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Svadzian A, Daniels B, Sulis G, Das J, Daftary A, Kwan A, Das V, Das R, Pai M. Do private providers initiate anti-tuberculosis therapy on the basis of chest radiographs? A standardised patient study in urban India. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 13:100152. [PMID: 37383564 PMCID: PMC10306035 DOI: 10.1016/j.lansea.2023.100152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/08/2023] [Accepted: 01/11/2023] [Indexed: 06/30/2023]
Abstract
Background The initiation of anti-tuberculosis treatment (ATT) based on results of WHO-approved microbiological diagnostics is an important marker of quality tuberculosis (TB) care. Evidence suggests that other diagnostic processes leading to treatment initiation may be preferred in high TB incidence settings. This study examines whether private providers start anti-TB therapy on the basis of chest radiography (CXR) and clinical examinations. Methods This study uses the standardized patient (SP) methodology to generate accurate and unbiased estimates of private sector, primary care provider practice when a patient presents a standardized TB case scenario with an abnormal CXR. Using multivariate log-binomial and linear regressions with standard errors clustered at the provider level, we analyzed 795 SP visits conducted over three data collection waves from 2014 to 2020 in two Indian cities. Data were inverse-probability-weighted based on the study sampling strategy, resulting in city-wave-representative results. Findings Amongst SPs who presented to a provider with an abnormal CXR, 25% (95% CI: 21-28%) visits resulted in ideal management, defined as the provider prescribing a microbiological test and not offering a concurrent prescription for a corticosteroid or antibiotic (including anti-TB medications). In contrast, 23% (95% CI: 19-26%) of 795 visits were prescribed anti-TB medications. Of 795 visits, 13% (95% CI: 10-16%) resulted in anti-TB treatment prescriptions/dispensation and an order for confirmatory microbiological testing. Interpretation One in five SPs presenting with abnormal CXR were prescribed ATT by private providers. This study contributes novel insights to empiric treatment prevalence based on CXR abnormality. Further work is needed to understand how providers make trade-offs between existing diagnostic practices, new technologies, profits, clinical outcomes, and the market dynamics with laboratories. Funding This study was funded by the Bill & Melinda Gates Foundation (grant OPP1091843), and the Knowledge for Change Program at The World Bank.
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Affiliation(s)
- Anita Svadzian
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Benjamin Daniels
- McCourt School of Public Policy, Georgetown University, Washington, DC, USA
| | - Giorgia Sulis
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jishnu Das
- McCourt School of Public Policy, Georgetown University, Washington, DC, USA
- Centre for Policy Research, New Delhi, India
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, ON, Canada
- Centre for the Aids Programme of Research in South Africa MRC-HIV-TB Pathogenesis and Treatment, Research Unit, Durban, South Africa
| | - Ada Kwan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, USA
| | - Ranendra Das
- Institute for Socio-Economic Research on Development and Democracy, Delhi, India
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- McGill International TB Centre, McGill University, Montreal, QC, Canada
- Manipal McGill Program for Infectious Diseases, Manipal Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Berhanu RH, Lebina L, Nonyane BAS, Milovanovic M, Kinghorn A, Connell L, Nyathi S, Young K, Hausler H, Naidoo P, Brey Z, Shearer K, Genade L, Martinson NA. Yield of Facility-based Targeted Universal Testing for Tuberculosis With Xpert and Mycobacterial Culture in High-Risk Groups Attending Primary Care Facilities in South Africa. Clin Infect Dis 2023; 76:1594-1603. [PMID: 36610730 PMCID: PMC10156124 DOI: 10.1093/cid/ciac965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 12/08/2022] [Accepted: 12/19/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND We report the yield of targeted universal tuberculosis (TB) testing of clinic attendees in high-risk groups. METHODS Clinic attendees in primary healthcare facilities in South Africa with one of the following risk factors underwent sputum testing for TB: human immunodeficiency virus (HIV), contact with a TB patient in the past year, and having had TB in the past 2 years. A single sample was collected for Xpert-Ultra (Xpert) and culture. We report the proportion positive for Mycobacterium tuberculosis. Data were analyzed descriptively. The unadjusted clinical and demographic factors' relative risk of TB detected by culture or Xpert were calculated and concordance between Xpert and culture is described. RESULTS A total of 30 513 participants had a TB test result. Median age was 39 years, and 11 553 (38%) were men. The majority (n = 21734, 71%) had HIV, 12 492 (41%) reported close contact with a TB patient, and 1573 (5%) reported prior TB. Overall, 8.3% were positive for M. tuberculosis by culture and/or Xpert compared with 6.0% with trace-positive results excluded. In asymptomatic participants, the yield was 6.7% and 10.1% in symptomatic participants (with trace-positives excluded). Only 10% of trace-positive results were culture-positive. We found that 55% of clinic attendees with a sputum result positive for M. tuberculosis did not have a positive TB symptom screen. CONCLUSIONS A high proportion of clinic attendees with specific risk factors (HIV, close TB contact, history of TB) test positive for M. tuberculosis when universal testing is implemented.
