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Mesman AW, Calderon RI, Hauns L, Pollock NR, Mendoza M, Holmberg RC, Franke MF. Detection of Mycobacterium tuberculosis transrenal DNA in urine samples among adults in Peru. Tuberculosis (Edinb) 2024; 148:102549. [PMID: 39098064 DOI: 10.1016/j.tube.2024.102549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 07/22/2024] [Accepted: 07/23/2024] [Indexed: 08/06/2024]
Abstract
Diagnosis of pulmonary tuberculosis (TB) relies on a sputum sample, which cannot be obtained from all symptomatic individuals. Mycobacterium tuberculosis (Mtb) transrenal DNA (trDNA) has been detected in urine, an easily obtainable, noninvasive, alternative sample type. However, reported sensitivities have been variable and likely depend on collection and assay procedures and aspects of trDNA biology. We analyzed three serial urine samples from each of 75 adults with culture-confirmed pulmonary TB disease in Lima, Peru for detection of trDNA using short-fragment real-time PCR. Additionally, we examined host, urine, and sampling factors associated with detection. Overall per-sample sensitivity was 38 % (95 % Confidence Interval [CI] 30-45 %). On an individual level (i.e., any of the three samples positive), sensitivity was 73 % (95 % CI: 62-83 %). Sensitivity was highest among samples from patients with smear-positive TB, 92 % (95 % CI: 62-100 %). Specificity from a single sample from each of 10 healthy controls was 100 % (95 % CI: 69-100 %). Adjusting our assay positivity threshold increased individual-level sensitivity to 88 % (95 % CI: 78-94 %) overall without affecting the specificity. We did not find associations between Mtb trDNA detection and individual characteristics or urine sample characteristics. Overall, our results support the potential of trDNA detection for TB diagnosis.
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Affiliation(s)
- Annelies W Mesman
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA, 02115, USA.
| | - Roger I Calderon
- Socios En Salud Sucursal Perú, Av. Javier Prado Este 492, San Isidro, Lima, 15001, Peru.
| | - Laura Hauns
- Akonni Biosystems, 400 Sagner Ave, Frederick, MD, 21701, USA.
| | - Nira R Pollock
- Department of Laboratory Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
| | - Milagros Mendoza
- Socios En Salud Sucursal Perú, Av. Javier Prado Este 492, San Isidro, Lima, 15001, Peru.
| | | | - Molly F Franke
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA, 02115, USA.
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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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Mesman AW, Calderon RI, Hauns L, Pollock NR, Mendoza M, Holmberg RC, Franke MF. Detection of Mycobacterium tuberculosis transrenal DNA in urine samples among adult patients in Peru. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.07.26.23293199. [PMID: 37546779 PMCID: PMC10402216 DOI: 10.1101/2023.07.26.23293199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Diagnosis of tuberculosis (TB) relies on a sputum sample, which cannot be obtained from all symptomatic patients. Mycobacterium tuberculosis (Mtb) transrenal DNA (trDNA) has been detected in urine, an easily obtainable, noninvasive, alternative sample type. However, reported sensitivities have been variable and likely depend on collection/assay procedures and aspects of trDNA biology. We analyzed three serial urine samples from each of 75 adults with culture-confirmed pulmonary TB disease in Lima, Peru for detection of trDNA using short-fragment real-time PCR. Additionally, we examined host, urine, and sampling factors associated with detection. Overall sample sensitivity was 38% (95% Confidence Interval [CI] 30-45%). On a patient level (i.e., any of three samples positive), sensitivity was 73% (95% CI: 62-83%). Sensitivity was highest among samples from patients with smear-positive TB, 92% (95% CI: 62-100%). Specificity from a single sample from each of 10 healthy controls was 100% (95% CI: 69-100%). Adjusting our assay positivity threshold increased patient-level sensitivity to 88% (95% CI: 78-94%) overall without affecting the specificity. We did not find associations between Mtb trDNA detection and either patient characteristics or urine sample characteristics. Overall, our results support the potential of trDNA detection for TB diagnosis.
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Affiliation(s)
- Annelies W Mesman
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA
| | | | | | - Nira R Pollock
- Department of Laboratory Medicine, Boston Children’s Hospital, Boston, MA
| | | | | | - Molly F Franke
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA
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Jayasooriya S, Dimambro-Denson F, Beecroft C, Balen J, Awokola B, Mitchell C, Kampmann B, Campbell F, Dodd P, Mortimer K. Patients with presumed tuberculosis in sub-Saharan Africa that are not diagnosed with tuberculosis: a systematic review and meta-analysis. Thorax 2023; 78:50-60. [PMID: 35074900 PMCID: PMC9763185 DOI: 10.1136/thoraxjnl-2021-217663] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 12/07/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Many patients in sub-Saharan Africa whom a diagnosis of tuberculosis is considered are subsequently not diagnosed with tuberculosis. The proportion of patients this represents, and their alternative diagnoses, have not previously been systematically reviewed. METHODS We searched four databases from inception to 27 April 2020, without language restrictions. We included all adult pulmonary tuberculosis diagnostic studies from sub-Saharan Africa, excluding case series and inpatient studies. We extracted the proportion of patients with presumed tuberculosis subsequently not diagnosed with tuberculosis and any alternative diagnoses received. We conducted a random effects meta-analysis to obtain pooled estimates stratified by passive and active case finding. RESULTS Our search identified 1799 studies, of which 18 studies (2002-2019) with 14 527 participants from 10 African countries were included. The proportion of patients with presumed tuberculosis subsequently not diagnosed with tuberculosis was 48.5% (95% CI 39.0 to 58.0) in passive and 92.8% (95% CI 85.0 to 96.7) in active case-finding studies. This proportion increased with declining numbers of clinically diagnosed tuberculosis cases. A history of tuberculosis was documented in 55% of studies, with just five out of 18 reporting any alternative diagnoses. DISCUSSION Nearly half of all patients with presumed tuberculosis in sub-Saharan Africa do not have a final diagnosis of active tuberculosis. This proportion may be higher when active case-finding strategies are used. Little is known about the healthcare needs of these patients. Research is required to better characterise these patient populations and plan health system solutions that meet their needs. PROSPERO REGISTRATION NUMBER CRD42018100004.
