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Takamiya M, Takarinda K, Balachandra S, Musuka G, Radin E, Hakim A, Pearson ML, Choto R, Sandy C, Maphosa T, Rogers JH. Missed opportunities for TB diagnostic testing among people living with HIV in Zimbabwe: Cross-sectional analysis of the Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) survey 2015-16. J Clin Tuberc Other Mycobact Dis 2024; 35:100427. [PMID: 38516197 PMCID: PMC10955630 DOI: 10.1016/j.jctube.2024.100427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024] Open
Abstract
Background Using data from the Zimbabwe Population-based HIV Impact Assessment survey 2015-2016, we examined the TB care cascade and factors associated with not receiving TB diagnostic testing among adult PLHIV with TB symptoms. Methods Statistical Analysis was limited to PLHIV aged 15 years and older in HIV care. Weighted logistic regression with not receiving TB testing as outcome was adjusted for covariates with crude odd ratios (ORs) with p < 0.25. All analyses accounted for multistage survey design. Results Among 3507 adult PLHIV in HIV care, 2288 (59.7 %, 95 % CI:58.1-61.3) were female and 2425 (63.6 %, 95 % CI:61.1-66.1) lived in rural areas. 1197(48.7 %, 95 % CI:46.5-51.0) reported being screened for TB symptoms at their last HIV care visit. In the previous 12 months, 639 (26.0 %, 95 % CI:23.9-28.1) reported having symptoms and of those, 239 (37.8 %, 95 % CI:33.3-42.2) received TB testing. Of PLHIV tested for TB, 36 (49.5 %, 95 % CI:35.0-63.1) were diagnosed with TB; 32 (90.3 %, 95 % CI:78.9-100) of those diagnosed with TB received treatment. Never having used IPT was associated with not receiving TB testing. Conclusion The results suggest suboptimal utilization of TB screening and diagnostic testing among PLHIV. New approaches are needed to reach opportunities missed in the HIV/TB integrated services.
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Affiliation(s)
| | | | | | | | | | - Avi Hakim
- U.S. Centers for Disease Control and Prevention (CDC), Atlanta, GA, United States
| | - Michele L. Pearson
- U.S. Centers for Disease Control and Prevention (CDC), Atlanta, GA, United States
| | - Regis Choto
- Ministry of Health and Child Care, Harare, Zimbabwe
| | | | - Talent Maphosa
- U.S. Centers for Disease Control and Prevention (CDC), Harare, Zimbabwe
| | - John H. Rogers
- U.S. Centers for Disease Control and Prevention (CDC), Harare, Zimbabwe
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Zvinoera K, Olaru ID, Khan P, Mutsvangwa J, Denkinger CM, Kampira V, Coutinho D, Mutunzi H, Pepukai M, Chikaka E, Zinyowera S, Mharakurwa S, Kranzer K. The impact of changing the diagnostic algorithm for TB in Manicaland, Zimbabwe. Public Health Action 2021; 11:196-201. [PMID: 34956848 DOI: 10.5588/pha.21.0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/29/2021] [Indexed: 11/10/2022] Open
Abstract
SETTING Governmental health facilities performing TB diagnostics in Manicaland, Zimbabwe. OBJECTIVE To investigate the effect of making Xpert® MTB/RIF the primary TB diagnostic for all patients presenting with presumptive TB on 1) the number of samples investigated for TB, 2) the proportion testing TB-positive, and 3) the proportion of unsuccessful results over time. DESIGN This retrospective study used data from GeneX-pert downloads, laboratory registers and quality assurance reports between 1 January 2017 and 31 December 2018. RESULTS The total number of Xpert tests performed in Manicaland increased from 3,967 in the first quarter of 2017 to 7,011 in the last quarter of 2018. Mycobacterium tuberculosis DNA was detected in 4.9-8.6% of the samples investigated using Xpert, with a higher yield in 2017 than in 2018. The overall proportion of unsuccessful Xpert assays due to "no results", errors and invalid results was 6.3%, and highly variable across sites. CONCLUSION Roll out of more sensitive TB diagnostics does not necessarily result in an increase of microbiologically confirmed TB diagnosis. While the number of samples tested using Xpert increased, the proportion of TB-positive tests decreased. GeneXpert soft- and hardware infrastructure needs to be strengthened to reduce the rate of unsuccessful assays and therefore, costs and staff time.
