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de Faria MGBF, Andrade RLDP, Leite KFDS, Bonfim RO, Valênça ABM, Ramos ACV, Berra TZ, Arcêncio RA, Rujula MJP, Ballestero JGDA, Chimara E, Ruffino Netto A, Gomes DMDO, Bollela VR, Monroe AA. Operational indicators for pulmonary tuberculosis diagnosis in people living with HIV before and after Xpert MTB/RIF implementation in the state of São Paulo, Brazil. PLoS One 2024; 19:e0305063. [PMID: 38848395 PMCID: PMC11161080 DOI: 10.1371/journal.pone.0305063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 05/22/2024] [Indexed: 06/09/2024] Open
Abstract
Tuberculosis (TB) in people living with HIV (PLHIV) is usually paucibacillary and the smear microscopy has limitations and may lead to high proportions of non-confirmed pulmonary tuberculosis (NC-PTB). Despite culture being the reference method, it usually takes 6 to 8 weeks to produce the results. This study aimed to analyze the effect of a rapid molecular test (Xpert) in the confirmatory rate of PTB among PLHIV, from 2010 to 2020, in São Paulo state, Brazil. This is an ecological study with time series analysis of the trend and the NC-PTB rates before and after Xpert implementation in 21 municipalities. The use of Xpert started and gradually increased after 2014, while the rate of NC-PTB in PLHIV decreased over this time, being more significant between late 2015 and mid-2017. The city of Ribeirão Preto stands out for having the highest percentage (75.0%) of Xpert testing among PLHIV and for showing two reductions in the NC-PTB rate. The cities with low Xpert coverage had a slower and smaller decrease in the NC-PTB rate. Despite being available since 2014, a significant proportion of PLHIV suspected of PTB in the state of São Paulo did not have an Xpert ordered by the doctors. The implementation of Xpert reduced the NC-PTB rates with growing effect as the coverage increased in the municipality.
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Affiliation(s)
| | | | | | - Rafaele Oliveira Bonfim
- Ribeirão Preto College of Nursing, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | | | - Thais Zamboni Berra
- Ribeirão Preto College of Nursing, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | | | | | - Erica Chimara
- Adolfo Lutz Institute, Government of the State of São Paulo, São Paulo, Brazil
| | - Antônio Ruffino Netto
- Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | - Valdes Roberto Bollela
- Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Aline Aparecida Monroe
- Ribeirão Preto College of Nursing, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
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2
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Kim S, Can MH, Agizew TB, Auld AF, Balcells ME, Bjerrum S, Dheda K, Dorman SE, Esmail A, Fielding K, Garcia-Basteiro AL, Hanrahan CF, Kebede W, Kohli M, Luetkemeyer AF, Mita C, Reeve BWP, Silva DR, Sweeney S, Theron G, Trajman A, Vassall A, Warren JL, Yotebieng M, Cohen T, Menzies NA. Factors associated with tuberculosis treatment initiation among bacteriologically negative individuals evaluated for tuberculosis: an individual patient data meta-analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.07.24305445. [PMID: 38645191 PMCID: PMC11030305 DOI: 10.1101/2024.04.07.24305445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Background Globally, over one-third of pulmonary tuberculosis (TB) disease diagnoses are made based on clinical criteria after a negative diagnostic test result. Understanding factors associated with clinicians' decisions to initiate treatment for individuals with negative test results is critical for predicting the potential impact of new diagnostics. Methods We performed a systematic review and individual patient data meta-analysis using studies conducted between January/2010 and December/2022 (PROSPERO: CRD42022287613). We included trials or cohort studies that enrolled individuals evaluated for TB in routine settings. In these studies participants were evaluated based on clinical examination and routinely-used diagnostics, and were followed for ≥1 week after the initial test result. We used hierarchical Bayesian logistic regression to identify factors associated with treatment initiation following a negative result on an initial bacteriological test (e.g., sputum smear microscopy, Xpert MTB/RIF). Findings Multiple factors were positively associated with treatment initiation: male sex [adjusted Odds Ratio (aOR) 1.61 (1.31-1.95)], history of prior TB [aOR 1.36 (1.06-1.73)], reported cough [aOR 4.62 (3.42-6.27)], reported night sweats [aOR 1.50 (1.21-1.90)], and having HIV infection but not on ART [aOR 1.68 (1.23-2.32)]. Treatment initiation was substantially less likely for individuals testing negative with Xpert [aOR 0.77 (0.62-0.96)] compared to smear microscopy and declined in more recent years. Interpretation Multiple factors influenced decisions to initiate TB treatment despite negative test results. Clinicians were substantially less likely to treat in the absence of a positive test result when using more sensitive, PCR-based diagnostics.
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Affiliation(s)
- Sun Kim
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Melike Hazal Can
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Andrew F. Auld
- U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Maria Elvira Balcells
- Infectious Disease Department, School of Medicine, Pontificia Universidad Católica de Chile
| | - Stephanie Bjerrum
- Department of Clinical Research, University of Southern Denmark, Odense Denmark
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, Cape Town, South Africa
- South African MRC Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
- Faculty of Infectious and Tropical Diseases, Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Aliasgar Esmail
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, Cape Town, South Africa
- South African MRC Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Katherine Fielding
- TB Centre, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Alberto L. Garcia-Basteiro
- ISGlobal, Hospital Clínic – Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Barcelona, Spain
| | - Colleen F. Hanrahan
- Epidemiology Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Wakjira Kebede
- School of Medical Laboratory Sciences, Jimma University, Jimma Ethiopia
- Mycobacteriology Research Center of Jimma University, Ethiopia
| | | | | | - Carol Mita
- Countway Library of Medicine, Harvard University, Boston, MA, USA
| | - Byron W. P. Reeve
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Denise Rossato Silva
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Sedona Sweeney
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Grant Theron
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Anete Trajman
- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- McGill University, Montreal, QC, Canada
| | - Anna Vassall
- Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Joshua L. Warren
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Marcel Yotebieng
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, New York City, NY, USA
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Nicolas A. Menzies
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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3
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Iúdice TNDS, da Conceição ML, de Brito AC, de Souza NM, Mesquita CR, Guimarães RJDPSE, Furlaneto IP, Saboia ADS, Lourenço MCDS, Lima KVB, Conceição EC. The Role of GeneXpert ® for Tuberculosis Diagnostics in Brazil: An Examination from a Historical and Epidemiological Perspective. Trop Med Infect Dis 2023; 8:483. [PMID: 37999602 PMCID: PMC10674801 DOI: 10.3390/tropicalmed8110483] [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: 10/01/2023] [Revised: 10/16/2023] [Accepted: 10/20/2023] [Indexed: 11/25/2023] Open
Abstract
The rapid molecular test (RMT) performed on the GeneXpert® system is widely used as a control strategy and surveillance technique for tuberculosis (TB). In the region of the Americas, TB incidence is slowly increasing owing to an upward trend in Brazil, which is among the high TB-burden countries (HBCs), ranking in the 19th position. In this context, we aimed to (i) describe the implementation and history of RMT-TB (Xpert® MTB/RIF and Xpert® MTB/RIF Ultra) in Brazil; (ii) to evaluate the national RMT laboratory distribution, TB, and resistance to RIF detection by RMT; and (iii) to correlate these data with Brazilian TB incidence. The quantitative data of Xpert® MTB/RIF and Xpert® MTB/RIF Ultra assays performed in the pulmonary TB investigation from 2014 to 2020 were provided by the Brazilian Ministry of Health. A spatial visualization using ArcGIS software was performed. The Southeast region constituted about half of the RMT laboratories-from 39.4% to 45.9% of the total value over the five regions. Regarding the federal units, the São Paulo state alone represented from 20.2% to 34.1% (5.0 to 8.5 times the value) of RMT laboratories over the years observed. There were significant differences (p < 0.0001) in the frequency of RMT laboratories between all years of the historical series. There was an unequal distribution of RMT laboratories between Brazilian regions and federal units. This alerts us for the surveillance of rapid molecular detection of TB in different parts of the country, with the possibility of improving the distribution of tests in areas of higher incidence in order to achieve the level of disease control recommended by national and worldwide authorities.
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Affiliation(s)
- Tirça Naiara da Silva Iúdice
- Programa de Pós-Graduação Biologia Parasitária na Amazônia, Universidade do Estado do Pará, Belém-Pará 66087-670, PA, Brazil; (T.N.d.S.I.); (C.R.M.)
| | | | - Artemir Coelho de Brito
- Coordenação-Geral de Vigilância da Tuberculose, Micoses Endêmicas e Micobactérias Não Tuberculosas—CGTM, Ministério da Saúde, Brasília 70000-000, DF, Brazil; (A.C.d.B.)
| | - Nicole Menezes de Souza
- Coordenação-Geral de Vigilância da Tuberculose, Micoses Endêmicas e Micobactérias Não Tuberculosas—CGTM, Ministério da Saúde, Brasília 70000-000, DF, Brazil; (A.C.d.B.)
| | - Cristal Ribeiro Mesquita
- Programa de Pós-Graduação Biologia Parasitária na Amazônia, Universidade do Estado do Pará, Belém-Pará 66087-670, PA, Brazil; (T.N.d.S.I.); (C.R.M.)
| | | | | | - Alessandra de Souza Saboia
- Laboratório de Bacteriologia e Bioensaios em Micobactérias, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil; (A.d.S.S.); (M.C.d.S.L.)
| | - Maria Cristina da Silva Lourenço
- Laboratório de Bacteriologia e Bioensaios em Micobactérias, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil; (A.d.S.S.); (M.C.d.S.L.)
| | - Karla Valéria Batista Lima
- Programa de Pós-Graduação Biologia Parasitária na Amazônia, Universidade do Estado do Pará, Belém-Pará 66087-670, PA, Brazil; (T.N.d.S.I.); (C.R.M.)
- Seção de Bacteriologia e Micologia, Instituto Evandro Chagas, Ananindeua 67030-000, PA, Brazil;
| | - Emilyn Costa Conceição
- Pós-Graduação em Pesquisa Clínica e Doenças Infecciosas, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Manguinhos, Rio de Janeiro 67030-000, RJ, Brazil
- Department of Science and Innovation–National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
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4
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Maleyeff L, Li F, Haneuse S, Wang R. Assessing exposure-time treatment effect heterogeneity in stepped-wedge cluster randomized trials. Biometrics 2023; 79:2551-2564. [PMID: 36416302 PMCID: PMC10203056 DOI: 10.1111/biom.13803] [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: 12/18/2021] [Accepted: 11/16/2022] [Indexed: 11/24/2022]
Abstract
A stepped-wedge cluster randomized trial (CRT) is a unidirectional crossover study in which timings of treatment initiation for clusters are randomized. Because the timing of treatment initiation is different for each cluster, an emerging question is whether the treatment effect depends on the exposure time, namely, the time duration since the initiation of treatment. Existing approaches for assessing exposure-time treatment effect heterogeneity either assume a parametric functional form of exposure time or model the exposure time as a categorical variable, in which case the number of parameters increases with the number of exposure-time periods, leading to a potential loss in efficiency. In this article, we propose a new model formulation for assessing treatment effect heterogeneity over exposure time. Rather than a categorical term for each level of exposure time, the proposed model includes a random effect to represent varying treatment effects by exposure time. This allows for pooling information across exposure-time periods and may result in more precise average and exposure-time-specific treatment effect estimates. In addition, we develop an accompanying permutation test for the variance component of the heterogeneous treatment effect parameters. We conduct simulation studies to compare the proposed model and permutation test to alternative methods to elucidate their finite-sample operating characteristics, and to generate practical guidance on model choices for assessing exposure-time treatment effect heterogeneity in stepped-wedge CRTs.
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Affiliation(s)
- Lara Maleyeff
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut, USA
| | - Sebastien Haneuse
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Rui Wang
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
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5
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Zanon IDB, Meves R, Klautau GB. The Relative Lymphocyte Count is Lower when the Etiological Agent in Pott Disease is Successfully Isolated. Rev Bras Ortop 2023; 58:92-100. [PMID: 36969768 PMCID: PMC10038726 DOI: 10.1055/s-0042-1756638] [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: 10/26/2021] [Accepted: 07/18/2022] [Indexed: 03/26/2023] Open
Abstract
Objective To describe the clinico-epidemiological, laboratory, and radiological characteristics of tuberculous spondylodiscitis in the Brazilian population, and to assess whether there are differences between patients in whom the etiological agent in Pott disease was isolated or not. Methods Patients diagnosed with tuberculosis (TB) of the spine (Pott disease) underwent follow-up between 2009 and 2019 at a quaternary hospital and were divided into 2 groups: successful isolation (SI) of the etiological agent (through bacilloscopy, culture, or positive molecular rapid test) and unsuccessful isolation (UI) of the etiological agent. Results From a total of 26 patients diagnosed with TB of the spine, 21 (80.7%) were male, with a mean age of 40 ± 22.5 years. The average lymphocyte counts were higher in the UI group (25.35 ± 13.08; p = 0.025) compared to the SI group (14.18 ± 7.48). Moreover, the monocyte/lymphocyte ratio was lower in the UI group (0.39 ± 0.22; p = 0.009) than in the SI group (0.89 ± 0.65). Relative lymphocyte counts higher than or equal to 16.7 had a sensitivity of 76.9% and specificity of 62.5% in the UI group. Values higher than or equal to 0.58 for the monocyte/lymphocyte ratio showed a sensitivity of 84.6% and specificity of 75.0% in the UI group. Conclusion No differences were observed regarding the clinico-epidemiological and radiological characteristics of the two experimental groups. However, the UI group had higher lymphocyte counts and a lower monocyte/lymphocyte ratio.
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Affiliation(s)
- Igor de Barcellos Zanon
- Grupo de Afecções da Coluna Vertebral, Departamento de Ortopedia e Traumatologia, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil
| | - Robert Meves
- Faculdade de Ciências Médicas, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil
| | - Giselle Burlamaqui Klautau
- Grupo de Afecções da Coluna Vertebral, Departamento de Ortopedia e Traumatologia, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil
- Faculdade de Ciências Médicas, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil
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6
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Marley G, Zou X, Nie J, Cheng W, Xie Y, Liao H, Wang Y, Tao Y, Tucker JD, Sylvia S, Chou R, Wu D, Ong J, Tang W. Improving cascade outcomes for active TB: A global systematic review and meta-analysis of TB interventions. PLoS Med 2023; 20:e1004091. [PMID: 36595536 PMCID: PMC9847969 DOI: 10.1371/journal.pmed.1004091] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 01/18/2023] [Accepted: 12/13/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND To inform policy and implementation that can enhance prevention and improve tuberculosis (TB) care cascade outcomes, this review aimed to summarize the impact of various interventions on care cascade outcomes for active TB. METHODS AND FINDINGS In this systematic review and meta-analysis, we retrieved English articles with comparator arms (like randomized controlled trials (RCTs) and before and after intervention studies) that evaluated TB interventions published from January 1970 to September 30, 2022, from Embase, CINAHL, PubMed, and the Cochrane library. Commentaries, qualitative studies, conference abstracts, studies without standard of care comparator arms, and studies that did not report quantitative results for TB care cascade outcomes were excluded. Data from studies with similar comparator arms were pooled in a random effects model, and outcomes were reported as odds ratio (OR) with 95% confidence interval (CI) and number of studies (k). The quality of evidence was appraised using GRADE, and the study was registered on PROSPERO (CRD42018103331). Of 21,548 deduplicated studies, 144 eligible studies were included. Of 144 studies, 128 were from low/middle-income countries, 84 were RCTs, and 25 integrated TB and HIV care. Counselling and education was significantly associated with testing (OR = 8.82, 95% CI:1.71 to 45.43; I2 = 99.9%, k = 7), diagnosis (OR = 1.44, 95% CI:1.08 to 1.92; I2 = 97.6%, k = 9), linkage to care (OR = 3.10, 95% CI = 1.97 to 4.86; I2 = 0%, k = 1), cure (OR = 2.08, 95% CI:1.11 to 3.88; I2 = 76.7%, k = 4), treatment completion (OR = 1.48, 95% CI: 1.07 to 2.03; I2 = 73.1%, k = 8), and treatment success (OR = 3.24, 95% CI: 1.88 to 5.55; I2 = 75.9%, k = 5) outcomes compared to standard-of-care. Incentives, multisector collaborations, and community-based interventions were associated with at least three TB care cascade outcomes; digital interventions and mixed interventions were associated with an increased likelihood of two cascade outcomes each. These findings remained salient when studies were limited to RCTs only. Also, our study does not cover the entire care cascade as we did not measure gaps in pre-testing, pretreatment, and post-treatment outcomes (like loss to follow-up and TB recurrence). CONCLUSIONS Among TB interventions, education and counseling, incentives, community-based interventions, and mixed interventions were associated with multiple active TB care cascade outcomes. However, cost-effectiveness and local-setting contexts should be considered when choosing such strategies due to their high heterogeneity.
