1
|
Xiong Y, Millones AK, Farroñay S, Torres I, Acosta D, Jordan DR, Jimenez J, Wippel C, Jenkins HE, Lecca L, Yuen CM. Impact of the private sector on spatial accessibility to chest radiography services in Lima, Peru. IJTLD OPEN 2024; 1:144-146. [PMID: 38698907 PMCID: PMC11065097 DOI: 10.5588/ijtldopen.23.0460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Affiliation(s)
- Yiqi Xiong
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA
| | | | | | | | | | - Demetrice R. Jordan
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Christoph Wippel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Helen E. Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Leonid Lecca
- Socios En Salud Sucursal Peru, Lima, Peru
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Courtney M. Yuen
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
2
|
Eneogu RA, Mitchell EMH, Ogbudebe C, Aboki D, Anyebe V, Dimkpa CB, Egbule D, Nsa B, van der Grinten E, Soyinka FO, Abdur-Razzaq H, Useni S, Lawanson A, Onyemaechi S, Ubochioma E, Scholten J, Verhoef J, Nwadike P, Chukwueme N, Nongo D, Gidado M. Iterative evaluation of mobile computer-assisted digital chest x-ray screening for TB improves efficiency, yield, and outcomes in Nigeria. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002018. [PMID: 38232129 DOI: 10.1371/journal.pgph.0002018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 11/29/2023] [Indexed: 01/19/2024]
Abstract
Wellness on Wheels (WoW) is a model of mobile systematic tuberculosis (TB) screening of high-risk populations combining digital chest radiography with computer-aided automated detection (CAD) and chronic cough screening to identify presumptive TB clients in communities, health facilities, and prisons in Nigeria. The model evolves to address technical, political, and sustainability challenges. Screening methods were iteratively refined to balance TB yield and feasibility across heterogeneous populations. Performance metrics were compared over time. Screening volumes, risk mix, number needed to screen (NNS), number needed to test (NNT), sample loss, TB treatment initiation and outcomes. Efforts to mitigate losses along the diagnostic cascade were tracked. Persons with high CAD4TB score (≥80), who tested negative on a single spot GeneXpert were followed-up to assess TB status at six months. An experimental calibration method achieved a viable CAD threshold for testing. High risk groups and key stakeholders were engaged. Operations evolved in real time to fix problems. Incremental improvements in mean client volumes (128 to 140/day), target group inclusion (92% to 93%), on-site testing (84% to 86%), TB treatment initiation (87% to 91%), and TB treatment success (71% to 85%) were recorded. Attention to those as highest risk boosted efficiency (the NNT declined from 8.2 ± SD8.2 to 7.6 ± SD7.7). Clinical diagnosis was added after follow-up among those with ≥ 80 CAD scores and initially spot -sputum negative found 11 additional TB cases (6.3%) after 121 person-years of follow-up. Iterative adaptation in response to performance metrics foster feasible, acceptable, and efficient TB case-finding in Nigeria. High CAD scores can identify subclinical TB and those at risk of progression to bacteriologically-confirmed TB disease in the near term.
Collapse
Affiliation(s)
- Rupert A Eneogu
- United States Agency for International Development (USAID), Abuja, Nigeria
| | - Ellen M H Mitchell
- Mycobacterial Diseases and Neglected Tropical Diseases Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Danjuma Aboki
- Nasarawa State TB and Leprosy Control Program, Nasarawa, Nigeria
| | | | | | - Daniel Egbule
- Nasarawa State TB and Leprosy Control Program, Nasarawa, Nigeria
| | | | | | | | | | | | - Adebola Lawanson
- National TB and Leprosy Program, Federal Ministry of Health Nigeria, Abuja, Nigeria
| | - Simeon Onyemaechi
- National TB and Leprosy Program, Federal Ministry of Health Nigeria, Abuja, Nigeria
| | - Emperor Ubochioma
- National TB and Leprosy Program, Federal Ministry of Health Nigeria, Abuja, Nigeria
| | | | | | | | | | - Debby Nongo
- United States Agency for International Development (USAID), Abuja, Nigeria
| | | |
Collapse
|
3
|
Vanobberghen F, Keter AK, Jacobs BK, Glass TR, Lynen L, Law I, Murphy K, van Ginneken B, Ayakaka I, van Heerden A, Maama L, Reither K. Computer-aided detection thresholds for digital chest radiography interpretation in tuberculosis diagnostic algorithms. ERJ Open Res 2024; 10:00508-2023. [PMID: 38196890 PMCID: PMC10772898 DOI: 10.1183/23120541.00508-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/25/2023] [Indexed: 01/11/2024] Open
Abstract
Objectives Use of computer-aided detection (CAD) software is recommended to improve tuberculosis screening and triage, but threshold determination is challenging if reference testing has not been performed in all individuals. We aimed to determine such thresholds through secondary analysis of the 2019 Lesotho national tuberculosis prevalence survey. Methods Symptom screening and chest radiographs were performed in participants aged ≥15 years; those symptomatic or with abnormal chest radiographs provided samples for Xpert MTB/RIF and culture testing. Chest radiographs were processed using CAD4TB version 7. We used six methodological approaches to deal with participants who did not have bacteriological test results to estimate pulmonary tuberculosis prevalence and assess diagnostic accuracy. Results Among 17 070 participants, 5214 (31%) had their tuberculosis status determined; 142 had tuberculosis. Prevalence estimates varied between methodological approaches (0.83-2.72%). Using multiple imputation to estimate tuberculosis status for those eligible but not tested, and assuming those not eligible for testing were negative, a CAD4TBv7 threshold of 13 had a sensitivity of 89.7% (95% CI 84.6-94.8) and a specificity of 74.2% (73.6-74.9), close to World Health Organization (WHO) target product profile criteria. Assuming all those not tested were negative produced similar results. Conclusions This is the first study to evaluate CAD4TB in a community screening context employing a range of approaches to account for unknown tuberculosis status. The assumption that those not tested are negative - regardless of testing eligibility status - was robust. As threshold determination must be context specific, our analytically straightforward approach should be adopted to leverage prevalence surveys for CAD threshold determination in other settings with a comparable proportion of eligible but not tested participants.
Collapse
Affiliation(s)
- Fiona Vanobberghen
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Alfred Kipyegon Keter
- Institute of Tropical Medicine, Antwerp, Belgium
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
- Ghent University, Ghent, Belgium
| | | | - Tracy R. Glass
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Irwin Law
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Keelin Murphy
- Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Irene Ayakaka
- SolidarMed, Partnerships for Health, Maseru, Lesotho
| | - Alastair van Heerden
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
- SAMRC/Wits Developmental Pathways for Health Research Unit (DPHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Llang Maama
- Disease Control Directorate, National Tuberculosis Program, Ministry of Health, Maseru, Lesotho
| | - Klaus Reither
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| |
Collapse
|
4
|
Abuzerr S, Zinszer K. Computer-aided diagnostic accuracy of pulmonary tuberculosis on chest radiography among lower respiratory tract symptoms patients. Front Public Health 2023; 11:1254658. [PMID: 37965525 PMCID: PMC10641698 DOI: 10.3389/fpubh.2023.1254658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/09/2023] [Indexed: 11/16/2023] Open
Abstract
Even though the Gaza Strip is a low pulmonary tuberculosis (TB) burden region, it is well-known that TB is primarily a socioeconomic problem associated with overcrowding, poor hygiene, a lack of fresh water, and limited access to healthcare, which is the typical case in the Gaza Strip. Therefore, this study aimed at assessing the accuracy of the automatic software computer-aided detection for tuberculosis (CAD4TB) in diagnosing pulmonary TB on chest radiography and compare the CAD4TB software reading with the results of geneXpert. Using a census sampling method, the study was conducted in radiology departments in the Gaza Strip hospitals between 1 December 2022 and 31 March 2023. A digital X-ray, printer, and online X-ray system backed by CAD4TBv6 software were used to screen patients with lower respiratory tract symptoms. GeneXpert analysis was performed for all patients having a score > 40. A total of 1,237 patients presenting with lower respiratory tract symptoms participated in this current study. Chest X-ray readings showed that 7.8% (n = 96) were presumptive for TB. The CAD4TBv6 scores showed that 11.8% (n = 146) of recruited patients were presumptive for TB. GeneXpert testing on sputum samples showed that 6.2% (n = 77) of those with a score > 40 on CAD4TB were positive for pulmonary TB. Significant differences were found in chest X-ray readings, CAD4TBv6 scores, and GeneXpert results among sociodemographic and health status variables (P-value < 0.05). The study showed that the incidence rate of TB in the Gaza Strip is 3.5 per 100,000 population in the Gaza strip. The sensitivity of the CAD4TBv6 score and the symptomatic review for tuberculosis with a threshold score of >40 is 80.2%, and the specificity is 94.0%. The positive Likelihood Ratio is 13.3%, Negative Likelihood Ratio is 0.2 with 7.8% prevalence. Positive Predictive Value is 52.7%, Negative Predictive Value is 98.3%, and accuracy is 92.9%. In a resource-limited country with a high burden of neglected disease, combining chest X-ray readings by CAD4TB and symptomatology is extremely valuable for screening a population at risk. CAD4TB is noticeably more efficient than other methods for TB screening and early diagnosis in people who would otherwise go undetected.
