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Kay A, Vasiliu A, Carratala-Castro L, Mtafya B, Mendez Reyes JE, Maphalala N, Munguambe S, Mulengwa D, Ness T, Saavedra B, Bacha J, Maphalala G, Mejia R, Mtetwa G, Acacio S, Manjate P, Mambuque E, Shiba N, Kota N, Ziyane M, Ntinginya NE, Lange C, Kirchner HL, DiNardo AR, Garcia-Basteiro AL, Mandalakas AM. Performance of a stool-based quantitative PCR assay for the diagnosis of tuberculosis in adolescents and adults: a multinational, prospective diagnostic accuracy study. THE LANCET. MICROBE 2024; 5:e433-e441. [PMID: 38461830 PMCID: PMC11142891 DOI: 10.1016/s2666-5247(23)00391-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/23/2023] [Accepted: 11/21/2023] [Indexed: 03/12/2024]
Abstract
BACKGROUND Despite increasing availability of rapid molecular tests for the diagnosis of tuberculosis in high-burden settings, many people with tuberculosis are undiagnosed. Reliance on sputum as the primary specimen for tuberculosis diagnostics contributes to this diagnostic gap. We evaluated the diagnostic accuracy and additive yield of a novel stool quantitative PCR (qPCR) assay for the diagnosis of tuberculosis in three countries in Africa with high tuberculosis burdens. METHODS We undertook a prospective diagnostic accuracy study in Eswatini, Mozambique, and Tanzania from Sept 21, 2020, to Feb 2, 2023, to compare the diagnostic accuracy for tuberculosis of a novel stool qPCR test with the current diagnostic standard for Mycobacterium tuberculosis DNA detection from sputum and stool, Xpert-MTB/RIF Ultra (Xpert Ultra). Sputum, stool, and urine samples were provided by a cohort of participants, aged 10 years or older, diagnosed with tuberculosis. Participants with tuberculosis (cases) were enrolled within 72 h of treatment initiation for tuberculosis diagnosed clinically or following laboratory confirmation. Participants without tuberculosis (controls) consisted of household contacts of the cases who did not develop tuberculosis during a 6-month follow-up. The performance was compared with a robust composite microbiological reference standard (CMRS). FINDINGS The cohort of adolescents and adults (n=408) included 268 participants with confirmed or clinical tuberculosis (cases), 147 (55%) of whom were living with HIV, and 140 participants (controls) without tuberculosis. The sensitivity of the novel stool qPCR was 93·7% (95% CI 87·4-97·4) compared with participants with detectable growth on M tuberculosis culture, and 88·1% (81·3-93·0) compared with sputum Xpert Ultra. The stool qPCR had an equivalent sensitivity as sputum Xpert Ultra (94·8%, 89·1-98·1) compared with culture. Compared with the CMRS, the sensitivity of the stool qPCR was higher than the current standard for tuberculosis diagnostics on stool, Xpert Ultra (80·4%, 73·4-86·2 vs 73·5%, 66·0-80·1; p=0·025 on paired comparison). The qPCR also identified 17-21% additional tuberculosis cases compared to sputum Xpert Ultra or sputum culture. In controls without tuberculosis, the specificity of the stool qPCR was 96·9% (92·2-99·1). INTERPRETATION In this study, a novel qPCR for the diagnosis of tuberculosis from stool specimens had a higher accuracy in adolescents and adults than the current diagnostic PCR gold standard on stool, Xpert-MTB/RIF Ultra, and equivalent sensitivity to Xpert-MTB/RIF Ultra on sputum. FUNDING National Institutes of Health (NIH) Allergy and Infectious Diseases, and NIH Fogarty International Center.
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Affiliation(s)
- Alexander Kay
- Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA; Baylor College of Medicine Children's Foundation Eswatini, Mbabane, Eswatini.
| | - Anca Vasiliu
- Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Lucia Carratala-Castro
- Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Bariki Mtafya
- National Institute for Medical Research (NIMR)-Mbeya Medical Research Center, Mbeya, Tanzania
| | | | - Nontobeko Maphalala
- Baylor College of Medicine Children's Foundation Eswatini, Mbabane, Eswatini
| | - Shilzia Munguambe
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Durbbin Mulengwa
- Baylor College of Medicine Children's Foundation Eswatini, Mbabane, Eswatini
| | - Tara Ness
- Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Belen Saavedra
- Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Jason Bacha
- Baylor College of Medicine Children's Foundation Mbeya, Mbeya, Tanzania
| | | | - Rojelio Mejia
- Pediatric Tropical Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Godwin Mtetwa
- Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Sozinho Acacio
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Patricia Manjate
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Edson Mambuque
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Nosisa Shiba
- Baylor College of Medicine Children's Foundation Eswatini, Mbabane, Eswatini
| | - Nokwanda Kota
- Baylor College of Medicine Children's Foundation Eswatini, Mbabane, Eswatini
| | - Mangaliso Ziyane
- Baylor College of Medicine Children's Foundation Eswatini, Mbabane, Eswatini; Eswatini Health Laboratory Service, Mbabane, Eswatini
| | - Nyanda Elias Ntinginya
- National Institute for Medical Research (NIMR)-Mbeya Medical Research Center, Mbeya, Tanzania
| | - Christoph Lange
- Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA; Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany; Respiratory Medicine and International Health, University of Lübeck, Lübeck, Germany
| | - H Lester Kirchner
- Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA; Department of Population Health Sciences, Geisinger, Danville, PA, USA
| | - Andrew R DiNardo
- Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA; Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - Alberto L Garcia-Basteiro
- Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Barcelona, Spain
| | - Anna Maria Mandalakas
- Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA; Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany; Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health School of Public Health, Houston, TX, USA
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Pérez-Butragueño M, Ramos-Rincón JM, Tesfamariam A, Comeche B, Mohammed N, Tiziano G, Endirays J, Biru D, Elala T, Edri A, Prieto L, Górgolas M. Impact of Xpert MTB/RIF in the Diagnosis of Childhood Tuberculosis in Rural Ethiopia. J Trop Pediatr 2022; 68:6644981. [PMID: 35848941 DOI: 10.1093/tropej/fmac055] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND This study assesses the impact of the Xpert MTB/RIF in the diagnosis of childhood tuberculosis (TB) in a rural hospital in a resource-constrained setting. METHODS Retrospective cross-sectional study in children evaluated for presumptive TB from 1 June 2016 to 31 May 2017 at the Gambo General Hospital in rural Southern Ethiopia. Children were evaluated according to a defined protocol based on national guidelines. Samples were submitted for Xpert MTB/RIF assay to the nearest reference laboratory. RESULTS Of the 201 children assessed for presumptive TB, 46.3% (93/201) were diagnosed with TB. Of these, 49.5% (46/93) were microbiologically confirmed, mostly by Xpert MTB/RIF (only one patient was diagnosed by smear alone). The rest were clinically diagnosed. Microbiologically confirmed patients had a higher mean age, longer duration of fever and cough and lymphadenopathy more frequently than those clinically diagnosed. Gastric aspirates were Xpert MTB/RIF-positive in 18.2% of the samples (26/143); none were smear-positive (0/140). Sputum samples were Xpert MTB/RIF-positive in 27.1% (13/35) of the samples and smear-positive in 8.6% (3/35). There were no HIV-positive patients and just one case of rifampicin-resistant TB. A long delay (median 15 days) was detected in returning the results. CONCLUSION Xpert MTB/RIF serves as an important adjunctive test for diagnosing childhood TB in rural settings, with microbiological confirmation in up to half the TB cases. Processes need to be optimized to achieve an early diagnosis. The diagnosis of childhood TB in high-burden countries such as Ethiopia still relies largely upon diagnostic algorithms and the clinician's skills.Lay summaryWorld Health Organization recommends the use of Xpert MTB/RIF to improve the microbiological diagnosis of childhood tuberculosis (TB) since 2014, but the impact of this test under real conditions in rural areas of low-income countries is not clear. We conducted a cross-sectional study in children evaluated for presumptive TB from 1 June 2016 to 31 May 2017 at the Gambo General Hospital in rural Southern Ethiopia. Children were evaluated according to a clinical protocol based on national guidelines and samples were submitted for Xpert MTB/RIF assay to the nearest reference laboratory.Of the 201 children assessed, 46.3% (93/201) were diagnosed with tuberculosis. Of these, 48.4% (45/93) were microbiologically confirmed by Xpert MTB/RIF [smear microscopy only diagnosed the 5.4% (5/93)]. Patients with microbiologically confirmed tuberculosis had a higher mean age, longer duration of fever and cough and had lymphadenopathy more frequently than those clinically diagnosed. A long delay in returning the results (median 15 days) was detected. Xpert MTB/RIF serves as an important test for diagnosing childhood TB in rural settings, with microbiological confirmation in up to half the cases. Processes need to be optimized to achieve an early diagnosis. The diagnosis of childhood TB in high-burden countries still relies largely upon diagnostic algorithms and the clinician's skills.
