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Lee S, Almendares O, Prince-Guerra J, Anderson M, Heilig CM, Tate JE, Kirking HL. Performance of Existing and Novel Symptom- and Antigen Testing-Based COVID-19 Case Definitions in a Community Setting. Am J Epidemiol 2023; 192:438-447. [PMID: 36345134 DOI: 10.1093/aje/kwac196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 10/05/2022] [Accepted: 11/01/2022] [Indexed: 11/11/2022] Open
Abstract
Point-of-care antigen tests are an important tool for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) detection, yet are less clinically sensitive than real-time reverse-transcription polymerase chain reaction (RT-PCR), affecting their efficacy as screening procedures. Our goal in this analysis was to see whether we could improve this sensitivity by considering antigen test results in combination with other relevant information, namely exposure status and reported symptoms. In November 2020, we collected 3,419 paired upper respiratory specimens tested by RT-PCR and the Abbott BinaxNOW (Abbott Laboratories, Abbott Park, Illinois) antigen test at 2 community testing sites in Pima County, Arizona. We used symptom, exposure, and antigen-testing data to evaluate the sensitivity and specificity of various symptom definitions in predicting RT-PCR positivity. Our analysis yielded 6 novel multisymptom case definitions with and without antigen test results, the best of which overall achieved a Youden's J index of 0.66, as compared with 0.53 for antigen testing alone. Using a random forest as a guide, we show that this definition, along with our others, does not lose the ability to generalize well to new data despite achieving optimal performance in our sample. Our methodology is broadly applicable, and our code is publicly available to aid public health practitioners in developing or fine-tuning their own case definitions.
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Althomsons SP, Winglee K, Heilig CM, Talarico S, Silk B, Wortham J, Hill AN, Navin TR. Using Machine Learning Techniques and National Tuberculosis Surveillance Data to Predict Excess Growth in Genotyped Tuberculosis Clusters. Am J Epidemiol 2022; 191:1936-1943. [PMID: 35780450 PMCID: PMC10790200 DOI: 10.1093/aje/kwac117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 05/05/2022] [Accepted: 06/28/2022] [Indexed: 02/01/2023] Open
Abstract
The early identification of clusters of persons with tuberculosis (TB) that will grow to become outbreaks creates an opportunity for intervention in preventing future TB cases. We used surveillance data (2009-2018) from the United States, statistically derived definitions of unexpected growth, and machine-learning techniques to predict which clusters of genotype-matched TB cases are most likely to continue accumulating cases above expected growth within a 1-year follow-up period. We developed a model to predict which clusters are likely to grow on a training and testing data set that was generalizable to a validation data set. Our model showed that characteristics of clusters were more important than the social, demographic, and clinical characteristics of the patients in those clusters. For instance, the time between cases before unexpected growth was identified as the most important of our predictors. A faster accumulation of cases increased the probability of excess growth being predicted during the follow-up period. We have demonstrated that combining the characteristics of clusters and cases with machine learning can add to existing tools to help prioritize which clusters may benefit most from public health interventions. For example, consideration of an entire cluster, not only an individual patient, may assist in interrupting ongoing transmission.
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Affiliation(s)
- Sandy P. Althomsons
- Division of TB Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Kathryn Winglee
- Division of TB Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Charles M. Heilig
- Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Sarah Talarico
- Division of TB Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Benjamin Silk
- Division of TB Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Jonathan Wortham
- Division of TB Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Andrew N. Hill
- Division of TB Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Thomas R. Navin
- Division of TB Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
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Wong KK, Heilig CM, Hause A, Myers TR, Olson CK, Gee J, Marquez P, Strid P, Shay DK. Menstrual irregularities and vaginal bleeding after COVID-19 vaccination reported to v-safe active surveillance, USA in December, 2020–January, 2022: an observational cohort study. Lancet Digit Health 2022; 4:e667-e675. [PMID: 35961858 PMCID: PMC9363036 DOI: 10.1016/s2589-7500(22)00125-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 06/13/2022] [Accepted: 06/17/2022] [Indexed: 10/24/2022]
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Reses HE, Fajans M, Lee SH, Heilig CM, Chu VT, Thornburg NJ, Christensen K, Bhattacharyya S, Fry A, Hall AJ, Tate JE, Kirking HL, Nabity SA. Performance of existing and novel surveillance case definitions for COVID-19 in household contacts of PCR-confirmed COVID-19. BMC Public Health 2021; 21:1747. [PMID: 34563163 PMCID: PMC8465785 DOI: 10.1186/s12889-021-11683-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 08/30/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Optimized symptom-based COVID-19 case definitions that guide public health surveillance and individual patient management in the community may assist pandemic control. METHODS We assessed diagnostic performance of existing cases definitions (e.g. influenza-like illness, COVID-like illness) using symptoms reported from 185 household contacts to a PCR-confirmed case of COVID-19 in Wisconsin and Utah, United States. We stratified analyses between adults and children. We also constructed novel case definitions for comparison. RESULTS Existing COVID-19 case definitions generally showed high sensitivity (86-96%) but low positive predictive value (PPV) (36-49%; F-1 score 52-63) in this community cohort. Top performing novel symptom combinations included taste or smell dysfunction and improved the balance of sensitivity and PPV (F-1 score 78-80). Performance indicators were generally lower for children (< 18 years of age). CONCLUSIONS Existing COVID-19 case definitions appropriately screened in household contacts with COVID-19. Novel symptom combinations incorporating taste or smell dysfunction as a primary component improved accuracy. Case definitions tailored for children versus adults should be further explored.
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Affiliation(s)
- Hannah E Reses
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mark Fajans
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Scott H Lee
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Charles M Heilig
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Victoria T Chu
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Natalie J Thornburg
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - Alicia Fry
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Aron J Hall
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jacqueline E Tate
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Hannah L Kirking
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Scott A Nabity
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Song R, Click ES, McCarthy KD, Heilig CM, Mchembere W, Smith JP, Fajans M, Musau SK, Okeyo E, Okumu A, Orwa J, Gethi D, Odeny L, Lee SH, Perez-Velez CM, Wright CA, Cain KP. Sensitive and Feasible Specimen Collection and Testing Strategies for Diagnosing Tuberculosis in Young Children. JAMA Pediatr 2021; 175:e206069. [PMID: 33616611 PMCID: PMC7900937 DOI: 10.1001/jamapediatrics.2020.6069] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Criterion-standard specimens for tuberculosis diagnosis in young children, gastric aspirate (GA) and induced sputum, are invasive and rarely collected in resource-limited settings. A far less invasive approach to tuberculosis diagnostic testing in children younger than 5 years as sensitive as current reference standards is important to identify. OBJECTIVE To characterize the sensitivity of preferably minimally invasive specimen and assay combinations relative to maximum observed yield from all specimens and assays combined. DESIGN, SETTING, AND PARTICIPANTS In this prospective cross-sectional diagnostic study, the reference standard was a panel of up to 2 samples of each of 6 specimen types tested for Mycobacterium tuberculosis complex by Xpert MTB/RIF assay and mycobacteria growth indicator tube culture. Multiple different combinations of specimens and tests were evaluated as index tests. A consecutive series of children was recruited from inpatient and outpatient settings in Kisumu County, Kenya, between October 2013 and August 2015. Participants were children younger than 5 years who had symptoms of tuberculosis (unexplained cough, fever, malnutrition) and parenchymal abnormality on chest radiography or who had cervical lymphadenopathy. Children with 1 or more evaluable specimen for 4 or more primary study specimen types were included in the analysis. Data were analyzed from February 2015 to October 2020. MAIN OUTCOMES AND MEASURES Cumulative and incremental diagnostic yield of combinations of specimen types and tests relative to the maximum observed yield. RESULTS Of the 300 enrolled children, the median (interquartile range) age was 2.0 (1.0-3.6) years, and 151 (50.3%) were female. A total of 294 met criteria for analysis. Of 31 participants with confirmed tuberculosis (maximum observed yield), 24 (sensitivity, 77%; interdecile range, 68%-87%) had positive results on up to 2 GA samples and 20 (sensitivity, 64%; interdecile range, 53%-76%) had positive test results on up to 2 induced sputum samples. The yields of 2 nasopharyngeal aspirate (NPA) samples (23 of 31 [sensitivity, 74%; interdecile range, 64%-84%]), of 1 NPA sample and 1 stool sample (22 of 31 [sensitivity, 71%; interdecile range, 60%-81%]), or of 1 NPA sample and 1 urine sample (21.5 of 31 [sensitivity, 69%; interdecile range, 58%-80%]) were similar to reference-standard specimens. Combining up to 2 each of GA and NPA samples had an average yield of 90% (28 of 31). CONCLUSIONS AND RELEVANCE NPA, in duplicate or in combination with stool or urine specimens, was readily obtainable and had diagnostic yield comparable with reference-standard specimens. This combination could improve tuberculosis diagnosis among children in resource-limited settings. Combining GA and NPA had greater yield than that of the current reference standards and may be useful in certain clinical and research settings.
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Affiliation(s)
- Rinn Song
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts,Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | | | | | | | - Walter Mchembere
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Jonathan P. Smith
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia,Northrop Grumman, Atlanta, Georgia
| | - Mark Fajans
- US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Susan K. Musau
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Elisha Okeyo
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Albert Okumu
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - James Orwa
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Dickson Gethi
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Lazarus Odeny
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Scott H. Lee
- US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Carlos M. Perez-Velez
- Tuberculosis Clinic, Pima County Health Department, Tucson, Arizona,Infectious Diseases, University of Arizona College of Medicine, Tucson
| | - Colleen A. Wright
- Division of Anatomical Pathology, University of Stellenbosch, Cape Town, South Africa
| | - Kevin P. Cain
- US Centers for Disease Control and Prevention, Kisumu, Kenya
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Barr DA, Lewis JM, Feasey N, Schutz C, Kerkhoff AD, Jacob ST, Andrews B, Kelly P, Lakhi S, Muchemwa L, Bacha HA, Hadad DJ, Bedell R, van Lettow M, Zachariah R, Crump JA, Alland D, Corbett EL, Gopinath K, Singh S, Griesel R, Maartens G, Mendelson M, Ward AM, Parry CM, Talbot EA, Munseri P, Dorman SE, Martinson N, Shah M, Cain K, Heilig CM, Varma JK, von Gottberg A, Sacks L, Wilson D, Squire SB, Lalloo DG, Davies G, Meintjes G. Mycobacterium tuberculosis bloodstream infection prevalence, diagnosis, and mortality risk in seriously ill adults with HIV: a systematic review and meta-analysis of individual patient data. Lancet Infect Dis 2020; 20:742-752. [PMID: 32178764 PMCID: PMC7254058 DOI: 10.1016/s1473-3099(19)30695-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 10/09/2019] [Accepted: 11/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The clinical and epidemiological significance of HIV-associated Mycobacterium tuberculosis bloodstream infection (BSI) is incompletely understood. We hypothesised that M tuberculosis BSI prevalence has been underestimated, that it independently predicts death, and that sputum Xpert MTB/RIF has suboptimal diagnostic yield for M tuberculosis BSI. METHODS We did a systematic review and individual patient data (IPD) meta-analysis of studies performing routine mycobacterial blood culture in a prospectively defined patient population of people with HIV aged 13 years or older. Studies were identified through searching PubMed and Scopus up to Nov 10, 2018, without language or date restrictions and through manual review of reference lists. Risk of bias in the included studies was assessed with an adapted QUADAS-2 framework. IPD were requested for all identified studies and subject to harmonised inclusion criteria: age 13 years or older, HIV positivity, available CD4 cell count, a valid mycobacterial blood culture result (excluding patients with missing data from lost or contaminated blood cultures), and meeting WHO definitions for suspected tuberculosis (presence of screening symptom). Predicted probabilities of M tuberculosis BSI from mixed-effects modelling were used to estimate prevalence. Estimates of diagnostic yield of sputum testing with Xpert (or culture if Xpert was unavailable) and of urine lipoarabinomannan (LAM) testing for M tuberculosis BSI were obtained by two-level random-effect meta-analysis. Estimates of mortality associated with M tuberculosis BSI were obtained by mixed-effect Cox proportional-hazard modelling and of effect of treatment delay on mortality by propensity-score analysis. This study is registered with PROSPERO, number 42016050022. FINDINGS We identified 23 datasets for inclusion (20 published and three unpublished at time of search) and obtained IPD from 20, representing 96·2% of eligible IPD. Risk of bias for the included studies was assessed to be generally low except for on the patient selection domain, which was moderate in most studies. 5751 patients met harmonised IPD-level inclusion criteria. Technical factors such as number of blood cultures done, timing of blood cultures relative to blood sampling, and patient factors such as inpatient setting and CD4 cell count, explained significant heterogeneity between primary studies. The predicted probability of M tuberculosis BSI in hospital inpatients with HIV-associated tuberculosis, WHO danger signs, and a CD4 count of 76 cells per μL (the median for the cohort) was 45% (95% CI 38-52). The diagnostic yield of sputum in patients with M tuberculosis BSI was 77% (95% CI 63-87), increasing to 89% (80-94) when combined with urine LAM testing. Presence of M tuberculosis BSI compared with its absence in patients with HIV-associated tuberculosis increased risk of death before 30 days (adjusted hazard ratio 2·48, 95% CI 2·05-3·08) but not after 30 days (1·25, 0·84-2·49). In a propensity-score matched cohort of participants with HIV-associated tuberculosis (n=630), mortality increased in patients with M tuberculosis BSI who had a delay in anti-tuberculosis treatment of longer than 4 days compared with those who had no delay (odds ratio 3·15, 95% CI 1·16-8·84). INTERPRETATION In critically ill adults with HIV-tuberculosis, M tuberculosis BSI is a frequent manifestation of tuberculosis and predicts mortality within 30 days. Improved diagnostic yield in patients with M tuberculosis BSI could be achieved through combined use of sputum Xpert and urine LAM. Anti-tuberculosis treatment delay might increase the risk of mortality in these patients. FUNDING This study was supported by Wellcome fellowships 109105Z/15/A and 105165/Z/14/A.
