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Hwang EJ, Jeong WG, David PM, Arentz M, Ruhwald M, Yoon SH. AI for Detection of Tuberculosis: Implications for Global Health. Radiol Artif Intell 2024; 6:e230327. [PMID: 38197795 PMCID: PMC10982823 DOI: 10.1148/ryai.230327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 12/03/2023] [Accepted: 12/18/2023] [Indexed: 01/11/2024]
Abstract
Tuberculosis, which primarily affects developing countries, remains a significant global health concern. Since the 2010s, the role of chest radiography has expanded in tuberculosis triage and screening beyond its traditional complementary role in the diagnosis of tuberculosis. Computer-aided diagnosis (CAD) systems for tuberculosis detection on chest radiographs have recently made substantial progress in diagnostic performance, thanks to deep learning technologies. The current performance of CAD systems for tuberculosis has approximated that of human experts, presenting a potential solution to the shortage of human readers to interpret chest radiographs in low- or middle-income, high-tuberculosis-burden countries. This article provides a critical appraisal of developmental process reporting in extant CAD software for tuberculosis, based on the Checklist for Artificial Intelligence in Medical Imaging. It also explores several considerations to scale up CAD solutions, encompassing manufacturer-independent CAD validation, economic and political aspects, and ethical concerns, as well as the potential for broadening radiography-based diagnosis to other nontuberculosis diseases. Collectively, CAD for tuberculosis will emerge as a representative deep learning application, catalyzing advances in global health and health equity. Keywords: Computer-aided Diagnosis (CAD), Conventional Radiography, Thorax, Lung, Machine Learning Supplemental material is available for this article. © RSNA, 2024.
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Affiliation(s)
- Eui Jin Hwang
- From the Department of Radiology, Seoul National University Hospital
and Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu,
Seoul 03080, Korea (E.J.H., S.H.Y.); Department of Radiology, Chonnam National
University Hwasun Hospital, Hwasun, Korea (W.G.J.); Faculty of Pharmacy,
University of Montréal, Montréal, Canada (P.M.D.);
OBVIA–Observatoire sur les Impacts Sociétaux de l'IA et du
Numérique, Québec, Canada (P.M.D.); and FIND–The Global
Alliance for Diagnostics, Geneva, Switzerland (M.A., M.R.)
| | - Won Gi Jeong
- From the Department of Radiology, Seoul National University Hospital
and Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu,
Seoul 03080, Korea (E.J.H., S.H.Y.); Department of Radiology, Chonnam National
University Hwasun Hospital, Hwasun, Korea (W.G.J.); Faculty of Pharmacy,
University of Montréal, Montréal, Canada (P.M.D.);
OBVIA–Observatoire sur les Impacts Sociétaux de l'IA et du
Numérique, Québec, Canada (P.M.D.); and FIND–The Global
Alliance for Diagnostics, Geneva, Switzerland (M.A., M.R.)
| | - Pierre-Marie David
- From the Department of Radiology, Seoul National University Hospital
and Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu,
Seoul 03080, Korea (E.J.H., S.H.Y.); Department of Radiology, Chonnam National
University Hwasun Hospital, Hwasun, Korea (W.G.J.); Faculty of Pharmacy,
University of Montréal, Montréal, Canada (P.M.D.);
OBVIA–Observatoire sur les Impacts Sociétaux de l'IA et du
Numérique, Québec, Canada (P.M.D.); and FIND–The Global
Alliance for Diagnostics, Geneva, Switzerland (M.A., M.R.)
| | - Matthew Arentz
- From the Department of Radiology, Seoul National University Hospital
and Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu,
Seoul 03080, Korea (E.J.H., S.H.Y.); Department of Radiology, Chonnam National
University Hwasun Hospital, Hwasun, Korea (W.G.J.); Faculty of Pharmacy,
University of Montréal, Montréal, Canada (P.M.D.);
OBVIA–Observatoire sur les Impacts Sociétaux de l'IA et du
Numérique, Québec, Canada (P.M.D.); and FIND–The Global
Alliance for Diagnostics, Geneva, Switzerland (M.A., M.R.)
| | - Morten Ruhwald
- From the Department of Radiology, Seoul National University Hospital
and Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu,
Seoul 03080, Korea (E.J.H., S.H.Y.); Department of Radiology, Chonnam National
University Hwasun Hospital, Hwasun, Korea (W.G.J.); Faculty of Pharmacy,
University of Montréal, Montréal, Canada (P.M.D.);
OBVIA–Observatoire sur les Impacts Sociétaux de l'IA et du
Numérique, Québec, Canada (P.M.D.); and FIND–The Global
Alliance for Diagnostics, Geneva, Switzerland (M.A., M.R.)
| | - Soon Ho Yoon
- From the Department of Radiology, Seoul National University Hospital
and Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu,
Seoul 03080, Korea (E.J.H., S.H.Y.); Department of Radiology, Chonnam National
University Hwasun Hospital, Hwasun, Korea (W.G.J.); Faculty of Pharmacy,
University of Montréal, Montréal, Canada (P.M.D.);
OBVIA–Observatoire sur les Impacts Sociétaux de l'IA et du
Numérique, Québec, Canada (P.M.D.); and FIND–The Global
Alliance for Diagnostics, Geneva, Switzerland (M.A., M.R.)