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Affiliation(s)
- Mario Pérez-Butragueño
- Department of Medicine and Pediatrics, Gambo General Rural Hospital, Gambo, Ethiopia.,Department of Pediatrics, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - José-Manuel Ramos-Rincón
- Department of Medicine and Pediatrics, Gambo General Rural Hospital, Gambo, Ethiopia.,Department of Internal Medicine, Hospital Universitario General de Alicante-ISABIAL and Miguel Hernández University of Elche, Alicante, Spain
| | - Abraham Tesfamariam
- Department of Medicine and Pediatrics, Gambo General Rural Hospital, Gambo, Ethiopia
| | - Belén Comeche
- Department of Medicine and Pediatrics, Gambo General Rural Hospital, Gambo, Ethiopia.,National Referral Unit for Tropical Diseases, Infectious Diseases Department, Hospital Universitario Ramón y Cajal, IRICYS, Madrid, Spain
| | - Nurih Mohammed
- Department of Medicine and Pediatrics, Gambo General Rural Hospital, Gambo, Ethiopia
| | - Gebre Tiziano
- Department of Medicine and Pediatrics, Gambo General Rural Hospital, Gambo, Ethiopia
| | - Jacob Endirays
- Department of Medicine and Pediatrics, Gambo General Rural Hospital, Gambo, Ethiopia
| | - Dejene Biru
- Department of Medicine and Pediatrics, Gambo General Rural Hospital, Gambo, Ethiopia
| | - Tamasghen Elala
- Department of Medicine and Pediatrics, Gambo General Rural Hospital, Gambo, Ethiopia
| | - Abu Edri
- Department of Medicine and Pediatrics, Gambo General Rural Hospital, Gambo, Ethiopia
| | - Laura Prieto
- Department of Medicine and Pediatrics, Gambo General Rural Hospital, Gambo, Ethiopia.,Department of Internal Medicine, Division of Infectious Diseases, Hospital Universitario Fundación Jimenez Díaz, Autonomous University Madrid, Madrid, Spain
| | - Miguel Górgolas
- Department of Medicine and Pediatrics, Gambo General Rural Hospital, Gambo, Ethiopia.,Department of Internal Medicine, Division of Infectious Diseases, Hospital Universitario Fundación Jimenez Díaz, Autonomous University Madrid, Madrid, Spain
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Gunasekera KS, Vonasek B, Oliwa J, Triasih R, Lancioni C, Graham SM, Seddon JA, Marais BJ. Diagnostic Challenges in Childhood Pulmonary Tuberculosis-Optimizing the Clinical Approach. Pathogens 2022; 11:pathogens11040382. [PMID: 35456057 PMCID: PMC9032883 DOI: 10.3390/pathogens11040382] [Citation(s) in RCA: 2] [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: 12/17/2021] [Revised: 02/08/2022] [Accepted: 03/14/2022] [Indexed: 12/25/2022] Open
Abstract
The management of childhood tuberculosis (TB) is hampered by the low sensitivity and limited accessibility of microbiological testing. Optimizing clinical approaches is therefore critical to close the persistent gaps in TB case detection and prevention necessary to realize the child mortality targets of the End TB Strategy. In this review, we provide practical guidance summarizing the evidence and guidelines describing the use of symptoms and signs in decision making for children being evaluated for either TB preventive treatment (TPT) or TB disease treatment in high-TB incidence settings. Among at-risk children being evaluated for TPT, a symptom screen may be used to differentiate children who require further investigation for TB disease before receiving TPT. For symptomatic children being investigated for TB disease, an algorithmic approach can inform which children should receive TB treatment, even in the absence of imaging or microbiological confirmation. Though clinical approaches have limitations in accuracy, they are readily available and can provide valuable guidance for decision making in resource-limited settings to increase treatment access. We discuss the trade-offs in using them to make TB treatment decisions.
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Affiliation(s)
- Kenneth S. Gunasekera
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT 06510, USA
- Correspondence:
| | - Bryan Vonasek
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI 53726, USA;
| | - Jacquie Oliwa
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi P.O. Box 43640-00100, Kenya;
- Department of Paediatrics and Child Health, School of Medicine, University of Nairobi, Nairobi P.O. Box 30197-00100, Kenya
| | - Rina Triasih
- Department of Pediatrics, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta 55284, Indonesia;
| | - Christina Lancioni
- Department of Pediatrics, School of Medicine, Oregon Health and Science University, Portland, OR 97239, USA;
| | - Stephen M. Graham
- Centre for International Child Health, University of Melbourne and Murdoch Children’s Research Institute, Royal Children’s Hospital, Melbourne, VIC 3052, Australia;
- Burnet Institute, Melbourne, VIC 3004, Australia
| | - James A. Seddon
- Department of Infectious Diseases, Imperial College London, London W2 1PG, UK;
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town 8000, South Africa
| | - Ben J. Marais
- University of Sydney and The Children’s Hospital at Westmead, Sydney, NSW 2145, Australia;
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Diagnostic Advances in Childhood Tuberculosis—Improving Specimen Collection and Yield of Microbiological Diagnosis for Intrathoracic Tuberculosis. Pathogens 2022; 11:pathogens11040389. [PMID: 35456064 PMCID: PMC9025862 DOI: 10.3390/pathogens11040389] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/17/2022] [Accepted: 03/18/2022] [Indexed: 01/26/2023] Open
Abstract
There is no microbiological gold standard for childhood tuberculosis (TB) diagnosis. The paucibacillary nature of the disease, challenges in sample collection in young children, and the limitations of currently available microbiological tests restrict microbiological confirmation of intrathoracic TB to the minority of children. Recent WHO guidelines recommend the use of novel rapid molecular assays as initial diagnostic tests for TB and endorse alternative sample collection methods for children. However, the uptake of these tools in high-endemic settings remains low. In this review, we appraise historic and new microbiological tests and sample collection techniques that can be used for the diagnosis of intrathoracic TB in children. We explore challenges and possible ways to improve diagnostic yield despite limitations, and identify research gaps to address in order to improve the microbiological diagnosis of intrathoracic TB in children.
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Gunasekera KS, Walters E, van der Zalm MM, Palmer M, Warren JL, Hesseling AC, Cohen T, Seddon JA. Development of a Treatment-decision Algorithm for Human Immunodeficiency Virus-uninfected Children Evaluated for Pulmonary Tuberculosis. Clin Infect Dis 2021; 73:e904-e912. [PMID: 33449999 PMCID: PMC8366829 DOI: 10.1093/cid/ciab018] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Limitations in the sensitivity and accessibility of diagnostic tools for childhood tuberculosis contribute to the substantial gap between estimated cases and cases notified to national tuberculosis programs. Thus, tools to make accurate and rapid clinical diagnoses are necessary to initiate antituberculosis treatment in more children. METHODS We analyzed data from a prospective cohort of children <13 years old being routinely evaluated for pulmonary tuberculosis in Cape Town, South Africa, from March 2012 to November 2017. We developed a regression model to describe the contributions of baseline clinical evaluation to the diagnosis of tuberculosis using standardized, retrospective case definitions. We included baseline chest radiographic and Xpert MTB/RIF assay results to the model to develop an algorithm with ≥90% sensitivity in predicting tuberculosis. RESULTS Data from 478 children being evaluated for pulmonary tuberculosis were analyzed (median age, 16.2 months; interquartile range, 9.8-30.9 months); 242 (50.6%) were retrospectively classified with tuberculosis, bacteriologically confirmed in 104 (43.0%). The area under the receiver operating characteristic curve for the final model was 0.87. Clinical evidence identified 71.4% of all tuberculosis cases in this cohort, and inclusion of baseline chest radiographic results increased the proportion to 89.3%. The algorithm was 90.1% sensitive and 52.1% specific, and maintained a sensitivity of >90% among children <2 years old or with low weight for age. CONCLUSIONS Clinical evidence alone was sufficient to make most clinical antituberculosis treatment decisions. The use of evidence-based algorithms may improve decentralized, rapid treatment initiation, reducing the global burden of childhood mortality.