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Affiliation(s)
- K Zvinoera
- Ministry of Health and Child Care, Mutare Provincial Hospital, Mutare, Zimbabwe
| | - I D Olaru
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK.,Biomedical Research and Training Institute, Harare, Zimbabwe
| | - P Khan
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - J Mutsvangwa
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - C M Denkinger
- Division of Tropical Medicine, Centre for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany.,German Centre for Infection Research (DZIF), partner site Heidelberg University Hospital, Heidelberg, Germany
| | - V Kampira
- Ministry of Health and Child Care, Mutare Provincial Hospital, Mutare, Zimbabwe
| | - D Coutinho
- Ministry of Health and Child Care, Mutare Provincial Hospital, Mutare, Zimbabwe
| | - H Mutunzi
- AIDS and TB Department, Ministry of Health and Child Care, Harare, Zimbabwe
| | - M Pepukai
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - E Chikaka
- Department of Health Sciences, College of Health and Natural Sciences, Africa University, Old Mutare, Zimbabwe
| | - S Zinyowera
- National Microbiology Reference Laboratory, Ministry of Health and Child Care, Harare, Zimbabwe
| | - S Mharakurwa
- Department of Health Sciences, College of Health and Natural Sciences, Africa University, Old Mutare, Zimbabwe
| | - K Kranzer
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK.,Biomedical Research and Training Institute, Harare, Zimbabwe.,Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, Munich, Germany
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Yuldashev S, Parpieva N, Alimov S, Turaev L, Safaev K, Dumchev K, Gadoev J, Korotych O, Harries AD. Scaling Up Molecular Diagnostic Tests for Drug-Resistant Tuberculosis in Uzbekistan from 2012-2019: Are We on the Right Track? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094685. [PMID: 33924862 PMCID: PMC8124440 DOI: 10.3390/ijerph18094685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/12/2021] [Accepted: 03/19/2021] [Indexed: 11/16/2022]
Abstract
Uzbekistan has a large burden of drug-resistant tuberculosis (TB). To deal with this public health threat, the National TB Program introduced rapid molecular diagnostic tests such as Xpert MTB/RIF (Xpert) and line probe assays (LPAs) for first-line and second-line drugs. We documented the scale-up of Xpert and LPAs from 2012–2019 and assessed whether this led to an increase in patients with laboratory-confirmed multidrug-resistant/rifampicin-resistant TB (MDR/RR-TB) and extensively drug-resistant TB (XDR-TB). This was a descriptive study using secondary program data. The numbers of GeneXpert instruments cumulatively increased from six to sixty-seven, resulting in annual assays increasing from 5574 to 107,330. A broader use of the technology resulted in a lower proportion of tests detecting Mycobacterium tuberculosis with half of the positive results showing rifampicin resistance. LPA instruments cumulatively increased from two to thirteen; the annual first-line assays for MDR-TB increased from 2582 to 6607 while second-line assays increased from 1435 in 2016 to 6815 in 2019 with about one quarter to one third of diagnosed patients showing second-line drug resistance. Patient numbers with laboratory-confirmed MDR-TB remained stable (from 1728 to 2060) but there was a large increase in patients with laboratory-confirmed XDR-TB (from 31 to 696). Programmatic implications and ways forward are discussed.
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Affiliation(s)
- Sharofiddin Yuldashev
- Republican Specialized Scientific Practical Medical Centre of Phthisiology and Pulmonology under Ministry of Health of the Republic of Uzbekistan, 1 Majlisiy str, Tashkent 100086, Uzbekistan; (N.P.); (S.A.); (L.T.); (K.S.)
- Correspondence: ; Tel.: +998-90-175-18-48
| | - Nargiza Parpieva
- Republican Specialized Scientific Practical Medical Centre of Phthisiology and Pulmonology under Ministry of Health of the Republic of Uzbekistan, 1 Majlisiy str, Tashkent 100086, Uzbekistan; (N.P.); (S.A.); (L.T.); (K.S.)
| | - Salikhdjan Alimov
- Republican Specialized Scientific Practical Medical Centre of Phthisiology and Pulmonology under Ministry of Health of the Republic of Uzbekistan, 1 Majlisiy str, Tashkent 100086, Uzbekistan; (N.P.); (S.A.); (L.T.); (K.S.)
| | - Laziz Turaev
- Republican Specialized Scientific Practical Medical Centre of Phthisiology and Pulmonology under Ministry of Health of the Republic of Uzbekistan, 1 Majlisiy str, Tashkent 100086, Uzbekistan; (N.P.); (S.A.); (L.T.); (K.S.)
