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Millington KA, White RG, Lipman M, McQuaid CF, Hauser J, Wooding V, Potter J, Abubakar I, Wingfield T. The 2023 UN high-level meeting on tuberculosis: renewing hope, momentum, and commitment to end tuberculosis. Lancet Respir Med 2024; 12:10-13. [PMID: 37972624 DOI: 10.1016/s2213-2600(23)00409-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 10/26/2023] [Indexed: 11/19/2023]
Affiliation(s)
- Kerry A Millington
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Richard G White
- TB Centre and Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Marc Lipman
- Respiratory Medicine, Division of Medicine, University College London, London, UK
| | - C Finn McQuaid
- TB Centre and Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Jessica Potter
- Respiratory Medicine, Division of Medicine, University College London, London, UK
| | - Ibrahim Abubakar
- Faculty of Population Health Sciences, School of Life and Medical Sciences, University College London, London, UK
| | - Tom Wingfield
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK; WHO Collaborating Centre on Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
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Ringwald B, Mwiine AA, Chikovore J, Makanda G, Amoah-Larbi J, Millington KA, Horton KC. Ending TB means responding to socially produced vulnerabilities of all genders. BMJ Glob Health 2023; 8:e014151. [PMID: 38070882 PMCID: PMC10728965 DOI: 10.1136/bmjgh-2023-014151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 11/12/2023] [Indexed: 12/18/2023] Open
Affiliation(s)
- Beate Ringwald
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Amon Ashaba Mwiine
- School of Women and Gender Studies, Makerere University, Kampala, Uganda
| | - Jeremiah Chikovore
- Public Health, Societies and Belonging, Human Sciences Research Council, Durban, South Africa
| | | | | | - Kerry A Millington
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Katherine C Horton
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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Wingfield T, Karmadwala F, MacPherson P, Millington KA, Walker NF, Cuevas LE, Squire SB. Challenges and opportunities to end tuberculosis in the COVID-19 era. Lancet Respir Med 2021; 9:556-558. [PMID: 33773121 PMCID: PMC7988354 DOI: 10.1016/s2213-2600(21)00161-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 03/22/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Tom Wingfield
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK; Social Medicine, Infectious diseases, and Migration Group, Department of Global Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
| | - Fatima Karmadwala
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
| | - Peter MacPherson
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi; Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Kerry A Millington
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
| | - Naomi F Walker
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK; Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Luis E Cuevas
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK; Zankli Research Centre, Bingham University, Nasarawa State, Nigeria
| | - S Bertel Squire
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK; Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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Wingfield T, Cuevas LE, MacPherson P, Millington KA, Squire SB. Tackling two pandemics: a plea on World Tuberculosis Day. Lancet Respir Med 2020; 8:536-538. [PMID: 32220280 PMCID: PMC7118542 DOI: 10.1016/s2213-2600(20)30151-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 03/20/2020] [Indexed: 12/30/2022]
Affiliation(s)
- Tom Wingfield
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK; Social Medicine, Infectious diseases, and Migration (SIM) Group, Department of Global Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
| | - Luis E Cuevas
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK; Zankli Research Centre, Bingham University, Nasarawa State, Nigeria
| | - Peter MacPherson
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi; Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Kerry A Millington
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
| | - S Bertel Squire
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK; Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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Sridhar S, Karnani N, Connell DW, Millington KA, Dosanjh D, Bakir M, Soysal A, Deeks J, Lalvani A. Increased risk of Mycobacterium tuberculosis infection in household child contacts exposed to passive tobacco smoke. Pediatr Infect Dis J 2014; 33:1303-6. [PMID: 25105895 PMCID: PMC5741175 DOI: 10.1097/inf.0000000000000506] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Risk factors associated with Mycobacterium tuberculosis infection were investigated in a prospective cohort of household child tuberculosis contacts. A significantly increased risk of acquiring infection was associated with exposure to passive cigarette smoke, higher number of index cases, younger age and reduced household monthly income.
