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Coussens AK, Zaidi SMA, Allwood BW, Dewan PK, Gray G, Kohli M, Kredo T, Marais BJ, Marks GB, Martinez L, Ruhwald M, Scriba TJ, Seddon JA, Tisile P, Warner DF, Wilkinson RJ, Esmail H, Houben RMGJ. Classification of early tuberculosis states to guide research for improved care and prevention: an international Delphi consensus exercise. THE LANCET. RESPIRATORY MEDICINE 2024; 12:484-498. [PMID: 38527485 DOI: 10.1016/s2213-2600(24)00028-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 03/27/2024]
Abstract
The current active-latent paradigm of tuberculosis largely neglects the documented spectrum of disease. Inconsistency with regard to definitions, terminology, and diagnostic criteria for different tuberculosis states has limited the progress in research and product development that are needed to achieve tuberculosis elimination. We aimed to develop a new framework of classification for tuberculosis that accommodates key disease states but is sufficiently simple to support pragmatic research and implementation. Through an international Delphi exercise that involved 71 participants representing a wide range of disciplines, sectors, income settings, and geographies, consensus was reached on a set of conceptual states, related terminology, and research gaps. The International Consensus for Early TB (ICE-TB) framework distinguishes disease from infection by the presence of macroscopic pathology and defines two subclinical and two clinical tuberculosis states on the basis of reported symptoms or signs of tuberculosis, further differentiated by likely infectiousness. The presence of viable Mycobacterium tuberculosis and an associated host response are prerequisites for all states of infection and disease. Our framework provides a clear direction for tuberculosis research, which will, in time, improve tuberculosis clinical care and elimination policies.
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Affiliation(s)
- Anna K Coussens
- Infectious Diseases and Immune Defence Division, The Walter and Eliza Hall Institute of Medical Research (WEHI), Parkville, VIC, Australia; Centre for Infectious Diseases Research in Africa, University of Cape Town, Cape Town, South Africa; Institute of Infectious Disease and Molecular Medicine, and Department of Pathology, University of Cape Town, Cape Town, South Africa; Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
| | - Syed M A Zaidi
- WHO Collaborating Centre on Tuberculosis Research and Innovation, Institute for Global Health, and MRC Clinical Trials Unit, University College London, London, UK; Department of Public Health, National University of Medical Sciences, Rawalpindi, Pakistan
| | - Brian W Allwood
- Division of Pulmonology, Department of Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Puneet K Dewan
- Tuberculosis and HIV, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Glenda Gray
- Health Systems Research Unit, South Africa Medical Research Council, Cape Town, South Africa
| | | | - Tamara Kredo
- Health Systems Research Unit, South Africa Medical Research Council, Cape Town, South Africa
| | - Ben J Marais
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW, Australia; WHO Collaborating Centre in Tuberculosis, University of Sydney, Sydney, NSW, Australia
| | - Guy B Marks
- Department of Clinical Medicine, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Leo Martinez
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | | | - Thomas J Scriba
- Centre for Infectious Diseases Research in Africa, University of Cape Town, Cape Town, South Africa; South African Tuberculosis Vaccine Initiative, University of Cape Town, Cape Town, South Africa; Institute of Infectious Disease and Molecular Medicine, and Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - James A Seddon
- Department of Infectious Disease, Imperial College London, London, UK; Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | | | - Digby F Warner
- Centre for Infectious Diseases Research in Africa, University of Cape Town, Cape Town, South Africa; Institute of Infectious Disease and Molecular Medicine, and Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Robert J Wilkinson
- Centre for Infectious Diseases Research in Africa, University of Cape Town, Cape Town, South Africa; Department of Infectious Disease, Imperial College London, London, UK; The Francis Crick Institute, London, UK
| | - Hanif Esmail
- Centre for Infectious Diseases Research in Africa, University of Cape Town, Cape Town, South Africa; WHO Collaborating Centre on Tuberculosis Research and Innovation, Institute for Global Health, and MRC Clinical Trials Unit, University College London, London, UK.
| | - Rein M G J Houben
- TB Modelling Group, TB Centre, and Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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2
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Mbuli C, Vuchas C, Konso J, Adamou Mana Z, Ngangue YR, Esther N, Nyah Ndi N, Wandji IAG, Fundoh M, Ganava M, Malama T, Denis N, Teyim P, Bisso A, Snijders R, Mitchell EM, Hasker E, Soma I, Sander M, Mitarai S. Use of the Lung Flute ECO to assist in sputum collection for tuberculosis testing: a randomised crossover trial. ERJ Open Res 2024; 10:00902-2023. [PMID: 38803415 PMCID: PMC11129641 DOI: 10.1183/23120541.00902-2023] [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: 07/31/2023] [Accepted: 12/22/2023] [Indexed: 05/29/2024] Open
Abstract
The Lung Flute ECO, a self-powered, low-cost oscillatory positive expiratory pressure device, assisted people with presumptive tuberculosis to produce an adequate sputum volume for diagnostic testing and was well tolerated https://bit.ly/47sDq8W.
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Affiliation(s)
- Cyrille Mbuli
- Center for Health Promotion and Research, Bamenda, Cameroon
| | - Comfort Vuchas
- Center for Health Promotion and Research, Bamenda, Cameroon
| | - Joceline Konso
- Center for Health Promotion and Research, Bamenda, Cameroon
| | | | | | - Neba Esther
- Bamenda Regional Hospital, Bamenda, Cameroon
| | - Norah Nyah Ndi
- Cameroon Baptist Convention Health Services and Baptist Institute of Health Sciences, Bamenda, Cameroon
| | | | - Mercy Fundoh
- National TB Program – Northwest Region, Bamenda, Cameroon
| | - Maurice Ganava
- National TB Program – Far North Region, Maroua, Cameroon
| | | | - Nsame Denis
- Bamenda Regional Hospital, Bamenda, Cameroon
| | - Pride Teyim
- Tuberculosis Reference Laboratory Douala, Douala, Cameroon
| | | | | | | | - Epco Hasker
- Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Melissa Sander
- Center for Health Promotion and Research, Bamenda, Cameroon
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Reeve BWP, Ndlangalavu G, Mishra H, Palmer Z, Tshivhula H, Rockman L, Naidoo S, Mbu DL, Naidoo CC, Derendinger B, Walzl G, Malherbe ST, van Helden PD, Semitala FC, Yoon C, Gupta RK, Noursadeghi M, Warren RM, Theron G. Point-of-care C-reactive protein and Xpert MTB/RIF Ultra for tuberculosis screening and diagnosis in unselected antiretroviral therapy initiators: a prospective, cross-sectional, diagnostic accuracy study. Lancet Glob Health 2024; 12:e793-e803. [PMID: 38583458 PMCID: PMC11035478 DOI: 10.1016/s2214-109x(24)00052-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/14/2023] [Accepted: 01/25/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Tuberculosis, a major cause of death in people living with HIV, remains challenging to diagnose. Diagnostic accuracy data are scarce for promising triage and confirmatory tests such as C-reactive protein (CRP), sputum and urine Xpert MTB/RIF Ultra (Xpert Ultra), and urine Determine TB LAM Ag (a lateral flow lipoarabinomannan [LF-LAM] test), without symptom selection. We evaluated novel triage and confirmatory tests in ambulatory people with HIV initiating antiretroviral therapy (ART). METHODS 897 ART-initiators were recruited irrespective of symptoms and sputum induction offered. For triage (n=800), we evaluated point-of-care blood-based CRP testing, compared with the WHO-recommended four-symptom screen (W4SS). For sputum-based confirmatory testing (n=787), we evaluated Xpert Ultra versus Xpert MTB/RIF (Xpert). For urine-based confirmatory testing (n=732), we evaluated Xpert Ultra and LF-LAM. We used a sputum culture reference standard. FINDINGS 463 (52%) of 897 participants were female. The areas under the receiver operator characteristic curves for CRP was 0·78 (95% CI 0·73-0·83) and for number of W4SS symptoms was 0·70 (0·64-0·75). CRP (≥10 mg/L) had similar sensitivity to W4SS (77% [95% CI 68-85; 80/104] vs 77% [68-85; 80/104]; p>0·99] but higher specificity (64% [61-68; 445/696] vs 48% [45-52; 334/696]; p<0·0001]; reducing unnecessary confirmatory testing by 138 (95% CI 117-160) per 1000 people and number-needed-to-test from 6·91 (95% CI 6·25-7·81) to 4·87 (4·41-5·51). Sputum samples with Xpert Ultra, which required induction in 49 (31%) of 158 of people (95% CI 24-39), had higher sensitivity than Xpert (71% [95% CI 61-80; 74/104] vs 56% [46-66; 58/104]; p<0·0001). Of the people with one or more confirmatory sputum or urine test results that were positive, the proportion detected by Xpert Ultra increased from 45% (26-64) to 66% (46-82) with induction. Programmatically done haemoglobin, triage test combinations, and urine tests showed comparatively worse results. INTERPRETATION CRP is a more specific triage test than W4SS in those initiating ART. Sputum induction improves diagnostic yield. Sputum samples with Xpert Ultra is a more accurate confirmatory test than with Xpert. FUNDING South African Medical Research Council, EDCTP2, US National Institutes of Health-National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- 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