| | - Khasan Safaev
- Republican Specialized Scientific Practical Medical Centre of Phthisiology and Pulmonology under Ministry of Health of the Republic of Uzbekistan, 1 Majlisiy str, Tashkent 100086, Uzbekistan; (N.P.); (S.A.); (L.T.); (K.S.)
| | - Kostyantyn Dumchev
- The Charitable Organization “Ukrainian Institute of Public Health Policy”, Biloruska St, 5, 02000 Kyiv, Ukraine;
| | - Jamshid Gadoev
- World Health Organization Country Office to Uzbekistan, M. Tarobiy St, 16, Tashkent 100100, Uzbekistan;
| | - Oleksandr Korotych
- World Health Organization Regional Office for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen, Denmark;
| | - Anthony D. Harries
- International Union against Tuberculosis and Lung Disease, 68 Boulevard Saint Michel, 75006 Paris, France;
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
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Universal Access to Xpert MTB/RIF Testing for Diagnosis of Tuberculosis in Uzbekistan: How Well Are We Doing? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18062915. [PMID: 33809168 PMCID: PMC8000337 DOI: 10.3390/ijerph18062915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 11/17/2022]
Abstract
As per national guidelines in Uzbekistan, all presumptive tuberculosis patients should be tested using the Xpert MTB/RIF assay for diagnosing tuberculosis. There is no published evidence how well this is being implemented. In this paper, we report on the Xpert coverage among presumptive tuberculosis patients in 2018 and 2019, factors associated with non-testing and delays involved. Analysis of national aggregate data indicated that Xpert testing increased from 24% in 2018 to 46% in 2019, with variation among the regions: 21% in Tashkent region to 100% in Karakalpakstan. In a cohort (January-March 2019) constituted of 40 randomly selected health facilities in Tashkent city and Bukhara region, there were 1940 patients of whom 832 (43%, 95% confidence interval (CI): 41-45%) were not Xpert-tested. Non-testing was significantly higher in Bukhara region (73%) compared to Tashkent city (28%). In multivariable analysis, patient's age, distance between primary health centre (PHC) and Xpert laboratory, diagnostic capacity and site of PHC were associated with non-testing. The median (interquartile range) duration from date of initial visit to PHC to receiving results was 1 (1-2) day in Tashkent city compared to 3 (1-6) days in Bukhara region (p-value < 0.001). While there is commendable progress, universal access to Xpert testing is not a reality yet.
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Oga-Omenka C, Bada F, Agbaje A, Dakum P, Menzies D, Zarowsky C. Ease and equity of access to free DR-TB services in Nigeria- a qualitative analysis of policies, structures and processes. Int J Equity Health 2020; 19:221. [PMID: 33302956 PMCID: PMC7731779 DOI: 10.1186/s12939-020-01342-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 12/01/2020] [Indexed: 12/04/2022] Open
Abstract
Introduction Persistent low rates of case notification and treatment coverage reflect that accessing diagnosis and treatment for drug-resistant tuberculosis (DR-TB) in Nigeria remains a challenge, even though it is provided free of charge to patients. Equity in health access requires availability of comparable, appropriate services to all, based on needs, and irrespective of socio-demographic characteristics. Our study aimed to identify the reasons for Nigeria’s low rates of case-finding and treatment for DR-TB. To achieve this, we analyzed elements that facilitate or hinder equitable access for different groups of patients within the current health system to support DR-TB management in Nigeria. Methods We conducted documentary review of guidelines and workers manuals, as well as 57 qualitative interviews, including 10 focus group discussions, with a total of 127 participants, in Nigeria. Between August and November 2017, we interviewed patients who were on treatment, their treatment supporter, and providers in Ogun and Plateau States, as well as program managers in Benue and Abuja. We adapted and used Levesque’s patient-centered access to care framework to analyze DR-TB policy documents and interview data. Results Thematic analysis revealed inequitable access to DR-TB care for some patient socio-demographic groups. While patients were mostly treated equally at the facility level, some patients experienced more difficulty accessing care based on their gender, age, occupation, educational level and religion. Health system factors including positive provider attitudes and financial support provided to the patients facilitated equity and ease of access. However, limited coverage and the absence of patients’ access rights protection and considerations in the treatment guidelines and workers manuals likely hampered access. Conclusion In the context of Nigeria’s low case-finding and treatment coverage, applying an equity of access framework was necessary to highlight gaps in care. Differing social contexts of patients adversely affected their access to DR-TB care. We identified several strengths in DR-TB care delivery, including the current financial support that should be sustained. Our findings highlight the need for government’s commitment and continued interventions.