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Affiliation(s)
- David A Barr
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK; Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Joseph M Lewis
- Liverpool School of Tropical Medicine, Liverpool, UK; Malawi-Liverpool-Wellcome Clinical Research Programme, Queen Elizabeth Central Hospital, College of Medicine, Blantyre, Malawi
| | - Nicholas Feasey
- Liverpool School of Tropical Medicine, Liverpool, UK; Malawi-Liverpool-Wellcome Clinical Research Programme, Queen Elizabeth Central Hospital, College of Medicine, Blantyre, Malawi
| | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Cape Town, South Africa; Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases, and Global Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - Ben Andrews
- Institute for Global Health, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Paul Kelly
- Blizard Institute, Barts and London School of Medicine, Queen Mary University of London, London, UK
| | - Shabir Lakhi
- Department of Internal Medicine, University of Zambia School of Medicine and University Teaching Hospital, Lusaka, Zambia
| | - Levy Muchemwa
- Department of Internal Medicine, University of Zambia School of Medicine and University Teaching Hospital, Lusaka, Zambia; Defence Force School of Health Sciences, Lusaka, Zambia
| | - Helio A Bacha
- Instituto de Infectologia Emilio Ribas, São Paulo, Brazil
| | - David J Hadad
- Universidade Federal do Espirito Santo, Centro de Ciêncicas da Saúde, Departamento de Clinica Médica, Vitoria, Brazil
| | - Richard Bedell
- Dignitas International, Zomba, Malawi; Division of Global Health, University of British Columbia, Vancouver, BC, Canada
| | - Monique van Lettow
- Dignitas International, Zomba, Malawi; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Rony Zachariah
- Medecins Sans Frontieres, Operational Centre Brussels, Brussels, Belgium
| | - John A Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand; Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, NC, USA; Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - David Alland
- Division of Infectious Disease, Department of Medicine, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Elizabeth L Corbett
- Malawi-Liverpool-Wellcome Clinical Research Programme, Queen Elizabeth Central Hospital, College of Medicine, Blantyre, Malawi; London School of Hygiene and Tropical Medicine, London, UK
| | | | - Sarman Singh
- Division of Clinical Microbiology and Molecular Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rulan Griesel
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town, South Africa; Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Amy M Ward
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Christopher M Parry
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK; Liverpool School of Tropical Medicine, Liverpool, UK; School of Tropical Medicine and Global Health, University of Nagasaki, Nagasaki, Japan
| | - Elizabeth A Talbot
- Infectious Disease and International Health, Dartmouth Medical School, Hanover, NH, USA
| | - Patricia Munseri
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Susan E Dorman
- Johns Hopkins University Centre for TB Research, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Neil Martinson
- Johns Hopkins University Centre for TB Research, Johns Hopkins School of Medicine, Baltimore, MD, USA; Perinatal HIV Research Unit, South African Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Centre of Excellence for Biomedical TB Research, University of the Witwatersrand, Johannesburg, South Africa
| | - Maunank Shah
- Johns Hopkins University Centre for TB Research, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kevin Cain
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Charles M Heilig
- Center for Surveillance, Epidemiology, and Laboratory Services, Atlanta, GA, USA; US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jay K Varma
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Anne von Gottberg
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | - Leonard Sacks
- Office of Medical Policy, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Douglas Wilson
- Department of Internal Medicine, Edendale Hospital, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | | | | | - Gerry Davies
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Cape Town, South Africa; Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Department of Medicine, University of Cape Town, Cape Town, South Africa
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7
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Warria K, Nyamthimba P, Chweya A, Agaya J, Achola M, Reichler M, Cowden J, Heilig CM, Borgdorff MW, Cain KP, Yuen CM. Tuberculosis disease and infection among household contacts of bacteriologically confirmed and non-confirmed tuberculosis patients. Trop Med Int Health 2020; 25:695-701. [PMID: 32170771 DOI: 10.1111/tmi.13392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the prevalence of tuberculosis infection and disease in household contacts of patients with bacteriologically confirmed tuberculosis disease and contacts of non-bacteriologically confirmed disease in western Kenya. METHODS We enrolled newly diagnosed index patients and their household contacts from March 2014 to June 2016. All contacts were evaluated with a symptom questionnaire, tuberculin skin test (TST) and HIV test. Clinical evaluation and sputum testing were performed for those with symptoms, positive TST result or HIV infection. RESULTS We enrolled 1155 contacts of 330 index patients with bacteriologically confirmed tuberculosis and 192 contacts of 55 index patients with non-bacteriologically confirmed tuberculosis. 3.5% of contacts of patients with bacteriologically confirmed tuberculosis were diagnosed with tuberculosis, whereas no contacts of index patients with non-bacteriologically confirmed tuberculosis were. Of those diagnosed with tuberculosis disease, 58.5% reported symptoms, 34.1% reported no symptoms but had positive TST results, and 7.3% had neither symptoms nor positive TST but were HIV-positive. Among 872 contacts with a TST result, 50.9% of contacts of index patients with bacteriologically confirmed tuberculosis and 41.0% of contacts of index patients with non-bacteriologically confirmed tuberculosis had a positive result (prevalence ratio = 1.16, 95% confidence interval 0.92-1.48). CONCLUSION In a high-burden setting, tuberculosis disease was more prevalent among contacts of patients with bacteriologically confirmed tuberculosis than contacts of patients with non-bacteriologically confirmed disease. TST was feasible to perform and helped to detect cases that would have been missed had only symptomatic contacts been evaluated.
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Affiliation(s)
- Ken Warria
- Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Alex Chweya
- Kenya Medical Research Institute, Kisumu, Kenya
| | - Janet Agaya
- Kenya Medical Research Institute, Kisumu, Kenya
| | - Millicent Achola
- Kenya Medical Research Institute, US Army Medical Research Directorate - Kenya, Kisumu, Kenya
| | - Mary Reichler
- U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Charles M Heilig
- U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Kevin P Cain
- U.S. Centers for Disease Control and Prevention, Kisumu, Kenya
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8
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Yuen CM, Agaya J, Mchembere W, Okelloh D, Achola M, Opole J, Cowden J, Heilig CM, Borgdorff MW, Cain KP. Optimizing the efficiency of tuberculosis active case-finding in health facilities and communities. Int J Tuberc Lung Dis 2020; 23:844-849. [PMID: 31439117 DOI: 10.5588/ijtld.18.0700] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING: Efficient tuberculosis (TB) active case-finding strategies are important in settings with high TB burdens and limited resources, such as those in western Kenya.OBJECTIVE: To guide efforts to optimize screening efficiency, we identified the predictors of TB among people screened in health facilities and communities.DESIGN: During February 2015-June 2016, adults aged ≥15 years reporting any TB symptom were identified in health facilities and community mobile screening units, and evaluated for TB. We assessed the predictors of TB using a modified Poisson regression with generalized estimating equations to account for clustering according to screening site.RESULTS: TB was diagnosed in 484 (20.3%) of 2394 symptomatic adults in health facilities and 39 (3.4%) of 1424 in communities. In health facilities, >10% of symptomatic adults in all demographic groups had TB, and no predictors were associated with a ≥2-fold increased risk. In communities, the independent predictors of TB were male sex (adjusted prevalence ratio [aPR] = 4.26, 95%CI 2.43-7.45), HIV infection (aPR 2.37, 95%CI 1.18-4.77), and household TB contact in the last 2 years (aPR 2.84, 95%CI 1.62-4.96).CONCLUSION: Our findings support the notion of general TB screening in health facilities and evaluation of the adult household contacts of TB patients.
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Affiliation(s)
- C M Yuen
- Harvard Medical School, Boston, MA, USA
| | - J Agaya
- Kenya Medical Research Institute, Kisumu
| | | | - D Okelloh
- Kenya Medical Research Institute, Kisumu
| | - M Achola
- Kenya Medical Research Institute, US Army Medical Research Directorate-Kenya, Kisumu
| | - J Opole
- Kenya Medical Research Institute, Kisumu
| | - J Cowden
- US Army Medical Research Directorate-Kenya, Kisumu, Kenya
| | - C M Heilig
- Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
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Dorman SE, Nahid P, Kurbatova EV, Goldberg SV, Bozeman L, Burman WJ, Chang KC, Chen M, Cotton M, Dooley KE, Engle M, Feng PJ, Fletcher CV, Ha P, Heilig CM, Johnson JL, Lessem E, Metchock B, Miro JM, Nhung NV, Pettit AC, Phillips PPJ, Podany AT, Purfield AE, Robergeau K, Samaneka W, Scott NA, Sizemore E, Vernon A, Weiner M, Swindells S, Chaisson RE. High-dose rifapentine with or without moxifloxacin for shortening treatment of pulmonary tuberculosis: Study protocol for TBTC study 31/ACTG A5349 phase 3 clinical trial. Contemp Clin Trials 2020; 90:105938. [PMID: 31981713 PMCID: PMC7307310 DOI: 10.1016/j.cct.2020.105938] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 01/17/2020] [Accepted: 01/20/2020] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Phase 2 clinical trials of tuberculosis treatment have shown that once-daily regimens in which rifampin is replaced by high dose rifapentine have potent antimicrobial activity that may be sufficient to shorten overall treatment duration. Herein we describe the design of an ongoing phase 3 clinical trial testing the hypothesis that once-daily regimens containing high dose rifapentine in combination with other anti-tuberculosis drugs administered for four months can achieve cure rates not worse than the conventional six-month treatment regimen. METHODS/DESIGN S31/A5349 is a multicenter randomized controlled phase 3 non-inferiority trial that compares two four-month regimens with the standard six-month regimen for treating drug-susceptible pulmonary tuberculosis in HIV-negative and HIV-positive patients. Both of the four-month regimens contain high-dose rifapentine instead of rifampin, with ethambutol replaced by moxifloxacin in one regimen. All drugs are administered seven days per week, and under direct observation at least five days per week. The primary outcome is tuberculosis disease-free survival at twelve months after study treatment assignment. A total of 2500 participants will be randomized; this gives 90% power to show non-inferiority with a 6.6% margin of non-inferiority. DISCUSSION This phase 3 trial formally tests the hypothesis that augmentation of rifamycin exposures can shorten tuberculosis treatment to four months. Trial design and standardized implementation optimize the likelihood of obtaining valid results. Results of this trial may have important implications for clinical management of tuberculosis at both individual and programmatic levels. TRIAL REGISTRATION NCT02410772. Registered 8 April 2015,https://www.clinicaltrials.gov/ct2/show/NCT02410772?term=02410772&rank=1.
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Affiliation(s)
- Susan E Dorman
- Medical University of South Carolina, Charleston, SC, USA.
| | - Payam Nahid
- University of California, San Francisco, California, USA
| | | | | | - Lorna Bozeman
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Kwok-Chiu Chang
- Tuberculosis and Chest Service, Department of Health, Hong Kong
| | - Michael Chen
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mark Cotton
- Stellenbosch University, Cape Town, South Africa
| | - Kelly E Dooley
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Melissa Engle
- Audie L. Murphy Veterans Affairs Medical Center / University of Texas Health Science Center, San Antonio, TX, USA
| | - Pei-Jean Feng
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Phan Ha
- Vietnam National TB Program (NTP)/UCSF Research Collaboration, Hanoi, Viet Nam
| | | | - John L Johnson
- Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda
| | | | | | - Jose M Miro
- Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Nguyen Viet Nhung
- Vietnam National TB Program (NTP)/UCSF Research Collaboration, Hanoi, Viet Nam
| | - April C Pettit
- Vanderbilt University Medical Center, Department of Medicine, Division of Infectious Diseases, Nashville, TN, USA
| | | | | | - Anne E Purfield
- US Centers for Disease Control and Prevention, Atlanta, GA, USA; U.S. Public Health Service Commissioned Corps, Rockville, MD, USA
| | | | | | - Nigel A Scott
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Erin Sizemore
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Andrew Vernon
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Marc Weiner
- Audie L. Murphy Veterans Affairs Medical Center / University of Texas Health Science Center, San Antonio, TX, USA
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10
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Lee SH, Maenner MJ, Heilig CM. A comparison of machine learning algorithms for the surveillance of autism spectrum disorder. PLoS One 2019; 14:e0222907. [PMID: 31553774 PMCID: PMC6760799 DOI: 10.1371/journal.pone.0222907] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 09/10/2019] [Indexed: 11/18/2022] Open
Abstract
Objective The Centers for Disease Control and Prevention (CDC) coordinates a labor-intensive process to measure the prevalence of autism spectrum disorder (ASD) among children in the United States. Random forests methods have shown promise in speeding up this process, but they lag behind human classification accuracy by about 5%. We explore whether more recently available document classification algorithms can close this gap. Materials and methods Using data gathered from a single surveillance site, we applied 8 supervised learning algorithms to predict whether children meet the case definition for ASD based solely on the words in their evaluations. We compared the algorithms’ performance across 10 random train-test splits of the data, using classification accuracy, F1 score, and number of positive calls to evaluate their potential use for surveillance. Results Across the 10 train-test cycles, the random forest and support vector machine with Naive Bayes features (NB-SVM) each achieved slightly more than 87% mean accuracy. The NB-SVM produced significantly more false negatives than false positives (P = 0.027), but the random forest did not, making its prevalence estimates very close to the true prevalence in the data. The best-performing neural network performed similarly to the random forest on both measures. Discussion The random forest performed as well as more recently available models like the NB-SVM and the neural network, and it also produced good prevalence estimates. NB-SVM may not be a good candidate for use in a fully-automated surveillance workflow due to increased false negatives. More sophisticated algorithms, like hierarchical convolutional neural networks, may not be feasible to train due to characteristics of the data. Current algorithms might perform better if the data are abstracted and processed differently and if they take into account information about the children in addition to their evaluations. Conclusion Deep learning models performed similarly to traditional machine learning methods at predicting the clinician-assigned case status for CDC’s autism surveillance system. While deep learning methods had limited benefit in this task, they may have applications in other surveillance systems.