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Affiliation(s)
- Gifty Marley
- Dermatology Hospital of Southern Medical University, Guangzhou, China
- University of North Carolina Project-China, Guangzhou, China
| | - Xia Zou
- Global Health Research Center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Juan Nie
- Department of Research and Education, Guangzhou Concord Cancer Center, Guangzhou, China
| | - Weibin Cheng
- Institute for Healthcare Artificial Intelligence Application, Guangdong Second Provincial General Hospital, Guangzhou, China
- School of Data Science, City University of Hong Kong, Hong Kong, China
| | - Yewei Xie
- University of North Carolina Project-China, Guangzhou, China
| | - Huipeng Liao
- University of North Carolina Project-China, Guangzhou, China
| | - Yehua Wang
- University of North Carolina Project-China, Guangzhou, China
| | - Yusha Tao
- University of North Carolina Project-China, Guangzhou, China
| | - Joseph D. Tucker
- University of North Carolina Project-China, Guangzhou, China
- Faculty of Infectious and Tropical Diseases, London School of Health and Tropical Medicine, London, United Kingdom
| | - Sean Sylvia
- University of North Carolina Project-China, Guangzhou, China
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Roger Chou
- Oregon Health & Science University, Portland, Oregon, United States of America
| | - Dan Wu
- University of North Carolina Project-China, Guangzhou, China
- Faculty of Infectious and Tropical Diseases, London School of Health and Tropical Medicine, London, United Kingdom
| | - Jason Ong
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Weiming Tang
- Dermatology Hospital of Southern Medical University, Guangzhou, China
- University of North Carolina Project-China, Guangzhou, China
- * E-mail:
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7
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Lee JH, Garg T, Lee J, McGrath S, Rosman L, Schumacher SG, Benedetti A, Qin ZZ, Gore G, Pai M, Sohn H. Impact of molecular diagnostic tests on diagnostic and treatment delays in tuberculosis: a systematic review and meta-analysis. BMC Infect Dis 2022; 22:940. [PMID: 36517736 PMCID: PMC9748908 DOI: 10.1186/s12879-022-07855-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 11/08/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Countries with high TB burden have expanded access to molecular diagnostic tests. However, their impact on reducing delays in TB diagnosis and treatment has not been assessed. Our primary aim was to summarize the quantitative evidence on the impact of nucleic acid amplification tests (NAAT) on diagnostic and treatment delays compared to that of the standard of care for drug-sensitive and drug-resistant tuberculosis (DS-TB and DR-TB). METHODS We searched MEDLINE, EMBASE, Web of Science, and the Global Health databases (from their inception to October 12, 2020) and extracted time delay data for each test. We then analysed the diagnostic and treatment initiation delay separately for DS-TB and DR-TB by comparing smear vs Xpert for DS-TB and culture drug sensitivity testing (DST) vs line probe assay (LPA) for DR-TB. We conducted random effects meta-analyses of differences of the medians to quantify the difference in diagnostic and treatment initiation delay, and we investigated heterogeneity in effect estimates based on the period the test was used in, empiric treatment rate, HIV prevalence, healthcare level, and study design. We also evaluated methodological differences in assessing time delays. RESULTS A total of 45 studies were included in this review (DS = 26; DR = 20). We found considerable heterogeneity in the definition and reporting of time delays across the studies. For DS-TB, the use of Xpert reduced diagnostic delay by 1.79 days (95% CI - 0.27 to 3.85) and treatment initiation delay by 2.55 days (95% CI 0.54-4.56) in comparison to sputum microscopy. For DR-TB, use of LPAs reduced diagnostic delay by 40.09 days (95% CI 26.82-53.37) and treatment initiation delay by 45.32 days (95% CI 30.27-60.37) in comparison to any culture DST methods. CONCLUSIONS Our findings indicate that the use of World Health Organization recommended diagnostics for TB reduced delays in diagnosing and initiating TB treatment. Future studies evaluating performance and impact of diagnostics should consider reporting time delay estimates based on the standardized reporting framework.
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Affiliation(s)
- Jae Hyoung Lee
- grid.21107.350000 0001 2171 9311Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Tushar Garg
- grid.21107.350000 0001 2171 9311Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Jungsil Lee
- grid.8991.90000 0004 0425 469XLondon School of Hygiene & Tropical Medicine, London, UK
| | - Sean McGrath
- grid.38142.3c000000041936754XDepartment of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Lori Rosman
- grid.21107.350000 0001 2171 9311Welch Medical Library, John Hopkins University School of Medicine, Baltimore, USA
| | - Samuel G. Schumacher
- grid.452485.a0000 0001 1507 3147Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Andrea Benedetti
- grid.14709.3b0000 0004 1936 8649Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada ,grid.63984.300000 0000 9064 4811Respiratory Epidemiology & Clinical Research Unit, McGill University Health Centre, Montreal, Canada
| | | | - Genevieve Gore
- grid.14709.3b0000 0004 1936 8649Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal, Canada
| | - Madhukar Pai
- grid.14709.3b0000 0004 1936 8649McGill International TB Centre, McGill University, Montreal, Canada
| | - Hojoon Sohn
- grid.31501.360000 0004 0470 5905Department of Preventive Medicine, College of Medicine, Seoul National University, Seoul, South Korea
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8
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Li Y, de Macedo Couto R, Pelissari DM, Costa Alves L, Bartholomay P, Maciel EL, Sanchez M, Castro MC, Cohen T, Menzies NA. Excess tuberculosis cases and deaths following an economic recession in Brazil: an analysis of nationally representative disease registry data. Lancet Glob Health 2022; 10:e1463-e1472. [PMID: 36049488 PMCID: PMC9472578 DOI: 10.1016/s2214-109x(22)00320-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 06/22/2022] [Accepted: 07/05/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND In 2019, tuberculosis incidence and mortality in Brazil were 46 and 3·3 per 100 000 population, respectively, and the country has reported rising tuberculosis case rates since 2016, following an economic crisis beginning in mid-2014. We aimed to estimate the number of excess tuberculosis cases and deaths during the recession period, and assessed potential causes. METHODS In this multi-level regression modelling study, we extracted tuberculosis case notifications from Brazil's National Notifiable Disease Information System (known as SINAN), and tuberculosis deaths from the Mortality Information System (known as SIM), for all ages. We fitted mixed-effects regression models estimating trends in these outcomes-stratified by sex, age group, and state-during the pre-recession period (Jan 1, 2010-Dec 31, 2014). We calculated excess cases and deaths between Jan 1, 2015, and Dec 31, 2019 (the recession period) as the difference between reported values and a counterfactual of continued pre-recession trends. We examined the relationship between excess cases and possible explanatory factors using ordinary least squares regression. We tested the robustness of our findings to alternative model specifications related to the pre-recession period and criteria for defining tuberculosis deaths. FINDINGS We estimated 22 900 excess tuberculosis cases (95% uncertainty interval 18 100-27 500) during 2015-19. By 2019, reported cases were 12% (10-13) higher than predicted by historical trends. 54% (44-66) of excess cases occurred among 20-29-year-old men. In this group, reported cases in 2019 were 30% (25-36) higher than predicted. Excess cases were positively associated with an increasing fraction of cases among incarcerated individuals (p=0·001) and higher unemployment (p=0·04) at the state level. Estimated excess deaths for 2015-19 were not statistically significant from 0 (-600 [-2100 to 1000]). These results were robust to alternative definitions of the pre-recession period and criteria for defining tuberculosis deaths. INTERPRETATION Tuberculosis cases in Brazil rose substantially in 2015-19 during the recession, largely affecting young men. This increase seems to be linked to increasing tuberculosis transmission among incarcerated populations. Rising tuberculosis case rates threaten tuberculosis control in Brazil, and highlight the threat posed by prison-based tuberculosis transmission. FUNDING US National Institutes of Health. TRANSLATION For the Portuguese translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Yunfei Li
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA.
| | | | | | | | | | - Ethel L Maciel
- Laboratorio de Epidemiologia, Universidade Federal do Espirito Santo, Vitória, Brazil
| | - Mauro Sanchez
- Department of Tropical Medicine, University of Brasilia, Brasilia, Brazil
| | - Marcia C Castro
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
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Ule Belotti NC, Madela NK, Tonelli Nardi SM, Mariano DC, de Souza NG, Oliveira RS, Paro Pedro HDS. Evaluation of xpert Mycobacterium tuberculosis rifampicin for tuberculosis diagnosis in a reference laboratory. Int J Mycobacteriol 2022; 11:435-441. [PMID: 36510931 DOI: 10.4103/ijmy.ijmy_195_22] [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: 12/14/2022] Open
Abstract
Background The Xpert Mycobacterium tuberculosis Rifampicin (MTB-RIF) is a technological innovation that presents precision and speed in the diagnosis of tuberculosis (TB). The study aimed to evaluate the performance of Xpert MTB/RIF in the TB diagnosis and compare its results with those of culture, species identification, Antimicrobial Susceptibility Testing (AST), and rpoB gene sequencing of discordant results in AST, used for the diagnosis of TB in a reference laboratory. Methods Cross-sectional descriptive study of pulmonary and extrapulmonary samples requesting Xpert MTB/RIF and culture for TB diagnosis from 2015 to 2019 at Adolfo Lutz Institute-São Paulo/Brazil. The analysis was performed with Epi-Info 7.2.1, presenting the distribution of frequencies and, for comparative analyses, Pearson's Chi-square test and Fisher's exact test were used, considering P ≤ 0.05 as statistically significant. For variables agreement, the Kappa method was used. Results A total of 1575 pulmonary and extrapulmonary samples were analyzed using Xpert MTB/RIF and culture, of which 293 were positive for the MTB Complex in both methodologies with a sensitivity of 94.55%; specificity of 95.97%; accuracy 95.69%; positive predictive value 85.53%; negative predictive value 98.59%, substantial agreement by Kappa 0.87, and detection sensitivity even at lower levels of bacillary load (P < 0.05). The Xpert MTB/RIF and AST showed concordant results (P < 0.05). Conclusion The study brings forward that the Xpert MTB/RIF shows substantial agreement with the results of culture and AST, contributing to the diagnosis of TB and the rapid detection of resistance. The sequencing of resistant cultures in Xpert MTB/RIF and sensitivity in AST identified the H526N mutation, characterized by a low level of resistance to RIF.
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Affiliation(s)
| | - Naiady Konno Madela
- Biomedical Sciences Center, Adolfo Lutz Institute, São José do Rio Preto, São Paulo, Brazil
| | | | | | - Nilza Gomes de Souza
- Tuberculosis Department, Epidemiological Surveillance Group, São José do Rio Preto, São Paulo, Brazil
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10
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Cattamanchi A, Reza TF, Nalugwa T, Adams K, Nantale M, Oyuku D, Nabwire S, Babirye D, Turyahabwe S, Tucker A, Sohn H, Ferguson O, Thompson R, Shete PB, Handley MA, Ackerman S, Joloba M, Moore DAJ, Davis JL, Dowdy DW, Fielding K, Katamba A. Multicomponent Strategy with Decentralized Molecular Testing for Tuberculosis. N Engl J Med 2021; 385:2441-2450. [PMID: 34936740 PMCID: PMC9212879 DOI: 10.1056/nejmoa2105470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Effective strategies are needed to facilitate the prompt diagnosis and treatment of tuberculosis in countries with a high burden of the disease. METHODS We conducted a cluster-randomized trial in which Ugandan community health centers were assigned to a multicomponent diagnostic strategy (on-site molecular testing for tuberculosis, guided restructuring of clinic workflows, and monthly feedback of quality metrics) or routine care (on-site sputum-smear microscopy and referral-based molecular testing). The primary outcome was the number of adults treated for confirmed tuberculosis within 14 days after presenting to the health center for evaluation during the 16-month intervention period. Secondary outcomes included completion of tuberculosis testing, same-day diagnosis, and same-day treatment. Outcomes were also assessed on the basis of proportions. RESULTS A total of 20 health centers underwent randomization, with 10 assigned to each group. Of 10,644 eligible adults (median age, 40 years) whose data were evaluated, 60.1% were women and 43.8% had human immunodeficiency virus infection. The intervention strategy led to a greater number of patients being treated for confirmed tuberculosis within 14 days after presentation (342 patients across 10 intervention health centers vs. 220 across 10 control health centers; adjusted rate ratio, 1.56; 95% confidence interval [CI], 1.21 to 2.01). More patients at intervention centers than at control centers completed tuberculosis testing (adjusted rate ratio, 1.85; 95% CI, 1.21 to 2.82), received a same-day diagnosis (adjusted rate ratio, 1.89; 95% CI, 1.39 to 2.56), and received same-day treatment for confirmed tuberculosis (adjusted rate ratio, 2.38; 95% CI, 1.57 to 3.61). Among 706 patients with confirmed tuberculosis, a higher proportion in the intervention group than in the control group were treated on the same day (adjusted rate ratio, 2.29; 95% CI, 1.23 to 4.25) or within 14 days after presentation (adjusted rate ratio, 1.22; 95% CI, 1.06 to 1.40). CONCLUSIONS A multicomponent diagnostic strategy that included on-site molecular testing plus implementation supports to address barriers to delivery of high-quality tuberculosis evaluation services led to greater numbers of patients being tested, receiving a diagnosis, and being treated for confirmed tuberculosis. (Funded by the National Heart, Lung, and Blood Institute; XPEL-TB ClinicalTrials.gov number, NCT03044158.).
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Affiliation(s)
- Adithya Cattamanchi
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Tania F Reza
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Talemwa Nalugwa
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Katherine Adams
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Mariam Nantale
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Denis Oyuku
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Sarah Nabwire
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Diana Babirye
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Stavia Turyahabwe
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Austin Tucker
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Hojoon Sohn
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Olivia Ferguson
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Ryan Thompson
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Priya B Shete
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Margaret A Handley
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Sara Ackerman
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Moses Joloba
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - David A J Moore
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - J Lucian Davis
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - David W Dowdy
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Katherine Fielding
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Achilles Katamba
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
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11
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Bartholomay P, Pinheiro RS, Dockhorn F, Pelissari DM, de Araújo WN. Brazilian cohort study of risk factors associated with unsuccessful outcomes of drug resistant tuberculosis. BMC Infect Dis 2021; 21:1049. [PMID: 34627179 PMCID: PMC8502313 DOI: 10.1186/s12879-021-06756-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 09/11/2021] [Indexed: 11/10/2022] Open
Abstract
Background Treatment outcomes were evaluated of a cohort of new pulmonary tuberculosis (TB) cases that were rifampicin resistant, multidrug-resistant, or extensively resistant during 2013 and 2014 in Brazil. The objective of this study is to identify factors associated with unfavorable treatment outcomes for drug-resistant TB cases. Methods The Brazilian Special Tuberculosis Treatment Information System (SITE-TB) was the main data source. The independent variables were classified into four blocks (block I: individual characteristics; block II: clinical characteristics and proposed treatment; block III: treatment follow-up characteristics; and block IV: TB history). The category of successful therapeutic outcome was compared with lost to follow-up, failure, and death. Considering the multiple outcomes as the dependent variable, the odds ratios (OR) and its respective 95% confidence interval (95% CI) were estimated by multinomial logistic regression. Results After applying the exclusion criteria, 980 (98.8%) individuals were included in the study. Of these, 621 (63.4%) had successful treatment, 163 (16.6%) lost to follow-up, 76 (7.8%) failed, and 120 (12.2%) died. Important factors associated with lost to follow-up in the final model included use of illicit drugs (OR = 2.5 95% CI: 1.57–3.82). Outcome failure was associated with having disease in both lungs (OR = 2.0; 95% CI: 1.09–3.62) and using more than one or not using injectable medication (OR = 2.8; 95% CI: 1.05–7.69). Major factors for the death outcome were at least 60 years old (OR = 3.4; 95% CI: 1.90–6.03) and HIV positive (OR = 2.7; 95% CI: 1.45–4.83). Conclusions The factors associated with unfavorable treatment outcomes were different. Some of these factors are specific to each outcome, which reflects the complexity of providing care to these individuals. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06756-7.