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Affiliation(s)
- Charity Oga-Omenka
- The School of Public Health of the University of Montreal (ÉSPUM), 7101, Parc avenue, 3rd floor, Montreal, Quebec, H3N 1X9, Canada. .,Centre de recherche en santé publique, Université de Montréal (CReSP), Montreal, Canada. .,McGill University International TB Centre, Montreal, Quebec, Canada.
| | - Florence Bada
- International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja, Nigeria
| | - Aderonke Agbaje
- International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja, Nigeria
| | - Patrick Dakum
- International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja, Nigeria
| | - Dick Menzies
- McGill University International TB Centre, Montreal, Quebec, Canada.,Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
| | - Christina Zarowsky
- The School of Public Health of the University of Montreal (ÉSPUM), 7101, Parc avenue, 3rd floor, Montreal, Quebec, H3N 1X9, Canada.,Centre de recherche en santé publique, Université de Montréal (CReSP), Montreal, Canada.,School of Public Health, University of the Western Cape, Cape Town, South Africa
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6
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Oga-Omenka C, Tseja-Akinrin A, Sen P, Mac-Seing M, Agbaje A, Menzies D, Zarowsky C. Factors influencing diagnosis and treatment initiation for multidrug-resistant/rifampicin-resistant tuberculosis in six sub-Saharan African countries: a mixed-methods systematic review. BMJ Glob Health 2020; 5:e002280. [PMID: 32616481 PMCID: PMC7333807 DOI: 10.1136/bmjgh-2019-002280] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/10/2020] [Accepted: 04/15/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Drug-resistant tuberculosis burdens fragile health systems in sub-Saharan Africa (SSA), complicated by high prevalence of HIV. Several African countries reported large gaps between estimated incidence and diagnosed or treated cases. Our review aimed to identify barriers and facilitators influencing diagnosis and treatment for drug-resistant tuberculosis (DR-TB) in SSA, which is necessary to develop effective strategies to find the missing incident cases and improve quality of care. METHODS Using an integrative design, we reviewed and narratively synthesised qualitative, quantitative and mixed-methods studies from nine electronic databases: Medline, Global Health, CINAHL, EMBASE, Scopus, Web of Science, International Journal of Tuberculosis and Lung Disease, PubMed and Google Scholar (January 2006 to June 2019). RESULTS Of 3181 original studies identified, 55 full texts were screened, and 29 retained. The studies included were from 6 countries, mostly South Africa. Barriers and facilitators to DR-TB care were identified at the health system and patient levels. Predominant health system barriers were laboratory operational issues, provider knowledge and attitudes and information management. Facilitators included GeneXpert MTB/RIF (Xpert) diagnosis and decentralisation of services. At the patient level, predominant barriers were patients being lost to follow-up or dying due to lengthy diagnostic and treatment delays, negative public sector care perceptions, family, work or school commitments and using private sector care. Some patient-level facilitators were HIV positivity and having more symptoms. CONCLUSION Case detection and treatment for DR -TB in SSA currently relies on individual patients presenting voluntarily to the hospital for care. Specific interventions targeting identified barriers may improve rates and timeliness of detection and treatment.
