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Cherri Z, Lau K, Nellums LB, Himmels J, Deal A, McGuire E, Mounier-Jack S, Norredam M, Crawshaw A, Carter J, Seedat F, Clemente NS, Bouaddi O, Friedland JS, Edelstein M, Hargreaves S. The immune status of migrant populations in Europe and implications for vaccine-preventable disease control: a systematic review and meta-analysis. J Travel Med 2024:taae033. [PMID: 38423523 DOI: 10.1093/jtm/taae033] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/10/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Ensuring vaccination coverage reaches established herd immunity thresholds (HIT) is the cornerstone of any vaccination programme. Diverse migrant populations in European countries have been associated with cases of vaccine-preventable diseases (VPD) and outbreaks, yet it is not clear to what extent they are an under-immunised group. METHODS We did a systematic review and meta-analysis to synthesise peer-reviewed published primary research reporting data on the immune status of migrants in EU/EEA countries, the UK and Switzerland, calculating their pooled immunity coverage for measles, mumps, rubella, and diphtheria using random-effects models. We searched on Web of Science, Embase, Global Health and MEDLINE (January 1st 2000 to June 10th 2022), with no language restrictions. The protocol is registered with PROSPERO (CRD42018103666). FINDINGS Of 1103 abstracts screened, 62 met eligibility criteria, of which 39 were included in the meta-analysis. The meta-analysis included 75 089 migrants, predominantly from outside Europe. Pooled immunity coverage among migrant populations was well below the recommended HIT for diphtheria (n = 7, 57.4% [95% CI: 43.1-71.7%] I2 = 99% vs HIT 83-86%), measles (n = 21, 83.7% [95% CI: 79.2-88.2] I2 = 99% vs HIT 93-95%), and mumps (n = 8, 67.1% [95% CI: 50.6-83.6] I2 = 99% vs HIT 88-93%), and midway for rubella (n = 29, 85.6% [95% CI: 83.1-88.1%] I2 = 99% vs HIT 83-94%), with high heterogeneity across studies. INTERPRETATION Migrants in Europe are an under-immunised group for a range of important VPDs, with this study reinforcing the importance of engaging children, adolescents, and adults in 'catch-up' vaccination initiatives on arrival for vaccines, doses, and boosters they may have missed in their home countries. Co-designing strategies to strengthen catch-up vaccination across the life-course in under-immunised groups is an important next step if we are to meet European and global targets for VPD elimination and control and ensure vaccine equity.
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Affiliation(s)
- Zeinab Cherri
- The Migrant Health Research Group, Institute for Infection and Immunity, St Georges, University of London, London, UK
| | - Karen Lau
- The Migrant Health Research Group, Institute for Infection and Immunity, St Georges, University of London, London, UK
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London
- Lancet Migration European Regional Hub
| | - Laura B Nellums
- Faculty of Medicine and Heath Sciences, University of Nottingham, Nottingham UK
| | - Jan Himmels
- The Migrant Health Research Group, Institute for Infection and Immunity, St Georges, University of London, London, UK
| | - Anna Deal
- The Migrant Health Research Group, Institute for Infection and Immunity, St Georges, University of London, London, UK
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London
| | - Emma McGuire
- The Migrant Health Research Group, Institute for Infection and Immunity, St Georges, University of London, London, UK
| | - Sandra Mounier-Jack
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London
| | - Marie Norredam
- Danish Research Centre for Migration, Ethnicity and Health, Section of Health Services Research, Department of Public Health, University of Copenhagen, Denmark
- Department of Infectious Diseases, Hvidovre Hospital, University of Copenhagen
| | - Alison Crawshaw
- The Migrant Health Research Group, Institute for Infection and Immunity, St Georges, University of London, London, UK
| | - Jessica Carter
- The Migrant Health Research Group, Institute for Infection and Immunity, St Georges, University of London, London, UK
| | - Farah Seedat
- The Migrant Health Research Group, Institute for Infection and Immunity, St Georges, University of London, London, UK
| | - Nuria Sanchez Clemente
- The Migrant Health Research Group, Institute for Infection and Immunity, St Georges, University of London, London, UK
| | - Oumnia Bouaddi
- Lancet Migration European Regional Hub
- International School of Public Health, Mohammed VI University of Sciences and Health, Casablanca, Morocco, and Mohammed VI Center for Research and Innovation, Rabat, Morocco
| | - Jon S Friedland
- Institute for Infection and Immunity, St Georges, University of London, London, UK
| | - Michael Edelstein
- Department of Infectious Diseases, Hvidovre Hospital, University of Copenhagen
| | - Sally Hargreaves
- The Migrant Health Research Group, Institute for Infection and Immunity, St Georges, University of London, London, UK
- Lancet Migration European Regional Hub
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Hayward SE, Vanqa N, Makanda G, Tisile P, Ngwatyu L, Foster I, Mcinziba A, Biewer A, Mbuyamba R, Galloway M, Bunyula S, Westhuizen HM, Friedland JS, Marino-Medina A, Viljoen L, Schoeman I, Hoddinott G, Nathavitharana RR. "As a patient I do not belong to the clinic, I belong to the community." Co-developing a multi-level, person-centred tuberculosis stigma intervention in Cape Town, South Africa. Res Sq 2024:rs.3.rs-3921970. [PMID: 38405783 PMCID: PMC10889064 DOI: 10.21203/rs.3.rs-3921970/v1] [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] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Background Anticipated, internal, and enacted stigma are major barriers to TB care engagement, and directly impact patient well-being. Unfortunately, targeted stigma interventions are lacking. We aimed to co-develop a person-centred stigma intervention with TB-affected community members and health workers in South Africa. Methods Using a community-based participatory research approach, we conducted ten group discussions with people diagnosed with TB (past or present), caregivers, and health workers (total n=87) in Khayelitsha, Cape Town. Group discussions were facilitated by TB survivors. Discussion guides explored experiences and drivers of stigma and used human-centred design principles to co-develop solutions. Recordings were transcribed, coded, thematically analysed and then further interpreted using the socio-ecological model. Results Intervention components across socio-ecological levels shared common behaviour change strategies, namely education, empowerment, engagement, and innovation. At the individual level, participants recommended counselling to improve TB knowledge and provide ongoing support. TB survivors can guide messaging to nurture stigma resilience by highlighting that TB can affect anyone and is curable, and provide lived experiences of TB to decrease internal stigma. At the interpersonal level, support clubs and family-centred counselling were suggested to dispel TB-related myths and foster support. At the institutional level, health worker stigma reduction training informed by TB survivor perspectives was recommended. Consideration of how integration of TB/HIV care services may exacerbate TB/HIV intersectional stigma and ideas for restructured service delivery models were suggested to decrease anticipated and enacted stigma. At the community level, participants recommended awareness-raising events led by TB survivors, including TB information in school curricula. At the policy level, solutions focused on reducing the visibility generated by a TB diagnosis and resultant stigma in health facilities and shifting tasks to community health workers. Conclusions Decreasing TB stigma requires a multi-level approach. Co-developing a person-centred intervention with affected communities is feasible and generates stigma intervention components that are directed and implementable. Such community-informed intervention components should be prioritised by TB programs, including integrated TB/HIV care services.
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Affiliation(s)
| | | | | | | | | | | | | | - Amanda Biewer
- Beth Israel Deaconess Medical Center, Harvard Medical School
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3
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Foster I, Biewer A, Vanqa N, Makanda G, Tisile P, Hayward SE, Wademan DT, Anthony MG, Mbuyamba R, Galloway M, Human W, Westhuizen HM, Friedland JS, Marino-Medina A, Schoeman I, Hoddinott G, Nathavitharana RR. "This is an illness. No one is supposed to be treated badly": Community-based stigma assessments in South Africa to inform TB stigma intervention design. Res Sq 2023:rs.3.rs-3716733. [PMID: 38168425 PMCID: PMC10760241 DOI: 10.21203/rs.3.rs-3716733/v1] [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] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Background Though TB-related stigma is a recognized barrier to care, interventions are lacking and gaps remain in understanding the drivers and experiences of TB-related stigma. We undertook community-based mixed methods stigma assessments to inform stigma intervention design. Methods We adapted the Stop TB Partnership stigma assessment tool, and trained three peer research associates (PRAs; two TB survivors, one community health worker) to conduct surveys with people with TB (PWTB, n=93) and caregivers of children with TB (n=24) at peri-urban and rural clinic sites in Khayelitsha, Western Cape, and Hammanskraal, Gauteng Province, South Africa. We descriptively analyzed responses for each stigma experience (anticipated, internal, and enacted), calculated stigma scores, and undertook generalized linear regression analysis. We further conducted 25 in-depth interviews with PWTB (n=22) and caregivers TB (n=3). Using inductive thematic analysis, we performed open coding to identify emergent themes, and selective coding to identify relevant quotes. Themes were organised using the CARD (Constraints, Actions, Risks and Desires) framework. Results Surveys revealed at least one-third of PWTB and one-quarter of caregivers report experiences of anticipated, internal, and/or enacted stigma, which affected engagement throughout the care cascade. Participants in rural locations (compared to peri-urban) reported higher anticipated, internal, and enacted stigma (β-coefficient 0.72, 0.71, and 0.74). Interview participants described how stigma experiences, including HIV intersectional stigma, act individually and in concert as key constraints to impede care, and underpins failure to disclose a TB diagnosis, isolation, and exclusion. Stigma resilience arose through understanding that TB can affect anyone and should not diminish self-worth. Risks of stigma, driven by fears related to disease severity and infectiousness, led to care disengagement and impaired psychological wellbeing. Participants desired counselling, identifying a specific role for TB survivors as peer counsellors, and community education. Conclusions Stigma is highly prevalent and negatively impacts TB care and the well-being of PWTB, warranting its assessment as a primary outcome indicator rather than intermediary contributor to poor cascade outcomes. Multicomponent stigma interventions are needed, including counselling for PWTB and education for health workers and communities. Such interventions must incorporate contextual differences based on gender or setting, and use survivor-guided messaging to foster stigma resilience.
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Affiliation(s)
| | - Amanda Biewer
- Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Nosivuyile Vanqa
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | | | | | | | - Dillon T Wademan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Michaile G Anthony
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | | | | | | | | | | | | | | | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
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4
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Whittington AM, Turner FS, Baark F, Templeman S, Kirwan DE, Roufosse C, Krishnan N, Robertson BD, Chong DLW, Porter JC, Gilman RH, Friedland JS. An acidic microenvironment in Tuberculosis increases extracellular matrix degradation by regulating macrophage inflammatory responses. PLoS Pathog 2023; 19:e1011495. [PMID: 37418488 PMCID: PMC10355421 DOI: 10.1371/journal.ppat.1011495] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 07/19/2023] [Accepted: 06/20/2023] [Indexed: 07/09/2023] Open
Abstract
Mycobacterium tuberculosis (M.tb) infection causes marked tissue inflammation leading to lung destruction and morbidity. The inflammatory extracellular microenvironment is acidic, however the effect of this acidosis on the immune response to M.tb is unknown. Using RNA-seq we show that acidosis produces system level transcriptional change in M.tb infected human macrophages regulating almost 4000 genes. Acidosis specifically upregulated extracellular matrix (ECM) degradation pathways with increased expression of Matrix metalloproteinases (MMPs) which mediate lung destruction in Tuberculosis. Macrophage MMP-1 and -3 secretion was increased by acidosis in a cellular model. Acidosis markedly suppresses several cytokines central to control of M.tb infection including TNF-α and IFN-γ. Murine studies demonstrated expression of known acidosis signaling G-protein coupled receptors OGR-1 and TDAG-8 in Tuberculosis which are shown to mediate the immune effects of decreased pH. Receptors were then demonstrated to be expressed in patients with TB lymphadenitis. Collectively, our findings show that an acidic microenvironment modulates immune function to reduce protective inflammatory responses and increase extracellular matrix degradation in Tuberculosis. Acidosis receptors are therefore potential targets for host directed therapy in patients.
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Affiliation(s)
| | - Frances S. Turner
- Edinburgh Genomics, University of Edinburgh, Edinburgh, United Kingdom
| | - Friedrich Baark
- Department of Infectious Disease, Imperial College London, London, United Kingdom
| | - Sam Templeman
- Department of Infectious Disease, Imperial College London, London, United Kingdom
| | - Daniela E. Kirwan
- Institute of Infection and Immunity, St. George’s, University of London, London, United Kingdom
| | - Candice Roufosse
- Department of Infectious Disease, Imperial College London, London, United Kingdom
| | - Nitya Krishnan
- Department of Infectious Disease, Imperial College London, London, United Kingdom
| | - Brian D. Robertson
- Department of Infectious Disease, Imperial College London, London, United Kingdom
| | - Deborah L. W. Chong
- Institute of Infection and Immunity, St. George’s, University of London, London, United Kingdom
| | - Joanna C. Porter
- Centre for Inflammation & Tissue Repair, Respiratory Medicine, University College London, London, United Kingdom
| | - Robert H. Gilman
- Department of International Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Jon S. Friedland
- Institute of Infection and Immunity, St. George’s, University of London, London, United Kingdom
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5
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Tanoglu A, Erdem H, Friedland JS, Ankaralı H, Garcia-Goez JF, Albayrak A, El-Kholy A, Ceviker SA, Amer F, Erol S, Darazam IA, Rabiei MM, Sarwar MZ, Zeb M, Nawaz H, Ceylan MR, Cernat R, Tasbakan M, Ayoade F, Ruch Y, Tigen ET, Angioni G, Rajani DP, Akhtar N, Surme S, Sengoz G, Karlıdag GE, Marino A, Ripon RK, Çağ Y, Aydın Ö, Akkoyunlu Y, Seyman D, Angamuthu K, Cascio A, Popescu CP, Sirmatel F, Eren E, Dar RE, Munu FU, Tanoglu EG, Echeverry E, Velez JD, Artuk C, Balin SO, Pandya N, Erdem A, Demiray EKD, Aypak A. Clinicopathological profile of peritoneal tuberculosis and a new scoring model for predicting mortality: an international ID-IRI study. Eur J Clin Microbiol Infect Dis 2023:10.1007/s10096-023-04630-9. [PMID: 37318601 DOI: 10.1007/s10096-023-04630-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/03/2023] [Indexed: 06/16/2023]
Abstract
Existing literature about peritoneal tuberculosis (TBP) is relatively insufficient. The majority of reports are from a single center and do not assess predictive factors for mortality. In this international study, we investigated the clinicopathological characteristics of a large series of patients with TBP and determined the key features associated with mortality. TBP patients detected between 2010 and 2022 in 38 medical centers in 13 countries were included in this retrospective cohort. Participating physicians filled out an online questionnaire to report study data. In this study, 208 patients with TBP were included. Mean age of TBP cases was 41.4 ± 17.5 years. One hundred six patients (50.9%) were females. Nineteen patients (9.1%) had HIV infection, 45 (21.6%) had diabetes mellitus, 30 (14.4%) had chronic renal failure, 12 (5.7%) had cirrhosis, 7 (3.3%) had malignancy, and 21 (10.1%) had a history of immunosuppressive medication use. A total of 34 (16.3%) patients died and death was attributable to TBP in all cases. A pioneer mortality predicting model was established and HIV positivity, cirrhosis, abdominal pain, weakness, nausea and vomiting, ascites, isolation of Mycobacterium tuberculosis in peritoneal biopsy samples, TB relapse, advanced age, high serum creatinine and ALT levels, and decreased duration of isoniazid use were significantly related with mortality (p < 0.05). This is the first international study on TBP and is the largest case series to date. We suggest that using the mortality predicting model will allow early identification of high-risk patients likely to die of TBP.
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Affiliation(s)
- Alpaslan Tanoglu
- Department of Internal Medicine and Gastroenterology, Sancaktepe Sehit Prof Dr Ilhan Varank Training and Research Hospital, University of Health Sciences, 34785, Istanbul, Turkey.
| | - Hakan Erdem
- Department of Infectious Diseases & Clinical Microbiology, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
- MKCC Cardiac Centre, Awali, Bahrain
| | | | - Handan Ankaralı
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Jose Fernando Garcia-Goez
- Infectious Disease Service Hospital Universitario Fundacion Valle del Lili Colombia, Facultad de Medicina Universidad Icesi, Cali, Colombia
| | - Ayse Albayrak
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - Amani El-Kholy
- Department of Clinical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sevil Alkan Ceviker
- Department of Infectious Diseases, Faculty of Medicine, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Fatma Amer
- Department of Medical Microbiology and Immunology, Zagazig Faculty of Medicine, Zagazig, Egypt
| | - Serpil Erol
- Department of Infectious Diseases, Haydarpasa Numune Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | | | | | | | - Misbah Zeb
- Department of Infectious Diseases, Mayo Hospital, Lahore, Pakistan
| | - Hassan Nawaz
- Department of Infectious Diseases, Mayo Hospital, Lahore, Pakistan
| | | | - Roxana Cernat
- Department of Infectious Diseases, Clinical Hospital for Infectious Diseases, Constanta, Romania
| | - Meltem Tasbakan
- Department of Infectious Diseases, Ege University, Izmir, Turkey
| | - Folusakin Ayoade
- Department of Infectious Diseases, University of Miami, Miami, FL, USA
| | - Yvon Ruch
- Department of Infectious Diseases, Strasbourg University, Strasbourg, France
| | - Elif Tükenmez Tigen
- Department of Infectious Diseases, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey
| | - Goffredo Angioni
- Department of Infectious Diseases, Hospital SS Trinità, Borgomanero, Italy
| | - Dhanji P Rajani
- Microcare Laboratory & Tuberculosis Research Centre, Surat, Gujarat, India
| | - Nasim Akhtar
- Pakistan Institute of Medical Sciences, Islamabad, Pakistan
| | - Serkan Surme
- Department of Infectious Diseases, Haseki Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Gonul Sengoz
- Department of Infectious Diseases, Haseki Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Gulden Eser Karlıdag
- Department of Infectious Diseases, Elazig Fethi Sekin City Hospital, University of Health Sciences, Elazig, Turkey
| | - Andrea Marino
- Unit of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, Catania, Italy
| | - Rezaul Karim Ripon
- Department of Public Health and Informatics, Jahangirnagar University, Savar Union, Bangladesh
| | - Yasemin Çağ
- Department of Infectious Diseases and Clinical Microbiology, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Özlem Aydın
- Department of Infectious Diseases and Clinical Microbiology, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Yasemin Akkoyunlu
- Department of Infectious Diseases, Bezmialem Vakif University, Istanbul, Turkey
| | - Derya Seyman
- Department of Infectious Diseases, Antalya Education and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Kumar Angamuthu
- Department of Infectious Diseases, Almana General Hospitals, Dammam, Saudi Arabia
| | - Antonio Cascio
- Infectious Disease Unit, Policlinico "P. Giaccone", University of Palermo, Palermo, Italy
| | - Corneliu Petru Popescu
- Department of Infectious Diseases, Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Bucharest, Romania
| | - Fatma Sirmatel
- Department of Infectious Diseases, Bolu Abant Izzet Baysal University Medical Faculty, Bolu, Turkey
| | - Esma Eren
- Department of Infectious Diseases, Kayseri City Hospital, Kayseri, Turkey
| | - Razi Even Dar
- Department of Infectious Diseases, Caemal, Haifa, Israel
| | - Foday Usman Munu
- Department of Infectious Diseases, Lakka Government Hospital, Freetown, Sierra Leone
| | - Esra Guzel Tanoglu
- Department of Molecular Biology and Genetics, University of Health Sciences, Istanbul, Turkey
| | - Esteban Echeverry
- Infectious Disease Service Hospital Universitario Fundacion Valle del Lili Colombia, Facultad de Medicina Universidad Icesi, Cali, Colombia
| | - Juan Diego Velez
- Infectious Disease Service Hospital Universitario Fundacion Valle del Lili Colombia, Facultad de Medicina Universidad Icesi, Cali, Colombia
| | - Cumhur Artuk
- Department of Infectious Diseases & Clinical Microbiology, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Safak Ozer Balin
- Department of Infectious Diseases, Fırat University Medical Faculty, Elazig, Turkey
| | - Nirav Pandya
- Department of Infectious Diseases, Bhailal Amin General Hospital, Vadodara, India
| | - Aysegul Erdem
- Department of Pathology, Ataturk Sanatoryum Training and Research Hospital, Ankara, Turkey
| | | | - Adalet Aypak
- Department of Infectious Diseases and Clinical Microbiology, Ankara City Training and Research Hospital, Ankara, Turkey
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Margineanu I, Rustage K, Noori T, Zenner D, Greenaway C, Pareek M, Akkerman O, Hayward S, Friedland JS, Goletti D, Stienstra Y, Hargreaves S. Country-specific approaches to latent tuberculosis screening targeting migrants in EU/EEA* countries: A survey of national experts, September 2019 to February 2020. Euro Surveill 2022; 27. [PMID: 35332865 PMCID: PMC8950856 DOI: 10.2807/1560-7917.es.2022.27.12.2002070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Migrants in low tuberculosis (TB) incidence countries in the European Union (EU)/European Economic Area (EEA) are an at-risk group for latent tuberculosis infection (LTBI) and are increasingly included in LTBI screening programmes. Aim To investigate current approaches and implement LTBI screening in recently arrived migrants in the EU/EEA and Switzerland. Methods At least one TB expert working at a national level from the EU/EEA and one TB expert from Switzerland completed an electronic questionnaire. We used descriptive analyses to calculate percentages, and framework analysis to synthesise free-text responses. Results Experts from 32 countries were invited to participate (30 countries responded): 15 experts reported an LTBI screening programme targeting migrants in their country; five reported plans to implement one in the near future; and 10 reported having no programme. LTBI screening was predominantly for asylum seekers (n = 12) and refugees (n = 11). Twelve countries use ‘country of origin’ as the main eligibility criteria. The countries took similar approaches to diagnosis and treatment but different approaches to follow-up. Six experts reported that drop-out rates in migrants were higher compared with non-migrant groups. Most of the experts (n = 22) called for a renewed focus on expanding efforts to screen for LTBI in migrants arriving in low-incidence countries. Conclusion We found a range of approaches to LTBI screening of migrants in the EU/EEA and Switzerland. Findings suggest a renewed focus is needed to expand and strengthen efforts to meaningfully include migrants in these programmes, in order to meet regional and global elimination targets for TB.