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Affiliation(s)
- Scott H Lee
- Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Matthew J Maenner
- Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Charles M Heilig
- Centers for Disease Control and Prevention, Atlanta, GA, United States of America
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11
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Lee SH, Levin D, Finley PD, Heilig CM. Chief complaint classification with recurrent neural networks. J Biomed Inform 2019; 93:103158. [PMID: 30926471 PMCID: PMC10563436 DOI: 10.1016/j.jbi.2019.103158] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 03/19/2019] [Accepted: 03/22/2019] [Indexed: 10/27/2022]
Abstract
Syndromic surveillance detects and monitors individual and population health indicators through sources such as emergency department records. Automated classification of these records can improve outbreak detection speed and diagnosis accuracy. Current syndromic systems rely on hand-coded keyword-based methods to parse written fields and may benefit from the use of modern supervised-learning classifier models. In this paper, we implement two recurrent neural network models based on long short-term memory (LSTM) and gated recurrent unit (GRU) cells and compare them to two traditional bag-of-words classifiers: multinomial naïve Bayes (MNB) and a support vector machine (SVM). The MNB classifier is one of only two machine learning algorithms currently being used for syndromic surveillance. All four models are trained to predict diagnostic code groups as defined by Clinical Classification Software, first to predict from discharge diagnosis, and then from chief complaint fields. The classifiers are trained on 3.6 million de-identified emergency department records from a single United States jurisdiction. We compare performance of these models primarily using the F1 score, and we measure absolute model performance to determine which conditions are the most amenable to surveillance based on chief complaint alone. Using discharge diagnoses, the LSTM classifier performs best, though all models exhibit an F1 score above 96.00. Using chief complaints, the GRU performs best (F1 = 47.38), and MNB with bigrams performs worst (F1 = 39.40). We also note that certain syndrome types are easier to detect than others. For example, chief complaints using the GRU model predicts alcohol-related disorders well (F1 = 78.91) but predicts influenza poorly (F1 = 14.80). In all instances, the RNN models outperformed the bag-of-words classifiers suggesting deep learning models could substantially improve the automatic classification of unstructured text for syndromic surveillance.
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Affiliation(s)
- Scott H Lee
- Centers for Disease Control and Prevention, Atlanta, GA, United States.
| | - Drew Levin
- Sandia National Laboratories, Albuquerque, NM, United States
| | | | - Charles M Heilig
- Centers for Disease Control and Prevention, Atlanta, GA, United States
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12
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García MC, Heilig CM, Lee SH, Faul M, Guy G, Iademarco MF, Hempstead K, Raymond D, Gray J. Opioid Prescribing Rates in Nonmetropolitan and Metropolitan Counties Among Primary Care Providers Using an Electronic Health Record System - United States, 2014-2017. MMWR Morb Mortal Wkly Rep 2019; 68:25-30. [PMID: 30653483 PMCID: PMC6336190 DOI: 10.15585/mmwr.mm6802a1] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Drug overdose is the leading cause of unintentional injury-associated death in the United States. Among 70,237 fatal drug overdoses in 2017, prescription opioids were involved in 17,029 (24.2%) (1). Higher rates of opioid-related deaths have been recorded in nonmetropolitan (rural) areas (2). In 2017, 14 rural counties were among the 15 counties with the highest opioid prescribing rates.* Higher opioid prescribing rates put patients at risk for addiction and overdose (3). Using deidentified data from the Athenahealth electronic health record (EHR) system, opioid prescribing rates among 31,422 primary care providers† in the United States were analyzed to evaluate trends from January 2014 to March 2017. This analysis assessed how prescribing practices varied among six urban-rural classification categories of counties, before and after the March 2016 release of CDC's Guideline for Prescribing Opioids for Chronic Pain (Guideline) (4). Patients in noncore (the most rural) counties had an 87% higher chance of receiving an opioid prescription compared with persons in large central metropolitan counties during the study period. Across all six county groups, the odds of receiving an opioid prescription decreased significantly after March 2016. This decrease followed a flat trend during the preceding period in micropolitan and large central metropolitan county groups; in contrast, the decrease continued previous downward trends in the other four county groups. Data from EHRs can effectively supplement traditional surveillance methods for monitoring trends in opioid prescribing and other areas of public health importance, with minimal lag time under ideal conditions. As less densely populated areas appear to indicate both substantial progress in decreasing opioid prescribing and ongoing need for reduction, community health care practices and intervention programs must continue to be tailored to community characteristics.
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13
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Auld SC, Lee SH, Click ES, Miramontes R, Day CL, Gandhi NR, Heilig CM. IFN-γ Release Assay Result Is Associated with Disease Site and Death in Active Tuberculosis. Ann Am Thorac Soc 2016; 13:2151-2158. [PMID: 27580246 PMCID: PMC5466186 DOI: 10.1513/annalsats.201606-482oc] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 08/30/2016] [Indexed: 12/31/2022] Open
Abstract
RATIONALE The IFN-γ release assays and tuberculin skin tests are used to support the diagnosis of both latent and active tuberculosis. However, we previously demonstrated that a negative tuberculin test in active tuberculosis is associated with disseminated disease and death. It is unknown whether the same associations exist for IFN-γ release assays. OBJECTIVES To determine the association between these tests and site of tuberculosis and death among persons with active tuberculosis. METHODS We analyzed IFN-γ release assays and tuberculin test results for all persons with culture-confirmed tuberculosis reported to the U.S. National Tuberculosis Surveillance System from 2010 to 2014. We used logistic regression to calculate the association between these tests and site of disease and death. MEASUREMENTS AND MAIN RESULTS A total of 24,803 persons with culture-confirmed tuberculosis had either of these test results available for analysis. Persons with a positive tuberculin test had lower odds of disseminated disease (i.e., miliary or combined pulmonary and extrapulmonary disease), but there was no difference in the odds of disseminated disease with a positive IFN-γ release assay. However, persons who were positive to either of these tests had lower odds of death. An indeterminate IFN-γ release assay result was associated with greater odds of both disseminated disease and death. CONCLUSIONS Despite perceived equivalence in clinical practice, IFN-γ release assays and tuberculin test results have different associations with tuberculosis site, yet similar associations with the risk of death. Furthermore, an indeterminate IFN-γ release assay result in a person with active tuberculosis is not unimportant, and rather carries greater odds of disseminated disease and death. Prospective study may improve our understanding of the underlying mechanisms by which these tests are associated with disease localization and death.
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Affiliation(s)
- Sara C. Auld
- Division of Pulmonary and Critical Care Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Scott H. Lee
- Center for Surveillance, Epidemiology, and Laboratory Services
| | | | - Roque Miramontes
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Cheryl L. Day
- Emory Vaccine Center and Department of Microbiology, Emory University, Atlanta, Georgia; and
| | - Neel R. Gandhi
- Departments of Epidemiology, Global Health, and Medicine, Emory University Rollins School of Public Health and School of Medicine, Atlanta, Georgia
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14
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Abstract
Mycobacterium africanum is endemic to West Africa and causes tuberculosis (TB). We reviewed reported cases of TB in the United States during 2004-2013 that had lineage assigned by genotype (spoligotype and mycobacterial interspersed repetitive unit variable number tandem repeats). M. africanum caused 315 (0.4%) of 73,290 TB cases with lineage assigned by genotype. TB caused by M. africanum was associated more with persons from West Africa (adjusted odds ratio [aOR] 253.8, 95% CI 59.9-1,076.1) and US-born black persons (aOR 5.7, 95% CI 1.2-25.9) than with US-born white persons. TB caused by M. africanum did not show differences in clinical characteristics when compared with TB caused by M. tuberculosis. Clustered cases defined as >2 cases in a county with identical 24-locus mycobacterial interspersed repetitive unit genotypes, were less likely for M. africanum (aOR 0.1, 95% CI 0.1-0.4), which suggests that M. africanum is not commonly transmitted in the United States.
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15
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Kim L, Moonan PK, Heilig CM, Yelk Woodruff RS, Kammerer JS, Haddad MB. Factors associated with recurrent tuberculosis more than 12 months after treatment completion. Int J Tuberc Lung Dis 2016; 20:49-56. [PMID: 26688528 DOI: 10.5588/ijtld.15.0442] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Even among persons who have completed a course of treatment for their first tuberculosis (TB) episode, patients with a history of TB are at higher risk for having TB. OBJECTIVE To describe factors from the initial TB episode associated with recurrent TB among patients who completed treatment and remained free of TB for at least 12 months. DESIGN During 1993-2006, US TB cases stratified by birth origin were examined. Cox proportional hazards regression was used to assess the association of factors during the initial episode with recurrence at least 12 months after treatment completion. RESULTS Among 632 US-born patients, TB recurrence was associated with age 25-44 years (adjusted hazard ratio [aHR] 1.77, 99% confidence interval [CI] 1.02-3.09, attributable fraction [AF] 1-34%), substance use (aHR 1.57, 99%CI 1.23-2.02, AF 8-22%), and treatment supervised by health departments (aHR 1.42, 99%CI 1.03-1.97, AF 2-28%). Among 211 foreign-born patients, recurrence was associated with human immunodeficiency virus infection (aHR 2.24, 99%CI 1.27-3.98, AF 2-9%) and smear-positive TB (aHR 1.56, 99%CI 1.06-2.30, AF 3-33%). CONCLUSION Factors associated with recurrence differed by origin of birth, and might be useful for anticipating greater risk for recurrent TB among certain patients with a history of TB.
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Affiliation(s)
- L Kim
- Epidemic Intelligence Service, Atlanta, Georgia, USA; Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - P K Moonan
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - C M Heilig
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - R S Yelk Woodruff
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - J S Kammerer
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - M B Haddad
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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16
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Abstract
The notions of individual and collective ethics were first explicitly defined in the biostatistical literature in 1971 to motivate a mathematical solution to a posed ethical dilemma. This paper reviews key antecedents to these concepts and traces explicit references to them over time, primarily in the biostatistical literature. Following a historical exposition of these texts, a critical thematic analysis shows the following: the normative force of these concepts has not been adequately argued. Individual and collective ethics do not solve the problem of how to use accumulating data to inform ethical action. The notions of the “individual” and the “collective” are too vague to prompt clear moral imperatives, especially in difficult cases. These concepts have not been successfully linked to a standard ethical framework. Finally, the paper concludes with the observation that a systematic, comprehensive ethical framework must be identified to fulfill the intuitions behind individual and collective ethics.
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Affiliation(s)
- Charles M Heilig
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA 30341-371 7, USA.
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17
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Sharma A, Musau S, Heilig CM, Okumu AO, Opiyo EO, Basiye FL, Miruka FO, Kioko JK, Sitienei JK, Cain KP. Assessing the effect of decentralisation of laboratory diagnosis for drug-resistant tuberculosis in Kenya. Int J Tuberc Lung Dis 2016; 19:1348-53. [PMID: 26467587 DOI: 10.5588/ijtld.15.0328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Drug susceptibility testing (DST) is recommended in Kenya to identify multidrug-resistant tuberculosis (MDR-TB) in persons registered for tuberculosis (TB) retreatment. DST is performed at a central laboratory with a two-step growth-based process and a regional laboratory with a simultaneous molecular- and growth-based process. OBJECTIVE To compare proportions of retreatment cases who underwent DST and turnaround times for hospitals referring to the central vs. regional laboratory. DESIGN Cases were persons registered for TB retreatment from 1 January 2012 to 31 December 2013. Records of 11 hospitals and 7 hospitals referring patients to the regional and central laboratories, respectively, were reviewed. RESULTS Respectively 238/432 (55%) and 88/355 (25%) cases from hospitals referring to the regional and central laboratories underwent DST. The mean time from case registration to receipt of DST results and initiation of MDR-TB treatment was quicker in hospitals referring to the regional laboratory. The time required for the transportation of specimens, specimen testing and receipt of DST results at hospitals was shorter for the regional laboratory (P < 0.05). CONCLUSION Testing was faster and more complete at hospitals referring to the regional laboratory. A comprehensive review of MDR-TB detection in Kenya is required to increase the proportion of cases receiving DST.
