Ohio, United States of America
| | | | - Alfred Omondi
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya
| | - Denna Michael
- National Institute for Medical Research (NIMR), Mwanza, Tanzania
| | | | | | - April Pettit
- Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Tuberculosis Center, Nashville, Tennessee, United States of American
- * E-mail:
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Stevens WS, Scott L, Noble L, Gous N, Dheda K. Impact of the GeneXpert MTB/RIF Technology on Tuberculosis Control. Microbiol Spectr 2017; 5. [PMID: 28155817 DOI: 10.1128/microbiolspec.tbtb2-0040-2016] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Indexed: 11/20/2022] Open
Abstract
Molecular technology revolutionized the diagnosis of tuberculosis (TB) with a paradigm shift to faster, more sensitive, clinically relevant patient care. The most recent molecular leader is the GeneXpert MTB/RIF assay (Xpert) (Cepheid, Sunnyvale, CA), which was endorsed by the World Health Organization with unprecedented speed in December 2010 as the initial diagnostic for detection of HIV-associated TB and for where high rates of drug resistance are suspected. South Africa elected to take an aggressive smear replacement approach to facilitate earlier diagnosis and treatment through the decision to implement the Xpert assay nationally in March 2011, against the backdrop of approximately 6.3 million HIV-infected individuals, one of highest global TB and HIV coinfection rates, no available implementation models, uncertainties around field performance and program costs, and lack of guidance on how to operationalize the assay into existing complex clinical algorithms. South Africa's national implementation was conducted as a phased, forecasted, and managed approach (March 2011 to September 2013), through political will and both treasury-funded and donor-funded support. Today there are 314 GeneXperts across 207 microscopy centers; over 8 million assays have been conducted, and South Africa accounts for over half the global test cartridge usage. As with any implementation of new technology, challenges were encountered, both predicted and unexpected. This chapter discusses the challenges and consequences of such large-scale implementation efforts, the opportunities for new innovations, and the need to strengthen health systems, as well as the impact of the Xpert assay on rifampin-sensitive and multidrug-resistant TB patient care that translated into global TB control as we move toward the sustainable development goals.
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Affiliation(s)
- Wendy Susan Stevens
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, and National Health Laboratory Service and National Priority Program of the National Health Laboratory Service, Johannesburg, South Africa
| | - Lesley Scott
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Lara Noble
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Natasha Gous
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, and National Health Laboratory Service and National Priority Program of the National Health Laboratory Service, Johannesburg, South Africa
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Xpert MTB/RIF Assay Shows Faster Clearance of Mycobacterium tuberculosis DNA with Higher Levels of Rifapentine Exposure. J Clin Microbiol 2016; 54:3028-3033. [PMID: 27733634 PMCID: PMC5121396 DOI: 10.1128/jcm.01313-16] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 09/15/2016] [Indexed: 12/15/2022] Open
Abstract
The Xpert MTB/RIF assay is both sensitive and specific as a diagnostic test. Xpert also reports quantitative output in cycle threshold (CT) values, which may provide a dynamic measure of sputum bacillary burden when used longitudinally. We evaluated the relationship between Xpert CT trajectory and drug exposure during tuberculosis (TB) treatment to assess the potential utility of Xpert CT for treatment monitoring. We obtained serial sputum samples from patients with smear-positive pulmonary TB who were consecutively enrolled at 10 international clinical trial sites participating in study 29X, a CDC-sponsored Tuberculosis Trials Consortium study evaluating the tolerability, safety, and antimicrobial activity of rifapentine at daily doses of up to 20 mg/kg of body weight. Xpert was performed at weeks 0, 2, 4, 6, 8, and 12. Longitudinal CT data were modeled using a nonlinear mixed effects model in relation to rifapentine exposure (area under the concentration-time curve [AUC]). The rate of change of CT was higher in subjects receiving rifapentine than in subjects receiving standard-dose rifampin. Moreover, rifapentine exposure, but not assigned dose, was significantly associated with rate of change in CT (P = 0.02). The estimated increase in CT slope for every additional 100 μg · h/ml of rifapentine drug exposure (as measured by AUC) was 0.11 CT/week (95% confidence interval [CI], 0.05 to 0.17). Increasing rifapentine exposure is associated with a higher rate of change of Xpert CT, indicating faster clearance of Mycobacterium tuberculosis DNA. These data suggest that the quantitative outputs of the Xpert MTB/RIF assay may be useful as a dynamic measure of TB treatment response.
