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Biewer AM, Tzelios C, Tintaya K, Roman B, Hurwitz S, Yuen CM, Mitnick CD, Nardell E, Lecca L, Tierney DB, Nathavitharana RR. Accuracy of digital chest x-ray analysis with artificial intelligence software as a triage and screening tool in hospitalized patients being evaluated for tuberculosis in Lima, Peru. PLOS Glob Public Health 2024; 4:e0002031. [PMID: 38324610 PMCID: PMC10849246 DOI: 10.1371/journal.pgph.0002031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 01/08/2024] [Indexed: 02/09/2024]
Abstract
Tuberculosis (TB) transmission in healthcare facilities is common in high-incidence countries. Yet, the optimal approach for identifying inpatients who may have TB is unclear. We evaluated the diagnostic accuracy of qXR (Qure.ai, India) computer-aided detection (CAD) software versions 3.0 and 4.0 (v3 and v4) as a triage and screening tool within the FAST (Find cases Actively, Separate safely, and Treat effectively) transmission control strategy. We prospectively enrolled two cohorts of patients admitted to a tertiary hospital in Lima, Peru: one group had cough or TB risk factors (triage) and the other did not report cough or TB risk factors (screening). We evaluated the sensitivity and specificity of qXR for the diagnosis of pulmonary TB using culture and Xpert as primary and secondary reference standards, including stratified analyses based on risk factors. In the triage cohort (n = 387), qXR v4 sensitivity was 0.91 (59/65, 95% CI 0.81-0.97) and specificity was 0.32 (103/322, 95% CI 0.27-0.37) using culture as reference standard. There was no difference in the area under the receiver-operating-characteristic curve (AUC) between qXR v3 and qXR v4 with either a culture or Xpert reference standard. In the screening cohort (n = 191), only one patient had a positive Xpert result, but specificity in this cohort was high (>90%). A high prevalence of radiographic lung abnormalities, most notably opacities (81%), consolidation (62%), or nodules (58%), was detected by qXR on digital CXR images from the triage cohort. qXR had high sensitivity but low specificity as a triage in hospitalized patients with cough or TB risk factors. Screening patients without cough or risk factors in this setting had a low diagnostic yield. These findings further support the need for population and setting-specific thresholds for CAD programs.
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Affiliation(s)
- Amanda M. Biewer
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Christine Tzelios
- Harvard Medical School, Boston, Massachusetts, United States of America
| | | | | | - Shelley Hurwitz
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Courtney M. Yuen
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Carole D. Mitnick
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Edward Nardell
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | | | - Dylan B. Tierney
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- Massachusetts Department of Public Health, Boston, Massachusetts, United States of America
| | - Ruvandhi R. Nathavitharana
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
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Iruedo JO, Pather MK. Lived experiences of patients and families with decentralised drug-resistant tuberculosis care in the Eastern Cape, South Africa. Afr J Prim Health Care Fam Med 2023; 15:e1-e16. [PMID: 38197684 PMCID: PMC10784182 DOI: 10.4102/phcfm.v15i1.4255] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 11/03/2023] [Accepted: 11/07/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND South Africa adopted the decentralised Drug Resistant Tuberculosis (DR-TB) care model in 2011 with a view of improving clinical outcomes. AIM This study explores the experiences and perceptions of patients and family members on the effectiveness of a decentralised community DR-TB care model in the Oliver Reginald Kaizana (OR) Tambo district municipality of the Eastern Cape, South Africa. METHOD In this phenomenological qualitative research design, a semi-structured interview with prompts was conducted on 30 participants (15 patients and 15 family members). Framework approach to thematic content analysis was adopted for qualitative data analysis. RESULTS Four themes emerged from the patients' interviews: adequate knowledge of DR-TB and its transmission, fear of death and isolation, long travel distances, and exorbitant transportation cost. A 'ready' health system influenced the effectiveness of community DR-TB management, while interviews with family members yielded five themes: misconceptions about DR-TB, rapid diagnosis and adherence counselling, long travel distances, activated healthcare workers, and little role of traditional healer. CONCLUSION A perceived effectiveness of a community DR-TB care model in the OR Tambo district was demonstrated through the quality and comprehensiveness of care rendered by a 'ready' health system with activated health care workers (HCWs) who provided robust support and adequate knowledge of DR-TB and its treatment/side effects. However, misconceptions about DR-TB, long travel distances to treatment facilities, high cost of transportation and stigma remained challenging for most patients and family members.Contribution: This study provides insight into the lived experiences of a decentralised community DR-TB care model in the OR Tambo district in 2020.
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Affiliation(s)
- Joshua O Iruedo
- Department of Family Medicine and Primary Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town.
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Biewer A, Tzelios C, Tintaya K, Roman B, Hurwitz S, Yuen CM, Mitnick CD, Nardell E, Lecca L, Tierney DB, Nathavitharana RR. Accuracy of digital chest x-ray analysis with artificial intelligence software as a triage and screening tool in hospitalized patients being evaluated for tuberculosis in Lima, Peru. medRxiv 2023:2023.05.17.23290110. [PMID: 37292955 PMCID: PMC10246158 DOI: 10.1101/2023.05.17.23290110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Introduction Tuberculosis (TB) transmission in healthcare facilities is common in high-incidence countries. Yet, the optimal approach for identifying inpatients who may have TB is unclear. We evaluated the diagnostic accuracy of qXR (Qure.ai, India) computer-aided detection (CAD) software versions 3.0 and 4.0 (v3 and v4) as a triage and screening tool within the FAST (Find cases Actively, Separate safely, and Treat effectively) transmission control strategy. Methods We prospectively enrolled two cohorts of patients admitted to a tertiary hospital in Lima, Peru: one group had cough or TB risk factors (triage) and the other did not report cough or TB risk factors (screening). We evaluated the sensitivity and specificity of qXR for the diagnosis of pulmonary TB using culture and Xpert as primary and secondary reference standards, including stratified analyses based on risk factors. Results In the triage cohort (n=387), qXR v4 sensitivity was 0.91 (59/65, 95% CI 0.81-0.97) and specificity was 0.32 (103/322, 95% CI 0.27-0.37) using culture as reference standard. There was no difference in the area under the receiver-operating-characteristic curve (AUC) between qXR v3 and qXR v4 with either a culture or Xpert reference standard. In the screening cohort (n=191), only one patient had a positive Xpert result, but specificity in this cohort was high (>90%). A high prevalence of radiographic lung abnormalities, most notably opacities (81%), consolidation (62%), or nodules (58%), was detected by qXR on digital CXR images from the triage cohort. Conclusions qXR had high sensitivity but low specificity as a triage in hospitalized patients with cough or TB risk factors. Screening patients without cough or risk factors in this setting had a low diagnostic yield. These findings further support the need for population and setting-specific thresholds for CAD programs.
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Affiliation(s)
- Amanda Biewer
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | | | | | | | | | - Courtney M Yuen
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Carole D Mitnick
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Edward Nardell
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | | | - Dylan B Tierney
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA
- Massachusetts Department of Public Health, Boston, MA
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Yates TA, Karat AS, Bozzani F, McCreesh N, MacGregor H, Beckwith PG, Govender I, Colvin CJ, Kielmann K, Grant AD. Time to change the way we think about tuberculosis infection prevention and control in health facilities: insights from recent research. Antimicrob Steward Healthc Epidemiol 2023; 3:e117. [PMID: 37502244 PMCID: PMC10369445 DOI: 10.1017/ash.2023.192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/25/2023] [Accepted: 05/26/2023] [Indexed: 07/29/2023]
Abstract
In clinical settings where airborne pathogens, such as Mycobacterium tuberculosis, are prevalent, they constitute an important threat to health workers and people accessing healthcare. We report key insights from a 3-year project conducted in primary healthcare clinics in South Africa, alongside other recent tuberculosis infection prevention and control (TB-IPC) research. We discuss the fragmentation of TB-IPC policies and budgets; the characteristics of individuals attending clinics with prevalent pulmonary tuberculosis; clinic congestion and patient flow; clinic design and natural ventilation; and the facility-level determinants of the implementation (or not) of TB-IPC interventions. We present modeling studies that describe the contribution of M. tuberculosis transmission in clinics to the community tuberculosis burden and economic evaluations showing that TB-IPC interventions are highly cost-effective. We argue for a set of changes to TB-IPC, including better coordination of policymaking, clinic decongestion, changes to clinic design and building regulations, and budgeting for enablers to sustain implementation of TB-IPC interventions. Additional research is needed to find the most effective means of improving the implementation of TB-IPC interventions; to develop approaches to screening for prevalent pulmonary tuberculosis that do not rely on symptoms; and to identify groups of patients that can be seen in clinic less frequently.
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Affiliation(s)
- Tom A. Yates
- Division of Infection and Immunity, Faculty of Medicine, University College London, London, UK
| | - Aaron S. Karat
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- The Institute for Global Health and Development, Queen Margaret University, Musselburgh, UK
| | | | - Nicky McCreesh
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Hayley MacGregor
- The Institute of Development Studies, University of Sussex, Brighton, UK
| | - Peter G. Beckwith
- Department of Medicine, University of Cape Town, Rondebosch, South Africa
| | - Indira Govender
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Christopher J. Colvin
- Division of Social and Behavioural Sciences, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Karina Kielmann
- The Institute for Global Health and Development, Queen Margaret University, Musselburgh, UK
- Institute of Tropical Medicine, Antwerp, Belgium
| | - Alison D. Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, DurbanSouth Africa
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Shah R, Khakhkhar T, Modi B. Efficacy and Safety of Different Drug Regimens for Tuberculosis Preventive Treatment: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e38182. [PMID: 37252497 PMCID: PMC10224701 DOI: 10.7759/cureus.38182] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2023] [Indexed: 05/31/2023] Open
Abstract
Tuberculosis prevention treatment (TPT) is crucial to the eradication of tuberculosis (TB). Through a comprehensive review and meta-analysis, we compared the efficacy and safety of different TPT regimens. We searched PubMed, Google Scholar, and medrxiv.org with search terms Tuberculosis Preventive Treatment, TPT, efficacy, safety, and drug regimens for TPT and all RCT, irrespective of age, setting, or co-morbidities, comparing at least one TPT regimen to placebo, no therapy, or other TPT regimens were screened and those reporting either efficacy or safety or both were included. The meta-analysis data were synthesized with Review Manager and the risk ratio (RR) was calculated. Out of 4465 search items, 15 RCTs (randomized-controlled trials) were included. The TB infection rate was 82/6308 patients in the rifamycin plus isoniazid group (HR) as compared to 90/6049 in the isoniazid monotherapy (H) group (RR: 0.89 (95% CI: 0.66, 1.19; p=0.43). A total of 965/6478 vs 1065/6219 adverse drug reactions (ADRs) occurred in HR and H groups respectively (RR: 0.86 (95%CI: 0.80 0.93); P<0.0001). Efficacy analysis of the rifampicin plus pyrazinamide (RZ) vs H showed that the risk ratio of infection rate was not considerably varied (RR: 0.97 (95% CI: 0.47, 2.03); P=0.94). Safety analysis showed in 229/572 patients developed ADRs in rifampicin plus pyrazinamide as compared to 129/600 ADRs in the isoniazid group. (RR: 1.87 (95% CI: 1.44, 2.43)). Safety analysis of only rifamycin (R) vs H group showed 23/718 ADRs in R vs 57/718 ADRs in H group (RR: 0.40 (95% CI: 0.25 0.65); P=0.0002). Rifamycin plus isoniazid (3HP/R) has no edge over other regimens in terms of efficacy but this regimen was found significantly safer as compared to any other regimens used for TPT. Rifampicin plus pyrazinamide (RZ) was found equally efficacious but less safe as compared to other regimens.
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Affiliation(s)
- Rima Shah
- Department of Pharmacology, All India Institute of Medical Sciences, Rajkot, Rajkot, IND
| | - Tejas Khakhkhar
- Department of Pharmacology, Gujarat Medical and Education Research Society (GMERS) Medical College, Porbandar, IND
| | - Bhavesh Modi
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Rajkot, Rajkot, IND
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Nathavitharana RR, Mishra H, Sullivan A, Hurwitz S, Lederer P, Meintjes J, Nardell E, Theron G. Predicting Airborne Infection Risk: Association Between Personal Ambient Carbon Dioxide Level Monitoring and Incidence of Tuberculosis Infection in South African Health Workers. Clin Infect Dis 2022; 75:1297-1306. [PMID: 35348657 PMCID: PMC9383651 DOI: 10.1093/cid/ciac183] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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] [Received: 09/21/2021] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND High rates of tuberculosis (TB) transmission occur in hospitals in high-incidence countries, yet there is no validated way to evaluate the impact of hospital design and function on airborne infection risk. We hypothesized that personal ambient carbon dioxide (CO2) monitoring could serve as a surrogate measure of rebreathed air exposure associated with TB infection risk in health workers (HWs). METHODS We analyzed baseline and repeat (12-month) interferon-γ release assay (IGRA) results in 138 HWs in Cape Town, South Africa. A random subset of HWs with a baseline negative QuantiFERON Plus (QFT-Plus) underwent personal ambient CO2 monitoring. RESULTS Annual incidence of TB infection (IGRA conversion) was high (34%). Junior doctors were less likely to have a positive baseline IGRA than other HWs (OR, 0.26; P = .005) but had similar IGRA conversion risk. IGRA converters experienced higher median CO2 levels compared to IGRA nonconverters using quantitative QFT-Plus thresholds of ≥0.35 IU/mL (P < .02) or ≥1 IU/mL (P < .01). Median CO2 levels were predictive of IGRA conversion (odds ratio [OR], 2.04; P = .04, ≥1 IU/mL threshold). Ordinal logistic regression demonstrated that the odds of a higher repeat quantitative IGRA result increased by almost 2-fold (OR, 1.81; P = .01) per 100 ppm unit increase in median CO2 levels, suggesting a dose-dependent response. CONCLUSIONS HWs face high occupational TB risk. Increasing median CO2 levels (indicative of poor ventilation and/or high occupancy) were associated with higher likelihood of HW TB infection. Personal ambient CO2 monitoring may help target interventions to decrease TB transmission in healthcare facilities and help HWs self-monitor occupational risk, with implications for other airborne infections including coronavirus disease 2019.
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Affiliation(s)
- Ruvandhi R Nathavitharana
- Correspondence: R. R. Nathavitharana, Beth Israel Deaconess Medical Center/Harvard Medical School, Division of Infectious Diseases, 110 Francis Street, Suite GB, Boston, MA 02215 ()
| | | | - Amanda Sullivan
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Shelley Hurwitz
- Division of Infectious Diseases, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | | | - Jack Meintjes
- Unit for Infection Prevention and Control, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Edward Nardell
- Division of Global Health Equity, Brigham & Women’s Hospital, Boston, Massachusetts, USA
| | - 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, Stellenbosch University, Cape Town, South Africa
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Paudel S, Padmawati RS, Ghimire A, Yonzon CL, Mahendradhata Y. Feasibility of Find cases Actively, Separate safely and Treat effectively (FAST) strategy for early diagnosis of TB in Nepal: An implementation research. PLoS One 2021; 16:e0258883. [PMID: 34699542 PMCID: PMC8547636 DOI: 10.1371/journal.pone.0258883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 10/07/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Tuberculosis is one of the leading causes of death worldwide. Diagnosing TB in an early stage and initiating effective treatment is one of the best ways to reduce the burden of tuberculosis. Feasibility of Find cases Actively, Separate safely and Treat effectively (FAST) Strategy helps to improve the early diagnosis of tuberculosis cases among inpatient settings as well as out patient department patients and prevent TB transmission in hospital. This study aimed to assess the feasibility of the FAST strategy, organizational factors, technical factors, barriers and enablers for the proper implementation of the FAST strategy in Nepal. Methods A qualitative study was conducted from April 2019 to August 2019. Data was collected by using focus group discussion, key informant interviews, and client exit interviews. A retrospective research was conducted in different hospitals in Nepal where FAST strategy was implemented. The patients, health care workers, province, district, and National level stakeholders were interviewed. Thematic analysis was used to assess the feasibility as well as barriers and enablers of the FAST strategy. Results Study identified that the ‘current setting’ of implementation and service delivery arrangement at hospitals were not well arranged as per requirements. The research findings showed hospital ownership is crucial for mobilizing staff and proper space management inside hospitals. Study identified that unavailability of a separate room, limited capacity of GeneXpert machine, irregular supply of GeneXpert cartridge, and insufficient human resources for screening and counseling are the major barriers of FAST implementation in Nepal. Conclusion FAST strategy is feasible to implement in healthcare settings in Nepal although the technical and organizational factors should be managed to ensure effective function of the strategy as per the approach. Hospital ownership is essential to mobilize health workers, improve client flow system and proper space management for FAST services.