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Affiliation(s)
- Patricia Bartholomay
- Tropical Disease Post-Graduation Program, University of Brasilia, Brasília, DF, Brazil. .,National Tuberculosis Control Program, Health Surveillance Secretariat, Ministry of Health, Brasília, DF, Brazil.
| | | | - Fernanda Dockhorn
- National Tuberculosis Control Program, Health Surveillance Secretariat, Ministry of Health, Brasília, DF, Brazil
| | - Daniele Maria Pelissari
- National Tuberculosis Control Program, Health Surveillance Secretariat, Ministry of Health, Brasília, DF, Brazil
| | - Wildo Navegantes de Araújo
- Tropical Disease Post-Graduation Program, University of Brasilia, Brasília, DF, Brazil.,National Institute for Science and Technology for Health Technology Assessment, Porto Alegre, RS, Brazil
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12
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Rabideau DJ, Wang R. Randomization-based inference for a marginal treatment effect in stepped wedge cluster randomized trials. Stat Med 2021; 40:4442-4456. [PMID: 34018624 DOI: 10.1002/sim.9040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 05/05/2021] [Accepted: 05/05/2021] [Indexed: 12/17/2022]
Abstract
In a cross-sectional stepped wedge cluster randomized trial (SWT), clusters are randomized to crossover from control to intervention at different time periods and outcomes are assessed for a different set of individuals in each cluster-period. Randomization-based inference is an attractive analysis strategy for SWTs because it does not require full parametric specification of the outcome distribution or correlation structure and its validity does not rely on having a large number of clusters. Existing randomization-based approaches for SWTs, however, either focus on hypothesis testing and omit technical details on confidence interval (CI) calculation with noncontinuous outcomes, or employ weighted cluster-period summary statistics for p-value and CI calculation, which can result in suboptimal efficiency if weights do not incorporate information on varying cluster-period sizes. In this article, we propose a framework for calculating randomization-based p-values and CIs for a marginal treatment effect in SWTs by using test statistics derived from individual-level generalized linear models. We also investigate how study design features, such as stratified randomization, subsequently impact various SWT analysis methods including the proposed approach. Data from the XpertMTB/RIF tuberculosis trial are reanalyzed to illustrate our method and compare it to alternatives.
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Affiliation(s)
- Dustin J Rabideau
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Rui Wang
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts.,Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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13
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Foster N, Cunnama L, McCarthy K, Ramma L, Siapka M, Sinanovic E, Churchyard G, Fielding K, Grant AD, Cleary S. Strengthening health systems to improve the value of tuberculosis diagnostics in South Africa: A cost and cost-effectiveness analysis. PLoS One 2021; 16:e0251547. [PMID: 33989317 PMCID: PMC8121360 DOI: 10.1371/journal.pone.0251547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 04/28/2021] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND In South Africa, replacing smear microscopy with Xpert-MTB/RIF (Xpert) for tuberculosis diagnosis did not reduce mortality and was cost-neutral. The unchanged mortality has been attributed to suboptimal Xpert implementation. We developed a mathematical model to explore how complementary investments may improve cost-effectiveness of the tuberculosis diagnostic algorithm. METHODS Complementary investments in the tuberculosis diagnostic pathway were compared to the status quo. Investment scenarios following an initial Xpert test included actions to reduce pre-treatment loss-to-follow-up; supporting same-day clinical diagnosis of tuberculosis after a negative result; and improving access to further tuberculosis diagnostic tests following a negative result. We estimated costs, deaths and disability-adjusted-life-years (DALYs) averted from provider and societal perspectives. Sensitivity analyses explored the mediating influence of behavioural, disease- and organisational characteristics on investment effectiveness. FINDINGS Among a cohort of symptomatic patients tested for tuberculosis, with an estimated active tuberculosis prevalence of 13%, reducing pre-treatment loss-to-follow-up from ~20% to ~0% led to a 4% (uncertainty interval [UI] 3; 4%) reduction in mortality compared to the Xpert scenario. Improving access to further tuberculosis diagnostic tests from ~4% to 90% among those with an initial negative Xpert result reduced overall mortality by 28% (UI 27; 28) at $39.70/ DALY averted. Effectiveness of investment scenarios to improve access to further diagnostic tests was dependent on a high return rate for follow-up visits. INTERPRETATION Investing in direct and indirect costs to support the TB diagnostic pathway is potentially highly cost-effective.
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Affiliation(s)
- Nicola Foster
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Health Research, Lancaster University, Lancaster, United Kingdom
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Lucy Cunnama
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kerrigan McCarthy
- Division of Public Health, Surveillance and Response, National Institute for Communicable Disease of the National Health Laboratory Service, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lebogang Ramma
- Department of Health and Rehabilitation Sciences, University of Cape Town, Cape Town, South Africa
| | - Mariana Siapka
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Edina Sinanovic
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Gavin Churchyard
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Aurum Institute, Johannesburg, South Africa
| | - Katherine Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alison D. Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Susan Cleary
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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14
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Haraka F, Kakolwa M, Schumacher SG, Nathavitharana RR, Denkinger CM, Gagneux S, Reither K, Ross A. Impact of the diagnostic test Xpert MTB/RIF on patient outcomes for tuberculosis. Cochrane Database Syst Rev 2021; 5:CD012972. [PMID: 34097769 PMCID: PMC8208889 DOI: 10.1002/14651858.cd012972.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The World Health Organization (WHO) recommends Xpert MTB/RIF in place of smear microscopy to diagnose tuberculosis (TB), and many countries have adopted it into their diagnostic algorithms. However, it is not clear whether the greater accuracy of the test translates into improved health outcomes. OBJECTIVES To assess the impact of Xpert MTB/RIF on patient outcomes in people being investigated for tuberculosis. SEARCH METHODS We searched the following databases, without language restriction, from 2007 to 24 July 2020: Cochrane Infectious Disease Group (CIDG) Specialized Register; CENTRAL; MEDLINE OVID; Embase OVID; CINAHL EBSCO; LILACS BIREME; Science Citation Index Expanded (Web of Science), Social Sciences citation index (Web of Science), and Conference Proceedings Citation Index - Social Science & Humanities (Web of Science). We also searched the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and the Pan African Clinical Trials Registry for ongoing trials. SELECTION CRITERIA We included individual- and cluster-randomized trials, and before-after studies, in participants being investigated for tuberculosis. We analysed the randomized and non-randomized studies separately. DATA COLLECTION AND ANALYSIS: For each study, two review authors independently extracted data, using a piloted data extraction tool. We assessed the risk of bias using Cochrane and Effective Practice and Organisation of Care (EPOC) tools. We used random effects meta-analysis to allow for heterogeneity between studies in setting and design. The certainty of the evidence in the randomized trials was assessed by GRADE. MAIN RESULTS We included 12 studies: eight were randomized controlled trials (RCTs), and four were before-and-after studies. Most included RCTs had a low risk of bias in most domains of the Cochrane 'Risk of bias' tool. There was inconclusive evidence of an effect of Xpert MTB/RIF on all-cause mortality, both overall (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.75 to 1.05; 5 RCTs, 9932 participants, moderate-certainty evidence), and restricted to studies with six-month follow-up (RR 0.98, 95% CI 0.78 to 1.22; 3 RCTs, 8143 participants; moderate-certainty evidence). There was probably a reduction in mortality in participants known to be infected with HIV (odds ratio (OR) 0.80, 95% CI 0.67 to 0.96; 5 RCTs, 5855 participants; moderate-certainty evidence). It is uncertain whether Xpert MTB/RIF has no or a modest effect on the proportion of participants starting tuberculosis treatment who had a successful treatment outcome (OR) 1.10, 95% CI 0.96 to 1.26; 3RCTs, 4802 participants; moderate-certainty evidence). There was also inconclusive evidence of an effect on the proportion of participants who were treated for tuberculosis (RR 1.10, 95% CI 0.98 to 1.23; 5 RCTs, 8793 participants; moderate-certainty evidence). The proportion of participants treated for tuberculosis who had bacteriological confirmation was probably higher in the Xpert MTB/RIF group (RR 1.44, 95% CI 1.29 to 1.61; 6 RCTs, 2068 participants; moderate-certainty evidence). The proportion of participants with bacteriological confirmation who were lost to follow-up pre-treatment was probably reduced (RR 0.59, 95% CI 0.41 to 0.85; 3 RCTs, 1217 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS We were unable to confidently rule in or rule out the effect on all-cause mortality of using Xpert MTB/RIF rather than smear microscopy. Xpert MTB/RIF probably reduces mortality among participants known to be infected with HIV. We are uncertain whether Xpert MTB/RIF has a modest effect or not on the proportion treated or, among those treated, on the proportion with a successful outcome. It probably does not have a substantial effect on these outcomes. Xpert MTB/RIF probably increases both the proportion of treated participants who had bacteriological confirmation, and the proportion with a laboratory-confirmed diagnosis who were treated. These findings may inform decisions about uptake alongside evidence on cost-effectiveness and implementation.
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Affiliation(s)
- Frederick Haraka
- Elizabeth Glaser Pediatric AIDS Foundation, Dar es Salaam, Tanzania
- Ifakara Health Institute, Bagamoyo, Tanzania
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | | | | | - Ruvandhi R Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Claudia M Denkinger
- FIND, Geneva, Switzerland
- Division of Tropical Medicine, Centre for Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Sebastien Gagneux
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Klaus Reither
- Ifakara Health Institute, Bagamoyo, Tanzania
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Amanda Ross
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
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15
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Vessière A, Font H, Gabillard D, Adonis-Koffi L, Borand L, Chabala C, Khosa C, Mavale S, Moh R, Mulenga V, Mwanga-Amumpere J, Taguebue JV, Eang MT, Delacourt C, Seddon JA, Lounnas M, Godreuil S, Wobudeya E, Bonnet M, Marcy O. Impact of systematic early tuberculosis detection using Xpert MTB/RIF Ultra in children with severe pneumonia in high tuberculosis burden countries (TB-Speed pneumonia): a stepped wedge cluster randomized trial. BMC Pediatr 2021; 21:136. [PMID: 33743621 PMCID: PMC7980598 DOI: 10.1186/s12887-021-02576-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 02/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background In high tuberculosis (TB) burden settings, there is growing evidence that TB is common in children with pneumonia, the leading cause of death in children under 5 years worldwide. The current WHO standard of care (SOC) for young children with pneumonia considers a diagnosis of TB only if the child has a history of prolonged symptoms or fails to respond to antibiotic treatments. As a result, many children with TB-associated severe pneumonia are currently missed or diagnosed too late. We therefore propose a diagnostic trial to assess the impact on mortality of adding the systematic early detection of TB using Xpert MTB/RIF Ultra (Ultra) performed on nasopharyngeal aspirates (NPA) and stool samples to the WHO SOC for children with severe pneumonia, followed by immediate initiation of anti-TB treatment in children testing positive on any of the samples. Methods TB-Speed Pneumonia is a pragmatic stepped-wedge cluster randomized controlled trial conducted in six countries with high TB incidence rate (Côte d’Ivoire, Cameroon, Uganda, Mozambique, Zambia and Cambodia). We will enrol 3780 children under 5 years presenting with WHO-defined severe pneumonia across 15 hospitals over 18 months. All hospitals will start managing children using the WHO SOC for severe pneumonia; one hospital will be randomly selected to switch to the intervention every 5 weeks. The intervention consists of the WHO SOC plus rapid TB detection on the day of admission using Ultra performed on 1 nasopharyngeal aspirate and 1 stool sample. All children will be followed for 3 months, with systematic trial visits at day 3, discharge, 2 weeks post-discharge, and week 12. The primary endpoint is all-cause mortality 12 weeks after inclusion. Qualitative and health economic evaluations are embedded in the trial. Discussion In addition to testing the main hypothesis that molecular detection and early treatment will reduce TB mortality in children, the strength of such pragmatic research is that it provides some evidence regarding the feasibility of the intervention as part of routine care. Should this intervention be successful, safe and well tolerated, it could be systematically implemented at district hospital level where children with severe pneumonia are referred. Trial registration ClinicalTrials.gov, NCT03831906. Registered 6 February 2019.
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Affiliation(s)
- Aurélia Vessière
- University of Bordeaux, Inserm, Institut de Recherche pour le Développement (IRD), UMR 1219, Bordeaux, France.
| | - Hélène Font
- University of Bordeaux, Inserm, Institut de Recherche pour le Développement (IRD), UMR 1219, Bordeaux, France
| | - Delphine Gabillard
- University of Bordeaux, Inserm, Institut de Recherche pour le Développement (IRD), UMR 1219, Bordeaux, France
| | | | - Laurence Borand
- Epidemiology and Public Health Unit, Pasteur Institute in Cambodia, Phnom Penh, Cambodia
| | - Chishala Chabala
- University of Zambia School of Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Celso Khosa
- Instituto Nacional de Saúde, Maputo, Mozambique
| | - Sandra Mavale
- Paediatrics Department, Maputo Central Hospital, Maputo, Mozambique
| | - Raoul Moh
- Programme PAC-CI, CHU de Treichville, Abidjan, Ivory Coast
| | - Veronica Mulenga
- Children's Hospital, University Teaching Hospital, Lusaka, Zambia
| | | | | | - Mao Tan Eang
- National Center for Tuberculosis and Leprosy (CENAT/NTP), Ministry of Health, Phnom Penh, Cambodia
| | - Christophe Delacourt
- Department of Paediatric Pulmonology, Necker University Teaching Hospital, Paris, France
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa.,Department of Infectious Diseases, Imperial College London, London, UK
| | | | | | - Eric Wobudeya
- Makerere University-Johns Hopkins University Research Collaboration (MU-JHU) Care Ltd, Kampala, Uganda
| | - Maryline Bonnet
- IRD UMI233/Inserm U1175, University of Montpellier, Montpellier, France
| | - Olivier Marcy
- University of Bordeaux, Inserm, Institut de Recherche pour le Développement (IRD), UMR 1219, Bordeaux, France
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16
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Ejeh FE, Undiandeye A, Okon K, Moshood KH. Prevalence of rifampicin resistance tuberculosis among HIV/TB coinfected patients in Benue State, Nigeria. Pan Afr Med J 2021; 38:203. [PMID: 33995809 PMCID: PMC8106797 DOI: 10.11604/pamj.2021.38.203.19034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 01/19/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction the emergence of HIV/TB co-infection has changed the global health landscape globally, particularly in sub-Saharan Africa and Asia with a high prevalence rate. It has further worsened and compound patient diagnosis, treatment/management approach and infection control. Rifampicin resistance TB (RR-TB) is a good indicator of treatment failure and infection control in the community. This study determines the prevalence of RR-TB among HIV/TB coinfected patients in Benue State, Nigeria. Methods the case-control study was carried out at Federal Medical Centre, Makurdi and General Hospital, Otupko, between January 2017 and February 2018. One thousand and ten suspected tuberculosis and HIV patients were enrolled in the study, diagnosed according to WHO guidelines. Sputum samples were collected and then analyzed by acid-fast bacilli smear test and GeneXpert MTB/RIF assay. Results overall prevalence of tuberculosis by acid-fast test was 74 (7.3%), 171 (16.93%) by GeneXpert assay and 2.18% by RR-TB test respectively. Significant difference was observed between the detection technique and demographic variables, high prevalence among urban patient compared to rural (8.85%vs 5.40%; X2= 4.38; P = 0.036) and ethnic background of the patients (X2= 23.21; P = 0.000) by acid fast test. With GeneXpert, high prevalence recorded among patient within age-group15-45years (X2= 8.01; P = 0.046) and ethnic group (X2= 6.30; P = 0.044). The occurrence of HIV/TB co-infection was less associated with Idoma ethnic group (COR; 0.440; 95% C.I; 0.246 - 0.786). Conclusion the relatively high prevalence of HIV/TB co-infection and RR-TB is a tremendous public health threat, considering society's attendant implication. Further surveillance studies are needed to evaluate the situation in Benue State better.
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Affiliation(s)
- Francis Enenche Ejeh
- Department of Veterinary Microbiology, University of Maiduguri, Maiduguri, Nigeria
| | | | - Kenneth Okon
- Department of Medical Microbiology, Federal Medical Centre, Makurdi, Nigeria
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da Silva SCA, Vater MC, Ramalho DMDP, de Almeida IN, de Miranda SS, Kritski A. Cost-effectiveness of Xpert®MTB/RIF in the diagnosis of tuberculosis: pragmatic study. Rev Soc Bras Med Trop 2021; 54:e07552020. [PMID: 33605382 PMCID: PMC7891564 DOI: 10.1590/0037-8682-0755-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/15/2021] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION The intensification of research and innovation with the creation of networks of rapid and effective molecular tests as strategies for the end of tuberculosis are essential to avoid late diagnosis and for the eradication of the disease. We aimed to evaluate the cost-effectiveness of Xpert®MTB/RIF (Xpert) in the diagnosis of drug-resistant tuberculosis in reference units, in scenarios with and without subsidies, and the respective cost adjustment for today. METHODS The analyses were performed considering as criterion of effectiveness, negative culture or clinical improvement in the sixth month of follow-up. The comparison was performed using two diagnostic strategies for the drug susceptibility test (DST), BactecTMMGITTM960 System, versus Xpert. The cost effectiveness and incremental cost-effectiveness ratio (ICER) were calculated and dollar-corrected for American inflation (US$ 1.00 = R$ 5,29). RESULTS Subsidized Xpert had the lowest cost of US$ 33.48 (R$67,52) and the highest incremental average efficiency (13.57), thus being a dominated analysis. After the inflation was calculated, the mean cost was DST-MGIT=US$ 74.85 (R$ 396,73) and Xpert = US$ 37.33 (R$197,86) with subsidies. CONCLUSIONS The Xpert in the diagnosis of TB-DR in these reference units was cost-effective with subsidies. In the absence of a subsidy, Xpert in TB-DR is not characterized as cost effective. This factor reveals the vulnerability of countries dependent on international organizations' subsidy policies.
