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Karat AS, Omar T, Tlali M, Charalambous S, Chihota VN, Churchyard GJ, Fielding KL, Martinson NA, McCarthy KM, Grant AD. Lessons learnt conducting minimally invasive autopsies in private mortuaries as part of HIV and tuberculosis research in South Africa. Public Health Action 2019; 9:186-190. [PMID: 32042614 DOI: 10.5588/pha.19.0032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 09/03/2019] [Indexed: 11/10/2022] Open
Abstract
Current estimates of the burden of tuberculosis (TB) disease and cause-specific mortality in human immunodeficiency virus (HIV) positive people rely heavily on indirect methods that are less reliable for ascertaining individual-level causes of death and on mathematical models. Minimally invasive autopsy (MIA) is useful for diagnosing infectious diseases, provides a reasonable proxy for the gold standard in cause of death ascertainment (complete diagnostic autopsy) and, used routinely, could improve cause-specific mortality estimates. From our experience in performing MIAs in HIV-positive adults in private mortuaries in South Africa (during the Lesedi Kamoso Study), we describe the challenges we faced and make recommendations for the conduct of MIA in future studies or surveillance programmes, including strategies for effective communication, approaches to obtaining informed consent, risk management for staff and efficient preparation for the procedure.
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Affiliation(s)
- A S Karat
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - T Omar
- Division of Anatomical Pathology, Faculty of Health Sciences, University of the Witwatersrand, National Health Laboratory Service, Johannesburg, South Africa
| | - M Tlali
- The Aurum Institute, Johannesburg, South Africa
| | - S Charalambous
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - V N Chihota
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - G J Churchyard
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK.,The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - K L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - N A Martinson
- Perinatal HIV Research Unit, and South African Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa.,Johns Hopkins University Center for TB Research, Baltimore, MD, USA.,Department of Science and Technology/National Research Foundation Centre of Excellence for Biomedical TB Research, University of the Witwatersrand, Johannesburg, South Africa
| | - K M McCarthy
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Division of Public Health, Surveillance and Response, National Institute for Communicable Disease of the National Health Laboratory Service, Johannesburg, South Africa
| | - A D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Hanifa Y, Toro Silva S, Karstaedt A, Sahid F, Charalambous S, Chihota VN, Churchyard GJ, von Gottberg A, McCarthy K, Nicol MP, Ndlovu NT, Stevens W, Fielding KL, Grant AD. What causes symptoms suggestive of tuberculosis in HIV-positive people with negative initial investigations? Int J Tuberc Lung Dis 2019; 23:157-165. [PMID: 30678747 PMCID: PMC6394279 DOI: 10.5588/ijtld.18.0251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE: To identify the causes of symptoms suggestive of tuberculosis (TB) among people living with the human immunodeficiency virus (PLHIV) in South Africa. METHODS: A consecutive sample of HIV clinic attendees with symptoms suggestive of TB (⩾1 of cough, weight loss, fever or night sweats) at enrolment and at 3 months, and negative initial TB investigations, were systematically evaluated with standard protocols and diagnoses assigned using standard criteria. TB was ‘confirmed’ if Mycobacterium tuberculosis was identified within 6 months of enrolment, and ‘clinical’ if treatment started without microbiological confirmation. RESULTS: Among 103 participants, 50/103 were preantiretroviral therapy (ART) and 53/103 were on ART; respectively 68% vs. 79% were female; the median age was 35 vs. 45 years; the median CD4 count was 311 vs. 508 cells/mm3. Seventy-two (70%) had ⩾5% measured weight loss and 50 (49%) had cough. The most common final diagnoses were weight loss due to severe food insecurity (n = 20, 19%), TB (n = 14, 14%: confirmed n = 7; clinical n = 7), other respiratory tract infection (n = 14, 14%) and post-TB lung disease (n = 9, 9%). The basis for TB diagnosis was imaging (n = 7), bacteriological confirmation from sputum (n = 4), histology, lumbar puncture and other (n = 1 each). CONCLUSION: PLHIV with persistent TB symptoms require further evaluation for TB using all available modalities, and for food insecurity in those with weight loss.
