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Agrawal R, Ludi Z, Betzler BK, Testi I, Mahajan S, Rousellot A, Kempen JH, Smith JR, McCluskey P, Nguyen QD, Pavesio C, Gupta V. The Collaborative Ocular Tuberculosis Study (COTS) calculator-a consensus-based decision tool for initiating antitubercular therapy in ocular tuberculosis. Eye (Lond) 2023; 37:1416-1423. [PMID: 35764876 PMCID: PMC10170101 DOI: 10.1038/s41433-022-02147-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/15/2022] [Accepted: 06/14/2022] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To introduce the Collaborative Ocular Tuberculosis Study (COTS) Calculator, an online clinical scoring system for initiating antitubercular therapy (ATT) in patients with ocular tuberculosis (TB). METHOD The COTS Calculator was derived from COTS Consensus (COTS CON) data, which has previously published consensus guidelines. Using a two-step Delphi method, 81 experts evaluated 486 clinical scenario-based questions, ranking their likelihood of initiating ATT in each specific scenario. Each scenario was a permutation of the results and/or availability of five following components-clinical phenotype, endemicity, two immunological (tuberculin skin test, interferon-γ release assay) and one radiological (chest X-Ray) test results-and a sixth component further stratifying three of the clinical phenotypes. The median scores and interquartile ranges (IQR) of each scenario were tabulated, representing the expert consensus on whether to initiate ATT in that scenario. The consensus table was encoded to develop the COTS Calculator. RESULTS The COTS Calculator can be accessed online at: https://www.oculartb.net/cots-calc . The attending physician can select the conditions present in the patient, which will generate a median score from 1 to 5. 114 out of 486 scenarios (24%) deliberated had a median score of 5 indicating expert consensus to initiate ATT. CONCLUSION The COTS Calculator is an efficient, low-cost, evidence and experience-based clinical tool to guide ATT initiation. While it holds substantial promise in improving standard-of-care for ocular-TB patients, future validation studies can help to as certain its clinical utility and reliability.
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Affiliation(s)
- Rupesh Agrawal
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore.
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
- Duke NUS Medical School, Singapore, Singapore.
- Singapore Eye Research Institute, Singapore, Singapore.
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital, London, UK.
| | - Zhang Ludi
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Bjorn K Betzler
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ilaria Testi
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital, London, UK
| | | | - Andres Rousellot
- Ciudad Autónoma de Buenos Aires, Consultorios Oftalmológicos Benisek-Ascarza, Buenos Aires, Argentina
| | - John H Kempen
- Department of Ophthalmology, Schepens Eye Research Institute, Massachusetts Eye and Ear/Harvard Medical School, Boston, MA, USA
- Sight for Souls, Fort Myers, FL, USA
- Department of Ophthalmology, Addis Ababa University, Addis Ababa, Ethiopia
- MyungSung Christian Medical Center (MCM) Eye Unit, MCM General Hospital, MyungSung Medical School, Addis Ababa, Ethiopia
| | - Justine R Smith
- Flinders University College of Medicine & Public Health, Adelaide, SA, Australia
- Queensland Eye Institute, Brisbane, QLD, Australia
| | - Peter McCluskey
- Save Sight Institute, Department of Ophthalmology, The University of Sydney, Sydney, NSW, Australia
| | - Quan Dong Nguyen
- Byers Eye Institute, Stanford Medical School, Palo alto, CA, USA
| | - Carlos Pavesio
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital, London, UK
| | - Vishali Gupta
- Advanced Eye Centre, Post-Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
