Comparison of two diagnostic intervention packages for community-based active case finding for tuberculosis: an open-label randomized controlled trial

Two in every five patients with active tuberculosis (TB) remain undiagnosed or unreported. Therefore community-based, active case-finding strategies require urgent implementation. However, whether point-of-care (POC), portable battery-operated, molecular diagnostic tools deployed at a community level, compared with conventionally used POC smear microscopy, can shorten time-to-treatment initiation, thus potentially curtailing transmission, remains unclear. To clarify this issue, we performed an open-label, randomized controlled trial in periurban informal settlements of Cape Town, South Africa, where we TB symptom screened 5,274 individuals using a community-based scalable mobile clinic. Some 584 individuals with HIV infection or symptoms of TB underwent targeted diagnostic screening and were randomized (1:1) to same-day smear microscopy (n = 296) or on-site DNA-based molecular diagnosis (n = 288; GeneXpert). The primary aim was to compare time to TB treatment initiation between the arms. Secondary aims included feasibility and detection of probably infectious people. Of participants who underwent targeted screening, 9.9% (58 of 584) had culture-confirmed TB. Time-to-treatment initiation occurred significantly earlier in the Xpert versus the smear-microscopy arm (8 versus 41 d, P = 0.002). However, overall, Xpert detected only 52% of individuals with culture-positive TB. Notably, Xpert detected almost all of the probably infectious patients compared with smear microscopy (94.1% versus 23.5%, P = <0.001). Xpert was associated with a shorter median time to treatment of probably infectious patients (7 versus 24 d, P = 0.02) and a greater proportion of infectious patients were on treatment at 60 d compared with the probably noninfectious patients (76.5% versus 38.2%, P < 0.01). Overall, a greater proportion of POC Xpert-positive participants were on treatment at 60 d compared with all culture-positive participants (100% versus 46.5%, P < 0.01). These findings challenge the traditional paradigm of a passive case-finding, public health strategy and argues for the implementation of portable DNA-based diagnosis with linkage to care as a community-oriented, transmission-interruption strategy. The study was registered with the South African National Clinical Trials Registry (application ID 4367; DOH-27-0317-5367) and ClinicalTrials.gov (NCT03168945).

Bacterial and host determinants of cough aerosol culture positivity in patients with drug-resistant versus drug-susceptible tuberculosis

A burgeoning epidemic of drug-resistant tuberculosis (TB) threatens to derail global control efforts. Although the mechanisms remain poorly clarified, drug-resistant strains are widely believed to be less infectious than drug-susceptible strains. Consequently, we hypothesized that lower proportions of patients with drug-resistant TB would have culturable Mycobacterium tuberculosis from respirable, cough-generated aerosols compared to patients with drug-susceptible TB, and that multiple factors, including mycobacterial genomic variation, would predict culturable cough aerosol production. We enumerated the colony forming units in aerosols (≤10 µm) from 452 patients with TB (227 with drug resistance), compared clinical characteristics, and performed mycobacterial whole-genome sequencing, dormancy phenotyping and drug-susceptibility analyses on M. tuberculosis from sputum. After considering treatment duration, we found that almost half of the patients with drug-resistant TB were cough aerosol culture-positive. Surprisingly, neither mycobacterial genomic variants, lineage, nor dormancy status predicted cough aerosol culture positivity. However, mycobacterial sputum bacillary load and clinical characteristics, including a lower symptom score and stronger cough, were strongly predictive, thereby supporting targeted transmission-limiting interventions. Effective treatment largely abrogated cough aerosol culture positivity; however, this was not always rapid. These data question current paradigms, inform public health strategies and suggest the need to redirect TB transmission-associated research efforts toward host-pathogen interactions.

Recovery of Mycobacterium tuberculosis from positive mycobacterium growth indicator tubes stored at room temperature for up to 6 years in low-income and High-Tuberculosis-Burden Country

Background

Biobanking of Mycobacterium tuberculosis (Mtb) sputum samples for future research activities recommends the use of -70°C or -80°C freezers. Infrastructure for biobanking is not readily available in the majority of low-income countries. This study aimed to assess the recovery rate of Mtb isolates stored at room temperature for more than 6 years in Zimbabwe.