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Affiliation(s)
| | - Maria Claudia Vater
- Universidade Federal do Rio de Janeiro, Programa Acadêmico de Tuberculose, Rio de Janeiro, RJ, Brasil
- Universidade Federal do Rio de Janeiro, Núcleo de Bioética e Ética Aplicada, Rio de Janeiro, RJ, Brasil
| | | | - Isabela Neves de Almeida
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Laboratório de Pesquisa em Micobactérias, Departamento de Clínica Médica, Belo Horizonte, MG, Brasil
- Universidade Federal de Ouro Preto, Escola de Farmácia, Departamento de Análises Clínicas, Ouro Preto, MG, Brasil
| | - Silvana Spíndola de Miranda
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Laboratório de Pesquisa em Micobactérias, Departamento de Clínica Médica, Belo Horizonte, MG, Brasil
| | - Afrânio Kritski
- Universidade Federal do Rio de Janeiro, Programa Acadêmico de Tuberculose, Rio de Janeiro, RJ, Brasil
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18
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Deo S, Jindal P, Papineni S. Integrating Xpert MTB/RIF for TB diagnosis in the private sector: evidence from large-scale pilots in Patna and Mumbai, India. BMC Infect Dis 2021; 21:123. [PMID: 33509114 PMCID: PMC7844908 DOI: 10.1186/s12879-021-05817-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 01/18/2021] [Indexed: 12/30/2022] Open
Abstract
Background Xpert MTB/RIF (Xpert) has been recommended by WHO as the initial diagnostic test for TB and rifampicin-resistance detection. Existing evidence regarding its uptake is limited to public health systems and corresponding resource and infrastructure challenges. It cannot be readily extended to private providers, who treat more than half of India’s TB cases and demonstrate complex diagnostic behavior. Methods We used routine program data collected from November 2014 to April 2017 from large-scale private sector engagement pilots in Mumbai and Patna. It included diagnostic vouchers issued to approximately 150,000 patients by about 1400 providers, aggregated to 18,890 provider-month observations. We constructed three metrics to capture provider behavior with regards to adoption of Xpert and studied their longitudinal variation: (i) Uptake (ordering of test), (ii) Utilization for TB diagnosis, and (iii) Non-adherence to negative results. We estimated multivariate linear regression models to assess heterogeneity in provider behavior based on providers’ prior experience and Xpert testing volumes. Results Uptake of Xpert increased considerably in both Mumbai (from 36 to 60.4%) and Patna (from 12.2 to 45.1%). However, utilization of Xpert for TB diagnosis and non-adherence to negative Xpert results did not show systematic trends over time. In regression models, cumulative number of Xpert tests ordered was significantly associated with Xpert uptake in Patna and utilization for diagnosis in Mumbai (p-value< 0.01). Uptake of Xpert and its utilization for diagnosis was predicted to be higher in high-volume providers compared to low-volume providers and this gap was predicted to widen over time. Conclusions Private sector engagement led to substantial increase in uptake of Xpert, especially among high-volume providers, but did not show strong evidence of Xpert results being integrated with TB diagnosis. Increasing availability and affordability of a technically superior diagnostic tool may not be sufficient to fundamentally change diagnosis and treatment of TB in the private sector. Behavioral interventions, specifically aimed at, integrating Xpert results into clinical decision making of private providers may be required to impact patient-level outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-05817-1.
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Affiliation(s)
- Sarang Deo
- Indian School of Business, AC 3, L1, #3113, ISB Campus, Gachibowli, Hyderabad, 500032, India.
| | - Pankaj Jindal
- Indian School of Business, AC 3, L1, #3113, ISB Campus, Gachibowli, Hyderabad, 500032, India.,UCLA Anderson School of Management, Los Angeles, United States
| | - Sirisha Papineni
- Harvard Medical School, Boston, United States.,World Health Partners, New Delhi, India
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19
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Deo S, Jindal P, Sabharwal M, Parulkar A, Singh R, Kadam R, Dabas H, Dewan P. Field sales force model to increase adoption of a novel tuberculosis diagnostic test among private providers: evidence from India. BMJ Glob Health 2020; 5:e003600. [PMID: 33376100 PMCID: PMC7778745 DOI: 10.1136/bmjgh-2020-003600] [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] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 11/30/2020] [Accepted: 12/03/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Impact of novel high-quality tuberculosis (TB) tests such as Xpert MTB/RIF has been limited due to low uptake among private providers in high-burden countries including India. Our objective was to assess the impact of a demand generation intervention comprising field sales force on the uptake of high-quality TB tests by providers and its financial sustainability for private labs in the long run. METHODS We implemented a demand generation intervention across five Indian cities between October 2014 and June 2016 and compared the change in the quantity of Xpert cartridges ordered by labs in these cities from before (February 2013-September 2014) to after intervention (October 2014-December 2015) to corresponding change in labs in comparable non-intervention cities. We embedded this difference-in-differences estimate within a financial model to calculate the internal rate of return (IRR) if the labs were to invest in an Xpert machine with or without the demand generation intervention. RESULTS The intervention resulted in an estimated 60 additional Xpert cartridges ordered per lab-month in the intervention group, which yielded an estimated increase of 11 500 tests over the post-intervention period, at an additional cost of US$13.3-US$17.63 per test. Further, we found that investing in this intervention would increase the IRR from 4.8% to 5.5% for hospital labs but yield a negative IRR for standalone labs. CONCLUSIONS Field sales force model can generate additional demand for Xpert at private labs, but additional strategies may be needed to ensure its financial sustainability.
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Affiliation(s)
- Sarang Deo
- Max Institute of Healthcare Management, Indian School of Business, Mohali, Punjab, India
- Operations Management, Indian School of Business, Hyderabad, Telangana, India
| | - Pankaj Jindal
- Operations Management, Indian School of Business, Hyderabad, Telangana, India
| | | | | | - Ritu Singh
- Clinton Health Access Initiative, New Delhi, India
| | | | | | - Puneet Dewan
- Bill and Melinda Gates Foundation, New Delhi, India
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20
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Izudi J, Tamwesigire IK, Bajunirwe F. Association between GeneXpert Diagnosis and Same-Day Initiation of Tuberculosis Treatment in Rural Eastern Uganda. Am J Trop Med Hyg 2020; 103:1447-1454. [DOI: 10.4269/ajtmh.19-0900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Jonathan Izudi
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Imelda K. Tamwesigire
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Francis Bajunirwe
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
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21
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de Oliveira MCB, Sant'Anna CC, Raggio Luiz R, Kritski AL. Unfavorable Outcomes in Tuberculosis: Multidimensional Factors among Adolescents in Rio de Janeiro, Brazil. Am J Trop Med Hyg 2020; 103:2492-2500. [PMID: 32959763 DOI: 10.4269/ajtmh.20-0209] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Since 2018, adolescents have been included as a target group for tuberculosis (TB) surveillance by the WHO. However, they are considered a neglected population, as there are considerable gaps in information about them. We aimed to analyze the risk factors for unfavorable TB treatment outcomes among adolescents in Rio de Janeiro, a Brazilian city with a high burden of TB. This is a retrospective study of adolescents (10-18 years) with TB notified in Rio de Janeiro, from four national database systems, covering 2014-2016. "Extreme vulnerability" was defined as adolescents who presented one of the following characteristics: homelessness, incarceration, tobacco use, illicit drug use, or alcohol abuse. Logistic regression analysis was used to identify factors associated with favorable (cure/completed treatment) and unfavorable outcomes (lost to follow-up, death, and treatment failure). A total of 725 adolescents with TB were included: 610 (84.1%) were cured, 94 (13%) were lost to follow-up, six (0.8%) died because of TB, 13 (1.8%) died because of other causes, and two (0.3%) failed treatment. Unfavorable outcomes were associated with retreatment (adjusted odds ratio [aOR]: 4.51; 95% CI: 2.23-9.17), TB-HIV coinfection (aOR: 10.15; 95% CI: 4.15-25.34), extreme vulnerability (aOR: 3.01; 95% CI: 1.70-5.33), and living in the two districts (3.1 and 3.3) with worst conditions: large population and rates of homicides and shantytowns (aOR: 4.11; 95% CI: 1.79-9.46 and aOR: 5.35; 95% CI: 2.20-13.03, respectively). Our findings underscore the need for strengthening early identification and interventions for adolescents at high risk of unfavorable outcomes, especially those living in shantytowns.
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Affiliation(s)
- Marcia C B de Oliveira
- Post Graduation Program in Medical Clinics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Clemax C Sant'Anna
- Pediatrics Department, Faculty of Medicine, Instituto de Puericultura e Pediatria Martagão Gesteira, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ronir Raggio Luiz
- Instituto de Estudos de Saúde Coletiva, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Afrânio L Kritski
- Academic Program of Tuberculosis, School of Medicine, Institute of Torax Disease, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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22
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Ochodo EA, Kalema N, Schumacher S, Steingart K, Young T, Mallett S, Deeks J, Cobelens F, Bossuyt PM, Nicol MP, Cattamanchi A. Variation in the observed effect of Xpert MTB/RIF testing for tuberculosis on mortality: A systematic review and analysis of trial design considerations. Wellcome Open Res 2020; 4:173. [PMID: 32851196 PMCID: PMC7438967 DOI: 10.12688/wellcomeopenres.15412.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2020] [Indexed: 12/21/2022] Open
Abstract
Background: Most studies evaluating the effect of Xpert MTB/RIF testing for tuberculosis (TB) concluded that it did not reduce overall mortality compared to usual care. We conducted a systematic review to assess whether key study design and execution features contributed to earlier identification of patients with TB and decreased pre-treatment loss to follow-up, thereby reducing the potential impact of Xpert MTB/RIF testing. Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Scopus for literature published from 1 st January 2009 to February 2019. We included all primary intervention studies that had evaluated the effect of Xpert MTB/RIF on mortality compared to usual care in participants with presumptive pulmonary TB. We critically reviewed features of included studies across: Study setting and context, Study population, Participant recruitment and enrolment, Study procedures, and Study follow-up. Results: We included seven randomised and one non-randomised study. All included studies demonstrated relative reductions in overall mortality in the Xpert MTB/RIF arm ranging from 6% to 40%. However, mortality reduction was reported to be statistically significant in two studies. Study features that could explain the lack of observed effect on mortality included: the higher quality of care at study sites; inclusion of patients with a higher pre-test probability of TB leading to higher than expected empirical rates; performance of additional diagnostic testing not done in usual care leading to increased TB diagnosis or empiric treatment initiation; the recruitment of participants likely to return for follow-up; and involvement of study staff in ensuring adherence with care and follow-up. Conclusion: Most studies of Xpert MTB/RIF were designed and conducted in a manner that resulted in more patients being diagnosed and treated for TB, minimising the potential difference in mortality Xpert MTB/RIF testing could have achieved compared to usual care.
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Affiliation(s)
- Eleanor A. Ochodo
- Department of Global Health, Stellenbosch University, Cape Town, Western Cape, 8000, South Africa
| | - Nelson Kalema
- Infectious Diseases Institute, Makerere University, Kampala, 22418, Uganda
| | - Samuel Schumacher
- Tuberculosis Department, Foundation for Innovative New Diagnostics, Geneva, 1202, Switzerland
| | - Karen Steingart
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Taryn Young
- Department of Global Health, Stellenbosch University, Cape Town, Western Cape, 8000, South Africa
| | - Susan Mallett
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Trust, University of Birmingham, Edgbaston, Birmingham, UK
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Jon Deeks
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Trust, University of Birmingham, Edgbaston, Birmingham, UK
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Frank Cobelens
- Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers, Amsterdam, 1105 BP, The Netherlands
| | - Patrick M. Bossuyt
- Deapartment of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, Amsterdam, 1105 AZ, The Netherlands
| | - Mark P. Nicol
- School of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, 6009, Australia
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco Medical Center, San Francisco, California, 94110, USA
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Ballestero JGDA, Garcia JM, Bollela VR, Ruffino-Netto A, Dalcolmo MMP, Moncaio ACS, Miguel NS, Rigolin IZ, Palha PF. Management of multidrug-resistant tuberculosis: main recommendations of the Brazilian guidelines. ACTA ACUST UNITED AC 2020; 46:e20190290. [PMID: 32402012 PMCID: PMC7462689 DOI: 10.36416/1806-3756/e20190290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 11/26/2019] [Indexed: 11/17/2022]
Abstract
Over the years, various recommendations have been made in pursuit of controlling resistance to antituberculosis drugs, especially multidrug resistance, in Brazil. Given the importance of standardizing those recommendations, the aim of this study was to describe the main recommendations of the Brazilian guidelines, primarily those related to the treatment and follow-up of cases of tuberculosis. From August through October of 2018, a document search was conducted via the websites of the Brazilian National Ministry of Health, the Brazilian National Tuberculosis Control Program, the JBP, and the Official Gazette of the Federal Republic of Brazil. Data were collected systematically by using a protocol designed specifically for this study. Documents published between 2004 and 2018 were selected. It was possible to understand and trace the history of the measures for the control of multidrug-resistant tuberculosis in Brazil from 2004, when the first documents related to the disease were published, up to 2018, when the second edition of the Brazilian National Guidelines for the Control of Tuberculosis was published. The contents of the documents were analyzed and grouped by case definition, diagnostic criteria, treatment, use of directly observed treatment; mechanisms of social protection for patients; data tools; and organization of care. This analysis allowed us to understand the efforts towards standardizing some measures in Brazil, not only identifying advances in the alignment with international prerogatives (case definition, incorporation of diagnostic technology, and treatment regimens) but also underscoring the need for greater clarity regarding the mechanisms of social protection and the organization of the care provided via the Brazilian health care system.
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Affiliation(s)
- Jaqueline Garcia de Almeida Ballestero
- Departamento de Enfermagem Materno-Infantil e Saúde Pública, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | | | - Valdes Roberto Bollela
- Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Antonio Ruffino-Netto
- Departamento de Medicina Social, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Margareth Maria Pretti Dalcolmo
- Centro de Referência Professor Hélio Fraga, Escola Nacional de Saúde Pública Sérgio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brazil
| | | | - Nicoly Sanches Miguel
- Centro de Ciências Biológicas e da Saúde, Universidade de Araraquara, Araraquara, SP, Brasil
| | - Isabela Zaccaro Rigolin
- Centro de Ciências Biológicas e da Saúde, Universidade de Araraquara, Araraquara, SP, Brasil
| | - Pedro Fredemir Palha
- Departamento de Enfermagem Materno-Infantil e Saúde Pública, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
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Kennedy-Shaffer L, De Gruttola V, Lipsitch M. Novel methods for the analysis of stepped wedge cluster randomized trials. Stat Med 2020; 39:815-844. [PMID: 31876979 PMCID: PMC7247054 DOI: 10.1002/sim.8451] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 11/24/2019] [Accepted: 12/01/2019] [Indexed: 12/15/2022]
Abstract
Stepped wedge cluster randomized trials (SW-CRTs) have become increasingly popular and are used for a variety of interventions and outcomes, often chosen for their feasibility advantages. SW-CRTs must account for time trends in the outcome because of the staggered rollout of the intervention. Robust inference procedures and nonparametric analysis methods have recently been proposed to handle such trends without requiring strong parametric modeling assumptions, but these are less powerful than model-based approaches. We propose several novel analysis methods that reduce reliance on modeling assumptions while preserving some of the increased power provided by the use of mixed effects models. In one method, we use the synthetic control approach to find the best matching clusters for a given intervention cluster. Another method makes use of within-cluster crossover information to construct an overall estimator. We also consider methods that combine these approaches to further improve power. We test these methods on simulated SW-CRTs, describing scenarios in which these methods have increased power compared with existing nonparametric methods while preserving nominal validity when mixed effects models are misspecified. We also demonstrate theoretical properties of these estimators with less restrictive assumptions than mixed effects models. Finally, we propose avenues for future research on the use of these methods; motivation for such research arises from their flexibility, which allows the identification of specific causal contrasts of interest, their robustness, and the potential for incorporating covariates to further increase power. Investigators conducting SW-CRTs might well consider such methods when common modeling assumptions may not hold.