Collapse
Affiliation(s)
- Samer Abuzerr
- Department of Medical Sciences, University College of Science and Technology, Gaza, Palestine
| | - Kate Zinszer
- School of Public Health, Department of Social and Preventive Medicine, University of Montreal, Montréal, QC, Canada
| |
Collapse
|
5
|
Hua D, Nguyen K, Petrina N, Young N, Cho JG, Yap A, Poon SK. Benchmarking the diagnostic test accuracy of certified AI products for screening pulmonary tuberculosis in digital chest radiographs: Preliminary evidence from a rapid review and meta-analysis. Int J Med Inform 2023; 177:105159. [PMID: 37549498 DOI: 10.1016/j.ijmedinf.2023.105159] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/16/2023] [Accepted: 07/19/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND AND OBJECTIVE The global market for AI systems used in lung tuberculosis (TB) detection has expanded significantly in recent years. Verifying their performance across diverse settings is crucial before medical organisations can invest in them and pursue safe, wide-scale deployment. The goal of this research was to synthesise the clinical evidence for the diagnostic accuracy of certified AI products designed for screening TB in chest X-rays (CXRs) compared to a microbiological reference standard. METHODS Four databases were searched between June to September 2022. Data concerning study methodology, system characteristics, and diagnostic accuracy metrics was extracted and summarised. Study bias was evaluated using QUADAS-2 and by examining sources of funding. Forest plots for diagnostic odds ratio (DOR) and summary receiver operating characteristic (SROC) curves were constructed for the AI products individually and collectively. RESULTS 10 out of 3642 studies satisfied the review criteria however only 8 were subject to meta-analysis following bias assessment. Three AI products were evaluated with a 95 % confidence interval producing the following pooled estimates for accuracy rankings: qXR v2 (sensitivity of 0.944 [0.887-0.973], specificity of 0.692 [0.549-0.805], DOR of 3.63 [3.17-4.09], Lunit INSIGHT CXR v3.1 (sensitivity of 0.853 [0.787-0.901], specificity of 0.646 [0.627-0.665], DOR of 2.37 [1.96-2.78]), and CAD4TB v3.07 (sensitivity of 0.917 [0.848-0.956], specificity of 0.371 [0.336-0.408], DOR of 1.91 [1.4-2.47]). Overall, the products had a sensitivity of 0.903 (0.859-0.934), specificity of 0.526 (0.409-0.641), and DOR of 2.31 (1.78-2.84). CONCLUSION Current publicly available evidence indicates considerable variability in the diagnostic accuracy of available AI products although overall they have high sensitivity and modest specificity which is improving with time. These preliminary results are limited by the small number of studies and poor coverage for low TB burden settings. More research is needed to expand the clinical evidence base for the performance of AI products.
Collapse
Affiliation(s)
- David Hua
- School of Computer Science, The University of Sydney, Australia; Sydney Law School, The University of Sydney, Australia
| | - Khang Nguyen
- School of Computer Science, The University of Sydney, Australia
| | - Neysa Petrina
- School of Computer Science, The University of Sydney, Australia
| | - Noel Young
- Lumus Imaging, Australia; Western Sydney Local Health District, Australia
| | - Jin-Gun Cho
- Sydney Medical School, The University of Sydney, Australia; Lumus Imaging, Australia; Western Sydney Local Health District, Australia
| | - Adeline Yap
- School of Computer Science, The University of Sydney, Australia
| | - Simon K Poon
- School of Computer Science, The University of Sydney, Australia; Western Sydney Local Health District, Australia.
| |
Collapse
|
6
|
Rehman A, Khan A, Fatima G, Naz S, Razzak I. Review on chest pathogies detection systems using deep learning techniques. Artif Intell Rev 2023; 56:1-47. [PMID: 37362896 PMCID: PMC10027283 DOI: 10.1007/s10462-023-10457-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Chest radiography is the standard and most affordable way to diagnose, analyze, and examine different thoracic and chest diseases. Typically, the radiograph is examined by an expert radiologist or physician to decide about a particular anomaly, if exists. Moreover, computer-aided methods are used to assist radiologists and make the analysis process accurate, fast, and more automated. A tremendous improvement in automatic chest pathologies detection and analysis can be observed with the emergence of deep learning. The survey aims to review, technically evaluate, and synthesize the different computer-aided chest pathologies detection systems. The state-of-the-art of single and multi-pathologies detection systems, which are published in the last five years, are thoroughly discussed. The taxonomy of image acquisition, dataset preprocessing, feature extraction, and deep learning models are presented. The mathematical concepts related to feature extraction model architectures are discussed. Moreover, the different articles are compared based on their contributions, datasets, methods used, and the results achieved. The article ends with the main findings, current trends, challenges, and future recommendations.
Collapse
Affiliation(s)
- Arshia Rehman
- COMSATS University Islamabad, Abbottabad-Campus, Abbottabad, Pakistan
| | - Ahmad Khan
- COMSATS University Islamabad, Abbottabad-Campus, Abbottabad, Pakistan
| | - Gohar Fatima
- The Islamia University of Bahawalpur, Bahawal Nagar Campus, Bahawal Nagar, Pakistan
| | - Saeeda Naz
- Govt Girls Post Graduate College No.1, Abbottabad, Pakistan
| | - Imran Razzak
- School of Computer Science and Engineering, University of New South Wales, Sydney, Australia
| |
Collapse
|
7
|
Fehr J, Gunda R, Siedner MJ, Hanekom W, Ndung’u T, Grant A, Lippert C, Wong EB. CAD4TB software updates: different triaging thresholds require caution by users and regulation by authorities. Int J Tuberc Lung Dis 2023; 27:157-160. [PMID: 36853104 PMCID: PMC9904401 DOI: 10.5588/ijtld.22.0437] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- J. Fehr
- Africa Health Research Institute, KwaZulu-Natal, South Africa
,Digital Health & Machine Learning, Hasso Plattner Institute for Digital Engineering, Potsdam, Germany
,Digital Engineering Faculty, University of Potsdam, Potsdam, Germany
| | - R. Gunda
- Africa Health Research Institute, KwaZulu-Natal, South Africa
,School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
,Division of Infection and Immunity, University College London, London, UK
| | - M. J. Siedner
- Africa Health Research Institute, KwaZulu-Natal, South Africa
,School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
,Harvard Medical School, Boston, MA, USA
,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - W. Hanekom
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - T. Ndung’u
- Africa Health Research Institute, KwaZulu-Natal, South Africa
,Division of Infection and Immunity, University College London, London, UK
,HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
,Ragon Institute of MGH, MIT and Harvard University, Cambridge, MA, USA
| | - A. Grant
- Africa Health Research Institute, KwaZulu-Natal, South Africa
,School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
,London School of Hygiene & Tropical Medicine, London, UK
,School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - C. Lippert
- Digital Health & Machine Learning, Hasso Plattner Institute for Digital Engineering, Potsdam, Germany
,Digital Engineering Faculty, University of Potsdam, Potsdam, Germany
,Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - E. B. Wong
- Africa Health Research Institute, KwaZulu-Natal, South Africa
,Division of Infectious Diseases, University of Alabama at Birmingham, AL, USA
| |
Collapse
|
8
|
A spatial analysis of TB cases and abnormal X-rays detected through active case-finding in Karachi, Pakistan. Sci Rep 2023; 13:1336. [PMID: 36693930 PMCID: PMC9873642 DOI: 10.1038/s41598-023-28529-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 01/19/2023] [Indexed: 01/25/2023] Open
Abstract
Tuberculosis (TB) is the leading cause of avoidable deaths from an infectious disease globally and a large of number of people who develop TB each year remain undiagnosed. Active case-finding has been recommended by the World Health Organization to bridge the case-detection gap for TB in high burden countries. However, concerns remain regarding their yield and cost-effectiveness. Data from mobile chest X-ray (CXR) supported active case-finding community camps conducted in Karachi, Pakistan from July 2018 to March 2020 was retrospectively analyzed. Frequency analysis was carried out at the camp-level and outcomes of interest for the spatial analyses were mycobacterium TB positivity (MTB+) and X-ray abnormality rates. The Global Moran's I statistic was used to test for spatial autocorrelation for MTB+ and abnormal X-rays within Union Councils (UCs) in Karachi. A total of 1161 (78.1%) camps yielded no MTB+ cases, 246 (16.5%) camps yielded 1 MTB+, 52 (3.5%) camps yielded 2 MTB+ and 27 (1.8%) yielded 3 or more MTB+. A total of 79 (5.3%) camps accounted for 193 (44.0%) of MTB+ cases detected. Statistically significant clustering for MTB positivity (Global Moran's I: 0.09) and abnormal chest X-rays (Global Moran's I: 0.36) rates was identified within UCs in Karachi. Clustering of UCs with high MTB positivity were identified in Karachi West district. Statistically significant spatial variation was identified in yield of bacteriologically positive TB cases and in abnormal CXR through active case-finding in Karachi. Cost-effectiveness of active case-finding programs can be improved by identifying and focusing interventions in hotspots and avoiding locations with no known TB cases reported through routine surveillance.
Collapse
|
9
|
Diagnostic Accuracy of the Artificial Intelligence Methods in Medical Imaging for Pulmonary Tuberculosis: A Systematic Review and Meta-Analysis. J Clin Med 2022; 12:jcm12010303. [PMID: 36615102 PMCID: PMC9820940 DOI: 10.3390/jcm12010303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/21/2022] [Accepted: 12/24/2022] [Indexed: 01/03/2023] Open
Abstract
Tuberculosis (TB) remains one of the leading causes of death among infectious diseases worldwide. Early screening and diagnosis of pulmonary tuberculosis (PTB) is crucial in TB control, and tend to benefit from artificial intelligence. Here, we aimed to evaluate the diagnostic efficacy of a variety of artificial intelligence methods in medical imaging for PTB. We searched MEDLINE and Embase with the OVID platform to identify trials published update to November 2022 that evaluated the effectiveness of artificial-intelligence-based software in medical imaging of patients with PTB. After data extraction, the quality of studies was assessed using quality assessment of diagnostic accuracy studies 2 (QUADAS-2). Pooled sensitivity and specificity were estimated using a bivariate random-effects model. In total, 3987 references were initially identified and 61 studies were finally included, covering a wide range of 124,959 individuals. The pooled sensitivity and the specificity were 91% (95% confidence interval (CI), 89-93%) and 65% (54-75%), respectively, in clinical trials, and 94% (89-96%) and 95% (91-97%), respectively, in model-development studies. These findings have demonstrated that artificial-intelligence-based software could serve as an accurate tool to diagnose PTB in medical imaging. However, standardized reporting guidance regarding AI-specific trials and multicenter clinical trials is urgently needed to truly transform this cutting-edge technology into clinical practice.
