1
|
Jeppson MA, Rasmussen Z, Castro R, Nalugwa T, Kisakye E, Mangeni W, Andama A, Jaganath D, Cattamanchi A, Mohanty SK. Integration of Electrochemical Sensing and Machine Learning to Detect Tuberculosis via Methyl Nicotinate in Patient Breath. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.23.24307746. [PMID: 38826389 PMCID: PMC11142263 DOI: 10.1101/2024.05.23.24307746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
Tuberculosis (TB) remains a significant global health issue; making early, accurate, and inexpensive point-of-care detection critical for effective treatment. This paper presents a clinical demonstration of an electrochemical sensor that detects methyl-nicotinate (MN), a volatile organic biomarker associated with active pulmonary tuberculosis. The sensor was initially tested on a patient cohort comprised of 57 adults in Kampala, Uganda, of whom 42 were microbiologically confirmed TB-positive and 15 TB-negative. The sensor employed a copper(II) liquid metal salt solution with a square wave voltammetry method tailored for MN detection using commercially available screen-printed electrodes. An exploratory machine learning analysis was performed using XGBOOST. Utilizing this approach, the sensor was 78% accurate with 71% sensitivity and 100% specificity. These initial results suggest the sensing methodology is effective in identifying TB from complex breath samples, providing a promising tool for non-invasive and rapid TB detection in clinical settings.
Collapse
|
2
|
d’Elbée M, Harker M, Mafirakureva N, Nanfuka M, Huyen Ton Nu Nguyet M, Taguebue JV, Moh R, Khosa C, Mustapha A, Mwanga-Amumpere J, Borand L, Nolna SK, Komena E, Cumbe S, Mugisha J, Natukunda N, Mao TE, Wittwer J, Bénard A, Bernard T, Sohn H, Bonnet M, Wobudeya E, Marcy O, Dodd PJ. Cost-effectiveness and budget impact of decentralising childhood tuberculosis diagnosis in six high tuberculosis incidence countries: a mathematical modelling study. EClinicalMedicine 2024; 70:102528. [PMID: 38685930 PMCID: PMC11056392 DOI: 10.1016/j.eclinm.2024.102528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/23/2024] [Accepted: 02/21/2024] [Indexed: 05/02/2024] Open
Abstract
Background The burden of childhood tuberculosis remains high globally, largely due to under-diagnosis. Decentralising childhood tuberculosis diagnosis services to lower health system levels could improve case detection, but there is little empirically based evidence on cost-effectiveness or budget impact. Methods In this mathematical modelling study, we assessed the cost-effectiveness and budget impact of decentralising a comprehensive diagnosis package for childhood tuberculosis to district hospitals (DH-focused) or primary health centres (PHC-focused) compared to standard of care (SOC). The project was conducted in Cambodia, Cameroon, Côte d'Ivoire, Mozambique, Sierra Leone, and Uganda between August 1st, 2018 and September 30th, 2021. A mathematical model was developed to assess the health and economic outcomes of the intervention from a health system perspective. Estimated outcomes were tuberculosis cases, deaths, disability-adjusted life years (DALYs) and incremental cost-effectiveness ratios (ICERs). We also calculated the budget impact of nationwide implementation. The TB-Speed Decentralization study is registered with ClinicalTrials.gov, NCT04038632. Findings For the DH-focused strategy versus SOC, ICERs ranged between $263 (Cambodia) and $342 (Côte d'Ivoire) per DALY averted. For the PHC-focused strategy versus SOC, ICERs ranged between $477 (Cambodia) and $599 (Côte d'Ivoire) per DALY averted. Results were sensitive to TB prevalence and the discount rate used. The additional costs of implementing the DH-focused strategy ranged between $12.8 M (range 10.8-16.4) (Cambodia) and $50.4 M (36.5-74.4) (Mozambique), and between $13.9 M (12.6-15.6) (Sierra Leone) and $134.6 M (127.1-143.0) (Uganda) for the PHC-focused strategy. Interpretation The DH-focused strategy may be cost-effective in some countries, depending on the cost-effectiveness threshold used for policy making. Either intervention would require substantial early investment. Funding Unitaid.
Collapse
Affiliation(s)
- Marc d’Elbée
- University of Bordeaux, National Institute for Health and Medical Research (Inserm) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux, France
- Ceped UMR 196, Université Paris Cité, Research Institute for Sustainable Development (IRD), Inserm, Paris, France
| | - Martin Harker
- TB Modelling Group, TB Centre, and Global Centre for Health Economics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Mastula Nanfuka
- MU-JHU Care Ltd, MUJHU Research Collaboration, Kampala, Uganda
| | - Minh Huyen Ton Nu Nguyet
- University of Bordeaux, National Institute for Health and Medical Research (Inserm) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux, France
| | | | - Raoul Moh
- Teaching Unit of Dermatology and Infectiology, UFR of Medical Sciences, Félix-Houphouët Boigny University, Abidjan, Côte d’Ivoire
- Programme PAC-CI, CHU de Treichville, Abidjan, Côte d’Ivoire
| | - Celso Khosa
- Instituto Nacional de Saúde, Marracuene, Mozambique
| | | | | | - Laurence Borand
- Epidemiology and Public Health Unit, Clinical Research Group, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Eric Komena
- Programme PAC-CI, CHU de Treichville, Abidjan, Côte d’Ivoire
| | | | | | | | | | - Jérôme Wittwer
- University of Bordeaux, National Institute for Health and Medical Research UMR 1219, Bordeaux, France
| | - Antoine Bénard
- CHU Bordeaux, Service d'information Médicale, USMR & CIC-EC 14-01, Bordeaux, France
| | | | - Hojoon Sohn
- Seoul National University College of Medicine, Seoul, South Korea
| | - Maryline Bonnet
- TransVIHMI, University of Montpellier, IRD /INSERM, Montpellier, France
| | - Eric Wobudeya
- MU-JHU Care Ltd, MUJHU Research Collaboration, Kampala, Uganda
| | - Olivier Marcy
- University of Bordeaux, National Institute for Health and Medical Research (Inserm) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux, France
| | - Peter J. Dodd
- School of Health & Related Research, University of Sheffield, Sheffield, United Kingdom
| |
Collapse
|
3
|
Odongo D, Omech B, Acanga A. Cost-effectiveness analysis of adding tuberculosis household contact investigation on passive case-finding strategy in Southwestern Uganda. PLoS One 2023; 18:e0288761. [PMID: 38127969 PMCID: PMC10735033 DOI: 10.1371/journal.pone.0288761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/04/2023] [Indexed: 12/23/2023] Open
Abstract
INTRODUCTION The standard passive case-finding strategy implemented by most developing countries is inadequate to detect new cases of Tuberculosis. A household contact investigation is an alternative approach. However, there is limited cost-effectiveness data to support planning and implementation in low and middle-income countries. The study aimed to evaluate the cost-effectiveness of adding household contact investigation (HCI) to the passive case-finding (PCF) strategy in the Tuberculosis control program in Southwestern Uganda. METHODS We conducted an economic evaluation using a retrospective study approach and bottom-up costing (ingredients) techniques. It was a synthesis-based evaluation of existing data extracted from the District Health Information System (DHIS 2), TB registers, and a primary cost survey. The study compared two methods of Tuberculosis (TB) case finding (PCF and HCI) strategies. Regarding PCF, patients either self-reported their signs and symptoms or were prompted by healthcare workers. At the same time, HCI was done by home visiting and screening contacts of TB patients. Patients and household contacts presumed to have Tuberculosis were requested to produce samples for analysis. We applied a static decision-analytic modeling framework to examine both strategies' costs and effectiveness. The study relied on cost and probability estimates from National Tuberculosis (TB) program data, activity costs, and published literature. It was performed from the societal and provider perspectives over 1.5 years across 12 facilities in Ntungamo, Sheema, and Rwampara Districts. The primary effectiveness measure was the number of TB cases detected (yield) and the number needed to screen (NNS). The TB yield was calculated from the number of patients screened during the period under study. The incremental cost-effectiveness ratio (ICER) was expressed as cost in 2021 US$ per additional TB case detected. We did not apply a discount rate because of the short analytic time horizon. RESULTS The unit costs of detecting a Tuberculosis case were US$ (United States dollar) 204.22 for PCF and US$ 315.07 for HCI. Patient and caregiver costs are five times more in PCF than in HCI [US$26.37 Vs. US$ 5.42]. The ICER was US$ 3,596.94 per additional TB case detected. The TB screening yields were 0.52% (1496/289140) for passive case finding and 5.8% (197/3414) for household contact investigation. Household contact investigation yield among children 0-14 Vs. 15+ years [6.2% Vs.5.4%] P = 0.04. The Yield among People living with HIV (PLHIV) Vs. HIV-negative [15.8% Vs.5.3%] P = 0.03 in HHCI. The PCF yield in men Vs. Women [1.12% Vs.0.28%] P<0.01. The NNS in PCF was 193 [95% CI: 186-294] and 17 [95% CI: 14-22] in HCI. CONCLUSION Our baseline assumptions and the specific implementations of adding HCI to existing PCF programs in the context of rural African settings prove to be not cost-effective, rather than HCI as a strategy. HCI effectively identifies children and PLHIV with TB and should be prioritized. Meanwhile, the Passive case-finding strategy effectively finds men with TB and costs lower than household contact investigation.