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Affiliation(s)
| | | | - Claire Beecroft
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Julie Balen
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Babatunde Awokola
- Vaccines and Immunity Theme, Medical Research Council The Gambia, Banjul, Gambia
| | - Caroline Mitchell
- Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, UK
| | - Beate Kampmann
- Vaccines and Immunity Theme, Medical Research Council The Gambia, Banjul, Gambia
- Paediatric Infection & Immunity, London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, UK
| | - Fiona Campbell
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Pete Dodd
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Kevin Mortimer
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Deparment of Respiratory Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
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Divala TH, Fielding KL, Kandulu C, Nliwasa M, Sloan DJ, Gupta-Wright A, Corbett EL. Utility of broad-spectrum antibiotics for diagnosing pulmonary tuberculosis in adults: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2020; 20:1089-1098. [PMID: 32437700 PMCID: PMC7456780 DOI: 10.1016/s1473-3099(20)30143-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 01/15/2020] [Accepted: 02/18/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Suboptimal diagnostics for pulmonary tuberculosis drive the use of the so-called trial of antibiotics, a course of broad-spectrum antibiotics without activity against Mycobacterium tuberculosis that is given to patients who are mycobacteriology negative but symptomatic, with the aim of distinguishing pulmonary tuberculosis from bacterial lower respiratory tract infection. The underlying assumption-that patients with lower respiratory tract infection will improve, whereas those with pulmonary tuberculosis will not-has an unclear evidence base for such a widely used intervention (at least 26·5 million courses are prescribed per year). We aimed to collate available evidence on the diagnostic performance of the trial of antibiotics. METHODS In this systematic review and meta-analysis we searched the MEDLINE, Embase, and Global Health databases for studies published up to March 15, 2019, that investigated the sensitivity and specificity of the trial of antibiotics against mycobacteriology tests in adults (≥15 years) with tuberculosis symptoms. We used the QUADAS-2 tool to assess the risk of bias. We estimated pooled values for sensitivity and specificity of trial of antibiotics (as the index text) versus mycobacteriology tests (as the reference standard) using random-effects bivariate modelling, and we used the I2 statistic to assess heterogeneity between studies contributing to these estimates. This study is registered with PROSPERO, number CRD42017083915. FINDINGS Of the 9410 articles identified by our search, eight studies were eligible for inclusion. The studies were from seven countries in Africa, South America, and Asia, and involved 2786 participants. Six studies used mycobacterial culture as the reference standard, and six used penicillins for the trial of antibiotics. The treatment duration, number of antimicrobial courses, and definition of what constituted response to treatment varied substantially between studies. The pooled sensitivity (67%, 95% CI 42-85) and specificity (73%, 58-85) of the trial of antibiotics versus mycobacteriology tests were below internationally defined minimum performance profiles for tuberculosis diagnostics and had substantial heterogeneity (I2 was 96% for sensitivity and 99% for specificity). Each included study failed on one or more domain of the QUADAS-2 tool. INTERPRETATION Current policy and practice regarding the trial of antibiotics appear inappropriate, given the weak evidence base, poor diagnostic performance, potential contribution to the global antimicrobial resistance crisis, and adverse individual and public health consequences from the misclassification of tuberculosis status. Antibiotic strategies during tuberculosis investigations should instead optimise clinical outcomes, ideally guided by clinical trials in both inpatient and outpatient groups. FUNDING Helse Nord RHF, Wellcome Trust, and the UK Commonwealth Scholarship Commission.
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Affiliation(s)
- Titus H Divala
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Helse Nord Tuberculosis Initiative, University of Malawi College of Medicine, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
| | - Katherine L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Chikondi Kandulu
- Helse Nord Tuberculosis Initiative, University of Malawi College of Medicine, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Marriott Nliwasa
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Helse Nord Tuberculosis Initiative, University of Malawi College of Medicine, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Derek J Sloan
- School of Medicine, University of St Andrews, St Andrews, UK
| | - Ankur Gupta-Wright
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Elizabeth L Corbett
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Helse Nord Tuberculosis Initiative, University of Malawi College of Medicine, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
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6
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Boyles TH, Nduna M, Pitsi T, Scott L, Fox MP, Maartens G. A Clinical Prediction Score Including Trial of Antibiotics and C-Reactive Protein to Improve the Diagnosis of Tuberculosis in Ambulatory People With HIV. Open Forum Infect Dis 2020; 7:ofz543. [PMID: 32042850 PMCID: PMC7000838 DOI: 10.1093/ofid/ofz543] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 01/02/2020] [Indexed: 11/15/2022] Open
Abstract
Background The use of a “trial of antibiotics” as empiric therapy for bacterial pneumonia as a diagnostic tool for tuberculosis in people with HIV (PWH) was removed from World Health Organization (WHO) recommendations in 2007, based on expert opinion. Current guidelines recommend antibiotics only after 2 Xpert MTB/RIF tests (if available), chest x-ray, and clinical assessment have suggested that tuberculosis is unlikely. Despite this, a “trial of antibiotics” remains common in algorithms in low-resource settings, but its value is uncertain. C-reactive protein (CRP), which has been proposed as a “rule-out” test for tuberculosis, may be an objective marker of response to antibiotics. Methods We performed a passive case-finding cohort study of adult PWH with a positive WHO symptom screen. All participants received antibiotics at first visit according to the local protocol and were reviewed to ascertain clinical response. Point-of-care CRP was measured at both visits. All patients had sputum tested with Xpert MTB/RIF Ultra (Ultra), and the reference standard was based on 2 sputum mycobacterial cultures. We explored multivariable prediction models (MPM) for tuberculosis based on 1 or 2 visits. Results Seventy-five of 207 patients (36%) had confirmed tuberculosis. Clinical response to antibiotics after 2 days was a good predictor of disease. An MPM based on 2 visits, without CRP, had acceptable discrimination (c-statistic, 0.75) and calibration (goodness-of-fit P = .07). Addition of CRP after antibiotics improved the model moderately (c-statistic, 0.78). CRP at first visit was not an independent predictor of tuberculosis. Conclusions In adult PWH seeking care for symptoms suggestive of tuberculosis, lack of response to antibiotics is a strong predictor of disease and is likely to be useful, particularly when access to Ultra is limited. CRP adds value when measured after antibiotics but is of limited value at first visit.