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Affiliation(s)
- Lee Kennedy-Shaffer
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, MA, USA
| | - Victor De Gruttola
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, MA, USA
| | - Marc Lipsitch
- Department of Epidemiology, Department of Immunology and Infectious Diseases, and Center for Communicable Disease Dynamics, Harvard T.H. Chan School of Public Health, MA, USA
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Effect of the Xpert MTB/RIF on the detection of pulmonary tuberculosis cases and rifampicin resistance in Shanghai, China. BMC Infect Dis 2020; 20:153. [PMID: 32070292 PMCID: PMC7029590 DOI: 10.1186/s12879-020-4871-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 02/11/2020] [Indexed: 11/23/2022] Open
Abstract
Background Xpert MTB/RIF (Xpert) is an automated molecular test recommended by World Health Organization (WHO) for diagnosis of tuberculosis (TB). This study evaluated the effect of Xpert implementation on the detection of pulmonary TB (PTB) and rifampicin-resistant TB (RR-TB) cases in Shanghai, China. Methods Xpert was routinely implemented in 2018 for all presumptive PTB patients. All PTB patients above 15 years-old identified within the Provincial TB Control Program during the first half of each of 2017 and 2018, were enrolled to compare the difference in proportions of bacteriological confirmation, patients with drug susceptibility test (DST) results for rifampicin (ie, DST coverage) and RR-TB detection before and after Xpert’s implementation. Results A total of 6047 PTB patients were included in the analysis with 1691 tested by Xpert in 2018. Percentages of bacteriological confirmation, DST coverage and RR-TB detection in 2017 and 2018 were 50% vs. 59%, 36% vs. 49% and 2% vs. 3%, respectively (all p-values < 0.05). Among 1103 PTB patients who completed sputum smear, culture and Xpert testing in 2018, Xpert detected an additional 121 (11%) PTB patients who were negative by smear and culture, but missed 248 (23%) smear and/or culture positive patients. Besides, it accounted for an increase of 9% in DST coverage and 1% in RR-TB detection. The median time from first visit to a TB hospital to RR-TB detection was 62 days (interquartile range -IQR 48–84.2) in 2017 vs. 9 days (IQR 2–45.7) in 2018 (p-value < 0.001). In the multivariate model, using Xpert was associated with decreased time to RR-TB detection (adjusted hazard ratio = 4.62, 95% confidence interval: 3.18–6.71). Conclusions Integrating Xpert with smear, culture and culture-based DST in a routine setting significantly increased bacteriological confirmation, DST coverage and RR-TB detection with a dramatic reduction in the time to RR-TB diagnosis in Shanghai, China. Our findings can be useful for other regions that attempt to integrate Xpert into routine PTB and RR-TB case-finding cascade. Further study should focus on the identification and elimination of operational level challenges to fully utilize the benefit of rapid diagnosis by Xpert.
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Grant AD, Charalambous S, Tlali M, Karat AS, Dorman SE, Hoffmann CJ, Johnson S, Vassall A, Churchyard GJ, Fielding KL. Algorithm-guided empirical tuberculosis treatment for people with advanced HIV (TB Fast Track): an open-label, cluster-randomised trial. Lancet HIV 2020; 7:e27-e37. [PMID: 31727580 DOI: 10.1016/s2352-3018(19)30266-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 07/16/2019] [Accepted: 07/30/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Tuberculosis, which is often undiagnosed, is the major cause of death among HIV-positive people. We aimed to test whether the use of a clinical algorithm enabling the initiation of empirical tuberculosis treatment by nurses in primary health-care clinics would reduce mortality compared with standard of care for adults with advanced HIV disease. METHODS In this open-label cluster-randomised controlled trial, we recruited individuals from 24 primary health-care clinics in South Africa. The clinics were randomly assigned (1:1) to either deliver an intervention or routine care (control) using computer-generated random numbers. Eligible participants were HIV-positive adults (aged ≥18 years) with CD4 counts of 150 cells per μL or less, who had not had antiretroviral therapy (ART) in the past 6 months or tuberculosis treatment in the past 3 months, and did not require urgent hospital referral. In intervention clinics, study nurses assessed participants on the basis of tuberculosis symptoms, body-mass index, point-of-care haemoglobin concentrations, and urine lipoarabinomannan assay results. Participants classified by a study algorithm as having high probability of tuberculosis (positive urine lipoarabinomannan assay, body-mass index <18·5 kg/m2, or haemoglobin concentration <100 g/L) were recommended to start tuberculosis treatment immediately followed by ART 2 weeks later; participants classified as medium probability (tuberculosis symptoms, no high probability criteria) were recommended to have symptom-guided investigation; and participants classified as low probability (no tuberculosis symptoms or high probability criteria) were recommended to start ART immediately. In standard-of-care clinics, participants received treatment in accordance with South African guidelines. Investigators and participants were aware of treatment allocation. The primary outcome was all-cause mortality at 6 months, assessed in the intention-to-treat population. Safety was also analysed in the intention-to treat population. This trial is registered with the ISRCTN registry, ISRCTN35344604, and the South African National Clinical Trials Register, DOH-27-0812-3902. FINDINGS Between Dec 19, 2012, and Dec 18, 2014, 3091 individuals were screened for eligibility, of whom 3053 were recruited, and 3022 (1507 participants in the intervention group and 1515 participants in the control group) were analysed for the primary outcome. 930 (61·7%) of 1507 participants in the intervention group versus 172 (11·4%) of 1515 participants in the control group had started tuberculosis treatment by 2 months. At 6 months, the mortality rate was 19·0 deaths per 100 person-years for the intervention group versus 21·6 deaths per 100 person-years in the control group (unadjusted hazard ratio [HR] 0·92, 95% CI 0·67-1·26, p=0·58; adjusted HR 0·87, 0·61-1·24, p=0·41). 28 (1·9%) of 1507 participants in the intervention group and ten (0·7%) of 1515 participants in the control group reported serious or severe adverse events. Grade 3 or 4 nausea and vomiting was the most common adverse event (ten participants in the intervention group and four participants in the control group). Among participants with adverse events, eight participants (six participants in the intervention group and two participants in the control group) died; none of the six deaths in the intervention group were attributed to the study intervention. INTERPRETATION Our intervention substantially increased coverage of tuberculosis treatment in this high-risk population, but did not reduce mortality. FUNDING Joint Global Health Trials (Medical Research Council, Department for International Development, Wellcome Trust).
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Affiliation(s)
- Alison D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK; Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
| | - Salome Charalambous
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; The Aurum Institute, Johannesburg, South Africa
| | - Mpho Tlali
- The Aurum Institute, Johannesburg, South Africa
| | - Aaron S Karat
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Susan E Dorman
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Suzanne Johnson
- Foundation for Professional Development, Pretoria, South Africa
| | - Anna Vassall
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Gavin J Churchyard
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; The Aurum Institute, Johannesburg, South Africa; Advancing Care and Treatment for TB/HIV, South African Medical Research Council, Johannesburg, South Africa
| | - Katherine L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Outcomes of Community-Based Systematic Screening of Household Contacts of Patients with Multidrug-Resistant Tuberculosis in Myanmar. Trop Med Infect Dis 2019; 5:tropicalmed5010002. [PMID: 31881646 PMCID: PMC7157714 DOI: 10.3390/tropicalmed5010002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 11/03/2019] [Accepted: 11/13/2019] [Indexed: 01/17/2023] Open
Abstract
Screening of household contacts of patients with multidrug-resistant tuberculosis (MDR-TB) is a crucial active TB case-finding intervention. Before 2016, this intervention had not been implemented in Myanmar, a country with a high MDR-TB burden. In 2016, a community-based screening of household contacts of MDR-TB patients using a systematic TB-screening algorithm (symptom screening and chest radiography followed by sputum smear microscopy and Xpert-MTB/RIF assays) was implemented in 33 townships in Myanmar. We assessed the implementation of this intervention, how well the screening algorithm was followed, and the yield of active TB. Data collected between April 2016 and March 2017 were analyzed using logistic and log-binomial regression. Of 620 household contacts of 210 MDR-TB patients enrolled for screening, 620 (100%) underwent TB symptom screening and 505 (81%) underwent chest radiography. Of 240 (39%) symptomatic household contacts, 71 (30%) were not further screened according to the algorithm. Children aged <15 years were less likely to follow the algorithm. Twenty-four contacts were diagnosed with active TB, including two rifampicin- resistant cases (yield of active TB = 3.9%, 95% CI: 2.3%-6.5%). The highest yield was found among children aged <5 years (10.0%, 95% CI: 3.6%-24.7%). Household contact screening should be strengthened, continued, and scaled up for all MDR-TB patients in Myanmar.
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Agizew T, Boyd R, Auld AF, Payton L, Pals SL, Lekone P, Chihota V, Finlay A. Treatment outcomes, diagnostic and therapeutic impact: Xpert vs. smear. A systematic review and meta-analysis. Int J Tuberc Lung Dis 2019; 23:82-92. [PMID: 30674379 DOI: 10.5588/ijtld.18.0203] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Compared with smear microscopy, Xpert® MTB/RIF has the potential to reduce delays in tuberculosis (TB) diagnosis and treatment initiation, and improve treatment outcomes. We reviewed publications comparing treatment outcomes of drug-susceptible TB patients diagnosed using Xpert vs. smear. METHODS Citations (2000-2016) reporting treatment outcomes of patients diagnosed using Xpert compared with smear were selected from PubMed, Scopus and conference abstracts. We conducted a systematic review and meta-analysis. Favorable (cured, completed) and unfavorable (failure, death, loss to follow-up) outcomes were pooled for meta-analysis; we also reviewed the number of TB cases diagnosed, time to treatment and empiric treatment. The Mantel-Haenszel method with a fixed-effect model was used; I² was calculated to measure heterogeneity. RESULTS From 13 citations, 43 594 TB patients were included and 4825 were with known TB treatment outcome. From the pooled analysis, an unfavorable outcomes among those diagnosed using Xpert compared with smear was 20.2%, 541/2675 vs. 21.9%, 470/2150 (risk ratio 0.92, 95%CI 0.82-1.02). Statistical heterogeneity was low (I² = 0.0%, P = 0.910). Compared with smear, Xpert was reported to be superior in increasing the number of TB patients diagnosed (2/9 citations), increasing bacteriologically confirmed TB (7/9 citations), reducing empiric treatment (3/5 citations), reducing time to diagnosis (2/3 citations), and reducing time to treatment initiation (1/5 citations). CONCLUSIONS Xpert implementation showed no discernible impact on treatment outcomes compared with conventional smear despite reduced time to diagnosis, time to treatment or reduced level of empiric treatment. Further research is required to learn more about gaps in the existing health system.
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Affiliation(s)
- T Agizew
- Centers for Disease Control and Prevention (CDC), Gaborone, Botswana, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - R Boyd
- Centers for Disease Control and Prevention (CDC), Gaborone, Botswana, Division of Tuberculosis Elimination
| | - A F Auld
- Division of Global HIV and Tuberculosis, CDC, Atlanta, Georgia, USA
| | - L Payton
- Centers for Disease Control and Prevention (CDC), Gaborone, Botswana
| | - S L Pals
- Division of Global HIV and Tuberculosis, CDC, Atlanta, Georgia, USA
| | - P Lekone
- Centers for Disease Control and Prevention (CDC), Gaborone, Botswana
| | - V Chihota
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa, Aurum Institute, Johannesburg, South Africa
| | - A Finlay
- Centers for Disease Control and Prevention (CDC), Gaborone, Botswana, Division of Tuberculosis Elimination
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29
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Agizew T, Chihota V, Nyirenda S, Tedla Z, Auld AF, Mathebula U, Mathoma A, Boyd R, Date A, Pals SL, Lekone P, Finlay A. Tuberculosis treatment outcomes among people living with HIV diagnosed using Xpert MTB/RIF versus sputum-smear microscopy in Botswana: a stepped-wedge cluster randomised trial. BMC Infect Dis 2019; 19:1058. [PMID: 31842773 PMCID: PMC6915885 DOI: 10.1186/s12879-019-4697-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 12/09/2019] [Indexed: 12/22/2022] Open
Abstract
Background Xpert® MTB/RIF (Xpert) has high sensitivity for diagnosing tuberculosis (TB) compared to sputum-smear microscopy (smear) and can reduce time-to-diagnosis, time-to-treatment and potentially unfavorable patient-level treatment outcome. Methods People living with HIV (PLHIV) initiating antiretroviral therapy at 22 HIV clinics were enrolled and underwent systematic screening for TB (August 2012–November 2014). GeneXpert instruments were deployed following a stepped-wedge design at 13 centers from October 2012–June 2013. Treatment outcomes classified as an unfavorable outcome (died, treatment failure or loss-to-follow-up) or favorable outcome (cured and treatment completed). To determine outcome, smear was performed at month 5 or 6. Empiric treatment was defined as initiating treatment without/before receiving TB-positive results. Adjusting for intra-facility correlation, we compared patient-level treatment outcomes between patients screened using smear (smear arm)- and Xpert-based algorithms (Xpert arm). Results Among 6041 patients enrolled (smear arm, 1816; Xpert arm, 4225), 256 (199 per 2985 and 57 per 1582 person-years of follow-up in Xpert and smear arms, respectively; adjusted incidence rate ratio, 9.07; 95% confidence interval [CI]: 4.70–17.48; p < 0.001) received TB diagnosis and were treated. TB treatment outcomes were available for 203 patients (79.3%; Xpert, 157; smear, 46). Unfavorable outcomes were reported for 21.7% (10/46) in the smear and 13.4% (21/157) in Xpert arm (adjusted hazard ratio, 1.40; 95% CI: 0.75–2.26; p = 0.268). Compared to smear, in Xpert arm median days from sputum collection to TB treatment was 6 days (interquartile range [IQR] 2–17 versus 22 days [IQR] 3–51), p = 0.005; patients with available sputum test result had microbiologically confirmed TB in 59.0% (102/173) versus 41.9% (18/43), adjusted Odds Ratio [aOR], 2.00, 95% CI: 1.01–3.96, p = 0.048). In smear arm empiric treatment was 68.4% (39/57) versus 48.7% (97/199), aOR, 2.28, 95% CI: 1.24–4.20, p = 0.011), compared to Xpert arm. Conclusions TB treatment outcomes were similar between the smear and Xpert arms. However, compared to the smear arm, more patients in the Xpert arm received a TB diagnosis, had a microbiologically confirmed TB, and had a shorter time-to-treatment, and had a lower empiric treatment. Further research is recommended to identify potential gaps in the Botswana health system and similar settings. Trial registration ClinicalTrials.gov Identifier: NCT02538952. Retrospectively registered on 2 September 2015.
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Affiliation(s)
- Tefera Agizew
- Centers for Disease Control and Prevention, Gaborone, Botswana. .,Faculty of Health Sciences, Department of Public Health, University of the Witwatersrand, Johannesburg, South Africa. .,Faculty of Medicine, University of Botswana, Gaborone, Botswana.
| | - Violet Chihota
- Faculty of Health Sciences, Department of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,Aurum Institute, Johannesburg, South Africa
| | | | - Zegabriel Tedla
- Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Andrew F Auld
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Unami Mathebula
- Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Anikie Mathoma
- Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Rosanna Boyd
- Centers for Disease Control and Prevention, Gaborone, Botswana.,Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Anand Date
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sherri L Pals
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Phenyo Lekone
- Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Alyssa Finlay
- Centers for Disease Control and Prevention, Gaborone, Botswana.,Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, GA, USA
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30
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Ochodo EA, Kalema N, Schumacher S, Steingart K, Young T, Mallett S, Deeks J, Cobelens F, Bossuyt PM, Nicol MP, Cattamanchi A. Variation in the observed effect of Xpert MTB/RIF testing for tuberculosis on mortality: A systematic review and analysis of trial design considerations. Wellcome Open Res 2019; 4:173. [PMID: 32851196 PMCID: PMC7438967 DOI: 10.12688/wellcomeopenres.15412.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2019] [Indexed: 02/15/2024] Open
Abstract
Background: Most studies evaluating the effect of Xpert MTB/RIF testing for tuberculosis (TB) concluded that it did not reduce overall mortality compared to usual care. We conducted a systematic review to assess whether key study design and execution features contributed to earlier identification of patients with TB and decreased pre-treatment loss to follow-up, thereby reducing the potential impact of Xpert MTB/RIF testing. Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Scopus for literature published from 1 st January 2009 to February 2019. We included all primary intervention studies that had evaluated the effect of Xpert MTB/RIF on mortality compared to usual care in participants with presumptive pulmonary TB. We critically reviewed features of included studies across: Study setting and context, Study population, Participant recruitment and enrolment, Study procedures, and Study follow-up. Results: We included seven randomised and one non-randomised study. All included studies demonstrated relative reductions in overall mortality in the Xpert MTB/RIF arm ranging from 6% to 40%. However, mortality reduction was reported to be statistically significant in two studies. Study features that could explain the lack of observed effect on mortality included: the higher quality of care at study sites; inclusion of patients with a higher pre-test probability of TB leading to higher than expected empirical rates; performance of additional diagnostic testing not done in usual care leading to increased TB diagnosis or empiric treatment initiation; the recruitment of participants likely to return for follow-up; and involvement of study staff in ensuring adherence with care and follow-up. Conclusion: Most studies of Xpert MTB/RIF were designed and conducted in a manner that resulted in more patients being diagnosed and treated for TB, minimising the potential difference in mortality Xpert MTB/RIF testing could have achieved compared to usual care.