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Affiliation(s)
- Rebecca H Berhanu
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Limakatso Lebina
- Perinatal HIV Research Unit (PHRU), University of Witwatersrand, Soweto, South Africa
| | - Bareng A S Nonyane
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, USA
| | - Minja Milovanovic
- Perinatal HIV Research Unit (PHRU), University of Witwatersrand, Soweto, South Africa
| | - Anthony Kinghorn
- Perinatal HIV Research Unit (PHRU), University of Witwatersrand, Soweto, South Africa
| | | | | | | | - Harry Hausler
- TB HIV Care, Cape Town, South Africa
- Department of Family Medicine, University of Pretoria, Pretoria, South Africa
| | - Pren Naidoo
- Public Health Management Consultant, Cape Town, South Africa
| | - Zameer Brey
- Bill and Melinda Gates Foundation–South Africa, Johannesburg, South Africa
| | - Kate Shearer
- Department of Medicine, Division of Infectious Diseases, Baltimore, Maryland, USA
- Centre for TB Research, Johns Hopkins University, Baltimore, Maryland, USA
| | - Leisha Genade
- Perinatal HIV Research Unit (PHRU), University of Witwatersrand, Soweto, South Africa
| | - Neil A Martinson
- Perinatal HIV Research Unit (PHRU), University of Witwatersrand, Soweto, South Africa
- Centre for TB Research, Johns Hopkins University, Baltimore, Maryland, USA
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Kia P, Ruman U, Pratiwi AR, Hussein MZ. Innovative Therapeutic Approaches Based on Nanotechnology for the Treatment and Management of Tuberculosis. Int J Nanomedicine 2023; 18:1159-1191. [PMID: 36919095 PMCID: PMC10008450 DOI: 10.2147/ijn.s364634] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 02/06/2023] [Indexed: 03/11/2023] Open
Abstract
Tuberculosis (TB), derived from bacterium named Mycobacterium tuberculosis, has become one of the worst infectious and contagious illnesses in the world after HIV/AIDS. Long-term therapy, a high pill burden, lack of compliance, and strict management regimens are disadvantages which resulted in the extensively drug-resistant (XDR) along with multidrug-resistant (MDR) in the treatment of TB. One of the main thrust areas for the current scenario is the development of innovative intervention tools for early diagnosis and therapeutics towards Mycobacterium tuberculosis (MTB). This review discusses various nanotherapeutic agents that have been developed for MTB diagnostics, anti-TB drugs and vaccine. Undoubtedly, the concept of employing nanoparticles (NPs) has strong potential in this therapy and offers impressive outcomes to conquer the disease. Nanocarriers with different types were designed for drug delivery applications via various administration methods. Controlling and maintaining the drug release might be an example of the benefits of utilizing a drug-loaded NP in TB therapy over conventional drug therapy. Furthermore, the drug-encapsulated NP is able to lessen dosage regimen and can resolve the problems of insufficient compliance. Over the past decade, NPs were developed in both diagnostic and therapeutic methods, while on the other hand, the therapeutic system has increased. These "theranostic" NPs were designed for nuclear imaging, optical imaging, ultrasound, imaging with magnetic resonance and the computed tomography, which includes both single-photon computed tomography and positron emission tomography. More specifically, the current manuscript focuses on the status of therapeutic and diagnostic approaches in the treatment of TB.