Collapse
Affiliation(s)
- Dickens Odongo
- Department of Environmental Health and Disease Control, Faculty of Public Health, Lira University, Lira, Uganda
| | - Bernard Omech
- Department of Environmental Health and Disease Control, Faculty of Public Health, Lira University, Lira, Uganda
| | - Alfred Acanga
- Faculty of Management Sciences, Lira University, Lira, Uganda
| |
Collapse
|
4
|
Malhotra A, Thompson R, De Vos M, David A, Schumacher S, Sohn H. Determining cost and placement decisions for moderate complexity NAATs for tuberculosis drug susceptibility testing. PLoS One 2023; 18:e0290496. [PMID: 37616318 PMCID: PMC10449112 DOI: 10.1371/journal.pone.0290496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 08/10/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Access to drug resistant testing for tuberculosis (TB) remains a challenge in high burden countries. Recently, the World Health Organization approved the use of several moderate complexity automated nucleic acid amplification tests (MC-NAAT) that have performance profiles suitable for placement in a range of TB laboratory tiers to improve drug susceptibility tests (DST) coverage. METHODS We conducted cost analysis of two MC-NAATs with different testing throughput: Lower Throughput (LT, < 24 tests per run) and Higher Throughput (HT, upto 90+ tests per run) for placement in a hypothetical laboratory in a resource limited setting. We used per-test cost as the main indicator to assess 1) drivers of cost by resource types and 2) optimized levels of annual testing volumes for the respective MC-NAATs. RESULTS The base-case per test cost of $18.52 (range: $13.79 - $40.70) for LT test and $15.37 (range: $9.61 - $37.40) for HT test. Per test cost estimates were most sensitive to the number of testing days per week, followed by equipment costs and TB-specific workloads. In general, HT NAATs were cheaper at all testing volume levels, but at lower testing volumes (less than 2,000 per year) LT tests can be cheaper if the durability of the testing system is markedly better and/or procured equipment costs are lower than that of HT NAAT. CONCLUSION Assuming equivalent performance and infrastructural needs, placement strategies for MC-NAATs need to be prioritized by laboratory system's operational factors, testing demands, and costs.
Collapse
Affiliation(s)
- Akash Malhotra
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Ryan Thompson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Margaretha De Vos
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Anura David
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Hojoon Sohn
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, South Korea
| |
Collapse
|
5
|
Katamba A, Ssengooba W, Sserubiri J, Semugenze D, Kasule GW, Nyombi A, Byaruhanga R, Turyahabwe S, Joloba ML. Evaluation of Xpert MTB/XDR test for susceptibility testing of Mycobacterium tuberculosis to first and second-line drugs in Uganda. PLoS One 2023; 18:e0284545. [PMID: 37590288 PMCID: PMC10434885 DOI: 10.1371/journal.pone.0284545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/31/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Drug-Resistant Tuberculosis (DR-TB) is one of the major challenges to TB control. DESIGN AND METHODS This was a blinded, laboratory-based cross-sectional study using sputum samples or culture isolates. Samples were from patients with rifampicin-resistant-TB and/or with high risk for isoniazid (INH) resistance and/or 2nd line fluoroquinolones (FQ) and injectable agents (IAs). The diagnostic accuracy of the Xpert® MTB/XDR test was compared to MGIT960 and the Hain Genotype® MTBDRplus and MDRsl assays (LPA) as reference DST methods. Factors for laboratory uptake of the Xpert® MTB/XDR test were also evaluated. RESULTS Of the 100 stored sputum samples included in this study, 65/99 (65.6%) were resistant to INH, 5/100 (5.0%) were resistant to FQ and none were resistant to IAs using MGIT960. The sensitivity and specificity, n (%; 95% Confidence Interval, CI) of Xpert® MTB/XDR test for; INH was 58 (89.2; 79.1-95.5) and 30 (88.2; 72.5-96.6) and for FQ; 4 (80.0; 28.3-99.4) and 95 (100; 96.2-100), respectively. Using LPA as a reference standard, a total of 52/98 (53.1%) were resistant to INH, 3/100 (3.0%) to FQ, and none to IA. The sensitivity and specificity, n (%; 95%CI) of Xpert® MTB/XDR test compared to LPA for; INH was 50 (96.1; 86.7-99.5) and 34 (74.0; 58.8-85.7) for FQ 3 (100; 29.2-100) and 96 (99.0; 94.3-99.9) respectively. The factors for laboratory uptake and roll-out of the Xpert® MTB/XDR test included: no training needed for technicians with, and one day for those without, previous Xpert-ultra experience, recording and reporting needs were not different from those of Xpert-ultra, the error rate was 4/100 (4%), one (1%) indeterminate rate and test turn-around-time were 1hr/45 minutes. CONCLUSION There is high sensitivity and specificity of Xpert® MTB/XDR test for isoniazid and fluoroquinolones. There are acceptable Xpert® MTB/XDR test attributes for the test uptake and roll-out.
Collapse
Affiliation(s)
- Achilles Katamba
- Department of Medicine, School of Medicine, Clinical Epidemiology and Biostatistics Unit and Uganda Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Willy Ssengooba
- Department of Medical Microbiology, Makerere University, Kampala, Uganda
- Lung Institute, Makerere University, Kampala, Uganda
- Biomedical Research Center, Makerere University, Kampala, Uganda
| | - James Sserubiri
- Department of Medical Microbiology, Makerere University, Kampala, Uganda
- Biomedical Research Center, Makerere University, Kampala, Uganda
| | - Derrick Semugenze
- Department of Medical Microbiology, Makerere University, Kampala, Uganda
- Biomedical Research Center, Makerere University, Kampala, Uganda
| | | | - Abdunoor Nyombi
- Ministry of Health, National Tuberculosis, and Leprosy Programme, Kampala, Uganda
| | - Raymond Byaruhanga
- Ministry of Health, National Tuberculosis, and Leprosy Programme, Kampala, Uganda
| | - Stavia Turyahabwe
- Ministry of Health, National Tuberculosis, and Leprosy Programme, Kampala, Uganda
| | - Moses L. Joloba
- Department of Medical Microbiology, Makerere University, Kampala, Uganda
- Biomedical Research Center, Makerere University, Kampala, Uganda
- Ministry of Health, National Tuberculosis, and Leprosy Programme, Kampala, Uganda
| |
Collapse
|
6
|
Katamba A, Ssengooba W, Sserubiri J, Semugenze D, William KG, Abdunoor N, Byaruhanga R, Turyahabwe S, Joloba ML. Evaluation of Xpert ® MTB/XDR test for susceptibility testing of Mycobacterium tuberculosis to first and second-line drugs in Uganda. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.03.23288099. [PMID: 37066316 PMCID: PMC10104194 DOI: 10.1101/2023.04.03.23288099] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
Background Drug-Resistant Tuberculosis (DR-TB) is one of the key challenges toward TB control. There is an urgent need for rapid and accurate drug susceptibility tests (DST) for the most commonly used 1 st and 2 nd line TB drugs. Design and Methods In a blinded, laboratory-based cross-sectional study, we set out to validate the performance of the Xpert ® MTB/XDR test for DST of M. tuberculosis . Sputum samples or culture isolates collected between January 2020 and December 2021 from patients with rifampicin resistance -TB and/or with higher suspicion index for isoniazid (INH) resistance and/or 2 nd line fluoroquinolones (FQ) and injectable agents (IAs) were tested using the Xpert ® MTB/XDR test from 11/September 2021 to 26/May /2022. Diagnostic accuracy and factors for laboratory uptake of Xpert ® MTB/XDR test were compared to MGIT960 and the Hain Genotype® MTBDR plus and MDRsl assays (LPA) as reference DST methods. Results A total of 100 stored sputum samples were included in this study. Of the samples tested using MGIT960, 65/99 (65.6%) were resistant to INH, 5/100 (5.0%) resistant to FQ and none were resistant to IAs. The sensitivity and specificity, n (%; 95%Confidence Interval, CI) of Xpert ® MTB/XDR test for; INH were 58 (89.2; 79.1-95.5) and 30 (88.2; 72.5-96.6), FQ; 4 (80.0; 28.3-99.4) and 95 (100; 96.2-100), respectively. The specificity for AIs was 100 (100; 96.3-100). Using LPA as a reference standard, a total of 52/98 (53.1%) were resistant to INH, 3/100 (3.0%) to FQ, and none to IA. The sensitivity and specificity, n (%; 95%CI) of Xpert ® MTB/XDR test compared to LPA for; INH was 50 (96.1; 86.7-99.5) and 34 (74.0; 58.8-85.7) and FQ 3 (100; 29.2-100) and 96 (99.0; 94.3-99.9) respectively. The specificity of IAs was 96 (100; 96.2-100). The factors for laboratory uptake and roll-out included; no training needed for technicians with previous Xpert-ultra experience and one day for those without, recording and reporting needs were not different from those of Xpert ultra, the error rate was 4/100 (4%), no uninterpretable results reported, test turn-around-time was 1hr/45 minutes and workflow similar to that of the Xpert-ultra test. Conclusion There is high sensitivity and specificity of Xpert ® MTB/XDR test for isoniazid, fluoroquinolones, and Injectable agents. There are acceptable Xpert ® MTB/XDR test attributes for test uptake and roll-out.
