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Wei JH, Qian XQ, Wan YM, Zhao XK, Zhang CY, Guo W, Zhu ZQ. Analysis of unsuccessful tests and the effect of prolonged clinical sample preprocessing in the GeneXpert MTB/RIF assay. BMC Infect Dis 2024; 24:770. [PMID: 39090540 PMCID: PMC11295300 DOI: 10.1186/s12879-024-09684-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 07/29/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND The GeneXpert MTB/RIF (Xpert) assay is a widely used technology for detecting Mycobacterium tuberculosis (MTB) in clinical samples. However, the study on the failure of the Xpert assay during routine implementation and its potential solutions is limited. METHODS We retrospectively analyzed the records of unsuccessful tests in the Xpert and the GeneXpert MTB/RIF Ultra (Ultra) assays between April 2017 and April 2021 at the Shanghai Public Health Clinical Center. To further investigate the effect of prolonged preprocessing on clinical sputum, an additional 120 sputum samples were collected for Xpert testing after 15 min, 3 h, and 6 h preprocessing. The analysis was performed by SPSS version 19.0 software. RESULTS A total of 11,314 test records were analyzed, of which 268 (2.37%) had unsuccessful test results. Among these, 221 (1.95%) were reported as "Error", 43 (0.38%) as "Invalid", and 4 (0.04%) as "No result". The most common clinical specimen for Xpert tests was sputum, accounting for 114 (2.17%) unsuccessful tests. The failure rate of urine specimens was lower than that of sputum (OR = 0.12, 95% CI: 0.02-0.88, χ2 = 6.22, p = 0.021). In contrast, the failure rate of stool specimens was approximately twice as high as that of sputum (OR = 1.93, 95% CI: 1.09-3.40, χ2 = 5.35, p = 0.014). In the prolonged preprocessing experiment, 102 cases (85%) yielded consistent results in Xpert tests. Furthermore, 7 cases (5.83%) detected an increase in MTB load, 8 cases (6.67%) detected a decrease in MTB load, and 3 cases (2.5%) yielded incongruent results in MTB and rifampicin resistance detection. CONCLUSIONS The primary cause of unsuccessful tests in the Xpert assay was reported as "Error". Despite varying failure rates depending on the samples, the Xpert assay can be applied to extrapulmonary samples. For paucibacillary specimens, retesting the remaining preprocessed mixture should be carefully considered.
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Affiliation(s)
- Jian-Hao Wei
- Department of Laboratory Medicine, Shanghai Geriatric Medical Center, Zhongshan Hospital Minhang Meilong, Fudan University, Shanghai, China
| | - Xue-Qin Qian
- Department of Laboratory Medicine, Shanghai Public Health Clinical Center, Shanghai, China
| | - Yan-Min Wan
- Department of Infectious Disease, Huashan Hospital, Shanghai, China
| | - Xiao-Kai Zhao
- Zhejiang Yunying Medical Technology Co., Ltd., Jiaxing, Zhejiang, China
| | - Chun-Yan Zhang
- Department of Laboratory Medicine, Shanghai Geriatric Medical Center, Zhongshan Hospital Minhang Meilong, Fudan University, Shanghai, China
| | - Wei Guo
- Department of Laboratory Medicine, Shanghai Geriatric Medical Center, Zhongshan Hospital Minhang Meilong, Fudan University, Shanghai, China
| | - Zhao-Qin Zhu
- Department of Laboratory Medicine, Shanghai Public Health Clinical Center, Shanghai, China.
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Nwokoye N, Odume B, Nwadike P, Anaedobe I, Mangoro Z, Umoren M, Ogbudebe C, Chukwuogo O, Useni S, Nongo D, Eneogu R, Elom E, De Haas P, Gidado M. Impact of the Stool-Based Xpert Test on Childhood Tuberculosis Diagnosis in Selected States in Nigeria. Trop Med Infect Dis 2024; 9:100. [PMID: 38787033 PMCID: PMC11126095 DOI: 10.3390/tropicalmed9050100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/20/2024] [Accepted: 04/24/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND In Nigeria, most children with tuberculosis (TB) present at primary health clinics where there are limited personnel skilled in collecting appropriate respiratory specimens from those who cannot produce sputum. KNCV Nigeria, in collaboration with the National Tuberculosis Control Program, implemented a modified simple, one-step (SOS), stool-based Xpert MTB/RIF method for diagnosis of TB in children who cannot expectorate sputum. We evaluated the impact of its implementation on childhood TB diagnosis. METHOD A cross-sectional study was conducted across 14 selected states using secondary data of children presumed to have TB. Stool was collected from children presumed to have TB and processed using Xpert. RESULT Out of 52,117 presumptive TB cases, 52% were male and 59.7% were under 5 years old. A total of 2440 (5%) cases were diagnosed with TB, and 2307 (95%) were placed on treatment. Annual TB notifications increased significantly after the introduction of the stool-based Xpert test when compared to those in the pre-implementation period. Increasing contributions from stool testing were observed throughout the implementation period, except in 2020 during the COVID-19 era. Overall, stool Xpert testing improved childhood TB notification in the studied states. Interventions aimed at awareness creation, capacity building, and active case finding improved the performance of the test.