| | - 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
| | - Hridesh Mishra
- 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; Public Health Research Institute, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, USA
| | - Zaida Palmer
- 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
| | - Happy Tshivhula
- 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
| | - Loren Rockman
- 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
| | - Selisha Naidoo
- 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
| | - Desiree L Mbu
- 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
| | - Charissa C Naidoo
- 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
| | - Brigitta Derendinger
- 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
| | - Gerhard Walzl
- 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
| | - Stephanus T Malherbe
- 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
| | - Paul D van Helden
- 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
| | - Fred C Semitala
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda; Department of Internal Medicine, Makerere University College of Health Sciences, Makerere, Kampala, Uganda
| | - Christina Yoon
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda; Department of Medicine, Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Rishi K Gupta
- Division of Infection and Immunity, University College London, London, UK
| | | | - Robin 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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de Jong D, Carrell C, Maganga JK, Mhango L, Shigella PS, Gill M, Shogren R, Mullins B, Warrick JW, Changalucha JM, van Dam GJ, Pham K, Downs JA, Corstjens PLAM. Flow-S: A Field-Deployable Device with Minimal Hands-On Effort to Concentrate and Quantify Schistosoma Circulating Anodic Antigen (CAA) from Large Urine Volumes. Diagnostics (Basel) 2024; 14:820. [PMID: 38667466 PMCID: PMC11048900 DOI: 10.3390/diagnostics14080820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/26/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
A laboratory-based lateral flow (LF) test that utilizes up-converting reporter particles (UCP) for ultrasensitive quantification of Schistosoma circulating anodic antigen (CAA) in urine is a well-accepted test to identify active infection. However, this UCP-LF CAA test requires sample pre-treatment steps not compatible with field applications. Flow, a new low-cost disposable, allows integration of large-volume pre-concentration of urine analytes and LF detection into a single field-deployable device. We assessed a prototype Flow-Schistosoma (Flow-S) device with an integrated UCP-LF CAA test strip, omitting all laboratory-based steps, to enable diagnosis of active Schistosoma infection in the field using urine. Flow-S is designed for large-volume (5-20 mL) urine, applying passive paper-based filtration and antibody-based CAA concentration. Samples tested for schistosome infection were collected from women of reproductive age living in a Tanzania region where S. haematobium infection is endemic. Fifteen negative and fifteen positive urine samples, selected based on CAA levels quantified in paired serum, were analyzed with the prototype Flow-S. The current Flow-S prototype, with an analytical lower detection limit of 1 pg CAA/mL, produced results correlated with the laboratory-based UCP-LF CAA test. Urine precipitates occurred in frozen banked samples and affected accurate quantification; however, this should not occur in fresh urine. Based on the findings of this study, Flow-S appears suitable to replace the urine pre-treatment required for the laboratory-based UCP-LF CAA test, thus allowing true field-based applications with fresh urine samples. The urine precipitates observed with frozen samples, though less important given the goal of testing fresh urines, warrant additional investigation to evaluate methods for mitigation. Flow-S devices permit testing of pooled urine samples with applications for population stratified testing. A field test with fresh urine samples, a further optimized Flow-S device, and larger statistical power has been scheduled.
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Affiliation(s)
- Daniëlle de Jong
- Department of Cell and Chemical Biology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands
| | | | - Jane K. Maganga
- Mwanza Intervention Trials Unit/National Institute for Medical Research, Mwanza, Tanzania
| | - Loyce Mhango
- Mwanza Intervention Trials Unit/National Institute for Medical Research, Mwanza, Tanzania
| | - Peter S. Shigella
- Mwanza Intervention Trials Unit/National Institute for Medical Research, Mwanza, Tanzania
| | - Maddy Gill
- Salus Discovery LLC, Madison, WI 53703, USA
| | | | | | | | - John M. Changalucha
- Mwanza Intervention Trials Unit/National Institute for Medical Research, Mwanza, Tanzania
| | - Govert J. van Dam
- Department of Parasitology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands
| | - Khanh Pham
- Division of Infectious Diseases, Weill Cornell Medicine, New York, NY 10065, USA
| | - Jennifer A. Downs
- Mwanza Intervention Trials Unit/National Institute for Medical Research, Mwanza, Tanzania
- Center for Global Health, Weill Cornell Medicine, New York, NY 10065, USA
- Department of Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Paul L. A. M. Corstjens
- Department of Cell and Chemical Biology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands
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Russomando G, Sanabria D, Díaz Acosta CC, Rojas L, Franco L, Arenas R, Delogu G, Ndiaye MDB, Bayaa R, Rakotosamimanana N, Goletti D, Hoffmann J. C1q and HBHA-specific IL-13 levels as surrogate plasma biomarkers for monitoring tuberculosis treatment efficacy: a cross-sectional cohort study in Paraguay. Front Immunol 2024; 15:1308015. [PMID: 38545118 PMCID: PMC10967656 DOI: 10.3389/fimmu.2024.1308015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction New diagnostic tools are needed to rapidly assess the efficacy of pulmonary tuberculosis (PTB) treatment. The aim of this study was to evaluate several immune biomarkers in an observational and cross-sectional cohort study conducted in Paraguay. Methods Thirty-two patients with clinically and microbiologically confirmed PTB were evaluated before starting treatment (T0), after 2 months of treatment (T1) and at the end of treatment (T2). At each timepoint plasma levels of IFN-y, 17 pro- and anti-inflammatory cytokines/chemokines and complement factors C1q, C3 and C4 were assessed in unstimulated and Mtb-specific stimulated whole blood samples using QuantiFERON-TB gold plus and recombinant Mycobacterium smegmatis heparin binding hemagglutinin (rmsHBHA) as stimulation antigen. Complete blood counts and liver enzyme assays were also evaluated and correlated with biomarker levels in plasma. Results In unstimulated plasma, C1q (P<0.001), C4 (P<0.001), hemoglobin (P<0.001), lymphocyte proportion (P<0.001) and absolute white blood cell count (P=0.01) were significantly higher in PTB patients at baseline than in cured patients. C1q and C4 levels were found to be related to Mycobacterium tuberculosis load in sputum. Finally, a combinatorial analysis identified a plasma host signature comprising the detection of C1q and IL-13 levels in response to rmsHBHA as a tool differentiating PTB patients from cured TB profiles, with an AUC of 0.92 (sensitivity 94% and specificity 79%). Conclusion This observational study provides new insights on host immune responses throughout anti-TB treatment and emphasizes the role of host C1q and HBHA-specific IL-13 response as surrogate plasma biomarkers for monitoring TB treatment efficacy.