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Affiliation(s)
- Ioana Margineanu
- University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Kieran Rustage
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Teymur Noori
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | | | | | | | - Onno Akkerman
- University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Sally Hayward
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom.,The Migrant Health Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Jon S Friedland
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Delia Goletti
- Translational Research Unit, Department of Epidemiology and Preclinical Research, National Institute for Infectious Diseases L. Spallanzani, Rome Italy
| | - Ymkje Stienstra
- University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Sally Hargreaves
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
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- The ESGITM/ESGMYC Study Groups are acknowledged at the end of the article
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7
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Migliori GB, Wu SJ, Matteelli A, Zenner D, Goletti D, Ahmedov S, Al-Abri S, Allen DM, Balcells ME, Garcia-Basteiro AL, Cambau E, Chaisson RE, Chee CBE, Dalcolmo MP, Denholm JT, Erkens C, Esposito S, Farnia P, Friedland JS, Graham S, Hamada Y, Harries AD, Kay AW, Kritski A, Manga S, Marais BJ, Menzies D, Ng D, Petrone L, Rendon A, Silva DR, Schaaf HS, Skrahina A, Sotgiu G, Thwaites G, Tiberi S, Tukvadze N, Zellweger JP, D Ambrosio L, Centis R, Ong CWM. Clinical standards for the diagnosis, treatment and prevention of TB infection. Int J Tuberc Lung Dis 2022; 26:190-205. [PMID: 35197159 PMCID: PMC8886963 DOI: 10.5588/ijtld.21.0753] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND: Tuberculosis (TB) preventive therapy (TPT) decreases the risk of developing TB disease and its associated morbidity and mortality. The aim of these clinical standards is to guide the assessment, management of TB infection (TBI) and implementation of TPT.METHODS: A panel of global experts in the field of TB care was identified; 41 participated in a Delphi process. A 5-point Likert scale was used to score the initial standards. After rounds of revision, the document was approved with 100% agreement.RESULTS: Eight clinical standards were defined: Standard 1, all individuals belonging to at-risk groups for TB should undergo testing for TBI; Standard 2, all individual candidates for TPT (including caregivers of children) should undergo a counselling/health education session; Standard 3, testing for TBI: timing and test of choice should be optimised; Standard 4, TB disease should be excluded prior to initiation of TPT; Standard 5, all candidates for TPT should undergo a set of baseline examinations; Standard 6, all individuals initiating TPT should receive one of the recommended regimens; Standard 7, all individuals who have started TPT should be monitored; Standard 8, a TBI screening and testing register should be kept to inform the cascade of care.CONCLUSION: This is the first consensus-based set of Clinical Standards for TBI. This document guides clinicians, programme managers and public health officers in planning and implementing adequate measures to assess and manage TBI.
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Affiliation(s)
- G B Migliori
- Respiratory Diseases Clinical Epidemiology Unit, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy
| | - S J Wu
- Division of Infectious Diseases, Department of Medicine, National University Hospital, National University Health System, Singapore City
| | - A Matteelli
- Division of Infectious and Tropical Diseases, Spedali Civili University Hospital, Brescia, Italy, WHO Collaborating Centre for TB/HIV Collaborative Activities and for TB Elimination Strategy, University of Brescia, Brescia, Italy
| | - D Zenner
- Centre for Global Public Health, Institute for Population Health Sciences, Queen Mary University, London, UK
| | - D Goletti
- Translational Research Unit, National Institute for Infectious Diseases "Lazzaro Spallanzani", IRCCS, Rome, Italy
| | - S Ahmedov
- USAID, Bureau for Global Health, TB Division, Washington, DC, USA
| | - S Al-Abri
- Directorate General for Disease Surveillance and Control, Ministry of Health, Muscat, Oman
| | - D M Allen
- Division of Infectious Diseases, Department of Medicine, National University Hospital, National University Health System, Singapore City, Infectious Disease Translational Research Programme, Department of Medicine, National University of Singapore, Yong Loo Lin School of Medicine, Singapore City
| | - M E Balcells
- Department of Infectious Diseases, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - A L Garcia-Basteiro
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique, ISGlobal, Barcelona Centre for International Health Research, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - E Cambau
- IAME UMR1137, INSERM, University of Paris, F-75018 Paris; AP-HP-Bichat Hospital, Associate laboratory of National Reference Center for Mycobacteria and Antimycobacterial Resistance, Paris, France
| | - R E Chaisson
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - C B E Chee
- Tuberculosis Control Unit, Tan Tock Seng Hospital, Singapore, Singapore
| | - M P Dalcolmo
- Helio Fraga Reference Center, Oswaldo Cruz Foundation Ministry of Health, Rio de Janeiro, Brazil
| | - J T Denholm
- Victorian Tuberculosis Program, Melbourne Health, Melbourne, VIC, Australia, Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Australia
| | - C Erkens
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | - S Esposito
- Paediatric Clinic, Pietro Barilla Children´s Hospital, University of Parma, Parma, Italy
| | - P Farnia
- Mycobacteriology Research Center (MRC), National Research Institute of Tuberculosis and Lung Disease (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - J S Friedland
- Institute for Infection and Immunity, St George´s, University of London, London, UK
| | - S Graham
- Department of Paediatrics, Center for International Child Health, University of Melbourne, Melbourne, VIC, Australia, Murdoch Children´s Research Institute, Royal Children´s Hospital, Melbourne, Australia
| | - Y Hamada
- Institute for Global Health, University College London, London, UK
| | - A D Harries
- International Union Against Tuberculosis and Lung Disease, Paris, France, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - A W Kay
- The Global Tuberculosis Program, Texas Children´s Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - A Kritski
- Academic Tuberculosis Program Center, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - S Manga
- Operational Center, Medecins Sans Frontieres (MSF), Paris, France
| | - B J Marais
- Department of Infectious Diseases and Microbiology, The Children´s Hospital at Westmead, Westmead, NSW, Australia, The University of Sydney Institute for Infectious Diseases, Sydney, NSW, Australia
| | - D Menzies
- Montréal Chest Institute, Montréal, QC, Canada, Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montréal, QC, Canada, McGill International Tuberculosis Centre, Montréal, QC, Canada
| | - D Ng
- Infectious Diseases, National Centre for Infectious Diseases, Singapore
| | - L Petrone
- Translational Research Unit, National Institute for Infectious Diseases "Lazzaro Spallanzani", IRCCS, Rome, Italy
| | - A Rendon
- Centro de Investigación, Prevención y Tratamiento de Infecciones Respiratorias CIPTIR, University Hospital of Monterrey UANL (Universidad Autonoma de Nuevo Leon), Monterrey, Mexico
| | - D R Silva
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - 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
| | - A Skrahina
- Republican Research and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus
| | - G Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - G Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam, Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - S Tiberi
- Department of Infection, Royal London Hospital, Barts Health NHS Trust, London, UK, Blizard Institute, Queen Mary University of London, London, UK
| | - N Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - J-P Zellweger
- TB Competence Center, Swiss Lung Association, Berne, Switzerland
| | - L D Ambrosio
- Public Health Consulting Group, Lugano, Switzerland
| | - R Centis
- Respiratory Diseases Clinical Epidemiology Unit, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy
| | - C W M Ong
- Division of Infectious Diseases, Department of Medicine, National University Hospital, National University Health System, Singapore City, Infectious Disease Translational Research Programme, Department of Medicine, National University of Singapore, Yong Loo Lin School of Medicine, Singapore City, National University of Singapore Institute for Health Innovation & Technology (iHealthtech), Singapore, Singapore
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8
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Poh XY, Loh FK, Friedland JS, Ong CWM. Neutrophil-Mediated Immunopathology and Matrix Metalloproteinases in Central Nervous System - Tuberculosis. Front Immunol 2022; 12:788976. [PMID: 35095865 PMCID: PMC8789671 DOI: 10.3389/fimmu.2021.788976] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/20/2021] [Indexed: 12/19/2022] Open
Abstract
Tuberculosis (TB) remains one of the leading infectious killers in the world, infecting approximately a quarter of the world’s population with the causative organism Mycobacterium tuberculosis (M. tb). Central nervous system tuberculosis (CNS-TB) is the most severe form of TB, with high mortality and residual neurological sequelae even with effective TB treatment. In CNS-TB, recruited neutrophils infiltrate into the brain to carry out its antimicrobial functions of degranulation, phagocytosis and NETosis. However, neutrophils also mediate inflammation, tissue destruction and immunopathology in the CNS. Neutrophils release key mediators including matrix metalloproteinase (MMPs) which degrade brain extracellular matrix (ECM), tumor necrosis factor (TNF)-α which may drive inflammation, reactive oxygen species (ROS) that drive cellular necrosis and neutrophil extracellular traps (NETs), interacting with platelets to form thrombi that may lead to ischemic stroke. Host-directed therapies (HDTs) targeting these key mediators are potentially exciting, but currently remain of unproven effectiveness. This article reviews the key role of neutrophils and neutrophil-derived mediators in driving CNS-TB immunopathology.
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Affiliation(s)
- Xuan Ying Poh
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Fei Kean Loh
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jon S Friedland
- Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
| | - Catherine W M Ong
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore, Singapore.,Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, Singapore
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9
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Hayward SE, Deal A, Rustage K, Nellums LB, Sweetland AC, Boccia D, Hargreaves S, Friedland JS. The relationship between mental health and risk of active tuberculosis: a systematic review. BMJ Open 2022; 12:e048945. [PMID: 34992103 PMCID: PMC8739435 DOI: 10.1136/bmjopen-2021-048945] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 10/06/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Tuberculosis (TB) and mental illnesses are highly prevalent globally and often coexist. While poor mental health is known to modulate immune function, whether mental disorders play a causal role in TB incidence is unknown. This systematic review examines the association between mental health and TB disease risk to inform clinical and public health measures. DESIGN Systematic review, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. SEARCH STRATEGY AND SELECTION CRITERIA MEDLINE, PsycINFO and PsycEXTRA databases were searched alongside reference list and citation searching. Inclusion criteria were original research studies published 1 January 1970-11 May 2020 reporting data on the association between mental health and TB risk. DATA EXTRACTION, APPRAISAL AND SYNTHESIS Data were extracted on study design and setting, sample characteristics, measurement of mental illness and TB, and outcomes including effect size or prevalence. Studies were critically appraised using Critical Appraisal Skills Programme (CASP) and Appraisal Tool for Cross-Sectional Studies (AXIS) checklists. RESULTS 1546 records published over 50 years were screened, resulting in 10 studies included reporting data from 607 184 individuals. Studies span across Asia, South America and Africa, and include mood and psychotic disorders. There is robust evidence from cohort studies in Asia demonstrating that depression and schizophrenia can increase risk of active TB, with effect estimates ranging from HR=1.15 (95% CI 1.03 to 1.28) to 2.63 (95% CI 1.74 to 3.96) for depression and HR=1.52 (95% CI 1.29 to 1.79) to RR=3.04 for schizophrenia. These data align with evidence from cross-sectional studies, for example, a large survey across low-income and middle-income countries (n=242 952) reports OR=3.68 (95% CI 3.01 to 4.50) for a depressive episode in those with TB symptoms versus those without. CONCLUSIONS Individuals with mental illnesses including depression and schizophrenia experience increased TB incidence and represent a high-risk population to target for screening and treatment. Integrated care for mental health and TB is needed, and interventions tackling mental illnesses and underlying drivers may help reduce TB incidence globally. PROSPERO REGISTRATION NUMBER CRD42019158071.
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Affiliation(s)
- Sally E Hayward
- Institute for Infection and Immunity, St George's, University of London, London, UK
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Anna Deal
- Institute for Infection and Immunity, St George's, University of London, London, UK
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Kieran Rustage
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Laura B Nellums
- Institute for Infection and Immunity, St George's, University of London, London, UK
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Annika C Sweetland
- Department of Psychiatry, Columbia Vagelos College of Physicians and Surgeons, New York State Psychiatric Institute, New York, New York, USA
| | - Delia Boccia
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Sally Hargreaves
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Jon S Friedland
- Institute for Infection and Immunity, St George's, University of London, London, UK
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10
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Rustage K, Crawshaw A, Majeed-Hajaj S, Deal A, Nellums L, Ciftci Y, Fuller SS, Goldsmith L, Friedland JS, Hargreaves S. Participatory approaches in the development of health interventions for migrants: a systematic review. BMJ Open 2021; 11:e053678. [PMID: 34697122 PMCID: PMC8548676 DOI: 10.1136/bmjopen-2021-053678] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE Analysis of participatory approaches to developing health interventions for migrants and how approaches embody core participatory principles of inclusivity and democracy. DESIGN A systematic review of original articles. Electronic searches within the databases MEDLINE, Embase, Global Health and PsychINFO (from inception-November 2020). ELIGIBILITY CRITERIA FOR STUDY SELECTION Original peer-reviewed articles reporting research to develop and implement a health intervention for migrants, incorporating participatory approaches. We defined migrants as foreign-born individuals. Only articles reporting the full research cycle (inception, design, implementation, analysis, evaluation, dissemination) were included. DATA EXTRACTION We extracted information related to who was involved in research (migrants or other non-academic stakeholders), the research stage at which they were involved (inception, design, implementation, analysis, evaluation, dissemination), the method of their involvement and how this aligned with the core principles of participatory research-categorising studies as exhibiting active or pseudo (including proxy and indirect) participation. RESULTS 1793 publications were screened, of which 28 were included in our analysis. We found substantial variation in the application of participatory approaches in designing health interventions targeting migrants: across 168 individual research stages analysed across the 28 studies, we recorded 46 instances of active participation of migrants, 30 instances of proxy participation and 24 instances of indirect participation. All studies involved non-academic stakeholders in at least one stage of the research, only two studies exhibited evidence of active participation of migrants across all research stages. Evidence is limited due to the variability of terms and approaches used. CONCLUSIONS Important shortfalls in the meaningful inclusion of migrants in developing health interventions exist, suggesting a more rigorous and standardised approach is warranted to better define and deliver participatory research and improve quality. REGISTRATION This review followed Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines and is registered on the Open Science Framework (osf.io/2bnz5).
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Affiliation(s)
- Kieran Rustage
- Migrant Health Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Alison Crawshaw
- Migrant Health Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
| | | | - Anna Deal
- Migrant Health Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
- Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Laura Nellums
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | | | - Sebastian S Fuller
- Migrant Health Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Lucy Goldsmith
- Migrant Health Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
- Population Health Research Institute, St George's University of London, London, UK
| | - Jon S Friedland
- Migrant Health Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Sally Hargreaves
- Migrant Health Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
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11
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Hayward SE, Deal A, Rustage K, Nellums LB, Sweetland AC, Boccia D, Hargreaves S, Friedland JS. A systematic review of the association between mental health and tuberculosis disease risk. Eur J Public Health 2021. [DOI: 10.1093/eurpub/ckab164.885] [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: 11/12/2022] Open
Abstract
Abstract
Background
Tuberculosis (TB) and mental illnesses are highly prevalent globally and often co-exist. Whilst poor mental health is known to modulate immune function, whether mental disorders causally increase TB incidence is unknown. This systematic review examines the association between mental health and TB disease risk to inform clinical and public health measures.
Methods
We carried out a systematic review following PRISMA guidelines (PROSPERO CRD42019158071). We searched MEDLINE, PsycINFO and PsycEXTRA databases alongside reference list and citation searching. Inclusion criteria were original research studies published 01/01/1970-11/05/2020 reporting data on the relationship between mental health and risk of TB disease. CASP and AXIS checklists were used to critically appraise included studies.
Results
We screened 1546 records published over 50 years, resulting in data synthesised from 607,184 individuals. Settings include Asia, South America, and Africa, and both mood (e.g. depression) and psychotic (e.g. schizophrenia) disorders are investigated. Robust evidence from cohort studies in Asia shows that depression and schizophrenia can increase risk of TB disease, with effect estimates ranging from HR = 1.15 [95% CI 1.03-1.28] to HR = 2.63 [95% CI 1.74-3.96] for depression and HR = 1.52 [95% CI 1.29-1.79] to RR = 3.04 for schizophrenia, and a dose-response relationship reported in one study. These data are consistent with data from cross-sectional studies, such as a large survey across low- and middle-income countries (n = 242,952) reporting OR = 3.36 [95% CI 3.01-4.50] for a depressive episode in those with TB versus those without.