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Affiliation(s)
- Nkiru Nwokoye
- Technical Department, KNCV Nigeria, Abuja 900103, Nigeria; (B.O.); (P.N.); (I.A.); (Z.M.); (M.U.); (C.O.); (O.C.); (S.U.)
| | - Bethrand Odume
- Technical Department, KNCV Nigeria, Abuja 900103, Nigeria; (B.O.); (P.N.); (I.A.); (Z.M.); (M.U.); (C.O.); (O.C.); (S.U.)
| | - Peter Nwadike
- Technical Department, KNCV Nigeria, Abuja 900103, Nigeria; (B.O.); (P.N.); (I.A.); (Z.M.); (M.U.); (C.O.); (O.C.); (S.U.)
| | - Ikechukwu Anaedobe
- Technical Department, KNCV Nigeria, Abuja 900103, Nigeria; (B.O.); (P.N.); (I.A.); (Z.M.); (M.U.); (C.O.); (O.C.); (S.U.)
| | - Zirra Mangoro
- Technical Department, KNCV Nigeria, Abuja 900103, Nigeria; (B.O.); (P.N.); (I.A.); (Z.M.); (M.U.); (C.O.); (O.C.); (S.U.)
| | - Michael Umoren
- Technical Department, KNCV Nigeria, Abuja 900103, Nigeria; (B.O.); (P.N.); (I.A.); (Z.M.); (M.U.); (C.O.); (O.C.); (S.U.)
| | - Chidubem Ogbudebe
- Technical Department, KNCV Nigeria, Abuja 900103, Nigeria; (B.O.); (P.N.); (I.A.); (Z.M.); (M.U.); (C.O.); (O.C.); (S.U.)
| | - Ogoamaka Chukwuogo
- Technical Department, KNCV Nigeria, Abuja 900103, Nigeria; (B.O.); (P.N.); (I.A.); (Z.M.); (M.U.); (C.O.); (O.C.); (S.U.)
| | - Sani Useni
- Technical Department, KNCV Nigeria, Abuja 900103, Nigeria; (B.O.); (P.N.); (I.A.); (Z.M.); (M.U.); (C.O.); (O.C.); (S.U.)
| | - Debby Nongo
- Program Management Department, HIV/AIDS & TB Office, USAID, Abuja 900103, Nigeria; (D.N.); (R.E.)
| | - Rupert Eneogu
- Program Management Department, HIV/AIDS & TB Office, USAID, Abuja 900103, Nigeria; (D.N.); (R.E.)
| | - Emeka Elom
- The Programs and Coordination Department, National Tuberculosis, Leprosy & Buruli Ulcer Control Program, Abuja 904101, Nigeria;
| | - Petra De Haas
- Technical Department, KNCV Tuberculosis Foundation, 2516 AB The Hague, The Netherlands; (P.D.H.); (M.G.)
| | - Mustapha Gidado
- Technical Department, KNCV Tuberculosis Foundation, 2516 AB The Hague, The Netherlands; (P.D.H.); (M.G.)
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Agarwal A, Mathur SB. Stool CBNAAT: Alternative tool in the diagnosis of pulmonary tuberculosis in children. Indian J Tuberc 2023; 70 Suppl 1:S29-S34. [PMID: 38110257 DOI: 10.1016/j.ijtb.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/26/2023] [Accepted: 08/02/2023] [Indexed: 12/20/2023]
Abstract
Tuberculosis (TB) remains a significant public health concern, especially in children. The World Health Organization now provides estimates on pediatric TB cases and deaths, underscoring the urgency of addressing this issue. In India, childhood TB contributes significantly to the global burden, with a notable gap between reported cases and estimated incidence. Diagnosing pulmonary TB in children presents challenges, primarily due to difficulties in obtaining suitable respiratory specimens. Rapid tests like Cartridge-Based Nucleic Acid Amplification Test (CBNAAT) have shown promise in enhancing diagnostic sensitivity. Recent research suggests that stool samples offer a non-invasive alternative for diagnosing pulmonary TB in children, with good diagnostic accuracy observed for stool CBNAAT. Furthermore, stool CBNAAT results demonstrate high agreement with gastric aspirate CBNAAT in TB diagnosis. Various stool processing methods, such as centrifugation, filtration, and sedimentation, have shown improved results for CBNAAT testing. However, it is crucial to standardize these methods to ensure consistent and comparable outcomes. Integrating stool CBNAAT into existing diagnostic algorithms for pediatric TB can enhance accuracy and efficiency in diagnosis. When implementing these algorithms, local resources, epidemiological context, and healthcare settings should be taken into account. Stool CBNAAT holds promise for microbiological confirmation of pediatric pulmonary TB, especially in resource-limited settings where obtaining representative respiratory specimens is challenging. Further comparative studies and standardization of stool processing methods are necessary to determine the most suitable approach in different contexts. By doing so, we can make significant strides in improving TB diagnosis and management in children.
