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Powell L, Denoeud-Ndam L, Herrera N, Masaba R, Tchounga B, Siamba S, Ouma M, Petnga SJ, Machekano R, Pamen B, Okomo G, Simo L, Casenghi M, Rakhmanina N, Tiam A. HIV matters when diagnosing TB in young children: an ancillary analysis in children enrolled in the INPUT stepped wedge cluster randomized study. BMC Infect Dis 2023; 23:234. [PMID: 37069518 PMCID: PMC10107571 DOI: 10.1186/s12879-023-08216-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 04/03/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND Children under age five years, particularly those living with HIV (CLHIV), are at risk for rapid progression of tuberculosis (TB). We aimed to describe TB clinical presentations, diagnostic pathways and treatment outcomes in CLHIV compared to children without HIV in Cameroon and Kenya. METHODS This sub-analysis of a cluster-randomized trial evaluating the integration of pediatric TB services from May 2019 to March 2021 enrolled children age < 5 years with TB. We estimated the HIV infection rate with 95% confidence interval (CI). We compared TB clinical presentations, diagnostic pathways and treatment outcomes in CLHIV and children without HIV. Finally, we investigated whether HIV infection was associated with a shorter time to TB diagnosis (≤ 3 months from symptoms onset) after adjusting for covariates. Univariable and multivariable logistic regression analysis were performed with adjusted odds ratios (AORs) presented as measures of the association of covariates with HIV status and with shorter time to TB diagnosis. RESULTS We enrolled 157 children with TB (mean age was 1.5 years) and 22/157 (14.0% [9.0-20.4%]) were co-infected with HIV. CLHIV were more likely to initially present with acute malnutrition (AOR 3.16 [1.14-8.71], p = 0.027). Most TB diagnoses (140/157, 89%) were made clinically with pulmonary TB being the most common presentation; however, there was weak evidence of more frequent bacteriologic confirmation of TB in CLHIV, 18% vs. 9% (p = 0.067), due to the contribution of lateral-flow urine lipoarabinomannan to the diagnosis. HIV positivity (AOR: 6.10 [1.32-28.17], p = 0.021) was independently associated with a shorter time to TB diagnosis as well as fatigue (AOR: 6.58 [2.28-18.96], p = 0.0005), and existence of a household contact diagnosed with TB (AOR: 5.60 [1.58-19.83], p = 0.0075), whereas older age (AOR: 0.35 [0.15-0.85], p = 0.020 for age 2-5 years), night sweats (AOR: 0.24 [0.10-0.60], p = 0.0022) and acute malnutrition (AOR: 0.36 [0.14-0.92], p = 0.034) were associated with a delayed diagnosis. The case fatality rate was 9% (2/22) in CLHIV and 4% (6/135) in children without HIV, p = 0.31. CONCLUSIONS These results altogether advocate for better integration of TB services into all pediatric entry points with a special focus on nutrition services, and illustrate the importance of non-sputum-based TB diagnostics especially in CLHIV. TRIAL REGISTRATION NCT03862261, first registration 05/03/2019.
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Affiliation(s)
- L Powell
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - L Denoeud-Ndam
- Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland.
| | - N Herrera
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| | - R Masaba
- Elizabeth Glaser Pediatric AIDS Foundation, Nairobi, Kenya
| | - B Tchounga
- Elizabeth Glaser Pediatric AIDS Foundation, Yaounde, Cameroon
| | - S Siamba
- Elizabeth Glaser Pediatric AIDS Foundation, Nairobi, Kenya
| | - M Ouma
- Elizabeth Glaser Pediatric AIDS Foundation, Nairobi, Kenya
| | - S J Petnga
- Elizabeth Glaser Pediatric AIDS Foundation, Yaounde, Cameroon
| | - R Machekano
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| | - B Pamen
- Department of Disease, Epidemic and pandemic control, Ministry of Health, Yaounde, Cameroon
| | - G Okomo
- Department of Health, Homa Bay county Government, Homa Bay, Kenya
| | - L Simo
- Elizabeth Glaser Pediatric AIDS Foundation, Yaounde, Cameroon
| | - M Casenghi
- Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland
| | - N Rakhmanina
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| | - A Tiam
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
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Perier C, Nasinghe E, Charles I, Ssetaba LJ, Ahyong V, Bangs D, Beatty PR, Czudnochowski N, Diallo A, Dugan E, Fabius JM, Fong Baker H, Gardner J, Isaacs S, Joanah B, Kalantar K, Kateete D, Knight M, Krasilnikov M, Krogan NJ, Langelier C, Lee E, Li LM, Licht D, Lien K, Lyons Z, Mboowa G, Mwebaza I, Mwesigwa S, Nalwadda G, Nichols R, Penaranda ME, Petnic S, Phelps M, Popper SJ, Rape M, Reingold A, Robbins R, Rosenberg OS, Savage DF, Schildhauer S, Settles ML, Sserwadda I, Stanley S, Tato CM, Tsitsiklis A, Van Dis E, Vanaerschot M, Vinden J, Cox JS, Joloba ML, Schaletzky J. Workshop-based learning and networking: a scalable model for research capacity strengthening in low- and middle-income countries. Glob Health Action 2022; 15:2062175. [PMID: 35730550 PMCID: PMC9225690 DOI: 10.1080/16549716.2022.2062175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Science education and research have the potential to drive profound change in low- and middle-income countries (LMICs) through encouraging innovation, attracting industry, and creating job opportunities. However, in LMICs, research capacity is often limited, and acquisition of funding and access to state-of-the-art technologies is challenging. The Alliance for Global Health and Science (the Alliance) was founded as a partnership between the University of California, Berkeley (USA) and Makerere University (Uganda), with the goal of strengthening Makerere University’s capacity for bioscience research. The flagship program of the Alliance partnership is the MU/UCB Biosciences Training Program, an in-country, hands-on workshop model that trains a large number of students from Makerere University in infectious disease and molecular biology research. This approach nucleates training of larger and more diverse groups of students, development of mentoring and bi-directional research partnerships, and support of the local economy. Here, we describe the project, its conception, implementation, challenges, and outcomes of bioscience research workshops. We aim to provide a blueprint for workshop implementation, and create a valuable resource for bioscience research capacity strengthening in LMICs.