Conclusions
Individuals with mental illnesses including depression and schizophrenia experience increased TB incidence and represent a high-risk population to target for screening and treatment. Integrated care for mental health and TB is needed, and interventions tackling mental illnesses and underlying drivers may help reduce TB incidence globally.
Key messages
This systematic review examines data from 607,184 individuals and finds evidence that mental health is a risk factor for TB disease. Those suffering from depression and schizophrenia are an at-risk population that could be identified and targeted for TB screening and treatment.
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Affiliation(s)
- SE Hayward
- Institute for Infection and Immunity, St George's, University of London, London, UK
- Faculty of Public Health and Policy, LSHTM, London, UK
| | - A Deal
- Institute for Infection and Immunity, St George's, University of London, London, UK
- Faculty of Public Health and Policy, LSHTM, London, UK
| | - K Rustage
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - LB Nellums
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - AC Sweetland
- Department of Psychiatry, Columbia Vagelos College of Physicians and Surgeons, New York State Psychiatric Institute, New York, USA
| | - D Boccia
- Faculty of Public Health and Policy, LSHTM, London, UK
| | - S Hargreaves
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - JS Friedland
- Institute for Infection and Immunity, St George's, University of London, London, UK
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12
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Deal A, Halliday R, Crawshaw AF, Hayward SE, Burnard A, Rustage K, Carter J, Mehrotra A, Knights F, Campos-Matos I, Majeed A, Friedland JS, Edelstein M, Mounier-Jack S, Hargreaves S. Migration and outbreaks of vaccine-preventable disease in Europe: a systematic review. Lancet Infect Dis 2021; 21:e387-e398. [PMID: 34626552 DOI: 10.1016/s1473-3099(21)00193-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/04/2021] [Accepted: 03/17/2021] [Indexed: 12/25/2022]
Abstract
Migrant populations are one of several underimmunised groups in the EU or European Economic Area (EU/EEA), yet little is known about their involvement in outbreaks of vaccine-preventable diseases. This information is vital to develop targeted strategies to improve the health of diverse migrant communities. We did a systematic review (PROSPERO CRD42019157473; Jan 1, 2000, to May 22, 2020) adhering to PRISMA guidelines, to identify studies on vaccine-preventable disease outbreaks (measles, mumps, rubella, diphtheria, pertussis, polio, hepatitis A, varicella, Neisseria meningitidis, and Haemophilus influenzae) involving migrants residing in the EU/EEA and Switzerland. We identified 45 studies, reporting on 47 distinct vaccine-preventable disease outbreaks across 13 countries. Most reported outbreaks involving migrants were of measles (n=24; 6496 cases), followed by varicella (n=11; 505 cases), hepatitis A (n=7; 1356 cases), rubella (n=3; 487 cases), and mumps (n=2; 293 cases). 19 (40%) outbreaks, predominantly varicella and measles, were reported in temporary refugee camps or shelters. Of 11 varicella outbreaks, nine (82%) were associated with adult migrants. Half of measles outbreaks (n=11) were associated with migrants from eastern European countries. In conclusion, migrants are involved in vaccine-preventable disease outbreaks in Europe, with adult and child refugees residing in shelters or temporary camps at particular risk, alongside specific nationality groups. Vulnerability varies by disease, setting, and demographics, highlighting the importance of tailoring catch-up vaccination interventions to specific groups in order to meet regional and global vaccination targets as recommended by the new Immunisation Agenda 2030 framework for action. A better understanding of vaccine access and intent in migrant groups and a greater focus on co-designing interventions is urgently needed, with direct implications for COVID-19 vaccine delivery.
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Affiliation(s)
- Anna Deal
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK; Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Rae Halliday
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Alison F Crawshaw
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Sally E Hayward
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK; Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Amelia Burnard
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Kieran Rustage
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Jessica Carter
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | | | - Felicity Knights
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Ines Campos-Matos
- Public Health England, London, UK; UCL Collaborative Centre for Inclusion Health, University College London, London, UK
| | - Azeem Majeed
- Department of Primary Care & Public Health, Imperial College London, London, UK
| | - Jon S Friedland
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | | | - Sandra Mounier-Jack
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Sally Hargreaves
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK.
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13
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Rustage K, Lobe J, Hayward SE, Kristensen KL, Margineanu I, Stienstra Y, Goletti D, Zenner D, Noori T, Pareek M, Greenaway C, Friedland JS, Nellums LB, Hargreaves S. Initiation and completion of treatment for latent tuberculosis infection in migrants globally: a systematic review and meta-analysis. Lancet Infect Dis 2021; 21:1701-1712. [PMID: 34363771 PMCID: PMC8612939 DOI: 10.1016/s1473-3099(21)00052-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 01/06/2021] [Accepted: 01/15/2021] [Indexed: 01/01/2023]
Abstract
Background Latent tuberculosis infection (LTBI) is one of the most prevalent infections globally and can lead to the development of active tuberculosis disease. In many low-burden countries, LTBI is concentrated within migrant populations often because of a higher disease burden in the migrant's country of origin. National programmes consequently focus on screening and treating LTBI in migrants to prevent future tuberculosis cases; however, how effective these programmes are is unclear. We aimed to assess LTBI treatment initiation and outcomes among migrants, and the factors that influence both. Methods For this systematic review and meta-analysis, we searched Embase, MEDLINE, and Global Health, and manually searched grey literature from Jan 1, 2000, to April 21, 2020. We included primary research articles reporting on LTBI treatment initiation or completion, or both, in migrants and excluded articles in which data were not stratified by migrant status, or in which the data were related to outcomes before 2000. There were no geographical or language restrictions. All included studies were quality appraised using recognised tools depending on their design, and we assessed the heterogeneity of analyses using I2. We extracted data on the numbers of migrants initiating and completing treatment. Our primary outcomes were LTBI treatment initiation and completion in migrants (defined as foreign-born). We used random-effects meta-regression to examine the influence of factors related to these outcomes. The study is registered with PROSPERO (CRD42019140338). Findings 2199 publications were retrieved screened, after which 39 publications from 13 mostly high-income, low-burden countries were included in our analyses, with treatment initiation and completion data reported for 31 598 migrants positive for LTBI, with not all articles reporting the full pathway from initiation to completion. The pooled estimate for the true proportion of migrants testing positive who initiated treatment was 69% (95% CI 51–84; I2= 99·62%; 4409 of 8764). The pooled estimate for the true proportion of migrants on treatment in datasets, who subsequently completed it was 74% (95% CI = 66–81; I2= 99·19%; 15 516 of 25 629). Where data were provided for the entire treatment pathway, the pooled estimate for the true proportion of migrants who initiated and completed treatment after a positive test was only 52% (95% CI 40–64; I2= 98·90%; 3289 of 6652). Meta-regression showed that LTBI programmes are improving, with more recent reported data (2010–20) associated with better rates of treatment initiation and completion, with multiple complex factors affecting treatment outcomes in migrants. Interpretation Although our analysis highlights that LTBI treatment initiation and completion in migrants has improved considerably from 2010–20, there is still room for improvement, with drop out reported along the entire treatment pathway. The delivery of these screening and treatment programmes will require further strengthening if the targets to eradicate tuberculosis in low-incidence countries are to be met, with greater focus needed on engaging migrants more effectively in the clinic and understanding the diverse and unique barriers and facilitators to migrants initiating and completing treatment. Funding European Society of Clinical Microbiology and Infectious Diseases, the Rosetrees Trust, the National Institute for Health Research, and the Academy of Medical Sciences.
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Affiliation(s)
- Kieran Rustage
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Jessica Lobe
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Sally E Hayward
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's University of London, London, UK; Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Kristina L Kristensen
- Research Centre for Migration, Ethnicity and Health, University of Copenhagen, Copenhagen, Denmark; International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark
| | - Ioana Margineanu
- Department of Internal Medicineand Infectious Diseases, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ymkje Stienstra
- Research Centre for Migration, Ethnicity and Health, University of Copenhagen, Copenhagen, Denmark
| | - Delia Goletti
- Saint Camillus International University of Health and Medical Sciences, Rome, Italy
| | - Dominik Zenner
- Institute for Population Health Sciences, Queen Mary University of London, London, UK
| | - Teymur Noori
- European Centre for Disease Prevention and Control, Solna, Sweden
| | - Manish Pareek
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Christina Greenaway
- Division of Infectious Diseases, Jewish General Hospital, McGill University, Montreal, QC, Canada; Center for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Jon S Friedland
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Laura B Nellums
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Sally Hargreaves
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's University of London, London, UK.
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14
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Miow QH, Vallejo AF, Wang Y, Hong JM, Bai C, Teo FS, Wang AD, Loh HR, Tan TZ, Ding Y, She HW, Gan SH, Paton NI, Lum J, Tay A, Chee CB, Tambyah PA, Polak ME, Wang YT, Singhal A, Elkington PT, Friedland JS, Ong CW. Doxycycline host-directed therapy in human pulmonary tuberculosis. J Clin Invest 2021; 131:e141895. [PMID: 34128838 DOI: 10.1172/jci141895] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 06/11/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUNDMatrix metalloproteinases (MMPs) are key regulators of tissue destruction in tuberculosis (TB) and may be targets for host-directed therapy. We conducted a phase II double-blind, randomized, controlled trial investigating doxycycline, a licensed broad-spectrum MMP inhibitor, in patients with pulmonary TB.METHODSThirty patients with pulmonary TB were enrolled within 7 days of initiating anti-TB treatment and randomly assigned to receive either 100 mg doxycycline or placebo twice a day for 14 days, in addition to standard care.RESULTSWhole blood RNA-sequencing demonstrated that doxycycline accelerated restoration of dysregulated gene expression in TB towards normality, rapidly down-regulating type I and II interferon and innate immune response genes, and up-regulating B-cell modules relative to placebo. The effects persisted for 6 weeks after doxycycline discontinuation, concurrent with suppressed plasma MMP-1. Doxycycline significantly reduced sputum MMP-1, -8, -9, -12 and -13, suppressed type I collagen and elastin destruction, reduced pulmonary cavity volume without altering sputum mycobacterial loads, and was safe.CONCLUSIONAdjunctive doxycycline with standard anti-TB treatment suppressed pathological MMPs in PTB patients. Larger studies on adjunctive doxycycline to limit TB immunopathology are merited.TRIAL REGISTRATIONClinicalTrials.gov NCT02774993.FUNDINGSingapore National Medical Research Council (NMRC/CNIG/1120/2014, NMRC/Seedfunding/0010/2014, NMRC/CISSP/2015/009a); the Singapore Infectious Diseases Initiative (SIDI/2013/013); National University Health System (PFFR-28 January 14, NUHSRO/2014/039/BSL3-SeedFunding/Jul/01); the Singapore Immunology Network Immunomonitoring platform (BMRC/IAF/311006, H16/99/b0/011, NRF2017_SISFP09); an ExxonMobil Research Fellowship, NUHS Clinician Scientist Program (NMRC/TA/0042/2015, CSAINV17nov014); the UK Medical Research Council (MR/P023754/1, MR/N006631/1); a NUS Postdoctoral Fellowship (NUHSRO/2017/073/PDF/03); The Royal Society Challenge Grant (CHG\R1\170084); the Sir Henry Dale Fellowship, Wellcome Trust (109377/Z/15/Z); and A*STAR.
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Affiliation(s)
- Qing Hao Miow
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andres F Vallejo
- Clinical and Experimental Sciences, Sir Henry Wellcome Laboratories, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Yu Wang
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jia Mei Hong
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Chen Bai
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Felicia Sw Teo
- Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, National University Health System, Singapore
| | - Alvin Dy Wang
- Department of Medicine, Ng Teng Fong General Hospital, Singapore
| | - Hong Rong Loh
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tuan Zea Tan
- Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | - Ying Ding
- National Centre for Infectious Diseases, Singapore
| | - Hoi Wah She
- Tuberculosis Control Unit, Tan Tock Seng Hospital, Singapore
| | - Suay Hong Gan
- Tuberculosis Control Unit, Tan Tock Seng Hospital, Singapore
| | - Nicholas I Paton
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Alicia Tay
- Singapore Immunology Network, A*STAR, Singapore
| | - Cynthia Be Chee
- Tuberculosis Control Unit, Tan Tock Seng Hospital, Singapore
| | - Paul A Tambyah
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Marta E Polak
- Clinical and Experimental Sciences, Sir Henry Wellcome Laboratories, Faculty of Medicine, University of Southampton, Southampton, United Kingdom.,Institute for Life Sciences, University of Southampton, Southampton, United Kingdom
| | - Yee Tang Wang
- Tuberculosis Control Unit, Tan Tock Seng Hospital, Singapore
| | | | - Paul T Elkington
- NIHR Respiratory Biomedical Research Centre, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | | | - Catherine Wm Ong
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Institute for Health Innovation and Technology, National University of Singapore, Singapore
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15
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Abstract
In 2019 10 million people developed symptomatic tuberculosis (TB) disease and 1.2 million died. In active TB the inflammatory response causes tissue destruction, which leads to both acute morbidity and mortality. Tissue destruction in TB is driven by host innate immunity and mediated via enzymes, chiefly matrix metalloproteinases (MMPs) which are secreted by leukocytes and stromal cells and degrade the extracellular matrix. Here we review the growing evidence implicating platelets in TB immunopathology. TB patients typically have high platelet counts, which correlate with disease severity, and a hypercoagulable profile. Platelets are present in human TB granulomas and platelet-associated gene transcripts are increased in TB patients versus healthy controls. Platelets most likely drive TB immunopathology through their effect on other immune cells, particularly monocytes, to lead to upregulation of activation markers, increased MMP secretion, and enhanced phagocytosis. Finally, we consider current evidence supporting use of targeted anti-platelet agents in the treatment of TB due to growing interest in developing host-directed therapies to limit tissue damage and improve treatment outcomes. In summary, platelets are implicated in TB disease and contribute to MMP-mediated tissue damage via their cellular interactions with other leukocytes, and are potential targets for novel host-directed therapies.
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Affiliation(s)
- Daniela E Kirwan
- Institute for Infection & Immunity, St. George's, University of London, London, United Kingdom
| | - Deborah L W Chong
- Institute for Infection & Immunity, St. George's, University of London, London, United Kingdom
| | - Jon S Friedland
- Institute for Infection & Immunity, St. George's, University of London, London, United Kingdom
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16
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Kristensen KL, Ravn P, Petersen JH, Hargreaves S, Nellums LB, Friedland JS, Andersen PH, Norredam M, Lillebaek T. Long-term risk of tuberculosis among migrants according to migrant status: a cohort study. Int J Epidemiol 2021; 49:776-785. [PMID: 32380550 DOI: 10.1093/ije/dyaa063] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The majority of tuberculosis (TB) cases in low-incidence countries occur in migrants. Only few studies have assessed the long-term TB risk in migrants after immigration, and datasets have not considered this across a range of diverse migrant groups. This nationwide study aimed to investigate long-term TB risk among migrants according to migrant status and region of origin. METHODS This cohort study included all migrants aged ≥ 18 years who obtained residence in Denmark from 1993 to 2015, with a mean follow-up of 10.8 years [standard deviation (SD) 7.3]. Migrants were categorized based on legal status of residence and region of origin. Incidence rates (IR) and rate ratios (IRR) were estimated by Poisson regression. RESULTS A total of 142 314 migrants were included. Across all migrants, the TB risk was highest during year 1 of residence (IR 275/100 000 person-years; 95% CI 249-305) followed by a gradual decline, though TB risk remained high for over a decade. Compared with the Danish-born population, the IRRs after 7-8 years were particularly higher among former asylum seekers (IRR 31; 95% CI 20-46), quota refugees (IRR 31; 95% CI 16-71), and family-reunified with refugees (IRR 22; 95% CI 12-44). Sub-Saharan African migrants also experienced elevated risk (IRR 75; 95% CI 51-109). The proportion of migrants with pulmonary TB was 52.4%. CONCLUSION All migrant groups experienced an initial high TB risk, but long-term risk remained high in key migrant groups. Most European countries focus TB screening on or soon after arrival. Our study suggests that approaches to TB screening should be adapted, with migrant populations benefiting from long-term access to preventive health services.
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Affiliation(s)
- Kristina Langholz Kristensen
- International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark.,Department of Pulmonary and Infectious Diseases, Nordsjaellands Hospital, Hilleroed, Denmark
| | - Pernille Ravn
- Department of Medicine, Section of Infectious Diseases, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | | | - Sally Hargreaves
- Institute for Infection & Immunity, St George's University of London, London, UK
| | - Laura B Nellums
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jon S Friedland
- Institute for Infection & Immunity, St George's University of London, London, UK
| | - Peter Henrik Andersen
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark
| | - Marie Norredam
- Research Centre for Migration, Ethnicity and Health, University of Copenhagen, Copenhagen, Denmark.,Department of Infectious Diseases, Section of Immigrant Medicine, University Hospital Hvidovre, Hvidovre, Denmark
| | - Troels Lillebaek
- International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark.,Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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17
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Nellums LB, Powis J, Jones L, Miller A, Rustage K, Russell N, Friedland JS, Hargreaves S. "It's a life you're playing with": A qualitative study on experiences of NHS maternity services among undocumented migrant women in England. Soc Sci Med 2021; 270:113610. [PMID: 33383485 PMCID: PMC7895812 DOI: 10.1016/j.socscimed.2020.113610] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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] [Subscribe] [Scholar Register] [Revised: 12/08/2020] [Accepted: 12/10/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Undocumented migrant women experience complex barriers to maternity services, are less likely to receive the recommended level of maternity care, and have poorer obstetric outcomes than non-migrant women. There are concerns increasing restrictions on entitlement to health services have a detrimental impact on access to services and obstetric outcomes, particularly among undocumented migrant women. The study aimed to investigate the experiences of undocumented migrant women who have been pregnant in England, and factors affecting access to care and health outcomes. METHODS We conducted in-depth semi-structured interviews June-December 2017 with a purposive sample of migrant women born outside the UK (aged>18) who had experiences of pregnancy and undocumented status (without permission to reside) in the UK, recruited through Doctors of the World (DOTW) UK. Interpreting services were used on request. Interviews were recorded, transcribed, and analysed using thematic analysis. Ethical approval: Imperial College London Research Ethics Committee (ICREC reference: 17IC3924). RESULTS Semi-structured interviews were conducted with 20 participants, 10 of whom had their first antenatal appointment after the national target of 13 weeks, and nine of whom reported complications. Themes defining women's experiences of pregnancy included: restricted agency, intersecting stressors, and an ongoing cycle of precarity, defined by legal status, social isolation, and economic status. CONCLUSIONS This study provides new evidence of women's experiences of pregnancy in the UK in the context of increasingly restrictive health policies including charging and data sharing. Six recommendations are made to ensure the UK and other migrant receiving countries work towards reducing inequalities and achieving national and global targets for maternal and child health and universal health coverage.