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Affiliation(s)
- Y Hanifa
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - S Toro Silva
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - A Karstaedt
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, University of the Witwatersrand, Johannesburg
| | - F Sahid
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, University of the Witwatersrand, Johannesburg
| | - S Charalambous
- The Aurum Institute, Johannesburg, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - V N Chihota
- The Aurum Institute, Johannesburg, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - G J Churchyard
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK, The Aurum Institute, Johannesburg, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Advancing Care and Treatment for TB-HIV, South African Medical Research Council Collaborating Centre for HIV and TB, Tygerberg
| | - A von Gottberg
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases, Johannesburg, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | | | - M P Nicol
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, National Health Laboratory Service, Johannesburg
| | | | - W Stevens
- National Health Laboratory Service, Johannesburg, Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - K L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - A D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Gwavava C, Chihota VN, Gangaidzo IT, Gumbo T. Dysentery in patients infected with human immunodeficiency virus in Zimbabwe: an emerging role forSchistosoma mansoniandEscherichia coliO157? Annals of Tropical Medicine & Parasitology 2016. [DOI: 10.1080/00034983.2001.11813663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Kufa T, Chihota VN, Charalambous S, Churchyard GJ. Isoniazid preventive therapy use among patients on antiretroviral therapy: a missed opportunity. Int J Tuberc Lung Dis 2015; 18:312-4. [PMID: 24670568 DOI: 10.5588/ijtld.13.0505] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Isoniazid preventive therapy (IPT) with antiretroviral therapy (ART) reduces incident tuberculosis among patients infected with the human immunodeficiency virus. We describe IPT use among patients on ART at two primary care clinics in South Africa. Of 597 participants interviewed, 100 (16.8%) reported IPT use; 73.4% (365/497) with no reported IPT use were eligible for IPT. IPT use was associated with age <35 years (aOR 1.90, 95%CI 1.18-3.06), and receiving care at one clinic as opposed to the other (aOR 4.72, 95%CI 2.69-7.93). The high proportion of patients on ART eligible for IPT represents a missed opportunity for IPT scale-up.
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Affiliation(s)
- T Kufa
- The Aurum Institute, Johannesburg, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - V N Chihota
- The Aurum Institute, Johannesburg, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - S Charalambous
- The Aurum Institute, Johannesburg, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - G J Churchyard
- The Aurum Institute, Johannesburg, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Chihota VN, van Halsema CL, Grant AD, Fielding KL, van Helden PD, Churchyard GJ, Gey van Pittius NC. Spectrum of non-tuberculous mycobacteria identified using standard biochemical testing vs. 16S sequencing. Int J Tuberc Lung Dis 2012; 17:267-9. [PMID: 23228479 DOI: 10.5588/ijtld.12.0425] [Citation(s) in RCA: 4] [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
Non-tuberculous mycobacterial isolates from gold miners were speciated using standard biochemical testing (SBT) and 16S rDNA sequencing. Of 237 isolates tested, SBT identified 126, compared with all 237 identified using sequencing. Of 111 isolates unspeciated by SBT but identified by sequencing, 38 (34.2%) were identified as Mycobacterium gordonae and 8 (7.2%) were new species. Of 126 isolates speciated by both methods, 37 were discordant, with 14/17 M. gordonae isolates incorrectly identified as M. scrofulaceum using SBT. The majority of these were the potentially pathogenic strain D, M. gordonae. Sequencing is preferable where available to guide treatment.
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Affiliation(s)
- V N Chihota
- The Aurum Institute, Parktown, South Africa.