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Affiliation(s)
- Celine Perier
- H. Wheeler Center for Emerging & Neglected Diseases (CEND), University of California, Berkeley, CA, USA
| | | | - Isabelle Charles
- H. Wheeler Center for Emerging & Neglected Diseases (CEND), University of California, Berkeley, CA, USA
| | | | - Vida Ahyong
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Derek Bangs
- Department of Molecular and Cell Biology, University of California, Berkeley, CA, USA
| | - P Robert Beatty
- Department of Molecular and Cell Biology, University of California, Berkeley, CA, USA
| | | | - Amy Diallo
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Eli Dugan
- Department of Molecular and Cell Biology, University of California, Berkeley, CA, USA
| | - Jacqueline M Fabius
- Quantitative Biosciences Institute (QBI), University of California, San Francisco, CA, USA
| | - Hildy Fong Baker
- School of Public Health, Center for Global Public Health (CGPH), University of California, Berkeley, CA, USA
| | - Jackson Gardner
- Department of Medicine, University of California, San Francisco, CA, USA
| | | | - Birungi Joanah
- School of Biomedical Sciences, Makerere University, Kampala, Uganda
| | | | - David Kateete
- School of Biomedical Sciences, Makerere University, Kampala, Uganda
| | - Matt Knight
- Department of Plant and Microbial Biology, University of California, Berkeley, CA, USA
| | - Maria Krasilnikov
- Department of Molecular Biology and Microbiology, Tufts Graduate School of Biomedical Sciences, Boston, MA, USA
| | - Nevan J Krogan
- Quantitative Biosciences Institute (QBI), University of California, San Francisco, CA, USA.,Gladstone Institute of Data Science and Biotechnology, J. David Gladstone Institutes, San Francisco, CA, USA
| | | | - Eric Lee
- Graduate Group in Infectious Diseases and Immunity, School of Public Health, University of California, Berkeley, CA, USA
| | - Lucy M Li
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Daniel Licht
- Department of Molecular and Cell Biology, University of California, Berkeley, CA, USA
| | - Katie Lien
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Zilose Lyons
- California China Climate Institute, University of California, Berkeley, CA, USA
| | - Gerald Mboowa
- School of Biomedical Sciences, Makerere University, Kampala, Uganda
| | - Ivan Mwebaza
- School of Biomedical Sciences, Makerere University, Kampala, Uganda
| | | | | | - Robert Nichols
- Department of Molecular and Cell Biology, University of California, Berkeley, CA, USA
| | | | - Sarah Petnic
- Quality and Clinical Excellence Department, Providence Queen of the Valley Medical Center, Napa, CA, USA
| | | | - Stephen J Popper
- Sustainable Sciences Institute, San Francisco, CA, USA.,School of Public Health, Department of Infectious Disease and Vaccinology, University of California, Berkeley, CA, USA
| | - Michael Rape
- Howard Hughes Medical Institute, University of California, Berkeley, CA, USA
| | - Arthur Reingold
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | | | - Oren S Rosenberg
- Department of Medicine, University of California, San Francisco, CA, USA
| | - David F Savage
- Department of Molecular and Cell Biology, University of California, Berkeley, CA, USA
| | | | | | - Ivan Sserwadda
- School of Biomedical Sciences, Makerere University, Kampala, Uganda
| | - Sarah Stanley
- Department of Molecular and Cell Biology, University of California, Berkeley, CA, USA.,Division of Infectious Disease and Vaccinology, School of Public Health, University of California, Berkeley, CA, USA
| | | | | | - Erik Van Dis
- Department of Immunology, University of Washington School of Medicine, Seattle, WA, USA
| | | | - Joanna Vinden
- Division of Infectious Diseases and Immunity, School of Public Health, University of California, Berkeley, CA, USA
| | - Jeffery S Cox
- H. Wheeler Center for Emerging & Neglected Diseases (CEND), University of California, Berkeley, CA, USA.,Department of Molecular and Cell Biology, University of California, Berkeley, CA, USA
| | - Moses L Joloba
- School of Biomedical Sciences, Makerere University, Kampala, Uganda
| | - Julia Schaletzky
- H. Wheeler Center for Emerging & Neglected Diseases (CEND), University of California, Berkeley, CA, USA
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Dhana A, Hamada Y, Kengne AP, Kerkhoff AD, Broger T, Denkinger CM, Rangaka MX, Gupta-Wright A, Fielding K, Wood R, Huerga H, Rücker SCM, Bjerrum S, Johansen IS, Thit SS, Kyi MM, Hanson J, Barr DA, Meintjes G, Maartens G. Diagnostic accuracy of WHO screening criteria to guide lateral-flow lipoarabinomannan testing among HIV-positive inpatients: A systematic review and individual participant data meta-analysis. J Infect 2022; 85:40-48. [PMID: 35588942 PMCID: PMC10152564 DOI: 10.1016/j.jinf.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND WHO recommends urine lateral-flow lipoarabinomannan (LF-LAM) testing with AlereLAM in HIV-positive inpatients only if screening criteria are met. We assessed the performance of WHO screening criteria and alternative screening tests/strategies to guide LF-LAM testing and compared diagnostic accuracy of the WHO AlereLAM algorithm (WHO screening criteria followed by AlereLAM if screen positive) with AlereLAM and FujiLAM (a novel LF-LAM test) testing in all HIV-positive inpatients. METHODS We searched MEDLINE, Embase, and Cochrane Library from Jan 1, 2011 to March 1, 2020 for studies among adult/adolescent HIV-positive inpatients regardless of tuberculosis signs and symptoms. The reference standards were (1) AlereLAM or FujiLAM for screening tests/strategies and (2) culture or Xpert for AlereLAM/FujiLAM. We determined proportion of inpatients eligible for AlereLAM using WHO screening criteria; assessed accuracy of WHO criteria and alternative screening tests/strategies to guide LF-LAM testing; compared accuracy of WHO AlereLAM algorithm with AlereLAM/FujiLAM testing in all; and determined diagnostic yield of AlereLAM, FujiLAM, and Xpert MTB/RIF (Xpert). We estimated pooled proportions with a random-effects model, assessed diagnostic accuracy using random-effects bivariate models, and assessed diagnostic yield descriptively. FINDINGS We obtained data from all 5 identified studies (n = 3,504). The pooled proportion of inpatients eligible for AlereLAM using WHO criteria was 93% (95%CI 91, 95). Among screening tests/strategies to guide LF-LAM testing, WHO criteria, C-reactive protein (≥5 mg/L), and CD4 count (<200 cells/μL) had high sensitivities but low specificities; cough (≥2 weeks), hemoglobin (<8 g/dL), body mass index (<18.5 kg/m2), lymphadenopathy, and WHO-defined danger signs had higher specificities but suboptimal sensitivities. AlereLAM in all had the same sensitivity (62%) and specificity (88%) as WHO AlereLAM algorithm. Sensitivity of FujiLAM and AlereLAM was 69% and 48%, while specificity was 88% and 96%, respectively. In 2 studies that collected sputum and non-sputum samples for Xpert and/or culture, diagnostic yield of sputum Xpert was 40-41%, AlereLAM was 39-76%, and urine Xpert was 35-62%. In one study, FujiLAM diagnosed 80% of tuberculosis cases (vs 39% for AlereLAM), and sputum Xpert combined with AlereLAM, urine Xpert, or FujiLAM diagnosed 61%, 81%, and 92% of all cases, respectively. INTERPRETATION WHO criteria and alternative screening tests/strategies have limited utility in guiding LF-LAM testing, suggesting that AlereLAM testing in all HIV-positive medical inpatients be implemented. Routine FujiLAM may improve tuberculosis diagnosis. FUNDING None.
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Affiliation(s)
- Ashar Dhana
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Yohhei Hamada
- Centre for International Cooperation and Global TB Information, The Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan; Institute for Global Health, University College London, London, UK
| | - Andre P Kengne
- Non-communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, USA
| | - Tobias Broger
- Division of Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany; FIND, Geneva, Switzerland
| | - Claudia M Denkinger
- Division of Infectious Disease and Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany; German Center of Infection Research, Heidelberg, Germany; FIND, Geneva, Switzerland
| | - Molebogeng X Rangaka
- Institute for Global Health, University College London, London, UK; Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Ankur Gupta-Wright
- Institute for Global Health, University College London, London, UK; Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Robin Wood
- Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Helena Huerga
- Field Epidemiology Department, Epicentre, Paris, France
| | | | - Stephanie Bjerrum
- Department of Clinical Research, Infectious Diseases, University of Southern Denmark, Odense, Denmark
| | - Isik S Johansen
- Research Unit for Infectious Diseases, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Swe Swe Thit
- Department of Medicine, University of Medicine 2, Yangon, Yangon Division, Myanmar
| | - Mar Mar Kyi
- Department of Medicine, University of Medicine 2, Yangon, Yangon Division, Myanmar
| | - Josh Hanson
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - David A Barr
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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4
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Abdulgader SM, Okunola AO, Ndlangalavu G, Reeve BWP, Allwood BW, Koegelenberg CFN, Warren RM, Theron G. Diagnosing Tuberculosis: What Do New Technologies Allow Us to (Not) Do? Respiration 2022; 101:797-813. [PMID: 35760050 PMCID: PMC9533455 DOI: 10.1159/000525142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/10/2022] [Indexed: 12/11/2022] Open
Abstract
New tuberculosis (TB) diagnostics are at a crossroads: their development, evaluation, and implementation is severely damaged by resource diversion due to COVID-19. Yet several technologies, especially those with potential for non-invasive non-sputum-based testing, hold promise for efficiently triaging and rapidly confirming TB near point-of-care. Such tests are, however, progressing through the pipeline slowly and will take years to reach patients and health workers. Compellingly, such tests will create new opportunities for difficult-to-diagnose populations, including primary care attendees (all-comers in high burden settings irrespective of reason for presentation) and community members (with early stage disease or risk factors like HIV), many of whom cannot easily produce sputum. Critically, all upcoming technologies have limitations that implementers and health workers need to be cognizant of to ensure optimal deployment without undermining confidence in a technology that still offers improvements over the status quo. In this state-of-the-art review, we critically appraise such technologies for active pulmonary TB diagnosis. We highlight strengths, limitations, outstanding research questions, and how current and future tests could be used in the presence of these limitations and uncertainties. Among triage tests, CRP (for which commercial near point-of-care devices exist) and computer-aided detection software with digital chest X-ray hold promise, together with late-stage blood-based assays that detect host and/or microbial biomarkers; however, aside from a handful of prototypes, the latter category has a shortage of promising late-stage alternatives. Furthermore, positive results from new triage tests may have utility in people without TB; however, their utility for informing diagnostic pathways for other diseases is under-researched (most sick people tested for TB do not have TB). For confirmatory tests, few true point-of-care options will be available soon; however, combining novel approaches like tongue swabs with established tests like Ultra have short-term promise but first require optimizations to specimen collection and processing procedures. Concerningly, no technologies yet have compelling evidence of meeting the World Health Organization optimal target product profile performance criteria, especially for important operational criteria crucial for field deployment. This is alarming as the target product profile criteria are themselves almost a decade old and require urgent revision, especially to cater for technologies made prominent by the COVID-19 diagnostic response (e.g., at-home testing and connectivity solutions). Throughout the review, we underscore the importance of how target populations and settings affect test performance and how the criteria by which these tests should be judged vary by use case, including in active case finding. Lastly, we advocate for health workers and researchers to themselves be vocal proponents of the uptake of both new tests and those − already available tests that remain suboptimally utilized.