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Affiliation(s)
- Laura B Nellums
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, Hucknall Road, NG5 1PB, UK; Institute for Infection and Immunity, St. George's, University of London, Cranmer Terrace, SW17 0RE, UK.
| | - Jaynaide Powis
- Infectious Diseases & Immunity, Imperial College London, Hammersmith Hospital, Du Cane Road, London, W12 ONN, UK
| | - Lucy Jones
- Doctors of the World UK (Médecins du Monde), 29th Floor, One Canada Square, London, E14 5AA, UK
| | - Anna Miller
- Doctors of the World UK (Médecins du Monde), 29th Floor, One Canada Square, London, E14 5AA, UK
| | - Kieran Rustage
- Institute for Infection and Immunity, St. George's, University of London, Cranmer Terrace, SW17 0RE, UK
| | - Neal Russell
- Institute for Infection and Immunity, St. George's, University of London, Cranmer Terrace, SW17 0RE, UK
| | - Jon S Friedland
- Institute for Infection and Immunity, St. George's, University of London, Cranmer Terrace, SW17 0RE, UK
| | - Sally Hargreaves
- Institute for Infection and Immunity, St. George's, University of London, Cranmer Terrace, SW17 0RE, UK.
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18
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Walker NF, Opondo C, Meintjes G, Jhilmeet N, Friedland JS, Elkington PT, Wilkinson RJ, Wilkinson KA. Invariant Natural Killer T-cell Dynamics in Human Immunodeficiency Virus-associated Tuberculosis. Clin Infect Dis 2021; 70:1865-1874. [PMID: 31190065 PMCID: PMC7156773 DOI: 10.1093/cid/ciz501] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 02/12/2019] [Accepted: 06/11/2019] [Indexed: 01/04/2023] Open
Abstract
Background Tuberculosis (TB) is the leading cause of mortality and morbidity in people living with human immunodeficiency virus (HIV) infection (PLWH). PLWH with TB disease are at risk of the paradoxical TB-associated immune reconstitution inflammatory syndrome (TB-IRIS) when they commence antiretroviral therapy. However, the pathophysiology is incompletely understood and specific therapy is lacking. We investigated the hypothesis that invariant natural killer T (iNKT) cells contribute to innate immune dysfunction associated with TB-IRIS. Methods In a cross-sectional study of 101 PLWH and HIV-uninfected South African patients with active TB and controls, iNKT cells were enumerated using α-galactosylceramide-loaded CD1d tetramers and subsequently functionally characterized by flow cytometry. In a second study of 49 people with HIV type 1 (HIV-1) and active TB commencing antiretroviral therapy, iNKT cells in TB-IRIS patients and non-IRIS controls were compared longitudinally. Results Circulating iNKT cells were reduced in HIV-1 infection, most significantly the CD4+ subset, which was inversely associated with HIV-1 viral load. iNKT cells in HIV-associated TB had increased surface CD107a expression, indicating cytotoxic degranulation. Relatively increased iNKT cell frequency in patients with HIV-1 infection and active TB was associated with development of TB-IRIS following antiretroviral therapy initiation. iNKT cells in TB-IRIS were CD4+CD8– subset depleted and degranulated around the time of TB-IRIS onset. Conclusions Reduced iNKT cell CD4+ subsets as a result of HIV-1 infection may skew iNKT cell functionality toward cytotoxicity. Increased CD4– cytotoxic iNKT cells may contribute to immunopathology in TB-IRIS.
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Affiliation(s)
- Naomi F Walker
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa.,Infectious Diseases and Immunity, and Imperial College Wellcome Trust Centre for Global Health, Imperial College London, United Kingdom.,Department of Medicine, University of Cape Town, Observatory, South Africa.,Tuberculosis Centre and Department of Clinical Research
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa.,Department of Medicine, University of Cape Town, Observatory, South Africa
| | - Nishtha Jhilmeet
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
| | - Jon S Friedland
- Institute of Infection and Immunity, St George's, University of London
| | - Paul T Elkington
- Infectious Diseases and Immunity, and Imperial College Wellcome Trust Centre for Global Health, Imperial College London, United Kingdom.,National Institute for Health Research Biomedical Research Centre, School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa.,Department of Medicine, University of Cape Town, Observatory, South Africa.,Francis Crick Institute, London.,Department of Medicine, Imperial College London, United Kingdom
| | - Katalin A Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa.,Department of Medicine, University of Cape Town, Observatory, South Africa.,Francis Crick Institute, London
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19
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Hayward SE, Rustage K, Nellums LB, van der Werf MJ, Noori T, Boccia D, Friedland JS, Hargreaves S. Extrapulmonary tuberculosis among migrants in Europe, 1995 to 2017. Clin Microbiol Infect 2020; 27:1347.e1-1347.e7. [PMID: 33352301 PMCID: PMC8437049 DOI: 10.1016/j.cmi.2020.12.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/07/2020] [Accepted: 12/10/2020] [Indexed: 11/18/2022]
Abstract
Objectives The proportion of tuberculosis (TB) cases occurring in migrants in Europe is increasing. Extrapulmonary TB poses challenges in diagnosis and treatment and causes serious morbidity and mortality, yet its extent in migrant populations is unclear. We assessed patterns of extrapulmonary TB in migrants across the European Union (EU)/European Free Trade Association (EFTA). We investigated the proportion of extrapulmonary TB cases among migrants versus non-migrants, and variations by specific site of disease, reporting European region, and migrant region of origin. Methods We carried out a cross-sectional secondary database analysis, utilizing 23 years of data collected between 1995 and 2017 from the European Surveillance System of the European Centre for Disease Prevention and Control for 32 EU/EFTA countries. Results In total, 1 270 896 TB cases were included, comprising 326 987 migrants (25.7%) and 943 909 non-migrants (74.3%). Of TB cases among migrants, 45.2% (n = 147 814) were extrapulmonary compared to 21.7% (n = 204 613) among non-migrants (p < 0.001). Lymphatic, bone/joint and peritoneal/digestive TB were more common among migrant than non-migrant extrapulmonary cases. A lower proportion of extrapulmonary TB was seen in Eastern Europe (17.4%, n = 98 656 of 566 170) and Southern Europe (29.6%, n = 62 481 of 210 828) compared with Western (35.7%, n = 89 498 of 250 517) and Northern Europe (41.8%, n = 101 792 of 243 381). Migrants from South-East Asia and Sub-Saharan Africa were at highest risk of extrapulmonary disease, with 62.0% (n = 55 401 of 89 353) and 54.5% (n = 38 327 of 70 378) of cases, respectively, being extrapulmonary. Conclusions Among TB cases in the EU/EFTA, extrapulmonary disease is significantly more common in migrants than in non-migrants. There is a need to improve clinical awareness of extrapulmonary TB and to integrate its detection into screening programmes.
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Affiliation(s)
- Sally E Hayward
- Institute for Infection and Immunity, St George's, University of London, London, UK; Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK.
| | - Kieran Rustage
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Laura B Nellums
- Institute for Infection and Immunity, St George's, University of London, London, UK; Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | | | - Teymur Noori
- European Centre for Disease Prevention and Control (ECDC), Solna, Sweden
| | - Delia Boccia
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jon S Friedland
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Sally Hargreaves
- Institute for Infection and Immunity, St George's, University of London, London, UK
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20
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Carter J, Friedland JS, Kirwan DE, Nathavitharana RR. Translating scientific discoveries during pandemics: ensuring equity for people affected by COVID-19 and tuberculosis. ERJ Open Res 2020; 6:00562-2020. [PMID: 33204676 PMCID: PMC7659031 DOI: 10.1183/23120541.00562-2020] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 09/01/2020] [Indexed: 12/15/2022] Open
Abstract
The coronavirus SARS-CoV-2 has reached almost every corner of the globe. Trillions of dollars are being invested in the COVID-19 pandemic response to support frontline clinical and public health efforts and spur rapid advances in scientific research. Concurrently, we are in the grip of a pandemic of greater longevity that receives scant public attention despite causing 4000 deaths each day [1]. It strikes disproportionately at the poor, treatment is unsatisfactory, and there is no effective vaccine with lasting immunity. This is tuberculosis (TB), another respiratory pathogen that has much in common with COVID-19. In contrast to COVID-19, citizens of rich countries do not feel threatened by TB, which has long been associated with poverty and is therefore not a strategic priority. The rise in isolationism, nationalism, xenophobia, and racism has had negative impacts on health policy that have impaired global and national responses to TB [2]. It is against these barriers that the global response to COVID-19 has also been struggling. Worryingly, early models predict that the COVID-19 pandemic may drive an additional 6.3 million TB cases and 1.3 million deaths by 2025 [3] and early data indicate interactions between these diseases [4, 5]. Despite the political rhetoric suggesting that “we are all in this together” when it comes to COVID-19, closer inspection through the lens of TB reminds us that when it comes to benefitting from scientific advances to improve health, we are not all equal. The #COVID19 pandemic has emphasised major global health inequities: this editorial argues lessons learnt from TB must remind us of the gaps in the research agenda that must be addressed to ensure that scientific advances are equitably disseminatedhttps://bit.ly/3bTZHS3
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Affiliation(s)
- Jessica Carter
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Jon S Friedland
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Daniela E Kirwan
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Ruvandhi R Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School Boston, Boston, MA, USA
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21
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Ong CWM, Migliori GB, Raviglione M, MacGregor-Skinner G, Sotgiu G, Alffenaar JW, Tiberi S, Adlhoch C, Alonzi T, Archuleta S, Brusin S, Cambau E, Capobianchi MR, Castilletti C, Centis R, Cirillo DM, D'Ambrosio L, Delogu G, Esposito SMR, Figueroa J, Friedland JS, Ho BCH, Ippolito G, Jankovic M, Kim HY, Rosales Klintz S, Ködmön C, Lalle E, Leo YS, Leung CC, Märtson AG, Melazzini MG, Najafi Fard S, Penttinen P, Petrone L, Petruccioli E, Pontali E, Saderi L, Santin M, Spanevello A, van Crevel R, van der Werf MJ, Visca D, Viveiros M, Zellweger JP, Zumla A, Goletti D. Epidemic and pandemic viral infections: impact on tuberculosis and the lung: A consensus by the World Association for Infectious Diseases and Immunological Disorders (WAidid), Global Tuberculosis Network (GTN), and members of the European Society of Clinical Microbiology and Infectious Diseases Study Group for Mycobacterial Infections (ESGMYC). Eur Respir J 2020; 56:2001727. [PMID: 32586885 PMCID: PMC7527651 DOI: 10.1183/13993003.01727-2020] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [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: 05/11/2020] [Accepted: 06/12/2020] [Indexed: 01/08/2023]
Abstract
Major epidemics, including some that qualify as pandemics, such as severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), HIV, influenza A (H1N1)pdm/09 and most recently COVID-19, affect the lung. Tuberculosis (TB) remains the top infectious disease killer, but apart from syndemic TB/HIV little is known regarding the interaction of viral epidemics and pandemics with TB. The aim of this consensus-based document is to describe the effects of viral infections resulting in epidemics and pandemics that affect the lung (MERS, SARS, HIV, influenza A (H1N1)pdm/09 and COVID-19) and their interactions with TB. A search of the scientific literature was performed. A writing committee of international experts including the European Centre for Disease Prevention and Control Public Health Emergency (ECDC PHE) team, the World Association for Infectious Diseases and Immunological Disorders (WAidid), the Global Tuberculosis Network (GTN), and members of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Mycobacterial Infections (ESGMYC) was established. Consensus was achieved after multiple rounds of revisions between the writing committee and a larger expert group. A Delphi process involving the core group of authors (excluding the ECDC PHE team) identified the areas requiring review/consensus, followed by a second round to refine the definitive consensus elements. The epidemiology and immunology of these viral infections and their interactions with TB are discussed with implications for diagnosis, treatment and prevention of airborne infections (infection control, viral containment and workplace safety). This consensus document represents a rapid and comprehensive summary on what is known on the topic.
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Affiliation(s)
- Catherine Wei Min Ong
- Dept of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore
- These authors contributed equally
- Members of ESGMYC
| | - Giovanni Battista Migliori
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy
- These authors contributed equally
| | - Mario Raviglione
- Centre for Multidisciplinary Research in Health Science, University of Milan, Milan, Italy
- Global Studies Institute, University of Geneva, Geneva, Switzerland
| | | | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Dept of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Jan-Willem Alffenaar
- Sydney Pharmacy School, University of Sydney, Sydney, Australia
- Westmead Hospital, Sydney, Australia
- Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
- Members of ESGMYC
| | - Simon Tiberi
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Division of Infection, Royal London Hospital, Barts Health NHS Trust, London, UK
- Members of ESGMYC
| | - Cornelia Adlhoch
- Public Health Emergency Team, European Centre for Disease Prevention and Control, Stockholm, Sweden
- European Centre for Disease Prevention and Control Public Health Emergency team co-authors
| | - Tonino Alonzi
- Translational Research Unit, Epidemiology and Preclinical Research Dept, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
| | - Sophia Archuleta
- Dept of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Sergio Brusin
- Public Health Emergency Team, European Centre for Disease Prevention and Control, Stockholm, Sweden
- European Centre for Disease Prevention and Control Public Health Emergency team co-authors
| | - Emmanuelle Cambau
- AP-HP-Lariboisiere, Bacteriologie, Laboratory Associated to the National Reference Centre for Mycobacteria, IAME UMR1137, INSERM, University of Paris, Paris, France
- Members of ESGMYC
| | - Maria Rosaria Capobianchi
- Laboratory of Virology, Epidemiology and Preclinical Research Dept, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
| | - Concetta Castilletti
- Laboratory of Virology, Epidemiology and Preclinical Research Dept, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
| | - Rosella Centis
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy
| | - Daniela M Cirillo
- Emerging Bacterial Pathogens Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Members of ESGMYC
| | | | - Giovanni Delogu
- Università Cattolica Sacro Cuore, Roma, Italy
- Mater Olbia Hospital, Olbia, Italy
- Members of ESGMYC
| | - Susanna M R Esposito
- Pediatric Clinic, Pietro Barilla Children's Hospital, University of Parma, Parma, Italy
| | | | - Jon S Friedland
- St George's, University of London, London, UK
- Members of ESGMYC
| | - Benjamin Choon Heng Ho
- Tuberculosis Control Unit, Dept of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
| | - Giuseppe Ippolito
- Scientific Direction, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
| | - Mateja Jankovic
- School of Medicine, University of Zagreb and Clinic for Respiratory Diseases, University Hospital Center Zagreb, Zagreb, Croatia
- Members of ESGMYC
| | - Hannah Yejin Kim
- Sydney Pharmacy School, University of Sydney, Sydney, Australia
- Westmead Hospital, Sydney, Australia
- Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
| | - Senia Rosales Klintz
- Public Health Emergency Team, European Centre for Disease Prevention and Control, Stockholm, Sweden
- European Centre for Disease Prevention and Control Public Health Emergency team co-authors
| | - Csaba Ködmön
- Public Health Emergency Team, European Centre for Disease Prevention and Control, Stockholm, Sweden
- European Centre for Disease Prevention and Control Public Health Emergency team co-authors
| | - Eleonora Lalle
- Laboratory of Virology, Epidemiology and Preclinical Research Dept, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
| | - Yee Sin Leo
- National Centre for Infectious Diseases, Singapore
| | - Chi-Chiu Leung
- Hong Kong Tuberculosis, Chest and Heart Diseases Association, Wanchai, Hong Kong, China
| | - Anne-Grete Märtson
- Dept of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Saeid Najafi Fard
- Translational Research Unit, Epidemiology and Preclinical Research Dept, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
| | - Pasi Penttinen
- Public Health Emergency Team, European Centre for Disease Prevention and Control, Stockholm, Sweden
- European Centre for Disease Prevention and Control Public Health Emergency team co-authors
| | - Linda Petrone
- Translational Research Unit, Epidemiology and Preclinical Research Dept, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
| | - Elisa Petruccioli
- Translational Research Unit, Epidemiology and Preclinical Research Dept, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
| | | | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Dept of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Miguel Santin
- Dept of Infectious Diseases, Bellvitge University Hospital-Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
- Dept of Clinical Science, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
- Members of ESGMYC
| | - Antonio Spanevello
- Division of Pulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS, Tradate, Italy
- Dept of Medicine and Surgery, Respiratory Diseases, University of Insubria, Varese-Como, Italy
| | - Reinout van Crevel
- Radboudumc Center for Infectious Diseases, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
- Members of ESGMYC
| | - Marieke J van der Werf
- Public Health Emergency Team, European Centre for Disease Prevention and Control, Stockholm, Sweden
- European Centre for Disease Prevention and Control Public Health Emergency team co-authors
| | - Dina Visca
- Division of Pulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS, Tradate, Italy
- Dept of Medicine and Surgery, Respiratory Diseases, University of Insubria, Varese-Como, Italy
| | - Miguel Viveiros
- Global Health and Tropical Medicine, Institute of Hygiene and Tropical Medicine, NOVA University of Lisbon, Lisbon, Portugal
- Members of ESGMYC
| | | | - Alimuddin Zumla
- Dept of Infection, Division of Infection and Immunity, University College London and NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, UK
| | - Delia Goletti
- Translational Research Unit, Epidemiology and Preclinical Research Dept, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
- Saint Camillus International University of Health and Medical Sciences, Rome, Italy
- Members of ESGMYC
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22
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Langholz Kristensen K, Lillebaek T, Holm Petersen J, Hargreaves S, Nellums LB, Friedland JS, Andersen PH, Ravn P, Norredam M. Tuberculosis incidence among migrants according to migrant status: a cohort study, Denmark, 1993 to 2015. ACTA ACUST UNITED AC 2020; 24. [PMID: 31690363 PMCID: PMC6836680 DOI: 10.2807/1560-7917.es.2019.24.44.1900238] [Citation(s) in RCA: 14] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Migrants account for the majority of tuberculosis (TB) cases in low-incidence countries in western Europe. TB incidence among migrants might be influenced by patterns of migration, but this is not well understood. Aim To investigate differences in TB risk across migrant groups according to migrant status and region of origin. Methods This prospective cohort study included migrants ≥ 18 years of age who obtained residency in Denmark between 1 January 1993 and 31 December 2015, matched 1:6 to Danish-born individuals. Migrants were grouped according to legal status of residency and region of origin. Incidence rates (IR) and incidence rate ratios (IRR) were estimated by Poisson regression. Results The cohort included 142,314 migrants. Migrants had significantly higher TB incidence (IR: 120/100,000 person-years (PY); 95% confidence interval (CI): 115–126) than Danish-born individuals (IR: 4/100,000 PY; 95% CI: 3–4). The IRR was significantly higher in all migrant groups compared with Danish-born (p < 0.01). A particularly higher risk was seen among family-reunified to refugees (IRR: 61.8; 95% CI: 52.7–72.4), quota refugees (IRR: 46.0; 95% CI: 36.6–57.6) and former asylum seekers (IRR: 45.3; 95% CI: 40.2–51.1), whereas lower risk was seen among family-reunified to Danish/Nordic citizens (IRR 15.8; 95% CI: 13.6–18.4) and family-reunified to immigrants (IRR: 16.9; 95% CI: 13.5–21.3). Discussion All migrants had higher TB risk compared with the Danish-born population. While screening programmes focus mostly on asylum seekers, other migrant groups with high risk of TB are missed. Awareness of TB risk in all high-risk groups should be strengthened and screening programmes should be optimised.
