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Nkereuwem E, Agbla S, Sallahdeen A, Owolabi O, Sillah AK, Genekah M, Tunkara A, Kandeh S, Jawara M, Saidy L, Bush A, Togun T, Kampmann B. Reduced lung function and health-related quality of life after treatment for pulmonary tuberculosis in Gambian children: a cross-sectional comparative study. Thorax 2023; 78:281-287. [PMID: 36109164 PMCID: PMC9985734 DOI: 10.1136/thorax-2022-219085] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/25/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Post-tuberculosis (post-TB) lung disease is an under-recognised consequence of pulmonary tuberculosis (pTB). We aimed to estimate the prevalence of residual lung function impairment and reduced health-related quality of life (HRQoL) in children after pTB treatment completion. METHODS We conducted a cross-sectional comparative study of children aged less than 15 years at TB diagnosis who had completed treatment for pTB at least 6 months previously with a comparator group of age-matched children without a history of pTB. Symptoms, spirometry and HRQoL measured with PedsQL scale were collected. Variables associated with lung function impairment were identified through logistic regression models. RESULTS We enrolled 68 post-TB cases (median age 8.9 (IQR 7.2-11.2) years) and 91 children in the comparison group (11.5 (8.0-13.7) years). Spirometry from 52 (76.5%) post-TB cases and 89 (94.5%) of the comparison group met the quality criteria for acceptability and repeatability. Lung function impairment was present in 20/52 (38.5%) post-TB cases and 15/86 (17.4%) in the comparison group, p=0.009. Previous pTB and a history of chronic cough were significantly associated with the presence of lung function impairment (p=0.047 and 0.006 respectively). Forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and FEV1/FVC z-scores were significantly lower in the post-TB cases compared with the comparison group (p= <0.001, 0.014 and <0.001, respectively). The distribution of the self-reported physical health score, and parent-reported physical, emotional, psychological, social and total HRQoL scores were significantly lower in the post-TB cases compared with the comparison group. CONCLUSIONS Previous TB in children is associated with significantly impaired lung function and HRQoL.
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Affiliation(s)
- Esin Nkereuwem
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Fajara, Gambia .,Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Schadrac Agbla
- Department of Health Data Science, University of Liverpool, Liverpool, UK.,Department of Infectious Diseases Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Azeezat Sallahdeen
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Fajara, Gambia
| | - Olumuyiwa Owolabi
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Fajara, Gambia
| | - Abdou K Sillah
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Fajara, Gambia
| | - Monica Genekah
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Fajara, Gambia
| | - Abdoulie Tunkara
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Fajara, Gambia
| | - Sheriff Kandeh
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Fajara, Gambia
| | - Maryama Jawara
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Fajara, Gambia
| | - Lamin Saidy
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Fajara, Gambia
| | - Andrew Bush
- Department of Paediatric Respiratory Medicine, National Heart & Lung Institute, Imperial College London - Royal Brompton Campus, London, UK.,Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Toyin Togun
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Fajara, Gambia.,Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.,TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Beate Kampmann
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Fajara, Gambia.,Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.,Vaccine Centre, London School of Hygiene & Tropical Medicine, London, UK
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Programmatic Implementation of Contact Investigation in Eight African Countries. Trop Med Infect Dis 2022; 8:tropicalmed8010029. [PMID: 36668936 PMCID: PMC9866584 DOI: 10.3390/tropicalmed8010029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/08/2022] [Accepted: 12/20/2022] [Indexed: 12/31/2022] Open
Abstract
The objective was to implement CI under national tuberculosis programmatic conditions and to advocate for its scaling up. Contact investigation was implemented in 150 Basic Management Units identified across eight countries. The target populations (children <5 years and persons living with HIV (PLHIV)) were evaluated during home and clinic visits using standardized tools, clinical examinations and, according to each country, additional tests. Contacts with active TB received TB treatment and those eligible received TB preventive therapy (TPT). Data were collected each quarter using standardized forms. Meetings were organized with partners to share preliminary results and advocate for scaling up. From October 2020 to December 2021, 9049 home visits were performed. The proportions of children <5 years and PLHIV who were screened and diagnosed with active TB were, respectively, 2.6% and 10.1%. Ninety-three percent of children <5 years and 98% of PLHIV living at home received TPT or TB treatment, respectively. The scale-up for contact investigation partially or at national level in 2022 was effective in six of the eight countries included in the project. These results indicate that CI is feasible under programmatic conditions within the National TB Programs of African countries.
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Seid G, Alemu A, Dagne B, Sinshaw W, Gumi B. Tuberculosis in Household Contacts of Tuberculosis Patients in sub-Saharan African countries: A Systematic Review and Meta-analysis. J Clin Tuberc Other Mycobact Dis 2022; 29:100337. [DOI: 10.1016/j.jctube.2022.100337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Rahman MT, Malik AA, Amanullah F, Creswell J. Improving Tuberculosis Case Detection in Children: Summary of Innovations and Findings From 18 Countries. J Pediatric Infect Dis Soc 2022; 11:S117-S124. [PMID: 36103996 DOI: 10.1093/jpids/piac093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Despite a growing focus on the plight of tuberculosis (TB) among children, 56% of the 1.2 million children who develop TB annually are not detected and notified. TB REACH is a platform of the Stop TB Partnership that supports innovative interventions to improve TB case detection and preventative treatment. We present summary findings from 27 TB REACH-supported projects in 18 countries. Interventions were designed around intensified case-finding approaches (facility-based systematic screening and contact investigation), capacity building (including decentralized care delivery and supported decision-making), and improving diagnostic methods (ie, introduction of alternative respiratory specimens and new tools to aid the diagnosis). These interventions were evaluated on how they worked to identify children with TB, prevent further transmission of TB among children, and strengthen the health system involved with childhood TB care. Overall, 13 715 children were detected with TB, improving case notifications by 34%. In addition, nearly 5000 eligible contacts were enrolled on TB preventive treatment through these interventions. Focusing efforts and funding on childhood TB can produce marked improvements in case detection.
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Affiliation(s)
- Md Toufiq Rahman
- Innovations & Grants Team, Stop TB Partnership, Geneva, Switzerland
| | - Amyn A Malik
- Yale Institute for Global Health, New Haven, Connecticut, USA.,Interactive Research and Development (IRD) Global, Singapore
| | | | - Jacob Creswell
- Innovations & Grants Team, Stop TB Partnership, Geneva, Switzerland
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Preventive Treatment for Household Contacts of Drug-Susceptible Tuberculosis Patients. Pathogens 2022; 11:pathogens11111258. [DOI: 10.3390/pathogens11111258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/16/2022] Open
Abstract
People who live in the household of someone with infectious pulmonary tuberculosis are at a high risk of tuberculosis infection and subsequent progression to tuberculosis disease. These individuals are prioritized for contact investigation and tuberculosis preventive treatment (TPT). The treatment of TB infection is critical to prevent the progression of infection to disease and is prioritized in household contacts. Despite the availability of TPT, uptake in household contacts is poor. Multiple barriers prevent the optimal implementation of these policies. This manuscript lays out potential next steps for closing the policy-to-implementation gap in household contacts of all ages.