Collapse
|
10
|
Kagujje M, Kerkhoff AD, Nteeni M, Dunn I, Mateyo K, Muyoyeta M. The Performance of Computer-Aided Detection Digital Chest X-ray Reading Technologies for Triage of Active Tuberculosis Among Persons With a History of Previous Tuberculosis. Clin Infect Dis 2022; 76:e894-e901. [PMID: 36004409 PMCID: PMC9907528 DOI: 10.1093/cid/ciac679] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/04/2022] [Accepted: 08/19/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Digital chest X-ray (dCXR) computer-aided detection (CAD) technology uses lung shape and texture analysis to determine the probability of tuberculosis (TB). However, many patients with previously treated TB have sequelae, which also distort lung shape and texture. We evaluated the diagnostic performance of 2 CAD systems for triage of active TB in patients with previously treated TB. METHODS We conducted a retrospective analysis of data from a cross-sectional active TB case finding study. Participants ≥15 years, with ≥1 current TB symptom and complete data on history of previous TB, dCXR, and TB microbiological reference (Xpert MTB/RIF) were included. dCXRs were evaluated using CAD4TB (v.7.0) and qXR (v.3.0). We determined the diagnostic accuracy of both systems, overall and stratified by history of TB, using a single threshold for each system that achieved 90% sensitivity and maximized specificity in the overall population. RESULTS Of 1884 participants, 452 (24.0%) had a history of previous TB. Prevalence of microbiologically confirmed TB among those with and without history of previous TB was 12.4% and 16.9%, respectively. Using CAD4TB, sensitivity and specificity were 89.3% (95% CI: 78.1-96.0%) and 24.0% (19.9-28.5%) and 90.5% (86.1-93.3%) and 60.3% (57.4-63.0%) among those with and without previous TB, respectively. Using qXR, sensitivity and specificity were 94.6% (95% CI: 85.1-98.9%) and 22.2% (18.2-26.6%) and 89.7% (85.1-93.2%) and 61.8% (58.9-64.5%) among those with and without previous TB, respectively. CONCLUSIONS The performance of CAD systems as a TB triage tool is decreased among persons previously treated for TB.
Collapse
Affiliation(s)
- Mary Kagujje
- Correspondence: M. Kagujje, Centre for Infectious Disease Research in Zambia, Plot 34620 Off Alick Nkhata Road between ERB and FAZ, Mass Media, PO Box 34681, Lusaka, Zambia ()
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine Zuckerberg, San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, USA
| | - Mutinta Nteeni
- Department of Radiology, Levy Mwanawasa University Teaching Hospital, Lusaka, Zambia
| | - Ian Dunn
- Department of Radiology, University of British Columbia, Vancouver, Canada
| | - Kondwelani Mateyo
- Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
| | | |
Collapse
|
11
|
Asante-Poku A, Morgan P, Osei-Wusu S, Aboagye SY, Asare P, Otchere ID, Adadey SM, Mnika K, Esoh K, Mawuta KH, Arthur N, Forson A, Mazandu GK, Wonkam A, Yeboah-Manu D. Genetic Analysis of TB Susceptibility Variants in Ghana Reveals Candidate Protective Loci in SORBS2 and SCL11A1 Genes. Front Genet 2022; 12:729737. [PMID: 35242163 PMCID: PMC8886735 DOI: 10.3389/fgene.2021.729737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 12/08/2021] [Indexed: 12/31/2022] Open
Abstract
Despite advancements made toward diagnostics, tuberculosis caused by Mycobacterium africanum (Maf) and Mycobacterium tuberculosis sensu stricto (Mtbss) remains a major public health issue. Human host factors are key players in tuberculosis (TB) outcomes and treatment. Research is required to probe the interplay between host and bacterial genomes. Here, we explored the association between selected human/host genomic variants and TB disease in Ghana. Paired host genotype datum and infecting bacterial isolate information were analyzed for associations using a multinomial logistic regression. Mycobacterium tuberculosis complex (MTBC) isolates were obtained from 191 TB patients and genotyped into different phylogenetic lineages by standard methods. Two hundred and thirty-five (235) nondisease participants were used as healthy controls. A selection of 29 SNPs from TB disease-associated genes with high frequency among African populations was assayed using a TaqMan® SNP Genotyping Assay and iPLEX Gold Sequenom Mass Genotyping Array. Using 26 high-quality SNPs across 326 case-control samples in an association analysis, we found a protective variant, rs955263, in the SORBS2 gene against both Maf and Mtb infections (PBH = 0.05; OR = 0.33; 95% CI = 0.32–0.34). A relatively uncommon variant, rs17235409 in the SLC11A1 gene was observed with an even stronger protective effect against Mtb infection (MAF = 0.06; PBH = 0.04; OR = 0.05; 95% CI = 0.04–0.05). These findings suggest SLC11A1 and SORBS2 as a potential protective gene of substantial interest for TB, which is an important pathogen in West Africa, and highlight the need for in-depth host-pathogen studies in West Africa.
Collapse
Affiliation(s)
- Adwoa Asante-Poku
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
- West African Centre for Cell Biology of Infectious Pathogens, University of Ghana, Accra, Ghana
- Department of Biochemistry, Cell, and Molecular Biology, University of Ghana, Accra, Ghana
- *Correspondence: Adwoa Asante-Poku,
| | - Portia Morgan
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
- West African Centre for Cell Biology of Infectious Pathogens, University of Ghana, Accra, Ghana
- Department of Biochemistry, Cell, and Molecular Biology, University of Ghana, Accra, Ghana
| | - Stephen Osei-Wusu
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
- West African Centre for Cell Biology of Infectious Pathogens, University of Ghana, Accra, Ghana
- Department of Biochemistry, Cell, and Molecular Biology, University of Ghana, Accra, Ghana
| | - Samuel Yaw Aboagye
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Prince Asare
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
- West African Centre for Cell Biology of Infectious Pathogens, University of Ghana, Accra, Ghana
- Department of Biochemistry, Cell, and Molecular Biology, University of Ghana, Accra, Ghana
| | - Isaac Darko Otchere
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
- West African Centre for Cell Biology of Infectious Pathogens, University of Ghana, Accra, Ghana
- Department of Biochemistry, Cell, and Molecular Biology, University of Ghana, Accra, Ghana
| | - Samuel Mawuli Adadey
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Khuthala Mnika
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Kevin Esoh
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Kenneth Hayibor Mawuta
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
- West African Centre for Cell Biology of Infectious Pathogens, University of Ghana, Accra, Ghana
| | - Nelly Arthur
- Department of Chest Diseases, Korle-Bu Teaching Hospital Korle-Bu, Accra, Ghana
| | - Audrey Forson
- Department of Chest Diseases, Korle-Bu Teaching Hospital Korle-Bu, Accra, Ghana
| | - Gaston Kuzamunu Mazandu
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Ambroise Wonkam
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Dorothy Yeboah-Manu
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
- West African Centre for Cell Biology of Infectious Pathogens, University of Ghana, Accra, Ghana
- Department of Biochemistry, Cell, and Molecular Biology, University of Ghana, Accra, Ghana
| |
Collapse
|
12
|
Nishtar T, Burki S, Ahmad FS, Ahmad T. Diagnostic accuracy of computer aided reading of chest x-ray in screening for pulmonary tuberculosis in comparison with Gene-Xpert. Pak J Med Sci 2022; 38:62-68. [PMID: 35035402 PMCID: PMC8713241 DOI: 10.12669/pjms.38.1.4531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/07/2021] [Accepted: 07/31/2021] [Indexed: 11/16/2022] Open
Abstract
Background & Objectives: Pakistan ranked fifth amongst 22 high-burden Tuberculosis countries, and it is an epidemic in Pakistan, hence screening is performed nationally, as part of the ambitious ZERO TB drive. Our objective was to assess the diagnostic accuracy of Computer Aided Detection (CAD4TB) software on chest Xray in screening for pulmonary tuberculosis in comparison with gene-Xpert. Methods: The study was conducted by Radiology Department Lady Reading Hospital Peshawar in affiliation with Indus Hospital network over a period of one year. Screening was done by using mobile Xray unit equipped with CAD4TB software with scoring system. All of those having score of more than 70 and few selected cases with strong clinical suspicion but score of less than 70 were referred to dedicated TB clinic for Gene-Xpert analysis. Results: Among 26,997 individuals screened, 2617 (9.7%) individuals were found presumptive for pulmonary TB. Sputum samples for Gene-Xpert were obtained in 2100 (80.24%) individuals, out of which 1825 (86.9%) were presumptive for pulmonary TB on CAD4TB only. Gene-Xpert was positive in 159 (8.7%) patients and negative in 1,666(91.3%). Sensitivity and specificity of CAD4TB and symptomatology with threshold score of ≥70 was 83.2% and 12.7% respectively keeping Gene-Xpert as gold standard. Conclusion: Combination of chest X-ray analysis by CAD4TB and symptomatology is of immense value to screen a large population at risk in a developing high burden country. It is significantly a more effective tool for screening and early diagnosis of TB in individuals, who would otherwise go undiagnosed.