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Affiliation(s)
- Graciela Russomando
- Instituto de Investigaciones en Ciencias de la Salud, National University of Asunción, Asunción, Paraguay
| | - Diana Sanabria
- Instituto de Investigaciones en Ciencias de la Salud, National University of Asunción, Asunción, Paraguay
| | | | - Leticia Rojas
- Instituto de Investigaciones en Ciencias de la Salud, National University of Asunción, Asunción, Paraguay
| | - Laura Franco
- Instituto de Investigaciones en Ciencias de la Salud, National University of Asunción, Asunción, Paraguay
| | - Rossana Arenas
- Hospital General de San Lorenzo, Ministerio de Salud Pública y Bienestar Social (MSPyBS), Asunción, Paraguay
| | - Giovanni Delogu
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie – Sezione di Microbiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Rim Bayaa
- Medical and Scientific Department, Fondation Mérieux, Lyon, France
| | | | - Delia Goletti
- Translational Research Unit, Department of Epidemiology and Preclinical Research, “L. Spallanzani” National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
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Stuck L, Klinkenberg E, Abdelgadir Ali N, Basheir Abukaraig EA, Adusi-Poku Y, Alebachew Wagaw Z, Fatima R, Kapata N, Kapata-Chanda P, Kirenga B, Maama-Maime LB, Mfinanga SG, Moyo S, Mvusi L, Nandjebo N, Nguyen HV, Nguyen HB, Obasanya J, Adedapo Olufemi B, Patrobas Dashi P, Raleting Letsie TJ, Ruswa N, Rutebemberwa E, Senkoro M, Sivanna T, Yuda HC, Law I, Onozaki I, Tiemersma E, Cobelens F. Prevalence of subclinical pulmonary tuberculosis in adults in community settings: an individual participant data meta-analysis. THE LANCET. INFECTIOUS DISEASES 2024:S1473-3099(24)00011-2. [PMID: 38490237 DOI: 10.1016/s1473-3099(24)00011-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 12/17/2023] [Accepted: 01/09/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Subclinical pulmonary tuberculosis, which presents without recognisable symptoms, is frequently detected in community screening. However, the disease category is poorly clinically defined. We explored the prevalence of subclinical pulmonary tuberculosis according to different case definitions. METHODS We did a one-stage individual participant data meta-analysis of nationally representative surveys that were conducted in countries with high incidence of tuberculosis between 2007 and 2020, that reported the prevalence of pulmonary tuberculosis based on chest x-ray and symptom screening in participants aged 15 years and older. Screening and diagnostic criteria were standardised across the surveys, and tuberculosis was defined by positive Mycobacterium tuberculosis sputum culture. We estimated proportions of subclinical tuberculosis for three case definitions: no persistent cough (ie, duration ≥2 weeks), no cough at all, and no symptoms (ie, absence of cough, fever, chest pain, night sweats, and weight loss), both unadjusted and adjusted for false-negative chest x-rays and uninterpretable culture results. FINDINGS We identified 34 surveys, of which 31 were eligible. Individual participant data were obtained and included for 12 surveys (620 682 participants) across eight countries in Africa and four in Asia. Data on 602 863 participants were analysed, of whom 1944 had tuberculosis. The unadjusted proportion of subclinical tuberculosis was 59·1% (n=1149/1944; 95% CI 55·8-62·3) for no persistent cough and 39·8% (773/1944; 36·6-43·0) for no cough of any duration. The adjusted proportions were 82·8% (95% CI 78·6-86·6) for no persistent cough and 62·5% (56·6-68·7) for no cough at all. In a subset of four surveys, the proportion of participants with tuberculosis but without any symptoms was 20·3% (n=111/547; 95% CI 15·5-25·1) before adjustment and 27·7% (95% CI 21·0-36·4) after adjustment. Tuberculosis without cough, irrespective of its duration, was more frequent among women (no persistent cough: adjusted odds ratio 0·79, 95% CI 0·63-0·97; no cough: adjusted odds ratio 0·76, 95% CI 0·62-0·93). Among participants with tuberculosis, 29·1% (95% CI 25·2-33·3) of those without persistent cough and 23·1% (18·8-27·4) of those without any cough had positive smear examinations. INTERPRETATION The majority of people in the community who have pulmonary tuberculosis do not report cough, a quarter report no tuberculosis-suggestive symptoms at all, and a quarter of those not reporting any cough have positive sputum smears, suggesting infectiousness. In high-incidence settings, subclinical tuberculosis could contribute considerably to the tuberculosis burden and to Mycobacterium tuberculosis transmission. FUNDING Mr Willem Bakhuys Roozeboom Foundation.
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Affiliation(s)
- Logan Stuck
- Department of Global Health, Amsterdam University Medical Centers, Amsterdam, Netherlands; Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
| | - Eveline Klinkenberg
- Department of Global Health, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Nahid Abdelgadir Ali
- Global Fund Project Management Unit, International Health, Federal Ministry of Health, Khartoum, Sudan
| | | | - Yaw Adusi-Poku
- National Tuberculosis Control Programme, Ghana Health Service, Accra, Ghana
| | | | - Razia Fatima
- Research Unit, Common Management Unit [TB, HIV/AIDS & Malaria], Islamabad, Pakistan
| | - Nathan Kapata
- Ministry of Health, Lusaka, Zambia; Zambia National Public Health Institute, Lusaka, Zambia
| | | | - Bruce Kirenga
- Makerere University Lung Institute & Division of Pulmonary Medicine, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Sayoki G Mfinanga
- National Institute for Medical Research, Muhimbili Research Centre, Dar es Salaam, Tanzania; University College London, London, UK; Alliance for Africa Health and Research (A4A), Dar es Salaam, Tanzania
| | - Sizulu Moyo
- Human Sciences Research Council, Cape Town, South Africa
| | - Lindiwe Mvusi
- Tuberculosis Programme, National Department of Health, Pretoria, South Africa
| | | | | | - Hoa Binh Nguyen
- National Lung Hospital, National Tuberculosis Control Programme, Ha Noi, Viet Nam
| | | | - Bashorun Adedapo Olufemi
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | | | | | - Nunurai Ruswa
- Ministry of Health and Social Services, Windhoek, Namibia
| | | | - Mbazi Senkoro
- National Institute for Medical Research, Muhimbili Research Centre, Dar es Salaam, Tanzania
| | - Tieng Sivanna
- National Center for TB and Leprosy Control, Phnom Penh, Cambodia
| | - Huot Chan Yuda
- National Center for TB and Leprosy Control, Phnom Penh, Cambodia
| | - Irwin Law
- Global Tuberculosis Programme, WHO, Geneva, Switzerland
| | - Ikushi Onozaki
- Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan
| | | | - Frank Cobelens
- Department of Global Health, Amsterdam University Medical Centers, Amsterdam, Netherlands; Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands.
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7
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Yadav S, Rawal G, Jeyaraman M, Jeyaraman N. Advancements in Tuberculosis Diagnostics: A Comprehensive Review of the Critical Role and Future Prospects of Xpert MTB/RIF Ultra Technology. Cureus 2024; 16:e57311. [PMID: 38690500 PMCID: PMC11059844 DOI: 10.7759/cureus.57311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2024] [Indexed: 05/02/2024] Open
Abstract
Tuberculosis remains a persistent global health challenge, demanding swift and accurate diagnostic methods for effective treatment. The emergence of the Xpert MTB/RIF Ultra system marks a significant milestone in combating tuberculosis, streamlining the identification of Mycobacterium tuberculosis, and advancing our pursuit of eradicating the disease. Delving into the therapeutic landscape of tuberculosis and rifampicin resistance, this scientific narrative review offers a comprehensive exploration. It begins by delving into the historical backdrop and the hurdles encountered with traditional tuberculosis diagnostics. From there, it traces the journey of the Xpert MTB/RIF technology, underscoring its molecular underpinnings. In this narrative review, the performance of the Xpert MTB/RIF Ultra system undergoes thorough scrutiny, encompassing investigations into sensitivity, specificity, and comparisons with alternative diagnostic methods. The spotlight shines on its clinical applications across diverse scenarios, from diagnosing pulmonary and extrapulmonary tuberculosis to its pivotal role in identifying rifampicin resistance. The study also evaluates its clinical efficacy in enhancing patient outcomes and supporting global tuberculosis control initiatives. However, the review does not shy away from discussing the challenges and limitations associated with the Xpert MTB/RIF Ultra system. It meticulously addresses concerns regarding cost, infrastructure requirements, and potential diagnostic inaccuracies. Offering a panoramic view, the review assesses the system's impact in resource-constrained settings and its potential to bolster tuberculosis elimination endeavors worldwide. Peering into the future, it explores ongoing research avenues and potential enhancements in Xpert MTB/RIF Ultra technology, envisioning a landscape of improved performance, broader applications, and emerging diagnostic innovations in the realm of tuberculosis diagnostics.