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Eneogu RA, Mitchell EMH, Ogbudebe C, Aboki D, Anyebe V, Dimkpa CB, Egbule D, Nsa B, van der Grinten E, Soyinka FO, Abdur-Razzaq H, Useni S, Lawanson A, Onyemaechi S, Ubochioma E, Scholten J, Verhoef J, Nwadike P, Chukwueme N, Nongo D, Gidado M. Iterative evaluation of mobile computer-assisted digital chest x-ray screening for TB improves efficiency, yield, and outcomes in Nigeria. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002018. [PMID: 38232129 DOI: 10.1371/journal.pgph.0002018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 11/29/2023] [Indexed: 01/19/2024]
Abstract
Wellness on Wheels (WoW) is a model of mobile systematic tuberculosis (TB) screening of high-risk populations combining digital chest radiography with computer-aided automated detection (CAD) and chronic cough screening to identify presumptive TB clients in communities, health facilities, and prisons in Nigeria. The model evolves to address technical, political, and sustainability challenges. Screening methods were iteratively refined to balance TB yield and feasibility across heterogeneous populations. Performance metrics were compared over time. Screening volumes, risk mix, number needed to screen (NNS), number needed to test (NNT), sample loss, TB treatment initiation and outcomes. Efforts to mitigate losses along the diagnostic cascade were tracked. Persons with high CAD4TB score (≥80), who tested negative on a single spot GeneXpert were followed-up to assess TB status at six months. An experimental calibration method achieved a viable CAD threshold for testing. High risk groups and key stakeholders were engaged. Operations evolved in real time to fix problems. Incremental improvements in mean client volumes (128 to 140/day), target group inclusion (92% to 93%), on-site testing (84% to 86%), TB treatment initiation (87% to 91%), and TB treatment success (71% to 85%) were recorded. Attention to those as highest risk boosted efficiency (the NNT declined from 8.2 ± SD8.2 to 7.6 ± SD7.7). Clinical diagnosis was added after follow-up among those with ≥ 80 CAD scores and initially spot -sputum negative found 11 additional TB cases (6.3%) after 121 person-years of follow-up. Iterative adaptation in response to performance metrics foster feasible, acceptable, and efficient TB case-finding in Nigeria. High CAD scores can identify subclinical TB and those at risk of progression to bacteriologically-confirmed TB disease in the near term.
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Affiliation(s)
- Rupert A Eneogu
- United States Agency for International Development (USAID), Abuja, Nigeria
| | - Ellen M H Mitchell
- Mycobacterial Diseases and Neglected Tropical Diseases Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Danjuma Aboki
- Nasarawa State TB and Leprosy Control Program, Nasarawa, Nigeria
| | | | | | - Daniel Egbule
- Nasarawa State TB and Leprosy Control Program, Nasarawa, Nigeria
| | | | | | | | | | | | - Adebola Lawanson
- National TB and Leprosy Program, Federal Ministry of Health Nigeria, Abuja, Nigeria
| | - Simeon Onyemaechi
- National TB and Leprosy Program, Federal Ministry of Health Nigeria, Abuja, Nigeria
| | - Emperor Ubochioma
- National TB and Leprosy Program, Federal Ministry of Health Nigeria, Abuja, Nigeria
| | | | | | | | | | - Debby Nongo
- United States Agency for International Development (USAID), Abuja, Nigeria
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Vanobberghen F, Keter AK, Jacobs BK, Glass TR, Lynen L, Law I, Murphy K, van Ginneken B, Ayakaka I, van Heerden A, Maama L, Reither K. Computer-aided detection thresholds for digital chest radiography interpretation in tuberculosis diagnostic algorithms. ERJ Open Res 2024; 10:00508-2023. [PMID: 38196890 PMCID: PMC10772898 DOI: 10.1183/23120541.00508-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/25/2023] [Indexed: 01/11/2024] Open
Abstract
Objectives Use of computer-aided detection (CAD) software is recommended to improve tuberculosis screening and triage, but threshold determination is challenging if reference testing has not been performed in all individuals. We aimed to determine such thresholds through secondary analysis of the 2019 Lesotho national tuberculosis prevalence survey. Methods Symptom screening and chest radiographs were performed in participants aged ≥15 years; those symptomatic or with abnormal chest radiographs provided samples for Xpert MTB/RIF and culture testing. Chest radiographs were processed using CAD4TB version 7. We used six methodological approaches to deal with participants who did not have bacteriological test results to estimate pulmonary tuberculosis prevalence and assess diagnostic accuracy. Results Among 17 070 participants, 5214 (31%) had their tuberculosis status determined; 142 had tuberculosis. Prevalence estimates varied between methodological approaches (0.83-2.72%). Using multiple imputation to estimate tuberculosis status for those eligible but not tested, and assuming those not eligible for testing were negative, a CAD4TBv7 threshold of 13 had a sensitivity of 89.7% (95% CI 84.6-94.8) and a specificity of 74.2% (73.6-74.9), close to World Health Organization (WHO) target product profile criteria. Assuming all those not tested were negative produced similar results. Conclusions This is the first study to evaluate CAD4TB in a community screening context employing a range of approaches to account for unknown tuberculosis status. The assumption that those not tested are negative - regardless of testing eligibility status - was robust. As threshold determination must be context specific, our analytically straightforward approach should be adopted to leverage prevalence surveys for CAD threshold determination in other settings with a comparable proportion of eligible but not tested participants.