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Farina E, D'Amore C, Lancella L, Boccuzzi E, Ciofi Degli Atti ML, Reale A, Rossi P, Villani A, Raponi M, Raucci U. Alert sign and symptoms for the early diagnosis of pulmonary tuberculosis: analysis of patients followed by a tertiary pediatric hospital. Ital J Pediatr 2022; 48:90. [PMID: 35698090 PMCID: PMC9195307 DOI: 10.1186/s13052-022-01288-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/27/2022] [Indexed: 12/03/2022] Open
Abstract
Background Intercepting earlier suspected TB (Tuberculosis) cases clinically is necessary to reduce TB incidence, so we described signs and symptoms of retrospective cases of pulmonary TB and tried to evaluate which could be early warning signs. Methods We conducted a retrospective descriptive study of pulmonary TB cases in children in years 2005–2017; in years 2018–2020 we conducted a cohort prospective study enrolling patients < 18 years accessed to Emergency Department (ED) with signs/symptoms suggestive of pulmonary TB. Results In the retrospective analysis, 226 patients with pulmonary TB were studied. The most frequently described items were contact history (53.5%) and having parents from countries at risk (60.2%). Cough was referred in 49.5% of patients at onset, fever in 46%; these symptoms were persistent (lasting ≥ 10 days) in about 20%. Lymphadenopathy is described in 15.9%. The prospective study enrolled 85 patients of whom 14 (16.5%) were confirmed to be TB patients and 71 (83.5%) were non-TB cases. Lymphadenopathy and contact history were the most correlated variables. Fever and cough lasting ≥ 10 days were less frequently described in TB cases compared to non-TB patients (p < 0.05). Conclusions In low TB endemic countries, pulmonary TB at onset is characterized by different symptoms, i.e. persistent fever and cough are less described, while more relevant are contact history and lymphadenopathy. It was not possible to create a score because signs/symptoms usually suggestive of pulmonary TB (considered in the questionnaire) were not significant risk factors in our reality, a low TB country. Supplementary Information The online version contains supplementary material available at 10.1186/s13052-022-01288-5.
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Affiliation(s)
- Elisa Farina
- Unit of Internal Medicine, Celio Military Hospital, Rome, Italy
| | - Carmen D'Amore
- Clinical Pathways and Epidemiology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Laura Lancella
- Division of Immunology and Infectious Diseases, Department (DPUO), University-Hospital Pediatric, Bambino Gesù Children's Hospital, IRCSS, Rome, Italy
| | - Elena Boccuzzi
- Department of Emergency and Clinical Pediatrics, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | | | - Antonino Reale
- Department of Emergency and Clinical Pediatrics, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Paolo Rossi
- Medical Direction, Bambino Gesù Children's Hospital, IRCSS, Rome, Italy
| | - Alberto Villani
- Department of Emergency and Clinical Pediatrics, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | | | - Umberto Raucci
- Department of Emergency and Clinical Pediatrics, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
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7
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Vonasek B, Ness T, Takwoingi Y, Kay AW, van Wyk SS, Ouellette L, Marais BJ, Steingart KR, Mandalakas AM. Screening tests for active pulmonary tuberculosis in children. Cochrane Database Syst Rev 2021; 6:CD013693. [PMID: 34180536 PMCID: PMC8237391 DOI: 10.1002/14651858.cd013693.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Globally, children under 15 years represent approximately 12% of new tuberculosis cases, but 16% of the estimated 1.4 million deaths. This higher share of mortality highlights the urgent need to develop strategies to improve case detection in this age group and identify children without tuberculosis disease who should be considered for tuberculosis preventive treatment. One such strategy is systematic screening for tuberculosis in high-risk groups. OBJECTIVES To estimate the sensitivity and specificity of the presence of one or more tuberculosis symptoms, or symptom combinations; chest radiography (CXR); Xpert MTB/RIF; Xpert Ultra; and combinations of these as screening tests for detecting active pulmonary childhood tuberculosis in the following groups. - Tuberculosis contacts, including household contacts, school contacts, and other close contacts of a person with infectious tuberculosis. - Children living with HIV. - Children with pneumonia. - Other risk groups (e.g. children with a history of previous tuberculosis, malnourished children). - Children in the general population in high tuberculosis burden settings. SEARCH METHODS We searched six databases, including the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase, on 14 February 2020 without language restrictions and contacted researchers in the field. SELECTION CRITERIA Cross-sectional and cohort studies where at least 75% of children were aged under 15 years. Studies were eligible if conducted for screening rather than diagnosing tuberculosis. Reference standards were microbiological (MRS) and composite reference standard (CRS), which may incorporate symptoms and CXR. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality using QUADAS-2. We consolidated symptom screens across included studies into groups that used similar combinations of symptoms as follows: one or more of cough, fever, or poor weight gain and one or more of cough, fever, or decreased playfulness. For combination of symptoms, a positive screen was the presence of one or more than one symptom. We used a bivariate model to estimate pooled sensitivity and specificity with 95% confidence intervals (CIs) and performed analyses separately by reference standard. We assessed certainty of evidence using GRADE. MAIN RESULTS Nineteen studies assessed the following screens: one symptom (15 studies, 10,097 participants); combinations of symptoms (12 studies, 29,889 participants); CXR (10 studies, 7146 participants); and Xpert MTB/RIF (2 studies, 787 participants). Several studies assessed more than one screening test. No studies assessed Xpert Ultra. For 16 studies (84%), risk of bias for the reference standard domain was unclear owing to concern about incorporation bias. Across other quality domains, risk of bias was generally low. Symptom screen (verified by CRS) One or more of cough, fever, or poor weight gain in tuberculosis contacts (4 studies, tuberculosis prevalence 2% to 13%): pooled sensitivity was 89% (95% CI 52% to 98%; 113 participants; low-certainty evidence) and pooled specificity was 69% (95% CI 51% to 83%; 2582 participants; low-certainty evidence). Of 1000 children where 50 have pulmonary tuberculosis, 339 would be screen-positive, of whom 294 (87%) would not have pulmonary tuberculosis (false positives); 661 would be screen-negative, of whom five (1%) would have pulmonary tuberculosis (false negatives). One or more of cough, fever, or decreased playfulness in children aged under five years, inpatient or outpatient (3 studies, tuberculosis prevalence 3% to 13%): sensitivity ranged from 64% to 76% (106 participants; moderate-certainty evidence) and specificity from 37% to 77% (2339 participants; low-certainty evidence). Of 1000 children where 50 have pulmonary tuberculosis, 251 to 636 would be screen-positive, of whom 219 to 598 (87% to 94%) would not have pulmonary tuberculosis; 364 to 749 would be screen-negative, of whom 12 to 18 (2% to 3%) would have pulmonary tuberculosis. One or more of cough, fever, poor weight gain, or tuberculosis close contact (World Health Organization four-symptom screen) in children living with HIV, outpatient (2 studies, tuberculosis prevalence 3% and 8%): pooled sensitivity was 61% (95% CI 58% to 64%; 1219 screens; moderate-certainty evidence) and pooled specificity was 94% (95% CI 86% to 98%; 201,916 screens; low-certainty evidence). Of 1000 symptom screens where 50 of the screens are on children with pulmonary tuberculosis, 88 would be screen-positive, of which 57 (65%) would be on children who do not have pulmonary tuberculosis; 912 would be screen-negative, of which 19 (2%) would be on children who have pulmonary tuberculosis. CXR (verified by CRS) CXR with any abnormality in tuberculosis contacts (8 studies, tuberculosis prevalence 2% to 25%): pooled sensitivity was 87% (95% CI 75% to 93%; 232 participants; low-certainty evidence) and pooled specificity was 99% (95% CI 68% to 100%; 3281 participants; low-certainty evidence). Of 1000 children, where 50 have pulmonary tuberculosis, 