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Malhotra A, Nonyane BAS, Shirey E, Mulder C, Hippner P, Mulatu F, Ratshinanga A, Mitiku P, Cohn S, Conradie G, Chihota V, Chaisson RE, Churchyard GJ, Golub J, Dowdy D, Sohn H, Charalambous S, Bedru A, Salazar-Austin N. Pragmatic cluster-randomized trial of home-based preventive treatment for TB in Ethiopia and South Africa (CHIP-TB). Trials 2023; 24:475. [PMID: 37491264 PMCID: PMC10367260 DOI: 10.1186/s13063-023-07514-7] [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: 03/30/2023] [Accepted: 07/16/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Each year, 1 million children develop TB resulting in over 200,000 child deaths. TB preventive treatment (TPT) is highly effective in preventing TB but remains poorly implemented for household child contacts. Home-based child contact management and TPT services may improve access to care. In this study, we aim to evaluate the effectiveness and cost-effectiveness of home-based contact management with TPT initiation in two TB high-burden African countries, Ethiopia and South Africa. METHODS This pragmatic cluster randomized trial compares home-based versus facility-based care delivery models for contact management. Thirty-six clinics with decentralized TB services (18 in Ethiopia and 18 in South Africa) were randomized in a 1:1 ratio to conduct either home-based or facility-based contact management. The study will attempt to enroll all eligible close child contacts of infectious drug-sensitive TB index patients diagnosed and treated for TB by one of the study clinics. Child TB contact management, including contact tracing, child evaluation, and TPT initiation and follow-up, will take place in the child's home for the intervention arm and at the clinic for the control arm. The primary outcome is the cluster-level ratio of the number of household child contacts less than 15 years of age in Ethiopia and less than 5 years of age in South Africa initiated on TPT per index patient, comparing the intervention to the control arm. Secondary outcomes include child contact identification and the TB prevention continuum of care. Other implementation outcomes include acceptability, feasibility, fidelity, cost, and cost-effectiveness of the intervention. DISCUSSION This implementation research trial will determine whether home-based contact management identifies and initiates more household child contacts on TPT than facility-based contact management. TRIAL REGISTRATION NCT04369326 . Registered on April 30, 2020.
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Affiliation(s)
- Akash Malhotra
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Bareng Aletta Sanny Nonyane
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Evan Shirey
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christiaan Mulder
- Department of TB Elimination and Health System Innovations, KNCV Tuberculosis Foundation, The Hague, The Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Piotr Hippner
- The Aurum Institute, Parktown, Johannesburg, South Africa
| | | | | | | | - Silvia Cohn
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Violet Chihota
- The Aurum Institute, Parktown, Johannesburg, South Africa
| | - Richard E Chaisson
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gavin J Churchyard
- The Aurum Institute, Parktown, Johannesburg, South Africa
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Jonathan Golub
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hojoon Sohn
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Salome Charalambous
- The Aurum Institute, Parktown, Johannesburg, South Africa
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
- Yale School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT, USA
| | - Ahmed Bedru
- KNCV Tuberculosis Foundation, Addis Ababa, Ethiopia
| | - Nicole Salazar-Austin
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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2
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Davies LRL, Smith MT, Cizmeci D, Fischinger S, Shih-Lu Lee J, Lu LL, Layton ED, Grant AD, Fielding K, Stein CM, Boom WH, Hawn TR, Fortune SM, Wallis RS, Churchyard GJ, Alter G, Seshadri C. IFN-γ independent markers of Mycobacterium tuberculosis exposure among male South African gold miners. EBioMedicine 2023; 93:104678. [PMID: 37379655 PMCID: PMC10320233 DOI: 10.1016/j.ebiom.2023.104678] [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: 01/26/2023] [Revised: 06/07/2023] [Accepted: 06/09/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND The prevalence of tuberculosis among men who work in the gold mines of South Africa is among the highest in the world, but a fraction of miners demonstrate consistently negative results upon tuberculin skin test (TST) and IFN-γ release assay (IGRA). We hypothesized that these "resisters" (RSTRs) may display unconventional immune signatures of exposure to M. tuberculosis (M.tb). METHODS In a cohort of RSTRs and matched controls with latent TB infection (LTBI), we profiled the functional breadth of M.tb antigen-specific T cell and antibody responses using multi-parameter flow cytometry and systems serology, respectively. FINDINGS RSTRs and LTBI controls both exhibited IFN-γ independent T-cell and IgG antibody responses to M.tb-specific antigens ESAT-6 and CFP-10. Antigen-specific antibody Fc galactosylation and sialylation were higher among RSTRs. In a combined T-cell and antibody analysis, M.tb lysate-stimulated TNF secretion by T cells correlated positively with levels of purified protein derivative-specific IgG. A multivariate model of the combined data was able to differentiate RSTR and LTBI subjects. INTERPRETATION IFN-γ independent immune signatures of exposure to M.tb, which are not detected by approved clinical diagnostics, are readily detectable in an occupational cohort uniquely characterized by intense and long-term infection pressure. Further, TNF may mediate a coordinated response between M.tb-specific T-cells and B-cells. FUNDING This work was supported by the US National Institutes of Health (R01-AI124348 to Boom, Stein, and Hawn; R01-AI125189 and R01-AI146072 to Seshadri; and 75N93019C00071 to Fortune, Alter, Seshadri, and Boom), the Doris Duke Charitable Foundation (Davies), the Bill & Melinda Gates Foundation (OPP1151836 and OPP1109001 to Hawn; and OPP1151840 to Alter), Mass Life Science Foundation (Fortune), and Good Ventures Fund (Fortune).
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Affiliation(s)
- Leela R L Davies
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA; Brigham and Women's Hospital, Boston, MA, USA
| | - Malisa T Smith
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Deniz Cizmeci
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA; Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | | | - Lenette L Lu
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA
| | - Erik D Layton
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Alison D Grant
- TB Centre, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Catherine M Stein
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA; Department of Population & Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - W Henry Boom
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Thomas R Hawn
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Sarah M Fortune
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA; Department of Immunology and Infectious Diseases, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Robert S Wallis
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA; The Aurum Institute, Parktown, South Africa
| | - Gavin J Churchyard
- The Aurum Institute, Parktown, South Africa; Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Galit Alter
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA; Moderna Therapeutics, Cambridge, MA, USA
| | - Chetan Seshadri
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Seattle Tuberculosis Research Advancement Center, Seattle, WA, USA.
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Jarrett RT, van der Heijden Y, Shotwell MS, Chihota V, Marzinke MA, Chaisson RE, Dooley KE, Churchyard GJ. High Isoniazid Exposures When Administered with Rifapentine Once Weekly for Latent Tuberculosis in Individuals with Human Immunodeficiency Virus. Antimicrob Agents Chemother 2023; 67:e0129722. [PMID: 36622148 PMCID: PMC9933705 DOI: 10.1128/aac.01297-22] [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: 09/26/2022] [Accepted: 12/14/2022] [Indexed: 01/10/2023] Open
Abstract
Isoniazid pharmacokinetics are not yet well-described during once weekly, high-dose administrations with rifapentine (3HP) for latent tuberculosis infection (LTBI). Fewer data describe 3HP with dolutegravir-based antiretroviral therapy for the treatment of human immunodeficiency virus (HIV). The only prior report of 3HP with dolutegravir reported elevated isoniazid exposures. We measured the plasma isoniazid levels in 30 adults receiving 3HP and dolutegravir for the treatment of LTBI and HIV. The patients were genotyped to determine NAT2 acetylator status, and a population PK model was estimated by nonlinear mixed-effects modeling. The results were compared to previously reported data describing 3HP with dolutegravir, 3HP alone, and isoniazid with neither dolutegravir nor rifapentine. The isoniazid concentrations were adequately described by a one compartment model with a transit compartment absorption process. The isoniazid clearance for slow (8.33 L/h) and intermediate (12 L/h) acetylators were similar to previously reported values. Rapid acetylators (N = 4) had clearance similar to those of intermediate acetylators and much slower than typically reported, but the small sample size was limiting. The absorption rate was lower than usual, likely due to the coadministration with food, and it was faster among individuals with a low body weight. Low-body weight participants were also observed to have greater oral bioavailability. The isoniazid exposures were consistent with, or greater than, the previously reported "elevated" concentrations among individuals receiving 3HP and dolutegravir. The concentrations were substantially greater than those presented in previous reports among individuals receiving 3HP or isoniazid without rifapentine or dolutegravir. We discuss the implications of these findings and the possibility of a drug-drug interaction that is mediated by cellular transport. (This study has been registered at ClinicalTrials.gov under identifier NCT03435146 and has South African National Clinical Trial Registration no. DOH-27-1217-5770.).
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Affiliation(s)
- Ryan T. Jarrett
- Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Yuri van der Heijden
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Vanderbilt Tuberculosis Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- The Aurum Institute, Johannesburg, South Africa
| | - Matthew S. Shotwell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Violet Chihota
- Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- The Aurum Institute, Johannesburg, South Africa
| | - Mark A. Marzinke
- Departments of Pathology and Medicine (Clinical Pharmacology), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Richard E. Chaisson
- Department of Medicine Infectious Diseases, Johns Hopkins University Center for Tuberculosis Research, Baltimore, Maryland, USA
- Department of International Health and Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kelly E. Dooley
- Departments of Pathology and Medicine (Clinical Pharmacology), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Medicine Infectious Diseases, Johns Hopkins University Center for Tuberculosis Research, Baltimore, Maryland, USA
| | - Gavin J. Churchyard
- Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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4
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Hanifa Y, Fielding KL, Chihota VN, Adonis L, Charalambous S, Foster N, Karstaedt A, McCarthy K, Nicol MP, Ndlovu NT, Sinanovic E, Sahid F, Stevens W, Vassall A, Churchyard GJ, Grant AD. The utility of repeat Xpert MTB/RIF testing to diagnose tuberculosis in HIV-positive adults with initial negative result. Gates Open Res 2022. [DOI: 10.12688/gatesopenres.12815.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Amongst HIV-positive adults in South Africa with initial negative Xpert results, we compared the yield from repeating Xpert MTB/RIF (“Xpert”) on sputum to guideline-recommended investigation for tuberculosis (TB). Methods: A systematic sample of adults attending for HIV care were enrolled in a cohort exploring TB investigation pathways. This substudy was restricted to those at highest risk of TB (CD4<200 cells/mm3 or unknown) who had a negative initial Xpert result. At attendance for the Xpert result, a repeat sputum sample was stored, and further investigations facilitated per national guidelines. Participants were reviewed monthly, with reinvestigation if indicated, for at least three months, when sputum and blood were cultured for mycobacteria, and the stored sputum tested using Xpert. We defined TB as “confirmed” if Xpert, line probe assay or Mycobacterium tuberculosis culture within six months of enrolment were positive, and “clinical” if TB treatment was started without microbiological confirmation. Results: Amongst 227 participants with an initial negative Xpert result (63% female, median age 37 years, median CD4 count 100 cells/mm3), 28 (12%) participants had TB diagnosed during study follow-up (16 confirmed, 12 clinical); stored sputum tested positive on Xpert in 5/227 (2%). Amongst 27 participants who started TB treatment, the basis was bacteriological confirmation 11/27 (41%); compatible imaging 11/27 (41%); compatible symptoms 2/27 (7%); and unknown 3/27 (11%). Conclusions: Amongst HIV-positive individuals at high risk of active TB with a negative Xpert result, further investigation using appropriate diagnostic modalities is more likely to lead to TB treatment than immediately repeating sputum for Xpert. TB diagnostic tests with improved sensitivity are needed.
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5
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Hanifa Y, Fielding KL, Chihota VN, Adonis L, Charalambous S, Foster N, Karstaedt A, McCarthy K, Nicol MP, Ndlovu NT, Sinanovic E, Sahid F, Stevens W, Vassall A, Churchyard GJ, Grant AD. The utility of repeat Xpert MTB/RIF testing to diagnose tuberculosis in HIV-positive adults with initial negative result. Gates Open Res 2022; 2:22. [PMID: 37700854 PMCID: PMC10495190 DOI: 10.12688/gatesopenres.12815.1] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2022] [Indexed: 09/14/2023] Open
Abstract
Background: Amongst HIV-positive adults in South Africa with initial negative Xpert results, we compared the yield from repeating Xpert MTB/RIF ("Xpert") on sputum to guideline-recommended investigation for tuberculosis (TB). Methods: A systematic sample of adults attending for HIV care were enrolled in a cohort exploring TB investigation pathways. This substudy was restricted to those at highest risk of TB (CD4<200 cells/mm 3 or unknown) who had a negative initial Xpert result. At attendance for the Xpert result, a repeat sputum sample was stored, and further investigations facilitated per national guidelines. Participants were reviewed monthly, with reinvestigation if indicated, for at least three months, when sputum and blood were cultured for mycobacteria, and the stored sputum tested using Xpert. We defined TB as "confirmed" if Xpert, line probe assay or Mycobacterium tuberculosis culture within six months of enrolment were positive, and "clinical" if TB treatment was started without microbiological confirmation. Results: Amongst 227 participants with an initial negative Xpert result (63% female, median age 37 years, median CD4 count 100 cells/mm 3), 28 (12%) participants had TB diagnosed during study follow-up (16 confirmed, 12 clinical); stored sputum tested positive on Xpert in 5/227 (2%). Amongst 27 participants who started TB treatment, the basis was bacteriological confirmation 11/27 (41%); compatible imaging 11/27 (41%); compatible symptoms 2/27 (7%); and unknown 3/27 (11%). Conclusions: Amongst HIV-positive individuals at high risk of active TB with a negative Xpert result, further investigation using appropriate diagnostic modalities is more likely to lead to TB treatment than immediately repeating sputum for Xpert. TB diagnostic tests with improved sensitivity are needed.
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Affiliation(s)
- Yasmeen Hanifa
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Violet N. Chihota
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nicola Foster
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Alan Karstaedt
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Mark P. Nicol
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Service, Johannesburg, South Africa
| | | | - Edina Sinanovic
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Faieza Sahid
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
- University of the Witwatersrand, Johannesburg, South Africa
| | - Wendy Stevens
- National Health Laboratory Service, Johannesburg, South Africa
- Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Anna Vassall
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Gavin J. Churchyard
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Advancing Care and Treatment for TB/HIV, South African Medical Research Council Collaborating Centre for HIV and TB, Johannesburg, South Africa
| | - Alison D. Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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6
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Dheda K, Charalambous S, Karat AS, von Delft A, Lalloo UG, van Zyl Smit R, Perumal R, Allwood BW, Esmail A, Wong ML, Duse AG, Richards G, Feldman C, Mer M, Nyamande K, Lalla U, Koegelenberg CFN, Venter F, Dawood H, Adams S, Ntusi NAB, van der Westhuizen HM, Moosa MYS, Martinson NA, Moultrie H, Nel J, Hausler H, Preiser W, Lasersohn L, Zar HJ, Churchyard GJ. A position statement and practical guide to the use of particulate filtering facepiece respirators (N95, FFP2, or equivalent) for South African health workers exposed to respiratory pathogens including Mycobacterium tuberculosis and SARS-CoV-2. Afr J Thorac Crit Care Med 2021; 27:10.7196/AJTCCM.2021.v27i4.173. [PMID: 34734176 PMCID: PMC8545268 DOI: 10.7196/ajtccm.2021.v27i4.173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2021] [Indexed: 12/21/2022] Open
Abstract
SUMMARY Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is transmitted mainly by aerosol in particles <10 µm that can remain suspended for hours before being inhaled. Because particulate filtering facepiece respirators ('respirators'; e.g. N95 masks) are more effective than surgical masks against bio-aerosols, many international organisations now recommend that health workers (HWs) wear a respirator when caring for individuals who may have COVID-19. In South Africa (SA), however, surgical masks are still recommended for the routine care of individuals with possible or confirmed COVID-19, with respirators reserved for so-called aerosol-generating procedures. In contrast, SA guidelines do recommend respirators for routine care of individuals with possible or confirmed tuberculosis (TB), which is also transmitted via aerosol. In health facilities in SA, distinguishing between TB and COVID-19 is challenging without examination and investigation, both of which may expose HWs to potentially infectious individuals. Symptom-based triage has limited utility in defining risk. Indeed, significant proportions of individuals with COVID-19 and/or pulmonary TB may not have symptoms and/or test negative. The prevalence of undiagnosed respiratory disease is therefore likely significant in many general clinical areas (e.g. waiting areas). Moreover, a proportion of HWs are HIV-positive and are at increased risk of severe COVID-19 and death. RECOMMENDATIONS Sustained improvements in infection prevention and control (IPC) require reorganisation of systems to prioritise HW and patient safety. While this will take time, it is unacceptable to leave HWs exposed until such changes are made. We propose that the SA health system adopts a target of 'zero harm', aiming to eliminate transmission of respiratory pathogens to all individuals in every healthcare setting. Accordingly, we recommend: the use of respirators by all staff (clinical and non-clinical) during activities that involve contact or sharing air in indoor spaces with individuals who: (i) have not yet been clinically evaluated; or (ii) are thought or known to have TB and/or COVID-19 or other potentially harmful respiratory infections;the use of respirators that meet national and international manufacturing standards;evaluation of all respirators, at the least, by qualitative fit testing; andthe use of respirators as part of a 'package of care' in line with international IPC recommendations. We recognise that this will be challenging, not least due to global and national shortages of personal protective equipment (PPE). SA national policy around respiratory protective equipment enables a robust framework for manufacture and quality control and has been supported by local manufacturers and the Department of Trade, Industry and Competition. Respirator manufacturers should explore adaptations to improve comfort and reduce barriers to communication. Structural changes are needed urgently to improve the safety of health facilities: persistent advocacy and research around potential systems change remain essential.