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Hamada Y, Cirillo DM, Matteelli A, Penn-Nicholson A, Rangaka MX, Ruhwald M. Tests for tuberculosis infection: landscape analysis. Eur Respir J 2021; 58:2100167. [PMID: 33875495 DOI: 10.1183/13993003.00167-2021] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/05/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Only the tuberculin skin test (TST) and two interferon-γ release assays (IGRAs), QuantiFERON-TB Gold In-Tube and T-SPOT.TB, are currently endorsed by the World Health Organization as tests for tuberculosis (TB) infection. While IGRAs are more specific than the TST, they require sophisticated laboratory infrastructure and are costly to perform. However, both types of tests have limited performance to predict development of active TB. Tests with improved predictive performance and operational characteristics are needed. METHODS We reviewed the current landscape of tests for TB infection identified through a web-based survey targeting diagnostic manufacturers globally. RESULTS We identified 20 tests for TB infection: 15 in vitro tests and five skin tests. 13 of the in vitro tests are whole-blood IGRAs and 14 use early secreted antigenic target 6 (ESAT-6) and culture filtrate protein 10 (CFP-10), with or without additional antigens. 10 of the tests are based on assays other than an ELISA, such as a fluorescent lateral flow assay that requires less manual operation and shorter assay time and hence is more suitable for decentralisation compared with the existing IGRAs. Four of the five skin tests use ESAT-6 and CFP-10 proteins, while the remaining test uses a new antigen that is specific to Mycobacterium tuberculosis complex. CONCLUSIONS New tests have the potential to improve accuracy, operational characteristics and end-user access to tests for TB infection. However, published data in various populations and settings are limited for most new tests. Evaluation of these new tests in a standardised design would facilitate their endorsement and programmatic scale-up.
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Affiliation(s)
- Yohhei Hamada
- Institute for Global Health, University College London, London, UK
| | - Daniela Maria Cirillo
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Matteelli
- Dept of Infectious and Tropical Diseases, Collaborating Centre for TB/HIV Co-infection and TB Elimination, University of Brescia, Brescia, Italy
| | | | - Molebogeng X Rangaka
- Institute for Global Health, University College London, London, UK
- Division of Epidemiology and Biostatistics, University of Cape Town, Cape Town, South Africa
- These authors contributed equally
| | - Morten Ruhwald
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
- These authors contributed equally
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Cost-effectiveness of newer technologies for the diagnosis of Mycobacterium tuberculosis infection in Brazilian people living with HIV. Sci Rep 2020; 10:21823. [PMID: 33311520 PMCID: PMC7733491 DOI: 10.1038/s41598-020-78737-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 11/27/2020] [Indexed: 02/07/2023] Open
Abstract
Tuberculosis is the leading cause of death among people living with HIV (PLH). Preventive tuberculosis therapy reduces mortality in PLH, especially in those with a positive tuberculin skin test (TST). New, more specific technologies for detecting latent tuberculosis infection (LTBI) are now commercially available. We sought to analyse the cost-effectiveness of four different strategies for the diagnosis of LTBI in PLH in Brazil, from the Brazilian public health care system perspective. We developed a Markov state-transition model comparing four strategies for the diagnosis of LTBI over 20 years. The strategies consisted of TST with the currently used protein purified derivative (PPD RT 23), two novel skin tests using recombinant allergens (Diaskintest [Generium Pharmaceutical, Moscow, Russia] and EC [Zhifei Longcom Biologic Pharmacy Co., Anhui, China]), and the QuantiFERON-TB-Gold-Plus (Qiagen, Hilden, Germany). The main outcome was cost (in 2020 US dollars) per quality-adjusted life years (QALY). For the base case scenario, the Diaskintest was dominant over all other examined strategies. The cost saving estimate per QALY was US $1375. In sensitivity analyses, the Diaskintest and other newer tests remained cost-saving compared to TST. For PLH, TST could be replaced by more specific tests in Brazil, considering the current national recommendations.