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Affiliation(s)
- Eleanor A. Ochodo
- Department of Global Health, Stellenbosch University, Cape Town, Western Cape, 8000, South Africa
| | - Nelson Kalema
- Infectious Diseases Institute, Makerere University, Kampala, 22418, Uganda
| | - Samuel Schumacher
- Tuberculosis Department, Foundation for Innovative New Diagnostics, Geneva, 1202, Switzerland
| | - Karen Steingart
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Taryn Young
- Department of Global Health, Stellenbosch University, Cape Town, Western Cape, 8000, South Africa
| | - Susan Mallett
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Trust, University of Birmingham, Edgbaston, Birmingham, UK
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Jon Deeks
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Trust, University of Birmingham, Edgbaston, Birmingham, UK
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Frank Cobelens
- Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers, Amsterdam, 1105 BP, The Netherlands
| | - Patrick M. Bossuyt
- Deapartment of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, Amsterdam, 1105 AZ, The Netherlands
| | - Mark P. Nicol
- School of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, 6009, Australia
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco Medical Center, San Francisco, California, 94110, USA
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McGrath S, Sohn H, Steele R, Benedetti A. Meta-analysis of the difference of medians. Biom J 2019; 62:69-98. [PMID: 31553488 DOI: 10.1002/bimj.201900036] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 06/07/2019] [Accepted: 06/16/2019] [Indexed: 12/24/2022]
Abstract
We consider the problem of meta-analyzing two-group studies that report the median of the outcome. Often, these studies are excluded from meta-analysis because there are no well-established statistical methods to pool the difference of medians. To include these studies in meta-analysis, several authors have recently proposed methods to estimate the sample mean and standard deviation from the median, sample size, and several commonly reported measures of spread. Researchers frequently apply these methods to estimate the difference of means and its variance for each primary study and pool the difference of means using inverse variance weighting. In this work, we develop several methods to directly meta-analyze the difference of medians. We conduct a simulation study evaluating the performance of the proposed median-based methods and the competing transformation-based methods. The simulation results show that the median-based methods outperform the transformation-based methods when meta-analyzing studies that report the median of the outcome, especially when the outcome is skewed. Moreover, we illustrate the various methods on a real-life data set.
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Affiliation(s)
- Sean McGrath
- Department of Mathematics and Statistics, McGill University, Montreal, Quebec, Canada.,Respiratory Epidemiology and Clinical Research Unit, McGill University Health Centre, Montreal, Quebec, Canada
| | - Hojoon Sohn
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Russell Steele
- Department of Mathematics and Statistics, McGill University, Montreal, Quebec, Canada
| | - Andrea Benedetti
- Respiratory Epidemiology and Clinical Research Unit, McGill University Health Centre, Montreal, Quebec, Canada.,Department of Medicine, McGill University, Montreal, Quebec, Canada
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Zawedde-Muyanja S, Manabe YC, Sewankambo NK, Nakiyingi L, Nakanjako D. Xpert ® MTB/RIF associated with improved treatment initiation among patients with smear-negative tuberculosis. Int J Tuberc Lung Dis 2019; 22:1475-1480. [PMID: 30606320 PMCID: PMC6306042 DOI: 10.5588/ijtld.17.0460] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND: Delayed diagnosis and treatment initiation of smear-negative tuberculosis (TB) patients can lead to increased morbidity and mortality, particularly among those co-infected with the human immunodeficiency virus (HIV). OBJECTIVE: To compare TB treatment initiation among smear-negative presumptive TB patients in the 6 months before and after the introduction of Xpert® MTB/RIF testing at five rural tertiary hospitals in Uganda. METHODS: Patient records of the dates and results of sputum analysis were extracted from TB laboratory registers and linked to those on treatment initiation as indicated in the TB treatment registers. The proportion of smear-negative presumptive patients who initiated anti-tuberculosis treatment was compared before and after Xpert implementation using χ2 tests. Time to treatment was analysed using Kaplan-Meier survival analysis. RESULTS: Records from 3658 patients were analysed, 1894 before and 1764 after the introduction of Xpert testing. After the introduction of Xpert, 25% (437/1764) of smear-negative presumptive TB patients underwent testing. The proportion initiated on anti-tuberculosis treatment increased from 5.9% (112/1894) to 10.8% (190/1764) (P < 0.01). However, 37% (32/87) of patients with a confirmed TB diagnosis did not initiate treatment. Time to TB treatment initiation improved from 8 to 3.5 days between the study periods. CONCLUSION: Xpert testing was associated with improved TB treatment initiation among smear-negative presumptive TB patients. Improved utilisation and linkage to treatment could improve the impact of this test on patient-centred outcomes.
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Affiliation(s)
| | - Y C Manabe
- The Infectious Diseases Institute, Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - N K Sewankambo
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - L Nakiyingi
- The Infectious Diseases Institute, Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - D Nakanjako
- The Infectious Diseases Institute, Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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Schutz C, Ward A, Burton R, Nicol MP, Blumenthal L, Meintjes G, Kerkhoff AD. False rifampicin resistant results using Xpert MTB/RIF on urine samples in hospitalised HIV-infected patients. South Afr J HIV Med 2019; 20:978. [PMID: 31534789 PMCID: PMC6739559 DOI: 10.4102/sajhivmed.v20i1.978] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 05/24/2019] [Indexed: 11/01/2022] Open
Abstract
Background A small proportion of false rifampicin resistant results have previously been reported using GeneXpert MTB/RIF version G4 on sputum samples; however, this has not been investigated for urine samples in HIV-associated tuberculosis (TB). Objectives We sought to determine the proportion of false rifampicin resistant results using Xpert MTB/RIF version G4 on urine samples among HIV-infected inpatients investigated for TB. Methods Hospitalised HIV-infected patients undergoing systematic TB testing from two cohorts in Cape Town, South Africa, were enrolled. All patients with ≥1 urine Xpert result available were included. Rifampicin resistant urine Xpert results were classified into three mutually exclusive groups: (1) true rifampicin resistance, (2) false rifampicin resistance or (3) unknown after review of available microbiologic and clinical data. Results Overall, 1171 patients were included, from whom a total of 1704 urine Xpert results were available on unconcentrated and/or concentrated urine samples. There were 416 samples positive for TB (24.4% [95% CI 22.4-26.5]), of which 43/413 (10.4% [95% CI 7.6-13.8]) were rifampicin resistant (after excluding three results that were falsely positive due to contamination). Of 43 rifampicin resistant Xpert results (among 40 patients), 30 were classified as true resistance, 11 as false resistance and 2 could not be classified. Excluding unclassifiable results, 30/41 results were confirmed as true-positive urine Xpert rifampicin resistance (positive predictive value: 73.2% [95% CI 57.1-85.8]). Conclusion Urine Xpert testing showed a high proportion of false rifampicin resistance results. Urine Xpert rifampicin resistant results should be interpreted cautiously and confirmed when possible.
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Affiliation(s)
- Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine (IDM) and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Amy Ward
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine (IDM) and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rosie Burton
- GF Jooste Hospital; Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mark P Nicol
- Division of Medical Microbiology, University of Cape Town and National Health Laboratory Services, Cape Town, South Africa
| | - Liz Blumenthal
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine (IDM) and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine (IDM) and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, Department of Medicine, University of California, San Francisco, United States
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Martinez L, Castellanos ME, Hallowell BD, Whalen CC. Innovative Methods to Manage, Detect, and Prevent Tuberculosis. Am J Respir Crit Care Med 2019; 195:530-532. [PMID: 27911589 DOI: 10.1164/rccm.201608-1657rr] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Leonardo Martinez
- 1 Department of Epidemiology and Biostatistics and.,2 Institute of Global Health, College of Public Health, University of Georgia, Athens, Georgia
| | - María Eugenia Castellanos
- 1 Department of Epidemiology and Biostatistics and.,2 Institute of Global Health, College of Public Health, University of Georgia, Athens, Georgia
| | - Benjamin D Hallowell
- 1 Department of Epidemiology and Biostatistics and.,2 Institute of Global Health, College of Public Health, University of Georgia, Athens, Georgia
| | - Christopher C Whalen
- 1 Department of Epidemiology and Biostatistics and.,2 Institute of Global Health, College of Public Health, University of Georgia, Athens, Georgia
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Will more sensitive diagnostics identify tuberculosis missed by clinicians? Evaluating Xpert MTB/RIF testing in Guatemala. GACETA SANITARIA 2019; 34:127-132. [PMID: 31060754 DOI: 10.1016/j.gaceta.2019.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/22/2019] [Accepted: 02/26/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the impact of introducing Xpert as a follow-on test after smear microscopy on the total number pulmonary TB notifications. METHOD Genexpert systems were installed in six departments across Guatemala, and Xpert was indicated as a follow-on test for people with smear-negative results. We analyzed notifications to national tuberculosis (TB) programmes (NTP) and the project's laboratory data to assess coverage of the intervention and case detection yield. Changes in quarterly TB notifications were analyzed using a simple pre/post comparison and a regression model controlling for secular notification trends. Using a mix of project and NTP data we estimated the theoretical yield of the intervention if testing coverage achieved 100%. RESULTS Over 18,000 smear-negative individuals were eligible for Xpert testing during the intervention period. Seven thousand, one hundred and ninety-three people (39.6% of those eligible) were tested on Xpert resulting in the detection of 199 people with smear-negative, Xpert positive results (2.8% positivity rate). In the year before testing began 1098 people with smear positive and 195 people with smear negative results were notified in the six intervention departments. During the intervention, smear-positive notification remained roughly stable (1090 individuals, 0.7%), but smear-negative notifications increased by 167 individuals (85.6%) to an all-time high of 362. After controlling for secular notifications trends over an eight-quarter pre-intervention period, combined pulmonary TB notifications (both smear positive and negative) were 19% higher than trend predictions. If Xpert testing coverage approached 100% of those eligible, we estimate there would have been a+41% increase in TB notifications. CONCLUSIONS We measured a large gain in pulmonary notifications through the introduction of Xpert testing alone. This indicates a large number of people with TB in Guatemala are seeking health care and being tested, yet are not diagnosed or treated because they lack bacteriological confirmation. Wider use of more sensitive TB diagnostics and/or improvements in the number of people clinically diagnosed with TB have the potential to significantly increase TB notifications in this setting, and potentially in other settings where a low proportion of pulmonary notifications are clinically diagnosed.
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Ngwira LG, Corbett EL, Khundi M, Barnes GL, Nkhoma A, Murowa M, Cohn S, Moulton LH, Chaisson RE, Dowdy DW. Screening for Tuberculosis With Xpert MTB/RIF Assay Versus Fluorescent Microscopy Among Adults Newly Diagnosed With Human Immunodeficiency Virus in Rural Malawi: A Cluster Randomized Trial (Chepetsa). Clin Infect Dis 2019; 68:1176-1183. [PMID: 30059995 PMCID: PMC6769397 DOI: 10.1093/cid/ciy590] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 07/25/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) remains the leading cause of death among human immunodeficiency virus (HIV)-infected individuals globally. Screening for TB at the point of HIV diagnosis with a high-sensitivity assay presents an opportunity to reduce mortality. METHODS We performed a cluster randomized trial of TB screening among adults newly diagnosed with HIV in 12 primary health clinics in rural Thyolo, Malawi. Clinics were allocated in a 1:1 ratio to perform either point-of-care Xpert MTB/RIF assay (Xpert) or point-of-care light-emitting diode fluorescence microscopy (LED-FM) for individuals screening positive for TB symptoms. Asymptomatic participants were offered isoniazid preventive therapy in both arms. Investigators, but not clinic staff or participants, were masked to allocation. Our primary outcome was the incidence rate ratio (RR) of all-cause mortality within 12 months of HIV diagnosis. RESULTS Prevalent TB was diagnosed in 24 of 1001 (2.4%) individuals enrolled in clinics randomized to Xpert, compared with 10 of 841 (1.2%) in clinics randomized to LED-FM. All-cause mortality was 22% lower in the Xpert arm than in the LED-FM arm (6.7 vs 8.6 per 100 person-years; RR, 0.78 [95% confidence interval {CI}, .58-1.06]). A planned subgroup analysis suggested that participants with more advanced HIV (World Health Organization clinical stage 3 or 4) disease had lower mortality in clinics randomized to Xpert than to LED-FM (RR, 0.43 [95% CI, .22-.87]). CONCLUSIONS In rural Malawi, using point-of-care Xpert MTB/RIF to test symptomatic patients for TB at the time of HIV diagnosis reduced all-cause 12-month mortality among individuals with advanced HIV. CLINICAL TRIALS REGISTRATION NCT01450085.
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Affiliation(s)
- Lucky G Ngwira
- HIV and TB Group, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre
- Clinical Sciences Department, Liverpool School of Tropical Medicine, United Kingdom
| | - Elizabeth L Corbett
- HIV and TB Group, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre
- TB Centre, London School of Hygiene and Tropical Medicine, United Kingdom
| | - McEwen Khundi
- HIV and TB Group, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre
| | - Grace L Barnes
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Austin Nkhoma
- HIV and TB Group, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre
| | - Michael Murowa
- Malawi Ministry of Health, Lilongwe, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Silvia Cohn
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lawrence H Moulton
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Richard E Chaisson
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - David W Dowdy
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Soeroto AY, Lestari BW, Santoso P, Chaidir L, Andriyoko B, Alisjahbana B, van Crevel R, Hill PC. Evaluation of Xpert MTB-RIF guided diagnosis and treatment of rifampicin-resistant tuberculosis in Indonesia: A retrospective cohort study. PLoS One 2019; 14:e0213017. [PMID: 30818352 PMCID: PMC6394995 DOI: 10.1371/journal.pone.0213017] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 02/13/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Rifampicin-resistant tuberculosis (RR-TB) is largely underdetected in Indonesia. Xpert MTB/RIF (Xpert) has recently been introduced, prioritizing patients at risk of RR-TB, followed by phenotypic drug-susceptibility (DST) if rifampicin resistance is detected. OBJECTIVE This study investigated Xpert-based management of presumptive RR-TB cases under routine practice in West Java, Indonesia. METHODS We examined all records of patients tested with Xpert in the referral hospital for West Java in 2015-2016. We measured loss across a limited cascade of care, time to Xpert diagnosis and the commencement of initial second-line treatment, and identified factors associated with diagnostic and treatment delay. Additionally, we analyzed the appropriateness of treatment according to DST results. RESULTS Of 3415 patients with presumptive RR-TB, 3215 (94%) were tested by Xpert, of whom 339 (10.5%) were diagnosed as RR-TB. 288 (85%) of 339 RR-TB patients started initial second-line TB treatment, with 48 (14%) patients being lost between diagnosis and pre-treatment assessment. Second-line treatment was commenced at a median of 41 days (IQR 29-70) after RR-TB diagnosis. Delays in both diagnosis and treatment initiation were observed in 104 (52%) of 201 RR-TB patients with identifiable referral date. Rural residence was associated with delay to diagnosis (adjusted OR 2.7; 95%CI 1.5-5.2) and treatment initiation (adjusted OR 2.0; 1.2-3.4). Of 162 patients with available DST result, 107 (66%) had multidrug-resistant tuberculosis (MDR-TB) and 32 (20%) had either pre-extensively drug resistant (pre-XDR) or extensively drug resistant tuberculosis (XDR-TB). We estimated that with the current algorithm 41% of pre-XDR or XDR-TB patients are diagnosed, and 33% of them started on an appropriate treatment regimen. CONCLUSIONS Many patients with Xpert-diagnosed RR-TB either do not start MDR-TB treatment or encountered diagnostic and treatment delays under programmatic conditions in Indonesia, and most pre-XDR and XDR-TB cases remain undiagnosed. Further expansion and ongoing quality improvement of RR-TB services are urgently needed.