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Affiliation(s)
- K Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for
the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
- Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - S Charalambous
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - A S Karat
- TB Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - A von Delft
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- TB Proof, South Africa
| | - U G Lalloo
- Gateway Private Hospital Medical Centre, Umhlanga Ridge, South Africa
- Durban International Clinical Research Site, Durban, South Africa
| | - R van Zyl Smit
- Division of Pulmonology and Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - R Perumal
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for
the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - B W Allwood
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - A Esmail
- Clinical Trials Unit, University of Cape Town Lung Institute, South Africa
| | - M L Wong
- Division of Pulmonology, Department of Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - A G Duse
- Clinical Microbiology & Infectious Diseases, School of Pathology of the NHLS & University of the Witwatersrand, Johannesburg, South Africa
| | - G Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - C Feldman
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - M Mer
- Department of Medicine, Divisions of Pulmonology and Critical Care, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - K Nyamande
- Department of Pulmonology, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu Natal, Durban, South Africa
| | - U Lalla
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - C F N Koegelenberg
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - F Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - H Dawood
- Greys Hospital, Pietermaritzburg, South Africa
| | - S Adams
- Division of Occupational Medicine, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - N A B Ntusi
- Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - H-M van der Westhuizen
- TB Proof, South Africa
- Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom
| | - M-Y S Moosa
- Department of Infectious Diseases, Division of Internal Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Southern African HIV Clinicians Society
| | - N A Martinson
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa
- Johns Hopkins University Center for TB Research, Baltimore, MD, USA
| | - H Moultrie
- National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa
- Clinical Microbiology & Infectious Diseases, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - J Nel
- Division of Infectious Diseases, Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - H Hausler
- TB HIV Care, Cape Town, South Africa
| | - W Preiser
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service Tygerberg, Cape Town,
South Africa
| | - L Lasersohn
- South African Society of Anaesthesiologists
- Department of Anaesthesia, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Critical Care, Chris Hani Baragwanath Hospital and University of the Witwatersrand, Johannesburg, South Africa
| | - H J Zar
- Department of Paediatrics & Child Health, Red Cross Children’s Hospital and SAMRC Unit on Child and Adolescent Health, University of Cape Town, South Africa
| | - G J Churchyard
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
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7
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Beckwith P, Tlali M, Charalambous S, Churchyard GJ, Fielding KL, Hoffmann CJ, Johnson S, Wood N, Grant AD, Karat AS. Causes and Outcomes of Admission and Investigation of Tuberculosis in Adults with Advanced HIV in South African Hospitals: Data from the TB Fast Track Trial. Am J Trop Med Hyg 2021; 105:1662-1671. [PMID: 34662866 PMCID: PMC8641325 DOI: 10.4269/ajtmh.21-0133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 02/03/2021] [Accepted: 08/04/2021] [Indexed: 11/10/2022] Open
Abstract
Tuberculosis (TB) remains the leading cause of hospitalization and in-hospital mortality in HIV-positive adults. Using data from hospital and clinic files, research databases, and autopsy, we describe causes and outcomes of admissions, and assess investigations for TB among adults with advanced HIV who were hospitalized after enrollment into the TB Fast Track trial in South Africa (2013–2015). A total of 251 adults [median CD4 count, 37.5 cells/μL; interquartile range, 14–68 cells/µL; 152 (60.6%) on antiretroviral therapy] experienced 304 admissions. Ninety-five of 251 of the first admissions (37.8%) were TB related; the next most common causes were AIDS-related illnesses (41 of 251, 16.3%) and surgical causes (21 of 251, 8.4%). Of those admitted with previously undiagnosed TB, 60% had CD4 counts less than 50 cells/µL. Overall, 137 of 251 individuals died as inpatients or within 90 days of their first discharge. Case fatality rates were particularly high for those admitted with TB (66%) and bacterial infections (80%). In 144 admissions for whom anti-TB treatment had not been started before admission, a sputum-based TB investigation was recorded in only 12 of 57 admissions (21.1%) in whom one or more TB symptom was recorded (24 of 57 started on treatment), and 6 of 87 admissions (6.9%) in whom no TB symptoms were recorded (14 of 87 started on treatment). Hospitalized adults with advanced HIV are at high risk of death. TB was a common cause of hospitalization but was under-investigated, even in those with symptoms. In addition to early identification of TB and other AIDS-related illnesses during hospitalization of adults with advanced HIV, improved pre-hospital management strategies are needed to interrupt disease progression and reduce poor outcomes in this already vulnerable population.
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Affiliation(s)
- Peter Beckwith
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mpho Tlali
- The Aurum Institute, Johannesburg, South Africa
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Gavin J Churchyard
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom.,The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,Advancing Care and Treatment for TB and HIV, South African Medical Research Council. Johannesburg, South Africa
| | - Katherine L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Suzanne Johnson
- Foundation for Professional Development, Pretoria, South Africa
| | - Natalie Wood
- North Bristol NHS Trust, Bristol, United Kingdom
| | - Alison D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,Africa Health Research Institute, School of Laboratory Medicine & Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Aaron S Karat
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
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8
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Velen K, Podewils LJ, Shah NS, Lewis JJ, Dinake T, Churchyard GJ, Reichler M, Charalambous S. Performance of GeneXpert MTB/RIF for Diagnosing Tuberculosis Among Symptomatic Household Contacts of Index Patients in South Africa. Open Forum Infect Dis 2021; 8:ofab025. [PMID: 33884274 PMCID: PMC8047860 DOI: 10.1093/ofid/ofab025] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 01/14/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND We describe the performance of GeneXpert MTB/RIF (Xpert) for diagnosing tuberculosis (TB) among symptomatic household contacts (HHCs) of rifampicin-resistant and drug-sensitive index cases. METHODS We conducted a cross-sectional study among HHCs of recently diagnosed (<2 weeks) smear-positive and Xpert-positive index cases in the Bojanala District, South Africa. The HHCs were screened for TB symptoms; persons with ≥1 TB symptom provided 1 sputum for smear microscopy, Xpert, and mycobacterial growth indicator tube (MGIT) culture. Diagnostic test performance of Xpert was determined using MGIT as the reference standard. RESULTS From August 2013 to July 2015, 619 HHCs from 216 index cases were enrolled: 60.6% were female, median age was 22 years (interquartile range, 9-40), and 126 (20.4%) self-reported/tested human immunodeficiency virus positive. A total of 54.3% (336 of 619) of contacts had ≥1 TB symptom (cough, fever, night sweats, weight loss), 297 of 336 (88.4%) of which provided a sputum; 289 (97.3%) had complete testing and 271 were included in the analysis. In total, 42 (6.8%) of 619 HHCs had microbiologically confirmed TB. The MGIT identified 33 HHCs as positive for Mycobacterium tuberculosis; of these, 7 were positive on Xpert resulting in a sensitivity of 21.2% (95% confidence interval [CI], 9.0-38.9), specificity of 98.3% (95% CI, 95.6-99.5), positive predictive value of 63.6% (95% CI, 30.8-89.1), and negative predictive value of 90.0 (95% CI, 85.7-93.4). CONCLUSIONS Among symptomatic HHCs investigated for TB, Xpert performed suboptimally compared with MGIT culture. The poor performance of Xpert for diagnosing TB suggests that a more sensitive test, such a Xpert Ultra or culture, may be needed to improve yield of contact investigation, where feasible.
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Affiliation(s)
| | | | - N Sarita Shah
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - James J Lewis
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Y Lab, the Public Services Innovation Lab for Wales, School of Social Sciences, Cardiff University, Cardiff, United Kingdom
| | - Tiro Dinake
- The Aurum Institute, Johannesburg, South Africa
| | - Gavin J Churchyard
- The Aurum Institute, Johannesburg, South Africa
- The School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | | | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa
- The School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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9
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Chimoyi L, Velen K, Churchyard GJ, Wallis R, Lewis JJ, Charalambous S. An ecological study to evaluate the association of Bacillus Calmette-Guerin (BCG) vaccination on cases of SARS-CoV2 infection and mortality from COVID-19. PLoS One 2020; 15:e0243707. [PMID: 33332418 PMCID: PMC7746266 DOI: 10.1371/journal.pone.0243707] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 08/27/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023] Open
Abstract
As the SARS-CoV2 pandemic has progressed, there have been marked geographical differences in the pace and extent of its spread. We evaluated the association of BCG vaccination on morbidity and mortality of SARS-CoV2, adjusted for country-specific responses to the epidemic, demographics and health. SARS-CoV2 cases and deaths as reported by 31 May 2020 in the World Health Organization situation reports were used. Countries with at least 28 days following the first 100 cases, and available information on BCG were included. We used log-linear regression models to explore associations of cases and deaths with the BCG vaccination policy in each country, adjusted for population size, gross domestic product, proportion aged over 65 years, stringency level measures, testing levels, smoking proportion, and the time difference from date of reporting the 100th case to 31 May 2020. We further looked at the association that might have been found if the analyses were done at earlier time points. The study included 97 countries with 73 having a policy of current BCG vaccination, 13 having previously had BCG vaccination, and 11 having never had BCG vaccination. In a log-linear regression model there was no effect of country-level BCG status on SARS-CoV2 cases or deaths. Univariable log-linear regression models showed a trend towards a weakening of the association over time. We found no statistical evidence for an association between BCG vaccination policy and either SARS-CoV2 morbidity or mortality. We urge countries to rather consider alternative tools with evidence supporting their effectiveness for controlling SARS-CoV2 morbidity and mortality.
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Affiliation(s)
- Lucy Chimoyi
- The Aurum Institute, Parktown, Johannesburg, South Africa
- * E-mail:
| | - Kavindhran Velen
- The Aurum Institute, Parktown, Johannesburg, South Africa
- Sydney School of Medicine (Central Clinical School), Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Gavin J. Churchyard
- The Aurum Institute, Parktown, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Parktown, Johannesburg, South Africa
| | - Robert Wallis
- The Aurum Institute, Parktown, Johannesburg, South Africa
| | - James J. Lewis
- Y Lab, Public Services Innovation Lab for Wales, School of Social Sciences, Cardiff University, Wales, United Kingdom
| | - Salome Charalambous
- The Aurum Institute, Parktown, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Parktown, Johannesburg, South Africa
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10
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Chimoyi LA, Lienhardt C, Moodley N, Shete P, Churchyard GJ, Charalambous S. Estimating the yield of tuberculosis from key populations to inform targeted interventions in South Africa: a scoping review. BMJ Glob Health 2020; 5:bmjgh-2020-002355. [PMID: 32636313 PMCID: PMC7342464 DOI: 10.1136/bmjgh-2020-002355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/24/2020] [Accepted: 05/18/2020] [Indexed: 11/20/2022] Open
Abstract
Introduction Tuberculosis (TB) case finding strategies are recommended to increase yield for TB in key populations. Several key populations are identified in the literature, but techniques for estimating yield and prioritising interventions are needed. Methods We conducted a scoping review of existing evidence on TB burden to assess contribution of key populations to the TB epidemic in South Africa. Reports, articles and conference abstracts from January 2000 to December 2016 were reviewed to determine TB incidence, prevalence and size of key populations in South Africa. Meta-analysis summarised prevalence and incidence rates of TB in selected key populations assessed for heterogeneity. TB risk was calculated for each key population. Number needed to screen (NNS) to diagnose one case of TB disease was computed. Population attributable fraction estimated the potential impact of interventions on TB cases per population. Results The search yielded 140 citations, of which 49 were included in the review and a final 32 were included in the meta-analysis. A high prevalence of TB disease was observed in HIV-infected patients with an estimated effect size (ES=0.25, 95% CI 0.20 to 0.30). Heterogeneity was high in this population (I2=94.8%, p value=0.000). The highest incidence rate of TB disease was observed in the HIV-infected population (ES=6.07, 95% CI 4.90 to 7.51). The risk of TB disease in South Africa was high in informal settlements (RR=5.8), HIV-infected (RR=5.4) and inmates (RR=5.0). Most cases of TB would be found in inmates (NNS=26) and household contacts of patients with TB (NNS=25). A larger impact would be observed if interventions are directed towards inmates (31%), people living with HIV (PLHIV (37%) and informal settlements (43%). Conclusions Our findings illustrate the of value using available epidemiological evidence to inform targeted TB interventions. This review suggests that targeting interventions towards inmates, PLHIV and informal settlements would have a bigger impact on TB burden in South Africa.
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Affiliation(s)
| | | | | | - Priya Shete
- Global Tuberculosis Program, World Health Organisation, Geneva, Switzerland
| | - Gavin J Churchyard
- The Aurum Institute, Johannesburg, South Africa.,Department of Infectious Disease, London School of Hygiene and Tropical Medicine, London, United Kingdo
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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11
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Dooley KE, Savic R, Gupte A, Marzinke MA, Zhang N, Edward VA, Wolf L, Sebe M, Likoti M, Fyvie MJ, Shibambo I, Beattie T, Chaisson RE, Churchyard GJ. Once-weekly rifapentine and isoniazid for tuberculosis prevention in patients with HIV taking dolutegravir-based antiretroviral therapy: a phase 1/2 trial. Lancet HIV 2020; 7:e401-e409. [PMID: 32240629 DOI: 10.1016/s2352-3018(20)30032-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 01/20/2020] [Accepted: 01/24/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Short-course preventive therapy with 12 doses of once-weekly rifapentine (900 mg) plus isoniazid (900 mg) could greatly improve tuberculosis control, especially in areas with high co-endemicity with HIV. However, a small previous trial of such therapy with dolutegravir in healthy, HIV-negative adults was halted early after two of the four patients developed serious adverse events. Because of the potential use of this therapy, and variable safety outcomes of tuberculosis drugs seen in patients with and without HIV, we aimed to characterise safety, pharmacokinetics, and virological suppression in adults who are HIV positive. METHODS DOLPHIN was a phase 1/2, single-arm trial done at The Aurum Institute (Tembisa Clinical Research Site, Tembisa, South Africa), with pharmacokinetic visits done at VxPharma (Pretoria, South Africa). Adults (≥18 years) with HIV infection and undetectable viral load (<40 copies per mL) after at least 8 weeks of efavirenz-based or dolutegravir-based regimens were recruited in three consecutive groups, subject to approval by the independent safety monitoring committee. Participants received 50 mg of daily dolutegravir in place of efavirenz for 8 weeks, then began once-weekly rifapentine (900 mg)-isoniazid (900 mg) for 12 weeks. Groups 1A (n=12) and 1B (n=18) had intensive dolutegravir pharmacokinetic sampling at week 8 (before rifapentine-isoniazid), at week 11 (after the third dose of rifapentine)-isoniazid and at week 16 after the eighth dose. Group 2 (n=30) were treated with the same schedule and had sparse dolutegravir pharmacokinetic sampling at weeks 8, 11, and 16. Participants were followed 4 weeks after completion of prophylactic tuberculosis treatment. HIV viral loads were measured at baseline and at weeks 11 and 24. Primary endpoints were adverse events (grade 3 or higher) and dolutegravir population pharmacokinetics, assessed in participants who began rifapentine-isoniazid. This trial was registered at ClinicalTrials.gov, NCT03435146. FINDINGS Between Jan 24, 2018, and Nov 25, 2018, 61 participants were enrolled into three groups; one participant withdrew (from group 1A). 43 (70%) of 60 participants were women and all participants were black African. Median age was 40 years (IQR 35-48), CD4 cell count was 683 cells per μL (447-935), and body-mass index was 28·9 kg/m2 (24·0-32·9). Three grade 3 adverse events occurred; two elevated creatinine and one hypertension. Rifapentine-isoniazid increased dolutegravir clearance by 36% (relative standard error 13%) resulting in a 26% decrease in dolutegravir area under the curve. Overall geometric mean ratio of trough concentrations with versus without rifapentine-isoniazid was 0·53 (90% CI 0·49-0·56) though this ratio varied by day after rifapentine-isoniazid dose. All but one trough value was above the 90% maximal inhibitory concentration for dolutegravir and HIV viral loads were less than 40 copies per mL in all patients. INTERPRETATION Our results suggest 12 doses of once-weekly rifapentine-isoniazid can be given for tuberculosis prophylaxis to patients with HIV taking dolutegravir-based antiretroviral therapy, without dose adjustments. Further exploration of the pharmacokinetics, safety, and efficacy in children and pharmacodynamics in individuals naive to antiretroviral therapy is needed. FUNDING UNITAID.