Collapse
Affiliation(s)
- Tahira Nishtar
- Tahira Nishtar FCPS, Department of Radiology, MTI-Lady Reading Hospital, Peshawar, Pakistan
| | - Shamsullah Burki
- Shamsullah Burki FCPS, Department of Radiology, MTI-Lady Reading Hospital, Peshawar, Pakistan
| | - Fatima Sultan Ahmad
- Fatima Sultan Ahmad (Registrar), Department of Radiology, MTI-Lady Reading Hospital, Peshawar, Pakistan
| | - Tabish Ahmad
- Tabish Ahmad (PGR-FCPS) Department of Radiology, MTI-Lady Reading Hospital, Peshawar, Pakistan
| |
Collapse
|
13
|
Wali A, Safdar N, Manair R, Khan MD, Khan A, Kurd SA, Khalil L. Early TB case detection by community-based mobile X-ray screening and Xpert testing in Balochistan. Public Health Action 2021; 11:174-179. [PMID: 34956844 PMCID: PMC8680181 DOI: 10.5588/pha.21.0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/26/2021] [Indexed: 11/10/2022] Open
Abstract
SETTING This survey was conducted at 35 sites of 20 cities in 15 districts with low programmatic TB case notifications in the past years in Balochistan. OBJECTIVE To assess the effectiveness of the systemic community-based screening and diagnosis for early detection of TB; and 2) to describe the characteristics and understand the strengths and weaknesses of the intervention in Balochistan, and sociodemographic factors associated with it. DESIGN This cross-sectional descriptive study was conducted using a mobile van equipped with a digital X-ray machine with computer-aided detection for TB (CAD4TB) software for screening, followed by confirmatory high sensitivity Xpert® MTB/RIF assay testing. RESULTS A total of 236 (3.4%) TB cases was detected out of 6,899 screened. About 1,168 (17%) presumptive TB cases were identified and 1,065 (91%) sputum samples were tested on Xpert. Among those diagnosed, 166 (70%) were Mycobacterium tuberculosis-positive and 70 (30%) were with clinical suspicion. Of the sputum samples tested, 87% (923/1065) had a probability score of >70 on CAD4TB. CONCLUSION Community-based screening with innovative activities, comprising sensitive screening and diagnostic tools, effectively improves TB case detection, which might suffice to reduce the prevalence of TB and break the chain of infection transmission in the at-risk population.
Collapse
Affiliation(s)
- A Wali
- Department of Primary and Secondary Healthcare, Government of Balochistan, Quetta, Pakistan
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - N Safdar
- Interactive Research and Development, Singapore
| | - R Manair
- Interactive Research and Development, Karachi, Pakistan
| | - M D Khan
- Provincial AIDS Control Programme, Department of Primary and Secondary Healthcare, Government of Balochistan, Quetta, Pakistan
| | - A Khan
- Planning and Development Department, Government of Balochistan, Quetta, Pakistan
| | - S A Kurd
- Vector-Borne Disease Control Programme, Department of Primary and Secondary Healthcare, Government of Balochistan, Quetta, Pakistan
| | - L Khalil
- Human Resource Development, Department of Primary and Secondary Healthcare, Government of Balochistan, Quetta, Pakistan
| |
Collapse
|
14
|
Digital Chest X-ray with Computer-aided Detection for TB Screening within Correctional Facilities. Ann Am Thorac Soc 2021; 19:1313-1319. [PMID: 34914539 DOI: 10.1513/annalsats.202103-380oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Realizing the Global Plan to End TB will require reaching at least 90% of people in key populations such as inmates through optimizing case-finding approaches. OBJECTIVES To evaluate the addition of digital chest x-ray (d-CXR) with computer-aided detection (CAD) to symptoms on TB yield among inmates. METHODS Consecutive adult inmates from four correctional facilities in South Africa were screened for TB using symptoms and d-CXR. Any person with >1 symptom or CAD>50 provided two sputa for liquid culture and GeneXpert MTB/RIF Ultra (Xpert Ultra) testing. In a sample of 800 symptom-negative inmates with CAD<50, Xpert Ultra testing was also conducted. TB yield was defined as the proportion of new bacteriologically-confirmed TB patients identified. RESULTS We enrolled 3,576 participants; 99.6% male, median age of 34 years (IQR: 28-41), and 584 (16.3%) HIV-positive. Of those screened, 867 (24.2%) participants required investigation [394 (11.2%) symptomatic, 685 (19.1%) on abnormal CAD and 867 (24.2%) with either]. Sputum was taken in 747 (86.2%) participants, with 28 (7.8 per 1000 population) new TB cases diagnosed. Based on hypothesized screening modalities, yield would have been 3.6 per 1,000 population on symptoms alone and 7.0 per 1,000 population on d-CXR alone. Amongst an additional 800 inmates tested whom initially screened symptom-negative and CAD<50, five TB cases were diagnosed. No difference in TB yield when comparing Xpert Ultra against culture (5.6 vs. 4.8 per 1,000 population; p=0.21). CONCLUSIONS The addition of d-CXR identified two times more undiagnosed TB than patients investigated on symptoms alone. Complimentary use of d-CXR may potentially overcome subjectivity inherent in symptom screening alone for identifying TB in this population.
Collapse
|
15
|
Ejaz T, Malik MI, Ahmed J, Azam R, Jamal Y, Saadia S. Clinico-radiological and bronchoscopic predictors of microbiological yield in sputum negative tuberculosis in Pakistan. Monaldi Arch Chest Dis 2021; 92. [PMID: 34873901 DOI: 10.4081/monaldi.2021.1976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 10/05/2021] [Indexed: 11/23/2022] Open
Abstract
To determine association of clinico-radiological factors and radiological activity with diagnostic yield in sputum-smear negative tuberculosis (TB). Prospective observational study in Military Hospital Rawalpindi from July to December 2018. Adult patients having no contraindications to bronchoscopy were included. HIV positive patients and those on anti-tuberculosis therapy for more than one week were excluded. High-Resolution Computed tomography (HRCT) findings were classified based on active and inactive tuberculosis features. Washings were sent for Acid-Fast Bacillus (AFB) smear, GeneXpert assay and cultures. Out of 215 patients, 42.3% (91) were diagnosed with microbiological or histological evidence of TB. On univariate analysis, cavitation (p-value <0.001), soft-tissue nodules (p-value 0.04), and endobronchial mucosal changes (p-value 0.02) were associated with culture positivity. Presence of cavitation (OR= 4.10; CI= 2.18,7.73; p-value<0.001) was the only independent predictor of microbiological yield. Diagnostic yield was 70%, 50%, 12.5% and 8.6% in patients with definitely active, probably active, indeterminate and inactive tuberculosis HRCT features respectively. Sensitivity, specificity, positive predictive value and negative predictive value of HRCT active TB were 95.38% (95% CI 87.10 -99.04), 48.00 % (95% CI 39.78 -56.30), 44.29% (95% CI 40.31 -48.33), 96.00 % (95%CI 88.70 -98.66) respectively. There was no significant association between age groups, smoking status and gender with diagnosis of tuberculosis in our study. Radiological activity and certain visualized bronchoscopic changes were associated with good diagnostic performance and can be used as predictive factors in diagnosis of active smear negative tuberculosis.
Collapse
Affiliation(s)
- Taymmia Ejaz
- Department of Medicine, Aga Khan University Hospital, Karachi.
| | - Mahmood Iqbal Malik
- Department of Pulmonology, Pak Emirates Military Hospital, National University of Medical Sciences, Rawalpindi.
| | - Jamal Ahmed
- Department of Pulmonology, Pak Emirates Military Hospital, National University of Medical Sciences, Rawalpindi.
| | - Rizwan Azam
- Department of Pulmonology, Pak Emirates Military Hospital, National University of Medical Sciences, Rawalpindi.
| | - Yousaf Jamal
- Department of Pulmonology, Pak Emirates Military Hospital, National University of Medical Sciences, Rawalpindi.
| | - Sheema Saadia
- Department of Medicine, Aga Khan University Hospital, Karachi.
| |
Collapse
|
16
|
Nsengiyumva NP, Hussain H, Oxlade O, Majidulla A, Nazish A, Khan AJ, Menzies D, Ahmad Khan F, Schwartzman K. Triage of Persons With Tuberculosis Symptoms Using Artificial Intelligence-Based Chest Radiograph Interpretation: A Cost-Effectiveness Analysis. Open Forum Infect Dis 2021; 8:ofab567. [PMID: 34917694 PMCID: PMC8671604 DOI: 10.1093/ofid/ofab567] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/05/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND In settings without access to rapid expert radiographic interpretation, artificial intelligence (AI)-based chest radiograph (CXR) analysis can triage persons presenting with possible tuberculosis (TB) symptoms, to identify those who require additional microbiological testing. However, there is limited evidence of the cost-effectiveness of this technology as a triage tool. METHODS A decision analysis model was developed to evaluate the cost-effectiveness of triage strategies with AI-based CXR analysis for patients presenting with symptoms suggestive of pulmonary TB in Karachi, Pakistan. These strategies were compared to the current standard of care using microbiological testing with smear microscopy or GeneXpert, without prior triage. Positive triage CXRs were considered to improve referral success for microbiologic testing, from 91% to 100% for eligible persons. Software diagnostic accuracy was based on a prospective field study in Karachi. Other inputs were obtained from the Pakistan TB Program. The analysis was conducted from the healthcare provider perspective, and costs were expressed in 2020 US dollars. RESULTS Compared to upfront smear microscopy for all persons with presumptive TB, triage strategies with AI-based CXR analysis were projected to lower costs by 19%, from $23233 per 1000 persons, and avert 3%-4% disability-adjusted life-years (DALYs), from 372 DALYs. Compared to upfront GeneXpert, AI-based triage strategies lowered projected costs by 37%, from $34346 and averted 4% additional DALYs, from 369 DALYs. Reinforced follow-up for persons with positive triage CXRs but negative microbiologic tests was particularly cost-effective. CONCLUSIONS In lower-resource settings, the addition of AI-based CXR triage before microbiologic testing for persons with possible TB symptoms can reduce costs, avert additional DALYs, and improve TB detection.