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Affiliation(s)
- A Sharma
- Epidemic Intelligence Service, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - S Musau
- Kenya Medical Research Institute, Kisian, Kenya
| | - C M Heilig
- Division of Tuberculosis Elimination, CDC, Atlanta, Georgia, USA
| | - A O Okumu
- Kenya Medical Research Institute, Kisian, Kenya
| | - E O Opiyo
- Kenya Medical Research Institute, Kisian, Kenya
| | - F L Basiye
- Division of Global HIV/AIDS, CDC, Kisumu, Kenya
| | - F O Miruka
- Division of Global HIV/AIDS, CDC, Kisumu, Kenya
| | - J K Kioko
- Division of Tuberculosis and Lung Disease, Ministry of Health, Kenya
| | - J K Sitienei
- Division of Communicable Disease Prevention and Control, Ministry of Health, Kenya
| | - K P Cain
- Division of Tuberculosis Elimination, CDC, Kisumu, Kenya
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18
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Cavanaugh JS, Modi S, Musau S, McCarthy K, Alexander H, Burmen B, Heilig CM, Shiraishi RW, Cain K. Comparative Yield of Different Diagnostic Tests for Tuberculosis among People Living with HIV in Western Kenya. PLoS One 2016; 11:e0152364. [PMID: 27023213 PMCID: PMC4811572 DOI: 10.1371/journal.pone.0152364] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 03/13/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Diagnosis followed by effective treatment of tuberculosis (TB) reduces transmission and saves lives in persons living with HIV (PLHIV). Sputum smear microscopy is widely used for diagnosis, despite limited sensitivity in PLHIV. Evidence is needed to determine the optimal diagnostic approach for these patients. METHODS From May 2011 through June 2012, we recruited PLHIV from 15 HIV treatment centers in western Kenya. We collected up to three sputum specimens for Ziehl-Neelsen (ZN) and fluorescence microscopy (FM), GeneXpert MTB/RIF (Xpert), and culture, regardless of symptoms. We calculated the incremental yield of each test, stratifying results by CD4 cell count and specimen type; data were analyzed to account for complex sampling. RESULTS From 778 enrolled patients, we identified 88 (11.3%) laboratory-confirmed TB cases. Of the 74 cases who submitted 2 specimens for microscopy and Xpert testing, ZN microscopy identified 25 (33.6%); Xpert identified those plus an additional 18 (incremental yield = 24.4%). Xpert testing of spot specimens identified 48 (57.0%) of 84 cases; whereas Xpert testing of morning specimens identified 50 (66.0%) of 76 cases. Two Xpert tests detected 22/24 (92.0%) TB cases with CD4 counts <100 cells/μL and 30/45 (67.0%) of cases with CD4 counts ≥100 cells/μl. CONCLUSIONS In PLHIV, Xpert substantially increased diagnostic yield compared to smear microscopy and had the highest yield when used to test morning specimens and specimens from PLHIV with CD4 count <100 cells/μL. TB programs unable to replace smear microscopy with Xpert for all symptomatic PLHIV should consider targeted replacement and using morning specimens.
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Affiliation(s)
- Joseph S. Cavanaugh
- United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- * E-mail:
| | - Surbhi Modi
- United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Susan Musau
- Kenya Medical Research Institute (KEMRI) Center for Global Health Research, Kisumu, Kenya
| | - Kimberly McCarthy
- United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Heather Alexander
- United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Barbara Burmen
- Kenya Medical Research Institute (KEMRI) Center for Global Health Research, Kisumu, Kenya
| | - Charles M. Heilig
- United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Ray W. Shiraishi
- United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Kevin Cain
- United States Centers for Disease Control and Prevention, Kisumu, Kenya
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19
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Nnadi CD, Anderson LF, Armstrong LR, Stagg HR, Pedrazzoli D, Pratt R, Heilig CM, Abubakar I, Moonan PK. Mind the gap: TB trends in the USA and the UK, 2000-2011. Thorax 2016; 71:356-63. [PMID: 26907187 DOI: 10.1136/thoraxjnl-2015-207915] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 01/05/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND TB remains a major public health concern, even in low-incidence countries like the USA and the UK. Over the last two decades, cases of TB reported in the USA have declined, while they have increased substantially in the UK. We examined factors associated with this divergence in TB trends between the two countries. METHODS We analysed all cases of TB reported to the US and UK national TB surveillance systems from 1 January 2000 through 31 December 2011. Negative binominal regression was used to assess potential demographic, clinical and risk factor variables associated with differences in observed trends. FINDINGS A total of 259,609 cases were reported. From 2000 to 2011, annual TB incidence rates declined from 5.8 to 3.4 cases per 100,000 in the USA, whereas in the UK, TB incidence increased from 11.4 to 14.4 cases per 100,000. The majority of cases in both the USA (56%) and the UK (64%) were among foreign-born persons. The number of foreign-born cases reported in the USA declined by 15% (7731 in 2000 to 6564 in 2011) while native-born cases fell by 54% (8442 in 2000 to 3883 in 2011). In contrast, the number of foreign-born cases reported in the UK increased by 80% (3380 in 2000 to 6088 in 2011), while the number of native-born cases remained largely unchanged (2158 in 2000 to 2137 in 2011). In an adjusted negative binomial regression model, significant differences in trend were associated with sex, age, race/ethnicity, site of disease, HIV status and previous history of TB (p<0.01). Among the foreign-born, significant differences in trend were also associated with time since UK or US entry (p<0.01). INTERPRETATION To achieve TB elimination in the UK, a re-evaluation of current TB control policies and practices with a focus on foreign-born are needed. In the USA, maintaining and strengthening control practices are necessary to sustain the progress made over the last 20 years.
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Affiliation(s)
- Chimeremma D Nnadi
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Lori R Armstrong
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Helen R Stagg
- Research Department of Infection and Population Health, University College London, London, UK
| | - Debora Pedrazzoli
- TB Modelling Group, TB Centre and CMMID, London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, UK
| | - Robert Pratt
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Charles M Heilig
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ibrahim Abubakar
- Tuberculosis Section, Public Health England, London, UK Research Department of Infection and Population Health, University College London, London, UK
| | - Patrick K Moonan
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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20
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Dorman SE, Savic RM, Goldberg S, Stout JE, Schluger N, Muzanyi G, Johnson JL, Nahid P, Hecker EJ, Heilig CM, Bozeman L, Feng PJI, Moro RN, MacKenzie W, Dooley KE, Nuermberger EL, Vernon A, Weiner M. Daily rifapentine for treatment of pulmonary tuberculosis. A randomized, dose-ranging trial. Am J Respir Crit Care Med 2015; 191:333-43. [PMID: 25489785 DOI: 10.1164/rccm.201410-1843oc] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Rifapentine has potent activity in mouse models of tuberculosis chemotherapy but its optimal dose and exposure in humans are unknown. OBJECTIVES We conducted a randomized, partially blinded dose-ranging study to determine tolerability, safety, and antimicrobial activity of daily rifapentine for pulmonary tuberculosis treatment. METHODS Adults with sputum smear-positive pulmonary tuberculosis were assigned rifapentine 10, 15, or 20 mg/kg or rifampin 10 mg/kg daily for 8 weeks (intensive phase), with isoniazid, pyrazinamide, and ethambutol. The primary tolerability end point was treatment discontinuation. The primary efficacy end point was negative sputum cultures at completion of intensive phase. MEASUREMENTS AND MAIN RESULTS A total of 334 participants were enrolled. At completion of intensive phase, cultures on solid media were negative in 81.3% of participants in the rifampin group versus 92.5% (P = 0.097), 89.4% (P = 0.29), and 94.7% (P = 0.049) in the rifapentine 10, 15, and 20 mg/kg groups. Liquid cultures were negative in 56.3% (rifampin group) versus 74.6% (P = 0.042), 69.7% (P = 0.16), and 82.5% (P = 0.004), respectively. Compared with the rifampin group, the proportion negative at the end of intensive phase was higher among rifapentine recipients who had high rifapentine areas under the concentration-time curve. Percentages of participants discontinuing assigned treatment for reasons other than microbiologic ineligibility were similar across groups (rifampin, 8.2%; rifapentine 10, 15, or 20 mg/kg, 3.4, 2.5, and 7.4%, respectively). CONCLUSIONS Daily rifapentine was well-tolerated and safe. High rifapentine exposures were associated with high levels of sputum sterilization at completion of intensive phase. Further studies are warranted to determine if regimens that deliver high rifapentine exposures can shorten treatment duration to less than 6 months. Clinical trial registered with www.clinicaltrials.gov (NCT 00694629).
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Affiliation(s)
- Susan E Dorman
- 1 Johns Hopkins University School of Medicine, Baltimore, Maryland
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21
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Kurbatova EV, Cegielski JP, Lienhardt C, Akksilp R, Bayona J, Becerra MC, Caoili J, Contreras C, Dalton T, Danilovits M, Demikhova OV, Ershova J, Gammino VM, Gelmanova I, Heilig CM, Jou R, Kazennyy B, Keshavjee S, Kim HJ, Kliiman K, Kvasnovsky C, Leimane V, Mitnick CD, Quelapio I, Riekstina V, Smith SE, Tupasi T, van der Walt M, Vasilyeva IA, Via LE, Viiklepp P, Volchenkov G, Walker AT, Wolfgang M, Yagui M, Zignol M. Sputum culture conversion as a prognostic marker for end-of-treatment outcome in patients with multidrug-resistant tuberculosis: a secondary analysis of data from two observational cohort studies. Lancet Respir Med 2015; 3:201-9. [PMID: 25726085 PMCID: PMC4401426 DOI: 10.1016/s2213-2600(15)00036-3] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 01/26/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND Sputum culture conversion is often used as an early microbiological endpoint in phase 2 clinical trials of tuberculosis treatment on the basis of its assumed predictive value for end-of-treatment outcome, particularly in patients with drug-susceptible tuberculosis. We aimed to assess the validity of sputum culture conversion on solid media at varying timepoints, and the time to conversion, as prognostic markers for end-of-treatment outcome in patients with multidrug-resistant (MDR) tuberculosis. METHODS We analysed data from two large cohort studies of patients with MDR tuberculosis. We defined sputum culture conversion as two or more consecutive negative cultures from sputum samples obtained at least 30 days apart. To estimate the association of 2 month and 6 month conversion with successful treatment outcome, we calculated odds ratios (ORs) and 95% CIs with random-effects multivariable logistic regression. We calculated predictive values with bivariate random-effects generalised linear mixed modelling. FINDINGS We assessed data for 1712 patients who had treatment success, treatment failure, or who died. Among patients with treatment success, median time to sputum culture conversion was significantly shorter than in those who had poor outcomes (2 months [IQR 1-3] vs 7 months [3 to ≥24]; log-rank p<0·0001). Furthermore, conversion status at 6 months (adjusted OR 14·07 [95% CI 10·05-19·71]) was significantly associated with treatment success compared with failure or death. Sputum culture conversion status at 2 months was significantly associated with treatment success only in patients who were HIV negative (adjusted OR 4·12 [95% CI 2·25-7·54]) or who had unknown HIV infection (3·59 [1·96-6·58]), but not in those who were HIV positive (0·38 [0·12-1·18]). Thus, the overall association of sputum culture conversion with a successful outcome was substantially greater at 6 months than at 2 months. 2 month conversion had low sensitivity (27·3% [95% confidence limit 16·6-41·4]) and high specificity (89·8% [82·3-94·4]) for prediction of treatment success. Conversely, 6 month sputum culture conversion status had high sensitivity (91·8% [85·9-95·4]), but moderate specificity (57·8% [42·5-71·6]). The maximum combined sensitivity and specificity for sputum culture conversion was reached between month 6 and month 10 of treatment. INTERPRETATION Time to sputum culture conversion, conversion status at 6 months, and conversion status at 2 months in patients without known HIV infection can be considered as proxy markers of end-of-treatment outcome in patients with MDR tuberculosis, although the overall association with treatment success is substantially stronger for 6 month than for 2 month conversion status. Investigators should consider these results regarding the validity of sputum culture conversion at various timepoints as an early predictor of treatment efficacy when designing phase 2 studies before investing substantial resources in large, long-term, phase 3 trials of new treatments for MDR tuberculosis. FUNDING US Agency for International Development, US Centers for Disease Control and Prevention, Division of Intramural Research of the US National Institute of Allergy and Infectious Diseases, Korea Centers for Disease Control and Prevention.