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Affiliation(s)
- Fiona Vanobberghen
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Alfred Kipyegon Keter
- Institute of Tropical Medicine, Antwerp, Belgium
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
- Ghent University, Ghent, Belgium
| | | | - Tracy R. Glass
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Irwin Law
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Keelin Murphy
- Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Irene Ayakaka
- SolidarMed, Partnerships for Health, Maseru, Lesotho
| | - Alastair van Heerden
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
- SAMRC/Wits Developmental Pathways for Health Research Unit (DPHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Llang Maama
- Disease Control Directorate, National Tuberculosis Program, Ministry of Health, Maseru, Lesotho
| | - Klaus Reither
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
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Prabhune A, Bhat S, Mallavaram A, Mehar Shagufta A, Srinivasan S. A Situational Analysis of the Impact of the COVID-19 Pandemic on Digital Health Research Initiatives in South Asia. Cureus 2023; 15:e48977. [PMID: 38111408 PMCID: PMC10726017 DOI: 10.7759/cureus.48977] [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] [Accepted: 11/17/2023] [Indexed: 12/20/2023] Open
Abstract
The objective of this paper was to evaluate and compare the quantity and sustainability of digital health initiatives in the South Asia region before and during the COVID-19 pandemic. The study used a two-step methodology of (a) descriptive analysis of digital health research articles published from 2016 to 2021 from South Asia in terms of stratification of research articles based on diseases and conditions they were developed, geography, and tasks wherein the initiative was applied and (b) a simple and replicable tool developed by authors to assess the sustainability of digital health initiatives using experimental or observational study designs. The results of the descriptive analysis highlight the following: (a) there was a 40% increase in the number of studies reported in 2020 when compared to 2019; (b) the three most common areas wherein substantive digital health research has been focused are health systems strengthening, ophthalmic disorders, and COVID-19; and (c) remote consultation, health information delivery, and clinical decision support systems are the top three commonly developed tools. We developed and estimated the inter-rater operability of the sustainability assessment tool ascertained with a Kappa value of 0.806 (±0.088). We conclude that the COVID-19 pandemic has had a positive impact on digital health research with an improvement in the number of digital health initiatives and an improvement in the sustainability score of studies published during the COVID-19 pandemic.
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Affiliation(s)
- Akash Prabhune
- Health and Information Technology, Institute of Health Management Research, Bangalore, IND
| | - Sachin Bhat
- Health and Information Technology, Institute of Health Management Research, Bangalore, IND
| | | | | | - Surya Srinivasan
- Health and Information Technology, Institute of Health Management Research, Bangalore, IND
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Fanni SC, Marcucci A, Volpi F, Valentino S, Neri E, Romei C. Artificial Intelligence-Based Software with CE Mark for Chest X-ray Interpretation: Opportunities and Challenges. Diagnostics (Basel) 2023; 13:2020. [PMID: 37370915 DOI: 10.3390/diagnostics13122020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/26/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
Chest X-ray (CXR) is the most important technique for performing chest imaging, despite its well-known limitations in terms of scope and sensitivity. These intrinsic limitations of CXR have prompted the development of several artificial intelligence (AI)-based software packages dedicated to CXR interpretation. The online database "AI for radiology" was queried to identify CE-marked AI-based software available for CXR interpretation. The returned studies were divided according to the targeted disease. AI-powered computer-aided detection software is already widely adopted in screening and triage for pulmonary tuberculosis, especially in countries with few resources and suffering from high a burden of this disease. AI-based software has also been demonstrated to be valuable for the detection of lung nodules detection, automated flagging of positive cases, and post-processing through the development of digital bone suppression software able to produce digital bone suppressed images. Finally, the majority of available CE-marked software packages for CXR are designed to recognize several findings, with potential differences in sensitivity and specificity for each of the recognized findings.
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Affiliation(s)
- Salvatore Claudio Fanni
- Department of Translational Research, Academic Radiology, University of Pisa, 56126 Pisa, Italy
| | - Alessandro Marcucci
- Department of Translational Research, Academic Radiology, University of Pisa, 56126 Pisa, Italy
| | - Federica Volpi
- Department of Translational Research, Academic Radiology, University of Pisa, 56126 Pisa, Italy
| | | | - Emanuele Neri
- Department of Translational Research, Academic Radiology, University of Pisa, 56126 Pisa, Italy
| | - Chiara Romei
- Department of Diagnostic Imaging, 2nd Radiology Unit, Pisa University-Hospital, Via Paradisa 2, 56124 Pisa, Italy
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Diagnostic Accuracy of the Artificial Intelligence Methods in Medical Imaging for Pulmonary Tuberculosis: A Systematic Review and Meta-Analysis. J Clin Med 2022; 12:jcm12010303. [PMID: 36615102 PMCID: PMC9820940 DOI: 10.3390/jcm12010303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/21/2022] [Accepted: 12/24/2022] [Indexed: 01/03/2023] Open
Abstract
Tuberculosis (TB) remains one of the leading causes of death among infectious diseases worldwide. Early screening and diagnosis of pulmonary tuberculosis (PTB) is crucial in TB control, and tend to benefit from artificial intelligence. Here, we aimed to evaluate the diagnostic efficacy of a variety of artificial intelligence methods in medical imaging for PTB. We searched MEDLINE and Embase with the OVID platform to identify trials published update to November 2022 that evaluated the effectiveness of artificial-intelligence-based software in medical imaging of patients with PTB. After data extraction, the quality of studies was assessed using quality assessment of diagnostic accuracy studies 2 (QUADAS-2). Pooled sensitivity and specificity were estimated using a bivariate random-effects model. In total, 3987 references were initially identified and 61 studies were finally included, covering a wide range of 124,959 individuals. The pooled sensitivity and the specificity were 91% (95% confidence interval (CI), 89-93%) and 65% (54-75%), respectively, in clinical trials, and 94% (89-96%) and 95% (91-97%), respectively, in model-development studies. These findings have demonstrated that artificial-intelligence-based software could serve as an accurate tool to diagnose PTB in medical imaging. However, standardized reporting guidance regarding AI-specific trials and multicenter clinical trials is urgently needed to truly transform this cutting-edge technology into clinical practice.