Collapse
Affiliation(s)
- Ntwali Placide Nsengiyumva
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Canada
| | | | - Olivia Oxlade
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Canada
| | | | - Ahsana Nazish
- Ghori Tuberculosis Clinic, Indus Hospital, Karachi, Pakistan
| | - Aamir J Khan
- Interactive Research and Development Global, Singapore
| | - Dick Menzies
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Canada
- Department of Medicine and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Faiz Ahmad Khan
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Canada
- Department of Medicine and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Kevin Schwartzman
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Canada
- Department of Medicine and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| |
Collapse
|
17
|
Swaminathan N, Perloff SR, Zuckerman JM. Prevention of Mycobacterium tuberculosis Transmission in Health Care Settings. Infect Dis Clin North Am 2021; 35:1013-1025. [PMID: 34752218 DOI: 10.1016/j.idc.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Patients with tuberculosis (TB) pose a risk to other patients and health care workers, and outbreaks in health care settings occur when appropriate infection control measures are not used. This article discusses strategies to prevent transmission of Mycobacterium tuberculosis within health care settings. All health care facilities should have an operational TB infection control plan that emphasizes the use of a hierarchy of controls (administrative, environmental, and personal respiratory protection). Resources available to clinicians who work in the prevention and investigation of nosocomial transmission of M tuberculosis also are discussed.
Collapse
Affiliation(s)
- Neeraja Swaminathan
- Department of Medicine, Einstein Medical Center, Klein Building, Suite 300, 5501 Old York Road, Philadelphia, PA 19141, USA
| | - Sarah R Perloff
- Division of Infectious Disease, Department of Medicine, Einstein Medical Center, Klein Building, Suite 300, 5501 Old York Road, Philadelphia, PA 19141, USA; Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Jerry M Zuckerman
- Department of Patient Safety and Quality, Hackensack Meridian Health, Edison, NJ, USA; Hackensack Meridian School of Medicine, Nutley, NJ, USA.
| |
Collapse
|
18
|
Qin ZZ, Ahmed S, Sarker MS, Paul K, Adel ASS, Naheyan T, Barrett R, Banu S, Creswell J. Tuberculosis detection from chest x-rays for triaging in a high tuberculosis-burden setting: an evaluation of five artificial intelligence algorithms. LANCET DIGITAL HEALTH 2021; 3:e543-e554. [PMID: 34446265 DOI: 10.1016/s2589-7500(21)00116-3] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 05/07/2021] [Accepted: 06/07/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Artificial intelligence (AI) algorithms can be trained to recognise tuberculosis-related abnormalities on chest radiographs. Various AI algorithms are available commercially, yet there is little impartial evidence on how their performance compares with each other and with radiologists. We aimed to evaluate five commercial AI algorithms for triaging tuberculosis using a large dataset that had not previously been used to train any AI algorithms. METHODS Individuals aged 15 years or older presenting or referred to three tuberculosis screening centres in Dhaka, Bangladesh, between May 15, 2014, and Oct 4, 2016, were recruited consecutively. Every participant was verbally screened for symptoms and received a digital posterior-anterior chest x-ray and an Xpert MTB/RIF (Xpert) test. All chest x-rays were read independently by a group of three registered radiologists and five commercial AI algorithms: CAD4TB (version 7), InferRead DR (version 2), Lunit INSIGHT CXR (version 4.9.0), JF CXR-1 (version 2), and qXR (version 3). We compared the performance of the AI algorithms with each other, with the radiologists, and with the WHO's Target Product Profile (TPP) of triage tests (≥90% sensitivity and ≥70% specificity). We used a new evaluation framework that simultaneously evaluates sensitivity, proportion of Xpert tests avoided, and number needed to test to inform implementers' choice of software and selection of threshold abnormality scores. FINDINGS Chest x-rays from 23 954 individuals were included in the analysis. All five AI algorithms significantly outperformed the radiologists. The areas under the receiver operating characteristic curve were 90·81% (95% CI 90·33-91·29) for qXR, 90·34% (89·81-90·87) for CAD4TB, 88·61% (88·03-89·20) for Lunit INSIGHT CXR, 84·90% (84·27-85·54) for InferRead DR, and 84·89% (84·26-85·53) for JF CXR-1. Only qXR (74·3% specificity [95% CI 73·3-74·9]) and CAD4TB (72·9% specificity [72·3-73·5]) met the TPP at 90% sensitivity. All five AI algorithms reduced the number of Xpert tests required by 50% while maintaining a sensitivity above 90%. All AI algorithms performed worse among older age groups (>60 years) and people with a history of tuberculosis. INTERPRETATION AI algorithms can be highly accurate and useful triage tools for tuberculosis detection in high-burden regions, and outperform human readers. FUNDING Government of Canada.
Collapse
Affiliation(s)
| | - Shahriar Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | - Kishor Paul
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | | | | | - Sayera Banu
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | |
Collapse
|
19
|
Tavaziva G, Harris M, Abidi SK, Geric C, Breuninger M, Dheda K, Esmail A, Muyoyeta M, Reither K, Majidulla A, Khan AJ, Campbell JR, David PM, Denkinger C, Miller C, Nathavitharana R, Pai M, Benedetti A, Khan FA. Chest X-ray analysis with deep learning-based software as a triage test for pulmonary tuberculosis: an individual patient data meta-analysis of diagnostic accuracy. Clin Infect Dis 2021; 74:1390-1400. [PMID: 34286831 PMCID: PMC9049274 DOI: 10.1093/cid/ciab639] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Automated radiologic analysis using computer-aided detection software (CAD) could facilitate chest X-ray (CXR) use in tuberculosis diagnosis. There is little to no evidence on the accuracy of commercially-available deep learning-based CAD in different populations, including patients with smear-negative tuberculosis and people living with HIV (PLWH). METHODS We collected CXRs and individual patient data (IPD) from studies evaluating CAD in patients self-referring for tuberculosis symptoms with culture or nucleic acid amplification testing as the reference. We re-analyzed CXRs with three CAD (CAD4TB version (v) 6, Lunit v3.1.0.0, and qXR v2). We estimated sensitivity and specificity within each study and pooled using IPD meta-analysis. We used multivariable meta-regression to identify characteristics modifying accuracy. RESULTS We included CXRs and IPD of 3727/3967 participants from 4/7 eligible studies. 17% (621/3727) were PLWH. 17% (645/3727) had microbiologically-confirmed tuberculosis. Despite using the same threshold score for classifying CXR in every study, sensitivity and specificity varied from study to study. The software had similar unadjusted accuracy (at 90% pooled sensitivity, pooled specificities were: CAD4TBv6, 56.9% [95%CI:51.7-61.9]; Lunit, 54.1% [44.6-63.3]; qXRv2, 60.5% [51.7-68.6]). Adjusted absolute differences in pooled sensitivity between PLWH and HIV-uninfected participants was: CAD4TBv6, -13.4% [-21.1, -6.9]; Lunit, +2.2% [-3.6, +6.3]; qXRv2: -13.4% [-21.5, -6.6]); between smear-negative and smear-positive tuberculosis was: CAD4TBv6, -12.3% [-19.5, -6.1]; Lunit, -17.2% [-24.6, -10.5]; qXRv2, -16.6% [-24.4, -9.9]. Accuracy was similar to human readers. CONCLUSIONS For CAD CXR analysis to be implemented as a high-sensitivity tuberculosis rule-out test, users will need threshold scores identified from their own patient populations, and stratified by HIV- and smear-status.
