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Dupnik K, Rivera VR, Dorvil N, Duffus Y, Akbarnejad H, Gao Y, Liu J, Apollon A, Dumont E, Riviere C, Severe P, Lavoile K, Duran Mendicuti MA, Pierre S, Rouzier V, Walsh KF, Byrne AL, Joseph P, Cremieux PY, Pape JW, Koenig SP. Potential Utility of C-reactive Protein for Tuberculosis Risk Stratification Among Patients With Non-Meningitic Symptoms at HIV Diagnosis in Low- and Middle-income Countries. Open Forum Infect Dis 2024; 11:ofae356. [PMID: 39022393 PMCID: PMC11252845 DOI: 10.1093/ofid/ofae356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/27/2024] [Indexed: 07/20/2024] Open
Abstract
Background The World Health Organization recommends initiating same-day antiretroviral therapy (ART) while tuberculosis (TB) testing is under way for patients with non-meningitic symptoms at HIV diagnosis, though safety data are limited. C-reactive protein (CRP) testing may improve TB risk stratification in this population. Methods In this baseline analysis of 498 adults (>18 years) with TB symptoms at HIV diagnosis who were enrolled in a trial of rapid ART initiation in Haiti, we describe test characteristics of varying CRP thresholds in the diagnosis of TB. We also assessed predictors of high CRP as a continuous variable using generalized linear models. Results Eighty-seven (17.5%) participants were diagnosed with baseline TB. The median CRP was 33.0 mg/L (interquartile range: 5.1, 85.5) in those with TB, and 2.6 mg/L (interquartile range: 0.8, 11.7) in those without TB. As the CRP threshold increased from ≥1 mg/L to ≥10 mg/L, the positive predictive value for TB increased from 22.4% to 35.4% and negative predictive value decreased from 96.9% to 92.3%. With CRP thresholds varying from <1 to <10 mg/L, a range from 25.5% to 64.9% of the cohort would have been eligible for same-day ART and 0.8% to 5.0% would have untreated TB at ART initiation. Conclusions CRP concentrations can be used to improve TB risk stratification, facilitating same-day decisions about ART initiation. Depending on the CRP threshold, one-quarter to two-thirds of patients could be eligible for same-day ART, with a reduction of 3- to 20-fold in the proportion with untreated TB, compared with a strategy of same-day ART while awaiting TB test results.
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Affiliation(s)
- Kathryn Dupnik
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Vanessa R Rivera
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Nancy Dorvil
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Yanique Duffus
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | | | - Yipeng Gao
- The Analysis Group, Boston, Massachusetts, USA
| | - Jingyi Liu
- The Analysis Group, Boston, Massachusetts, USA
| | - Alexandra Apollon
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Emelyne Dumont
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Cynthia Riviere
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Patrice Severe
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Kerlyne Lavoile
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Samuel Pierre
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Vanessa Rouzier
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
- St. Vincent's Hospital and Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Kathleen F Walsh
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Anthony L Byrne
- St. Vincent's Hospital and Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Patrice Joseph
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Jean William Pape
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
- St. Vincent's Hospital and Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Serena P Koenig
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Dupnik K, Rivera VR, Dorvil N, Akbarnejad H, Gao Y, Liu J, Apollon A, Dumond E, Riviere C, Severe P, Lavoile K, Duran Mendicuti MA, Pierre S, Rouzier V, Walsh KF, Byrne AL, Joseph P, Cremieux PY, Pape JW, Koenig SP. Potential Utility of C-reactive Protein for Tuberculosis Risk Stratification among Patients with Non-Meningitic Symptoms at HIV Diagnosis in Low- and Middle-Income Countries. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.12.19.23300232. [PMID: 38196598 PMCID: PMC10775334 DOI: 10.1101/2023.12.19.23300232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Article Summary We assessed the association between C-reactive protein (CRP) and Mycobacterium tuberculosis (TB) diagnosis in symptomatic patients at HIV diagnosis. We found that CRP concentrations can improve tuberculosis risk stratification, facilitating decision making about whether (specific) tuberculosis testing is indicated before antiretroviral therapy initiation. Background The World Health Organization recommends initiating same-day ART while tuberculosis testing is underway for patients with non-meningitic symptoms at HIV diagnosis, though safety data are limited. C-reactive protein (CRP) testing may improve tuberculosis risk stratification in this population. Methods In this baseline analysis of 498 adults (>18 years) with tuberculosis symptoms at HIV diagnosis who were enrolled in a trial of rapid ART initiation in Haiti, we describe test characteristics of varying CRP thresholds in the diagnosis of TB. We also assessed predictors of high CRP (≥3 mg/dL) using generalized linear models. Results Eighty-seven (17.5%) patients were diagnosed with baseline TB. The median CRP was 33.0 mg/L (IQR: 5.1, 85.5) in those with TB, and 2.6 mg/L (IQR: 0.8, 11.7) in those without TB. As the CRP threshold increased from ≥1 mg/L to ≥10 mg/L, the positive predictive value for TB increased from 22.4% to 35.4%, and negative predictive value decreased from 96.9% to 92.3%. With CRP thresholds varying from <1 to <10 mg/L, a range from 25.5% to 64.9% of the cohort would have been eligible for same-day ART, and 0.8% to 5.0% would have untreated TB at ART initiation. Conclusions CRP concentrations can be used to improve TB risk stratification, facilitating same-day decisions about ART initiation. Depending on the CRP threshold, one-quarter to two-thirds of patients could be eligible for same-day ART, with a reduction of 3-fold to 20-fold in the proportion with untreated TB, compared with a strategy of same-day ART while awaiting TB test results.
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Shojaan H, Kalami N, Ghasempour Alamdari M, Emami Alorizy SM, Ghaedi A, Bazrgar A, Khanzadeh M, Lucke-Wold B, Khanzadeh S. Diagnostic value of the neutrophil lymphocyte ratio in discrimination between tuberculosis and bacterial community acquired pneumonia: A meta-analysis. J Clin Tuberc Other Mycobact Dis 2023; 33:100395. [PMID: 37692090 PMCID: PMC10485633 DOI: 10.1016/j.jctube.2023.100395] [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: 09/12/2023] Open
Abstract
Background We conducted a systematic review and meta-analysis, based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, to evaluate current literature on diagnostic value of neutrophil to lymphocyte ratio (NLR) in discrimination between tuberculosis (TB) and bacterial community acquired pneumonia (B-CAP). Methods Literature search was conducted from July 20, 2023 using Scopus, PubMed, and Web of Science databases. STATA software (version 12.0; Stata Corporation) was used for all analyses. Results We found that patients with TB had significantly lower levels of NLR compared to those with B-CAP (SMD = -1.09, 95 %CI = -1.78- -0.40, P = 0.002). In the quality subgroup analysis, we found that patients with TB had significantly lower level of NLR compared to those with B-CAP consistent in moderate (SMD = -0.86, 95 %CI = -2.30, 0.57, P = 0.23) and high-quality studies (SMD = -1.25, 95 %CI = -2.07, -0.42). In the subgroup analysis based on continent, we found that patients with TB had significantly lower level of NLR compared to those with B-CAP in studies performed in Asian populations (SMD = -1.37, 95 %CI = -2.13, -0.61, P < 0.001), but not on African population (SMD = -0.02, 95 %CI = -1.06, 1.02, P = 0.97). The result of this study did not change after execution of sensitivity analysis. The pooled sensitivity of NLR was 0.86 (95% CI = 0.80, 0.91), and the pooled specificity was0.88 (95% CI = 0.69, 0.95). Conclusion Patients with TB had a significantly lower NLR levels compared to those with B-CAP, so we utilized this biomarker for distinguishing between the disorders.
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Affiliation(s)
- Horieh Shojaan
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Niusha Kalami
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | | | - Arshin Ghaedi
- Student Research Committee, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Aida Bazrgar
- Student Research Committee, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Monireh Khanzadeh
- Geriatric & Gerontology Department, Medical School, Tehran University of Medical and Health Sciences, Tehran, Iran
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Sankar P, Mishra BB. Early innate cell interactions with Mycobacterium tuberculosis in protection and pathology of tuberculosis. Front Immunol 2023; 14:1260859. [PMID: 37965344 PMCID: PMC10641450 DOI: 10.3389/fimmu.2023.1260859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/26/2023] [Indexed: 11/16/2023] Open
Abstract
Tuberculosis (TB) remains a significant global health challenge, claiming the lives of up to 1.5 million individuals annually. TB is caused by the human pathogen Mycobacterium tuberculosis (Mtb), which primarily infects innate immune cells in the lungs. These immune cells play a critical role in the host defense against Mtb infection, influencing the inflammatory environment in the lungs, and facilitating the development of adaptive immunity. However, Mtb exploits and manipulates innate immune cells, using them as favorable niche for replication. Unfortunately, our understanding of the early interactions between Mtb and innate effector cells remains limited. This review underscores the interactions between Mtb and various innate immune cells, such as macrophages, dendritic cells, granulocytes, NK cells, innate lymphocytes-iNKT and ILCs. In addition, the contribution of alveolar epithelial cell and endothelial cells that constitutes the mucosal barrier in TB immunity will be discussed. Gaining insights into the early cellular basis of immune reactions to Mtb infection is crucial for our understanding of Mtb resistance and disease tolerance mechanisms. We argue that a better understanding of the early host-pathogen interactions could inform on future vaccination approaches and devise intervention strategies.