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Affiliation(s)
- Tom H Boyles
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Matilda Nduna
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Thalitha Pitsi
- Hillbrow Community Healthcare Clinic, Johannesburg, South Africa
| | - Lesley Scott
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, School of Pathology, University of Witwatersrand, Johannesburg, South Africa
| | - Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA.,Department of Internal Medicine, Health Economics and Epidemiology Research Office, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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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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Guerra J, Mogollón D, González D, Sanchez R, Rueda ZV, Parra-López CA, Murcia MI. Active and latent tuberculosis among inmates in La Esperanza prison in Guaduas, Colombia. PLoS One 2019; 14:e0209895. [PMID: 30682199 PMCID: PMC6347203 DOI: 10.1371/journal.pone.0209895] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 12/13/2018] [Indexed: 12/29/2022] Open
Abstract
Introduction Active tuberculosis (TB) and latent tuberculosis infection (LTBI) are a public health threat in prisons around the world. The objectives of the study were to estimate the prevalence of LTBI and TB as well as to investigate TB transmission inside one prison, in Colombia. Methods A Cross-sectional study was conducted in inmates who agreed to participate. Inmates with respiratory symptoms (RS) of any duration underwent to medical evaluation and three sputum samples were taken for smear microscopy and culture for TB diagnosis. Drug susceptibility was analyzed using BACTEC MGIT 960 and GenoType MTBDRplus. Molecular genotyping of Mycobacterium tuberculosis isolates was performed by 24-Locus MIRU-VNTR and spoligotyping. LTBI was evaluated according to the result of the tuberculin skin test (TST). Close contact investigation was conducted inside the prison for inmates that shared the cell with the index TB case. Results Among 301/2,020 (15%) inmates with RS of any duration, 8% were diagnosed with active TB. The prevalence of active TB was 1,026 cases/100,000 inmates. We isolated M. tuberculosis in 19/24 (79%) TB cases, 94.7% were susceptible to first line drugs and only one was monoresistant to isoniazid. The most prevalent sub-lineage was Haarlem (68.4%), followed by LAM (26.3%) and T superfamily (5.3%). 24-Locus MIRU-VNTR typing results alone or in combination with spoligotyping identified three clusters containing two isolates each. Two clusters corresponded to inmates that shared the same cell, but each one was located in different blocks of the prison. Inmates from the last cluster were in the same block in nearby cells. TST reading was performed in 95.6% inmates, and 67.6% had a positive reaction. Conclusions The prevalence of LTBI and TB was higher in prison than in the general population. Molecular genotyping suggests that TB in this prison is mainly caused by strains imported by inmates or endogenous reactivation.
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Affiliation(s)
- Julio Guerra
- Grupo MICOBAC-UN, Departamento de Microbiología, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá DC, Colombia
| | - Daniel Mogollón
- Grupo MICOBAC-UN, Departamento de Microbiología, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá DC, Colombia
| | - Deccy González
- Programa de Tuberculosis y Lepra, Secretaría de Salud de Cundinamarca, Bogotá DC, Colombia
| | - Ricardo Sanchez
- Departamento de Psiquiatría, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá DC, Colombia
| | - Zulma Vanessa Rueda
- Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Antioquia, Colombia
| | - Carlos A. Parra-López
- Grupo MICOBAC-UN, Departamento de Microbiología, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá DC, Colombia
| | - Martha Isabel Murcia
- Grupo MICOBAC-UN, Departamento de Microbiología, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá DC, Colombia
- * E-mail:
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9
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Alnour TM. Smear microscopy as a diagnostic tool of tuberculosis: Review of smear negative cases, frequency, risk factors, and prevention criteria. ACTA ACUST UNITED AC 2018; 65:190-194. [DOI: 10.1016/j.ijtb.2018.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 02/02/2018] [Indexed: 11/16/2022]
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10
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Empiric TB Treatment of Severely Ill Patients With HIV and Presumed Pulmonary TB Improves Survival. J Acquir Immune Defic Syndr 2017; 72:297-303. [PMID: 26918546 DOI: 10.1097/qai.0000000000000970] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
RATIONALE In 2007, World Health Organization (WHO) issued emergency recommendations on empiric treatment of sputum acid-fast bacillus smear-negative patients with possible tuberculosis (TB) in HIV-prevalent areas, and called for operational research to evaluate their effectiveness. We sought to determine if early, empiric TB treatment of possible TB patients with abnormal chest radiography or severe illness as suggested by the 2007 WHO guidelines, is associated with improved survival. METHODS We prospectively enrolled consecutive HIV-seropositive inpatients at Mulago Hospital in Kampala, Uganda, from 2007 to 2011 with cough for ≥2 weeks. We retrospectively examined the effect of empiric TB treatment before discharge on 8-week survival among those with and without a WHO-defined "danger sign," including fever >39°C, tachycardia >120 beats per minute, or tachypnea >30 breaths per minute. We modeled the interaction between empiric TB treatment and danger signs, and their combined effect on 8-week survival, and adjusted for relevant covariates. RESULTS Among 631 sputum smear-negative patients, 322 (51%) had danger signs. Cumulative 8-week survival of patients with danger signs was significantly higher with empiric TB treatment (80%) than without treatment (64%, P < 0.001). After adjusting for duration of cough and concurrent hypoxemia, patients with danger signs who received empiric TB treatment had a 44% reduction in 8-week mortality (risk ratio 0.56, 95% confidence interval: 0.34-0.91, P = 0.020). CONCLUSIONS Empiric TB treatment of HIV-seropositive, smear-negative, presumed pulmonary TB patients with 1 or more danger signs is associated with improved 8-week survival. Enhanced implementation of the 2007 WHO empiric treatment recommendations should be encouraged whenever and wherever rapid and highly sensitive diagnostic tests for TB are unavailable.
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Walusimbi S, Kwesiga B, Rodrigues R, Haile M, de Costa A, Bogg L, Katamba A. Cost-effectiveness analysis of microscopic observation drug susceptibility test versus Xpert MTB/Rif test for diagnosis of pulmonary tuberculosis in HIV patients in Uganda. BMC Health Serv Res 2016; 16:563. [PMID: 27724908 PMCID: PMC5057383 DOI: 10.1186/s12913-016-1804-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 09/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Microscopic Observation Drug Susceptibility (MODS) and Xpert MTB/Rif (Xpert) are highly sensitive tests for diagnosis of pulmonary tuberculosis (PTB). This study evaluated the cost effectiveness of utilizing MODS versus Xpert for diagnosis of active pulmonary TB in HIV infected patients in Uganda. METHODS A decision analysis model comparing MODS versus Xpert for TB diagnosis was used. Costs were estimated by measuring and valuing relevant resources required to perform the MODS and Xpert tests. Diagnostic accuracy data of the tests were obtained from systematic reviews involving HIV infected patients. We calculated base values for unit costs and varied several assumptions to obtain the range estimates. Cost effectiveness was expressed as costs per TB patient diagnosed for each of the two diagnostic strategies. Base case analysis was performed using the base estimates for unit cost and diagnostic accuracy of the tests. Sensitivity analysis was performed using a range of value estimates for resources, prevalence, number of tests and diagnostic accuracy. RESULTS The unit cost of MODS was US$ 6.53 versus US$ 12.41 of Xpert. Consumables accounted for 59 % (US$ 3.84 of 6.53) of the unit cost for MODS and 84 % (US$10.37 of 12.41) of the unit cost for Xpert. The cost effectiveness ratio of the algorithm using MODS was US$ 34 per TB patient diagnosed compared to US$ 71 of the algorithm using Xpert. The algorithm using MODS was more cost-effective compared to the algorithm using Xpert for a wide range of different values of accuracy, cost and TB prevalence. The cost (threshold value), where the algorithm using Xpert was optimal over the algorithm using MODS was US$ 5.92. CONCLUSIONS MODS versus Xpert was more cost-effective for the diagnosis of PTB among HIV patients in our setting. Efforts to scale-up MODS therefore need to be explored. However, since other non-economic factors may still favour the use of Xpert, the current cost of the Xpert cartridge still needs to be reduced further by more than half, in order to make it economically competitive with MODS.