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Affiliation(s)
- Kelly E Dooley
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Radojkam Savic
- University of California San Francisco, San Francisco, CA, USA
| | - Akshay Gupte
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mark A Marzinke
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nan Zhang
- University of California San Francisco, San Francisco, CA, USA
| | - Vinodh A Edward
- The Aurum Institute, Johannesburg, South Africa; School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Lisa Wolf
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | | | | | | | - Richard E Chaisson
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gavin J Churchyard
- The Aurum Institute, Johannesburg, South Africa; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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12
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Kim HY, Zishiri V, Page-Shipp L, Makgopa S, Churchyard GJ, Dowdy D, Charalambous S, Hoffmann CJ. Symptom and digital chest X-ray TB screening in South African prisons: yield and cost-effectiveness. Int J Tuberc Lung Dis 2020; 24:295-302. [PMID: 32228759 DOI: 10.5588/ijtld.19.0214] [Citation(s) in RCA: 4] [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
BACKGROUND: Correctional inmates are at a high risk of tuberculosis (TB). The optimal approach to screening this population is unclear.METHODS: We retrospectively reviewed records from TB screening in 64 correctional facilities in South Africa between January 2015 and July 2016. Inmates received symptom screening (any of cough, fever, weight loss, or night sweats) combined with digital chest X-ray (CXR), when available. CXRs were assessed as 'abnormal' or with no abnormalities. Inmates with either a symptom or an 'abnormal' CXR were asked to provide a single spot sputum for Xpert® MTB/RIF testing. We estimated the incremental cost-effectiveness ratio (ICER) per additional TB case detected using CXR screening among asymptomatic inmates.RESULTS: Of 61 580 inmates, CXR screening was available for 41 852. Of these, 19 711 (47.1%) had TB symptoms. Among 22 141 inmates without symptoms, 1939/19 783 (9.8%) had an abnormal CXR, and 8 (1.2%) were Xpert-positive among those with Xpert tests done. Of 14 942 who received symptom screening only and had symptoms, 84% (12 616) had an Xpert result, and 105 (0.8%) were positive. The ICER for CXR screening was US$22 278.CONCLUSION: Having CXR in addition to symptom screening increased yield but added considerable cost. A major limitation of screening was the low specificity of the symptom screen.
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Affiliation(s)
- H-Y Kim
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Durban
| | | | | | | | - G J Churchyard
- The Aurum Institute, Johannesburg, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - D Dowdy
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - S Charalambous
- The Aurum Institute, Johannesburg, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - C J Hoffmann
- The Aurum Institute, Johannesburg, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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13
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González Fernández L, Casas EC, Singh S, Churchyard GJ, Brigden G, Gotuzzo E, Vandevelde W, Sahu S, Ahmedov S, Kamarulzaman A, Ponce‐de‐León A, Grinsztejn B, Swindells S. New opportunities in tuberculosis prevention: implications for people living with HIV. J Int AIDS Soc 2020; 23:e25438. [PMID: 31913556 PMCID: PMC6947976 DOI: 10.1002/jia2.25438] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 11/27/2019] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Tuberculosis (TB) is a leading cause of mortality among people living with HIV (PLHIV). An invigorated global END TB Strategy seeks to increase efforts in scaling up TB preventive therapy (TPT) as a central intervention for HIV programmes in an effort to contribute to a 90% reduction in TB incidence and 95% reduction in mortality by 2035. TPT in PLHIV should be part of a comprehensive approach to reduce TB transmission, illness and death that also includes TB active case-finding and prompt, effective and timely initiation of anti-TB therapy among PLHIV. However, the use and implementation of preventive strategies has remained deplorably inadequate and today TB prevention among PLHIV has become an urgent priority globally. DISCUSSION We present a summary of the current and novel TPT regimens, including current evidence of use with antiretroviral regimens (ART). We review challenges and opportunities to scale-up TB prevention within HIV programmes, including the use of differentiated care approaches and demand creation for effective TB/HIV services delivery. TB preventive vaccines and diagnostics, including optimal algorithms, while important topics, are outside of the focus of this commentary. CONCLUSIONS A number of new tools and strategies to make TPT a standard of care in HIV programmes have become available. The new TPT regimens are safe and effective and can be used with current ART, with attention being paid to potential drug-drug interactions between rifamycins and some classes of antiretrovirals. More research and development is needed to optimize TPT for small children, pregnant women and drug-resistant TB (DR-TB). Effective programmatic scale-up can be supported through context-adapted demand creation strategies and the inclusion of TPT in client-centred services, such as differentiated service delivery (DSD) models. Robust collaboration between the HIV and TB programmes represents a unique opportunity to ensure that TB, a preventable and curable condition, is no longer the number one cause of death in PLHIV.
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Affiliation(s)
| | - Esther C Casas
- Southern Africa Medical UnitMédecins Sans FrontièresCape TownSouth Africa
| | | | - Gavin J Churchyard
- Aurum InstituteParktownSouth Africa
- School of Public HealthUniversity of WitwatersrandJohannesburgSouth Africa
- Advancing Care and Treatment for TB/HIVSouth African Medical Research CouncilParktownSouth Africa
| | - Grania Brigden
- Department of TuberculosisInternational Union Against Tuberculosis and Lung DiseaseGenevaSwitzerland
| | - Eduardo Gotuzzo
- Department of Medicine and Director of the “Alexander von Humboldt” Institute of Tropical Medicine and Infectious DiseasesPeruvian University Cayetano HerediaLimaPeru
| | - Wim Vandevelde
- Global Network of People living with HIV (GNP+)Cape TownSouth Africa
| | | | - Sevim Ahmedov
- Bureau for Global Health, Infectious Diseases, TB DivisionUSAIDWashingtonDCUSA
| | | | - Alfredo Ponce‐de‐León
- Infectious Diseases DepartmentInstituto Nacional de Ciencias Médicas y Nutrición Salvador ZubiránMexico CityMexico
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14
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Grant AD, Charalambous S, Tlali M, Karat AS, Dorman SE, Hoffmann CJ, Johnson S, Vassall A, Churchyard GJ, Fielding KL. Algorithm-guided empirical tuberculosis treatment for people with advanced HIV (TB Fast Track): an open-label, cluster-randomised trial. Lancet HIV 2020; 7:e27-e37. [PMID: 31727580 DOI: 10.1016/s2352-3018(19)30266-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 07/16/2019] [Accepted: 07/30/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Tuberculosis, which is often undiagnosed, is the major cause of death among HIV-positive people. We aimed to test whether the use of a clinical algorithm enabling the initiation of empirical tuberculosis treatment by nurses in primary health-care clinics would reduce mortality compared with standard of care for adults with advanced HIV disease. METHODS In this open-label cluster-randomised controlled trial, we recruited individuals from 24 primary health-care clinics in South Africa. The clinics were randomly assigned (1:1) to either deliver an intervention or routine care (control) using computer-generated random numbers. Eligible participants were HIV-positive adults (aged ≥18 years) with CD4 counts of 150 cells per μL or less, who had not had antiretroviral therapy (ART) in the past 6 months or tuberculosis treatment in the past 3 months, and did not require urgent hospital referral. In intervention clinics, study nurses assessed participants on the basis of tuberculosis symptoms, body-mass index, point-of-care haemoglobin concentrations, and urine lipoarabinomannan assay results. Participants classified by a study algorithm as having high probability of tuberculosis (positive urine lipoarabinomannan assay, body-mass index <18·5 kg/m2, or haemoglobin concentration <100 g/L) were recommended to start tuberculosis treatment immediately followed by ART 2 weeks later; participants classified as medium probability (tuberculosis symptoms, no high probability criteria) were recommended to have symptom-guided investigation; and participants classified as low probability (no tuberculosis symptoms or high probability criteria) were recommended to start ART immediately. In standard-of-care clinics, participants received treatment in accordance with South African guidelines. Investigators and participants were aware of treatment allocation. The primary outcome was all-cause mortality at 6 months, assessed in the intention-to-treat population. Safety was also analysed in the intention-to treat population. This trial is registered with the ISRCTN registry, ISRCTN35344604, and the South African National Clinical Trials Register, DOH-27-0812-3902. FINDINGS Between Dec 19, 2012, and Dec 18, 2014, 3091 individuals were screened for eligibility, of whom 3053 were recruited, and 3022 (1507 participants in the intervention group and 1515 participants in the control group) were analysed for the primary outcome. 930 (61·7%) of 1507 participants in the intervention group versus 172 (11·4%) of 1515 participants in the control group had started tuberculosis treatment by 2 months. At 6 months, the mortality rate was 19·0 deaths per 100 person-years for the intervention group versus 21·6 deaths per 100 person-years in the control group (unadjusted hazard ratio [HR] 0·92, 95% CI 0·67-1·26, p=0·58; adjusted HR 0·87, 0·61-1·24, p=0·41). 28 (1·9%) of 1507 participants in the intervention group and ten (0·7%) of 1515 participants in the control group reported serious or severe adverse events. Grade 3 or 4 nausea and vomiting was the most common adverse event (ten participants in the intervention group and four participants in the control group). Among participants with adverse events, eight participants (six participants in the intervention group and two participants in the control group) died; none of the six deaths in the intervention group were attributed to the study intervention. INTERPRETATION Our intervention substantially increased coverage of tuberculosis treatment in this high-risk population, but did not reduce mortality. FUNDING Joint Global Health Trials (Medical Research Council, Department for International Development, Wellcome Trust).
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Affiliation(s)
- Alison D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK; Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
| | - Salome Charalambous
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; The Aurum Institute, Johannesburg, South Africa
| | - Mpho Tlali
- The Aurum Institute, Johannesburg, South Africa
| | - Aaron S Karat
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Susan E Dorman
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Suzanne Johnson
- Foundation for Professional Development, Pretoria, South Africa
| | - Anna Vassall
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Gavin J Churchyard
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; The Aurum Institute, Johannesburg, South Africa; Advancing Care and Treatment for TB/HIV, South African Medical Research Council, Johannesburg, South Africa
| | - Katherine L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Karat AS, Omar T, Tlali M, Charalambous S, Chihota VN, Churchyard GJ, Fielding KL, Martinson NA, McCarthy KM, Grant AD. Lessons learnt conducting minimally invasive autopsies in private mortuaries as part of HIV and tuberculosis research in South Africa. Public Health Action 2019; 9:186-190. [PMID: 32042614 DOI: 10.5588/pha.19.0032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 05/17/2019] [Accepted: 09/03/2019] [Indexed: 11/10/2022] Open
Abstract
Current estimates of the burden of tuberculosis (TB) disease and cause-specific mortality in human immunodeficiency virus (HIV) positive people rely heavily on indirect methods that are less reliable for ascertaining individual-level causes of death and on mathematical models. Minimally invasive autopsy (MIA) is useful for diagnosing infectious diseases, provides a reasonable proxy for the gold standard in cause of death ascertainment (complete diagnostic autopsy) and, used routinely, could improve cause-specific mortality estimates. From our experience in performing MIAs in HIV-positive adults in private mortuaries in South Africa (during the Lesedi Kamoso Study), we describe the challenges we faced and make recommendations for the conduct of MIA in future studies or surveillance programmes, including strategies for effective communication, approaches to obtaining informed consent, risk management for staff and efficient preparation for the procedure.
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Affiliation(s)
- A S Karat
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - T Omar
- Division of Anatomical Pathology, Faculty of Health Sciences, University of the Witwatersrand, National Health Laboratory Service, Johannesburg, South Africa
| | - M Tlali
- The Aurum Institute, Johannesburg, South Africa
| | - S Charalambous
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - V N Chihota
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - G J Churchyard
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK.,The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - K L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - N A Martinson
- Perinatal HIV Research Unit, and South African Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa.,Johns Hopkins University Center for TB Research, Baltimore, MD, USA.,Department of Science and Technology/National Research Foundation Centre of Excellence for Biomedical TB Research, University of the Witwatersrand, Johannesburg, South Africa
| | - K M McCarthy
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Division of Public Health, Surveillance and Response, National Institute for Communicable Disease of the National Health Laboratory Service, Johannesburg, South Africa
| | - A D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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16
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Johnson KT, Churchyard GJ, Sohn H, Dowdy DW. Cost-effectiveness of Preventive Therapy for Tuberculosis With Isoniazid and Rifapentine Versus Isoniazid Alone in High-Burden Settings. Clin Infect Dis 2019; 67:1072-1078. [PMID: 29617965 DOI: 10.1093/cid/ciy230] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 03/27/2018] [Indexed: 01/29/2023] Open
Abstract
Background A short-course regimen of 3 months of weekly rifapentine and isoniazid (3HP) has recently been recommended by the World Health Organization as an alternative to at least 6 months of daily isoniazid (isoniazid preventive therapy [IPT]) for prevention of tuberculosis (TB). The contexts in which 3HP may be cost-effective compared to IPT among people living with human immunodeficiency virus are unknown. Methods We used a Markov state transition model to estimate the incremental cost-effectiveness of 3HP relative to IPT in high-burden settings, using a cohort of 1000 patients in a Ugandan HIV clinic as an emblematic scenario. Cost-effectiveness was expressed as 2017 US dollars per disability-adjusted life year (DALY) averted from a healthcare perspective over a 20-year time horizon. We explored the conditions under which 3HP would be considered cost-effective relative to IPT. Results Per 1000 individuals on antiretroviral therapy in the reference scenario, treatment with 3HP rather than IPT was estimated to avert 9 cases of TB and 1 death, costing $9402 per DALY averted relative to IPT. Cost-effectiveness depended strongly on the price of rifapentine, completion of 3HP, and prevalence of latent TB. At a willingness to pay of $1000 per DALY averted, 3HP is likely to be cost-effective relative to IPT only if the price of rifapentine can be greatly reduced (to approximately $20 per course) and high treatment completion (85%) can be achieved. Conclusions 3HP may be a cost-effective alternative to IPT in high-burden settings, but cost-effectiveness depends on the price of rifapentine, achievable completion rates, and local willingness to pay.
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Affiliation(s)
- Karl T Johnson
- Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, Maryland
| | | | - Hojoon Sohn
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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17
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Abstract
In a Perspective, Gavin Churchyard and Sue Swindells discuss the importance of strategies to target latent tuberculosis infection in high risk populations and thus disrupt a reservoir for new infections in high burden countries.
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Affiliation(s)
- Gavin J. Churchyard
- Aurum Institute, Parktown, South Africa
- University of Witwatersrand, School of Public Health, Johannesburg, South Africa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Sue Swindells
- University of Nebraska Medical Center, Omaha, Nebraska, United States of America
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18
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Affiliation(s)
- Gavin J Churchyard
- From the Aurum Institute, Parktown, and the School of Public Health, University of Witwatersrand, Johannesburg - both in South Africa
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19
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Hanifa Y, Toro Silva S, Karstaedt A, Sahid F, Charalambous S, Chihota VN, Churchyard GJ, von Gottberg A, McCarthy K, Nicol MP, Ndlovu NT, Stevens W, Fielding KL, Grant AD. What causes symptoms suggestive of tuberculosis in HIV-positive people with negative initial investigations? Int J Tuberc Lung Dis 2019; 23:157-165. [PMID: 30678747 PMCID: PMC6394279 DOI: 10.5588/ijtld.18.0251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE: To identify the causes of symptoms suggestive of tuberculosis (TB) among people living with the human immunodeficiency virus (PLHIV) in South Africa. METHODS: A consecutive sample of HIV clinic attendees with symptoms suggestive of TB (⩾1 of cough, weight loss, fever or night sweats) at enrolment and at 3 months, and negative initial TB investigations, were systematically evaluated with standard protocols and diagnoses assigned using standard criteria. TB was ‘confirmed’ if Mycobacterium tuberculosis was identified within 6 months of enrolment, and ‘clinical’ if treatment started without microbiological confirmation. RESULTS: Among 103 participants, 50/103 were preantiretroviral therapy (ART) and 53/103 were on ART; respectively 68% vs. 79% were female; the median age was 35 vs. 45 years; the median CD4 count was 311 vs. 508 cells/mm3. Seventy-two (70%) had ⩾5% measured weight loss and 50 (49%) had cough. The most common final diagnoses were weight loss due to severe food insecurity (n = 20, 19%), TB (n = 14, 14%: confirmed n = 7; clinical n = 7), other respiratory tract infection (n = 14, 14%) and post-TB lung disease (n = 9, 9%). The basis for TB diagnosis was imaging (n = 7), bacteriological confirmation from sputum (n = 4), histology, lumbar puncture and other (n = 1 each). CONCLUSION: PLHIV with persistent TB symptoms require further evaluation for TB using all available modalities, and for food insecurity in those with weight loss.