Methods

Census samples of all confirmed rifampicin-resistant/multidrug-resistant tuberculosis isolates that were stored in mycobacterial growth indicator tubes (MGITs) at room temperature from 2011 to 2016 were identified and retrieved. The samples were subcultured on MGIT and 7H10 solid media for the extraction of genomic deoxyribonucleic acid using the phenol/chloroform method followed by precipitation with isopropanol.

Results

A total of 248/400 (62%) isolates were successfully recovered. Recovery rates increased with declining time since the last culture, with 51% for samples stored for 6 years which increased to 77% for those stored for 1 year. The isolates that grew but were contaminated during the first subculture at the National Microbiology Reference Laboratory in Harare could not be recovered through decontamination because of limited resources. Decontamination was only possible during the second culture at the University of Stellenbosch.

Conclusion

Storage of Mtb isolates at room temperature is a viable option in low-income countries where currently recommended biobanking procedures may not be available. This low-cost biobanking will facilitate research activities years later as new questions arise. Standard infection prevention and control when handling Mtb samples stored under room temperature for long periods is strongly recommended as these bacteria remain viable longer than previously reported.

Anesthesia-related and perioperative mortality: An audit of 8493 cases at a tertiary pediatric teaching hospital in South Africa

AIM

This study aimed to quantify the incidence of anesthesia-related and perioperative mortality at a large tertiary pediatric hospital in South Africa.

METHODS

This study included all children aged <18 years who died prior to discharge from hospital and within 30 days of their last anesthetic at the Red Cross War Memorial Children's Hospital between January 1, 2015 to December 31, 2015. A panel of three senior anesthetists reviewed each death to reach a consensus as to whether: (i) anesthesia caused the death; (ii) anesthesia may have contributed to or influenced the timing of death; or (iii) anesthesia was entirely unrelated to the death.

RESULTS

There were 47 deaths within 30 days of anesthesia prior to discharge from hospital during this 12-month period. The in-hospital mortality within 24 h of administration of anesthesia was 16.5 per 10 000 cases (95% confidence intervals [CI]=7.8-25.1) and within 30 days of administration of anesthesia was 55.3 per 10 000 cases (95% CI=39.5-71.2). Age under 1 year (OR 4.5; 95% CI=2.5-8.0, P=.012) and cardiac surgery and interventional cardiology procedures (OR 2.5; 95% CI=1.2-5.2, P<.01) were both independent predictors of increased risk of perioperative mortality.

CONCLUSION

The overall 24-h and 30-day anesthesia-related and in-hospital perioperative mortality rates in our study are comparable with other similar studies from tertiary pediatric centers.

Safe Mycobacterium tuberculosis DNA extraction method that does not compromise integrity

Concern has been raised about the efficacy of the heat killing of mycobacteria during the isolation of DNA. We demonstrate a method that allows for the efficient killing of Mycobacterium tuberculosis without compromising DNA integrity for subsequent molecular investigation. This method reduces the risk of infection to the research scientist.

Reduction of the rate of false-positive cultures of Mycobacterium tuberculosis in a laboratory with a high culture positivity rate

Our laboratory, engaged in a prospective study of adult pulmonary tuberculosis, processed on average 1186 sputum samples per year for the detection of Mycobacterium tuberculosis (M. tuberculosis). Approximately 55% of all sputum samples were culture-positive. The study protocol required that all patients had their M. tuberculosis isolates DNA fingerprinted at diagnosis, and at subsequent time points if the patients either failed treatment or presented again with tuberculosis. Over a 22-month period, there were 14 apparent treatment failures from 109 patients who had completed 6 months of therapy. Only two of these were true treatment failures, while the other 12 had DNA fingerprints that were different from those obtained at diagnosis. It was concluded that these 12 cultures represented episodes of laboratory cross-contamination. Retrospective DNA fingerprinting of patient isolates was done so that each patient had at least two independent isolates fingerprinted. This survey revealed that 7.3% of DNA fingerprints were discordant. False-positive cultures with discordant DNA fingerprints generally arose late in chemotherapy and the isolates were usually co-processed with other strongly smear-positive sputum samples. Simple modifications of laboratory procedures were made, and over a following 10.5-month period the false-positive rate was reduced to 2.1%. These modifications did not increase the workload or the cost of processing samples and can thus be used successfully by any laboratory, and particularly by those in resource-poor settings.