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Affiliation(s)
- Simon Walusimbi
- Department of Microbiology, Makerere University College of Health Sciences, Kampala, Uganda.,Department of Public Health Sciences, Karolinska Institute, Solna, Sweden
| | | | - Rashmi Rodrigues
- Department of Public Health Sciences, Karolinska Institute, Solna, Sweden
| | - Melles Haile
- Department of Microbiology, Public Health Agency of Sweden, Solna, Sweden
| | - Ayesha de Costa
- Department of Public Health Sciences, Karolinska Institute, Solna, Sweden
| | - Lennart Bogg
- Department of Public Health Sciences, Karolinska Institute, Solna, Sweden.,School of Health, Care and social Welfare, Malardalen University, Vasteras, Sweden
| | - Achilles Katamba
- Department of Medicine, Clinical Epidemiology Unit, Makerere University, College of Health Sciences, Kampala, Uganda.
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Walusimbi S, Semitala F, Bwanga F, Haile M, De Costa A, Davis L, Joloba M, Hoffner S, Kamya M. Outcomes of a clinical diagnostic algorithm for management of ambulatory smear and Xpert MTB/Rif negative HIV infected patients with presumptive pulmonary TB in Uganda: a prospective study. Pan Afr Med J 2016; 23:154. [PMID: 27303572 PMCID: PMC4894731 DOI: 10.11604/pamj.2016.23.154.7995] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 02/01/2016] [Indexed: 01/21/2023] Open
Abstract
Introduction Diagnostic guidelines for Tuberculosis (TB) in HIV infected patients previously relied on microscopy where the value of initial antibiotic treatment for exclusion of pulmonary TB (PTB) was limited. New guidelines rely on the Xpert MTB Rif test (Xpert). However, the value of the antibiotic treatment remains unclear particularly in individuals who are smear-negative and Xpert-negative-given Xpert has only moderate sensitivity for smear-negative PTB. We assessed an algorithm involving initial treatment with antibiotics prior empiric TB treatment in HIV patients with presumptive PTB who were both smear and Xpert negative. Methods We performed a prospective study with six month follow-up to establish patient response to a course of broad spectrum antibiotics prior empiric TB treatment between March 2012 and June 2013. We calculated the proportion of patients who responded to the antibiotic treatment and those who did not. We computed the crude and adjusted odds ratios with their 95% confidence intervals, for response to the antibiotic treatment on various patient characteristics. We report treatment outcomes for patients who received broad spectrum antibiotics only or who were initiated empiric TB treatment. Results Our cohort comprised 162 smear-negative and Xpert-negative patients, of whom 59% (96 of 162) were female, 81% (131 of 162) were on antiretroviral therapy (ART) for a median of 8.7 months. Overall, 88% (141 of 160) responded to the antibiotic treatment, 8% (12 of 160) got empiric TB treatment and 4% (7 out of 160) were treated for other respiratory disease. The odds of improvement on antibiotics were lower in patients with advanced HIV disease than in patients with early HIV disease. Adjusted odds ratios were significant for HIV clinical stage (AOR; 0.038,) and duration on ART (AOR; 1.038,). Conclusion The majority of HIV patients with presumptive PTB with smear-negative and Xpert negative results improved on the antibiotic treatment and did not require empiric TB treatment. Initial antibiotic treatment appeared more successful in patients with less advanced HIV disease. Findings from our study suggest it is useful to initiate HIV infected patients with presumptive PTB having smear and Xpert negative results on an initial course of antibiotic treatment prior empiric TB treatment.
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Affiliation(s)
- Simon Walusimbi
- Department of Microbiology, Makerere University College of Health Sciences, Kampala, Uganda; Department of Public Health Sciences, Karolinska Institute, Solna, Sweden; Makerere University Joint AIDS Program, Kampala, Uganda
| | - Fred Semitala
- Makerere University Joint AIDS Program, Kampala, Uganda; Department of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Freddie Bwanga
- Department of Microbiology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Melles Haile
- Department of Public Health Sciences, Karolinska Institute, Solna, Sweden; Department of Microbiology, Public Health Agency of Sweden, Solna, Sweden
| | - Ayesha De Costa
- Department of Public Health Sciences, Karolinska Institute, Solna, Sweden
| | - Lucian Davis
- University of California San Francisco, Pulmonary and Critical Care Medicine, San Francisco, United States
| | - Moses Joloba
- Department of Microbiology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Sven Hoffner
- Department of Public Health Sciences, Karolinska Institute, Solna, Sweden; Department of Microbiology, Public Health Agency of Sweden, Solna, Sweden
| | - Moses Kamya
- Department of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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Dheda K, Theron G, Welte A. Cost-effectiveness of Xpert MTB/RIF and investing in health care in Africa. LANCET GLOBAL HEALTH 2015; 2:e554-6. [PMID: 25304623 DOI: 10.1016/s2214-109x(14)70305-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Keertan Dheda
- Lung Infection and Immunity Unit, Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - Grant Theron
- Lung Infection and Immunity Unit, Department of Medicine, University of Cape Town, Cape Town, South Africa; Institute of Infectious Diseases and Molecular Medicine, Cape Town, South Africa
| | - Alex Welte
- South African Centre for Epidemiological Modelling and Analysis, Stellenbosch University, Stellenbosch, South Africa
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Langley I, Lin HH, Squire SB. Cost-effectiveness of Xpert MTB/RIF and investing in health care in Africa. LANCET GLOBAL HEALTH 2015; 3:e83-4. [PMID: 25617201 DOI: 10.1016/s2214-109x(14)70370-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Ivor Langley
- Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK.