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Affiliation(s)
- Kenneth S Gunasekera
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Elisabetta Walters
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Marieke M van der Zalm
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Megan Palmer
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Joshua L Warren
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Anneke C Hesseling
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - James A Seddon
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
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Jaganath D, Wambi P, Reza TF, Nakafeero J, Aben EO, Kiconco E, Nannyonga G, Nsereko M, Sekadde MP, Mudiope M, Kato-Maeda M, Starke J, Andama A, Mohanty S, Wobudeya E, Cattamanchi A. A Prospective Evaluation of Xpert MTB/RIF Ultra for Childhood Pulmonary Tuberculosis in Uganda. J Pediatric Infect Dis Soc 2021; 10:586-592. [PMID: 33416072 PMCID: PMC8163061 DOI: 10.1093/jpids/piaa159] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/01/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Xpert MTB/RIF Ultra (Xpert Ultra) has improved the sensitivity to detect pulmonary tuberculosis (TB) in adults. However, there have been limited prospective evaluations of its diagnostic accuracy in children. METHODS We enrolled children undergoing assessment for pulmonary TB in Kampala, Uganda, over a 12-month period. Children received a complete TB evaluation and were classified as Confirmed, Unconfirmed, or Unlikely TB. We calculated the sensitivity and specificity of Xpert Ultra among children with Confirmed vs Unlikely TB. We also determined the diagnostic accuracy with clinical, microbiological, and extended microbiological reference standards (MRSs). RESULTS Of the 213 children included, 23 (10.8%) had Confirmed TB, 88 (41.3%) had Unconfirmed TB, and 102 (47.9%) had Unlikely TB. The median age was 3.9 years, 13% were HIV-positive, and 61.5% were underweight. Xpert Ultra sensitivity was 69.6% (95% confidence interval [CI]: 47.1-86.8) among children with Confirmed TB and decreased to 23.4% (95% CI: 15.9-32.4) with the clinical reference standard. Specificity was 100% (95% CI: 96.4-100) among children with Unlikely TB and decreased to 94.7% (95% CI: 90.5-97.4) with a MRS. Sensitivity was 52.9% (95% CI: 35.1-70.2) and specificity 95.5% (95% CI: 91.4-98.1) with the extended MRS. Of the 26 positive Xpert Ultra results, 6 (23.1%) were "Trace-positive," with most (5/6) occurring in children with Unconfirmed TB. CONCLUSIONS Xpert Ultra is a useful tool for diagnosing pulmonary TB in children, but there remains a need for more sensitive tests to detect culture-negative TB.
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Affiliation(s)
- Devan Jaganath
- Division of Pediatric Infectious Diseases, University of California–San Francisco, San Francisco, California, USA,Division of Pulmonary and Critical Care Medicine, University of California–San Francisco, San Francisco, California, USA,Center for Tuberculosis, University of California–San Francisco, San Francisco, California, USA,Corresponding Author: Devan Jaganath, MD, MPH, Division of Pediatric Infectious Diseases, University of California, 550 16th St., 4th Floor, San Francisco, CA, USA. E-mail:
| | - Peter Wambi
- Mulago National Referral Hospital, Kampala, Uganda
| | - Tania F Reza
- Division of Pulmonary and Critical Care Medicine, University of California–San Francisco, San Francisco, California, USA,Center for Tuberculosis, University of California–San Francisco, San Francisco, California, USA
| | | | | | - Emma Kiconco
- Mulago National Referral Hospital, Kampala, Uganda
| | | | | | - Moorine P Sekadde
- National TB and Leprosy Program, Ministry of Health, Kampala, Uganda
| | | | - Midori Kato-Maeda
- Division of Pulmonary and Critical Care Medicine, University of California–San Francisco, San Francisco, California, USA,Center for Tuberculosis, University of California–San Francisco, San Francisco, California, USA
| | - Jeffrey Starke
- Division of Pediatric Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Alfred Andama
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Swomitra Mohanty
- Departments of Chemical Engineering and Materials Science Engineering, University of Utah, Salt Lake City, Utah, USA
| | | | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, University of California–San Francisco, San Francisco, California, USA,Center for Tuberculosis, University of California–San Francisco, San Francisco, California, USA,Department of Medicine, Center for Vulnerable Populations, University of California–San Francisco, San Francisco, California, USA
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7
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Sandoval M, Swamy P, Kay AW, Alonso PU, Dube GS, Hlophe-Dlamini H, Mandalakas AM. Distinct Risk Factors for Clinical and Bacteriologically Confirmed Tuberculosis among Child Household Contacts in a High-Burden Setting. Am J Trop Med Hyg 2020; 103:2506-2509. [PMID: 32996456 DOI: 10.4269/ajtmh.20-0522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The identification and screening of children at high risk of tuberculosis is essential to the control and prevention of child tuberculosis (TB). BUTIMBA, an active case finding and household contact-tracing project implemented between 2013 and 2015 in Eswatini, evaluated 5,413 contacts of 1,568 index cases, of whom 82 (1.5%) were diagnosed with TB disease. We conducted univariate and multivariate clustered logistic regression analyses of risk factors for any TB diagnosis among child household contacts of TB cases. Children younger than 5 years and children with positive HIV status were more likely to have TB than children aged 5-14 years and children with negative HIV status, respectively (adjusted odds ratio [aOR]: 2.2, P < 0.001; aOR: 5.0, P < 0.001). Children with one or more TB symptoms were more likely to be diagnosed with TB based on clinical criteria, but less likely to have bacteriologically confirmed TB, highlighting subjectivity in determination of child TB.
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Affiliation(s)
- Micaela Sandoval
- The Global Tuberculosis Program, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas.,UTHealth School of Public Health, Houston, Texas
| | - Padma Swamy
- The Global Tuberculosis Program, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Alexander W Kay
- Baylor College of Medicine Children's Foundation-Swaziland, Mbabane, Eswatini.,The Global Tuberculosis Program, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Pilar Ustero Alonso
- Baylor College of Medicine Children's Foundation-Swaziland, Mbabane, Eswatini.,The Global Tuberculosis Program, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Gloria Sisi Dube
- Eswatini National Tuberculosis Control Program, Manzini, Eswatini
| | | | - Anna M Mandalakas
- The Global Tuberculosis Program, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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8
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Costa-Lima JFD, Pimentel LMLM, Santos FCF, Salazar MP, Duarte RS, Mello FCDQ, Schindler HC. Rapid detection of Mycobacterium tuberculosis in children using blood and urine specimens. Rev Soc Bras Med Trop 2020; 53:e20200051. [PMID: 32997049 PMCID: PMC7523525 DOI: 10.1590/0037-8682-0051-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/17/2020] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Laboratory and clinical features of childhood tuberculosis (TB) are non-specific and establishing an accurate diagnosis remains a challenge. This study evaluated a Single tube nested-PCR (STNPCR) to detect genomic DNA of Mycobacterium tuberculosis complex in blood and urine. METHODS Biological samples were obtained from children (<15 years old) with clinical suspicion of pulmonary and extrapulmonary TB at public hospitals in Recife-Pernambuco, Brazil. Cultures yielded negative results in a majority of childhood TB cases, which are generally paucibacillary. A set of clinical, epidemiological, radiological, and laboratory criteria with evident clinical improvement after anti-TB treatment were frequently used to define childhood TB cases. RESULTS Ninety children with clinical suspicion were enrolled in this study (44 with TB and 46 without TB). The pulmonary TB group had 20 confirmed cases and 46 negative controls, while the extrapulmonary TB group had 24 confirmed cases. The STNPCR showed sensitivities to pulmonary and extrapulmonary TB of 47.4% and 52.2% (blood) and 38.8% and 20% (urine), respectively. Considering the low performance of STNPCR on separate samples, we decided to perform a combined analysis (parallel sensitivity analysis) of the results from blood and urine samples. The parallel sensitivity increased to 65% in blood and 62.5% in urine. The specificity in both samples ranged from 93.5-97.8%. CONCLUSIONS Although STNPCR showed moderate sensitivity, the specificity is high; therefore, the test can be used as an auxiliary tool to diagnose TB in children. It is a rapid test that demonstrated better performance than other diagnostic tests in paucibacillary samples as it does in childhood tuberculosis.