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Affiliation(s)
- Y Hanifa
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - S Toro Silva
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - A Karstaedt
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, University of the Witwatersrand, Johannesburg
| | - F Sahid
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, University of the Witwatersrand, Johannesburg
| | - S Charalambous
- The Aurum Institute, Johannesburg, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - V N Chihota
- The Aurum Institute, Johannesburg, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - G J Churchyard
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK, The Aurum Institute, Johannesburg, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Advancing Care and Treatment for TB-HIV, South African Medical Research Council Collaborating Centre for HIV and TB, Tygerberg
| | - A von Gottberg
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases, Johannesburg, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | | | - M P Nicol
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, National Health Laboratory Service, Johannesburg
| | | | - W Stevens
- National Health Laboratory Service, Johannesburg, Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - K L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - A D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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20
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Chang ST, Chihota VN, Fielding KL, Grant AD, Houben RM, White RG, Churchyard GJ, Eckhoff PA, Wagner BG. Correction to: Small contribution of gold mines to the ongoing tuberculosis epidemic in South Africa: a modeling-based study. BMC Med 2018; 16:242. [PMID: 30591052 PMCID: PMC6309054 DOI: 10.1186/s12916-018-1238-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 12/11/2018] [Indexed: 11/10/2022] Open
Abstract
The original article [1] did not contain comprehensive information regarding two authors' affiliations that may be considered a potential competing interest.
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Affiliation(s)
| | - Violet N Chihota
- Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Katherine L Fielding
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Alison D Grant
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Rein M Houben
- TB Modelling Group, CMMID, TB Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Richard G White
- TB Modelling Group, CMMID, TB Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Gavin J Churchyard
- Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Advancing Treatment and Care for TB/HIV, South African Medical Research Council, Johannesburg, South Africa
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21
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Kufa T, Fielding KL, Hippner P, Kielmann K, Vassall A, Churchyard GJ, Grant AD, Charalambous S. An intervention to optimise the delivery of integrated tuberculosis and HIV services at primary care clinics: results of the MERGE cluster randomised trial. Contemp Clin Trials 2018; 72:43-52. [PMID: 30053431 DOI: 10.1016/j.cct.2018.07.013] [Citation(s) in RCA: 3] [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] [Received: 11/30/2017] [Revised: 07/04/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To evaluate the effect of an intervention to optimize TB/HIV integration on patient outcomes. METHODS Cluster randomised control trial at 18 primary care clinics in South Africa. The intervention was placement of a nurse (TB/HIV integration officer) to facilitate provision of integrated TB/HIV services, and a lay health worker (TB screening officer) to facilitate TB screening for 24 months. Primary outcomes were i) incidence of hospitalisation/death among individuals newly diagnosed with HIV, ii) incidence of hospitalisation/death among individuals newly diagnosed with TB and iii) proportion of HIV-positive individuals newly diagnosed with TB who were retained in HIV care 12 months after enrolment. RESULTS Of 3328 individuals enrolled, 3024 were in the HIV cohort, 731 in TB cohort and 427 in TB-HIV cohort. For the HIV cohort, the hospitalisation/death rate was 12.5 per 100 person-years (py) (182/1459py) in the intervention arm vs. 10.4/100py (147/1408 py) in the control arms respectively (Relative Risk (RR) 1.17 [95% CI 0.92-1.49]).For the TB cohort, hospitalisation/ death rate was 17.1/100 py (67/ 392py) vs. 11.1 /100py (32/289py) in intervention and control arms respectively (RR 1.37 [95% CI 0.78-2.43]). For the TB-HIV cohort, retention in care at 12 months was 63.0% (213/338) and 55.9% (143/256) in intervention and control arms (RR 1.11 [95% 0.89-1.38]). CONCLUSIONS The intervention as implemented failed to improve patient outcomes beyond levels at control clinics. Effective strategies are needed to achieve better TB/HIV service integration and improve TB and HIV outcomes in primary care clinics. TRIAL REGISTRATION South African Register of Clinical Trials (registration number DOH-27-1011-3846).
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Affiliation(s)
- T Kufa
- The Aurum Institute, Johannesburg, South Africa; The School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa.
| | - K L Fielding
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - P Hippner
- The Aurum Institute, Johannesburg, South Africa
| | - K Kielmann
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom
| | - A Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - G J Churchyard
- The Aurum Institute, Johannesburg, South Africa; The School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - A D Grant
- The School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom; Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, South Africa
| | - S Charalambous
- The Aurum Institute, Johannesburg, South Africa; The School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Maraba N, Hoffmann CJ, Chihota VN, Chang LW, Ismail N, Candy S, Madibogo E, Katzwinkel M, Churchyard GJ, McCarthy K. Using mHealth to improve tuberculosis case identification and treatment initiation in South Africa: Results from a pilot study. PLoS One 2018; 13:e0199687. [PMID: 29969486 PMCID: PMC6029757 DOI: 10.1371/journal.pone.0199687] [Citation(s) in RCA: 15] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 06/12/2018] [Indexed: 11/18/2022] Open
Abstract
Background Tuberculosis (TB) incidence in South Africa is among the highest globally. Initial loss to follow-up (ILFU), defined as not starting on TB treatment within 28 days of testing positive, is undermining control efforts. We assessed the feasibility, acceptability, and potential of a mHealth application to reduce ILFU. Methods An mHealth application was developed to capture patients TB investigation data, provide results and monitor treatment initiation. This was implemented in two primary health clinics (PHC) in inner-city Johannesburg. Feasibility was assessed by comparing documentation of personal details, specimen results for same individuals during implementation period (paper register and Mhealth application). Effectiveness was assessed by comparing proportion of patients with results within 48 hours, and proportion started on treatment within 28 days of testing TB positive during pre- implementation (paper register) and implementation (mHealth application) periods. In-depth interviews with patients and providers were conducted to assess acceptability of application. Results Pre-implementation, 457 patients were recorded in paper registers [195 (42.7%) male, median age 34 years (interquartile range IQR (28–40), 45 (10.5%) sputum Xpert positive]. During implementation, 319 patients were recorded in paper register and the mHealth application [131 (41.1%) male, median age 32 years (IQR 27–38), 33 (10.3%) sputum Xpert positive]. The proportion with complete personal details: [mHealth 95.0% versus paper register 94.0%, (p = 0.54)] and proportion with documented results: [mHealth 97.4% versus paper register 97.8%, (p = 0.79)] were not different in the two methods. The proportion of results available within 48 hours: [mHealth 96.8% versus paper register 68.6%), (p <0.001)], and the proportion on treatment within 28 days [mHealth 28/33 (84.8%) versus paper register 30/44 (68.2%), (p = 0.08)] increased during implementation but was not statistically significant. In-depth interviews showed that providers easily integrated the mHealth application into routine TB investigation and patients positively received the delivery of results via text message. Time from sputum collection to TB treatment initiation decreased from 4 days (pre-implementation) to 3 days but was not statistically significant. Conclusions We demonstrated that implementation of the mHealth application was feasible, acceptable to health care providers and patients, and has potential to reduce the time to TB treatment initiation and ILFU in PHC settings.
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Affiliation(s)
- Noriah Maraba
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Christopher J. Hoffmann
- The Aurum Institute, Johannesburg, South Africa
- John Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Violet N. Chihota
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Larry W. Chang
- John Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Nazir Ismail
- National Institute of Communicable Disease, Johannesburg, South Africa
| | - Sue Candy
- National Institute of Communicable Disease, Johannesburg, South Africa
| | - Edwin Madibogo
- Department of Health and Social Development, City of Johannesburg, Johannesburg, South Africa
| | | | - Gavin J. Churchyard
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Advancing Treatment and Care for TB and HIV, South African Medical Research Council Collaborating Center for HIV/TB, Johannesburg, South Africa
- London School of Tropical and Hygiene Medicine, London, United Kingdom
| | - Kerrigan McCarthy
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- National Institute of Communicable Disease, Johannesburg, South Africa
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23
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Karat AS, Maraba N, Tlali M, Charalambous S, Chihota VN, Churchyard GJ, Fielding KL, Hanifa Y, Johnson S, McCarthy KM, Kahn K, Chandramohan D, Grant AD. Performance of verbal autopsy methods in estimating HIV-associated mortality among adults in South Africa. BMJ Glob Health 2018; 3:e000833. [PMID: 29997907 PMCID: PMC6035502 DOI: 10.1136/bmjgh-2018-000833] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 06/02/2018] [Accepted: 06/04/2018] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Verbal autopsy (VA) can be integrated into civil registration and vital statistics systems, but its accuracy in determining HIV-associated causes of death (CoD) is uncertain. We assessed the sensitivity and specificity of VA questions in determining HIV status and antiretroviral therapy (ART) initiation and compared HIV-associated mortality fractions assigned by different VA interpretation methods. METHODS Using the WHO 2012 instrument with added ART questions, VA was conducted for deaths among adults with known HIV status (356 HIV positive and 103 HIV negative) in South Africa. CoD were assigned using physician-certified VA (PCVA) and computer-coded VA (CCVA) methods and compared with documented HIV status. RESULTS The sensitivity of VA questions in detecting HIV status and ART initiation was 84.3% (95% CI 80 to 88) and 91.0% (95% CI 86 to 95); 283/356 (79.5%) HIV-positive individuals were assigned HIV-associated CoD by PCVA, 166 (46.6%) by InterVA-4.03, 201 (56.5%) by InterVA-5, and 80 (22.5%) and 289 (81.2%) by SmartVA-Analyze V.1.1.1 and V.1.2.1. Agreement between PCVA and older CCVA methods was poor (chance-corrected concordance [CCC] <0; cause-specific mortality fraction [CSMF] accuracy ≤56%) but better between PCVA and updated methods (CCC 0.21-0.75; CSMF accuracy 65%-98%). All methods were specific (specificity 87% to 96%) in assigning HIV-associated CoD. CONCLUSION All CCVA interpretation methods underestimated the HIV-associated mortality fraction compared with PCVA; InterVA-5 and SmartVA-Analyze V.1.2.1 performed better than earlier versions. Changes to VA methods and classification systems are needed to track progress towards targets for reducing HIV-associated mortality.
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Affiliation(s)
- Aaron S Karat
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Mpho Tlali
- The Aurum Institute, Johannesburg, South Africa
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Violet N Chihota
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gavin J Churchyard
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Katherine L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Yasmeen Hanifa
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Suzanne Johnson
- Foundation for Professional Development, Pretoria, South Africa
| | - Kerrigan M McCarthy
- The Aurum Institute, Johannesburg, South Africa
- Division of Public Health, Surveillance and Response, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
- Epidemiology and Global Health Unit, Department of Public Health and Clinical Medicine, Umeâ University, Umeâ, Sweden
| | - Daniel Chandramohan
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Alison D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Africa Health Research Institute, Somkhele, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Abstract
OBJECTIVES We piloted an intervention to determine if support from a case manager would assist adults being investigated for tuberculosis (TB) to link into TB and HIV care. DESIGN Pilot interventional cohort study. PARTICIPANTS AND SETTING Patients identified by primary healthcare clinic staff in South Africa as needing TB investigations were enrolled. INTERVENTION Participants were supported for 3 months by case managers who facilitated the care pathway by promoting HIV testing, getting laboratory results, calling patients to return for results and facilitating treatment initiation. OUTCOMES MEASURED Linkage to TB care was defined as starting TB treatment within 28 days in those with a positive test result; linkage to HIV care, for HIV-positive people, was defined as having blood taken for CD4 count and, for those eligible, starting antiretroviral therapy within 3 months. Intervention implementation was measured by number of attempts to contact participants. RESULTS Among 562 participants (307 (54.6%) female, median age: 36 years (IQR 29-44)), most 477 (84.8%) had previously tested for HIV; of these, 328/475 (69.1%) self-reported being HIV-positive. Overall, 189/562 (33.6%) participants needed linkage to care (132 HIV care linkage only; 35 TB treatment linkage only; 22 both). Of 555 attempts to contact these 189 participants, 407 were to facilitate HIV care linkage, 78 for TB treatment linkage and 70 for both. At the end of 3-month follow-up, 40 participants had not linked to care (29 of the 132 (22.0%) participants needing linkage to HIV care only, 4 of the 35 (11.4%) needing to start on TB treatment only and 7 of the 22 (31.8%) needing both). CONCLUSION Many people testing for TB need linkage to care. Despite case manager support, non-linkage into HIV care remained higher than desirable, suggesting a need to modify this intervention before implementation. Innovative strategies to enable linkage to care are needed.
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Affiliation(s)
- Noriah Maraba
- The Aurum Institute, Johannesburg, Gauteng, South Africa
- School of Public Health, Faculty of Health Science, University of Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Violet Chihota
- The Aurum Institute, Johannesburg, Gauteng, South Africa
- School of Public Health, Faculty of Health Science, University of Witwatersrand, Johannesburg, Gauteng, South Africa
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Kerrigan McCarthy
- School of Public Health, Faculty of Health Science, University of Witwatersrand, Johannesburg, Gauteng, South Africa
- National Institute for Communicable Diseases, Sandringham, South Africa
| | - Gavin J Churchyard
- The Aurum Institute, Johannesburg, Gauteng, South Africa
- School of Public Health, Faculty of Health Science, University of Witwatersrand, Johannesburg, Gauteng, South Africa
- Advancing Treatment and Care for TB and HIV, South African Medical Research Council Collaborating Centre for HIV/TB, Cape Town, South Africa
- London School of Hygiene and Tropical Medicine, London, UK
| | - Alison D Grant
- School of Public Health, Faculty of Health Science, University of Witwatersrand, Johannesburg, Gauteng, South Africa
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- School of Nursing and Public Health, Africa Health Research Institute, University of Kwazulu-Natal, Durban, South Africa
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25
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Chang ST, Chihota VN, Fielding KL, Grant AD, Houben RM, White RG, Churchyard GJ, Eckhoff PA, Wagner BG. Small contribution of gold mines to the ongoing tuberculosis epidemic in South Africa: a modeling-based study. BMC Med 2018; 16:52. [PMID: 29642897 PMCID: PMC5896106 DOI: 10.1186/s12916-018-1037-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 03/13/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Gold mines represent a potential hotspot for Mycobacterium tuberculosis (Mtb) transmission and may be exacerbating the tuberculosis (TB) epidemic in South Africa. However, the presence of multiple factors complicates estimation of the mining contribution to the TB burden in South Africa. METHODS We developed two models of TB in South Africa, a static risk model and an individual-based model that accounts for longer-term trends. Both models account for four populations - mine workers, peri-mining residents, labor-sending residents, and other residents of South Africa - including the size and prevalence of latent TB infection, active TB, and HIV of each population and mixing between populations. We calibrated to mine- and country-level data and used the static model to estimate force of infection (FOI) and new infections attributable to local residents in each community compared to other residents. Using the individual-based model, we simulated a counterfactual scenario to estimate the fraction of overall TB incidence in South Africa attributable to recent transmission in mines. RESULTS We estimated that the majority of FOI in each community is attributable to local residents: 93.9% (95% confidence interval 92.4-95.1%), 91.5% (91.4-91.5%), and 94.7% (94.7-94.7%) in gold mining, peri-mining, and labor-sending communities, respectively. Assuming a higher rate of Mtb transmission in mines, 4.1% (2.6-5.8%), 5.0% (4.5-5.5%), and 9.0% (8.8-9.1%) of new infections in South Africa are attributable to gold mine workers, peri-mining residents, and labor-sending residents, respectively. Therefore, mine workers with TB disease, who constitute ~ 2.5% of the prevalent TB cases in South Africa, contribute 1.62 (1.04-2.30) times as many new infections as TB cases in South Africa on average. By modeling TB on a longer time scale, we estimate 63.0% (58.5-67.7%) of incident TB disease in gold mining communities to be attributable to recent transmission, of which 92.5% (92.1-92.9%) is attributable to local transmission. CONCLUSIONS Gold mine workers are estimated to contribute a disproportionately large number of Mtb infections in South Africa on a per-capita basis. However, mine workers contribute only a small fraction of overall Mtb infections in South Africa. Our results suggest that curtailing transmission in mines may have limited impact at the country level, despite potentially significant impact at the mining level.
