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Osman M, Meehan SA, von Delft A, Preez KD, Dunbar R, Marx FM, Boulle A, Welte A, Naidoo P, Hesseling AC. Correction: Early mortality in tuberculosis patients initially lost to follow up following diagnosis in provincial hospitals and primary health care facilities in Western Cape, South Africa. PLoS One 2024; 19:e0300768. [PMID: 38483890 PMCID: PMC10939207 DOI: 10.1371/journal.pone.0300768] [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: 03/17/2024] Open
Abstract
[This corrects the article DOI: 10.1371/journal.pone.0252084.].
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Meehan SA, Hesseling AC, von Delft A, Marx FM, Hughes JA, Bock P, Banke-Thomas A, Dunbar R, Phelanyane F, Smith M, Osman M. Association between tuberculosis and pregnancy outcomes: a retrospective cohort study of women in Cape Town, South Africa. BMJ Open 2024; 14:e081209. [PMID: 38326258 PMCID: PMC10860026 DOI: 10.1136/bmjopen-2023-081209] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 01/26/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND Tuberculosis (TB) remains a leading cause of mortality among women of childbearing age and a significant contributor to maternal mortality. Pregnant women with TB are at high risk of adverse pregnancy outcomes. This study aimed to determine risk factors for an adverse pregnancy outcome among pregnant women diagnosed with TB. METHODS Using TB programmatic data, this retrospective cohort analysis included all women who were routinely diagnosed with TB in the public sector between October 2018 and March 2020 in two health subdistricts of Cape Town, and who were documented to be pregnant during their TB episode. Adverse pregnancy outcome was defined as either a live birth of an infant weighing <2500 g and/or with a gestation period <37 weeks or as stillbirth, miscarriage, termination of pregnancy, maternal or early neonatal death. Demographics, TB and pregnancy characteristics were described by HIV status. Logistic regression was used to determine risk factors for adverse pregnancy outcome. RESULTS Of 248 pregnant women, half (52%) were living with HIV; all were on antiretroviral therapy at the time of their TB diagnosis. Pregnancy outcomes were documented in 215 (87%) women, of whom 74 (34%) had an adverse pregnancy outcome. Being older (35-44 years vs 25-34 years (adjusted OR (aOR): 3.99; 95% CI: 1.37 to 11.57), living with HIV (aOR: 2.72; 95% CI: 0.99 to 4.63), having an unfavourable TB outcome (aOR: 2.29; 95% CI: 1.03 to 5.08) and having presented to antenatal services ≤1 month prior to delivery (aOR: 10.57; 95% CI: 4.01 to 27.89) were associated with higher odds of an adverse pregnancy outcome. CONCLUSIONS Pregnancy outcomes among women with TB were poor, irrespective of HIV status. Pregnant women with TB are a complex population who need additional support prior to, during and after TB treatment to improve TB treatment and pregnancy outcomes. Pregnancy status should be considered for inclusion in TB registries.
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Affiliation(s)
- Sue-Ann Meehan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - 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
| | - Arne von Delft
- Centre for Infectious Disease Epidemiology and Research (CIDER), School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
- Health Intelligence Directorate, Department of Health and Wellness, Western Cape Department of Health, Cape Town, South Africa
| | - Florian M Marx
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Infectious Disease and Tropical Medicine, Centre for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Jennifer A Hughes
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Aduragbemi Banke-Thomas
- School of Human Sciences, Faculty of Education, Health and Human Sciences, University of Greenwich, London, UK
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Florence Phelanyane
- Centre for Infectious Disease Epidemiology and Research (CIDER), School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
- Health Intelligence Directorate, Department of Health and Wellness, Western Cape Department of Health, Cape Town, South Africa
| | - Mariette Smith
- Centre for Infectious Disease Epidemiology and Research (CIDER), School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
- Health Intelligence Directorate, Department of Health and Wellness, Western Cape Department of Health, Cape Town, South Africa
| | - Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- School of Human Sciences, Faculty of Education, Health and Human Sciences, University of Greenwich, London, UK
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Meehan SA, Hesseling AC, Boulle A, Chetty J, Connell L, Dlamini-Miti NJ, Dunbar R, Du Preez K, George G, Hoddinott G, Jennings K, Marx FM, Mudaly V, Naidoo P, Ndlovu N, Ngozo J, Smith M, Strauss M, Tanna G, Vanqa N, von Delft A, Osman M. Reducing Initial Loss to Follow-up Among People With Bacteriologically Confirmed Tuberculosis: LINKEDin, a Quasi-experimental Study in South Africa. Open Forum Infect Dis 2024; 11:ofad648. [PMID: 38221986 PMCID: PMC10787480 DOI: 10.1093/ofid/ofad648] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 12/16/2023] [Indexed: 01/16/2024] Open
Abstract
Every person diagnosed with tuberculosis (TB) needs to initiate treatment. The World Health Organization estimated that 61% of people who developed TB in 2021 were included in a TB treatment registration system. Initial loss to follow-up (ILTFU) is the loss of persons to care between diagnosis and treatment initiation/registration. LINKEDin, a quasi-experimental study, evaluated the effect of 2 interventions (hospital recording and an alert-and-response patient management intervention) in 6 subdistricts across 3 high-TB burden provinces of South Africa. Using integrated electronic reports, we identified all persons diagnosed with TB (Xpert MTB/RIF positive) in the hospital and at primary health care facilities. We prospectively determined linkage to care at 30 days after TB diagnosis. We calculated the risk of ILTFU during the baseline and intervention periods and the relative risk reduction in ILTFU between these periods. We found a relative reduction in ILTFU of 42.4% (95% CI, 28.5%-53.7%) in KwaZulu Natal (KZN) and 22.3% (95% CI, 13.3%-30.4%) in the Western Cape (WC), with no significant change in Gauteng. In KZN and the WC, the relative reduction in ILTFU appeared greater in subdistricts where the alert-and-response patient management intervention was implemented (KZN: 49.3%; 95% CI, 32.4%-62%; vs 32.2%; 95% CI, 5.4%-51.4%; and WC: 34.2%; 95% CI, 20.9%-45.3%; vs 13.4%; 95% CI, 0.7%-24.4%). We reported a notable reduction in ILTFU in 2 provinces using existing routine health service data and applying a simple intervention to trace and recall those not linked to care. TB programs need to consider ILTFU a priority and develop interventions specific to their context to ensure improved linkage to care.
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Affiliation(s)
- Sue-Ann Meehan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - 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
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Health and Wellness, Health Intelligence Directorate, Western Cape Government, Cape Town, South Africa
| | - Jolene Chetty
- Interactive Research and Development South Africa (IRD SA), Sandton, Johannesburg
| | - Lucy Connell
- Right to Care South Africa, Helen Joseph Hospital, Johannesburg, South Africa
| | | | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Karen Du Preez
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gavin George
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
- Division of Social Medicine and Global Health, Lund University, Lund, Sweden
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Karen Jennings
- City of Cape Town Health Department, Cape Town, South Africa
| | - Florian M Marx
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
- DSI-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Vanessa Mudaly
- Department of Health and Wellness, Western Cape Government, Cape Town, South Africa
| | - Pren Naidoo
- Bill and Melinda gates Foundation, Johannesburg, South Africa
| | - Neo Ndlovu
- Right to Care South Africa, Helen Joseph Hospital, Johannesburg, South Africa
| | - Jacqueline Ngozo
- Kwa-Zulu Natal Department of Health and Wellness, Pietermaritzburg, South Africa
| | - Mariette Smith
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Health and Wellness, Health Intelligence Directorate, Western Cape Government, Cape Town, South Africa
| | - Michael Strauss
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Gaurang Tanna
- Bill and Melinda gates Foundation, Johannesburg, South Africa
| | - Nosivuyile Vanqa
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Arne von Delft
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Health and Wellness, Health Intelligence Directorate, Western Cape Government, Cape Town, South Africa
| | - Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- School of Human Sciences, University of Greenwich, London, UK
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van der Zalm MM, Jongen VW, Swanepoel R, Zimri K, Allwood B, Palmer M, Dunbar R, Goussard P, Schaaf HS, Hesseling AC, Seddon JA. Impaired lung function in adolescents with pulmonary tuberculosis during treatment and following treatment completion. EClinicalMedicine 2024; 67:102406. [PMID: 38261903 PMCID: PMC10796966 DOI: 10.1016/j.eclinm.2023.102406] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/08/2023] [Accepted: 12/14/2023] [Indexed: 01/25/2024] Open
Abstract
Background Little is known about post-tuberculosis lung disease in adolescents. We prospectively assessed lung function in adolescents with microbiologically confirmed pulmonary tuberculosis during treatment and after treatment completion. Methods In a prospective study, we enrolled adolescents diagnosed with microbiologically confirmed tuberculosis and healthy tuberculosis-exposed household controls, between October 2020 and July 2021 in Cape Town, South Africa. Spirometry, plethysmography, diffusion capacity lung function tests and 6-min walking test (6MWT) were completed according to international guidelines 2 months into treatment and following treatment completion. Abnormal lung function was defined as abnormal spirometry (z-score < -1.64 for forced expiratory volume in 1 s (FEV1) and/or forced vital capacity (FVC) and/or FEV1/FVC), plethysmography (total lung capacity (TLC) < 80% of predicted, residual volume over TLC of >45%) and/or diffusion capacity (DLCO z-score < -1.64). Findings One-hundred adolescents were enrolled; 50 (50%) with tuberculosis and 50 (50%) healthy tuberculosis-exposed controls. Of the 50 adolescents with tuberculosis, ten had multidrug-resistant tuberculosis. Mean age of the group was 14.9 years (SD 2.7), 6 (6.0%) were living with HIV and 9 (9.0%) were previously treated for tuberculosis. Lung function improved over time; during treatment abnormal lung function was found in 76% of adolescents with tuberculosis, compared to 65% after treatment completion. Spirometry indices were lower in adolescents with tuberculosis compared to controls, both at 2 months and after treatment completion. Plethysmography in adolescents with tuberculosis showed that air-trapping was more common during treatment than in controls (12% vs 0%, respectively, p = 0.017); which improved following treatment completion. Adolescents with tuberculosis both during and after treatment completion walked a shorter distance than controls. Interpretation Adolescents with tuberculosis have impaired lung function even after treatment completion. It is crucial to include adolescents in trials on the prevention and treatment of tuberculosis-associated respiratory morbidity. Funding EDCTP, National Institute of Health, Medical Research Council, BMBF.
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Affiliation(s)
- Marieke M. van der Zalm
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Vita W. Jongen
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Infectious Diseases, Public Health Service Amsterdam, Amsterdam, the Netherlands
| | - Ruan Swanepoel
- Division of Pulmonology, Department of Internal Medicine, Tygerberg Academic Hospital, Cape Town, South Africa
| | - Klassina Zimri
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Brian Allwood
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, South Africa
| | - Megan Palmer
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Pierre Goussard
- Paediatric Pulmonology, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - 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
| | - 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
| | - James A. Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Infectious Disease, Imperial College London, London, United Kingdom
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Dewandel I, van Niekerk M, Ghimenton-Walters E, Palmer M, Anthony MG, McKenzie C, Croucamp R, Alter G, Demers AM, van Zyl G, Claassen M, Goussard P, Swanepoel R, Hoddinott G, Bosch C, Dunbar R, Allwood B, McCollum ED, Schaaf HS, Hesseling AC, van der Zalm MM. UMOYA: a prospective longitudinal cohort study to evaluate novel diagnostic tools and to assess long-term impact on lung health in South African children with presumptive pulmonary TB-a study protocol. BMC Pulm Med 2023; 23:97. [PMID: 36949477 PMCID: PMC10032249 DOI: 10.1186/s12890-023-02329-3] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 01/17/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Despite a high paediatric tuberculosis (TB) burden globally, sensitive and specific diagnostic tools are lacking. In addition, no data exist on the impact of pulmonary TB on long-term child lung health in low- and middle-income countries. The prospective observational UMOYA study aims (1) to build a state-of-the-art clinical, radiological, and biological repository of well-characterised children with presumptive pulmonary TB as a platform for future studies to explore new emerging diagnostic tools and biomarkers for early diagnosis and treatment response; and (2) to investigate the short and long-term impact of pulmonary TB on lung health and quality of life in children. METHODS We will recruit up to 600 children (0-13 years) with presumptive pulmonary TB and 100 healthy controls. Recruitment started in November 2017 and is expected to continue until May 2023. Sputum and non-sputum-based samples are collected at enrolment and during follow-up in TB cases and symptomatic controls. TB treatment is started by routine care services. Intensive follow-up for 6 months will allow for TB cases to retrospectively be classified according to international consensus clinical case definitions for TB. Long-term follow-up, including imaging, comprehensive assessment of lung function and quality of life questionnaires, are done yearly up to 4 years after recruitment. DISCUSSION The UMOYA study will provide a unique platform to evaluate new emerging diagnostic tools and biomarkers for early diagnosis and treatment response and to investigate long-term outcomes of pulmonary TB and other respiratory events on lung health in children.