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Affiliation(s)
- Ekaterina V Kurbatova
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - J Peter Cegielski
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - Jaime Bayona
- Harvard Medical School and Partners In Health, Boston, MA, USA
| | | | | | | | - Tracy Dalton
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Olga V Demikhova
- Central Tuberculosis Research Institute, Russian Academy of Medical Sciences, Moscow, Russia
| | - Julia Ershova
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Victoria M Gammino
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Irina Gelmanova
- Harvard Medical School and Partners In Health, Boston, MA, USA
| | - Charles M Heilig
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ruwen Jou
- Reference Laboratory of Mycobacteriology, Taiwan Centers for Disease Control, Taipei, Taiwan
| | | | | | - Hee Jin Kim
- Korean Institute of Tuberculosis, Seoul, South Korea
| | | | - Charlotte Kvasnovsky
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Vaira Leimane
- Riga East University Hospital, Tuberculosis and Lung Disease Center, Riga, Latvia
| | | | | | - Vija Riekstina
- Riga East University Hospital, Tuberculosis and Lung Disease Center, Riga, Latvia
| | - Sarah E Smith
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - Irina A Vasilyeva
- Central Tuberculosis Research Institute, Russian Academy of Medical Sciences, Moscow, Russia
| | - Laura E Via
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Piret Viiklepp
- National Tuberculosis Registry, National Institute for Health Development, Tallinn, Estonia
| | | | - Allison Taylor Walker
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Melanie Wolfgang
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention, Atlanta, GA, USA
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Reves R, Heilig CM, Tapy JM, Bozeman L, Kyle RP, Hamilton CD, Bock N, Narita M, Wing D, Hershfield E, Goldberg SV. Intermittent tuberculosis treatment for patients with isoniazid intolerance or drug resistance. Int J Tuberc Lung Dis 2015; 18:571-80. [PMID: 24903795 DOI: 10.5588/ijtld.13.0304] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Twenty tuberculosis (TB) clinics in the United States and Canada. OBJECTIVE To evaluate the efficacy and safety of a 6-month intermittent regimen of rifampin (RMP), pyrazinamide (PZA) and ethambutol (EMB) in human immunodeficiency virus (HIV) negative patients with culture-confirmed pulmonary or extra-pulmonary tuberculosis and either isoniazid (INH) resistance or INH intolerance. DESIGN Patients were enrolled in a single-arm clinical trial to receive intermittent dosing after at least 14 initial daily doses of RMP+PZA+EMB. Treatment was continued twice (BIW) or thrice weekly (TIW) per physician/patient preference for a total of 6 months, with 2 years of follow-up for relapse after treatment. RESULTS From 1999 to 2004, 98 patients were enrolled, 78 with reported INH resistance and 20 with INH intolerance. BIW dosing was used in 77 and TIW in 21. Study treatment was completed in 73 (74%). Reasons for discontinuation were hepatic adverse events (n= 12), other adverse effects (n= 3) and other reasons (n= 10). Failure (n= 1) and relapse (n= 2) occurred in 3 (3.5%, 95%CI 1.2-9.8) of 86 patients eligible for efficacy analysis, all occurring in patients with cavitary, acid-fast bacilli smear-positive pulmonary TB. CONCLUSIONS Intermittent RMP+PZA+EMB appears to be effective in HIV-negative patients, but the regimen is poorly tolerated, possibly due to the prolonged use of PZA. Alternative regimens of lower toxicity are needed.
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Affiliation(s)
- R Reves
- Denver Public Health Department, Denver, Colorado, USA
| | - C M Heilig
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - J M Tapy
- Denver Public Health Department, Denver, Colorado, USA
| | - L Bozeman
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - R P Kyle
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - C D Hamilton
- Family Health International 360, Durham, North Carolina, USA
| | - N Bock
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - M Narita
- University of Washington, Seattle, Washington, USA
| | - D Wing
- South Texas-Audie Murphy VA Hospital Research Collaboration, Harlingen, Texas, USA
| | - E Hershfield
- University of Manitoba, Winnipeg, Manitoba, Canada
| | - S V Goldberg
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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23
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Joloba ML, Johnson JL, Feng PJI, Bozeman L, Goldberg SV, Morgan K, Gitta P, Boom HW, Heilig CM, Mayanja-Kizza H, Eisenach KD. What is the most reliable solid culture medium for tuberculosis treatment trials? Tuberculosis (Edinb) 2014; 94:311-6. [PMID: 24698569 DOI: 10.1016/j.tube.2014.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Revised: 02/25/2014] [Accepted: 03/02/2014] [Indexed: 11/26/2022]
Abstract
We conducted a prospective study to determine which solid medium is the most reliable overall and after two months of therapy to detect Mycobacterium tuberculosis complex (MTB). MTB isolation and contamination rates on LJ and Middlebrook 7H10 and 7H11 agar with and without selective antibiotics were examined in a single laboratory and compared against a constructed reference standard and MGIT 960 results. Of 50 smear positive adults with pulmonary TB enrolled, 45 successfully completed standard treatment. Two spot sputum specimens were collected before treatment and at week 8 and one spot specimen each at weeks 2, 4, 6, and 12. The MTB recovery rate among all solid media for pre-treatment specimens was similar. After 8 weeks, selective (S) 7H11 had the highest positivity rate. Latent class analysis was used to construct the primary reference standard. The 98.7% sensitivity of 7H11S (95% Wilson confidence interval 96.4%-99.6%) was highest among the 5 solid media (P = 0.003 by bootstrap); the 82.6% specificity of 7H10S (95% CI 75.7%-87.8%) was highest (P = 0.098). Our results support 7H11S as the medium of choice. Further studies in different areas where recovery and contamination are likely to vary, are recommended.
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Affiliation(s)
- Moses L Joloba
- Department of Medical Microbiology, College of Health Sciences, Makerere University, Kampala, Uganda; Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda.
| | - John L Johnson
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda; Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Pei-Jean I Feng
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis and TB Prevention, Atlanta, GA, USA.
| | - Lorna Bozeman
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis and TB Prevention, Atlanta, GA, USA.
| | - Stefan V Goldberg
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis and TB Prevention, Atlanta, GA, USA.
| | - Karen Morgan
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda.
| | - Phineas Gitta
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda.
| | - Henry W Boom
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda; Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Charles M Heilig
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis and TB Prevention, Atlanta, GA, USA.
| | | | - Kathleen D Eisenach
- Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA; Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
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24
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Heilig CM, Feng PJI, Joloba ML, Johnson JL, Morgan K, Gitta P, Boom WH, Mayanja-Kizza H, Eisenach KD, Bozeman L, Goldberg SV. How we determined the most reliable solid medium for studying treatment of tuberculosis. Tuberculosis (Edinb) 2014; 94:317-22. [PMID: 24661816 DOI: 10.1016/j.tube.2014.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 02/20/2014] [Accepted: 02/21/2014] [Indexed: 12/25/2022]
Abstract
Phase 2 clinical trials for tuberculosis (TB) treatment require reliable culture methods to determine presence or absence of Mycobacterium tuberculosis (Mtb) over the course of therapy, as these trials are based primarily on bacteriological endpoints. We evaluate which of 5 solid media is most reliable: Lowenstein-Jensen (LJ) egg-base medium and 4 Middlebrook agar media (nonselective 7H10 and 7H11 and selective 7H10 and 7H11). We analyze 393 specimens from 50 HIV-negative Ugandan adults with newly-diagnosed, pulmonary TB and high acid-fast bacillus smear grade. Specimens were collected every 2-4 weeks during the first 12 weeks of therapy. We compare the results for each culture to 2 composite reference standards--one that was deemed positive if any solid culture was positive for Mtb and another based on latent-class analysis. Both reference standards established that the 2 selective Middlebrook media most reliably determine the presence or absence of Mtb (P < 0.003), largely because of their lower contamination rates. We also showed that results on Middlebrook media were similar to each other, while LJ was most frequently discordant. Contaminated results appeared more likely to be truly negative than to harbor undetected Mtb.
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Affiliation(s)
- Charles M Heilig
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Atlanta, GA, USA.
| | - Pei-Jean I Feng
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Atlanta, GA, USA
| | - Moses L Joloba
- Department of Medical Microbiology, College of Health Sciences, Makerere University, Kampala, Uganda; Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - John L Johnson
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda; Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Karen Morgan
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Phineas Gitta
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - W Henry Boom
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda; Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | | | - Kathleen D Eisenach
- Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA; Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lorna Bozeman
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Atlanta, GA, USA
| | - Stefan V Goldberg
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Atlanta, GA, USA
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25
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Oramasionwu GE, Heilig CM, Udomsantisuk N, Kimerling ME, Eng B, Nguyen HD, Thai S, Keo C, McCarthy KD, Varma JK, Cain KP. The utility of stool cultures for diagnosing tuberculosis in people living with the human immunodeficiency virus. Int J Tuberc Lung Dis 2014; 17:1023-8. [PMID: 23827025 DOI: 10.5588/ijtld.13.0061] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delayed diagnosis of tuberculosis (TB) increases mortality. OBJECTIVE To evaluate whether stool culture improves the diagnosis of TB in people living with the human immunodeficiency virus (PLHIV). DESIGN We analysed cross-sectional data of TB diagnosis in PLHIV in Cambodia, Thailand and Viet Nam. Logistic regression was used to assess the association between positive stool culture and TB, and to calculate the incremental yield of stool culture. RESULTS A total of 1693 PLHIV were enrolled with a stool culture result. Of 228 PLHIV with culture-confirmed TB from any site, 101 (44%) had a positive stool culture; of these, 91 (90%) had pulmonary TB (PTB). After adjusting for confounding factors, a positive stool culture was associated with smear-negative (odds ratio [OR] 26, 95% confidence interval [CI] 12-58), moderately smear-positive (OR 60, 95%CI 23-159) and highly smear-positive (OR 179, 95%CI 59-546) PTB compared with no PTB. No statistically significant association existed with extra-pulmonary TB compared with no extra-pulmonary TB (OR 2, 95%CI 1-5). The incremental yield of one stool culture above two sputum cultures (5%, 95%CI 3-8) was comparable to an additional sputum culture (7%, 95%CI 4-11). CONCLUSION Nearly half of the PLHIV with TB had a positive stool culture that was strongly associated with PTB. Stool cultures may be used to diagnose TB in PLHIV.
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Affiliation(s)
- G E Oramasionwu
- Epidemic Intelligence Service, Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA
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26
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Shepardson D, Marks SM, Chesson H, Kerrigan A, Holland DP, Scott N, Tian X, Borisov AS, Shang N, Heilig CM, Sterling TR, Villarino ME, Mac Kenzie WR. Cost-effectiveness of a 12-dose regimen for treating latent tuberculous infection in the United States. Int J Tuberc Lung Dis 2013; 17:1531-7. [PMID: 24200264 PMCID: PMC5451112 DOI: 10.5588/ijtld.13.0423] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
SETTING A large randomized controlled trial recently showed that for treating latent tuberculous infection (LTBI) in persons at high risk of progression to tuberculosis (TB) disease, a 12-dose regimen of weekly rifapentine plus isoniazid (3HP) administered as directly observed treatment (DOT) can be as effective as 9 months of daily self-administered isoniazid (9H). OBJECTIVES To assess the cost-effectiveness of 3HP compared to 9H. DESIGN A computational model was designed to simulate individuals with LTBI treated with 9H or 3HP. Costs and health outcomes were estimated to determine the incremental costs per active TB case prevented and per quality-adjusted life year (QALY) gained by 3HP compared to 9H. RESULTS Over a 20-year period, treatment of LTBI with 3HP rather than 9H resulted in 5.2 fewer cases of TB and 25 fewer lost QALYs per 1000 individuals treated. From the health system and societal perspectives, 3HP would cost respectively US$21,525 and $4294 more per TB case prevented, and respectively $4565 and $911 more per QALY gained. CONCLUSIONS 3HP may be a cost-effective alternative to 9H, particularly if the cost of rifapentine decreases, the effectiveness of 3HP can be maintained without DOT, and 3HP treatment is limited to those with a high risk of progression to TB disease.
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Affiliation(s)
- D Shepardson
- Division of Tuberculosis Elimination, National Center for HIV/AIDS, Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA; Steven M Teutsch Prevention Effectiveness Fellowship Program, Office of Surveillance, Epidemiology and Laboratory Sciences, CDC, Atlanta, Georgia, USA; Department of Mathematics and Statistics, Mount Holyoke College, South Hadley, Massachusetts, USA
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27
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Auld SC, Click ES, Heilig CM, Miramontes R, Cain KP, Bisson GP, Kenzie WRM. Tuberculin skin test result and risk of death among persons with active TB. PLoS One 2013; 8:e78779. [PMID: 24244358 PMCID: PMC3823982 DOI: 10.1371/journal.pone.0078779] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 09/20/2013] [Indexed: 12/01/2022] Open
Abstract
Background Although the tuberculin skin test (TST) is frequently used to aid in the diagnosis of tuberculosis (TB) disease and to identify persons with latent TB infection, it is an imperfect test and approximately 10–25% of persons with microbiologically confirmed TB disease have a negative TST. Previous studies have suggested that persons with a negative TST are more likely to present with severe TB disease and have an increased rate of TB-related death. Methods We analyzed culture-confirmed TB cases captured in US TB surveillance data from 1993 to 2008 and performed multivariate logistic regression analysis to determine the association between TST result and death. Results Of 284,866 cases of TB reported in the US, 58,180 persons were eligible for inclusion in the analysis and 3,270 of those persons died after initiating TB treatment. Persons with a negative TST accounted for only 14% of the eligible cases but accounted for 42% of the deaths. Persons with a TST≥15 mm had 67% lower odds of death than persons with a negative TST (adjusted odds ratio 0.33, 95% confidence interval 0.30–0.36). Conclusions A negative TST is associated with an increased risk of death among persons with culture-confirmed TB disease, even after adjustment for HIV status, site of TB disease, sputum smear AFB status, drug susceptibility, age, sex, and origin of birth. In addition to indicating risk of developing disease, the TST may also be a marker for increased risk of death.