63 would be screen-positive, of whom 19 (30%) would not have pulmonary tuberculosis; 937 would be screen-negative, of whom 6 (1%) would have pulmonary tuberculosis. Xpert MTB/RIF (verified by MRS) Xpert MTB/RIF, inpatient or outpatient (2 studies, tuberculosis prevalence 1% and 4%): sensitivity was 43% and 100% (16 participants; very low-certainty evidence) and specificity was 99% and 100% (771 participants; moderate-certainty evidence). Of 1000 children, where 50 have pulmonary tuberculosis, 31 to 69 would be Xpert MTB/RIF-positive, of whom 9 to 19 (28% to 29%) would not have pulmonary tuberculosis; 969 to 931 would be Xpert MTB/RIF-negative, of whom 0 to 28 (0% to 3%) would have tuberculosis. Studies often assessed more symptoms than those included in the index test and symptom definitions varied. These differences complicated data aggregation and may have influenced accuracy estimates. Both symptoms and CXR formed part of the CRS (incorporation bias), which may have led to overestimation of sensitivity and specificity. AUTHORS' CONCLUSIONS We found that in children who are tuberculosis contacts or living with HIV, screening tests using symptoms or CXR may be useful, but our review is limited by design issues with the index test and incorporation bias in the reference standard. For Xpert MTB/RIF, we found insufficient evidence regarding screening accuracy. Prospective evaluations of screening tests for tuberculosis in children will help clarify their use. In the meantime, screening strategies need to be pragmatic to address the persistent gaps in prevention and case detection that exist in resource-limited settings.
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Affiliation(s)
- Bryan Vonasek
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Department of Pediatrics, Division of Infectious Diseases, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Tara Ness
- 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
| | - 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
| | - Susanna S van Wyk
- Centre for Evidence-based Health Care, Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Ben J Marais
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
- Children's Hospital at Westmead, University of Sydney, Sydney, Australia
| | - 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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Nordholm AC, Lillebaek T. It is time to optimise the management of latent tuberculosis infection in children. Eur Respir J 2021; 57:57/4/2004438. [PMID: 33888534 DOI: 10.1183/13993003.04438-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 12/11/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Anne Christine Nordholm
- International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark
| | - Troels Lillebaek
- International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark
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Kakaire R, Kiwanuka N, Zalwango S, Sekandi JN, Quach THT, Castellanos ME, Quinn F, Whalen CC. Excess Risk of Tuberculous Infection among Extra-Household Contacts of Tuberculosis Cases in an African City. Clin Infect Dis 2020; 73:e3438-e3445. [PMID: 33064142 DOI: 10.1093/cid/ciaa1556] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Indexed: 01/14/2023] Open
Abstract
RATIONALE Although households of tuberculosis cases represent a setting for intense transmission of M. tuberculosis, household exposure accounts for less than 20% of transmission within a community. OBJECTIVES To estimate excess risk of M. tuberculosis infection among household and extra-household contacts of index cases. METHODS We performed a cross-sectional study in Kampala, Uganda, to delineate social networks of tuberculosis cases and matched controls without tuberculosis. We estimated the age-stratified prevalence difference of tuberculous infection between case and control networks, partitioned as household and extra-household contacts. RESULTS We enrolled 123 index cases, 124 index controls, and 2415 first-degree network contacts. The prevalence of infection was highest among household contacts of cases (61.5%), lowest among household contacts of controls (25.2%), and intermediary among extra-household tuberculosis contacts (44.9%) and extra-household control contacts (41.2%). The age-adjusted prevalence difference between extra-household contacts of cases and their controls was 5.4%. The prevalence of infection was similar among the majority of extra-household case contacts and corresponding controls (47%). CONCLUSIONS Most first-degree social network members of tuberculosis cases do not have adequate contact with the index case to experience additional risk for infection but appear instead to acquire infection through unrecognized exposures with infectious cases in the community.
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Affiliation(s)
- Robert Kakaire
- Global Health Institute, College of Public Health, University of Georgia, Athens, Georgia, United States.,Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia, United States
| | - Noah Kiwanuka
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Juliet N Sekandi
- Global Health Institute, College of Public Health, University of Georgia, Athens, Georgia, United States.,Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia, United States
| | - Trang Ho Thu Quach
- Global Health Institute, College of Public Health, University of Georgia, Athens, Georgia, United States.,Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia, United States.,Faculty of Pharmacy, Ho Chi Minh City University of Technology (HUTECH), Vietnam
| | - Maria Eugenia Castellanos
- Global Health Institute, College of Public Health, University of Georgia, Athens, Georgia, United States.,Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia, United States
| | - Frederick Quinn
- Department of Infectious Diseases, College of Veterinary Medicine, University of Georgia, Athens, Georgia, United States
| | - Christopher C Whalen
- Global Health Institute, College of Public Health, University of Georgia, Athens, Georgia, United States.,Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia, United States
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10
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Basu Roy R, Sambou B, Sissoko M, Holder B, Gomez MP, Egere U, Sillah AK, Koukounari A, Kampmann B. Protection against mycobacterial infection: A case-control study of mycobacterial immune responses in pairs of Gambian children with discordant infection status despite matched TB exposure. EBioMedicine 2020; 59:102891. [PMID: 32675024 PMCID: PMC7502674 DOI: 10.1016/j.ebiom.2020.102891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/29/2020] [Accepted: 06/29/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Children are particularly susceptible to tuberculosis. However, most children exposed to Mycobacterium tuberculosis are able to control the pathogen without evidence of infection. Correlates of human protective immunity against tuberculosis infection are lacking, and their identification would aid vaccine design. METHODS We recruited pairs of asymptomatic children with discordant tuberculin skin test status but the same sleeping proximity to the same adult with sputum smear-positive tuberculosis in a matched case-control study in The Gambia. Participants were classified as either Highly TB-Exposed Uninfected or Highly TB-Exposed Infected children. Serial luminescence measurements using an in vitro functional auto-luminescent Bacillus Calmette-Guérin (BCG) whole blood assay quantified the dynamics of host control of mycobacterial growth. Assay supernatants were analysed with a multiplex cytokine assay to measure associated inflammatory responses. FINDINGS 29 pairs of matched Highly TB-Exposed Uninfected and Highly TB-Exposed Infected children aged 5 to 15 years old were enroled. Samples from Highly TB-Exposed Uninfected children had higher levels of mycobacterial luminescence at 96 hours than Highly TB-Exposed Infected children. Highly TB-Exposed Uninfected children also produced less BCG-specific interferon-γ than Highly TB-Exposed Infected children at 24 hours and at 96 hours. INTERPRETATION Highly TB-Exposed Uninfected children showed less control of mycobacterial growth compared to Highly TB-Exposed Infected children in a functional assay, whilst cytokine responses mirrored infection status. FUNDING Clinical Research Training Fellowship funded under UK Medical Research Council/Department for International Development Concordat agreement and part of EDCTP2 programme supported by European Union (MR/K023446/1). Also MRC Program Grants (MR/K007602/1, MR/K011944/1, MC_UP_A900/1122).