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Affiliation(s)
| | - Violet N Chihota
- Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.,Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Katherine L Fielding
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Alison D Grant
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.,Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK.,Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Rein M Houben
- TB Modelling Group, CMMID, TB Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Richard G White
- TB Modelling Group, CMMID, TB Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Gavin J Churchyard
- Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.,Advancing Treatment and Care for TB/HIV, South African Medical Research Council, Johannesburg, South Africa
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Page-Shipp L, Lewis JJ, Velen K, Senoge S, Zishiri E, Popane F, Chihota VN, Clark D, Churchyard GJ, Charalambous S. Household point of care CD4 testing and isoniazid preventive therapy initiation in a household TB contact tracing programme in two districts of South Africa. PLoS One 2018; 13:e0192089. [PMID: 29499060 PMCID: PMC5834159 DOI: 10.1371/journal.pone.0192089] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 10/24/2017] [Accepted: 01/16/2018] [Indexed: 01/03/2023] Open
Abstract
Background In South Africa, TB household contact tracing provides an opportunity for increased TB and HIV case finding. We aimed to determine the effect of two new potential interventions for TB contact tracing programmes: Point of Care CD4 (PoC CD4) on HIV linkage to care and household Isoniazid Preventive Therapy (IPT) provision on uptake and retention of IPT. Methods A pragmatic, three-arm, cluster-randomized trial was undertaken. TB Household contacts were randomised to 3 arms: 1) Standard of Care TB and HIV testing (SOC); 2) SOC with POC CD4 for those testing HIV positive; 3) SOC with POC CD4 and IPT for eligible household members. Linkage to care within 90 days was assessed either through patient visits (at 10 weeks and 6 months) or via telephonic contact. Results 2,243 index TB patients and 3,012 contacts (64,3% female, median age 30 years) were enrolled. On self-report, 26(1.2%) were currently receiving TB treatment and 1816 (60.3%) reported a prior HIV test. HIV testing uptake was 34.7% in the SoC arm, 40.2% in the PoC CD4 arm (RR1.16, CI 0.99–1.36, p-value = 0.060) and 39.9% in the PoC CD4 + HH-IPT arm (RR = 1.15, CI 0.99–1.35, p-value = 0.075). Linkage to care within 3 months was 30.8% in the SoC arm and 42.1% in the POC CD4 arms (RR 1.37; CI: 0.68–2.76, p-value = 0.382). 20/21 contacts (95.2%) initiated IPT in the PoC CD4 + HH-IPT arm, compared to 3/20 (15.0%) in the PoC CD4 arm (p = 0.004; p-value from Fisher’s exact test < 0.001). Among 3,008 contacts screened for tuberculosis, 15 (3.4%) had bacteriologically confirmed TB with an overall yield of TB of 0.5% (95% CI: 0.3%, 0.8%). Conclusions Household PoC CD4 testing and IPT initiation is feasible. There was only weak evidence that PoCCD4 led to a small increase in HCT uptake and no evidence for an increase in linkage-to-care. IPT initiation and completion was increased by the household intervention. Although feasible, these interventions had low impact due to the low uptake of HIV testing in households.
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Affiliation(s)
| | - James J. Lewis
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kavindhran Velen
- The Aurum Institute, Johannesburg, South Africa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | | | - Dave Clark
- The Aurum Institute, Johannesburg, South Africa
| | - Gavin J. Churchyard
- The Aurum Institute, Johannesburg, South Africa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- The School of Public Health, University of Witwatersrand, Johannesburg, South Africa
- Advancing Care and Treatment for TB and HIV, Medical Research Council Collaborating Centre of Excellence, Johannesburg, South Africa
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa
- The School of Public Health, University of Witwatersrand, Johannesburg, South Africa
- Advancing Care and Treatment for TB and HIV, Medical Research Council Collaborating Centre of Excellence, Johannesburg, South Africa
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McCarthy K, Fielding K, Churchyard GJ, Grant AD. Empiric tuberculosis treatment in South African primary health care facilities - for whom, where, when and why: Implications for the development of tuberculosis diagnostic tests. PLoS One 2018; 13:e0191608. [PMID: 29364960 PMCID: PMC5783417 DOI: 10.1371/journal.pone.0191608] [Citation(s) in RCA: 11] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 01/08/2018] [Indexed: 11/18/2022] Open
Abstract
Background The extent and circumstances under which empiric tuberculosis (TB) treatment (treatment without microbiological confirmation at treatment initiation) is administered in primary health care settings in South Africa are not well described. Methods We used data from a pragmatic evaluation of Xpert MTB/RIF in which persons undergoing TB investigations by PHC nurses were followed for six months. Following Xpert or smear-microscopy at enrolment, investigations for tuberculosis were undertaken at the discretion of health care workers. We identified persons whose TB treatment was initiated empirically (no microbiological confirmation at time of treatment initiation at a primary health care facility) and describe pathways to treatment initiation. Results Of 4665 evaluable participants, 541 persons were initiated on treatment of whom 167 (31%) had negative sputum tests at enrolment. Amongst these 167, the median number of participant visits to health care providers prior to treatment initiation was 3 (interquartile range [IQR] 2–4). Chest radiography, sputum culture or hospital referral was done in 106/167 (63%). Reasons for TB treatment start were: 1) empiric (n = 82, 49%); 2) a positive laboratory test (n = 49, 29%); 3) referral and treatment start at a higher level of care (n = 28, 17%); and 4) indeterminable (n = 8, 5%). Empiric treatment accounted for 15% (82/541) of all TB treatment initiations and 1.7% (82/4665) of all persons undergoing TB investigations. Chest radiography findings compatible with TB (63/82 [77%]) were the basis for treatment initiation amongst the majority of empirically treated participants. Microbiological confirmation of TB was subsequently obtained for 11/82 (13%) empirically-treated participants. Median time to empiric treatment start was 3.9 weeks (IQR 1.4–11 weeks) after enrolment. Conclusion Uncommon prescription of empiric TB treatment with reliance on chest radiography in a nurse-managed programme underscores the need for highly sensitive TB diagnostics suitable for point-of-care, and strong health systems to support TB diagnosis in this setting.
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Affiliation(s)
- Kerrigan McCarthy
- The Aurum Institute; Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- National Institute for Communicable Diseases, Johannesburg, South Africa
- * E-mail:
| | - Katherine Fielding
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Gavin J. Churchyard
- The Aurum Institute; Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Advancing Treatment and Care, South African Medical Research Council, Johannesburg, South Africa
| | - Alison D. Grant
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Shrestha S, Chihota V, White RG, Grant AD, Churchyard GJ, Dowdy DW. Impact of Targeted Tuberculosis Vaccination Among a Mining Population in South Africa: A Model-Based Study. Am J Epidemiol 2017; 186:1362-1369. [PMID: 29253139 DOI: 10.1093/aje/kwx192] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 02/14/2017] [Indexed: 12/16/2022] Open
Abstract
Optimizing the use of new tools, such as vaccines, may play a crucial role in reaching global targets for tuberculosis (TB) control. Some of the most promising candidate vaccines target adults, although high-coverage mass vaccinations may be logistically more challenging among this population than among children. Vaccine-delivery strategies that target high-risk groups or settings might yield proportionally greater impact than do those that target the general population. We developed an individual-based TB transmission model representing a hypothetical population consisting of people who worked in South African gold mines or lived in associated labor-sending communities. We simulated the implementation of a postinfection adult vaccine with 60% efficacy and a mean effect duration of 10 years. We then compared the impact of a mine-targeted vaccination strategy, in which miners were vaccinated while in the mines, with that of a community-targeted strategy, in which random individuals within the labor-sending communities were vaccinated. Mine-targeted vaccination averted an estimated 0.37 TB cases per vaccine dose compared with 0.25 for community-targeted vaccination, for a relative efficacy of 1.46 (95% range, 1.13-1.91). The added benefit of mine-targeted vaccination primarily reflected the disproportionate demographic burden of TB among the population of adult males as a whole. As novel vaccines for TB are developed, venue-based vaccine delivery that targets high-risk demographic groups may improve both vaccine feasibility and the impact on transmission.
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Affiliation(s)
- Sourya Shrestha
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Violet Chihota
- Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Richard G White
- TB Modelling Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Alison D Grant
- TB Center, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Africa Center for Population Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Gavin J Churchyard
- Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - David W Dowdy
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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Auld SC, Kasmar AG, Dowdy DW, Mathema B, Gandhi NR, Churchyard GJ, Rustomjee R, Shah NS. Research Roadmap for Tuberculosis Transmission Science: Where Do We Go From Here and How Will We Know When We're There? J Infect Dis 2017; 216:S662-S668. [PMID: 29112744 PMCID: PMC5793854 DOI: 10.1093/infdis/jix353] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
High rates of tuberculosis transmission are driving the ongoing global tuberculosis epidemic, and there is a pressing need for research focused on understanding and, ultimately, halting transmission. The ongoing tuberculosis–human immunodeficiency virus (HIV) coepidemic and rising rates of drug-resistant tuberculosis in parts of the world add further urgency to this work. Success in this research will require a concerted, multidisciplinary effort on the part of tuberculosis scientists, clinicians, programs, and funders and must span the research spectrum from biomedical sciences to the social sciences, public health, epidemiology, cost-effectiveness analyses, and operations research. Heterogeneity of tuberculosis disease, both among individual patients and among communities, poses a substantial challenge to efforts to interrupt transmission. As such, it is likely that effective interventions to stop transmission will require a combination of approaches that will vary across different epidemiologic settings. This research roadmap summarizes key gaps in our current understanding of transmission, as laid out in the preceding articles in this series. We also hope that it will be a call to action for the global tuberculosis community to make a sustained commitment to tuberculosis transmission science. Halting transmission today is an essential step on the path to end tuberculosis tomorrow.
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Affiliation(s)
- Sara C Auld
- School of Medicine and Rollins School of Public Health, Emory University
| | - Anne G Kasmar
- Bill and Melinda Gates Foundation, Seattle, Washington
| | - David W Dowdy
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore
| | - Barun Mathema
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Neel R Gandhi
- School of Medicine and Rollins School of Public Health, Emory University
| | - Gavin J Churchyard
- Aurum Institute and the School of Public Health, University of Witwatersrand.,Advancing Care for tuberculosis and HIV, South African Medical Research Council, Johannesburg, South Africa
| | - Roxana Rustomjee
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland
| | - N Sarita Shah
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, Georgia
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Abstract
The transmission of tuberculosis is complex. Necessary factors include a source case with respiratory disease that has developed sufficiently for Mycobacterium tuberculosis to be present in the airways. Viable bacilli must then be released as an aerosol via the respiratory tract of the source case. This is presumed to occur predominantly by coughing but may also happen by other means. Airborne bacilli must be capable of surviving in the external environment before inhalation into a new potential host-steps influenced by ambient conditions and crowding and by M. tuberculosis itself. Innate and adaptive host defenses will then influence whether new infection results; a process that is difficult to study owing to a paucity of animal models and an inability to measure infection directly. This review offers an overview of these steps and highlights the many gaps in knowledge that remain.
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Affiliation(s)
| | - Christopher Chiu
- Section of Infectious Diseases & Immunity, Imperial College London, United Kingdom
| | - Gavin J Churchyard
- Aurum Institute and
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Hanif Esmail
- Radcliffe Department of Medicine, University of Oxford, United Kingdom
- Wellcome Center for Infectious Diseases Research in Africa, University of Cape Town, South Africa
| | - David M Lewinsohn
- Department of Molecular Microbiology and Immunology, Oregon Health & Science University, Portland
| | - Neel R Gandhi
- School of Medicine and Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kevin P Fennelly
- Pulmonary Clinical Medicine Section, Cardiovascular Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
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Hanifa Y, Fielding KL, Chihota VN, Adonis L, Charalambous S, Foster N, Karstaedt A, McCarthy K, Nicol MP, Ndlovu NT, Sinanovic E, Sahid F, Stevens W, Vassall A, Churchyard GJ, Grant AD. A clinical scoring system to prioritise investigation for tuberculosis among adults attending HIV clinics in South Africa. PLoS One 2017; 12:e0181519. [PMID: 28771504 PMCID: PMC5542442 DOI: 10.1371/journal.pone.0181519] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [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: 08/18/2016] [Accepted: 06/21/2017] [Indexed: 12/23/2022] Open
Abstract
Background The World Health Organization (WHO) recommendation for regular tuberculosis (TB) screening of HIV-positive individuals with Xpert MTB/RIF as the first diagnostic test has major resource implications. Objective To develop a diagnostic prediction model for TB, for symptomatic adults attending for routine HIV care, to prioritise TB investigation. Design Cohort study exploring a TB testing algorithm. Setting HIV clinics, South Africa. Participants Representative sample of adult HIV clinic attendees; data from participants reporting ≥1 symptom on the WHO screening tool were split 50:50 to derive, then internally validate, a prediction model. Outcome TB, defined as “confirmed” if Xpert MTB/RIF, line probe assay or M. tuberculosis culture were positive; and “clinical” if TB treatment started without microbiological confirmation, within six months of enrolment. Results Overall, 79/2602 (3.0%) participants on ART fulfilled TB case definitions, compared to 65/906 (7.2%) pre-ART. Among 1133/3508 (32.3%) participants screening positive on the WHO tool, 1048 met inclusion criteria for this analysis: 52/515 (10.1%) in the derivation and 58/533 (10.9%) in the validation dataset had TB. Our final model comprised ART status (on ART > 3 months vs. pre-ART or ART < 3 months); body mass index (continuous); CD4 (continuous); number of WHO symptoms (1 vs. >1 symptom). We converted this to a clinical score, using clinically-relevant CD4 and BMI categories. A cut-off score of ≥3 identified those with TB with sensitivity and specificity of 91.8% and 34.3% respectively. If investigation was prioritised for individuals with score of ≥3, 68% (717/1048) symptomatic individuals would be tested, among whom the prevalence of TB would be 14.1% (101/717); 32% (331/1048) of tests would be avoided, but 3% (9/331) with TB would be missed amongst those not tested. Conclusion Our clinical score may help prioritise TB investigation among symptomatic individuals.
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Affiliation(s)
- Yasmeen Hanifa
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Violet N Chihota
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nicola Foster
- Health Economics Unit, School of public health and family medicine, University of Cape Town, Cape Town, South Africa
| | - Alan Karstaedt
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, South Africa.,University of the Witwatersrand, Johannesburg, South Africa
| | | | - Mark P Nicol
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,National Health Laboratory Service, Johannesburg, South Africa
| | | | - Edina Sinanovic
- Health Economics Unit, School of public health and family medicine, University of Cape Town, Cape Town, South Africa
| | - Faieza Sahid
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, South Africa.,University of the Witwatersrand, Johannesburg, South Africa
| | - Wendy Stevens
- National Health Laboratory Service, Johannesburg, South Africa.,Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Anna Vassall
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Gavin J Churchyard
- London School of Hygiene & Tropical Medicine, London, United Kingdom.,The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Advancing Treatment and Care for TB/HIV, South African Medical Research Council Collaborating Centre for HIV and TB, Johannesburg, South Africa
| | - Alison D Grant
- London School of Hygiene & Tropical Medicine, London, United Kingdom.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,School of Nursing and Public Health, Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa
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Karat AS, Tlali M, Fielding KL, Charalambous S, Chihota VN, Churchyard GJ, Hanifa Y, Johnson S, McCarthy K, Martinson NA, Omar T, Kahn K, Chandramohan D, Grant AD. Measuring mortality due to HIV-associated tuberculosis among adults in South Africa: Comparing verbal autopsy, minimally-invasive autopsy, and research data. PLoS One 2017; 12:e0174097. [PMID: 28334030 PMCID: PMC5363862 DOI: 10.1371/journal.pone.0174097] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [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: 11/04/2016] [Accepted: 03/04/2017] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) aims to reduce tuberculosis (TB) deaths by 95% by 2035; tracking progress requires accurate measurement of TB mortality. International Classification of Diseases (ICD) codes do not differentiate between HIV-associated TB and HIV more generally. Verbal autopsy (VA) is used to estimate cause of death (CoD) patterns but has mostly been validated against a suboptimal gold standard for HIV and TB. This study, conducted among HIV-positive adults, aimed to estimate the accuracy of VA in ascertaining TB and HIV CoD when compared to a reference standard derived from a variety of clinical sources including, in some, minimally-invasive autopsy (MIA). METHODS AND FINDINGS Decedents were enrolled into a trial of empirical TB treatment or a cohort exploring diagnostic algorithms for TB in South Africa. The WHO 2012 instrument was used; VA CoD were assigned using physician-certified VA (PCVA), InterVA-4, and SmartVA-Analyze. Reference CoD were assigned using MIA, research, and health facility data, as available. 259 VAs were completed: 147 (57%) decedents were female; median age was 39 (interquartile range [IQR] 33-47) years and CD4 count 51 (IQR 22-102) cells/μL. Compared to reference CoD that included MIA (n = 34), VA underestimated mortality due to HIV/AIDS (94% reference, 74% PCVA, 47% InterVA-4, and 41% SmartVA-Analyze; chance-corrected concordance [CCC] 0.71, 0.42, and 0.31, respectively) and HIV-associated TB (41% reference, 32% PCVA; CCC 0.23). For individual decedents, all VA methods agreed poorly with reference CoD that did not include MIA (n = 259; overall CCC 0.14, 0.06, and 0.15 for PCVA, InterVA-4, and SmartVA-Analyze); agreement was better at population level (cause-specific mortality fraction accuracy 0.78, 0.61, and 0.57, for the three methods, respectively). CONCLUSIONS Current VA methods underestimate mortality due to HIV-associated TB. ICD and VA methods need modifications that allow for more specific evaluation of HIV-related deaths and direct estimation of mortality due to HIV-associated TB.