| | - Hsien-Ho Lin
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei City, Taiwan
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Nakiyingi L, Nonyane BAS, Ssengooba W, Kirenga BJ, Nakanjako D, Lubega G, Byakika-Kibwika P, Joloba ML, Ellner JJ, Dorman SE, Mayanja-Kizza H, Manabe YC. Predictors for MTB Culture-Positivity among HIV-Infected Smear-Negative Presumptive Tuberculosis Patients in Uganda: Application of New Tuberculosis Diagnostic Technology. PLoS One 2015. [PMID: 26222142 PMCID: PMC4519276 DOI: 10.1371/journal.pone.0133756] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background The existing World Health Organization diagnostic algorithms for smear-negative TB perform poorly in HIV-infected individuals. New TB diagnostics such as urine TB lipoarabinomannan (LAM) could improve the accuracy and reduce delays in TB diagnosis in HIV-infected smear-negative presumptive TB. We sought to determine predictors for MTB culture-positivity among these patients. Methods This study was nested into a prospective evaluation of HIV-infected outpatients and inpatients clinically suspected to have TB who were screened by smear-microscopy on two spot sputum samples. Data on socio-demographics, clinical symptoms, antiretroviral therapy, CXR, CD4 count, mycobacterial sputum and blood cultures and TB-LAM were collected. Logistic regression and conditional inference tree analysis were used to determine the most predictive indicators for MTB culture-positivity. Results Of the 418 smear-negative participants [female, 64%; median age (IQR) 32 (28-39) years, median CD4 106 (IQR 22 - 298) cells/mm3], 96/418 (23%) were sputum and/ or blood culture-positive for Mycobacterium tuberculosis (MTB) complex. Abnormal CXR (aOR 3.68, 95% CI 1.76- 7.71, p=0.001) and positive urine TB-LAM (aOR 6.21, 95% CI 3.14-12.27, p< 0.001) were significantly associated with MTB culture-positivity. Previous TB treatment (aOR 0.41, 95% CI 0.17-0.99, p=0.049) reduced the likelihood of a positive MTB culture. A conditional inference tree analysis showed that positive urine TB-LAM and abnormal CXR were the most predictive indicators of MTB culture-positivity. A combination of urine TB-LAM test and CXR had sensitivity and specificity of 50% and 86.1% respectively overall, and 70.8% and 84.1% respectively among those with CD4<100 cells/mm3. Conclusions A positive urine TB-LAM test and an abnormal CXR significantly predict MTB culture-positivity among smear-negative HIV-infected presumptive TB patients while previous TB treatment reduces the likelihood of a positive MTB culture. Validation studies to assess the performance of diagnostic algorithms that include urine TB-LAM in the diagnosis of smear-negative TB in HIV-infected individuals are warranted.
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Affiliation(s)
- Lydia Nakiyingi
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Medicine, School of Medicine, Makerere University College of Heath Sciences, Kampala, Uganda
- * E-mail:
| | - Bareng A. S. Nonyane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Willy Ssengooba
- Department of Medical Microbiology, Makerere University College of Heath Sciences, Kampala, Uganda
| | - Bruce J. Kirenga
- Department of Medicine, School of Medicine, Makerere University College of Heath Sciences, Kampala, Uganda
| | - Damalie Nakanjako
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Medicine, School of Medicine, Makerere University College of Heath Sciences, Kampala, Uganda
| | - Gloria Lubega
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Pauline Byakika-Kibwika
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Medicine, School of Medicine, Makerere University College of Heath Sciences, Kampala, Uganda
| | - Moses L. Joloba
- Department of Medical Microbiology, Makerere University College of Heath Sciences, Kampala, Uganda
| | - Jerry J. Ellner
- Boston Medical Center, Boston University School of Medicine, Boston, MA, United States of America
| | - Susan E. Dorman
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Harriet Mayanja-Kizza
- Department of Medicine, School of Medicine, Makerere University College of Heath Sciences, Kampala, Uganda
| | - Yukari C. Manabe
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
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Semitala FC, Chaisson LH, den Boon S, Walter N, Cattamanchi A, Awor M, Katende J, Huang L, Joloba M, Albert H, Kamya MR, Davis JL. Impact of mycobacterial culture among HIV-infected adults with presumed TB in Uganda: a prospective cohort study. Public Health Action 2015; 5:106-11. [PMID: 26400379 PMCID: PMC4487479 DOI: 10.5588/pha.14.0096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 02/25/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementation of new tuberculosis (TB) diagnostic strategies in resource-constrained settings is challenging. We measured the impact of solid and liquid mycobacterial cultures on treatment practices for patients undergoing TB evaluation in Kampala, Uganda. METHODS We enrolled consecutive smear-negative, human immunodeficiency virus positive adults with cough of ⩾2 weeks from September 2009 to April 2010. Laboratory technicians performed mycobacterial cultures on solid and liquid media. We compared empiric treatment decisions with solid and liquid culture in terms of diagnostic yield and time to results, and assessed impact on patient management. RESULTS Of 200 patients enrolled, 26 (13%) had culture-confirmed TB: 22 (85%) on solid culture alone, 2 (8%) on liquid culture alone, and 2 (8%) on both solid and liquid culture. Thirty-four patients received empiric anti-tuberculosis treatment, but only 10 (29%) were culture-positive. Median time to a positive result on solid culture was 92 days (interquartile range [IQR] 69-148) compared to 106 days (IQR 66-157) for liquid culture. No patients initiated treatment following a positive result on liquid culture. CONCLUSION The introduction of mycobacterial culture did not influence care for patients undergoing evaluation for TB in Kampala, Uganda. Attention to contextual factors surrounding implementation is needed to ensure the effective introduction of new testing strategies in low-income countries.
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Affiliation(s)
- F. C. Semitala
- Department of Medicine, Mulago Hospital, Makerere University College of Health Sciences, Kampala, Uganda
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - L. H. Chaisson
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
| | - S. den Boon
- Makerere University-University of California San Francisco Research Collaboration, Kampala, Uganda
| | - N. Walter
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver, Colorado, USA
| | - A. Cattamanchi
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
- Makerere University-University of California San Francisco Research Collaboration, Kampala, Uganda
- Curry International Tuberculosis Center, San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
| | - M. Awor
- Makerere University-University of California San Francisco Research Collaboration, Kampala, Uganda
| | - J. Katende
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - L. Huang
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
| | - M. Joloba
- Department of Microbiology, Makerere University School of Biomedical Sciences, Kampala, Uganda
| | - H. Albert
- Foundation for Innovative New Diagnostics, Kampala, Uganda
| | - M. R. Kamya
- Department of Medicine, Mulago Hospital, Makerere University College of Health Sciences, Kampala, Uganda
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - J. L. Davis
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
- Makerere University-University of California San Francisco Research Collaboration, Kampala, Uganda
- Curry International Tuberculosis Center, San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
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Hantous-Zannad S, Zidi A, Néji H, Attia M, Baccouche I, Ben Miled-M'rad K. [The role of imaging in thoracic tuberculosis]. REVUE DE PNEUMOLOGIE CLINIQUE 2015; 71:93-109. [PMID: 24874403 DOI: 10.1016/j.pneumo.2014.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 02/03/2014] [Accepted: 02/05/2014] [Indexed: 06/03/2023]
Abstract
Tuberculosis is an infectious disease mostly due to Mycobacterium tuberculosis. It is frequent in developing countries and its incidence is rising in developed countries. Lungs are the most involved organs of the chest but other structures can be affected. Imaging is fundamental in the management of the disease. Confirmation of diagnosis can be made only by bacteriologic and/or histologic exams. The first approach of diagnosis is based on clinical symptoms and chest X-ray signs. Radiologic signs depend on patient's age, his immune status and his previous contact with M. tuberculosis. Conventional chest X-ray remains the first-line exam to realize. It can suggest the diagnosis on the appearance and location of the lesions. CT scan is recommended for the positive diagnosis in case of discrepancy between clinical and radiographic signs, as for the diagnosis of parenchymal, vascular, lymph nodes, pleural, parietal or mediastinal complications. It is also essential for the evaluation of parenchyma sequelae. MRI and PET-scan have limited indications. The purpose of this article is to illustrate different radiological forms of chest tuberculosis, its sequelae and complications and to highlight the role of each imaging technique in the patient's management.