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Albert H, Nathavitharana RR, Isaacs C, Pai M, Denkinger CM, Boehme CC. Development, roll-out and impact of Xpert MTB/RIF for tuberculosis: what lessons have we learnt and how can we do better? Eur Respir J 2016; 48:516-25. [PMID: 27418550 PMCID: PMC4967565 DOI: 10.1183/13993003.00543-2016] [Citation(s) in RCA: 208] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 05/14/2016] [Indexed: 12/03/2022]
Abstract
The global roll-out of Xpert MTB/RIF (Cepheid Inc., Sunnyvale, CA, USA) has changed the diagnostic landscape of tuberculosis (TB). More than 16 million tests have been performed in 122 countries since 2011, and detection of multidrug-resistant TB has increased three- to eight-fold compared to conventional testing. The roll-out has galvanised stakeholders, from donors to civil society, and paved the way for universal drug susceptibility testing. It has attracted new product developers to TB, resulting in a robust molecular diagnostics pipeline. However, the roll-out has also highlighted gaps that have constrained scale-up and limited impact on patient outcomes. The roll-out has been hampered by high costs for under-funded programmes, unavailability of a complete solution package (notably comprehensive training, quality assurance, implementation plans, inadequate service and maintenance support) and lack of impact assessment. Insufficient focus has been afforded to effective linkage to care of diagnosed patients, and clinical impact has been blunted by weak health systems. In many countries the private sector plays a dominant role in TB control, yet this sector has limited access to subsidised pricing. In light of these lessons, we advocate for a comprehensive diagnostics implementation approach, including increased engagement of in-country stakeholders for product launch and roll-out, broader systems strengthening in preparation for new technologies, as well as quality impact data from programmatic settings. A comprehensive diagnostic solution approach including systems strengthening is essential for TB diagnostics impacthttp://ow.ly/uWSy300CfJT
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Affiliation(s)
| | - Ruvandhi R Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Madhukar Pai
- Dept of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Claudia M Denkinger
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA FIND, Geneva, Switzerland
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Bronner Murrison L, Ananthakrishnan R, Sukumar S, Augustine S, Krishnan N, Pai M, Dowdy DW. Use of Rapid, Point-of-Care Assays by Private Practitioners in Chennai, India: Priorities for Tuberculosis Diagnostic Testing. PLoS One 2016; 11:e0155775. [PMID: 27304061 PMCID: PMC4909228 DOI: 10.1371/journal.pone.0155775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 05/24/2016] [Indexed: 11/18/2022] Open
Abstract
SETTING Private practitioners are frequently the first point of healthcare contact for patients with tuberculosis (TB) in India. As new molecular tests are developed for point-of-care (POC) diagnosis of TB, it is imperative to understand these individuals' practices and preferences for POC testing. OBJECTIVE To evaluate rapid testing practices and identify priorities for novel POC TB tests among private practitioners in Chennai. DESIGN We conducted a cross-sectional survey of 228 practitioners practicing in the private sector from January 2014 to February 2015 who saw at least one TB patient in the previous year. Practitioners were randomly selected from both the general community and a list of practitioners who referred patients to a public-private mix program for TB treatment. We used standardized questionnaires to collect data on current practices related to point-of-care diagnosis and interest in hypothetical POC tests. We used multivariable Poisson regression with robust estimates of standard error to calculate measures of association. RESULTS Among 228 private practitioners, about half (48%) utilized any rapid testing in their current practice, most commonly for glucose (43%), pregnancy (21%), and malaria (5%). Providers using POC tests were more likely to work in hospitals (56% vs. 43%, P = 0.05) and less likely to be chest specialists (21% vs. 54%, P<0.001). Only half (51%) of providers would use a hypothetical POC test for TB that was accurate, equipment-free, and took 20 minutes to complete. Chest specialists were half as likely to express interest in performing the hypothetical POC TB test in-house as other practitioners (aPR 0.5, 95%CI: 0.2-0.9). Key challenges to performing POC testing for TB in this study included time constraints, easy access to local private labs and lack of an attached lab facility. CONCLUSION As novel POC tests for TB are developed and scaled up, attention must be paid to integrating these diagnostics into healthcare providers' routine practice and addressing barriers for POC testing.