Collapse
Affiliation(s)
- Gamuchirai Tavaziva
- McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Miriam Harris
- McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Canada.,Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Syed K Abidi
- McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Coralie Geric
- McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Canada.,Departments of Medicine & Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Canada
| | - Marianne Breuninger
- Division of Infectious Diseases, Department I of Internal Medicine, University of Cologne, Cologne, Germany
| | - Keertan Dheda
- Centre for Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa.,Faculty of Infectious and Tropical Diseases, Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, UK
| | - Aliasgar Esmail
- Centre for Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Monde Muyoyeta
- Zambart, Lusaka, Zambia.,Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Klaus Reither
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Arman Majidulla
- Interactive Research & Development (IRD) Pakistan, Karachi, Pakistan
| | | | - Jonathon R Campbell
- McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Canada.,Departments of Medicine & Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Canada
| | - Pierre-Marie David
- Département des Médicaments et Santé des Populations, Faculty of Pharmacy, Université de Montréal, Montreal, Canada
| | - Claudia Denkinger
- Division of Tropical Medicine, Center of Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Ruvandhi Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Madhukar Pai
- McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Canada.,Departments of Medicine & Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Canada
| | - Andrea Benedetti
- McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Canada.,Departments of Medicine & Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Canada
| | - Faiz Ahmad Khan
- McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Canada.,Departments of Medicine & Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Canada
| |
Collapse
|
20
|
Fehr J, Konigorski S, Olivier S, Gunda R, Surujdeen A, Gareta D, Smit T, Baisley K, Moodley S, Moosa Y, Hanekom W, Koole O, Ndung'u T, Pillay D, Grant AD, Siedner MJ, Lippert C, Wong EB. Computer-aided interpretation of chest radiography reveals the spectrum of tuberculosis in rural South Africa. NPJ Digit Med 2021; 4:106. [PMID: 34215836 PMCID: PMC8253848 DOI: 10.1038/s41746-021-00471-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 05/21/2021] [Indexed: 02/01/2023] Open
Abstract
Computer-aided digital chest radiograph interpretation (CAD) can facilitate high-throughput screening for tuberculosis (TB), but its use in population-based active case-finding programs has been limited. In an HIV-endemic area in rural South Africa, we used a CAD algorithm (CAD4TBv5) to interpret digital chest x-rays (CXR) as part of a mobile health screening effort. Participants with TB symptoms or CAD4TBv5 score above the triaging threshold were referred for microbiological sputum assessment. During an initial pilot phase, a low CAD4TBv5 triaging threshold of 25 was selected to maximize TB case finding. We report the performance of CAD4TBv5 in screening 9,914 participants, 99 (1.0%) of whom were found to have microbiologically proven TB. CAD4TBv5 was able to identify TB cases at the same sensitivity but lower specificity as a blinded radiologist, whereas the next generation of the algorithm (CAD4TBv6) achieved comparable sensitivity and specificity to the radiologist. The CXRs of people with microbiologically confirmed TB spanned a range of lung field abnormality, including 19 (19.2%) cases deemed normal by the radiologist. HIV serostatus did not impact CAD4TB's performance. Notably, 78.8% of the TB cases identified during this population-based survey were asymptomatic and therefore triaged for sputum collection on the basis of CAD4TBv5 score alone. While CAD4TBv6 has the potential to replace radiologists for triaging CXRs in TB prevalence surveys, population-specific piloting is necessary to set the appropriate triaging thresholds. Further work on image analysis strategies is needed to identify radiologically subtle active TB.
Collapse
Affiliation(s)
- Jana Fehr
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Digital Health & Machine Learning, Hasso Plattner Institute for Digital Engineering, Berlin, Germany
| | - Stefan Konigorski
- Digital Health & Machine Learning, Hasso Plattner Institute for Digital Engineering, Berlin, Germany
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stephen Olivier
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Resign Gunda
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | | | - Dickman Gareta
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Theresa Smit
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Kathy Baisley
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- London School of Hygiene & Tropical Medicine, London, UK
| | - Sashen Moodley
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Yumna Moosa
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Willem Hanekom
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | - Olivier Koole
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- London School of Hygiene & Tropical Medicine, London, UK
| | - Thumbi Ndung'u
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Division of Infection and Immunity, University College London, London, UK
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
- Ragon Institute of MGH, MIT and Harvard University, Cambridge, MA, USA
- Max Planck Institute for Infection Biology, Berlin, Germany
| | - Deenan Pillay
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | - Alison D Grant
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- London School of Hygiene & Tropical Medicine, London, UK
- School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Mark J Siedner
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- Harvard Medical School, Boston, MA, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Christoph Lippert
- Digital Health & Machine Learning, Hasso Plattner Institute for Digital Engineering, Berlin, Germany
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emily B Wong
- Africa Health Research Institute, KwaZulu-Natal, South Africa.
- Harvard Medical School, Boston, MA, USA.
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA.
| |
Collapse
|
21
|
Mungai BN, Joekes E, Masini E, Obasi A, Manduku V, Mugi B, Ong’angò J, Kirathe D, Kiplimo R, Sitienei J, Oronje R, Morton B, Squire SB, MacPherson P. 'If not TB, what could it be?' Chest X-ray findings from the 2016 Kenya Tuberculosis Prevalence Survey. Thorax 2021; 76:607-614. [PMID: 33504563 PMCID: PMC8223623 DOI: 10.1136/thoraxjnl-2020-216123] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 12/20/2020] [Accepted: 12/23/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND The prevalence of diseases other than TB detected during chest X-ray (CXR) screening is unknown in sub-Saharan Africa. This represents a missed opportunity for identification and treatment of potentially significant disease. Our aim was to describe and quantify non-TB abnormalities identified by TB-focused CXR screening during the 2016 Kenya National TB Prevalence Survey. METHODS We reviewed a random sample of 1140 adult (≥15 years) CXRs classified as 'abnormal, suggestive of TB' or 'abnormal other' during field interpretation from the TB prevalence survey. Each image was read (blinded to field classification and study radiologist read) by two expert radiologists, with images classified into one of four major anatomical categories and primary radiological findings. A third reader resolved discrepancies. Prevalence and 95% CIs of abnormalities diagnosis were estimated. FINDINGS Cardiomegaly was the most common non-TB abnormality at 259 out of 1123 (23.1%, 95% CI 20.6% to 25.6%), while cardiomegaly with features of cardiac failure occurred in 17 out of 1123 (1.5%, 95% CI 0.9% to 2.4%). We also identified chronic pulmonary pathology including suspected COPD in 3.2% (95% CI 2.3% to 4.4%) and non-specific patterns in 4.6% (95% CI 3.5% to 6.0%). Prevalence of active-TB and severe post-TB lung changes was 3.6% (95% CI 2.6% to 4.8%) and 1.4% (95% CI 0.8% to 2.3%), respectively. INTERPRETATION Based on radiological findings, we identified a wide variety of non-TB abnormalities during population-based TB screening. TB prevalence surveys and active case finding activities using mass CXR offer an opportunity to integrate disease screening efforts. FUNDING National Institute for Health Research (IMPALA-grant reference 16/136/35).
Collapse
Affiliation(s)
| | - Elizabeth Joekes
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK,Worldwide Radiology, Liverpool, UK
| | - Enos Masini
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland,Stop TB Partnership, Geneva, Switzerland
| | - Angela Obasi
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK,Axess Sexual Health, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | | | | | - Dickson Kirathe
- Division of National Tuberculosis, Leprosy and Lung Disease Program, Nairobi, Kenya
| | - Richard Kiplimo
- Division of National Tuberculosis, Leprosy and Lung Disease Program, Nairobi, Kenya
| | - Joseph Sitienei
- Division of National Tuberculosis, Leprosy and Lung Disease Program, Nairobi, Kenya
| | - Rose Oronje
- African Institute for Development Policy, Nairobi, Kenya
| | - Ben Morton
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi,Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, Liverpool, UK
| | - Stephen Bertel Squire
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi,Tropical & Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Peter MacPherson
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi,Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | | |
Collapse
|
22
|
Qin ZZ, Naheyan T, Ruhwald M, Denkinger CM, Gelaw S, Nash M, Creswell J, Kik SV. A new resource on artificial intelligence powered computer automated detection software products for tuberculosis programmes and implementers. Tuberculosis (Edinb) 2021; 127:102049. [PMID: 33440315 DOI: 10.1016/j.tube.2020.102049] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 12/22/2020] [Accepted: 12/27/2020] [Indexed: 01/25/2023]
Abstract
Recently, the number of artificial intelligence powered computer-aided detection (CAD) products that detect tuberculosis (TB)-related abnormalities from chest X-rays (CXR) available on the market has increased. Although CXR is a relatively effective and inexpensive method for TB screening and triaging, a shortage of skilled radiologists in many high TB-burden countries limits its use. CAD technology offers a solution to this problem. Before adopting a CAD product, TB programmes need to consider not only the diagnostic accuracy but also implementation-relevant features including operational characteristics, deployment mechanism, input and machine compatibility, output format, options for integration into the legacy system, costs, data sharing and privacy aspects, and certification. A landscaping analysis was conducted to collect this information among CAD developers known to have or soon to have a TB product. The responses were reviewed and finalized with the developers, and are published on an open-access website: www.ai4hlth.org. CAD products are constantly being improved and the site will continuously be updated to account for updates and new products. This unique online resource aims to inform the TB community about available CAD tools, their features and set-up procedures, to enable TB programmes to identify the most suitable product to incorporate in interventions.
Collapse
Affiliation(s)
- Zhi Zhen Qin
- Stop TB Partnership, Chemin Du Pommier 40, Le Grand-Saconnex, Geneva, 1218, Switzerland.
| | - Tasneem Naheyan
- Stop TB Partnership, Chemin Du Pommier 40, Le Grand-Saconnex, Geneva, 1218, Switzerland
| | - Morten Ruhwald
- Foundation for Innovative New Diagnostics, Chemin des Mines, Geneva, 1201, Switzerland
| | - Claudia M Denkinger
- Foundation for Innovative New Diagnostics, Chemin des Mines, Geneva, 1201, Switzerland; Division of Tropical Medicine, Center of Infectious Diseases, University Hospital Heidelberg, Heidelberg, Im Neuenheimer Feld 324, Heidelberg, 69120, Germany
| | - Sifrash Gelaw
- International Organization for Migration, Global Teleradiology and QC Center, Migration Health Division, Manila (Global) Administrative Center, 24F Citibank Tower, 8741 Paseo de Roxas, Makati City, Metro Manila, 1226, Philippines
| | - Madlen Nash
- McGill International TB Centre, 1001 Boulevard Décarie, Montréal, QC H4A 3J1, Canada
| | - Jacob Creswell
- Stop TB Partnership, Chemin Du Pommier 40, Le Grand-Saconnex, Geneva, 1218, Switzerland
| | - Sandra Vivian Kik
- Foundation for Innovative New Diagnostics, Chemin des Mines, Geneva, 1201, Switzerland.