Wildlife, people and development: veterinary contributions to wildlife health and resource management in Africa

Human population pressures, habitat loss, environmental degradation and illegal hunting in Africa have resulted in the loss of biodiversity and near extinction of certain wildlife species. The dilemma for Africa is the balancing of conservation and development. If wildlife is not to become a relic of the past then it must have more than just aesthetic value. It must contribute materially to the well being of people who live close to the resource. In fact, appropriate management of biodiversity would lay the foundations for a more positive future for the rural people of Africa, with the key being the adoption of an active adaptive management philosophy. This paper reviews the issue of sustainable use of wildlife resources and how the Veterinary profession contributes positively to wildlife health management in Africa. These contributions have been through increasing veterinary inputs into wildlife management and research, disease surveillance and prevention, training and education. Wildlife and ecosystems are increasingly having to be managed in order to save and maintain biological diversity. Veterinarians have a crucial role to play towards the maintenance of wildlife health as part of a multi-disciplinary wildlife management team.

Plasma cortisol as an indicator of stress due to capture and translocation in wildlife species

Plasma cortisol concentrations were determined by radioimmunoassay in 712 individual animals of 18 wildlife species after either physical or chemical restraint, tranquillisation or trauma, in order to define baseline values and to assess the possibility of using cortisol as an indicator of stress. The cortisol levels appeared to rise after capture in all the species examined except the Cape buffalo. On the basis of the plasma cortisol levels, chemical capture was less stressful than physical restraint. Animals which were tranquillised had lower than 'normal' cortisol levels, whereas animals that had suffered trauma or which died after they were captured had higher than normal cortisol levels.

Flaccid trunk paralysis in free-ranging elephants (Loxodonta africana) in Zimbabwe

An epizootic of flaccid trunk paralysis began in free-ranging Zimbabwean elephants (Loxodonta africana) on the southern shore of Lake Kariba in 1989. It involved a selective neuropathy of peripheral nerves supplying the trunk, with axon and myelin degeneration, muscle atrophy, compensatory hypertrophy, and fine endomyseal fibrosis, without inflammatory changes.

Comparative blood characteristics of ranched and free-ranging American bison (Bison bison)

Blood samples were obtained from 20 bison (Bison bison) from a ranch in northern lower Michigan, as well as from 20 free-ranging bison of the same sex and similar age from the Badlands National Park in South Dakota. Hematologic and serum biochemical values were determined. The values were comparable in both groups, except for those for BUN, aspartate transaminase, and phosphorus, which were significantly (P less than 0.001) higher in the ranched bison than in the free-ranging bison. These differences were attributed to nutritional effects. Impact of age on blood characteristics was assessed in the ranched bison only by comparing values from calves weighing less than 185 kg with those from bison weighing more than 185 kg. Calves had significantly (P less than 0.001) higher values for phosphorus and RBC counts and lower total protein values than adults. Adult bison had higher eosinophil and neutrophil counts with lower numbers of lymphocytes, suggestive of a stress leukogram, whereas calves had the typical bovine neutrophil:lymphocyte ratio.

Overwinter survival of carfentanil-immobilized male bison

A problem with studies that examine immobilization-related drug effects on large mammals is that no true control group exists because untreated (non-captured) animals in the same population have not been examined. We present data to show that overwinter survival in male bison (Bison bison) immobilized with carfentanil was the same as untreated bison. This unique experimental design allows us to conclude that the drug had no long-term effect on male bison overwinter survival.