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Affiliation(s)
- Aaron S. Karat
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Mpho Tlali
- The Aurum Institute, Johannesburg, South Africa
| | - Katherine L. Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Violet N. Chihota
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gavin J. Churchyard
- The Aurum Institute, Johannesburg, South Africa
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Yasmeen Hanifa
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Suzanne Johnson
- Foundation for Professional Development, Pretoria, South Africa
| | - Kerrigan McCarthy
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Public Health, Surveillance and Response, National Institute for Communicable Disease of the National Health Laboratory Service, Johannesburg, South Africa
| | - Neil A. Martinson
- Perinatal HIV Research Unit, and Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
- Johns Hopkins University Center for TB Research, Baltimore, United States of America
- Department of Science and Technology / National Research Foundation Centre of Excellence for Biomedical TB Research, University of the Witwatersrand, Johannesburg, South Africa
| | - Tanvier Omar
- Department of Anatomical Pathology, National Health Laboratory Service and University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
- Epidemiology and Global Health Unit, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Daniel Chandramohan
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Alison D. Grant
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Dheda K, Gumbo T, Maartens G, Dooley KE, McNerney R, Murray M, Furin J, Nardell EA, London L, Lessem E, Theron G, van Helden P, Niemann S, Merker M, Dowdy D, Van Rie A, Siu GKH, Pasipanodya JG, Rodrigues C, Clark TG, Sirgel FA, Esmail A, Lin HH, Atre SR, Schaaf HS, Chang KC, Lange C, Nahid P, Udwadia ZF, Horsburgh CR, Churchyard GJ, Menzies D, Hesseling AC, Nuermberger E, McIlleron H, Fennelly KP, Goemaere E, Jaramillo E, Low M, Jara CM, Padayatchi N, Warren RM. The epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant, extensively drug-resistant, and incurable tuberculosis. Lancet Respir Med 2017; 5:S2213-2600(17)30079-6. [PMID: 28344011 DOI: 10.1016/s2213-2600(17)30079-6] [Citation(s) in RCA: 376] [Impact Index Per Article: 53.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/24/2016] [Accepted: 12/08/2016] [Indexed: 12/25/2022]
Abstract
Global tuberculosis incidence has declined marginally over the past decade, and tuberculosis remains out of control in several parts of the world including Africa and Asia. Although tuberculosis control has been effective in some regions of the world, these gains are threatened by the increasing burden of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis. XDR tuberculosis has evolved in several tuberculosis-endemic countries to drug-incurable or programmatically incurable tuberculosis (totally drug-resistant tuberculosis). This poses several challenges similar to those encountered in the pre-chemotherapy era, including the inability to cure tuberculosis, high mortality, and the need for alternative methods to prevent disease transmission. This phenomenon mirrors the worldwide increase in antimicrobial resistance and the emergence of other MDR pathogens, such as malaria, HIV, and Gram-negative bacteria. MDR and XDR tuberculosis are associated with high morbidity and substantial mortality, are a threat to health-care workers, prohibitively expensive to treat, and are therefore a serious public health problem. In this Commission, we examine several aspects of drug-resistant tuberculosis. The traditional view that acquired resistance to antituberculous drugs is driven by poor compliance and programmatic failure is now being questioned, and several lines of evidence suggest that alternative mechanisms-including pharmacokinetic variability, induction of efflux pumps that transport the drug out of cells, and suboptimal drug penetration into tuberculosis lesions-are likely crucial to the pathogenesis of drug-resistant tuberculosis. These factors have implications for the design of new interventions, drug delivery and dosing mechanisms, and public health policy. We discuss epidemiology and transmission dynamics, including new insights into the fundamental biology of transmission, and we review the utility of newer diagnostic tools, including molecular tests and next-generation whole-genome sequencing, and their potential for clinical effectiveness. Relevant research priorities are highlighted, including optimal medical and surgical management, the role of newer and repurposed drugs (including bedaquiline, delamanid, and linezolid), pharmacokinetic and pharmacodynamic considerations, preventive strategies (such as prophylaxis in MDR and XDR contacts), palliative and patient-orientated care aspects, and medicolegal and ethical issues.
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Affiliation(s)
- Keertan Dheda
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa.
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly E Dooley
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ruth McNerney
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Megan Murray
- Department of Global Health and Social Medicine, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Edward A Nardell
- TH Chan School of Public Health, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Leslie London
- School of Public Health and Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Grant Theron
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Paul van Helden
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Stefan Niemann
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Schleswig-Holstein, Germany; German Centre for Infection Research (DZIF), Partner Site Borstel, Borstel, Schleswig-Holstein, Germany
| | - Matthias Merker
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Schleswig-Holstein, Germany
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Annelies Van Rie
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; International Health Unit, Epidemiology and Social Medicine, Faculty of Medicine, University of Antwerp, Antwerp, Belgium
| | - Gilman K H Siu
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR, China
| | - Jotam G Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Camilla Rodrigues
- Department of Microbiology, P.D. Hinduja National Hospital & Medical Research Centre, Mumbai, India
| | - Taane G Clark
- Faculty of Infectious and Tropical Diseases and Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Frik A Sirgel
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Aliasgar Esmail
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Hsien-Ho Lin
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Sachin R Atre
- Center for Clinical Global Health Education (CCGHE), Johns Hopkins University, Baltimore, MD, USA; Medical College, Hospital and Research Centre, Pimpri, Pune, India
| | - H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kwok Chiu Chang
- Tuberculosis and Chest Service, Centre for Health Protection, Department of Health, Hong Kong SAR, China
| | - Christoph Lange
- Division of Clinical Infectious Diseases, German Center for Infection Research, Research Center Borstel, Borstel, Schleswig-Holstein, Germany; International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany; Department of Medicine, Karolinska Institute, Stockholm, Sweden; Department of Medicine, University of Namibia School of Medicine, Windhoek, Namibia
| | - Payam Nahid
- Division of Pulmonary and Critical Care, San Francisco General Hospital, University of California, San Francisco, CA, USA
| | - Zarir F Udwadia
- Pulmonary Department, Hinduja Hospital & Research Center, Mumbai, India
| | | | - Gavin J Churchyard
- Aurum Institute, Johannesburg, South Africa; School of Public Health, University of Witwatersrand, Johannesburg, South Africa; Advancing Treatment and Care for TB/HIV, South African Medical Research Council, Johannesburg, South Africa
| | - Dick Menzies
- Montreal Chest Institute, McGill University, Montreal, QC, Canada
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Eric Nuermberger
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kevin P Fennelly
- Pulmonary Clinical Medicine Section, Division of Intramural Research, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Eric Goemaere
- MSF South Africa, Cape Town, South Africa; School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Marcus Low
- Treatment Action Campaign, Johannesburg, South Africa
| | | | - Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), MRC HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Robin M Warren
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
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Kendall EA, Shrestha S, Cohen T, Nuermberger E, Dooley KE, Gonzalez-Angulo L, Churchyard GJ, Nahid P, Rich ML, Bansbach C, Forissier T, Lienhardt C, Dowdy DW. Priority-Setting for Novel Drug Regimens to Treat Tuberculosis: An Epidemiologic Model. PLoS Med 2017; 14:e1002202. [PMID: 28045934 PMCID: PMC5207633 DOI: 10.1371/journal.pmed.1002202] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 11/16/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Novel drug regimens are needed for tuberculosis (TB) treatment. New regimens aim to improve on characteristics such as duration, efficacy, and safety profile, but no single regimen is likely to be ideal in all respects. By linking these regimen characteristics to a novel regimen's ability to reduce TB incidence and mortality, we sought to prioritize regimen characteristics from a population-level perspective. METHODS AND FINDINGS We developed a dynamic transmission model of multi-strain TB epidemics in hypothetical populations reflective of the epidemiological situations in India (primary analysis), South Africa, the Philippines, and Brazil. We modeled the introduction of various novel rifampicin-susceptible (RS) or rifampicin-resistant (RR) TB regimens that differed on six characteristics, identified in consultation with a team of global experts: (1) efficacy, (2) duration, (3) ease of adherence, (4) medical contraindications, (5) barrier to resistance, and (6) baseline prevalence of resistance to the novel regimen. We compared scale-up of these regimens to a baseline reflective of continued standard of care. For our primary analysis situated in India, our model generated baseline TB incidence and mortality of 157 (95% uncertainty range [UR]: 113-187) and 16 (95% UR: 9-23) per 100,000 per year at the time of novel regimen introduction and RR TB incidence and mortality of 6 (95% UR: 4-10) and 0.6 (95% UR: 0.3-1.1) per 100,000 per year. An optimal RS TB regimen was projected to reduce 10-y TB incidence and mortality in the India-like scenario by 12% (95% UR: 6%-20%) and 11% (95% UR: 6%-20%), respectively, compared to current-care projections. An optimal RR TB regimen reduced RR TB incidence by an estimated 32% (95% UR: 18%-46%) and RR TB mortality by 30% (95% UR: 18%-44%). Efficacy was the greatest determinant of impact; compared to a novel regimen meeting all minimal targets only, increasing RS TB treatment efficacy from 94% to 99% reduced TB mortality by 6% (95% UR: 1%-13%, half the impact of a fully optimized regimen), and increasing the efficacy against RR TB from 76% to 94% lowered RR TB mortality by 13% (95% UR: 6%-23%). Reducing treatment duration or improving ease of adherence had smaller but still substantial impact: shortening RS TB treatment duration from 6 to 2 mo lowered TB mortality by 3% (95% UR: 1%-6%), and shortening RR TB treatment from 20 to 6 mo reduced RR TB mortality by 8% (95% UR: 4%-13%), while reducing nonadherence to the corresponding regimens by 50% reduced TB and RR TB mortality by 2% (95% UR: 1%-4%) and 6% (95% UR: 3%-10%), respectively. Limitations include sparse data on key model parameters and necessary simplifications to model structure and outcomes. CONCLUSIONS In designing clinical trials of novel TB regimens, investigators should consider that even small changes in treatment efficacy may have considerable impact on TB-related incidence and mortality. Other regimen improvements may still have important benefits for resource allocation and outcomes such as patient quality of life.
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Affiliation(s)
- Emily A. Kendall
- Johns Hopkins University School of Medicine, Division of Infectious Diseases, Baltimore, Maryland, United States of America
- * E-mail:
| | - Sourya Shrestha
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland, United States of America
| | - Ted Cohen
- Yale School of Public Health, Department of Epidemiology of Microbial Diseases, New Haven, Connecticut, United States of America
| | - Eric Nuermberger
- Johns Hopkins University School of Medicine, Division of Infectious Diseases, Baltimore, Maryland, United States of America
| | - Kelly E. Dooley
- Johns Hopkins University School of Medicine, Division of Infectious Diseases, Baltimore, Maryland, United States of America
- Johns Hopkins University School of Medicine, Division of Clinical Pharmacology, Baltimore, Maryland, United States of America
| | | | | | - Payam Nahid
- University of California San Francisco, Division of Pulmonary and Critical Care Medicine, San Francisco, California, United States of America
| | - Michael L. Rich
- Partners In Health, Boston, Massachusetts, United States of America
- Brigham and Women's Hospital, Division of Global Health Equity, Boston, Massachusetts, United States of America
| | - Cathy Bansbach
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Thomas Forissier
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | | | - David W. Dowdy
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland, United States of America
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35
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Karat AS, Omar T, von Gottberg A, Tlali M, Chihota VN, Churchyard GJ, Fielding KL, Johnson S, Martinson NA, McCarthy K, Wolter N, Wong EB, Charalambous S, Grant AD. Autopsy Prevalence of Tuberculosis and Other Potentially Treatable Infections among Adults with Advanced HIV Enrolled in Out-Patient Care in South Africa. PLoS One 2016; 11:e0166158. [PMID: 27829072 PMCID: PMC5102350 DOI: 10.1371/journal.pone.0166158] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [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: 05/06/2016] [Accepted: 10/23/2016] [Indexed: 11/19/2022] Open
Abstract
Background Early mortality among HIV-positive adults starting antiretroviral therapy (ART) remains high in resource-limited settings, with tuberculosis (TB) the leading cause of death. However, current methods to estimate TB-related deaths are inadequate and most autopsy studies do not adequately represent those attending primary health clinics (PHCs). This study aimed to determine the autopsy prevalence of TB and other infections in adults enrolled at South African PHCs in the context of a pragmatic trial of empiric TB treatment (“TB Fast Track”). Methods and Findings Adults with CD4 ≤150 cells/μL, not on ART or TB treatment, were enrolled to TB Fast Track and followed up for at least six months. Minimally invasive autopsy (MIA) was conducted as soon as possible after death. Lungs, liver, and spleen were biopsied; blood, CSF, and urine aspirated; and bronchoalveolar lavage fluid obtained. Samples underwent mycobacterial, bacterial, and fungal culture; molecular testing (including Xpert® MTB/RIF); and histological examination. 34 MIAs were conducted: 18 (53%) decedents were female; median age was 39 (interquartile range 33–44) years; 25 (74%) deaths occurred in hospitals; median time from death to MIA was five (IQR 3–6) days. 16/34 (47%) had evidence of TB (14/16 [88%] with extrapulmonary disease; 6/16 [38%] not started on treatment antemortem); 23 (68%) had clinically important bacterial infections; four (12%) cryptococcal disease; three (9%) non-tuberculous mycobacterial disease; and two (6%) Pneumocystis pneumonia. Twenty decedents (59%) had evidence of two or more concurrent infections; 9/16 (56%) individuals with TB had evidence of bacterial disease and two (13%) cryptococcal disease. Conclusions TB, followed by bacterial infections, were the leading findings at autopsy among adults with advanced HIV enrolled from primary care clinics. To reduce mortality, strategies are needed to identify and direct those at highest risk into a structured pathway that includes expedited investigation and/or treatment of TB and other infections.
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Affiliation(s)
- Aaron S. Karat
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Tanvier Omar
- Department of Anatomical Pathology, National Health Laboratory Service and University of the Witwatersrand, Johannesburg, South Africa
| | - Anne von Gottberg
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mpho Tlali
- The Aurum Institute, Johannesburg, South Africa
| | - Violet N. Chihota
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gavin J. Churchyard
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Katherine L. Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Suzanne Johnson
- Foundation for Professional Development, Pretoria, South Africa
| | - Neil A. Martinson
- Perinatal HIV Research Unit, and Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
- Johns Hopkins University Center for TB Research, Baltimore, Maryland, United States of America
- Department of Science and Technology / National Research Foundation Centre of Excellence for Biomedical TB Research, University of the Witwatersrand, Johannesburg, South Africa
| | - Kerrigan McCarthy
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Public Health, Surveillance and Response, National Institute for Communicable Disease of the National Health Laboratory Service, Johannesburg, South Africa
| | - Nicole Wolter
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Emily B. Wong
- Africa Health Research Institute, Durban, South Africa
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alison D. Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Africa Health Research Institute, Durban, South Africa
- University of KwaZulu-Natal, Durban, South Africa
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Maraba N, Karat AS, McCarthy K, Churchyard GJ, Charalambous S, Kahn K, Grant AD, Chihota V. Verbal autopsy-assigned causes of death among adults being investigated for TB in South Africa. Trans R Soc Trop Med Hyg 2016; 110:510-516. [PMID: 27794093 PMCID: PMC5091329 DOI: 10.1093/trstmh/trw058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 09/06/2016] [Indexed: 11/24/2022] Open
Abstract
Background Adults being investigated for TB in South Africa experience high mortality, yet causes of death (CoD) are not well defined. We determined CoD in this population using verbal autopsy (VA), and compared HIV- and TB-associated CoD using physician-certified verbal autopsy (PCVA) and InterVA-4 software. Methods All contactable consenting caregivers of participants who died during a trial comparing Xpert MTB/RIF to smear microscopy were interviewed using the WHO VA tool. CoD were assigned using PCVA and InterVA-4. Kappa statistic (K) and concordance correlation coefficient (CCC) were calculated for comparison. Results Among 231 deaths, relatives of 137 deceased were interviewed. Of the 137 deceased 76 (55.4%) were males, median age 41 years (IQR 33–50). PCVA assigned 70 (51.1%) TB immediate CoD (44 [62.8%] pulmonary TB; 26 [37.1%] extra-pulmonary TB); 21 (15.3%) HIV/AIDS-related; and 46 (33.5%) other CoD. InterVA-4 assigned 48 (35.0%) TB deaths; 49 (35.7%) HIV/AIDS-related deaths; and 40 (29.1%) other CoD. Agreement between PCVA and InterVA-4 CoD was slight at individual level (K=0.20; 95% CI 0.10–0.30) and poor at population level (CCC 0.67; 95% CI 0.38–0.99). Conclusions TB and HIV are leading CoD among adults being investigated for TB. PCVA and InterVA agreement at individual level was slight and poor at population level. VA methodology needs further development where TB and HIV are common.