Collapse
Affiliation(s)
- Achilles Katamba
- Makerere University, Department of Medicine, school of Medicine, Clinical Epidemiology and Biostatistics Unit, Uganda Implementation Research Consortium, Kampala, Uganda
| | - Willy Ssengooba
- Makerere University, Department of Medical Microbiology
- Makerere University Lung Institute
- Makerere University, Biomedical Research Center
| | - James Sserubiri
- Makerere University, Department of Medical Microbiology
- Makerere University, Biomedical Research Center
| | - Derrick Semugenze
- Makerere University, Department of Medical Microbiology
- Makerere University, Biomedical Research Center
| | | | - Nyombi Abdunoor
- Ministry of Health, National Tuberculosis and Leprosy Programme
| | | | | | - Moses L Joloba
- Makerere University, Department of Medical Microbiology
- Makerere University, Biomedical Research Center
- Ministry of Health, National Tuberculosis and Leprosy Programme
| |
Collapse
|
7
|
Thompson RR, Nalugwa T, Oyuku D, Tucker A, Nantale M, Nakaweesa A, Musinguzi J, Reza TF, Zimmer AJ, Ferguson O, Turyahabwe S, Joloba M, Cattamanchi A, Katamba A, Dowdy DW, Sohn H. Multicomponent strategy with decentralised molecular testing for tuberculosis in Uganda: a cost and cost-effectiveness analysis. Lancet Glob Health 2023; 11:e278-e286. [PMID: 36669808 PMCID: PMC9848406 DOI: 10.1016/s2214-109x(22)00509-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Decentralised molecular testing for tuberculosis could reduce missed diagnoses and losses to follow-up in high-burden settings. The aim of this study was to evaluate the cost and cost-effectiveness of the Xpert Performance Evaluation for Linkage to Tuberculosis Care (XPEL-TB) study strategy, a multicomponent strategy including decentralised molecular testing for tuberculosis, in Uganda. METHODS We conducted a costing and cost-effectiveness analysis nested in a pragmatic cluster-randomised trial of onsite (decentralised) versus hub-and-spoke (centralised) testing for tuberculosis with Xpert MTB/RIF Ultra (Xpert) in 20 community health centres in Uganda. We collected empirical data on the cost of the XPEL-TB strategy (decentralised Xpert testing, workflow redesign, and performance feedback) and routine tuberculosis testing (onsite smear microscopy with specimen transport for centralised Xpert testing) from the health system perspective. Time-and-motion studies were performed to estimate activity-based service costs. Cost-effectiveness was assessed as the incremental cost (2019 US$) per tuberculosis diagnosis and per 14-day treatment initiation. FINDINGS The XPEL-TB study ran from Oct 22, 2018, to March 1, 2020. Effectiveness and cost-effectiveness outcomes were assessed from Dec 1, 2018, to Nov 30, 2019 and included 4867 women and 3139 men. On a per-test basis, the cost of decentralised ($20·46, range $17·85-25·72) and centralised ($18·20, range $16·58-24·25) Xpert testing was similar. However, decentralised testing resulted in more patients receiving appropriate Xpert testing, so the per-patient cost of decentralised testing was higher: $20·28 (range $17·68-25·48) versus $9·59 (range $7·62-14·34). The XPEL-TB strategy was estimated to cost $1332 (95% uncertainty range $763-5558) per incremental tuberculosis diagnosis and $687 ($501-1207) per incremental patient initiating tuberculosis treatment within 14 days. Cost-effectiveness was reduced in sites performing fewer than 150-250 tests annually. INTERPRETATION The XPEL-TB strategy facilitated higher rates of Xpert testing for tuberculosis at a similar per-test cost and modest incremental cost per tuberculosis diagnosis and treatment initiation. Decentralised Xpert testing, with appropriate implementation supports, should be scaled up to clinics with sufficient testing volume to support a single-module device. FUNDING The National Heart, Lung, and Blood Institute.
Collapse
Affiliation(s)
- Ryan R Thompson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Talemwa Nalugwa
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Denis Oyuku
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Austin Tucker
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Mariam Nantale
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Annet Nakaweesa
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Johnson Musinguzi
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Tania F Reza
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Alexandra J Zimmer
- McGill International Tuberculosis Centre, McGill University, Montreal, QC, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Olivia Ferguson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stavia Turyahabwe
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda; National Tuberculosis and Leprosy Program, Uganda Ministry of Health, Kampala, Uganda
| | - Moses Joloba
- National Tuberculosis and Leprosy Program, Uganda Ministry of Health, Kampala, Uganda; School of Biomedical Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Adithya Cattamanchi
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda; Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA; Partnerships for Research in Implementation Science for Equity Center, University of California San Francisco, San Francisco, CA, USA
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda; Clinical Epidemiology & Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Hojoon Sohn
- Department of Preventive Medicine, College of Medicine, Seoul National University, Seoul, South Korea.
| |
Collapse
|
8
|
Ejalu DL, Irioko A, Kirabo R, Mukose AD, Ekirapa E, Kagaayi J, Namutundu J. Cost-effectiveness of GeneXpert Omni compared with GeneXpert MTB/Rif for point-of-care diagnosis of tuberculosis in a low-resource, high-burden setting in Eastern Uganda: a cost-effectiveness analysis based on decision analytical modelling. BMJ Open 2022; 12:e059823. [PMID: 35998960 PMCID: PMC9403108 DOI: 10.1136/bmjopen-2021-059823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To determine the cost-effectiveness of Xpert Omni compared with Xpert MTB/Rif for point-of-care diagnosis of tuberculosis among presumptive cases in a low-resource, high burden facility. DESIGN Cost-effectiveness analysis from the provider's perspective. SETTING A low-resource, high tuberculosis burden district in Eastern Uganda. PARTICIPANTS A provider's perspective was used, and thus, data were collected from experts in the field of tuberculosis diagnosis purposively selected at the local, subnational and national levels. METHODS A decision analysis model was contracted from TreeAge comparing Xpert MTB/Rif and Xpert Omni. Cost estimation was done using the ingredients' approach. One-way deterministic sensitivity analyses were performed to identify the most influential model parameters. OUTCOME MEASURE The outcome measure was incremental cost per additional test diagnosed expressed as the incremental cost-effectiveness ratio. RESULTS The total cost per test for Xpert MTB/Rif was US$14.933. Cartridge and reagent kits contributed to 67% of Xpert MTB/Rif costs. Sample transport costs increased the cost per test of Xpert MTB/Rif by $1.28. The total cost per test for Xpert Omni was $16.153. Cartridge and reagent kits contributed to over 71.2% of Xpert Omni's cost per test. The incremental cost-effectiveness ratio for using Xpert Omni as a replacement for Xpert MTB/Rif was US$30.73 per additional case detected. There was no dominance noted in the cost-effectiveness analysis, meaning no strategy was dominant over the other. CONCLUSION The use of Xpert Omni at the point-of-care health facility was more effective but with an increased cost compared with Xpert MTB/Rif at the centralised referral testing facility.
Collapse
Affiliation(s)
- David Livingstone Ejalu
- Faculty of Health Sciences, Uganda Martyrs University, Kampala, Uganda
- Department of Epidemiology and Biostatistics, Makerere University, College of Health Sciences, School of Public Health, Kampala, Uganda
| | - Aaron Irioko
- Department of Epidemiology and Biostatistics, Makerere University, College of Health Sciences, School of Public Health, Kampala, Uganda
- Department of Medical Laboratory Technology, Uganda Institute of Allied Health and Management Sciences, Kampala, Uganda
| | - Rhoda Kirabo
- Department of Epidemiology and Biostatistics, Makerere University, College of Health Sciences, School of Public Health, Kampala, Uganda
| | - Aggrey David Mukose
- Department of Epidemiology and Biostatistics, Makerere University, College of Health Sciences, School of Public Health, Kampala, Uganda
| | - Elizabeth Ekirapa
- Department of Health Policy Planning and Management, Marerere University College of Health Sciences, School of Public Health, Kampala, Uganda
| | - Joseph Kagaayi
- Department of Epidemiology and Biostatistics, Makerere University, College of Health Sciences, School of Public Health, Kampala, Uganda
| | - Juliana Namutundu
- Department of Epidemiology and Biostatistics, Makerere University, College of Health Sciences, School of Public Health, Kampala, Uganda
| |
Collapse
|
9
|
Cox SR, Kadam A, Atre S, Gupte AN, Sohn H, Gupte N, Sawant T, Mhadeshwar V, Thompson R, Kendall E, Hoffmann C, Suryavanshi N, Kerrigan D, Tripathy S, Kakrani A, Barthwal MS, Mave V, Golub JE. Tuberculosis (TB) Aftermath: study protocol for a hybrid type I effectiveness-implementation non-inferiority randomized trial in India comparing two active case finding (ACF) strategies among individuals treated for TB and their household contacts. Trials 2022; 23:635. [PMID: 35932062 PMCID: PMC9354295 DOI: 10.1186/s13063-022-06503-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/01/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Approximately 7% of all reported tuberculosis (TB) cases each year are recurrent, occurring among people who have had TB in the recent or distant past. TB recurrence is particularly common in India, which has the largest TB burden worldwide. Although patients recently treated for TB are at high risk of developing TB again, evidence around effective active case finding (ACF) strategies in this population is scarce. We will conduct a hybrid type I effectiveness-implementation non-inferiority randomized trial to compare the effectiveness, cost-effectiveness, and feasibility of two ACF strategies among individuals who have completed TB treatment and their household contacts (HHCs). METHODS We will enroll 1076 adults (≥ 18 years) who have completed TB treatment at a public TB unit (TU) in Pune, India, along with their HHCs (averaging two per patient, n = 2152). Participants will undergo symptom-based ACF by existing healthcare workers (HCWs) at 6-month intervals and will be randomized to either home-based ACF (HACF) or telephonic ACF (TACF). Symptomatic participants will undergo microbiologic testing through the program. Asymptomatic HHCs will be referred for TB preventive treatment (TPT) per national guidelines. The primary outcome is rate per 100 person-years of people diagnosed with new or recurrent TB by study arm, within 12 months following treatment completion. The secondary outcome is proportion of HHCs < 6 years, by study arm, initiated on TPT after ruling out TB disease. Study staff will collect socio-demographic and clinical data to identify risk factors for TB recurrence and will measure post-TB lung impairment. In both arms, an 18-month "mop-up" visit will be conducted to ascertain outcomes. We will use the RE-AIM framework to characterize implementation processes and explore acceptability through in-depth interviews with index patients, HHCs and HCWs (n = 100). Cost-effectiveness will be assessed by calculating the incremental cost per TB case detected within 12 months and projected for disability-adjusted life years averted based on modeled estimates of morbidity, mortality, and time with infectious TB. DISCUSSION This novel trial will guide India's scale-up of post-treatment ACF and provide an evidence base for designing strategies to detect recurrent and new TB in other high burden settings. TRIAL REGISTRATION NCT04333485 , registered April 3, 2020. CTRI/2020/05/025059 [Clinical Trials Registry of India], registered May 6 2020.
Collapse
Affiliation(s)
- Samyra R Cox
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA.