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Badaro R, Machado BAS, Duthie MS, Araujo-Neto CA, Pedral-Sampaio D, Nakatani M, Reed SG. The single recombinant M. tuberculosis protein DPPD provides enhanced performance of skin testing among HIV-infected tuberculosis patients. AMB Express 2020; 10:133. [PMID: 32737693 PMCID: PMC7394993 DOI: 10.1186/s13568-020-01068-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/18/2020] [Indexed: 11/10/2022] Open
Abstract
Diagnostic testing for M. tuberculosis infection has advanced with QuantiFERON and GeneXpert, but simple cost-effective alternatives for widespread TB screening has remained elusive and purified protein derivative (PPD)-based tuberculin skin testing (TST) remains the most widely used method. PPD-based tests have reduced performance, however, in BCG vaccinees and in individuals with immune deficiencies. We compared the performance of skin testing with the recombinant DPPD protein against that of a standard PPD-based skin test. Our data indicates similar performance of DPPD and PPD (r2 = 0.7689) among HIV-negative, active TB patients, all of whom presented greater than 10 mm induration following administration. In contrast to results demonstrating that PPD induced indurations greater than 5 mm (i.e., the recommended threshold for positive results in this population) in only half (19 of 38) of the HIV positive TB patients, 89.5% (34 of 38) of these participants developed indurations greater than 5 mm when challenged with DPPD. Importantly, none of the patients that were positive following PPD administration were negative following DPPD administration, indicating markedly improved sensitivity of DPPD among HIV-infected individuals. Our data indicate that DPPD has superior performance in skin testing than the current TST standard.
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Chattu VK, Sakhamuri S, Motilal S, Pounder LJ, Persad VK, Pierre N, Persad S, Pooran N, Pottinger AM. Tuberculosis Skin Test Screening in the National Tuberculosis Program of Trinidad and Tobago. Healthcare (Basel) 2020; 8:healthcare8030236. [PMID: 32727008 PMCID: PMC7551204 DOI: 10.3390/healthcare8030236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 11/16/2022] Open
Abstract
Globally, a quarter of the population is infected with tuberculosis (TB), caused by Mycobacterium tuberculosis. About 5–10% of latent TB infections (LTBI) progress to active disease during the lifetime. Prevention of TB and treating LTBI is a critical component of the World Health Organization’s (WHO) End TB Strategy. This study aims to examine the screening practices for prevention and treatment employed by the National Tuberculosis Program of Trinidad and Tobago in comparison to the WHO’s standard guidelines. A cross-sectional retrospective study was conducted from the TB registers (2018–2019) for persons aged 18 years and above with recorded tuberculin skin test reactions (TST). Bivariate comparisons for categorical variables were made using Chi-square or Fisher’s exact test. Binary logistic regression was used for exploring predictors of TST positivity with adjustment for demographic confounders in multivariable models. Of the total 1972 eligible entries studied, 384 (19.4%) individuals were tested positive with TST. TB contact screening (aOR 2.49; 95% CI 1.65, 3.75) and Bacillus Calmette–Guerin (BCG) vaccination status (aOR 1.66; 95% CI, 1.24 to 2.22) were associated with a positive TST reaction, whereas, preplacement screening failed to show such association when compared to those screened as suspect cases. The findings suggest that TB contact screening and positive BCG vaccination status are associated with TST positivity independent of age and gender.
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Affiliation(s)
- Vijay Kumar Chattu
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
- Occupational Medicine Clinic, St. Michael’s Hospital, Toronto, ON M5C 2C5, Canada
- Institute of International Relations, The University of the West Indies, St. Augustine, Trinidad and Tobago
- Correspondence: (V.K.C.); (S.S.); Tel.: +1-416-864-6060 (V.K.C.)
| | - Sateesh Sakhamuri
- Department of Clinical Medical Sciences, Faculty of Medical Sciences, The University of the West Indies, St Augustine, Trinidad and Tobago; (L.J.P.); (V.K.P.); (N.P.); (S.P.); (N.P.); (A.M.P.)