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Affiliation(s)
- Juliana Figueirêdo da Costa-Lima
- Instituto Aggeu Magalhães/Fundação Oswaldo Cruz, Laboratório de Imunoepidemiologia, Departamento de Imunologia, Recife, PE, Brasil
- Universidade Federal do Rio de Janeiro, Programa de Pós-Graduação Stricto Sensu em Clínica Médica, Rio de Janeiro, RJ, Brasil
| | | | - Fabiana Cristina Fulco Santos
- Instituto Aggeu Magalhães/Fundação Oswaldo Cruz, Laboratório de Imunoepidemiologia, Departamento de Imunologia, Recife, PE, Brasil
| | - Marcela Pereira Salazar
- Instituto Aggeu Magalhães/Fundação Oswaldo Cruz, Laboratório de Imunoepidemiologia, Departamento de Imunologia, Recife, PE, Brasil
| | - Rafael Silva Duarte
- Universidade Federal do Rio de Janeiro, Instituto de Microbiologia Paulo Góes, Laboratório de Micobactérias, Rio de Janeiro, RJ, Brasil
| | - Fernanda Carvalho de Queiroz Mello
- Universidade Federal do Rio de Janeiro, Instituto de Doenças do Tórax, Faculdade de Medicina, Rio de Janeiro, RJ, Brasil
- Universidade Federal do Rio de Janeiro, Programa de Pós-Graduação Stricto Sensu em Clínica Médica, Rio de Janeiro, RJ, Brasil
| | - Haiana Charifker Schindler
- Instituto Aggeu Magalhães/Fundação Oswaldo Cruz, Laboratório de Imunoepidemiologia, Departamento de Imunologia, Recife, PE, Brasil
- Universidade Federal de Pernambuco, Hospital das Clínicas, Departamento Materno Infantil, Recife, PE, Brasil
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9
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Agashe VM, Johari AN, Shah M, Anjum R, Romano C, Drago L, Sharma HK, Benzakour T. Diagnosis of Osteoarticular Tuberculosis: Perceptions, Protocols, Practices, and Priorities in the Endemic and Non-Endemic Areas of the World-A WAIOT View. Microorganisms 2020; 8:microorganisms8091312. [PMID: 32872175 PMCID: PMC7563388 DOI: 10.3390/microorganisms8091312] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/18/2020] [Accepted: 08/23/2020] [Indexed: 02/07/2023] Open
Abstract
There has been a major resurgence of tuberculosis (TB) and drug-resistant tuberculosis in the last few decades. Although it has been brought under control in most Western countries, it is still a major cause of death in endemic regions like India. Osteoarticular tuberculosis (OA TB) forms a small proportion of the total cases of tuberculosis. Perceptions and practices of orthopedic surgeons are entirely different in endemic and non-endemic regions around the world, due to the vast difference in exposure. Literature from endemic areas puts stress on clinico-radiological diagnosis and empirical anti-tubercular treatment (ATT). Such practices, although non-invasive, simple to implement, and economical, carry a significant risk of missing TB mimics and developing drug resistance. However, OA TB is still perceived as a “diagnostic enigma” in non-endemic regions, leading to a delay in diagnosis. Hence, a high index of suspicion, especially in a high-risk population, is needed to improve the diagnosis. Evolving drug resistance continues to thwart efforts to control the disease globally. This review article discusses the perceptions and practices in different parts of the world, with India as an example of the endemic world, and lays down priorities for overcoming the challenges of diagnosing osteoarticular TB.
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Affiliation(s)
| | - Ashok N. Johari
- ENABLE International Centre for Paediatric Musculoskeletal Care, Mumbai 400016, India;
| | - Mudit Shah
- Dr. Agashe’s Maternity and Surgical Nursing Home, 116 Bazar ward, MN, Road Kurla, Mumbai 400070, India;
| | - Rashid Anjum
- Department of Orthopaedics, ASCOMS and Hospital, J and K, Jammu 180017, India
- Correspondence:
| | - Carlo Romano
- Studio Medico Associato Cecca-Romanò, 20121 Milano, Italy;
| | - Lorenzo Drago
- Clinical Microbiology, University of Milan, 20100 Milan, Italy;
| | - Hemant K. Sharma
- Hull University Teaching Hospitals, Anlaby Road, Hull HU3 2JZ, UK;
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Kay AW, González Fernández L, Takwoingi Y, Eisenhut M, Detjen AK, Steingart KR, Mandalakas AM. Xpert MTB/RIF and Xpert MTB/RIF Ultra assays for active tuberculosis and rifampicin resistance in children. Cochrane Database Syst Rev 2020; 8:CD013359. [PMID: 32853411 PMCID: PMC8078611 DOI: 10.1002/14651858.cd013359.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Every year, at least one million children become ill with tuberculosis and around 200,000 children die. Xpert MTB/RIF and Xpert Ultra are World Health Organization (WHO)-recommended rapid molecular tests that simultaneously detect tuberculosis and rifampicin resistance in adults and children with signs and symptoms of tuberculosis, at lower health system levels. To inform updated WHO guidelines on molecular assays, we performed a systematic review on the diagnostic accuracy of these tests in children presumed to have active tuberculosis. OBJECTIVES Primary objectives • To determine the diagnostic accuracy of Xpert MTB/RIF and Xpert Ultra for (a) pulmonary tuberculosis in children presumed to have tuberculosis; (b) tuberculous meningitis in children presumed to have tuberculosis; (c) lymph node tuberculosis in children presumed to have tuberculosis; and (d) rifampicin resistance in children presumed to have tuberculosis - For tuberculosis detection, index tests were used as the initial test, replacing standard practice (i.e. smear microscopy or culture) - For detection of rifampicin resistance, index tests replaced culture-based drug susceptibility testing as the initial test Secondary objectives • To compare the accuracy of Xpert MTB/RIF and Xpert Ultra for each of the four target conditions • To investigate potential sources of heterogeneity in accuracy estimates - For tuberculosis detection, we considered age, disease severity, smear-test status, HIV status, clinical setting, specimen type, high tuberculosis burden, and high tuberculosis/HIV burden - For detection of rifampicin resistance, we considered multi-drug-resistant tuberculosis burden • To compare multiple Xpert MTB/RIF or Xpert Ultra results (repeated testing) with the initial Xpert MTB/RIF or Xpert Ultra result SEARCH METHODS: We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, Science Citation Index, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and the International Standard Randomized Controlled Trials Number (ISRCTN) Registry up to 29 April 2019, without language restrictions. SELECTION CRITERIA Randomized trials, cross-sectional trials, and cohort studies evaluating Xpert MTB/RIF or Xpert Ultra in HIV-positive and HIV-negative children younger than 15 years. Reference standards comprised culture or a composite reference standard for tuberculosis and drug susceptibility testing or MTBDRplus (molecular assay for detection of Mycobacterium tuberculosis and drug resistance) for rifampicin resistance. We included studies evaluating sputum, gastric aspirate, stool, nasopharyngeal or bronchial lavage specimens (pulmonary tuberculosis), cerebrospinal fluid (tuberculous meningitis), fine needle aspirates, or surgical biopsy tissue (lymph node tuberculosis). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality using the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2). For each target condition, we used the bivariate model to estimate pooled sensitivity and specificity with 95% confidence intervals (CIs). We stratified all analyses by type of reference standard. We assessed certainty of evidence using the GRADE approach. MAIN RESULTS For pulmonary tuberculosis, 299 data sets (68,544 participants) were available for analysis; for tuberculous meningitis, 10 data sets (423 participants) were available; for lymph node tuberculosis, 10 data sets (318 participants) were available; and for rifampicin resistance, 14 data sets (326 participants) were available. Thirty-nine studies (80%) took place in countries with high tuberculosis burden. Risk of bias was low except for the reference standard domain, for which risk of bias was unclear because many studies collected only one specimen for culture. Detection of pulmonary tuberculosis For sputum specimens, Xpert MTB/RIF pooled sensitivity (95% CI) and specificity (95% CI) verified by culture were 64.6% (55.3% to 72.9%) (23 studies, 493 participants; moderate-certainty evidence) and 99.0% (98.1% to 99.5%) (23 studies, 6119 participants; moderate-certainty evidence). For other specimen types (nasopharyngeal aspirate, 4 studies; gastric aspirate, 14 studies; stool, 11 studies), Xpert MTB/RIF pooled sensitivity ranged between 45.7% and 73.0%, and pooled specificity ranged between 98.1% and 99.6%. For sputum specimens, Xpert Ultra pooled sensitivity (95% CI) and specificity (95% CI) verified by culture were 72.8% (64.7% to 79.6%) (3 studies, 136 participants; low-certainty evidence) and 97.5% (95.8% to 98.5%) (3 studies, 551 participants; high-certainty evidence). For nasopharyngeal specimens, Xpert Ultra sensitivity (95% CI) and specificity (95% CI) were 45.7% (28.9% to 63.3%) and 97.5% (93.7% to 99.3%) (1 study, 195 participants). For all specimen types, Xpert MTB/RIF and Xpert Ultra sensitivity were lower against a composite reference standard than against culture. Detection of tuberculous meningitis For cerebrospinal fluid, Xpert MTB/RIF pooled sensitivity and specificity, verified by culture, were 54.0% (95% CI 27.8% to 78.2%) (6 studies, 28 participants; very low-certainty evidence) and 93.8% (95% CI 84.5% to 97.6%) (6 studies, 213 participants; low-certainty evidence). Detection of lymph node tuberculosis For lymph node aspirates or biopsies, Xpert MTB/RIF pooled sensitivity and specificity, verified by culture, were 90.4% (95% CI 55.7% to 98.6%) (6 studies, 68 participants; very low-certainty evidence) and 89.8% (95% CI 71.5% to 96.8%) (6 studies, 142 participants; low-certainty evidence). Detection of rifampicin resistance Xpert MTB/RIF pooled sensitivity and specificity were 90.0% (67.6% to 97.5%) (6 studies, 20 participants; low-certainty evidence) and 98.3% (87.7% to 99.8%) (6 studies, 203 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS We found Xpert MTB/RIF sensitivity to vary by specimen type, with gastric aspirate specimens having the highest sensitivity followed by sputum and stool, and nasopharyngeal specimens the lowest; specificity in all specimens was > 98%. Compared with Xpert MTB/RIF, Xpert Ultra sensitivity in sputum was higher and specificity slightly lower. Xpert MTB/RIF was accurate for detection of rifampicin resistance. Xpert MTB/RIF was sensitive for diagnosing lymph node tuberculosis. For children with presumed tuberculous meningitis, treatment decisions should be based on the entirety of clinical information and treatment should not be withheld based solely on an Xpert MTB/RIF result. The small numbers of studies and participants, particularly for Xpert Ultra, limits our confidence in the precision of these estimates.
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MESH Headings
- Adolescent
- Antibiotics, Antitubercular/therapeutic use
- Bias
- Child
- Feces/microbiology
- Gastrointestinal Contents/microbiology
- Humans
- Molecular Typing/methods
- Molecular Typing/standards
- Mycobacterium tuberculosis/drug effects
- Mycobacterium tuberculosis/isolation & purification
- Rifampin/therapeutic use
- Sensitivity and Specificity
- Sputum/microbiology
- Tuberculosis, Lymph Node/diagnosis
- Tuberculosis, Lymph Node/drug therapy
- Tuberculosis, Lymph Node/microbiology
- Tuberculosis, Meningeal/cerebrospinal fluid
- Tuberculosis, Meningeal/diagnosis
- Tuberculosis, Meningeal/drug therapy
- Tuberculosis, Meningeal/microbiology
- Tuberculosis, Multidrug-Resistant/diagnosis
- Tuberculosis, Multidrug-Resistant/drug therapy
- Tuberculosis, Multidrug-Resistant/microbiology
- Tuberculosis, Pulmonary/diagnosis
- Tuberculosis, Pulmonary/drug therapy
- Tuberculosis, Pulmonary/microbiology
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Affiliation(s)
- Alexander W Kay
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Michael Eisenhut
- Paediatric Department, Luton & Dunstable University Hospital NHS Foundation Trust, Luton, UK
| | | | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Anna M Mandalakas
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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11
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Togun T, Hoggart CJ, Agbla SC, Gomez MP, Egere U, Sillah AK, Saidy B, Mendy F, Pai M, Kampmann B. A three-marker protein biosignature distinguishes tuberculosis from other respiratory diseases in Gambian children. EBioMedicine 2020; 58:102909. [PMID: 32711253 PMCID: PMC7381493 DOI: 10.1016/j.ebiom.2020.102909] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/02/2020] [Accepted: 07/08/2020] [Indexed: 01/30/2023] Open
Abstract
Background Our study aimed to identify a host cytokine biosignature that could distinguish childhood tuberculosis (TB) from other respiratory diseases (OD). Methods Cytokine responses in prospectively recruited children with symptoms suggestive of TB were measured in whole blood assay supernatants, harvested after overnight incubation, using a Luminex platform. We used logistic regression models with Least Absolute Shrinkage and Selection Operator (LASSO) penalty to identify the optimal biosignature associated with confirmed TB disease in the training set. We subsequently assessed its performance in the test set. Findings Of the 431 children included in the study, 44 had bacteriologically confirmed TB, 60 had clinically diagnosed TB while 327 had OD. All children were HIV-negative. Application of LASSO regression models to the training set (n = 260) resulted in the combination of IL-1ra, IL-7 and IP-10 from unstimulated samples as the optimally discriminant cytokine biosignature associated with bacteriologically confirmed TB. In the test set (n = 171), this biosignature distinguished children diagnosed with TB disease, irrespective of microbiological confirmation, from OD with area under the receiver operator characteristic curve (AUC) of 0•74 (95% CI: 0•67, 0•81), and demonstrated sensitivity and specificity of 72•2% (95% CI: 60•4, 82•1%) and 75•0% (95% CI: 64•9, 83•4%) respectively, with its performance independent of their age group and their age- and sex-adjusted nutritional status. Interpretation This novel biosignature of childhood TB derived from unstimulated supernatants is promising. Independent validation with further optimisation will improve its performance and translational potential. Funding Steinberg Fellowship (McGill University); Grand Challenges Canada; MRC Program Grant.
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Affiliation(s)
- Toyin Togun
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Atlantic Boulevard, Fajara, The Gambia; The Vaccine Centre, and Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom.
| | - Clive J Hoggart
- Section of Paediatrics, Imperial College London, St Mary's Campus, London, United Kingdom; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Schadrac C Agbla
- Department of Health Data Sciences, University of Liverpool, Liverpool, United Kingdom; Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom
| | - Marie P Gomez
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Atlantic Boulevard, Fajara, The Gambia
| | - Uzochukwu Egere
- Community Health Systems Group, Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Abdou K Sillah
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Atlantic Boulevard, Fajara, The Gambia
| | - Binta Saidy
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Atlantic Boulevard, Fajara, The Gambia
| | - Francis Mendy
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Atlantic Boulevard, Fajara, The Gambia
| | - Madhukar Pai
- McGill International TB Centre, and Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Quebec, Canada; Manipal-McGill Centre for Infectious Diseases, Manipal University, Manipal, India
| | - Beate Kampmann
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Atlantic Boulevard, Fajara, The Gambia; The Vaccine Centre, and Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom.