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Affiliation(s)
- Sankalp Yadav
- Medicine, Shri Madan Lal Khurana Chest Clinic, New Delhi, IND
| | - Gautam Rawal
- Respiratory Medical Critical Care, Max Super Speciality Hospital, New Delhi, IND
| | - Madhan Jeyaraman
- Clinical Research, Viriginia Tech India, Dr. MGR Educational and Research Institute, Chennai, IND
- Orthopaedics, ACS Medical College and Hospital, Dr. MGR Educational and Research Institute, Chennai, IND
| | - Naveen Jeyaraman
- Orthopaedics, ACS Medical College and Hospital, Dr. MGR Educational and Research Institute, Chennai, IND
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Savage N. Tracking down tuberculosis. Nature 2024:10.1038/d41586-024-00087-8. [PMID: 38273057 DOI: 10.1038/d41586-024-00087-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
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Sharma M, Nduba V, Njagi LN, Murithi W, Mwongera Z, Hawn TR, Patel SN, Horne DJ. TBscreen: A passive cough classifier for tuberculosis screening with a controlled dataset. SCIENCE ADVANCES 2024; 10:eadi0282. [PMID: 38170773 PMCID: PMC10776005 DOI: 10.1126/sciadv.adi0282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 12/01/2023] [Indexed: 01/05/2024]
Abstract
Recent respiratory disease screening studies suggest promising performance of cough classifiers, but potential biases in model training and dataset quality preclude robust conclusions. To examine tuberculosis (TB) cough diagnostic features, we enrolled subjects with pulmonary TB (N = 149) and controls with other respiratory illnesses (N = 46) in Nairobi. We collected a dataset with 33,000 passive coughs and 1600 forced coughs in a controlled setting with similar demographics. We trained a ResNet18-based cough classifier using images of passive cough scalogram as input and obtained a fivefold cross-validation sensitivity of 0.70 (±0.11 SD). The smartphone-based model had better performance in subjects with higher bacterial load {receiver operating characteristic-area under the curve (ROC-AUC): 0.87 [95% confidence interval (CI): 0.87 to 0.88], P < 0.001} or lung cavities [ROC-AUC: 0.89 (95% CI: 0.88 to 0.89), P < 0.001]. Overall, our data suggest that passive cough features distinguish TB from non-TB subjects and are associated with bacterial burden and disease severity.
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Affiliation(s)
- Manuja Sharma
- Department of Electrical and Computer Engineering, University of Washington, 185 E Stevens Way NE, Seattle, WA 98195, USA
| | - Videlis Nduba
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Mbagathi Rd, Nairobi 610101, Kenya
| | - Lilian N. Njagi
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Mbagathi Rd, Nairobi 610101, Kenya
| | - Wilfred Murithi
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Mbagathi Rd, Nairobi 610101, Kenya
| | - Zipporah Mwongera
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Mbagathi Rd, Nairobi 610101, Kenya
| | - Thomas R. Hawn
- Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Shwetak N. Patel
- Department of Electrical and Computer Engineering, University of Washington, 185 E Stevens Way NE, Seattle, WA 98195, USA
- Paul G. Allen School of Computer Science and Engineering, University of Washington, 185 E Stevens Way NE, Seattle, WA 98195, USA
| | - David J. Horne
- Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA
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Emery JC, Dodd PJ, Banu S, Frascella B, Garden FL, Horton KC, Hossain S, Law I, van Leth F, Marks GB, Nguyen HB, Nguyen HV, Onozaki I, Quelapio MID, Richards AS, Shaikh N, Tiemersma EW, White RG, Zaman K, Cobelens F, Houben RMGJ. Estimating the contribution of subclinical tuberculosis disease to transmission: An individual patient data analysis from prevalence surveys. eLife 2023; 12:e82469. [PMID: 38109277 PMCID: PMC10727500 DOI: 10.7554/elife.82469] [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: 08/04/2022] [Accepted: 08/04/2023] [Indexed: 12/20/2023] Open
Abstract
Background Individuals with bacteriologically confirmed pulmonary tuberculosis (TB) disease who do not report symptoms (subclinical TB) represent around half of all prevalent cases of TB, yet their contribution to Mycobacterium tuberculosis (Mtb) transmission is unknown, especially compared to individuals who report symptoms at the time of diagnosis (clinical TB). Relative infectiousness can be approximated by cumulative infections in household contacts, but such data are rare. Methods We reviewed the literature to identify studies where surveys of Mtb infection were linked to population surveys of TB disease. We collated individual-level data on representative populations for analysis and used literature on the relative durations of subclinical and clinical TB to estimate relative infectiousness through a cumulative hazard model, accounting for sputum-smear status. Relative prevalence of subclinical and clinical disease in high-burden settings was used to estimate the contribution of subclinical TB to global Mtb transmission. Results We collated data on 414 index cases and 789 household contacts from three prevalence surveys (Bangladesh, the Philippines, and Viet Nam) and one case-finding trial in Viet Nam. The odds ratio for infection in a household with a clinical versus subclinical index case (irrespective of sputum smear status) was 1.2 (0.6-2.3, 95% confidence interval). Adjusting for duration of disease, we found a per-unit-time infectiousness of subclinical TB relative to clinical TB of 1.93 (0.62-6.18, 95% prediction interval [PrI]). Fourteen countries across Asia and Africa provided data on relative prevalence of subclinical and clinical TB, suggesting an estimated 68% (27-92%, 95% PrI) of global transmission is from subclinical TB. Conclusions Our results suggest that subclinical TB contributes substantially to transmission and needs to be diagnosed and treated for effective progress towards TB elimination. Funding JCE, KCH, ASR, NS, and RH have received funding from the European Research Council (ERC) under the Horizon 2020 research and innovation programme (ERC Starting Grant No. 757699) KCH is also supported by UK FCDO (Leaving no-one behind: transforming gendered pathways to health for TB). This research has been partially funded by UK aid from the UK government (to KCH); however, the views expressed do not necessarily reflect the UK government's official policies. PJD was supported by a fellowship from the UK Medical Research Council (MR/P022081/1); this UK-funded award is part of the EDCTP2 programme supported by the European Union. RGW is funded by the Wellcome Trust (218261/Z/19/Z), NIH (1R01AI147321-01), EDTCP (RIA208D-2505B), UK MRC (CCF17-7779 via SET Bloomsbury), ESRC (ES/P008011/1), BMGF (OPP1084276, OPP1135288 and INV-001754), and the WHO (2020/985800-0).
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Affiliation(s)
- Jon C Emery
- TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical MedicineLondonUnited Kingdom
| | - Peter J Dodd
- School of Health and Related Research, University of SheffieldSheffieldUnited Kingdom
| | - Sayera Banu
- International Centre for Diarrhoeal Disease ResearchDhakaBangladesh
| | | | - Frances L Garden
- South West Sydney Clinical Campuses, University of New South WalesSydneyAustralia
- Ingham Institute of Applied Medical ResearchSydneyAustralia
| | - Katherine C Horton
- TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical MedicineLondonUnited Kingdom
| | - Shahed Hossain
- James P. Grant School of Public Health, BRAC UniversityDhakaBangladesh
| | - Irwin Law
- Global Tuberculosis Programme, World Health OrganizationGenevaSwitzerland
| | - Frank van Leth
- Department of Health Sciences, VU UniversityAmsterdamNetherlands
- Amsterdam Public Health Research InstituteAmsterdamNetherlands
| | - Guy B Marks
- South West Sydney Clinical Campuses, University of New South WalesSydneyAustralia
- Woolcock Institute of Medical ResearchSydneyAustralia
| | - Hoa Binh Nguyen
- National Lung Hospital, National Tuberculosis Control ProgramHa NoiViet Nam
| | - Hai Viet Nguyen
- National Lung Hospital, National Tuberculosis Control ProgramHa NoiViet Nam
| | - Ikushi Onozaki
- Research Institute of Tuberculosis, Japan Anti-Tuberculosis AssociationTokyoJapan
| | | | - Alexandra S Richards
- TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical MedicineLondonUnited Kingdom
| | - Nabila Shaikh
- TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical MedicineLondonUnited Kingdom
- Sanofi PasteurReadingUnited Kingdom
| | | | - Richard G White
- TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical MedicineLondonUnited Kingdom
| | - Khalequ Zaman
- International Centre for Diarrhoeal Disease ResearchDhakaBangladesh
| | - Frank Cobelens
- Department of Global Health and Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers, University of AmsterdamAmsterdamNetherlands
| | - Rein MGJ Houben
- TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical MedicineLondonUnited Kingdom
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Wen XH, Han YL, Cao XS, Zhao W, Yan Z, Yan L, Wen JX, Hu ZD, Zheng WQ. Diagnostic value of nucleic acid amplification tests for tuberculous pleural effusion. Future Microbiol 2023; 18:971-983. [PMID: 37702019 DOI: 10.2217/fmb-2023-0025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Diagnosing tuberculous pleural effusion (TPE) is challenging for pulmonologists and laboratory scientists. The gold standards for TPE diagnosis are pleural fluid Ziehl-Neelsen staining, Mycobacterium tuberculosis (Mtb) culture and pleural biopsy. These tools have limitations, including low sensitivity, long turnaround time and invasiveness. The nucleic acid amplification test (NAAT) is a rapid and minimally invasive tool for diagnosing TPE. This review summarizes the diagnostic accuracy of available NAATs for TPE, with a focus on the evidence from systematic reviews and meta-analyses. The NAATs summarized in this review include in-house NAATs, GeneXpert-MTB/RIF, GeneXpert-MTB/RIF Ultra, simultaneous amplification and testing-tuberculosis, FluoroType MTB and loop-mediated isothermal amplification.