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA.
| | - Abhay Kadam
- Johns Hopkins India, G-4 & G-5, PHOENIX Building, OPP. to Residency Club, Pune, Maharashtra, 411001, India
| | - Sachin Atre
- Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Maharashtra, 411018, India
| | - Akshay N Gupte
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Hojoon Sohn
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Nikhil Gupte
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
- Johns Hopkins India, G-4 & G-5, PHOENIX Building, OPP. to Residency Club, Pune, Maharashtra, 411001, India
| | - Trupti Sawant
- Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Maharashtra, 411018, India
| | - Vishal Mhadeshwar
- Johns Hopkins India, G-4 & G-5, PHOENIX Building, OPP. to Residency Club, Pune, Maharashtra, 411001, India
| | - Ryan Thompson
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | - Emily Kendall
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Christopher Hoffmann
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Nishi Suryavanshi
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
- Johns Hopkins India, G-4 & G-5, PHOENIX Building, OPP. to Residency Club, Pune, Maharashtra, 411001, India
| | - Deanna Kerrigan
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- George Washington University, 2121 I St NW, Washington, D.C., 20052, USA
| | - Srikanth Tripathy
- Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Maharashtra, 411018, India
| | - Arjunlal Kakrani
- Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Maharashtra, 411018, India
| | - Madhusudan S Barthwal
- Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Maharashtra, 411018, India
| | - Vidya Mave
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
- Johns Hopkins India, G-4 & G-5, PHOENIX Building, OPP. to Residency Club, Pune, Maharashtra, 411001, India
| | - Jonathan E Golub
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
| |
Collapse
|
10
|
Otoo JA, Schlappi TS. REASSURED Multiplex Diagnostics: A Critical Review and Forecast. BIOSENSORS 2022; 12:bios12020124. [PMID: 35200384 PMCID: PMC8869588 DOI: 10.3390/bios12020124] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/05/2022] [Accepted: 02/11/2022] [Indexed: 05/05/2023]
Abstract
The diagnosis of infectious diseases is ineffective when the diagnostic test does not meet one or more of the necessary standards of affordability, accessibility, and accuracy. The World Health Organization further clarifies these standards with a set of criteria that has the acronym ASSURED (Affordable, Sensitive, Specific, User-friendly, Rapid and robust, Equipment-free and Deliverable to end-users). The advancement of the digital age has led to a revision of the ASSURED criteria to REASSURED: Real-time connectivity, Ease of specimen collection, Affordable, Sensitive, Specific, User-friendly, Rapid and robust, Equipment-free or simple, and Deliverable to end-users. Many diagnostic tests have been developed that aim to satisfy the REASSURED criteria; however, most of them only detect a single target. With the progression of syndromic infections, coinfections and the current antimicrobial resistance challenges, the need for multiplexed diagnostics is now more important than ever. This review summarizes current diagnostic technologies for multiplexed detection and forecasts which methods have promise for detecting multiple targets and meeting all REASSURED criteria.
Collapse
|
11
|
Kaso AW, Hailu A. Costs and cost-effectiveness of Gene Xpert compared to smear microscopy for the diagnosis of pulmonary tuberculosis using real-world data from Arsi zone, Ethiopia. PLoS One 2021; 16:e0259056. [PMID: 34695153 PMCID: PMC8544827 DOI: 10.1371/journal.pone.0259056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 10/11/2021] [Indexed: 12/27/2022] Open
Abstract
Background Early diagnosis and treatment are one of the key strategies of tuberculosis control globally, and there are strong efforts in detecting and treating tuberculosis cases in Ethiopia. Smear microscopy examination has been a routine diagnostic test for pulmonary tuberculosis diagnosis in resource-constrained settings for decades. Recently, many countries, including Ethiopia, are scaling up the use of Gene Xpert without the evaluation of the cost and cost-effectiveness implications of this strategy. Therefore, this study evaluated the cost and cost-effectiveness of Gene Xpert (MTB/RIF) and smear microscopy tests to diagnosis tuberculosis patients in Ethiopia. Methods We compared the costs and cost-effectiveness of tuberculosis diagnosis using smear microscopy and Gene Xpert among 1332 patients per intervention in the Arsi zone. We applied combinations of top-down and bottom-up costing approaches. The costs were estimated from the health providers’ perspective within one year (2017–2018). We employed “cases detected” as an effectiveness measure, and the incremental cost-effectiveness ratio was calculated by dividing the changes in cost and change in effectiveness. All costs and incremental cost-effectiveness ratio were reported in 2018 US$. Results The unit cost per test for Gene Xpert was $12.9 whereas it is $3.1 for AFB smear microscopy testing. The cost per TB case detected was $77.9 for Gene Xpert while it was $55.8 for the smear microscopy method. The cartridge kit cost accounted for 42% of the overall Gene Xpert’s costs and the cost of the reagents and consumables accounted for 41.3% ($1.3) of the unit cost for the smear microscopy method. The ICER for the Gene Xpert strategy was $20.0 per tuberculosis case detected. Conclusion Using Gene Xpert as a routine test instead of standard care (smear microscopy) can be potentially cost-effective. In the cost scenario analysis, the price of the cartridge, the number of tests performed per day, and the life span of the capital equipment were the drivers of the unit cost of the Gene Xpert method. Therefore, Gene Xpert can be a part of the routine TB diagnostic testing strategy in Ethiopia.
Collapse
Affiliation(s)
- Abdene Weya Kaso
- School of Public Health, College of Medicine and Health Science, Dilla University, Dilla, Ethiopia
- * E-mail:
| | - Alemayehu Hailu
- Department of Global Public Health and Primary Care, Bergen Centre for Ethics and Priority Setting, University of Bergen, Bergen, Norway
| |
Collapse
|
12
|
Ssengooba W, de Dieu Iragena J, Komakech K, Okello I, Nalunjogi J, Katagira W, Kimuli I, Adakun S, Joloba ML, Torrea G, Kirenga BJ. Discordance of the Repeat GeneXpert MTB/RIF Test for Rifampicin Resistance Detection Among Patients Initiating MDR-TB Treatment in Uganda. Open Forum Infect Dis 2021; 8:ofab173. [PMID: 34189166 PMCID: PMC8223903 DOI: 10.1093/ofid/ofab173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/31/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The Global Laboratory Initiative (GLI) guidelines recommend repeat for GeneXpertMTB/RIF (XpertMTB/RIF) in patients with a low pretest probability of rifampicin resistance (RR). METHODS This was a cross-sectional study using results of sputum specimens collected from participants screened for the STREAM 2 trial. We recruited all patients with XpertMTB/RIF RR-TB detected who were referred for RR/multidrug-resistant (MDR) TB treatment initiation at Mulago National Referral Hospital, Kampala, between September 2017 and October 2019. At baseline, smear microscopy, repeat XpertMTB/RIF, Xpert Ultra, and MTBDRplus assays were done on sputum specimens. Culture-based drug susceptibility testing (DST) was performed on discordant specimens. We analyzed the prevalence and factors associated with discordance between initial and repeat XpertMTB/RIF RR and false XpertMTB/RIF RR. False XpertMTB/RIF RR was defined as no RR detected by any of Xpert Ultra, LPA, or culture DST (reference comparator). RESULTS A total of 126/130 patients had repeat XpertMTB/RIF results, of whom 97 (77.0%) had M. tuberculosis detected, 81 (83.5%) had RR detected, and 1 (1.0%) had RR indeterminate. The prevalence of discordant XpertMTB/RIF RR was 15/96 (15.6%), whereas false XpertMTB/RIF RR prevalence was 10/96 (10.4%).Low-bacillary load sputum specimens were more likely to have discordant XpertMTB/RIF RR and false XpertMTB/RIF RR results (adjusted odds ratio [aOR], 0.04; 95% CI, 0.00-0.37; P = .01; aOR, 0.02; 95% CI, 0.01-0.35; P = .01, respectively). CONCLUSIONS Our findings show a high false-positive rifampicin resistance rate in low-TB burden patients, which calls for repeat testing in order to prevent unnecessary prescription of anti-MDR-TB therapy.
Collapse
Affiliation(s)
- Willy Ssengooba
- College of Health Sciences, Makerere University Lung Institute, Kampala, Uganda
- Mycobacteriology (BSL-3) Laboratory, Department of Medical Microbiology, Makerere University, Kampala, Uganda
| | - Jean de Dieu Iragena
- Communicable Diseases Cluster, HIV/TB and Hepatitis Programme, World Health Organization Regional Office for Africa, Brazzaville, Congo
| | - Kevin Komakech
- Mycobacteriology (BSL-3) Laboratory, Department of Medical Microbiology, Makerere University, Kampala, Uganda
| | - Iginitius Okello
- College of Health Sciences, Makerere University Lung Institute, Kampala, Uganda
| | - Joanitah Nalunjogi
- College of Health Sciences, Makerere University Lung Institute, Kampala, Uganda
| | - Winceslaus Katagira
- College of Health Sciences, Makerere University Lung Institute, Kampala, Uganda
| | - Ivan Kimuli
- College of Health Sciences, Makerere University Lung Institute, Kampala, Uganda
| | - Susan Adakun
- College of Health Sciences, Makerere University Lung Institute, Kampala, Uganda
- National Tuberculosis Treatment Unit, Mulago Hospital, Kampala, Uganda
| | - Moses L Joloba
- College of Health Sciences, Makerere University Lung Institute, Kampala, Uganda
- Mycobacteriology (BSL-3) Laboratory, Department of Medical Microbiology, Makerere University, Kampala, Uganda
| | - Gabriela Torrea
- Unit of Mycobacteriology, Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bruce J Kirenga
- College of Health Sciences, Makerere University Lung Institute, Kampala, Uganda
| |
Collapse
|
13
|
Tucker A, Oyuku D, Nalugwa T, Nantale M, Ferguson O, Farr K, Reza TF, Shete PB, Cattamanchi A, Dowdy DW, Sohn H, Katamba A. Costs along the TB diagnostic pathway in Uganda. Int J Tuberc Lung Dis 2021; 25:61-63. [PMID: 33384046 DOI: 10.5588/ijtld.20.0532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- A Tucker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - D Oyuku
- Uganda Tuberculosis Implementation Research Consortium (U-TIRC), Kampala, Uganda
| | - T Nalugwa
- Uganda Tuberculosis Implementation Research Consortium (U-TIRC), Kampala, Uganda
| | - M Nantale
- Uganda Tuberculosis Implementation Research Consortium (U-TIRC), Kampala, Uganda
| | - O Ferguson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - K Farr
- Implementation Science Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - T F Reza
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, San Francisco, CA, USA, Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - P B Shete
- Uganda Tuberculosis Implementation Research Consortium (U-TIRC), Kampala, Uganda, Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, San Francisco, CA, USA, Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - A Cattamanchi
- Uganda Tuberculosis Implementation Research Consortium (U-TIRC), Kampala, Uganda, Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, San Francisco, CA, USA, Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - D W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, Uganda Tuberculosis Implementation Research Consortium (U-TIRC), Kampala, Uganda
| | - H Sohn
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - A Katamba
- Uganda Tuberculosis Implementation Research Consortium (U-TIRC), Kampala, Uganda, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| |
Collapse
|
14
|
Shanmugakani RK, Bonam W, Erickson D, Mehta S. An isothermal amplification-based point-of-care diagnostic platform for the detection of Mycobacterium tuberculosis: A proof-of-concept study. CURRENT RESEARCH IN BIOTECHNOLOGY 2021; 3:154-159. [PMID: 34308334 PMCID: PMC8301208 DOI: 10.1016/j.crbiot.2021.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The timely diagnosis of active tuberculosis disease (TB) is crucial to interrupt the transmission and combat the spread of Mycobacterium tuberculosis (Mtb), the causative agent for TB. Here, we demonstrate the development of a specimen-direct rapid diagnostic method for TB which consists of an isothermal amplification device, Tiny Isothermal Nucleic acid quantification sYstem (TINY), coupled with helicase-dependent amplification (HDA). HDA, an isothermal amplification technique is established over TINY using pUCIDT-AMP vector carrying IS6110, the target DNA sequence for Mtb. The limit of detection of this technique for detecting the IS6110 within a threshold time of 50 min is 2.5 × 105 copies of IS6110. HDA in TINY for TB detection was evaluated using three IS6110-positive Mtb strains - H37Rv, CDC 1551, and Erdman wild-type and one IS6110-negative Mycobacterium avium. For spiked oral swabs, HDA in TINY detects IS6110 without any non-specificity in relatively short turnaround time (<1.5 h), highlighting its potential utility as a specimen-direct point-of-care diagnostic for TB. TINY does not require an uninterrupted power supply and its lightweight and small footprint offers portability and easier operation in clinical settings with poor infrastructure. Overall, HDA in TINY could serve as an efficient rapid, and portable platform for the qualitative detection of TB at the point-of-care.