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Affiliation(s)
- Sagun Paudel
- Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.,Public Health Youth Society of Nepal, Pokhara, Nepal
| | - Retna Siwi Padmawati
- Department of Health Behavior, Environment, and Social Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Ashmita Ghimire
- Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Choden Lama Yonzon
- Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Yodi Mahendradhata
- Department of Health Policy and Management, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
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Tierney DB, Orvis E, Nathavitharana RR, Hurwitz S, Tintaya K, Vargas D, Segura P, de la Gala S, Lecca L, Mitnick CD, Nardell EA. FAST tuberculosis transmission control strategy speeds the start of tuberculosis treatment at a general hospital in Lima, Peru. Infect Control Hosp Epidemiol 2021;:1-7. [PMID: 34612182 DOI: 10.1017/ice.2021.422] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To evaluate the effect of the FAST (Find cases Actively, Separate safely, Treat effectively) strategy on time to tuberculosis diagnosis and treatment for patients at a general hospital in a tuberculosis-endemic setting. Design: Prospective cohort study with historical controls. Participants: Patients diagnosed with pulmonary tuberculosis during hospitalization at Hospital Nacional Hipolito Unanue in Lima, Peru. Methods: The FAST strategy was implemented from July 24, 2016, to December 31, 2019. We compared the proportion of patients with drug susceptibility testing and tuberculosis treatment during FAST to the 6-month period prior to FAST. Times to diagnosis and tuberculosis treatment were also compared using Kaplan-Meier plots and Cox regressions. Results: We analyzed 75 patients diagnosed with pulmonary tuberculosis through FAST. The historical cohort comprised 76 patients. More FAST patients underwent drug susceptibility testing (98.7% vs 57.8%; OR, 53.8; P < .001), which led to the diagnosis of drug-resistant tuberculosis in 18 (24.3%) of 74 of the prospective cohort and 4 (9%) of 44 of the historical cohort (OR, 3.2; P = .03). Overall, 55 FAST patients (73.3%) started tuberculosis treatment during hospitalization compared to 39 (51.3%) controls (OR, 2.44; P = .012). FAST reduced the time from hospital admission to the start of TB treatment (HR, 2.11; 95% CI, 1.39–3.21; P < .001). Conclusions: Using the FAST strategy improved the diagnosis of drug-resistant tuberculosis and the likelihood and speed of starting treatment among patients with pulmonary tuberculosis at a general hospital in a tuberculosis-endemic setting. In these settings, the FAST strategy should be considered to reduce tuberculosis transmission while simultaneously improving the quality of care.
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Nathavitharana RR, Lederer P, Chaplin M, Bjerrum S, Steingart KR, Shah M. Impact of diagnostic strategies for tuberculosis using lateral flow urine lipoarabinomannan assay in people living with HIV. Cochrane Database Syst Rev 2021; 8:CD014641. [PMID: 34416013 PMCID: PMC8407503 DOI: 10.1002/14651858.cd014641] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Tuberculosis is the primary cause of hospital admission in people living with HIV, and the likelihood of death in the hospital is unacceptably high. The Alere Determine TB LAM Ag test (AlereLAM) is a point-of-care test and the only lateral flow lipoarabinomannan assay (LF-LAM) assay currently commercially available and recommended by the World Health Organization (WHO). A 2019 Cochrane Review summarised the diagnostic accuracy of LF-LAM for tuberculosis in people living with HIV. This systematic review assesses the impact of the use of LF-LAM (AlereLAM) on mortality and other patient-important outcomes. OBJECTIVES To assess the impact of the use of LF-LAM (AlereLAM) on mortality in adults living with HIV in inpatient and outpatient settings. To assess the impact of the use of LF-LAM (AlereLAM) on other patient-important outcomes in adults living with HIV, including time to diagnosis of tuberculosis, and time to initiation of tuberculosis treatment. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (PubMed); Embase (Ovid); Science Citation Index Expanded (Web of Science), BIOSIS Previews, Scopus, LILACS; ProQuest Dissertations and Theses; ClinicalTrials.gov; and the WHO ICTRP up to 12 March 2021. SELECTION CRITERIA Randomized controlled trials that compared a diagnostic intervention including LF-LAM with diagnostic strategies that used smear microscopy, mycobacterial culture, a nucleic acid amplification test such as Xpert MTB/RIF, or a combination of these tests. We included adults (≥ 15 years) living with HIV. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for eligibility, extracted data, and analysed risk of bias using the Cochrane tool for assessing risk of bias in randomized studies. We contacted study authors for clarification as needed. We used risk ratio (RR) with 95% confidence intervals (CI). We used a fixed-effect model except in the presence of clinical or statistical heterogeneity, in which case we used a random-effects model. We assessed the certainty of the evidence using GRADE. MAIN RESULTS We included three trials, two in inpatient settings and one in outpatient settings. All trials were conducted in sub-Saharan Africa and assessed the impact of diagnostic strategies that included LF-LAM on mortality when the test was used in conjunction with other tuberculosis diagnostic tests or clinical assessment for clinical decision-making in adults living with HIV. Inpatient settings In inpatient settings, the use of LF-LAM testing as part of a tuberculosis diagnostic strategy likely reduces mortality in people living with HIV at eight weeks compared to routine tuberculosis diagnostic testing without LF-LAM (pooled RR 0.85, 95% CI 0.76 to 0.94; 5102 participants, 2 trials; moderate-certainty evidence). That is, people living with HIV who received LF-LAM had 15% lower risk of mortality. The absolute effect was 34 fewer deaths per 1000 (from 14 fewer to 55 fewer). In inpatient settings, the use of LF-LAM testing as part of a tuberculosis diagnostic strategy probably results in a slight increase in the proportion of people living with HIV who were started on tuberculosis treatment compared to routine tuberculosis diagnostic testing without LF-LAM (pooled RR 1.26, 95% CI 0.94 to 1.69; 5102 participants, 2 trials; moderate-certainty evidence). Outpatient settings In outpatient settings, the use of LF-LAM testing as part of a tuberculosis diagnostic strategy may reduce mortality in people living with HIV at six months compared to routine tuberculosis diagnostic testing without LF-LAM (RR 0.89, 95% CI 0.71 to 1.11; 2972 participants, 1 trial; low-certainty evidence). Although this trial did not detect a difference in mortality, the direction of effect was towards a mortality reduction, and the effect size was similar to that in inpatient settings. In outpatient settings, the use of LF-LAM testing as part of a tuberculosis diagnostic strategy may result in a large increase in the proportion of people living with HIV who were started on tuberculosis treatment compared to routine tuberculosis diagnostic testing without LF-LAM (RR 5.44, 95% CI 4.70 to 6.29, 3022 participants, 1 trial; low-certainty evidence). Other patient-important outcomes Assessment of other patient-important and implementation outcomes in the trials varied. The included trials demonstrated that a higher proportion of people living with HIV were able to produce urine compared to sputum for tuberculosis diagnostic testing; a higher proportion of people living with HIV were diagnosed with tuberculosis in the group that received LF-LAM; and the incremental diagnostic yield was higher for LF-LAM than for urine or sputum Xpert MTB/RIF. AUTHORS' CONCLUSIONS In inpatient settings, the use of LF-LAM as part of a tuberculosis diagnostic testing strategy likely reduces mortality and probably results in a slight increase in tuberculosis treatment initiation in people living with HIV. The reduction in mortality may be due to earlier diagnosis, which facilitates prompt treatment initiation. In outpatient settings, the use of LF-LAM testing as part of a tuberculosis diagnostic strategy may reduce mortality and may result in a large increase in tuberculosis treatment initiation in people living with HIV. Our results support the implementation of LF-LAM to be used in conjunction with other WHO-recommended tuberculosis diagnostic tests to assist in the rapid diagnosis of tuberculosis in people living with HIV.
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Affiliation(s)
- Ruvandhi R Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Philip Lederer
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, USA
| | - Marty Chaplin
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Stephanie Bjerrum
- Department of Clinical Research, Research Unit of Infectious Diseases, University of Southern Denmark, Odense, Denmark
| | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Maunank Shah
- Department of Medicine, Division of Infectious Diseases, John Hopkins University School of Medicine, Baltimore, Maryland, USA
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Vigenschow A, Edoa JR, Adegbite BR, Agbo PA, Adegnika AA, Alabi A, Massinga-Loembe M, Grobusch MP. Knowledge, attitudes and practices regarding tuberculosis amongst healthcare workers in Moyen-Ogooué Province, Gabon. BMC Infect Dis 2021; 21:486. [PMID: 34039304 PMCID: PMC8157668 DOI: 10.1186/s12879-021-06225-1] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 05/12/2021] [Indexed: 11/10/2022] Open
Abstract
Background In countries with a high tuberculosis incidence such as Gabon, healthcare workers are at enhanced risk to become infected with tuberculosis due to their occupational exposure. In addition, transmission can occur between patients and visitors, if a tuberculosis infection is not suspected in time. Knowledge about tuberculosis and correct infection control measures are therefore highly relevant in healthcare settings. Methods We conducted an interviewer-administered knowledge, attitude and practice survey amongst healthcare workers in 20 healthcare facilities at all levels in the Moyen-Ogooué province, Gabon. Correctly answered knowledge questions were scored and then categorised into four knowledge levels. Additionally, factors associated with high knowledge levels were identified. Fisher’s Exact test was used to identify factors associated with high knowledge levels. Results A total of 103 questionnaires were completed by various healthcare personnel. The most-frequently scored category was ‘intermediate knowledge’, which was scored by 40.8% (42/103), followed by ‘good knowledge’ with 28.2% (29/103) and ‘poor knowledge’ with 21.4% (22/103) of participating healthcare workers, respectively. ‘Excellent knowledge’ was achieved by 9.7% (10/103) of the interviewees. Apart from the profession, education level, type of employing healthcare facility, as well as former training on tuberculosis were significantly associated with high knowledge scores. Attitudes were generally positive towards tuberculosis infection control efforts. Of note, healthcare workers reported that infection control measures were not consistently practiced; 72.8% (75/103) of the participants were scared of becoming infected with tuberculosis, and 98.1% saw a need for improvement of local tuberculosis control. Conclusions The survey results lead to the assumption that healthcare workers in the Moyen-Ogooué province are at high risk to become infected with tuberculosis. There is an urgent need for improvement of tuberculosis infection control training for local healthcare personnel, particularly for less trained staff such as assistant nurses. Furthermore, the lack of adequate infection control measures reported by staff could possibly be correlated with a lack of adequate facility structures and protective equipment and requires further investigation. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06225-1.
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Affiliation(s)
- Anja Vigenschow
- Centre de Recherches Médicales de Lambaréné and African. Partner Institution, German Center for Infection Research, Lambaréné, Gabon.,Institute of Tropical Medicine, Tübingen University, Tübingen, Germany
| | - Jean Ronald Edoa
- Centre de Recherches Médicales de Lambaréné and African. Partner Institution, German Center for Infection Research, Lambaréné, Gabon
| | - Bayode Romeo Adegbite
- Centre de Recherches Médicales de Lambaréné and African. Partner Institution, German Center for Infection Research, Lambaréné, Gabon.,Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam University Medical Centers, location AMC, Amsterdam Infection & Immunity, Amsterdam Public Health, University of Amsterdam, Amsterdam, The Netherlands
| | - Pacome Achimi Agbo
- Centre de Recherches Médicales de Lambaréné and African. Partner Institution, German Center for Infection Research, Lambaréné, Gabon
| | - Ayola A Adegnika
- Centre de Recherches Médicales de Lambaréné and African. Partner Institution, German Center for Infection Research, Lambaréné, Gabon.,Institute of Tropical Medicine, Tübingen University, Tübingen, Germany
| | - Abraham Alabi
- Centre de Recherches Médicales de Lambaréné and African. Partner Institution, German Center for Infection Research, Lambaréné, Gabon
| | - Marguerite Massinga-Loembe
- Centre de Recherches Médicales de Lambaréné and African. Partner Institution, German Center for Infection Research, Lambaréné, Gabon.,Institute of Tropical Medicine, Tübingen University, Tübingen, Germany
| | - Martin P Grobusch
- Centre de Recherches Médicales de Lambaréné and African. Partner Institution, German Center for Infection Research, Lambaréné, Gabon. .,Institute of Tropical Medicine, Tübingen University, Tübingen, Germany. .,Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam University Medical Centers, location AMC, Amsterdam Infection & Immunity, Amsterdam Public Health, University of Amsterdam, Amsterdam, The Netherlands.
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11
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Räisänen PE, Haanperä M, Soini H, Ruutu P, Nuorti JP, Lyytikäinen O. Transmission of tuberculosis between foreign-born and Finnish-born populations in Finland, 2014-2017. PLoS One 2021; 16:e0250674. [PMID: 33891668 PMCID: PMC8064540 DOI: 10.1371/journal.pone.0250674] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/08/2021] [Indexed: 11/19/2022] Open
Abstract
We describe the epidemiology of tuberculosis (TB) and characterized Mycobacterium tuberculosis (M. tuberculosis) isolates to evaluate transmission between foreign-born and Finnish-born populations. Data on TB cases were obtained from the National Infectious Disease Register and denominator data on legal residents and their country of birth from the Population Information System. M. tuberculosis isolates were genotyped by spoligotyping and Mycobacterial Interspersed Repetitive Unit Variable Number Tandem Repeat (MIRU-VNTR). We characterized clusters by age, sex, origin and region of living which included both foreign-born cases and those born in Finland. During 2014-2017, 1015 TB cases were notified; 814 were confirmed by culture. The proportion of foreign-born cases increased from 33.3% to 39.0%. Foreign-born TB cases were younger (median age, 28 vs. 75 years), and had extrapulmonary TB or multidrug-TB more often than Finnish-born cases (P<0.01 for all comparisons). Foreign-born cases were born in 60 different countries; most commonly in Somalia (25.5%). Altogether 795 isolates were genotyped; 31.2% belonged to 80 different clusters (range, 2-13 cases/cluster). Fourteen (17.5%) clusters included isolates from both Finnish-born and foreign-born cases. An epidemiological link between cases was identified by (epidemiological) background information in two clusters. Although the proportion of foreign-born TB cases was considerable, our data suggests that transmission of TB between foreign and Finnish born population is uncommon.
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Affiliation(s)
- Pirre Emilia Räisänen
- Health Sciences unit, Faculty of Social Sciences, Tampere University, Tampere, Finland
- Infectious Disease Control and Vaccinations Unit, Department of Health Security, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Marjo Haanperä
- Expert Microbiology Unit, Department of Health Security, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Hanna Soini
- Infectious Disease Control and Vaccinations Unit, Department of Health Security, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Petri Ruutu
- Infectious Disease Control and Vaccinations Unit, Department of Health Security, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - J Pekka Nuorti
- Health Sciences unit, Faculty of Social Sciences, Tampere University, Tampere, Finland
- Infectious Disease Control and Vaccinations Unit, Department of Health Security, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Outi Lyytikäinen
- Infectious Disease Control and Vaccinations Unit, Department of Health Security, Finnish Institute for Health and Welfare, Helsinki, Finland
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12
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Feasey HRA, Corbett EL, Nliwasa M, Mair L, Divala TH, Kamchedzera W, Khundi ME, Burchett HED, Webb EL, Maheswaran H, Squire SB, MacPherson P. Tuberculosis diagnosis cascade in Blantyre, Malawi: a prospective cohort study. BMC Infect Dis 2021; 21:178. [PMID: 33588804 PMCID: PMC7883960 DOI: 10.1186/s12879-021-05860-y] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/31/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) control relies on early diagnosis and treatment. International guidelines recommend systematic TB screening at health facilities, but implementation is challenging. We investigated completion of recommended TB screening steps in Blantyre, Malawi. METHODS A prospective cohort recruited adult outpatients attending Bangwe primary clinic. Entry interviews were linked to exit interviews. The proportion of participants progressing through each step of the diagnostic pathway were estimated. Factors associated with request for sputum were investigated using multivariable logistic regression. RESULTS Of 5442 clinic attendances 2397 (44%) had exit interviews. In clinically indicated participants (n = 445) 256 (57.5%) were asked about cough, 36 (8.1%) were asked for sputum, 21 (4.7%) gave sputum and 1 (0.2%) received same-day results. Significant associations with request for sputum were: any TB symptom (aOR:3.20, 95%CI:2.02-5.06), increasing age (aOR:1.02, 95%CI:1.01-1.04 per year) and for HIV-negative participants only, a history of previous TB (aOR:3.37, 95%CI:1.45-7.81). Numbers requiring sputum tests (26/day) outnumbered diagnostic capacity (8-12/day). CONCLUSIONS Patients were lost at every stage of the TB care cascade, with same day sputum submission following all steps of the diagnosis cascade achieved in only 4.7% if clinically indicated. Infection control strategies should be implemented, with reporting on early steps of the TB care cascade formalised. High-throughput screening interventions, such as digital CXR, that can achieve same-day TB diagnosis are urgently needed to meet WHO End TB goals.