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Affiliation(s)
- Saranya Sridhar
- Tuberculosis Research Centre, Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, Norfolk Place, London
| | - Nisha Karnani
- Tuberculosis Research Centre, Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, Norfolk Place, London
| | - David W. Connell
- Tuberculosis Research Centre, Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, Norfolk Place, London
| | - Kerry A. Millington
- Tuberculosis Research Centre, Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, Norfolk Place, London
| | - Davinder Dosanjh
- Tuberculosis Research Centre, Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, Norfolk Place, London
| | - Mustafa Bakir
- Department of Paediatrics, Marmara University School of Medicine, Istanbul, Turkey
| | - Ahmet Soysal
- Department of Paediatrics, Marmara University School of Medicine, Istanbul, Turkey
| | - Jonathan Deeks
- Department of Public Health, Epidemiology and Biostatistics, Public Health School of Health and Population Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Ajit Lalvani
- Tuberculosis Research Centre, Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, Norfolk Place, London
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Ntinginya EN, Squire SB, Millington KA, Mtafya B, Saathoff E, Heinrich N, Rojas-Ponce G, Kowuor D, Maboko L, Reither K, Clowes P, Hoelscher M, Rachow A. Performance of the Xpert® MTB/RIF assay in an active case-finding strategy: a pilot study from Tanzania. Int J Tuberc Lung Dis 2012; 16:1468-70. [PMID: 22964006 DOI: 10.5588/ijtld.12.0127] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [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
In this pilot study, we evaluated the Xpert® MTB/RIF assay in an active case-finding strategy, using two spot sputum samples collected within a 1-hour interval from household contacts of smear-positive TB index cases. Tuberculosis (TB) confirmed by culture served as the reference standard. Among 219 enrolled contacts, the yield of active TB was 2.3%. While the sensitivity of smear microscopy was 60% (95%CI 14.7-94.7), Xpert MTB/RIF achieved a sensitivity of 100% (95%CI 47.81-100.0). All culture-confirmed cases tested positive by Xpert MTB/RIF on the first submitted sample, suggesting that the evaluation of only one sample could be sufficient for TB diagnosis in this context.
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Affiliation(s)
- E N Ntinginya
- National Institute for Medical Research, Mbeya Medical Research Programme, Mbeya, Tanzania.
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Dosanjh DPS, Bakir M, Millington KA, Soysal A, Aslan Y, Efee S, Deeks JJ, Lalvani A. Novel M tuberculosis antigen-specific T-cells are early markers of infection and disease progression. PLoS One 2011; 6:e28754. [PMID: 22216109 PMCID: PMC3247216 DOI: 10.1371/journal.pone.0028754] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2011] [Accepted: 11/14/2011] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Mycobacterium tuberculosis Region-of-Difference-1 gene products present opportunities for specific diagnosis of M. tuberculosis infection, yet immune responses to only two gene-products, Early Secretory Antigenic Target-6 (ESAT-6) and Culture Filtrate Protein-10 (CFP-10), have been comprehensively investigated. METHODS T-cell responses to Rv3873, Rv3878 and Rv3879c were quantified by IFN-γ-enzyme-linked-immunospot (ELISpot) in 846 children with recent household tuberculosis exposure and correlated with kinetics of tuberculin skin test (TST) and ESAT-6/CFP-10-ELISpot conversion over six months and clinical outcome over two years. RESULTS Responses to Rv3873, Rv3878, and Rv3879c were present in 20-25% of contacts at enrolment. Rv3873 and Rv3879c responses were associated with and preceded TST conversion (P=0.02 and P=0.04 respectively), identifying these antigens as early targets of cell-mediated immunity following M. tuberculosis exposure. Responses to Rv3873 were additionally associated with subsequent ESAT-6/CFP-10-ELISpot conversion (P=0.04). Responses to Rv3873 and Rv3878 predicted progression to active disease (adjusted incidence rate ratio [95% CI] 3.06 [1.05,8.95; P=0.04], and 3.32 [1.14,9.71; P=0.03], respectively). Presence of a BCG-vaccination scar was associated with a 67% (P=0.03) relative risk reduction for progression to active tuberculosis. CONCLUSIONS These RD1-derived antigens are early targets of cellular immunity following tuberculosis exposure and T-cells specific for these antigens predict progression to active tuberculosis suggesting diagnostic and prognostic utility.