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Affiliation(s)
- Noriah Maraba
- The Aurum Institute, Parktown, Johannesburg, South Africa .,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Kerrigan McCarthy
- Division of Public Health Surveillance and Response, National Institute for Communicable diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | - Gavin J Churchyard
- The Aurum Institute, Parktown, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,London School of Hygiene & Tropical Medicine, UK.,Advancing Treatment and Care for TB and HIV, South African Medical Research Council Collaborating Centre for HIV/TB
| | - Salome Charalambous
- The Aurum Institute, Parktown, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt); School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå 90187, Sweden.,INDEPTH Network, Accra, Ghana
| | - Alison D Grant
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,London School of Hygiene & Tropical Medicine, UK.,School of Nursing, Public Health, Africa Center for Population Health, University of Kwa-Zulu Natal
| | - Violet Chihota
- The Aurum Institute, Parktown, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Velen K, Charalambous S, Innes C, Churchyard GJ, Hoffmann CJ. Chronic hepatitis B increases mortality and complexity among HIV-coinfected patients in South Africa: a cohort study. HIV Med 2016; 17:702-7. [PMID: 26991340 PMCID: PMC6717432 DOI: 10.1111/hiv.12367] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To assess the effect of chronic hepatitis B on survival and clinical complexity among people living with HIV following antiretroviral therapy (ART) initiation. METHODS We evaluated mortality and single-drug substitutions up to 3 years from ART initiation (median follow-up 2.75 years; interquartile range 2-3 years) among patients with and without chronic hepatitis B (CHB) enrolled in a workplace HIV care programme in South Africa. RESULTS Mortality was increased for CHB patients with hepatitis B virus (HBV) DNA levels > 10 000 copies/mL (adjusted hazard ratio 3.1; 95% confidence interval 1.2-8.0) compared with non-CHB patients. We did not observe a similar difference between non-CHB patients and those with CHB and HBV DNA < 10 000 copies/mL (adjusted hazard ratio 0.70; 95% confidence interval 0.2-2.3). Single-drug substitutions occurred more frequently among coinfected patients regardless of HBV DNA level. CONCLUSIONS Our findings suggest that CHB may increase mortality and complicate ART management.
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Affiliation(s)
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Craig Innes
- The Aurum Institute, Johannesburg, South Africa
| | - Gavin J Churchyard
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Christopher J Hoffmann
- The Aurum Institute, Johannesburg, South Africa
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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38
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Evans TG, Churchyard GJ, Penn-Nicholson A, Chen C, Gao X, Tait DR, Hatherill M. Epidemiologic studies and novel clinical research approaches that impact TB vaccine development. Tuberculosis (Edinb) 2016; 99 Suppl 1:S21-5. [DOI: 10.1016/j.tube.2016.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Hanifa Y, Fielding KL, Chihota VN, Adonis L, Charalambous S, Karstaedt A, McCarthy K, Nicol MP, Ndlovu NT, Sahid F, Churchyard GJ, Grant AD. Diagnostic Accuracy of Lateral Flow Urine LAM Assay for TB Screening of Adults with Advanced Immunosuppression Attending Routine HIV Care in South Africa. PLoS One 2016; 11:e0156866. [PMID: 27271432 PMCID: PMC4896615 DOI: 10.1371/journal.pone.0156866] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [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: 12/10/2015] [Accepted: 05/19/2016] [Indexed: 12/03/2022] Open
Abstract
Background We assessed the diagnostic accuracy of Determine TB-LAM (LF-LAM) to screen for tuberculosis among ambulatory adults established in HIV care in South Africa. Methods A systematic sample of adults attending for HIV care, regardless of symptomatology, were enrolled in the XPHACTOR study, which tested a novel algorithm for prioritising investigation with Xpert MTB/RIF. In this substudy, restricted to participants with enrolment CD4<200x106/l, urine was stored at enrolment for later testing with LF-LAM. Sputum was sent for immediate Xpert MTB/RIF if any of: current cough, fever ≥3 weeks, body mass index (BMI)<18.5kg/m2, CD4<100x106/l (or <200x106/l if pre-ART), weight loss ≥10% or strong clinical suspicion were present; otherwise, sputum was stored for Xpert testing at study completion. Participants were reviewed monthly, with reinvestigation if indicated, to 3 months, when sputum and blood were taken for mycobacterial culture. We defined tuberculosis as “confirmed” if Xpert, line probe assay or culture for M. tuberculosis within six months of enrolment were positive, and “clinical” if tuberculosis treatment started without microbiological confirmation. Results Amongst 424 participants, 61% were female and 57% were taking ART (median duration 22 months); median age, CD4 and BMI were 39 years, 111x106/l, and 23 kg/m2. 56/424 (13%) participants had tuberculosis (40 confirmed, 16 clinical). 24/424 (5.7%) vs. 8/424 (1.9%) were LAM-positive using grade 1 vs. grade 2 cut-off. Using grade 1 cut-off, sensitivity for confirmed TB (all clinical TB excluded) was 12.5% (95% CI 4.2%, 26.8%) and in CD4<100x106/l vs. CD4 ≥100x106/l was 16.7% (95% CI 4.7%, 37.4%) vs. 6.3% (95% CI 0.2%, 30.2%). Specificity was >95% irrespective of diagnostic reference standard, CD4 stratum, or whether grade 1 or grade 2 cut-off was used. Conclusion Sensitivity of LF-LAM is too low to recommend as part of intensified case finding in ambulatory patients established in HIV care.
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Affiliation(s)
- Yasmeen Hanifa
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | | | - Violet N. Chihota
- Aurum Institute, Johannesburg, South Africa
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Salome Charalambous
- Aurum Institute, Johannesburg, South Africa
- University of the Witwatersrand, Johannesburg, South Africa
| | - Alan Karstaedt
- University of the Witwatersrand, Johannesburg, South Africa
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
| | | | - Mark P. Nicol
- National Health Laboratory Service, Johannesburg, South Africa
- University of Cape Town, Cape Town, South Africa
| | | | - Faieza Sahid
- University of the Witwatersrand, Johannesburg, South Africa
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
| | - Gavin J. Churchyard
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Aurum Institute, Johannesburg, South Africa
- University of the Witwatersrand, Johannesburg, South Africa
- Advancing Care and Treatment (ACT) for TB/HIV, South African Medical Research Council Collaborating Centre for HIV and TB, Cape Town, South Africa
| | - Alison D. Grant
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- University of the Witwatersrand, Johannesburg, South Africa
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Velen K, Lewis JJ, Charalambous S, Page-Shipp L, Popane F, Churchyard GJ, Hoffmann CJ. Household HIV Testing Uptake among Contacts of TB Patients in South Africa. PLoS One 2016; 11:e0155688. [PMID: 27195957 PMCID: PMC4873208 DOI: 10.1371/journal.pone.0155688] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 05/03/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND In high HIV prevalence settings, offering HIV testing may be a reasonable part of contact tracing of index tuberculosis (TB) patients. We evaluated the uptake of HIV counselling and testing (HCT) among household contacts of index TB patients and the proportion of newly diagnosed HIV-infected persons linked into care as part of a household TB contact tracing study. METHODS We recruited index TB patients at public health clinics in two South African provinces to obtain consent for household contact tracing. During scheduled household visits we offered TB symptom screening to all household members and HCT to individuals ≥14years of age. Factors associated with HCT uptake were investigated using a random effects logistic regression model. RESULTS & DISCUSSION Out of 1,887 listed household members ≥14 years old, 984 (52%) were available during a household visit and offered HCT of which 108 (11%) self-reported being HIV infected and did not undergo HCT. Of the remaining 876, a total of 304 agreed to HCT (35%); 26 (8.6%) were newly diagnosed as HIV positive. In multivariable analysis, factors associated with uptake of HCT were prior testing (odds ratio 1.6; 95% confidence interval [CI]: 1.1-2.3) and another member in the household testing (odds ratio 2.4; 95% CI: 1.7-3.4). Within 3 months of testing HIV-positive, 35% reported initiating HIV care. CONCLUSION HCT as a component of household TB contact tracing reached individuals without prior HIV testing, however uptake of HIV testing was poor. Strategies to improve HIV testing in household contacts should be evaluated.
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Affiliation(s)
- Kavindhran Velen
- The Aurum Institute, Johannesburg, South Africa
- The School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - James J. Lewis
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa
- The School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | | | | | - Gavin J. Churchyard
- The Aurum Institute, Johannesburg, South Africa
- The School of Public Health, University of Witwatersrand, Johannesburg, South Africa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Advancing Care and Treatment for TB and HIV, MRC Collaborating Centre of Excellence, Johannesburg, South Africa
| | - Christopher J. Hoffmann
- The Aurum Institute, Johannesburg, South Africa
- The School of Public Health, University of Witwatersrand, Johannesburg, South Africa
- Johns Hopkins University School of Medicine, Baltimore, United States of America
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Hermans SM, Grant AD, Chihota V, Lewis JJ, Vynnycky E, Churchyard GJ, Fielding KL. The timing of tuberculosis after isoniazid preventive therapy among gold miners in South Africa: a prospective cohort study. BMC Med 2016; 14:45. [PMID: 27004413 PMCID: PMC4804575 DOI: 10.1186/s12916-016-0589-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 03/02/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The durability of isoniazid preventive therapy (IPT) in preventing tuberculosis (TB) is limited in high-prevalence settings. The underlying mechanism (reactivation of persistent latent TB or reinfection) is not known. We aimed to investigate the timing of TB incidence during and after IPT and associated risk factors in a very high TB and HIV-prevalence setting, and to compare the observed rate with a modelled estimate of TB incidence rate after IPT due to reinfection. METHODS In a post-hoc analysis of a cluster-randomized trial of community-wide IPT among South African gold miners, all intervention arm participants that were dispensed IPT for at least one of the intended 9 months were included. An incident TB case was defined as any participant with a positive sputum smear or culture, or with a clinical TB diagnosis assigned by a senior study clinician. Crude TB incidence rates were calculated during and after IPT, overall and by follow-up time. HIV status was not available. Multivariable Cox regression was used to analyse risk factors by follow-up time after IPT. Estimates from a published mathematical model of trial data were used to calculate the average reinfection TB incidence in the first year after IPT. RESULTS Among 18,520 participants (96% male, mean age 41 years, median follow-up 2.1 years), 708 developed TB. The TB incidence rate during the intended IPT period was 1.3/100 person-years (pyrs; 95% confidence interval (CI), 1.0-1.6) and afterwards 2.3/100 pyrs (95% CI, 1.9-2.7). TB incidence increased within 6 months followed by a stable rate over time. There was no evidence for changing risk factors for TB disease over time after miners stopped IPT. The average TB incidence rate attributable to reinfection in the first year was estimated at 1.3/100 pyrs, compared to an observed rate of 2.2/100 pyrs (95% CI, 1.8-2.7). CONCLUSIONS The durability of protection by IPT was lost within 6-12 months in this setting with a high HIV prevalence and a high annual risk of M. tuberculosis infection. The observed rate was higher than the modelled rate, suggesting that reactivation of persistent latent infection played a role in the rapid return to baseline TB incidence.
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Affiliation(s)
- Sabine M. Hermans
- />TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- />Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- />Desmond Tutu HIV Centre, Institute for Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- />Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Alison D. Grant
- />TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- />The School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- />School of Nursing & Public Health (Africa Centre for Population Health), University of KwaZulu-Natal, Durban, South Africa
| | - Violet Chihota
- />The School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- />Aurum Institute, Johannesburg, South Africa
| | - James J. Lewis
- />TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Emilia Vynnycky
- />TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- />Public Health England, London, UK
| | - Gavin J. Churchyard
- />TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- />The School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- />Aurum Institute, Johannesburg, South Africa
- />Advancing Care and Treatment for TB and HIV, MRC Collaborating Centre of Excellence, Johannesburg, South Africa
| | - Katherine L. Fielding
- />TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- />The School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Kufa T, Chihota VN, Charalambous S, Churchyard GJ. Isoniazid preventive therapy use among patients on antiretroviral therapy: a missed opportunity. Int J Tuberc Lung Dis 2015; 18:312-4. [PMID: 24670568 DOI: 10.5588/ijtld.13.0505] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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
Isoniazid preventive therapy (IPT) with antiretroviral therapy (ART) reduces incident tuberculosis among patients infected with the human immunodeficiency virus. We describe IPT use among patients on ART at two primary care clinics in South Africa. Of 597 participants interviewed, 100 (16.8%) reported IPT use; 73.4% (365/497) with no reported IPT use were eligible for IPT. IPT use was associated with age <35 years (aOR 1.90, 95%CI 1.18-3.06), and receiving care at one clinic as opposed to the other (aOR 4.72, 95%CI 2.69-7.93). The high proportion of patients on ART eligible for IPT represents a missed opportunity for IPT scale-up.
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Affiliation(s)
- T Kufa
- The Aurum Institute, Johannesburg, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - V N Chihota
- The Aurum Institute, Johannesburg, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - S Charalambous
- The Aurum Institute, Johannesburg, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - G J Churchyard
- The Aurum Institute, Johannesburg, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Zishiri V, Chihota V, McCarthy K, Charalambous S, Churchyard GJ, Hoffmann CJ. Pooling sputum from multiple individuals for Xpert® MTB/RIF testing: a strategy for screening high-risk populations. Int J Tuberc Lung Dis 2015; 19:87-90. [PMID: 25519796 DOI: 10.5588/ijtld.14.0372] [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 Symptom-based screening for tuberculosis (TB) disease is limited by poor performance of symptom screening in several key populations. We tested the hypothesis that pooling sputum from multiple individuals for Xpert(®) MTB/RIF testing would reduce the number of tests required while retaining an acceptable sensitivity, thus allowing the use of Xpert for TB screening. METHODS We compared pooling ratios that would require the least number of assays using Xpert and determined that for a population with a TB prevalence of approximately 3%, a 1:5 pooling ratio is optimal. To evaluate sensitivity, we generated pools of one specimen with known Mycobacterium tuberculosis culture positivity (smear microscopy-positive or -negative) with four culture-negative specimens. RESULTS All 20 of the pools generated from a smear- and culture-positive sputum sample were positive using Xpert. Of the 22 pools with a smear-negative, culture-positive sample, we included 17 in the analysis, of which 13 (76%) were Xpert-positive. CONCLUSIONS Pooling of sputum samples using Xpert achieved reasonable sensitivity and warrants further evaluation of the systematic screening of high TB prevalence populations.