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Affiliation(s)
- Helena R. A. Feasey
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
| | - Elizabeth L. Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
| | - Marriott Nliwasa
- Helse Nord Tuberculosis Initiative, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Luke Mair
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Titus H. Divala
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
- Helse Nord Tuberculosis Initiative, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Wala Kamchedzera
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Mc Ewen Khundi
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
| | - Helen E. D. Burchett
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
| | - Emily L. Webb
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
| | | | | | - Peter MacPherson
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
- Liverpool School of Tropical Medicine, Liverpool, UK
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Fox GJ, Redwood L, Chang V, Ho J. The Effectiveness of Individual and Environmental Infection Control Measures in Reducing the Transmission of Mycobacterium tuberculosis: A Systematic Review. Clin Infect Dis 2020; 72:15-26. [DOI: 10.1093/cid/ciaa719] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 06/04/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Transmission of Mycobacterium tuberculosis in healthcare settings is a preventable driver of the global tuberculosis epidemic. We aimed to assess the evidence for infection control interventions, including cough etiquette, engineering and personal respiratory protection measures, to prevent transmission of M. tuberculosis in healthcare settings.
Methods
Three independent systematic reviews were performed using 6 databases and clinical trials websites. Randomized trials, cohort studies, before-after studies, and case-control studies were included. Searches were performed for controlled studies evaluating respiratory hygiene, engineering, and personal respiratory protection measures. Outcome measures included the incidence of tuberculosis infection and disease. Studies involving transmission to either humans or animals were included.
Results
Evaluation of respiratory hygiene and cough etiquette interventions identified 4 human studies, with 22 855 participants, and 1 guinea pig study. Studies in humans evaluated the effects of multiple concurrent interventions. Patient use of surgical masks reduced infection by 14.8%, and tuberculosis disease was reduced by between 0.5% and 28.9%. Engineering and environmental interventions were evaluated in 10 studies of humans, including 31 776 human participants, and 2 guinea pig studies. Mechanical ventilation was associated with between 2.9% and 14% less infection. Nine studies of personal respiratory protection were included, including 33 913 participants. Infection was reduced by between 0% and 14.8% in studies where particulate respirators were used. The quality of included studies was assessed as low.
Conclusions
Respiratory hygiene, engineering, and environmental infection controls and personal respiratory protection interventions were associated with reduced transmission of M. tuberculosis and reduced tuberculosis disease in healthcare settings.
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Affiliation(s)
- Greg J Fox
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Woolcock Institute of Medical Research, Glebe, New South Wales, Australia
| | - Lisa Redwood
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Vicky Chang
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jennifer Ho
- Woolcock Institute of Medical Research, Glebe, New South Wales, Australia
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Abstract
Traditional tuberculosis (TB) infection control focuses on the known patient with TB, usually on appropriate treatment. A refocused, intensified TB infection control approach is presented. Combined with active case finding and rapid molecular diagnostics, an approach called FAST is described as a convenient way to call attention to the untreated patient. Natural ventilation is the mainstay of air disinfection in much of the world. Germicidal ultraviolet technology is the most sustainable approach to air disinfection under resource-limited conditions. Testing and treatment of latent TB infection works to prevent reactivation but requires greater risk targeting in both low- and high-risk settings.
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Affiliation(s)
- Edward A Nardell
- Division of Global Health Equity, Harvard Medical School, Brigham & Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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15
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Sun HY, Wang JY, Chen YC, Hsueh PR, Chen YH, Chuang YC, Fang CT, Chang SC, Wang JD. Impact of introducing fluorescent microscopy on hospital tuberculosis control: A before-after study at a high caseload medical center in Taiwan. PLoS One 2020; 15:e0230067. [PMID: 32243434 PMCID: PMC7122812 DOI: 10.1371/journal.pone.0230067] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 02/20/2020] [Indexed: 11/23/2022] Open
Abstract
Background Undiagnosed tuberculosis (TB) patients hospitalized because of comorbidities constitute a challenge to TB control in hospitals. We aimed to assess the impact of introducing highly sensitive fluorescent microscopy for examining sputum smear to replace conventional microscopy under a high TB risk setting. Methods We measured the impact of switch to fluorescent microscopy on the smear detection rate of culture-confirmed pulmonary TB, timing of respiratory isolation, and total non-isolated infectious person-days in hospital at a high-caseload medical center (approximately 400 TB cases annually) in Taipei. Multivariable Cox regression was applied to adjust for effects of covariates. The effect attributable to the improved smear detection rate was determined using causal mediation analysis. Results After switch to fluorescence microscopy, median non-isolated infectious duration decreased from 12.5 days to 3 days (P<0.001). Compared with conventional microscopy, fluorescence microscopy increased sputum smear detection rate by two-fold (for all patients: from 22.8% to 48.1%, P<0.001; for patients with cavitary lung lesion: from 43% to 82%, P = 0.029) and was associated with a 2-fold higher likelihood of prompt respiratory isolation (odds ratio mediated by the increase in sputum smear detection rate: 1.8, 95% CI 1.3–2.5). Total non-isolated infectious patient-days in hospital decreased by 69% (from 4,778 patient-days per year to 1,502 patient-days per year). Conclusions In a high TB caseload setting, highly sensitive rapid diagnostic tools could substantially improve timing of respiratory isolation and reduce the risk of nosocomial TB transmission.
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Affiliation(s)
- Hsin-Yun Sun
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jann-Yuan Wang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Po-Ren Hsueh
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yi-Hsuan Chen
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yu-Chung Chuang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chi-Tai Fang
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
- * E-mail:
| | - Shan-Chwen Chang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jung-Der Wang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
- Departments of Internal Medicine and Occupational and Environmental Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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16
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Lisboa M, Fronteira I, Mason PH, Martins MDRO. Using hospital auxiliary worker and 24-h TB services as potential tools to overcome in-hospital TB delays: a quasi-experimental study. Hum Resour Health 2020; 18:28. [PMID: 32245488 PMCID: PMC7126367 DOI: 10.1186/s12960-020-0457-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 02/07/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND In-hospital logistic management barriers (LMB) are considered to be important risk factors for delays in TB diagnosis and treatment initiation (TB-dt), which perpetuates TB transmission and the development of TB morbidity and mortality. We assessed the contribution of hospital auxiliary workers (HAWs) and 24-h TB laboratory services using Xpert (24h-Xpert) on the delays in TB-dt and TB mortality at Beira Central Hospital, Mozambique. METHODS A quasi-experimental design was used. Implementation strategy-HAWs and laboratory technicians were selected and trained, accordingly. Interventions-having trained HAW and TB laboratory technicians as expediters of TB LMB issues and assurer of 24h-Xpert, respectively. Implementation outcomes-time from hospital admission to sputum examination results, time from hospital admission to treatment initiation, proportion of same-day TB cases diagnosed, initiated TB treatment, and TB patient with unfavorable outcome after hospitalization (hospital TB mortality). A nonparametric test was used to test the differences between groups and adjusted OR (95% CI) were computed using multivariate logistic regression. RESULTS We recruited 522 TB patients. Median (IQR) age was 34 (16) years, and 52% were from intervention site, 58% males, 60% new case of TB, 12% MDR-TB, 72% TB/HIV co-infected, and 43% on HIV treatment at admission. In the intervention hospital, 93% of patients had same-day TB-dt in comparison with a median (IQR) time of 15 (2) days in the control hospital. TB mortality in the intervention hospital was lower than that in the control hospital (13% vs 49%). TB patients admitted to the intervention hospital were nine times more likely to obtain an early laboratory diagnosis of TB, six times more likely to reduce delays in TB treatment initiation, and eight times less likely to die, when compared to those who were admitted to the control hospital, adjusting for other factors. CONCLUSION In-hospital delays in TB-dt and high TB mortality in Mozambique are common and probably due, in part, to LMB amenable to poor-quality TB care. Task shifting of TB logistic management services to HAWs and lower laboratory technicians, to ensure 24h-Xpert through "on-the-spot strategy," may contribute to timely TB detection, proper treatment, and reduction of TB mortality.
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Affiliation(s)
- Miguelhete Lisboa
- Centro de Investigação Operacional da Beira (CIOB), Instituto Nacional de Saúde (INS), Rua Correia de Brito #1323 – Ponta-Gea, Beira, Mozambique
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical (IHMT), Universidade NOVA de Lisboa (UNL), Rua da Junqueira No. 100 |, 1349-008 Lisbon, Portugal
| | - Inês Fronteira
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical (IHMT), Universidade NOVA de Lisboa (UNL), Rua da Junqueira No. 100 |, 1349-008 Lisbon, Portugal
| | - Paul H. Mason
- School of Social Sciences, Monash University, Wellington Road, Clayton, Victoria 3800 Australia
| | - Maria do Rosário O. Martins
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical (IHMT), Universidade NOVA de Lisboa (UNL), Rua da Junqueira No. 100 |, 1349-008 Lisbon, Portugal
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17
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Lisboa M, Fronteira I, Mason PH, Martins MDRO. National TB program shortages as potential factor for poor-quality TB care cascade: Healthcare workers' perspective from Beira, Mozambique. PLoS One 2020; 15:e0228927. [PMID: 32059032 PMCID: PMC7021283 DOI: 10.1371/journal.pone.0228927] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 01/26/2020] [Indexed: 11/25/2022] Open
Abstract
Background Mozambique is one of the countries with the deadly implementation gaps in the tuberculosis (TB) care and services delivery. In-hospital delays in TB diagnosis and treatment, transmission and mortality still persist, in part, due to poor-quality of TB care cascade. Objective We aimed to assess, from the healthcare workers’ (HCW) perspective, factors associated with poor-quality TB care cascade and explore local sustainable suggestions to improve in-hospital TB management. Methods In-depth interviews and focus group discussions were conducted with different categories of HCW. Audio-recording and written notes were taken, and content analysis was performed through atlas.ti7. Results Bottlenecks within hospital TB care cascade, lack of TB staff and task shifting, centralized and limited time of TB laboratory services, and fear of healthcare workers getting infected by TB were mentioned to be the main factors associated with implementation gaps. Interviewees believe that task shifting from nurses to hospital auxiliary workers, and from higher and well-trained to lower HCW are accepted and feasible. The expansion and use of molecular TB diagnostic tools are seen by the interviewees as a proper way to fight effectively against both sensitive and MDR TB. Ensuring provision of N95 respiratory masks is believed to be an essential requirement for effective engagement of the HCW on high-quality in-hospital TB care. For monitoring and evaluation, TB quality improvement teams in each health facility are considered to be an added value. Conclusion Shortage of resources within the national TB control programme is one of the potential factors for poor-quality of the TB care cascade. Task shifting of TB care and services delivery, decentralization of the molecular TB diagnostic tools, and regular provision of N95 respiratory masks should contribute not just to reduce the impact of resource scarceness, but also to ensure proper TB diagnosis and treatment to both sensitive and MDR TB.
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Affiliation(s)
- Miguelhete Lisboa
- Centro de Investigação Operacional da Beira (CIOB), Instituto Nacional de Saúde (INS), Beira, Mozambique
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical (IHMT), Universidade NOVA de Lisboa, Lisbon, Portugal
- * E-mail:
| | - Inês Fronteira
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical (IHMT), Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Paul H. Mason
- School of Social Sciences, Monash University, Clayton, Australia
| | - Maria do Rosário O. Martins
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical (IHMT), Universidade NOVA de Lisboa, Lisbon, Portugal
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18
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Nathavitharana RR, Lederer P, Tierney DB, Nardell E. Treatment as prevention and other interventions to reduce transmission of multidrug-resistant tuberculosis. Int J Tuberc Lung Dis 2020; 23:396-404. [PMID: 31064617 DOI: 10.5588/ijtld.18.0276] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Drug-resistant tuberculosis (DR-TB) represents a major programmatic challenge at the national and global levels. Only ∼30% of patients with multidrug-resistant TB (MDR-TB) were diagnosed, and ∼25% were initiated on treatment for MDR-TB in 2016. Increasing evidence now points towards primary transmission of DR-TB, rather than inadequate treatment, as the main driver of the DR-TB epidemic. The cornerstone of DR-TB transmission prevention should be earlier diagnosis and prompt initiation of effective treatment for all patients with DR-TB. Despite the extensive scale-up of Xpert® MTB/RIF testing, major implementation barriers continue to limit its impact. Although there is longstanding evidence in support of the rapid impact of treatment on patient infectiousness, delays in the initiation of effective DR-TB treatment persist, resulting in ongoing transmission. However, it is also imperative to address the burden of latent drug-resistant tuberculous infection because it is estimated that many DR-TB patients will become infectious before seeking care and encounter various diagnostic delays before treatment. Addressing latent DR-TB primarily consists of identifying, treating and following the contacts of patients with MDR-TB, typically through household contact evaluation. Adjunctive measures, such as improved ventilation and use of germicidal ultraviolet technology can further reduce TB transmission in high-risk congregate settings. Although many gaps remain in our biological understanding of TB transmission, implementation barriers to early diagnosis and rapid initiation of effective DR-TB treatment can and must be overcome if we are to impact DR-TB incidence in the short and long term.
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Affiliation(s)
- R R Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - P Lederer
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
| | - D B Tierney
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - E Nardell
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
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19
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Barrera-Cancedda AE, Riman KA, Shinnick JE, Buttenheim AM. Implementation strategies for infection prevention and control promotion for nurses in Sub-Saharan Africa: a systematic review. Implement Sci 2019; 14:111. [PMID: 31888673 PMCID: PMC6937686 DOI: 10.1186/s13012-019-0958-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 02/01/2019] [Accepted: 12/02/2019] [Indexed: 12/13/2022] Open
Abstract
Background Despite impressive reductions in infectious disease burden within Sub-Saharan Africa (SSA), half of the top ten causes of poor health or death in SSA are communicable illnesses. With emerging and re-emerging infections affecting the region, the possibility of healthcare-acquired infections (HAIs) being transmitted to patients and healthcare workers, especially nurses, is a critical concern. Despite infection prevention and control (IPC) evidence-based practices (EBP) to minimize the transmission of HAIs, many healthcare systems in SSA are challenged to implement them. The purpose of this review is to synthesize and critique what is known about implementation strategies to promote IPC for nurses in SSA. Methods The databases, PubMed, Ovid/Medline, Embase, Cochrane, and CINHAL, were searched for articles with the following criteria: English language, peer-reviewed, published between 1998 and 2018, implemented in SSA, targeted nurses, and promoted IPC EBPs. Further, 6241 search results were produced and screened for eligibility to identify implementation strategies used to promote IPC for nurses in SSA. A total of 61 articles met the inclusion criteria for the final review. The articles were evaluated using the Joanna Briggs Institute’s (JBI) quality appraisal tools. Results were reported using PRISMA guidelines. Results Most studies were conducted in South Africa (n = 18, 30%), within the last 18 years (n = 41, 67%), and utilized a quasi-experimental design (n = 22, 36%). Few studies (n = 14, 23%) had sample populations comprising nurses only. The majority of studies focused on administrative precautions (n = 36, 59%). The most frequent implementation strategies reported were education (n = 59, 97%), quality management (n = 39, 64%), planning (n = 33, 54%), and restructure (n = 32, 53%). Penetration and feasibility were the most common outcomes measured for both EBPs and implementation strategies used to implement the EBPs. The most common MAStARI and MMAT scores were 5 (n = 19, 31%) and 50% (n = 3, 4.9%) respectively. Conclusions As infectious diseases, especially emerging and re-emerging infectious diseases, continue to challenge healthcare systems in SSA, nurses, the keystones to IPC practice, need to have a better understanding of which, in what combination, and in what context implementation strategies should be best utilized to ensure their safety and that of their patients. Based on the results of this review, it is clear that implementation of IPC EBPs in SSA requires additional research from an implementation science-specific perspective to promote IPC protocols for nurses in SSA.