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Jerene D, Muleta C, Dressie S, Ahmed A, Tarekegn G, Haile T, Bedru A, Mustapha G, Gebhard A, Wares F. The yield of chest X-ray based versus symptom-based screening among patients with diabetes mellitus in public health facilities in Addis Ababa, Ethiopia. J Clin Tuberc Other Mycobact Dis 2022; 29:100333. [PMID: 36238947 PMCID: PMC9551073 DOI: 10.1016/j.jctube.2022.100333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Patients with diabetes mellitus (DM) are at increased risk of developing TB, but the best screening algorithm for early detection and treatment of TB remains unknown. Our objective was to determine if combining routine chest X-ray screening could have a better yield compared with symptom-based screening alone. Methods We conducted this cross-sectional study between September 2020 and September 2021 in 26 public health facilities in Addis Ababa, Ethiopia. All DM patients attending the clinics during the study period were offered chest X-ray and symptom screening simultaneously followed by confirmatory Xpert testing. We analyzed the number and proportion of patients with TB by the diagnostic algorithm category and performed binary logistic regression analysis to identify predictors of TB diagnosis. Results Of 7394 patients screened, 54.6 % were female, and their median age was 53 years. Type-2 diabetes accounted for 89.6 % of all participants of the patients. Of 172 symptomatic patients, chest X-ray suggested TB in 19, and 11 of these were confirmed to have TB (8 bacterilogicially confirmed and 3 clinically diagnosed). Only 2 of the 152 asymptomatic patients without X-ray findings had TB (both bacteriologically confirmed). X-ray was not done for one patient. On the other hand, 28 of 7222 symptom-negative patients had X-ray findings suggestive of TB, and 7 of these were subsequently confirmed with TB (6 clinically diagnosed). When combined with 8 patients who were on treatment for TB at the time of the screening, the overall point prevalence of TB was 380 per 100,000. The direct cost associated with the X-ray-based screening was 42-times higher. Conclusion Chest X-ray led to detection of about a third of TB patients which otherwise would have been missed but the algorithm is more expensive. Its full cost implication needs further economic evaluation.
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Affiliation(s)
- Degu Jerene
- KNCV Tuberculosis Foundation, Division of TB Elimination and Health Systems Innovation, The Hague, the Netherlands,Corresponding author at: KNCV Tuberculosis Foundation, Maanweg 174 – 2516, AB, 2501 CC, The Hague, the Netherlands.
| | - Chaltu Muleta
- KNCV Tuberculosis Foundation, Ethiopia Country Office, Addis Ababa, Ethiopia
| | - Solomon Dressie
- Addis Ababa City Administration Regional Health Bureau, Disease Prevention and Control, Addis Ababa, Ethiopia
| | - Abdurezak Ahmed
- Addis Ababa University, Tikur Anbessa Specialized Hospital, Department of Internal Medicine, Diabetic Clinic, Addis Ababa, Ethiopia
| | - Getahun Tarekegn
- Addis Ababa University, Tikur Anbessa Specialized Hospital, Department of Internal Medicine, Diabetic Clinic, Addis Ababa, Ethiopia
| | - Tewodros Haile
- Addis Ababa University, Tikur Anbessa Specialized Hospital, Department of Internal Medicine, Pulmonary and Critical Care Medicine Unit, Addis Ababa, Ethiopia
| | - Ahmed Bedru
- KNCV Tuberculosis Foundation, Ethiopia Country Office, Addis Ababa, Ethiopia
| | - Gidado Mustapha
- KNCV Tuberculosis Foundation, Division of TB Elimination and Health Systems Innovation, The Hague, the Netherlands
| | - Agnes Gebhard
- KNCV Tuberculosis Foundation, Division of TB Elimination and Health Systems Innovation, The Hague, the Netherlands
| | - Fraser Wares
- KNCV Tuberculosis Foundation, Division of TB Elimination and Health Systems Innovation, The Hague, the Netherlands
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Naufal F, Chaisson LH, Robsky KO, Delgado-Barroso P, Alvarez-Manzo HS, Miller CR, Shapiro AE, Golub JE. Number needed to screen for TB in clinical, structural or occupational risk groups. Int J Tuberc Lung Dis 2022; 26:500-508. [PMID: 35650693 DOI: 10.5588/ijtld.21.0749] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND: Screening for active TB using active case-finding (ACF) may reduce TB incidence, prevalence, and mortality; however, yield of ACF interventions varies substantially across populations. We systematically reviewed studies reporting on ACF to calculate the number needed to screen (NNS) for groups at high risk for TB.METHODS: We conducted a literature search for studies reporting ACF for adults published between November 2010 and February 2020. We determined active TB prevalence detected through various screening strategies and calculated crude NNS for - TB confirmed using culture or Xpert® MTB/RIF, and weighted mean NNS stratified by screening strategy, risk group, and country-level TB incidence.RESULTS: We screened 27,223 abstracts; 90 studies were included (41 in low/moderate and 49 in medium/high TB incidence settings). High-risk groups included inpatients, outpatients, people living with diabetes (PLWD), migrants, prison inmates, persons experiencing homelessness (PEH), healthcare workers, and miners. Screening strategies included symptom-based screening, chest X-ray and Xpert testing. NNS varied widely across and within incidence settings based on risk groups and screening methods. Screening tools with higher sensitivity (e.g., Xpert, CXR) were associated with lower NNS estimates.CONCLUSIONS: NNS for ACF strategies varies substantially between adult risk groups. Specific interventions should be tailored based on local epidemiology and costs.