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Affiliation(s)
| | - Bibhuti Bhusan Mishra
- Department of Immunology and Microbial Disease, Albany Medical College, Albany, NY, United States
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Landscape of TB Infection and Prevention among People Living with HIV. Pathogens 2022; 11:pathogens11121552. [PMID: 36558886 PMCID: PMC9786705 DOI: 10.3390/pathogens11121552] [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: 11/05/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022] Open
Abstract
Tuberculosis (TB) is one of the leading causes of mortality in people living with HIV (PLHIV) and contributes to up to a third of deaths in this population. The World Health Organization guidelines aim to target early detection and treatment of TB among PLHIV, particularly in high-prevalence and low-resource settings. Prevention plays a key role in the fight against TB among PLHIV. This review explores TB screening tools available for PLHIV, including symptom-based screening, chest radiography, tuberculin skin tests, interferon gamma release assays, and serum biomarkers. We then review TB Preventive Treatment (TPT), shown to reduce the progression to active TB and mortality among PLHIV, and available TPT regimens. Last, we highlight policy-practice gaps and barriers to implementation as well as ongoing research needs to lower the burden of TB and HIV coinfection through preventive activities, innovative diagnostic tests, and cost-effectiveness studies.
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Dhana A, Hamada Y, Kengne AP, Kerkhoff AD, Rangaka MX, Kredo T, Baddeley A, Miller C, Singh S, Hanifa Y, Grant AD, Fielding K, Affolabi D, Merle CS, Wachinou AP, Yoon C, Cattamanchi A, Hoffmann CJ, Martinson N, Mbu ET, Sander MS, Balcha TT, Skogmar S, Reeve BWP, Theron G, Ndlangalavu G, Modi S, Cavanaugh J, Swindells S, Chaisson RE, Ahmad Khan F, Howard AA, Wood R, Thit SS, Kyi MM, Hanson J, Drain PK, Shapiro AE, Kufa T, Churchyard G, Nguyen DT, Graviss EA, Bjerrum S, Johansen IS, Gersh JK, Horne DJ, LaCourse SM, Al-Darraji HAA, Kamarulzaman A, Kempker RR, Tukvadze N, Barr DA, Meintjes G, Maartens G. Tuberculosis screening among ambulatory people living with HIV: a systematic review and individual participant data meta-analysis. THE LANCET. INFECTIOUS DISEASES 2022; 22:507-518. [PMID: 34800394 PMCID: PMC8942858 DOI: 10.1016/s1473-3099(21)00387-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/24/2021] [Accepted: 06/21/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND The WHO-recommended tuberculosis screening and diagnostic algorithm in ambulatory people living with HIV is a four-symptom screen (known as the WHO-recommended four symptom screen [W4SS]) followed by a WHO-recommended molecular rapid diagnostic test (eg Xpert MTB/RIF [hereafter referred to as Xpert]) if W4SS is positive. To inform updated WHO guidelines, we aimed to assess the diagnostic accuracy of alternative screening tests and strategies for tuberculosis in this population. METHODS In this systematic review and individual participant data meta-analysis, we updated a search of PubMed (MEDLINE), Embase, the Cochrane Library, and conference abstracts for publications from Jan 1, 2011, to March 12, 2018, done in a previous systematic review to include the period up to Aug 2, 2019. We screened the reference lists of identified pieces and contacted experts in the field. We included prospective cross-sectional, observational studies and randomised trials among adult and adolescent (age ≥10 years) ambulatory people living with HIV, irrespective of signs and symptoms of tuberculosis. We extracted study-level data using a standardised data extraction form, and we requested individual participant data from study authors. We aimed to compare the W4SS with alternative screening tests and strategies and the WHO-recommended algorithm (ie, W4SS followed by Xpert) with Xpert for all in terms of diagnostic accuracy (sensitivity and specificity), overall and in key subgroups (eg, by antiretroviral therapy [ART] status). The reference standard was culture. This study is registered with PROSPERO, CRD42020155895. FINDINGS We identified 25 studies, and obtained data from 22 studies (including 15 666 participants; 4347 [27·7%] of 15 663 participants with data were on ART). W4SS sensitivity was 82% (95% CI 72-89) and specificity was 42% (29-57). C-reactive protein (≥10 mg/L) had similar sensitivity to (77% [61-88]), but higher specificity (74% [61-83]; n=3571) than, W4SS. Cough (lasting ≥2 weeks), haemoglobin (<10 g/dL), body-mass index (<18·5 kg/m2), and lymphadenopathy had high specificities (80-90%) but low sensitivities (29-43%). The WHO-recommended algorithm had a sensitivity of 58% (50-66) and a specificity of 99% (98-100); Xpert for all had a sensitivity of 68% (57-76) and a specificity of 99% (98-99). In the one study that assessed both, the sensitivity of sputum Xpert Ultra was higher than sputum Xpert (73% [62-81] vs 57% [47-67]) and specificities were similar (98% [96-98] vs 99% [98-100]). Among outpatients on ART (4309 [99·1%] of 4347 people on ART), W4SS sensitivity was 53% (35-71) and specificity was 71% (51-85). In this population, a parallel strategy (two tests done at the same time) of W4SS with any chest x-ray abnormality had higher sensitivity (89% [70-97]) and lower specificity (33% [17-54]; n=2670) than W4SS alone; at a tuberculosis prevalence of 5%, this strategy would require 379 more rapid diagnostic tests per 1000 people living with HIV than W4SS but detect 18 more tuberculosis cases. Among outpatients not on ART (11 160 [71·8%] of 15 541 outpatients), W4SS sensitivity was 85% (76-91) and specificity was 37% (25-51). C-reactive protein (≥10 mg/L) alone had a similar sensitivity to (83% [79-86]), but higher specificity (67% [60-73]; n=3187) than, W4SS and a sequential strategy (both test positive) of W4SS then C-reactive protein (≥5 mg/L) had a similar sensitivity to (84% [75-90]), but higher specificity than (64% [57-71]; n=3187), W4SS alone; at 10% tuberculosis prevalence, these strategies would require 272 and 244 fewer rapid diagnostic tests per 1000 people living with HIV than W4SS but miss two and one more tuberculosis cases, respectively. INTERPRETATION C-reactive protein reduces the need for further rapid diagnostic tests without compromising sensitivity and has been included in the updated WHO tuberculosis screening guidelines. However, C-reactive protein data were scarce for outpatients on ART, necessitating future research regarding the utility of C-reactive protein in this group. Chest x-ray can be useful in outpatients on ART when combined with W4SS. The WHO-recommended algorithm has suboptimal sensitivity; Xpert for all offers slight sensitivity gains and would have major resource implications. FUNDING World Health Organization.
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Affiliation(s)
- Ashar Dhana
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Yohhei Hamada
- Centre for International Cooperation and Global Tuberculosis Information, The Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan; Institute for Global Health, University College London, London, UK
| | - Andre P Kengne
- Non-communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, CA, USA
| | - Molebogeng X Rangaka
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Institute for Global Health, University College London, London, UK
| | - Tamara Kredo
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa; Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Annabel Baddeley
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Cecily Miller
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Satvinder Singh
- Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
| | - Yasmeen Hanifa
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Alison D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Africa Health Research Institute, School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Corinne S Merle
- UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, Geneva, Switzerland
| | | | - Christina Yoon
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Center for Tuberculosis, University of California, San Francisco, CA, USA
| | - Adithya Cattamanchi
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Center for Tuberculosis, University of California, San Francisco, CA, USA
| | | | - Neil Martinson
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa; Johns Hopkins University Center for Tuberculosis Research, Baltimore, MD, USA
| | | | | | - Taye T Balcha
- Clinical Infection Medicine, Lund University, Malmö, Sweden; Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Sten Skogmar
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Byron W P Reeve
- DSI-NRF 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, Western Cape, South Africa
| | - Grant Theron
- DSI-NRF 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, Western Cape, South Africa
| | - Gcobisa Ndlangalavu
- DSI-NRF 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, Western Cape, South Africa
| | - Surbhi Modi
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - Richard E Chaisson
- Johns Hopkins University Center for Tuberculosis Research, Baltimore, MD, USA
| | - Faiz Ahmad Khan
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Andrea A Howard
- ICAP at Columbia University, New York, NY, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Robin Wood
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Swe Swe Thit
- Department of Medicine, University of Medicine 2, Yangon, Yangon Division, Myanmar
| | - Mar Mar Kyi
- Department of Medicine, University of Medicine 2, Yangon, Yangon Division, Myanmar
| | - Josh Hanson
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Paul K Drain
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Adrienne E Shapiro
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Tendesayi Kufa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Gavin Churchyard
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; The Aurum Institute, Parktown, South Africa
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, USA
| | - Stephanie Bjerrum
- Department of Clinical Research, Infectious Diseases, University of Southern Denmark, Odense, Denmark
| | - Isik S Johansen
- Research Unit for Infectious Diseases, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | | | - David J Horne
- Department of Medicine, Division of Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Sylvia M LaCourse
- Department of Medicine, Division of Infectious Diseases, University of Washington, Seattle, WA, USA; Department of Global Health, Division of Infectious Diseases, University of Washington, Seattle, WA, USA
| | | | - Adeeba Kamarulzaman
- Centre of Excellence for Research in AIDS, University of Malaya, Kuala Lumpur, Malaysia
| | - Russell R Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Nestani Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - David A Barr
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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Wykowski JH, Phillips C, Ngo T, Drain PK. A systematic review of potential screening biomarkers for active TB disease. J Clin Tuberc Other Mycobact Dis 2021; 25:100284. [PMID: 34805557 PMCID: PMC8590066 DOI: 10.1016/j.jctube.2021.100284] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The standard TB Four Symptom Screen does not meet the World Health Organization (WHO) ideal screening criteria for having greater than 90% sensitivity to identify active TB disease, regardless of HIV status. To identify novel screening biomarkers for active TB, we performed a systematic review of any cohort or case-control study reporting associations between screening biomarkers and active TB disease. METHODS We searched PubMed and Embase for articles published before October 10, 2021. We included studies from high or medium tuberculosis burden countries. We excluded articles focusing on C-reactive protein and lipoarabinomannan. For all included biomarkers, we calculated sensitivity, specificity and 95% confidence intervals, and assessed study quality using a tool adapted from the QUADAS-2 risk of bias. RESULTS From 8,062 abstracts screened, we included 79 articles. The articles described 302 unique biomarkers, including host antibodies, host proteins, TB antigens, microRNAs, whole blood gene PCRs, and combinations of biomarkers. Of these, 23 biomarkers had sensitivity greater than 90% and specificity greater than 70%, meeting WHO criteria for an ideal screening test. Among the eleven biomarkers described in people living with HIV, only one had a sensitivity greater than 90% and specificity greater than 70% for active TB. CONCLUSION Further evaluation of biomarkers of active TB should be pursued to accelerate identification of TB disease.