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Affiliation(s)
- S Hantous-Zannad
- Service d'imagerie médicale, hôpital Abderrahmane Mami, Ariana, Tunisie.
| | - A Zidi
- Service d'imagerie médicale, hôpital Abderrahmane Mami, Ariana, Tunisie
| | - H Néji
- Service d'imagerie médicale, hôpital Abderrahmane Mami, Ariana, Tunisie
| | - M Attia
- Service d'imagerie médicale, hôpital Abderrahmane Mami, Ariana, Tunisie
| | - I Baccouche
- Service d'imagerie médicale, hôpital Abderrahmane Mami, Ariana, Tunisie
| | - K Ben Miled-M'rad
- Service d'imagerie médicale, hôpital Abderrahmane Mami, Ariana, Tunisie
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Aliyu G, El-Kamary SS, Abimiku A, Hungerford L, Obasanya J, Blattner W. Cost-effectiveness of point-of-care digital chest-x-ray in HIV patients with pulmonary mycobacterial infections in Nigeria. BMC Infect Dis 2014; 14:675. [PMID: 25495355 PMCID: PMC4269933 DOI: 10.1186/s12879-014-0675-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 12/01/2014] [Indexed: 11/27/2022] Open
Abstract
Background Chest-x-ray is routinely used in the diagnosis of smear negative tuberculosis (TB). This study assesses the incremental cost per true positive test of a point-of-care digital chest-x-ray, in the diagnosis of pulmonary mycobacterial infections among HIV patients with presumed tuberculosis undetected by smear microscopy. Methods Consecutive patients with clinical suspicion of pulmonary tuberculosis were serially tested for Human immunodeficiency virus (HIV), their sputum examined for Acid Fast Bacilli then cultured in broth and solid media. Cultures characterized as tuberculous (M.tb) and non-tuberculous (NTM) mycobacteria by Hain assays were used as gold standards. A chest-x-ray was classified as: (1) consistent for TB, (2) not consistent for TB and (3) no pathology. Results Of the 1391 suspected cases enrolled, complete data were available for 952 (68%): 753/952 (79%) had negative smear tests while 150/753 (20%) had cultures positive for TB. Of those, 82/150 (55%) had chest-x-ray signs consistent with TB and 29/82 (35%) were positive for HIV. Within the co-infected, 9/29 (31%) had NTM infections. Among all suspects, the cost per positive case detected using smear microscopy test was $52.84; the overall incremental cost per positive case using chest-x-ray in smear negatives was $23.42, and in smear negative, HIV positive patients the cost was $15.77. Conclusion Point-of-care chest-x-ray is a cost-effective diagnostic tool for smear negative HIV positive patients with pulmonary mycobacterial infection. Electronic supplementary material The online version of this article (doi:10.1186/s12879-014-0675-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gambo Aliyu
- Health and Human Services, Federal Capital Territory, Abuja, Nigeria.
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Linguissi LSG, Mayengue PI, Sidibé A, Vouvoungui JC, Missontsa M, Madzou-Laboum IK, Essassa GB, Oyakhirome S, Frank M, Penlap V, Ntoumi F. Prevalence of national treatment algorithm defined smear positive pulmonary tuberculosis in HIV positive patients in Brazzaville, Republic of Congo. BMC Res Notes 2014; 7:578. [PMID: 25164493 PMCID: PMC4167258 DOI: 10.1186/1756-0500-7-578] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 08/18/2014] [Indexed: 11/10/2022] Open
Abstract
Background In the Republic in Congo, the national algorithm for the diagnosis of pulmonary tuberculosis (TB) relies on Ziehl-Neelsen (ZN) sputum smear microscopy, chest X-ray radiography (CXR) and clinical symptoms. Microscopy positive pulmonary TB (MPT+) is defined as symptoms of TB and a positive ZN smear. Microscopy negative pulmonary TB (MPT-) is defined as symptoms of TB, a negative ZN smear but CXR changes consistent with TB. The present cross-sectional study was designed to determine the prevalence of positive and negative MPT individuals among HIV positive and HIV negative individuals presenting to an ambulatory TB treatment center (CTA) in Brazzaville. Methods All study participants underwent a physical examination, chest radiography and three ZN sputum smear examinations and HIV testing. Viral load and CD4 counts were determined for HIV positive individuals. Results 775 individuals presented with symptoms of TB. 425 individuals accepted the voluntary HIV test. 133 (31.3%) were HIV positive (HIV+) and 292 (68.7%) were HIV negative (HIV-). Of the 292 HIV- individuals 167 (57%) were classified as positive MPT and 125 (43%) as negative MPT. Of the 133 HIV positive individuals 39 (29%) were classified as MPT + and 94 (71%) as MPT-. Conclusion Our study shows that the prevalence of positive MPT individuals is lower among HIV positive individuals compared to HIV negative individuals in agreement to reports from other countries. The data suggest that a substantial number of HIV positive pulmonary TB cases are not detected by the national algorithm and highlight the need for new diagnostic tests in this population.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Francine Ntoumi
- Fondation Congolaise pour la Recherche Médicale, Brazzaville, Republic of Congo.