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Affiliation(s)
- Shima M Abdulgader
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anna O Okunola
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gcobisa Ndlangalavu
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Byron W P Reeve
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Brian W Allwood
- Division of Pulmonology, Department of Medicine, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
| | - Coenraad F N Koegelenberg
- Division of Pulmonology, Department of Medicine, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
| | - Rob M Warren
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Grant Theron
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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5
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Abstract
Rapid detection of Mycobacterium tuberculosis complex and determination of drug resistance are essential for early diagnosis and treatment of tuberculosis (TB). Xpert MTB/RIF Ultra (Xpert Ultra), a molecular test that can simultaneously identify M. tuberculosis complex and resistance to rifampicin directly on clinical samples, is currently used. Xpert Ultra represents a helpful tool for rapid pulmonary TB diagnosis, especially in patients with paucibacillary infection. The aim of this review is to provide an overview of the diagnostic performance of Xpert Ultra in detection of extra-pulmonary tuberculosis.
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Affiliation(s)
- Laura Rindi
- Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia, Università di Pisa, Pisa, Italy
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6
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Sharma V, Singh A, Gaur M, Rawat D, Yadav A, Rajan, Kumar C, Varma-Basil M, Lohiya S, Khanna V, Khanna A, Chaudhry A, Singh Y, Misra R. Evaluating the efficacy of stool sample on Xpert MTB/RIF Ultra and its comparison with other sample types by meta-analysis for TB diagnostics. Eur J Clin Microbiol Infect Dis 2022; 41:893-906. [PMID: 35508741 DOI: 10.1007/s10096-022-04449-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/19/2022] [Indexed: 11/03/2022]
Abstract
Precise and timely detection of tuberculosis (TB) is crucial to reduce transmission. This study aims to assess the accuracy of Xpert MTB/RIF Ultra on stool samples and systematically review the performance of Xpert MTB/RIF Ultra with different sample types by meta-analysis. Stool samples of smear-negative pulmonary TB (PTB), cervical lymph node TB, and abdominal TB patients were tested on the Xpert MTB/RIF Ultra system. Meta-analysis was performed on a set of 44 studies. Data were grouped by sample type, and the pooled sensitivity and specificity of Xpert MTB/RIF Ultra were calculated. The sensitivity of Xpert MTB/RIF Ultra with stool samples was 100% for smear-negative PTB, 27.27% for cervical lymph node TB, and 50% for abdominal TB patients, with 100% specificity for all included TB groups. The summary estimate for all PTB samples showed 84.2% sensitivity and 94.5% specificity, and EPTB samples showed 88.6% sensitivity and 96.4% specificity. Among all sample types included in our meta-analysis, urine showed the best performance for EPTB diagnosis. This pilot study supports the use of stool as an alternative non-invasive sample on Xpert MTB/RIF Ultra for rapid testing, suitable for both PTB and EPTB diagnosis.
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Affiliation(s)
- Vishal Sharma
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Anoop Singh
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Mohita Gaur
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Deepti Rawat
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Anjali Yadav
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Rajan
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Chanchal Kumar
- Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, 110007, India
| | - Mandira Varma-Basil
- Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, 110007, India
| | - Sheelu Lohiya
- Chest Clinic, Lok Nayak Hospital, Delhi, 110002, India
| | - Vishal Khanna
- Chest Clinic, Lok Nayak Hospital, Delhi, 110002, India
| | - Ashwani Khanna
- State TB Officer & In-Charge, Chest Clinic, Lok Nayak Hospital, Delhi, 110002, India
| | - Anil Chaudhry
- Rajan Babu Institute of Pulmonary Medicine and Tuberculosis, Kingsway Camp, Delhi, 110009, India
| | - Yogendra Singh
- Department of Zoology, University of Delhi, Delhi, 110007, India.
| | - Richa Misra
- Department of Zoology, University of Delhi, Delhi, 110007, India. .,Department of Zoology, Sri Venkateswara College, University of Delhi, Delhi, 110021, India.
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7
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Dhana A, Hamada Y, Kengne AP, Kerkhoff AD, Rangaka MX, Kredo T, Baddeley A, Miller C, Gupta-Wright A, Fielding K, Wood R, Huerga H, Rücker SCM, Heidebrecht C, Wilson D, Bjerrum S, Johansen IS, Thit SS, Kyi MM, Hanson J, Barr DA, Meintjes G, Maartens G. Tuberculosis screening among HIV-positive inpatients: a systematic review and individual participant data meta-analysis. Lancet HIV 2022; 9:e233-e241. [PMID: 35338834 PMCID: PMC8964502 DOI: 10.1016/s2352-3018(22)00002-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/16/2021] [Accepted: 12/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Since 2011, WHO has recommended that HIV-positive inpatients be routinely screened for tuberculosis with the WHO four-symptom screen (W4SS) and, if screened positive, receive a molecular WHO-recommended rapid diagnostic test (eg, Xpert MTB/RIF [Xpert] assay). To inform updated WHO tuberculosis screening guidelines, we conducted a systematic review and individual participant data meta-analysis to assess the performance of W4SS and alternative screening tests to guide Xpert testing and compare the diagnostic accuracy of the WHO Xpert algorithm (ie, W4SS followed by Xpert) with Xpert for all HIV-positive inpatients. METHODS We searched MEDLINE, Embase, and Cochrane Library from Jan 1, 2011, to March 1, 2020, for studies of adult and adolescent HIV-positive inpatients enrolled regardless of tuberculosis signs and symptoms. The separate reference standards were culture and Xpert. Xpert was selected since it is most likely to be the confirmatory test used in practice. We assessed the proportion of inpatients eligible for Xpert testing using the WHO algorithm; assessed the accuracy of W4SS and alternative screening tests or strategies to guide diagnostic testing; and compared the accuracy of the WHO Xpert algorithm (W4SS followed by Xpert) with Xpert for all. We obtained pooled proportion estimates with a random-effects model, assessed diagnostic accuracy by fitting random-effects bivariate models, and assessed diagnostic yield descriptively. This systematic review has been registered on PROSPERO (CRD42020155895). FINDINGS Of 6162 potentially eligible publications, six were eligible and we obtained data for all of the six publications (n=3660 participants). The pooled proportion of inpatients eligible for an Xpert was 90% (95% CI 89-91; n=3658). Among screening tests to guide diagnostic testing, W4SS and C-reactive protein (≥5 mg/L) had highest sensitivities (≥96%) but low specificities (≤12%); cough (≥2 weeks), haemoglobin concentration (<8 g/dL), body-mass index (<18·5 kg/m2), and lymphadenopathy had higher specificities (61-90%) but suboptimal sensitivities (12-57%). The WHO Xpert algorithm (W4SS followed by Xpert) had a sensitivity of 76% (95% CI 67-84) and specificity of 93% (88-96; n=637). Xpert for all had similar accuracy to the WHO Xpert algorithm: sensitivity was 78% (95% CI 69-85) and specificity was 93% (87-96; n=639). In two cohorts that had sputum and non-sputum samples collected for culture or Xpert, diagnostic yield of sputum Xpert was 41-70% and 61-64% for urine Xpert. INTERPRETATION The W4SS and other potential screening tests to guide Xpert testing have suboptimal accuracy in HIV-positive inpatients. On the basis of these findings, WHO now strongly recommends molecular rapid diagnostic testing in all medical HIV-positive inpatients in settings where tuberculosis prevalence is higher than 10%. FUNDING World Health Organization.