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Affiliation(s)
- Davinder P. S. Dosanjh
- Tuberculosis Research Unit, Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Mustafa Bakir
- Department of Paediatrics, Marmara University School of Medicine, Istanbul, Turkey
| | - Kerry A. Millington
- Tuberculosis Research Unit, Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Ahmet Soysal
- Department of Paediatrics, Marmara University School of Medicine, Istanbul, Turkey
| | - Yasemin Aslan
- Department of Paediatrics, Marmara University School of Medicine, Istanbul, Turkey
| | - Serpil Efee
- Department of Paediatrics, Marmara University School of Medicine, Istanbul, Turkey
| | - Jonathan J. Deeks
- Unit of Public Health, Epidemiology and Biostatistics, School of Population Health and Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Ajit Lalvani
- Tuberculosis Research Unit, Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Montamat-Sicotte DJ, Millington KA, Willcox CR, Hingley-Wilson S, Hackforth S, Innes J, Kon OM, Lammas DA, Minnikin DE, Besra GS, Willcox BE, Lalvani A. A mycolic acid-specific CD1-restricted T cell population contributes to acute and memory immune responses in human tuberculosis infection. J Clin Invest 2011; 121:2493-503. [PMID: 21576820 DOI: 10.1172/jci46216] [Citation(s) in RCA: 80] [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: 12/23/2010] [Accepted: 03/30/2011] [Indexed: 11/17/2022] Open
Abstract
Current tuberculosis (TB) vaccine strategies are largely aimed at activating conventional T cell responses to mycobacterial protein antigens. However, the lipid-rich cell wall of Mycobacterium tuberculosis (M. tuberculosis) is essential for pathogenicity and provides targets for unconventional T cell recognition. Group 1 CD1-restricted T cells recognize mycobacterial lipids, but their function in human TB is unclear and their ability to establish memory is unknown. Here, we characterized T cells specific for mycolic acid (MA), the predominant mycobacterial cell wall lipid and key virulence factor, in patients with active TB infection. MA-specific T cells were predominant in TB patients at diagnosis, but were absent in uninfected bacillus Calmette-Guérin-vaccinated (BCG-vaccinated) controls. These T cells were CD1b restricted, detectable in blood and disease sites, produced both IFN-γ and IL-2, and exhibited effector and central memory phenotypes. MA-specific responses contracted markedly with declining pathogen burden and, in patients followed longitudinally, exhibited recall expansion upon antigen reencounter in vitro long after successful treatment, indicative of lipid-specific immunological memory. T cell recognition of MA is therefore a significant component of the acute adaptive and memory immune response in TB, suggesting that mycobacterial lipids may be promising targets for improved TB vaccines.
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Affiliation(s)
- Damien J Montamat-Sicotte
- Tuberculosis Research Unit, National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Millington KA, Gooding S, Hinks TSC, Reynolds DJM, Lalvani A. Mycobacterium tuberculosis-specific cellular immune profiles suggest bacillary persistence decades after spontaneous cure in untreated tuberculosis. J Infect Dis 2010; 202:1685-9. [PMID: 20958211 DOI: 10.1086/656772] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Individuals with self-healed tuberculosis from the preantibiotic era offer a unique insight into the natural history of and protective immunity to tuberculosis. In 27 such persons whose tuberculosis self-healed >50 years earlier, circulating Mycobacterium tuberculosis antigen-specific interferon γ (IFN-γ)- and interleukin 2 (IL-2)-secreting T cells were detected ex vivo in 16 and 19 individuals, respectively. The M. tuberculosis-specific T cell cytokine profile was dominated by effector memory T cells that secrete both IFN-γ and IL-2 and included T cells that secrete only IFN-γ or IL-2, suggesting persistence of antigen secreted by viable bacilli. Of 10 individuals with no M. tuberculosis antigen-specific IFN-γ-secreting T cells detectable ex vivo, 7 had evidence of central memory T cells, consistent with clearance of infection.