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Affiliation(s)
- Xu-Hui Wen
- Department of Laboratory Medicine, the Affiliated Hospital of Inner Mongolia Medical University, Hohhot, 010010, China
- Department of Parasitology, Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot, 010050, China
| | - Yu-Ling Han
- Department of Laboratory Medicine, the Affiliated Hospital of Inner Mongolia Medical University, Hohhot, 010010, China
- Department of Parasitology, Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot, 010050, China
| | - Xi-Shan Cao
- Department of Laboratory Medicine, the Affiliated Hospital of Inner Mongolia Medical University, Hohhot, 010010, China
| | - Wen Zhao
- Department of Laboratory Medicine, the Affiliated Hospital of Inner Mongolia Medical University, Hohhot, 010010, China
| | - Zhi Yan
- Department of Laboratory Medicine, the Affiliated Hospital of Inner Mongolia Medical University, Hohhot, 010010, China
- Department of Parasitology, Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot, 010050, China
| | - Li Yan
- Department of Respiratory & Critical Care Medicine, the Affiliated Hospital of Inner Mongolia Medical University, Hohhot, 010010, China
| | - Jian-Xun Wen
- Department of Medical Experiment Center, Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot, 010050, China
| | - Zhi-De Hu
- Department of Laboratory Medicine, the Affiliated Hospital of Inner Mongolia Medical University, Hohhot, 010010, China
| | - Wen-Qi Zheng
- Department of Laboratory Medicine, the Affiliated Hospital of Inner Mongolia Medical University, Hohhot, 010010, China
- Department of Parasitology, Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot, 010050, China
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Pei PP, Fitzmaurice KP, Le MH, Panella C, Jones ML, Pandya A, Horsburgh CR, Freedberg KA, Weinstein MC, Paltiel AD, Reddy KP. The Value-of-Information and Value-of-Implementation from Clinical Trials of Diagnostic Tests for HIV-Associated Tuberculosis: A Modeling Analysis. MDM Policy Pract 2023; 8:23814683231198873. [PMID: 37743931 PMCID: PMC10517616 DOI: 10.1177/23814683231198873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 07/27/2023] [Indexed: 09/26/2023] Open
Abstract
Objectives. Conventional value-of-information (VOI) analysis assumes complete uptake of an optimal decision. We employed an extended framework that includes value-of-implementation (VOM)-the benefit of encouraging adoption of an optimal strategy-and estimated how future trials of diagnostic tests for HIV-associated tuberculosis could improve public health decision making and clinical and economic outcomes. Methods. We evaluated the clinical outcomes and costs, given current information, of 3 tuberculosis screening strategies among hospitalized people with HIV in South Africa: sputum Xpert (Xpert), sputum Xpert plus urine AlereLAM (Xpert+AlereLAM), and sputum Xpert plus the newer, more sensitive, and costlier urine FujiLAM (Xpert+FujiLAM). We projected the incremental net monetary benefit (INMB) of decision making based on results of a trial comparing mortality with each strategy, rather than decision making based solely on current knowledge of FujiLAM's improved diagnostic performance. We used a validated microsimulation to estimate VOI (the INMB of reducing parameter uncertainty before decision making) and VOM (the INMB of encouraging adoption of an optimal strategy). Results. With current information, adopting Xpert+FujiLAM yields 0.4 additional life-years/person compared with current practices (assumed 50% Xpert and 50% Xpert+AlereLAM). While the decision to adopt this optimal strategy is unaffected by information from the clinical trial (VOI = $ 0 at $3,000/year-of-life saved willingness-to-pay threshold), there is value in scaling up implementation of Xpert+FujiLAM, which results in an INMB (representing VOM) of $650 million over 5 y. Conclusions. Conventional VOI methods account for the value of switching to a new optimal strategy based on trial data but fail to account for the persuasive value of trials in increasing uptake of the optimal strategy. Evaluation of trials should include a focus on their value in reducing barriers to implementation. Highlights In conventional VOI analysis, it is assumed that the optimal decision will always be adopted even without a trial. This can potentially lead to an underestimation of the value of trials when adoption requires new clinical trial evidence. To capture the influence that a trial may have on decision makers' willingness to adopt the optimal decision, we also consider value-of-implementation (VOM), a metric quantifying the benefit of new study information in promoting wider adoption of the optimal strategy. The overall value-of-a-trial (VOT) includes both VOI and VOM.Our model-based analysis suggests that the information obtained from a trial of screening strategies for HIV-associated tuberculosis in South Africa would have no value, when measured using traditional methods of VOI assessment. A novel strategy, which includes the urine FujiLAM test, is optimal from a health economic standpoint but is underutilized. A trial would reduce uncertainties around downstream health outcomes but likely would not change the optimal decision. The high VOT (nearly $700 million over 5 y) lies solely in promoting uptake of FujiLAM, represented as VOM.Our results highlight the importance of employing a more comprehensive approach for evaluating prospective trials, as conventional VOI methods can vastly underestimate their value. Trialists and funders can and should assess the VOT metric instead when considering trial designs and costs. If VOI is low, the VOM and cost of a trial can be compared with the benefits and costs of other outreach programs to determine the most cost-effective way to improve uptake.
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Affiliation(s)
- Pamela P. Pei
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | | | - Mylinh H. Le
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher Panella
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Michelle L. Jones
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - C. Robert Horsburgh
- School of Public Health and School of Medicine, Boston University, Boston, MA, USA
| | - Kenneth A. Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Milton C. Weinstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - A. David Paltiel
- Public Health Modeling Unit, Yale School of Public Health, New Haven, CT, USA
| | - Krishna P. Reddy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
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Reeve BW, Ndlangalavu G, Mishra H, Palmer Z, Tshivhula H, Rockman L, Naidoo S, Mbu DL, Naidoo CC, Derendinger B, Walzl G, Malherbe ST, van Helden PD, Semitala FC, Yoon C, Gupta RK, Noursadeghi M, Warren RM, Theron G. Point-of-care C-reactive protein and Xpert MTB/RIF Ultra for tuberculosis screening and diagnosis in unselected antiretroviral therapy initiators: a prospective diagnostic accuracy study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.30.23290716. [PMID: 37333303 PMCID: PMC10274965 DOI: 10.1101/2023.05.30.23290716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Background Tuberculosis (TB), a major cause of death in people living with HIV (PLHIV), remains challenging to diagnose. Diagnostic accuracy data are lacking for promising triage tests, such as C-reactive protein (CRP), and confirmatory tests, such as sputum and urine Xpert MTB/RIF Ultra (Ultra), and urine LAM, without prior symptom selection. Methods 897 PLHIV initiating antiretroviral therapy were consecutively recruited in settings with high TB incidence, irrespective of symptoms. Participants were offered sputum induction, with a liquid culture reference standard. First, we evaluated point-of-care CRP testing on blood, compared to the World Health Organization (WHO)-recommended four-symptom screen (W4SS) for triage (n=800). Second, we evaluated Xpert MTB/RIF Ultra (Ultra) versus Xpert MTB/RIF (Xpert) for sputum-based confirmatory testing (n=787), with or without sputum induction. Third, we evaluated Ultra and Determine LF-LAM for urine-based confirmatory testing (n=732). Findings CRP and number of W4SS symptoms had areas under the receiver operator characteristic curve of 0.78 (95% confidence interval 0.73, 0.83) and 0.70 (0.64, 0.75), respectively. For triage, CRP (≥10 mg/l) has similar sensitivity to W4SS [77% (68, 85) vs. 77% (68, 85); p>0.999] but higher specificity [64% (61, 68) vs. 48% (45, 52); p<0.001]; reducing unnecessary confirmatory testing by 138 per 1000 people and the number-needed-to-test from 6.91 (6.25, 7.81) to 4.87 (4.41, 5.51). Using sputum, which required induction in 31% (24, 39) of people, Ultra had higher sensitivity than Xpert [71% (61, 80) vs. 56% (46, 66); p<0.001] but lower specificity [98% (96, 100) vs. 99% (98, 100); p<0.001]. The proportion of people with ≥1 positive confirmatory result detected by Ultra increased from 45% (26, 64) to 66% (46, 82) when induction was done. Programmatically-done haemoglobin, triage test combinations, and urine tests showed comparatively worse performance. Interpretation Among ART-initiators in a high burden setting, CRP is a more specific triage test than W4SS. Sputum induction improves yield. Sputum Ultra is a more accurate confirmatory test than Xpert. Funding SAMRC (MRC-RFA-IFSP-01-2013), EDCTP2 (SF1401, OPTIMAL DIAGNOSIS), NIH/NIAD (U01AI152087). Research in context Evidence before this study: Novel triage and confirmatory tests are urgently needed for TB, especially in key risk groups like PLHIV. Many TB cases do not meet World Health Organization (WHO)-recommended four-symptom screen (W4SS) criteria despite accounting for significant transmission and morbidity. W4SS also lacks specificity, which makes onward referral of triage-positive people for expensive confirmatory testing inefficient and hampers diagnostic scale-up. Alternative triage approaches like CRP have promise, but have comparatively little data in ART-initiators, especially when done without syndromic preselection and using point-of-care (POC) tools. After triage, confirmatory testing can be challenging due to sputum scarcity and paucibacillary early-stage disease. Next generation WHO-endorsed rapid molecular tests (including Xpert MTB/RIF Ultra; Ultra) are a standard-of-care for confirmatory testing. However, there are no supporting data in ART-initiators, among whom Ultra may offer large sensitivity gains over predecessors like Xpert MTB/RIF (Xpert). The added value of sputum induction to augment diagnostic sampling for confirmatory testing is also unclear. Lastly, the performance of urine tests (Ultra, Determine LF-LAM) in this population requires more data.Added value of this study: We evaluated repurposed and new tests for triage and confirmatory testing using a rigorous microbiological reference standard in a highly vulnerable high-priority patient population (ART-initiators) regardless of symptoms and ability to naturally expectorate sputum. We showed POC CRP triage is feasible, performs better than W4SS, and that combinations of different triage approaches offer no advantages over CRP alone. Sputum Ultra has superior sensitivity to Xpert; often detecting W4SS-negative TB. Furthermore, without induction, confirmatory sputum-based testing would not be possible in a third of people. Urine tests had poor performance. This study contributed unpublished data to systematic reviews and meta-analyses used by the WHO to inform global policy supporting use of CRP triage and Ultra in PLHIV.Implication of all the available evidence: POC CRP triage testing is feasible and superior to W4SS and, together with sputum induction in people who triage CRP-positive should, after appropriate cost and implementation research, be considered for roll-out in ART-initiators in high burden settings. Such people should be offered Ultra, which outperforms Xpert.
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Segala FV, Papagni R, Cotugno S, De Vita E, Susini MC, Filippi V, Tulone O, Facci E, Lattanzio R, Marotta C, Manenti F, Bavaro DF, De Iaco G, Putoto G, Veronese N, Barbagallo M, Saracino A, Di Gennaro F. Stool Xpert MTB/RIF as a possible diagnostic alternative to sputum in Africa: a systematic review and meta-analysis. Front Public Health 2023; 11:1117709. [PMID: 37293615 PMCID: PMC10244509 DOI: 10.3389/fpubh.2023.1117709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/08/2023] [Indexed: 06/10/2023] Open
Abstract
Introduction Worldwide, COVID-19 pandemic lead to a large fall in the number of newly reported TB cases. In sub-Saharan Africa, microbiological diagnosis of TB is generally based on smear microscopy and Xpert MTB/RIF on sputum samples, but good quality sputum samples are often difficult to obtain, leading clinicians to rely on more invasive procedures for diagnosis. Aim of this study was to investigate pooled sensitivity and specificity of Xpert MTB/RIF on stool samples compared to respiratory microbiological reference standards in African countries. Methods Four investigators independently searched PubMed, SCOPUS, and Web of Science until 12th October 2022, then screened titles and abstracts of all potentially eligible articles. The authors applied the eligibility criteria, considered the full texts. All the studies reported the data regarding true positive (TP), true negative (TN), false positive (FP) and false negative (FN). Risk of bias and applicability concerns were assessed with the Quadas-2 tool. Results overall, among 130 papers initially screened, we evaluated 47 works, finally including 13 papers for a total of 2,352 participants, mainly children. The mean percentage of females was 49.6%, whilst the mean percentage of patients reporting HIV was 27.7%. Pooled sensitivity for Xpert MTB/RIF assay for detecting pulmonary tuberculosis was 68.2% (95%CI: 61.1-74.7%) even if characterized by a high heterogeneity (I2=53.7%). Specificity was almost 100% (99%, 95%CI: 97-100%; I2 = 45.7%). When divided for reference standard, in the six studies using sputum and nasogastric aspirate the accuracy was optimal (AUC = 0.99, SE = 0.02), whilst in the studies using only sputum for tuberculosis detection the AUC was 0.85 (with a SE = 0.16). The most common source of bias was exclusion of enrolled patients in the analysis. Conclusions Our study confirms that, in Africa, stool Xpert MTB/RIF may be a useful rule-in test for children above and below 5 years of age under evaluation for pulmonary tuberculosis. Sensitivity increased substantially when using both sputum and nasogastric aspirate as reference samples.
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Affiliation(s)
- Francesco Vladimiro Segala
- Department of Precision and Regenerative Medicine and Ionian Area, Clinic of Infectious Diseases, University of Bari, Bari, Italy
- Operational Research Unit, Doctors With Africa CUAMM, Padua, Italy
| | - Roberta Papagni
- Department of Precision and Regenerative Medicine and Ionian Area, Clinic of Infectious Diseases, University of Bari, Bari, Italy
| | - Sergio Cotugno
- Department of Precision and Regenerative Medicine and Ionian Area, Clinic of Infectious Diseases, University of Bari, Bari, Italy
| | - Elda De Vita
- Department of Precision and Regenerative Medicine and Ionian Area, Clinic of Infectious Diseases, University of Bari, Bari, Italy
| | | | | | - Ottavia Tulone
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, Palermo, Italy
| | - Enzo Facci
- Doctors With Africa CUAMM, Wolisso, Ethiopia
| | - Rossana Lattanzio
- Department of Precision and Regenerative Medicine and Ionian Area, Clinic of Infectious Diseases, University of Bari, Bari, Italy
| | - Claudia Marotta
- Operational Research Unit, Doctors With Africa CUAMM, Padua, Italy
| | | | - Davide Fiore Bavaro
- Department of Precision and Regenerative Medicine and Ionian Area, Clinic of Infectious Diseases, University of Bari, Bari, Italy
| | - Giuseppina De Iaco
- Department of Precision and Regenerative Medicine and Ionian Area, Clinic of Infectious Diseases, University of Bari, Bari, Italy
| | - Giovanni Putoto
- Operational Research Unit, Doctors With Africa CUAMM, Padua, Italy
| | - Nicola Veronese
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, Palermo, Italy
| | - Mario Barbagallo
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, Palermo, Italy
| | - Annalisa Saracino
- Department of Precision and Regenerative Medicine and Ionian Area, Clinic of Infectious Diseases, University of Bari, Bari, Italy
| | - Francesco Di Gennaro
- Department of Precision and Regenerative Medicine and Ionian Area, Clinic of Infectious Diseases, University of Bari, Bari, Italy
- Operational Research Unit, Doctors With Africa CUAMM, Padua, Italy
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15
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Affiliation(s)
- Madhukar Pai
- McGill International TB Centre & McGill School of Population and Global Health, McGill University, Montreal, Quebec, Canada.
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16
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Charalambous S, Velen K, Rueda Z, Croda J, Herce ME, Shenoi SV, Altice FL, Muyoyeta M, Telisinghe L, Grandjean L, Keshavjee S, Andrews JR. Scaling up evidence-based approaches to tuberculosis screening in prisons. Lancet Public Health 2023; 8:e305-e310. [PMID: 36780916 DOI: 10.1016/s2468-2667(23)00002-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 12/09/2022] [Accepted: 12/20/2022] [Indexed: 02/12/2023]
Abstract
People deprived of liberty have among the highest rates of tuberculosis globally. The incidence of tuberculosis is ten times greater than the incidence of tuberculosis in the general population. In 2021, WHO updated its guidance to strongly recommend systematic screening for tuberculosis in prisons and penitentiary systems. Which case-finding strategies should be adopted, and how to effectively implement these strategies in these settings, will be crucial questions facing ministries of health and justice. In this Viewpoint, we review the evidence base for tuberculosis screening and diagnostic strategies in prisons, highlighting promising approaches and knowledge gaps. Drawing upon past experiences of implementing active case-finding and care programmes in settings with a high tuberculosis burden, we discuss challenges and opportunities for improving the tuberculosis diagnosis and treatment cascade in these settings. We argue that improved transparency in reporting of tuberculosis notifications and outcomes in prisons and renewed focus and resourcing from WHO and other stakeholders will be crucial for building the commitment and investments needed from countries to address the continued crisis of tuberculosis in prisons.