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Affiliation(s)
- Ashar Dhana
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Yohhei Hamada
- Centre for International Cooperation and Global TB Information, The Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan; Institute for Global Health, University College London, London, UK
| | - Andre P Kengne
- Non-communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, USA
| | - Molebogeng X Rangaka
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Institute for Global Health, University College London, London, UK
| | - Tamara Kredo
- Non-communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa; Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | | | | | - Ankur Gupta-Wright
- Institute for Global Health, University College London, London, UK; Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Robin Wood
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Helena Huerga
- Field Epidemiology Department, Epicentre, Paris, France
| | | | | | - Douglas Wilson
- Department of Internal Medicine, Edendale Hospital, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Stephanie Bjerrum
- Research Unit for Infectious Diseases, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Isik S Johansen
- Research Unit for Infectious Diseases, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Swe Swe Thit
- Department of Medicine, University of Medicine, Yangon, Myanmar
| | - Mar Mar Kyi
- Department of Medicine, University of Medicine, Yangon, Myanmar
| | - Josh Hanson
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - David A Barr
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
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8
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Yin X, Ye QQ, Wu KF, Zeng JY, Li NX, Mo JJ, Huang PY, Xie LM, Xie LY, Guo XG. Diagnostic value of Lipoarabinomannan antigen for detecting Mycobacterium tuberculosis in adults and children with or without HIV infection. J Clin Lab Anal 2022; 36:e24238. [PMID: 35034374 PMCID: PMC8842169 DOI: 10.1002/jcla.24238] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/05/2021] [Accepted: 01/01/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives Even today, tuberculosis (TB) remains a leading public health problem; yet, the current diagnostic methods still have a few shortcomings. Lipoarabinomannan (LAM) provides an opportunity for TB diagnosis, and urine LAM detection seems to have a promising and widely applicable prospect. Design or methods Four databases were systematically searched for eligible studies, and the quality of the studies was evaluated using the quality assessment of diagnostic accuracy studies‐2 (QUADAS‐2). Graphs and tables were created to show sensitivity, specificity, likelihood ratios, diagnostic odds ratio (DOR), the area under the curve (AUC), and so on. Results Based on the included 67 studies, the pooled sensitivity of urine LAM was 48% and specificity was 89%. In the subgroup analyses, the FujiLAM test had higher sensitivity (69%) and specificity (92%). Furthermore, among patients infected with human immunodeficiency virus (HIV), 50% of TB patients were diagnosed using a urine LAM test. Besides, the CD4+ cell count was inversely proportional to the sensitivity. Conclusions Urine LAM is a promising diagnostic test for TB, particularly using the FujiLAM in HIV‐infected adults whose CD4+ cell count is ≤100 per μl. Besides, the urine LAM test shows various sensitivities and specificities in different subgroups in terms of age, HIV infection status, CD4+ cell count, and testing method.
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Affiliation(s)
- Xin Yin
- Department of Clinical Laboratory Medicine, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Department of Pediatrics, The Pediatrics School of Guangzhou Medical University, Guangzhou, China
| | - Qi-Qing Ye
- Department of Pediatrics, The Pediatrics School of Guangzhou Medical University, Guangzhou, China
| | - Ke-Fan Wu
- Department of Clinical Medicine, The Sixth Clinical School of Guangzhou Medical university, Guangzhou, China
| | - Ji-Yuan Zeng
- Department of Pediatrics, The Pediatrics School of Guangzhou Medical University, Guangzhou, China
| | - Nan-Xi Li
- Department of Psychiatric Medicine, The Mental Health School of Guangzhou Medical University, Guangzhou, China
| | - Jun-Jian Mo
- Department of Clinical Medicine, The Sixth Clinical School of Guangzhou Medical university, Guangzhou, China
| | - Pei-Ying Huang
- Nanshan School, Guangzhou Medical University, Guangzhou, China
| | - Li-Min Xie
- Department of Clinical Medicine, The Third Clinical School of Guangzhou Medical University, Guangzhou, China
| | - Li-Ying Xie
- Department of Pediatrics, The Pediatrics School of Guangzhou Medical University, Guangzhou, China
| | - Xu-Guang Guo
- Department of Clinical Laboratory Medicine, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Department of Clinical Medicine, The Third Clinical School of Guangzhou Medical University, Guangzhou, China.,Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Key Laboratory of Reproduction and Genetics of Guangdong Higher Education Institutes, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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9
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Peng X, Liao Q, Fang M, Zhu Y, Shi Y, Quan S, Wang Y, Duan L, Shi X, Liu Y, Wang M, Wei Q, Zhou H, Wang Y, Wu X, Yao Y, Sun L, Shen A, Wan C. Detection of pulmonary tuberculosis in children using the Xpert MTB/RIF Ultra assay on sputum: a multicenter study. Eur J Clin Microbiol Infect Dis 2021; 41:235-243. [PMID: 34734347 DOI: 10.1007/s10096-021-04340-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/23/2021] [Indexed: 11/25/2022]
Abstract
Microbiological confirmation is rare in children with active tuberculosis; therefore, a more accurate test is needed to detect pulmonary tuberculosis in children. In this multicenter study, we evaluated the utility of the Xpert MTB/RIF Ultra (Ultra) on sputum, an assay recommended by the World Health Organization to test for childhood tuberculosis in high-burden settings. Children with symptoms suggestive of tuberculosis were enrolled at three hospitals in China and categorized as having active tuberculosis or nontuberculosis. The sensitivity and specificity of Ultra were 42.1% (48/114) and 99.0% (208/210), respectively. Using three MTB culture results as the reference, the sensitivity of Ultra in the subset of 38 children with culture-positive and 76 children with culture-negative was 68.4% (26/38) and 28.9% (22/76), respectively(p < 0.001). A single MTB culture combined with a single Ultra could detect 54 (54/114,47.4%) cases with active TB, while repeated MTB culture combined with a single Ultra detected 60 (60/114, 52.6%) cases with active TB(p = 0.427). Among 155 children (58 with TB and 97 with RTIs) simultaneously tested with the Ultra and Xpert MTB/RIF (Xpert), the sensitivity of the Xpert (24.1%, 14/58) was lower than that of the Ultra (41.4%, 24/58; p = 0.048). Eight children were found to have rifampin-resistant MTB strains. The Xpert MTB/RIF Ultra assay should be implemented to test for pulmonary tuberculosis in children to achieve higher confirmation rates.