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Affiliation(s)
- Kerry A Millington
- Tuberculosis Research Unit, Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Dodd PJ, Millington KA, Ghani AC, Mutsvangwa J, Butterworth AE, Lalvani A, Corbett EL. Interpreting tuberculin skin tests in a population with a high prevalence of HIV, tuberculosis, and nonspecific tuberculin sensitivity. Am J Epidemiol 2010; 171:1037-45. [PMID: 20382638 PMCID: PMC2858871 DOI: 10.1093/aje/kwq017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [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] [Indexed: 11/23/2022] Open
Abstract
Understanding the epidemiology and clinical course of tuberculosis is hampered by the absence of a perfect test for latent tuberculosis infection. The tuberculin skin test (TST) is widely used but suffers poor specificity in those receiving the bacille Calmette-Guérin vaccine and poor sensitivity in individuals with human immunodeficiency virus (HIV) infections. TST responses for a target population in Harare, Zimbabwe (HIV prevalence, 21%), recruited in 2005–2006, were interpreted by using a separate calibration population in Harare, for which interferon-gamma release assays (enzyme-linked immunosorbent spot (ELISpot)) results were also known. Statistical fitting of the responses in the calibration population allowed computation of the probability that an individual in the target population with a given TST and HIV result would have tested ELISpot positive. From this, estimates of the prevalence of tuberculosis infection, and optimal TST cutpoints to minimize misdiagnosis, were computed for different assumptions about ELISpot performance. Different assumptions about the sensitivity and specificity of ELISpot gave a 40%–57% prevalence of tuberculosis infection in the target population (including HIV-infected individuals) and optimal TST cutpoints typically in the 10 mm–20 mm range. However, the optimal cutpoint for HIV-infected individuals was consistently 0 mm. This calibration method may provide a valuable tool for interpreting TST results in other populations.
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Affiliation(s)
- Peter J Dodd
- Department of Infectious Disease Epidemiology, St. Mary's Medical School, Imperial College London, Norfolk Place, London W2 1PG, United Kingdom.
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Bakir M, Dosanjh DPS, Deeks JJ, Soysal A, Millington KA, Efe S, Aslan Y, Polat D, Kodalli N, Yagci A, Barlan I, Bahceciler N, Demiralp EE, Lalvani A. Use of T cell-based diagnosis of tuberculosis infection to optimize interpretation of tuberculin skin testing for child tuberculosis contacts. Clin Infect Dis 2009; 48:302-12. [PMID: 19123864 DOI: 10.1086/595847] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Treatment of recent tuberculosis infection in children aged <2 years is essential, because of high risk of progression to disease, but diagnosis is hindered by the inaccuracy of the tuberculin skin test (TST). More-accurate T cell-based tests of infection could enhance diagnosis by optimizing interpretation of the TST results. METHODS A total of 979 child tuberculosis contacts in Istanbul underwent the TST and enzyme-linked immunospot assay. Using enzyme-linked immunospot test results as a reference standard, we assessed the effect of age and bacille Calmette-Guérin (BCG) vaccination on the sensitivity and specificity of the TST, and we computed the optimal TST cutoff points, using receiver operating characteristic curves. RESULTS With a TST cutoff point of >or=10 mm, the sensitivity of the TST was 66% for children aged <2 years, which was lower than that for older children (P= .006). Specificity was 75% for BCG-vaccinated children, compared with 92% for unvaccinated children (P= .001). Optimal cutoff points improved TST specificity for children with 1 BCG scar, with little loss of sensitivity. Despite the use of optimal cutoff points, TST sensitivity remained <70% for children aged <2 years, specificity remained <87% for BCG-vaccinated children aged >or=2 years, and overall accuracy was low for children with >1 BCG scar. CONCLUSIONS Negative results of the TST cannot exclude tuberculosis infection for child tuberculosis contacts aged <2 years, which supports the use of preventive therapy regardless of the TST results for this age group. In children aged >or=2 years, the accuracy of the TST can be improved by adjustment of cutoff points for BCG-vaccinated children but remains poor for children with >1 BCG scar. This methodology can define optimal TST cutoff points for diagnosis of tuberculosis infection tailored to target populations.