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Affiliation(s)
- Kristina Langholz Kristensen
- Department of Pulmonary and Infectious Diseases, Nordsjællands Hospital, Hillerød, Denmark.,International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark
| | - Troels Lillebaek
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark
| | | | - Sally Hargreaves
- Institute for Infection & Immunity, St. George's, University of London, London, United Kingdom
| | - Laura B Nellums
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Jon S Friedland
- Institute for Infection & Immunity, St. George's, University of London, London, United Kingdom
| | - Peter Henrik Andersen
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark
| | - Pernille Ravn
- Department of Medicine, Infectious Disease Section, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Marie Norredam
- Department of Infectious Diseases, Section of Immigrants Medicine, University Hospital Hvidovre, Hvidovre, Denmark.,Research Centre for Migration, Ethnicity and Health, University of Copenhagen, Copenhagen, Denmark
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23
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Hayward SE, van der Werf MJ, Noori T, Nellums LB, Boccia D, Friedland JS, Hargreaves S. Extrapulmonary tuberculosis among migrants in the EU/EFTA: Implications for policy and practice. Eur J Public Health 2020. [DOI: 10.1093/eurpub/ckaa165.793] [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: 11/12/2022] Open
Abstract
Abstract
Background
The proportion of tuberculosis (TB) cases in the European Union/European Free Trade Association (EU/EFTA) that occur in migrants is increasing. Extrapulmonary TB poses challenges in diagnosis and treatment and causes serious morbidity and mortality. To date, there has been no in-depth exploration of extrapulmonary TB in migrants across Europe.
Methods
We analysed 22 years of data from the European Centre for Disease Prevention and Control's European Surveillance System (TESSy) for 32 EU/EFTA countries between 1995 and 2017. We investigated whether the proportion of TB cases that were extrapulmonary varied between migrants and non-migrants, and whether this varied by a) country/region of origin, b) reporting country/region, and c) site of disease.
Results
1,270,896 TB cases were included in the analysis, comprising 326,987 (25.7%) migrants, and 943,909 (74.3%) non-migrants. The proportion of TB that is extrapulmonary is significantly higher in migrants than in non-migrants: 45.2% (n = 147,814) of cases in migrants were extrapulmonary, compared to 21.7% (n = 204,613) in non-migrants (χ2=6.7x104, p < 0.001). A relatively low proportion of extrapulmonary TB was seen in Eastern (17.4%) and Southern (29.6%) Europe compared with Western (35.7%) and Northern (41.8%) Europe, with migrants having a greater proportion of extrapulmonary TB only in Northern/Western Europe. Migrants from South-East Asia and Sub-Saharan Africa were at highest risk of extrapulmonary TB, with over half of all cases being extrapulmonary (62.0% and 54.5% respectively).
Conclusions
Among TB cases in the EU/EFTA, extrapulmonary disease is significantly more common in migrants than non-migrants, which has clinical and policy implications for patient detection and management. There is a need to improve clinical awareness of extrapulmonary TB, integrate detection of extrapulmonary TB into latent TB infection screening programmes, and harmonise data collection on migrant status in health systems.
Key messages
Migrants in the EU/EFTA are disproportionately affected by extrapulmonary TB compared to non-migrants. This has clinical and policy implications for diagnosis, screening, and data collection.
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Affiliation(s)
- S E Hayward
- Institute for Infection and Immunity, St George's, University of London, London, UK
- Faculty of Public Health and Policy, LSHTM, London, UK
| | - M J van der Werf
- European Centre for Disease Prevention and Control, Solna, Sweden
| | - T Noori
- European Centre for Disease Prevention and Control, Solna, Sweden
| | - L B Nellums
- Institute for Infection and Immunity, St George's, University of London, London, UK
- Division of Epidemiology & Public Health, University of Nottingham, Nottingham, UK
| | - D Boccia
- Faculty of Public Health and Policy, LSHTM, London, UK
| | - J S Friedland
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - S Hargreaves
- Institute for Infection and Immunity, St George's, University of London, London, UK
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24
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Sloth LB, Nielsen RT, Østergaard C, Nellums LB, Hargreaves S, Friedland JS, Norredam M. Antibiotic resistance patterns of Escherichia coli in migrants vs non-migrants: a study of 14 561 urine samples. J Travel Med 2019; 26:taz080. [PMID: 31651032 PMCID: PMC6927324 DOI: 10.1093/jtm/taz080] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 08/31/2019] [Revised: 10/10/2019] [Accepted: 10/10/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND To investigate the distribution of urine isolates and antibiotic resistance patterns in the predominant uropathogen Escherichia coli in migrant and non-migrant individuals. METHODS We linked a cohort consisting of all migrants obtaining residence as refugees or family-reunited migrants in Denmark between January 1993 and December 2015 to hospital urine samples examined from January 2000 to December 2015 at the Department of Microbiology, University Hospital Hvidovre, Denmark. Samples from non-migrant individuals, Danish-born from Danish parents, were included as comparison. Analysis was carried out using multivariate logistic regression. RESULTS There were 14 561 first-time urine samples included, with E. coli being the most prevalent bacterial pathogen. Of the identified isolates, 4686/11 737 were E. coli among non-migrants and 1032/2824 among migrants.Sulfamethoxazol-Trimethoprim (SXT) resistance was found in 34.3% (350/1020) of E. coli isolates among migrants and 23.2% (1070/4619) among non-migrant patients [odds ratio (OR) 1.73, 95% confidence interval (CI): 1.47-2.03]. Ciprofloxacin resistance was found in 5.8% (36/618) of isolates among migrants and 2.2% (67/3092) among non-migrants (OR 2.20, 95% CI: 1.37-3.53). Gentamicin (GEN) resistance was seen in 10.8% (61/565) and 4.7% (110/2328) of isolates (OR 2.33, 95% CI:1.63-3.34), Cefuroxime resistance in 8.5% (87/1019) and 3.4% (158/4618) (OR 2.40, 95% CI:1.77-3.24), Ampicillin (AMP) resistance in 51.4% and 40.8% (OR 1.65, 95% CI: 1.42-1.92) and Piperacillin-Tazobactam resistance in 6.9% (30/432) and 4.2% (65/1532) for migrant and non-migrant patients, respectively. When stratifying according to migrant status, family-reunited had higher odds of resistance than refugees for SXT, GEN and AMP. CONCLUSIONS Prevalence of antibiotic resistance was significantly higher in E. coli isolates among migrants, both refugees and family-reunited, than non-migrant patients. Differences could not be explained by comorbidity or income. The results emphasize the importance of urine sample testing in both local-born and migrants before antibiotic start-up and point to the benefit of considering migration to secure individual treatment and equal health outcomes.
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Affiliation(s)
- Louise B Sloth
- Section of Immigrant Medicine, Department of Infectious Diseases, University Hospital Hvidovre, Hvidovre, Denmark
| | - Rikke T Nielsen
- Department of Clinical Microbiology, University Hospital Hvidovre, Hvidovre, Denmark
- Research Centre for Migration, Ethnicity and Health, University of Copenhagen, Copenhagen, Denmark
| | - Christian Østergaard
- Department of Clinical Microbiology, University Hospital Hvidovre, Hvidovre, Denmark
| | - Laura B Nellums
- Infection and Immunity, St. George’s, University of London, London, UK
| | - Sally Hargreaves
- Infection and Immunity, St. George’s, University of London, London, UK
| | - Jon S Friedland
- Infection and Immunity, St. George’s, University of London, London, UK
| | - Marie Norredam
- Section of Immigrant Medicine, Department of Infectious Diseases, University Hospital Hvidovre, Hvidovre, Denmark
- Research Centre for Migration, Ethnicity and Health, University of Copenhagen, Copenhagen, Denmark
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25
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Tanoglu A, Erdem H, Friedland JS, Almajid FM, Batirel A, Kulzhanova S, Konkayeva M, Smagulova Z, Pehlivanoglu F, de Saram S, Gulsun S, Amer F, Balkan II, Tekin R, Cascio A, Dauby N, Sirmatel F, Tasbakan M, Erdem A, Wegdan AA, Aydin O, Cesur S, Deniz S, Senbayrak S, Denk A, Duzenli T, Siméon S, Oncul A, Ozseker B, Yakar T, Ormeci N. Clinicopathological profile of gastrointestinal tuberculosis: a multinational ID-IRI study. Eur J Clin Microbiol Infect Dis 2019; 39:493-500. [DOI: 10.1007/s10096-019-03749-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 10/24/2019] [Indexed: 12/30/2022]
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26
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Hargreaves S, Himmels J, Nellums LB, McGuire E, Friedland JS. Vaccination status of migrant populations in EU/EEA countries and implications for VPD control. Eur J Public Health 2019. [DOI: 10.1093/eurpub/ckz185.015] [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: 11/14/2022] Open
Abstract
Abstract
Background
Migrant populations in the EU/EEA are increasingly being associated with outbreaks of vaccine-preventable diseases (VPDs), including the large-scale measles outbreak currently ongoing across Europe; however, it is unclear to what extent migrants represent an under-immunised group in the European context and implications for VPD control. Ensuring high levels of vaccination coverage is a key priority for all countries through the European Vaccine Action Plan, with EU/EEA Member States committed to eliminating measles and rubella, sustaining polio-free status, and controlling hepatitis B infection. We synthesised existing EU/EEA data to assess under-immunisation in migrants (defined as foreign born) residing in EU/EEA countries.
Methods
We did a systematic review and meta-analysis (PROSPERO CRD42018103666) in accordance with PRISMA guidelines. Inclusion criteria were primary research studies pertaining to vaccination status (measles, mumps, rubella, diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type b [Hib]) in migrants residing in all EU/EEA countries. Pooled prevalence (95% CIs) were calculated for the meta-analysis using a random effects model.
Results
56 studies met our criteria (14 EU/EEA countries); 36 studies, which included data from 80,432 migrants, were included in the meta-analysis. Vaccination status of migrants for key VPDs varied substantially, with pooled immunisation coverage well below the herd immunity threshold (HIT) targets for measles 80% (95% CI: 73-87%; HIT 92-95%), mumps 65% (95% CI: 48-82%; HIT 75-86%), and diphtheria 51% (95% CI: 29-73%; HIT 83-86%). Polio type 1 and 2 coverage was high (97% [95% CI: 95-98%]; 95 [95% CI: 92-97%], respectively).
Conclusions
Migrants represent an under-immunised group in Europe, thus a high priority group for catch-up vaccination. Innovative strategies to engage them in vaccine uptake will be critical if we are to make European targets for the elimination and/or control of key VPDs.
Key messages
Migrants represent an under-immunised group in Europe and a high priority group for catch-up vaccination campaigns. Innovative strategies to engage them in vaccine uptake will be critical if we are to make European targets for the elimination and control of vaccine-preventable diseases.
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Affiliation(s)
- S Hargreaves
- Institute for Infection and Immunity, St George’s University of London, London, UK
| | - J Himmels
- Institute for Infection and Immunity, St George’s University of London, London, UK
| | - L B Nellums
- Institute for Infection and Immunity, St George’s University of London, London, UK
| | - E McGuire
- Institute for Infection and Immunity, St George’s University of London, London, UK
| | - J S Friedland
- Institute for Infection and Immunity, St George’s University of London, London, UK
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27
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Kristensen KL, Lillebaek T, Petersen JH, Hargreaves S, Nellums L, Friedland JS, Andersen PH, Ravn P, Noerredam M. Long-term incidence of tuberculosis among migrants according to migrant status: a cohort study. Tuberculosis (Edinb) 2019. [DOI: 10.1183/13993003.congress-2019.oa3819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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28
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Fox KA, Kirwan DE, Whittington AM, Krishnan N, Robertson BD, Gilman RH, López JW, Singh S, Porter JC, Friedland JS. Platelets Regulate Pulmonary Inflammation and Tissue Destruction in Tuberculosis. Am J Respir Crit Care Med 2019; 198:245-255. [PMID: 29420060 DOI: 10.1164/rccm.201710-2102oc] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [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: 01/01/2023] Open
Abstract
RATIONALE Platelets may interact with the immune system in tuberculosis (TB) to regulate human inflammatory responses that lead to morbidity and spread of infection. OBJECTIVES To identify a functional role of platelets in the innate inflammatory and matrix-degrading response in TB. METHODS Markers of platelet activation were examined in plasma from 50 patients with TB before treatment and 50 control subjects. Twenty-five patients were followed longitudinally. Platelet-monocyte interactions were studied in a coculture model infected with live, virulent Mycobacterium tuberculosis (M.tb) and dissected using qRT-PCR, Luminex multiplex arrays, matrix degradation assays, and colony counts. Immunohistochemistry detected CD41 (cluster of differentiation 41) expression in a pulmonary TB murine model, and secreted platelet factors were measured in BAL fluid from 15 patients with TB and matched control subjects. MEASUREMENTS AND MAIN RESULTS Five of six platelet-associated mediators were upregulated in plasma of patients with TB compared with control subjects, with concentrations returning to baseline by Day 60 of treatment. Gene expression of the monocyte collagenase MMP-1 (matrix metalloproteinase-1) was upregulated by platelets in M.tb infection. Platelets also enhanced M.tb-induced MMP-1 and -10 secretion, which drove type I collagen degradation. Platelets increased monocyte IL-1 and IL-10 and decreased IL-12 and MDC (monocyte-derived chemokine; also known as CCL-22) secretion, as consistent with an M2 monocyte phenotype. Monocyte killing of intracellular M.tb was decreased. In the lung, platelets were detected in a TB mouse model, and secreted platelet mediators were upregulated in human BAL fluid and correlated with MMP and IL-1β concentrations. CONCLUSIONS Platelets drive a proinflammatory, tissue-degrading phenotype in TB.
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Affiliation(s)
- Katharine A Fox
- 1 Infectious Diseases and Immunity, Wellcome Trust Centre for Global Health Research, and
| | - Daniela E Kirwan
- 1 Infectious Diseases and Immunity, Wellcome Trust Centre for Global Health Research, and
| | - Ashley M Whittington
- 1 Infectious Diseases and Immunity, Wellcome Trust Centre for Global Health Research, and
| | - Nitya Krishnan
- 2 Medical Research Council Centre for Molecular Bacteriology and Infection, Department of Medicine, Imperial College London, United Kingdom
| | - Brian D Robertson
- 2 Medical Research Council Centre for Molecular Bacteriology and Infection, Department of Medicine, Imperial College London, United Kingdom
| | - Robert H Gilman
- 3 Department of International Health, Johns Hopkins University, Baltimore Maryland.,4 Laboratorio de Investigación en Enfermedades Infecciosas, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - José W López
- 5 Laboratorio de Bioinformática y Biología Molecular, Universidad Peruana Cayetano Heredia, Lima, Peru.,6 Instituto Nacional de Salud del Niño, Lima, Peru; and
| | - Shivani Singh
- 1 Infectious Diseases and Immunity, Wellcome Trust Centre for Global Health Research, and
| | - Joanna C Porter
- 7 Centre for Inflammation and Tissue Repair, Respiratory Medicine, University College London, United Kingdom
| | - Jon S Friedland
- 1 Infectious Diseases and Immunity, Wellcome Trust Centre for Global Health Research, and
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29
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Knight GM, Zimic M, Funk S, Gilman RH, Friedland JS, Grandjean L. The relative fitness of drug-resistant Mycobacterium tuberculosis: a modelling study of household transmission in Peru. J R Soc Interface 2019; 15:rsif.2018.0025. [PMID: 29950511 PMCID: PMC6030636 DOI: 10.1098/rsif.2018.0025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 06/05/2018] [Indexed: 12/22/2022] Open
Abstract
The relative fitness of drug-resistant versus susceptible bacteria in an environment dictates resistance prevalence. Estimates for the relative fitness of resistant Mycobacterium tuberculosis (Mtb) strains are highly heterogeneous and mostly derived from in vitro experiments. Measuring fitness in the field allows us to determine how the environment influences the spread of resistance. We designed a household structured, stochastic mathematical model to estimate the fitness costs associated with multidrug resistance (MDR) carriage in Mtb in Lima, Peru during 2010–2013. By fitting the model to data from a large prospective cohort study of TB disease in household contacts, we estimated the fitness, relative to susceptible strains with a fitness of 1, of MDR-Mtb to be 0.32 (95% credible interval: 0.15–0.62) or 0.38 (0.24–0.61), if only transmission or progression to disease, respectively, was affected. The relative fitness of MDR-Mtb increased to 0.56 (0.42–0.72) when the fitness cost influenced both transmission and progression to disease equally. We found the average relative fitness of MDR-Mtb circulating within households in Lima, Peru during 2010–2013 to be significantly lower than concurrent susceptible Mtb. If these fitness levels do not change, then existing TB control programmes are likely to keep MDR-TB prevalence at current levels in Lima, Peru.
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Affiliation(s)
- Gwenan M Knight
- National Institute of Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Commonwealth Building, Hammersmith Campus, Du Cane Road, London W12 0NN, UK .,Infectious Diseases and Immunity, Imperial College London, Commonwealth Building, Hammersmith Campus, Du Cane Road, London W12 0NN, UK.,Centre for the Mathematical Modelling of Infectious Diseases, Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.,TB Centre, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Mirko Zimic
- Laboratorio de Bioinformática y Biología Molecular, Facultad de Ciencias, Universidad Peruana Cayetano Heredia, 31 Avenue Honorio Delgado 430, Distrito de Lima, Peru
| | - Sebastian Funk
- Centre for the Mathematical Modelling of Infectious Diseases, Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Robert H Gilman
- Laboratorio de Bioinformática y Biología Molecular, Facultad de Ciencias, Universidad Peruana Cayetano Heredia, 31 Avenue Honorio Delgado 430, Distrito de Lima, Peru.,Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, USA
| | - Jon S Friedland
- Infectious Diseases and Immunity, Imperial College London, Commonwealth Building, Hammersmith Campus, Du Cane Road, London W12 0NN, UK.,Wellcome Trust Imperial College Centre for Global Health, St Mary's Hospital Campus, Imperial College London, Praed Street, London, W2 1NY, UK
| | - Louis Grandjean
- TB Centre, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.,Laboratorio de Bioinformática y Biología Molecular, Facultad de Ciencias, Universidad Peruana Cayetano Heredia, 31 Avenue Honorio Delgado 430, Distrito de Lima, Peru.,Wellcome Trust Imperial College Centre for Global Health, St Mary's Hospital Campus, Imperial College London, Praed Street, London, W2 1NY, UK
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30
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Hargreaves S, Rustage K, Nellums LB, McAlpine A, Pocock N, Devakumar D, Aldridge RW, Abubakar I, Kristensen KL, Himmels JW, Friedland JS, Zimmerman C. Occupational health outcomes among international migrant workers: a systematic review and meta-analysis. Lancet Glob Health 2019; 7:e872-e882. [PMID: 31122905 PMCID: PMC6565984 DOI: 10.1016/s2214-109x(19)30204-9] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/25/2019] [Accepted: 03/29/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Globally, there are more than 150 million international migrant workers-individuals who are employed outside of their country of origin-comprising the largest international migrant group. A substantial number of migrants work in hazardous and exploitative environments, where they might be at considerable risk of injury and ill health. However, little data on occupational health outcomes of migrant workers exist, with which to inform global policy making and delivery of health services. METHODS For this systematic review and meta-analysis, we searched Embase, MEDLINE, Ovid Global Health, and PsychINFO databases for primary research published between Jan 1, 2008, and Jan 24, 2018, reporting occupational health outcomes among international migrant workers (defined as individuals who are or have been employed outside their country of origin), without language or geographical restrictions. We excluded studies containing mixed cohorts of migrants and native workers in which migrant data could not be disaggregated, and studies that did not explicitly report migrant status. The main outcome was prevalence of occupational health outcomes (defined as any injury, mortality, or physical or psychiatric morbidity due to an individual's work or workplace environment) among international migrant workers. Summary estimates were calculated using random-effects models. The study protocol has been registered with PROSPERO, number CRD42018099465. FINDINGS Of the 1218 studies identified by our search, 36 studies were included in our systematic review, and 18 studies were included in the meta-analysis. The systematic review included occupational health outcomes for 12 168 international migrant workers employed in 13 countries and territories, mostly employed in unskilled manual labour. Migrant workers originated from 25 low-income and middle-income countries, and worked in the following sectors: agriculture; domestic, retail, and service sectors; construction and trade; and manufacturing and processing. Migrant workers had various psychiatric and physical morbidities, and workplace accidents and injuries were relatively common. In the meta-analysis, among 7260 international migrant workers, the pooled prevalence of having at least one occupational morbidity was 47% (95% CI 29-64; I2=99·70%). Among 3890 migrant workers, the prevalence of having at least one injury or accident, including falls from heights, fractures and dislocations, ocular injuries, and cuts was 22% (7-37; I2=99·35%). INTERPRETATION International migrant workers are at considerable risk of work-related ill health and injury, and their health needs are critically overlooked in research and policy. Governments, policy makers, and businesses must enforce and improve occupational health and safety measures, which should be accompanied by accessible, affordable, and appropriate health care and insurance coverage to meet the care needs of this important working population. FUNDING Wellcome Trust.