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Affiliation(s)
- Xiaoshan Peng
- Department of Pediatrics Infectious Diseases, West China Second Hospital, Sichuan University, No.20, 3Rd Section of Renmin South Road, Chengdu, 610041, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, No.20, 3Rd Section of Renmin South Road, Chengdu, 610041, China
| | - Qiong Liao
- Department of Pediatrics Infectious Diseases, West China Second Hospital, Sichuan University, No.20, 3Rd Section of Renmin South Road, Chengdu, 610041, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, No.20, 3Rd Section of Renmin South Road, Chengdu, 610041, China
| | - Min Fang
- Department of Pediatrics Infectious Diseases, The No. 1 People's Hospital of Liangshan Yizu Autonomous Prefecture, Liangshan, China
| | - Yu Zhu
- Department of Pediatrics Infectious Diseases, West China Second Hospital, Sichuan University, No.20, 3Rd Section of Renmin South Road, Chengdu, 610041, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, No.20, 3Rd Section of Renmin South Road, Chengdu, 610041, China
| | - Yan Shi
- Department of Pediatrics Infectious Diseases, The No. 1 People's Hospital of Liangshan Yizu Autonomous Prefecture, Liangshan, China
| | - Shuting Quan
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China.,Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China.,Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China
| | - Yacui Wang
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China.,Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China.,Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China
| | - Li Duan
- Department of Pediatrics Infectious Diseases, The No. 1 People's Hospital of Liangshan Yizu Autonomous Prefecture, Liangshan, China
| | - Xiaomei Shi
- Department of Pediatrics Infectious Diseases, The No. 1 People's Hospital of Liangshan Yizu Autonomous Prefecture, Liangshan, China
| | - Yang Liu
- Department of Pediatrics Infectious Diseases, West China Second Hospital, Sichuan University, No.20, 3Rd Section of Renmin South Road, Chengdu, 610041, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, No.20, 3Rd Section of Renmin South Road, Chengdu, 610041, China
| | - Manzhi Wang
- Changsha Central Hospital, University of South China, Changsha, China
| | - Qingsong Wei
- Changsha Central Hospital, University of South China, Changsha, China
| | - Haiyi Zhou
- Changsha Central Hospital, University of South China, Changsha, China
| | - Yanchun Wang
- Department of Infections, Kunming Children's Hospital, Kunming, China
| | - Xirong Wu
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China.,Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China.,Department of Respiratory, Beijing Children's Hospital, Beijing, China
| | - Yao Yao
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China.,Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China.,Department of Respiratory, Beijing Children's Hospital, Beijing, China
| | - Lin Sun
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China. .,Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China. .,Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China.
| | - Adong Shen
- National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China. .,Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China. .,Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, No. 56 Nanlishi Road, Xicheng District, Beijing, 100045, China. .,Children's Hospital Affiliated To Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, China.
| | - Chaomin Wan
- Department of Pediatrics Infectious Diseases, West China Second Hospital, Sichuan University, No.20, 3Rd Section of Renmin South Road, Chengdu, 610041, China. .,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, No.20, 3Rd Section of Renmin South Road, Chengdu, 610041, China.
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10
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Minnies S, Reeve BWP, Rockman L, Nyawo G, Naidoo CC, Kitchin N, Rautenbach C, Wright CA, Whitelaw A, Schubert P, Warren RM, Theron G. Xpert MTB/RIF Ultra is highly sensitive for the diagnosis of tuberculosis lymphadenitis in an HIV-endemic setting. J Clin Microbiol 2021;:JCM0131621. [PMID: 34469182 DOI: 10.1128/JCM.01316-21] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Tuberculosis lymphadenitis (TBL) is the most common extrapulmonary tuberculosis (EPTB) manifestation. Xpert MTB/RIF Ultra (Ultra) is a World Health Organization-endorsed diagnostic test, but performance data for TBL, including on noninvasive specimens, are limited. Fine-needle aspiration biopsy specimens (FNABs) from outpatients (≥18 years) with presumptive TBL (n = 135) underwent (i) routine Xpert MTB/RIF testing (later with Ultra once programmatically available), (ii) MGIT 960 culture (if Xpert or Ultra negative or rifampicin resistant), and (iii) study Ultra testing. Concentrated paired urine specimens underwent Ultra testing. Primary analyses used a microbiological reference standard (MRS). In a head-to-head comparison (n = 92) of an FNAB study Ultra and Xpert, Ultra had increased sensitivity (91% [95% confidence interval: 79, 98] versus 72% [57, 84]; P = 0.016) and decreased specificity (76% [61, 87] versus 93% [82, 99]; P = 0.020) and diagnosed patients not on treatment. Neither HIV nor alternative reference standards affected sensitivity and specificity. In patients with both routine and study Ultra tests, the latter detected more cases (+20% [0, 42]; P = 0.034), and false-negative study Ultra results were more inhibited than true-positive results. Study Ultra false positives had less mycobacterial DNA than true positives (trace-positive proportions, 59% [13/22] versus 12% [5/51]; P < 0.001). “Trace” exclusion or recategorization removed potential benefits offered over Xpert. Urine Ultra tests had low sensitivity (18% [7, 35]). Ultra testing on FNABs is highly sensitive and detects more TBL than Xpert (Ultra still missed some cases due in part to inhibition). Patients with FNAB Ultra-positive “trace” results, most of whom will be culture negative, may require additional clinical investigation. Urine Ultra testing could reduce the number of patients needing invasive sampling.
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11
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Matoga MM, Bisson GP, Gupta A, Miyahara S, Sun X, Fry C, Manabe YC, Kumwenda J, Cecilia K, Nyirenda M, Ngongondo M, Mbewe A, Lagat D, Wallis C, Mugerwa H, Hosseinipour MC. Urine Lipoarabinomannan Testing in Adults With Advanced Human Immunodeficiency Virus in a Trial of Empiric Tuberculosis Therapy. Clin Infect Dis 2021; 73:e870-e877. [PMID: 34398958 PMCID: PMC8366821 DOI: 10.1093/cid/ciab179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The urine lipoarabinomannan (LAM) antigen test is a tuberculosis (TB) diagnostic test with highest sensitivity in individuals with advanced human immunodeficiency virus (HIV). Its role in TB diagnostic algorithms for HIV-positive outpatients remains unclear. METHODS The AIDS Clinical Trials Group (ACTG) A5274 trial demonstrated that empiric TB therapy did not improve 24-week survival compared to isoniazid preventive therapy (IPT) in TB screen-negative HIV-positive adults initiating antiretroviral therapy with CD4 counts <50 cells/µL. Retrospective LAM testing was performed on stored urine obtained at baseline. We determined the proportion of LAM-positive participants and conducted modified intent-to-treat analysis excluding LAM-positive participants to determine the effect on 24-week survival, TB incidence, and time to TB using Kaplan-Meier method. RESULTS A5274 enrolled 850 participants; 53% were male and the median CD4 count was 18 (interquartile range, 9-32) cells/µL. Of the 850, 566 (67%) had LAM testing (283 per arm); 28 (5%) were positive (21 [7%] and 7 [2%] in the empiric and IPT arms, respectively). Of those LAM-positive, 1 participant in each arm died and 5 of 21 and 0 of 7 in empiric and IPT arms, respectively, developed TB. After excluding these 28 cases, there were 19 and 21 deaths in the empiric and IPT arms, respectively (P = .88). TB incidence remained higher (4.6% vs 2%, P = .04) and time to TB remained faster in the empiric arm (P = .04). CONCLUSIONS Among outpatients with advanced HIV who screened negative for TB by clinical symptoms, microscopy, and Xpert testing, LAM testing identified an additional 5% of individuals with TB. Positive LAM results did not change mortality or TB incidence.