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Affiliation(s)
- F Naufal
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - L H Chaisson
- Division of Infectious Diseases, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - K O Robsky
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - P Delgado-Barroso
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - H S Alvarez-Manzo
- Department of Molecular Microbiology and Immunology, Johns Hopkins University, Baltimore, MD, USA
| | - C R Miller
- World Health Organization, Geneva, Switzerland
| | - A E Shapiro
- Departments of Global Health and Medicine, University of Washington, Seattle, WA
| | - J E Golub
- Division of Infectious Diseases, Department of Medicine, University of Illinois at Chicago, Chicago, IL, Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA, Department of International Health, Johns Hopkins University, Baltimore, MD, USA
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Van't Hoog A, Viney K, Biermann O, Yang B, Leeflang MM, Langendam MW. Symptom- and chest-radiography screening for active pulmonary tuberculosis in HIV-negative adults and adults with unknown HIV status. Cochrane Database Syst Rev 2022; 3:CD010890. [PMID: 35320584 PMCID: PMC9109771 DOI: 10.1002/14651858.cd010890.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Systematic screening in high-burden settings is recommended as a strategy for early detection of pulmonary tuberculosis disease, reducing mortality, morbidity and transmission, and improving equity in access to care. Questioning for symptoms and chest radiography (CXR) have historically been the most widely available tools to screen for tuberculosis disease. Their accuracy is important for the design of tuberculosis screening programmes and determines, in combination with the accuracy of confirmatory diagnostic tests, the yield of a screening programme and the burden on individuals and the health service. OBJECTIVES To assess the sensitivity and specificity of questioning for the presence of one or more tuberculosis symptoms or symptom combinations, CXR, and combinations of these as screening tools for detecting bacteriologically confirmed pulmonary tuberculosis disease in HIV-negative adults and adults with unknown HIV status who are considered eligible for systematic screening for tuberculosis disease. Second, to investigate sources of heterogeneity, especially in relation to regional, epidemiological, and demographic characteristics of the study populations. SEARCH METHODS We searched the MEDLINE, Embase, LILACS, and HTA (Health Technology Assessment) databases using pre-specified search terms and consulted experts for unpublished reports, for the period 1992 to 2018. The search date was 10 December 2018. This search was repeated on 2 July 2021. SELECTION CRITERIA Studies were eligible if participants were screened for tuberculosis disease using symptom questions, or abnormalities on CXR, or both, and were offered confirmatory testing with a reference standard. We included studies if diagnostic two-by-two tables could be generated for one or more index tests, even if not all participants were subjected to a microbacteriological reference standard. We excluded studies evaluating self-reporting of symptoms. DATA COLLECTION AND ANALYSIS We categorized symptom and CXR index tests according to commonly used definitions. We assessed the methodological quality of included studies using the QUADAS-2 instrument. We examined the forest plots and receiver operating characteristic plots visually for heterogeneity. We estimated summary sensitivities and specificities (and 95% confidence intervals (CI)) for each index test using bivariate random-effects methods. We analyzed potential sources of heterogeneity in a hierarchical mixed-model. MAIN RESULTS The electronic database search identified 9473 titles and abstracts. Through expert consultation, we identified 31 reports on national tuberculosis prevalence surveys as eligible (of which eight were already captured in the search of the electronic databases), and we identified 957 potentially relevant articles through reference checking. After removal of duplicates, we assessed 10,415 titles and abstracts, of which we identified 430 (4%) for full text review, whereafter we excluded 364 articles. In total, 66 articles provided data on 59 studies. We assessed the 2 July 2021 search results; seven studies were potentially eligible but would make no material difference to the review findings or grading of the evidence, and were not added in this edition of the review. We judged most studies at high risk of bias in one or more domains, most commonly because of incorporation bias and verification bias. We judged applicability concerns low in more than 80% of studies in all three domains. The three most common symptom index tests, cough for two or more weeks (41 studies), any cough (21 studies), and any tuberculosis symptom (29 studies), showed a summary sensitivity of 42.1% (95% CI 36.6% to 47.7%), 51.3% (95% CI 42.8% to 59.7%), and 70.6% (95% CI 61.7% to 78.2%, all very low-certainty evidence), and a specificity of 94.4% (95% CI 92.6% to 95.8%, high-certainty evidence), 87.6% (95% CI 81.6% to 91.8%, low-certainty evidence), and 65.1% (95% CI 53.3% to 75.4%, low-certainty evidence), respectively. The data on symptom index tests were more heterogenous than those for CXR. The studies on any tuberculosis symptom were the most heterogeneous, but had the lowest number of variables explaining this variation. Symptom index tests also showed regional variation. The summary sensitivity of any CXR abnormality (23 studies) was 94.7% (95% CI 92.2% to 96.4%, very low-certainty evidence) and 84.8% (95% CI 76.7% to 90.4%, low-certainty evidence) for CXR abnormalities suggestive of tuberculosis (19 studies), and specificity was 89.1% (95% CI 85.6% to 91.8%, low-certainty evidence) and 95.6% (95% CI 92.6% to 97.4%, high-certainty evidence), respectively. Sensitivity was more heterogenous than specificity, and could be explained by regional variation. The addition of cough for two or more weeks, whether to any (pulmonary) CXR abnormality or to CXR abnormalities suggestive of tuberculosis, resulted in a summary sensitivity and specificity of 99.2% (95% CI 96.8% to 99.8%) and 84.9% (95% CI 81.2% to 88.1%) (15 studies; certainty of evidence not assessed). AUTHORS' CONCLUSIONS The summary estimates of the symptom and CXR index tests may inform the choice of screening and diagnostic algorithms in any given setting or country where screening for tuberculosis is being implemented. The high sensitivity of CXR index tests, with or without symptom questions in parallel, suggests a high yield of persons with tuberculosis disease. However, additional considerations will determine the design of screening and diagnostic algorithms, such as the availability and accessibility of CXR facilities or the resources to fund them, and the need for more or fewer diagnostic tests to confirm the diagnosis (depending on screening test specificity), which also has resource implications. These review findings should be interpreted with caution due to methodological limitations in the included studies and regional variation in sensitivity and specificity. The sensitivity and specificity of an index test in a specific setting cannot be predicted with great precision due to heterogeneity. This should be borne in mind when planning for and implementing tuberculosis screening programmes.