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Affiliation(s)
| | - Kathryn A Riman
- School of Nursing, University of Pennsylvania, Philadelphia, PA, 19104, USA
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20
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Nathavitharana RR, Yoon C, Macpherson P, Dowdy DW, Cattamanchi A, Somoskovi A, Broger T, Ottenhoff THM, Arinaminpathy N, Lonnroth K, Reither K, Cobelens F, Gilpin C, Denkinger CM, Schumacher SG. Guidance for Studies Evaluating the Accuracy of Tuberculosis Triage Tests. J Infect Dis 2019; 220:S116-S125. [PMID: 31593600 PMCID: PMC6782021 DOI: 10.1093/infdis/jiz243] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Approximately 3.6 million cases of active tuberculosis (TB) go potentially undiagnosed annually, partly due to limited access to confirmatory diagnostic tests, such as molecular assays or mycobacterial culture, in community and primary healthcare settings. This article provides guidance for TB triage test evaluations. A TB triage test is designed for use in people with TB symptoms and/or significant risk factors for TB. Triage tests are simple and low-cost tests aiming to improve ease of access and implementation (compared with confirmatory tests) and decrease the proportion of patients requiring more expensive confirmatory testing. Evaluation of triage tests should occur in settings of intended use, such as community and primary healthcare centers. Important considerations for triage test evaluation include study design, population, sample type, test throughput, use of thresholds, reference standard (ideally culture), and specimen flow. The impact of a triage test will depend heavily on issues beyond accuracy, primarily centered on implementation.
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Affiliation(s)
- Ruvandhi R Nathavitharana
- Department of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston,Correspondence: R. Nathavitharana, MBBS, MPH, Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Lowry Building, Suite GB, 110 Francis Street, Boston MA 02215
| | - Christina Yoon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco
| | - Peter Macpherson
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, United Kingdom,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Malawi
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco,Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, University of California San Francisco
| | - Akos Somoskovi
- Intellectual Ventures Laboratory, Global Good Fund, Bellevue, Washington
| | - Tobias Broger
- Foundation for Innovative Diagnostics (FIND), Geneva, Switzerland
| | - Tom H M Ottenhoff
- Department of Infectious Diseases, Leiden University Medical Center, The Netherlands
| | - Nimalan Arinaminpathy
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, Stockholm, Sweden
| | - Knut Lonnroth
- Department of Public Health Sciences, Karolinska Instituet, Stockholm, Sweden
| | - Klaus Reither
- University of Basel, Switzerland,Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Frank Cobelens
- Department of Global Health, Amsterdam UMC, University of Amsterdam, The Netherlands
| | | | - Claudia M Denkinger
- Foundation for Innovative Diagnostics (FIND), Geneva, Switzerland,University Hospital Heidelberg, Division of Tropical Medicine, Centre of Infectious Diseases, Germany
| | - Samuel G Schumacher
- University Hospital Heidelberg, Division of Tropical Medicine, Centre of Infectious Diseases, Germany
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21
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Reeve BWP, Centis R, Theron G. Still dying in plain sight: missed and misclassified deaths due to tuberculosis in hospitals. Eur Respir J 2019; 54:54/3/1901578. [PMID: 31575725 DOI: 10.1183/13993003.01578-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 08/10/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Byron William Patrick Reeve
- NRF/DST 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
| | - Rosella Centis
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy
| | - Grant Theron
- NRF/DST 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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22
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Hapolo E, Ilai J, Francis T, du Cros P, Taune M, Chan G. TB treatment delay associated with drug resistance and admission at Daru General Hospital in Papua New Guinea. Public Health Action 2019; 9:S50-S56. [PMID: 31579650 DOI: 10.5588/pha.18.0075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 09/13/2018] [Accepted: 12/11/2018] [Indexed: 11/10/2022] Open
Abstract
SETTING Daru General Hospital, Daru Island, Papua New Guinea, where high rates of tuberculosis (TB) have been reported. Prompt diagnosis and effective treatment are needed for improving TB outcomes and to prevent nosocomial transmission. OBJECTIVE To assess the time to treatment initiation and the risk factors associated with delayed treatment for patients started on TB treatment at Daru General Hospital from January to September 2017. DESIGN This was a retrospective cohort study that entailed reviewing the records from treatment, admission, discharge and presumptive TB registers. RESULTS The study included 360 patients on TB treatment. The median time from presentation to treatment initiation was 7 days [IQR 3-11]. Treatment was started <7 days for 215 patients (60%); however, only 16.2% commenced treatment <2 days. Risk factors for delayed treatment were diagnosis of TB as an inpatient (OR 2.67, 95% CI 1.35-5.28, P = 0.005) and having drug-resistant TB (OR 2.65, 95% CI 1.5-4.68. P = 0.001). CONCLUSION A high proportion of TB patients commenced treatment <7 days. Inpatient status, DR-TB and lack of microbiological confirmation were associated with delays in treatment initiation. We recommend that programmes monitor the time from presentation to treatment initiation, and propose that a period of >3 days from presentation to treatment initiation be considered as delayed treatment initiation.
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Affiliation(s)
- E Hapolo
- Daru General Hospital, Daru, Western Province, Papua New Guinea
| | - J Ilai
- Daru General Hospital, Daru, Western Province, Papua New Guinea
| | - T Francis
- Daru General Hospital, Daru, Western Province, Papua New Guinea
| | - P du Cros
- Burnet Institute, Melbourne, Victoria, Australia
| | - M Taune
- Daru General Hospital, Daru, Western Province, Papua New Guinea
| | - G Chan
- Burnet Institute, Melbourne, Victoria, Australia
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23
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Abstract
Tuberculosis (TB) is a major issue in global health and affects millions of people each year. Multidrug-resistant tuberculosis (MDR-TB) annually causes many deaths worldwide. Development of a way to diagnose and treat patients with MDR-TB can potentially reduce the incidence of the disease. The current study reviews the risk factors, pattern of progression, mechanism of resistance, and interaction between bacteria and the host immune system, which disrupts the immune response. It also targets the components of Mycobacterium tuberculosis (Mtb) and diagnosis and treatment options that could be available for clinical use in the near future. Mutations play an important role in development of MDR-TB and the selection of appropriate mutations can help to understand the type of resistance in patients to anti-TB drugs. In this way, they can be initially treated with proper and effective therapeutic choices, which can accelerate the course of treatment and improve patient health. Targeting the components and enzymes of Mtb is necessary for understanding bacterial survival and finding a way to destroy the pathogen and allow patients to recover faster and prevent the spread of disease, especially resistant strains.
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Affiliation(s)
- Majid Faridgohar
- Infectious Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran.,Department of Microbiology and Immunology, Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran
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24
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Miller AC, Livchits V, Ahmad Khan F, Atwood S, Kornienko S, Kononenko Y, Vasilyeva I, Keshavjee S. Turning Off the Tap: Using the FAST Approach to Stop the Spread of Drug-Resistant Tuberculosis in the Russian Federation. J Infect Dis 2019; 218:654-658. [PMID: 29659912 PMCID: PMC6047444 DOI: 10.1093/infdis/jiy190] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 04/04/2018] [Indexed: 11/25/2022] Open
Abstract
Background We report the association of the FAST strategy (find cases actively, separate safely, and treat effectively) with reduction of hospital-based acquisition of multidrug-resistant tuberculosis in the Russian Federation. Methods We used preintervention and postintervention cohorts in 2 Russian hospitals to determine whether the FAST strategy was associated with a reduced odds of converting MDR tuberculosis within 12 months among patients with tuberculosis susceptible to isoniazid and rifampin at baseline. Results Sixty-three of 709 patients (8.9%) with isoniazid and rifampin–susceptible tuberculosis acquired MDR tuberculosis; 55 (12.2%) were in the early cohort, and 8 (3.1%) were in the FAST cohort. The FAST strategy was associated with a reduced odds (adjusted odds ratio, 0.16; 95% confidence interval, .07–.39) and 9.2% absolute reduction in the risk of MDR tuberculosis acquisition. Conclusion Use of the FAST strategy in 2 Russian hospitals was associated with significantly less MDR tuberculosis 12 months after implementation.
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Affiliation(s)
- Ann C Miller
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | | | - Faiz Ahmad Khan
- Respiratory Epidemiology and Clinical Research Unit, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Sidney Atwood
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Yulia Kononenko
- Republic of Karelia Clinical Tuberculosis Hospital, Petrozavodsk, Russian Federation
| | - Irina Vasilyeva
- Ministry of Health of the Russian Federation.,Research Institute of Phthisiopulmonology, I. M. Sechenov First Moscow State Medical University, Moscow
| | - Salmaan Keshavjee
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts.,Partners in Health, Boston, Massachusetts
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25
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van der Westhuizen HM, Nathavitharana RR, Pillay C, Schoeman I, Ehrlich R. The high-quality health system 'revolution': Re-imagining tuberculosis infection prevention and control. J Clin Tuberc Other Mycobact Dis 2019; 17:100118. [PMID: 31788560 PMCID: PMC6880133 DOI: 10.1016/j.jctube.2019.100118] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 12/26/2022] Open
Abstract
The Lancet Commission on High-Quality Health Systems called for a 'revolution' in the quality of care provided in low- and middle-income countries. We argue that this provides a helpful framework to demonstrate how effective tuberculosis infection prevention and control (TB IPC) implementation should be linked with health system strengthening, moving it from the silo of the national TB programmes. Using this framework, we identify and discuss links between TB IPC implementation and patient safety, human resources for health, prioritising person-centred care, building trust in health systems and refining the tools used to measure TB IPC implementation. Prioritising patient experience has been a recent addition to the definition of high-quality care. In high TB burden settings, the encounter with TB IPC measures may be a TB patient's initial contact with the healthcare system and may cause feelings of stigmatisation. We advocate for re-imagining the way we implement TB IPC, by drawing on the principles of person-centred care through incorporating the experiences of people using healthcare services. Health workers who developed occupational TB also offer a unique perspective: they have both experienced TB IPC and have played a role in implementing it in their workplace. They can be powerful advocates for person-centred TB IPC implementation. Through framing TB IPC as part of health system strengthening and consciously including person-centred perspectives in TB IPC design, measurement and guidelines, we hope to influence future TB IPC research and practice.
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Affiliation(s)
- Helene-Mari van der Westhuizen
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care building, Oxford University, OX2 6GG, United Kingdom.,TB Proof, South Africa
| | - Ruvandhi R Nathavitharana
- TB Proof, South Africa.,Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, 110 Francis Street, Suite GB, Boston MA 02215, USA
| | - Clio Pillay
- TB Proof, South Africa.,Department of Public Health, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, United Kingdom
| | | | - Rodney Ehrlich
- Department of Public Health and Family Medicine, University of Cape Town, Anzio Rd, Observatory, Cape Town 7925, South Africa
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26
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Machekera SM, Wilkinson E, Hinderaker SG, Mabhala M, Zishiri C, Ncube RT, Timire C, Takarinda KC, Sengai T, Sandy C. A comparison of the yield and relative cost of active tuberculosis case-finding algorithms in Zimbabwe. Public Health Action 2019; 9:63-68. [PMID: 31417855 DOI: 10.5588/pha.18.0098] [Citation(s) in RCA: 5] [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: 12/05/2018] [Accepted: 02/09/2019] [Indexed: 11/10/2022] Open
Abstract
Setting Ten districts and three cities in Zimbabwe. Objective To compare the yield and relative cost of identifying a case of tuberculosis (TB) using the three WHO-recommended algorithms (WHO2b, symptom inquiry only; WHO2d, chest X-ray [CXR] after a positive symptom inquiry; WHO3b, CXR only) and the Zimbabwe active case finding (ZimACF) algorithm (symptom inquiry plus CXR) to everyone. Design Cross-sectional study using data from the ZimACF project. Results A total of 38 574 people were screened from April to December 2017; 488 (1.3%) were diagnosed with TB using the ZimACF algorithm. Fewer TB cases would have been diagnosed with the WHO-recommended algorithms. This ranged from 7% fewer (34 cases) with WHO3b, 18% fewer (88 cases) with WHO2b and 25% fewer (122 cases) with WHO2d. The need for CXR ranged from 36% (WHO2d) to 100% (WHO3b). The need for bacteriological confirmation ranged from 7% (WHO2d) to 40% (ZimACF). The relative cost per case of TB diagnosed ranged from US$180 with WHO3b to US$565 for the ZimACF algorithm. Conclusion The ZimACF algorithm had the highest case yield, but at a much higher cost per case than the WHO algorithms. It is possible to switch to algorithm WHO3b, but the trade-off between cost and yield needs to be reviewed by the Zimbabwean National TB Programme.
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Affiliation(s)
- S M Machekera
- International Union Against Tuberculosis and Lung Diseases, Harare, Zimbabwe
| | - E Wilkinson
- Institute of Medicine, University of Chester, Chester, UK
| | - S G Hinderaker
- Centre of International Health, University of Bergen, Bergen, Norway
| | - M Mabhala
- Department of Public Health and Wellbeing, University of Chester, Chester, UK
| | - C Zishiri
- International Union Against Tuberculosis and Lung Diseases, Harare, Zimbabwe
| | - R T Ncube
- International Union Against Tuberculosis and Lung Diseases, Harare, Zimbabwe
| | - C Timire
- International Union Against Tuberculosis and Lung Diseases, Harare, Zimbabwe.,Ministry of Health and Child Care, Harare, Zimbabwe
| | - K C Takarinda
- International Union Against Tuberculosis and Lung Diseases, Harare, Zimbabwe.,Ministry of Health and Child Care, Harare, Zimbabwe
| | - T Sengai
- Family AIDS Caring Trust, Mutare, Zimbabwe
| | - C Sandy
- Ministry of Health and Child Care, Harare, Zimbabwe
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27
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Migliori GB, Nardell E, Yedilbayev A, D'Ambrosio L, Centis R, Tadolini M, van den Boom M, Ehsani S, Sotgiu G, Dara M. Reducing tuberculosis transmission: a consensus document from the World Health Organization Regional Office for Europe. Eur Respir J 2019; 53:13993003.00391-2019. [PMID: 31023852 DOI: 10.1183/13993003.00391-2019] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/18/2019] [Indexed: 12/11/2022]
Abstract
Evidence-based guidance is needed on 1) how tuberculosis (TB) infectiousness evolves in response to effective treatment and 2) how the TB infection risk can be minimised to help countries to implement community-based, outpatient-based care.This document aims to 1) review the available evidence on how quickly TB infectiousness responds to effective treatment (and which factors can lower or boost infectiousness), 2) review policy options on the infectiousness of TB patients relevant to the World Health Organization European Region, 3) define limitations of the available evidence and 4) provide recommendations for further research.The consensus document aims to target all professionals dealing with TB (e.g TB specialists, pulmonologists, infectious disease specialists, primary healthcare professionals, and other clinical and public health professionals), as well as health staff working in settings where TB infection is prevalent.
