1
|
Kay A, Vasiliu A, Carratala-Castro L, Mtafya B, Mendez Reyes JE, Maphalala N, Munguambe S, Mulengwa D, Ness T, Saavedra B, Bacha J, Maphalala G, Mejia R, Mtetwa G, Acacio S, Manjate P, Mambuque E, Shiba N, Kota N, Ziyane M, Ntinginya NE, Lange C, Kirchner HL, DiNardo AR, Garcia-Basteiro AL, Mandalakas AM. Performance of a stool-based quantitative PCR assay for the diagnosis of tuberculosis in adolescents and adults: a multinational, prospective diagnostic accuracy study. Lancet Microbe 2024; 5:e433-e441. [PMID: 38461830 DOI: 10.1016/s2666-5247(23)00391-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/23/2023] [Accepted: 11/21/2023] [Indexed: 03/12/2024]
Abstract
BACKGROUND Despite increasing availability of rapid molecular tests for the diagnosis of tuberculosis in high-burden settings, many people with tuberculosis are undiagnosed. Reliance on sputum as the primary specimen for tuberculosis diagnostics contributes to this diagnostic gap. We evaluated the diagnostic accuracy and additive yield of a novel stool quantitative PCR (qPCR) assay for the diagnosis of tuberculosis in three countries in Africa with high tuberculosis burdens. METHODS We undertook a prospective diagnostic accuracy study in Eswatini, Mozambique, and Tanzania from Sept 21, 2020, to Feb 2, 2023, to compare the diagnostic accuracy for tuberculosis of a novel stool qPCR test with the current diagnostic standard for Mycobacterium tuberculosis DNA detection from sputum and stool, Xpert-MTB/RIF Ultra (Xpert Ultra). Sputum, stool, and urine samples were provided by a cohort of participants, aged 10 years or older, diagnosed with tuberculosis. Participants with tuberculosis (cases) were enrolled within 72 h of treatment initiation for tuberculosis diagnosed clinically or following laboratory confirmation. Participants without tuberculosis (controls) consisted of household contacts of the cases who did not develop tuberculosis during a 6-month follow-up. The performance was compared with a robust composite microbiological reference standard (CMRS). FINDINGS The cohort of adolescents and adults (n=408) included 268 participants with confirmed or clinical tuberculosis (cases), 147 (55%) of whom were living with HIV, and 140 participants (controls) without tuberculosis. The sensitivity of the novel stool qPCR was 93·7% (95% CI 87·4-97·4) compared with participants with detectable growth on M tuberculosis culture, and 88·1% (81·3-93·0) compared with sputum Xpert Ultra. The stool qPCR had an equivalent sensitivity as sputum Xpert Ultra (94·8%, 89·1-98·1) compared with culture. Compared with the CMRS, the sensitivity of the stool qPCR was higher than the current standard for tuberculosis diagnostics on stool, Xpert Ultra (80·4%, 73·4-86·2 vs 73·5%, 66·0-80·1; p=0·025 on paired comparison). The qPCR also identified 17-21% additional tuberculosis cases compared to sputum Xpert Ultra or sputum culture. In controls without tuberculosis, the specificity of the stool qPCR was 96·9% (92·2-99·1). INTERPRETATION In this study, a novel qPCR for the diagnosis of tuberculosis from stool specimens had a higher accuracy in adolescents and adults than the current diagnostic PCR gold standard on stool, Xpert-MTB/RIF Ultra, and equivalent sensitivity to Xpert-MTB/RIF Ultra on sputum. FUNDING National Institutes of Health (NIH) Allergy and Infectious Diseases, and NIH Fogarty International Center.