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Affiliation(s)
- Robindra Basu Roy
- Department of Academic Paediatrics, Section of Paediatric Infectious Disease, Imperial College London, St. Mary's Hospital, Praed Street, London W2 1NY, United Kingdom; Vaccines and Immunity Theme, MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Atlantic Road, Fajara, The Gambia; Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - Basil Sambou
- Vaccines and Immunity Theme, MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Atlantic Road, Fajara, The Gambia
| | - Muhamed Sissoko
- Vaccines and Immunity Theme, MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Atlantic Road, Fajara, The Gambia
| | - Beth Holder
- Department of Academic Paediatrics, Section of Paediatric Infectious Disease, Imperial College London, St. Mary's Hospital, Praed Street, London W2 1NY, United Kingdom; Institute of Reproductive and Developmental Biology, Department of Metabolism, Digestion & Reproduction, Imperial College London, Du Cane Road, W12 0HS, United Kingdom
| | - Marie P Gomez
- Vaccines and Immunity Theme, MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Atlantic Road, Fajara, The Gambia
| | - Uzochukwu Egere
- Vaccines and Immunity Theme, MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Atlantic Road, Fajara, The Gambia; Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place L3 5QA, United Kingdom
| | - Abdou K Sillah
- Vaccines and Immunity Theme, MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Atlantic Road, Fajara, The Gambia
| | - Artemis Koukounari
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Beate Kampmann
- Vaccines and Immunity Theme, MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Atlantic Road, Fajara, The Gambia; Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom; The Vaccine Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom.
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Sathar F, Velen K, Peterson M, Charalambous S, Chetty-Makkan CM. "Knock Knock": a qualitative study exploring the experience of household contacts on home visits and their attitude towards people living with TB in South Africa. BMC Public Health 2020; 20:1047. [PMID: 32615942 PMCID: PMC7331256 DOI: 10.1186/s12889-020-09150-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/18/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Household contract tracing (HHCT) is an important strategy for active tuberculosis case finding and offers an opportunity for testing of other diseases such as HIV. However, there is limited data on the patient-centered approach to HHCT. Our study aimed to describe experiences and preferences of household contacts (HHCs) for HHCT. METHODS We conducted a qualitative study in Rustenburg, South Africa from September 2013 to March 2015. Twenty-four HHCs (≥18 years) had audio-recorded in-depth interviews. We used an inductive thematic analysis approach to develop themes. We made an a priori assumption that we would reach saturation with at least 20 interviews. RESULTS There were 16 (66.7%) females (median age = 36 years) and eight (33.3%) males (median age = 34 years). Two themes developed: (i) Positive attitude of HHCs towards TB services provided at home and (ii) HHCs relationship to and acceptance of people living with TB (PLTB). The first main theme emphasized that HHCs appreciated the home visits. Participants preferred home visits because they had negative experiences at the clinic such as delayed waiting times and long queues. HHCs supported the screening of children for TB at home. Participants suggested that the research staff could expand their services by screening for diabetes and hypertension alongside TB screening. In the second main theme, there was a sense of responsibility from the HHCs towards accepting the diagnosis of PLTB and caring for them. A sub-theme that emerged was that as their knowledge on TB disease improved, they accepted the TB status of the PLTB empowering them to take care of the PLTB. CONCLUSIONS HHCs are supportive of HHCT and felt empowered by receiving TB education that ultimately allowed them to better understand and care for PLTB. HHCs were supportive of screening children for TB at home. Future HHCT activities should consider raising community awareness on the benefits of TB contact tracing at households.
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Affiliation(s)
- Farzana Sathar
- The Aurum Institute, 29 Queens Road, Parktown, Johannesburg, Gauteng, 2193, South Africa.
| | - Kavindhran Velen
- The Aurum Institute, 29 Queens Road, Parktown, Johannesburg, Gauteng, 2193, South Africa
| | - Meaghan Peterson
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Salome Charalambous
- The Aurum Institute, 29 Queens Road, Parktown, Johannesburg, Gauteng, 2193, South Africa.,School of Public Health, University of Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Candice M Chetty-Makkan
- The Aurum Institute, 29 Queens Road, Parktown, Johannesburg, Gauteng, 2193, South Africa.,School of Public Health, University of Witwatersrand, Johannesburg, Gauteng, South Africa
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12
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van Loon W, Gomez MP, Jobe D, Franken KLMC, Ottenhoff THM, Coninx M, Kestens L, Sutherland JS, Kampmann B, Tientcheu LD. Use of resuscitation promoting factors to screen for tuberculosis infection in household-exposed children in The Gambia. BMC Infect Dis 2020; 20:469. [PMID: 32615981 PMCID: PMC7330976 DOI: 10.1186/s12879-020-05194-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Interferon-γ release assays (IGRA) with Resuscitation promoting factor (Rpf) proteins enhanced tuberculosis (TB) screening and diagnosis in adults but have not been evaluated in children. Children often develop paucibacillary TB and their immune response differs from that of adults, which together affect TB disease diagnostics and immunodiagnostics. We assessed the ability of Rpf to identify infection among household TB-exposed children in The Gambia and investigated their ability to discriminate Mycobacterium tuberculosis complex (MTBC) infection from active TB disease in children. METHODS Detailed clinical investigations were done on 93 household TB-exposed Gambian children and a tuberculin skin test (TST) was administered to asymptomatic children. Venous blood was collected for overnight stimulation with ESAT-6/CFP-10-fusion protein (EC), purified protein derivative and RpfA, B, C, D and E. Interferon gamma (IFN-γ) production was measured by ELISA in supernatants and corrected for the background level. Infection status was defined by IGRA with EC and TB disease by mycobacterial confirmation and/or clinical diagnosis. We compared IFN-γ levels between infected and uninfected children and between infected and TB diseased children using a binomial logistic regression model while correcting for age and sex. A Receiver Operating Characteristics analysis was done to find the best cut-off for IFN-γ level and calculate sensitivity and specificity. RESULTS Interferon gamma production was significantly higher in infected (IGRA+, n = 45) than in uninfected (IGRA-, n = 20) children after stimulation with RpfA, B, C, and D (P = 0.03; 0.007; 0.03 and 0.003, respectively). Using RpfB and D-specific IFN-γ cut-offs (33.9 pg/mL and 67.0 pg/mL), infection was classified with a sensitivity-specificity combination of 73-92% and 77-72% respectively, which was similar to and better than 65-75% for TST. Moreover, IFN-γ production was higher in infected than in TB diseased children (n = 28, 5 bacteriologically confirmed, 23 clinically diagnosed), following RpfB and D stimulation (P = 0.02 and 0.03, respectively). CONCLUSION RpfB and RpfD show promising results for childhood MTBC infection screening, and both performed similar to and better than the TST in our study population. Additionally, both antigens appear to discriminate between infection and disease in children and thus warrant further investigation as screening and diagnostic antigens for childhood TB.