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Affiliation(s)
- James H. Wykowski
- Department of Medicine, 925 9 Ave Seattle, WA 98104, University of Washington, Seattle, USA
| | - Chris Phillips
- Department of Global Health, 925 9 Ave Seattle, WA 98104, University of Washington, Seattle, USA
| | - Thao Ngo
- Department of Global Health, 925 9 Ave Seattle, WA 98104, University of Washington, Seattle, USA
| | - Paul K. Drain
- Department of Medicine, 925 9 Ave Seattle, WA 98104, University of Washington, Seattle, USA
- Department of Global Health, 925 9 Ave Seattle, WA 98104, University of Washington, Seattle, USA
- Department of Epidemiology, 925 9 Ave Seattle, WA 98104, University of Washington, Seattle, USA
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Carvalho ACC, Amorim G, Melo MGM, Silveira AKA, Vargas PHL, Moreira ASR, Rocha MS, Souza AB, Arriaga MB, Araújo-Pereira M, Figueiredo MC, Durovni B, Lapa-E-Silva JR, Cavalcante S, Rolla VC, Sterling TR, Cordeiro-Santos M, Andrade BB, Silva EC, Kritski AL. Pre-Treatment Neutrophil Count as a Predictor of Antituberculosis Therapy Outcomes: A Multicenter Prospective Cohort Study. Front Immunol 2021; 12:661934. [PMID: 34276654 PMCID: PMC8284392 DOI: 10.3389/fimmu.2021.661934] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 06/01/2021] [Indexed: 12/26/2022] Open
Abstract
Background Neutrophils have been associated with lung tissue damage in many diseases, including tuberculosis (TB). Whether neutrophil count can serve as a predictor of adverse treatment outcomes is unknown. Methods We prospectively assessed 936 patients (172 HIV-seropositive) with culture-confirmed pulmonary TB, enrolled in a multicenter prospective cohort study from different regions in Brazil, from June 2015 to June 2019, and were followed up to two years. TB patients had a baseline visit before treatment (month 0) and visits at month 2 and 6 (or at the end of TB treatment). Smear microscopy, and culture for Mycobacterium tuberculosis (MTB) were performed at TB diagnosis and during follow-up. Complete blood counts were measured at baseline. Treatment outcome was defined as either unfavorable (death, treatment failure or TB recurrence) or favorable (cure or treatment completion). We performed multivariable logistic regression, with propensity score regression adjustment, to estimate the association between neutrophil count with MTB culture result at month 2 and unfavorable treatment outcome. We used a propensity score adjustment instead of a fully adjusted regression model due to the relatively low number of outcomes. Results Among 682 patients who had MTB culture results at month 2, 40 (5.9%) had a positive result. After regression with propensity score adjustment, no significant association between baseline neutrophil count (103/mm3) and positive MTB culture at month 2 was found among either HIV-seronegative (OR = 1.06, 95% CI = [0.95;1.19] or HIV-seropositive patients (OR = 0.77, 95% CI = [0.51; 1.20]). Of 691 TB patients followed up for at least 18 months and up to 24 months, 635 (91.9%) were either cured or completed treatment, and 56 (8.1%) had an unfavorable treatment outcome. A multivariable regression with propensity score adjustment found an association between higher neutrophil count (103/mm3) at baseline and unfavorable outcome among HIV-seronegative patients [OR= 1.17 (95% CI= [1.06;1.30]). In addition, adjusted Cox regression found that higher baseline neutrophil count (103/mm3) was associated with unfavorable treatment outcomes overall and among HIV-seronegative patients (HR= 1.16 (95% CI = [1.05;1.27]). Conclusion Increased neutrophil count prior to anti-TB treatment initiation was associated with unfavorable treatment outcomes, particularly among HIV-seronegative patients. Further prospective studies evaluating neutrophil count in response to drug treatment and association with TB treatment outcomes are warranted.
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Affiliation(s)
- Anna Cristina C Carvalho
- Laboratório de Inovações em Terapias, Ensino e Bioprodutos (LITEB), Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.,Programa Acadêmico de Tuberculose da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Gustavo Amorim
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Mayla G M Melo
- Programa Acadêmico de Tuberculose da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Laboratório de Micobacteriologia Molecular, Faculdade de Medicina e Complexo Hospitalar Hospital Universitário Clementino Fraga Filho-Instituto de Doenças do Tórax da Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ana Karla A Silveira
- Programa Acadêmico de Tuberculose da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Laboratório de Micobacteriologia Molecular, Faculdade de Medicina e Complexo Hospitalar Hospital Universitário Clementino Fraga Filho-Instituto de Doenças do Tórax da Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro H L Vargas
- Programa Acadêmico de Tuberculose da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Laboratório de Micobacteriologia Molecular, Faculdade de Medicina e Complexo Hospitalar Hospital Universitário Clementino Fraga Filho-Instituto de Doenças do Tórax da Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Adriana S R Moreira
- Programa Acadêmico de Tuberculose da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Michael S Rocha
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Instituto Brasileiro para Investigação da Tuberculose, Fundação José Silveira, Salvador, Brazil
| | - Alexandra B Souza
- Gerência de Micobacteriologia, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
| | - María B Arriaga
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Laboratório de Inflamação e Biomarcadores, Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
| | - Mariana Araújo-Pereira
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Laboratório de Inflamação e Biomarcadores, Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
| | - Marina C Figueiredo
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Betina Durovni
- Secretaria Municipal de Saúde do Rio de Janeiro, Rio de Janeiro, Brazil
| | - José R Lapa-E-Silva
- Programa Acadêmico de Tuberculose da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Valeria C Rolla
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Timothy R Sterling
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Marcelo Cordeiro-Santos
- Gerência de Micobacteriologia, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
| | - Bruno B Andrade
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Laboratório de Inflamação e Biomarcadores, Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil.,Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States.,Curso de Medicina, Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil.,Curso de Medicina, Universidade Salvador (UNIFACS), Salvador, Brazil
| | - Elisangela C Silva
- Programa Acadêmico de Tuberculose da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Laboratório de Micobacteriologia Molecular, Faculdade de Medicina e Complexo Hospitalar Hospital Universitário Clementino Fraga Filho-Instituto de Doenças do Tórax da Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Laboratório Reconhecer Biologia, Centro de Biociência e Biotecniologia, Universidade Estadual do Norte Fluminense Darcy Ribeiro, Rio de Janeiro, Brazil
| | - Afrânio L Kritski
- Programa Acadêmico de Tuberculose da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Laboratório de Micobacteriologia Molecular, Faculdade de Medicina e Complexo Hospitalar Hospital Universitário Clementino Fraga Filho-Instituto de Doenças do Tórax da Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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9
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Zifodya JS, Kreniske JS, Schiller I, Kohli M, Dendukuri N, Schumacher SG, Ochodo EA, Haraka F, Zwerling AA, Pai M, Steingart KR, Horne DJ. Xpert Ultra versus Xpert MTB/RIF for pulmonary tuberculosis and rifampicin resistance in adults with presumptive pulmonary tuberculosis. Cochrane Database Syst Rev 2021; 2:CD009593. [PMID: 33616229 DOI: 10.1002/14651858.cd009593.pub5] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Xpert MTB/RIF and Xpert MTB/RIF Ultra (Xpert Ultra) are World Health Organization (WHO)-recommended rapid tests that simultaneously detect tuberculosis and rifampicin resistance in people with signs and symptoms of tuberculosis. This review builds on our recent extensive Cochrane Review of Xpert MTB/RIF accuracy. OBJECTIVES To compare the diagnostic accuracy of Xpert Ultra and Xpert MTB/RIF for the detection of pulmonary tuberculosis and detection of rifampicin resistance in adults with presumptive pulmonary tuberculosis. For pulmonary tuberculosis and rifampicin resistance, we also investigated potential sources of heterogeneity. We also summarized the frequency of Xpert Ultra trace-positive results, and estimated the accuracy of Xpert Ultra after repeat testing in those with trace-positive results. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, Science Citation Index, Web of Science, LILACS, Scopus, the WHO ICTRP, the ISRCTN registry, and ProQuest to 28 January 2020 with no language restriction. SELECTION CRITERIA We included diagnostic accuracy studies using respiratory specimens in adults with presumptive pulmonary tuberculosis that directly compared the index tests. For pulmonary tuberculosis detection, the reference standards were culture and a composite reference standard. For rifampicin resistance, the reference standards were culture-based drug susceptibility testing and line probe assays. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data using a standardized form, including data by smear and HIV status. We assessed risk of bias using QUADAS-2 and QUADAS-C. We performed meta-analyses comparing pooled sensitivities and specificities, separately for pulmonary tuberculosis detection and rifampicin resistance detection, and separately by reference standard. Most analyses used a bivariate random-effects model. For tuberculosis detection, we estimated accuracy in studies in participants who were not selected based on prior microscopy testing or history of tuberculosis. We performed subgroup analyses by smear status, HIV status, and history of tuberculosis. We summarized Xpert Ultra trace results. MAIN RESULTS We identified nine studies (3500 participants): seven had unselected participants (2834 participants). All compared Xpert Ultra and Xpert MTB/RIF for pulmonary tuberculosis detection; seven studies used a paired comparative accuracy design, and two studies used a randomized design. Five studies compared Xpert Ultra and Xpert MTB/RIF for rifampicin resistance detection; four studies used a paired design, and one study used a randomized design. Of the nine included studies, seven (78%) were mainly or exclusively in high tuberculosis burden countries. For pulmonary tuberculosis detection, most studies had low risk of bias in all domains. Pulmonary tuberculosis detection Xpert Ultra pooled sensitivity and specificity (95% credible interval) against culture were 90.9% (86.2 to 94.7) and 95.6% (93.0 to 97.4) (7 studies, 2834 participants; high-certainty evidence) versus Xpert MTB/RIF pooled sensitivity and specificity of 84.7% (78.6 to 89.9) and 98.4% (97.0 to 99.3) (7 studies, 2835 participants; high-certainty evidence). The difference in the accuracy of Xpert Ultra minus Xpert MTB/RIF was estimated at 6.3% (0.1 to 12.8) for sensitivity and -2.7% (-5.7 to -0.5) for specificity. If the point estimates for Xpert Ultra and Xpert MTB/RIF are applied to a hypothetical cohort of 1000 patients, where 10% of those presenting with symptoms have pulmonary tuberculosis, Xpert Ultra will miss 9 cases, and Xpert MTB/RIF will miss 15 cases. The number of people wrongly diagnosed with pulmonary tuberculosis would be 40 with Xpert Ultra and 14 with Xpert MTB/RIF. In smear-negative, culture-positive participants, pooled sensitivity was 77.5% (67.6 to 85.6) for Xpert Ultra versus 60.6% (48.4 to 71.7) for Xpert MTB/RIF; pooled specificity was 95.8% (92.9 to 97.7) for Xpert Ultra versus 98.8% (97.7 to 99.5) for Xpert MTB/RIF (6 studies). In people living with HIV, pooled sensitivity was 87.6% (75.4 to 94.1) for Xpert Ultra versus 74.9% (58.7 to 86.2) for Xpert MTB/RIF; pooled specificity was 92.8% (82.3 to 97.0) for Xpert Ultra versus 99.7% (98.6 to 100.0) for Xpert MTB/RIF (3 studies). In participants with a history of tuberculosis, pooled sensitivity was 84.2% (72.5 to 91.7) for Xpert Ultra versus 81.8% (68.7 to 90.0) for Xpert MTB/RIF; pooled specificity was 88.2% (70.5 to 96.6) for Xpert Ultra versus 97.4% (91.7 to 99.5) for Xpert MTB/RIF (4 studies). The proportion of Ultra trace-positive results ranged from 3.0% to 30.4%. Data were insufficient to estimate the accuracy of Xpert Ultra repeat testing in individuals with initial trace-positive results. Rifampicin resistance detection Pooled sensitivity and specificity were 94.9% (88.9 to 97.9) and 99.1% (97.7 to 99.8) (5 studies, 921 participants; high-certainty evidence) for Xpert Ultra versus 95.3% (90.0 to 98.1) and 98.8% (97.2 to 99.6) (5 studies, 930 participants; high-certainty evidence) for Xpert MTB/RIF. The difference in the accuracy of Xpert Ultra minus Xpert MTB/RIF was estimated at -0.3% (-6.9 to 5.7) for sensitivity and 0.3% (-1.2 to 2.0) for specificity. If the point estimates for Xpert Ultra and Xpert MTB/RIF are applied to a hypothetical cohort of 1000 patients, where 10% of those presenting with symptoms have rifampicin resistance, Xpert Ultra will miss 5 cases, and Xpert MTB/RIF will miss 5 cases. The number of people wrongly diagnosed with rifampicin resistance would be 8 with Xpert Ultra and 11 with Xpert MTB/RIF. We identified a higher number of rifampicin resistance indeterminate results with Xpert Ultra, pooled proportion 7.6% (2.4 to 21.0) compared to Xpert MTB/RIF pooled proportion 0.8% (0.2 to 2.4). The estimated difference in the pooled proportion of indeterminate rifampicin resistance results for Xpert Ultra versus Xpert MTB/RIF was 6.7% (1.4 to 20.1). AUTHORS' CONCLUSIONS Xpert Ultra has higher sensitivity and lower specificity than Xpert MTB/RIF for pulmonary tuberculosis, especially in smear-negative participants and people living with HIV. Xpert Ultra specificity was lower than that of Xpert MTB/RIF in participants with a history of tuberculosis. The sensitivity and specificity trade-off would be expected to vary by setting. For detection of rifampicin resistance, Xpert Ultra and Xpert MTB/RIF had similar sensitivity and specificity. Ultra trace-positive results were common. Xpert Ultra and Xpert MTB/RIF provide accurate results and can allow rapid initiation of treatment for rifampicin-resistant and multidrug-resistant tuberculosis.
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Affiliation(s)
- Jerry S Zifodya
- Department of Medicine, Section of Pulmonary, Critical Care, & Environmental Medicine , Tulane University, New Orleans, LA, USA
| | - Jonah S Kreniske
- Department of Internal Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Ian Schiller
- Centre for Outcomes Research, McGill University Health Centre - Research Institute, Montreal, Canada
| | - Mikashmi Kohli
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Nandini Dendukuri
- Centre for Outcomes Research, McGill University Health Centre - Research Institute, Montreal, Canada
| | | | - Eleanor A Ochodo
- Centre for Evidence-based Health Care, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Frederick Haraka
- Elizabeth Glaser Pediatric AIDS Foundation, Dar es Salaam, Tanzania
- Ifakara Health Institute, Bagamoyo, Tanzania
| | - Alice A Zwerling
- School of Epidemiology & Public Health, University of Ottawa, Ottawa, Canada
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - David J Horne
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, and Firland Northwest TB Center, University of Washington, Seattle, WA, USA
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10
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Brennan A, Maskew M, Larson BA, Tsikhutsu I, Bii M, Vezi L, Fox M, Venter WDF, Ehrenkranz PD, Rosen S. Prevalence of TB symptoms, diagnosis and treatment among people living with HIV (PLHIV) not on ART presenting at outpatient clinics in South Africa and Kenya: baseline results from a clinical trial. BMJ Open 2020; 10:e035794. [PMID: 32895266 PMCID: PMC7476481 DOI: 10.1136/bmjopen-2019-035794] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE We used screening data and routine clinic records for intervention arm patients in the Simplified Algorithm for Treatment Eligibility (SLATE) trials to describe the prevalence of tuberculosis (TB) symptoms, diagnosis and treatment among people living with HIV (PLHIV), not on antiretroviral therapy (ART) and presenting at outpatient clinics in South Africa and Kenya. We compared the performance of the WHO four-symptom TB screening tool with a baseline Xpert test. SETTING Outpatient HIV clinics in South Africa and Kenya. PARTICIPANTS Eligible patients were non-pregnant, PLHIV, >18 years of age, not on ART, willing to provide written informed consent. A total of 594 patients in South Africa and 240 in Kenya were eligible. RESULTS Prevalence of any TB symptom was 38% in Kenya, 35% (SLATE I) and 47% (SLATE II) in South Africa. During SLATE I, 70% of patients in Kenya and 57% in South Africa with ≥1 TB symptom were tested for TB. In SLATE II, 79% of patients with ≥1 TB symptom were tested. Of those, 19% tested positive for TB in Kenya, 15% (SLATE I) and 5% (SLATE II) tested positive in South Africa. Of the 28 patients who tested positive in both trials, 20 initiated TB treatment. The lowest median CD4 counts were among those with active TB (Kenya 124 cells/mm3; South Africa 193 cells/mm3). When comparing the WHO four-symptom screening tool to the Xpert test (SLATE II), we found that increasing the number of symptoms required for a positive screen from one to three or four decreased sensitivity but increased the positive predictive value to >30%. CONCLUSIONS 80% of patients assessed for ART initiation presented with ≥1 TB symptoms. Reconsideration of the 'any symptom' rule may be appropriate, with ART initiation among patients with fewer/milder symptoms commencing while TB test results are pending. TRIAL REGISTRATION NUMBER NCT02891135 and NCT03315013.