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van Halsema CL, Fielding KL, Chihota VN, Lewis JJ, Churchyard GJ, Grant AD. Trends in drug-resistant tuberculosis in a gold-mining workforce in South Africa, 2002-2008. Int J Tuberc Lung Dis 2012; 16:967-73. [PMID: 22584100 DOI: 10.5588/ijtld.11.0122] [Citation(s) in RCA: 16] [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 AND OBJECTIVE To describe trends in drug-resistant tuberculosis (TB) in two gold-mining workforces, South Africa, 2002-2008. DESIGN TB programme data analysis. RESULTS TB case notification rates decreased between 2002 and 2008 from 4006 to 3018 per 100,000 and from 3192 to 2468/100,000 for Companies A and B, respectively. Human immunodeficiency virus (HIV) prevalence exceeded 80% in TB episodes with known status. The proportion of TB episodes with multidrug-resistant TB (MDR-TB) increased from 6/129 (4.7%) to 17/85 (20.0%) among previously treated cases, and from 4/38 (10.4%) to 7/28 (25.0%) in Companies A and B, respectively (tests for trend, Company A, P < 0.001; Company B, P = 0.304). Case notifications of MDR-TB increased during 2002-2008 from 39.8 to 122.9/100,000/year in Company A and from 7.8 to 96.8/100,000/year in Company B. Coverage of second-line drug susceptibility testing (DST) among MDR-TB episodes was low. Previous treatment exposure was a strong risk factor for MDR-TB (prevalence ratio 8.78, 95%CI 5.94-12.97 in previously treated vs. untreated individuals). CONCLUSION Despite decreasing TB notifications overall, MDR-TB notifications and proportions of episodes with MDR-TB increased in the larger company. Cure must be ensured in first episodes to prevent acquired resistance. Improved coverage of culture, DST and HIV testing is required to allow treatment to be optimised.
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Chihota VN, Grant AD, Fielding K, Ndibongo B, van Zyl A, Muirhead D, Churchyard GJ. Liquid vs. solid culture for tuberculosis: performance and cost in a resource-constrained setting. Int J Tuberc Lung Dis 2010; 14:1024-1031. [PMID: 20626948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023] Open
Abstract
SETTING National Health Laboratory Services tuberculosis (TB) laboratory, South Africa. OBJECTIVES To compare Mycobacterium Growth Indicator Tube (MGIT) with Löwenstein-Jensen (LJ) medium with regard to Mycobacterium tuberculosis yield, time to positive culture and contamination, and to assess MGIT cost-effectiveness. DESIGN Sputum from gold miners was cultured on MGIT and LJ. We estimated cost per culture, and, for smear-negative samples, incremental cost per additional M. tuberculosis gained with MGIT using a decision-tree model. RESULTS Among 1267 specimens, MGIT vs. LJ gave a higher yield of mycobacteria (29.7% vs. 22.8%), higher contamination (16.7% vs. 9.3%) and shorter time to positive culture (median 14 vs. 25 days for smear-negative specimens). Among smear-negative samples that were culture-positive on MGIT but negative/contaminated on LJ, 77.3% were non-tuberculous mycobacteria (NTM). Cost per culture on LJ, MGIT and MGIT+LJ was respectively US$12.35, US$16.62 and US$19.29. The incremental cost per additional M. tuberculosis identified by standard biochemical tests and microscopic cording was respectively US$504.08 and US$328.10 using MGIT vs. LJ, or US$160.80 and US$$109.07 using MGIT+LJ vs. LJ alone. CONCLUSION MGIT gives higher yield and faster results at relatively high cost. The high proportion of NTM underscores the need for rapid speciation tests. Minimising contaminated cultures is key to cost-effectiveness.
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Affiliation(s)
- V N Chihota
- Aurum Institute for Health Research, Johannesburg, South Africa.
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Warren RM, Victor TC, Streicher EM, Richardson M, van der Spuy GD, Johnson R, Chihota VN, Locht C, Supply P, van Helden PD. Clonal expansion of a globally disseminated lineage of Mycobacterium tuberculosis with low IS6110 copy numbers. J Clin Microbiol 2005; 42:5774-82. [PMID: 15583312 PMCID: PMC535222 DOI: 10.1128/jcm.42.12.5774-5782.2004] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Knowledge of the clonal expansion of Mycobacterium tuberculosis and accurate identification of predominant evolutionary lineages in this species remain limited, especially with regard to low-IS6110-copy-number strains. In this study, 170 M. tuberculosis isolates with </=6 IS6110 insertions identified in Cape Town, South Africa, were characterized by principal genetic grouping, restriction fragment length polymorphism analysis, spoligotyping, IS6110 insertion site mapping, and variable-number tandem repeat (VNTR) typing. These analyses indicated that all but one of the isolates analyzed were members of principal genetic group 2 and of the same low-IS6110-copy-number lineage. The remaining isolate was a member of principal genetic group 1 and a different low-IS6110-copy-number lineage. Phylogenetic reconstruction suggests clonal expansion through sequential acquisition of additional IS6110 copies, expansion and contraction of VNTR sequences, and the deletion of specific direct-variable-repeat sequences. Furthermore, comparison of the genotypic data of 91 representative low-IS6110-copy-number isolates from Cape Town, other southern African regions, Europe, and the United States suggests that certain low-IS6110-copy-number strain spoligotypes and IS6110 fingerprints were acquired in the distant past. These clones have subsequently become widely disseminated and now play an important role in the global tuberculosis epidemic.