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Affiliation(s)
- W van Loon
- Institute of Tropical Medicine and International Health, Charité-University Medicine Berlin, Berlin, Germany
- Vaccines and Immunity Theme, MRC Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia
| | - M P Gomez
- Vaccines and Immunity Theme, MRC Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia
| | - D Jobe
- Vaccines and Immunity Theme, MRC Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia
| | - K L M C Franken
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - T H M Ottenhoff
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - M Coninx
- Vaccines and Immunity Theme, MRC Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia
| | - L Kestens
- Immunology Department, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
- Faculty of Pharmaceutical, Biomedical and Veterinary Sciences, University of Antwerp, Antwerp, Belgium
| | - J S Sutherland
- Vaccines and Immunity Theme, MRC Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia
| | - B Kampmann
- Vaccines and Immunity Theme, MRC Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia
- The Vaccine Centre, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - L D Tientcheu
- Vaccines and Immunity Theme, MRC Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia.
- Department of Biochemistry, Faculty of Science, University of Yaoundé 1, Yaoundé, Cameroon.
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.
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13
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Petersen E, Chakaya J, Jawad FM, Ippolito G, Zumla A. Latent tuberculosis infection: diagnostic tests and when to treat. THE LANCET. INFECTIOUS DISEASES 2020; 19:231-233. [PMID: 30833050 DOI: 10.1016/s1473-3099(19)30059-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 01/21/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Eskild Petersen
- Institute of Clinical Medicine, University of Aarhus, Denmark; The Royal Hospital, Muscat, Oman.
| | - Jeremiah Chakaya
- International Union Against TB and Lung Diseases, Paris, France; Department of Medicine, Kenyatta University, Nairobi, Kenya
| | | | - Giuseppe Ippolito
- National Institute for Infectious Diseases, Lazzaro Spallanzani, IRCCS, Rome, Italy
| | - Alimuddin Zumla
- Division of Infection and Immunity, Center for Clinical Microbiology, University College London, London, UK; National Institute of Health Research Biomedical Research Centre at UCL Hospitals, London, UK
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14
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Andreas NJ, Basu Roy R, Gomez-Romero M, Horneffer-van der Sluis V, Lewis MR, Camuzeaux SSM, Jiménez B, Posma JM, Tientcheu L, Egere U, Sillah A, Togun T, Holmes E, Kampmann B. Performance of metabonomic serum analysis for diagnostics in paediatric tuberculosis. Sci Rep 2020; 10:7302. [PMID: 32350385 PMCID: PMC7190829 DOI: 10.1038/s41598-020-64413-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 03/13/2020] [Indexed: 12/31/2022] Open
Abstract
We applied a metabonomic strategy to identify host biomarkers in serum to diagnose paediatric tuberculosis (TB) disease. 112 symptomatic children with presumptive TB were recruited in The Gambia and classified as bacteriologically-confirmed TB, clinically diagnosed TB, or other diseases. Sera were analysed using 1H nuclear magnetic resonance (NMR) spectroscopy and mass spectrometry (MS). Multivariate data analysis was used to distinguish patients with TB from other diseases. Diagnostic accuracy was evaluated using Receiver Operating Characteristic (ROC) curves. Model performance was tested in a validation cohort of 36 children from the UK. Data acquired using 1H NMR demonstrated a sensitivity, specificity and Area Under the Curve (AUC) of 69% (95% confidence interval [CI], 56-73%), 83% (95% CI, 73-93%), and 0.78 respectively, and correctly classified 20% of the validation cohort from the UK. The most discriminatory MS data showed a sensitivity of 67% (95% CI, 60-71%), specificity of 86% (95% CI, 75-93%) and an AUC of 0.78, correctly classifying 83% of the validation cohort. Amongst children with presumptive TB, metabolic profiling of sera distinguished bacteriologically-confirmed and clinical TB from other diseases. This novel approach yielded a diagnostic performance for paediatric TB comparable to that of Xpert MTB/RIF and interferon gamma release assays.