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Affiliation(s)
- Sally Hargreaves
- Institute for Infection and Immunity, St George's, University of London, London, UK; Section of Infectious Diseases and Immunity, Imperial College London, London, UK.
| | - Kieran Rustage
- Institute for Infection and Immunity, St George's, University of London, London, UK; Section of Infectious Diseases and Immunity, Imperial College London, London, UK
| | - Laura B Nellums
- Institute for Infection and Immunity, St George's, University of London, London, UK; Section of Infectious Diseases and Immunity, Imperial College London, London, UK
| | - Alys McAlpine
- Gender, Violence and Health Centre, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Nicola Pocock
- Gender, Violence and Health Centre, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Delan Devakumar
- Institute for Global Health, University College London, London
| | | | | | - Kristina L Kristensen
- Danish Research Centre for Migration, Ethnicity and Health, University of Copenhagen, Copenhagen, Denmark
| | - Jan W Himmels
- Institute for Infection and Immunity, St George's, University of London, London, UK; Section of Infectious Diseases and Immunity, Imperial College London, London, UK
| | - Jon S Friedland
- Institute for Infection and Immunity, St George's, University of London, London, UK; Section of Infectious Diseases and Immunity, Imperial College London, London, UK
| | - Cathy Zimmerman
- Gender, Violence and Health Centre, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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Abstract
Flucloxacillin, a beta-lactam antibiotic, is a commonly prescribed antibiotic for the treatment of infections caused by staphylococci and streptococci, most notably Staphylococcus aureus Paracetamol is one of the most dispensed medications by NHS England and is used for the treatment of fever and pain.1 However most doctors are unaware that concurrent use of these drugs can cause a potentially fatal drug interaction due to pyroglutamic acidosis (PGA), also known as 5-oxoprolinaemia. PGA is a rare cause of raised anion gap metabolic acidosis due to disruption of the γ-glutamyl cycle. We report the case of a patient with multiple comorbidities who developed PGA due to coadministration of paracetamol and flucloxacillin.
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Affiliation(s)
- William Osborne
- Department of Infectious Diseases, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | | | | | - Jon S Friedland
- Institute of Infection and Immunity, St George's, University of London, London, UK
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Ravensbergen SJ, Nellums LB, Hargreaves S, Stienstra Y, Friedland JS. National approaches to the vaccination of recently arrived migrants in Europe: A comparative policy analysis across 32 European countries. Travel Med Infect Dis 2019; 27:33-38. [PMID: 30336255 PMCID: PMC6370981 DOI: 10.1016/j.tmaid.2018.10.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 10/11/2018] [Accepted: 10/14/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Migrants may be underimmunised and at higher risk of vaccine-preventable diseases, yet there has been no comprehensive examination of what policies are currently implemented across Europe targeting child and adult migrants. We analysed vaccination policies for migrants in 32 EU/EEA countries and Switzerland. METHODS Using framework analysis, we did a comparative analysis of national policies and guidelines pertaining to vaccination in recently arrived migrants through a systematic guideline and literature review and by approaching national experts. RESULTS Six (18.8%) of 32 countries had comprehensive policies specific to the vaccination of migrants (two focused only on child migrants, four on both adults and children). Nineteen (59.4%) countries applied their national vaccination schedule for migrant vaccinations, predominantly focusing on children; and five (15.6%) countries had circulated additional migrant-specific resources to relevant health-care providers. In six (18.8%) countries, policies on migrant vaccination focused on outbreak-specific vaccines only. In ten (31.3%) countries, policies focused on priority vaccinations, with polio being the vaccine most commonly administered and heterogeneity noted in vaccines recommended to adults, adolescents, and children. Eighteen (56.3%) countries recommended that an individual should be considered as unvaccinated where vaccination records were missing, and vaccines re-administered. Nine (28.1%) countries reported that specific vaccinations were mandatory. CONCLUSION There is considerable variation in policies across Europe regarding approaches to vaccination in adult and child migrants, and a lack of clarity on optimum ways forward, what vaccines to offer, with a need for robust research in this area. More emphasis must be placed on ensuring migrant-specific guidance is disseminated to front-line healthcare professionals to improve vaccine delivery and uptake in diverse migration populations across the region.
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Affiliation(s)
- Sofanne J Ravensbergen
- Department of Internal Medicine/Infectious Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Laura B Nellums
- Institute for Infection and Immunity, St George's, University of London, London, WC1E 7HU, UK; Section of Infectious Diseases & Immunity, Imperial College London, London, UK
| | - Sally Hargreaves
- Institute for Infection and Immunity, St George's, University of London, London, WC1E 7HU, UK; Section of Infectious Diseases & Immunity, Imperial College London, London, UK.
| | - Ymkje Stienstra
- Department of Internal Medicine/Infectious Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jon S Friedland
- Institute for Infection and Immunity, St George's, University of London, London, WC1E 7HU, UK; Section of Infectious Diseases & Immunity, Imperial College London, London, UK
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Aldridge RW, Nellums LB, Bartlett S, Barr AL, Patel P, Burns R, Hargreaves S, Miranda JJ, Tollman S, Friedland JS, Abubakar I. Global patterns of mortality in international migrants: a systematic review and meta-analysis. Lancet 2018; 392:2553-2566. [PMID: 30528484 PMCID: PMC6294735 DOI: 10.1016/s0140-6736(18)32781-8] [Citation(s) in RCA: 131] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 10/14/2018] [Accepted: 10/23/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND 258 million people reside outside their country of birth; however, to date no global systematic reviews or meta-analyses of mortality data for these international migrants have been done. We aimed to review and synthesise available mortality data on international migrants. METHODS In this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Library, and Google Scholar databases for observational studies, systematic reviews, and randomised controlled trials published between Jan 1, 2001, and March 31, 2017, without language restrictions. We included studies reporting mortality outcomes for international migrants of any age residing outside their country of birth. Studies that recruited participants exclusively from intensive care or high dependency hospital units, with an existing health condition or status, or a particular health exposure were excluded. We also excluded studies limited to maternal or perinatal outcomes. We screened studies using systematic review software and extracted data from published reports. The main outcomes were all-cause and International Classification of Diseases, tenth revision (ICD-10) cause-specific standardised mortality ratios (SMRs) and absolute mortality rates. We calculated summary estimates using random-effects models. This study is registered with PROSPERO, number CRD42017073608. FINDINGS Of the 12 480 articles identified by our search, 96 studies were eligible for inclusion. The studies were geographically diverse and included data from all global regions and for 92 countries. 5464 mortality estimates for more than 15·2 million migrants were included, of which 5327 (97%) were from high-income countries, 115 (2%) were from middle-income countries, and 22 (<1%) were from low-income countries. Few studies included mortality estimates for refugees (110 estimates), asylum seekers (144 estimates), or labour migrants (six estimates). The summary estimate of all-cause SMR for international migrants was lower than one when compared with the general population in destination countries (0·70 [95% CI 0·65-0·76]; I2=99·8%). All-cause SMR was lower in both male migrants (0·72 [0·63-0·81]; I2=99·8%) and female migrants (0·75 [0·67-0·84]; I2=99·8%) compared with the general population. A mortality advantage was evident for refugees (SMR 0·50 [0·46-0·54]; I2=89·8%), but not for asylum seekers (1·05 [0·89-1·24]; I2=54·4%), although limited data was available on these groups. SMRs for all causes of death were lower in migrants compared with the general populations in the destination country across all 13 ICD-10 categories analysed, with the exception of infectious diseases and external causes. Heterogeneity was high across the majority of analyses. Point estimates of all-cause age-standardised mortality in migrants ranged from 420 to 874 per 100 000 population. INTERPRETATION Our study showed that international migrants have a mortality advantage compared with general populations, and that this advantage persisted across the majority of ICD-10 disease categories. The mortality advantage identified will be representative of international migrants in high-income countries who are studying, working, or have joined family members in these countries. However, our results might not reflect the health outcomes of more marginalised groups in low-income and middle-income countries because little data were available for these groups, highlighting an important gap in existing research. Our results present an opportunity to reframe the public discourse on international migration and health in high-income countries. FUNDING Wellcome Trust, National Institute for Health Research, Medical Research Council, Alliance for Health Policy and Systems Research, Department for International Development, Fogarty International Center, Grand Challenges Canada, International Development Research Centre Canada, Inter-American Institute for Global Change Research, National Cancer Institute, National Heart, Lung and Blood Institute, National Institute of Mental Health, Swiss National Science Foundation, World Diabetes Foundation, UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, and European Society for Clinical Microbiology and Infectious Diseases (ESCMID) Study Group Research Funding for the ESCMID Study Group for Infections in Travellers and Migrants.
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Affiliation(s)
- Robert W Aldridge
- Centre for Public Health Data Science, Institute of Health Informatics, University College London, London, UK.
| | - Laura B Nellums
- Institute of Infection and Immunity, St George's, University of London, London, UK; International Health Unit, Section of Infectious Diseases, Imperial College London, London, UK
| | - Sean Bartlett
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Parth Patel
- School of Public Health, Imperial College London, London, UK
| | - Rachel Burns
- Centre for Public Health Data Science, Institute of Health Informatics, University College London, London, UK
| | - Sally Hargreaves
- Institute of Infection and Immunity, St George's, University of London, London, UK; International Health Unit, Section of Infectious Diseases, Imperial College London, London, UK
| | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases and Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Stephen Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana
| | - Jon S Friedland
- Institute of Infection and Immunity, St George's, University of London, London, UK; International Health Unit, Section of Infectious Diseases, Imperial College London, London, UK
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK
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Hargreaves S, Nellums LB, Ravensbergen SJ, Friedland JS, Stienstra Y. Divergent approaches in the vaccination of recently arrived migrants to Europe: a survey of national experts from 32 countries, 2017. Euro Surveill 2018; 23:1700772. [PMID: 30326996 PMCID: PMC6194906 DOI: 10.2807/1560-7917.es.2018.23.41.1700772] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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: 11/17/2017] [Accepted: 06/14/2018] [Indexed: 12/13/2022] Open
Abstract
BackgroundMigrants within the European Union and European Economic Area (EU/EEA) may be underimmunised and lack documentation on previous vaccinations. We investigated approaches to vaccination in recently arrived adult and child migrants, and guideline availability and implementation. Methods: Between March and May 2017, a national vaccination expert from every EU/EEA country and Switzerland completed an electronic questionnaire. We used descriptive analyses to calculate percentages, and framework analysis to synthesise free-text responses. Results: We approached 32 countries (response rate 100%). Although 28 experts reported vaccination guidance at national level, specific guidelines for recently arrived migrants were only available in six countries and not consistently implemented. Twenty-three countries administered vaccinations during on-arrival health checks. Most experts recommended multiple vaccination opportunities be made available: at point of entry (n = 13) or at holding level (reception centres, migrant camps, detention centres) (n = 21). In 30 countries, child migrants without evidence of previous vaccination were re-vaccinated according to the national schedule. Diphtheria-pertussis-tetanus and polio vaccinations were given to migrant children in all countries, measles-mumps-rubella (MMR) in 31 countries, hepatitis B vaccination in 25. Low levels of catch-up vaccination were reported in adult migrants, with only 13 countries offering MMR and 10 countries charging fees. Conclusion: Existing guidance is often not migrant-specific and may not be applied in practice; clarification is needed on which vaccines should be given. Strategies are needed specifically for catch-up vaccination in adult migrants. Vaccinations should be offered in multiple settings, free of charge, with sufficient guidance and training provided to front-line healthcare professionals.
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Affiliation(s)
- Sally Hargreaves
- These authors are joint first authors
- The Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
- The International Health Unit, Section of Infectious Diseases and Immunity, Imperial College London, London, United Kingdom
| | - Laura B Nellums
- These authors are joint first authors
- The Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
- The International Health Unit, Section of Infectious Diseases and Immunity, Imperial College London, London, United Kingdom
| | - Sofanne J Ravensbergen
- These authors are joint first authors
- Department of Internal Medicine/Infectious Diseases, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Jon S Friedland
- The Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
- The International Health Unit, Section of Infectious Diseases and Immunity, Imperial College London, London, United Kingdom
| | - Ymkje Stienstra
- Department of Internal Medicine/Infectious Diseases, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
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Brilha S, Ong CWM, Weksler B, Romero N, Couraud PO, Friedland JS. Author Correction: Matrix metalloproteinase-9 activity and a downregulated Hedgehog pathway impair blood-brain barrier function in an in vitro model of CNS tuberculosis. Sci Rep 2018; 8:13956. [PMID: 30206340 PMCID: PMC6134131 DOI: 10.1038/s41598-018-31948-8] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has not been fixed in the paper.
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Affiliation(s)
- Sara Brilha
- Infectious Diseases and Immunity, Imperial College, London, UK.,Centre for Inflammation and Tissue Repair, University College, London, UK
| | - Catherine W M Ong
- Infectious Diseases and Immunity, Imperial College, London, UK.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Babette Weksler
- Department of Medicine, Weill Cornell University, New York, USA
| | - Nacho Romero
- Department of Life, Health and Chemical Sciences, Open University, Milton, Keynes, UK
| | - Pierre-Olivier Couraud
- Institut Cochin, Inserm U1016, CNRS UMR8104, Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Jon S Friedland
- Infectious Diseases and Immunity, Imperial College, London, UK.
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Nellums LB, Friedland JS, Hargreaves S. Antimicrobial resistance among migrants in Europe - Authors' reply. Lancet Infect Dis 2018; 18:945. [PMID: 30152357 DOI: 10.1016/s1473-3099(18)30495-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 07/27/2018] [Indexed: 06/08/2023]
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Nellums LB, Thompson H, Holmes A, Castro-Sánchez E, Otter JA, Norredam M, Friedland JS, Hargreaves S. Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis. Lancet Infect Dis 2018; 18:796-811. [PMID: 29779917 PMCID: PMC6032478 DOI: 10.1016/s1473-3099(18)30219-6] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 01/12/2018] [Accepted: 03/13/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London.
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Affiliation(s)
| | | | - Alison Holmes
- Department of Medicine, Imperial College London, London, UK
| | | | | | - Marie Norredam
- Danish Research Centre for Migration Ethnicity and Health, University of Copenhagen, Copenhagen, Denmark; Section of Immigrant Medicine, Department of Infectious Disease, Copenhagen University Hospital, Hvidovre, Denmark
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Brilha S, Chong DLW, Khawaja AA, Ong CWM, Guppy NJ, Porter JC, Friedland JS. Integrin α2β1 Expression Regulates Matrix Metalloproteinase-1-Dependent Bronchial Epithelial Repair in Pulmonary Tuberculosis. Front Immunol 2018; 9:1348. [PMID: 29988449 PMCID: PMC6024194 DOI: 10.3389/fimmu.2018.01348] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 02/01/2018] [Accepted: 05/31/2018] [Indexed: 11/22/2022] Open
Abstract
Pulmonary tuberculosis (TB) is caused by inhalation of Mycobacterium tuberculosis, which damages the bronchial epithelial barrier to establish local infection. Matrix metalloproteinase-1 plays a crucial role in the immunopathology of TB, causing breakdown of type I collagen and cavitation, but this collagenase is also potentially involved in bronchial epithelial repair. We hypothesized that the extracellular matrix (ECM) modulates M. tuberculosis-driven matrix metalloproteinase-1 expression by human bronchial epithelial cells (HBECs), regulating respiratory epithelial cell migration and repair. Medium from monocytes stimulated with M. tuberculosis induced collagenase activity in bronchial epithelial cells, which was reduced by ~87% when cells were cultured on a type I collagen matrix. Matrix metalloproteinase-1 had a focal localization, which is consistent with cell migration, and overall secretion decreased by 32% on type I collagen. There were no associated changes in the specific tissue inhibitors of metalloproteinases. Decreased matrix metalloproteinase-1 secretion was due to ligand-binding to the α2β1 integrin and was dependent on the actin cytoskeleton. In lung biopsies, samples from patients with pulmonary TB, integrin α2β1 is highly expressed on the bronchial epithelium. Areas of lung with disrupted collagen matrix showed an increase in matrix metalloproteinases-1 expression compared with areas where collagen was comparable to control lung. Type I collagen matrix increased respiratory epithelial cell migration in a wound-healing assay, and this too was matrix metalloproteinase-dependent, since it was blocked by the matrix metalloproteinase inhibitor GM6001. In summary, we report a novel mechanism by which α2β1-mediated signals from the ECM modulate matrix metalloproteinase-1 secretion by HBECs, regulating their migration and epithelial repair in TB.