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12
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Amanullah F, Bacha JM, Fernandez LG, Mandalakas AM. Quality matters: Redefining child TB care with an emphasis on quality. J Clin Tuberc Other Mycobact Dis 2019; 17:100130. [PMID: 31788571 PMCID: PMC6880125 DOI: 10.1016/j.jctube.2019.100130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Children have been neglected in the fight against tuberculosis (TB) for decades. Despite being the number one infectious disease killer, TB does not feature on the child survival agendas partly due to absent and inaccurate data. Quality is a missing ingredient in TB care in children, yet high rates of unfavorable TB outcomes highlight its importance in this age group. Quality care is particularly important for TB affected children in the absence of a point of care sensitive and specific diagnostic test. Using the current models of child TB care, it will take another 200 years to end TB. Without focusing on the quality of child TB care, the ambitious country specific United Nations High Level Meeting for TB targets will carry minimal impact. High TB burden countries must also adopt Universal Health Care (UHC) and ensure that quality TB care is made free and equitable for all children, adolescents and their affected families. We advocate for the importance of evaluating the quality of child TB care, and provide a basic framework for quality in child TB with special attention given to creating differentiated service delivery models for children and families affected by TB.
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Affiliation(s)
- Farhana Amanullah
- The Indus Hospital, Department of Pediatrics, Korangi Crossing, 4th Floor IHRC, Karachi, Pakistan
- Interactive Research and Development, Pakistan
- Corresponding author.
| | - Jason Michael Bacha
- Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, TX, United States
- Baylor College of Medicine Children's Foundation-Tanzania, Mbeya, Tanzania
- The Global Tuberculosis Program, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Lucia Gonzalez Fernandez
- The Global Tuberculosis Program, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
- The International AIDS Society. Geneva. Switzerland
| | - Anna Maria Mandalakas
- The Global Tuberculosis Program, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
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13
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Hotez PJ, Odom John AR, LaBeaud AD. Pediatric tropical medicine: The neglected diseases of children. PLoS Negl Trop Dis 2019; 13:e0007008. [PMID: 31071087 PMCID: PMC6508612 DOI: 10.1371/journal.pntd.0007008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Peter J. Hotez
- Texas Children’s Hospital Center for Vaccine Development, Departments of Pediatrics and Molecular Virology and Microbiology, National School of Tropical Medicine, Baylor College of Medicine, Houston, Texas, United States of America
- Department of Biology, Baylor University, Waco, Texas, United States of America
- * E-mail: (PJH); (AROJ); (ADL)
| | - Audrey R. Odom John
- Departments of Pediatrics and Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri, United States of America
- * E-mail: (PJH); (AROJ); (ADL)
| | - A. Desiree LaBeaud
- Department of Pediatrics, Division of Infectious Diseases, Stanford University, Stanford, California, United States of America
- * E-mail: (PJH); (AROJ); (ADL)
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14
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Hanrahan CF, Dansey H, Mutunga L, France H, Omar SV, Ismail N, Bassett J, Van Rie A. Diagnostic strategies for childhood tuberculosis in the context of primary care in a high burden setting: the value of alternative sampling methods. Paediatr Int Child Health 2019; 39:88-94. [PMID: 30378470 DOI: 10.1080/20469047.2018.1533321] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Background: Hospital studies have demonstrated the usefulness of alternative sampling strategies to expectorated sputum and new diagnostics for the diagnosis of childhood tuberculosis (TB) but there is limited evidence of how these approaches work in the primary-care setting. Aim: To assess the feasibility and yield of a variety of sample types and diagnostic tests for childhood TB at a primary-care clinic. Methods: A prospective cohort of children (<10 years) with signs and symptoms of TB was enrolled at a primary-care clinic in Johannesburg, South Africa. Tuberculin skin testing (TST) and chest X-ray (CXR) were performed in all. In those unable to expectorate, one induced sputum (IS), one ambulatory gastric aspirate (GA) and two nasopharyngeal aspirates (NPA) were collected. Stool was collected from all. Samples were processed for smear microscopy, liquid culture and Xpert MTB/RIF. The Determine TB LAM Ag (LAM) test was used for HIV-positive children. Results: From July 2013-December 2014, 119 children were enrolled, 21 (18%) of whom were HIV-positive. TST was positive in 25/105 (24%) and 70/116 (70%) had a positive CXR. Four (3%) had confirmed TB, 101 (85%) unconfirmed TB and 15 (13%) unlikely TB. Of the 469 samples collected, smear microscopy was positive in none, Xpert was positive in four (<1%) and culture was positive in two (<1%). Three of 11 (27%) HIV-positive patients were positive by LAM. Treatment was commenced in 48/119 (40%). Conclusions: At primary-care, alternative sampling strategies proved feasible but resulted in a low diagnostic yield. Extensive efforts to bacteriologically diagnose children did not contribute to clinical management.
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Affiliation(s)
- Colleen F Hanrahan
- a Department of Epidemiology , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Heather Dansey
- b Witkoppen Health and Welfare Centre , Gauteng , South Africa
| | - Lillian Mutunga
- b Witkoppen Health and Welfare Centre , Gauteng , South Africa
| | - Holly France
- b Witkoppen Health and Welfare Centre , Gauteng , South Africa
| | - Shaheed V Omar
- c Centre for Tuberculosis, National Institute for Communicable Diseases , National Health Laboratory Service , Johannesburg , South Africa
| | - Nazir Ismail
- c Centre for Tuberculosis, National Institute for Communicable Diseases , National Health Laboratory Service , Johannesburg , South Africa
| | - Jean Bassett
- b Witkoppen Health and Welfare Centre , Gauteng , South Africa
| | - Annelies Van Rie
- d Department of Epidemiology and Social Medicine , University of Antwerp , Antwerp , Belgium
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15
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Rebecca B, Chacko A, Verghese V, Rose W. Spectrum of Pediatric Tuberculosis in a Tertiary Care Setting in South India. J Trop Pediatr 2018; 64:544-547. [PMID: 29447374 DOI: 10.1093/tropej/fmy007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Pediatric tuberculosis (TB) is often underdiagnosed with poor estimate of its true burden. Availability of Xpert MTB/RIF assay enhances diagnostic capacity of pediatric TB. METHODS A 3-year retrospective review of hospital records was done for all children diagnosed with confirmed and unconfirmed TB. Comparison was made between intrathoracic, single-site extrathoracic and disseminated TB. RESULTS In total, 274 children had TB with 130 (47.4%) having confirmed TB. Pulmonary (23.4%), lymph node (23%) and central nervous system (12.8%) TB were the three commonest forms. HIV TB coinfection was 2.9%. Mycobacterial culture was positive in 90 (32.8%) and XPert MTB/RIF in 85 patients (31%). Mycobacterial confirmation was obtained in 45 (56.3%) intrathoracic TB, 69 (45.4%) extrathoracic TB and 16 (38.1%) disseminated TB. Correlation between positive Xpert and mycobacterial culture was poor (kappa 0.38). Rifampicin resistance was present in 25 (19.2%) of the 130 microbiologically confirmed TB. CONCLUSION Extrathoracic TB is common in children. Mycobacterial confirmation in pediatric TB is improved with use of Xpert.