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Muwonge A, Malama S, Bronsvoort BMDC, Biffa D, Ssengooba W, Skjerve E. A comparison of tools used for tuberculosis diagnosis in resource-limited settings: a case study at Mubende referral hospital, Uganda. PLoS One 2014; 9:e100720. [PMID: 24967713 PMCID: PMC4072677 DOI: 10.1371/journal.pone.0100720] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Accepted: 05/23/2014] [Indexed: 11/29/2022] Open
Abstract
Background This study compared TB diagnostic tools and estimated levels of misdiagnosis in a resource-limited setting. Furthermore, we estimated the diagnostic utility of three-TB-associated predictors in an algorithm with and without Direct Ziehl-Neelsen (DZM). Materials and Methods Data was obtained from a cross-sectional study in 2011 conducted at Mubende regional referral hospital in Uganda. An individual was included if they presented with a two weeks persistent cough and or lymphadenitis/abscess. 344 samples were analyzed on DZM in Mubende and compared to duplicates analyzed on direct fluorescent microscopy (DFM), growth on solid and liquid media at Makerere University. Clinical variables from a questionnaire and DZM were used to predict TB status in multivariable logistic and Cox proportional hazard models, while optimization and visualization was done with receiver operating characteristics curve and algorithm-charts in Stata, R and Lucid-Charts respectively. Results DZM had a sensitivity and specificity of 36.4% (95% CI = 24.9–49.1) and 97.1%(95% CI = 94.4–98.7) compared to DFM which had a sensitivity and specificity of 80.3%(95% CI = 68.7–89.1) and 97.1%(95% CI = 94.4–98.7) respectively. DZM false negative results were associated with patient’s HIV status, tobacco smoking and extra-pulmonary tuberculosis. One of the false negative cases was infected with multi drug resistant TB (MDR). The three-predictor screening algorithm with and without DZM classified 50% and 33% of the true cases respectively, while the adjusted algorithm with DZM classified 78% of the true cases. Conclusion The study supports the concern that using DZM alone risks missing majority of TB cases, in this case we found nearly 60%, of who one was an MDR case. Although adopting DFM would reduce this proportion to 19%, the use of a three-predictor screening algorithm together with DZM was almost as good as DFM alone. It’s utility is whoever subject to HIV screening all TB suspects.
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Affiliation(s)
- Adrian Muwonge
- Department of Food Safety and Infection Biology, Centre for Epidemiology and Biostatistics, Norwegian University of Life Sciences, Oslo, Norway
- The Roslin Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Easter Bush, Midlothian, Edinburgh, United Kingdom
- * E-mail:
| | - Sydney Malama
- Institute of Economic and Social Research University of Zambia, Lusaka, Zambia
| | - Barend M. de C. Bronsvoort
- The Roslin Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Easter Bush, Midlothian, Edinburgh, United Kingdom
| | - Demelash Biffa
- College of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Willy Ssengooba
- Mycobacteriology Laboratory, Department of Medical Microbiology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Eystein Skjerve
- Department of Food Safety and Infection Biology, Centre for Epidemiology and Biostatistics, Norwegian University of Life Sciences, Oslo, Norway
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Do high rates of empirical treatment undermine the potential effect of new diagnostic tests for tuberculosis in high-burden settings? THE LANCET. INFECTIOUS DISEASES 2014; 14:527-32. [PMID: 24438820 DOI: 10.1016/s1473-3099(13)70360-8] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In tuberculosis-endemic settings, patients are often treated empirically, meaning that they are placed on treatment based on clinical symptoms or tests that do not provide a microbiological diagnosis (eg, chest radiography). New tests for tuberculosis, such as the Xpert MTB/RIF assay (Cepheid, Sunnyvale, CA, USA), are being implemented at substantial cost. To inform policy and rationally drive implementation, data are needed for how these tests affect morbidity, mortality, transmission, and population-level tuberculosis burden. If people diagnosed by use of new diagnostics would have received empirical treatment a few days later anyway, then the incremental benefit might be small. Will new diagnostics substantially improve outcomes and disease burden, or simply displace empirical treatment? Will the extent and accuracy of empirical treatment change with the introduction of a new test? In this Personal View, we review emerging data for how empirical treatment is frequently same-day, and might still be the predominant form of treatment in high-burden settings, even after Xpert implementation; and how Xpert might displace so-called true-positive, rather than false-positive, empirical treatment. We suggest types of studies needed to accurately assess the effect of new tuberculosis tests and the role of empirical treatment in real-world settings. Until such questions can be addressed, and empirical treatment is appropriately characterised, we postulate that the estimated population-level effect of new tests such as Xpert might be substantially overestimated.
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Rueda ZV, López L, Vélez LA, Marín D, Giraldo MR, Pulido H, Orozco LC, Montes F, Arbeláez MP. High incidence of tuberculosis, low sensitivity of current diagnostic scheme and prolonged culture positivity in four colombian prisons. A cohort study. PLoS One 2013; 8:e80592. [PMID: 24278293 PMCID: PMC3836852 DOI: 10.1371/journal.pone.0080592] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 10/06/2013] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To determine the incidence of pulmonary tuberculosis (TB) in inmates, factors associated with TB, and the time to sputum smear and culture conversion during TB treatment. METHODS Prospective cohort study. All prisoners with respiratory symptoms (RS) of any duration were evaluated. After participants signed consent forms, we collected three spontaneous sputum samples on consecutive days. We performed auramine-rhodamine staining, culturing with the thin-layer agar method, Löwestein-Jensen medium and MGIT, susceptibility testing for first-line drugs; and HIV testing. TB cases were followed, and the times to smear and culture conversion to negative were evaluated. RESULTS Of 9,507 prisoners held in four prisons between April/30/2010 and April/30/2012, among them 4,463 were screened, 1,305 were evaluated for TB because of the lower RS of any duration, and 72 were diagnosed with TB. The annual incidence was 505 cases/100,000 prisoners. Among TB cases, the median age was 30 years, 25% had <15 days of cough, 12.5% had a history of prior TB, and 40.3% had prior contact with a TB case. TB-HIV coinfection was diagnosed in three cases. History of prior TB, contact with a TB case, and being underweight were risk factors associated with TB. Overweight was a protective factor. Almost a quarter of TB cases were detected only by culture; three cases were isoniazid resistant, and two resistant to streptomycin. The median times to culture conversion was 59 days, and smear conversion was 33. CONCLUSIONS The TB incidence in prisons is 20 times higher than in the general Colombian population. TB should be considered in inmates with lower RS of any duration. Our data demonstrate that patients receiving adequate anti-TB treatment remain infectious for prolonged periods. These findings suggest that current recommendations regarding isolation of prisoners with TB should be reconsidered, and suggest the need for mycobacterial cultures during follow-up.