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Affiliation(s)
- Alana Brennan
- Departments of Epidemiology, Boston University, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University, Boston, Massachusetts, USA
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bruce A Larson
- Department of Global Health, Boston University, Boston, Massachusetts, USA
| | - Isaac Tsikhutsu
- Kenya Medical Research Institute, Nairobi, Kenya
- Henry M. Jackson Foundation Medical Research International, Inc, Nairobi, Kenya
| | - Margaret Bii
- Kenya Medical Research Institute, Nairobi, Kenya
- Henry M. Jackson Foundation Medical Research International, Inc, Nairobi, Kenya
| | - Lungisile Vezi
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew Fox
- Departments of Epidemiology, Boston University, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University, Boston, Massachusetts, USA
| | | | | | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University, Boston, Massachusetts, USA
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11
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Ndlovu LN, Peetluk L, Moodley S, Nhamoyebonde S, Ngoepe AT, Mazibuko M, Khan K, Karim F, Pym AS, Maruri F, Moosa MYS, van der Heijden YF, Sterling TR, Leslie A. Increased Neutrophil Count and Decreased Neutrophil CD15 Expression Correlate With TB Disease Severity and Treatment Response Irrespective of HIV Co-infection. Front Immunol 2020; 11:1872. [PMID: 32983107 PMCID: PMC7485225 DOI: 10.3389/fimmu.2020.01872] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/13/2020] [Indexed: 12/12/2022] Open
Abstract
Tuberculosis remains a leading cause of death globally despite curative treatment, partly due to the difficulty of identifying patients who will not respond to therapy. Simple host biomarkers that correlate with response to drug treatment would facilitate improvement in outcomes and the evaluation of novel therapies. In a prospective longitudinal cohort study, we evaluated neutrophil count and phenotype at baseline, as well as during TB treatment in 79 patients [50 (63%) HIV-positive] with microbiologically confirmed drug susceptible TB undergoing standard treatment. At time of diagnosis, blood neutrophils were highly expanded and surface expression of the neutrophil marker CD15 greatly reduced compared to controls. Both measures changed rapidly with the commencement of drug treatment and returned to levels seen in healthy control by treatment completion. Additionally, at the time of diagnosis, high neutrophil count, and low CD15 expression was associated with higher sputum bacterial load and more severe lung damage on chest x-ray, two clinically relevant markers of disease severity. Furthermore, CD15 expression level at diagnosis was associated with TB culture conversion after 2 months of therapy (OR: 0.14, 95% CI: 0.02, 0.89), a standard measure of early TB treatment success. Importantly, our data was not significantly impacted by HIV co-infection. These data suggest that blood neutrophil metrics could potentially be exploited to develop a simple and rapid test to help determine TB disease severity, monitor drug treatment response, and identify subjects at diagnosis who may respond poorly to treatment.
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Affiliation(s)
- Lerato N Ndlovu
- Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa.,Department of Infectious Diseases, University of KwaZulu-Natal, Durban, South Africa
| | - Lauren Peetluk
- Vanderbilt Tuberculosis Center, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Sashen Moodley
- Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Shepherd Nhamoyebonde
- Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa.,Department of Infectious Diseases, University of KwaZulu-Natal, Durban, South Africa
| | - Abigail T Ngoepe
- Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Matilda Mazibuko
- Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Khadija Khan
- Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Farina Karim
- Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Alexander S Pym
- Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Fernanda Maruri
- Vanderbilt Tuberculosis Center, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Mahomed-Yunus S Moosa
- Department of Infectious Diseases, University of KwaZulu-Natal, Durban, South Africa
| | - Yuri F van der Heijden
- Vanderbilt Tuberculosis Center, Vanderbilt University School of Medicine, Nashville, TN, United States.,Global Division, The Aurum Institute, Johannesburg, South Africa
| | - Timothy R Sterling
- Vanderbilt Tuberculosis Center, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Alasdair Leslie
- Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa.,Department of Infectious Diseases, University of KwaZulu-Natal, Durban, South Africa.,Department of Infection and Immunity, University College London, London, United Kingdom
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12
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Howlett P, Du Bruyn E, Morrison H, Godsent IC, Wilkinson KA, Ntsekhe M, Wilkinson RJ. The immunopathogenesis of tuberculous pericarditis. Microbes Infect 2020; 22:172-181. [PMID: 32092538 DOI: 10.1016/j.micinf.2020.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 02/03/2020] [Indexed: 10/25/2022]
Abstract
Tuberculous pericarditis is a severe form of extrapulmonary tuberculosis and is the commonest cause of pericardial effusion in high incidence settings. Mortality ranges between 8 and 34%, and it is the leading cause of pericardial constriction in Africa and Asia. Current understanding of the disease is based on models derived from studies performed in the 1940-50s. This review summarises recent advances in the histology, microbiology and immunology of tuberculous pericarditis, with special focus on the effect of Human Immunodeficiency Virus (HIV) and the determinants of constriction.
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Affiliation(s)
- Patrick Howlett
- National Heart & Lung Institute, Imperial College London, Guy Scadding Building, Cale Street, London, SW3 6LY, United Kingdom; Department of Medicine, University of Cape Town, Observatory 7925, South Africa.
| | - Elsa Du Bruyn
- Department of Medicine, University of Cape Town, Observatory 7925, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa
| | - Hazel Morrison
- The Jenner Institute, University of Oxford, Old Road Campus Research Build, Roosevelt Dr, Oxford OX3 7DQ, United Kingdom
| | - Isiguzo C Godsent
- National Heart & Lung Institute, Imperial College London, Guy Scadding Building, Cale Street, London, SW3 6LY, United Kingdom; Department of Medicine, Federal Teaching Hospital Abakaliki, Nigeria
| | - Katalin A Wilkinson
- Department of Medicine, University of Cape Town, Observatory 7925, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa; Francis Crick Institute, 1 Midland Rd, London NW1 1AT, United Kingdom
| | - Mpiko Ntsekhe
- Department of Medicine, University of Cape Town, Observatory 7925, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa
| | - Robert J Wilkinson
- Department of Medicine, University of Cape Town, Observatory 7925, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa; Francis Crick Institute, 1 Midland Rd, London NW1 1AT, United Kingdom; Department of Infectious Diseases, Imperial College London, W2 1PG, United Kingdom
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13
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Miyahara R, Piyaworawong S, Naranbhai V, Prachamat P, Kriengwatanapong P, Tsuchiya N, Wongyai J, Bupachat S, Yamada N, Summanapan S, Mahasirimongkol S, Yanai H. Predicting the risk of pulmonary tuberculosis based on the neutrophil-to-lymphocyte ratio at TB screening in HIV-infected individuals. BMC Infect Dis 2019; 19:667. [PMID: 31357936 PMCID: PMC6664723 DOI: 10.1186/s12879-019-4292-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 07/16/2019] [Indexed: 01/14/2023] Open
Abstract
Background The neutrophil to lymphocyte ratio (NL ratio) has been reported to be a predictive biomarker of tuberculosis (TB). We assessed the association between the NL ratio and the incidence of active TB cases within 1 year after TB screening among HIV-infected individuals in Thailand. Methods A day care center that supports HIV-infected individuals in northernmost Thailand performed TB screening and follow-up visits. We compared the baseline characteristics between the TB screening positive group and the TB screening negative group. The threshold value of NL ratio was determined by cubic-spline curves and NL ratios were categorized as high or low NL ratio. We assessed the association between NL ratio and progression to active TB within 1-year using the Cox-proportional hazard model. Results Of the 1064 HIV-infected individuals who screened negative for TB at baseline, 5.6% (N = 60) eventually developed TB and 26 died after TB diagnosis. A high NL ratio was associated with a higher risk of TB (adjusted hazard ratio (aHR) 2.19, 95% CI: 1.23–3.90), after adjusting for age, sex, ethnicity, CD4 counts, and other risk factors. A high NL ratio in HIV-infected individuals with normal chest X-ray predicted TB development risk. In particular, a high NL ratio with TB symptoms could predict the highest risk of TB development (aHR 2.58, 95%CI: 1.07–6.23). Conclusions Our results showed that high NL ratio increased the risk of TB. NL ratio combined with TB symptoms could increase the accuracy of TB screening among HIV-infected individuals. Electronic supplementary material The online version of this article (10.1186/s12879-019-4292-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Reiko Miyahara
- Department of Human Genetics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan. .,Genome Medical Science Project, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan.