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Affiliation(s)
- Giovanni Battista Migliori
- Respiratory Diseases Clinical Epidemiology Unit, Clinical Scientific Institutes Maugeri, IRCCS, Tradate, Italy.,These authors contributed equally to this work
| | - Edward Nardell
- Division of Global Health Equity, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA.,These authors contributed equally to this work
| | | | | | - Rosella Centis
- Respiratory Diseases Clinical Epidemiology Unit, Clinical Scientific Institutes Maugeri, IRCCS, Tradate, Italy
| | - Marina Tadolini
- Dept of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Martin van den Boom
- Joint Tuberculosis, HIV and Viral Hepatitis Programme, WHO Regional Office for Europe, Copenhagen, Denmark.,These authors contributed equally to this work
| | - Soudeh Ehsani
- Joint Tuberculosis, HIV and Viral Hepatitis Programme, WHO Regional Office for Europe, Copenhagen, Denmark
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Dept of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy.,These authors contributed equally to this work
| | - Masoud Dara
- Joint Tuberculosis, HIV and Viral Hepatitis Programme, WHO Regional Office for Europe, Copenhagen, Denmark
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28
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Kendall EA, Sahu S, Pai M, Fox GJ, Varaine F, Cox H, Cegielski JP, Mabote L, Vassall A, Dowdy DW. What will it take to eliminate drug-resistant tuberculosis? Int J Tuberc Lung Dis 2019; 23:535-546. [PMID: 31097060 PMCID: PMC6600801 DOI: 10.5588/ijtld.18.0217] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Drug-resistant tuberculosis (DR-TB) is challenging to diagnose, treat, and prevent, but this situation is slowly changing. If the world is to drastically reduce the incidence of DR-TB, we must stop creating new DR-TB as an essential first step. The DR-TB epidemic that is ongoing should also be directly addressed. First-line drug resistance must be rapidly detected using universal molecular testing for resistance to at least rifampin and, preferably, other key drugs at initial TB diagnosis. DR-TB treatment outcomes must also improve dramatically. Effective use of currently available, new, and repurposed drugs, combined with patient-centered treatment that aids adherence and reduces catastrophic costs, are essential. Innovations within sight, such as short, highly effective, broadly indicated regimens, paired with point-of-care drug susceptibility testing, could accelerate progress in treatment outcomes. Preventing or containing resistance to second-line and novel drugs is also critical and will require high-quality systems for diagnosis, regimen selection, and treatment monitoring. Finally, earlier detection and/or prevention of DR-TB is necessary, with particular attention to airborne infection control, case finding, and preventive therapy for contacts of patients with DR-TB. Implementing these strategies can overcome the barrier that DR-TB represents for global TB elimination efforts, and could ultimately make global elimination of DR-TB (fewer than one annual case per million population worldwide) attainable. There is a strong cost-effectiveness case to support pursuing DR-TB elimination; however, achieving this goal will require substantial global investment plus political and societal commitment at national and local levels.
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Affiliation(s)
- E A Kendall
- Johns Hopkins University, Baltimore, Maryland, USA
| | - S Sahu
- Stop TB Partnership, Geneva, Switzerland
| | - M Pai
- McGill International TB Center, McGill University, Montreal, Quebec, Canada
| | - G J Fox
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - F Varaine
- Médecins Sans Frontières, Paris, France
| | - H Cox
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; **Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - L Mabote
- AIDS and Rights Alliance for Southern Africa, Cape Town, South Africa
| | - A Vassall
- London School of Hygiene & Tropical Medicine, London, UK
| | - D W Dowdy
- Johns Hopkins University, Baltimore, Maryland, USA
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29
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Graves SK, Augusto O, Viegas SO, Lederer P, David C, Lee K, Hassane A, Cossa A, Amade S, Peleve S, Zindoga P, Massawo L, Torriani FJ, Nunes EA. Tuberculosis infection risk, preventive therapy care cascade and incidence of tuberculosis disease in healthcare workers at Maputo Central Hospital. BMC Infect Dis 2019; 19:346. [PMID: 31023260 PMCID: PMC6485058 DOI: 10.1186/s12879-019-3966-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 10/31/2018] [Accepted: 04/08/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Mozambican healthcare workers have high rates of latent and active tuberculosis, but occupational screening for tuberculosis is not routine in this setting. Furthermore, the specificity of tuberculin skin testing in this population compared with interferon gamma release assay testing has not been established. METHODS This study was conducted among healthcare workers at Maputo Central Hospital, a public teaching quaternary care hospital in Mozambique. With a cross sectional study design, risk factors for tuberculosis were assessed using multivariable logistic regression. The care cascade is reported for participants who were prescribed six months of isoniazid preventive therapy for HIV or highly reactive testing for latent tuberculosis infection. The agreement of interferon-gamma release assay results with positive tuberculin skin testing was calculated. RESULTS Of 690 screened healthcare workers, three (0.4%) had active tuberculosis and 426 (61.7%) had latent tuberculosis infection. Less education, age 35-49, longer hospital service, and work in the surgery department were associated with increased likelihood of being tuberculosis infected at baseline (p < 0.05). Sex, Bacillus Calmette-Guerin vaccination, HIV, outside tuberculosis contacts, and professional category were not. Three new cases of active tuberculosis developed during the follow-up period, two while on preventive therapy. Among 333 participants offered isoniazid preventive therapy, five stopped due to gastrointestinal side effects and 181 completed treatment. For HIV seropositive individuals, the agreement of interferon gamma release assay positivity with positive tuberculin skin testing was 50% among those with a quantitative skin test result of 5-10 mm, and among those with a skin test result ≥10 mm it was 87.5%. For HIV seronegative individuals, the agreement of interferon gamma release assay positivity with a tuberculin skin test result of 10-14 mm was 63.6%, and for those with a quantitative skin test result ≥15 mm it was 82.2%. CONCLUSIONS There is a high prevalence of tuberculosis infected healthcare workers at Maputo Central Hospital. The surgery department was most heavily affected, suggesting occupational risk. Isoniazid preventive therapy initiation was high and just over half completed therapy. An interferon gamma release assay was useful to discern LTBI from false positives among those with lower quantitative tuberculin skin test results.
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Affiliation(s)
- Susannah K. Graves
- Division of Infectious Diseases, Department of Internal Medicine, University of California, San Diego, 9500 Gilman Drive MC 0711, La Jolla, CA 92093-0711 USA
| | - Orvalho Augusto
- Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Sofia Omar Viegas
- Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique
| | - Philip Lederer
- Department of Medicine, Boston University School of Medicine, Boston, MA USA
| | - Catarina David
- Department of Internal Medicine, Maputo Central Hospital, Av Agostinho Neto-364, Maputo, Mozambique
| | - Kristen Lee
- Department of Medicine, Boston University School of Medicine, Boston, MA USA
| | - Anila Hassane
- Department of Internal Medicine, Maputo Central Hospital, Av Agostinho Neto-364, Maputo, Mozambique
| | - Anilsa Cossa
- Department of Internal Medicine, Maputo Central Hospital, Av Agostinho Neto-364, Maputo, Mozambique
| | - Salma Amade
- Department of Internal Medicine, Maputo Central Hospital, Av Agostinho Neto-364, Maputo, Mozambique
| | - Susete Peleve
- Department of Internal Medicine, Maputo Central Hospital, Av Agostinho Neto-364, Maputo, Mozambique
| | - Pereira Zindoga
- Department of Internal Medicine, Maputo Central Hospital, Av Agostinho Neto-364, Maputo, Mozambique
| | - Leguesse Massawo
- Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique
| | - Francesca J. Torriani
- Division of Infectious Diseases, Department of Internal Medicine, University of California, San Diego, 9500 Gilman Drive MC 0711, La Jolla, CA 92093-0711 USA
- UC San Diego Infection Prevention and Clinical Epidemiology and TB Control Units at UC San Diego Health, 200 W Arbor Drive MC 8951, San Diego, California 92103 USA
| | - Elizabete A. Nunes
- Department of Internal Medicine, Maputo Central Hospital, Av Agostinho Neto-364, Maputo, Mozambique
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Acuña-Villaorduña C, Ayakaka I, Schmidt-Castellani LG, Mumbowa F, Marques-Rodrigues P, Gaeddert M, White LF, Palaci M, Ellner JJ, Dietze R, Joloba M, Fennelly KP, Jones-López EC. Host Determinants of Infectiousness in Smear-Positive Patients With Pulmonary Tuberculosis. Open Forum Infect Dis 2019; 6:ofz184. [PMID: 31205972 PMCID: PMC6557197 DOI: 10.1093/ofid/ofz184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/10/2019] [Indexed: 12/12/2022] Open
Abstract
Background Epidemiologic data suggests that only a minority of tuberculosis (TB) patients are infectious. Cough aerosol sampling is a novel quantitative method to measure TB infectiousness. Methods We analyzed data from three studies conducted in Uganda and Brazil over a 13-year period. We included sputum acid fast bacilli (AFB) and culture positive pulmonary TB patients and used a cough aerosol sampling system (CASS) to measure the number of colony-forming units (CFU) of Mycobacterium tuberculosis in cough-generated aerosols as a measure for infectiousness. Aerosol data was categorized as: aerosol negative (CFU = 0) and aerosol positive (CFU > 0). Logistic regression models were built to identify factors associated with aerosol positivity. Results M. tuberculosis was isolated by culture from cough aerosols in 100/233 (43%) TB patients. In an unadjusted analysis, aerosol positivity was associated with fewer days of antituberculous therapy before CASS sampling (p = .0001), higher sputum AFB smear grade (p = .01), shorter days to positivity in liquid culture media (p = .02), and larger sputum volume (p = .03). In an adjusted analysis, only fewer days of TB treatment (OR 1.47 per 1 day of therapy, 95% CI 1.16-1.89; p = .001) was associated with aerosol positivity. Conclusion Cough generated aerosols containing viable M. tuberculosis, the infectious moiety in TB, are detected in a minority of TB patients and rapidly become non-culturable after initiation of antituberculous treatment. Mechanistic studies are needed to further elucidate these findings.
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Affiliation(s)
- Carlos Acuña-Villaorduña
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Massachusetts.,Lemuel Shattuck Hospital, Boston University School of Public Health, Massachusetts
| | - Irene Ayakaka
- Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | | | - Francis Mumbowa
- Department of Microbiology, Makerere University College of Medicine, Kampala, Uganda
| | | | - Mary Gaeddert
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Massachusetts
| | - Laura F White
- Department of Biostatistics, Boston University School of Public Health, Massachusetts
| | - Moises Palaci
- Núcleo de Doenças Infecciosas, Universidade Federal do Espírito Santo, Vitória, Brazil
| | - Jerrold J Ellner
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Massachusetts
| | - Reynaldo Dietze
- Núcleo de Doenças Infecciosas, Universidade Federal do Espírito Santo, Vitória, Brazil.,Global Health & Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Moses Joloba
- Department of Microbiology, Makerere University College of Medicine, Kampala, Uganda
| | - Kevin P Fennelly
- Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Edward C Jones-López
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Massachusetts
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31
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Ehrlich R, Spiegel J, Yassi A. Diverse approaches to preventing occupational tuberculosis in health workers: cross-disciplinary or cross purposes? Public Health Action 2019; 9:11-14. [PMID: 30963037 DOI: 10.5588/pha.18.0086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 12/19/2018] [Indexed: 12/29/2022] Open
Affiliation(s)
- R Ehrlich
- Centre for Environmental and Occupational Health Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - J Spiegel
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - A Yassi
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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32
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Affiliation(s)
- Rodney Ehrlich
- Centre for Environmental and Occupational Health Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Occupational Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nick van de Water
- Division of Occupational Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Annalee Yassi
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada
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33
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Khan PY, Yates TA, Osman M, Warren RM, van der Heijden Y, Padayatchi N, Nardell EA, Moore D, Mathema B, Gandhi N, Eldholm V, Dheda K, Hesseling AC, Mizrahi V, Rustomjee R, Pym A. Transmission of drug-resistant tuberculosis in HIV-endemic settings. Lancet Infect Dis 2019; 19:e77-88. [PMID: 30554996 DOI: 10.1016/S1473-3099(18)30537-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 08/10/2018] [Accepted: 08/10/2018] [Indexed: 12/17/2022]
Abstract
The emergence and expansion of the multidrug-resistant tuberculosis epidemic is a threat to the global control of tuberculosis. Multidrug-resistant tuberculosis is the result of the selection of resistance-conferring mutations during inadequate antituberculosis treatment. However, HIV has a profound effect on the natural history of tuberculosis, manifesting in an increased rate of disease progression, leading to increased transmission and amplification of multidrug-resistant tuberculosis. Interventions specific to HIV-endemic areas are urgently needed to block tuberculosis transmission. These interventions should include a combination of rapid molecular diagnostics and improved chemotherapy to shorten the duration of infectiousness, implementation of infection control measures, and active screening of multidrug-resistant tuberculosis contacts, with prophylactic regimens for individuals without evidence of disease. Development and improvement of the efficacy of interventions will require a greater understanding of the factors affecting the transmission of multidrug-resistant tuberculosis in HIV-endemic settings, including population-based molecular epidemiology studies. In this Series article, we review what we know about the transmission of multidrug-resistant tuberculosis in settings with high burdens of HIV and define the research priorities required to develop more effective interventions, to diminish ongoing transmission and the amplification of drug resistance.
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35
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Moonan PK, Nair SA, Agarwal R, Chadha VK, Dewan PK, Gupta UD, Ho CS, Holtz TH, Kumar AM, Kumar N, Kumar P, Maloney SA, Mase SR, Oeltmann JE, Paramasivan CN, Parmar MM, Rade KK, Ramachandran R, Rao R, Salhorta VS, Sarin R, Sarin S, Sachdeva KS, Selvaraju S, Singla R, Surie D, Tonsing J, Tripathy SP, Khaparde SD. Tuberculosis preventive treatment: the next chapter of tuberculosis elimination in India. BMJ Glob Health 2018; 3:e001135. [PMID: 30364389 PMCID: PMC6195150 DOI: 10.1136/bmjgh-2018-001135] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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] [Received: 08/22/2018] [Revised: 09/10/2018] [Accepted: 09/11/2018] [Indexed: 01/07/2023] Open
Abstract
The End TB Strategy envisions a world free of tuberculosis—zero deaths, disease and suffering due to tuberculosis by 2035. This requires reducing the global tuberculosis incidence from >1250 cases per million people to <100 cases per million people within the next two decades. Expanding testing and treatment of tuberculosis infection is critical to achieving this goal. In high-burden countries, like India, the implementation of tuberculosis preventive treatment (TPT) remains a low priority. In this analysis article, we explore potential challenges and solutions of implementing TPT in India. The next chapter in tuberculosis elimination in India will require cost-effective and sustainable interventions aimed at tuberculosis infection. This will require constant innovation, locally driven solutions to address the diverse and dynamic tuberculosis epidemiology and persistent programme monitoring and evaluation. As new tools, regimens and approaches emerge, midcourse adjustments to policy and practice must be adopted. The development and implementation of new tools and strategies will call for close collaboration between local, national and international partners—both public and private—national health authorities, non-governmental organisations, research community and the diagnostic and pharmaceutical industry. Leading by example, India can contribute to global knowledge through operational research and programmatic implementation for combating tuberculosis infection.