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Affiliation(s)
- Anja Van't Hoog
- Anja van't Hoog, Health Research & Training Consultancy, Utrecht, Netherlands
| | - Kerri Viney
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- School of Public Health, The University of Sydney, Sydney, Australia
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Olivia Biermann
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Bada Yang
- Epidemiology and Data Science, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Mariska Mg Leeflang
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Miranda W Langendam
- Epidemiology and Data Science, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
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10
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Digital Chest X-ray with Computer-aided Detection for TB Screening within Correctional Facilities. Ann Am Thorac Soc 2021; 19:1313-1319. [PMID: 34914539 DOI: 10.1513/annalsats.202103-380oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Realizing the Global Plan to End TB will require reaching at least 90% of people in key populations such as inmates through optimizing case-finding approaches. OBJECTIVES To evaluate the addition of digital chest x-ray (d-CXR) with computer-aided detection (CAD) to symptoms on TB yield among inmates. METHODS Consecutive adult inmates from four correctional facilities in South Africa were screened for TB using symptoms and d-CXR. Any person with >1 symptom or CAD>50 provided two sputa for liquid culture and GeneXpert MTB/RIF Ultra (Xpert Ultra) testing. In a sample of 800 symptom-negative inmates with CAD<50, Xpert Ultra testing was also conducted. TB yield was defined as the proportion of new bacteriologically-confirmed TB patients identified. RESULTS We enrolled 3,576 participants; 99.6% male, median age of 34 years (IQR: 28-41), and 584 (16.3%) HIV-positive. Of those screened, 867 (24.2%) participants required investigation [394 (11.2%) symptomatic, 685 (19.1%) on abnormal CAD and 867 (24.2%) with either]. Sputum was taken in 747 (86.2%) participants, with 28 (7.8 per 1000 population) new TB cases diagnosed. Based on hypothesized screening modalities, yield would have been 3.6 per 1,000 population on symptoms alone and 7.0 per 1,000 population on d-CXR alone. Amongst an additional 800 inmates tested whom initially screened symptom-negative and CAD<50, five TB cases were diagnosed. No difference in TB yield when comparing Xpert Ultra against culture (5.6 vs. 4.8 per 1,000 population; p=0.21). CONCLUSIONS The addition of d-CXR identified two times more undiagnosed TB than patients investigated on symptoms alone. Complimentary use of d-CXR may potentially overcome subjectivity inherent in symptom screening alone for identifying TB in this population.
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11
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Nsengiyumva NP, Hussain H, Oxlade O, Majidulla A, Nazish A, Khan AJ, Menzies D, Ahmad Khan F, Schwartzman K. Triage of Persons With Tuberculosis Symptoms Using Artificial Intelligence-Based Chest Radiograph Interpretation: A Cost-Effectiveness Analysis. Open Forum Infect Dis 2021; 8:ofab567. [PMID: 34917694 PMCID: PMC8671604 DOI: 10.1093/ofid/ofab567] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/05/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND In settings without access to rapid expert radiographic interpretation, artificial intelligence (AI)-based chest radiograph (CXR) analysis can triage persons presenting with possible tuberculosis (TB) symptoms, to identify those who require additional microbiological testing. However, there is limited evidence of the cost-effectiveness of this technology as a triage tool. METHODS A decision analysis model was developed to evaluate the cost-effectiveness of triage strategies with AI-based CXR analysis for patients presenting with symptoms suggestive of pulmonary TB in Karachi, Pakistan. These strategies were compared to the current standard of care using microbiological testing with smear microscopy or GeneXpert, without prior triage. Positive triage CXRs were considered to improve referral success for microbiologic testing, from 91% to 100% for eligible persons. Software diagnostic accuracy was based on a prospective field study in Karachi. Other inputs were obtained from the Pakistan TB Program. The analysis was conducted from the healthcare provider perspective, and costs were expressed in 2020 US dollars. RESULTS Compared to upfront smear microscopy for all persons with presumptive TB, triage strategies with AI-based CXR analysis were projected to lower costs by 19%, from $23233 per 1000 persons, and avert 3%-4% disability-adjusted life-years (DALYs), from 372 DALYs. Compared to upfront GeneXpert, AI-based triage strategies lowered projected costs by 37%, from $34346 and averted 4% additional DALYs, from 369 DALYs. Reinforced follow-up for persons with positive triage CXRs but negative microbiologic tests was particularly cost-effective. CONCLUSIONS In lower-resource settings, the addition of AI-based CXR triage before microbiologic testing for persons with possible TB symptoms can reduce costs, avert additional DALYs, and improve TB detection.