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Affiliation(s)
- Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa; School of Public Health, Wits University, Johannesburg, South Africa; Division of Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, CT, USA.
| | | | - Zulma Rueda
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MT, Canada; School of Medicine, Universidad Pontificia Bolivariana, Medellin, Colombia
| | - Julio Croda
- Division of Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, CT, USA; Departamento de Clínica Médica, Universidade Federal de Mato Grosso do Sul, Campo Grande, Brazil; Fiocruz Mato Grosso do Sul, Campo Grade, Brazil
| | - Michael E Herce
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Sheela V Shenoi
- Division of Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, CT, USA; Section of Infectious Diseases, School of Medicine, Yale University, New Haven, CT, USA; University of Malaya, Centre of Excellence on Research in AIDS, Kuala Lumpur, Malaysia
| | - Frederick L Altice
- Division of Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, CT, USA; Section of Infectious Diseases, School of Medicine, Yale University, New Haven, CT, USA; University of Malaya, Centre of Excellence on Research in AIDS, Kuala Lumpur, Malaysia
| | - Monde Muyoyeta
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Lily Telisinghe
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Louis Grandjean
- Department of Infection, Immunity and Inflammation, Institute of Child Health, University College London, UK
| | - Salmaan Keshavjee
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
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17
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Lee HJ, Kim NH, Lee EH, Yoon YS, Jeong YJ, Lee BC, Koo B, Jang YO, Kim SH, Kang YA, Lee SW, Shin Y. Multicenter Testing of a Simple Molecular Diagnostic System for the Diagnosis of Mycobacterium Tuberculosis. BIOSENSORS 2023; 13:259. [PMID: 36832025 PMCID: PMC9954000 DOI: 10.3390/bios13020259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/04/2023] [Accepted: 02/10/2023] [Indexed: 06/18/2023]
Abstract
Mycobacterium tuberculosis (MTB) is a communicable disease and still remains a threat to common health. Thus, early diagnosis and treatment are required to prevent the spread of infection. Despite the recent advances in molecular diagnostic systems, the commonly used MTB diagnostic tools are laboratory-based assays, such as mycobacterial culture, MTB PCR, and Xpert MTB/RIF. To address this limitation, point-of-care testing (POCT)-based molecular diagnostic technologies capable of sensitive and accurate detection even in environments with limited sources are needed. In this study, we propose simple tuberculosis (TB) molecular diagnostic assay by combining sample preparation and DNA-detection steps. The sample preparation is performed using a syringe filter with amine-functionalized diatomaceous earth and homobifunctional imidoester. Subsequently, the target DNA is detected by quantitative PCR (polymerase chain reaction). The results can be obtained within 2 h from samples with large volumes, without any additional instruments. The limit of detection of this system is 10 times higher than those of conventional PCR assays. We validated the clinical utility of the proposed method in 88 sputum samples obtained from four hospitals in the Republic of Korea. Overall, the sensitivity of this system was superior to those of other assays. Therefore, the proposed system can be useful for MTB diagnosis in limited-resource settings.
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Affiliation(s)
- Hyo Joo Lee
- Department of Biotechnology, College of Life Science and Biotechnology, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Nam Hun Kim
- INFUSIONTECH, 38 Heungan-daero, 427 Beon-gil, Dongan-gu, Anyang-si 14059, Republic of Korea
| | - Eun Hye Lee
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si 06273, Republic of Korea
| | - Young Soon Yoon
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang-si 10326, Republic of Korea
| | - Yun Jeong Jeong
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang-si 10326, Republic of Korea
| | - Byung Chul Lee
- INFUSIONTECH, 38 Heungan-daero, 427 Beon-gil, Dongan-gu, Anyang-si 14059, Republic of Korea
| | - Bonhan Koo
- Department of Biotechnology, College of Life Science and Biotechnology, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Yoon Ok Jang
- Department of Biotechnology, College of Life Science and Biotechnology, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul 05505, Republic of Korea
| | - Young Ae Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Sei Won Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Yong Shin
- Department of Biotechnology, College of Life Science and Biotechnology, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
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18
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Prasitpuriprecha C, Jantama SS, Preeprem T, Pitakaso R, Srichok T, Khonjun S, Weerayuth N, Gonwirat S, Enkvetchakul P, Kaewta C, Nanthasamroeng N. Drug-Resistant Tuberculosis Treatment Recommendation, and Multi-Class Tuberculosis Detection and Classification Using Ensemble Deep Learning-Based System. Pharmaceuticals (Basel) 2022; 16:ph16010013. [PMID: 36678508 PMCID: PMC9864877 DOI: 10.3390/ph16010013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/14/2022] [Accepted: 12/17/2022] [Indexed: 12/25/2022] Open
Abstract
This research develops the TB/non-TB detection and drug-resistant categorization diagnosis decision support system (TB-DRC-DSS). The model is capable of detecting both TB-negative and TB-positive samples, as well as classifying drug-resistant strains and also providing treatment recommendations. The model is developed using a deep learning ensemble model with the various CNN architectures. These architectures include EfficientNetB7, mobileNetV2, and Dense-Net121. The models are heterogeneously assembled to create an effective model for TB-DRC-DSS, utilizing effective image segmentation, augmentation, and decision fusion techniques to improve the classification efficacy of the current model. The web program serves as the platform for determining if a patient is positive or negative for tuberculosis and classifying several types of drug resistance. The constructed model is evaluated and compared to current methods described in the literature. The proposed model was assessed using two datasets of chest X-ray (CXR) images collected from the references. This collection of datasets includes the Portal dataset, the Montgomery County dataset, the Shenzhen dataset, and the Kaggle dataset. Seven thousand and eight images exist across all datasets. The dataset was divided into two subsets: the training dataset (80%) and the test dataset (20%). The computational result revealed that the classification accuracy of DS-TB against DR-TB has improved by an average of 43.3% compared to other methods. The categorization between DS-TB and MDR-TB, DS-TB and XDR-TB, and MDR-TB and XDR-TB was more accurate than with other methods by an average of 28.1%, 6.2%, and 9.4%, respectively. The accuracy of the embedded multiclass model in the web application is 92.6% when evaluated with the test dataset, but 92.8% when evaluated with a random subset selected from the aggregate dataset. In conclusion, 31 medical staff members have evaluated and utilized the online application, and the final user preference score for the web application is 9.52 out of a possible 10.