Collapse
Affiliation(s)
- Rathina Kumar Shanmugakani
- Institute for Nutritional Sciences, Global Health, and
Technology, Cornell University, Ithaca, NY, USA
- Division of Nutritional Sciences, Cornell University,
Ithaca, NY, USA
| | - Wesley Bonam
- Arogyavaram Medical Centre, Andhra Pradesh, India
| | - David Erickson
- Institute for Nutritional Sciences, Global Health, and
Technology, Cornell University, Ithaca, NY, USA
- Division of Nutritional Sciences, Cornell University,
Ithaca, NY, USA
- Sibley School of Mechanical and Aerospace Engineering,
Cornell University, Ithaca, NY, USA
| | - Saurabh Mehta
- Institute for Nutritional Sciences, Global Health, and
Technology, Cornell University, Ithaca, NY, USA
- Division of Nutritional Sciences, Cornell University,
Ithaca, NY, USA
| |
Collapse
|
15
|
Werner K, Lin TK, Risko N, Osiro M, Kalanzi J, Wallis L. The costs of delivering emergency care at regional referral hospitals in Uganda: a micro-costing study. BMC Health Serv Res 2021; 21:232. [PMID: 33726738 PMCID: PMC7961167 DOI: 10.1186/s12913-021-06197-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 02/19/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Uganda experiences a high morbidity and mortality burden due to conditions amenable to emergency care, yet few public hospitals have dedicated emergency units. As a result, little is known about the costs and effects of delivering lifesaving emergency care, hindering health systems planning, budgeting and prioritization exercises. To determine healthcare costs of emergency care services at public facilities in Uganda, we estimate the median cost of care for five sentinel conditions and 13 interventions. METHODS A direct, activity-based costing was carried out at five regional referral hospitals over a four-week period from September to October 2019. Hospital costs were determined using bottom-up micro-costing methodology from a provider perspective. Resource use was enumerated via observation and unit costs were derived from National Medical Stores lists. Cost per condition per patient and measures of central tendency for conditions and interventions were calculated. Kruskal-Wallis H-tests and Nemyeni post-hoc tests were conducted to determine significant differences between costs of the conditions. RESULTS Eight hundred seventy-two patient cases were captured with an overall median cost of care of $15.53 USD ($14.44 to $19.22). The median cost per condition was highest for post-partum haemorrhage at $17.25 ($15.02 to $21.36), followed by road traffic injuries at $15.96 ($14.51 to $20.30), asthma at $15.90 ($14.76 to $19.30), pneumonia at $15.55 ($14.65 to $20.12), and paediatric diarrhoea at $14.61 ($13.74 to $15.57). The median cost per intervention was highest for fracture reduction and splinting at $27.77 ($22.00 to $31.50). Cost values differ between sentinel conditions (p < 0.05) with treatments for paediatric diarrhoea having the lowest median cost of all conditions (p < 0.05). CONCLUSION This study is the first to describe the direct costs of emergency care in hospitals in Uganda by observing the delivery of clinical services, using robust activity-based costing and time motion methodology. We find that emergency care interventions for key drivers of morbidity and mortality can be delivered at considerably lower costs than many priority health interventions. Further research assessing acute care delivery would be useful in planning wider health care delivery systems development.
Collapse
Affiliation(s)
- Kalin Werner
- Division of Emergency Medicine, University of Cape, Cape Town, South Africa.
| | - Tracy Kuo Lin
- Department of Social and Behavioral Sciences, Institute for Health & Aging, University of California, San Francisco, San Francisco, CA, USA
| | - Nicholas Risko
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Martha Osiro
- Division of Emergency Medicine, University of Cape, Cape Town, South Africa
| | | | - Lee Wallis
- Division of Emergency Medicine, University of Cape, Cape Town, South Africa
| |
Collapse
|
16
|
Baruch Baluku J, Musaazi J, Mulwana R, Bengo D, Sekaggya Wiltshire C, Andia-Biraro I. Sensitivity and specificity of the mean corpuscular volume and CD4/CD8 ratio in discriminating between rifampicin resistant and rifampicin sensitive tuberculosis. J Clin Tuberc Other Mycobact Dis 2020; 21:100205. [PMID: 33294630 PMCID: PMC7695869 DOI: 10.1016/j.jctube.2020.100205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background There is need for simple, cost effective and widely available point of care tests for low level health facilities in developing countries to screen for drug resistant tuberculosis (TB) after bacteriological confirmation of TB by smear microscopy. We evaluated the sensitivity and specificity of the mean corpuscular volume (MCV) and CD4/CD8 ratio in discriminating between rifampicin resistant (RR-TB) and rifampicin sensitive (RS-TB) tuberculosis. Methods We performed a secondary analysis of data from a cross sectional study that enrolled adult participants with bacteriologically confirmed pulmonary TB at a national tuberculosis treatment center in Uganda. Blood samples were tested for CD4 and CD8 cell counts, HIV serology and a full hemogram. Rifampicin sensitivity and the bacillary load grade were determined by Xpert MTB/RIF®. Fifty-five participants that had RR-TB (cases) were matched with 110 participants that had RS-TB (controls) for age, sex and HIV status in a ratio of 1:2 respectively. Sensitivity (Se), specificity (Sp), area under curve (AUC) analysis and determination of optimal cut-offs were performed using receiver operating characteristic curves. Results Cases differed from controls with respect to residence (p = 0.031), bacillary load grade (p < 0.010) and MCV (p = 0.021). The Se, Sp and AUC of the MCV (cut-off of > 74.6 femtolitres (fl)) were 88.9%, 34% and 0.607 (p = 0.021) respectively for RR-TB. Among HIV positive participants, the respective Se, Sp and AUC of the MCV for RR-TB (cut-off of > 72.5 fl) were 97.2%, 22.2% and 0.608 (p = 0.061). The respective Se, Sp and AUC of the CD4/CD8 ratio (cut-off of > 0.40) were 67.3%, 50.0% and 0.559 (p = 0.199) on the overall and 54.1%, 71.6% and 0.628 (p = 0.024) among the HIV positive participants for RR-TB. Conclusion The MCV had a high sensitivity but very low specificity for RR-TB. The CD4/CD8 ratio had a low sensitivity and specificity for RR-TB among HIV positive individuals. The utility of either test is low due to low diagnostic accuracy.