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Affiliation(s)
- Isabelle Dewandel
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Margaret van Niekerk
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elisabetta Ghimenton-Walters
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Newcastle-Upon-Tyne National Health Service Hospitals Foundation Trust, Newcastle upon Tyne, UK
| | - Megan Palmer
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Michaile G Anthony
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Carla McKenzie
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Rolanda Croucamp
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Galit Alter
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology, and Harvard, Cambridge, MA, USA
- Moderna Therapeutics, Cambridge, MA, USA
| | - Anne-Marie Demers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Microbiology, Department of Laboratory Medicine, Centre Hospitalier Universitaire Sainte-Justine, Quebec, Canada
- Department of Microbiology, Immunology and Infectious Diseases, Faculty of Medicine, University of Montreal, Quebec, Canada
| | - Gert van Zyl
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- National Health Laboratory Service, Tygerberg Business Unit, Cape Town, South Africa
| | - Mathilda Claassen
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Pierre Goussard
- Department of Paediatric Pulmonology, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
| | - Ruan Swanepoel
- Department of Pulmonology and Lung Function, Tygerberg Hospital, Cape Town, South Africa
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Corne Bosch
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Brian Allwood
- Department of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Eric D McCollum
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, Baltimore, USA
| | - 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
| | - 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
| | - Marieke M van der Zalm
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
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Nicholson TJ, Hoddinott G, Seddon JA, Claassens MM, van der Zalm MM, Lopez E, Bock P, Caldwell J, Da Costa D, de Vaal C, Dunbar R, Du Preez K, Hesseling AC, Joseph K, Kriel E, Loveday M, Marx FM, Meehan SA, Purchase S, Naidoo K, Naidoo L, Solomon-Da Costa F, Sloot R, Osman M. A systematic review of risk factors for mortality among tuberculosis patients in South Africa. Syst Rev 2023; 12:23. [PMID: 36814335 PMCID: PMC9946877 DOI: 10.1186/s13643-023-02175-8] [Citation(s) in RCA: 4] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 01/17/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Tuberculosis (TB)-associated mortality in South Africa remains high. This review aimed to systematically assess risk factors associated with death during TB treatment in South African patients. METHODS We conducted a systematic review of TB research articles published between 2010 and 2018. We searched BioMed Central (BMC), PubMed®, EBSCOhost, Cochrane, and SCOPUS for publications between January 2010 and December 2018. Searches were conducted between August 2019 and October 2019. We included randomised control trials (RCTs), case control, cross sectional, retrospective, and prospective cohort studies where TB mortality was a primary endpoint and effect measure estimates were provided for risk factors for TB mortality during TB treatment. Due to heterogeneity in effect measures and risk factors evaluated, a formal meta-analysis of risk factors for TB mortality was not appropriate. A random effects meta-analysis was used to estimate case fatality ratios (CFRs) for all studies and for specific subgroups so that these could be compared. Quality assessments were performed using the Newcastle-Ottawa scale or the Cochrane Risk of Bias Tool. RESULTS We identified 1995 titles for screening, 24 publications met our inclusion criteria (one cross-sectional study, 2 RCTs, and 21 cohort studies). Twenty-two studies reported on adults (n = 12561) and two were restricted to children < 15 years of age (n = 696). The CFR estimated for all studies was 26.4% (CI 18.1-34.7, n = 13257 ); 37.5% (CI 24.8-50.3, n = 5149) for drug-resistant (DR) TB; 12.5% (CI 1.1-23.9, n = 1935) for drug-susceptible (DS) TB; 15.6% (CI 8.1-23.2, n = 6173) for studies in which drug susceptibility was mixed or not specified; 21.3% (CI 15.3-27.3, n = 7375) for people living with HIV/AIDS (PLHIV); 19.2% (CI 7.7-30.7, n = 1691) in HIV-negative TB patients; and 6.8% (CI 4.9-8.7, n = 696) in paediatric studies. The main risk factors associated with TB mortality were HIV infection, prior TB treatment, DR-TB, and lower body weight at TB diagnosis. CONCLUSIONS In South Africa, overall mortality during TB treatment remains high, people with DR-TB have an elevated risk of mortality during TB treatment and interventions to mitigate high mortality are needed. In addition, better prospective data on TB mortality are needed, especially amongst vulnerable sub-populations including young children, adolescents, pregnant women, and people with co-morbidities other than HIV. Limitations included a lack of prospective studies and RCTs and a high degree of heterogeneity in risk factors and comparator variables. SYSTEMATIC REVIEW REGISTRATION The systematic review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42018108622. This study was funded by the Bill and Melinda Gates Foundation (Investment ID OPP1173131) via the South African TB Think Tank.
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Affiliation(s)
- Tamaryn J Nicholson
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
| | - Mareli M Claassens
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Human, Biological and Translational Medical Sciences, School of Medicine, University of Namibia, Windhoek, Namibia
| | - Marieke M van der Zalm
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elisa Lopez
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- IS Global, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-Universidad de Barcelona, Barcelona, Spain
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Judy Caldwell
- Community Services and Health Directorate, City of Cape Town, Cape Town, South Africa
| | - Dawood Da Costa
- Division of Medical Microbiology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Celeste de Vaal
- Division of Forensic Medicine and Toxicology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Karen Du Preez
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - 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
| | - Kay Joseph
- Community Services and Health Directorate, City of Cape Town, Cape Town, South Africa
| | - Ebrahim Kriel
- Metro Health Services, Southern and Western Substructure, Western Cape Government: Health, Cape Town, South Africa
| | - Marian Loveday
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa, CAPRISA-SA-MRC HIV-TB Pathogenesis and Treatment Research Unit, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Florian M Marx
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Sue-Ann Meehan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Susan Purchase
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa, CAPRISA-SA-MRC HIV-TB Pathogenesis and Treatment Research Unit, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Lenny Naidoo
- Community Services and Health Directorate, City of Cape Town, Cape Town, South Africa
| | | | - Rosa Sloot
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
- School of Human Sciences, Faculty of Education, Health and Human Sciences, University of Greenwich, London, United Kingdom.
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Wilson E, Donnell D, Skalland T, Floyd S, Moore A, Bell-Mandla N, Bwalya J, Kasese N, Dunbar R, Shanaube K, Kosloff B, Laeyendecker O, Agyei Y, Hoddinott G, Bock P, Fidler S, Hayes R, Ayles H. Impact of universal testing and treatment on sexual risk behaviour and herpes simplex virus type 2: a prespecified secondary outcomes analysis of the HPTN 071 (PopART) community-randomised trial. Lancet HIV 2022; 9:e760-e770. [PMID: 36332653 PMCID: PMC9646971 DOI: 10.1016/s2352-3018(22)00253-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 08/23/2022] [Accepted: 09/01/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Comprehensive HIV prevention strategies have raised concerns that knowledge of interventions to reduce risk of HIV infection might mitigate an individual's perception of risk, resulting in riskier sexual behaviour. We investigated the prespecified secondary outcomes of the HPTN 071 (PopART) trial to determine whether a combination HIV prevention strategy, including universal HIV testing and treatment, changed sexual behaviour; specifically, we investigated whether there was evidence of sexual risk compensation. METHODS HPTN 071 (PopART) was a cluster-randomised trial conducted during 2013-18, in which we randomly assigned 21 communities with high HIV prevalence in Zambia and South Africa (total population, approximately 1 million) to combination prevention intervention with universal antiretroviral therapy (ART; arm A), prevention intervention with ART provided according to local guidelines (universal since 2016; arm B), or standard of care (arm C). The trial included a population cohort of approximately 2000 randomly selected adults (aged 18-44 years) in each community (N=38 474 at baseline) who were followed up for 36 months. A prespecified secondary objective was to evaluate the impact of the PopART intervention compared with standard of care on herpes simplex virus type 2 (HSV-2) and sexual behaviour (N=20 422 completed final visit). Secondary endpoints included differences in sexual risk behaviour measures at 36 months and were assessed using a two-stage method for matched cluster-randomised trials. This trial is registered with ClinicalTrials. gov, number NCT01900977. FINDINGS The PopART intervention did not substantially change probability of self-reported multiple sex partners, sexual debut, or pregnancy in women at 36 months. Adjusted for baseline community prevalence, reported condomless sex was significantly lower in arm A versus arm C (adjusted prevalence ratio 0·80 [95% CI 0·64-0·99]; p=0·04) but not in arm B versus arm C (0·94 [0·76-1·17]; p=0·55). 3-year HSV-2 incidence was reduced in arm B versus arm C (adjusted risk ratio 0·76 [95% CI 0·63-0·92]; p=0·010); no significant change was shown between arm A versus arm C (0·89 [0·73-1·08]; p=0·199). INTERPRETATION We found little evidence of any change in sexual behaviour owing to the PopART interventions, and reassuringly for public health, we saw no evidence of sexual risk compensation. The findings do not help to explain the differences between the two intervention groups of the HPTN 071 (PopART) trial. FUNDING National Institute of Allergy and Infectious Diseases, the National Institutes of Health, the International Initiative for Impact Evaluation (3ie), the Bill & Melinda Gates Foundation, the US President's Emergency Plan for AIDS Relief, and the Medical Research Council UK.
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Affiliation(s)
- Ethan Wilson
- Fred Hutchinson Cancer Center, Seattle, WA, USA.
| | | | | | - Sian Floyd
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Nomtha Bell-Mandla
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | | | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Barry Kosloff
- London School of Hygiene and Tropical Medicine, London, UK; Zambart, Lusaka, Zambia
| | - Oliver Laeyendecker
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA; Johns Hopkins Univiersity School of Medicine, Baltimore, MD, USA
| | - Yaw Agyei
- Johns Hopkins Univiersity School of Medicine, Baltimore, MD, USA
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sarah Fidler
- Imperial College London, London, UK; NIHR Imperial Biomedical Research Centre, London, UK
| | - Richard Hayes
- London School of Hygiene and Tropical Medicine, London, UK
| | - Helen Ayles
- London School of Hygiene and Tropical Medicine, London, UK; Zambart, Lusaka, Zambia
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8
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Hargreaves JR, Pliakas T, Hoddinott G, Mainga T, Mubekapi‐Musadaidzwa C, Donnell D, Wilson E, Piwowar‐Manning E, Agyei Y, Bell‐Mandla NF, Dunbar R, Schaap A, Macleod D, Floyd S, Bock P, Fidler S, Seeley J, Stangl A, Bond V, Ayles H, Hayes RJ. The association between HIV stigma and HIV incidence in the context of universal testing and treatment: analysis of data from the HPTN 071 (PopART) trial in Zambia and South Africa. J Int AIDS Soc 2022; 25 Suppl 1:e25931. [PMID: 35818869 PMCID: PMC9274206 DOI: 10.1002/jia2.25931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 05/03/2022] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION To investigate the association between individual and community-level measures of HIV stigma and HIV incidence within the 21 communities participating in the HPTN (071) PopART trial in Zambia and South Africa. METHODS Secondary analysis of data from a population-based cohort followed-up over 36 months between 2013 and 2018. The outcome was rate of incident HIV infection among individuals who were HIV negative at cohort entry. Individual-level exposures, measured in a random sample of all participants, were: (1) perception of stigma in the community, (2) perception of stigma in health settings and (3) fear and judgement towards people living with HIV. Individual-level analyses were conducted with adjusted, individual-level Poisson regression. Community-level HIV stigma exposures drew on data reported by people living with HIV, health workers and community members. We used linear regression to explore the association between HIV stigma and community-level HIV incidence. RESULTS Among 8172 individuals who were HIV negative and answered individual-level stigma questions at enrolment to the cohort, there was no evidence of a statistically significant association between any domain of HIV stigma and risk of incident HIV infection. Among the full cohort of 26,110 individuals among whom HIV incidence was measured, there was no evidence that community-level HIV incidence was associated with any domain of HIV stigma. CONCLUSIONS HIV stigma is often cited as a barrier to the effectiveness of HIV prevention programming. However, in the setting for the HPTN 071 "PopART trial," measured stigma alone was not associated with the risk of HIV infection.
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Affiliation(s)
- James R. Hargreaves
- Department of Public Health, Environments and Society, Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Triantafyllos Pliakas
- Department of Public Health, Environments and Society, Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Tila Mainga
- Zambart, School of Public HealthUniversity of ZambiaLusakaZambia
| | - Constance Mubekapi‐Musadaidzwa
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | | | - Ethan Wilson
- Fred Hutchinson Cancer Research CenterSeattleWashingtonUSA
| | | | - Yaw Agyei
- Johns Hopkins UniversitySchool of MedicineBaltimoreMarylandUSA
| | - Nomtha F. Bell‐Mandla
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Ab Schaap
- Zambart, School of Public HealthUniversity of ZambiaLusakaZambia
| | - David Macleod
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUK
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUK
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Sarah Fidler
- Department of Medicine, Imperial College NIHR BRCImperial College LondonLondonUK
| | - Janet Seeley
- Department of Global Health and Development, Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Anne Stangl
- International Center for Research on WomenWashingtonDCUSA
- Hera SolutionsBaltimoreMarylandUSA
| | - Virginia Bond
- Zambart, School of Public HealthUniversity of ZambiaLusakaZambia
- Department of Global Health and Development, Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Helen Ayles
- Zambart, School of Public HealthUniversity of ZambiaLusakaZambia
- Department of Clinical Research, Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
| | - Richard J. Hayes
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUK
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Marx FM, Meehan SA, Jivan D, Dunbar R, Hoddinott G, Hesseling AC, Osman M. Use of interactive messaging to reduce pre-diagnosis loss to follow-up for TB care. Int J Tuberc Lung Dis 2022; 26:26-32. [PMID: 34969425 DOI: 10.5588/ijtld.21.0332] [Citation(s) in RCA: 0] [Impact Index Per Article: 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
OBJECTIVE: To investigate the uptake and usage of a WhatsApp-based interactive communication strategy to avert pre-diagnosis loss to follow-up (LTFU) from TB care in a high-incidence setting.METHODS: We enrolled adults (≥18 years) who underwent routine sputum TB testing in two primary healthcare clinics in Khayelitsha, Cape Town, South Africa. The intervention consisted of structured WhatsApp-based reminders (prompts) sent prior to a routine clinic appointment scheduled 2-3 days after the diagnostic visit. Pre-diagnosis LTFU was defined as failure to return for the scheduled appointment and within 10 days.RESULTS: We approached 332 adults with presumptive TB, of whom 103 (31%) were successfully enrolled; 213 (64%) did not own a WhatsApp-compatible phone. Of 103 participants, 74 (72%) actively responded to WhatsApp prompts; 69 (67%) opted to include a close contact in group communication to co-receive reminders. Pre-diagnosis LTFU was low overall (n = 7, 6.8%) and was not associated with failure to respond to WhatsApp prompts.CONCLUSION: In this high-incidence setting, enrolment in a WhatsApp-based communication intervention among adults with presumptive TB was low, mainly due to low availability of WhatsApp-compatible phones. Among participants, we observed high message response rates and low LTFU, suggesting potential for interactive messaging services to support pre-diagnosis TB care.