| |
Collapse
|
23
|
Nijiati M, Zhang Z, Abulizi A, Miao H, Tuluhong A, Quan S, Guo L, Xu T, Zou X. Deep learning assistance for tuberculosis diagnosis with chest radiography in low-resource settings. JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2021; 29:785-796. [PMID: 34219703 DOI: 10.3233/xst-210894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Tuberculosis (TB) is a major health issue with high mortality rates worldwide. Recently, tremendous researches of artificial intelligence (AI) have been conducted targeting at TB to reduce the diagnostic burden. However, most researches are conducted in the developed urban areas. The feasibility of applying AI in low-resource settings remains unexplored. In this study, we apply an automated detection (AI) system to screen a large population in an underdeveloped area and evaluate feasibility and contribution of applying AI to help local radiologists detect and diagnose TB using chest X-ray (CXR) images. First, we divide image data into one training dataset including 2627 TB-positive cases and 7375 TB-negative cases and one testing dataset containing 276 TB-positive cases and 619 TB-negative cases, respectively. Next, in building AI system, the experiment includes image labeling and preprocessing, model training and testing. A segmentation model named TB-UNet is also built to detect diseased regions, which uses ResNeXt as the encoder of U-Net. We use AI-generated confidence score to predict the likelihood of each testing case being TB-positive. Then, we conduct two experiments to compare results between the AI system and radiologists with and without AI assistance. Study results show that AI system yields TB detection accuracy of 85%, which is much higher than detection accuracy of radiologists (62%) without AI assistance. In addition, with AI assistance, the TB diagnostic sensitivity of local radiologists is improved by 11.8%. Therefore, this study demonstrates that AI has great potential to help detection, prevention, and control of TB in low-resource settings, particularly in areas with more scant doctors and higher rates of the infected population.
Collapse
Affiliation(s)
| | - Ziqi Zhang
- Tsinghua-Berkeley Shenzhen Institute, Tsinghua University, Shenzhen, China
| | | | - Hengyuan Miao
- Tsinghua-Berkeley Shenzhen Institute, Tsinghua University, Shenzhen, China
| | | | - Shenwen Quan
- Shenzhen Zhiying Medical Co., Ltd, Shenzhen, China
| | - Lin Guo
- Shenzhen Zhiying Medical Co., Ltd, Shenzhen, China
| | - Tao Xu
- Tsinghua-Berkeley Shenzhen Institute, Tsinghua University, Shenzhen, China
- Biomanufacturing and Rapid Forming Technology Key Laboratory of Beijing, Department of Mechanical Engineering, Tsinghua University, Beijing, China
- Key Laboratory for Advanced Materials Processing Technology, Ministry of Education, Department of Mechanical Engineering, Tsinghua University, Beijing, China
| | - Xiaoguang Zou
- The First People's Hospital of Kashi, Xinjiang, China
| |
Collapse
|
24
|
Rajpurkar P, O’Connell C, Schechter A, Asnani N, Li J, Kiani A, Ball RL, Mendelson M, Maartens G, van Hoving DJ, Griesel R, Ng AY, Boyles TH, Lungren MP. CheXaid: deep learning assistance for physician diagnosis of tuberculosis using chest x-rays in patients with HIV. NPJ Digit Med 2020; 3:115. [PMID: 32964138 PMCID: PMC7481246 DOI: 10.1038/s41746-020-00322-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 08/14/2020] [Indexed: 01/17/2023] Open
Abstract
Tuberculosis (TB) is the leading cause of preventable death in HIV-positive patients, and yet often remains undiagnosed and untreated. Chest x-ray is often used to assist in diagnosis, yet this presents additional challenges due to atypical radiographic presentation and radiologist shortages in regions where co-infection is most common. We developed a deep learning algorithm to diagnose TB using clinical information and chest x-ray images from 677 HIV-positive patients with suspected TB from two hospitals in South Africa. We then sought to determine whether the algorithm could assist clinicians in the diagnosis of TB in HIV-positive patients as a web-based diagnostic assistant. Use of the algorithm resulted in a modest but statistically significant improvement in clinician accuracy (p = 0.002), increasing the mean clinician accuracy from 0.60 (95% CI 0.57, 0.63) without assistance to 0.65 (95% CI 0.60, 0.70) with assistance. However, the accuracy of assisted clinicians was significantly lower (p < 0.001) than that of the stand-alone algorithm, which had an accuracy of 0.79 (95% CI 0.77, 0.82) on the same unseen test cases. These results suggest that deep learning assistance may improve clinician accuracy in TB diagnosis using chest x-rays, which would be valuable in settings with a high burden of HIV/TB co-infection. Moreover, the high accuracy of the stand-alone algorithm suggests a potential value particularly in settings with a scarcity of radiological expertise.
Collapse
Affiliation(s)
- Pranav Rajpurkar
- Stanford University Department of Computer Science, Stanford, CA USA
| | - Chloe O’Connell
- Massachusetts General Hospital Department of Anesthesia, Boston, MA USA
| | - Amit Schechter
- Stanford University Department of Computer Science, Stanford, CA USA
| | - Nishit Asnani
- Stanford University Department of Computer Science, Stanford, CA USA
| | - Jason Li
- Stanford University Department of Computer Science, Stanford, CA USA
| | - Amirhossein Kiani
- Stanford University Department of Computer Science, Stanford, CA USA
| | | | - Marc Mendelson
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Rulan Griesel
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew Y. Ng
- Stanford University Department of Computer Science, Stanford, CA USA
| | - Tom H. Boyles
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | |
Collapse
|
25
|
Evaluation of computer aided detection of tuberculosis on chest radiography among people with diabetes in Karachi Pakistan. Sci Rep 2020; 10:6276. [PMID: 32286389 PMCID: PMC7156514 DOI: 10.1038/s41598-020-63084-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 03/25/2020] [Indexed: 12/19/2022] Open
Abstract
Pakistan ranks fifth among high tuberculosis (TB) burden countries and also has seventh highest burden for diabetes mellitus (DM). DM increases the risk of developing TB and contributes to adverse TB treatment outcomes hence screening and integrated management for both diseases in high burden countries is suggested. Computer-Aided Detection for TB (CAD4TB) can potentially be used as triage tool in low resource settings to pre-screen individuals for Xpert MTB/RIF testing. The aim of this study was to evaluate the diagnostic accuracy and performance of CAD4TB software in people with diabetes (PWD) enrolled in a TB screening program in Karachi, Pakistan. A total of 694 individuals with a diagnosis of DM (of whom 31.1% were newly diagnosed) were screened with CAD4TB and simultaneously provided sputum for Xpert MTB/RIF testing. Of the 74 (10.7%) participants who had bacteriologically positive (MTB+) results on Xpert testing, 54 (73%) had a CAD4TB score >70; and 155 (25%) participants who tested MTB-negative had scores >70. The area under the receiver operator curve was 0.78 (95% CI: 0.77-0.80). Our study findings indicate that CAD4TB offers good diagnostic accuracy as a triage test for TB screening among PWD using Xpert MTB/RIF as the reference standard.
Collapse
|
26
|
Computer aided detection of tuberculosis on chest radiographs: An evaluation of the CAD4TB v6 system. Sci Rep 2020; 10:5492. [PMID: 32218458 PMCID: PMC7099074 DOI: 10.1038/s41598-020-62148-y] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 03/06/2020] [Indexed: 11/11/2022] Open
Abstract
There is a growing interest in the automated analysis of chest X-Ray (CXR) as a sensitive and inexpensive means of screening susceptible populations for pulmonary tuberculosis. In this work we evaluate the latest version of CAD4TB, a commercial software platform designed for this purpose. Version 6 of CAD4TB was released in 2018 and is here tested on a fully independent dataset of 5565 CXR images with GeneXpert (Xpert) sputum test results available (854 Xpert positive subjects). A subset of 500 subjects (50% Xpert positive) was reviewed and annotated by 5 expert observers independently to obtain a radiological reference standard. The latest version of CAD4TB is found to outperform all previous versions in terms of area under receiver operating curve (ROC) with respect to both Xpert and radiological reference standards. Improvements with respect to Xpert are most apparent at high sensitivity levels with a specificity of 76% obtained at a fixed 90% sensitivity. When compared with the radiological reference standard, CAD4TB v6 also outperformed previous versions by a considerable margin and achieved 98% specificity at the 90% sensitivity setting. No substantial difference was found between the performance of CAD4TB v6 and any of the various expert observers against the Xpert reference standard. A cost and efficiency analysis on this dataset demonstrates that in a standard clinical situation, operating at 90% sensitivity, users of CAD4TB v6 can process 132 subjects per day at an average cost per screen of $5.95 per subject, while users of version 3 process only 85 subjects per day at a cost of $8.38 per subject. At all tested operating points version 6 is shown to be more efficient and cost effective than any other version.