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Affiliation(s)
- Sara Brilha
- Infectious Diseases and Immunity, Imperial College London, London, United Kingdom.,Centre for Inflammation and Tissue Repair, University College London, London, United Kingdom
| | - Deborah L W Chong
- Centre for Inflammation and Tissue Repair, University College London, London, United Kingdom
| | - Akif A Khawaja
- Centre for Inflammation and Tissue Repair, University College London, London, United Kingdom
| | - Catherine W M Ong
- Infectious Diseases and Immunity, Imperial College London, London, United Kingdom.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Naomi J Guppy
- UCL Advanced Diagnostics, University College London, London, United Kingdom
| | - Joanna C Porter
- Centre for Inflammation and Tissue Repair, University College London, London, United Kingdom
| | - Jon S Friedland
- Infectious Diseases and Immunity, Imperial College London, London, United Kingdom
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Proaño A, Bui DP, López JW, Vu NM, Bravard MA, Lee GO, Tracey BH, Xu Z, Comina G, Ticona E, Mollura DJ, Friedland JS, Moore DAJ, Evans CA, Caligiuri P, Gilman RH. Cough Frequency During Treatment Associated With Baseline Cavitary Volume and Proximity to the Airway in Pulmonary TB. Chest 2018; 153:1358-1367. [PMID: 29559307 PMCID: PMC6026292 DOI: 10.1016/j.chest.2018.03.006] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 02/14/2018] [Accepted: 03/01/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Cough frequency, and its duration, is a biomarker that can be used in low-resource settings without the need of laboratory culture and has been associated with transmission and treatment response. Radiologic characteristics associated with increased cough frequency may be important in understanding transmission. The relationship between cough frequency and cavitary lung disease has not been studied. METHODS We analyzed data in 41 adults who were HIV negative and had culture-confirmed, drug-susceptible pulmonary TB throughout treatment. Cough recordings were based on the Cayetano Cough Monitor, and sputum samples were evaluated using microscopic observation drug susceptibility broth culture; among culture-positive samples, bacillary burden was assessed by means of time to positivity. CT scans were analyzed by a US-board-certified radiologist and a computer-automated algorithm. The algorithm evaluated cavity volume and cavitary proximity to the airway. CT scans were obtained within 1 month of treatment initiation. We compared small cavities (≤ 7 mL) and large cavities (> 7 mL) and cavities located closer to (≤ 10 mm) and farther from (> 10 mm) the airway to cough frequency and cough cessation until treatment day 60. RESULTS Cough frequency during treatment was twofold higher in participants with large cavity volumes (rate ratio [RR], 1.98; P = .01) and cavities located closer to the airway (RR, 2.44; P = .001). Comparably, cough ceased three times faster in participants with smaller cavities (adjusted hazard ratio [HR], 2.89; P = .06) and those farther from the airway (adjusted HR, 3.61;, P = .02). Similar results were found for bacillary burden and culture conversion during treatment. CONCLUSIONS Cough frequency during treatment is greater and lasts longer in patients with larger cavities, especially those closer to the airway.
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Affiliation(s)
- Alvaro Proaño
- Laboratorio de Investigación en Enfermedades Infecciosas, Laboratorio de Investigación y Desarrollo, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | - David P Bui
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ
| | - José W López
- Laboratorio de Bioinformática y Biología Molecular, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Peru; Instituto Nacional de Salud del Niño San Borja, Lima, Peru
| | - Nancy M Vu
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH
| | - Marjory A Bravard
- Innovation for Health and Development, Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru; Asociación Benéfica PRISMA, Lima, Peru; Department of General Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - Gwenyth O Lee
- Department of Global Community Health and Behavioral Sciences, Tulane University, New Orleans, LA
| | - Brian H Tracey
- Department of Electrical and Computer Engineering, Tufts University, Medford, MA
| | - Ziyue Xu
- Center for Infectious Disease Imaging, Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD
| | - Germán Comina
- Escuela Profesional de Ingeniería Física, Facultad de Ciencias, Universidad Nacional de Ingeniería, Lima, Peru; Department of Global Community Health and Behavioral Sciences, Tulane University, New Orleans, LA
| | - Eduardo Ticona
- Facultad de Medicina, Universidad Nacional Mayor de San Marcos, Lima, Peru; Servicio de Enfermedades Infecciosas y Tropicales, Hospital Nacional Dos de Mayo, Lima, Peru
| | - Daniel J Mollura
- Center for Infectious Disease Imaging, Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD
| | - Jon S Friedland
- Section of Infectious Diseases & Immunity and Wellcome Trust Imperial College Centre for Global Health Research, Imperial College London, London, England
| | - David A J Moore
- Laboratorio de Investigación en Enfermedades Infecciosas, Laboratorio de Investigación y Desarrollo, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Peru; Asociación Benéfica PRISMA, Lima, Peru; TB Centre, London School of Hygiene and Tropical Medicine, London, England
| | - Carlton A Evans
- Innovation for Health and Development, Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru; Asociación Benéfica PRISMA, Lima, Peru; Section of Infectious Diseases & Immunity and Wellcome Trust Imperial College Centre for Global Health Research, Imperial College London, London, England
| | - Philip Caligiuri
- Department of Radiology & Imaging Sciences, University of Utah School of Medicine, Salt Lake City, UT
| | - Robert H Gilman
- Laboratorio de Investigación en Enfermedades Infecciosas, Laboratorio de Investigación y Desarrollo, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Peru; Asociación Benéfica PRISMA, Lima, Peru; Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
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Hargreaves S, Nellums LB, Ramsay M, Saliba V, Majeed A, Mounier-Jack S, Friedland JS. Who is responsible for the vaccination of migrants in Europe? Lancet 2018; 391:1752-1754. [PMID: 29739550 DOI: 10.1016/s0140-6736(18)30846-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 03/29/2018] [Indexed: 01/05/2023]
Affiliation(s)
- Sally Hargreaves
- International Health Unit, Section of Infectious Diseases and Immunity, Imperial College London, London W12 ONS, UK.
| | - Laura B Nellums
- International Health Unit, Section of Infectious Diseases and Immunity, Imperial College London, London W12 ONS, UK
| | | | | | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London
| | - Sandra Mounier-Jack
- Health Protection Research Unit in Immunisation, London School of Hygiene & Tropical Medicine, London, UK
| | - Jon S Friedland
- International Health Unit, Section of Infectious Diseases and Immunity, Imperial College London, London W12 ONS, UK
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41
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López JW, Loader MCI, Smith D, Pastorius D, Bravard M, Caviedes L, Romero KM, Clark T, Checkley W, Ticona E, Friedland JS, Gilman RH. Exhaled Nitric Oxide is Not a Biomarker for Pulmonary Tuberculosis. Am J Trop Med Hyg 2018; 98:1637-1639. [PMID: 29714162 PMCID: PMC6086145 DOI: 10.4269/ajtmh.17-0425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
To reduce transmission of tuberculosis (TB) in resource-limited countries where TB remains a major cause of mortality, novel diagnostic tools are urgently needed. We evaluated the fractional concentration of exhaled nitric oxide (FeNO) as an easily measured, noninvasive potential biomarker for diagnosis and monitoring of treatment response in participants with pulmonary TB including multidrug resistant–TB in Lima, Peru. In a longitudinal study however, we found no differences in baseline median FeNO levels between 38 TB participants and 93 age-matched controls (13 parts per billion [ppb] [interquartile range (IQR) = 8–26] versus 15 ppb [IQR = 12–24]), and there was no change over 60 days of treatment (15 ppb [IQR = 10–19] at day 60). Taking this and previous evidence together, we conclude FeNO is not of value in either the diagnosis of pulmonary TB or as a marker of treatment response.
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Affiliation(s)
- José W López
- Instituto Nacional de Salud del Niño, San Borja, Lima, Peru.,Laboratorio de Investigación en Enfermedades Infecciosas, Laboratorio de Investigación y Desarrollo, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Maria-Cristina I Loader
- Laboratorio de Investigación en Enfermedades Infecciosas, Laboratorio de Investigación y Desarrollo, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Peru.,Asociación Benéfica PRISMA, Lima, Peru.,Section of Infectious Diseases and Immunity, Wellcome Centre for Global Health, Imperial College London, London, United Kingdom
| | | | | | - Marjory Bravard
- Department of General Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Asociación Benéfica PRISMA, Lima, Peru.,Laboratorio de Investigación en Enfermedades Infecciosas, Laboratorio de Investigación y Desarrollo, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Luz Caviedes
- Laboratorio de Investigación en Enfermedades Infecciosas, Laboratorio de Investigación y Desarrollo, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - Taryn Clark
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.,Section of Emergency Medicine, Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana.,Asociación Benéfica PRISMA, Lima, Peru
| | - William Checkley
- CRONICAS Center in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru.,Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Eduardo Ticona
- Facultad de Medicina de la Universidad Nacional Mayor de San Marcos, Lima, Peru.,Hospital Nacional Dos de Mayo, Lima, Peru
| | - Jon S Friedland
- Section of Infectious Diseases and Immunity, Wellcome Centre for Global Health, Imperial College London, London, United Kingdom
| | - Robert H Gilman
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.,Asociación Benéfica PRISMA, Lima, Peru.,Laboratorio de Investigación en Enfermedades Infecciosas, Laboratorio de Investigación y Desarrollo, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Peru
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Nakken CS, Skovdal M, Nellums LB, Friedland JS, Hargreaves S, Norredam M. Vaccination status and needs of asylum-seeking children in Denmark: a retrospective data analysis. Public Health 2018; 158:110-116. [PMID: 29653865 PMCID: PMC5947822 DOI: 10.1016/j.puhe.2018.02.018] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 01/30/2018] [Accepted: 02/04/2018] [Indexed: 11/23/2022]
Abstract
Objectives Asylum seekers to Europe may come from war-torn countries where health systems have broken down, and there is evidence that asylum-seeking children have low coverage of childhood vaccinations, as well as uptake of immunisations in host countries. Such gaps in immunisation have important implications for effective national vaccination programmes. How we approach vaccination in children and adults entering Western Europe, where as a group they face barriers to health services and screening, is a growing debate; however, there are limited data on the vaccination status of these hard-to-reach communities, and robust evidence is needed to inform immunisation strategies. The aim of this study was to explore the vaccination status and needs of asylum-seeking children and adolescents in Denmark. Study design We conducted a retrospective data analysis of anonymised patient records for asylum-seeking children and adolescents extracted from the Danish Red Cross database. Methods We retrospectively searched the Danish Red Cross database for children and adolescents (aged 3 months–17 years) with active asylum applications in Denmark as of October 28, 2015. Data were extracted for demographic characteristics, vaccination status and vaccinations needed by asylum-seeking children presenting to Red Cross asylum centres for routine statutory health screening. Results We explored the vaccination status and needs of 2126 asylum-seeking children and adolescents. About 64% of the study population were male and 36% were female. Eight nationalities were represented, where 33% of the total of children and adolescents were not immunised in accordance with Danish national guidelines, while 7% were considered partly vaccinated, and 60% were considered adequately vaccinated. Afghan (57% not vaccinated/unknown) and Eritrean (54% not vaccinated/unknown) children were the least likely to be vaccinated of all nationalities represented, as were boys (37% not vaccinated/unknown) compared with girls (27% not vaccinated/unknown) and children and adolescents aged between 12 and 17 years (48% not vaccinated/unknown) compared with 6- to 11-year olds (26%) and 0- to 5-year olds (22%). The health screenings resulted in 1328 vaccinations. The most commonly needed vaccines were diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type b, (DTaP/IPV/Hib) which comprised 49% of the vaccines distributed, followed by the pneumococcal vaccine (Prevnar) (28%) and measles, mumps and rubella (MMR) vaccine (23%). Conclusions The finding that nearly one-third of asylum-seeking children and adolescents in Denmark were in need of further vaccinations highlights the gaps in immunisation coverage in these populations. These results point to the need to improve access to health services and promote national vaccine programmes targeted at these communities to facilitate vaccination uptake and increase immunisation coverage to reduce the risk of preventable infectious diseases among asylum-seeking children. Little is known on the state of immunisation of refugees arriving in Western receiving countries. Variations in status on arrival to Denmark were associated with gender, country of origin and age groups. Vaccination needs were found to be associated with country of origin, while gender did not act as a significant determinant. Immunisations for vaccine-preventable diseases is critical for protecting refugee health and host communities.
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Affiliation(s)
- C S Nakken
- Danish Research Center for Migration, Ethnicity and Health, Section for Health Services Research, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1353, Copenhagen K, Denmark
| | - M Skovdal
- Danish Research Center for Migration, Ethnicity and Health, Section for Health Services Research, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1353, Copenhagen K, Denmark
| | - L B Nellums
- Infectious Diseases and Immunity, Department of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, W12 0NN, London, UK.
| | - J S Friedland
- Infectious Diseases and Immunity, Department of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, W12 0NN, London, UK
| | - S Hargreaves
- Infectious Diseases and Immunity, Department of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, W12 0NN, London, UK
| | - M Norredam
- Danish Research Center for Migration, Ethnicity and Health, Section for Health Services Research, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1353, Copenhagen K, Denmark; Section of Immigrant Medicine, Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre Hospital, Hvidovre, Denmark
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43
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Singh S, Maniakis‐Grivas G, Singh UK, Asher RM, Mauri F, Elkington PT, Friedland JS. Interleukin-17 regulates matrix metalloproteinase activity in human pulmonary tuberculosis. J Pathol 2018; 244:311-322. [PMID: 29210073 PMCID: PMC5838784 DOI: 10.1002/path.5013] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 10/21/2017] [Accepted: 11/24/2017] [Indexed: 12/21/2022]
Abstract
Tuberculosis (TB) is characterized by extensive pulmonary matrix breakdown. Interleukin-17 (IL-17) is key in host defence in TB but its role in TB-driven tissue damage is unknown. We investigated the hypothesis that respiratory stromal cell matrix metalloproteinase (MMP) production in TB is regulated by T-helper 17 (TH -17) cytokines. Biopsies of patients with pulmonary TB were analysed by immunohistochemistry (IHC), and patient bronchoalveolar lavage fluid (BALF) MMP and cytokine concentrations were measured by Luminex assays. Primary human airway epithelial cells were stimulated with conditioned medium from human monocytes infected with Mycobacterium tuberculosis (Mtb) and TH -17 cytokines. MMP secretion, activity, and gene expression were determined by ELISA, Luminex assay, zymography, RT-qPCR, and dual luciferase reporter assays. Signalling pathways were examined using phospho-western analysis and siRNA. IL-17 is expressed in TB patient granulomas and MMP-3 is expressed in adjacent pulmonary epithelial cells. IL-17 had a divergent, concentration-dependent effect on MMP secretion, increasing epithelial secretion of MMP-3 (p < 0.001) over 72 h, whilst decreasing that of MMP-9 (p < 0.0001); mRNA levels were similarly affected. Both IL-17 and IL-22 increased fibroblast Mtb-dependent MMP-3 secretion but IL-22 did not modulate epithelial MMP-3 expression. Both IL-17 and IL-22, but not IL-23, were significantly up-regulated in BALF from TB patients. IL-17-driven MMP-3 was dependent on p38 MAP kinase and the PI3K p110α subunit. In summary, IL-17 drives airway stromal cell-derived MMP-3, a mediator of tissue destruction in TB, alone and with monocyte-dependent networks in TB. This is regulated by p38 MAP kinase and PI3K pathways. © 2017 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of Pathological Society of Great Britain and Ireland.
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Affiliation(s)
- Shivani Singh
- Infectious Diseases and ImmunityImperial CollegeLondonUK
| | | | - Utpal K Singh
- Tuberculosis Unit, Department of MedicineNalanda University HospitalsAgam KuanPatnaIndia
| | - Radha M Asher
- Infectious Diseases and ImmunityImperial CollegeLondonUK
| | - Francesco Mauri
- Department of Histopathology, Hammersmith HospitalsImperial College LondonUK
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Nellums LB, Rustage K, Hargreaves S, Friedland JS. Multidrug-resistant tuberculosis treatment adherence in migrants: a systematic review and meta-analysis. BMC Med 2018; 16:27. [PMID: 29466983 PMCID: PMC5822608 DOI: 10.1186/s12916-017-1001-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/21/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multidrug-resistant tuberculosis (MDR-TB) is a growing concern in meeting global targets for TB control. In high-income low-TB-incidence countries, a disproportionate number of MDR-TB cases occur in migrant (foreign-born) populations, with concerns about low adherence rates in these patients compared to the host non-migrant population. Tackling MDR-TB in this context may, therefore, require unique approaches. We conducted a systematic review and meta-analysis to identify and synthesise data on MDR-TB treatment adherence in migrant patients to inform evidence-based strategies to improve care pathways and health outcomes in this group. METHODS This systematic review and meta-analysis was conducted in line with PRISMA guidelines (PROSPERO 42017070756). The databases Embase, MEDLINE, Global Health and PubMed were searched to 24 May 2017 for primary research reporting MDR-TB treatment adherence and outcomes in migrant populations, with no restrictions on dates or language. A meta-analysis was conducted using random-effects models. RESULTS From 413 papers identified in the database search, 15 studies reporting on MDR-TB treatment outcomes for 258 migrants and 174 non-migrants were included in the systematic review and meta-analysis. The estimated rate of adherence to MDR-TB treatment across migrant patients was 71% [95% confidence interval (CI) = 58-84%], with non-adherence reported among 20% (95% CI = 4-37%) of migrant patients. A key finding was that there were no differences in estimated rates of adherence [risk ratio (RR) = 1.05; 95% CI = 0.82-1.34] or non-adherence (RR = 0.97; 95% CI = 0.79-1.36) between migrants and non-migrants. CONCLUSIONS MDR-TB treatment adherence rates among migrants in high-income low-TB-incidence countries are approaching global targets for treatment success (75%), and are comparable to rates in non-migrants. The findings highlight that only just over 70% of migrant and non-migrant patients adhere to MDR-TB treatment. The results point to the importance of increasing adherence in all patient groups, including migrants, with an emphasis on tailoring care based on social risk factors for poor adherence. We believe that MDR-TB treatment targets are not ambitious enough.
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Affiliation(s)
- Laura B. Nellums
- Infectious Diseases & Immunity, Department of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London, W12 ONN UK
| | - Kieran Rustage
- Infectious Diseases & Immunity, Department of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London, W12 ONN UK
| | - Sally Hargreaves
- Infectious Diseases & Immunity, Department of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London, W12 ONN UK
| | - Jon S. Friedland
- Infectious Diseases & Immunity, Department of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London, W12 ONN UK
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Kirwan DE, Ugarte-Gil C, Gilman RH, Hasan Rizvi SM, Cerrillo G, Cok J, Ticona E, Cabrera JL, Matos ED, Evans CA, Moore DAJ, Friedland JS, The Lymph Node Tuberculosis Lntb Working Group. Histological Examination in Obtaining a Diagnosis in Patients with Lymphadenopathy in Lima, Peru. Am J Trop Med Hyg 2017; 97:1271-1276. [PMID: 29031289 PMCID: PMC5637594 DOI: 10.4269/ajtmh.16-0961] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The differential diagnosis for lymphadenopathy is wide and clinical presentations overlap, making obtaining an accurate diagnosis challenging. We sought to characterize the clinical and radiological characteristics, histological findings, and diagnoses for a cohort of patients with lymphadenopathy of unknown etiology. 121 Peruvian adults with lymphadenopathy underwent lymph node biopsy for microbiological and histopathological evaluation. Mean patient age was 41 years (Interquartile Range 26–52), 56% were males, and 39% were HIV positive. Patients reported fever (31%), weight loss (23%), and headache (22%); HIV infection was associated with fever (P < 0.05) and gastrointestinal symptoms (P < 0.05). Abnormalities were reported in 40% of chest X-rays (N = 101). Physicians suspected TB in 92 patients (76%), lymphoma in 19 patients (16%), and other malignancy in seven patients (5.8%). Histological diagnoses (N = 117) included tuberculosis (34%), hyperplasia (27%), lymphoma (13%), and nonlymphoma malignancy (14%). Hyperplasia was more common (P < 0.001) and lymphoma less common (P = 0.005) among HIV-positive than HIV-negative patients. There was a trend toward reduced frequency of caseous necrosis in samples from HIV-positive than HIV-negative TB patients (67 versus 93%, P = 0.055). The spectrum of diagnoses was broad, and clinical and radiological features correlated poorly with diagnosis. On the basis of clinical features, physicians over-diagnosed TB, and under-diagnosed malignancy. Although this may not be inappropriate in resource-limited settings where TB is the most frequent easily treatable cause of lymphadenopathy, diagnostic delays can be detrimental to patients with malignancy. It is important that patients with lymphadenopathy undergo a full diagnostic work-up including sampling for histological evaluation to obtain an accurate diagnosis.