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Affiliation(s)
- Arto Yuwono Soeroto
- Department of Internal Medicine, Respirology and Critical Illness Division, Faculty of Medicine Universitas Padjadjaran, Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Bony Wiem Lestari
- Department of Public Health, Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
- TB-HIV Research Center, Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
- Department of Internal Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- * E-mail: ,
| | - Prayudi Santoso
- Department of Internal Medicine, Respirology and Critical Illness Division, Faculty of Medicine Universitas Padjadjaran, Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Lidya Chaidir
- TB-HIV Research Center, Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
| | - Basti Andriyoko
- Department of Clinical Pathology, Faculty of Medicine Universitas Padjadjaran, Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Bachti Alisjahbana
- TB-HIV Research Center, Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
| | - Reinout van Crevel
- Department of Internal Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Philip C. Hill
- Center for International Health, University of Otago, Dunedin, New Zealand
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Huerga H, Ferlazzo G, Wanjala S, Bastard M, Bevilacqua P, Ardizzoni E, Sitienei J, Bonnet M. Mortality in the first six months among HIV-positive and HIV-negative patients empirically treated for tuberculosis. BMC Infect Dis 2019; 19:132. [PMID: 30744603 PMCID: PMC6369550 DOI: 10.1186/s12879-019-3775-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/04/2019] [Indexed: 01/20/2023] Open
Abstract
Background Empirical treatment of tuberculosis (TB) may be necessary in patients with negative or no Xpert MTB/RIF results. In a context with access to Xpert, we assessed mortality in the 6 months after the initial TB consultation among HIV-positive and HIV-negative patients who received empirical TB treatment or TB treatment based on bacteriological confirmation and we compared it with the mortality among those who did not receive TB treatment. Methods This prospective cohort study included consecutively adult patients with signs and symptoms of TB attending an outpatient TB clinic in Western Kenya. At the first consultation, patients received a clinical exam and chest X-ray. Sputum was collected for microscopy, Xpert and Mycobacterium tuberculosis complex (MTB) culture. Patients not started on TB treatment were reassessed after 5 days. All patients bacteriologically confirmed (positive Xpert or culture) received TB treatment. Empirical treatment was defined as a decision to start TB treatment without bacteriological confirmation. Patients were reassessed after 6 months. Results Of 606 patients included, 344/606 (56.8%) were women. Median age was 35 years [Interquartile Range (IQR):27–47] and 398/594 (67.0%) were HIV-positive. In total, 196/606 (32.3%) patients were Xpert- or culture-positive and 331/606 (54.6%) started TB treatment. Overall, 100/398 (25.1%) HIV-positive and 31/196 (15.8%) HIV-negative patients received empirical treatment. Mortality in the 6 months following the first consultation was 1.6 and 0.8/100 patient-months among HIV-positive and HIV-negative patients respectively. In the multivariate analyses, TB treatment - whether empirical or based on bacteriological confirmation- was not associated with increased mortality among HIV-positive patients (aHR:2.51, 95%CI:0.79–7.90 and aHR:1.25, 95%CI:0.37–4.21 respectively). However, HIV-negative patients who received empirical treatment had a higher risk of mortality (aHR:4.85, 95%CI:1.08–21.67) compared to those not started on treatment. HIV-negative patients treated for TB based on bacteriological confirmation did not have a different risk of mortality (aHR:0.77, 95%CI:0.08–7.41). Conclusions Our findings suggest that in a context with access to Xpert, clinicians should continue using empirical TB treatment in HIV-positive patients with signs and symptoms of TB and negative Xpert results. However, differential diagnoses other than TB should be actively sought before initiating empirical TB treatment, particularly in HIV-negative patients.
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Affiliation(s)
| | | | | | | | | | - Elisa Ardizzoni
- Médecins Sans Frontières, Paris, France.,Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Maryline Bonnet
- Epicentre, Paris, France.,IRD UMI 233 TransVIHMI - UM - INSERM U1175, Montpellier, France
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Di Tanna GL, Khaki AR, Theron G, McCarthy K, Cox H, Mupfumi L, Trajman A, Zijenah LS, Mason P, Bandason T, Durovni B, Bara W, Hoelscher M, Clowes P, Mangu C, Chanda D, Pym A, Mwaba P, Cobelens F, Nicol MP, Dheda K, Churchyard G, Fielding K, Metcalfe JZ. Effect of Xpert MTB/RIF on clinical outcomes in routine care settings: individual patient data meta-analysis. Lancet Glob Health 2019; 7:e191-e199. [PMID: 30683238 PMCID: PMC6366854 DOI: 10.1016/s2214-109x(18)30458-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 07/20/2018] [Accepted: 09/27/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Xpert MTB/RIF, the most widely used automated nucleic acid amplification test for tuberculosis, is available in more than 130 countries. Although diagnostic accuracy is well documented, anticipated improvements in patient outcomes have not been clearly identified. We performed an individual patient data meta-analysis to examine improvements in patient outcomes associated with Xpert MTB/RIF. METHODS We searched PubMed, Embase, ClinicalTrials.gov, and the Pan African Clinical Trials Registry from inception to Feb 1, 2018, for randomised controlled trials (RCTs) comparing the use of Xpert MTB/RIF with sputum smear microscopy as tests for tuberculosis diagnosis in adults (aged 18 years or older). We excluded studies of patients with extrapulmonary tuberculosis, and studies in which mortality was not assessed. We used a two-stage approach for our primary analysis and a one-stage approach for the sensitivity analysis. To assess the primary outcome of cumulative 6-month all-cause mortality, we first performed logistic regression models (random effects for cluster randomised trials, with robust SEs for multicentre studies) for each trial, and then pooled the odds ratio (OR) estimates by a fixed-effects (inverse variance) or random-effects (Der Simonian Laird) meta-analysis. We adjusted for age and gender, and stratified by HIV status and previous tuberculosis-treatment history. The study protocol has been registered with PROSPERO, number CRD42014013394. FINDINGS Our search identified 387 studies, of which five RCTs were eligible for analysis. 8567 adult clinic attendees (4490 [63·5%] of 7074 participants for whom data were available were HIV-positive) were tested for tuberculosis with Xpert MTB/RIF (Xpert group) versus sputum smear microscopy (sputum smear group), across five low-income and middle-income countries (South Africa, Brazil, Zimbabwe, Zambia, and Tanzania). The primary outcome (reported in three studies) occurred in 182 (4·5%) of 4050 patients in the Xpert group and 217 (5·3%) of 4093 patients in the smear group (pooled adjusted OR 0·88, 95% CI 0·68-1·14 [p=0·34]; for HIV-positive individuals OR 0·83, 0·65-1·05 [p=0·12]). Kaplan-Meier estimates showed a lower rate of death (12·73 per 100 person-years in the Xpert group vs 16·38 per 100 person-years in the sputum smear group) for HIV-positive patients (hazard ratio 0·76, 95% CI 0·60-0·97; p=0·03). The risk of bias was assessed as reasonable and the statistical heterogeneity across studies was low (I2<20% for the primary outcome). INTERPRETATION Despite individual patient data analysis from five RCTs, we were unable to confidently rule in nor rule out an Xpert MTB/RIF-associated reduction in mortality among outpatients tested for tuberculosis. Reduction in mortality among HIV-positive patients in a secondary analysis suggests the possibility of population-level impact. FUNDING US National Institutes of Health.
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Affiliation(s)
- Gian Luca Di Tanna
- TB Centre, Riskcenter-IREA, Department of Econometrics, Statistics and Applied Economics, University of Barcelona, Barcelona, Spain
| | - Ali Raza Khaki
- Division of Oncology, University of Washington, Seattle, WA, USA
| | - Grant Theron
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Kerrigan McCarthy
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Helen Cox
- Division of Medical Microbiology, and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Lucy Mupfumi
- Botswana Harvard AIDS Institute, Gaborone, Botswana
| | - Anete Trajman
- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil, McGill University, Montreal, QC, Canada
| | - Lynn Sodai Zijenah
- Department of Immunology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | | | - Tsitsi Bandason
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | | | - Wilbert Bara
- Zimbabwe Ministry of Health and Child Welfare, Harare, Zimbabwe
| | - Michael Hoelscher
- Mbeya Medical Research Center, Mbeya, Tanzania, Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, Munich, Germany
| | - Petra Clowes
- Mbeya Medical Research Center, Mbeya, Tanzania, Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, Munich, Germany
| | | | - Duncan Chanda
- University Teaching Hospital and University of Zambia School of Medicine, Lusaka, Zambia
| | - Alexander Pym
- Africa Health Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Peter Mwaba
- University Teaching Hospital and University of Zambia School of Medicine, Lusaka, Zambia
| | - Frank Cobelens
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, Netherlands
| | - Mark P Nicol
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa, Division of Medical Microbiology, and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Keertan Dheda
- London School of Hygiene and Tropical Medicine, London, UK, Lung Infection and Immunity Unit, Division of Pulmonology, University of Cape Town, Cape Town, South Africa
| | - Gavin Churchyard
- The Aurum Institute, Johannesburg, South Africa, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa, Advancing Care and Treatment for TB/HIV, South African Medical Research Council, Johannesburg, South Africa
| | | | - John Z Metcalfe
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA, USA
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Shazzadur Rahman AAM, Langley I, Galliez R, Kritski A, Tomeny E, Squire SB. Modelling the impact of chest X-ray and alternative triage approaches prior to seeking a tuberculosis diagnosis. BMC Infect Dis 2019; 19:93. [PMID: 30691448 PMCID: PMC6348624 DOI: 10.1186/s12879-019-3684-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 01/07/2019] [Indexed: 11/19/2022] Open
Abstract
Background Tuberculosis is a major challenge to health in the developing world. Triage prior to diagnostic testing could potentially reduce the volume of tests and costs associated with using the more accurate, but costly, Xpert MTB/RIF assay. An effective methodology to predict the impact of introducing triage prior to tuberculosis diagnostic testing could be useful in helping to guide policy. Methods The development and use of operational modelling to project the impact on case detection and health system costs of alternative triage approaches for tuberculosis, with or without X-ray, based on data from Porto Alegre City, Brazil. Results Most of the triage approaches modelled without X-ray were predicted to provide no significant benefit. One approach based on an artificial neural network applied to patient and symptom characteristics was projected to increase case detection (82% vs. 75%) compared to microscopy, and reduce costs compared to Xpert without triage. In addition, use of X-ray before diagnostic testing for HIV-negative patients could maintain diagnostic yield of using Xpert without triage, and reduce costs. Conclusion A model for the impact assessment of alternative triage approaches has been tested. The results from using the approach demonstrate its usefulness in informing policy in a typical high burden setting for tuberculosis. Electronic supplementary material The online version of this article (10.1186/s12879-019-3684-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Ivor Langley
- Centre for Applied Health Research and Delivery, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Rafael Galliez
- Rede TB, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Afrânio Kritski
- Rede TB, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ewan Tomeny
- Centre for Applied Health Research and Delivery, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - S Bertel Squire
- Centre for Applied Health Research and Delivery, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
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Maciel EL, Braga JU, Bertolde AI, Zandonade E. Reflections upon the article "Evaluation of the impact that the changes in tuberculosis treatment implemented in Brazil in 2009 have had on disease control in the country"Authors' replyEvaluation of the impact that the changes in tuberculosis treatment implemented in Brazil in 2009 have had on disease control in the countryHow Do You Know Which Health Care Effectiveness Research You Can Trust A Guide to Study Design for the PerplexedSegmented regression analysis of interrupted time series studies in medication use researchConducting interrupted time series analysis for single-and multiple-group comparisonsInterrupted time series regression for the evaluation of public health interventions a tutorialHow to obtain the confidence interval from a P value. ACTA ACUST UNITED AC 2019; 44:249-252. [PMID: 30043894 PMCID: PMC6188688 DOI: 10.1590/s1806-37562018000000096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Affiliation(s)
- Ethel Leonor Maciel
- . Laboratório de Epidemiologia, Universidade Federal do Espírito Santo, Vitória (ES) Brasil
| | - José Ueleres Braga
- . Departamento de Epidemiologia e Métodos Quantitativos, Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz, Rio de Janeiro (RJ) Brasil.,. Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, Rio de Janeiro (RJ) Brasil
| | - Adelmo Inácio Bertolde
- . Departamento de Estatística, Universidade Federal do Espírito Santo, Vitória (ES) Brasil
| | - Eliana Zandonade
- . Departamento de Estatística, Universidade Federal do Espírito Santo, Vitória (ES) Brasil
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Casela M, Cerqueira SMA, Casela TDO, Pereira MA, Santos SQD, Pozo FAD, Freire SM, Matos ED. Rapid molecular test for tuberculosis: impact of its routine use at a referral hospital. ACTA ACUST UNITED AC 2019; 44:112-117. [PMID: 29791546 PMCID: PMC6044659 DOI: 10.1590/s1806-37562017000000201] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 12/07/2017] [Indexed: 01/02/2023]
Abstract
Objective: To evaluate the impact of the use of the molecular test for Mycobacterium tuberculosis and its resistance to rifampin (Xpert MTB/RIF), under routine conditions, at a referral hospital in the Brazilian state of Bahia. Methods: This was a descriptive study using the database of the Mycobacteriology Laboratory of the Octávio Mangabeira Specialized Hospital, in the city of Salvador, and georeferencing software. We evaluated 3,877 sputum samples collected from symptomatic respiratory patients, under routine conditions, between June of 2014 and March of 2015. All of the samples were submitted to sputum smear microscopy and the Xpert MTB/RIF test. Patients were stratified by gender, age, and geolocation. Results: Among the 3,877 sputum samples evaluated, the Xpert MTB/RIF test detected M. tuberculosis in 678 (17.5%), of which 60 (8.8%) showed resistance to rifampin. The Xpert MTB/RIF test detected M. tuberculosis in 254 patients who tested negative for sputum smear microscopy, thus increasing the diagnostic power by 59.9%. Conclusions: The use of the Xpert MTB/RIF test, under routine conditions, significantly increased the detection of cases of tuberculosis among sputum smear-negative patients.
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Affiliation(s)
- Marilda Casela
- Hospital Especializado Octávio Mangabeira, Secretaria de Saúde do Estado da Bahia, Salvador, BA, Brasil
| | | | | | - Mariana Araújo Pereira
- Laboratório de Imunologia e Biologia Molecular, Instituto de Ciências da Saúde, Universidade Federal da Bahia, Salvador, BA, Brazil
| | - Samanta Queiroz Dos Santos
- Laboratório de Imunologia e Biologia Molecular, Instituto de Ciências da Saúde, Universidade Federal da Bahia, Salvador, BA, Brazil
| | | | - Songeli Menezes Freire
- Laboratório de Imunologia e Biologia Molecular, Instituto de Ciências da Saúde, Universidade Federal da Bahia, Salvador, BA, Brazil
| | - Eliana Dias Matos
- Departamento de Medicina, Escola Bahiana de Medicina e Saúde Pública, Salvador, BA, Brazil
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Houben RMGJ, Lalli M, Kranzer K, Menzies NA, Schumacher SG, Dowdy DW. What if They Don't Have Tuberculosis? The Consequences and Trade-offs Involved in False-positive Diagnoses of Tuberculosis. Clin Infect Dis 2019; 68:150-156. [PMID: 29982375 PMCID: PMC6293007 DOI: 10.1093/cid/ciy544] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 06/28/2018] [Indexed: 12/23/2022] Open
Abstract
To find the millions of missed tuberculosis (TB) cases, national TB programs are under pressure to expand TB disease screening and to target populations with lower disease prevalence. Together with imperfect performance and application of existing diagnostic tools, including empirical diagnosis, broader screening risks placing individuals without TB on prolonged treatment. These false-positive diagnoses have profound consequences for TB patients and prevention efforts, yet are usually overlooked in policy decision making. In this article we describe the pathways to a false-positive TB diagnosis, including trade-offs involved in the development and application of diagnostic algorithms. We then consider the wide range of potential consequences for individuals, households, health systems, and reliability of surveillance data. Finally, we suggest practical steps that the TB community can take to reduce the frequency and potential harms of false-positive TB diagnosis and to more explicitly assess the trade-offs involved in the screening and diagnostic process.