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Affiliation(s)
- Sara C. Auld
- Division of Tuberculosis Elimination, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Epidemic Intelligence Service, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- * E-mail:
| | - Eleanor S. Click
- Division of Tuberculosis Elimination, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Charles M. Heilig
- Division of Tuberculosis Elimination, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Roque Miramontes
- Division of Tuberculosis Elimination, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Kevin P. Cain
- U.S. Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Gregory P. Bisson
- Department of Medicine, Infectious Diseases Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - William R. Mac. Kenzie
- Division of Tuberculosis Elimination, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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28
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Auld SC, Click ES, Heilig CM, Miramontes R, Cain KP, Bisson GP, Mac Kenzie WR. Association between tuberculin skin test result and clinical presentation of tuberculosis disease. BMC Infect Dis 2013; 13:460. [PMID: 24093965 PMCID: PMC3851915 DOI: 10.1186/1471-2334-13-460] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Accepted: 09/27/2013] [Indexed: 11/10/2022] Open
Abstract
Background The tuberculin skin test (TST) is used to test for latent tuberculosis (TB) infection and support the diagnosis of active TB. However, little is known about the relationship between the TST result and the clinical presentation of TB disease. Methods We analyzed US TB surveillance data, 1993–2010, and used multinomial logistic regression to calculate the association between TST result (0–4 mm [negative], 5–9 mm, 10–14 mm, and ≥ 15 mm) and clinical presentation of disease (miliary, combined pulmonary and extrapulmonary, extrapulmonary only, non-cavitary pulmonary, and cavitary pulmonary). For persons with pulmonary disease, multivariate logistic regression was used to calculate the odds of having acid-fast bacilli (AFB) positive sputum. Results There were 64,238 persons with culture-confirmed TB included in the analysis, which was stratified by HIV status and birthplace (US- vs. foreign-born). Persons with a TST ≥ 15 mm were less likely to have miliary or combined pulmonary and extrapulmonary disease, but more likely to have cavitary pulmonary disease than non-cavitary pulmonary disease. Persons with non-cavitary pulmonary disease with a negative TST were significantly more likely to have AFB positive sputum. Conclusions Clinical presentation of TB disease differed according to TST result and persons with a negative TST were more likely to have disseminated disease (i.e., miliary or combined pulmonary and extrapulmonary). Further study of the TST result may improve our understanding of the host-pathogen relationship in TB disease.
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Affiliation(s)
- Sara C Auld
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention, Atlanta, USA.
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29
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Hey SP, Heilig CM, Weijer C. Accumulating Evidence and Research Organization (AERO) model: a new tool for representing, analyzing, and planning a translational research program. Trials 2013; 14:159. [PMID: 23721523 PMCID: PMC3673838 DOI: 10.1186/1745-6215-14-159] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Accepted: 05/08/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Maximizing efficiency in drug development is important for drug developers, policymakers, and human subjects. Limited funds and the ethical imperative of risk minimization demand that researchers maximize the knowledge gained per patient-subject enrolled. Yet, despite a common perception that the current system of drug development is beset by inefficiencies, there remain few approaches for systematically representing, analyzing, and communicating the efficiency and coordination of the research enterprise. In this paper, we present the first steps toward developing such an approach: a graph-theoretic tool for representing the Accumulating Evidence and Research Organization (AERO) across a translational trajectory. METHODS This initial version of the AERO model focuses on elucidating two dimensions of robustness: (1) the consistency of results among studies with an identical or similar outcome metric; and (2) the concordance of results among studies with qualitatively different outcome metrics. The visual structure of the model is a directed acyclic graph, designed to capture these two dimensions of robustness and their relationship to three basic questions that underlie the planning of a translational research program: What is the accumulating state of total evidence? What has been the translational trajectory? What studies should be done next? RESULTS We demonstrate the utility of the AERO model with an application to a case study involving the antibacterial agent, moxifloxacin, for the treatment of drug-susceptible tuberculosis. We then consider some possible elaborations for the AERO model and propose a number of ways in which the tool could be used to enhance the planning, reporting, and analysis of clinical trials. CONCLUSION The AERO model provides an immediate visual representation of the number of studies done at any stage of research, depicting both the robustness of evidence and the relationship of each study to the larger translational trajectory. In so doing, it makes some of the invisible or inchoate properties of the research system explicit - helping to elucidate judgments about the accumulating state of evidence and supporting decision-making for future research.
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Affiliation(s)
- Spencer Phillips Hey
- Studies for Translation, Ethics, and Medicine (STREAM) Group, Biomedical Ethics Unit, McGill University, Montreal, QC, Canada.
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Padayatchi N, Mac Kenzie WR, Hirsch-Moverman Y, Feng PJ, Villarino E, Saukkonen J, Heilig CM, Weiner M, El-Sadr WM. Lessons from a randomised clinical trial for multidrug-resistant tuberculosis. Int J Tuberc Lung Dis 2013; 16:1582-7. [PMID: 23131255 DOI: 10.5588/ijtld.12.0315] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The treatment of multidrug-resistant tuberculosis (MDR-TB) is currently based upon expert opinion and findings from case series, rather than upon randomised clinical trials (RCTs). OBJECTIVE To describe the challenges encountered during an RCT for the treatment of MDR-TB. METHODS Tuberculosis Trials Consortium Study 30 was a pilot, Phase I/II, double-blind, placebo-controlled, RCT of the safety and tolerability of 16 weeks of daily, low-dose linezolid treatment for MDR-TB. RESULTS A total of 36 patients, 56% of the target of 64 patients, consented to participate, for an average of 0.69 enrolments per week. Of the 36 patients enrolled, only 25 (69%) completed at least 90 doses of study treatment. Among the 12 (33%) patients who did not complete all 112 doses of the study treatment, the median time to study withdrawal was 15 days (range 0-92). After the study, we discovered discordance between treatment assignment and study drug for at least 9 (25%) of the 36 patients. CONCLUSIONS Recruitment and retention in this MDR-TB clinical trial posed substantial challenges, suggesting the need for a large, multidisciplinary group of study staff to support the participants. Withdrawal tended to occur early in study treatment. The discrepancy in assigned study medication reflects the need for stronger administrative controls for study drugs.
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Affiliation(s)
- N Padayatchi
- Centre for AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
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31
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Millett GA, Jeffries WL, Peterson JL, Malebranche DJ, Lane T, Flores SA, Fenton KA, Wilson PA, Steiner R, Heilig CM. Common roots: a contextual review of HIV epidemics in black men who have sex with men across the African diaspora. Lancet 2012; 380:411-23. [PMID: 22819654 DOI: 10.1016/s0140-6736(12)60722-3] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pooled estimates from across the African diaspora show that black men who have sex with men (MSM) are 15 times more likely to be HIV positive compared with general populations and 8·5 times more likely compared with black populations. Disparities in the prevalence of HIV infection are greater in African and Caribbean countries that criminalise homosexual activity than in those that do not criminalise such behaviour. With the exception of US and African epidemiological studies, most studies of black MSM mainly focus on outcomes associated with HIV behavioural risk rather than on prevalence, incidence, or undiagnosed infection. Nevertheless, black MSM across the African diaspora share common experiences such as discrimination, cultural norms valuing masculinity, concerns about confidentiality during HIV testing or treatment, low access to HIV drugs, threats of violence or incarceration, and few targeted HIV prevention resources.
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Affiliation(s)
- Gregorio A Millett
- National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA 20201, USA.
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32
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Millett GA, Peterson JL, Flores SA, Hart TA, Jeffries WL, Wilson PA, Rourke SB, Heilig CM, Elford J, Fenton KA, Remis RS. Comparisons of disparities and risks of HIV infection in black and other men who have sex with men in Canada, UK, and USA: a meta-analysis. Lancet 2012; 380:341-8. [PMID: 22819656 DOI: 10.1016/s0140-6736(12)60899-x] [Citation(s) in RCA: 542] [Impact Index Per Article: 45.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND We did a meta-analysis to assess factors associated with disparities in HIV infection in black men who have sex with men (MSM) in Canada, the UK, and the USA. METHODS We searched Embase, Medline, Google Scholar, and online conference proceedings from Jan 1, 1981, to Dec 31, 2011, for racial comparative studies with quantitative outcomes associated with HIV risk or HIV infection. Key words and Medical Subject Headings (US National Library of Medicine) relevant to race were cross-referenced with citations pertinent to homosexuality in Canada, the UK, and the USA. Data were aggregated across studies for every outcome of interest to estimate overall effect sizes, which were converted into summary ORs for 106,148 black MSM relative to 581,577 other MSM. FINDINGS We analysed seven studies from Canada, 13 from the UK, and 174 from the USA. In every country, black MSM were as likely to engage similarly in serodiscordant unprotected sex as other MSM. Black MSM in Canada and the USA were less likely than other MSM to have a history of substance use (odds ratio, OR, 0·53, 95% CI 0·38-0·75, for Canada and 0·67, 0·50-0·92, for the USA). Black MSM in the UK (1·86, 1·58-2·18) and the USA (3·00, 2·06-4·40) were more likely to be HIV positive than were other MSM, but HIV-positive black MSM in each country were less likely (22% in the UK and 60% in the USA) to initiate combination antiretroviral therapy (cART) than other HIV-positive MSM. US HIV-positive black MSM were also less likely to have health insurance, have a high CD4 count, adhere to cART, or be virally suppressed than were other US HIV-positive MSM. Notably, despite a two-fold greater odds of having any structural barrier that increases HIV risk (eg, unemployment, low income, previous incarceration, or less education) compared with other US MSM, US black MSM were more likely to report any preventive behaviour against HIV infection (1·39, 1·23-1·57). For outcomes associated with HIV infection, disparities were greatest for US black MSM versus other MSM for structural barriers, sex partner demographics (eg, age, race), and HIV care outcomes, whereas disparities were least for sexual risk outcomes. INTERPRETATION Similar racial disparities in HIV and sexually transmitted infections and cART initiation are seen in MSM in the UK and the USA. Elimination of disparities in HIV infection in black MSM cannot be accomplished without addressing structural barriers or differences in HIV clinical care access and outcomes. FUNDING None.
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Affiliation(s)
- Gregorio A Millett
- National Center for HIV/AIDS, Viral, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Willis MD, Winston CA, Heilig CM, Cain KP, Walter ND, Mac Kenzie WR. Seasonality of tuberculosis in the United States, 1993-2008. Clin Infect Dis 2012; 54:1553-60. [PMID: 22474225 DOI: 10.1093/cid/cis235] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Although seasonal variation in tuberculosis incidence has been described in several recent studies, the mechanism underlying this seasonality remains unknown. Seasonality of tuberculosis disease may indicate the presence of season-specific risk factors that could potentially be controlled if they were better understood. We conducted this study to determine whether tuberculosis is seasonal in the United States and to describe patterns of seasonality in specific populations. METHODS We performed a time series decomposition analysis of tuberculosis cases reported to the Centers for Disease Control and Prevention from 1993 through 2008. Seasonal amplitude of tuberculosis disease (the difference between the months with the highest and lowest mean case counts), was calculated for the population as a whole and for populations with select demographic, clinical, and epidemiologic characteristics. RESULTS A total of 243 432 laboratory-confirmed tuberculosis cases were reported over a period of 16 years. A mean of 21.4% more cases were diagnosed in March, the peak month, compared with November, the trough month. The magnitude of seasonality did not vary with latitude. The greatest seasonal amplitude was found among children aged <5 years and in cases associated with disease clusters. CONCLUSIONS Tuberculosis is a seasonal disease in the United States, with a peak in spring and trough in late fall. The latitude independence of seasonality suggests that reduced winter sunlight exposure may not be a strong contributor to tuberculosis risk. Increased seasonality among young children and clustered cases suggests that disease that is the result of recent transmission is more influenced by season than disease resulting from activation of latent infection.
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Affiliation(s)
- Matthew D Willis
- Epidemic Intelligence Service Program, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
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34
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Corneli AL, Sorenson JR, Bentley ME, Henderson GE, Bowling JM, Nkhoma J, Moses A, Zulu C, Chilima J, Ahmed Y, Heilig CM, Jamieson DJ, van der Horst C. Improving participant understanding of informed consent in an HIV-prevention clinical trial: a comparison of methods. AIDS Behav 2012; 16:412-21. [PMID: 21656146 PMCID: PMC3923514 DOI: 10.1007/s10461-011-9977-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Empirical research on informed consent has shown that study participants often do not fully understand consent information. This study assessed participant understanding of three mock consent approaches describing an HIV-prevention clinical trial in Lilongwe, Malawi prior to trial implementation. Pregnant women (n = 297) were systematically selected from antenatal-care waiting lines and sequentially allocated to receive an enhanced standard consent form (group 1), a context-specific consent form (group 2), or context-specific counseling cards (group 3). Understanding of research concepts and study procedures was assessed immediately postintervention and at 1-week follow-up. At postintervention, participants in groups 2 and 3 understood more about research concepts and study procedures compared with group 1. Group 3 participants also understood more about study procedures compared with group 2. At follow-up, participants in groups 2 and 3 continued to understand more about research concepts and study procedures. Context-specific approaches improved understanding of consent information in this study.
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Affiliation(s)
- Amy L Corneli
- Department of Health Behavior and Health Education, The University of North Carolina at Chapel Hill, USA.