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Affiliation(s)
- Ntwali Placide Nsengiyumva
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Canada
| | | | - Olivia Oxlade
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Canada
| | | | - Ahsana Nazish
- Ghori Tuberculosis Clinic, Indus Hospital, Karachi, Pakistan
| | - Aamir J Khan
- Interactive Research and Development Global, Singapore
| | - Dick Menzies
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Canada
- Department of Medicine and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Faiz Ahmad Khan
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Canada
- Department of Medicine and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Kevin Schwartzman
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Canada
- Department of Medicine and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
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12
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Fehr J, Konigorski S, Olivier S, Gunda R, Surujdeen A, Gareta D, Smit T, Baisley K, Moodley S, Moosa Y, Hanekom W, Koole O, Ndung'u T, Pillay D, Grant AD, Siedner MJ, Lippert C, Wong EB. Computer-aided interpretation of chest radiography reveals the spectrum of tuberculosis in rural South Africa. NPJ Digit Med 2021; 4:106. [PMID: 34215836 PMCID: PMC8253848 DOI: 10.1038/s41746-021-00471-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 05/21/2021] [Indexed: 02/01/2023] Open
Abstract
Computer-aided digital chest radiograph interpretation (CAD) can facilitate high-throughput screening for tuberculosis (TB), but its use in population-based active case-finding programs has been limited. In an HIV-endemic area in rural South Africa, we used a CAD algorithm (CAD4TBv5) to interpret digital chest x-rays (CXR) as part of a mobile health screening effort. Participants with TB symptoms or CAD4TBv5 score above the triaging threshold were referred for microbiological sputum assessment. During an initial pilot phase, a low CAD4TBv5 triaging threshold of 25 was selected to maximize TB case finding. We report the performance of CAD4TBv5 in screening 9,914 participants, 99 (1.0%) of whom were found to have microbiologically proven TB. CAD4TBv5 was able to identify TB cases at the same sensitivity but lower specificity as a blinded radiologist, whereas the next generation of the algorithm (CAD4TBv6) achieved comparable sensitivity and specificity to the radiologist. The CXRs of people with microbiologically confirmed TB spanned a range of lung field abnormality, including 19 (19.2%) cases deemed normal by the radiologist. HIV serostatus did not impact CAD4TB's performance. Notably, 78.8% of the TB cases identified during this population-based survey were asymptomatic and therefore triaged for sputum collection on the basis of CAD4TBv5 score alone. While CAD4TBv6 has the potential to replace radiologists for triaging CXRs in TB prevalence surveys, population-specific piloting is necessary to set the appropriate triaging thresholds. Further work on image analysis strategies is needed to identify radiologically subtle active TB.
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Affiliation(s)
- Jana Fehr
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Digital Health & Machine Learning, Hasso Plattner Institute for Digital Engineering, Berlin, Germany
| | - Stefan Konigorski
- Digital Health & Machine Learning, Hasso Plattner Institute for Digital Engineering, Berlin, Germany
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stephen Olivier
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Resign Gunda
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | | | - Dickman Gareta
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Theresa Smit
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Kathy Baisley
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- London School of Hygiene & Tropical Medicine, London, UK
| | - Sashen Moodley
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Yumna Moosa
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Willem Hanekom
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | - Olivier Koole
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- London School of Hygiene & Tropical Medicine, London, UK
| | - Thumbi Ndung'u
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Division of Infection and Immunity, University College London, London, UK
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
- Ragon Institute of MGH, MIT and Harvard University, Cambridge, MA, USA
- Max Planck Institute for Infection Biology, Berlin, Germany
| | - Deenan Pillay
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | - Alison D Grant
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- London School of Hygiene & Tropical Medicine, London, UK
- School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Mark J Siedner
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- Harvard Medical School, Boston, MA, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Christoph Lippert
- Digital Health & Machine Learning, Hasso Plattner Institute for Digital Engineering, Berlin, Germany
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emily B Wong
- Africa Health Research Institute, KwaZulu-Natal, South Africa.
- Harvard Medical School, Boston, MA, USA.
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA.
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13
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Laney AS, Pontali E. Computer-assisted interpretation of chest radiographs: signs of hope for silicosis and tuberculosis. Int J Tuberc Lung Dis 2020; 24:362-363. [PMID: 32317057 DOI: 10.5588/ijtld.19.0805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- A S Laney
- Surveillance Branch, Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, USA
| | - E Pontali
- Department of Infectious Diseases, Galliera Hospital, Genoa, Italy
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14
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Evaluation of computer aided detection of tuberculosis on chest radiography among people with diabetes in Karachi Pakistan. Sci Rep 2020; 10:6276. [PMID: 32286389 PMCID: PMC7156514 DOI: 10.1038/s41598-020-63084-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 03/25/2020] [Indexed: 12/19/2022] Open
Abstract
Pakistan ranks fifth among high tuberculosis (TB) burden countries and also has seventh highest burden for diabetes mellitus (DM). DM increases the risk of developing TB and contributes to adverse TB treatment outcomes hence screening and integrated management for both diseases in high burden countries is suggested. Computer-Aided Detection for TB (CAD4TB) can potentially be used as triage tool in low resource settings to pre-screen individuals for Xpert MTB/RIF testing. The aim of this study was to evaluate the diagnostic accuracy and performance of CAD4TB software in people with diabetes (PWD) enrolled in a TB screening program in Karachi, Pakistan. A total of 694 individuals with a diagnosis of DM (of whom 31.1% were newly diagnosed) were screened with CAD4TB and simultaneously provided sputum for Xpert MTB/RIF testing. Of the 74 (10.7%) participants who had bacteriologically positive (MTB+) results on Xpert testing, 54 (73%) had a CAD4TB score >70; and 155 (25%) participants who tested MTB-negative had scores >70. The area under the receiver operator curve was 0.78 (95% CI: 0.77-0.80). Our study findings indicate that CAD4TB offers good diagnostic accuracy as a triage test for TB screening among PWD using Xpert MTB/RIF as the reference standard.