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Affiliation(s)
- Patrick K Moonan
- Global Tuberculosis Branch, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Reshu Agarwal
- CDC India Country Office, U.S. Centers for Disease Control and Prevention, New Delhi, India
| | - Vineet K Chadha
- Department of Epidemiology and Research, National Tuberculosis Institute, Bangalore, India
| | - Puneet K Dewan
- Global Health, Bill and Melinda Gates Foundation, Seattle, USA
| | - Umesh D Gupta
- National JALMA Institute for Leprosy and other Mycobacterial Diseases, Agra, India
| | - Christine S Ho
- CDC India Country Office, U.S. Centers for Disease Control and Prevention, New Delhi, India
| | - Timothy H Holtz
- CDC India Country Office, U.S. Centers for Disease Control and Prevention, New Delhi, India
| | - Ajay M Kumar
- Department of Research, International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Nishant Kumar
- Revised National Tuberculosis Control Programme, India Ministry of Health and Family Welfare, New Delhi, India
| | | | - Susan A Maloney
- Global Tuberculosis Branch, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sundari R Mase
- WHO India Country Office, World Health Organization, New Delhi, India
| | - John E Oeltmann
- Global Tuberculosis Branch, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - C N Paramasivan
- India Country Office, Foundation for Innovative New Diagnostics, New Delhi, India
| | - Malik M Parmar
- India Country Office, World Health Organization, New Delhi, India
| | - Kiran K Rade
- India Country Office, World Health Organization, New Delhi, India
| | | | - Raghuram Rao
- Revised National Tuberculosis Control Programme, India Ministry of Health and Family Welfare, New Delhi, India
| | - Virendra S Salhorta
- Revised National Tuberculosis Control Programme, India Ministry of Health and Family Welfare, New Delhi, India
| | - Rohit Sarin
- National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India
| | - Sanjay Sarin
- India Country Office, Foundation for Innovative New Diagnostics, New Delhi, India
| | - Kuldeep S Sachdeva
- Revised National Tuberculosis Control Programme, India Ministry of Health and Family Welfare, New Delhi, India
| | - Sriram Selvaraju
- Department of Epidemiology, National Institute for Research in Tuberculosis, Chennai, India
| | - Rupak Singla
- Department of Tuberculosis and Respiratory Diseases, National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India
| | - Diya Surie
- Global Tuberculosis Branch, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jamhoih Tonsing
- South-east Asia Office, International Union Against Tuberculosis and Lung Disease, New Delhi, India
| | | | - Sunil D Khaparde
- Revised National Tuberculosis Control Programme, India Ministry of Health and Family Welfare, New Delhi, India
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Auld SC, Shah NS, Cohen T, Martinson NA, Gandhi NR. Where is tuberculosis transmission happening? Insights from the literature, new tools to study transmission and implications for the elimination of tuberculosis. Respirology 2018; 23:10.1111/resp.13333. [PMID: 29869818 PMCID: PMC6281783 DOI: 10.1111/resp.13333] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 05/14/2018] [Accepted: 05/20/2018] [Indexed: 12/12/2022]
Abstract
More than 10 million new cases of tuberculosis (TB) are diagnosed worldwide each year. The majority of these cases occur in low- and middle-income countries where the TB epidemic is predominantly driven by transmission. Efforts to 'end TB' will depend upon our ability to halt ongoing transmission. However, recent studies of new approaches to interrupt transmission have demonstrated inconsistent effects on reducing population-level TB incidence. TB transmission occurs across a wide range of settings, that include households and hospitals, but also community-based settings. While home-based contact investigations and infection control programmes in hospitals and clinics have a successful track record as TB control activities, there is a gap in our knowledge of where, and between whom, community-based transmission of TB occurs. Novel tools, including molecular epidemiology, geospatial analyses and ventilation studies, provide hope for improving our understanding of transmission in countries where the burden of TB is greatest. By integrating these diverse and innovative tools, we can enhance our ability to identify transmission events by documenting the opportunity for transmission-through either an epidemiologic or geospatial connection-alongside genomic evidence for transmission, based upon genetically similar TB strains. A greater understanding of locations and patterns of transmission will translate into meaningful improvements in our current TB control activities by informing targeted, evidence-based public health interventions.
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Affiliation(s)
- Sara C Auld
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - N Sarita Shah
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Neil A Martinson
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
- Center for TB Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neel R Gandhi
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
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Nathavitharana RR, Daru P, Barrera AE, Mostofa Kamal SM, Islam S, Ul-Alam M, Sultana R, Rahman M, Hossain MS, Lederer P, Hurwitz S, Chakraborty K, Kak N, Tierney DB, Nardell E. FAST implementation in Bangladesh: high frequency of unsuspected tuberculosis justifies challenges of scale-up. Int J Tuberc Lung Dis 2018; 21:1020-1025. [PMID: 28826452 DOI: 10.5588/ijtld.16.0794] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
SETTING National Institute of Diseases of the Chest and Hospital, Dhaka; Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders, Dhaka; and Chittagong Chest Disease Hospital, Chittagong, Bangladesh. OBJECTIVE To present operational data and discuss the challenges of implementing FAST (Find cases Actively, Separate safely and Treat effectively) as a tuberculosis (TB) transmission control strategy. DESIGN FAST was implemented sequentially at three hospitals. RESULTS Using Xpert® MTB/RIF, 733/6028 (12.2%, 95%CI 11.4-13.0) patients were diagnosed with unsuspected TB. Patients with a history of TB who were admitted with other lung diseases had more than twice the odds of being diagnosed with unsuspected TB as those with no history of TB (OR 2.6, 95%CI 2.2-3.0, P < 0.001). Unsuspected multidrug-resistant TB (MDR-TB) was diagnosed in 89/1415 patients (6.3%, 95%CI 5.1-7.7). Patients with unsuspected TB had nearly five times the odds of being diagnosed with MDR-TB than those admitted with a known TB diagnosis (OR 4.9, 95%CI 3.1-7.6, P < 0.001). Implementation challenges include staff shortages, diagnostic failure, supply-chain issues and reliance on external funding. CONCLUSION FAST implementation revealed a high frequency of unsuspected TB in hospitalized patients in Bangladesh. Patients with a previous history of TB have an increased risk of being diagnosed with unsuspected TB. Ensuring financial resources, stakeholder engagement and laboratory capacity are important for sustainability and scalability.
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Affiliation(s)
- R R Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - P Daru
- University Research Co., Washington DC
| | - A E Barrera
- Faculty of Nursing Science, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - S M Mostofa Kamal
- National Institute of Diseases of the Chest Hospital, Dhaka, Bangladesh
| | - S Islam
- National Institute of Diseases of the Chest Hospital, Dhaka, Bangladesh
| | - M Ul-Alam
- National Institute of Diseases of the Chest Hospital, Dhaka, Bangladesh
| | - R Sultana
- National Institute of Diseases of the Chest Hospital, Dhaka, Bangladesh
| | - M Rahman
- National Institute of Diseases of the Chest Hospital, Dhaka, Bangladesh
| | - Md S Hossain
- National Institute of Diseases of the Chest Hospital, Dhaka, Bangladesh
| | - P Lederer
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts
| | - S Hurwitz
- Division of Biostatistics, Brigham and Women's Hospital Center for Clinical Investigation, Boston, Massachusetts
| | | | - N Kak
- University Research Co., Washington DC
| | - D B Tierney
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - E Nardell
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Schmidt BM, Engel ME, Abdullahi L, Ehrlich R. Effectiveness of control measures to prevent occupational tuberculosis infection in health care workers: a systematic review. BMC Public Health 2018; 18:661. [PMID: 29801449 PMCID: PMC5970465 DOI: 10.1186/s12889-018-5518-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 12/12/2017] [Accepted: 04/26/2018] [Indexed: 12/11/2022] Open
Abstract
Background A number of guideline documents have been published over the past decades on preventing occupational transmission of tuberculosis (TB) infection in health care workers (HCWs). However, direct evidence for the effectiveness of these controls is limited particularly in low-and middle-income (LMIC) countries. Thus, we sought to evaluate whether recommended administrative, environmental and personal protective measures are effective in preventing tuberculin skin test conversion among HCWs, and whether there has been recent research appropriate to LMIC needs. Methods Using inclusion criteria that included tuberculin skin test (TST) conversion as the outcome and longitudinal study design, we searched a number of electronic databases, complemented by hand-searching of reference lists and contacting experts. Reviewers independently selected studies, extracted data and assessed study quality using recommended criteria and overall evidence quality using GRADE criteria. Results Ten before-after studies were found, including two from upper middle income countries. All reported a decline in TST conversion frequency after the intervention. Among five studies that provided rates, the size of the decline varied, ranging from 35 to 100%. Since all were observational studies assessed as having high or unclear risk of bias on at least some criteria, the overall quality of evidence was rated as low using GRADE criteria. Conclusion We found consistent but low quality of evidence for the effectiveness of combined control measures in reducing TB infection transmission in HCWs in both high-income and upper-middle income country settings. However, research is needed in low-income high TB burden, including non-hospital, settings, and on contextual factors determining implementation of recommended control measures. Explicit attention to the reporting of methodological quality is recommended. Trial registration This systematic review was registered with PROSPERO in 2014 and its registration number is CRD42014009087.
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Affiliation(s)
- Bey-Marrié Schmidt
- School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Falmouth Rd, Observatory, Cape Town, 7925, South Africa.
| | - Mark E Engel
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Leila Abdullahi
- Vaccines for Africa, Institute of Infectious Disease and Molecular Medicine & Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Rodney Ehrlich
- Centre for Environmental and Occupational Health Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Nathavitharana RR, Peters J, Lederer P, von Delft A, Farley JE, Pai M, Jaramillo E, Raviglione M, Nardell E. Engaging health-care workers to reduce tuberculosis transmission. Lancet Infect Dis 2018; 16:883-5. [PMID: 27477968 DOI: 10.1016/s1473-3099(16)30199-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 06/15/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Ruvandhi R Nathavitharana
- TB Proof, Cape Town, South Africa; Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Jurgens Peters
- TB Proof, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Philip Lederer
- TB Proof, Cape Town, South Africa; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA USA
| | - Arne von Delft
- TB Proof, Cape Town, South Africa; School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Jason E Farley
- School of Nursing and Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Madhukar Pai
- Department of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
| | - Ernesto Jaramillo
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Mario Raviglione
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Edward Nardell
- Division of Global Health Equity, Brigham and Women's' Hospital, Boston, MA, USA
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Abstract
Diagnostic and treatment delays contribute to increased death and disability among the 490,000 adults and children who develop multidrug-resistant (MDR) tuberculosis every year. Since the treatment of MDR tuberculosis is complex, costly and often toxic, tuberculosis control programs should prioritize strategies to prevent drug-resistant tuberculosis. Opportunities to limit transmission and prevent disease progression in close contacts of MDR tuberculosis cases are often neglected. Effective MDR tuberculosis preventive strategies could minimize the costs for patients and healthcare systems. This review characterizes the biological basis for the development of MDR tuberculosis, outlines the evidence for strategies to reduce transmission and highlights programmatic approaches to the management of patients infected with drug-resistant strains of Mycobacterium tuberculosis.
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Affiliation(s)
- Anthony L Byrne
- St Vincent's Hospital, Heart Lung Clinic, Sydney, Australia.,Western Sydney Local Health District, Lung & Sleep Centre, Blacktown Hospital, Sydney, Australia.,Socios En Salud Sucursal Partners In Health, Lima, Peru
| | - Greg J Fox
- Central Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Ben J Marais
- Marie Bashir Institute for Infectious Diseases & Biosecurity (MBI), University of Sydney, Sydney, Australia
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Kawkitinarong K, Suwanpimolkul G, Kateruttanakul P, Manosuthi W, Ubolyam S, Sophonphan J, Avihingsanon A, Ruxrungtham K. Real-Life Clinical Practice of Using the Xpert MTB/RIF Assay in Thailand. Clin Infect Dis 2018; 64:S171-S178. [PMID: 28475796 DOI: 10.1093/cid/cix151] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Delayed diagnosis of tuberculosis (TB) and drug-resistant TB are major challenges of TB control in Thailand. This study assessed the practicality of the Xpert MTB/RIF assay in a real-life setting with high prevalence of human immunodeficiency virus (HIV) infection and pulmonary tuberculosis (PTB). Methods This prospective study was conducted at 3 large tertiary care hospitals. Patients who had suspected PTB were enrolled into the study. Expectorated sputum samples were sent for staining, mycobacterial culture, and Xpert MTB/RIF. Results Four hundred ninety-four patients were enrolled. From 355 cases with final diagnosis of PTB, 263 (71.8%) had definite diagnosis and 92 cases had probable diagnosis. Among TB culture-positive cases, Xpert MTB/RIF had 100% and 81% sensitivity in sputum smear-positive and smear-negative groups, respectively. The specificity was 95.7%. The sensitivity and positive predictive value of Xpert MTB/RIF in culture-negative but clinically diagnosed PTB was 37.8% and 83.8%, respectively. Centrifugation was required in 59% cases with scanty sputum. Five cases were false-positive by Xpert MTB/RIF in patients with nontuberculous mycobacteria, old PTB scar, and immune reconstitution syndrome. Discordant rifampicin susceptibility results of Xpert MTB/RIF and mycobacteria growth indicator tube (MGIT) were confirmed by using rpoB gene sequencing, which raised the sensitivity of Xpert MTB/RIF in detecting rifampicin resistance to 93.8%. Conclusions Xpert MTB/RIF is an effective tool in diagnosing PTB but will be more cost-effective for sputum-negative patients and in settings with high prevalence of rifampicin resistance. Early diagnosis of TB results in early treatment and implementation of strategies to limit spreading of TB. Sputum centrifugation may increase the yield of Xpert MTB/RIF.
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Affiliation(s)
- Kamon Kawkitinarong
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, and
| | - Gompol Suwanpimolkul
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, and
| | | | - Weerawat Manosuthi
- Bamrasnaradura Infectious Diseases Institute, Ministry of Public Health, Nonthaburi; and
| | - Sasiwimol Ubolyam
- HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Jiratchaya Sophonphan
- HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Anchalee Avihingsanon
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, and.,HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Kiat Ruxrungtham
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, and.,HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Thai Red Cross AIDS Research Centre, Bangkok, Thailand
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Flick RJ, Munthali A, Simon K, Hosseinipour M, Kim MH, Mlauzi L, Kazembe PN, Ahmed S. Assessing infection control practices to protect health care workers and patients in Malawi from nosocomial transmission of Mycobacterium tuberculosis. PLoS One 2017; 12:e0189140. [PMID: 29211793 PMCID: PMC5718482 DOI: 10.1371/journal.pone.0189140] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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: 04/09/2017] [Accepted: 11/20/2017] [Indexed: 01/21/2023] Open
Abstract
Transmission of Mycobacterium tuberculosis (TB) in health settings threatens health care workers and people living with HIV in sub-Saharan Africa. Nosocomial transmission is reduced with implementation of infection control (IC) guidelines. The objective of this study is to describe implementation of TB IC measures in Malawi. We conducted a cross-sectional study utilizing anonymous health worker questionnaires, semi-structured interviews with facility managers, and direct observations at 17 facilities in central Malawi. Of 592 health care workers surveyed, 34% reported that all patients entering the facility were screened for cough and only 8% correctly named the four most common signs and symptoms of TB in adults. Of 33 managers interviewed, 7 (21%) and 1 (3%) provided the correct TB screening questions for use in adults and children, respectively. Of 592 health workers, only 2.4% had been screened for TB in the previous year. Most (90%) reported knowing their HIV status, 53% were tested at their facility of employment, and half reported they would feel comfortable receiving ART or TB treatment at their facility of employment. We conclude that screening is infrequently conducted and knowledge gaps may undercut its effectiveness. Further, health care workers do not routinely access TB and HIV diagnostic and treatment services at their facility of employment.
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Affiliation(s)
- Robert J. Flick
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- University of Colorado School of Medicine, Denver, United States of America
| | - Adamson Munthali
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
| | - Katherine Simon
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Baylor International Pediatric AIDS Initiative at Texas Children’s Hospital, Baylor College of Medicine, Houston, United States of America
| | - Mina Hosseinipour
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- University of North Carolina at Chapel Hill, Chapel Hill, United States of America
| | - Maria H. Kim
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Baylor International Pediatric AIDS Initiative at Texas Children’s Hospital, Baylor College of Medicine, Houston, United States of America
| | - Lameck Mlauzi
- Malawi Ministry of Health National Tuberculosis Control Programme, Lilongwe, Malawi
| | - Peter N. Kazembe
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Baylor International Pediatric AIDS Initiative at Texas Children’s Hospital, Baylor College of Medicine, Houston, United States of America
| | - Saeed Ahmed
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Baylor International Pediatric AIDS Initiative at Texas Children’s Hospital, Baylor College of Medicine, Houston, United States of America
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Abstract
To reduce the incidence of tuberculosis, it is insufficient to simply understand the dynamics of tuberculosis transmission. Rather, we must design and rigorously evaluate interventions to halt transmission, prioritizing those interventions most likely to achieve population-level impact. Synergy in reducing tuberculosis transmission may be attainable by combining interventions that shrink the reservoir of latent Mycobacterium tuberculosis infection (preventive therapy), shorten the time between disease onset and treatment initiation (case finding and diagnosis), and prevent transmission in key settings, such as the built environment (infection control). In evaluating efficacy and estimating population-level impact, cluster-randomized trials and mechanistic models play particularly prominent roles. Historical and contemporary evidence suggests that effective public health interventions can halt tuberculosis transmission, but an evidence-based approach based on knowledge of local epidemiology is necessary for success. We provide a roadmap for designing, evaluating, and modeling interventions to interrupt the process of transmission that fuels a diverse array of tuberculosis epidemics worldwide.