Effects of capture on biological parameters in free-ranging bighorn sheep (Ovis canadensis): evaluation of normal, stressed and mortality outcomes and documentation of postcapture survival

Blood samples and physiological data were collected from 634 bighorn sheep (Ovis canadensis) captured by four different methods between 1980 and 1986 in the western United States. These parameters were evaluated for selected physiological, biochemical and hematological values. Postcapture biological parameters were compared among bighorn sheep according to four different outcomes; normal, stressed or compromised, capture myopathy (CM) mortality, and accidental mortality. Significant differences (P less than 0.05) were noted between outcome groups relative to certain parameters: temperature, respiration, creatinine phosphokinase (CPK), lactic dehydrogenase (LDH), serum glutamic oxaloacetic transaminase (SGOT), blood urea nitrogen (BUN), glucose, white blood cell count (WBC) and plasma pH. Such differences between groups may help in evaluating the clinical status of bighorn sheep at capture, enabling one to predict those animals that might develop CM at a later date, indicate candidates for preventive medical treatment prior to release, and/or which should be followed closely to determine long-term survival. Evaluation of follow-up data (n = 77) related to outcome status and long-term survival of bighorn sheep indicated that less than 4% (3 of 77) were dead within 1 mo of capture (one of these had been classified as normal and two as stressed or compromised at capture); less than 3% (3 of 77) were dead greater than 1 mo, and less than 6 mo after capture two were classified in the stressed outcome and one as diseased. Eighty-eight percent (68 of 77) were alive from 1 mo to 5 yr after capture (53 were classified as normal, 12 as stressed or compromised and 3 as diseased), and 2% (1 of 77) had chronic CM but was still alive (this animal had been classified as normal). Of 77 sheep in the follow-up group, less than 3% (2 of 77) were not observed following capture (one was classified as normal and one as stressed and diseased). Of the fatalities, less than 3% (2 of 40) had been captured by the net-gun and less than 4% (1 of 27) by drive-net. Those two unobserved in the follow-up group also had been caught with the net-gun, 5% (2 of 40). The single surviving CM case had been captured by the net-gun. Although the net-gun appears to be one of the safest methods of capturing individual bighorn sheep, based on evaluation of capture data and biological parameters, it may not be associated with the best long-term survival in some bighorn sheep.(ABSTRACT TRUNCATED AT 400 WORDS)

Effects of capture on biological parameters in free-ranging bighorn sheep (Ovis canadensis): evaluation of drop-net, drive-net, chemical immobilization and the net-gun

Blood samples and physiological data were collected from 634 bighorn sheep captured between 1980 and 1986 in the western United States. Bighorn sheep were evaluated for physiological parameters (temperature, pulse and respiration), selected biochemical parameters (cortisol, creatine phosphokinase (CPK), serum glutamic oxaloacetic transaminase (SGOT), lactic dehydrogenase (LDH), alkaline phosphotase (AP), potassium, sodium, chloride, creatinine, blood urea nitrogen (BUN), selenium, glucose, total protein, plasma pH and plasma PCO2), and selected hematological parameters (packed cell volume (PCV), hemoglobin (HB), red blood cell count (RBC), and white blood cell count (WBC]. These parameters were compared among bighorn sheep captured by four different methods: drop-net (n = 158), drive-net (n = 249), chemical immobilization (n = 90) and the net-gun (n = 137). Biological parameters affected by stress, including temperature, respiration, cortisol, CPK, SGOT, potassium, glucose and WBC revealed significant differences among capture methods (P less than 0.05). Some blood parameter differences, including temperature, respiration, cortisol, glucose and WBC could be explained partially by the distribution of age and sex within capture method groups. Drop-net and net-gun methods of capture appeared to produce the least amount of alteration to biological parameters related to capture stress or compromise and capture mortality. Drive-net was similar to the former methods while chemical immobilization caused the greatest changes in the above physiological, biochemical and hematological parameters.