| | | | - Vivek Naranbhai
- Massachusetts General Hospital, Boston, USA.,Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | | | | | - Naho Tsuchiya
- Department of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | | | | | - Norio Yamada
- Research Institute of Tuberculosis (RIT), Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | | | | | - Hideki Yanai
- Research Institute of Tuberculosis (RIT), Anti-Tuberculosis Association (JATA), Tokyo, Japan.,JATA, Fukujuji Hospital, Tokyo, Japan
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14
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Horne DJ, Kohli M, Zifodya JS, Schiller I, Dendukuri N, Tollefson D, Schumacher SG, Ochodo EA, Pai M, Steingart KR. Xpert MTB/RIF and Xpert MTB/RIF Ultra for pulmonary tuberculosis and rifampicin resistance in adults. Cochrane Database Syst Rev 2019; 6:CD009593. [PMID: 31173647 PMCID: PMC6555588 DOI: 10.1002/14651858.cd009593.pub4] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Xpert MTB/RIF (Xpert MTB/RIF) and Xpert MTB/RIF Ultra (Xpert Ultra), the newest version, are the only World Health Organization (WHO)-recommended rapid tests that simultaneously detect tuberculosis and rifampicin resistance in persons with signs and symptoms of tuberculosis, at lower health system levels. A previous Cochrane Review found Xpert MTB/RIF sensitive and specific for tuberculosis (Steingart 2014). Since the previous review, new studies have been published. We performed a review update for an upcoming WHO policy review. OBJECTIVES To determine diagnostic accuracy of Xpert MTB/RIF and Xpert Ultra for tuberculosis in adults with presumptive pulmonary tuberculosis (PTB) and for rifampicin resistance in adults with presumptive rifampicin-resistant tuberculosis. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, Science Citation Index, Web of Science, Latin American Caribbean Health Sciences Literature, Scopus, the WHO International Clinical Trials Registry Platform, the International Standard Randomized Controlled Trial Number Registry, and ProQuest, to 11 October 2018, without language restriction. SELECTION CRITERIA Randomized trials, cross-sectional, and cohort studies using respiratory specimens that evaluated Xpert MTB/RIF, Xpert Ultra, or both against the reference standard, culture for tuberculosis and culture-based drug susceptibility testing or MTBDRplus for rifampicin resistance. DATA COLLECTION AND ANALYSIS Four review authors independently extracted data using a standardized form. When possible, we also extracted data by smear and HIV status. We assessed study quality using QUADAS-2 and performed meta-analyses to estimate pooled sensitivity and specificity separately for tuberculosis and rifampicin resistance. We investigated potential sources of heterogeneity. Most analyses used a bivariate random-effects model. For tuberculosis detection, we first estimated accuracy using all included studies and then only the subset of studies where participants were unselected, i.e. not selected based on prior microscopy testing. MAIN RESULTS We identified in total 95 studies (77 new studies since the previous review): 86 studies (42,091 participants) evaluated Xpert MTB/RIF for tuberculosis and 57 studies (8287 participants) for rifampicin resistance. One study compared Xpert MTB/RIF and Xpert Ultra on the same participant specimen.Tuberculosis detectionOf the total 86 studies, 45 took place in high tuberculosis burden and 50 in high TB/HIV burden countries. Most studies had low risk of bias.Xpert MTB/RIF pooled sensitivity and specificity (95% credible Interval (CrI)) were 85% (82% to 88%) and 98% (97% to 98%), (70 studies, 37,237 unselected participants; high-certainty evidence). We found similar accuracy when we included all studies.For a population of 1000 people where 100 have tuberculosis on culture, 103 would be Xpert MTB/RIF-positive and 18 (17%) would not have tuberculosis (false-positives); 897 would be Xpert MTB/RIF-negative and 15 (2%) would have tuberculosis (false-negatives).Xpert Ultra sensitivity (95% confidence interval (CI)) was 88% (85% to 91%) versus Xpert MTB/RIF 83% (79% to 86%); Xpert Ultra specificity was 96% (94% to 97%) versus Xpert MTB/RIF 98% (97% to 99%), (1 study, 1439 participants; moderate-certainty evidence).Xpert MTB/RIF pooled sensitivity was 98% (97% to 98%) in smear-positive and 67% (62% to 72%) in smear-negative, culture-positive participants, (45 studies). Xpert MTB/RIF pooled sensitivity was 88% (83% to 92%) in HIV-negative and 81% (75% to 86%) in HIV-positive participants; specificities were similar 98% (97% to 99%), (14 studies).Rifampicin resistance detectionXpert MTB/RIF pooled sensitivity and specificity (95% Crl) were 96% (94% to 97%) and 98% (98% to 99%), (48 studies, 8020 participants; high-certainty evidence).For a population of 1000 people where 100 have rifampicin-resistant tuberculosis, 114 would be positive for rifampicin-resistant tuberculosis and 18 (16%) would not have rifampicin resistance (false-positives); 886 would be would be negative for rifampicin-resistant tuberculosis and four (0.4%) would have rifampicin resistance (false-negatives).Xpert Ultra sensitivity (95% CI) was 95% (90% to 98%) versus Xpert MTB/RIF 95% (91% to 98%); Xpert Ultra specificity was 98% (97% to 99%) versus Xpert MTB/RIF 98% (96% to 99%), (1 study, 551 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS We found Xpert MTB/RIF to be sensitive and specific for diagnosing PTB and rifampicin resistance, consistent with findings reported previously. Xpert MTB/RIF was more sensitive for tuberculosis in smear-positive than smear-negative participants and HIV-negative than HIV-positive participants. Compared with Xpert MTB/RIF, Xpert Ultra had higher sensitivity and lower specificity for tuberculosis and similar sensitivity and specificity for rifampicin resistance (1 study). Xpert MTB/RIF and Xpert Ultra provide accurate results and can allow rapid initiation of treatment for multidrug-resistant tuberculosis.
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Affiliation(s)
- David J Horne
- University of WashingtonDepartment of Medicine, Division of Pulmonary and Critical Care Medicine, and Firland Northwest TB CenterSeattleUSA
| | - Mikashmi Kohli
- McGill UniversityDepartment of Epidemiology, Biostatistics and Occupational HealthMontrealCanada
| | - Jerry S Zifodya
- University of WashingtonPulmonary and Critical Care Medicine325 9th Avenue – Campus Box 359762SeattleUSA98104
| | - Ian Schiller
- McGill University Health Centre ‐ Research InstituteDivision of Clinical EpidemiologyMontrealCanada
| | - Nandini Dendukuri
- McGill University Health Centre ‐ Research InstituteDivision of Clinical EpidemiologyMontrealCanada
| | | | | | - Eleanor A Ochodo
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesPO Box 241Cape TownSouth Africa8000
| | - Madhukar Pai
- McGill UniversityDepartment of Epidemiology, Biostatistics and Occupational HealthMontrealCanada
| | - Karen R Steingart
- Department of Clinical Sciences, Liverpool School of Tropical MedicineHonorary Research FellowPembroke PlaceLiverpoolUK
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15
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Bajema KL, Bassett IV, Coleman SM, Ross D, Freedberg KA, Wald A, Drain PK. Subclinical tuberculosis among adults with HIV: clinical features and outcomes in a South African cohort. BMC Infect Dis 2019; 19:14. [PMID: 30611192 PMCID: PMC6321698 DOI: 10.1186/s12879-018-3614-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 12/11/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Subclinical tuberculosis is an asymptomatic disease phase with important relevance to persons living with HIV. We describe the prevalence, clinical characteristics, and risk of mortality for HIV-infected adults with subclinical tuberculosis. METHODS Untreated adults with HIV presenting for outpatient care in Durban, South Africa were screened for tuberculosis-related symptoms and had sputum tested by acid-fast bacilli smear and tuberculosis culture. Active tuberculosis and subclinical tuberculosis were defined as having any tuberculosis symptom or no tuberculosis symptoms with culture-positive sputum. We evaluated the association between tuberculosis disease category and 12-month survival using Cox regression, adjusting for age, sex, and CD4 count. RESULTS Among 654 participants, 96 were diagnosed with active tuberculosis disease and 28 with subclinical disease. The median CD4 count was 68 (interquartile range 39-161) cells/mm3 in patients with active tuberculosis, 136 (72-312) cells/mm3 in patients with subclinical disease, and 249 (125-394) cells/mm3 in those without tuberculosis disease (P < 0.001). The proportion of smear positive cases did not differ significantly between the subclinical (29%) and active tuberculosis groups (14%, P 0.08). Risk of mortality was not increased in individuals with subclinical tuberculosis relative to no tuberculosis (adjusted hazard ratio 0.84, 95% confidence interval 0.26-2.73). CONCLUSIONS Nearly one-quarter of tuberculosis cases among HIV-infected adults were subclinical, which was characterized by an intermediate degree of immunosuppression. Although there was no significant difference in survival, anti-tuberculous treatment of subclinical cases was common. TRIAL REGISTRATION Prospectively registered on ClinicalTrials.gov , NCT01188941 (August 26, 2010).