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Affiliation(s)
- Nicholas J Andreas
- Centre for International Child Health, Department of Paediatrics, Imperial College London, St. Mary's Hospital, Praed Street, London, W2 1NY, United Kingdom
- Division of Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College London, Sir Alexander Fleming Building, South Kensington, London, SW7 2AZ, United Kingdom
| | - Robindra Basu Roy
- Centre for International Child Health, Department of Paediatrics, Imperial College London, St. Mary's Hospital, Praed Street, London, W2 1NY, United Kingdom
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Vaccines and Immunity Theme, Atlantic Road, Fajara, The Gambia
- The Vaccine Centre, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom
| | - Maria Gomez-Romero
- Division of Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College London, Sir Alexander Fleming Building, South Kensington, London, SW7 2AZ, United Kingdom
- MRC-NIHR National Phenome Centre, Department of Surgery and Cancer, Imperial College London, IRDB Building, Du Cane Road, London, W12 0NN, United Kingdom
- Clinical Phenotyping Centre, Department of Surgery and Cancer, Imperial College London, Sir Alexander Fleming Building, South Kensington, London, SW7 2AZ, United Kingdom
| | - Verena Horneffer-van der Sluis
- Division of Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College London, Sir Alexander Fleming Building, South Kensington, London, SW7 2AZ, United Kingdom
- MRC-NIHR National Phenome Centre, Department of Surgery and Cancer, Imperial College London, IRDB Building, Du Cane Road, London, W12 0NN, United Kingdom
| | - Matthew R Lewis
- Division of Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College London, Sir Alexander Fleming Building, South Kensington, London, SW7 2AZ, United Kingdom
- MRC-NIHR National Phenome Centre, Department of Surgery and Cancer, Imperial College London, IRDB Building, Du Cane Road, London, W12 0NN, United Kingdom
- Clinical Phenotyping Centre, Department of Surgery and Cancer, Imperial College London, Sir Alexander Fleming Building, South Kensington, London, SW7 2AZ, United Kingdom
| | - Stephane S M Camuzeaux
- MRC-NIHR National Phenome Centre, Department of Surgery and Cancer, Imperial College London, IRDB Building, Du Cane Road, London, W12 0NN, United Kingdom
| | - Beatriz Jiménez
- Division of Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College London, Sir Alexander Fleming Building, South Kensington, London, SW7 2AZ, United Kingdom
- MRC-NIHR National Phenome Centre, Department of Surgery and Cancer, Imperial College London, IRDB Building, Du Cane Road, London, W12 0NN, United Kingdom
- Clinical Phenotyping Centre, Department of Surgery and Cancer, Imperial College London, Sir Alexander Fleming Building, South Kensington, London, SW7 2AZ, United Kingdom
| | - Joram M Posma
- Division of Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College London, Sir Alexander Fleming Building, South Kensington, London, SW7 2AZ, United Kingdom
| | - Leopold Tientcheu
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Vaccines and Immunity Theme, Atlantic Road, Fajara, The Gambia
| | - Uzochukwu Egere
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Vaccines and Immunity Theme, Atlantic Road, Fajara, The Gambia
| | - Abdou Sillah
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Vaccines and Immunity Theme, Atlantic Road, Fajara, The Gambia
| | - Toyin Togun
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Vaccines and Immunity Theme, Atlantic Road, Fajara, The Gambia
- The Vaccine Centre, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom
| | - Elaine Holmes
- Division of Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College London, Sir Alexander Fleming Building, South Kensington, London, SW7 2AZ, United Kingdom
| | - Beate Kampmann
- Centre for International Child Health, Department of Paediatrics, Imperial College London, St. Mary's Hospital, Praed Street, London, W2 1NY, United Kingdom.
- MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Vaccines and Immunity Theme, Atlantic Road, Fajara, The Gambia.
- The Vaccine Centre, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom.
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15
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McIntosh AI, Jenkins HE, Horsburgh CR, Jones-López EC, Whalen CC, Gaeddert M, Marques-Rodrigues P, Ellner JJ, Dietze R, White LF. Partitioning the risk of tuberculosis transmission in household contact studies. PLoS One 2019; 14:e0223966. [PMID: 31639145 PMCID: PMC6804987 DOI: 10.1371/journal.pone.0223966] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 10/02/2019] [Indexed: 01/25/2023] Open
Abstract
Household contact studies of tuberculosis (TB) are a common way to study disease transmission dynamics. However these studies lack a mechanism for accounting for community transmission, which is known to be significant, particularly in high burden settings. We illustrate a statistical approach for estimating both the correlates with transmission of TB in a household setting and the probability of community transmission using a modified Bayesian mixed-effects model. This is applied to two household contact studies in Vitória, Brazil from 2008-2013 and Kampala, Uganda from 1995-2004 that enrolled households with an individual that was recently diagnosed with pulmonary TB. We estimate the probability of community transmission to be higher in Uganda (ranging from 0.21 to 0.69, depending on HHC age and HIV status of the index case) than in Brazil (ranging from 0.13 for young children to 0.50 in adults). These estimates are consistent with a higher overall burden of disease in Uganda compared to Brazil. Our method also estimates an increasing risk of community-acquired TB with age of the household contact, consistent with existing literature. This approach is a useful way to integrate the role of the community in understanding TB disease transmission dynamics in household contact studies.
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Affiliation(s)
- Avery I. McIntosh
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Helen E. Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - C. Robert Horsburgh
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Edward C. Jones-López
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Christopher C. Whalen
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia, United States of America
| | - Mary Gaeddert
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, United States of America
| | | | - Jerrold J. Ellner
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, United States of America
| | | | - Laura F. White
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
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16
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The evolving research agenda for paediatric tuberculosis infection. THE LANCET. INFECTIOUS DISEASES 2019; 19:e322-e329. [PMID: 31221543 DOI: 10.1016/s1473-3099(18)30787-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 10/19/2018] [Accepted: 12/11/2018] [Indexed: 12/30/2022]
Abstract
Following exposure to tuberculosis and subsequent infection, children often progress to tuberculosis disease more rapidly than adults. And yet the natural history of tuberculosis in children, as a continuum from exposure to infection and then to disease, is poorly understood. Children are rarely diagnosed with tuberculosis infection in routine care in international settings and few receive tuberculosis infection treatment. In this Personal View, we review the most up-to-date knowledge in three areas of childhood tuberculosis infection-namely, pathophysiology, diagnosis, and treatment. We then outline what is missing in each of these three areas to generate a priority research agenda. Finally, we suggest potential study designs that might answer these questions. Understanding of pathophysiology could be improved through animal models, laboratory studies assessing the immunological responses of blood or respiratory samples to Mycobacterium spp in vitro, as well as investigating immune responses in children exposed to tuberculosis. Identification of children with sub-clinical disease and at high risk of progression to clinically overt disease, would allow treatment to be targeted at those most likely to benefit. Optimisation and discovery of novel treatments for tuberculosis infection in children should account for mechanisms of action of tuberculosis drugs, as well as child-specific factors including pharmacokinetics and appropriate formulations. To conduct these studies, a change in mindset is required, with a recognition that the diagnosis and treatment of tuberculosis infection in children is a necessary component in addressing the overall tuberculosis epidemic. Collaboration between stakeholders will be required and funding will need to increase, both for research and implementation. The consequences of inaction, however, will lead to further decades of children suffering from what should increasingly be recognised as a preventable disease.