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Affiliation(s)
- Charity Oga-Omenka
- École de santé publique de l'Université de Montréal (ESPUM), Montréal, Quebec, Canada
- Centre de recherche en santé publique, Université de Montréal (CReSP), Montréal, Quebec, Canada
- McGill International TB Centre, Montreal, Quebec, Canada
| | | | - Paulami Sen
- McGill International TB Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Muriel Mac-Seing
- École de santé publique de l'Université de Montréal (ESPUM), Montréal, Quebec, Canada
- Centre de recherche en santé publique, Université de Montréal (CReSP), Montréal, Quebec, Canada
| | | | - Dick Menzies
- McGill International TB Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Christina Zarowsky
- École de santé publique de l'Université de Montréal (ESPUM), Montréal, Quebec, Canada
- Centre de recherche en santé publique, Université de Montréal (CReSP), Montréal, Quebec, Canada
- School of Public Health, University of the Western Cape, Cape Town, South Africa
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Effect of the Xpert MTB/RIF on the detection of pulmonary tuberculosis cases and rifampicin resistance in Shanghai, China. BMC Infect Dis 2020; 20:153. [PMID: 32070292 PMCID: PMC7029590 DOI: 10.1186/s12879-020-4871-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 02/11/2020] [Indexed: 11/23/2022] Open
Abstract
Background Xpert MTB/RIF (Xpert) is an automated molecular test recommended by World Health Organization (WHO) for diagnosis of tuberculosis (TB). This study evaluated the effect of Xpert implementation on the detection of pulmonary TB (PTB) and rifampicin-resistant TB (RR-TB) cases in Shanghai, China. Methods Xpert was routinely implemented in 2018 for all presumptive PTB patients. All PTB patients above 15 years-old identified within the Provincial TB Control Program during the first half of each of 2017 and 2018, were enrolled to compare the difference in proportions of bacteriological confirmation, patients with drug susceptibility test (DST) results for rifampicin (ie, DST coverage) and RR-TB detection before and after Xpert’s implementation. Results A total of 6047 PTB patients were included in the analysis with 1691 tested by Xpert in 2018. Percentages of bacteriological confirmation, DST coverage and RR-TB detection in 2017 and 2018 were 50% vs. 59%, 36% vs. 49% and 2% vs. 3%, respectively (all p-values < 0.05). Among 1103 PTB patients who completed sputum smear, culture and Xpert testing in 2018, Xpert detected an additional 121 (11%) PTB patients who were negative by smear and culture, but missed 248 (23%) smear and/or culture positive patients. Besides, it accounted for an increase of 9% in DST coverage and 1% in RR-TB detection. The median time from first visit to a TB hospital to RR-TB detection was 62 days (interquartile range -IQR 48–84.2) in 2017 vs. 9 days (IQR 2–45.7) in 2018 (p-value < 0.001). In the multivariate model, using Xpert was associated with decreased time to RR-TB detection (adjusted hazard ratio = 4.62, 95% confidence interval: 3.18–6.71). Conclusions Integrating Xpert with smear, culture and culture-based DST in a routine setting significantly increased bacteriological confirmation, DST coverage and RR-TB detection with a dramatic reduction in the time to RR-TB diagnosis in Shanghai, China. Our findings can be useful for other regions that attempt to integrate Xpert into routine PTB and RR-TB case-finding cascade. Further study should focus on the identification and elimination of operational level challenges to fully utilize the benefit of rapid diagnosis by Xpert.
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Harries AD, Kumar AMV. Challenges and Progress with Diagnosing Pulmonary Tuberculosis in Low- and Middle-Income Countries. Diagnostics (Basel) 2018; 8:diagnostics8040078. [PMID: 30477096 PMCID: PMC6315832 DOI: 10.3390/diagnostics8040078] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/19/2018] [Accepted: 11/21/2018] [Indexed: 01/16/2023] Open
Abstract
Case finding and the diagnosis of tuberculosis (TB) are key activities to reach the World Health Organization's End TB targets by 2030. This paper focuses on the diagnosis of pulmonary TB (PTB) in low- and middle-income countries. Sputum smear microscopy, despite its many limitations, remains the primary diagnostic tool in peripheral health facilities; however, this is being replaced by molecular diagnostic techniques, particularly Xpert MTB/RIF, which allows a bacteriologically confirmed diagnosis of TB along with information about whether or not the organism is resistant to rifampicin within two hours. Other useful diagnostic tools at peripheral facilities include chest radiography, urine lipoarabinomannan (TB-LAM) in HIV-infected patients with advanced immunodeficiency, and the loop-mediated isothermal amplification (TB-LAMP) test which may be superior to smear microscopy. National Reference Laboratories work at a higher level, largely performing culture and phenotypic drug susceptibility testing which is complemented by genotypic methods such as line probe assays for detecting resistance to isoniazid, rifampicin, and second-line drugs. Tuberculin skin testing, interferon gamma release assays, and commercial serological tests are not recommended for the diagnosis of active TB. Linking diagnosis to treatment and care is often poor, and this aspect of TB management needs far more attention than it currently receives.
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Affiliation(s)
- Anthony D Harries
- International Union Against Tuberculosis and Lung Disease, 68 Boulevard Saint Michel, 75006 Paris, France.
- London School of Hygiene and Tropical Medicine, Keppel Street, Bloomsbury, London WC1E 7HT, UK.
| | - Ajay M V Kumar
- International Union Against Tuberculosis and Lung Disease, 68 Boulevard Saint Michel, 75006 Paris, France.
- International Union Against Tuberculosis and Lung Disease, South-East Asia Regional Office, C-6, Qutub Institutional Area, 110016 New Delhi, India.
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