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Affiliation(s)
| | - Gregory P Bisson
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amita Gupta
- Center for Clinical Global Health Education, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sachiko Miyahara
- Center for Biostatistics in AIDS Research, Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Xin Sun
- Center for Biostatistics in AIDS Research, Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Carrie Fry
- Frontier Science Foundation, Amherst, New York, USA
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Johnstone Kumwenda
- Malawi College of Medicine–Johns Hopkins University Research Project, Blantyre, Malawi
| | | | - Mulinda Nyirenda
- Malawi College of Medicine–Johns Hopkins University Research Project, Blantyre, Malawi
| | | | - Abineli Mbewe
- University of North Carolina Project, Lilongwe, Malawi
| | - David Lagat
- Moi University School of Medicine, Eldoret, Kenya
| | - Carole Wallis
- Bioanalytical Research Corporation and Lancet Laboratories, Johannesburg, South Africa
| | | | - Mina C Hosseinipour
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,USA
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12
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MacLean E, Nathavitharana RR. Progress toward Developing Sensitive Non-Sputum-Based Tuberculosis Diagnostic Tests: the Promise of Urine Cell-Free DNA. J Clin Microbiol 2021; 59:e0070621. [PMID: 33980646 DOI: 10.1128/JCM.00706-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A highly accurate, non-sputum-based test for tuberculosis (TB) detection is a key priority for the field of TB diagnostics. A recent study in the Journal of Clinical Microbiology by Oreskovic and colleagues (J Clin Microbiol 59:e00074-21, 2021, https://doi.org/10.1128/JCM.00074-21) reports the performance of an optimized urine cell-free DNA (cfDNA) test using sequence-specific purification combined with short-target PCR to improve the accuracy of TB detection. Their retrospective clinical study utilized frozen urine samples (n = 73) from study participants diagnosed with active pulmonary TB in South Africa and compared results to non-TB patients in South Africa and the United States in an early-phase validation study. Overall, this cfDNA technique detected TB with a sensitivity of 83.7% (95% CI: 71.0 to 91.5) and specificity of 100% (95% CI: 86.2 to 100), which meet the World Health Organization's published performance criteria. Sensitivity was 73.3% in people without HIV (95% CI: 48.1 to 89.1) and 76% in people with smear-negative TB (95% CI: 56.5 to 88.5). In this commentary, we discuss the results of this optimized urine TB cfDNA assay within the larger context of TB diagnostics and pose additional questions for further research.
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Wood RC, Andama A, Hermansky G, Burkot S, Asege L, Job M, Katumba D, Nakaye M, Mwebe SZ, Mulondo J, Bachman CM, Nichols KP, Le Ny ALM, Ortega C, Olson RN, Weigel KM, Olson AM, Madan D, Bell D, Cattamanchi A, Worodria W, Semitala FC, Somoskovi A, Cangelosi GA, Minch KJ. Characterization of oral swab samples for diagnosis of pulmonary tuberculosis. PLoS One 2021; 16:e0251422. [PMID: 33999938 PMCID: PMC8128230 DOI: 10.1371/journal.pone.0251422] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 04/26/2021] [Indexed: 12/15/2022] Open
Abstract
Oral swab analysis (OSA) has been shown to detect Mycobacterium tuberculosis (MTB) DNA in patients with pulmonary tuberculosis (TB). In previous analyses, qPCR testing of swab samples collected from tongue dorsa was up to 93% sensitive relative to sputum GeneXpert, when 2 swabs per patient were tested. The present study modified sample collection methods to increase sample biomass and characterized the viability of bacilli present in tongue swabs. A qPCR targeting conserved bacterial ribosomal rRNA gene (rDNA) sequences was used to quantify bacterial biomass in samples. There was no detectable reduction in total bacterial rDNA signal over the course of 10 rapidly repeated tongue samplings, indicating that swabs collect only a small portion of the biomass available for testing. Copan FLOQSwabs collected ~2-fold more biomass than Puritan PurFlock swabs, the best brand used previously (p = 0.006). FLOQSwabs were therefore evaluated in patients with possible TB in Uganda. A FLOQSwab was collected from each patient upon enrollment (Day 1) and, in a subset of sputum GeneXpert Ultra-positive patients, a second swab was collected on the following day (Day 2). Swabs were tested for MTB DNA by manual IS6110-targeted qPCR. Relative to sputum GeneXpert Ultra, single-swab sensitivity was 88% (44/50) on Day 1 and 94.4% (17/18) on Day 2. Specificity was 79.2% (42/53). Among an expanded sample of Ugandan patients, 62% (87/141) had colony-forming bacilli in their tongue dorsum swab samples. These findings will help guide further development of this promising TB screening method.
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Affiliation(s)
- Rachel C. Wood
- Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Alfred Andama
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Gleda Hermansky
- Intellectual Ventures Laboratory, Bellevue, Washington, United States of America
| | - Stephen Burkot
- Intellectual Ventures’ Global Good Fund, Bellevue, Washington, United States of America
| | - Lucy Asege
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - David Katumba
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Martha Nakaye
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Jerry Mulondo
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Christine M. Bachman
- Intellectual Ventures’ Global Good Fund, Bellevue, Washington, United States of America
| | - Kevin P. Nichols
- Intellectual Ventures Laboratory, Bellevue, Washington, United States of America
| | - Anne-Laure M. Le Ny
- Intellectual Ventures Laboratory, Bellevue, Washington, United States of America
| | - Corrie Ortega
- Intellectual Ventures Laboratory, Bellevue, Washington, United States of America
| | - Rita N. Olson
- Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Kris M. Weigel
- Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Alaina M. Olson
- Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Damian Madan
- Intellectual Ventures Laboratory, Bellevue, Washington, United States of America
| | - David Bell
- Intellectual Ventures’ Global Good Fund, Bellevue, Washington, United States of America
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - William Worodria
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Fred C. Semitala
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Akos Somoskovi
- Intellectual Ventures’ Global Good Fund, Bellevue, Washington, United States of America
| | - Gerard A. Cangelosi
- Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Kyle J. Minch
- Intellectual Ventures Laboratory, Bellevue, Washington, United States of America
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14
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Andama A, Jaganath D, Crowder R, Asege L, Nakaye M, Katumba D, Mukwatamundu J, Mwebe S, Semitala CF, Worodria W, Joloba M, Mohanty S, Somoskovi A, Cattamanchi A. The transition to Xpert MTB/RIF ultra: diagnostic accuracy for pulmonary tuberculosis in Kampala, Uganda. BMC Infect Dis 2021; 21:49. [PMID: 33430790 PMCID: PMC7802232 DOI: 10.1186/s12879-020-05727-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 12/21/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) has endorsed the next-generation Xpert MTB/RIF Ultra (Ultra) cartridge, and Uganda is currently transitioning from the older generation Xpert MTB/RIF (Xpert) cartridge to Ultra as the initial diagnostic test for pulmonary tuberculosis (TB). We assessed the diagnostic accuracy of Ultra for pulmonary TB among adults in Kampala, Uganda. METHODS We sampled adults referred for Xpert testing at two hospitals and a health center over a 12-month period. We enrolled adults with positive Xpert and a random 1:1 sample with negative Xpert results. Expectorated sputum was collected for Ultra, and for solid and liquid culture testing for Xpert-negative patients. We measured sensitivity and specificity of Ultra overall and by HIV status, prior history of TB, and hospitalization, in reference to Xpert and culture results. We also assessed how classification of results in the new "trace" category affects Ultra accuracy. RESULTS Among 698 participants included, 211 (30%) were HIV-positive and 336 (48%) had TB. The sensitivity of Ultra was 90.5% (95% CI 86.8-93.4) and specificity was 98.1% (95% CI 96.1-99.2). There were no significant differences in sensitivity and specificity by HIV status, prior history of TB or hospitalization. Xpert and Ultra results were concordant in 670 (96%) participants, with Ultra having a small reduction in specificity (difference 1.9, 95% CI 0.2 to 3.6, p=0.01). When "trace" results were considered positive for all patients, sensitivity increased by 2.1% (95% CI 0.3 to 3.9, p=0.01) without a significant reduction in specificity (- 0.8, 95% CI - 0.3 to 2.0, p=0.08). CONCLUSIONS After 1 year of implementation, Ultra had similar performance to Xpert. Considering "trace" results to be positive in all patients increased case detection without significant loss of specificity. Longitudinal studies are needed to compare the benefit of greater diagnoses to the cost of overtreatment.