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Affiliation(s)
- F M Marx
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa, DSI-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis, Faculty of Science, Stellenbosch University, Stellenbosch, South Africa
| | - S-A Meehan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - D Jivan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - R Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - G Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - A C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - M Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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10
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du Preez K, Osman M, Seddon JA, Naidoo P, Schaaf HS, Munch Z, Dunbar R, Mvusi L, Dlamini SS, Hesseling AC. The Impact of the Evolving Human Immunodeficiency Virus Response on the Epidemiology of Tuberculosis in South African Children and Adolescents. Clin Infect Dis 2021; 73:e967-e975. [PMID: 33532853 PMCID: PMC8366817 DOI: 10.1093/cid/ciab095] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 09/04/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Few studies have evaluated tuberculosis control in children and adolescents. We used routine tuberculosis surveillance data to quantify age- and human immunodeficiency virus (HIV)-stratified trends over time and investigate the relationship between tuberculosis, HIV, age, and sex. METHODS All children and adolescents (0-19 years) routinely treated for drug-susceptible tuberculosis in South Africa and recorded in a de-duplicated national electronic tuberculosis treatment register (2004-2016) were included. Age- and HIV-stratified tuberculosis case notification rates (CNRs) were calculated in four age bands: 0-4, 5-9, 10-14, and 15-19 years. The association between HIV infection, age, and sex in children and adolescents with tuberculosis was evaluated using multivariable logistic regression. RESULTS Of 719 400 children and adolescents included, 339 112 (47%) were 0-4 year olds. The overall tuberculosis CNR for 0-19 year olds declined by 54% between 2009 and 2016 (incidence rate ratio [IRR] = 0.46; 95% confidence interval [CI], .45-.47). Trends varied by age and HIV, with the smallest reductions (2013-2016) in HIV-positive 0-4 year olds (IRR = 0.90; 95% CI, .85-.95) and both HIV-positive (IRR = .84; 95% CI, .80-.88) and HIV-negative (IRR = 0.89; 95% CI, .86-.92) 15-19 year olds. Compared with 0- to 4-year-old males, odds of HIV coinfection among 15-19 year olds were nearly twice as high in females (adjusted odds ratio [aOR] = 2.49; 95% CI, 2.38-2.60) than in males (aOR = 1.35; 95% CI, 1.29-1.42). CONCLUSIONS South Africa's national response to the HIV epidemic has made a substantial contribution to the observed declining trends in tuberculosis CNRs in children and adolescents. The slow decline of tuberculosis CNRs in adolescents and young HIV-positive children is concerning. Understanding how tuberculosis affects children and adolescents beyond conventional age bands and by sex can inform targeted tuberculosis control strategies.
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Affiliation(s)
- Karen du Preez
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Infectious Diseases, Imperial College London, United Kingdom
| | - Pren Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - 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
| | - Zahn Munch
- Department of Geography and Environmental Studies, Stellenbosch University, Stellenbosch, South Africa
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Lindiwe Mvusi
- National TB Control & Management Cluster, National Department of Health, South Africa
| | - Sicelo S Dlamini
- Research Information Monitoring, Evaluation & Surveillance (RIMES), National TB Control & Management Cluster, National Department of Health, South Africa
| | - 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
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11
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Osman M, van Schalkwyk C, Naidoo P, Seddon JA, Dunbar R, Dlamini SS, Welte A, Hesseling AC, Claassens MM. Mortality during tuberculosis treatment in South Africa using an 8-year analysis of the national tuberculosis treatment register. Sci Rep 2021; 11:15894. [PMID: 34354135 PMCID: PMC8342475 DOI: 10.1038/s41598-021-95331-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 07/20/2021] [Indexed: 11/18/2022] Open
Abstract
In 2011, the South African HIV treatment eligibility criteria were expanded to allow all tuberculosis (TB) patients lifelong ART. The impact of this change on TB mortality in South Africa is not known. We evaluated mortality in all adults (≥ 15 years old) treated for drug-susceptible TB in South Africa between 2009 and 2016. Using a Cox regression model, we quantified risk factors for mortality during TB treatment and present standardised mortality ratios (SMR) stratified by year, age, sex, and HIV status. During the study period, 8.6% (219,618/2,551,058) of adults on TB treatment died. Older age, male sex, previous TB treatment and HIV infection (with or without the use of ART) were associated with increased hazard of mortality. There was a 19% reduction in hazard of mortality amongst all TB patients between 2009 and 2016 (adjusted hazard ratio: 0.81 95%CI 0.80-0.83). The highest SMR was in 15-24-year-old women, more than double that of men (42.3 in 2016). Between 2009 and 2016, the SMR for HIV-positive TB patients increased, from 9.0 to 19.6 in women, and 7.0 to 10.6 in men. In South Africa, case fatality during TB treatment is decreasing and further interventions to address specific risk factors for TB mortality are required. Young women (15-24-year-olds) with TB experience a disproportionate burden of mortality and interventions targeting this age-group are needed.
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Affiliation(s)
- Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Parow, Cape Town, 7505, South Africa.
| | - Cari van Schalkwyk
- DSI-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Pren Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Parow, Cape Town, 7505, South Africa
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Parow, Cape Town, 7505, South Africa
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Parow, Cape Town, 7505, South Africa
| | - Sicelo S Dlamini
- Research Information Monitoring, Evaluation & Surveillance (RIMES), National TB Control & Management Cluster, National Department of Health, Pretoria, South Africa
| | - Alex Welte
- DSI-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Parow, Cape Town, 7505, South Africa
| | - Mareli M Claassens
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Parow, Cape Town, 7505, South Africa.
- Department of Biochemistry and Microbiology, School of Medicine, University of Namibia, Bach Street, Windhoek, Namibia.
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12
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Osman M, Meehan SA, von Delft A, Du Preez K, Dunbar R, Marx FM, Boulle A, Welte A, Naidoo P, Hesseling AC. Early mortality in tuberculosis patients initially lost to follow up following diagnosis in provincial hospitals and primary health care facilities in Western Cape, South Africa. PLoS One 2021; 16:e0252084. [PMID: 34125843 PMCID: PMC8202951 DOI: 10.1371/journal.pone.0252084] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 05/06/2021] [Indexed: 11/18/2022] Open
Abstract
In South Africa, low tuberculosis (TB) treatment coverage and high TB case fatality remain important challenges. Following TB diagnosis, patients must link with a primary health care (PHC) facility for initiation or continuation of antituberculosis treatment and TB registration. We aimed to evaluate mortality among TB patients who did not link to a TB treatment facility for TB treatment within 30 days of their TB diagnosis, i.e. who were “initial loss to follow-up (ILTFU)” in Cape Town, South Africa. We prospectively included all patients with a routine laboratory or clinical diagnosis of TB made at PHC or hospital level in Khayelitsha and Tygerberg sub-districts in Cape Town, using routine TB data from an integrated provincial health data centre between October 2018 and March 2020. Overall, 74% (10,208/13,736) of TB patients were diagnosed at PHC facilities and ILTFU was 20.0% (2,742/13,736). Of ILTFU patients, 17.1% (468/2,742) died, with 69.7% (326/468) of deaths occurring within 30 days of diagnosis. Most ILTFU deaths (85.5%; 400/468) occurred in patients diagnosed in hospital. Multivariable logistic regression identified increasing age, HIV positive status, and hospital-based TB diagnosis (higher in the absence of TB treatment initiation and being ILTFU) as predictors of mortality. Although hospitals account for a modest proportion of diagnosed TB patients they have high TB-associated mortality. A hospital-based TB diagnosis is a critical opportunity to identify those at high risk of early and overall mortality. Interventions to diagnose TB before hospital admission, improve linkage to TB treatment following diagnosis, and reduce mortality in hospital-diagnosed TB patients should be prioritised.
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Affiliation(s)
- Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- * E-mail:
| | - Sue-Ann Meehan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Arne von Delft
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Health, Health Impact Assessment Directorate, Western Cape Government, Cape Town, South Africa
| | - Karen Du Preez
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Florian M. Marx
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- DSI-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Health, Health Impact Assessment Directorate, Western Cape Government, Cape Town, South Africa
| | - Alex Welte
- DSI-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Pren Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - 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
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Dasyam N, Sharples K, Barrow C, Bauer E, Mester B, McCusker M, Painter G, Weinkove R, Brimble M, Dunbar R, Gasser O, Hermans I. A randomised trial of dentric cell vaccination with NY-ESO-1 and alpha- galactosylceramide in patients with metastatic melanoma (ACTRN12612001101875). Cytotherapy 2021. [DOI: 10.1016/s1465324921004254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Osman M, du Preez K, Seddon JA, Claassens MM, Dunbar R, Dlamini SS, Welte A, Naidoo P, Hesseling AC. Mortality in South African Children and Adolescents Routinely Treated for Tuberculosis. Pediatrics 2021; 147:peds.2020-032490. [PMID: 33692161 PMCID: PMC8405866 DOI: 10.1542/peds.2020-032490] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/09/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND In South Africa, tuberculosis (TB) is a leading cause of death among those <20 years of age. We describe changes in TB mortality among children and adolescents in South Africa over a 13-year period, identify risk factors for mortality, and estimate excess TB-related mortality. METHODS Retrospective analysis of all patients <20 years of age routinely recorded in the national electronic drug-susceptible TB treatment register (2004-2016). We developed a multivariable Cox regression model for predictors of mortality and used estimates of mortality among the general population to calculate standardized mortality ratios (SMRs). RESULTS Between 2004 and 2016, 729 463 children and adolescents were recorded on TB treatment; 84.0% had treatment outcomes and 2.5% (18 539) died during TB treatment. The case fatality ratio decreased from 3.3% in 2007 to 1.9% in 2016. In the multivariable Cox regression model, ages 0 to 4, 10 to 14, and 15 to 19 years (compared with ages 5 to 9 years) were associated with increased risk of mortality, as was HIV infection, previous TB treatment, and extrapulmonary involvement. The SMR of 15 to 19-year-old female patients was more than double that of male patients the same age (55.3 vs 26.2). Among 10 to 14-year-olds and those who were HIV-positive, SMRs increased over time. CONCLUSIONS Mortality in South African children and adolescents treated for TB is declining but remains considerable, with 2% dying during 2016. Adolescents (10 to 19 years) and those people living with HIV have the highest risk of mortality and the greatest SMRs. Interventions to reduce mortality during TB treatment, specifically targeting those at highest risk, are urgently needed.
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Affiliation(s)
- Muhammad Osman
- Desmond Tutu Tuberculosis Centre, Departments of Paediatrics and Child Health and
| | - Karen du Preez
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - James A. Seddon
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa,Department of Infectious Diseases, Imperial College London, London, United Kingdom
| | - Mareli M. Claassens
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa,Department of Biochemistry and Microbiology, School of Medicine, University of Namibia, Windhoek, Namibia
| | - Rory Dunbar
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Sicelo S. Dlamini
- Research Information Monitoring, Evaluation, and Surveillance, National Tuberculosis Control and Management Cluster, National Department of Health, Pretoria, South Africa
| | - Alex Welte
- Department of Science and Innovation – National Research Foundation South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Pren Naidoo
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Anneke C. Hesseling
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
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Osman M, Verster J, Dempers JJ, Du Preez K, von Delft A, Dunbar R, Welte A, Naidoo P, Hesseling AC. Tuberculosis in persons with sudden unexpected death, in Cape Town, South Africa. Int J Infect Dis 2021; 105:75-82. [PMID: 33582368 PMCID: PMC8358423 DOI: 10.1016/j.ijid.2021.02.036] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/27/2021] [Accepted: 02/07/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Globally, tuberculosis (TB) remains one of the leading causes of death from a single infectious agent, but there has been little work to estimate mortality before the diagnosis of TB. We investigated the burden of diagnosed and undiagnosed TB in adult and child sudden unexpected deaths (SUDs) evaluated at Tygerberg Forensic Pathology Services, South Africa. METHODS In a retrospective descriptive study spanning 2016, we identified all SUDs where active TB was detected at post-mortem and matched with routine health service data to differentiate decedents who were diagnosed or undiagnosed with TB before death. A patient pathway analysis of the health service activities preceding SUD in adults with active TB was conducted. RESULTS Active TB was identified at post-mortem in 6.2% (48/770) of SUDs and was undiagnosed before death in 91.7% (44/48). The prevalence of active TB was 8.1% in adult SUDs (90.1% undiagnosed before SUD) and 1.8% in children (none diagnosed before SUD). Patient pathway analysis was possible for 15 adult SUDs, and this documented primary health care clinic attendances and hospital admissions in the six months preceding death and missed opportunities for TB investigations. CONCLUSION The prevalence of TB among SUDs in the Eastern Metro of Cape Town is high. Most active TB at post-mortem was undiagnosed before death, and multiple missed opportunities for TB investigation and diagnosis were noted. The systematic evaluation of all SUDs for TB could improve the reporting of undiagnosed TB and support risk mitigation for healthcare workers involved with the post-mortem process.