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Affiliation(s)
- Rein M G J Houben
- Tuberculosis Modelling Group, Tuberculosis Centre and Centre for Mathematical Modelling of Infectious Diseases
- Infectious Disease Epidemiology Department, Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Marek Lalli
- Tuberculosis Modelling Group, Tuberculosis Centre and Centre for Mathematical Modelling of Infectious Diseases
- Infectious Disease Epidemiology Department, Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Katharina Kranzer
- Infectious Disease Epidemiology Department, Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, United Kingdom
- Research Centre Borstel, National and Supranational Reference Laboratory, Germany
| | - Nick A Menzies
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | | | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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The performance and yield of tuberculosis testing algorithms using microscopy, chest x-ray, and Xpert MTB/RIF. J Clin Tuberc Other Mycobact Dis 2018; 14:1-6. [PMID: 31720409 PMCID: PMC6830149 DOI: 10.1016/j.jctube.2018.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 11/19/2018] [Accepted: 11/26/2018] [Indexed: 12/14/2022] Open
Abstract
Setting The introduction of Xpert MTB/RIF (Xpert) and renewed interest in chest x-ray (CXR) for tuberculosis testing has provided additional choices to the smear-based diagnostic algorithms used by TB programs previously. More programmatic data is needed to better understand the implications of possible approaches. Objective We sought to evaluate how different testing algorithms using microscopy, Xpert and CXR impacted the number of people detected with TB in a district hospital in Nepal. Design Consecutively recruited patients with TB-related symptoms were offered smear microscopy, CXR and Xpert. We tested six hypothetical algorithms and compared yield, bacteriologically positive (Bac+) cases missed, and tests conducted. Results Among 929 patients, Bac+ prevalence was 17.3% (n = 161). Smear microscopy detected 121 (75.2% of Bac+). Depending on the radiologists' interpretation of CXR, Xpert testing could be reduced by (31%-60%). Smear microscopy reduced Xpert cartridge need slightly, but increased the overall diagnostic tests performed. Conclusion Xpert detected a large proportion of Bac+ TB cases missed by microscopy. CXR was useful in greatly reducing the number of diagnostic tests needed even among presumptive TB patients. Loose CXR readings should be used to identify more people for TB testing. More analysis of costs and standardized CXR reading should be considered.
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Eichner FA, Groenwold RHH, Grobbee DE, Oude Rengerink K. Systematic review showed that stepped-wedge cluster randomized trials often did not reach their planned sample size. J Clin Epidemiol 2018; 107:89-100. [PMID: 30458261 DOI: 10.1016/j.jclinepi.2018.11.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/15/2018] [Accepted: 11/14/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine how often stepped-wedge cluster randomized controlled trials reach their planned sample size, and what reasons are reported for choosing a stepped-wedge trial design. STUDY DESIGN AND SETTING We conducted a PubMed literature search (period 2012 to 2017) and included articles describing the results of a stepped-wedge cluster randomized trial. We calculated the percentage of studies reaching their prespecified number of participants and clusters, and we summarized the reasons for choosing the stepped-wedge trial design as well as difficulties during enrollment. RESULTS Forty-six individual stepped-wedge studies from a total of 53 articles were included in our review. Of the 35 studies, for which recruitment rate could be calculated, 69% recruited their planned number of participants, with 80% having recruited the planned number of clusters. Ethical reasons were the most common motivation for choosing the stepped-wedge trial design. Most important difficulties during study conduct were dropout of clusters and delayed implementation of the intervention. CONCLUSION About half of recently published stepped-wedge trials reached their planned sample size indicating that recruitment is also a major problem in these trials. Still, the stepped-wedge trial design can yield practical, ethical, and methodological advantages.
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Affiliation(s)
- Felizitas A Eichner
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Rolf H H Groenwold
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Diederick E Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Katrien Oude Rengerink
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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Results from a roving, active case finding initiative to improve tuberculosis detection among older people in rural cambodia using the Xpert MTB/RIF assay and chest X-ray. J Clin Tuberc Other Mycobact Dis 2018; 13:22-27. [PMID: 31720408 PMCID: PMC6830163 DOI: 10.1016/j.jctube.2018.11.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 10/22/2018] [Accepted: 11/10/2018] [Indexed: 11/29/2022] Open
Abstract
Background Cambodia has one of the highest tuberculosis (TB) prevalence rates in the world. People aged 55 years and over account for an estimated 50% of the country's TB burden, yet this group has a low notification rate owing to specific barriers in accessing health services. One-off active case finding (ACF) days with mobile GeneXpert and X-ray systems were organized at 75 government health facilities in four operational districts. Symptomatic community members with an abnormal chest X-ray were tested using the Xpert MTB/RIF assay. People with TB were then treated at health facilities after screening services moved onto the next site. Methods De-identified project data were analysed to produce descriptive statistics about the people tested on Xpert and those diagnosed with TB. A linear regression was fit through the 12 quarters of National TB Program (NTP) TB case notification data immediately prior to ACF. The regression was used to calculate trend-expected notifications during and after the ACF quarters. Notifications from the ACF quarters were then compared to actual notifications from the previous year and to the trend-expected notifications during the ACF quarter by age group and type of TB. Finally, NTP TB treatment outcomes for the patients started on treatment during the ACF quarter were compared to those from a year prior. Results 2068 individuals submitted sputum for Xpert MTB/RIF testing, resulting in the identification of 319 (15.4%) bacteriologically-positive TB patients and an additional 574 people who were clinically diagnosed with TB. In the ACF quarters, new bacteriologically-positive notifications increased +119.2% for all ages and +262.7% for people aged 55 and over compared with trend-expected notifications. Treatment initiation figures remained above trend-expected notifications for three full quarters after ACF. The treatment success rate across all operational districts was significantly higher for patients detected in the ACF quarters (88.8% vs 94.5%, p = 0.012). Conclusion A series of roving, one-off ACF days at government health facilities were able to increase TB diagnosis, treatment initiation and treatment outcomes in a key population with high TB prevalence. Targeted ACF interventions such as this could be used to reduce a backlog of untreated, prevalent TB.
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Osorio L, Garcia JA, Parra LG, Garcia V, Torres L, Degroote S, Ridde V. A scoping review on the field validation and implementation of rapid diagnostic tests for vector-borne and other infectious diseases of poverty in urban areas. Infect Dis Poverty 2018; 7:87. [PMID: 30173662 PMCID: PMC6120097 DOI: 10.1186/s40249-018-0474-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 08/01/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Health personnel face challenges in diagnosing vector-borne and other diseases of poverty in urban settings. There is a need to know what rapid diagnostic technologies are available, have been properly assessed, and are being implemented to improve control of these diseases in the urban context. This paper characterizes evidence on the field validation and implementation in urban areas of rapid diagnostics for vector-borne diseases and other diseases of poverty. MAIN BODY A scoping review was conducted. Peer-reviewed and grey literature were searched using terms describing the targeted infectious diseases, diagnostics evaluations, rapid tests, and urban setting. The review was limited to studies published between 2000 and 2016 in English, Spanish, French, and Portuguese. Inclusion and exclusion criteria were refined post hoc to identify relevant literature regardless of study design and geography. A total of 179 documents of the 7806 initially screened were included in the analysis. Malaria (n = 100) and tuberculosis (n = 47) accounted for the majority of studies that reported diagnostics performance, impact, and implementation outcomes. Fewer studies, assessing mainly performance, were identified for visceral leishmaniasis (n = 9), filariasis and leptospirosis (each n = 5), enteric fever and schistosomiasis (each n = 3), dengue and leprosy (each n = 2), and Chagas disease, human African trypanosomiasis, and cholera (each n = 1). Reported sensitivity of rapid tests was variable depending on several factors. Overall, specificities were high (> 80%), except for schistosomiasis and cholera. Impact and implementation outcomes, mainly acceptability and cost, followed by adoption, feasibility, and sustainability of rapid tests are being evaluated in the field. Challenges to implementing rapid tests range from cultural to technical and administrative issues. CONCLUSIONS Rapid diagnostic tests for vector-borne and other diseases of poverty are being used in the urban context with demonstrated impact on case detection. However, most evidence comes from malaria rapid diagnostics, with variable results. While rapid tests for tuberculosis and visceral leishmaniasis require further implementation studies, more evidence on performance of current tests or development of new alternatives is needed for dengue, Chagas disease, filariasis, leptospirosis, enteric fever, human African trypanosomiasis, schistosomiasis and cholera.
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Affiliation(s)
- Lyda Osorio
- Epidemiology and Population Health Research Group, School of Public Health, Universidad del Valle, Calle 4B No. 36-00 Edif 118 Escuela de Salud Pública, Universidad del Valle Campus San Fernando, Cali, Colombia
| | - Jonny Alejandro Garcia
- Epidemiology and Population Health Research Group, School of Public Health, Universidad del Valle, Calle 4B No. 36-00 Edif 118 Escuela de Salud Pública, Universidad del Valle Campus San Fernando, Cali, Colombia
- School of Medicine, Universidad del Valle, Cali, Colombia
| | - Luis Gabriel Parra
- Epidemiology and Population Health Research Group, School of Public Health, Universidad del Valle, Calle 4B No. 36-00 Edif 118 Escuela de Salud Pública, Universidad del Valle Campus San Fernando, Cali, Colombia
- School of Medicine, Universidad del Valle, Cali, Colombia
| | - Victor Garcia
- Epidemiology and Population Health Research Group, School of Public Health, Universidad del Valle, Calle 4B No. 36-00 Edif 118 Escuela de Salud Pública, Universidad del Valle Campus San Fernando, Cali, Colombia
| | - Laura Torres
- Epidemiology and Population Health Research Group, School of Public Health, Universidad del Valle, Calle 4B No. 36-00 Edif 118 Escuela de Salud Pública, Universidad del Valle Campus San Fernando, Cali, Colombia
| | - Stéphanie Degroote
- University of Montreal Public Health Research Institute (IRSPUM), Montreal, Canada
| | - Valéry Ridde
- University of Montreal Public Health Research Institute (IRSPUM), Montreal, Canada
- French Institute for Research on Sustainable Development (IRD), Paris Descartes University, Population and Development Center (CEPED), Université Paris Sorbonne Cité, National Institute of Health and Medical Research (INSERM), Health, Vulnerabilities and Gender Relations South (SAGESUD), Paris, France
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Lalli M, Hamilton M, Pretorius C, Pedrazzoli D, White RG, Houben RMGJ. Investigating the impact of TB case-detection strategies and the consequences of false positive diagnosis through mathematical modelling. BMC Infect Dis 2018; 18:340. [PMID: 30031378 PMCID: PMC6054844 DOI: 10.1186/s12879-018-3239-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 07/05/2018] [Indexed: 01/09/2023] Open
Abstract
Background Increasing case notifications is one of the top programmatic priorities of National TB Control Programmes (NTPs). To find more cases, NTPs often need to consider expanding TB case-detection activities to populations with increasingly low prevalence of disease. Together with low-specificity diagnostic algorithms, these strategies can lead to an increasingly high number of false positive diagnoses, which has important adverse consequences. Methods We apply TIME, a widely-used country-level model, to quantify the expected impact of different case-finding strategies under two scenarios. In the first scenario, we compare the impact of implementing two different diagnostic algorithms (higher sensitivity only versus higher sensitivity and specificity) to reach programmatic screening targets. In the second scenario, we examine the impact of expanding coverage to a population with a lower prevalence of disease. Finally, we explore the implications of modelling without taking into consideration the screening of healthy individuals. Outcomes considered were changes in notifications, the ratio of additional false positive to true positive diagnoses, the positive predictive value (PPV), and incidence. Results In scenario 1, algorithm A of prolonged cough and GeneXpert yielded fewer additional notifications compared to algorithm B of any symptom and smear microscopy (n = 4.0 K vs 13.8 K), relative to baseline between 2017 and 2025. However, algorithm A resulted in an increase in PPV, averting 2.4 K false positive notifications thus resulting in a more efficient impact on incidence. Scenario 2 demonstrated an absolute decrease of 11% in the PPV as intensified case finding activities expanded into low-prevalence populations without improving diagnostic accuracy, yielding an additional 23 K false positive diagnoses for an additional 1.3 K true positive diagnoses between 2017 and 2025. Modelling the second scenario without taking into account screening amongst healthy individuals overestimated the impact on cases averted by a factor of 6. Conclusion Our findings show that total notifications can be a misleading indicator for TB programme performance, and should be interpreted carefully. When evaluating potential case-finding strategies, NTPs should consider the specificity of diagnostic algorithms and the risk of increasing false-positive diagnoses. Similarly, modelling the impact of case-finding strategies without taking into account potential adverse consequences can overestimate impact and lead to poor strategic decision-making. Electronic supplementary material The online version of this article (10.1186/s12879-018-3239-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marek Lalli
- Department of Infectious Disease Epidemiology, Keppel Street, WC1E 7HT, London, UK.
| | | | | | - Debora Pedrazzoli
- Department of Infectious Disease Epidemiology, Keppel Street, WC1E 7HT, London, UK
| | - Richard G White
- Department of Infectious Disease Epidemiology, Keppel Street, WC1E 7HT, London, UK
| | - Rein M G J Houben
- Department of Infectious Disease Epidemiology, Keppel Street, WC1E 7HT, London, UK
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Mohr E, Daniels J, Muller O, Furin J, Chabalala B, Steele SJ, Cox V, Dolby T, Ferlazzo G, Shroufi A, Duran LT, Cox H. Missed opportunities for earlier diagnosis of rifampicin-resistant tuberculosis despite access to Xpert ® MTB/RIF. Int J Tuberc Lung Dis 2018; 21:1100-1105. [PMID: 28911352 DOI: 10.5588/ijtld.17.0372] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To assess the proportion of rifampicin-resistant tuberculosis (RR-TB) patients with potential earlier RR-TB diagnoses in Khayelitsha, South Africa. DESIGN We conducted a retrospective analysis among RR-TB patients diagnosed from 2012 to 2014. Patients were considered to have missed opportunities for earlier diagnosis if 1) they were incorrectly screened according to the Western Cape diagnostic algorithm; 2) the first specimen was not tested using Xpert® MTB/RIF; 3) no specimen was ever tested; or 4) the initial Xpert test showed a negative result, but no subsequent specimen was sent for follow-up testing in human immunodeficiency virus-positive patients. RESULTS Among 543 patients, 386 (71%) were diagnosed with Xpert and 112 (21%) had had at least one presentation at a health care facility within the 6 months before the presentation at which RR-TB was diagnosed. Overall, 95/543 (18%) patients were screened incorrectly at some point: 48 at diagnostic presentation only, 38 at previous presentation only, and 9 at both previous and diagnostic presentations. CONCLUSIONS These data show that a significant proportion of RR-TB patients might have been diagnosed earlier, and suggest that case detection could be improved if diagnostic algorithms were followed more closely. Further training and monitoring is required to ensure the greatest benefit from universal Xpert implementation.
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Affiliation(s)
- E Mohr
- Médecins Sans Frontières (MSF), Khayelitsha, South Africa
| | - J Daniels
- Médecins Sans Frontières (MSF), Khayelitsha, South Africa
| | - O Muller
- Médecins Sans Frontières (MSF), Khayelitsha, South Africa
| | - J Furin
- Harvard Medical School, Boston, Massachusetts, USA
| | - B Chabalala
- Médecins Sans Frontières (MSF), Khayelitsha, South Africa
| | | | - V Cox
- MSF, Eshowe, University of Cape Town Center for Infectious Disease Epidemiology and Research, Cape Town
| | - T Dolby
- National Health Laboratory Service, Cape Town
| | | | | | - L T Duran
- Médecins Sans Frontières (MSF), Khayelitsha, South Africa
| | - H Cox
- Division of Medical Microbiology and the Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Sieiro TLDA, Aurílio RB, Soares ECC, Chiang SS, Sant Anna CC. The role of the Xpert MTB/RIF assay among adolescents suspected of pulmonary tuberculosis in Rio de Janeiro, Brazil. Rev Soc Bras Med Trop 2018; 51:234-236. [PMID: 29768561 DOI: 10.1590/0037-8682-0298-2017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 09/29/2017] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION The teste rápido molecular para tuberculose (TRM-TB) was introduced in 2014 in Brazil for tuberculosis screening. However, its role in adolescents in Brazil has not been studied. METHODS A descriptive study of adolescents with suspected tuberculosis using National Laboratory software. RESULTS Of 852 (15.4%) suspected cases, 131 were positive by TRM-TB and 2% were resistant to rifampicin. Among TRM-TB-positive cases, 105 (91.4%) were culture-positive. Sixty-four of 96 samples were sensitive to rifampicin by TRM-TB; 11 were resistant to other drugs by drug sensitivity test (DST). CONCLUSIONS Among suspected cases, 16% were diagnosed by TRM-TB, of which 17% were drug-resistant by DST.
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Affiliation(s)
| | - Rafaela Baroni Aurílio
- Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Elizabeth Cristina C Soares
- Centro Administrativo São Sebastião, Secretaria Municipal de Saúde do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Silvia S Chiang
- Department of Pediatrics, Alpert Medical School of Brown University, Center for International Health Research, Rhode Island Hospital, Providence, USA
| | - Clemax Couto Sant Anna
- Departamento de Pediatria, Faculdade de Medicina, Universidade Federal do Rio de Janeiro. Rio de Janeiro, RJ, Brasil.,Rede TB de Pesquisa, Rede Nacional de Pesquisa em Tuberculose, Rio de Janeiro, RJ, Brasil
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