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Affiliation(s)
- Kristina L. Bajema
- Department of Medicine, University of Washington, 1959 NE Pacific St., Box 356429, Seattle, WA 98195 USA
| | - Ingrid V. Bassett
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston University School of Public Health, Boston, USA
| | | | - Douglas Ross
- Department of Medicine, St. Mary’s Hospital, Durban, South Africa
| | - Kenneth A. Freedberg
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston University School of Public Health, Boston, USA
| | - Anna Wald
- Departments of Medicine, Epidemiology, and Laboratory Medicine, Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, USA
| | - Paul K. Drain
- Departments of Medicine, Global Health, and Epidemiology, University of Washington, Seattle, USA
- Departments of Surgery and Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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16
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Musubire AK, Meya DB, Rhein J, Meintjes G, Bohjanen PR, Nuwagira E, Muzoora C, Boulware DR, Hullsiek KH. Blood neutrophil counts in HIV-infected patients with cryptococcal meningitis: Association with mortality. PLoS One 2018; 13:e0209337. [PMID: 30596708 PMCID: PMC6312212 DOI: 10.1371/journal.pone.0209337] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 12/04/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The mortality from cryptococcal meningitis remains high, despite the availability of antiretroviral therapy (ART) and amphotericin-based fungal regimens. The role of neutrophils in cryptococcosis is controversial. Our objective was to examine the association between blood neutrophil counts and outcomes in terms of mortality, the incidence of bacterial infections (including Mycobacterium tuberculosis) and hospitalization among HIV-infected patients presenting with cryptococcal meningitis. METHODS We used data from participants from the Cryptococcal Optimal ART Timing (COAT) trial (2010-2012; Uganda and South Africa) and the Adjunctive Sertraline for Treatment of Cryptococcal Meningitis (ASTRO-CM) trial (2013-2017; Uganda). We estimated 30-day mortality risk with Cox proportional hazards models by baseline neutrophil counts (a) on a continuous scale and (b) with indicators for both relatively high (> 3,500 cells/mm3) and low (≤ 1,000 cells/mm3) counts. Follow-up neutrophil counts from the COAT trial were used to examine the time-dependent association of neutrophil counts with 12-month mortality and rehospitalization. RESULTS 801 participants had an absolute neutrophil value at meningitis diagnosis. The median baseline absolute neutrophil count was 2100 cells/mm3 (IQR, 1400 to 3300 cells/mm3). Baseline neutrophil count was positively associated with 30-day mortality (adjusted hazard ratio = 1.09, 95%CI, 1.04-1.13, per 1000 cells/mm3 increase; p<0.001). Baseline absolute neutrophil counts ≤ 1000 cells/mm3 did not have increased risk of 30-day mortality compared to those with baseline neutrophils of 1001-3500 cells/mm3; however, baseline >3500 cells/mm3 had significantly increased risk, with an adjusted hazard ratio of 1.85(95%CI, 1.40-2.44; p<0.001). Among the COAT participants with follow-up neutrophil data, there was a strong association between time-updated neutrophil count and 12-month mortality (adjusted hazard ratio = 1.16, 95% CI 1.09-1.24; p<0.001. CONCLUSION Higher blood neutrophil counts in HIV-infected patients with cryptococcal meningitis were associated with mortality. Neutrophils role requires further investigation as to whether this may be a mediator directly contributing to mortality or merely a marker of underlying pathologies that increase mortality risk.
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Affiliation(s)
- Abdu Kisekka Musubire
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- * E-mail:
| | - David B. Meya
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University and Mulago Hospital Complex, Kampala, Uganda
| | - Joshua Rhein
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Division of Infectious Diseases & International Medicine, Dept. of Medicine, University of Minnesota, Minnesota, Minneapolis, United States of America
| | - Graeme Meintjes
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University Cape Town, Cape Town, South Africa
| | - Paul R. Bohjanen
- Division of Infectious Diseases & International Medicine, Dept. of Medicine, University of Minnesota, Minnesota, Minneapolis, United States of America
| | - Edwin Nuwagira
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Conrad Muzoora
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - David R. Boulware
- Division of Infectious Diseases & International Medicine, Dept. of Medicine, University of Minnesota, Minnesota, Minneapolis, United States of America
| | - Kathy Huppler Hullsiek
- Division of Biostatistics, School of Public Health, University of Minnesota, Minnesota, Minneapolis, United States of America
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17
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Hamada Y, Lujan J, Schenkel K, Ford N, Getahun H. Sensitivity and specificity of WHO's recommended four-symptom screening rule for tuberculosis in people living with HIV: a systematic review and meta-analysis. THE LANCET HIV 2018; 5:e515-e523. [DOI: 10.1016/s2352-3018(18)30137-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 06/11/2018] [Accepted: 06/11/2018] [Indexed: 04/09/2023]
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18
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Incipient and Subclinical Tuberculosis: a Clinical Review of Early Stages and Progression of Infection. Clin Microbiol Rev 2018; 31:31/4/e00021-18. [PMID: 30021818 DOI: 10.1128/cmr.00021-18] [Citation(s) in RCA: 303] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Tuberculosis (TB) is the leading infectious cause of mortality worldwide, due in part to a limited understanding of its clinical pathogenic spectrum of infection and disease. Historically, scientific research, diagnostic testing, and drug treatment have focused on addressing one of two disease states: latent TB infection or active TB disease. Recent research has clearly demonstrated that human TB infection, from latent infection to active disease, exists within a continuous spectrum of metabolic bacterial activity and antagonistic immunological responses. This revised understanding leads us to propose two additional clinical states: incipient and subclinical TB. The recognition of incipient and subclinical TB, which helps divide latent and active TB along the clinical disease spectrum, provides opportunities for the development of diagnostic and therapeutic interventions to prevent progression to active TB disease and transmission of TB bacilli. In this report, we review the current understanding of the pathogenesis, immunology, clinical epidemiology, diagnosis, treatment, and prevention of both incipient and subclinical TB, two emerging clinical states of an ancient bacterium.
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19
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Bajema KL, Stankiewicz Karita HC, Tenforde MW, Hawes SE, Heffron R. Maternal Hepatitis B Infection and Pregnancy Outcomes in the United States: A Population-Based Cohort Study. Open Forum Infect Dis 2018; 5:ofy134. [PMID: 29992174 PMCID: PMC6022545 DOI: 10.1093/ofid/ofy134] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 06/07/2018] [Indexed: 02/07/2023] Open
Abstract
Background Hepatitis B virus (HBV) infection in pregnancy has been associated with risk of adverse maternal and infant outcomes in highly endemic settings, but this association is not well characterized in the United States. Methods We conducted a retrospective population-based cohort study in Washington State using linked birth certificate and hospital discharge records from 1992–2014. Among pregnant women with hepatitis B (n = 4391) and a hepatitis B–negative group (n = 22 410), we compared the risk of gestational diabetes, pre-eclampsia, eclampsia, placenta previa, preterm delivery, low birthweight, small for gestational age, and large for gestational age using multivariate logistic regression. Results Hepatitis B–infected pregnant women were more likely to be Asian (61% vs 8%, P < .001), foreign-born (76% vs 23%, P < .001), and older in age (77% vs 64% ≥26 years, P < .001). They were less commonly overweight or obese (33% vs 50%, P < .001). There was a lower risk of small for gestational age infants among HBV-infected women (adjusted RR [aRR], 0.79; 95% confidence interval [CI], 0.67–0.93). The risk of other adverse outcomes was not significantly different between hepatitis B–infected and –negative women (gestational diabetes: aRR, 1.11; 95% CI, 0.92–1.34; pre-eclampsia: aRR, 1.06; 95% CI, 0.82–1.35; eclampsia: aRR, 2.31; 95% CI, 0.90–5.91; placenta previa: aRR, 1.16; 95% CI, 0.35–3.84; preterm delivery: aRR, 1.15; 95% CI, 0.98–1.34; low birth weight: aRR, 1.08; 95% CI, 0.90–1.29; large for gestational age: aRR, 1.01; 95% CI, 0.82–1.24). Conclusions In a low-burden setting in the United States, hepatitis B infection was not associated with adverse pregnancy outcomes.