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Affiliation(s)
- A Andama
- Department of Internal Medicine, Makerere University College of Health Sciences, Ground Floor Pathology Building, Room A4, Kampala, Uganda. .,Infectious Diseases Research Collaboration, Kampala, Uganda.
| | - D Jaganath
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, University of California San Francisco, San Francisco, California, USA.,Center for Tuberculosis, University of California San Francisco, San Francisco, California, USA.,Department of Pediatrics, Division of Pediatric Infectious Diseases, University of California San Francisco, San Francisco, California, USA
| | - R Crowder
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, University of California San Francisco, San Francisco, California, USA.,Center for Tuberculosis, University of California San Francisco, San Francisco, California, USA
| | - L Asege
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - M Nakaye
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - D Katumba
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - J Mukwatamundu
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - S Mwebe
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - C F Semitala
- Department of Internal Medicine, Makerere University College of Health Sciences, Ground Floor Pathology Building, Room A4, Kampala, Uganda.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | - W Worodria
- Department of Internal Medicine, Makerere University College of Health Sciences, Ground Floor Pathology Building, Room A4, Kampala, Uganda.,Mulago National Referral Hospital, Kampala, Uganda
| | - M Joloba
- Department of Medical Microbiology, Makerere University College of Health Sciences, Kampala, Uganda
| | - S Mohanty
- Department of Chemical Engineering, Department of Materials Science Engineering, University of Utah, Salt Lake City, USA
| | - A Somoskovi
- Global Good Intellectual Ventures Laboratory, Seattle, USA
| | - A Cattamanchi
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, University of California San Francisco, San Francisco, California, USA.,Center for Tuberculosis, University of California San Francisco, San Francisco, California, USA.,Center for Vulnerable Populations, Department of Medicine, University of California San Francisco, San Francisco, USA.,Curry International Tuberculosis Center, University of California San Francisco, San Francisco, USA
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15
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Abstract
INTRODUCTION Tuberculosis (TB) remains a major global health burden. There still remains a large gap between the notified and estimated incident cases. Extrapulmonary (EP) TB represents 15% of all TB cases and the diagnosis is more challenging due to the paucity of the organism. Smear microscopy is often insensitive and culture methods are prolonged. With the introduction of Xpert MTB/RIF and more recently Xpert Ultra, this has changed TB diagnostics by providing a rapid accessible platform to diagnose TB and identify rifampicin resistance within 2 h. AREAS COVERED The diagnostic accuracy and the clinical role of Xpert MTB/RIF and Xpert Ultra in the different forms of EPTB. EXPERT OPINION Whilst significant advances have been made in TB diagnostics, there is still a need to optimize the diagnostic yield of Xpert MTB/RIF and Xpert Ultra in EPTB samples. Research is needed to facilitate standardization and optimal preparation of samples as well as understanding the role of Xpert MTB/RIF and Xpert Ultra in different burden settings. Alongside the current GeneXpert platform, the launch of rapid second-line drug resistance polymerase chain reactions and whole genome sequencing may help tackle the global health burden with a more comprehensive diagnostic approach and appropriate treatment.
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Affiliation(s)
- Mirae Park
- Imperial College Healthcare NHS Trust, St Mary's Hospital , London, UK.,National Heart and Lung Institute, Imperial College London , London, UK
| | - Onn Min Kon
- Imperial College Healthcare NHS Trust, St Mary's Hospital , London, UK.,National Heart and Lung Institute, Imperial College London , London, UK
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16
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Magni R, Rruga F, Alsaab F, Sharif S, Howard M, Espina V, Kim B, Lepene B, Lee G, Alayouni MA, Steinberg H, Araujo R, Kashanchi F, Riccardi F, Morreira S, Araujo A, Poli F, Jaganath D, Semitala FC, Worodria W, Andama A, Choudhary A, Honnen WJ, Petricoin EF 3rd, Cattamanchi A, Colombatti R, de Waard JH, Oberhelman R, Pinter A, Gilman RH, Liotta LA, Luchini A. Lipoarabinomannan antigenic epitope differences in tuberculosis disease subtypes. Sci Rep 2020; 10:13944. [PMID: 32811861 DOI: 10.1038/s41598-020-70669-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 07/30/2020] [Indexed: 12/12/2022] Open
Abstract
An accurate urine test for diverse populations with active tuberculosis could be transformative for preventing TB deaths. Urinary liporabinomannan (LAM) testing has been previously restricted to HIV co-infected TB patients. In this study we evaluate urinary LAM in HIV negative, pediatric and adult, pulmonary and extrapulmonary tuberculosis patients. We measured 430 microbiologically confirmed pretreatment tuberculosis patients and controls from Peru, Guinea Bissau, Venezuela, Uganda and the United States using three monoclonal antibodies, MoAb1, CS35, and A194, which recognize distinct LAM epitopes, a one-sided immunoassay, and blinded cohorts. We evaluated sources of assay variability and comorbidities (HIV and diabetes). All antibodies successfully discriminated TB positive from TB negative patients. ROAUC from the average of three antibodies’ responses was 0.90; 95% CI 0.87–0.93, 90% sensitivity, 73.5% specificity (80 pg/mL). MoAb1, recognizing the 5-methylthio-d-xylofuranose(MTX)-mannose(Man) cap epitope, performed the best, was less influenced by glycosuria and identified culture positive pediatric (N = 19) and extrapulmonary (N = 24) patients with high accuracy (ROAUC 0.87, 95% CI 0.77–0.98, 0.90 sensitivity 0.80 specificity at 80 pg/mL; ROAUC = 0.96, 95% CI 0.92–0.99, 96% sensitivity, 80% specificity at 82 pg/mL, respectively). The MoAb1 antibody, recognizing the MTX-Man cap epitope, is a novel analyte for active TB detection in pediatric and extrapulmonary disease.
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17
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Kasibante J, Rutakingirwa MK, Kagimu E, Ssebambulidde K, Ellis J, Tugume L, Mpoza E, Cresswell F, Meya DB. Tuberculosis preventive therapy (TPT) to prevent tuberculosis co-infection among adults with HIV-associated cryptococcal meningitis: A clinician's perspective. J Clin Tuberc Other Mycobact Dis 2020; 20:100180. [PMID: 32875123 PMCID: PMC7452161 DOI: 10.1016/j.jctube.2020.100180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
As part of the END TB strategy, the World Health organization (WHO) recommends provision of tuberculosis preventive therapy (TPT) to all people at high risk of developing active TB disease. Patients with HIV-associated cryptococcal meningitis are severely immunocompromised and therefore should be eligible for TPT. In this commentary we discuss the challenges associated with starting tuberculosis preventive therapy in patients with HIV associated cryptococcal meningitis in a clinical setting, we highlight the benefit, existing gaps and research opportunities of tuberculosis preventive therapy in this patient population.
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Affiliation(s)
- John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Jayne Ellis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,Clinical Research Department, London School of Hygiene & Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, UK
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Fiona Cresswell
- Clinical Research Department, London School of Hygiene & Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, UK.,Medical Research Council - Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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18
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Ndege R, Ngome O, Bani F, Temba Y, Wilson H, Vanobberghen F, Hella J, Gingo W, Sasamalo M, Mnzava D, Kimera N, Hiza H, Wigayi J, Mapesi H, Kato IB, Mhimbira F, Reither K, Battegay M, Paris DH, Weisser M, Rohacek M. Ultrasound in managing extrapulmonary tuberculosis: a randomized controlled two-center study. BMC Infect Dis 2020; 20:349. [PMID: 32414338 PMCID: PMC7226714 DOI: 10.1186/s12879-020-05073-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/04/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Patients with clinically suspected tuberculosis are often treated empirically, as diagnosis - especially of extrapulmonary tuberculosis - remains challenging. This leads to an overtreatment of tuberculosis and to underdiagnosis of possible differential diagnoses. METHODS This open-label, parallel-group, superiority randomized controlled trial is done in a rural and an urban center in Tanzania. HIV-positive and -negative adults (≥18 years) with clinically suspected extrapulmonary tuberculosis are randomized in a 1:1 ratio to an intervention- or control group, stratified by center and HIV status. The intervention consists of a management algorithm including extended focused assessment of sonography for HIV and tuberculosis (eFASH) in combination with chest X-ray and microbiological tests. Treatment with anti-tuberculosis drugs is started, if eFASH is positive, chest X-ray suggests tuberculosis, or a microbiological result is positive for tuberculosis. Patients in the control group are managed according national guidelines. Treatment is started if microbiology is positive or empirically according to the treating physician. The primary outcome is the proportion of correctly managed patients at 6 months (i.e patients who were treated with anti-tuberculosis treatment and had definite or probable tuberculosis, and patients who were not treated with anti-tuberculosis treatment and did not have tuberculosis). Secondary outcomes are the proportion of symptom-free patients at two and 6 months, and time to death. The sample size is 650 patients. DISCUSSION This study will determine, whether ultrasound in combination with other tests can increase the proportion of correctly managed patients with clinically suspected extrapulmonary tuberculosis, thus reducing overtreatment with anti-tuberculosis drugs. TRIAL REGISTRATION PACTR, Registration number: PACTR201712002829221, registered December 1st 2017.