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Affiliation(s)
- Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Janette Verster
- Division of Forensic Medicine and Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Forensic Pathology Service, Cape Town, South Africa
| | - Johan J Dempers
- Division of Forensic Medicine and Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Forensic Pathology Service, Cape Town, South Africa
| | - Karen Du Preez
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Arne von Delft
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa; Health Impact Assessment Directorate, Strategy and Health Support, Western Cape Government: Health, South Africa
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Alex Welte
- DSI-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Pren Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - 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
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Hargreaves JR, Pliakas T, Hoddinott G, Mainga T, Mubekapi-Musadaidzwa C, Donnell D, Piwowar-Manning E, Agyei Y, Mandla NF, Dunbar R, Macleod D, Floyd S, Bock P, Fidler S, Hayes RJ, Seeley J, Stangl A, Bond V, Ayles H. HIV Stigma and Viral Suppression Among People Living With HIV in the Context of Universal Test and Treat: Analysis of Data From the HPTN 071 (PopART) Trial in Zambia and South Africa. J Acquir Immune Defic Syndr 2020; 85:561-570. [PMID: 32991336 PMCID: PMC7654947 DOI: 10.1097/qai.0000000000002504] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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: 04/21/2020] [Accepted: 08/05/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND The impact of HIV stigma on viral suppression among people living with HIV (PLHIV) is not well characterized. SETTING Twenty-one communities in Zambia and South Africa, nested within the HPTN 071 (PopART) trial. METHODS We analyzed data on viral suppression (<400 copies HIV RNA/mL) among 5662 laboratory-confirmed PLHIV aged 18-44 years who were randomly sampled within the PopART trial population cohort 24 months after enrolment (PC24). We collected data on experiences and internalization of stigma from those PLHIV who self-reported their HIV status (n = 3963/5662) and data on perceptions of stigma from a 20% random sample of all PLHIV (n = 1154/5662). We also measured stigma at the community-level among PLHIV, community members, and health workers. We analyzed the association between individual- and community-level measures of HIV stigma and viral suppression among PLHIV, adjusting for confounding. RESULTS Of all 5662 PLHIV, 69.1% were virally suppressed at PC24. Viral suppression was highest among those 3963 cohort participants who self-reported living with HIV and were on ART (88.3%), and lower among those not on treatment (37.5%). Self-identifying PLHIV who reported internalized stigma were less likely to be virally suppressed (75.0%) than those who did not (80.7%; adjusted risk ratio, 0.94 95% CI: 0.89 to 0.98). Experiences, perceptions, and community-level measures of stigma were not associated with viral suppression. CONCLUSION Internalized stigma among PLHIV was associated with a lower level of viral suppression; other dimensions of stigma were not. Stigma reduction approaches that address internalized stigma should be an integral component of efforts to control the HIV epidemic.
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Affiliation(s)
- James R. Hargreaves
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Triantafyllos Pliakas
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Tila Mainga
- Zambart, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Constance Mubekapi-Musadaidzwa
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | | | - Yaw Agyei
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nomhle F. Mandla
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - David Macleod
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sian Floyd
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sarah Fidler
- Imperial College NIHR BRC, Imperial College London, London, United Kingdom; and
| | - Richard J. Hayes
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Janet Seeley
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anne Stangl
- International Center for Research on Women, Washington, DC
| | - Virginia Bond
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Zambart, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Helen Ayles
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Zambart, School of Medicine, University of Zambia, Lusaka, Zambia
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17
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du Preez K, Schaaf HS, Dunbar R, Swartz A, Naidoo P, Hesseling AC. Closing the reporting gap for childhood tuberculosis in South Africa: improving hospital referrals and linkages. Public Health Action 2020; 10:38-46. [PMID: 32368523 DOI: 10.5588/pha.19.0053] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 11/08/2019] [Indexed: 12/29/2022] Open
Abstract
Setting A referral hospital in Cape Town, Western Cape Province, Republic of South Africa. Objective To measure the impact of a hospital-based referral service (intervention) to reduce initial loss to follow-up among children with tuberculosis (TB) and ensure the completeness of routine TB surveillance data. Design A dedicated TB referral service was established in the paediatric wards at Tygerberg Hospital, Cape Town, in 2012. Allocated personnel provided TB education and counselling, TB referral support and weekly telephonic follow-up after hospital discharge. All children identified with TB were matched to electronic TB treatment registers (ETR.Net/EDRWeb). Multivariable logistic regression was used to compare reporting of culture-confirmed and drug-susceptible TB cases before (2007-2009) and during (2012) the intervention. Results Successful referral with linkage to care was confirmed in 267/272 (98%) and successful reporting in 227/272 (84%) children. Children with drug-susceptible, culture-confirmed TB were significantly more likely to be reported during the intervention period than in the pre-intervention period (OR 2.52, 95%CI 1.33-4.77). The intervention effect remained consistent in multivariable analysis (adjusted OR 2.62; 95%CI 1.31-5.25) after adjusting for age, sex, human immunodeficiency virus status and the presence of TB meningitis. Conclusions A simple hospital-based TB referral service can reduce initial loss to follow-up and improve recording and reporting of childhood TB in settings with decentralised TB services.
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Affiliation(s)
- K du Preez
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - H S Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Department of Paediatrics and Child Health, Tygerberg Hospital, Cape Town, South Africa
| | - R Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - A Swartz
- Western Cape Department of Health, Cape Town, South Africa
| | - P Naidoo
- Public health management consultant, Cape Town, South Africa
| | - A C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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18
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Bock P, Gunst C, Maschilla L, Holtman R, Grobbelaar N, Wademan D, Dunbar R, Fatti G, Kruger J, Ford N, Hoddinott G, Meehan S. Retention in care and factors critical for effectively implementing antiretroviral adherence clubs in a rural district in South Africa. J Int AIDS Soc 2019; 22:e25396. [PMID: 31588668 PMCID: PMC6778813 DOI: 10.1002/jia2.25396] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 09/03/2019] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Differentiated models of care that include referral of antiretroviral treatment (ART) clients to adherence clubs are an important strategy to help clinics manage increased number of clients living with HIV in resource-constrained settings. This study reported on (i) clinical outcomes among ART clients attending community-based adherence clubs and (ii) experiences of adherence clubs and perceptions of factors key to successful adherence club implementation among clients and healthcare workers. METHODS A retrospective cohort analysis of routine data and a descriptive analysis of data collected through self-administered surveys completed by clients and healthcare workers were completed. Clients starting ART at the study clinic, between January 2014 and December 2015, were included in the cohort analysis and followed up until December 2016. The survey data were collected from August to September 2017. The primary outcome for the cohort analysis was a comparison of loss to follow-up (LTFU) between clients staying in clinic care and those referred to adherence clubs. Survey data reported on client experiences of and healthcare worker perceptions of adherence club care. RESULTS Cohort analysis reported on 465 participants, median baseline CD4 count 374 (IQR: 234 to 532) cells/μl and median follow-up time 20.7 (IQR 14.1 to 27.7) months. Overall, 202 (43.4%) participants were referred to an adherence club. LTFU was lower in those attending an adherence club (aHR =0.25, 95% CI: 0.11 to 0.56). This finding was confirmed on analysis restricted to those eligible for adherence club referral (aHR =0.28, 95% CI: 0.12 to 0.65). Factors highlighted as associated with successful adherence club implementation included: (i) referral of stable clients to the club, (ii) an ideal club size of ≥20 members, (iii) club services led by a counsellor (iv) using churches or community halls as venues (v) effective communication between all parties, and (vi) timely delivery of prepacked medication. CONCLUSIONS This study showed good clinical outcomes, positive patient experiences and healthcare worker perceptions of the adherence club model. Factors associated with successful adherence club implementation, highlighted in this study, can be used to guide implementers in the scale-up of adherence club services across varied high-burden settings.
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Affiliation(s)
- Peter Bock
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Colette Gunst
- Department of HealthWestern Cape GovernmentCape Winelands DistrictSouth Africa
- Division of Family Medicine and Primary Health CareFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Leonard Maschilla
- Department of HealthWestern Cape GovernmentCape Winelands DistrictSouth Africa
| | - Rory Holtman
- Department of HealthWestern Cape GovernmentCape TownSouth Africa
| | | | - Dillon Wademan
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Rory Dunbar
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Geoffrey Fatti
- Kheth’ Impilo AIDS Free LivingCape TownSouth Africa
- Division of Epidemiology and BiostatisticsDepartment of Global HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - James Kruger
- Department of HealthWestern Cape GovernmentCape TownSouth Africa
| | | | - Graeme Hoddinott
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Sue‐Ann Meehan
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
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Dunbar R, Naidoo P, Beyers N, Langley I. Improving rifampicin-resistant tuberculosis diagnosis using Xpert ® MTB/RIF: modelling interventions and costs. Int J Tuberc Lung Dis 2019; 22:890-898. [PMID: 29991398 DOI: 10.5588/ijtld.17.0594] [Citation(s) in RCA: 0] [Impact Index Per Article: 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 Cape Town, South Africa. OBJECTIVE To model the diagnosis of rifampicin-resistant tuberculosis (RR-TB) and laboratory costs of smear/culture and Xpert-based algorithms and the effect of varying adherence and human immunodeficiency virus (HIV) testing in the Xpert-based algorithm. METHODS We used a validated operational model (100 000 population) and published laboratory cost data. We estimated the number and cost of RR-TB cases identified using the smear/culture- and Xpert-based algorithms. We modelled varying adherence and different levels of known HIV status against the Xpert-based algorithm. RESULTS The number of RR-TB cases identified increased from 603 with smear/culture to 1178 with the Xpert-based algorithm (100% adherence; 60% knew their HIV status). The overall laboratory cost increased from US$1 073 858 to US$2 430 050 and the cost per RR-TB case identified increased from US$1781 to US$2063 in the respective algorithms. When adherence to the Xpert-based algorithm was increased from 50% to 100% (60% knew their HIV status), the number of RR-TB cases identified increased from 721 to 1178. CONCLUSION The Xpert-based algorithm is efficient in identifying RR-TB, as the increase in costs is offset by the increase in the number of cases identified. Adherence to the Xpert-based algorithm is important to ensure that all presumptive TB cases receive the benefit of simultaneous TB and RR-TB testing.
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Affiliation(s)
- R Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - P Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - N Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - I Langley
- Centre for Applied Heath Research and Delivery, Liverpool School of Tropical Medicine, Liverpool, UK
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20
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Hayes RJ, Donnell D, Floyd S, Mandla N, Bwalya J, Sabapathy K, Yang B, Phiri M, Schaap A, Eshleman SH, Piwowar-Manning E, Kosloff B, James A, Skalland T, Wilson E, Emel L, Macleod D, Dunbar R, Simwinga M, Makola N, Bond V, Hoddinott G, Moore A, Griffith S, Deshmane Sista N, Vermund SH, El-Sadr W, Burns DN, Hargreaves JR, Hauck K, Fraser C, Shanaube K, Bock P, Beyers N, Ayles H, Fidler S. Effect of Universal Testing and Treatment on HIV Incidence - HPTN 071 (PopART). N Engl J Med 2019; 381:207-218. [PMID: 31314965 PMCID: PMC6587177 DOI: 10.1056/nejmoa1814556] [Citation(s) in RCA: 229] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND A universal testing and treatment strategy is a potential approach to reduce the incidence of human immunodeficiency virus (HIV) infection, yet previous trial results are inconsistent. METHODS In the HPTN 071 (PopART) community-randomized trial conducted from 2013 through 2018, we randomly assigned 21 communities in Zambia and South Africa (total population, approximately 1 million) to group A (combination prevention intervention with universal antiretroviral therapy [ART]), group B (the prevention intervention with ART provided according to local guidelines [universal since 2016]), or group C (standard care). The prevention intervention included home-based HIV testing delivered by community workers, who also supported linkage to HIV care and ART adherence. The primary outcome, HIV incidence between months 12 and 36, was measured in a population cohort of approximately 2000 randomly sampled adults (18 to 44 years of age) per community. Viral suppression (<400 copies of HIV RNA per milliliter) was assessed in all HIV-positive participants at 24 months. RESULTS The population cohort included 48,301 participants. Baseline HIV prevalence was 21% or 22% in each group. Between months 12 and 36, a total of 553 new HIV infections were observed during 39,702 person-years (1.4 per 100 person-years; women, 1.7; men, 0.8). The adjusted rate ratio for group A as compared with group C was 0.93 (95% confidence interval [CI], 0.74 to 1.18; P = 0.51) and for group B as compared with group C was 0.70 (95% CI, 0.55 to 0.88; P = 0.006). The percentage of HIV-positive participants with viral suppression at 24 months was 71.9% in group A, 67.5% in group B, and 60.2% in group C. The estimated percentage of HIV-positive adults in the community who were receiving ART at 36 months was 81% in group A and 80% in group B. CONCLUSIONS A combination prevention intervention with ART provided according to local guidelines resulted in a 30% lower incidence of HIV infection than standard care. The lack of effect with universal ART was unanticipated and not consistent with the data on viral suppression. In this trial setting, universal testing and treatment reduced the population-level incidence of HIV infection. (Funded by the National Institute of Allergy and Infectious Diseases and others; HPTN 071 [PopArt] ClinicalTrials.gov number, NCT01900977.).