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Abstract
Public health surveillance by necessity occurs without explicit patient consent. There is strong legal and scientific support for maintaining name-based reporting of infectious diseases and other types of public health surveillance. We present conditions under which surveillance without explicit patient consent is ethically justifiable using principles of contemporary clinical and public health ethics. Overriding individual autonomy must be justified in terms of the obligation of public health to improve population health, reduce inequities, attend to the health of vulnerable and systematically disadvantaged persons, and prevent harm. In addition, data elements collected without consent must represent the minimal necessary interference, lead to effective public health action, and be maintained securely.
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Affiliation(s)
- Lisa M Lee
- Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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36
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Heilig CM, Chia D, El-Sadr WM, Hirsch-Moverman Y, Kenzie WRM, Saukkonen J, Villarino ME, Padayatchi N. Justifying research risks in a clinical trial for treatment of multidrug-resistant tuberculosis. IRB 2011; 33:10-17. [PMID: 21932482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Charles M Heilig
- Division of Tuberculosis Elimination, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
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Cain KP, McCarthy KD, Heilig CM, Monkongdee P, Tasaneeyapan T, Kanara N, Kimerling ME, Chheng P, Thai S, Sar B, Phanuphak P, Teeratakulpisarn N, Phanuphak N, Nguyen HD, Hoang TQ, Le HT, Varma JK. An algorithm for tuberculosis screening and diagnosis in people with HIV. N Engl J Med 2010; 362:707-16. [PMID: 20181972 DOI: 10.1056/nejmoa0907488] [Citation(s) in RCA: 183] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Tuberculosis screening is recommended for people with human immunodeficiency virus (HIV) infection to facilitate early diagnosis and safe initiation of antiretroviral therapy and isoniazid preventive therapy. No internationally accepted, evidence-based guideline addresses the optimal means of conducting such screening, although screening for chronic cough is common. METHODS We consecutively enrolled people with HIV infection from eight outpatient clinics in Cambodia, Thailand, and Vietnam. For each patient, three samples of sputum and one each of urine, stool, blood, and lymph-node aspirate (for patients with lymphadenopathy) were obtained for mycobacterial culture. We compared the characteristics of patients who received a diagnosis of tuberculosis (on the basis of having one or more specimens that were culture-positive) with those of patients who did not have tuberculosis to derive an algorithm for screening and diagnosis. RESULTS Tuberculosis was diagnosed in 267 (15%) of 1748 patients (median CD4+ T-lymphocyte count, 242 per cubic millimeter; interquartile range, 82 to 396). The presence of a cough for 2 or 3 weeks or more during the preceding 4 weeks had a sensitivity of 22 to 33% for detecting tuberculosis. The presence of cough of any duration, fever of any duration, or night sweats lasting 3 or more weeks in the preceding 4 weeks was 93% sensitive and 36% specific for tuberculosis. In the 1199 patients with any of these symptoms, a combination of two negative sputum smears, a normal chest radiograph, and a CD4+ cell count of 350 or more per cubic millimeter helped to rule out a diagnosis of tuberculosis, whereas a positive diagnosis could be made only for the 113 patients (9%) with one or more positive sputum smears; mycobacterial culture was required for most other patients. CONCLUSIONS In persons with HIV infection, screening for tuberculosis should include asking questions about a combination of symptoms rather than only about chronic cough. It is likely that antiretroviral therapy and isoniazid preventive therapy can be started safely in people whose screening for all three symptoms is negative, whereas diagnosis in most others will require mycobacterial culture.
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Affiliation(s)
- Kevin P Cain
- U.S. Centers for Disease Control and Prevention, Division of Tuberculosis Elimination, Atlanta, GA 30333, USA.
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38
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Dorman SE, Johnson JL, Goldberg S, Muzanye G, Padayatchi N, Bozeman L, Heilig CM, Bernardo J, Choudhri S, Grosset JH, Guy E, Guyadeen P, Leus MC, Maltas G, Menzies D, Nuermberger EL, Villarino M, Vernon A, Chaisson RE. Substitution of moxifloxacin for isoniazid during intensive phase treatment of pulmonary tuberculosis. Am J Respir Crit Care Med 2009; 180:273-80. [PMID: 19406981 DOI: 10.1164/rccm.200901-0078oc] [Citation(s) in RCA: 193] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Moxifloxacin has potent activity against Mycobacterium tuberculosis in vitro and in a mouse model of antituberculosis (TB) chemotherapy, but data regarding its activity in humans are limited. OBJECTIVES Our objective was to compare the antimicrobial activity and safety of moxifloxacin versus isoniazid during the first 8 weeks of combination therapy for pulmonary TB. METHODS Adults with sputum smear-positive pulmonary TB were randomly assigned to receive either moxifloxacin 400 mg plus isoniazid placebo, or isoniazid 300 mg plus moxifloxacin placebo, administered 5 days/week for 8 weeks, in addition to rifampin, pyrazinamide, and ethambutol. All doses were directly observed. Sputum was collected for culture every 2 weeks. The primary outcome was negative sputum culture at completion of 8 weeks of treatment. MEASUREMENTS AND MAIN RESULTS Of 433 participants enrolled, 328 were eligible for the primary efficacy analysis. Of these, 35 (11%) were HIV positive, 248 (76%) had cavitation on baseline chest radiograph, and 213 (65%) were enrolled at African sites. Negative cultures at Week 8 were observed in 90/164 (54.9%) participants in the isoniazid arm, and 99/164 (60.4%) in the moxifloxacin arm (P = 0.37). In multivariate analysis, cavitation and enrollment at an African site were associated with lower likelihood of Week-8 culture negativity. The proportion of participants who discontinued assigned treatment was 31/214 (14.5%) for the moxifloxacin group versus 22/205 (10.7%) for the isoniazid group (RR, 1.35; 95% CI, 0.81, 2.25). CONCLUSIONS Substitution of moxifloxacin for isoniazid resulted in a small but statistically nonsignificant increase in Week-8 culture negativity.
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Affiliation(s)
- Susan E Dorman
- Johns Hopkins University Center for Tuberculosis Research, Baltimore, Maryland 21231, USA.
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Abstract
OBJECTIVE The rate of primary cesarean delivery in Puerto Rico in 2002 was 52% higher than in 1996 and 85% higher than among Puerto Rican women delivering on the U.S. mainland. Reasons for these differences were explored using birth certificate data. METHODS Distributions of mothers' age, education, parity, level of prenatal care, pregnancy weight gain, medical risk factors, labor induction, labor or delivery complications, and infant birth weight among births in Puerto Rico in 2002 (n=40,489) were compared with births in Puerto Rico in 1996 (n=51,357) and births to Puerto Rican women delivering on the mainland in 2002 (n=47,800). Multivariable log-linear regression models were used to estimate relative risks for primary cesarean delivery by year, place of delivery, and selected risk factors. RESULTS Risk for cesarean delivery was higher in Puerto Rico in 2002 than in both 1996 (relative risk 2.1, 95% confidence interval 2.0, 2.3) and on the mainland in 2002 (relative risk 2.4, 95% confidence interval 2.2, 2.6). This translates into one additional cesarean delivery in Puerto Rico in 2002 for every 4.2 live births, controlled for examined risk factors. Higher rates of cesarean delivery in Puerto Rico in 2002 could not be explained by examined risk factors. CONCLUSION Until further research reveals ways to safely reduce the rate of cesarean delivery in Puerto Rico, physicians, public health practitioners, and other stakeholders may want to focus their efforts on reducing rates among low-risk women and those with no labor complications. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Sherry L Farr
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia 30341, USA.
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40
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Tohill BC, Heilig CM, Klein RS, Rompalo A, Cu-Uvin S, Piwoz EG, Jamieson DJ, Duerr A. Nutritional biomarkers associated with gynecological conditions among US women with or at risk of HIV infection. Am J Clin Nutr 2007; 85:1327-34. [PMID: 17490970 DOI: 10.1093/ajcn/85.5.1327] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Women infected with HIV face a combination of health threats that include compromised nutrition and adverse gynecological conditions. This relation among HIV, nutrition, and gynecological conditions is complex and has rarely been investigated. OBJECTIVE Our objective was to investigate nutritional biomarkers associated with several gynecological conditions among US women with or at risk of HIV infection. DESIGN Data on 369 HIV-infected and 184 HIV-uninfected women with both nutritional and gynecological outcomes were analyzed from a cross-sectional nutritional substudy of the HIV Epidemiology Research Study (HERS). We examined micronutrient distributions comparing HIV-infected with HIV-uninfected participants and both subgroups with the US population. We then modeled the relation of 16 micronutrient serum concentrations to various gynecological conditions, producing partially adjusted odds ratios, adjusted for study site, risk cohort, and HIV status. RESULTS HIV-infected women's median antioxidant concentrations were lower than the medians of the US population. HERS women had lower median concentrations for vitamin A, selenium, and zinc irrespective of HIV status. Trichomoniasis prevalence was inversely related to serum alpha-carotene. Lower concentrations of vitamins A, C, and E and beta-carotene were associated with an increased risk of bacterial vaginosis. Higher concentrations of serum zinc were associated with lower risk of human papillomavirus. Candida colonization was higher among women with higher concentrations of total-iron-binding capacity. CONCLUSION We identified several significant associations of micronutrient concentrations with the prevalence of gynecological conditions. These findings warrant further investigation into possible causal relations.
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Affiliation(s)
- Beth C Tohill
- Centers for Disease Control and Prevention, National Center for Chronic Disease and Public Health Prevention, Division of Nutrition and Physical Activity and Division of Reproductive Health, Atlanta, GA 30341, USA.
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Corneli AL, Bentley ME, Sorenson JR, Henderson GE, van der Horst C, Moses A, Nkhoma J, Tenthani L, Ahmed Y, Heilig CM, Jamieson DJ. Using formative research to develop a context-specific approach to informed consent for clinical trials. J Empir Res Hum Res Ethics 2006; 1:45-60. [PMID: 19385837 PMCID: PMC3140046 DOI: 10.1525/jer.2006.1.4.45] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PARTICIPANT UNDERSTANDING is of particular concern when obtaining informed consent. Recommendations for improving understanding include disclosing information using culturallyappropriate and innovative approaches. To increase the effectiveness of the consent process for a clinical trial in Malawi on interventions to prevent mother-tochild transmission of HIV during breastfeeding, formative research was conducted to explore the community's understanding of medical research as well as how to explain research through local terms and meanings. Contextual analogies and other approaches were identified to explain consent information. Guided by theory, strategies for developing culturally appropriate interventions, and recommendations from the literature, we demonstrate how the formative data were used to develop culturally appropriate counseling cards specifically for the trial in Malawi. With appropriate contextual modifications, the steps outlined here could be applied in other clinical trials conducted elsewhere, as well as in other types of research.
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Koshiol JE, Schroeder JC, Jamieson DJ, Marshall SW, Duerr A, Heilig CM, Shah KV, Klein RS, Cu-Uvin S, Schuman P, Celentano D, Smith JS. Time to clearance of human papillomavirus infection by type and human immunodeficiency virus serostatus. Int J Cancer 2006; 119:1623-9. [PMID: 16646070 DOI: 10.1002/ijc.22015] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Persistent infection with high-risk human papillomavirus (HPV) is central to cervical carcinogenesis. Certain high-risk types, such as HPV16, may be more persistent than other HPV types, and type-specific HPV persistence may differ by HIV serostatus. This study evaluated the association between HPV type and clearance of HPV infections in 522 HIV-seropositive and 279 HIV-seronegative participants in the HIV Epidemiology Research Study (HERS, United States, 1993-2000). Type-specific HPV infections were detected using MY09/MY11/HMB01-based PCR and 26 HPV type-specific probes. The estimated duration of type-specific infections was measured from the first HPV-positive visit to the first of two consecutive negative visits. Hazard ratios (HRs) and 95% confidence intervals (CIs) for HPV clearance were calculated using Cox models adjusted for study site and risk behavior (sexual or injection drugs). A total of 1,800 HPV infections were detected in 801 women with 4.4 years median follow-up. HRs for clearance of HPV16 and related types versus low-risk HPV types were 0.79 (95% CI: 0.64-0.97) in HIV-positive women and 0.86 (95% CI: 0.59-1.27) in HIV-negative women. HRs for HPV18 versus low-risk types were 0.80 (95% CI: 0.56-1.16) and 0.57 (95% CI: 0.22-1.45) for HIV-positive and -negative women, respectively. HPV types within the high-risk category had low estimated clearance rates relative to low-risk types, but HRs were not substantially modified by HIV serostatus.
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Affiliation(s)
- Jill E Koshiol
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA.