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Affiliation(s)
- Anurag Agarwal
- Department of Pediatrics, Maulana Azad Medical College & Associated Hospitals, Bahadur Shah Zafar Marg, New Delhi, 110002, India.
| | - Surendra Bahadur Mathur
- Department of Pediatrics, Hamdard Institute of Medical Sciences and Research & HAHC Hospital, Hamdard Nagar, New Delhi, 110062, India
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4
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Babo Y, Seremolo B, Bogale M, Bedru A, Wabe Y, Churako H, Bilat A, Degaga T, de Haas P, Tiemersma E, Jerene D. Comparison of Xpert MTB/RIF Ultra Results of Stool and Sputum in Children with Presumptive Tuberculosis in Southern Ethiopia. Trop Med Infect Dis 2023; 8:350. [PMID: 37505646 PMCID: PMC10384425 DOI: 10.3390/tropicalmed8070350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 07/29/2023] Open
Abstract
The introduction of stool as a readily obtainable sample and the recently developed simple one-step (SOS) stool processing method on Xpert MTB/RIF Ultra (Xpert Ultra) offer an opportunity for TB diagnosis in children. We conducted this study in secondary health facilities in Ethiopia, which are the first-level referral facilities for childhood TB diagnosis and treatment, with the aim to determine if stool-based TB diagnosis can be performed with a reasonable level of concordance with sputum tests using Xpert MTB/RIF Ultra. Eligible children 0-14 years old with presumptive pulmonary TB were asked to provide stools in addition to routinely requested sputum samples. We determined the level of agreement between the stool and sputum test results. Of the 373 children included in the study, 61% were <5 years of age and 56% were male. Thirty-six children (9.7%) were diagnosed with TB, and all started treatment. The rate of concordance between stool and sputum was high, with a kappa value of 0.83 (p < 0.001). There were more Xpert Ultra positive results on stool (n = 27 (7.2%)) than on sputum/NGA (n = 23 (6.2%)). Laboratories in secondary hospitals can perform stool-based TB diagnosis in children, with high concordance between stool and sputum test results reaffirming the applicability of the SOS stool method.
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Affiliation(s)
- Yohannes Babo
- KNCV Tuberculosis Foundation, P.O. Box 703 Code 1110, Addis Ababa, Ethiopia
| | - Bihil Seremolo
- KNCV Tuberculosis Foundation, P.O. Box 703 Code 1110, Addis Ababa, Ethiopia
| | - Mamush Bogale
- KNCV Tuberculosis Foundation, P.O. Box 703 Code 1110, Addis Ababa, Ethiopia
| | - Ahmed Bedru
- KNCV Tuberculosis Foundation, P.O. Box 703 Code 1110, Addis Ababa, Ethiopia
| | - Yasin Wabe
- Worabe Comprehensive Specialized Hospital, Worabe, Ethiopia
| | - Haba Churako
- Wolaita Sodo University Hospital, Wolaita, Ethiopia
| | - Alemu Bilat
- Nigist Eleni Memorial Comprehensive Specialized Hospital, Hossana, Ethiopia
| | - Tamiru Degaga
- College of Medicine & Health Sciences, Arba Minch University, Arbaminch, Ethiopia
| | - Petra de Haas
- KNCV Tuberculosis Foundation, Maanweg 174, 2516 AB The Hague, The Netherlands
| | - Edine Tiemersma
- KNCV Tuberculosis Foundation, Maanweg 174, 2516 AB The Hague, The Netherlands
| | - Degu Jerene
- KNCV Tuberculosis Foundation, Maanweg 174, 2516 AB The Hague, The Netherlands
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Mafirakureva N, Klinkenberg E, Spruijt I, Levy J, Shaweno D, de Haas P, Kaswandani N, Bedru A, Triasih R, Gebremichael M, Dodd PJ, Tiemersma EW. Xpert Ultra stool testing to diagnose tuberculosis in children in Ethiopia and Indonesia: a model-based cost-effectiveness analysis. BMJ Open 2022; 12:e058388. [PMID: 35777870 PMCID: PMC9252203 DOI: 10.1136/bmjopen-2021-058388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The WHO currently recommends stool testing using GeneXpert MTB/Rif (Xpert) for the diagnosis of paediatric tuberculosis (TB). The simple one-step (SOS) stool method enables processing for Xpert testing at the primary healthcare (PHC) level. We modelled the impact and cost-effectiveness of implementing the SOS stool method at PHC for the diagnosis of paediatric TB in Ethiopia and Indonesia, compared with the standard of care. SETTING All children (age <15 years) presenting with presumptive TB at primary healthcare or hospital level in Ethiopia and Indonesia. PRIMARY OUTCOME Cost-effectiveness estimated as incremental costs compared with incremental disability-adjusted life-years (DALYs) saved. METHODS Decision tree modelling was used to represent pathways of patient care and referral. We based model parameters on ongoing studies and surveillance, systematic literature review, and expert opinion. We estimated costs using data available publicly and obtained through in-country expert consultations. Health outcomes were based on modelled mortality and discounted life-years lost. RESULTS The intervention increased the sensitivity of TB diagnosis by 19-25% in both countries leading to a 14-20% relative reduction in mortality. Under the intervention, fewer children seeking care at PHC were referred (or self-referred) to higher levels of care; the number of children initiating anti-TB treatment (ATT) increased by 18-25%; and more children (85%) initiated ATT at PHC level. Costs increased under the intervention compared with a base case using smear microscopy in the standard of care resulting in incremental cost-effectiveness ratios of US$132 and US$94 per DALY averted in Ethiopia and Indonesia, respectively. At a cost-effectiveness threshold of 0.5×gross domestic product per capita, the projected probability of the intervention being cost-effective in Ethiopia and Indonesia was 87% and 96%, respectively. The intervention remained cost-effective under sensitivity analyses. CONCLUSIONS The addition of the SOS stool method to national algorithms for diagnosing TB in children is likely to be cost-effective in both Ethiopia and Indonesia.