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15
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Lee Y, Raviglione MC, Flahault A. Use of Digital Technology to Enhance Tuberculosis Control: Scoping Review. J Med Internet Res 2020; 22:e15727. [PMID: 32053111 PMCID: PMC7055857 DOI: 10.2196/15727] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 10/22/2019] [Accepted: 10/22/2019] [Indexed: 02/06/2023] Open
Abstract
Background Tuberculosis (TB) is the leading cause of death from a single infectious agent, with around 1.5 million deaths reported in 2018, and is a major contributor to suffering worldwide, with an estimated 10 million new cases every year. In the context of the World Health Organization’s End TB strategy and the quest for digital innovations, there is a need to understand what is happening around the world regarding research into the use of digital technology for better TB care and control. Objective The purpose of this scoping review was to summarize the state of research on the use of digital technology to enhance TB care and control. This study provides an overview of publications covering this subject and answers 3 main questions: (1) to what extent has the issue been addressed in the scientific literature between January 2016 and March 2019, (2) which countries have been investing in research in this field, and (3) what digital technologies were used? Methods A Web-based search was conducted on PubMed and Web of Science. Studies that describe the use of digital technology with specific reference to keywords such as TB, digital health, eHealth, and mHealth were included. Data from selected studies were synthesized into 4 functions using narrative and graphical methods. Such digital health interventions were categorized based on 2 classifications, one by function and the other by targeted user. Results A total of 145 relevant studies were identified out of the 1005 published between January 2016 and March 2019. Overall, 72.4% (105/145) of the research focused on patient care and 20.7% (30/145) on surveillance and monitoring. Other programmatic functions 4.8% (7/145) and electronic learning 2.1% (3/145) were less frequently studied. Most digital health technologies used for patient care included primarily diagnostic 59.4% (63/106) and treatment adherence tools 40.6% (43/106). On the basis of the second type of classification, 107 studies targeted health care providers (107/145, 73.8%), 20 studies targeted clients (20/145, 13.8%), 17 dealt with data services (17/145, 11.7%), and 1 study was on the health system or resource management. The first authors’ affiliations were mainly from 3 countries: the United States (30/145 studies, 20.7%), China (20/145 studies, 13.8%), and India (17/145 studies, 11.7%). The researchers from the United States conducted their research both domestically and abroad, whereas researchers from China and India conducted all studies domestically. Conclusions The majority of research conducted between January 2016 and March 2019 on digital interventions for TB focused on diagnostic tools and treatment adherence technologies, such as video-observed therapy and SMS. Only a few studies addressed interventions for data services and health system or resource management.
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Affiliation(s)
- Yejin Lee
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Global Studies Institute, University of Geneva, Geneva, Switzerland
| | - Mario C Raviglione
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Global Studies Institute, University of Geneva, Geneva, Switzerland.,Centre for Multidisciplinary Research in Health Science (MACH), Università di Milano, Milan, Italy
| | - Antoine Flahault
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Global Studies Institute, University of Geneva, Geneva, Switzerland
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16
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Harris M, Qi A, Jeagal L, Torabi N, Menzies D, Korobitsyn A, Pai M, Nathavitharana RR, Ahmad Khan F. A systematic review of the diagnostic accuracy of artificial intelligence-based computer programs to analyze chest x-rays for pulmonary tuberculosis. PLoS One 2019; 14:e0221339. [PMID: 31479448 PMCID: PMC6719854 DOI: 10.1371/journal.pone.0221339] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 08/05/2019] [Indexed: 12/11/2022] Open
Abstract
We undertook a systematic review of the diagnostic accuracy of artificial intelligence-based software for identification of radiologic abnormalities (computer-aided detection, or CAD) compatible with pulmonary tuberculosis on chest x-rays (CXRs). We searched four databases for articles published between January 2005-February 2019. We summarized data on CAD type, study design, and diagnostic accuracy. We assessed risk of bias with QUADAS-2. We included 53 of the 4712 articles reviewed: 40 focused on CAD design methods (“Development” studies) and 13 focused on evaluation of CAD (“Clinical” studies). Meta-analyses were not performed due to methodological differences. Development studies were more likely to use CXR databases with greater potential for bias as compared to Clinical studies. Areas under the receiver operating characteristic curve (median AUC [IQR]) were significantly higher: in Development studies AUC: 0.88 [0.82–0.90]) versus Clinical studies (0.75 [0.66–0.87]; p-value 0.004); and with deep-learning (0.91 [0.88–0.99]) versus machine-learning (0.82 [0.75–0.89]; p = 0.001). We conclude that CAD programs are promising, but the majority of work thus far has been on development rather than clinical evaluation. We provide concrete suggestions on what study design elements should be improved.
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Affiliation(s)
- Miriam Harris
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
- Department of Medicine, McGill University Health Centre, Montreal, Canada
- Department of Medicine, Boston University–Boston Medical Center, Boston, Massachusetts, United States of America
- * E-mail:
| | - Amy Qi
- Department of Medicine, McGill University Health Centre, Montreal, Canada
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute & Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Luke Jeagal
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute & Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Nazi Torabi
- St. Michael's Hospital, Li Ka Shing International Healthcare Education Centre, Toronto, Canada
| | - Dick Menzies
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute & Research Institute of the McGill University Health Centre, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
| | - Alexei Korobitsyn
- Laboratories, Diagnostics & Drug Resistance Global TB Programme WHO, Geneva, Switzerland
| | - Madhukar Pai
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute & Research Institute of the McGill University Health Centre, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
| | - Ruvandhi R. Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Faiz Ahmad Khan
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute & Research Institute of the McGill University Health Centre, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
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