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Affiliation(s)
- Betsy Rebecca
- Department of Pediatrics, Christian Medical College, Vellore, 632004, India
| | - Anila Chacko
- Department of Pediatrics, Christian Medical College, Vellore, 632004, India
| | - Valsan Verghese
- Department of Pediatrics, Christian Medical College, Vellore, 632004, India
| | - Winsley Rose
- Department of Pediatrics, Christian Medical College, Vellore, 632004, India
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16
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Ollier V, Antoun F, Thouvenin G, Faye A, Kone-Paut I, Benoist G, Antoine D, Charlois C, Delacourt C. Potentially preventable tuberculosis cases in children exposed to a contaminant case. Arch Pediatr 2018; 25:421-425. [DOI: 10.1016/j.arcped.2018.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 06/11/2018] [Accepted: 07/23/2018] [Indexed: 11/16/2022]
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17
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Sali M, Buonsenso D, D'Alfonso P, De Maio F, Ceccarelli M, Battah B, Palucci I, Chiacchio T, Goletti D, Sanguinetti M, Valentini P, Delogu G. Combined use of Quantiferon and HBHA-based IGRA supports tuberculosis diagnosis and therapy management in children. J Infect 2018; 77:526-533. [PMID: 30267797 DOI: 10.1016/j.jinf.2018.09.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 09/06/2018] [Accepted: 09/20/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Interferon-γ release assays (IGRA) are designed for diagnosis of tuberculosis (TB) infection, and do not discriminate latent TB infection (LTBI) from active TB. Heparin-binding hemagglutinin antigen (HBHA) emerged as a promising antigen for TB diagnosis when used in IGRA format. Aim of this study was to prospectively evaluate the performance of an HBHA-based IGRA to support TB diagnosis and TB therapy monitoring in children with TB infection or active TB disease. METHODS Following clinical, microbiological and radiological assessment, children (0-14 years old) were tested by the QuantiFERON TB-Gold In tube (QFT) assay and an aliquot of whole-blood was stimulated with HBHA and IFNγ evaluated only in QFT-positive subjects. RESULTS Among the 550 children tested, 486 (88.4%) scored negative and 64 (11.6%) positive. None of the QFT-negative had active TB. Among the QFT-positive, 45 were with LTBI and 19 active TB. HBHA-IGRA scored positive in 41/45 children (91.1%) with LTBI and in 6/19 active TB children (31.6%) at diagnosis (p = 0.001); remarkably, 5 of these 6 children with active TB scoring HBHA-positive were asymptomatic. Moreover, following TB-specific therapy, most of the non-HBHA-responding children, gained an HBHA-positive response. CONCLUSIONS HBHA-based IGRA is a useful support in TB diagnosis and TB-therapy monitoring in children.
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Affiliation(s)
- Michela Sali
- Institute of Microbiology, Università Cattolica del Sacro Cuore - Fondazione Policlinico Universitario Gemelli, Rome, Italy
| | - Danilo Buonsenso
- Institute of Pediatrics, Università Cattolica del Sacro Cuore - Fondazione Policlinico Universitario Gemelli, Rome, Italy
| | - Pamela D'Alfonso
- Institute of Microbiology, Università Cattolica del Sacro Cuore - Fondazione Policlinico Universitario Gemelli, Rome, Italy
| | - Flavio De Maio
- Institute of Microbiology, Università Cattolica del Sacro Cuore - Fondazione Policlinico Universitario Gemelli, Rome, Italy
| | - Manuela Ceccarelli
- Institute of Pediatrics, Università Cattolica del Sacro Cuore - Fondazione Policlinico Universitario Gemelli, Rome, Italy
| | - Basem Battah
- Institute of Microbiology, Università Cattolica del Sacro Cuore - Fondazione Policlinico Universitario Gemelli, Rome, Italy
| | - Ivana Palucci
- Institute of Microbiology, Università Cattolica del Sacro Cuore - Fondazione Policlinico Universitario Gemelli, Rome, Italy
| | - Teresa Chiacchio
- Translational Research Unit, Epidemiology and Preclinical Research Department, National Institute for Infectious Diseases, IRCCS "Lazzaro Spallanzani", Rome, Italy
| | - Delia Goletti
- Translational Research Unit, Epidemiology and Preclinical Research Department, National Institute for Infectious Diseases, IRCCS "Lazzaro Spallanzani", Rome, Italy
| | - Maurizio Sanguinetti
- Institute of Microbiology, Università Cattolica del Sacro Cuore - Fondazione Policlinico Universitario Gemelli, Rome, Italy
| | - Piero Valentini
- Institute of Pediatrics, Università Cattolica del Sacro Cuore - Fondazione Policlinico Universitario Gemelli, Rome, Italy.
| | - Giovanni Delogu
- Institute of Microbiology, Università Cattolica del Sacro Cuore - Fondazione Policlinico Universitario Gemelli, Rome, Italy
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Sabi I, Rachow A, Mapamba D, Clowes P, Ntinginya NE, Sasamalo M, Kamwela L, Haraka F, Hoelscher M, Paris DH, Saathoff E, Reither K. Xpert MTB/RIF Ultra assay for the diagnosis of pulmonary tuberculosis in children: a multicentre comparative accuracy study. J Infect 2018; 77:321-327. [PMID: 30036606 DOI: 10.1016/j.jinf.2018.07.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 07/05/2018] [Accepted: 07/06/2018] [Indexed: 02/01/2023]
Abstract
OBJECTIVES We evaluated the diagnostic performance of the novel next-generation Xpert MTB/RIF Ultra (Xpert Ultra) in comparison to Xpert MTB/RIF (Xpert) assay for the detection of paediatric pulmonary tuberculosis in high burden settings. METHODS From May 2011 to September 2012, children with suspected pulmonary tuberculosis were enrolled at two Tanzanian sites and sputum samples were examined using sputum smear, Xpert and culture. Xpert Ultra was tested between January and June 2017 using sputum pellets, which had been stored at -80°C. The diagnostic accuracy of Ultra versus Xpert was determined using well-defined case definitions as reference standard. RESULTS In total, 215 children were included. The median age was 5.4 years, the HIV prevalence was 52% and 13% had culture-confirmed pulmonary tuberculosis. When only the first available sample of each patient was analysed, the sensitivity of Xpert Ultra was 64.3 % (95% CI: 44.1 to 81.4) while that of Xpert was 53.6% (95%CI: 33.9 to 72.5). The specificity of Xpert Ultra based on analysis of all available samples was 98.1% (95%CI: 93.4 to 99.7), that of Xpert was 100%. CONCLUSIONS Xpert Ultra was found to have a higher sensitivity, but slightly reduced specificity compared to Xpert in detecting pulmonary tuberculosis in children.
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Affiliation(s)
- Issa Sabi
- NIMR-Mbeya Medical Research Center, Mbeya, United Republic of Tanzania
| | - Andrea Rachow
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich (LMU), Munich, Germany; German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Daniel Mapamba
- NIMR-Mbeya Medical Research Center, Mbeya, United Republic of Tanzania
| | - Petra Clowes
- NIMR-Mbeya Medical Research Center, Mbeya, United Republic of Tanzania
| | | | | | - Lujeko Kamwela
- Ifakara Health Institute, Bagamoyo, United Republic of Tanzania
| | - Frederick Haraka
- Ifakara Health Institute, Bagamoyo, United Republic of Tanzania; Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Michael Hoelscher
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich (LMU), Munich, Germany; German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Daniel H Paris
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Elmar Saathoff
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich (LMU), Munich, Germany; German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Klaus Reither
- Ifakara Health Institute, Bagamoyo, United Republic of Tanzania; Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
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Variability in distribution and use of tuberculosis diagnostic tests in Kenya: a cross-sectional survey. BMC Infect Dis 2018; 18:328. [PMID: 30012092 PMCID: PMC6048895 DOI: 10.1186/s12879-018-3237-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 07/04/2018] [Indexed: 11/14/2022] Open
Abstract
Background Globally, 40% of all tuberculosis (TB) cases, 65% paediatric cases and 75% multi-drug resistant TB (MDR-TB) cases are missed due to underreporting and/or under diagnosis. A recent Kenyan TB prevalence survey found that a significant number of TB cases are being missed here. Understanding spatial distribution and patterns of use of TB diagnostic tests as per the guidelines could potentially help improve TB case detection by identifying diagnostic gaps. Methods We used 2015 Kenya National TB programme data to map TB case notification rates (CNR) in different counties, linked with their capacity to perform diagnostic tests (chest x-rays, smear microscopy, Xpert MTB/RIF®, culture and line probe assay). We then ran hierarchical regression models for adults and children to specifically establish determinants of use of Xpert® (as per Kenyan guidelines) with county and facility as random effects. Results In 2015, 82,313 TB cases were notified and 7.8% were children. The median CNR/100,000 amongst 0-14yr olds was 37.2 (IQR 20.6, 41.0) and 267.4 (IQR 202.6, 338.1) for ≥15yr olds respectively. 4.8% of child TB cases and 12.2% of adult TB cases had an Xpert® test done, with gaps in guideline adherence. There were 2,072 microscopy sites (mean microscopy density 4.46/100,000); 129 Xpert® sites (mean 0.31/100,000); two TB culture laboratories and 304 chest X-ray facilities (mean 0.74/100,000) with variability in spatial distribution across the 47 counties. Retreatment cases (i.e. failures, relapses/recurrences, defaulters) had the highest odds of getting an Xpert® test compared to new/transfer-in patients (AOR 7.81, 95% CI 7.33-8.33). Children had reduced odds of getting an Xpert® (AOR 0.41, CI 0.36-0.47). HIV-positive individuals had nearly twice the odds of getting an Xpert® test (AOR 1.82, CI 1.73-1.92). Private sector and higher-level hospitals had a tendency towards lower odds of use of Xpert®. Conclusions We noted under-use and gaps in guideline adherence for Xpert® especially in children. The under-use despite considerable investment undermines cost-effectiveness of Xpert®. Further research is needed to develop strategies enhancing use of diagnostics, including innovations to improve access (e.g. specimen referral) and overcoming local barriers to adoption of guidelines and technologies. Electronic supplementary material The online version of this article (10.1186/s12879-018-3237-z) contains supplementary material, which is available to authorized users.