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Affiliation(s)
| | - Eveline Klinkenberg
- Independent consultant, Connect TB, Den Haag, The Netherlands
- Global Health and Amsterdam Institute for Global Health and Development, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Ineke Spruijt
- Technical Division, KNCV Tuberculosis Foundation, Den Haag, The Netherlands
| | - Jens Levy
- Technical Division, KNCV Tuberculosis Foundation, Den Haag, The Netherlands
| | | | - Petra de Haas
- Technical Division, KNCV Tuberculosis Foundation, Den Haag, The Netherlands
| | - Nastiti Kaswandani
- Pediatric Department, RSCM Hospital, University of Indonesia Faculty of Medicine, Jakarta, Indonesia
| | - Ahmed Bedru
- Technical Division, KNCV Tuberculosis Foundation, Addis Ababa, Ethiopia
| | - Rina Triasih
- Department of Paediatrics, Universitas Gadjah Mada Fakultas Kedokteran, Yogyakarta, Indonesia
| | | | - Peter J Dodd
- ScHARR, The University of Sheffield, Sheffield, UK
| | - Edine W Tiemersma
- Technical Division, KNCV Tuberculosis Foundation, Den Haag, The Netherlands
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6
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Babafemi EO, Cherian BP, Ouma B, Mogoko GM. Paediatric tuberculosis diagnosis using Mycobacterium tuberculosis real-time polymerase chain reaction assay: a systematic review and meta-analysis. Syst Rev 2021; 10:278. [PMID: 34706779 PMCID: PMC8554997 DOI: 10.1186/s13643-021-01836-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 10/12/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Rapid and accurate diagnosis of paediatric tuberculosis (TB) is key to manage the disease and to control and prevent its transmission. Collection of quality sputum samples without invasion methods from paediatrics (age < 16 years) with presumptive pulmonary tuberculosis (PTB) remains a challenge. Thus, the aim of this meta-analysis was to assess the overall accuracy of a real-time polymerase chain reaction (RT-PCR)-based assay, for routine diagnosis of MTB in different samples from paediatrics with active pulmonary and extra-pulmonary tuberculosis using mycobacterial culture as the gold standard in clinical microbiology laboratories. METHODS We conducted a systematic review and meta-analysis to examine the diagnostic test accuracy of RT-PCR based assay for the detection of MTB in paediatric clinical samples. A systematic literature search was performed for publications in any language. MEDLINE via PubMed, EMBASE, and Web of Science were among 9 bibliographic databases searched from August 2019 until November 2020. Bivariate random-effects model of meta-analysis were performed to generate pooled summary estimates (95% CIs) for overall accuracy of RT-PCR based assay compared to mycobacterial culture as the reference standard. RESULTS Of the 1592 candidate studies, twenty-one eligible studies met our inclusion criteria. In total, the review and meta-analysis included 5536 (3209 PTB and 2327 EPTB). Summary estimates for pulmonary TB (11 studies) were as follows: sensitivity 56 (95% CI 51-62), specificity 97 (95% CI 96-98) and summary estimates for extra-pulmonary TB (10 studies) were as follows: sensitivity 87 (95% CI 82-91)) specificity 100 (95% CI 99-100). There was significant heterogeneity in sensitivity and specificity among the enrolled studies (p < 0.001). CONCLUSIONS Our results suggested that the RT-PCR based assay could be a useful test for the diagnosis of paediatrics TB with high sensitivity and specificity in low-income/high-burden and upper medium income/low-burden settings. From the study, RT-PCR assay demonstrated a high degree of sensitivity for extra-pulmonary TB and good sensitivity for pulmonary TB which is an important factor in achieving effective global control and for patient management in terms of initiating early and appropriate anti-tubercular therapy. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018104052.
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Affiliation(s)
| | - Benny P Cherian
- Liverpool John Moores University-City Campus, Liverpool, Merseyside, UK
| | - Beatrice Ouma
- Liverpool John Moores University-City Campus, Liverpool, Merseyside, UK
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The Simple One-Step (SOS) Stool Processing Method for Use with the Xpert MTB/RIF Assay for a Child-Friendly Diagnosis of Tuberculosis Closer to the Point of Care. J Clin Microbiol 2021; 59:e0040621. [PMID: 34076469 PMCID: PMC8373220 DOI: 10.1128/jcm.00406-21] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Young children cannot easily produce sputum for diagnosis of pulmonary tuberculosis (TB). Alternatively, Mycobacterium tuberculosis complex bacilli can be detected in stool by using the Xpert MTB/RIF (Ultra) assay (Xpert). Published stool processing methods contain somewhat complex procedures and require additional supplies. The aim of this study was to develop a simple one-step (SOS) stool processing method based on gravity sedimentation only, similar to Xpert testing of sputum samples, for the detection of M. tuberculosis in stool samples. We first assessed whether the SOS stool method could provide valid Xpert results without the need for bead-beating, dilution, and filtration steps. We concluded that this was the case, and we then validated the SOS stool method by testing spiked stool samples. By using the SOS stool method, 27 of the 29 spiked samples gave valid Xpert results, and M. tuberculosis was recovered from all 27 samples. The proof of principle of the SOS stool method was demonstrated in routine settings in Addis Ababa, Ethiopia. Nine of 123 children with presumptive TB had M. tuberculosis-positive results for nasogastric aspiration (NGA) samples, and 7 (77.8%) of those children also had M. tuberculosis-positive Xpert results for stool samples. Additionally, M. tuberculosis was detected in the stool samples but not the NGA samples from 2 children. The SOS stool processing method makes use of the standard Xpert assay kit, without the need for additional supplies or equipment. The method can potentially be rolled out to any Xpert site, bringing a bacteriologically confirmed diagnosis of TB in children closer to the point of care.