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Affiliation(s)
- Mustafa Bakir
- Department of Paediatrics, Marmara University School of Medicine, Istanbul, Turkey
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Bakir M, Millington KA, Soysal A, Deeks JJ, Efee S, Aslan Y, Dosanjh DPS, Lalvani A. Prognostic value of a T-cell-based, interferon-gamma biomarker in children with tuberculosis contact. Ann Intern Med 2008; 149:777-87. [PMID: 18936496 PMCID: PMC2730556 DOI: 10.7326/0003-4819-149-11-200812020-00248] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Enzyme-linked immunospot (ELISpot) assay is an increasingly widely used, T-cell-based, interferon-gamma-release assay for diagnosing tuberculosis infection, but whether positive results are prognostic of active tuberculosis is not known. OBJECTIVE To determine whether ELISpot results predict the development of active tuberculosis among persons with recent tuberculosis exposure. DESIGN Longitudinal cohort study of children and adolescents with tuberculosis contact recruited from October 2002 to April 2004. SETTING Community-based contact investigations in Turkey. PATIENTS 908 children and adolescents with recent household tuberculosis exposure. INTERVENTION Enzyme-linked immunospot assay, incorporating early secretory antigenic target-6 and culture filtrate protein-10, and tuberculin skin test were done at baseline. MEASUREMENTS Incidence rates ratios of progression to active tuberculosis for contacts with positive tuberculin skin test and ELISpot results, and relative incidence rates comparing contacts with positive and negative test results. RESULTS Isoniazid preventive therapy was given to 688 (76%) contacts according to local guidelines. Fifteen contacts developed active tuberculosis over 1201 person-years of follow-up. Of 381 contacts with positive ELISpot results, 11 developed active tuberculosis over 536 person-years of follow-up (incidence rate, 21 per 1000 person-years [95% CI, 10.2 to 36.7 per 1000 person-years]), a statistically significant 3- to 4-fold increased risk for progression relative to ELISpot-negative contacts. Of 550 contacts with positive tuberculin skin test results, 12 developed active tuberculosis over 722 person-years of follow-up (incidence rate, 17 per 1000 person-years [CI, 8.6 to 29.0 per 1000 person-years]). LIMITATION Only 3 of the 15 incident cases were confirmed by culture. CONCLUSION Positive ELISpot results predict subsequent development of active tuberculosis in recent tuberculosis contacts. Although tuberculosis contacts with positive ELISpot results have an incidence rate of tuberculosis similar to that of contacts with positive tuberculin skin test results, ELISpot testing could allow more focused targeting of preventive therapy to fewer contacts.
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Affiliation(s)
- Mustafa Bakir
- Marmara University School of Medicine, Istanbul, Turkey
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Abstract
T-cell interferon-gamma release assays (IGRAs) are more specific and probably more sensitive than the tuberculin skin test (TST) for the diagnosis of latent tuberculosis infection (LTBI). Patients with immune-mediated inflammatory diseases (IMID) and suspected LTBI who are candidates for anti-TNF therapy are at a significant risk of TB reactivation yet are prone to false-negative TST results because they are already on immunosuppressive medications. The role of these new blood tests in this patient population is therefore of considerable interest but is currently unclear. The limited published evidence-base shows that agreement between IGRA and TST results is poor in patients with IMID compared to patients without IMID, due to lower proportions of TST-positive results in patients with IMID. Discordant TST-positive, IGRA-negative results are associated with prior BCG vaccination and discordant TST-negative, IGRA-positive results are associated with steroid therapy. Notably, positive IGRA results are more closely associated with the presence of risk factors for LTBI than TST. The percentage of indeterminate IGRAs can be up to 12%. IGRA results in patients already taking anti-TNF agents currently remain uninterpretable. Given the clinical imperative to prevent reactivation of TB in patients starting anti-TNF therapy, screening algorithms should maximise diagnostic sensitivity for detection of LTBI. Therefore, a positive result to either an IGRA or TST, in addition to currently recommended clinical screening for risk factors for LTBI, should prompt consideration of preventive treatment of LTBI in this population.
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Affiliation(s)
- Ajit Lalvani
- Tuberculosis Immunology Group, Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, Norfolk Place, London W2 1PG, UK
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Affiliation(s)
- Ajit Lalvani
- Tuberculosis Immunology Group, Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom.