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Affiliation(s)
- Chutinun Prasitpuriprecha
- Department of Biopharmacy, Faculty of Pharmaceutical Sciences, Ubon Ratchathani University, Ubon Ratchathani 34190, Thailand
| | - Sirima Suvarnakuta Jantama
- Department of Biopharmacy, Faculty of Pharmaceutical Sciences, Ubon Ratchathani University, Ubon Ratchathani 34190, Thailand
| | - Thanawadee Preeprem
- Department of Biopharmacy, Faculty of Pharmaceutical Sciences, Ubon Ratchathani University, Ubon Ratchathani 34190, Thailand
| | - Rapeepan Pitakaso
- Department of Industrial Engineering, Faculty of Engineering, Ubon Ratchathani University, Ubon Ratchathani 34190, Thailand
| | - Thanatkij Srichok
- Department of Industrial Engineering, Faculty of Engineering, Ubon Ratchathani University, Ubon Ratchathani 34190, Thailand
| | - Surajet Khonjun
- Department of Industrial Engineering, Faculty of Engineering, Ubon Ratchathani University, Ubon Ratchathani 34190, Thailand
| | - Nantawatana Weerayuth
- Department of Mechanical Engineering, Faculty of Engineering, Ubon Ratchathani University, Ubon Ratchathani 34190, Thailand
| | - Sarayut Gonwirat
- Department of Computer Engineering and Automation, Faculty of Engineering and Industrial Technology, Kalasin University, Kalasin 46000, Thailand
| | - Prem Enkvetchakul
- Department of Information Technology, Faculty of Science, Buriram University, Buriram 31000, Thailand
| | - Chutchai Kaewta
- Department of Computer Science, Faculty of Computer Science, Ubon Ratchathani Rajabhat University, Ubon Ratchathani 34000, Thailand
| | - Natthapong Nanthasamroeng
- Department of Engineering Technology, Faculty of Industrial Technology, Ubon Ratchathani Rajabhat University, Ubon Ratchathani 34000, Thailand
- Correspondence: ; Tel.: +66-625474555
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Taye K, Tolesa N, Tadewos A, Ketema W. Patterns of Childhood Tuberculosis Diagnosis in Hawassa University Comprehensive Specialized Hospital, Hawassa, Sidama Regional State, Ethiopia. Pediatric Health Med Ther 2022; 13:349-359. [PMID: 36386042 PMCID: PMC9657258 DOI: 10.2147/phmt.s380092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 10/31/2022] [Indexed: 11/10/2022] Open
Abstract
Background Because of the pauci bacillary nature of childhood tuberculosis and the difficulties in obtaining proper sputum samples from young children, diagnosing childhood tuberculosis (TB) is difficult. Childhood TB needs early identification and care since it advances swiftly to more advanced stages. This study was aimed to determine the patterns of all forms of childhood tuberculosis diagnosis at Hawassa University Comprehensive Specialized Hospital in Hawassa, Ethiopia. Methods A retrospective cross-sectional study was conducted from February 1, 2017 to January 30, 2021 among 175 children diagnosed and treated for tuberculosis in the pediatric ward. Children medical charts and pediatrics ward logbook were used to extract pertinent data by structured checklists. SPSS version 23.0 was used for data entry and statistical analysis. Results Of 175 children, fever was the leading clinical symptoms and diagnosed in 166 (94.9%) children followed by weight loss (154, 88%), and cough (136, 77.7%). In twenty seven out of 88 (30.6%) children, gastric aspirate was positive for TB infection by Xpert MTB/Rif, while 3/40 (7.5%) were positive for TB using fine needle aspiration cytology (FNAC), 19/66 (28.8%) had suggestive TB by cerebrospinal fluid analysis (CSF), 10/29 (34.5%) were smear positive for TB and 70/162 (43.2%) were suspected for TB by chest X-ray. Conclusion Despite recent breakthroughs in quick microbiological detection, such as Xpert MTB/Rif, this study revealed that more than half of the children, 89/175 (51%), were treated for TB diseases solely based on clinical criteria. This will significantly underestimate the true nature of the illness or disease and make them vulnerable to mistreatment. As a result, in order to appropriately treat the disease and manage patients in our settings, getting a microbiological diagnosis of childhood tuberculosis requires improvement, and we call for expanded availability and use of a more sensitive and specific diagnostic technique to circumvent these concerns.
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Affiliation(s)
- Kefyalew Taye
- Department of Pediatrics and Child Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Nagasa Tolesa
- Department of Pediatrics and Child Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
- Department of Pediatrics and Child Health, College of Medicine and Health Sciences, Dembi Dollo University, Dembi Dollo, Ethiopia
| | - Agete Tadewos
- School of Medical Laboratory Science, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Worku Ketema
- Department of Pediatrics and Child Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
- Correspondence: Worku Ketema, Department of Pediatrics and Child Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia, Email
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20
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Diagnostic Accuracy of the Truenat MTB Plus Assay and Comparison with the Xpert MTB/RIF Assay to Detect Tuberculosis among Hospital Outpatients in Cameroon. J Clin Microbiol 2022; 60:e0015522. [PMID: 35861529 PMCID: PMC9383115 DOI: 10.1128/jcm.00155-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The Truenat MTB Plus assay is a rapid molecular test that has been recommended by the World Health Organization since 2020 as an initial test to detect tuberculosis (TB). The WHO highlighted the need to further evaluate assay performance to inform future recommendations, including in people living with HIV and compared to the Xpert MTB/RIF assay. We conducted a prospective evaluation of the diagnostic accuracy of the Truenat assay in Cameroon, a country with a high burden of HIV/TB. Adult outpatients were recruited at four hospitals; demographic information and medical history were collected, and participants produced two sputum specimens. Truenat and Xpert testing was performed on the same specimen, and performance was compared to TB culture as the reference standard. From November 2019 to December 2020, 945 participants were enrolled and included in the analysis. Among 251 participants with culture-positive TB, the sensitivity of Truenat MTB Plus was 91% (95% confidence interval [CI], 86 to 94%), similar to Xpert (90%; 95% CI, 86 to 93%). Among 74 HIV-positive participants with culture-positive TB, the sensitivity of Truenat MTB Plus was 85% (95% CI, 75 to 92%) compared to 81% for Xpert (95% CI, 70 to 89%). Among 47 participants with smear-negative TB, the sensitivity of Truenat MTB Plus was 55% (95% CI, 40 to 70%), similar to Xpert (53%; 95% CI, 38 to 68%). The specificity of Truenat MTB Plus was 96% (95% CI, 94 to 97%) compared to 99% (95% CI, 97 to 99%) for Xpert. For TB detection compared to the reference standard of TB culture, the performance of the Truenat MTB Plus assay was similar to that of Xpert in this population, including among people living with HIV.
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21
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Point-of-Care Ultrasound for Tuberculosis Management in Sub-Saharan Africa-A Balanced SWOT Analysis. Int J Infect Dis 2022; 123:46-51. [PMID: 35811083 DOI: 10.1016/j.ijid.2022.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/29/2022] [Accepted: 07/02/2022] [Indexed: 11/21/2022] Open
Abstract
Point-of-care ultrasound (POCUS) is an increasingly accessible skill, allowing for the decentralization of its use to non-specialist healthcare workers to guide routine clinical decision making. The advent of ultrasound-on-a-chip has transformed the technology into a portable mobile health device. Due to its high sensitivity to detect small consolidations, pleural effusions and sub pleural nodules, POCUS has recently been proposed as a sputum-free likely triage tool for tuberculosis (TB). To make an objective assessment of the potential and limitations of POCUS in routine TB management, we present a Strengths, Weaknesses, Opportunities & Threats (SWOT) analysis based on a review of the relevant literature and focusing on Sub-Saharan Africa (SSA). We idenitified numerous strengths and opportunities of POCUS for TB management e.g.; accessible, affordable, easy to use & maintain, expedited diagnosis, extra-pulmonary TB detection, safer pleural/pericardial puncture, use in children/pregnant women/PLHIV, targeted screening of TB contacts, monitoring TB sequelae, and creating AI decision support. Weaknesses and external threats such as operator dependency, lack of visualization of central lung pathology, poor specificity, lack of impact assessments and data from Sub-Saharan Africa must be taken into consideration to ensure that the potential of the technology can be fully realized in research as in practice.
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22
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Suttels V, Wachinou P, Toit JD, Boillat-Blanco N, Hartley MA. Ultrasound for point-of-care sputum-free tuberculosis detection: Building collaborative standardized image-banks. EBioMedicine 2022; 81:104078. [PMID: 35649304 PMCID: PMC9160315 DOI: 10.1016/j.ebiom.2022.104078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/11/2022] [Accepted: 05/11/2022] [Indexed: 11/28/2022] Open
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23
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Rangaka MX, Hamada Y, Abubakar I. Ending the tuberculosis syndemic: is COVID-19 the (in)convenient scapegoat for poor progress? THE LANCET RESPIRATORY MEDICINE 2022; 10:529-531. [PMID: 35338839 PMCID: PMC8942476 DOI: 10.1016/s2213-2600(22)00123-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 11/25/2022]
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24
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Houben RMGJ, Esmail H, Cobelens F, Williams CML, Coussens AK. Tuberculosis prevalence: beyond the tip of the iceberg. THE LANCET. RESPIRATORY MEDICINE 2022; 10:537-539. [PMID: 35659006 DOI: 10.1016/s2213-2600(22)00184-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Rein M G J Houben
- TB Modelling Group, TB Centre, and Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
| | - Hanif Esmail
- MRC Clinical Trials Unit and Institute for Global Health, University College London, London, UK; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Frank Cobelens
- Department of Global Health, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam, Netherlands; Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
| | | | - Anna K Coussens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Infectious Diseases and Immune Defence Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
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25
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The crucial need for tuberculosis translational research in the time of COVID-19. THE LANCET RESPIRATORY MEDICINE 2022; 10:531-533. [PMID: 35338842 PMCID: PMC8942478 DOI: 10.1016/s2213-2600(22)00099-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 11/21/2022]
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