Collapse
Affiliation(s)
- Joseph Baruch Baluku
- Mulago National Referral Hospital, Pulmonology Division, PO Box 7051 Kampala, Uganda.,Makerere University Lung Institute, PO Box 7749 Kampala, Uganda.,Mildmay Uganda, P.O Box 24985 Kampala, Uganda
| | - Joseph Musaazi
- Makerere University College of Health Sciences, Infectious Disease Institute, PO Box 7072 Kampala, Uganda
| | - Rose Mulwana
- Mulago National Referral Hospital, Pulmonology Division, PO Box 7051 Kampala, Uganda
| | - Derrick Bengo
- Mulago Hospital, Department of Clinical Hematology, PO Box 7051 Kampala, Uganda
| | - Christine Sekaggya Wiltshire
- Makerere University College of Health Sciences, Infectious Disease Institute, PO Box 7072 Kampala, Uganda.,Makerere University College of Health Sciences, Department of Internal Medicine, PO Box 7072 Kampala, Uganda
| | - Irene Andia-Biraro
- Makerere University College of Health Sciences, Department of Internal Medicine, PO Box 7072 Kampala, Uganda.,Makerere University, Uganda Virus Research Institute Center of Excellence in Training Programme on Infections and Immunity (MUII-PLUS), PO Box 49 Entebbe, Uganda
| |
Collapse
|
17
|
Cunnama L, Gomez GB, Siapka M, Herzel B, Hill J, Kairu A, Levin C, Okello D, DeCormier Plosky W, Garcia Baena I, Sweeney S, Vassall A, Sinanovic E. A Systematic Review of Methodological Variation in Healthcare Provider Perspective Tuberculosis Costing Papers Conducted in Low- and Middle-Income Settings, Using An Intervention-Standardised Unit Cost Typology. PHARMACOECONOMICS 2020; 38:819-837. [PMID: 32363543 PMCID: PMC7437656 DOI: 10.1007/s40273-020-00910-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND There is a need for easily accessible tuberculosis unit cost data, as well as an understanding of the variability of methods used and reporting standards of that data. OBJECTIVE The aim of this systematic review was to descriptively review papers reporting tuberculosis unit costs from a healthcare provider perspective looking at methodological variation; to assess quality using a study quality rating system and machine learning to investigate the indicators of reporting quality; and to identify the data gaps to inform standardised tuberculosis unit cost collection and consistent principles for reporting going forward. METHODS We searched grey and published literature in five sources and eight databases, respectively, using search terms linked to cost, tuberculosis and tuberculosis health services including tuberculosis treatment and prevention. For inclusion, the papers needed to contain empirical unit cost estimates for tuberculosis interventions from low- and middle-income countries, with reference years between 1990 and 2018. A total of 21,691 papers were found and screened in a phased manner. Data were extracted from the eligible papers into a detailed Microsoft Excel tool, extensively cleaned and analysed with R software (R Project, Vienna, Austria) using the user interface of RStudio. A study quality rating was applied to the reviewed papers based on the inclusion or omission of a selection of variables and their relative importance. Following this, machine learning using a recursive partitioning method was utilised to construct a classification tree to assess the reporting quality. RESULTS This systematic review included 103 provider perspective papers with 627 unit costs (costs not presented here) for tuberculosis interventions among a total of 140 variables. The interventions covered were active, passive and intensified case finding; tuberculosis treatment; above-service costs; and tuberculosis prevention. Passive case finding is the detection of tuberculosis cases where individuals self-identify at health facilities; active case finding is detection of cases of those not in health facilities, such as through outreach; and intensified case finding is detection of cases in high-risk populations. There was heterogeneity in some of the reported methods used such cost allocation, amortisation and the use of top-down, bottom-up or mixed approaches to the costing. Uncertainty checking through sensitivity analysis was only reported on by half of the papers (54%), while purposive and convenience sampling was reported by 72% of papers. Machine learning indicated that reporting on 'Intervention' (in particular), 'Urbanicity' and 'Site Sampling', were the most likely indicators of quality of reporting. The largest data gap identified was for tuberculosis vaccination cost data, the Bacillus Calmette-Guérin (BCG) vaccine in particular. There is a gap in available unit costs for 12 of 30 high tuberculosis burden countries, as well as for the interventions of above-service costs, tuberculosis prevention, and active and intensified case finding. CONCLUSION Variability in the methods and reporting used makes comparison difficult and makes it hard for decision makers to know which unit costs they can trust. The study quality rating system used in this review as well as the classification tree enable focus on specific reporting aspects that should improve variability and increase confidence in unit costs. Researchers should endeavour to be explicit and transparent in how they cost interventions following the principles as laid out in the Global Health Cost Consortium's Reference Case for Estimating the Costs of Global Health Services and Interventions, which in turn will lead to repeatability, comparability and enhanced learning from others.
Collapse
Affiliation(s)
- Lucy Cunnama
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Cape Town, South Africa.
| | - Gabriela B Gomez
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Mariana Siapka
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Ben Herzel
- Institute for Health Policy Studies, University of California, San Francisco, CA, USA
| | - Jeremy Hill
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Angela Kairu
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Cape Town, South Africa
| | - Carol Levin
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Dickson Okello
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Cape Town, South Africa
| | | | - Inés Garcia Baena
- TB Monitoring and Evaluation (TME), Global TB Programme, The World Health Organization, Geneva, Switzerland
| | - Sedona Sweeney
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Anna Vassall
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Edina Sinanovic
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Cape Town, South Africa
| |
Collapse
|
18
|
A yield and cost comparison of tuberculosis contact investigation and intensified case finding in Uganda. PLoS One 2020; 15:e0234418. [PMID: 32511264 PMCID: PMC7279581 DOI: 10.1371/journal.pone.0234418] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/25/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Resource constraints in Low and Middle-Income Countries (LMICs) limit tuberculosis (TB) contact investigation despite evidence its benefits could outweigh costs, with increased efficiency when compared with intensified case finding (ICF). However, there is limited data on yield and cost per TB case identified. We compared yield and cost per TB case identified for ICF and Tuberculosis-Contact Investigation (TB-CI) in Uganda. METHODS A retrospective cohort study based on data from 12 Ugandan hospitals was done between April and September 2017. Two methods of TB case finding (i.e. ICF and TB-CI) were compared. Regarding ICF, patients either self-reported their signs and symptoms or were prompted by health care workers, while TB-CI was done by home-visiting and screening contacts of TB patients. Patients who were presumed to have tuberculosis were requested to produce a sample for examination. TB yield was defined as a ratio of diagnoses to tests, and this was computed per method of diagnosis. The cost per TB case identified (medical, personnel, transportation and training) for each diagnosis method were computed using the activity-based approach, from the health care perspective. Cost data were analyzed using Windows Excel. RESULTS 454 index TB cases and 2,707 of their household contacts were investigated. Thirty-one per cent of contacts (840/2707) were found to be presumptive TB cases. A total of 7,685 tests were done, 6,967 for ICF and 718 for TB-CI. The yields were 18.62% (1297/6967) and 5.29% (38/718) for ICF and TB-CI, respectively. It cost US$ 120.60 to diagnose a case of TB using ICF compared to US$ 877.57 for TB-CI. CONCLUSION The yield of TB-CI was found to be four-times lower and seven-times costlier compared to ICF. These findings suggest that ICF can improve TB case detection at a low cost, particularly in high TB prevalent settings.
Collapse
|
19
|
Pooran A, Theron G, Zijenah L, Chanda D, Clowes P, Mwenge L, Mutenherwa F, Lecesse P, Metcalfe J, Sohn H, Hoelscher M, Pym A, Peter J, Dowdy D, Dheda K. Point of care Xpert MTB/RIF versus smear microscopy for tuberculosis diagnosis in southern African primary care clinics: a multicentre economic evaluation. LANCET GLOBAL HEALTH 2020; 7:e798-e807. [PMID: 31097281 DOI: 10.1016/s2214-109x(19)30164-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 12/28/2018] [Accepted: 02/28/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Rapid on-site diagnosis facilitates tuberculosis control. Performing Xpert MTB/RIF (Xpert) at point of care is feasible, even when performed by minimally trained health-care workers, and when compared with point-of-care smear microscopy, reduces time to diagnosis and pretreatment loss to follow-up. However, whether Xpert is cost-effective at point of care remains unclear. METHODS We empirically collected cost (US$, 2014) and clinical outcome data from participants presenting to primary health-care facilities in four African countries (South Africa, Zambia, Zimbabwe, and Tanzania) during the TB-NEAT trial. Costs were determined using an bottom-up ingredients approach. Effectiveness measures from the trial included number of cases diagnosed, initiated on treatment, and completing treatment. The primary outcome was the incremental cost-effectiveness of point-of-care Xpert relative to smear microscopy. The study was performed from the perspective of the health-care provider. FINDINGS Using data from 1502 patients, we calculated that the mean Xpert unit cost was lower when performed at a centralised laboratory (Lab Xpert) rather than at point of care ($23·00 [95% CI 22·12-23·88] vs $28·03 [26·19-29·87]). Per 1000 patients screened, and relative to smear microscopy, point-of-care Xpert cost an additional $35 529 (27 054-40 025) and was associated with an additional 24·3 treatment initiations ([-20·0 to 68·5]; $1464 per treatment), 63·4 same-day treatment initiations ([27·3-99·4]; $511 per same-day treatment), and 29·4 treatment completions ([-6·9 to 65·6]; $1211 per completion). Xpert costs were most sensitive to test volume, whereas incremental outcomes were most sensitive to the number of patients initiating and completing treatment. The probability of point-of-care Xpert being cost-effective was 90% at a willingness to pay of $3820 per treatment completion. INTERPRETATION In southern Africa, although point-of-care Xpert unit cost is higher than Lab Xpert, it is likely to offer good value for money relative to smear microscopy. With the current availability of point-of-care nucleic acid amplification platforms (eg, Xpert Edge), these data inform much needed investment and resource allocation strategies in tuberculosis endemic settings. FUNDING European Union European and Developing Countries Clinical Trials Partnership.
Collapse
Affiliation(s)
- Anil Pooran
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and University of Cape Town (UCT) Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, UCT, Cape Town, South Africa
| | - Grant Theron
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and University of Cape Town (UCT) Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, UCT, Cape Town, South Africa; Department of Science and Technology-National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, and South Africa Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Lynn Zijenah
- Department of Immunology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | | | - Petra Clowes
- National Institute of Medical Research, Mbeya Medical Research Centre, Mbeya, Tanzania; Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich, Munich, Germany
| | | | | | - Paul Lecesse
- Denver Health Residency in Emergency Medicine, Denver Health Medical Center, Denver, CO, USA
| | - John Metcalfe
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Hojoon Sohn
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Michael Hoelscher
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich, Munich, Germany; German Centre for Infection Research, Munich, Germany
| | - Alex Pym
- South African Medical Research Council, Africa Health Research Institute, and Durban, South Africa
| | - Jonny Peter
- Department of Medicine, UCT, Cape Town, South Africa
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and University of Cape Town (UCT) Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, UCT, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, UK.
| |
Collapse
|
20
|
Hao X, Lou H, Bai J, Ding Y, Yang J, Pan W. Cost-effectiveness analysis of Xpert in detecting Mycobacterium tuberculosis: A systematic review. Int J Infect Dis 2020; 95:98-105. [PMID: 32278935 DOI: 10.1016/j.ijid.2020.03.078] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/28/2020] [Accepted: 03/29/2020] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES To report the cost-effectiveness of Xpert in detecting Mycobacterium tuberculosis (MTB) through a comprehensive systematic review. METHODS Specialized bibliographic databases were searched. Study quality was evaluated by commonly-used industry standards. Due to heterogeneity, evidences were synthesized narratively. RESULTS Four studies from intermediate-to-low tuberculosis (TB)-burdern areas and 17 studies from high-TB-burden areas were included. Smear microscopy, clinical diagnosis and chest radiography were mostly used for comparison. Cost elements varied considerably depending on the perspectives. Cost-effectiveness and cost-utility analyses were used by seven and fourteen studies, respectively. All studies were of high quality (CHEERS score of 78.4 and QHES score of 86.9). Average cost per test was 29.8 US$ for Xpert compared with 3.83 US$ for smear microscopy. Cost-effectiveness analyses mostly supported application of Xpert into areas under varying TB burdens. CONCLUSIONS Xpert seems cost-effective under respective willingness-to-pay thresholds in nations with differences in socioeconomy, HIV stress and geographical distribution. Nevertheless, policymakers will benefit from localized studies since regional economic/financial statuses and health-care system should also be considered apart from the reports of cost-effectiveness.