Chemical immobilization of free-ranging North American bison (Bison bison) in Badlands National Park, South Dakota

Twenty-six free-ranging North American bison (Bison bison) (22 adult bulls, one yearling male and three adult females) were immobilized using a combination of carfentanil and xylazine. For carfentanil the dose range (mean +/- SD) was 1.8-5.0 micrograms/kg (2.4 +/- 0.7 micrograms/kg) and for xylazine 0.004-0.125 mg/kg (0.07 +/- 0.03 mg/kg). Induction time (mean +/- SE) was 14.2 +/- 2.9 min (median 8 min), while the total mean reversal time after administration of a narcotic antagonist was 9.0 +/- 1.4 min (median 8 min). Only one animal that received the highest initial dose of carfentanil (2.5 mg) showed evidence of becoming "re-narcotized." Five animals required two or more doses of carfentanil before becoming immobilized. Overall, small volumes of drug used (mean = 0.62 ml for carfentanil, 0.53 ml for xylazine) enabled the use of 1 to 2 ml darts, increasing both accuracy and impact safety. Darting success approached 100%.

Capture methods in five subspecies of free-ranging bighorn sheep: an evaluation of drop-net, drive-net, chemical immobilization and the net-gun

Six hundred thirty-four bighorn sheep (Ovis canadensis) were captured in the western United States between 1980 and 1986, using four different methods: drop-net (n = 158), drive-net (n = 249), chemical immobilization (n = 90) and net-gun (n = 137). The net-gun was found to have considerable advantages over the use of ground nets and chemical immobilization methods for capturing bighorn sheep. Evaluation of specific outcome categories for individual sheep, including normal, compromised (stress-induced), mortality from capture myopathy (CM), and accidental mortality, revealed significant differences in these rates between capture groups (P less than 0.05). The use of the net-gun resulted in the lowest proportion of compromised sheep at 11% (15/137), had no CM mortality, and resulted in a 2% (2/137) accidental mortality. The use of drop-nets resulted in 15% compromised sheep (24/158), a CM mortality rate of 2% (3/158), and an accidental mortality rate of 1% (2/158). A similar proportion of sheep were compromised with the drive-nets (16%, 39/249). This method also had the highest CM mortality rate at 3% (7/249), and an accidental mortality rate of less than 1% (2/249). Chemical immobilization resulted in the most compromised sheep at 19% (17/90), had a CM mortality rate of 2% (2/90), and caused the most accidental deaths at 6% (5/90). Drop-nets and drive-nets were comparable when combining total mortality with rates for compromised bighorn sheep, 18% and 19%, respectively (29/158 and 48/249). Chemical immobilization had the highest combined measure of risk at 27% (24/90) and net-gun lowest at 12% (17/137).(ABSTRACT TRUNCATED AT 250 WORDS)

Survey of desert bighorn sheep in California for exposure to selected infectious diseases

From February 1983 to June 1985, 188 desert bighorn sheep (Ovis canadensis nelsoni, = 161 and Oc cremnobates, = 27) from 18 herds in 17 mountain ranges and one captive herd were caught, marked, and had blood, fecal, and nasal mucus samples collected. Nasal swab specimens were cultured bacteriologically and virologically specifically for parainfluenza-3 (PI-3) virus. Bacterial flora differed from herd to herd. Pathogenic pneumophilic bacteria (eg, Pasteurella sp) seldom were found. Parainfluenza-3 virus was isolated from 6 bighorn sheep in 3 herds. Fecal specimens were examined for parasite ova and low numbers of lungworm (Protostrongylus sp) larvae were found in feces from 2 herds. Sera were evaluated for antibodies against respiratory syncytial virus, ovine progressive pneumonia, infectious bovine rhinotracheitis, PI-3, bovine viral diarrhea, brucellosis, leptospirosis, contagious ecthyma, bluetongue, and epizootic hemorrhagic disease. Blood clots were cultured virologically for bluetongue and epizootic hemorrhagic disease. Serologic evidence of bluetongue and/or epizootic hemorrhagic disease was found in 9 herds, and bluetongue virus (serotypes 10,11,13 and 17) was isolated from 3 herds. Antibody titers against PI-3 and respiratory syncytial virus were found in 9 and 13 herds, respectively. Evidence of bovine viral diarrhea infection was found in 6 herds, whereas infectious bovine rhinotracheitis was found in only 1 herd. Antibody titers against contagious ecthyma were found in 9 of 18 herds in California, and active lesions were seen occasionally. Evidence of ovine progressive pneumonia, leptospirosis, or brucellosis was not found.