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Affiliation(s)
- Richard J Hayes
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Deborah Donnell
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Sian Floyd
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Nomtha Mandla
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Justin Bwalya
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Kalpana Sabapathy
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Blia Yang
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Mwelwa Phiri
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Ab Schaap
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Susan H Eshleman
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Estelle Piwowar-Manning
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Barry Kosloff
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Anelet James
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Timothy Skalland
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Ethan Wilson
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Lynda Emel
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - David Macleod
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Rory Dunbar
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Musonda Simwinga
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Nozizwe Makola
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Virginia Bond
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Graeme Hoddinott
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Ayana Moore
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Sam Griffith
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Nirupama Deshmane Sista
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Sten H Vermund
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Wafaa El-Sadr
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - David N Burns
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - James R Hargreaves
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Katharina Hauck
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Christophe Fraser
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Kwame Shanaube
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Peter Bock
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Nulda Beyers
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Helen Ayles
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
| | - Sarah Fidler
- From the London School of Hygiene and Tropical Medicine (R.J.H., S. Floyd, K. Sabapathy, A.S., B.K., D.M., V.B., J.R.H., H.A.), Imperial College London (K.H., S. Fidler), and the National Institute for Health Research Imperial Biomedical Research Centre (S. Fidler), London, and the University of Oxford, Oxford (C.F.) - all in the United Kingdom; the Fred Hutchinson Cancer Research Center, Seattle (D.D., T.S., E.W., L.E.); the Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (N. Mandla, B.Y., A.J., R.D., N. Makola, G.H., P.B., N.B.); Zambart, Lusaka, Zambia (J.B., M.P., A.S., B.K., M.S., V.B., K. Shanaube, H.A.); Johns Hopkins University School of Medicine, Baltimore (S.H.E., E.P.-M.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda (D.N.B.) - both in Maryland; FHI 360, Durham, NC (A.M., S.G., N.D.S.); the Yale School of Public Health, New Haven, CT (S.H.V.); and ICAP at Columbia University, New York (W.E.-S.)
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21
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Osman M, Welte A, Dunbar R, Brown R, Hoddinott G, Hesseling AC, Marx FM. Morbidity and mortality up to 5 years post tuberculosis treatment in South Africa: A pilot study. Int J Infect Dis 2019; 85:57-63. [PMID: 31132472 DOI: 10.1016/j.ijid.2019.05.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/13/2019] [Accepted: 05/20/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND A high risk of tuberculosis (TB), chronic lung disease, and mortality have been reported among people with a history of previous TB treatment, but data from high-incidence settings remain limited. The aim of this study was to characterize general morbidity and mortality among adults who had successfully completed TB treatment in the past 5 years in a high-incidence setting in South Africa. METHODS Adults (≥18 years) who had completed treatment for pulmonary TB between 2013 and 2017 were randomly selected from TB treatment registers. Household visits were conducted to locate and interview former TB (FTB) patients, and bacteriological testing for TB was offered. Additional data sources were used to ascertain the vitality status of FTB patients who could not be located. RESULTS Addresses were located for 200 of the 223 FTB patients sampled and 89 FTB patients were contacted of whom 51 agreed to be interviewed. Approximately half reported persistent respiratory symptoms, such as shortness of breath and wheezing, and repeated lung infections. One (3.6%) of 28 patients who provided a sputum sample had culture-positive TB and another two were currently on re-treatment for TB. Fifteen deaths post treatment were ascertained, resulting in a standardized mortality ratio of 3.8 (95% confidence interval 2.3-6.3) after successful TB treatment relative to the general population. CONCLUSIONS In this high-incidence setting, locating and interviewing FTB patients was challenging. The study findings are consistent with a high rate of respiratory disease, including recurrent TB, and substantially elevated mortality among FTB patients.
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Affiliation(s)
- Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; DST-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa.
| | - Alex Welte
- DST-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Rosemary Brown
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - 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
| | - Florian M Marx
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; DST-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
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22
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Seeley J, Bond V, Yang B, Floyd S, MacLeod D, Viljoen L, Phiri M, Simuyaba M, Hoddinott G, Shanaube K, Bwalya C, de Villiers L, Jennings K, Mwanza M, Schaap A, Dunbar R, Sabapathy K, Ayles H, Bock P, Hayes R, Fidler S. Understanding the Time Needed to Link to Care and Start ART in Seven HPTN 071 (PopART) Study Communities in Zambia and South Africa. AIDS Behav 2019; 23:929-946. [PMID: 30415432 PMCID: PMC6458981 DOI: 10.1007/s10461-018-2335-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
To achieve UNAIDS 90:90:90 targets at population-level, knowledge of HIV status must be followed by timely linkage to care, initiation and maintenance of antiretroviral therapy (ART) for all people living with HIV (PLHIV). Interpreting quantitative patterns using qualitative data, we investigate time taken to link to care and initiate ART amongst individuals aware of their HIV-status in high HIV-prevalence urban communities in the HPTN 071 (PopART) study, a community-randomised trial of a combination HIV prevention package, including universal testing and treatment, in 21 communities in Zambia and South Africa. Data are drawn from the seven intervention communities where immediate ART irrespective if CD4 count was offered from the trial-start in 2014. Median time from HIV-diagnosis to ART initiation reduced after 2 years of delivering the intervention from 10 to 6 months in both countries but varied by gender and community of residence. Social and health system realities impact decisions made by PLHIV about ART initiation.
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Affiliation(s)
- Janet Seeley
- London School of Hygiene and Tropical Medicine, London, UK.
| | - Virginia Bond
- London School of Hygiene and Tropical Medicine, London, UK
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Blia Yang
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | - Sian Floyd
- London School of Hygiene and Tropical Medicine, London, UK
| | - David MacLeod
- London School of Hygiene and Tropical Medicine, London, UK
| | - Lario Viljoen
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | - Mwelwa Phiri
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Melvin Simuyaba
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Graeme Hoddinott
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | - Kwame Shanaube
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Chiti Bwalya
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Laing de Villiers
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | - Karen Jennings
- City of Cape Town Health Directorate, Cape Town, South Africa
| | - Margaret Mwanza
- Zambia Prevention Care and Treatment partnership (ZPCT), Lusaka, Zambia
| | - Ab Schaap
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Rory Dunbar
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | | | - Helen Ayles
- London School of Hygiene and Tropical Medicine, London, UK
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Peter Bock
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | - Richard Hayes
- London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Fidler
- Department of Medicine, Imperial College, London, UK
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23
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Dunbar R, Naidoo P, Beyers N, Langley I. High laboratory cost predicted per tuberculosis case diagnosed with increased case finding without a triage strategy. Int J Tuberc Lung Dis 2018; 21:1026-1034. [PMID: 28826453 DOI: 10.5588/ijtld.17.0156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Cape Town, South Africa. OBJECTIVE To model the effects of increased case finding and triage strategies on laboratory costs per tuberculosis (TB) case diagnosed. METHODS We used a validated operational model and published laboratory cost data. We modelled the effect of varying the proportion with TB among presumptive cases and Xpert cartridge price reductions on cost per TB case and per additional TB case diagnosed in the Xpert-based vs. smear/culture-based algorithms. RESULTS In our current scenario (18.3% with TB among presumptive cases), the proportion of cases diagnosed increased by 8.7% (16.7% vs. 15.0%), and the cost per case diagnosed increased by 142% (US$121 vs. US$50). The cost per additional case diagnosed was US$986. This would increase to US$1619 if the proportion with TB among presumptive cases was 10.6%. At 25.9-30.8% of TB prevalence among presumptive cases and a 50% reduction in Xpert cartridge price, the cost per TB case diagnosed would range from US$50 to US$59 (comparable to the US$48.77 found in routine practice with smear/culture). CONCLUSION The operational model illustrates the effect of increased case finding on laboratory costs per TB case diagnosed. Unless triage strategies are identified, the approach will not be sustainable, even if Xpert cartridge prices are reduced.
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Affiliation(s)
- R Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - P Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - N Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - I Langley
- Centre for Applied Heath Research and Delivery, Liverpool School of Tropical Medicine, Liverpool, UK
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24
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Osman M, Lee K, Du Preez K, Dunbar R, Hesseling AC, Seddon JA. Excellent Treatment Outcomes in Children Treated for Tuberculosis Under Routine Operational Conditions in Cape Town, South Africa. Clin Infect Dis 2018; 65:1444-1452. [PMID: 29048512 DOI: 10.1093/cid/cix602] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [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: 04/21/2017] [Accepted: 07/03/2017] [Indexed: 02/07/2023] Open
Abstract
Background Tuberculosis (TB) remains a leading cause of death in children globally. It is recognized that human immunodeficiency virus (HIV) infection increases the risk of developing TB, but our understanding of the impact of HIV on risk of mortality for children treated for TB is limited. We aimed to identify predictors of mortality in children treated for drug-susceptible TB. Methods A retrospective analysis of all children (<15 years of age) routinely treated between 2005 and 2012 for drug-susceptible TB in Cape Town was conducted using the programmatic electronic TB treatment database. Survival analysis using Cox regression was used to estimate hazard ratios for death. Logistic regression was used to estimate the odds of unfavorable outcomes. Results Of 29519 children treated for and notified with TB over the study period, <1% died during TB treatment and 89.5% were cured or completed treatment. The proportion of children with known HIV status increased from 13% in 2005 to 95% in 2012. Children aged <2 years had an increased hazard of death (adjusted hazard ratio [aHR], 3.13; 95% confidence interval [CI], 1.78-5.52) and greater odds of unfavorable outcome (adjusted odds ratio [aOR], 1.44; 95% CI, 1.24-1.66) compared with children aged 10-14 years. HIV-infected children had increased mortality compared to HIV-negative children (aHR, 6.85; 95% CI, 4.60-10.19) and increased odds of unfavorable outcome (aOR, 2.01; 95% CI, 1.81-2.23). Later year of TB treatment was a protective predictor for both mortality and unfavorable outcome. Conclusions We demonstrate a dramatic improvement in HIV testing in children with TB over time and excellent overall treatment outcomes. HIV infection and young age were associated with increased risk of death and unfavorable outcome.
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Affiliation(s)
- Muhammad Osman
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg
| | - Kevin Lee
- City of Cape Town Health Directorate, South Africa
| | - Karen Du Preez
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg
| | - Rory Dunbar
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg
| | - Anneke C Hesseling
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg
| | - James A Seddon
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg.,Centre for International Child Health, Imperial College London, United Kingdom
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Meidinger S, Brooks A, Lehnert K, Feisst V, Locke M, Dunbar R. 1289 CD26+ FAP+ fibroblasts increase ECM expression in keloid scarring. J Invest Dermatol 2018. [DOI: 10.1016/j.jid.2018.03.1305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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du Preez K, Schaaf HS, Dunbar R, Walters E, Swartz A, Solomons R, Hesseling AC. Complementary surveillance strategies are needed to better characterise the epidemiology, care pathways and treatment outcomes of tuberculosis in children. BMC Public Health 2018; 18:397. [PMID: 29566651 PMCID: PMC5865349 DOI: 10.1186/s12889-018-5252-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 08/22/2017] [Accepted: 03/02/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) in young and HIV-infected children is frequently diagnosed at hospital level. In settings where general hospitals do not function as TB reporting units, the burden and severity of childhood TB may not be accurately reflected in routine TB surveillance data. Given the paucibacillary nature of childhood TB, microbiological surveillance alone will miss the majority of hospital-managed children. The study objective was to combine complementary hospital-based surveillance strategies to accurately report the burden, spectrum and outcomes of childhood TB managed at referral hospital-level in a high TB burden setting. METHODS We conducted a prospective cohort study including all children (< 13 years) managed for TB at a large referral hospital in Cape Town, South Africa during 2012. Children were identified through newly implemented clinical surveillance in addition to existing laboratory surveillance. Data were collected from clinical patient records, the National Health Laboratory Service database, and provincial electronic TB registers. Descriptive statistics were used to report overall TB disease burden, spectrum, care pathways and treatment outcomes. Univariate analysis compared characteristics between children identified through the two hospital-based surveillance strategies to characterise the group of children missed by existing laboratory surveillance. RESULTS During 2012, 395 children (180 [45.6%] < 2 years) were managed for TB. Clinical surveillance identified 237 (60%) children in addition to laboratory surveillance. Ninety (24.3%) children were HIV co-infected; 113 (29.5%) had weight-for-age z-scores <- 3. Extra-pulmonary TB (EPTB) was diagnosed in 188 (47.6%); 77 (19.5%) with disseminated TB. Favourable TB treatment outcomes were reported in 300/344 (87.2%) children with drug-susceptible and 50/51 (98.0%) children with drug-resistant TB. Older children (OR 1.7; 95% CI 1.0-2.8), children with EPTB (OR 2.3; 95% CI 1.5-3.6) and in-hospital deaths (OR 5.4; 95% CI 1.1-26.9) were more frequently detected by laboratory surveillance. TB/HIV co-infected children were less likely to be identified through laboratory surveillance (OR 0.3; 95% CI 0.2-0.5). CONCLUSIONS The burden and spectrum of childhood TB disease managed at referral hospital level in high burden settings is substantial. Hospital-based surveillance in addition to routine TB surveillance is essential to provide a complete picture of the burden, spectrum and impact of childhood TB in settings where hospitals are not TB reporting units.
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Affiliation(s)
- Karen du Preez
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - 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.,Tygerberg Hospital, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elisabetta Walters
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Alvera Swartz
- Western Cape Department of Health, Cape Town, South Africa
| | - Regan Solomons
- Tygerberg Hospital, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - 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
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Dunbar R, Naidoo P, Beyers N, Langley I. Operational modelling: the mechanisms influencing TB diagnostic yield in an Xpert ® MTB/RIF-based algorithm. Int J Tuberc Lung Dis 2018; 21:381-388. [PMID: 28284252 DOI: 10.5588/ijtld.16.0432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Cape Town, South Africa. OBJECTIVE To compare the diagnostic yield for smear/culture and Xpert® MTB/RIF algorithms and to investigate the mechanisms influencing tuberculosis (TB) yield. METHOD We developed and validated an operational model of the TB diagnostic process, first with the smear/culture algorithm and then with the Xpert algorithm. We modelled scenarios by varying TB prevalence, adherence to diagnostic algorithms and human immunodeficiency virus (HIV) status. This enabled direct comparisons of diagnostic yield in the two algorithms to be made. RESULTS Routine data showed that diagnostic yield had decreased over the period of the Xpert algorithm roll-out compared to the yield when the smear/culture algorithm was in place. However, modelling yield under identical conditions indicated a 13.3% increase in diagnostic yield from the Xpert algorithm compared to smear/culture. The model demonstrated that the extensive use of culture in the smear/culture algorithm and the decline in TB prevalence are the main factors contributing to not finding an increase in diagnostic yield in the routine data. CONCLUSION We demonstrate the benefits of an operational model to determine the effect of scale-up of a new diagnostic algorithm, and recommend that policy makers use operational modelling to make appropriate decisions before new diagnostic algorithms are scaled up.