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Affiliation(s)
- Liza Bronner Murrison
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland, United States of America
| | | | | | | | | | - Madhukar Pai
- McGill International TB Centre & Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - David W. Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
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Pai M, Memish ZA. Antimicrobial resistance and the growing threat of drug-resistant tuberculosis. J Epidemiol Glob Health 2016; 6:45-7. [PMID: 26896704 PMCID: PMC7320441 DOI: 10.1016/j.jegh.2016.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- Madhukar Pai
- McGill Global Health Programs & McGill International TB Centre, McGill University, Montreal, Canada.
| | - Ziad A Memish
- Ministry of Health, Kingdom of Saudi Arabia & College of Medicine, Alfaisal University, Riyadh 11176, Saudi Arabia
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van Cutsem G, Isaakidis P, Farley J, Nardell E, Volchenkov G, Cox H. Infection Control for Drug-Resistant Tuberculosis: Early Diagnosis and Treatment Is the Key. Clin Infect Dis 2016; 62 Suppl 3:S238-43. [PMID: 27118853 PMCID: PMC4845888 DOI: 10.1093/cid/ciw012] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Multidrug-resistant (MDR) tuberculosis, "Ebola with wings," is a significant threat to tuberculosis control efforts. Previous prevailing views that resistance was mainly acquired through poor treatment led to decades of focus on drug-sensitive rather than drug-resistant (DR) tuberculosis, driven by the World Health Organization's directly observed therapy, short course strategy. The paradigm has shifted toward recognition that most DR tuberculosis is transmitted and that there is a need for increased efforts to control DR tuberculosis. Yet most people with DR tuberculosis are untested and untreated, driving transmission in the community and in health systems in high-burden settings. The risk of nosocomial transmission is high for patients and staff alike. Lowering transmission risk for MDR tuberculosis requires a combination approach centered on rapid identification of active tuberculosis disease and tuberculosis drug resistance, followed by rapid initiation of appropriate treatment and adherence support, complemented by universal tuberculosis infection control measures in healthcare facilities. It also requires a second paradigm shift, from the classic infection control hierarchy to a novel, decentralized approach across the continuum from early diagnosis and treatment to community awareness and support. A massive scale-up of rapid diagnosis and treatment is necessary to control the MDR tuberculosis epidemic. This will not be possible without intense efforts toward the implementation of decentralized, ambulatory models of care. Increasing political will and resources need to be accompanied by a paradigm shift. Instead of focusing on diagnosed cases, recognition that transmission is driven largely by undiagnosed, untreated cases, both in the community and in healthcare settings, is necessary. This article discusses this comprehensive approach, strategies available, and associated challenges.
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Affiliation(s)
- Gilles van Cutsem
- Médecins Sans Frontières Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | | | - Jason Farley
- School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Ed Nardell
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts
| | - Grigory Volchenkov
- Department of Tuberculosis Control, Vladimir Oblast Tuberculosis Dispensary, Russian Federation
| | - Helen Cox
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa Division of Medical Microbiology and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
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Pai M, Daftary A, Satyanarayana S. TB control: challenges and opportunities for India. Trans R Soc Trop Med Hyg 2016; 110:158-60. [PMID: 26884494 PMCID: PMC5916376 DOI: 10.1093/trstmh/trw003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/12/2015] [Accepted: 12/28/2015] [Indexed: 11/13/2022] Open
Abstract
India's TB control programme has treated over 19 million patients, but the incidence of TB continues to be high. TB is a major killer and drug-resistant TB is a growing threat. There are several likely reasons, including social conditions and co-morbidities that fuel the TB epidemic: under-investment by the government, weak programme implementation and management, suboptimal quality of care in the private sector, and insufficient advocacy around TB. Fortunately, India possesses the technical know-how, competence and resources to address these challenges. The End TB Strategy by WHO offers India an excellent blueprint to advance the agenda of TB control.