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Affiliation(s)
- David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Alison D Grant
- TB Centre.,Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - Keertan Dheda
- Division of Pulmonology, Department of Medicine, University of Cape Town, South Africa
| | - Edward Nardell
- Division of Global Health Equity, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, United Kingdom
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Abstract
Tuberculosis remains a global health problem with an enormous burden of disease, estimated at 10.4 million new cases in 2015. To stop the tuberculosis epidemic, it is critical that we interrupt tuberculosis transmission. Further, the interventions required to interrupt tuberculosis transmission must be targeted to high-risk groups and settings. A simple cascade for tuberculosis transmission has been proposed in which (1) a source case of tuberculosis (2) generates infectious particles (3) that survive in the air and (4) are inhaled by a susceptible individual (5) who may become infected and (6) then has the potential to develop tuberculosis. Interventions that target these events will interrupt tuberculosis transmission and accelerate the decline in tuberculosis incidence and mortality. The purpose of this article is to provide a high-level overview of what is known about tuberculosis transmission, using the tuberculosis transmission cascade as a framework, and to set the scene for the articles in this series, which address specific aspects of tuberculosis transmission.
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Affiliation(s)
- Gavin Churchyard
- Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa,
- Advancing Care & Treatment for TB/HIV, Johannesburg, South Africa, and
- South African Medical Research Council, Johannesburg, South Africa
| | - Peter Kim
- Division of AIDS, National Institutes of Health, Bethesda, Maryland, and
| | - N Sarita Shah
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, Georgia, and
| | - Roxana Rustomjee
- Division of AIDS, National Institutes of Health, Bethesda, Maryland, and
| | - Neel Gandhi
- Rollins School of Public Health, Emory University, Atlanta, Georgia, and
- Emory School of Medicine, Emory University, Atlanta, Georgia
| | - Barun Mathema
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York; and
| | - David Dowdy
- Johns Hopkins University, Baltimore, Maryland
| | - Anne Kasmar
- Bill and Melinda Gates Foundation, Seattle, Washington
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46
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van Cutsem G, Isaakidis P, Farley J, Nardell E, Volchenkov G, Cox H. Infection Control for Drug-Resistant Tuberculosis: Early Diagnosis and Treatment Is the Key. Clin Infect Dis 2017; 62 Suppl 3:S238-43. [PMID: 27118853 DOI: 10.1093/cid/ciw012] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Multidrug-resistant (MDR) tuberculosis, "Ebola with wings," is a significant threat to tuberculosis control efforts. Previous prevailing views that resistance was mainly acquired through poor treatment led to decades of focus on drug-sensitive rather than drug-resistant (DR) tuberculosis, driven by the World Health Organization's directly observed therapy, short course strategy. The paradigm has shifted toward recognition that most DR tuberculosis is transmitted and that there is a need for increased efforts to control DR tuberculosis. Yet most people with DR tuberculosis are untested and untreated, driving transmission in the community and in health systems in high-burden settings. The risk of nosocomial transmission is high for patients and staff alike. Lowering transmission risk for MDR tuberculosis requires a combination approach centered on rapid identification of active tuberculosis disease and tuberculosis drug resistance, followed by rapid initiation of appropriate treatment and adherence support, complemented by universal tuberculosis infection control measures in healthcare facilities. It also requires a second paradigm shift, from the classic infection control hierarchy to a novel, decentralized approach across the continuum from early diagnosis and treatment to community awareness and support. A massive scale-up of rapid diagnosis and treatment is necessary to control the MDR tuberculosis epidemic. This will not be possible without intense efforts toward the implementation of decentralized, ambulatory models of care. Increasing political will and resources need to be accompanied by a paradigm shift. Instead of focusing on diagnosed cases, recognition that transmission is driven largely by undiagnosed, untreated cases, both in the community and in healthcare settings, is necessary. This article discusses this comprehensive approach, strategies available, and associated challenges.
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Affiliation(s)
- Gilles van Cutsem
- Médecins Sans Frontières Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | | | - Jason Farley
- School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Ed Nardell
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts
| | - Grigory Volchenkov
- Department of Tuberculosis Control, Vladimir Oblast Tuberculosis Dispensary, Russian Federation
| | - Helen Cox
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa Division of Medical Microbiology and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
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47
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Shelby PW, Lia MP, Israel A. Collaborative public-private initiatives targeting multidrug-resistant tuberculosis (MDR-TB) supported by the Lilly MDR-TB Partnership: experiences in 2012-2016. J Healthc Leadersh 2017; 9:47-57. [PMID: 29355239 PMCID: PMC5774453 DOI: 10.2147/jhl.s130207] [Citation(s) in RCA: 5] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Since 2003, the Lilly Foundation has supported the noncommercial Lilly MDR-TB Partnership, which involves more than 45 local, national, global, and nongovernmental organizations and governments. The aim of the Lilly MDR-TB Partnership is to achieve significant global impact on multidrug-resistant tuberculosis (MDR-TB) by addressing a series of important local health care needs in highly affected countries: China, India, Russia, and South Africa. The main focus of activities during 2012–2016 was on community needs in primary care. Supported projects seek to make meaningful and measurable progress toward global and national TB objectives. The partnership programs share an overall conceptual approach known as “research, report, advocate”, based on the piloting of novel approaches on a small scale, with outcomes assessed at early stages. The results are analyzed and communicated to governments, health-policy experts, and local and national stakeholders, including those in other countries facing similar MDR-TB challenges. For successful, cost-effective initiatives, the analysis is used as support when advocating for the scaling up of initiatives to regional or national levels. This article discusses representative examples of projects supported by the Lilly MDR-TB Partnership in the time period 2012–2016. The examples illustrate the potential for globally informed, locally designed primary-care collaborations to strengthen health care systems and support TB policies and offer observations to inform future health care public–private partnerships.
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Affiliation(s)
| | | | - Amy Israel
- Lilly Global Health Programs, Geneva, Switzerland
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48
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Dheda K, Gumbo T, Maartens G, Dooley KE, McNerney R, Murray M, Furin J, Nardell EA, London L, Lessem E, Theron G, van Helden P, Niemann S, Merker M, Dowdy D, Van Rie A, Siu GKH, Pasipanodya JG, Rodrigues C, Clark TG, Sirgel FA, Esmail A, Lin HH, Atre SR, Schaaf HS, Chang KC, Lange C, Nahid P, Udwadia ZF, Horsburgh CR, Churchyard GJ, Menzies D, Hesseling AC, Nuermberger E, McIlleron H, Fennelly KP, Goemaere E, Jaramillo E, Low M, Jara CM, Padayatchi N, Warren RM. The epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant, extensively drug-resistant, and incurable tuberculosis. Lancet Respir Med 2017; 5:S2213-2600(17)30079-6. [PMID: 28344011 DOI: 10.1016/s2213-2600(17)30079-6] [Citation(s) in RCA: 376] [Impact Index Per Article: 53.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/24/2016] [Accepted: 12/08/2016] [Indexed: 12/25/2022]
Abstract
Global tuberculosis incidence has declined marginally over the past decade, and tuberculosis remains out of control in several parts of the world including Africa and Asia. Although tuberculosis control has been effective in some regions of the world, these gains are threatened by the increasing burden of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis. XDR tuberculosis has evolved in several tuberculosis-endemic countries to drug-incurable or programmatically incurable tuberculosis (totally drug-resistant tuberculosis). This poses several challenges similar to those encountered in the pre-chemotherapy era, including the inability to cure tuberculosis, high mortality, and the need for alternative methods to prevent disease transmission. This phenomenon mirrors the worldwide increase in antimicrobial resistance and the emergence of other MDR pathogens, such as malaria, HIV, and Gram-negative bacteria. MDR and XDR tuberculosis are associated with high morbidity and substantial mortality, are a threat to health-care workers, prohibitively expensive to treat, and are therefore a serious public health problem. In this Commission, we examine several aspects of drug-resistant tuberculosis. The traditional view that acquired resistance to antituberculous drugs is driven by poor compliance and programmatic failure is now being questioned, and several lines of evidence suggest that alternative mechanisms-including pharmacokinetic variability, induction of efflux pumps that transport the drug out of cells, and suboptimal drug penetration into tuberculosis lesions-are likely crucial to the pathogenesis of drug-resistant tuberculosis. These factors have implications for the design of new interventions, drug delivery and dosing mechanisms, and public health policy. We discuss epidemiology and transmission dynamics, including new insights into the fundamental biology of transmission, and we review the utility of newer diagnostic tools, including molecular tests and next-generation whole-genome sequencing, and their potential for clinical effectiveness. Relevant research priorities are highlighted, including optimal medical and surgical management, the role of newer and repurposed drugs (including bedaquiline, delamanid, and linezolid), pharmacokinetic and pharmacodynamic considerations, preventive strategies (such as prophylaxis in MDR and XDR contacts), palliative and patient-orientated care aspects, and medicolegal and ethical issues.
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Affiliation(s)
- Keertan Dheda
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa.
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly E Dooley
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ruth McNerney
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Megan Murray
- Department of Global Health and Social Medicine, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Edward A Nardell
- TH Chan School of Public Health, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Leslie London
- School of Public Health and Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Grant Theron
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Paul van Helden
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Stefan Niemann
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Schleswig-Holstein, Germany; German Centre for Infection Research (DZIF), Partner Site Borstel, Borstel, Schleswig-Holstein, Germany
| | - Matthias Merker
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Schleswig-Holstein, Germany
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Annelies Van Rie
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; International Health Unit, Epidemiology and Social Medicine, Faculty of Medicine, University of Antwerp, Antwerp, Belgium
| | - Gilman K H Siu
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR, China
| | - Jotam G Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Camilla Rodrigues
- Department of Microbiology, P.D. Hinduja National Hospital & Medical Research Centre, Mumbai, India
| | - Taane G Clark
- Faculty of Infectious and Tropical Diseases and Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Frik A Sirgel
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Aliasgar Esmail
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Hsien-Ho Lin
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Sachin R Atre
- Center for Clinical Global Health Education (CCGHE), Johns Hopkins University, Baltimore, MD, USA; Medical College, Hospital and Research Centre, Pimpri, Pune, India
| | - H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kwok Chiu Chang
- Tuberculosis and Chest Service, Centre for Health Protection, Department of Health, Hong Kong SAR, China
| | - Christoph Lange
- Division of Clinical Infectious Diseases, German Center for Infection Research, Research Center Borstel, Borstel, Schleswig-Holstein, Germany; International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany; Department of Medicine, Karolinska Institute, Stockholm, Sweden; Department of Medicine, University of Namibia School of Medicine, Windhoek, Namibia
| | - Payam Nahid
- Division of Pulmonary and Critical Care, San Francisco General Hospital, University of California, San Francisco, CA, USA
| | - Zarir F Udwadia
- Pulmonary Department, Hinduja Hospital & Research Center, Mumbai, India
| | | | - Gavin J Churchyard
- Aurum Institute, Johannesburg, South Africa; School of Public Health, University of Witwatersrand, Johannesburg, South Africa; Advancing Treatment and Care for TB/HIV, South African Medical Research Council, Johannesburg, South Africa
| | - Dick Menzies
- Montreal Chest Institute, McGill University, Montreal, QC, Canada
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Eric Nuermberger
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kevin P Fennelly
- Pulmonary Clinical Medicine Section, Division of Intramural Research, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Eric Goemaere
- MSF South Africa, Cape Town, South Africa; School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Marcus Low
- Treatment Action Campaign, Johannesburg, South Africa
| | | | - Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), MRC HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Robin M Warren
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
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49
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Nathavitharana RR, Bond P, Dramowski A, Kotze K, Lederer P, Oxley I, Peters JA, Rossouw C, van der Westhuizen HM, Willems B, Ting TX, von Delft A, von Delft D, Duarte R, Nardell E, Zumla A. Agents of change: The role of healthcare workers in the prevention of nosocomial and occupational tuberculosis. Presse Med 2017; 46:e53-e62. [PMID: 28256382 DOI: 10.1016/j.lpm.2017.01.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/04/2017] [Accepted: 01/17/2017] [Indexed: 11/29/2022] Open
Abstract
Healthcare workers (HCWs) play a central role in global tuberculosis (TB) elimination efforts but their contributions are undermined by occupational TB. HCWs have higher rates of latent and active TB than the general population due to persistent occupational TB exposure, particularly in settings where there is a high prevalence of undiagnosed TB in healthcare facilities and TB infection control (TB-IC) programmes are absent or poorly implemented. Occupational health programmes in high TB burden settings are often weak or non-existent and thus data that record the extent of the increased risk of occupational TB globally are scarce. HCWs represent a limited resource in high TB burden settings and occupational TB can lead to workforce attrition. Stigma plays a role in delayed diagnosis, poor treatment outcomes and impaired well-being in HCWs who develop TB. Ensuring the prioritization and implementation of TB-IC interventions and occupational health programmes, which include robust monitoring and evaluation, is critical to reduce nosocomial TB transmission to patients and HCWs. The provision of preventive therapy for HCWs with latent TB infection (LTBI) can also prevent progression to active TB. Unlike other patient groups, HCWs are in a unique position to serve as agents of change to raise awareness, advocate for necessary resource allocation and implement TB-IC interventions, with appropriate support from dedicated TB-IC officers at the facility and national TB programme level. Students and community health workers (CHWs) must be engaged and involved in these efforts. Nosocomial TB transmission is an urgent public health problem and adopting rights-based approaches can be helpful. However, these efforts cannot succeed without increased political will, supportive legal frameworks and financial investments to support HCWs in efforts to decrease TB transmission.
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Affiliation(s)
- Ruvandhi R Nathavitharana
- TB Proof, Cape Town, South Africa; Beth Israel Deaconess Medical Center, Division of Infectious Diseases, Boston, MA 02215, USA.
| | | | - Angela Dramowski
- TB Proof, Cape Town, South Africa; Paediatric Infectious Diseases, Stellenbosch University, Department of Paediatrics and Child Health, Cape Town, South Africa
| | - Koot Kotze
- TB Proof, Cape Town, South Africa; East London Hospital Complex, East London, South Africa
| | - Philip Lederer
- TB Proof, Cape Town, South Africa; Massachusetts General Hospital, Division of Infectious Diseases, , Boston, MA 02215, USA
| | - Ingrid Oxley
- Nelson Mandela Metropolitan University, Dietetics Division, , Port Elizabeth, South Africa
| | - Jurgens A Peters
- TB Proof, Cape Town, South Africa; London School of Hygiene and Tropical Medicine, Faculty of Infectious and Tropical Diseases, Clinical Research Department, London, UK
| | | | | | - Bart Willems
- TB Proof, Cape Town, South Africa; Stellenbosch University, Division of Community Health, Faculty of Medicine and Health Sciences, , Cape Town, South Africa
| | - Tiong Xun Ting
- TB Proof, Cape Town, South Africa; Clinical Research Center, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Arne von Delft
- TB Proof, Cape Town, South Africa; School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, 7925 Observatory, South Africa
| | | | - Raquel Duarte
- Institute of Public Health, Porto University, EpiUnit, Portugal; Centro Hospitalar de Vila Nova de Gaia, Vila Nova de Gaia, Portugal
| | - Edward Nardell
- Brigham and Women's Hospital, Division of Global Health and Social Medicine, 02115 Boston, MA, USA
| | - Alimuddin Zumla
- TB Proof, Cape Town, South Africa; University College London, and NIHR Biomedical Research Centre, University College London Hospital, Division of Infection and Immunity, London, UK
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50
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Shah NS, Auld SC, Brust JCM, Mathema B, Ismail N, Moodley P, Mlisana K, Allana S, Campbell A, Mthiyane T, Morris N, Mpangase P, van der Meulen H, Omar SV, Brown TS, Narechania A, Shaskina E, Kapwata T, Kreiswirth B, Gandhi NR. Transmission of Extensively Drug-Resistant Tuberculosis in South Africa. N Engl J Med 2017; 376:243-253. [PMID: 28099825 PMCID: PMC5330208 DOI: 10.1056/nejmoa1604544] [Citation(s) in RCA: 185] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Drug-resistant tuberculosis threatens recent gains in the treatment of tuberculosis and human immunodeficiency virus (HIV) infection worldwide. A widespread epidemic of extensively drug-resistant (XDR) tuberculosis is occurring in South Africa, where cases have increased substantially since 2002. The factors driving this rapid increase have not been fully elucidated, but such knowledge is needed to guide public health interventions. METHODS We conducted a prospective study involving 404 participants in KwaZulu-Natal Province, South Africa, with a diagnosis of XDR tuberculosis between 2011 and 2014. Interviews and medical-record reviews were used to elicit information on the participants' history of tuberculosis and HIV infection, hospitalizations, and social networks. Mycobacterium tuberculosis isolates underwent insertion sequence (IS)6110 restriction-fragment-length polymorphism analysis, targeted gene sequencing, and whole-genome sequencing. We used clinical and genotypic case definitions to calculate the proportion of cases of XDR tuberculosis that were due to inadequate treatment of multidrug-resistant (MDR) tuberculosis (i.e., acquired resistance) versus those that were due to transmission (i.e., transmitted resistance). We used social-network analysis to identify community and hospital locations of transmission. RESULTS Of the 404 participants, 311 (77%) had HIV infection; the median CD4+ count was 340 cells per cubic millimeter (interquartile range, 117 to 431). A total of 280 participants (69%) had never received treatment for MDR tuberculosis. Genotypic analysis in 386 participants revealed that 323 (84%) belonged to 1 of 31 clusters. Clusters ranged from 2 to 14 participants, except for 1 large cluster of 212 participants (55%) with a LAM4/KZN strain. Person-to-person or hospital-based epidemiologic links were identified in 123 of 404 participants (30%). CONCLUSIONS The majority of cases of XDR tuberculosis in KwaZulu-Natal, South Africa, an area with a high tuberculosis burden, were probably due to transmission rather than to inadequate treatment of MDR tuberculosis. These data suggest that control of the epidemic of drug-resistant tuberculosis requires an increased focus on interrupting transmission. (Funded by the National Institute of Allergy and Infectious Diseases and others.).