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Affiliation(s)
- Zulma Vanessa Rueda
- Grupo Investigador de Problemas en Enfermedades Infecciosas, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
- Grupo de Epidemiología, Facultad Nacional de Salud Pública, Universidad de Antioquia, Medellín, Colombia
- * E-mail:
| | - Lucelly López
- Escuela de Microbiología, Universidad de Antioquia, Medellín, Colombia
| | - Lázaro A. Vélez
- Grupo Investigador de Problemas en Enfermedades Infecciosas, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
- Sección de Enfermedades Infecciosas, Departamento de Medicina Interna, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - Diana Marín
- Facultad Nacional de Salud Pública, Universidad de Antioquia, Medellín, Colombia
| | - Margarita Rosa Giraldo
- Secretaría Seccional de Salud y Protección Social de Antioquia, Gobernación de Antioquia, Medellín, Colombia
| | | | - Luis Carlos Orozco
- Facultad de Enfermería, Universidad Industrial de Santander, Bucaramanga, Santander
| | - Fernando Montes
- Secretaría de Salud de Medellín, Alcaldía de Medellín, Medellín, Colombia
| | - María Patricia Arbeláez
- Grupo de Epidemiología, Facultad Nacional de Salud Pública, Universidad de Antioquia, Medellín, Colombia
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Abebe G, Deribew A, Apers L, Abdissa A, Kiflie Y, Koole O, Colebunders R. Evaluation of the 2007 WHO guideline to diagnose smear negative tuberculosis in an urban hospital in Ethiopia. BMC Infect Dis 2013; 13:427. [PMID: 24020936 PMCID: PMC3849989 DOI: 10.1186/1471-2334-13-427] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 09/05/2013] [Indexed: 11/29/2022] Open
Abstract
Background The 2007 World Health Organization (WHO) guideline to diagnose smear-negative tuberculosis (TB) in HIV-prevalent settings was mainly based on expert advice and therefore requires evaluation in real life situations. Methods In 2009, this guideline was introduced at the ALERT hospital in Ethiopia. From October 2009 to January 2011, the accuracy of the guideline was evaluated using Mycobacterium tuberculosis culture positivity as reference standard in HIV positive TB suspects. Results A total of 459 TB suspects were enrolled during the study period; 336 (73.2%) were HIV positive. Acid fast bacilli sputum smear microscopy was done for 74.7% (251/336) HIV positive TB suspects; 94.4% (237/251) were smear negative. A chest X-ray was performed in 92.8% (220/237) and a Mycobacterium tuberculosis culture in 63.7% (151/237). The median TB diagnostic delay for smear negative cases was 3 days (interquartile range 3–4 days). Of the 75 patients diagnosed with smear negative pulmonary TB, 89. 4% (67/75) were diagnosed by chest X-ray, 9.4% (7/75) by culture and 1.3% (1/75) by clinical suspicion only. In 147 smear negative TB suspects Mycobacterium tuberculosis culture and chest X-ray results were available. Among these 147 patients, the sensitivity of the chest X-ray to diagnose smear negative TB in HIV-positive TB suspects was 53.3% (95% CI: 26.7-78.7); the specificity 67.4% (95% CI: 58.7-75.3). Conclusion The 2007 WHO diagnostic algorithm for the diagnosis of smear negative TB is likely to reduce the diagnostic delay and therefore decrease morbidity and mortality of TB in a HIV prevalent settings like Ethiopia.
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Affiliation(s)
- Gemeda Abebe
- Department of Medical Laboratory Sciences and Pathology, Jimma University, Jimma, Ethiopia.
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Peter JG, Theron G, Pooran A, Thomas J, Pascoe M, Dheda K. Comparison of two methods for acquisition of sputum samples for diagnosis of suspected tuberculosis in smear-negative or sputum-scarce people: a randomised controlled trial. THE LANCET RESPIRATORY MEDICINE 2013; 1:471-8. [PMID: 24429245 DOI: 10.1016/s2213-2600(13)70120-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Sputum obtained either under instruction from a health-care worker or through induction can improve case detection of active tuberculosis. However, the best initial sputum sampling strategy for adults with suspected smear-negative or sputum-scarce tuberculosis in primary care is unclear. We compared these two methods of sample acquisition in such patients. METHODS In this randomised controlled trial, we enrolled adults (age ≥18 years) with sputum-scarce or smear-negative suspected tuberculosis from three primary care clinics in Cape Town, South Africa. Patients were randomly assigned (1:1) to receive either health-care worker instruction or induction to obtain sputum samples. Neither patients nor investigators were masked to allocation. The primary outcome was the proportion of patients who had started treatment after 8 weeks in a modified intention-to-treat population. Secondary outcomes were proportions starting treatment within different time periods, proportion of patients producing sputum for diagnosis, adverse effects, sputum samples' quality, and case detection by diagnostic method. This study is registered with ClinicalTrials.gov, number NCT01545661. FINDINGS We enrolled 481 patients, of whom 213 were assigned to health-care worker instruction versus 268 assigned to induction. The proportion of patients who started treatment in the 8 weeks after enrolment did not differ significantly between groups (53/213 [25%] vs 73/268 [27%]; OR 0·88, 95% CI 0·57-1·36; p=0·56). A higher proportion of instructed versus induced patients initiated empiric treatment based on clinical and radiography findings (32/53 [60%] vs 28/73 [38%]; p=0·015). An adequate sputum sample ≥1 mL was acquired in a lower proportion of instructed versus induced patients (164/213 [77%] vs 238/268 [89%]; p<0·0001), and culture-based diagnostic yield was lower in instructed versus induced patients (24/213 [11%] vs 51/268 [19%]; p=0·020). However, same-day tuberculosis case detection was similar in both groups using either smear microscopy (13/213 [6%] vs 22/268 [8%]; p=0·38) or Xpert-MTB/RIF assay (13/89 [15%] vs 20/138 [14%]; p=0·98). No serious adverse events occurred in either group; side-effects related to sample acquisition were reported in 32 of 268 (12%) patients who had sputum induction and none who had instruction. Cost per procedure was lower for instructed than for induced patients (US$2·14 vs US$7·88). INTERPRETATION Although induction provides an adequate sample and a bacteriological diagnosis more frequently than instruction by a health-care worker, it is more costly, does not result in a higher proportion of same-day diagnoses, and-because of widespread empiric treatment-may not result in more patients starting treatment. Thus, health-care worker instruction might be the preferred strategy for initial collection of sputum samples in adults with suspected sputum-scarce or smear-negative tuberculosis in a high burden primary care setting. FUNDING South African National Research Foundation, European Commission, National Institutes of Health, European and Developing Countries Clinical Trials Partnership, Discovery Foundation.
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Affiliation(s)
- Jonathan G Peter
- Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; TB Vaccine Group, Jenner Institute, University of Oxford, Oxford, UK
| | - Grant Theron
- Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Anil Pooran
- Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Johnson Thomas
- Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Mellissa Pascoe
- Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Department of Infection, University College London Medical School, London, UK.
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