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Dosanjh DPS, Hinks TSC, Innes JA, Deeks JJ, Pasvol G, Hackforth S, Varia H, Millington KA, Gunatheesan R, Guyot-Revol V, Lalvani A. Improved diagnostic evaluation of suspected tuberculosis. Ann Intern Med 2008; 148:325-36. [PMID: 18316751 PMCID: PMC2761734 DOI: 10.7326/0003-4819-148-5-200803040-00003] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The role of new T-cell-based blood tests for tuberculosis in the diagnosis of active tuberculosis is unclear. OBJECTIVE To compare the performance of 2 interferon-gamma assays and tuberculin skin testing in adults with suspected tuberculosis. DESIGN Prospective study conducted in routine practice. SETTING 2 urban hospitals in the United Kingdom. PATIENTS 389 adults, predominantly of South Asian and black ethnicity, with moderate to high clinical suspicion of active tuberculosis. INTERVENTION Tuberculin skin testing, the enzyme-linked immunospot assay (ELISpot) incorporating early secretory antigenic target-6 and culture filtrate protein-10 (standard ELISpot), and ELISpot incorporating a novel antigen, Rv3879c (ELISpot(PLUS)) were performed during diagnostic assessment by independent persons who were blinded to results of the other test. MEASUREMENTS Sensitivity, specificity, predictive values, and likelihood ratios. RESULTS 194 patients had a final diagnosis of active tuberculosis, of which 79% were culture-confirmed. Sensitivity for culture confirmed and highly probable tuberculosis was 89% (95% CI, 84% to 93%) with ELISpot(PLUS), 85% (CI, 79% to 90%) with standard ELISpot, 79% (CI, 72% to 85%) with 15-mm threshold tuberculin skin testing, and 83% (CI, 77% to 89%) with stratified thresholds of 15 and 10 mm in vaccinated and unvaccinated patients, respectively. The ELISpot(PLUS) assay was more sensitive than tuberculin skin testing with 15-mm cutoff points (P = 0.01) but not with stratified cutoff points (P = 0.10). The ELISpot(PLUS) assay had 4% higher diagnostic sensitivity than standard ELISpot (P = 0.02). Combined sensitivity of ELISpot(PLUS) and tuberculin skin testing was 99% (CI, 95% to 100%), conferring a negative likelihood ratio of 0.02 (CI, 0 to 0.06) when both test results were negative. LIMITATIONS Local standards for tuberculin skin testing differed from others used internationally. The study sample included few immunosuppressed patients. CONCLUSION The ELISpot(PLUS) assay is more sensitive than standard ELISpot and, when used in combination with tuberculin skin testing, enables rapid exclusion of active infection in patients with moderate to high pretest probability of tuberculosis.
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Lalvani A, Meroni PL, Millington KA, Modolo ML, Plebani M, Tincani A, Villalta D, Doria A, Ghirardello A. Recent advances in diagnostic technology: applications in autoimmune and infectious diseases. Clin Exp Rheumatol 2008; 26:S62-S66. [PMID: 18570756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Biomarkers are used ubiquitously as indicators of biological health. The development of genomic and proteomic multiplex technologies have enormously amplified biomarker discovery and application to diagnostic and therapeutic decisions in clinical practice. New technologies are now available that simultaneously identify a wide spectrum of biomarkers and save time and costs. Multiplexed assays can be coupled to other disease specific indicators (i.e., cytokines, single nucleotide polymorphisms) in order to get more powerful information. However, there is an urgent need for validation/standardization of the new assays before they are adopted into clinical diagnostics. It is worthy to note a new assay, T cell interferon gamma release (TIGRAs), which has recently been introduced in the diagnosis of latent tuberculosis infection. It seems to perform better than tuberculin skin test in patients with inflammatory rheumatic diseases. In this review, we focus on advantages and limits of novel approaches to the detection of autoantibody profiles in autoimmune diseases or pathogen signatures in microbiology.
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Affiliation(s)
- A Lalvani
- Department of Respiratory Medicine, Faculty of Medicine, Imperial College London, London, UK
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Abstract
PURPOSE OF REVIEW T-cell interferon-gamma release assays (TIGRAs), available as enzyme-linked immunospot (ELISpot) and enzyme-linked immunoassay (ELISA), potentially significantly advance on the tuberculin skin test (TST) for diagnosis of tuberculosis infection. We review all publications using TIGRAs in children to appraise paediatricians of the advantages and limitations of these new blood tests. RECENT FINDINGS Unlike TST, both tests are independent of Bacille Calmette-Guérin vaccination status, providing higher diagnostic specificity. In children with active tuberculosis ELISpot is more sensitive than TST and is unaffected by HIV infection, age under 3 years or malnutrition; ELISA data are currently limited. In the absence of a gold-standard test for latent tuberculosis infection, tuberculosis exposure was used as a surrogate marker; ELISpot generally correlates better with tuberculosis exposure than TST, while ELISA correlates broadly similarly. Indeterminate test results in young children are rare with ELISpot and are more common with ELISA. SUMMARY Although longitudinal studies quantifying risk of progression to tuberculosis in tuberculosis-exposed children with positive TIGRA results are required urgently, the small but rapidly expanding evidence-base since the first application of TIGRAs to childhood tuberculosis in 2003 combined with recent national guidelines makes a strong case for judicious use of TIGRAs in clinical management of paediatric tuberculosis.