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Affiliation(s)
- R Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - P Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - N Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - I Langley
- Centre for Applied Health Research and Delivery, Liverpool School of Tropical Medicine, Liverpool, UK
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Claassens MM, Dunbar R, Yang B, Lombard CJ. Scanty smears associated with initial loss to follow-up in South African tuberculosis patients. Int J Tuberc Lung Dis 2018; 21:196-201. [PMID: 28234084 DOI: 10.5588/ijtld.16.0292] [Citation(s) in RCA: 6] [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 Smear-positive patients should be started on anti-tuberculosis treatment promptly. However, studies show that up to 38% of diagnosed patients are initial loss to follow-up (LTFU), meaning they do not start treatment after diagnosis. We investigated determinants of initial LTFU at primary health care facilities. DESIGN In a facility-matched case-control study, health care facilities were visited from October 2010 to September 2012. After identification from registers, patients were traced and invited to complete a questionnaire. RESULTS Of 973 participants, 233 (24%) were cases and 740 (74%) controls. Initial LTFU was associated with smear grade (pooled adjusted odds ratio [aOR] 0.73, 95% confidence interval [CI] 0.64-0.90, scanty at baseline) for participants identified at facilities, but not with age (overall P = 0.80) or sex (aOR 0.83, 95%CI 0.58-1.20). Of the 233 cases, 197 (85%) were traced in the community, of whom 58 (29%) were found. Among the group found, initial LTFU was associated with age (aOR 3.38, 95%CI 1.15-9.95) and smear grade (aOR 0.08, 95%CI 0.02-0.34, scanty at baseline). CONCLUSION Scanty smear positivity was associated with initial LTFU. Tuberculosis programmes should start scanty smear-positive patients on treatment early and develop alternative community tracing strategies. Health care worker training could address the first aspect, and the use of technology to improve treatment initiation, such as mobile phone applications, the second.
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Affiliation(s)
- M M Claassens
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - R Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - B Yang
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - C J Lombard
- Biostatistics Unit, South African Medical Research Council, Parow, South Africa
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Naidoo P, Dunbar R, du Toit E, van Niekerk M, Squire SB, Beyers N, Madan J. Comparing laboratory costs of smear/culture and Xpert ® MTB/RIF-based tuberculosis diagnostic algorithms. Int J Tuberc Lung Dis 2018; 20:1377-1385. [PMID: 27725051 DOI: 10.5588/ijtld.16.0081] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Cape Town, South Africa, where Xpert® MTB/RIF was introduced as a screening test for all presumptive tuberculosis (TB) cases. OBJECTIVE To compare laboratory costs of smear/culture- and Xpert-based tuberculosis (TB) diagnostic algorithms in routine operational conditions. METHODS Economic costing was undertaken from a laboratory perspective, using an ingredients-based costing approach. Cost allocation was based on reviews of standard operating procedures and laboratory records, timing of test procedures, measurement of laboratory areas and manager interviews. We analysed laboratory test data to assess overall costs and cost per pulmonary TB and multidrug-resistant TB (MDR-TB) case diagnosed. Costs were expressed as 2013 Consumer Price Index-adjusted values. RESULTS Total TB diagnostic costs increased by 43%, from US$440 967 in the smear/culture-based algorithm (April-June 2011) to US$632 262 in the Xpert-based algorithm (April-June 2013). The cost per TB case diagnosed increased by 157%, from US$48.77 (n = 1601) to US$125.32 (n = 1281). The total cost per MDR-TB case diagnosed was similar, at US$190.14 and US$183.86, with 95 and 107 cases diagnosed in the respective algorithms. CONCLUSION The introduction of the Xpert-based algorithm resulted in substantial cost increases. This was not matched by the expected increase in TB diagnostic efficacy, calling into question the sustainability of this expensive new technology.
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Affiliation(s)
- P Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - R Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - E du Toit
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - M van Niekerk
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - S B Squire
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - N Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - J Madan
- Warwick Medical School, University of Warwick, Coventry, UK
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Bock P, Jennings K, Vermaak R, Cox H, Meintjes G, Fatti G, Kruger J, De Azevedo V, Maschilla L, Louis F, Gunst C, Grobbelaar N, Dunbar R, Limbada M, Floyd S, Grimwood A, Ayles H, Hayes R, Fidler S, Beyers N. Incidence of Tuberculosis Among HIV-Positive Individuals Initiating Antiretroviral Treatment at Higher CD4 Counts in the HPTN 071 (PopART) Trial in South Africa. J Acquir Immune Defic Syndr 2017; 77:93-101. [PMID: 29016524 DOI: 10.1097/qai.0000000000001560] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Antiretroviral treatment (ART) guidelines recommend life-long ART for all HIV-positive individuals. This study evaluated tuberculosis (TB) incidence on ART in a cohort of HIV-positive individuals starting ART regardless of CD4 count in a programmatic setting at 3 clinics included in the HPTN 071 (PopART) trial in South Africa. METHODS A retrospective cohort analysis of HIV-positive individuals aged ≥18 years starting ART, between January 2014 and November 2015, was conducted. Follow-up was continued until 30 May 2016 or censored on the date of (1) incident TB, (2) loss to follow-up from HIV care or death, or (3) elective transfer out; whichever occurred first. RESULTS The study included 2423 individuals. Median baseline CD4 count was 328 cells/μL (interquartile range 195-468); TB incidence rate was 4.41/100 person-years (95% confidence interval [CI]: 3.62 to 5.39). The adjusted hazard ratio of incident TB was 0.27 (95% CI: 0.12 to 0.62) when comparing individuals with baseline CD4 >500 and ≤500 cells/μL. Among individuals with baseline CD4 count >500 cells/μL, there were no incident TB cases in the first 3 months of follow-up. Adjusted hazard of incident TB was also higher among men (adjusted hazard ratio 2.16; 95% CI: 1.41 to 3.30). CONCLUSIONS TB incidence after ART initiation was significantly lower among individuals starting ART at CD4 counts above 500 cells/μL. Scale-up of ART, regardless of CD4 count, has the potential to significantly reduce TB incidence among HIV-positive individuals. However, this needs to be combined with strengthening of other TB prevention strategies that target both HIV-positive and HIV-negative individuals.
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Affiliation(s)
- Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Karen Jennings
- City of Cape Town Health Services, Cape Town, South Africa
| | - Redwaan Vermaak
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Helen Cox
- Institute of Infectious Disease and Molecular Medicine University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine University of Cape Town, Cape Town, South Africa.,Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Geoffrey Fatti
- Kheth' Impilo. AIDS Free Living, Cape Town, South Africa
| | - James Kruger
- Western Cape Department of Health, HIV Treatment & PMTCT Programme, Cape Town, South Africa
| | - Virginia De Azevedo
- Western Cape Department of Health, Cape Winelands District, Worcester, South Africa
| | - Leonard Maschilla
- Stellenbosch University Division of Family Medicine and Primary Health Care, Faculty of Medicine and Health Sciences, Tygerberg Campus, Western Cape, South Africa
| | | | - Colette Gunst
- Western Cape Department of Health, Cape Winelands District, Worcester, South Africa.,Stellenbosch University Division of Family Medicine and Primary Health Care, Faculty of Medicine and Health Sciences, Tygerberg Campus, Western Cape, South Africa
| | | | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | | | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Helen Ayles
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sarah Fidler
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Nulda Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
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Naidoo P, Dunbar R, Caldwell J, Lombard C, Beyers N. Has universal screening with Xpert® MTB/RIF increased the proportion of multidrug-resistant tuberculosis cases diagnosed in a routine operational setting? PLoS One 2017; 12:e0172143. [PMID: 28199375 PMCID: PMC5310774 DOI: 10.1371/journal.pone.0172143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 01/31/2017] [Indexed: 01/30/2023] Open
Abstract
SETTING Primary health services in Cape Town, South Africa where the introduction of Xpert® MTB/RIF (Xpert) enabled simultaneous screening for tuberculosis (TB) and drug susceptibility in all presumptive cases. STUDY AIM To compare the proportion of TB cases with drug susceptibility tests undertaken and multidrug-resistant tuberculosis (MDR-TB) diagnosed pre-treatment and during the course of 1st line treatment in the previous smear/culture and the newly introduced Xpert-based algorithms. METHODS TB cases identified in a previous stepped-wedge study of TB yield in five sub-districts over seven one-month time-points prior to, during and after the introduction of the Xpert-based algorithm were analysed. We used a combination of patient identifiers to identify all drug susceptibility tests undertaken from electronic laboratory records. Differences in the proportions of DST undertaken and MDR-TB cases diagnosed between algorithms were estimated using a binomial regression model. RESULTS Pre-treatment, the probability of having a DST undertaken (RR = 1.82)(p<0.001) and being diagnosed with MDR-TB (RR = 1.42)(p<0.001) was higher in the Xpert-based algorithm than in the smear/culture-based algorithm. For cases evaluated during the course of 1st-line TB treatment, there was no significant difference in the proportion with DST undertaken (RR = 1.02)(p = 0.848) or MDR-TB diagnosed (RR = 1.12)(p = 0.678) between algorithms. CONCLUSION Universal screening for drug susceptibility in all presumptive TB cases in the Xpert-based algorithm resulted in a higher overall proportion of MDR-TB cases being diagnosed and is an important strategy in reducing transmission. The previous strategy of only screening new TB cases when 1st line treatment failed did not compensate for cases missed pre-treatment.
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Affiliation(s)
- Pren Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | | | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Nulda Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
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Abstract
To address the uncertainty of the indirectly measured tuberculosis case detection rate, we used survey data stratified by HIV status to calculate the patient diagnostic rate, a directly measurable indicator, in 8 communities in South Africa. Rates were lower among HIV-negative than HIV-positive persons. Tuberculosis programs should focus on HIV-negative persons.
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du Toit E, Squire SB, Dunbar R, Machekano R, Madan J, Beyers N, Naidoo P. Comparing multidrug-resistant tuberculosis patient costs under molecular diagnostic algorithms in South Africa. Int J Tuberc Lung Dis 2016; 19:960-8. [PMID: 26162363 DOI: 10.5588/ijtld.14.0703] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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 Ten primary health care facilities in Cape Town, South Africa, 2010-2013. OBJECTIVE A comparison of costs incurred by patients in GenoType MDRTBplus line-probe assay (LPA) and Xpert MTB/RIF-based diagnostic algorithms from symptom onset until treatment initiation for multidrug-resistant tuberculosis (MDR-TB). METHODS Eligible patients identified from laboratory and facility records were interviewed 3-6 months after treatment initiation and a cost questionnaire completed. Direct and indirect costs, individual and household income, loss of individual income and change in household income were recorded in local currency, adjusted to 2013 costs and converted to $US. RESULTS Median number of visits to initiation of MDR-TB treatment was reduced from 20 to 7 (P < 0.001) and median costs fell from US$68.1 to US$38.3 (P = 0.004) in the Xpert group. From symptom onset to being interviewed, the proportion of unemployed increased from 39% to 73% in the LPA group (P < 0.001) and from 53% to 89% in the Xpert group (P < 0.001). Median household income decreased by 16% in the LPA group and by 13% in the Xpert group. CONCLUSION The introduction of an Xpert-based algorithm brought relief by reducing the costs incurred by patients, but loss of employment and income persist. Patients require support to mitigate this impact.
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Affiliation(s)
- E du Toit
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - S B Squire
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - R Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - R Machekano
- Biostatistics Unit, Centre for Evidence Based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - J Madan
- Warwick Medical School, University of Warwick, Coventry, UK
| | - N Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - P Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
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Naidoo P, Dunbar R, Lombard C, du Toit E, Caldwell J, Detjen A, Squire SB, Enarson DA, Beyers N. Comparing Tuberculosis Diagnostic Yield in Smear/Culture and Xpert® MTB/RIF-Based Algorithms Using a Non-Randomised Stepped-Wedge Design. PLoS One 2016; 11:e0150487. [PMID: 26930400 PMCID: PMC4773132 DOI: 10.1371/journal.pone.0150487] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 02/15/2016] [Indexed: 11/21/2022] Open
Abstract
Setting Primary health services in Cape Town, South Africa. Study Aim To compare tuberculosis (TB) diagnostic yield in an existing smear/culture-based and a newly introduced Xpert® MTB/RIF-based algorithm. Methods TB diagnostic yield (the proportion of presumptive TB cases with a laboratory diagnosis of TB) was assessed using a non-randomised stepped-wedge design as sites transitioned to the Xpert® based algorithm. We identified the full sequence of sputum tests recorded in the electronic laboratory database for presumptive TB cases from 60 primary health sites during seven one-month time-points, six months apart. Differences in TB yield and temporal trends were estimated using a binomial regression model. Results TB yield was 20.9% (95% CI 19.9% to 22.0%) in the smear/culture-based algorithm compared to 17.9% (95%CI 16.4% to 19.5%) in the Xpert® based algorithm. There was a decline in TB yield over time with a mean risk difference of -0.9% (95% CI -1.2% to -0.6%) (p<0.001) per time-point. When estimates were adjusted for the temporal trend, TB yield was 19.1% (95% CI 17.6% to 20.5%) in the smear/culture-based algorithm compared to 19.3% (95% CI 17.7% to 20.9%) in the Xpert® based algorithm with a risk difference of 0.3% (95% CI -1.8% to 2.3%) (p = 0.796). Culture tests were undertaken for 35.5% of smear-negative compared to 17.9% of Xpert® negative low MDR-TB risk cases and for 82.6% of smear-negative compared to 40.5% of Xpert® negative high MDR-TB risk cases in respective algorithms. Conclusion Introduction of an Xpert® based algorithm did not produce the expected increase in TB diagnostic yield. Studies are required to assess whether improving adherence to the Xpert® negative algorithm for HIV-infected individuals will increase yield. In light of the high cost of Xpert®, a review of its role as a screening test for all presumptive TB cases may be warranted.