- Eric Williams Medical Sciences Complex, North Central Regional Health Authority, Mount Hope, Trinidad and Tobago
- Correspondence: (V.K.C.); (S.S.); Tel.: +1-416-864-6060 (V.K.C.)
| | - Shastri Motilal
- Department of Paraclinical Sciences, Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago;
| | - Liam J. Pounder
- Department of Clinical Medical Sciences, Faculty of Medical Sciences, The University of the West Indies, St Augustine, Trinidad and Tobago; (L.J.P.); (V.K.P.); (N.P.); (S.P.); (N.P.); (A.M.P.)
| | - Vasishma Kanita Persad
- Department of Clinical Medical Sciences, Faculty of Medical Sciences, The University of the West Indies, St Augustine, Trinidad and Tobago; (L.J.P.); (V.K.P.); (N.P.); (S.P.); (N.P.); (A.M.P.)
| | - Neelmani Pierre
- Department of Clinical Medical Sciences, Faculty of Medical Sciences, The University of the West Indies, St Augustine, Trinidad and Tobago; (L.J.P.); (V.K.P.); (N.P.); (S.P.); (N.P.); (A.M.P.)
| | - Shivannie Persad
- Department of Clinical Medical Sciences, Faculty of Medical Sciences, The University of the West Indies, St Augustine, Trinidad and Tobago; (L.J.P.); (V.K.P.); (N.P.); (S.P.); (N.P.); (A.M.P.)
| | - Nikesha Pooran
- Department of Clinical Medical Sciences, Faculty of Medical Sciences, The University of the West Indies, St Augustine, Trinidad and Tobago; (L.J.P.); (V.K.P.); (N.P.); (S.P.); (N.P.); (A.M.P.)
| | - Akua Mosi Pottinger
- Department of Clinical Medical Sciences, Faculty of Medical Sciences, The University of the West Indies, St Augustine, Trinidad and Tobago; (L.J.P.); (V.K.P.); (N.P.); (S.P.); (N.P.); (A.M.P.)
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Picone CM, Freitas AC, Gutierrez EB, Avelino-Silva VI. Access and adherence to isoniazid preventive therapy and occurrence of active TB in a cohort of people living with HIV: a retrospective cohort study in Sao Paulo, Brazil. Rev Inst Med Trop Sao Paulo 2020; 62:e8. [PMID: 32049259 PMCID: PMC7014552 DOI: 10.1590/s1678-9946202062008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 01/06/2020] [Indexed: 11/29/2022] Open
Abstract
Tuberculosis (TB) is still a leading cause of morbidity and mortality among people living with HIV (PLHIV). The diagnosis of latent TB is required for the implementation of prophylactic therapy with isoniazid (PTI). However, low access to diagnosis of latent TB and non-adherence to PTI may hinder potential benefits of this essential intervention. In this study, we addressed the access and adherence to PTI in a cohort of PLHIV with positive tuberculin skin test (TST) in a reference HIV clinic in Sao Paulo, Brazil. We have also analyzed the occurrence of active TB over a median of 131 months after a positive TST among study participants. Our findings revealed that 88.3% of the 238 TST-positive patients had access to PTI, and 196 (93.3%) of those with access adhered to PTI. Active tuberculosis was diagnosed in three of the 196 TST-positive patients who adhered to PTI (1.5%; 95% confidence interval [CI] 0.3-4.4%), whereas seven cases were detected among 42 patients without access or who did not adhere to PTI (16.6%; 95% CI 7.0-31.3%). The apparent beneficial effect of PTI in our cohort is consistent with previous studies including PLHIV, and highlights the importance of reliably delivering each of the steps between screening for latent TB and provision of PTI.
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Affiliation(s)
- Camila Melo Picone
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Moléstias Infecciosas e Parasitárias, São Paulo, São Paulo, Brazil
| | - Angela Carvalho Freitas
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Moléstias Infecciosas e Parasitárias, São Paulo, São Paulo, Brazil
| | - Eliana B Gutierrez
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Moléstias Infecciosas e Parasitárias, São Paulo, São Paulo, Brazil
| | - Vivian Iida Avelino-Silva
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Moléstias Infecciosas e Parasitárias, São Paulo, São Paulo, Brazil
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Nationwide Shortage of Tuberculin Skin Test Antigens: CDC Recommendations for Patient Care and Public Health Practice. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2019; 68:552-553. [PMID: 31220054 PMCID: PMC6586373 DOI: 10.15585/mmwr.mm6824a4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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