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Affiliation(s)
- Ajit Lalvani
- Tuberculosis Immunology Group, Department of Respiratory Medicine, National Heart and Lung Institute, Wright-Fleming Institute of Infection & Immunity, Imperial College London, London, UK.
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Millington KA, Innes JA, Hackforth S, Hinks TSC, Deeks JJ, Dosanjh DPS, Guyot-Revol V, Gunatheesan R, Klenerman P, Lalvani A. Dynamic relationship between IFN-gamma and IL-2 profile of Mycobacterium tuberculosis-specific T cells and antigen load. J Immunol 2007; 178:5217-26. [PMID: 17404305 PMCID: PMC2743164 DOI: 10.4049/jimmunol.178.8.5217] [Citation(s) in RCA: 210] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Distinct IFN-gamma and IL-2 profiles of Ag-specific CD4(+) T cells have recently been associated with different clinical disease states and Ag loads in viral infections. We assessed the kinetics and functional profile of Mycobacterium tuberculosis Ag-specific T cells secreting IFN-gamma and IL-2 in 23 patients with untreated active tuberculosis when bacterial and Ag loads are high and after curative treatment, when Ag load is reduced. The frequencies of M. tuberculosis Ag-specific IFN-gamma-secreting T cells declined during 28 mo of follow-up with an average percentage decline of 5.8% per year (p = 0.005), while the frequencies of Ag-specific IL-2-secreting T cells increased during treatment (p = 0.02). These contrasting dynamics for the two cytokines led to a progressive convergence of the frequencies of IFN-gamma- and IL-2-secreting cells over 28 mo. Simultaneous measurement of IFN-gamma and IL-2 secretion at the single-cell level revealed a codominance of IFN-gamma-only secreting and IFN-gamma/IL-2 dual secreting CD4(+) T cells in active disease that shifted to dominance of IFN-gamma/IL-2-secreting CD4(+) T cells and newly detectable IL-2-only secreting CD4(+) T cells during and after treatment. These distinct T cell functional signatures before and after treatment suggest a novel immunological marker of mycobacterial load and clinical status in tuberculosis that now requires validation in larger prospective studies.
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Affiliation(s)
- Kerry A. Millington
- Tuberculosis Immunology Group, Department of Respiratory Medicine, National Heart and Lung Institute, Wright Fleming Institute of Infection and Immunity, Imperial College London, London, UK
- Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - John A. Innes
- Department of Infection & Tropical Medicine, Birmingham Heartlands Hospital, Birmingham, UK
| | - Sarah Hackforth
- Department of Infection & Tropical Medicine, Birmingham Heartlands Hospital, Birmingham, UK
| | - Timothy S. C. Hinks
- Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Jonathan J. Deeks
- Department of Public Health and Epidemiology University of Birmingham, Birmingham UK
| | - Davinder P. S. Dosanjh
- Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Valerie Guyot-Revol
- Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Rubamalaar Gunatheesan
- Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Paul Klenerman
- Peter Medawar Building for Pathogen Research, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Ajit Lalvani
- Tuberculosis Immunology Group, Department of Respiratory Medicine, National Heart and Lung Institute, Wright Fleming Institute of Infection and Immunity, Imperial College London, London, UK
- Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
- Corresponding author: Professor A. Lalvani, Tuberculosis Immunology Group, Department of Respiratory Medicine, National Heart and Lung Institute, Wright Fleming Institute of Infection & Immunity, Imperial College London, Norfolk Place, London W2 1PG, United Kingdom Tel/fax: +44 (0) 207 594 0883