Collapse
Affiliation(s)
- Xiaohui Hao
- Department of Medical Microbiology and Parasitology, Navy Medical University (Second Military Medical University), Shanghai, PR China; Department of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, PR China
| | - Hai Lou
- Department of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, PR China
| | - Jie Bai
- Department of Medical Microbiology and Parasitology, Navy Medical University (Second Military Medical University), Shanghai, PR China
| | - Yingying Ding
- Department of Medical Microbiology and Parasitology, Navy Medical University (Second Military Medical University), Shanghai, PR China
| | - Jinghui Yang
- Department of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, PR China
| | - Wei Pan
- Department of Medical Microbiology and Parasitology, Navy Medical University (Second Military Medical University), Shanghai, PR China.
| |
Collapse
|
21
|
Shete PB, Kahn JG. Economic analyses to inform public health decision-making for tuberculosis: the role of understanding implementation. BMC Med 2019; 17:224. [PMID: 31783754 PMCID: PMC6883591 DOI: 10.1186/s12916-019-1468-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 11/12/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Priya B Shete
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, Zuckerberg San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, California, 94110, USA. .,Consortium to Assess Prevention Economics, Institute for Health Policy Studies, University of California San Francisco, 3333 California Avenue, San Francisco, California, 94118, USA.
| | - James G Kahn
- Consortium to Assess Prevention Economics, Institute for Health Policy Studies, University of California San Francisco, 3333 California Avenue, San Francisco, California, 94118, USA.,Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th Street, San Francisco, California, 94158, USA
| |
Collapse
|
22
|
Schumacher SG, Wells WA, Nicol MP, Steingart KR, Theron G, Dorman SE, Pai M, Churchyard G, Scott L, Stevens W, Nabeta P, Alland D, Weyer K, Denkinger CM, Gilpin C. Guidance for Studies Evaluating the Accuracy of Sputum-Based Tests to Diagnose Tuberculosis. J Infect Dis 2019; 220:S99-S107. [PMID: 31593597 PMCID: PMC6782025 DOI: 10.1093/infdis/jiz258] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Tests that can replace sputum smear microscopy have been identified as a top priority diagnostic need for tuberculosis by the World Health Organization. High-quality evidence on diagnostic accuracy for tests that may meet this need is an essential requirement to inform decisions about policy and scale-up. However, test accuracy studies are often of low and inconsistent quality and poorly reported, leading to uncertainty about true test performance. Here we provide guidance for the design of diagnostic test accuracy studies of sputum smear-replacement tests. Such studies should have a cross-sectional or cohort design, enrolling either a consecutive series or a random sample of patients who require evaluation for tuberculosis. Adults with respiratory symptoms are the target population. The reference standard should at a minimum be a single, automated, liquid culture, but additional cultures, follow-up, clinical case definition, and specific measures to understand discordant results should also be included. Inclusion of smear microscopy and Xpert MTB/RIF (or MTB/RIF Ultra) as comparators is critical to allow broader comparability and generalizability of results, because disease spectrum can vary between studies and affects relative test performance. Given the complex nature of sputum (the primary specimen type used for pulmonary TB), careful design and reporting of the specimen flow is essential. Test characteristics other than accuracy (such as feasibility, implementation considerations, and data on impact on patient, population and health systems outcomes) are also important aspects.
Collapse
Affiliation(s)
| | - William A Wells
- United States Agency for International Development, Washington, District of Columbia
| | - Mark P Nicol
- School of Biomedical Sciences, University of Western Australia, Perth, Australia, United Kingdom
| | | | - Grant Theron
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, SA MRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | | | - Madhukar Pai
- McGill International TB Centre and Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
| | - Gavin Churchyard
- Aurum Institute, Cape Town, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Advancing Care and Treatment for TB/HIV, South African Medical Research Council, Parktown, South Africa
| | - Lesley Scott
- University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | - Wendy Stevens
- University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | | | | | - Karin Weyer
- World Health Organization, Geneva, Switzerland
| | - Claudia M Denkinger
- FIND, Geneva, Switzerland
- University Hospital Heidelberg, Division of Tropical Medicine, Centre of Infectious Diseases, Germany
| | | |
Collapse
|
23
|
Sohn H, Kasaie P, Kendall E, Gomez GB, Vassall A, Pai M, Dowdy D. Informing decision-making for universal access to quality tuberculosis diagnosis in India: an economic-epidemiological model. BMC Med 2019; 17:155. [PMID: 31382959 PMCID: PMC6683370 DOI: 10.1186/s12916-019-1384-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/05/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND India and many other high-burden countries have committed to providing universal access to high-quality diagnosis and drug susceptibility testing (DST) for tuberculosis (TB), but the most cost-effective approach to achieve this goal remains uncertain. Centralized testing at district-level hub facilities with a supporting sample transport network can generate economies of scale, but decentralization to the peripheral level may provide faster diagnosis and reduce losses to follow-up (LTFU). METHODS We generated functions to evaluate the costs of centralized and decentralized molecular testing for tuberculosis with Xpert MTB/RIF (Xpert), a WHO-endorsed test which can be performed at centralized and decentralized levels. We merged the cost estimates with an agent-based simulation of TB transmission in a hypothetical representative region in India to assess the impact and cost-effectiveness of each strategy. RESULTS Compared against centralized Xpert testing, decentralization was most favorable when testing volume at decentralized facilities and pre-treatment LTFU were high, and specimen transport network was exclusively established for TB. Assuming equal quality of centralized and decentralized testing, decentralization was cost-saving, saving a median $338,000 (interquartile simulation range [IQR] - $222,000; $889,000) per 20 million people over 10 years, in the most cost-favorable scenario. In the most cost-unfavorable scenario, decentralized testing would cost a median $3161 [IQR $2412; $4731] per disability-adjusted life year averted relative to centralized testing. CONCLUSIONS Decentralization of Xpert testing is likely to be cost-saving or cost-effective in most settings to which these simulation results might generalize. More decentralized testing is more cost-effective in settings with moderate-to-high peripheral testing volumes, high existing clinical LTFU, inability to share specimen transport costs with other disease entities, and ability to ensure high-quality peripheral Xpert testing. Decision-makers should assess these factors when deciding whether to decentralize molecular testing for tuberculosis.
Collapse
Affiliation(s)
- Hojoon Sohn
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., E6529, Baltimore, MD 21205 USA
| | - Parastu Kasaie
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., E6529, Baltimore, MD 21205 USA
| | - Emily Kendall
- Division of Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD 21205 USA
| | - Gabriela B. Gomez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, WC1E 7HT UK
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, WC1E 7HT UK
| | - Madhukar Pai
- Department of Epidemiology & Biostatistics & McGill International TB Centre, McGill University, Montreal, QC H3A 1A2 Canada
- Manipal McGill Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, India
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., E6529, Baltimore, MD 21205 USA
| |
Collapse
|
24
|
Kundrod KA, Smith CA, Hunt B, Schwarz RA, Schmeler K, Richards-Kortum R. Advances in technologies for cervical cancer detection in low-resource settings. Expert Rev Mol Diagn 2019; 19:695-714. [PMID: 31368827 DOI: 10.1080/14737159.2019.1648213] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Cervical cancer mortality rates remain high in low- and middle-income countries (LMICs) and other medically underserved areas due to challenges with implementation and sustainability of routine screening, accurate diagnosis, and early treatment of preinvasive lesions. Areas covered: In this review, we first discuss the standard of care for cervical cancer screening and diagnosis in high- and low-resource settings, biomarkers that correlate to cervical precancer and cancer, and needs for new tests. We review technologies for screening and diagnosis with a focus on tests that are already in use in LMICs or have the potential to be adapted for use in LMICs. Finally, we provide perspectives on the next five years of technology development for improved cervical cancer screening and diagnosis in LMICs. Expert opinion: Innovation toward improved molecular and imaging tests is needed to enable effective, affordable see-and-treat approaches to detect and treat cervical precancer in a single visit. Current molecular tests remain too complex and/or costly for widespread use. Especially with imaging tests, decision support may improve performance of new technologies.
Collapse
Affiliation(s)
| | - Chelsey A Smith
- Department of Bioengineering, Rice University , Houston , TX , USA
| | - Brady Hunt
- Department of Bioengineering, Rice University , Houston , TX , USA
| | | | - Kathleen Schmeler
- Department of Gynecologic Oncology, The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | | |
Collapse
|
25
|
Lee DJ, Kumarasamy N, Resch SC, Sivaramakrishnan GN, Mayer KH, Tripathy S, Paltiel AD, Freedberg KA, Reddy KP. Rapid, point-of-care diagnosis of tuberculosis with novel Truenat assay: Cost-effectiveness analysis for India's public sector. PLoS One 2019; 14:e0218890. [PMID: 31265470 PMCID: PMC6605662 DOI: 10.1371/journal.pone.0218890] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 06/11/2019] [Indexed: 11/19/2022] Open
Abstract
Background Truenat is a novel molecular assay that rapidly detects tuberculosis (TB) and rifampicin-resistance. Due to the portability of its battery-powered testing platform, it may be valuable in peripheral healthcare settings in India. Methods Using a microsimulation model, we compared four TB diagnostic strategies for HIV-negative adults with presumptive TB: (1) sputum smear microscopy in designated microscopy centers (DMCs) (SSM); (2) Xpert MTB/RIF in DMCs (Xpert); (3) Truenat in DMCs (Truenat DMC); and (4) Truenat for point-of-care testing in primary healthcare facilities (Truenat POC). We projected life expectancy, costs, incremental cost-effectiveness ratios (ICERs), and 5-year budget impact of deploying Truenat POC in India’s public sector. We defined a strategy “cost-effective” if its ICER was <US$990/year-of-life saved (YLS). Model inputs included: TB prevalence, 15% (among those not previously treated for TB) and 27% (among those previously treated for TB); sensitivity for TB detection, 89% (Xpert) and 86% (Truenat); per test cost, $12.63 (Xpert) and $13.20 (Truenat); and linkage-to-care after diagnosis, 84% (DMC) and 95% (POC). We varied these parameters in sensitivity analyses. Results Compared to SSM, Truenat POC increased life expectancy by 0.39 years and was cost-effective (ICER $210/YLS). Compared to Xpert, Truenat POC increased life expectancy by 0.08 years due to improved linkage-to-care and was cost-effective (ICER $120/YLS). In sensitivity analysis, the cost-effectiveness of Truenat POC, relative to Xpert, depended on the diagnostic sensitivity of Truenat and linkage-to-care with Truenat. Deploying Truenat POC instead of Xpert increased 5-year expenditures by $270 million, due mostly to treatment costs. Limitations of our study include uncertainty in Truenat’s sensitivity for TB and not accounting for the “start-up” costs of implementing Truenat in the field. Conclusions Used at the point-of-care in India, Truenat for TB diagnosis should improve linkage-to-care, increase life expectancy, and be cost-effective compared with smear microscopy or Xpert.