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Affiliation(s)
- Pooneh Kia
- Institute of Bioscience, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Umme Ruman
- Nanomaterials Synthesis and Characterization Laboratory (NSCL), Institute of Nanoscience and Nanotechnology (ION2), Universiti Putra Malaysia, UPM Serdang, Selangor, Malaysia
| | - Ariyati Retno Pratiwi
- Department of Oral Biology, Faculty of Dentistry, Universitas Brawijaya, Malang, Indonesia
| | - Mohd Zobir Hussein
- Nanomaterials Synthesis and Characterization Laboratory (NSCL), Institute of Nanoscience and Nanotechnology (ION2), Universiti Putra Malaysia, UPM Serdang, Selangor, Malaysia
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Stabilization of Tuberculosis Reporter Enzyme Fluorescence (REFtb) Diagnostic Reagents for Use at the Point of Care. Diagnostics (Basel) 2022; 12:diagnostics12071745. [PMID: 35885648 PMCID: PMC9324015 DOI: 10.3390/diagnostics12071745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/13/2022] [Accepted: 07/14/2022] [Indexed: 11/17/2022] Open
Abstract
Tuberculosis is one of the most frequent causes of death in humans worldwide. One of the primary reasons tuberculosis remains a public health threat is that diagnosis can take weeks to months, is often not very sensitive and cannot be accomplished in many remote environments. A rapid, sensitive and inexpensive point-of-care (POC) diagnostic would have a major impact on tuberculosis eradication efforts. The tuberculosis diagnostic system REFtb is based on specific detection of the constitutively expressed β-lactamase (BlaC) in Mycobacterium tuberculosis using a custom fluorogenic substrate designated as CDG-3. REFtb has potential as a diagnostic for tuberculosis that could be very inexpensive (<USD 2.00/test), used at the POC and could provide definitive diagnosis within 10 min. However, the reagents for REFtb are currently in liquid form, making them more susceptible to degradation and difficult to transport. We evaluated the improvement in the stability of REFtb reagents by lyophilization under a variety of conditions through their effects on the performance of REFtb. We found that lyophilization of REFtb components produces an easily reconstituted powder that displays similar performance to the liquid system and that lactose represents one of the most promising excipients for use in a final POC REFtb diagnostic system. These studies provide the foundation for the production of a stable POC REFtb system that could be easily distributed worldwide with minimal or no requirement for refrigeration.
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Saxena D, Duncan RA, Faust RR, Campagna A. Abdominal cyst of unclear aetiology: gastrointestinal stromal tumour or reactivation of abdominal tuberculosis. BMJ Case Rep 2022; 15:15/1/e245767. [PMID: 34992056 PMCID: PMC8739064 DOI: 10.1136/bcr-2021-245767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Differential diagnosis of a new abdominal mass is broad and includes infection, malignancy and other inflammatory processes. Definitive diagnosis may be challenging without invasive biopsy, as history, physical exam and imaging may be non-specific. A 69-year-old man with a history of abdominal tuberculosis presented with a new painful abdominal cyst consistent with reactivation of tuberculosis versus new malignancy. Investigations revealed 4+ acid-fast bacilli from the aspirate suggestive of tuberculosis, but no improvement was noted on antituberculous therapy. Core needle biopsy noted c-KIT-positive spindle cells, diagnostic for a gastrointestinal stromal tumour, while cultures grew non-tuberculous mycobacteria.