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Affiliation(s)
- Daniela E Kirwan
- Department of Medical Microbiology, St. George's Hospital, London, United Kingdom.,Department of Infectious Diseases and Immunity, Imperial College London, London, United Kingdom.,Wellcome Trust Centre for Global Health Research, Imperial College London, United Kingdom
| | - Cesar Ugarte-Gil
- Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Peru.,Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Robert H Gilman
- Laboratorio de Investigación en Enfermedades Infecciosas, Universidad Peruana Cayetano Heredia, Lima, Peru.,Department of International Health, Johns Hopkins University, Baltimore, Maryland
| | - Syed M Hasan Rizvi
- Department of Cellular Pathology, Barts Health NHS Trust, London, United Kingdom
| | - Gustavo Cerrillo
- Infectious Diseases and Tropical Medicine Unit, Hospital Nacional Dos de Mayo, Lima, Peru
| | - Jaime Cok
- Department of Pathology, Hospital Nacional Cayetano Heredia, Lima, Peru
| | - Eduardo Ticona
- Department of Medicine, Universidad de San Marcos, Lima, Peru.,Infectious Diseases and Tropical Medicine Unit, Hospital Nacional Dos De Mayo, Lima, Peru
| | - José Luis Cabrera
- Department of Pulmonology, Hospital Daniel Alcides Carrión, Callao, Peru
| | - Eduardo D Matos
- Department of Infectious Diseases, Hospital Nacional Arzobispo Loayza, Lima, Peru
| | - Carlton A Evans
- Innovation for Health and Development, Laboratory of Research and Development (IFHAD), Universidad Peruana Cayetano Heredia, Lima, Peru.,Wellcome Trust Centre for Global Health Research, Imperial College London, United Kingdom.,Department of Infectious Diseases and Immunity, Imperial College London, London, United Kingdom
| | - David A J Moore
- TB Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jon S Friedland
- Wellcome Trust Centre for Global Health Research, Imperial College London, United Kingdom.,Department of Infectious Diseases and Immunity, Imperial College London, London, United Kingdom
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46
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Saunders MJ, Wingfield T, Tovar MA, Baldwin MR, Datta S, Zevallos K, Montoya R, Valencia TR, Friedland JS, Moulton LH, Gilman RH, Evans CA. A score to predict and stratify risk of tuberculosis in adult contacts of tuberculosis index cases: a prospective derivation and external validation cohort study. Lancet Infect Dis 2017; 17:1190-1199. [PMID: 28827142 PMCID: PMC7611139 DOI: 10.1016/s1473-3099(17)30447-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 06/23/2017] [Accepted: 06/29/2017] [Indexed: 10/28/2022]
Abstract
BACKGROUND Contacts of tuberculosis index cases are at increased risk of developing tuberculosis. Screening, preventive therapy, and surveillance for tuberculosis are underused interventions in contacts, particularly adults. We developed a score to predict risk of tuberculosis in adult contacts of tuberculosis index cases. METHODS In 2002-06, we recruited contacts aged 15 years or older of index cases with pulmonary tuberculosis who lived in desert shanty towns in Ventanilla, Peru. We followed up contacts for tuberculosis until February, 2016. We used a Cox proportional hazards model to identify index case, contact, and household risk factors for tuberculosis from which to derive a score and classify contacts as low, medium, or high risk. We validated the score in an urban community recruited in Callao, Peru, in 2014-15. FINDINGS In the derivation cohort, we identified 2017 contacts of 715 index cases, and median follow-up was 10·7 years (IQR 9·5-11·8). 178 (9%) of 2017 contacts developed tuberculosis during 19 147 person-years of follow-up (incidence 0·93 per 100 person-years, 95% CI 0·80-1·08). Risk factors for tuberculosis were body-mass index, previous tuberculosis, age, sustained exposure to the index case, the index case being in a male patient, lower community household socioeconomic position, indoor air pollution, previous tuberculosis among household members, and living in a household with a low number of windows per room. The 10-year risks of tuberculosis in the low-risk, medium-risk, and high-risk groups were, respectively, 2·8% (95% CI 1·7-4·4), 6·2% (4·8-8·1), and 20·6% (17·3-24·4). The 535 (27%) contacts classified as high risk accounted for 60% of the tuberculosis identified during follow-up. The score predicted tuberculosis independently of tuberculin skin test and index-case drug sensitivity results. In the external validation cohort, 65 (3%) of 1910 contacts developed tuberculosis during 3771 person-years of follow-up (incidence 1·7 per 100 person-years, 95% CI 1·4-2·2). The 2·5-year risks of tuberculosis in the low-risk, medium-risk, and high-risk groups were, respectively, 1·4% (95% CI 0·7-2·8), 3·9% (2·5-5·9), and 8·6%· (5·9-12·6). INTERPRETATION Our externally validated risk score could predict and stratify 10-year risk of developing tuberculosis in adult contacts, and could be used to prioritise tuberculosis control interventions for people most likely to benefit. FUNDING Wellcome Trust, Department for International Development Civil Society Challenge Fund, Joint Global Health Trials consortium, Bill & Melinda Gates Foundation, Imperial College National Institutes of Health Research Biomedical Research Centre, Foundation for Innovative New Diagnostics, Sir Halley Stewart Trust, WHO, TB REACH, and Innovation for Health and Development.
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Affiliation(s)
- Matthew J Saunders
- Section of Infectious Diseases and Immunity, Imperial College London, London, UK; Wellcome Trust Imperial College Centre for Global Health Research, London, UK; Innovation for Health and Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru; Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru.
| | - Tom Wingfield
- Section of Infectious Diseases and Immunity, Imperial College London, London, UK; Wellcome Trust Imperial College Centre for Global Health Research, London, UK; Innovation for Health and Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru; Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru; Institute for Infection and Global Health, University of Liverpool, Liverpool, UK; Tropical and Infectious Diseases Unit, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
| | - Marco A Tovar
- Innovation for Health and Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru; Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru
| | - Matthew R Baldwin
- Innovation for Health and Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru; Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru; Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Sumona Datta
- Section of Infectious Diseases and Immunity, Imperial College London, London, UK; Wellcome Trust Imperial College Centre for Global Health Research, London, UK; Innovation for Health and Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru; Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru
| | - Karine Zevallos
- Innovation for Health and Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru; Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru
| | - Rosario Montoya
- Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru
| | - Teresa R Valencia
- Innovation for Health and Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Jon S Friedland
- Section of Infectious Diseases and Immunity, Imperial College London, London, UK; Wellcome Trust Imperial College Centre for Global Health Research, London, UK
| | - Larry H Moulton
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Robert H Gilman
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Carlton A Evans
- Section of Infectious Diseases and Immunity, Imperial College London, London, UK; Wellcome Trust Imperial College Centre for Global Health Research, London, UK; Innovation for Health and Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru; Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru
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Walker NF, Wilkinson KA, Meintjes G, Tezera LB, Goliath R, Peyper JM, Tadokera R, Opondo C, Coussens AK, Wilkinson RJ, Friedland JS, Elkington PT. Matrix Degradation in Human Immunodeficiency Virus Type 1-Associated Tuberculosis and Tuberculosis Immune Reconstitution Inflammatory Syndrome: A Prospective Observational Study. Clin Infect Dis 2017; 65:121-132. [PMID: 28475709 PMCID: PMC5815569 DOI: 10.1093/cid/cix231] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 03/29/2017] [Indexed: 12/11/2022] Open
Abstract
Background Extensive immunopathology occurs in human immunodeficiency virus (HIV)/tuberculosis (TB) coinfection, but the underlying molecular mechanisms are not well-defined. Excessive matrix metalloproteinase (MMP) activity is emerging as a key process but has not been systematically studied in HIV-associated TB. Methods We performed a cross-sectional study of matrix turnover in HIV type 1 (HIV-1)-infected and -uninfected TB patients and controls, and a prospective cohort study of HIV-1-infected TB patients at risk of TB immune reconstitution inflammatory syndrome (TB-IRIS), in Cape Town, South Africa. Sputum and plasma MMP concentrations were quantified by Luminex, plasma procollagen III N-terminal propeptide (PIIINP) by enzyme-linked immunosorbent assay, and urinary lipoarabinomannan (LAM) by Alere Determine TB LAM assay. Peripheral blood mononuclear cells from healthy donors were cultured with Mycobacterium tuberculosis and extracellular matrix in a 3D model of TB granuloma formation. Results MMP activity differed between HIV-1-infected and -uninfected TB patients and corresponded with specific TB clinical phenotypes. HIV-1-infected TB patients had reduced pulmonary MMP concentrations, associated with reduced cavitation, but increased plasma PIIINP, compared to HIV-1-uninfected TB patients. Elevated extrapulmonary extracellular matrix turnover was associated with TB-IRIS, both before and during TB-IRIS onset. The predominant collagenase was MMP-8, which was likely neutrophil derived and M. tuberculosis-antigen driven. Mycobacterium tuberculosis-induced matrix degradation was suppressed by the MMP inhibitor doxycycline in vitro. Conclusions MMP activity in TB differs by HIV-1 status and compartment, and releases matrix degradation products. Matrix turnover in HIV-1-infected patients is increased before and during TB-IRIS, informing novel diagnostic strategies. MMP inhibition is a potential host-directed therapy strategy for prevention and treatment of TB-IRIS.
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Affiliation(s)
- Naomi F Walker
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Infectious Diseases and Immunity, and Imperial College Wellcome Trust Centre for Global Health, Imperial College London, United Kingdom
- Department of Medicine, University of Cape Town, Observatory, South Africa
- Department of Clinical Research, London School of Hygiene and Tropical Medicine
| | - Katalin A Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Department of Medicine, University of Cape Town, Observatory, South Africa
- Francis Crick Institute, London, and
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Department of Medicine, University of Cape Town, Observatory, South Africa
| | - Liku B Tezera
- National Institute for Health Research Respiratory Biomedical Research Unit, Clinical and Experimental Sciences Academic Unit, Faculty of Medicine, University of Southampton, United Kingdom
| | - Rene Goliath
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
| | - Janique M Peyper
- Applied Proteomics and Chemical Biology Group, Department of Integrative Biomedical Sciences, and
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, and
| | - Rebecca Tadokera
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- HIV/AIDS, Sexually Transmitted Infections and Tuberculosis Programme, Human Sciences Research Council, Cape Town, South Africa
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, and
| | - Anna K Coussens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Department of Medicine, University of Cape Town, Observatory, South Africa
- Francis Crick Institute, London, and
- Department of Medicine, Imperial College London, United Kingdom
| | - Jon S Friedland
- Infectious Diseases and Immunity, and Imperial College Wellcome Trust Centre for Global Health, Imperial College London, United Kingdom
| | - Paul T Elkington
- Infectious Diseases and Immunity, and Imperial College Wellcome Trust Centre for Global Health, Imperial College London, United Kingdom
- National Institute for Health Research Respiratory Biomedical Research Unit, Clinical and Experimental Sciences Academic Unit, Faculty of Medicine, University of Southampton, United Kingdom
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48
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Hargreaves S, Duarte R, Friedland JS. The role of pre-migration medical screening in high TB burden countries. Int J Tuberc Lung Dis 2017. [DOI: 10.5588/ijtld.17.0317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
| | - Raquel Duarte
- EpiUnit, Instituto de Saúde Pública, Universidade do Porto, Faculdade de Medicina. Universidade do Porto, Porto, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
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49
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Brilha S, Sathyamoorthy T, Stuttaford LH, Walker NF, Wilkinson RJ, Singh S, Moores RC, Elkington PT, Friedland JS. Early Secretory Antigenic Target-6 Drives Matrix Metalloproteinase-10 Gene Expression and Secretion in Tuberculosis. Am J Respir Cell Mol Biol 2017; 56:223-232. [PMID: 27654284 DOI: 10.1165/rcmb.2016-0162oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Tuberculosis (TB) causes disease worldwide, and multidrug resistance is an increasing problem. Matrix metalloproteinases (MMPs), particularly the collagenase MMP-1, cause lung extracellular matrix destruction, which drives disease transmission and morbidity. The role in such tissue damage of the stromelysin MMP-10, a key activator of the collagenase MMP-1, was investigated in direct Mycobacterium tuberculosis (Mtb)-infected macrophages and in conditioned medium from Mtb-infected monocyte-stimulated cells. Mtb infection increased MMP-10 secretion from primary human macrophages 29-fold, whereas Mtb-infected monocytes increased secretion by 4.5-fold from pulmonary epithelial cells and 10.5-fold from fibroblasts. Inhibition of MMP-10 activity decreased collagen breakdown. In two independent cohorts of patients with TB from different continents, MMP-10 was increased in both induced sputum and bronchoalveolar lavage fluid compared with control subjects and patients with other respiratory diseases (both P < 0.05). Mtb drove 3.5-fold greater MMP-10 secretion from human macrophages than the vaccine strain bacillus Calmette-Guerin (P < 0.001), whereas both mycobacteria up-regulated TNF-α secretion equally. Using overlapping, short, linear peptides covering the sequence of early secretory antigenic target-6, a virulence factor secreted by Mtb, but not bacillus Calmette-Guerin, we found that stimulation of human macrophages with a single specific 15-amino acid peptide sequence drove threefold greater MMP-10 secretion than any other peptide (P < 0.001). Mtb-driven MMP-10 secretion was inhibited in a dose-dependent manner by p38 and extracellular signal-related kinase mitogen-activated protein kinase blockade (P < 0.001 and P < 0.01 respectively), but it was not affected by inhibition of NF-κB. In summary, Mtb activates inflammatory and stromal cells to secrete MMP-10, and this is partly driven by the virulence factor early secretory antigenic target-6, implicating it in TB-associated tissue destruction.
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Affiliation(s)
- Sara Brilha
- 1 Infectious Diseases and Immunity, Imperial College London, London, United Kingdom.,2 Centre for Inflammation and Tissue Repair, Respiratory Medicine, University College London, London, United Kingdom
| | | | - Laura H Stuttaford
- 1 Infectious Diseases and Immunity, Imperial College London, London, United Kingdom
| | - Naomi F Walker
- 1 Infectious Diseases and Immunity, Imperial College London, London, United Kingdom.,3 Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,4 Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Robert J Wilkinson
- 3 Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,5 Department of Medicine, Imperial College London, London, United Kingdom.,6 The Francis Crick Institute, London, United Kingdom.,7 Wellcome Trust Imperial College Centre for Global Health, Imperial College London, London, United Kingdom; and
| | - Shivani Singh
- 1 Infectious Diseases and Immunity, Imperial College London, London, United Kingdom
| | - Rachel C Moores
- 1 Infectious Diseases and Immunity, Imperial College London, London, United Kingdom
| | - Paul T Elkington
- 1 Infectious Diseases and Immunity, Imperial College London, London, United Kingdom.,8 National Institute of Health Research Respiratory Biomedical Research Unit, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Jon S Friedland
- 1 Infectious Diseases and Immunity, Imperial College London, London, United Kingdom.,7 Wellcome Trust Imperial College Centre for Global Health, Imperial College London, London, United Kingdom; and
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50
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Brilha S, Wysoczanski R, Whittington AM, Friedland JS, Porter JC. Monocyte Adhesion, Migration, and Extracellular Matrix Breakdown Are Regulated by Integrin αVβ3 in Mycobacterium tuberculosis Infection. J Immunol 2017. [PMID: 28646039 PMCID: PMC5523580 DOI: 10.4049/jimmunol.1700128] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In tuberculosis (TB), the innate inflammatory immune response drives tissue destruction, morbidity, and mortality. Monocytes secrete matrix metalloproteinases (MMPs), which have key roles in local tissue destruction and cavitation. We hypothesized that integrin signaling might regulate monocyte MMP secretion in pulmonary TB during cell adhesion to the extracellular matrix (ECM). Adhesion to type I collagen and fibronectin by Mycobacterium tuberculosis-stimulated monocytes increased MMP-1 gene expression by 2.6-fold and 4.3-fold respectively, and secretion by 60% (from 1208.1 ± 186 to 1934.4 ± 135 pg/ml; p < 0.0001) and 63% (1970.3 ± 95 pg/ml; p < 0.001). MMP-10 secretion increased by 90% with binding to type I collagen and 55% with fibronectin, whereas MMP-7 increased 57% with collagen. The ECM did not affect the secretion of tissue inhibitors of metalloproteinases-1 or -2. Integrin αVβ3 surface expression was specifically upregulated in stimulated monocytes and was further increased after adhesion to type I collagen. Binding of either β3 or αV integrin subunits increased MMP-1/10 secretion in M. tuberculosis-stimulated monocytes. In a cohort of TB patients, significantly increased integrin β3 mRNA accumulation in induced sputum was detected, to our knowledge, for the first time, compared with control subjects (p < 0.05). Integrin αVβ3 colocalized with areas of increased and functionally active MMP-1 on infected monocytes, and αVβ3 blockade markedly decreased type I collagen breakdown, and impaired both monocyte adhesion and leukocyte migration in a transwell system (p < 0.0001). In summary, our data demonstrate that M. tuberculosis stimulation upregulates integrin αVβ3 expression on monocytes, which upregulates secretion of MMP-1 and -10 on adhesion to the ECM. This leads to increased monocyte recruitment and collagenase activity, which will drive inflammatory tissue damage.
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Affiliation(s)
- Sara Brilha
- Department of Infectious Diseases and Immunity, Imperial College London, London W12 0NN, United Kingdom.,Centre for Inflammation and Tissue Repair, Respiratory Medicine, University College London, London WC1E 6JF, United Kingdom; and
| | - Riccardo Wysoczanski
- Department of Infectious Diseases and Immunity, Imperial College London, London W12 0NN, United Kingdom.,Centre for Molecular Medicine, University College London, London WC1E 6JF, United Kingdom
| | - Ashley M Whittington
- Department of Infectious Diseases and Immunity, Imperial College London, London W12 0NN, United Kingdom
| | - Jon S Friedland
- Department of Infectious Diseases and Immunity, Imperial College London, London W12 0NN, United Kingdom;
| | - Joanna C Porter
- Centre for Inflammation and Tissue Repair, Respiratory Medicine, University College London, London WC1E 6JF, United Kingdom; and
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