Collapse
Affiliation(s)
- David J. Lee
- Harvard Medical School, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- * E-mail: (DJL); (KPR)
| | - Nagalingeswaran Kumarasamy
- Chennai Antiviral Research and Treatment Clinical Research Site, Voluntary Health Services, Chennai, India
| | - Stephen C. Resch
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | | | - Kenneth H. Mayer
- Harvard Medical School, Boston, Massachusetts, United States of America
- The Fenway Institute, Fenway Health, Boston, Massachusetts, United States of America
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | | | - A. David Paltiel
- Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Kenneth A. Freedberg
- Harvard Medical School, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Krishna P. Reddy
- Harvard Medical School, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- * E-mail: (DJL); (KPR)
| |
Collapse
|
26
|
Raizada N, Khaparde SD, Swaminathan S, Sarin S, Salhotra VS, Kalra A, Khanna A, Chopra KK, Hanif M, Umadevi KR, Hissar S, Nair SA, Prakash CHS, Saha BK, Rao R, Denkinger C, Boehme C. Catalysing progressive uptake of newer diagnostics by health care providers through outreach and education in four major cities of India. PLoS One 2018; 13:e0193341. [PMID: 29509803 PMCID: PMC5839557 DOI: 10.1371/journal.pone.0193341] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 02/08/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Unlike in adults, diagnosis of TB can be challenging in children, as signs and symptoms of paediatric TB can be very non-specific and similar to other common childhood chest infections, which may lead to under or delayed diagnosis of TB disease. In spite of the increasing availability of rapid high-sensitivity diagnostics in public and private sectors, majority of paediatric TB cases are empirically diagnosed, without laboratory confirmation. To address these diagnostic challenges, World Health Organization (WHO) has recommended upfront Xpert MTB/RIF (Xpert) testing for the diagnosis of TB in paediatric presumptive pulmonary and extra-pulmonary TB (EPTB) cases. However, in spite of the increasing availability of rapid high-sensitivity diagnostics, a significant gap exists in its application with Xpert being rarely used as an upfront diagnostic among patients presumed to have TB. Under an ongoing paediatric project since April 2014, which provided free-of-cost upfront Xpert testing, several low-cost outreach and education interventions were undertaken to increase the diagnostic uptake by different providers catering to the paediatric population, thereby increasing adherence to global guidance. METHODS Providers catering to paediatric population in the project cities were systematically mapped and contacted using different outreach strategies. The focus of outreach efforts was to increase provider literacy and increase their awareness of the availability of free rapid diagnostic services with the goal of changing their diagnostic approaches. RESULTS From April 2014 to June 2016, more than 5,700 providers/facilities were mapped and 3,670 of them were approached. The number of providers/facilities engaged under the project increased more than 10-fold (43 in April, 2014 to 466 in June, 2016), with significant increase in project uptake, both from public and private sector. Overall 42,238 paediatric presumptive TB cases were enrolled in the project, across the four cities. Over the project period, quarterly diagnostic uptake and paediatric TB cases detection rates increased more than two-fold. TB detection rates were similar in patients from public and private sectors. CONCLUSIONS Ongoing efforts in scaling up new rapid diagnostics involves significant investments. These efforts need to be complemented with proactive provider engagement to ensure provider-literacy and awareness, for maximizing impact of this scale-up. The current project demonstrated the usefulness of outreach and education interventions for the effective uptake of newer diagnostics.
Collapse
Affiliation(s)
- Neeraj Raizada
- Foundation for Innovative New Diagnostics, New Delhi, India
| | | | | | - Sanjay Sarin
- Foundation for Innovative New Diagnostics, New Delhi, India
| | | | - Aakshi Kalra
- Foundation for Innovative New Diagnostics, New Delhi, India
- * E-mail:
| | | | | | - M. Hanif
- New Delhi TB Centre, New Delhi, India
| | - K. R. Umadevi
- National Institute for research in Tuberculosis, Chennai, India
| | - Syed Hissar
- National Institute for research in Tuberculosis, Chennai, India
| | | | | | - B. K. Saha
- Intermediate Reference Laboratory, Kolkata, India
| | - Raghuram Rao
- Central TB Division, Government of India, New Delhi, India
| | | | | |
Collapse
|
27
|
Ayakaka I, Ackerman S, Ggita JM, Kajubi P, Dowdy D, Haberer JE, Fair E, Hopewell P, Handley MA, Cattamanchi A, Katamba A, Davis JL. Identifying barriers to and facilitators of tuberculosis contact investigation in Kampala, Uganda: a behavioral approach. Implement Sci 2017; 12:33. [PMID: 28274245 PMCID: PMC5343292 DOI: 10.1186/s13012-017-0561-4] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 02/21/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The World Health Organization recommends routine household tuberculosis contact investigation in high-burden countries but adoption has been limited. We sought to identify barriers to and facilitators of TB contact investigation during its introduction in Kampala, Uganda. METHODS We collected cross-sectional qualitative data through focus group discussions and interviews with stakeholders, addressing three core activities of contact investigation: arranging household screening visits through index TB patients, visiting households to screen contacts and refer them to clinics, and evaluating at-risk contacts coming to clinics. We analyzed the data using a validated theory of behavior change, the Capability, Opportunity, and Motivation determine Behavior (COM-B) model, and sought to identify targeted interventions using the related Behavior Change Wheel implementation framework. RESULTS We led seven focus-group discussions with 61 health-care workers, two with 21 lay health workers (LHWs), and one with four household contacts of newly diagnosed TB patients. We, in addition, performed 32 interviews with household contacts from 14 households of newly diagnosed TB patients. Commonly noted barriers included stigma, limited knowledge about TB among contacts, insufficient time and space in clinics for counselling, mistrust of health-center staff among index patients and contacts, and high travel costs for LHWs and contacts. The most important facilitators identified were the personalized and enabling services provided by LHWs. We identified education, persuasion, enablement, modeling of health-positive behaviors, incentivization, and restructuring of the service environment as relevant intervention functions with potential to alleviate barriers to and enhance facilitators of TB contact investigation. CONCLUSIONS The use of a behavioral theory and a validated implementation framework provided a comprehensive approach for systematically identifying barriers to and facilitators of TB contact investigation. The behavioral determinants identified here may be useful in tailoring interventions to improve implementation of contact investigation in Kampala and other similar urban settings.
Collapse
Affiliation(s)
- Irene Ayakaka
- Uganda Tuberculosis Implementation Research Consortium, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sara Ackerman
- Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, CA USA
| | - Joseph M. Ggita
- Uganda Tuberculosis Implementation Research Consortium, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Phoebe Kajubi
- Child Health and Development Centre, School of Medicine; College of Health Sciences, Makerere University, Kampala, Uganda
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland USA
| | - Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital, and Harvard University Medical School, Boston, MA USA
| | - Elizabeth Fair
- Division of Pulmonary and Critical Care Medicine, and Curry International Tuberculosis Center, San Francisco General Hospital, University of California, San Francisco, CA USA
| | - Philip Hopewell
- Division of Pulmonary and Critical Care Medicine, and Curry International Tuberculosis Center, San Francisco General Hospital, University of California, San Francisco, CA USA
| | - Margaret A. Handley
- Department of Biostatistics and Epidemiology, School of Medicine, University of California, San Francisco, CA USA
- Division of General Internal Medicine, San Francisco General Hospital, University of California, San Francisco, CA USA
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, and Curry International Tuberculosis Center, San Francisco General Hospital, University of California, San Francisco, CA USA
| | - Achilles Katamba
- Clinical Epidemiology Unit, Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - J. Lucian Davis
- Department of Epidemiology of Microbial Diseases, School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, CT USA
| |
Collapse
|
28
|
Abstract
ABSTRACT
The laboratory, which utilizes some of the most sophisticated and rapidly changing technologies, plays a critical role in the diagnosis of tuberculosis. Some of these tools are being employed in resource-challenged countries for the rapid detection and characterization of
Mycobacterium tuberculosis
. Foremost, the laboratory defines appropriate specimen criteria for optimal test performance. The direct detection of mycobacteria in the clinical specimen, predominantly done by acid-fast staining, may eventually be replaced by rapid-cycle PCR. The widespread use of the Xpert MTB/RIF (Cepheid) assay, which detects both
M. tuberculosis
and key genetic determinants of rifampin resistance, is important for the early detection of multidrug-resistant strains. Culture, using both broth and solid media, remains the standard for establishing the laboratory-based diagnosis of tuberculosis. Cultured isolates are identified far less commonly by traditional biochemical profiling and more commonly by molecular methods, such as DNA probes and broad-range PCR with DNA sequencing. Non-nucleic acid-based methods of identification, such as high-performance liquid chromatography and, more recently, matrix-assisted laser desorption/ionization–time of flight mass spectrometry, may also be used for identification. Cultured isolates of
M. tuberculosis
should be submitted for susceptibility testing according to standard guidelines. The use of broth-based susceptibility testing is recommended to significantly decrease the time to result. Cultured isolates may also be submitted for strain typing for epidemiologic purposes. The use of massive parallel sequencing, also known as next-generation sequencing, promises to continue to this molecular revolution in mycobacteriology, as whole-genome sequencing provides identification, susceptibility, and typing information simultaneously.
Collapse
|