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Affiliation(s)
- Madhukar Pai
- McGill International TB Centre, McGill University, Montreal, Canada
| | - Amrita Daftary
- McGill International TB Centre, McGill University, Montreal, Canada
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Jenum S, Dhanasekaran S, Lodha R, Mukherjee A, Kumar Saini D, Singh S, Singh V, Medigeshi G, Haks MC, Ottenhoff THM, Doherty TM, Kabra SK, Ritz C, Grewal HMS. Approaching a diagnostic point-of-care test for pediatric tuberculosis through evaluation of immune biomarkers across the clinical disease spectrum. Sci Rep 2016; 6:18520. [PMID: 26725873 PMCID: PMC4698754 DOI: 10.1038/srep18520] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 11/09/2015] [Indexed: 02/07/2023] Open
Abstract
The World Health Organization (WHO) calls for an accurate, rapid, and simple point-of-care (POC) test for the diagnosis of pediatric tuberculosis (TB) in order to make progress "Towards Zero Deaths". Whereas the sensitivity of a POC test based on detection of Mycobacterium tuberculosis (MTB) is likely to have poor sensitivity (70-80% of children have culture-negative disease), host biomarkers reflecting the on-going pathological processes across the spectrum of MTB infection and disease may hold greater promise for this purpose. We analyzed transcriptional immune biomarkers direct ex-vivo and translational biomarkers in MTB-antigen stimulated whole blood in 88 Indian children with intra-thoracic TB aged 6 months to 15 years, and 39 asymptomatic siblings. We identified 12 biomarkers consistently associated with either clinical groups "upstream" towards culture-positive TB on the TB disease spectrum (CD14, FCGR1A, FPR1, MMP9, RAB24, SEC14L1, and TIMP2) or "downstream" towards a decreased likelihood of TB disease (BLR1, CD3E, CD8A, IL7R, and TGFBR2), suggesting a correlation with MTB-related pathology and high relevance to a future POC test for pediatric TB. A biomarker signature consisting of BPI, CD3E, CD14, FPR1, IL4, TGFBR2, TIMP2 and TNFRSF1B separated children with TB from asymptomatic siblings (AUC of 88%).
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Affiliation(s)
- Synne Jenum
- Department of Global Public Health and Primary Care, University of Bergen, and Department of Medical Microbiology, Vestre Viken Hospital Trust, Drammen, Norway
| | - S. Dhanasekaran
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, N-5021, Norway
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Aparna Mukherjee
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Kumar Saini
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sarman Singh
- Division of Clinical Microbiology & Molecular Medicine, Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Varinder Singh
- Department of Pediatrics, Kalawati Saran Children Hospital, New Delhi, India
| | - Guruprasad Medigeshi
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Marielle C. Haks
- Department of Infectious Diseases Group, Immunology and Immunogenetics of Bacterial Infectious Disease, Leiden University Medical Center, The Netherland
| | - Tom H. M. Ottenhoff
- Department of Infectious Diseases Group, Immunology and Immunogenetics of Bacterial Infectious Disease, Leiden University Medical Center, The Netherland
| | | | - Sushil K. Kabra
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark
| | - Harleen M. S. Grewal
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, N-5021, Norway
- Department of Microbiology, Haukeland university hospital, University of Bergen,N-5021, Norway
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Testing Pooled Sputum with Xpert MTB/RIF for Diagnosis of Pulmonary Tuberculosis To Increase Affordability in Low-Income Countries. J Clin Microbiol 2015; 53:2502-8. [PMID: 26019204 DOI: 10.1128/jcm.00864-15] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 05/18/2015] [Indexed: 11/20/2022] Open
Abstract
Tuberculosis (TB) is a global public health problem, with the highest burden occurring in low-income countries. In these countries, the use of more sensitive diagnostics, such as Xpert MTB/RIF (Xpert), is still limited by costs. A cost-saving strategy to diagnose other diseases is to pool samples from various individuals and test them with single tests. The samples in positive pool samples are then retested individually to identify the patients with the disease. We assessed a pooled testing strategy to optimize the affordability of Xpert for the diagnosis of TB. Adults with presumptive TB attending hospitals or identified by canvassing of households in Abuja, Nigeria, were asked to provide sputum for individual and pooled (4 per pool) testing. The agreement of the results of testing of individual and pooled samples and costs were assessed. A total of 738 individuals submitted samples, with 115 (16%) being Mycobacterium tuberculosis positive. Valid Xpert results for individual and pooled samples were available for 718 specimens. Of these, testing of pooled samples detected 109 (96%) of 114 individual M. tuberculosis-positive samples, with the overall agreement being 99%. Xpert semiquantitative M. tuberculosis levels had a positive correlation with the smear grades, and the individual sample-positive/pooled sample-negative results were likely due to the M. tuberculosis concentration being below the detection limit. The strategy reduced cartridge costs by 31%. Savings were higher with samples from individuals recruited in the community, where the proportion of positive specimens was low. The results of testing of pooled samples had a high level of agreement with the results of testing of individual samples, and use of the pooled testing strategy reduced costs and has the potential to increase the affordability of Xpert in countries with limited resources.