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Affiliation(s)
- Pren Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- * E-mail:
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Elizabeth du Toit
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Judy Caldwell
- City of Cape Town Health Directorate, Cape Town, South Africa
| | - Anne Detjen
- The International Union against TB and Lung Disease, Paris, France
| | - S. Bertel Squire
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - Nulda Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Rose PC, Schaaf HS, du Preez K, Seddon JA, Garcia-Prats AJ, Zimri K, Dunbar R, Hesseling AC. Completeness and accuracy of electronic recording of paediatric drug-resistant tuberculosis in Cape Town, South Africa. Public Health Action 2015; 3:214-9. [PMID: 26393032 DOI: 10.5588/pha.13.0041] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 07/15/2013] [Indexed: 11/10/2022] Open
Abstract
SETTING Cape Town, South Africa. OBJECTIVE To assess the completeness and accuracy of electronic recording of drug-resistant tuberculosis (DR-TB) in children. DESIGN Retrospective cohort study. All children aged <15 years treated for DR-TB during 2012 were included, with clinical data collected from routine health services. Matching was performed between clinical data and an extracted data set from an electronic register for DR-TB (EDR.web), and data sources were compared. RESULTS Seventy-seven children were identified clinically, of whom only 49 (64%) were found in EDR.web. Most data in EDR.web were complete and accurate, but there were some internal inconsistencies for confirmed TB. Only 4.4% of all EDR.web entries were children. CONCLUSION Only two thirds of children clinically treated for DR-TB were recorded in the electronic reporting system, suggesting under-reporting. We also found a lower than expected prevalence of childhood DR-TB, probably suggesting both under-diagnosis and under-recording of DR-TB in children. Clinicians at facility level should be able to access the electronic reporting system, and data transfer between clinical paper-based and electronic sources should be simplified. Cross-linking between electronic registers for drug-susceptible and DR-TB or consolidation of registers could improve the accuracy of recording. Improved recording and reporting of DR-TB in children is needed.
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Affiliation(s)
- P C Rose
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - H S Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa ; Tygerberg Children's Hospital, Cape Town, South Africa
| | - K du Preez
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - J A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa ; Department of Paediatrics, Imperial College, London, UK
| | - A J Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - K Zimri
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - R Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - A C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
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du Preez K, Schaaf HS, Dunbar R, Swartz A, Bissell K, Enarson DA, Hesseling AC. Incomplete registration and reporting of culture-confirmed childhood tuberculosis diagnosed in hospital. Public Health Action 2015; 1:19-24. [PMID: 26392930 DOI: 10.5588/pha.11.0010] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Accepted: 08/26/2011] [Indexed: 11/10/2022] Open
Abstract
SETTING The South African National Tuberculosis Programme (NTP) recommends the registration of tuberculosis (TB) patients at community clinics. TB in children is often diagnosed at referral hospitals, and there are concerns as to whether these children are accurately reflected in routine NTP reporting. OBJECTIVE To assess the completeness of registration of children with culture-confirmed TB diagnosed in a referral hospital, in the routine provincial electronic TB register (ETR.Net), and to describe TB treatment outcomes. DESIGN A retrospective cohort study including children aged <13 years diagnosed with culture-confirmed TB at Tygerberg Children's Hospital from July 2007 to June 2009. Data on demographic, clinical and referral factors were collated from hospital data sources. Electronic matching was used to identify children in the provincial ETR.Net. RESULTS Only 166 of 267 (62%) children were registered in ETR.Net. Children with TB meningitis and death prior to referral were significantly less likely to be registered. Treatment outcome data were available for only 70% of children; favourable outcomes were reported in 56%. CONCLUSIONS A large proportion of children diagnosed with confirmed TB at a referral hospital were not registered, resulting in underreporting of the burden and severity of childhood TB. Routine surveillance of childhood TB should include linkage of hospital data.
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Affiliation(s)
- K du Preez
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - H S Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - R Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - A Swartz
- Western Cape Department of Health, Cape Town, South Africa
| | - K Bissell
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - D A Enarson
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - A C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa
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Seddon JA, Hesseling AC, Dunbar R, Cox H, Hughes J, Fielding K, Godfrey-Faussett P, Schaaf HS. Decentralised care for the management of child contacts of multidrug-resistant tuberculosis. Public Health Action 2015; 2:66-70. [PMID: 26392954 DOI: 10.5588/pha.12.0023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 08/05/2012] [Indexed: 11/10/2022] Open
Abstract
SETTING Cape Town, South Africa. OBJECTIVE To determine the number of multidrug-resistant tuberculosis (MDR-TB) child contacts routinely identified by health services, and whether a model of decentralised care improves access. METHODS All MDR-TB source cases registered in Cape Town from April 2010 to March 2011 were included. All child contacts assessed at hospital and outreach clinics were recorded from May 2010 to June 2011. Electronic probabilistic matching was used to match source cases with potential child contacts; the number of children accessing decentralised (Khayelitsha) and hospital-based care was compared. RESULTS Of 1221 MDR-TB source cases identified, 189 (15.5%) were registered in Khayelitsha; 31 (16.4%) had at least one child contact assessed. In contrast, 95 (9.2%) of the 1032 source cases diagnosed in the other Cape Town subdistricts (hospital-based care) had at least one child contact assessed (P = 0.003). Children in Khayelitsha were seen at a median of 71 days (interquartile range [IQR] 37-121 days) after source case diagnosis compared to 90 days (IQR 56-132 days) in other subdistricts (P = 0.15). CONCLUSION Although decentralised care led to an increased number of child contacts being evaluated, both models led to the assessment of a small number of potential child MDR-TB contacts, with considerable delay in assessment.
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Affiliation(s)
- J A Seddon
- Desmond Tutu TB Centre, Faculty of Health Sciences, Stellenbosch University, Tygerberg, South Africa ; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - A C Hesseling
- Desmond Tutu TB Centre, Faculty of Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - R Dunbar
- Desmond Tutu TB Centre, Faculty of Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - H Cox
- Médecins Sans Frontières, Cape Town, South Africa
| | - J Hughes
- Médecins Sans Frontières, Cape Town, South Africa
| | - K Fielding
- Department of Infectious Diseases Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - P Godfrey-Faussett
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - H S Schaaf
- Desmond Tutu TB Centre, Faculty of Health Sciences, Stellenbosch University, Tygerberg, South Africa ; Tygerberg Children's Hospital, Tygerberg, South Africa
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Mngomezulu N, Cameron D, Olorunju S, Luthuli T, Dunbar R, Naidoo P. Reasons for the low bacteriological coverage of tuberculosis reported in Mpumalanga Province, South Africa. Public Health Action 2015; 5:122-6. [PMID: 26400383 PMCID: PMC4487486 DOI: 10.5588/pha.15.0003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 02/25/2015] [Indexed: 11/10/2022] Open
Abstract
SETTING Public sector hospitals and primary health clinics in the Mpumalanga Province of South Africa. OBJECTIVE To determine whether failure to adhere to tuberculosis (TB) diagnostic guidelines (i.e., submit sputum for smear microscopy) contributed to the low bacteriological coverage reported for TB in 2008 in Mpumalanga Province. METHODS We reviewed clinical records for new pulmonary TB cases at 30 of 118 randomly selected facilities that met the bacteriological coverage target of 80% and 30/87 facilities that did not. Data for hospital and clinic cases were abstracted into case report forms, captured electronically and compared with data from the electronic TB register (ETR). We assessed age, sex, human immunodeficiency virus (HIV) infection and facility type as potential confounders for recording of smear microscopy results. RESULTS Age, sex and HIV infection did not influence recording of results. In hospitals, 61.8% of pulmonary TB cases had sputum smear results in their clinical records compared to 93.6% at clinics (P < 0.001). Of the 711 cases (30.3%) that did not have smear results in the ETR, 342 (48.1%) did have smear results in their clinical records. CONCLUSION Both poor clinical practice (especially in hospitals) and poor record keeping have contributed to the low bacteriological coverage reported. These shortcomings need to be addressed to improve patient care and programme management.
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Affiliation(s)
- N. Mngomezulu
- Mpumalanga Department of Health, Mpumalanga, South Africa
| | - D. Cameron
- University of Pretoria, Pretoria, South Africa
| | - S. Olorunju
- Medical Research Council, Pretoria, South Africa
| | - T. Luthuli
- Mpumalanga Department of Health, Mpumalanga, South Africa
| | - R. Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - P. Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
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Osman M, Seddon JA, Dunbar R, Draper HR, Lombard C, Beyers N. The complex relationship between human immunodeficiency virus infection and death in adults being treated for tuberculosis in Cape Town, South Africa. BMC Public Health 2015; 15:556. [PMID: 26082037 PMCID: PMC4470058 DOI: 10.1186/s12889-015-1914-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [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: 12/05/2014] [Accepted: 06/08/2015] [Indexed: 12/13/2022] Open
Abstract
Background Despite recognised treatment strategies, mortality associated with tuberculosis (TB) remains significant. Risk factors for death during TB treatment have been described but the complex relationship between TB and HIV has not been fully understood. Methods A retrospective analysis of all deaths occurring during TB treatment in Cape Town, South Africa between 2009 and 2012 were done to investigate risk factors associated with this outcome. The main risk factor was HIV status at the start of treatment and its interaction with age, sex and other risk factors were evaluated using a binomial regression model and thus relative risks (RR) are reported. Results Overall in the 93,133 cases included in the study 4619 deaths (5 %) were recorded. Across all age groups HIV-positive patients were more than twice as likely to die as HIV-negative patients, RR = 2.19 (95 % CI: 2.03–2.37). However in an age specific analysis HIV-positive patients 15–24 and 25–34 years old were at an even higher risk of dying than HIV-negative patients, RR = 4.82 and RR = 3.76 respectively. Gender also modified the effect of HIV- with positive women having a higher risk of death than positive men, RR = 2.74 and RR = 1.94 respectively. Conclusion HIV carries an increased risk of death in this study but specific high-risk groups pertaining to the impact of HIV are identified. Innovative strategies to manage these high risk groups may contribute to reduction in HIV-associated death in TB patients.
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Affiliation(s)
- Muhammad Osman
- City of Cape Town Health Directorate, Cape Town, South Africa.
| | - James A Seddon
- Department of Paediatric Infectious Diseases, Imperial College London, Norfolk Place, London, W2 1PG, UK.
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa.
| | - Heather R Draper
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa.
| | - Carl Lombard
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa. .,Biostatistics Unit, Medical Research Council, Tygerberg, South Africa.
| | - Nulda Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa.
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Mndawe M, Ndambuki J, Kupolati W, Badejo A, Dunbar R. Assessment of the effects of climate change on the performance of pavement subgrade. African Journal of Science, Technology, Innovation and Development 2015. [DOI: 10.1080/20421338.2015.1023649] [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] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Poteracki J, Dunbar R, Wehrwein E. Proposal to Poster: A Model for Individualized Inquiry Based Research Projects in the Context of an Undergraduate Physiology Laboratory Course. FASEB J 2015. [DOI: 10.1096/fasebj.29.1_supplement.541.26] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- J Poteracki
- PhysiologyMichigan State Univ E.LansingMIUnited States
| | - R Dunbar
- BiologyUniv of Minnesota RochesterRochesterMNUnited States
| | - E Wehrwein
- PhysiologyMichigan State Univ E.LansingMIUnited States
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Sattar S, Van Schalkwyk C, Claassens M, Dunbar R, Floyd S, Enarson DA, Godfrey-Faussett P, Ayles H, Beyers N. Symptom reporting among prevalent tuberculosis cases who smoke, are HIV-positive or have hyperglycaemia. Public Health Action 2014; 4:222-5. [PMID: 26400700 DOI: 10.5588/pha.14.0081] [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] [Received: 07/29/2014] [Accepted: 10/18/2014] [Indexed: 11/10/2022] Open
Abstract
Data from a tuberculosis (TB) prevalence survey conducted in 24 communities in Zambia and the Western Cape, South Africa, January-December 2010, were analysed to determine the influence of smoking, hyperglycaemia and human immunodeficiency virus (HIV) infection on TB symptom reporting in culture-confirmed TB cases. Of 123 790 adults eligible for enrolment, 90 601 (73%) consented and 64 463 had evaluable sputum samples. ORs and 95%CIs were calculated using a robust standard errors logistic regression model adjusting for clustering at community level. HIV-positive TB cases were more likely to report cough, weight loss, night sweats and chest pain than non-HIV-positive TB cases. TB cases who smoked or had hyperglycaemia did not report symptoms differently from cases without these comorbidities.