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Orikiriza P, Smith J, Ssekyanzi B, Nyehangane D, Mugisha Taremwa I, Turyashemererwa E, Byamukama O, Tusabe T, Ardizzoni E, Marais BJ, Wobudeya E, Kemigisha E, Mwanga-Amumpaire J, Nampijja D, Bonnet M. Tuberculosis diagnostic accuracy of stool Xpert MTB/RIF and urine AlereLAM in vulnerable children. Eur Respir J 2021; 59:13993003.01116-2021. [PMID: 34140291 DOI: 10.1183/13993003.01116-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/16/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Non-sputum based diagnostic approaches are crucial in children at high risk of disseminated tuberculosis [TB] who cannot expectorate sputum. We evaluated the diagnostic accuracy of Xpert MTB/RIF from stool and urine AlereLipoarabinomannan [LAM] test in this group of children. METHODS Hospitalised children with presumptive TB and either age <2 years, HIV-positive or severe malnutrition were enrolled in a diagnostic cohort. At enrolment, we attempted to collect two urine, two stool and two respiratory samples. Urine and stool were tested with AlereLAM and Xpert MTB/RIF, respectively. Respiratory samples were tested with Xpert MTB/RIF and mycobacterial culture. Both a microbiological and a composite clinical reference standard were used. RESULTS The study enrolled 219 children; median age 16.4 months, 72 (32.9%) HIV-positive and 184 (84.4%) severely malnourished. Twelve (5.5%) and 58 (28.5%) children had confirmed and unconfirmed TB respectively. Stool and urine were collected in 219 (100%) and 216 (98.6%) children. Against the microbiological reference standard the sensitivity and specificity (n/N, 95% confidence intervals) of stool Xpert MTB/RIF was 50.0% (6/12, 21.1-78.9) and 99.1% (198/200 96.4-99.9), while that of urine AlereLAM was 50.0% (6/12, 21.1-78.9) and 74.6% (147/197, 67.9-80.5) respectively. Against the composite reference standard sensitivity was reduced to 11.4% (8/70) for stool and 26.2% (17/68) for urine, with no major difference by age group (<2 and >2 years) or HIV status. CONCLUSION The Xpert MTB/RIF assay has excellent specificity on stool, but sensitivity is suboptimal. Urine AlereLAM is compromised by poor sensitivity and specificity in children.
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Affiliation(s)
- Patrick Orikiriza
- Epicentre Mbarara Research Centre, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda.,Université de Montpellier, IRD, INSERM, TransVIHMI, Montpellier, France
| | | | | | | | | | | | - Onesmas Byamukama
- Epicentre Mbarara Research Centre, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
| | - Tobias Tusabe
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Elisa Ardizzoni
- Mycobacteriology department, Institute of Tropical Medicine, Antwerp, Belgium.,Médecins Sans Frontières, Paris, France
| | - Ben J Marais
- The Children's Hospital at Westmead and WHO Collaborating Centre for Tuberculosis, University of Sydney, Sydney, Australia
| | - Eric Wobudeya
- MUJHU Care Ltd, MUJHU Research Collaboration, Kampala, Uganda
| | - Elizabeth Kemigisha
- Epicentre Mbarara Research Centre, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
| | - Juliet Mwanga-Amumpaire
- Epicentre Mbarara Research Centre, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
| | - Dora Nampijja
- Mbarara University of Science and Technology, Mbarara, Uganda.,Pediatric department, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Maryline Bonnet
- Epicentre Mbarara Research Centre, Mbarara, Uganda .,Université de Montpellier, IRD, INSERM, TransVIHMI, Montpellier, France
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9
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Song R, Click ES, McCarthy KD, Heilig CM, Mchembere W, Smith JP, Fajans M, Musau SK, Okeyo E, Okumu A, Orwa J, Gethi D, Odeny L, Lee SH, Perez-Velez CM, Wright CA, Cain KP. Sensitive and Feasible Specimen Collection and Testing Strategies for Diagnosing Tuberculosis in Young Children. JAMA Pediatr 2021; 175:e206069. [PMID: 33616611 PMCID: PMC7900937 DOI: 10.1001/jamapediatrics.2020.6069] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Criterion-standard specimens for tuberculosis diagnosis in young children, gastric aspirate (GA) and induced sputum, are invasive and rarely collected in resource-limited settings. A far less invasive approach to tuberculosis diagnostic testing in children younger than 5 years as sensitive as current reference standards is important to identify. OBJECTIVE To characterize the sensitivity of preferably minimally invasive specimen and assay combinations relative to maximum observed yield from all specimens and assays combined. DESIGN, SETTING, AND PARTICIPANTS In this prospective cross-sectional diagnostic study, the reference standard was a panel of up to 2 samples of each of 6 specimen types tested for Mycobacterium tuberculosis complex by Xpert MTB/RIF assay and mycobacteria growth indicator tube culture. Multiple different combinations of specimens and tests were evaluated as index tests. A consecutive series of children was recruited from inpatient and outpatient settings in Kisumu County, Kenya, between October 2013 and August 2015. Participants were children younger than 5 years who had symptoms of tuberculosis (unexplained cough, fever, malnutrition) and parenchymal abnormality on chest radiography or who had cervical lymphadenopathy. Children with 1 or more evaluable specimen for 4 or more primary study specimen types were included in the analysis. Data were analyzed from February 2015 to October 2020. MAIN OUTCOMES AND MEASURES Cumulative and incremental diagnostic yield of combinations of specimen types and tests relative to the maximum observed yield. RESULTS Of the 300 enrolled children, the median (interquartile range) age was 2.0 (1.0-3.6) years, and 151 (50.3%) were