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Denkinger CM, Dolinger D, Schito M, Wells W, Cobelens F, Pai M, Zignol M, Cirillo DM, Alland D, Casenghi M, Gallarda J, Boehme CC, Perkins MD. Target product profile of a molecular drug-susceptibility test for use in microscopy centers. J Infect Dis 2015; 211 Suppl 2:S39-49. [PMID: 25765105 DOI: 10.1093/infdis/jiu682] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Current phenotypic testing for drug resistance in patients with tuberculosis is inadequate primarily with respect to turnaround time. Molecular tests hold the promise of an improved time to diagnosis. METHODS A target product profile for a molecular drug-susceptibility test (DST) was developed on the basis of a collaborative effort that included opinions gathered from researchers, clinicians, policy makers, and test developers on optimal clinical and operational characteristics in settings of intended use. In addition, the current diagnostic ecosystem and the diagnostic development landscape were mapped. RESULTS Molecular DSTs for detecting tuberculosis in microscopy centers should ideally evaluate for resistance to rifampin, fluoroquinolones, isoniazid, and pyrazinamide and enable the selection of the most appropriate treatment regimen. Performance characteristics of DSTs need to be optimized, but compromises can be made that depend on the trade-off between a false-positive result and a false-negative result. The operational requirements of a test will vary depending on the site of implementation. However, the most-important considerations pertain to quality control, maintenance and calibration, and the ability to export data. CONCLUSION This target product profile defines the needs as perceived by the tuberculosis stakeholder community and attempts to provide a means of communication with test developers to ensure that fit-for-purpose DSTs are being developed.
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Affiliation(s)
- Claudia M Denkinger
- FIND Division of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Marco Schito
- Division of AIDS, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | | | - Frank Cobelens
- KNCV Tuberculosis Foundation, the Hague Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, The Netherlands
| | - Madhukar Pai
- McGill International TB Centre Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
| | | | | | | | | | - Jim Gallarda
- Bill and Melinda Gates Foundation, Seattle, Washington
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Abstract
In a Guest Editorial on World TB Day, Madhukar Pai and Puneet Dewan identify programmatic and policy changes needed to end TB by 2035.
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Affiliation(s)
- Madhukar Pai
- McGill Global Health Programs & McGill International TB Centre, McGill University, Quebec, Canada
- * E-mail:
| | - Puneet Dewan
- Bill & Melinda Gates Foundation, New Delhi, India
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Minchella PA, Donkor S, McDermid JM, Sutherland JS. Iron homeostasis and progression to pulmonary tuberculosis disease among household contacts. Tuberculosis (Edinb) 2015; 95:288-93. [PMID: 25764944 DOI: 10.1016/j.tube.2015.02.042] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 02/16/2015] [Indexed: 12/26/2022]
Abstract
Early identification of individuals at risk for progressing to active tuberculosis (TB) disease may limit new transmission and improve clinical outcomes. Evidence indicates altered iron homeostasis may identify those at greater risk of disease progression in HIV co-infection. We aimed to investigate iron homeostasis biomarkers as risk factors for progression to TB. Archived plasma samples were analyzed from household contacts of pulmonary TB index cases in The Gambia. Contacts were classified as asymptomatic non-progressors (n = 17) or TB-progressors (n = 10), which included two HIV-infected participants. Iron homeostasis (hemoglobin, ferritin, hepcidin, soluble transferrin receptor, transferrin) was assessed in all contacts at study recruitment. Plasma was collected a median of 910 days prior to TB diagnosis. Low transferrin around the time of known exposure to infectious TB was a disease progression risk factor among all TB-progressors (Poisson incidence rate ratio: 0.55; 95% CI: 0.35-0.89). Iron homeostasis also differed between early and delayed TB-progressors, with higher ferritin and hepcidin concentrations observed among early TB-progressors (mean ferritin 50.2 vs. 26.2 ng/ml; P = 0.027; mean hepcidin 37.7 vs. 5.6 ng/ml; P = 0.036). Iron homeostasis is associated with progression to TB among household contacts. Further studies are needed to elucidate mechanisms and determine the clinical utility of monitoring iron homeostasis biomarkers.
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Affiliation(s)
| | - Simon Donkor
- Vaccinology Theme, Medical Research Council Unit, Fajara, Gambia
| | - Joann M McDermid
- Division of Nutritional Sciences, Cornell University, Ithaca, USA.
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