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Ewer K, Millington KA, Deeks JJ, Alvarez L, Bryant G, Lalvani A. Dynamic Antigen-specific T-Cell Responses after Point-Source Exposure toMycobacterium tuberculosis. Am J Respir Crit Care Med 2006; 174:831-9. [PMID: 16799072 DOI: 10.1164/rccm.200511-1783oc] [Citation(s) in RCA: 163] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The kinetics of Mycobacterium tuberculosis-specific Th1-type T-cell responses after M. tuberculosis infection are likely to be important in determining clinical outcome. OBJECTIVE To investigate the kinetics of T-cell responses, in the context of a point-source school tuberculosis outbreak, in three groups of contacts who differed by preventive treatment status and tuberculin skin test (TST) results: 38 treated TST-positive students, 11 untreated TST-positive staff, and 14 untreated students with negative or borderline TST results. METHODS We used the ex vivo IFN-gamma enzyme-linked immunospot assay (ELISpot) to track T cells specific for two region of difference 1 (RD1) antigens, early secretory antigenic target 6 and culture filtrate protein 10, for 18 mo after cessation of tuberculosis exposure. MAIN RESULTS The treated TST-positive students had an average 68% decline in frequencies of RD1-specific IFN-gamma-secreting T cells per year (p < 0.0001) and 6 of 38 students had no detectable RD1-specific T cells by 18 mo. No change in frequencies of these cells was observed in the untreated TST-positive staff (p = 0.38) and none were ELISpot-negative at 18 mo. Of the 14 untreated students, 7 were persistently ELISpot-positive (all of whom had borderline TST results), and 7 became ELISpot-negative (all but one had negative TST results) during follow-up. CONCLUSIONS The decrease in M. tuberculosis-specific T cells and their disappearance in a proportion of treated students likely reflect declining antigenic and bacterial load in vivo induced by antibiotic treatment. The observed disappearance of M. tuberculosis-specific T cells in the untreated TST-negative contacts suggests that an acute resolving infection may occur in some contacts.
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Affiliation(s)
- Katie Ewer
- Tuberculosis Immunology Group, Nuffield Department of Clinical Medicine, University of Oxford, UK
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Richeldi L, Luppi M, Losi M, Luppi F, Potenza L, Roversi P, Cerri S, Millington KA, Ewer K, Fabbri LM, Torelli G, Lalvani A. Diagnosis of occult tuberculosis in hematological malignancy by enumeration of antigen-specific T cells. Leukemia 2005; 20:379-81. [PMID: 16357840 DOI: 10.1038/sj.leu.2404053] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Soysal A, Millington KA, Bakir M, Dosanjh D, Aslan Y, Deeks JJ, Efe S, Staveley I, Ewer K, Lalvani A. Effect of BCG vaccination on risk of Mycobacterium tuberculosis infection in children with household tuberculosis contact: a prospective community-based study. Lancet 2005; 366:1443-51. [PMID: 16243089 DOI: 10.1016/s0140-6736(05)67534-4] [Citation(s) in RCA: 207] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Little is known about factors that affect the risk of acquiring infection in children exposed to Mycobacterium tuberculosis. The effect of BCG vaccination has been difficult to ascertain because the tuberculin skin test (TST), until recently the only method for detecting M tuberculosis infection, does not reliably distinguish between tuberculosis infection and BCG vaccination. METHODS We investigated risk factors for tuberculosis infection in 979 child household contacts of 414 adult index patients with sputum smear-positive pulmonary tuberculosis in Istanbul, Turkey. Children were aged up to 16 years (median 7, IQR 3-11) and 770 of 979 (79%) had a BCG scar. A T-cell-based enzyme-linked immunospot assay (ELISpot), which is not confounded by BCG vaccination, and TST were used to assess infection. Independent risk factors for infection were identified through multivariate analysis. FINDINGS Amount of tuberculosis exposure within the household and age (a marker of tuberculosis exposure outside the household) were strongly associated with likelihood of infection as measured by both TST and ELISpot. ELISpot also identified absence of BCG scar as an independent risk factor for infection in tuberculosis-exposed children; BCG-vaccinated children had an odds ratio of 0.60 (95% CI 0.43-0.83, p=0.003) for tuberculosis infection, compared with unvaccinated children. INTERPRETATION Contrary to the prevailing theory that BCG vaccination protects only against tuberculosis disease, our results suggest that the vaccine also protects against tuberculosis infection. This finding has important implications for our understanding of the biology of tuberculosis infection and development of improved tuberculosis vaccines.
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Affiliation(s)
- Ahmet Soysal
- Department of Paediatrics, Marmara University School of Medicine, Istanbul, Turkey
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