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Affiliation(s)
- V Zishiri
- The Aurum Institute, Johannesburg, South Africa
| | - V Chihota
- The Aurum Institute, Johannesburg, South Africa
| | - K McCarthy
- The Aurum Institute, Johannesburg, South Africa
| | | | - G J Churchyard
- The Aurum Institute, Johannesburg, South Africa; School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - C J Hoffmann
- The Aurum Institute, Johannesburg, South Africa; Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Ismail NA, Omar SV, Lewis JJ, Dowdy DW, Dreyer AW, van der Meulen H, Nconjana G, Clark DA, Churchyard GJ. Performance of a Novel Algorithm Using Automated Digital Microscopy for Diagnosing Tuberculosis. Am J Respir Crit Care Med 2015; 191:1443-9. [PMID: 25826383 DOI: 10.1164/rccm.201502-0390oc] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [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 TBDx automated microscopy is a novel technology that processes digital microscopic images to identify acid-fast bacilli (AFB). Use of TBDx as part of a diagnostic algorithm could improve the diagnosis of tuberculosis (TB), but its performance characteristics have not yet been formally tested. OBJECTIVES To evaluate the performance of the TBDx automated microscopy system in algorithms for diagnosis of TB. METHODS Prospective samples from patients with presumed TB were processed in parallel with conventional smear microscopy, TBDx microscopy, and liquid culture. All TBDx-positive specimens were also tested with the Xpert MTB/RIF (GXP) assay. We evaluated the sensitivity and specificity of two algorithms-(1) TBDx-GXP (TBDx with positive specimens tested by Xpert MTB/RIF) and (2) TBDx alone-against the gold standard liquid media culture. MEASUREMENTS AND MAIN RESULTS Of 1,210 samples, 1,009 were eligible for evaluation, of which 109 were culture positive for Mycobacterium tuberculosis. The TBDx system identified 70 specimens (68 culture positive) as having 10 or more putative AFB (high positive) and 207 (19 culture positive) as having 1-9 putative AFB (low positive). An algorithm in which "low-positive" results on TBDx were confirmed by GXP had 78% sensitivity (85 of 109) and 99.8% specificity (889 of 900), requiring 21% (207 of 1,009) specimens to be processed by GXP. As a stand-alone test, a "high-positive" result on TBDx had 62% sensitivity and 99.7% specificity. CONCLUSIONS TBDx used in diagnostic algorithms with GXP provided reasonable sensitivity and high specificity for active TB while dramatically reducing the number GXP tests performed. As a stand-alone microscopy system, its performance was equivalent to that of a highly experienced TB microscopist.
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Affiliation(s)
- Nazir A Ismail
- 1 Centre for Tuberculosis, National Institute for Communicable Diseases, Sandringham, South Africa.,2 University of Pretoria, Pretoria, South Africa
| | - Shaheed V Omar
- 1 Centre for Tuberculosis, National Institute for Communicable Diseases, Sandringham, South Africa
| | - James J Lewis
- 3 London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David W Dowdy
- 4 Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland
| | - Andries W Dreyer
- 1 Centre for Tuberculosis, National Institute for Communicable Diseases, Sandringham, South Africa.,5 Department of Clinical Microbiology and Infectious Diseases and
| | | | - George Nconjana
- 1 Centre for Tuberculosis, National Institute for Communicable Diseases, Sandringham, South Africa
| | | | - Gavin J Churchyard
- 3 London School of Hygiene and Tropical Medicine, London, United Kingdom.,7 School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; and.,6 Aurum Institute, Johannesburg, South Africa
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Churchyard GJ, Stevens WS, Mametja LD, McCarthy KM, Chihota V, Nicol MP, Erasmus LK, Ndjeka NO, Mvusi L, Vassall A, Sinanovic E, Cox HS, Dye C, Grant AD, Fielding KL. Xpert MTB/RIF versus sputum microscopy as the initial diagnostic test for tuberculosis: a cluster-randomised trial embedded in South African roll-out of Xpert MTB/RIF. Lancet Glob Health 2015; 3:e450-e457. [PMID: 26187490 DOI: 10.1016/s2214-109x(15)00100-x] [Citation(s) in RCA: 163] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 02/21/2015] [Accepted: 03/10/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND In South Africa, sputum smear microscopy has been replaced with Xpert MTB/RIF as the initial diagnostic test for tuberculosis. In a pragmatic parallel cluster-randomised trial, we evaluated the effect on patient and programme outcomes. METHODS We randomly allocated 20 laboratories (clusters) in medium-burden districts of South Africa to either an Xpert (immediate Xpert) or microscopy (Xpert deferred) group (1:1), stratified by province. At two primary care clinics per laboratory, a systematic sample of adults giving sputum for tuberculosis investigation was assessed for eligibility. The primary outcome was mortality at 6 months from enrolment. Masking of participants' group allocation was not possible because of the pragmatic trial design. The trial is registered with the ISRCTN registry (ISRCTN68905568) and the South African Clinical Trial Register (DOH-27-1011-3849). FINDINGS Between June and November, 2012, 4972 people were screened, and 4656 (93·6%) enrolled (median age 36 years; 2891 [62%] female; 2212 [62%] reported being HIV-positive). There was no difference between the Xpert and microscopy groups with respect to mortality at 6 months (91/2324 [3·9%] vs 116/2332 [5·0%], respectively; adjusted risk ratio [aRR] 1·10, 95% CI 0·75-1·62]). INTERPRETATION Xpert did not reduce mortality at 6 months compared with sputum microscopy. Improving outcomes in drug-sensitive tuberculosis programmes might require not only better diagnostic tests but also better linkage to care. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Gavin J Churchyard
- Aurum Institute, Johannesburg, South Africa; London School of Hygiene & Tropical Medicine, London, United Kingdom; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
| | - Wendy S Stevens
- National Health Laboratory Service, Johannesburg, South Africa; Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Mark P Nicol
- National Health Laboratory Service, Johannesburg, South Africa; Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Linda K Erasmus
- National Health Laboratory Service, Johannesburg, South Africa; Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, Johannesburg, South Africa
| | | | - Lindiwe Mvusi
- TB Cluster, National Department of Health, South Africa
| | - Anna Vassall
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Edina Sinanovic
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Helen S Cox
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | | | - Alison D Grant
- London School of Hygiene & Tropical Medicine, London, United Kingdom; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Telisinghe L, Hippner P, Churchyard GJ, Gresak G, Grant AD, Charalambous S, Fielding KL. Outcomes of on-site antiretroviral therapy provision in a South African correctional facility. Int J STD AIDS 2015; 27:1153-1161. [PMID: 25941052 DOI: 10.1177/0956462415584467] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [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: 10/13/2014] [Accepted: 03/31/2015] [Indexed: 12/15/2022]
Abstract
We evaluated a novel on-site antiretroviral therapy (ART) programme in a South African correctional facility using routinely collected programme data, from a retrospective cohort of adult inmates starting ART between 03/2007 and 03/2009 followed-up to 09/2009. We report (1) mortality (using survival analysis); (2) retention in the programme (to 09/2009); and (3) virological suppression at six and 12 months (<400 copies/ml) following ART initiation. In total, 404 started ART (median age 33 years; 91.3% men; median baseline CD4 cell count 152 cells/µl [interquartile range 85-225]). Among 299 starting ART for the first time (ART-naïve), 23 deaths occurred during 252 person-years (median follow-up nine months). Mortality rates were 17.2 at 0-6 months (95% confidence interval 10.9-26.9) and 2.8 at >6 months (95% confidence interval 1.1-7.5)/100 person-years; p < 0.001. At 09/2009, 35.6% (144/404) remained in the correctional facility, with 94.4% (136/144) retained in the programme; 38.4% (155/404) were released; and 20.0% (81/404) transferred to another facility. ART-naïve patients in care six and 12 months after ART initiation, 94.7% (124/131) and 92.5% (74/80) were virologically suppressed, respectively. High early mortality warrants the early identification and management of HIV-positive inmates. The high mobility of inmates necessitates systems for facilitating continuity of care. Good virological responses and retention supports decentralising HIV care to correctional facilities.
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Affiliation(s)
- Lilanganee Telisinghe
- The Aurum Institute, Johannesburg, South Africa .,CAPRISA, University of KwaZulu-Natal, Durban, South Africa
| | | | - Gavin J Churchyard
- The Aurum Institute, Johannesburg, South Africa.,London School of Hygiene and Tropical Medicine, London, UK.,School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | | | - Alison D Grant
- London School of Hygiene and Tropical Medicine, London, UK
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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Vynnycky E, Sumner T, Fielding KL, Lewis JJ, Cox AP, Hayes RJ, Corbett EL, Churchyard GJ, Grant AD, White RG. Tuberculosis control in South African gold mines: mathematical modeling of a trial of community-wide isoniazid preventive therapy. Am J Epidemiol 2015; 181:619-32. [PMID: 25792607 PMCID: PMC4388015 DOI: 10.1093/aje/kwu320] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [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: 02/18/2014] [Accepted: 10/16/2014] [Indexed: 01/22/2023] Open
Abstract
A recent major cluster randomized trial of screening, active disease treatment, and mass isoniazid preventive therapy for 9 months during 2006-2011 among South African gold miners showed reduced individual-level tuberculosis incidence but no detectable population-level impact. We fitted a dynamic mathematical model to trial data and explored 1) factors contributing to the lack of population-level impact, 2) the best-achievable impact if all implementation characteristics were increased to the highest level achieved during the trial ("optimized intervention"), and 3) how tuberculosis might be better controlled with additional interventions (improving diagnostics, reducing treatment delay, providing isoniazid preventive therapy continuously to human immunodeficiency virus-positive people, or scaling up antiretroviral treatment coverage) individually and in combination. We found the following: 1) The model suggests that a small proportion of latent infections among human immunodeficiency virus-positive people were cured, which could have been a key factor explaining the lack of detectable population-level impact. 2) The optimized implementation increased impact by only 10%. 3) Implementing additional interventions individually and in combination led to up to 30% and 75% reductions, respectively, in tuberculosis incidence after 10 years. Tuberculosis control requires a combination prevention approach, including health systems strengthening to minimize treatment delay, improving diagnostics, increased antiretroviral treatment coverage, and effective preventive treatment regimens.
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Affiliation(s)
- Emilia Vynnycky
- Correspondence to Dr. Emilia Vynnycky, Statistics, Modelling and Economics Department, Public Health England, 61 Colindale Avenue, London NW9 5EQ, United Kingdom (e-mail: or )
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Abstract
Background South Africa has one of the highest per capita rates of tuberculosis (TB) incidence in the world. In 2012, the South African government produced a National Strategic Plan (NSP) to control the spread of TB with the ambitious aim of zero new TB infections and deaths by 2032, and a halving of the 2012 rates by 2016. Methods We used a transmission model to investigate whether the NSP targets could be reached if immediate scale up of control methods had happened in 2014. We explored the potential impact of four intervention portfolios; 1) “NSP” represents the NSP strategy, 2) “WHO” investigates increasing antiretroviral therapy eligibility, 3) “Novel Strategies” considers new isoniazid preventive therapy strategies and HIV “Universal Test and Treat” and 4) “Optimised” contains the most effective interventions. Findings We find that even with this scale-up, the NSP targets are unlikely to be achieved. The portfolio that achieved the greatest impact was “Optimised”, followed closely by “NSP”. The “WHO” and “Novel Strategies” had little impact on TB incidence by 2050. Of the individual interventions explored, the most effective were active case finding and reductions in pre-treatment loss to follow up which would have a large impact on TB burden. Conclusion Use of existing control strategies has the potential to have a large impact on TB disease burden in South Africa. However, our results suggest that the South African TB targets are unlikely to be reached without new technologies. Despite this, TB incidence could be dramatically reduced by finding and starting more TB cases on treatment.
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Affiliation(s)
- Gwenan M. Knight
- TB Modelling Group, Centre for the Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- TB Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Peter J. Dodd
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Alison D. Grant
- TB Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Gavin J. Churchyard
- TB Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Richard G. White
- TB Modelling Group, Centre for the Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- TB Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
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49
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Fielding KL, Charalambous S, Hoffmann CJ, Johnson S, Tlali M, Dorman SE, Vassall A, Churchyard GJ, Grant AD. Evaluation of a point-of-care tuberculosis test-and-treat algorithm on early mortality in people with HIV accessing antiretroviral therapy (TB Fast Track study): study protocol for a cluster randomised controlled trial. Trials 2015; 16:125. [PMID: 25872501 PMCID: PMC4394596 DOI: 10.1186/s13063-015-0650-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [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: 11/21/2014] [Accepted: 03/13/2015] [Indexed: 11/10/2022] Open
Abstract
Background Early mortality for HIV-positive people starting antiretroviral therapy (ART) remains high in resource-limited settings, with tuberculosis the most important cause. Existing rapid diagnostic tests for tuberculosis lack sensitivity among HIV-positive people, and consequently, tuberculosis treatment is either delayed or started empirically (without bacteriological confirmation). We developed a management algorithm for ambulatory HIV-positive people, based on body mass index and point-of-care tests for haemoglobin and urine lipoarabinomannan (LAM), to identify those at high risk of tuberculosis and mortality. We designed a clinical trial to test whether implementation of this algorithm reduces six-month mortality among HIV-positive people with advanced immunosuppression. Methods/design The TB Fast Track study is an open, pragmatic, cluster randomised superiority trial, with 24 primary health clinics randomised to implement the intervention or standard of care. Adults (aged ≥18 years) with a CD4 count of 150 cells/μL or less, who have not received any tuberculosis treatment in the last three months, or ART in the last six months, are eligible. In intervention clinics, the study algorithm is used to classify individuals as at high, medium or low probability of tuberculosis. Those classified as high probability start tuberculosis treatment immediately, followed by ART after two weeks. Medium-probability patients follow the South African guidelines for test-negative tuberculosis and are reviewed within a week, to be re-categorised as low or high probability. Low-probability patients start ART as soon as possible. The primary outcome is all-cause mortality at six months. Secondary outcomes include severe morbidity, time to ART start and cost-effectiveness. Discussion This trial will test whether a primary care-friendly management algorithm will enable nurses to identify HIV-positive patients at the highest risk of tuberculosis, to facilitate prompt treatment and reduce early mortality. There remains an urgent need for better diagnostic tests for tuberculosis, especially for people with advanced HIV disease, which may render empirical treatment unnecessary. Trial registration This trial was registered with Current Controlled Trials (identifier: ISRCTN35344604) on 12 September 2012.
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Affiliation(s)
- Katherine L Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | | | - Christopher J Hoffmann
- School of Medicine, Johns Hopkins University, 1503 E. Jefferson Street, Baltimore, Maryland, 21231, USA.
| | - Suzanne Johnson
- Technical Assistance Cluster, Foundation for Professional Development, 173 Mary Road, Pretoria, 0184, South Africa.
| | - Mpho Tlali
- Aurum Institute, 29 Queens Road, Johannesburg, 2041, South Africa.
| | - Susan E Dorman
- School of Medicine, Johns Hopkins University, 1503 E. Jefferson Street, Baltimore, Maryland, 21231, USA.
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Gavin J Churchyard
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. .,Aurum Institute, 29 Queens Road, Johannesburg, 2041, South Africa.
| | - Alison D Grant
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
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Mabuto T, Zwane E, Chihota V, Gresak G, Charalambous S, Churchyard GJ, Hoffmann CJ. Tuberculosis active case finding: uptake and diagnostic yield among minibus drivers in urban South Africa. BMC Public Health 2015; 15:242. [PMID: 25880544 PMCID: PMC4364653 DOI: 10.1186/s12889-015-1592-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 02/27/2015] [Indexed: 01/24/2023] Open
Abstract
Background Tuberculosis (TB) active case finding is a part of TB control in areas of higher TB prevalence. Congested public transportation settings may be areas of increased TB transmission. We evaluated the uptake and diagnostic yield of an active TB screening program among minibus drivers in a large public transportation facility in Johannesburg, South Africa. Methods Over an eight month period, we intensively recruited minibus drivers for TB screening with a goal of 80% uptake among the estimated 2000 drivers. All participants were screened for TB symptoms, offered HIV testing, and had sputum collected for smear microscopy and liquid culture. Results 686 drivers were screened for TB, representing an uptake of only 34% of all drivers (43% of the target screening). Ten drivers (1.5%) were culture positive for TB, nine of whom were sputum smear microscopy negative. Factors associated with previously undiagnosed TB included a history of incarceration (odds ratio [OR] 5.5, 95% confidence interval: 1.1, 27.3) and HIV positivity (OR 5.3, 95% confidence interval: 1.1, 26.3). Conclusions We identified undiagnosed pulmonary TB cases among drivers but at a level that may be insufficient to justify systematic case finding in this population considering the poor uptake.
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Affiliation(s)
- Tonderai Mabuto
- The Aurum Institute, Johannesburg, South Africa. .,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | | | - Violet Chihota
- The Aurum Institute, Johannesburg, South Africa. .,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | | | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa. .,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Gavin J Churchyard
- The Aurum Institute, Johannesburg, South Africa. .,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. .,London School of Hygiene and Tropical Medicine, London, UK.
| | - Christopher J Hoffmann
- The Aurum Institute, Johannesburg, South Africa. .,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. .,Division of Infectious Diseases, Johns Hopkins University School of Medicine, 725 N Wolfe St, Rm 226, Baltimore, Maryland, 21205, USA.
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