Collapse
|
27
|
Lee Y, Raviglione MC, Flahault A. Use of Digital Technology to Enhance Tuberculosis Control: Scoping Review. J Med Internet Res 2020; 22:e15727. [PMID: 32053111 PMCID: PMC7055857 DOI: 10.2196/15727] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 10/22/2019] [Accepted: 10/22/2019] [Indexed: 02/06/2023] Open
Abstract
Background Tuberculosis (TB) is the leading cause of death from a single infectious agent, with around 1.5 million deaths reported in 2018, and is a major contributor to suffering worldwide, with an estimated 10 million new cases every year. In the context of the World Health Organization’s End TB strategy and the quest for digital innovations, there is a need to understand what is happening around the world regarding research into the use of digital technology for better TB care and control. Objective The purpose of this scoping review was to summarize the state of research on the use of digital technology to enhance TB care and control. This study provides an overview of publications covering this subject and answers 3 main questions: (1) to what extent has the issue been addressed in the scientific literature between January 2016 and March 2019, (2) which countries have been investing in research in this field, and (3) what digital technologies were used? Methods A Web-based search was conducted on PubMed and Web of Science. Studies that describe the use of digital technology with specific reference to keywords such as TB, digital health, eHealth, and mHealth were included. Data from selected studies were synthesized into 4 functions using narrative and graphical methods. Such digital health interventions were categorized based on 2 classifications, one by function and the other by targeted user. Results A total of 145 relevant studies were identified out of the 1005 published between January 2016 and March 2019. Overall, 72.4% (105/145) of the research focused on patient care and 20.7% (30/145) on surveillance and monitoring. Other programmatic functions 4.8% (7/145) and electronic learning 2.1% (3/145) were less frequently studied. Most digital health technologies used for patient care included primarily diagnostic 59.4% (63/106) and treatment adherence tools 40.6% (43/106). On the basis of the second type of classification, 107 studies targeted health care providers (107/145, 73.8%), 20 studies targeted clients (20/145, 13.8%), 17 dealt with data services (17/145, 11.7%), and 1 study was on the health system or resource management. The first authors’ affiliations were mainly from 3 countries: the United States (30/145 studies, 20.7%), China (20/145 studies, 13.8%), and India (17/145 studies, 11.7%). The researchers from the United States conducted their research both domestically and abroad, whereas researchers from China and India conducted all studies domestically. Conclusions The majority of research conducted between January 2016 and March 2019 on digital interventions for TB focused on diagnostic tools and treatment adherence technologies, such as video-observed therapy and SMS. Only a few studies addressed interventions for data services and health system or resource management.
Collapse
Affiliation(s)
- Yejin Lee
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Global Studies Institute, University of Geneva, Geneva, Switzerland
| | - Mario C Raviglione
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Global Studies Institute, University of Geneva, Geneva, Switzerland.,Centre for Multidisciplinary Research in Health Science (MACH), Università di Milano, Milan, Italy
| | - Antoine Flahault
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Global Studies Institute, University of Geneva, Geneva, Switzerland
| |
Collapse
|
28
|
Kulkarni S, Jha S. Artificial Intelligence, Radiology, and Tuberculosis: A Review. Acad Radiol 2020; 27:71-75. [PMID: 31759796 DOI: 10.1016/j.acra.2019.10.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/22/2019] [Accepted: 10/05/2019] [Indexed: 12/13/2022]
Abstract
Tuberculosis is a leading cause of death from infectious disease worldwide, and is an epidemic in many developing nations. Countries where the disease is common also tend to have poor access to medical care, including diagnostic tests. Recent advancements in artificial intelligence may help to bridge this gap. In this article, we review the applications of artificial intelligence in the diagnosis of tuberculosis using chest radiography, covering simple computer-aided diagnosis systems to more advanced deep learning algorithms. In so doing, we will demonstrate an area where artificial intelligence could make a substantial contribution to global health through improved diagnosis in the future.
Collapse
Affiliation(s)
- Sagar Kulkarni
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA.
| | - Saurabh Jha
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA
| |
Collapse
|
29
|
Phyo AM, Kumar AMV, Soe KT, Kyaw KWY, Thu AS, Wai PP, Aye S, Saw S, Win Maung HM, Aung ST. Contact Investigation of Multidrug-Resistant Tuberculosis Patients: A Mixed-Methods Study from Myanmar. Trop Med Infect Dis 2019; 5:E3. [PMID: 31887995 PMCID: PMC7157597 DOI: 10.3390/tropicalmed5010003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 11/13/2019] [Accepted: 11/22/2019] [Indexed: 12/03/2022] Open
Abstract
There is no published evidence on contact investigation among multidrug-resistant tuberculosis (MDR-TB) patients from Myanmar. We describe the cascade of contact investigation conducted in 27 townships of Myanmar from January 2018 to June 2019 and its implementation challenges. This was a mixed-methods study involving quantitative (cohort analysis of programme data) and qualitative components (thematic analysis of interviews of 8 contacts and 13 health care providers). There were 556 MDR-TB patients and 1908 contacts, of whom 1134 (59%) reached the health centres for screening (chest radiography and symptoms). Of the latter, 344 (30%) had presumptive TB and of them, 186 (54%) were investigated (sputum microscopy or Xpert MTB/RIF®). A total of 27 TB patients were diagnosed (six bacteriologically-confirmed including five with rifampicin resistance). The key reasons for not reaching township TB centres included lack of knowledge and lack of risk perception owing to wrong beliefs among contacts, financial constraints related to loss of wages and transportation charges, and inconvenient clinic hours. The reasons for not being investigated included inability to produce sputum, health care providers being unaware of or not agreeing to the investigation protocol, fixed clinic days and times, and charges for investigation. The National Tuberculosis Programme needs to note these findings and take necessary action.
Collapse
Affiliation(s)
- Aye Mon Phyo
- TB Department, International Union Against Tuberculosis and Lung Disease (The Union), Mandalay 15021, Myanmar; (A.S.T.); (P.P.W.); (S.A.)
| | - Ajay M. V. Kumar
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), 75006 Paris, France; (A.M.V.K.); (K.W.Y.K.)
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi 110016, India
- Department of Community Medicine, Yenepoya Medical College, Yenepoya (Deemed to be University), Mangaluru 575022, India
| | - Kyaw Thu Soe
- Department of Medical Research (Pyin Oo Lwin Branch), Ministry of Health and Sports, Pyin Oo Lwin 05081, Myanmar;
| | - Khine Wut Yee Kyaw
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), 75006 Paris, France; (A.M.V.K.); (K.W.Y.K.)
- Department of Operational Research, International Union against Tuberculosis and Lung Disease (The Union), Mandalay 15021, Myanmar
| | - Aung Si Thu
- TB Department, International Union Against Tuberculosis and Lung Disease (The Union), Mandalay 15021, Myanmar; (A.S.T.); (P.P.W.); (S.A.)
| | - Pyae Phyo Wai
- TB Department, International Union Against Tuberculosis and Lung Disease (The Union), Mandalay 15021, Myanmar; (A.S.T.); (P.P.W.); (S.A.)
| | - Sandar Aye
- TB Department, International Union Against Tuberculosis and Lung Disease (The Union), Mandalay 15021, Myanmar; (A.S.T.); (P.P.W.); (S.A.)
| | - Saw Saw
- Department of Medical Research, Ministry of Health and Sports, Yangon 11191, Myanmar;
| | - Htet Myet Win Maung
- National Tuberculosis Programme, Ministry of Health and Sports, Nay Pyi Taw 15011, Myanmar; (H.M.W.M.); (S.T.A.)
| | - Si Thu Aung
- National Tuberculosis Programme, Ministry of Health and Sports, Nay Pyi Taw 15011, Myanmar; (H.M.W.M.); (S.T.A.)
| |
Collapse
|
30
|
Harris M, Qi A, Jeagal L, Torabi N, Menzies D, Korobitsyn A, Pai M, Nathavitharana RR, Ahmad Khan F. A systematic review of the diagnostic accuracy of artificial intelligence-based computer programs to analyze chest x-rays for pulmonary tuberculosis. PLoS One 2019; 14:e0221339. [PMID: 31479448 PMCID: PMC6719854 DOI: 10.1371/journal.pone.0221339] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 08/05/2019] [Indexed: 12/11/2022] Open
Abstract
We undertook a systematic review of the diagnostic accuracy of artificial intelligence-based software for identification of radiologic abnormalities (computer-aided detection, or CAD) compatible with pulmonary tuberculosis on chest x-rays (CXRs). We searched four databases for articles published between January 2005-February 2019. We summarized data on CAD type, study design, and diagnostic accuracy. We assessed risk of bias with QUADAS-2. We included 53 of the 4712 articles reviewed: 40 focused on CAD design methods (“Development” studies) and 13 focused on evaluation of CAD (“Clinical” studies). Meta-analyses were not performed due to methodological differences. Development studies were more likely to use CXR databases with greater potential for bias as compared to Clinical studies. Areas under the receiver operating characteristic curve (median AUC [IQR]) were significantly higher: in Development studies AUC: 0.88 [0.82–0.90]) versus Clinical studies (0.75 [0.66–0.87]; p-value 0.004); and with deep-learning (0.91 [0.88–0.99]) versus machine-learning (0.82 [0.75–0.89]; p = 0.001). We conclude that CAD programs are promising, but the majority of work thus far has been on development rather than clinical evaluation. We provide concrete suggestions on what study design elements should be improved.
Collapse
Affiliation(s)
- Miriam Harris
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
- Department of Medicine, McGill University Health Centre, Montreal, Canada
- Department of Medicine, Boston University–Boston Medical Center, Boston, Massachusetts, United States of America
- * E-mail:
| | - Amy Qi
- Department of Medicine, McGill University Health Centre, Montreal, Canada
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute & Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Luke Jeagal
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute & Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Nazi Torabi
- St. Michael's Hospital, Li Ka Shing International Healthcare Education Centre, Toronto, Canada
| | - Dick Menzies
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute & Research Institute of the McGill University Health Centre, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
| | - Alexei Korobitsyn
- Laboratories, Diagnostics & Drug Resistance Global TB Programme WHO, Geneva, Switzerland
| | - Madhukar Pai
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute & Research Institute of the McGill University Health Centre, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
| | - Ruvandhi R. Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Faiz Ahmad Khan
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute & Research Institute of the McGill University Health Centre, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
| |
Collapse
|
31
|
|