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Koshiol J, Schroeder J, Jamieson DJ, Marshall SW, Duerr A, Heilig CM, Shah KV, Klein RS, Cu-Uvin S, Schuman P, Celentano D, Smith JS. Smoking and time to clearance of human papillomavirus infection in HIV-seropositive and HIV-seronegative women. Am J Epidemiol 2006; 164:176-83. [PMID: 16775041 DOI: 10.1093/aje/kwj165] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Persistent human papillomavirus (HPV) infection seems central to cervical carcinogenesis. Smoking is associated with cervical cancer in HPV DNA-positive women, but its association with HPV persistence is unclear, particularly with respect to human immunodeficiency virus (HIV) serostatus. The authors evaluated smoking and HPV clearance by HIV serostatus among 801 women from the HIV Epidemiology Research Study (United States, 1993-2000). Type-specific HPV duration was defined as the interval between initial MY09/11 polymerase chain reaction positivity and the first of two consecutive HPV-negative study visits. Hazard ratios adjusted for study site and risk behaviors (sexual activity or injection drug use) were estimated using Cox regression. This analysis included 522 HIV-seropositive and 279 HIV-seronegative women (median follow-up, 4.4 years). Ever smoking was associated with reduced clearance of high-risk HPV in HIV-seronegative women (hazard ratio (HR) = 0.51, 95% confidence interval (CI): 0.30, 0.88) but not in HIV-seropositive women (HR = 0.96, 95% CI: 0.65, 1.42); similar results were found for current smoking. Current smoking was not associated with clearance of any type-specific HPV in HIV-seropositive (HR = 0.99, 95% CI: 0.82, 1.20) or HIV-seronegative (HR = 0.93, 95% CI: 0.68, 1.26) women. HPV clearance did not appear to vary by amount or duration of smoking. Smoking did not modify overall clearance but was associated with lower high-risk HPV clearance in HIV-seronegative women.
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Affiliation(s)
- Jill Koshiol
- Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, USA.
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Duerr A, Paramsothy P, Jamieson DJ, Heilig CM, Klein RS, Cu-Uvin S, Schuman P, Anderson JR. Effect of HIV Infection on Atypical Squamous Cells of Undetermined Significance. Clin Infect Dis 2006; 42:855-61. [PMID: 16477565 DOI: 10.1086/500404] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2005] [Accepted: 11/22/2005] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Detection of atypical squamous cells of undetermined significance (ASCUS) is a cervical cytologic finding that is suggestive but not definitive of squamous intraepithelial lesions (SILs). METHODS We examined the risk, characteristics, and progression of ASCUS in women with and without human immunodeficiency virus (HIV) infection. Cervical Papanicolou (Pap) test and colposcopy data were obtained at the first 10 semiannual visits for the HIV Epidemiology Research study of 774 HIV-infected and 480 demographically similar, HIV-uninfected women in the United States. Multiple logistic regression models and Cox proportional hazards models were utilized. RESULTS ASCUS was more common among HIV-infected women (odds ratio [OR], 1.6 [95% confidence interval {CI}, 1.3-2.0] to 2.6 [95% CI, 1.9-3.6]) after adjustment for human papillomavirus (HPV) infection and other risk factors (e.g., race, condyloma, and prior Pap test result). Among women with normal Pap test results at enrollment, the cumulative incidence of ASCUS was 78% among HIV-infected women and 38% among HIV-uninfected women. HIV-infected and HIV-uninfected women with ASCUS did not differ by prevalence of indices of inflammation (inflammation on Pap test and leukocytes on cervical gram stain). HPV infection, including high risk types, was more common among HIV-infected women with ASCUS. Among women with ASCUS, 60% of HIV-infected and 25% of HIV-uninfected women developed SILs (P < .01). Compared with HIV-infected women with higher CD4+ lymphocyte counts, HIV-infected women with CD4+ lymphocyte counts < 200 cells/microL were more likely to present subsequently with a SIL detected by Pap test (OR, 1.7; 95% CI, 0.8-3.6). CONCLUSIONS Higher risk of SIL following the appearance of ASCUS among HIV-infected women, especially women with low CD4+ lymphocyte counts, supports the need for follow up with colposcopy and histologic examination, as indicated, to allow early detection and treatment of SIL.
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Affiliation(s)
- Ann Duerr
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.
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Tohill BC, Heilig CM, Klein RS, Rompalo A, Cu-Uvin S, Brown W, Duerr A. Vaginal flora morphotypic profiles and assessment of bacterial vaginosis in women at risk for HIV infection. Infect Dis Obstet Gynecol 2005; 12:121-6. [PMID: 15763911 PMCID: PMC1784599 DOI: 10.1080/10647440400020711] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Specific morphotypic profiles of normal and abnormal vaginal flora, including bacterial vaginosis (BV), were characterized. A prospective study of 350 women yielded concurrent Gram-stain data and clinical assessment (n = 3455 visits). Microbiological profiles were constructed by Gram stain. Eight profile definitions were based on dichotomizing the levels of Lactobacillus, Gardnerella, and curved, Gram-negative bacillus (Mobiluncus) morphotypes. Of these, two were rare, and the other six demonstrated a graded association with the clinical components of BV. The proposed profiles from the Gram stain reflect the morphotypic categories describing vaginal flora that may enable clearer elucidation of gynecologic and obstetric outcomes in various populations.
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Affiliation(s)
- Beth C Tohill
- Centers for Disease Control and Prevention, National Center for Chronic Disease and Public Health Prevention, Division of Nutrition and Physical Activity, Atlanta, GA 30341, USA.
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Abstract
McNemar's test is popular for assessing the difference between proportions when two observations are taken on each experimental unit. It is useful under a variety of epidemiological study designs that produce correlated binary outcomes. In studies involving outcome ascertainment, cost or feasibility concerns often lead researchers to employ error-prone surrogate diagnostic tests. Assuming an available gold standard diagnostic method, we address point and confidence interval estimation of the true difference in proportions and the paired-data odds ratio by incorporating external or internal validation data. We distinguish two special cases, depending on whether it is reasonable to assume that the diagnostic test properties remain the same for both assessments (e.g., at baseline and at follow-up). Likelihood-based analysis yields closed-form estimates when validation data are external and requires numeric optimization when they are internal. The latter approach offers important advantages in terms of robustness and efficient odds ratio estimation. We consider internal validation study designs geared toward optimizing efficiency given a fixed cost allocated for measurements. Two motivating examples are presented, using gold standard and surrogate bivariate binary diagnoses of bacterial vaginosis (BV) on women participating in the HIV Epidemiology Research Study (HERS).
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Affiliation(s)
- Robert H Lyles
- Department of Biostatistics, The Rollins School of Public Health of Emory University, 1518 Clifton Road N.E., Atlanta, Georgia 30322, USA.
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Costello C, Nelson KE, Suriyanon V, Sennun S, Tovanabutra S, Heilig CM, Shiboski S, Jamieson DJ, Robison V, Rungruenthanakit K, Duerr A. HIV-1 subtype E progression among northern Thai couples: traditional and non-traditional predictors of survival. Int J Epidemiol 2005; 34:577-84. [PMID: 15737969 DOI: 10.1093/ije/dyi023] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In the continuing effort to introduce antiretroviral therapy in resource-limited settings, there is a need to understand differences between natural history of HIV in different populations and to identify feasible clinical measures predictive of survival. METHODS We examined predictors of survival among 836 heterosexuals who were infected with HIV subtype CRF01_AE in Thailand. RESULTS From 1993 to 1999, 269 (49.4%) men and 65 (25.7%) women died. The median time from the estimated seroconversion to death was 7.8 years (95% confidence interval 7.0-9.1). Men and women with enrolment CD4 counts <200 cells/microl had about 2 and 11 times greater risk of death than those with CD4 counts of 200-500 and >500, respectively. Measurements available in resource-limited settings, including total lymphocyte count (TLC), anaemia, and low body mass index (BMI), also predicted survival. Men with two or more of these predictors had a median survival of 0.8 (0.5-1.8) years, compared with 2.7 (1.9-3.3) years for one predictor and 4.9 (4.1-5.2) years for no predictors. CONCLUSIONS The time from HIV infection to death appears shorter among this Thai population than among antiretroviral naive Western populations. CD4 count and viral load (VL) were strong, independent predictors of survival. When CD4 count and VL are unavailable, individuals at high risk for shortened HIV survival may be identified by a combination of low TLC, anaemia, and low BMI. This combination of accessible clinical measures of the disease stage may be useful for medical management in resource-limited settings.
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Affiliation(s)
- C Costello
- Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, USA
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Kingkeow D, Heilig CM, Costello C, Sennun S, Suriyanon V, Rungruengthanakit K, Taejaroenkul S, Nelson KE, Duerr A. Lymphocyte homeostasis in HIV-infected northern Thais. AIDS Res Hum Retroviruses 2004; 20:636-41. [PMID: 15242540 DOI: 10.1089/0889222041217491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Cross-sectional laboratory data were used to model the patterns of total lymphocyte count and lymphocyte subpopulation counts among persons with chronic HIV-1 subtype E (CRF01_AE) infection during the 6.5 years preceding death. The data cover 331 HIV-infected decedents from a heterosexual HIV transmission study of 590 northern Thai couples enrolled in 1992-1998. From blood collected at enrollment, the lymphocyte phenotypes (CD3, CD8, CD4, natural killer, and B cells) were stained using two-color monoclonal antibody combinations and quantified by flow cytometry. Piecewise linear splines modeled the associations between lymphocyte levels and time before death. Mean CD3, CD8, and B cell levels showed no temporal associations from 6.5 to 2 years before death, but each declined significantly during the 2 years before death. CD3 levels declined 31.0% [95% confidence interval (-40.3%, -19.8%)] and CD8 levels declined 24.6% (-35.4%, -13.5%) annually in the 2 years prior to death. In contrast, CD4 and NK cell levels declined little from 6.5 to 4.5 years before death but declined significantly over the 4.5 years prior to death. CD4 levels declined 22.1% (-29.2%, -12.0%) annually from 4.5 to 2 years prior to death and 63.7% (-72.3%, -53.6%) annually over the remaining 2 years. Similar lymphocyte patterns have been reported in U. S. and European populations with HIV-1 subtype B infection.
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Paramsothy P, Duerr A, Heilig CM, Cu-Uvin S, Anderson JR, Schuman P, Klein RS. Abnormal Vaginal Cytology in HIV-Infected and At-Risk Women After Hysterectomy. J Acquir Immune Defic Syndr 2004; 35:484-91. [PMID: 15021313 DOI: 10.1097/00126334-200404150-00006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the frequency of and risk factors for abnormal vaginal Papanicolaou smears in HIV-infected women after hysterectomy. METHODS Data were from the HIV Epidemiology Research (HER) study, a prospective multisite study of HIV-infected and uninfected women. Semiannual vaginal Papanicolaou smears and colposcopy data were obtained from 102 HIV-infected and 46 at-risk women who had hysterectomy either before or during the study. Analytic models used include Cox proportional hazards (women with hysterectomy during the study) and multiple logistic regressions, which corrected for repeated measures (all women). RESULTS Among the HIV-infected women, evidence of cervical intraepithelial neoplasia before or at hysterectomy was associated with abnormal cytology during follow-up; 63% had squamous intraepithelial lesions (SIL) on vaginal Papanicolaou smears following hysterectomy. CD4 counts of <200 cells/microL at hysterectomy and HIV viral load of >10,000 copies/mL at hysterectomy were predictive of SIL vaginal cytology. Prevalent SIL vaginal cytology was associated with low CD4 count and human papillomavirus risk type. Of the 102 HIV-infected women, 16 (16%) had vaginal intraepithelial neoplasia on biopsy. CONCLUSIONS The high rate of SIL on vaginal Papanicolaou smears and the presence of high-grade vaginal intraepithelial neoplasia among HIV-infected women after hysterectomy demonstrate the need for continued follow-up for lower genital tract lesions.
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Affiliation(s)
- Pangaja Paramsothy
- Contraceptive Research and Development (CONRAD) Program, Arlington, VA, USA
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Duerr A, Heilig CM, Meikle SF, Cu-Uvin S, Klein RS, Rompalo A, Sobel JD. Incident and persistent vulvovaginal candidiasis among human immunodeficiency virus-infected women: Risk factors and severity. Obstet Gynecol 2003; 101:548-56. [PMID: 12636961 DOI: 10.1016/s0029-7844(02)02729-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine risk factors for vulvovaginal candidiasis among women with or at risk for human immunodeficiency virus (HIV) infection. METHODS Data were from 856 HIV-infected women and 421 at-risk uninfected women observed semiannually at four study sites from April 1993 through February 1999. At enrollment women were 15-55 years old and had no acquired immunodeficiency syndrome-defining conditions. Three definitions for vulvovaginal candidiasis of differing severity were constructed using data from vaginal Candida culture and Gram stains scored for yeast and three signs on pelvic examination (vulvovaginal edema, erythema, or discharge): 1) culture or Gram stain positivity plus at least one clinical sign, 2) culture or Gram stain positivity plus at least two clinical signs, and 3) visible yeast on Gram stain plus at least one clinical sign. RESULTS The prevalence and cumulative incidence of each definition of vulvovaginal candidiasis were greater among HIV-infected women than among women not infected with HIV (P <.01 for all comparisons). Stratified by status at the preceding visit, vulvovaginal candidiasis was most likely among women with prior vulvovaginal candidiasis, least likely among women without earlier Candida colonization, and intermediately likely among women with preceding subclinical Candida colonization. Among HIV-infected women, lower CD4 count and higher HIV viral load were associated with vulvovaginal candidiasis. Several other factors were independently associated with vulvovaginal candidiasis, with strong associations for diabetes mellitus and pregnancy in particular. Vulvovaginal candidiasis was not more severe among HIV-infected women. CONCLUSION Vulvovaginal candidiasis occurred with higher incidence and greater persistence, but not greater severity, among HIV-infected women.
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Affiliation(s)
- Ann Duerr
- National Center for Chronic Disease Prevention & Health Promotion, Division of Reproductive Health-HIV Section, Centers for Disease Control and Prevention, Mailstop K-34, 4770 Buford Highway NE, Atlanta, GA 30341-3717, USA.
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