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Affiliation(s)
- R M Warren
- MRC Centre for Molecular and Cellular Biology, Department of Medical Biochemistry, Faculty of Health Sciences, University of Stellenbosch, P.O. Box 19063, Tygerberg, 7505, South Africa.
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Gwavava C, Chihota VN, Gangaidzo IT, Gumbo T. Dysentery in patients infected with human immunodeficiency virus in Zimbabwe: an emerging role for Schistosoma mansoni and Escherichia coli O157? Ann Trop Med Parasitol 2001; 95:509-13. [PMID: 11487372 DOI: 10.1080/00034980120076235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Information on bloody diarrhoea in HIV-positives is scarce. A prospective study was therefore performed, in Zimbabwe, to determine and compare the pathogens associated with bloody diarrhoea in 25 antiretroviral-naïve HIV-infected patients and 15 non-HIV-infected patients. Stool cultures and colonic biopsies were performed. Shigella was isolated from 18 (45%) of the subjects, Schistosoma mansoni from eight (16%), Escherichia coli H7:O157 from three (8%) and Campylobacter jejunii from two (5%). There was no evidence of Salmonella, Entamoeba histolytica or cytomegalovirus infection. Shigella dysenteriae type-1 occurred more often in the HIV-negatives than the HIV-positives (P = 0.02). Although HIV-associated bloody diarrhoea in Zimbabwe appears to be most frequently caused by Shigella, it may also be commonly the result of infection with Sc. mansoni or shiga-toxin-producing E. coli. A larger study specifically to examine the role of Sc. mansoni and E. coli O157 is warranted.
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Affiliation(s)
- C Gwavava
- Department of Medicine, University of Zimbabwe Medical School, P.O. Box A178, Avondale, Harare, Zimbabwe
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Chihota VN, Nyazema NZ, Mashingaidze S, Mutandiro B. TB infection: an exploratory study of BCG protective properties and the possible role of environmental mycobacteria. Cent Afr J Med 1998; 44:145-8. [PMID: 9810394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
OBJECTIVE To evaluate the presence of environmental mycobacterial strains and explore the implications for BCG vaccination against TB. DESIGN Multimethod approach which included structured interviews and medical records examination. Soil and water samples were analysed using standard microbiology methods. SETTING Beatrice Infectious Diseases Hospital, Public Health laboratories, University of Zimbabwe Medical School and several residential areas in Harare. SUBJECTS 129 tuberculosis inpatients at Beatrice Infectious Diseases Hospital, 26 Public Health Laboratory technicians handling TB specimens and 51 fourth year medical students. MAIN OUTCOME MEASURES Vaccination status of TB inpatients, medical students and laboratory technicians, protective efficacy of BCG in all subjects, presence of environmental mycobacterium in the environment. RESULTS The type of tuberculosis did not differ significantly between vaccinated and non-vaccinated TB patients x2(df = 1) = 0.171 p > 0.05. There was no apparent difference between the revaccinated and non-vaccinated laboratory technicians. One respondent out of each of the revaccinated and non-vaccinated laboratory technicians had developed pulmonary tuberculosis. Among the fourth year medical students, four had positive tuberculin test results, even though they had not been vaccinated at the University clinic. Environmental mycobacteria presumptively identified as Mycobacterium scrofulaceum and Mycobacterium intracellulare were isolated from both the water and soil samples taken from a few selected areas in Harare. Of the 129 TB in-patients, 88 (68.2%) had previously been vaccinated against TB. Similarly among the 51 medical students 44(86.3%) had been vaccinated. Laboratory technicians re-vaccinated on the job were nine out of 26. CONCLUSION The results obtained seemed to indicate that BCG protective efficacy did wane with time and revaccination appeared not to be useful. Environmental mycobacterium that could influence the BCG efficacy do exist in our environment.
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Affiliation(s)
- V N Chihota
- Department of Medical Microbiology, University of Zimbabwe Medical School, Harare, Zimbabwe
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