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17
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Ganmaa D, Khudyakov P, Buyanjargal U, Jargalsaikhan B, Baigal D, Munkhjargal O, Yansan N, Bolormaa S, Lkhagvasuren E, Sempos CT, Bromage S, Wu Z, Ochirbat B, Gunchin B, Martineau AR. Prevalence and Determinants of QuantiFERON-Diagnosed Tuberculosis Infection in 9810 Mongolian Schoolchildren. Clin Infect Dis 2019; 69:813-819. [PMID: 30481273 PMCID: PMC6695506 DOI: 10.1093/cid/ciy975] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 11/26/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND There is controversy regarding the potential influence of vitamin D deficiency, exposure to environmental tobacco smoke, BCG vaccination, season, and body habitus on susceptibility to Mycobacterium tuberculosis (MTB) infection. METHODS We conducted a cross-sectional analysis to identify determinants of a positive QuantiFERON-TB Gold (QFT) assay result in children aged 6-13 years attending 18 schools in Ulaanbaatar, Mongolia. Data relating to potential risk factors for MTB infection were collected by questionnaire, physical examination, and determination of serum 25-hydroxyvitamin D (25[OH]D) concentrations. Risk ratios (RRs) were calculated with adjustment for potential confounders, and population attributable fractions (PAFs) were calculated for modifiable risk factors identified. RESULTS Nine hundred forty-six of 9810 (9.6%) participants had a positive QFT result. QFT positivity was independently associated with household exposure to pulmonary tuberculosis (adjusted RR [aRR], 4.75 [95% confidence interval {CI}, 4.13-5.46, P < .001]; PAF, 13.1% [95% CI, 11.1%-15.0%]), vitamin D deficiency (aRR, 1.23 [95% CI, 1.08-1.40], P = .002; PAF, 5.7% [95% CI, 1.9%-9.3%]), exposure to environmental tobacco smoke (1 indoor smoker, aRR, 1.19 [95% CI, 1.04-1.35]; ≥2 indoor smokers, aRR, 1.30 [95% CI, 1.02-1.64]; P for trend = .006; PAF, 7.2% [95% CI, 2.2%-12.0%]), and increasing age (aRR per additional year, 1.14 [95% CI, 1.10-1.19], P < .001). No statistically significant independent association was seen for presence of a BCG scar, season of sampling, or body mass index. CONCLUSIONS Vitamin D deficiency and exposure to environmental tobacco smoke are potentially modifiable risk factors for MTB infection.
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Affiliation(s)
- Davaasambuu Ganmaa
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Mongolian Health Initiative, Ulaanbaatar
| | - Polyna Khudyakov
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Uyanga Buyanjargal
- Office of Dietary Supplements, National Institutes of Health, Bethesda, Maryland
| | | | | | | | | | | | - Enkhsaikhan Lkhagvasuren
- Mongolian Health Initiative, Ulaanbaatar
- Mongolian National Health Sciences University, Ulaanbaatar
| | - Christopher T Sempos
- Office of Dietary Supplements, National Institutes of Health, Bethesda, Maryland
| | | | - Zhenqiang Wu
- School of Population Health, University of Auckland, New Zealand
| | | | - Batbaatar Gunchin
- Mongolian Health Initiative, Ulaanbaatar
- Mongolian National Health Sciences University, Ulaanbaatar
| | - Adrian R Martineau
- Blizard Institute, Barts and London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
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18
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Basu Roy R, Sambou B, Uhía I, Roetynck S, Robertson BD, Kampmann B. An Auto-luminescent Fluorescent BCG Whole Blood Assay to Enable Evaluation of Paediatric Mycobacterial Responses Using Minimal Blood Volumes. Front Pediatr 2019; 7:151. [PMID: 31114771 PMCID: PMC6503113 DOI: 10.3389/fped.2019.00151] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 04/01/2019] [Indexed: 12/15/2022] Open
Abstract
Introduction: Understanding protective human immunity against mycobacteria is critical to developing and evaluating new vaccines against tuberculosis. Children are the most susceptible population to infection, disease, and death from tuberculosis, but also have the strongest evidence of BCG-inducible protection. Limited amounts of blood can be obtained for research purposes in paediatrics and therefore there is a need for high-yield, low-volume, human immunology assays. Methods: We transformed BCG Danish with plasmids encoding luciferase full operon derived from Photorhabdus luminescens together with Green Fluorescent Protein and antibiotic selection markers. We characterised the luminescent and fluorescent properties of this recombinant BCG strain (BCG-GFP-LuxFO) using a luminometer and flow cytometry and developed a paediatric whole blood in vitro infection model. Results: Luminescence of BCG-GFP-LuxFO correlated with optical density (Spearman Rank Correlation coefficient r = 0.985, p < 0.0001) and colony forming units (CFUs) in liquid culture medium (r = 0.971, p < 0.0001). Fluorescence of BCG-GFP-LuxFO in paediatric whole blood was confirmed by flow cytometry in granulocytes and monocytes 1 h following infection. Luminescence of BCG-GFP-LuxFO in whole blood corresponded with CFUs (r = 0.7123, p < 0.0001). Conclusion: The BCG-GFP-LuxFO assay requires 225 μL whole blood per sample, from which serial luminescence measurements can be obtained, together with biochemical analysis of supernatants and cellular assay applications using its fluorescent properties. This offers the opportunity to study human-mycobacterial interactions using multiple experimental modalities with only minimal blood volumes. It is therefore a valuable method for investigating paediatric immunity to tuberculosis.
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Affiliation(s)
- Robindra Basu Roy
- Department of Paediatrics, Centre for International Child Health, Imperial College London, London, United Kingdom.,Vaccines & Immunity Theme, MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine (LSHTM), Banjul, The Gambia
| | - Basil Sambou
- Vaccines & Immunity Theme, MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine (LSHTM), Banjul, The Gambia
| | - Iria Uhía
- MRC Centre for Molecular Bacteriology and Infection, Imperial College London, London, United Kingdom
| | - Sophie Roetynck
- Vaccines & Immunity Theme, MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine (LSHTM), Banjul, The Gambia
| | - Brian D Robertson
- MRC Centre for Molecular Bacteriology and Infection, Imperial College London, London, United Kingdom
| | - Beate Kampmann
- Department of Paediatrics, Centre for International Child Health, Imperial College London, London, United Kingdom.,Vaccines & Immunity Theme, MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine (LSHTM), Banjul, The Gambia.,Faculty of Infectious and Tropical Diseases, The Vaccine Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
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19
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Basu Roy R, Whittaker E, Seddon JA, Kampmann B. Tuberculosis susceptibility and protection in children. THE LANCET. INFECTIOUS DISEASES 2018; 19:e96-e108. [PMID: 30322790 DOI: 10.1016/s1473-3099(18)30157-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 01/27/2018] [Accepted: 02/09/2018] [Indexed: 12/14/2022]
Abstract
Children represent both a clinically important population susceptible to tuberculosis and a key group in whom to study intrinsic and vaccine-induced mechanisms of protection. After exposure to Mycobacterium tuberculosis, children aged under 5 years are at high risk of progressing first to tuberculosis infection, then to tuberculosis disease and possibly disseminated forms of tuberculosis, with accompanying high risks of morbidity and mortality. Children aged 5-10 years are somewhat protected, until risk increases again in adolescence. Furthermore, neonatal BCG programmes show the clearest proven benefit of vaccination against tuberculosis. Case-control comparisons from key cohorts, which recruited more than 15 000 children and adolescents in total, have identified that the ratio of monocytes to lymphocytes, activated CD4 T cell count, and a blood RNA signature could be correlates of risk for developing tuberculosis. Further studies of protected and susceptible populations are necessary to guide development of novel tuberculosis vaccines that could facilitate the achievement of WHO's goal to eliminate deaths from tuberculosis in childhood.