Collapse
Affiliation(s)
- Alexander Kay
- Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA; Baylor College of Medicine Children's Foundation Eswatini, Mbabane, Eswatini.
| | - Anca Vasiliu
- Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Lucia Carratala-Castro
- Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Bariki Mtafya
- National Institute for Medical Research (NIMR)-Mbeya Medical Research Center, Mbeya, Tanzania
| | | | - Nontobeko Maphalala
- Baylor College of Medicine Children's Foundation Eswatini, Mbabane, Eswatini
| | - Shilzia Munguambe
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Durbbin Mulengwa
- Baylor College of Medicine Children's Foundation Eswatini, Mbabane, Eswatini
| | - Tara Ness
- Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Belen Saavedra
- Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Jason Bacha
- Baylor College of Medicine Children's Foundation Mbeya, Mbeya, Tanzania
| | | | - Rojelio Mejia
- Pediatric Tropical Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Godwin Mtetwa
- Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Sozinho Acacio
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Patricia Manjate
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Edson Mambuque
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Nosisa Shiba
- Baylor College of Medicine Children's Foundation Eswatini, Mbabane, Eswatini
| | - Nokwanda Kota
- Baylor College of Medicine Children's Foundation Eswatini, Mbabane, Eswatini
| | - Mangaliso Ziyane
- Baylor College of Medicine Children's Foundation Eswatini, Mbabane, Eswatini; Eswatini Health Laboratory Service, Mbabane, Eswatini
| | - Nyanda Elias Ntinginya
- National Institute for Medical Research (NIMR)-Mbeya Medical Research Center, Mbeya, Tanzania
| | - Christoph Lange
- Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA; Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany; Respiratory Medicine and International Health, University of Lübeck, Lübeck, Germany
| | - H Lester Kirchner
- Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA; Department of Population Health Sciences, Geisinger, Danville, PA, USA
| | - Andrew R DiNardo
- Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA; Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - Alberto L Garcia-Basteiro
- Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Barcelona, Spain
| | - Anna Maria Mandalakas
- Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA; Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany; Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health School of Public Health, Houston, TX, USA
| |
Collapse
|
2
|
Carratala-Castro L, Ssengooba W, Kay A, Acácio S, Ehrlich J, DiNardo AR, Shiba N, Nsubuga JK, Munguambe S, Saavedra-Cervera B, Manjate P, Mulengwa D, Sibandze B, Ziyane M, Kasule G, Mambuque E, Sekadde MP, Wobudeya E, Joloba ML, Heyckendorf J, Lange C, Hermans S, Mandalakas A, García-Basteiro AL, Lopez-Varela E. A stool based qPCR for the diagnosis of TB in children and people living with HIV in Uganda, Eswatini and Mozambique (Stool4TB): a protocol for a multicenter diagnostic evaluation. BMC Infect Dis 2024; 24:233. [PMID: 38383310 PMCID: PMC10880221 DOI: 10.1186/s12879-023-08708-9] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 10/13/2023] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Tuberculosis (TB) is a major cause of mortality worldwide. Children and people living with HIV (PLHIV) have an increased risk of mortality, particularly in the absence of rapid diagnosis. The main challenges of diagnosing TB in these populations are due to the unspecific and paucibacillary disease presentation and the difficulty of obtaining respiratory samples. Thus, novel diagnostic strategies, based on non-respiratory specimens could improve clinical decision making and TB outcomes in high burden TB settings. We propose a multi-country, prospective diagnostic evaluation study with a nested longitudinal cohort evaluation to assess the performance of a new stool-based qPCR, developed by researchers at Baylor College of Medicine (Houston, Texas, USA) for TB bacteriological confirmation with promising results in pilot studies. METHODS The study will take place in high TB/HIV burden countries (Mozambique, Eswatini and Uganda) where we will enroll, over a period of 30 months, 650 PLHIV (> 15) and 1295 children under 8 years of age (irrespective of HIV status) presenting pressumptive TB. At baseline, all participants will provide clinical history, complete a physical assessment, and undergo thoracic chest X-ray imaging. To obtain bacteriological confirmation, participants will provide respiratory samples (1 for adults, 2 in children) and 1 stool sample for Xpert Ultra MTB/RIF (Cepheid, Sunnyvale, CA, USA). Mycobacterium tuberculosis (M.tb) liquid culture will only be performed in respiratory samples and lateral flow lipoarabinomannan (LF-LAM) in urine following WHO recommendations. Participants will complete 2 months follow-up if they are not diagnosed with TB, and 6 months if they are. For analytical purposes, the participants in the pediatric cohort will be classified into "confirmed tuberculosis", "unconfirmed tuberculosis" and "unlikely tuberculosis". Participants of the adult cohort will be classified as "bacteriologically confirmed TB", "clinically diagnosed TB" or "not TB". We will assess accuracy of the novel qPCR test compared to bacteriological confirmation and Tb diagnosis irrespective of laboratory results. Longitudinal qPCR results will be analyzed to assess its use as treatment response monitoring. DISCUSSION The proposed stool-based qPCR is an innovation because both the strategy of using a non-sputum based sample and a technique specially designed to detect M.tb DNA in stool. PROTOCOL REGISTRATION DETAILS ClinicalTrials.gov Identifier: NCT05047315.