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Floridia M, Ciccacci F, Andreotti M, Hassane A, Sidumo Z, Magid NA, Sotomane H, David M, Mutemba E, Cebola J, Mugunhe RJ, Riccardi F, Marazzi MC, Giuliano M, Palombi L, Mancinelli S. Tuberculosis Case Finding With Combined Rapid Point-of-Care Assays (Xpert MTB/RIF and Determine TB LAM) in HIV-Positive Individuals Starting Antiretroviral Therapy in Mozambique. Clin Infect Dis 2018; 65:1878-1883. [PMID: 29020319 DOI: 10.1093/cid/cix641] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 07/20/2017] [Indexed: 12/12/2022] Open
Abstract
Background Tuberculosis is a major health concern in several countries, and effective diagnostic algorithms for use in human immunodeficiency virus (HIV)-positive patients are urgently needed. Methods At prescription of antiretroviral therapy, all patients in 3 Mozambican health centers were screened for tuberculosis, with a combined approach: World Health Organization (WHO) 4-symptom screening (fever, cough, night sweats, and weight loss), a rapid test detecting mycobacterial lipoarabinomannan in urine (Determine TB LAM), and a molecular assay performed on a sputum sample (Xpert MTB/RIF; repeated if first result was negative). Patients with positive LAM or Xpert MTB/RIF results were referred for tuberculosis treatment. Results Among 972 patients with a complete diagnostic algorithm (58.5% female; median CD4 cell count, 278/μL; WHO HIV stage I, 66.8%), 98 (10.1%) tested positive with Xpert (90, 9.3%) or LAM (34, 3.5%) assays. Compared with a single-test Xpert strategy, dual Xpert tests improved case finding by 21.6%, LAM testing alone improved it by 13.5%, and dual Xpert tests plus LAM testing improved it by 32.4%. Rifampicin resistance in Xpert-positive patients was infrequent (2.5%). Among patients with positive results, 22 of 98 (22.4%) had no symptoms at WHO 4-symptom screening. Patients with tuberculosis diagnosed had significantly lower CD4 cell counts and hemoglobin levels, more advanced WHO stage, and higher HIV RNA levels. Fifteen (15.3%) did not start tuberculosis treatment, mostly owing to rapidly deteriorating clinical conditions or logistical constraints. The median interval between start of the diagnostic algorithm and start of tuberculosis treatment was 7 days. Conclusions The prevalence of tuberculosis among Mozambican HIV-positive patients starting antiretroviral therapy was 10%, with limited rifampicin resistance. Use of combined point-of-care tests increased case finding, with a short time to treatment. Interventions are needed to remove logistical barriers and prevent presentation in very advanced HIV/tuberculosis disease.
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Affiliation(s)
- Marco Floridia
- National Center for Global Health, Istituto Superiore di Sanità
| | | | - Mauro Andreotti
- National Center for Global Health, Istituto Superiore di Sanità
| | | | - Zita Sidumo
- DREAM Program, Community of S. Egidio, Maputo
| | | | | | | | - Elsa Mutemba
- DREAM Program, Community of S. Egidio, Beira, Mozambique
| | - Junia Cebola
- DREAM Program, Community of S. Egidio, Beira, Mozambique
| | | | - Fabio Riccardi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata
| | | | - Marina Giuliano
- National Center for Global Health, Istituto Superiore di Sanità
| | - Leonardo Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata
| | - Sandro Mancinelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata
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Lundtoft C, Awuah AAA, Nausch N, Enimil A, Mayatepek E, Owusu-Dabo E, Jacobsen M. Alternative Quantiferon cytokines for diagnosis of children with active tuberculosis and HIV co-infection in Ghana. Med Microbiol Immunol 2017; 206:259-265. [PMID: 28299430 DOI: 10.1007/s00430-017-0501-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 02/24/2017] [Indexed: 12/11/2022]
Abstract
IFN-γ release assays (IGRAs) often present false-negative or indeterminate results in children with tuberculosis. HIV co-infection may contribute to decreased sensitivity of IGRAs by impairing T-cell IFN-γ expression. Measurement of alternative cytokines in QuantiFERON® (QFT) supernatants can circumvent the IFN-γ-dependency and may improve QFT sensitivity. We aimed to identify additional cytokines from QFT supernatants for detection of Mycobacterium tuberculosis infection in children with tuberculosis and HIV co-infection from Ghana. Concentrations of 18 cytokines in QFT supernatants from children (0-16 years) with tuberculosis concomitantly infected with HIV (n = 25) or without HIV (n = 24) from Ghana were measured using cytometric bead array (CBA). 29% of the children showed positive IFN-γ test results, and five cytokines, i.e., IL-6, IL-21, TNF-α, IL-1α and IP-10, detected M. tuberculosis infection with comparable or, for IL-6, with significantly higher sensitivity (59%). Increased age and HIV co-infection were associated with decreased cytokine induction, and especially IL-21 and IP-10 were less prevalent in HIV co-infected children with tuberculosis. Combined cytokine analyses increased proportions of positive tests, and a four-cytokine subset (i.e., IL-6, IL-21, IFN-γ, IL-1α) predicted 78% of the children with tuberculosis correctly. Combined evaluation of IFN-γ and alternative cytokines improved IGRA-sensitivity in children with tuberculosis.
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Affiliation(s)
- Christian Lundtoft
- Pediatric Infectious Diseases Group, Department of General Pediatrics, Neonatology, and Pediatric Cardiology, University Children's Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Anthony Afum-Adjei Awuah
- Kumasi Centre for Collaborative Research in Tropical Medicine (KCCR), Kumasi, Ghana
- School of Public Health, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
| | - Norman Nausch
- Pediatric Infectious Diseases Group, Department of General Pediatrics, Neonatology, and Pediatric Cardiology, University Children's Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | | | - Ertan Mayatepek
- Pediatric Infectious Diseases Group, Department of General Pediatrics, Neonatology, and Pediatric Cardiology, University Children's Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Ellis Owusu-Dabo
- Kumasi Centre for Collaborative Research in Tropical Medicine (KCCR), Kumasi, Ghana
- School of Public Health, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
| | - Marc Jacobsen
- Pediatric Infectious Diseases Group, Department of General Pediatrics, Neonatology, and Pediatric Cardiology, University Children's Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany.
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