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Affiliation(s)
- Robert Ndege
- Ifakara Health Institute, Ifakara, United Republic of Tanzania, Off Mlabani Passage, P. O Box 53, Ifakara, Tanzania.
- St Francis Referral Hospital, Ifakara, United Republic of Tanzania.
| | - Omary Ngome
- Ifakara Health Institute, Ifakara, United Republic of Tanzania, Off Mlabani Passage, P. O Box 53, Ifakara, Tanzania
- Mwananyamala Regional Referral Hospital, Dar es salaam, United Republic of Tanzania
| | - Farida Bani
- Ifakara Health Institute, Ifakara, United Republic of Tanzania, Off Mlabani Passage, P. O Box 53, Ifakara, Tanzania
- St Francis Referral Hospital, Ifakara, United Republic of Tanzania
| | - Yvan Temba
- Ifakara Health Institute, Ifakara, United Republic of Tanzania, Off Mlabani Passage, P. O Box 53, Ifakara, Tanzania
- Mwananyamala Regional Referral Hospital, Dar es salaam, United Republic of Tanzania
| | - Herieth Wilson
- Ifakara Health Institute, Ifakara, United Republic of Tanzania, Off Mlabani Passage, P. O Box 53, Ifakara, Tanzania
- St Francis Referral Hospital, Ifakara, United Republic of Tanzania
| | - Fiona Vanobberghen
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Jerry Hella
- Ifakara Health Institute, Ifakara, United Republic of Tanzania, Off Mlabani Passage, P. O Box 53, Ifakara, Tanzania
| | - Winfrid Gingo
- St Francis Referral Hospital, Ifakara, United Republic of Tanzania
| | - Mohamed Sasamalo
- Ifakara Health Institute, Ifakara, United Republic of Tanzania, Off Mlabani Passage, P. O Box 53, Ifakara, Tanzania
| | - Dorcas Mnzava
- Ifakara Health Institute, Ifakara, United Republic of Tanzania, Off Mlabani Passage, P. O Box 53, Ifakara, Tanzania
| | - Namvua Kimera
- Ifakara Health Institute, Ifakara, United Republic of Tanzania, Off Mlabani Passage, P. O Box 53, Ifakara, Tanzania
| | - Helen Hiza
- Ifakara Health Institute, Ifakara, United Republic of Tanzania, Off Mlabani Passage, P. O Box 53, Ifakara, Tanzania
| | - John Wigayi
- Ifakara Health Institute, Ifakara, United Republic of Tanzania, Off Mlabani Passage, P. O Box 53, Ifakara, Tanzania
| | - Herry Mapesi
- Ifakara Health Institute, Ifakara, United Republic of Tanzania, Off Mlabani Passage, P. O Box 53, Ifakara, Tanzania
| | - Irene B Kato
- Mwananyamala Regional Referral Hospital, Dar es salaam, United Republic of Tanzania
| | - Francis Mhimbira
- Ifakara Health Institute, Ifakara, United Republic of Tanzania, Off Mlabani Passage, P. O Box 53, Ifakara, Tanzania
| | - Klaus Reither
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Manuel Battegay
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Division of Infectious Diseases, University Hospital Basel, Basel, Switzerland
| | - Daniel H Paris
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Maja Weisser
- Ifakara Health Institute, Ifakara, United Republic of Tanzania, Off Mlabani Passage, P. O Box 53, Ifakara, Tanzania
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Division of Infectious Diseases, University Hospital Basel, Basel, Switzerland
| | - Martin Rohacek
- Ifakara Health Institute, Ifakara, United Republic of Tanzania, Off Mlabani Passage, P. O Box 53, Ifakara, Tanzania.
- St Francis Referral Hospital, Ifakara, United Republic of Tanzania.
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland.
- Faculty of Medicine, University of Basel, Basel, Switzerland.
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19
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Cresswell FV, Ellis J, Kagimu E, Bangdiwala AS, Okirwoth M, Mugumya G, Rutakingirwa M, Kasibante J, Quinn CM, Ssebambulidde K, Rhein J, Nuwagira E, Tugume L, Martyn E, Skipper CP, Muzoora C, Grint D, Meya DB, Bahr NC, Elliott AM, Boulware DR. Standardized Urine-Based Tuberculosis (TB) Screening With TB-Lipoarabinomannan and Xpert MTB/RIF Ultra in Ugandan Adults With Advanced Human Immunodeficiency Virus Disease and Suspected Meningitis. Open Forum Infect Dis 2020; 7:ofaa100. [PMID: 32373646 PMCID: PMC7192026 DOI: 10.1093/ofid/ofaa100] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/20/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Diagnosis of extrapulmonary tuberculosis (TB) remains challenging. We sought to determine the prevalence of disseminated TB by testing urine with TB-lipoarabinomannan (TB-LAM) lateral flow assay and Xpert MTB/RIF Ultra (Ultra) in hospitalized adults. METHODS We prospectively enrolled human immunodeficiency virus (HIV)-positive adults with suspected meningitis in Uganda during 2018-2020. Participants underwent standardized urine-based TB screening. Urine (60 mcL) was tested with TB-LAM (Alere), and remaining urine was centrifuged with the cell pellet resuspended in 2 mL of urine for Xpert Ultra testing. RESULTS We enrolled 348 HIV-positive inpatients with median CD4 of 37 cells/mcL (interquartile range, 13-102 cells/mcL). Overall, 26% (90 of 348; 95% confidence interval [CI], 21%-30%) had evidence of disseminated TB by either urine assay. Of 243 participants with both urine TB-LAM and Ultra results, 20% (48 of 243) were TB-LAM-positive, 12% (29 of 243) were Ultra-positive, and 6% (14 of 243) were positive by both assays. In definite and probable TB meningitis, 37% (14 of 38) were TB-LAM-positive and 41% (15 of 37) were Ultra-positive. In cryptococcal meningitis, 22% (40 of 183) were TB-LAM-positive and 4.4% (6 of 135) were Ultra-positive. Mortality trended higher in those with evidence of disseminated TB by either assay (odds ratio = 1.44; 95% CI, 0.83-2.49; P = .19) and was 6-fold higher in those with definite TB meningitis who were urine Ultra-positive (odds ratio = 5.67; 95% CI, 1.13-28.5; P = .04). CONCLUSIONS In hospitalized Ugandans with advanced HIV disease and suspected meningitis, systematic screening with urine TB-LAM and Ultra found a high prevalence of urine TB test positivity (26%). In those with TB meningitis, urine tests were positive in over one third. There was little concordance between Ultra and TB-LAM, which warrants further investigation.
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Affiliation(s)
- Fiona V Cresswell
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Jayne Ellis
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Ananta S Bangdiwala
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael Okirwoth
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Gerald Mugumya
- Microbiology Laboratory, Kiruddu Referral Hospital, Kampala, Uganda
| | | | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Carson M Quinn
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Joshua Rhein
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, Kansas, USA
| | - Edwin Nuwagira
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Emily Martyn
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Caleb P Skipper
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Conrad Muzoora
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Daniel Grint
- Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, Kansas, USA
| | - Alison M Elliott
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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