female. A total of 294 met criteria for analysis. Of 31 participants with confirmed tuberculosis (maximum observed yield), 24 (sensitivity, 77%; interdecile range, 68%-87%) had positive results on up to 2 GA samples and 20 (sensitivity, 64%; interdecile range, 53%-76%) had positive test results on up to 2 induced sputum samples. The yields of 2 nasopharyngeal aspirate (NPA) samples (23 of 31 [sensitivity, 74%; interdecile range, 64%-84%]), of 1 NPA sample and 1 stool sample (22 of 31 [sensitivity, 71%; interdecile range, 60%-81%]), or of 1 NPA sample and 1 urine sample (21.5 of 31 [sensitivity, 69%; interdecile range, 58%-80%]) were similar to reference-standard specimens. Combining up to 2 each of GA and NPA samples had an average yield of 90% (28 of 31). CONCLUSIONS AND RELEVANCE NPA, in duplicate or in combination with stool or urine specimens, was readily obtainable and had diagnostic yield comparable with reference-standard specimens. This combination could improve tuberculosis diagnosis among children in resource-limited settings. Combining GA and NPA had greater yield than that of the current reference standards and may be useful in certain clinical and research settings.
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Affiliation(s)
- Rinn Song
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts,Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | | | | | | | - Walter Mchembere
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Jonathan P. Smith
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia,Northrop Grumman, Atlanta, Georgia
| | - Mark Fajans
- US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Susan K. Musau
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Elisha Okeyo
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Albert Okumu
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - James Orwa
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Dickson Gethi
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Lazarus Odeny
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Scott H. Lee
- US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Carlos M. Perez-Velez
- Tuberculosis Clinic, Pima County Health Department, Tucson, Arizona,Infectious Diseases, University of Arizona College of Medicine, Tucson
| | - Colleen A. Wright
- Division of Anatomical Pathology, University of Stellenbosch, Cape Town, South Africa
| | - Kevin P. Cain
- US Centers for Disease Control and Prevention, Kisumu, Kenya
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10
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Ketema L, Dememew ZG, Assefa D, Gudina T, Kassa A, Letta T, Ayele B, Tadesse Y, Tegegn B, Datiko DG, Negeri C, Bedru A, Klinkenberg E. Evaluating the integration of tuberculosis screening and contact investigation in tuberculosis clinics in Ethiopia: A mixed method study. PLoS One 2020; 15:e0241977. [PMID: 33211710 PMCID: PMC7676707 DOI: 10.1371/journal.pone.0241977] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 10/24/2020] [Indexed: 11/21/2022] Open
Abstract
Background Aligned with global childhood tuberculosis (TB) road map, Ethiopia developed its own in 2015. The key strategies outlined in the Ethiopian roadmap are incorporating TB screening in Integrated Maternal, Neonatal and Child Illnesses (IMNCI) clinic for children under five years (U5) and intensifying contact investigations at TB clinic. However, these strategies have never been evaluated. Objective To evaluate the integration of tuberculosis (TB) screening and contact investigation into Integrated Maternal, Neonatal and Child Illnesses (IMNCI) and TB clinics in Addis Ababa, Ethiopia. Methods The study used mixed methods with stepped-wedge design where 30 randomly selected health care facilities were randomized into three groups of 10 during August 2016-November 2017. The integration of TB screening into IMNCI clinic and contact investigation in TB clinic were introduced by a three-day childhood TB training for health providers. An in-depth interview was used to explore the challenges of the interventions and supplemented data on TB screening and contact investigation. Results Overall, 180896 children attended 30 IMNCI clinics and145444 (80.4%) were screened for TB. A total of 688 (0.4%) children had presumptive TB and 47(0.03%) had TB. During the pre-intervention period, 51873 of the 85278 children (60.8%) were screened for TB as compared to 93570 of the 95618 children (97.9%) in the intervention (p<0.001). This had resulted in 149 (0.30%) and 539 (0.6%) presumptive TB cases in pre-intervention and intervention periods (p<0.001), respectively. Also, nine TB cases (6.0%) in pre-intervention and 38 (7.1%) after intervention were identified (p = 0.72). In TB clinics, 559 under-five (U5) contacts were identified and 419 (80.1%) were screened. In all, 51(9.1%) presumed TB cases and 12 (2.1%) active TB cases were identified from the traced contacts. TB screening was done for 182 of the 275 traced contacts (66.2%) before intervention and for 237 of the 284 of the traced (83.5%) under intervention (p<0.001). Isoniazid prevention therapy (IPT) was initiated for 69 of 163 eligible contacts (42.3%) before intervention and for 159 of 194 eligible children (82.0%) under intervention (p<0.001). Over 95% of health providers indicated that the integration of TB screening into IMNCI and contact investigation in TB clinic is acceptable and practical. Gastric aspiration to collect sputum using nasogastric tube was reported to be difficult. Conclusions Integrating TB screening into IMNCI clinics and intensifying contact investigation in TB clinics is feasible improving TB screening, presumed TB cases, TB cases, contact screening and IPT coverage during the intervention period. Stool specimen could be non-invasive to address the challenge of sputum collection.