Collapse
Affiliation(s)
- Lucia Carratala-Castro
- Centro de Investigação em Saúde de Manhiça (CISM), Mozambique, Maputo.
- Fundación Privada Instituto de Salud Global Barcelona (ISGlobal), Spain, Barcelona.
| | | | - Alex Kay
- Baylor College of Medicine (BCM), Houston, TX, USA
- Baylor College of Medicine -Children's Foundation Eswatini, Mbabane, Eswatini, Swaziland
| | - Sozinho Acácio
- Centro de Investigação em Saúde de Manhiça (CISM), Mozambique, Maputo
- Instituto Nacional de Saúde (INS), Ministério da Saúde de Moçambique, Mozambique, Maputo
| | - Joanna Ehrlich
- Fundación Privada Instituto de Salud Global Barcelona (ISGlobal), Spain, Barcelona
| | - Andrew R DiNardo
- Baylor College of Medicine (BCM), Houston, TX, USA
- Radboud UMC, Nijmegen, Netherlands
| | - Nosisa Shiba
- Baylor College of Medicine -Children's Foundation Eswatini, Mbabane, Eswatini, Swaziland
| | | | - Shilzia Munguambe
- Centro de Investigação em Saúde de Manhiça (CISM), Mozambique, Maputo
| | - Belén Saavedra-Cervera
- Centro de Investigação em Saúde de Manhiça (CISM), Mozambique, Maputo
- Fundación Privada Instituto de Salud Global Barcelona (ISGlobal), Spain, Barcelona
| | - Patricia Manjate
- Centro de Investigação em Saúde de Manhiça (CISM), Mozambique, Maputo
| | - Durbbin Mulengwa
- Baylor College of Medicine -Children's Foundation Eswatini, Mbabane, Eswatini, Swaziland
| | - Busizwe Sibandze
- Baylor College of Medicine -Children's Foundation Eswatini, Mbabane, Eswatini, Swaziland
- Amsterdam UMC, location University of Amsterdam, Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
- National Tuberculosis Reference Laboratory, Mbabane, Eswatini, Swaziland
| | - Mangaliso Ziyane
- Amsterdam UMC, location University of Amsterdam, Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
- National Tuberculosis Reference Laboratory, Mbabane, Eswatini, Swaziland
| | | | - Edson Mambuque
- Centro de Investigação em Saúde de Manhiça (CISM), Mozambique, Maputo
| | | | | | | | - Jan Heyckendorf
- Department of Internal Medicine I, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany
- Respiratory Medicine and International Health, University of Lübeck, Lübeck, Germany
- Baylor College of Medicine and Texas Children Hospital, Global TB Program, Houston, TX, USA
| | - Sabine Hermans
- Amsterdam UMC, location University of Amsterdam, Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
- Amsterdam UMC, location University of Amsterdam, Centre for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam, the Netherlands
| | - Anna Mandalakas
- Baylor College of Medicine (BCM), Houston, TX, USA
- Research Center Borstel, Borstel, Germany
| | - Alberto L García-Basteiro
- Centro de Investigação em Saúde de Manhiça (CISM), Mozambique, Maputo
- Fundación Privada Instituto de Salud Global Barcelona (ISGlobal), Spain, Barcelona
| | - Elisa Lopez-Varela
- Centro de Investigação em Saúde de Manhiça (CISM), Mozambique, Maputo
- Fundación Privada Instituto de Salud Global Barcelona (ISGlobal), Spain, Barcelona
| |
Collapse
|