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Affiliation(s)
- Kristina L Bajema
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | | | - Mark W Tenforde
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Stephen E Hawes
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington
| | - Renee Heffron
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington.,Department of Global Health, University of Washington Schools of Public Health and Medicine, Seattle, Washington
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20
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Panteleev AV, Nikitina IY, Burmistrova IA, Kosmiadi GA, Radaeva TV, Amansahedov RB, Sadikov PV, Serdyuk YV, Larionova EE, Bagdasarian TR, Chernousova LN, Ganusov VV, Lyadova IV. Severe Tuberculosis in Humans Correlates Best with Neutrophil Abundance and Lymphocyte Deficiency and Does Not Correlate with Antigen-Specific CD4 T-Cell Response. Front Immunol 2017; 8:963. [PMID: 28871253 PMCID: PMC5566990 DOI: 10.3389/fimmu.2017.00963] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 07/28/2017] [Indexed: 12/26/2022] Open
Abstract
It is generally thought that Mycobacterium tuberculosis (Mtb)-specific CD4+ Th1 cells producing IFN-γ are essential for protection against tuberculosis (TB). In some studies, protection has recently been associated with polyfunctional subpopulation of Mtb-specific Th1 cells, i.e., with cells able to simultaneously secrete several type 1 cytokines. However, the role for Mtb-specific Th1 cells and their polyfunctional subpopulations during established TB disease is not fully defined. Pulmonary TB is characterized by a great variability of disease manifestations. To address the role for Mtb-specific Th1 responses during TB, we investigated how Th1 and other immune cells correlated with particular TB manifestations, such as the degree of pulmonary destruction, TB extent, the level of bacteria excretion, clinical disease severity, clinical TB forms, and “Timika X-ray score,” an integrative parameter of pulmonary TB pathology. In comparison with healthy Mtb-exposed controls, TB patients (TBP) did not exhibit deficiency in Mtb-specific cytokine-producing CD4+ cells circulating in the blood and differed by a polyfunctional profile of these cells, which was biased toward the accumulation of bifunctional TNF-α+IFN-γ+IL-2− lymphocytes. Importantly, however, severity of different TB manifestations was not associated with Mtb-specific cytokine-producing cells or their polyfunctional profile. In contrast, several TB manifestations were strongly correlated with leukocyte numbers, the percent or the absolute number of lymphocytes, segmented or band neutrophils. In multiple alternative statistical analyses, band neutrophils appeared as the strongest positive correlate of pulmonary destruction, bacteria excretion, and “Timika X-ray score.” In contrast, clinical TB severity was primarily and inversely correlated with the number of lymphocytes in the blood. The results suggest that: (i) different TB manifestations may be driven by distinct mechanisms; (ii) quantitative parameters and polyfunctional profile of circulating Mtb-specific CD4+ cells play a minor role in determining TB severity; and (iii) general shifts in production/removal of granulocytic and lymphocytic lineages represent an important factor of TB pathogenesis. Mechanisms leading to these shifts and their specific role during TB are yet to be determined but are likely to involve changes in human hematopoietic system.
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Affiliation(s)
| | - Irina Yu Nikitina
- Immunology Department, Central Tuberculosis Research Institute, Moscow, Russia
| | - Irina A Burmistrova
- Physiatry Department, Central Tuberculosis Research Institute, Moscow, Russia
| | - George A Kosmiadi
- Immunology Department, Central Tuberculosis Research Institute, Moscow, Russia
| | - Tatyana V Radaeva
- Immunology Department, Central Tuberculosis Research Institute, Moscow, Russia
| | - Rasul B Amansahedov
- Radiology Department, Central Tuberculosis Research Institute, Moscow, Russia
| | - Pavel V Sadikov
- Radiology Department, Central Tuberculosis Research Institute, Moscow, Russia
| | - Yana V Serdyuk
- Immunology Department, Central Tuberculosis Research Institute, Moscow, Russia
| | - Elena E Larionova
- Microbiology Department, Central Tuberculosis Research Institute, Moscow, Russia
| | - Tatef R Bagdasarian
- Physiatry Department, Central Tuberculosis Research Institute, Moscow, Russia
| | - Larisa N Chernousova
- Microbiology Department, Central Tuberculosis Research Institute, Moscow, Russia
| | - Vitaly V Ganusov
- Department of Microbiology, University of Tennessee, Knoxville, TN, United States
| | - Irina V Lyadova
- Immunology Department, Central Tuberculosis Research Institute, Moscow, Russia
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Abstract
The modulation of tuberculosis (TB)-induced immunopathology caused by human immunodeficiency virus (HIV)-1 coinfection remains incompletely understood but underlies the change seen in the natural history, presentation, and prognosis of TB in such patients. The deleterious combination of these two pathogens has been dubbed a "deadly syndemic," with each favoring the replication of the other and thereby contributing to accelerated disease morbidity and mortality. HIV-1 is the best-recognized risk factor for the development of active TB and accounts for 13% of cases globally. The advent of combination antiretroviral therapy (ART) has considerably mitigated this risk. Rapid roll-out of ART globally and the recent recommendation by the World Health Organization (WHO) to initiate ART for everyone living with HIV at any CD4 cell count should lead to further reductions in HIV-1-associated TB incidence because susceptibility to TB is inversely proportional to CD4 count. However, it is important to note that even after successful ART, patients with HIV-1 are still at increased risk for TB. Indeed, in settings of high TB incidence, the occurrence of TB often remains the first presentation of, and thereby the entry into, HIV care. As advantageous as ART-induced immune recovery is, it may also give rise to immunopathology, especially in the lower-CD4-count strata in the form of the immune reconstitution inflammatory syndrome. TB-immune reconstitution inflammatory syndrome will continue to impact the HIV-TB syndemic.
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22
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Nusbaum RJ, Calderon VE, Huante MB, Sutjita P, Vijayakumar S, Lancaster KL, Hunter RL, Actor JK, Cirillo JD, Aronson J, Gelman BB, Lisinicchia JG, Valbuena G, Endsley JJ. Pulmonary Tuberculosis in Humanized Mice Infected with HIV-1. Sci Rep 2016; 6:21522. [PMID: 26908312 PMCID: PMC4808832 DOI: 10.1038/srep21522] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 01/26/2016] [Indexed: 11/09/2022] Open
Abstract
Co-infection with HIV increases the morbidity and mortality associated with tuberculosis due to multiple factors including a poorly understood microbial synergy. We developed a novel small animal model of co-infection in the humanized mouse to investigate how HIV infection disrupts pulmonary containment of Mtb. Following dual infection, HIV-infected cells were localized to sites of Mtb-driven inflammation and mycobacterial replication in the lung. Consistent with disease in human subjects, we observed increased mycobacterial burden, loss of granuloma structure, and increased progression of TB disease, due to HIV co-infection. Importantly, we observed an HIV-dependent pro-inflammatory cytokine signature (IL-1β, IL-6, TNFα, and IL-8), neutrophil accumulation, and greater lung pathology in the Mtb-co-infected lung. These results suggest that in the early stages of acute co-infection in the humanized mouse, infection with HIV exacerbates the pro-inflammatory response to pulmonary Mtb, leading to poorly formed granulomas, more severe lung pathology, and increased mycobacterial burden and dissemination.
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Affiliation(s)
| | | | | | - Putri Sutjita
- University of Texas Medical Branch, Galveston, TX 77555, USA
| | | | | | - Robert L Hunter
- University of Texas-Houston Health Science Center, Houston, TX 77030, USA
| | - Jeffrey K Actor
- University of Texas-Houston Health Science Center, Houston, TX 77030, USA
| | | | - Judith Aronson
- University of Texas Medical Branch, Galveston, TX 77555, USA
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23
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Kerkhoff AD, Wood R, Vogt M, Lawn SD. Prognostic value of a quantitative analysis of lipoarabinomannan in urine from patients with HIV-associated tuberculosis. PLoS One 2014; 9:e103285. [PMID: 25075867 PMCID: PMC4116167 DOI: 10.1371/journal.pone.0103285] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 06/28/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Detection of the mycobacterial cell wall antigen lipoarabinomannan (LAM) in urine can be used to diagnose HIV-associated tuberculosis (TB) using a qualitative (positive/negative) read-out. However, it is not known whether the quantity of LAM present in urine provides additional prognostic information. METHODS/FINDINGS Consecutively recruited adult outpatients initiating antiretroviral therapy (ART) in South Africa were investigated for TB regardless of clinical symptoms using sputum smear microscopy and liquid culture (reference standard). Urine samples were tested using the Clearview TB-ELISA for LAM and the Xpert MTB/RIF assay. The ELISA optical densities (OD) were used as a quantitative assessment of urine LAM. Among 514 patients with complete sputum and urine LAM OD results, culture-confirmed TB was diagnosed in 84 patients. Twenty-three (27.3%) were LAM-positive with a median LAM OD of 0.68 (IQR 0.16-2.43; range, 0.10-3.29) and 61 (72.6%) were LAM negative (LAM OD <0.1 above background). Higher LAM ODs were associated with a range of prognostic indices, including lower CD4 cell counts, lower haemoglobin levels, higher blood neutrophil counts and higher mycobacterial load as assessed using both sputum and urine samples. The median LAM OD among patients who died was more than 6.8-fold higher than that of patients who remained alive at 3 months (P<0.001). The small number of deaths, however, precluded adequate assessment of mortality risk stratified according to urine LAM OD. CONCLUSIONS In patients with HIV-associated TB, concentrations of LAM in urine were strongly associated with a range of poor prognostic characteristics known to be associated with mortality risk. Urine LAM assays with a semi-quantitative (negative vs. low-positive vs. high-positive) read-out may have improved clinical utility over assays with a simple binary result.
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Affiliation(s)
- Andrew D. Kerkhoff
- George Washington University School of Medicine and Health Sciences, Washington, DC, United States of America
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Robin Wood
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Monica Vogt
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Stephen D. Lawn
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- * E-mail:
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