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Affiliation(s)
- S Sattar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - C Van Schalkwyk
- South African Centre for Epidemiological Modelling and Analysis, University of Stellenbosch, Cape Town, South Africa
| | - M Claassens
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - R Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - S Floyd
- London School of Hygiene & Tropical Medicine, London, UK
| | - D A Enarson
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | | | - H Ayles
- ZAMBART Project, University of Zambia Ridgeway Campus, Lusaka, Zambia
| | - N Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
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Naidoo P, du Toit E, Dunbar R, Lombard C, Caldwell J, Detjen A, Squire SB, Enarson DA, Beyers N. A comparison of multidrug-resistant tuberculosis treatment commencement times in MDRTBPlus line probe assay and Xpert® MTB/RIF-based algorithms in a routine operational setting in Cape Town. PLoS One 2014; 9:e103328. [PMID: 25079599 PMCID: PMC4117508 DOI: 10.1371/journal.pone.0103328] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 07/01/2014] [Indexed: 01/28/2023] Open
Abstract
Background Xpert MTB/RIF was introduced as a screening test for all presumptive tuberculosis cases in primary health services in Cape Town, South Africa. Study Aim To compare multidrug-resistant tuberculosis (MDR-TB) treatment commencement times in MDRTBPlus Line Probe Assay and Xpert MTB/RIF-based algorithms in a routine operational setting. Methods The study was undertaken in 10 of 29 high tuberculosis burden primary health facilities, selected through stratified random sampling. An observational study was undertaken as facilities transitioned to the Xpert MTB/RIF-based algorithm. MDR-TB diagnostic data were collected from electronic laboratory records and treatment data from clinical records and registers. Kaplan Meier time-to-event analysis was used to compare treatment commencement time, laboratory turnaround time and action delay between algorithms. A facility-level paired analysis was done: the median time-to-event was estimated per facility in each algorithm and mean differences between algorithms compared using a paired t-test. Cox proportional hazards regression was used to assess the effect of patient-level variables on treatment commencement time. The difference between algorithms was compared using the hazard ratio. Results The median treatment commencement time in the Xpert MTB/RIF-based algorithm was 17 days (95% CI 13 to 22 days), with a median laboratory turnaround time (to result available in the laboratory) of <1 day (95% CI<1 to 1 day). There was a decrease of 25 days (95% CI 17 to 32 days, p<0.001) in median MDR-TB treatment commencement time in the Xpert MTB/RIF-based algorithm. We found no significant effect on treatment commencement times for the patient-level variables assessed. Conclusion MDR-TB treatment commencement time was significantly reduced in the Xpert MTB/RIF-based algorithm. Changes in the health system may have contributed. However, an unacceptable level of delay remains. Health system and patient factors contributing to delay need to be evaluated and addressed to optimise test benefits.
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Affiliation(s)
- Pren Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- * E-mail:
| | - Elizabeth du Toit
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Carl Lombard
- Medical Research Council, Cape Town, South Africa
| | - Judy Caldwell
- Cape Town Health Directorate, Cape Town, South Africa
| | - Anne Detjen
- The International Union Against TB and Lung Disease, Paris, France
| | - S. Bertel Squire
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - Nulda Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Marx FM, Dunbar R, Enarson DA, Williams BG, Warren RM, van der Spuy GD, van Helden PD, Beyers N. The temporal dynamics of relapse and reinfection tuberculosis after successful treatment: a retrospective cohort study. Clin Infect Dis 2014; 58:1676-83. [PMID: 24647020 DOI: 10.1093/cid/ciu186] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is increasing evidence from tuberculosis high-burden settings that exogenous reinfection contributes considerably to recurrent disease. However, large longitudinal studies of endogenous reactivation (relapse) and reinfection tuberculosis are lacking. We hypothesize a relationship between relapse vs reinfection and the time between treatment completion and recurrent disease. METHODS Population-based retrospective cohort study on all smear-positive tuberculosis cases successfully treated between 1996 and 2008 in a suburban setting in Cape Town, South Africa. Inverse gaussian distributions were fitted to observed annual rates of relapse and reinfection, distinguished by DNA fingerprinting of Mycobacterium tuberculosis strains recultured from diagnostic samples. RESULTS Paired DNA fingerprint data were available for 130 (64%) of 203 recurrent smear-positive tuberculosis cases in the 13-year study period. Reinfection accounted for 66 (51%) of 130 recurrent cases overall, 9 (20%) of 44 recurrent cases within the first year, and 57 (66%) of 86 thereafter (P < .001). The relapse rate peaked at 3.93% (95% confidence interval [CI], 2.35%-5.96%) per annum 0.35 (95% CI, .15-.45) years after treatment completion. The reinfection tuberculosis rate peaked at 1.58% (95% CI, .94%-2.46%) per annum 1.20 (95% CI, .55-1.70) years after completion. CONCLUSIONS To our knowledge, this is the first study of sufficient size and duration using DNA fingerprinting to investigate tuberculosis relapse and reinfection over a lengthy period. Relapse occurred early after treatment completion, whereas reinfection dominated after 1 year and accounted for at least half of recurrent disease. This temporal relationship may explain the high variability in reinfection observed across smaller studies. We speculate that follow-up time in antituberculosis drug trials should take reinfection into account.
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Affiliation(s)
- Florian M Marx
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University Department for Pediatric Pneumology and Immunology, Charité-Universitätsmedizin, Berlin, Germany
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University
| | - Donald A Enarson
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Brian G Williams
- DST/NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Robin M Warren
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, US/MRC Centre for Molecular and Cellular Biology, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg Campus, Cape Town
| | - Gian D van der Spuy
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, US/MRC Centre for Molecular and Cellular Biology, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg Campus, Cape Town
| | - Paul D van Helden
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, US/MRC Centre for Molecular and Cellular Biology, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg Campus, Cape Town
| | - Nulda Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University
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Claassens MM, du Toit E, Dunbar R, Lombard C, Enarson DA, Beyers N, Borgdorff MW. Tuberculosis patients in primary care do not start treatment. What role do health system delays play? Int J Tuberc Lung Dis 2013; 17:603-7. [PMID: 23575324 DOI: 10.5588/ijtld.12.0505] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [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 Primary health care facilities in five provinces of South Africa. OBJECTIVE To investigate the association between the proportion of sputum results with a prolonged smear turnaround time and the proportion of smear-positive tuberculosis (TB) cases initially lost to follow-up. DESIGN The unit of investigation was a primary health care facility and the outcome was the initial loss to follow-up rate per facility, which was calculated by comparing the sputum register with the TB treatment register. A prolonged turnaround time was defined as more than 48 h from when the sputum sample was documented in the sputum register to receipt of the result at the facility. RESULTS The mean initial loss to follow-up rate was 25% (95%CI 22-28). Smear turnaround time overall was inversely associated with initial loss to follow-up (P = 0.008), when comparing Category 2 (33-66% turnaround time within 48 h) with Category 1 (0-32%) (OR 0.73, 95%CI 0.48-1.13, P = 0.163) and when comparing Category 3 (67-100%) with Category 1 (OR 0.62, 95%CI 0.39-0.99, P = 0.045). The population preventable fraction of initial loss to follow-up (when turnaround time was <48 h in ≥67% of smear results) was 21%. CONCLUSION Initial loss to follow-up should be reported as part of the TB programme to ensure that patients are initiated on treatment to prevent transmission within communities.
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Affiliation(s)
- M M Claassens
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa.
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Ayles H, Muyoyeta M, Du Toit E, Schaap A, Floyd S, Simwinga M, Shanaube K, Chishinga N, Bond V, Dunbar R, De Haas P, James A, Gey van Pittius NC, Claassens M, Fielding K, Fenty J, Sismanidis C, Hayes RJ, Beyers N, Godfrey-Faussett P. Effect of household and community interventions on the burden of tuberculosis in southern Africa: the ZAMSTAR community-randomised trial. Lancet 2013; 382:1183-94. [PMID: 23915882 DOI: 10.1016/s0140-6736(13)61131-9] [Citation(s) in RCA: 159] [Impact Index Per Article: 14.5] [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: 12/15/2022]
Abstract
BACKGROUND Southern Africa has had an unprecedented increase in the burden of tuberculosis, driven by the HIV epidemic. The Zambia, South Africa Tuberculosis and AIDS Reduction (ZAMSTAR) trial examined two public health interventions that aimed to reduce the burden of tuberculosis by facilitating either rapid sputum diagnosis or integrating tuberculosis and HIV services within the community. METHODS ZAMSTAR was a community-randomised trial done in Zambia and the Western Cape province of South Africa. Two interventions, community-level enhanced tuberculosis case-finding (ECF) and household level tuberculosis-HIV care, were implemented between Aug 1, 2006, and July 31, 2009, and assessed in a 2×2 factorial design between Jan 9, 2010, and Dec 6, 2010. All communities had a strengthened tuberculosis-HIV programme implemented in participating health-care centres. 24 communities, selected according to population size and tuberculosis notification rate, were randomly allocated to one of four study groups using a randomisation schedule stratified by country and baseline prevalence of tuberculous infection: group 1 strengthened tuberculosis-HIV programme at the clinic alone; group 2, clinic plus ECF; group 3, clinic plus household intervention; and group 4, clinic plus ECF and household interventions. The primary outcome was the prevalence of culture-confirmed pulmonary tuberculosis in adults (≥18 years), defined as Mycobacterium tuberculosis isolated from one respiratory sample, measured 4 years after the start of interventions in a survey of 4000 randomly selected adults in each community in 2010. The secondary outcome was the incidence of tuberculous infection, measured using tuberculin skin testing in a cohort of schoolchildren, a median of 4 years after a baseline survey done before the start of interventions. This trial is registered, number ISRCTN36729271. FINDINGS Prevalence of tuberculosis was evaluated in 64,463 individuals randomly selected from the 24 communities; 894 individuals had active tuberculosis. Averaging over the 24 communities, the geometric mean of tuberculosis prevalence was 832 per 100,000 population. The adjusted prevalence ratio for the comparison of ECF versus non-ECF intervention groups was 1·09 (95% CI 0·86-1·40) and of household versus non-household intervention groups was 0·82 (0·64-1·04). The incidence of tuberculous infection was measured in a cohort of 8809 children, followed up for a median of 4 years; the adjusted rate ratio for ECF versus non-ECF groups was 1·36 (95% CI 0·59-3·14) and for household versus non-household groups was 0·45 (0·20-1·05). INTERPRETATION Although neither intervention led to a statistically significant reduction in tuberculosis, two independent indicators of burden provide some evidence of a reduction in tuberculosis among communities receiving the household intervention. By contrast the ECF intervention had no effect on either outcome. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Helen Ayles
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
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Claassens MM, Jacobs E, Cyster E, Jennings K, James A, Dunbar R, Enarson DA, Borgdorff MW, Beyers N. Tuberculosis cases missed in primary health care facilities: should we redefine case finding? Int J Tuberc Lung Dis 2013; 17:608-14. [DOI: 10.5588/ijtld.12.0506] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Marx FM, Dunbar R, Enarson DA, Beyers N. The rate of sputum smear-positive tuberculosis after treatment default in a high-burden setting: a retrospective cohort study. PLoS One 2012; 7:e45724. [PMID: 23049846 PMCID: PMC3458061 DOI: 10.1371/journal.pone.0045724] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 08/23/2012] [Indexed: 11/19/2022] Open
Abstract
Rationale High rates of recurrent tuberculosis after successful treatment have been reported from different high burden settings in Sub-Saharan Africa. However, little is known about the rate of smear-positive tuberculosis after treatment default. In particular, it is not known whether or not treatment defaulters continue to be or become again smear-positive and thus pose a potential for transmission of infection to others. Objective To investigate, in a high tuberculosis burden setting, the rate of re-treatment for smear-positive tuberculosis among cases defaulting from standardized treatment compared to successfully treated cases. Methods Retrospective cohort study among smear-positive tuberculosis cases treated between 1996 and 2008 in two urban communities in Cape Town, South Africa. Episodes of re-treatment for smear-positive tuberculosis were ascertained via probabilistic record linkage. Survival analysis and Poisson regression were used to compare the rate of smear-positive tuberculosis after treatment default to that after successful treatment. Results A total of 2,136 smear-positive tuberculosis cases were included in the study. After treatment default, the rate of re-treatment for smear-positive tuberculosis was 6.86 (95% confidence interval [CI]: 5.59–8.41) per 100 person-years compared to 2.09 (95% CI: 1.81–2.41) after cure (adjusted Hazard Ratio [aHR]: 3.97; 95% CI: 3.00–5.26). Among defaulters, the rate was inversely associated with treatment duration and sputum conversion prior to defaulting. Smear grade at start of the index treatment episode (Smear3+: aHR 1.61; 95%CI 1.11–2.33) was independently associated with smear-positive tuberculosis re-treatment, regardless of treatment outcome. Conclusions In this high-burden setting, there is a high rate of subsequent smear-positive tuberculosis after treatment default. Treatment defaulters are therefore likely to contribute to the pool of infectious source cases in the community. Our findings underscore the importance of preventing treatment default, as a means of successful tuberculosis control in high-burden settings.
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Affiliation(s)
- Florian M Marx
- Charité - Universitätsmedizin, Department for Pediatric Pneumology and Immunology, Berlin, Germany.
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Lauring B, Taggart AKP, Tata JR, Dunbar R, Caro L, Cheng K, Chin J, Colletti SL, Cote J, Khalilieh S, Liu J, Luo WL, MacLean AA, Peterson LB, Polis AB, Sirah W, Wu TJ, Liu X, Jin L, Wu K, Boatman PD, Semple G, Behan DP, Connolly DT, Lai E, Wagner JA, Wright SD, Cuffie C, Mitchel YB, Rader DJ, Paolini JF, Waters MG, Plump A. Niacin Lipid Efficacy Is Independent of Both the Niacin Receptor GPR109A and Free Fatty Acid Suppression. Sci Transl Med 2012; 4:148ra115. [DOI: 10.1126/scitranslmed.3003877] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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