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Affiliation(s)
- Robindra Basu Roy
- Centre for International Child Health, Department of Paediatrics, Imperial College London, London, UK; Vaccines and Immunity Theme MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Elizabeth Whittaker
- Centre for International Child Health, Department of Paediatrics, Imperial College London, London, UK
| | - James A Seddon
- Centre for International Child Health, Department of Paediatrics, Imperial College London, London, UK
| | - Beate Kampmann
- Centre for International Child Health, Department of Paediatrics, Imperial College London, London, UK; Vaccines and Immunity Theme MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia.
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Martinez L, Shen Y, Handel A, Chakraburty S, Stein CM, Malone LL, Boom WH, Quinn FD, Joloba ML, Whalen CC, Zalwango S. Effectiveness of WHO's pragmatic screening algorithm for child contacts of tuberculosis cases in resource-constrained settings: a prospective cohort study in Uganda. THE LANCET RESPIRATORY MEDICINE 2017; 6:276-286. [PMID: 29273539 DOI: 10.1016/s2213-2600(17)30497-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/01/2017] [Accepted: 11/02/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Tuberculosis is a leading cause of global childhood mortality; however, interventions to detect undiagnosed tuberculosis in children are underused. Child contact tracing has been widely recommended but poorly implemented in resource-constrained settings. WHO has proposed a pragmatic screening approach for managing child contacts. We assessed the effectiveness of this screening approach and alternative symptom-based algorithms in identifying secondary tuberculosis in a prospectively followed cohort of Ugandan child contacts. METHODS We identified index patients aged at least 18 years with microbiologically confirmed pulmonary tuberculosis at Old Mulago Hospital (Kampala, Uganda) between Oct 1, 1995, and Dec 31, 2008. Households of index patients were visited by fieldworkers within 2 weeks of diagnosis. Coprevalent and incident tuberculosis were assessed in household contacts through clinical, radiographical, and microbiological examinations for 2 years. Disease rates were compared among children younger than 16 years with and without symptoms included in the WHO pragmatic guideline (presence of haemoptysis, fever, chronic cough, weight loss, night sweats, and poor appetite). Symptoms could be of any duration, except cough (>21 days) and fever (>14 days). A modified WHO decision-tree designed to detect high-risk asymptomatic child contacts was also assessed, in which all asymptomatic contacts were classified as high risk (children younger than 3 years or immunocompromised [HIV-infected]) or low risk (aged 3 years or older and immunocompetent [HIV-negative]). We also assessed a more restrictive algorithm (ie, assessing only children with presence of chronic cough and one other tuberculosis-related symptom). FINDINGS Of 1718 household child contacts, 126 (7%) had coprevalent tuberculosis and 24 (1%) developed incident tuberculosis, diagnosed over the 2-year study period. Of these 150 cases of tuberculosis, 95 (63%) were microbiologically confirmed with a positive sputum culture. Using the WHO approach, 364 (21%) of 1718 child contacts had at least one tuberculosis-related symptom and 85 (23%) were identified as having coprevalent tuberculosis, 67% of all coprevalent cases detected (diagnostic odds ratio 9·8, 95% CI 6·8-14·5; p<0·0001). 1354 (79%) of 1718 child contacts had no symptoms, of whom 41 (3%) had coprevalent tuberculosis. The WHO approach was effective in contacts younger than 5 years: 70 (33%) of 211 symptomatic contacts had coprevalent disease compared with 23 (6%) of 367 asymptomatic contacts (p<0·0001). This approach was also effective in contacts aged 5 years and older: 15 (10%) of 153 symptomatic contacts had coprevalent disease compared with 18 (2%) of 987 asymptomatic contacts (p<0·0001). More coprevalent disease was detected in child contacts recommended for screening when the study population was restricted by HIV-serostatus (11 [48%] of 23 symptomatic HIV-seropositive child contacts vs two [7%] of 31 asymptomatic HIV-seropositive child contacts) or to only culture-confirmed cases (47 [13%] culture confirmed cases of 364 symptomatic child contacts vs 29 [2%] culture confirmed cases of 1354 asymptomatic child contacts). In the modified algorithm, high-risk asymptomatic child contacts were at increased risk for coprevalent disease versus low-risk asymptomatic contacts (14 [6%] of 224 vs 27 [2%] of 1130; p=0·0021). The presence of tuberculosis infection did not predict incident disease in either symptomatic or asymptomatic child contacts: in symptomatic contacts, eight (5%) of 169 infected contacts and six (5%) of 111 uninfected contacts developed incident tuberculosis (p=0·80). Among asymptomatic contacts, incident tuberculosis occurred in six (<1%) of 795 contacts infected at baseline versus four (<1%) of 518 contacts uninfected at baseline, respectively (p=1·00). INTERPRETATION WHO's pragmatic, symptom-based algorithm was an effective case-finding tool, especially in children younger than 5 years. A modified decision-tree identified 6% of asymptomatic child contacts at high risk for subclinical disease. Increasing the feasibility of child-contact tracing using these approaches should be encouraged to decrease tuberculosis-related paediatric mortality in high-burden settings, but this should be partnered with increasing access to microbiological point-of-care testing. FUNDING National Institutes of Health, Tuberculosis Research Unit, AIDS International Training and Research Program of the Fogarty International Center, and the Center for AIDS Research.
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Affiliation(s)
- Leonardo Martinez
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA; Institute of Global Health, University of Georgia, Athens, GA, USA; Division of Infectious Diseases and Geographic Medicine, School of Medicine, Stanford University, Stanford, CA, USA.
| | - Ye Shen
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | - Andreas Handel
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | | | - Catherine M Stein
- Department of Population and Quantitative Health Sciences, Tuberculosis Research Unit & Department of Medicine, Case Western Reserve University, Cleveland, OH, USA; Uganda-CWRU Research Collaboration, Makerere University and Mulago Hospital, Kampala, Uganda
| | - LaShaunda L Malone
- Division of Infectious Disease, Department of Medicine and Tuberculosis Research Unit, Case Western Reserve University, Cleveland, OH, USA; Uganda-CWRU Research Collaboration, Makerere University and Mulago Hospital, Kampala, Uganda
| | - W Henry Boom
- Division of Infectious Disease, Department of Medicine and Tuberculosis Research Unit, Case Western Reserve University, Cleveland, OH, USA; Uganda-CWRU Research Collaboration, Makerere University and Mulago Hospital, Kampala, Uganda
| | - Frederick D Quinn
- University of Georgia, Department of Veterinary Medicine, Athens, GA, USA
| | - Moses L Joloba
- Department of Immunology/Molecular Biology and Department of Medical Microbiology, School of Biomedical Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Christopher C Whalen
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA; Institute of Global Health, University of Georgia, Athens, GA, USA
| | - Sarah Zalwango
- Uganda-CWRU Research Collaboration, Makerere University and Mulago Hospital, Kampala, Uganda
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