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Affiliation(s)
- L. Ketema
- KNVC Tuberculosis Foundation/Management Sciences for Health USAID/Challenge TB Project, Addis Ababa, Ethiopia
| | - Z. G. Dememew
- KNVC Tuberculosis Foundation/Management Sciences for Health USAID/Challenge TB Project, Addis Ababa, Ethiopia
- * E-mail:
| | - D. Assefa
- KNVC Tuberculosis Foundation/Management Sciences for Health USAID/Challenge TB Project, Addis Ababa, Ethiopia
| | - T. Gudina
- Federal Ministry of Health of Ethiopia, National TB Program and Child Health Unit, Addis Ababa, Ethiopia
| | - A. Kassa
- Federal Ministry of Health of Ethiopia, National TB Program and Child Health Unit, Addis Ababa, Ethiopia
| | - T. Letta
- Federal Ministry of Health of Ethiopia, National TB Program and Child Health Unit, Addis Ababa, Ethiopia
| | - B. Ayele
- Federal Ministry of Health of Ethiopia, National TB Program and Child Health Unit, Addis Ababa, Ethiopia
| | - Y. Tadesse
- Federal Ministry of Health of Ethiopia, National TB Program and Child Health Unit, Addis Ababa, Ethiopia
| | - B. Tegegn
- Addis Ababa City Administration Health Bureau, Addis Ababa, Ethiopia
| | - D. G. Datiko
- KNVC Tuberculosis Foundation/Management Sciences for Health USAID/Challenge TB Project, Addis Ababa, Ethiopia
| | - C. Negeri
- KNVC Tuberculosis Foundation/Management Sciences for Health USAID/Challenge TB Project, Addis Ababa, Ethiopia
| | - A. Bedru
- KNVC Tuberculosis Foundation/Management Sciences for Health USAID/Challenge TB Project, Addis Ababa, Ethiopia
| | - E. Klinkenberg
- KNCV Tuberculosis Foundation, The Hague, Netherlands
- Department of Global Health and Amsterdam Institute for Global Health and Development, Location Academic Medical Center, Amsterdam University Medical Centers, Amsterdam, Netherlands
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11
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Kay AW, González Fernández L, Takwoingi Y, Eisenhut M, Detjen AK, Steingart KR, Mandalakas AM. Xpert MTB/RIF and Xpert MTB/RIF Ultra assays for active tuberculosis and rifampicin resistance in children. Cochrane Database Syst Rev 2020; 8:CD013359. [PMID: 32853411 PMCID: PMC8078611 DOI: 10.1002/14651858.cd013359.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Every year, at least one million children become ill with tuberculosis and around 200,000 children die. Xpert MTB/RIF and Xpert Ultra are World Health Organization (WHO)-recommended rapid molecular tests that simultaneously detect tuberculosis and rifampicin resistance in adults and children with signs and symptoms of tuberculosis, at lower health system levels. To inform updated WHO guidelines on molecular assays, we performed a systematic review on the diagnostic accuracy of these tests in children presumed to have active tuberculosis. OBJECTIVES Primary objectives • To determine the diagnostic accuracy of Xpert MTB/RIF and Xpert Ultra for (a) pulmonary tuberculosis in children presumed to have tuberculosis; (b) tuberculous meningitis in children presumed to have tuberculosis; (c) lymph node tuberculosis in children presumed to have tuberculosis; and (d) rifampicin resistance in children presumed to have tuberculosis - For tuberculosis detection, index tests were used as the initial test, replacing standard practice (i.e. smear microscopy or culture) - For detection of rifampicin resistance, index tests replaced culture-based drug susceptibility testing as the initial test Secondary objectives • To compare the accuracy of Xpert MTB/RIF and Xpert Ultra for each of the four target conditions • To investigate potential sources of heterogeneity in accuracy estimates - For tuberculosis detection, we considered age, disease severity, smear-test status, HIV status, clinical setting, specimen type, high tuberculosis burden, and high tuberculosis/HIV burden - For detection of rifampicin resistance, we considered multi-drug-resistant tuberculosis burden • To compare multiple Xpert MTB/RIF or Xpert Ultra results (repeated testing) with the initial Xpert MTB/RIF or Xpert Ultra result SEARCH METHODS: We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, Science Citation Index, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and the International Standard Randomized Controlled Trials Number (ISRCTN) Registry up to 29 April 2019, without language restrictions. SELECTION CRITERIA Randomized trials, cross-sectional trials, and cohort studies evaluating Xpert MTB/RIF or Xpert Ultra in HIV-positive and HIV-negative children younger than 15 years. Reference standards comprised culture or a composite reference standard for tuberculosis and drug susceptibility testing or MTBDRplus (molecular assay for detection of Mycobacterium tuberculosis and drug resistance) for rifampicin resistance. We included studies evaluating sputum, gastric aspirate, stool, nasopharyngeal or bronchial lavage specimens (pulmonary tuberculosis), cerebrospinal fluid (tuberculous meningitis), fine needle aspirates, or surgical biopsy tissue (lymph node tuberculosis). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality using the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2). For each target condition, we used the bivariate model to estimate pooled sensitivity and specificity with 95% confidence intervals (CIs). We stratified all analyses by type of reference standard. We assessed certainty of evidence using the GRADE approach. MAIN RESULTS For pulmonary tuberculosis, 299 data sets (68,544 participants) were available for analysis; for tuberculous meningitis, 10 data sets (423 participants) were available; for lymph node tuberculosis, 10 data sets (318 participants) were available; and for rifampicin resistance, 14 data sets (326 participants) were available. Thirty-nine studies (80%) took place in countries with high tuberculosis burden. Risk of bias was low except for the reference standard domain, for which risk of bias was unclear because many studies collected only one specimen for culture. Detection of pulmonary tuberculosis For sputum specimens, Xpert MTB/RIF pooled sensitivity (95% CI) and specificity (95% CI) verified by culture were 64.6% (55.3% to 72.9%) (23 studies, 493 participants; moderate-certainty evidence) and 99.0% (98.1% to 99.5%) (23 studies, 6119 participants; moderate-certainty evidence). For other specimen types (nasopharyngeal aspirate, 4 studies; gastric aspirate, 14 studies; stool, 11 studies), Xpert MTB/RIF pooled sensitivity ranged between 45.7% and 73.0%, and pooled specificity ranged between 98.1% and 99.6%. For sputum specimens, Xpert Ultra pooled sensitivity (95% CI) and specificity (95% CI) verified by culture were 72.8% (64.7% to 79.6%) (3 studies, 136 participants; low-certainty evidence) and 97.5% (95.8% to 98.5%) (3 studies, 551 participants; high-certainty evidence). For nasopharyngeal specimens, Xpert Ultra sensitivity (95% CI) and specificity (95% CI) were 45.7% (28.9% to 63.3%) and 97.5% (93.7% to 99.3%) (1 study, 195 participants). For all specimen types, Xpert MTB/RIF and Xpert Ultra sensitivity were lower against a composite reference standard than against culture. Detection of tuberculous meningitis For cerebrospinal fluid, Xpert MTB/RIF pooled sensitivity and specificity, verified by culture, were 54.0% (95% CI 27.8% to 78.2%) (6 studies, 28 participants; very low-certainty evidence) and 93.8% (95% CI 84.5% to 97.6%) (6 studies, 213 participants; low-certainty evidence). Detection of lymph node tuberculosis For lymph node aspirates or biopsies, Xpert MTB/RIF pooled sensitivity and specificity, verified by culture, were 90.4% (95% CI 55.7% to 98.6%) (6 studies, 68 participants; very low-certainty evidence) and 89.8% (95% CI 71.5% to 96.8%) (6 studies, 142 participants; low-certainty evidence). Detection of rifampicin resistance Xpert MTB/RIF pooled sensitivity and specificity were 90.0% (67.6% to 97.5%) (6 studies, 20 participants; low-certainty evidence) and 98.3% (87.7% to 99.8%) (6 studies, 203 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS We found Xpert MTB/RIF sensitivity to vary by specimen type, with gastric aspirate specimens having the highest sensitivity followed by sputum and stool, and nasopharyngeal specimens the lowest; specificity in all specimens was > 98%. Compared with Xpert MTB/RIF, Xpert Ultra sensitivity in sputum was higher and specificity slightly lower. Xpert MTB/RIF was accurate for detection of rifampicin resistance. Xpert MTB/RIF was sensitive for diagnosing lymph node tuberculosis. For children with presumed tuberculous meningitis, treatment decisions should be based on the entirety of clinical information and treatment should not be withheld based solely on an Xpert MTB/RIF result. The small numbers of studies and participants, particularly for Xpert Ultra, limits our confidence in the precision of these estimates.
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MESH Headings
- Adolescent
- Antibiotics, Antitubercular/therapeutic use
- Bias
- Child
- Feces/microbiology
- Gastrointestinal Contents/microbiology
- Humans
- Molecular Typing/methods
- Molecular Typing/standards
- Mycobacterium tuberculosis/drug effects
- Mycobacterium tuberculosis/isolation & purification
- Rifampin/therapeutic use
- Sensitivity and Specificity
- Sputum/microbiology
- Tuberculosis, Lymph Node/diagnosis
- Tuberculosis, Lymph Node/drug therapy
- Tuberculosis, Lymph Node/microbiology
- Tuberculosis, Meningeal/cerebrospinal fluid
- Tuberculosis, Meningeal/diagnosis
- Tuberculosis, Meningeal/drug therapy
- Tuberculosis, Meningeal/microbiology
- Tuberculosis, Multidrug-Resistant/diagnosis
- Tuberculosis, Multidrug-Resistant/drug therapy
- Tuberculosis, Multidrug-Resistant/microbiology
- Tuberculosis, Pulmonary/diagnosis
- Tuberculosis, Pulmonary/drug therapy
- Tuberculosis, Pulmonary/microbiology
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Affiliation(s)
- Alexander W Kay
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Michael Eisenhut
- Paediatric Department, Luton & Dunstable University Hospital NHS Foundation Trust, Luton, UK
| | | | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Anna M Mandalakas
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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