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Affiliation(s)
- Damini Saxena
- General Internal Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Robert A Duncan
- Infectious Diseases, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Robert R Faust
- General Internal Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Anthony Campagna
- Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
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Kendall EA, Kitonsa PJ, Nalutaaya A, Erisa KC, Mukiibi J, Nakasolya O, Isooba D, Baik Y, Robsky KO, Kato-Maeda M, Cattamanchi A, Katamba A, Dowdy DW. The Spectrum of Tuberculosis Disease in an Urban Ugandan Community and Its Health Facilities. Clin Infect Dis 2021; 72:e1035-e1043. [PMID: 33283227 DOI: 10.1093/cid/ciaa1824] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/03/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND New, sensitive diagnostic tests facilitate identification and investigation of milder forms of tuberculosis (TB) disease. We used community-based TB testing with the Xpert MTB/RIF Ultra assay ("Ultra") to characterize individuals with previously undiagnosed TB and compare them to those from the same community who were diagnosed with TB through routine care. METHODS We offered community-based sputum Ultra testing to adult residents of a well-defined area (population 34 000 adults) in Kampala, Uganda, via door-to-door screening and venue-based testing, then used detailed interview and laboratory testing to characterize TB-positive individuals. We compared these individuals to residents diagnosed with pulmonary TB at local health facilities and a representative sample of residents without TB (controls). RESULTS Of 12 032 residents with interpretable Ultra results, 113 (940 [95% confidence interval {CI}, 780-1130] per 100 000) tested positive, including 71 (63%) positive at the lowest (trace) level. A spectrum of TB disease was observed in terms of chronic cough (93% among health facility-diagnosed cases, 77% among residents with positive community-based Ultra results at levels above trace, 33% among trace-positive community participants, and 18% among TB-negative controls), TB symptom prevalence (99%, 87%, 60%, and 38%, respectively), and C-reactive protein (75th percentile: 101 mg/L, 28 mg/L, 6 mg/L, and 4 mg/L, respectively). Community-diagnosed cases were less likely than health facility-diagnosed cases to have human immunodeficiency virus coinfection or previous TB. The specificity of Ultra was 99.4% (95% CI, 99.2%-99.5%) relative to a single spot sputum culture. CONCLUSIONS People with undiagnosed prevalent TB in the community have different characteristics than those diagnosed with pulmonary TB in health facilities. Newer diagnostic tests may identify a group of people with early or very mild disease.
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Affiliation(s)
- Emily A Kendall
- Division of Infectious Diseases and Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.,Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Peter J Kitonsa
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Annet Nalutaaya
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - K Caleb Erisa
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - James Mukiibi
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Olga Nakasolya
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - David Isooba
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Yeonsoo Baik
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Katherine O Robsky
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Midori Kato-Maeda
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Adithya Cattamanchi
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda.,Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda.,Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David W Dowdy
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Rapid Tuberculosis Diagnosis Using Reporter Enzyme Fluorescence. J Clin Microbiol 2019; 57:JCM.01462-19. [PMID: 31511338 PMCID: PMC6879286 DOI: 10.1128/jcm.01462-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 09/06/2019] [Indexed: 12/20/2022] Open
Abstract
Tuberculosis is the most frequent cause of death in humans from a single infectious agent. Due to low numbers of bacteria present in sputum during early infection, diagnosis does not usually occur until >3 to 4 months after symptoms develop. We created a new more sensitive diagnostic that can be carried out in 10 min with no processing or technical expertise. Tuberculosis is the most frequent cause of death in humans from a single infectious agent. Due to low numbers of bacteria present in sputum during early infection, diagnosis does not usually occur until >3 to 4 months after symptoms develop. We created a new more sensitive diagnostic that can be carried out in 10 min with no processing or technical expertise. This assay utilizes the Mycobacterium tuberculosis-specific biomarker BlaC in reporter enzyme fluorescence (REF) that has been optimized for clinical samples, designated REFtb, along with a more specific fluorogenic substrate, CDG-3. We report the first evaluation of clinical specimens with REFtb assays in comparison to the gold standards for tuberculosis diagnosis, culture and smear microscopy. REFtb assays allowed diagnosis of 160 patients from 16 different countries with a sensitivity of 89% for smear-positive, culture-positive samples and 88% for smear-negative, culture-positive samples with a specificity of 82%. The negative predictive value of REFtb for tuberculosis infection is 93%, and the positive predictive value is 79%. Overall, these data point toward the need for larger accuracy studies by third parties using a commercially available REFtb kit to determine whether incorporation of REFtb into the clinical toolbox for suspected tuberculosis patients would improve case identification. If results similar to our own can be obtained by all diagnostic laboratories, REFtb would allow proper treatment of more than 85% of patients that would be missed during their initial visit to a clinic using current diagnostic strategies, reducing the potential for further spread of disease.
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