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Affiliation(s)
- N Sarita Shah
- From the Emory University Rollins School of Public Health and School of Medicine (N.S.S., S.C.A., S.A., A.C., N.R.G.) and the Centers for Disease Control and Prevention (N.S.S.) - both in Atlanta; Albert Einstein College of Medicine and Montefiore Medical Center (N.S.S., J.C.M.B., N.R.G.), Columbia University Mailman School of Public Health (B.M., T.S.B.), and the American Museum of Natural History (A.N.) - all in New York; the National Institute for Communicable Diseases, Johannesburg (N.I., H.M., S.V.O.), University of KwaZulu-Natal and National Health Laboratory Service, Durban (P. Moodley, K.M., T.M., P. Mpangase), and the South African Medical Research Council, Cape Town (N.M., T.K.) - all in South Africa; and the Public Health Research Institute, New Jersey Medical School-Rutgers University, Newark (E.S., B.K.)
| | - Sara C Auld
- From the Emory University Rollins School of Public Health and School of Medicine (N.S.S., S.C.A., S.A., A.C., N.R.G.) and the Centers for Disease Control and Prevention (N.S.S.) - both in Atlanta; Albert Einstein College of Medicine and Montefiore Medical Center (N.S.S., J.C.M.B., N.R.G.), Columbia University Mailman School of Public Health (B.M., T.S.B.), and the American Museum of Natural History (A.N.) - all in New York; the National Institute for Communicable Diseases, Johannesburg (N.I., H.M., S.V.O.), University of KwaZulu-Natal and National Health Laboratory Service, Durban (P. Moodley, K.M., T.M., P. Mpangase), and the South African Medical Research Council, Cape Town (N.M., T.K.) - all in South Africa; and the Public Health Research Institute, New Jersey Medical School-Rutgers University, Newark (E.S., B.K.)
| | - James C M Brust
- From the Emory University Rollins School of Public Health and School of Medicine (N.S.S., S.C.A., S.A., A.C., N.R.G.) and the Centers for Disease Control and Prevention (N.S.S.) - both in Atlanta; Albert Einstein College of Medicine and Montefiore Medical Center (N.S.S., J.C.M.B., N.R.G.), Columbia University Mailman School of Public Health (B.M., T.S.B.), and the American Museum of Natural History (A.N.) - all in New York; the National Institute for Communicable Diseases, Johannesburg (N.I., H.M., S.V.O.), University of KwaZulu-Natal and National Health Laboratory Service, Durban (P. Moodley, K.M., T.M., P. Mpangase), and the South African Medical Research Council, Cape Town (N.M., T.K.) - all in South Africa; and the Public Health Research Institute, New Jersey Medical School-Rutgers University, Newark (E.S., B.K.)
| | - Barun Mathema
- From the Emory University Rollins School of Public Health and School of Medicine (N.S.S., S.C.A., S.A., A.C., N.R.G.) and the Centers for Disease Control and Prevention (N.S.S.) - both in Atlanta; Albert Einstein College of Medicine and Montefiore Medical Center (N.S.S., J.C.M.B., N.R.G.), Columbia University Mailman School of Public Health (B.M., T.S.B.), and the American Museum of Natural History (A.N.) - all in New York; the National Institute for Communicable Diseases, Johannesburg (N.I., H.M., S.V.O.), University of KwaZulu-Natal and National Health Laboratory Service, Durban (P. Moodley, K.M., T.M., P. Mpangase), and the South African Medical Research Council, Cape Town (N.M., T.K.) - all in South Africa; and the Public Health Research Institute, New Jersey Medical School-Rutgers University, Newark (E.S., B.K.)
| | - Nazir Ismail
- From the Emory University Rollins School of Public Health and School of Medicine (N.S.S., S.C.A., S.A., A.C., N.R.G.) and the Centers for Disease Control and Prevention (N.S.S.) - both in Atlanta; Albert Einstein College of Medicine and Montefiore Medical Center (N.S.S., J.C.M.B., N.R.G.), Columbia University Mailman School of Public Health (B.M., T.S.B.), and the American Museum of Natural History (A.N.) - all in New York; the National Institute for Communicable Diseases, Johannesburg (N.I., H.M., S.V.O.), University of KwaZulu-Natal and National Health Laboratory Service, Durban (P. Moodley, K.M., T.M., P. Mpangase), and the South African Medical Research Council, Cape Town (N.M., T.K.) - all in South Africa; and the Public Health Research Institute, New Jersey Medical School-Rutgers University, Newark (E.S., B.K.)
| | - Pravi Moodley
- From the Emory University Rollins School of Public Health and School of Medicine (N.S.S., S.C.A., S.A., A.C., N.R.G.) and the Centers for Disease Control and Prevention (N.S.S.) - both in Atlanta; Albert Einstein College of Medicine and Montefiore Medical Center (N.S.S., J.C.M.B., N.R.G.), Columbia University Mailman School of Public Health (B.M., T.S.B.), and the American Museum of Natural History (A.N.) - all in New York; the National Institute for Communicable Diseases, Johannesburg (N.I., H.M., S.V.O.), University of KwaZulu-Natal and National Health Laboratory Service, Durban (P. Moodley, K.M., T.M., P. Mpangase), and the South African Medical Research Council, Cape Town (N.M., T.K.) - all in South Africa; and the Public Health Research Institute, New Jersey Medical School-Rutgers University, Newark (E.S., B.K.)
| | - Koleka Mlisana
- From the Emory University Rollins School of Public Health and School of Medicine (N.S.S., S.C.A., S.A., A.C., N.R.G.) and the Centers for Disease Control and Prevention (N.S.S.) - both in Atlanta; Albert Einstein College of Medicine and Montefiore Medical Center (N.S.S., J.C.M.B., N.R.G.), Columbia University Mailman School of Public Health (B.M., T.S.B.), and the American Museum of Natural History (A.N.) - all in New York; the National Institute for Communicable Diseases, Johannesburg (N.I., H.M., S.V.O.), University of KwaZulu-Natal and National Health Laboratory Service, Durban (P. Moodley, K.M., T.M., P. Mpangase), and the South African Medical Research Council, Cape Town (N.M., T.K.) - all in South Africa; and the Public Health Research Institute, New Jersey Medical School-Rutgers University, Newark (E.S., B.K.)
| | - Salim Allana
- From the Emory University Rollins School of Public Health and School of Medicine (N.S.S., S.C.A., S.A., A.C., N.R.G.) and the Centers for Disease Control and Prevention (N.S.S.) - both in Atlanta; Albert Einstein College of Medicine and Montefiore Medical Center (N.S.S., J.C.M.B., N.R.G.), Columbia University Mailman School of Public Health (B.M., T.S.B.), and the American Museum of Natural History (A.N.) - all in New York; the National Institute for Communicable Diseases, Johannesburg (N.I., H.M., S.V.O.), University of KwaZulu-Natal and National Health Laboratory Service, Durban (P. Moodley, K.M., T.M., P. Mpangase), and the South African Medical Research Council, Cape Town (N.M., T.K.) - all in South Africa; and the Public Health Research Institute, New Jersey Medical School-Rutgers University, Newark (E.S., B.K.)
| | - Angela Campbell
- From the Emory University Rollins School of Public Health and School of Medicine (N.S.S., S.C.A., S.A., A.C., N.R.G.) and the Centers for Disease Control and Prevention (N.S.S.) - both in Atlanta; Albert Einstein College of Medicine and Montefiore Medical Center (N.S.S., J.C.M.B., N.R.G.), Columbia University Mailman School of Public Health (B.M., T.S.B.), and the American Museum of Natural History (A.N.) - all in New York; the National Institute for Communicable Diseases, Johannesburg (N.I., H.M., S.V.O.), University of KwaZulu-Natal and National Health Laboratory Service, Durban (P. Moodley, K.M., T.M., P. Mpangase), and the South African Medical Research Council, Cape Town (N.M., T.K.) - all in South Africa; and the Public Health Research Institute, New Jersey Medical School-Rutgers University, Newark (E.S., B.K.)
| | - Thuli Mthiyane
- From the Emory University Rollins School of Public Health and School of Medicine (N.S.S., S.C.A., S.A., A.C., N.R.G.) and the Centers for Disease Control and Prevention (N.S.S.) - both in Atlanta; Albert Einstein College of Medicine and Montefiore Medical Center (N.S.S., J.C.M.B., N.R.G.), Columbia University Mailman School of Public Health (B.M., T.S.B.), and the American Museum of Natural History (A.N.) - all in New York; the National Institute for Communicable Diseases, Johannesburg (N.I., H.M., S.V.O.), University of KwaZulu-Natal and National Health Laboratory Service, Durban (P. Moodley, K.M., T.M., P. Mpangase), and the South African Medical Research Council, Cape Town (N.M., T.K.) - all in South Africa; and the Public Health Research Institute, New Jersey Medical School-Rutgers University, Newark (E.S., B.K.)
| | - Natashia Morris
- From the Emory University Rollins School of Public Health and School of Medicine (N.S.S., S.C.A., S.A., A.C., N.R.G.) and the Centers for Disease Control and Prevention (N.S.S.) - both in Atlanta; Albert Einstein College of Medicine and Montefiore Medical Center (N.S.S., J.C.M.B., N.R.G.), Columbia University Mailman School of Public Health (B.M., T.S.B.), and the American Museum of Natural History (A.N.) - all in New York; the National Institute for Communicable Diseases, Johannesburg (N.I., H.M., S.V.O.), University of KwaZulu-Natal and National Health Laboratory Service, Durban (P. Moodley, K.M., T.M., P. Mpangase), and the South African Medical Research Council, Cape Town (N.M., T.K.) - all in South Africa; and the Public Health Research Institute, New Jersey Medical School-Rutgers University, Newark (E.S., B.K.)
| | - Primrose Mpangase
- From the Emory University Rollins School of Public Health and School of Medicine (N.S.S., S.C.A., S.A., A.C., N.R.G.) and the Centers for Disease Control and Prevention (N.S.S.) - both in Atlanta; Albert Einstein College of Medicine and Montefiore Medical Center (N.S.S., J.C.M.B., N.R.G.), Columbia University Mailman School of Public Health (B.M., T.S.B.), and the American Museum of Natural History (A.N.) - all in New York; the National Institute for Communicable Diseases, Johannesburg (N.I., H.M., S.V.O.), University of KwaZulu-Natal and National Health Laboratory Service, Durban (P. Moodley, K.M., T.M., P. Mpangase), and the South African Medical Research Council, Cape Town (N.M., T.K.) - all in South Africa; and the Public Health Research Institute, New Jersey Medical School-Rutgers University, Newark (E.S., B.K.)
| | - Hermina van der Meulen
- From the Emory University Rollins School of Public Health and School of Medicine (N.S.S., S.C.A., S.A., A.C., N.R.G.) and the Centers for Disease Control and Prevention (N.S.S.) - both in Atlanta; Albert Einstein College of Medicine and Montefiore Medical Center (N.S.S., J.C.M.B., N.R.G.), Columbia University Mailman School of Public Health (B.M., T.S.B.), and the American Museum of Natural History (A.N.) - all in New York; the National Institute for Communicable Diseases, Johannesburg (N.I., H.M., S.V.O.), University of KwaZulu-Natal and National Health Laboratory Service, Durban (P. Moodley, K.M., T.M., P. Mpangase), and the South African Medical Research Council, Cape Town (N.M., T.K.) - all in South Africa; and the Public Health Research Institute, New Jersey Medical School-Rutgers University, Newark (E.S., B.K.)
| | - Shaheed V Omar
- From the Emory University Rollins School of Public Health and School of Medicine (N.S.S., S.C.A., S.A., A.C., N.R.G.) and the Centers for Disease Control and Prevention (N.S.S.) - both in Atlanta; Albert Einstein College of Medicine and Montefiore Medical Center (N.S.S., J.C.M.B., N.R.G.), Columbia University Mailman School of Public Health (B.M., T.S.B.), and the American Museum of Natural History (A.N.) - all in New York; the National Institute for Communicable Diseases, Johannesburg (N.I., H.M., S.V.O.), University of KwaZulu-Natal and National Health Laboratory Service, Durban (P. Moodley, K.M., T.M., P. Mpangase), and the South African Medical Research Council, Cape Town (N.M., T.K.) - all in South Africa; and the Public Health Research Institute, New Jersey Medical School-Rutgers University, Newark (E.S., B.K.)
| | - Tyler S Brown
- From the Emory University Rollins School of Public Health and School of Medicine (N.S.S., S.C.A., S.A., A.C., N.R.G.) and the Centers for Disease Control and Prevention (N.S.S.) - both in Atlanta; Albert Einstein College of Medicine and Montefiore Medical Center (N.S.S., J.C.M.B., N.R.G.), Columbia University Mailman School of Public Health (B.M., T.S.B.), and the American Museum of Natural History (A.N.) - all in New York; the National Institute for Communicable Diseases, Johannesburg (N.I., H.M., S.V.O.), University of KwaZulu-Natal and National Health Laboratory Service, Durban (P. Moodley, K.M., T.M., P. Mpangase), and the South African Medical Research Council, Cape Town (N.M., T.K.) - all in South Africa; and the Public Health Research Institute, New Jersey Medical School-Rutgers University, Newark (E.S., B.K.)
| | - Apurva Narechania
- From the Emory University Rollins School of Public Health and School of Medicine (N.S.S., S.C.A., S.A., A.C., N.R.G.) and the Centers for Disease Control and Prevention (N.S.S.) - both in Atlanta; Albert Einstein College of Medicine and Montefiore Medical Center (N.S.S., J.C.M.B., N.R.G.), Columbia University Mailman School of Public Health (B.M., T.S.B.), and the American Museum of Natural History (A.N.) - all in New York; the National Institute for Communicable Diseases, Johannesburg (N.I., H.M., S.V.O.), University of KwaZulu-Natal and National Health Laboratory Service, Durban (P. Moodley, K.M., T.M., P. Mpangase), and the South African Medical Research Council, Cape Town (N.M., T.K.) - all in South Africa; and the Public Health Research Institute, New Jersey Medical School-Rutgers University, Newark (E.S., B.K.)
| | - Elena Shaskina
- From the Emory University Rollins School of Public Health and School of Medicine (N.S.S., S.C.A., S.A., A.C., N.R.G.) and the Centers for Disease Control and Prevention (N.S.S.) - both in Atlanta; Albert Einstein College of Medicine and Montefiore Medical Center (N.S.S., J.C.M.B., N.R.G.), Columbia University Mailman School of Public Health (B.M., T.S.B.), and the American Museum of Natural History (A.N.) - all in New York; the National Institute for Communicable Diseases, Johannesburg (N.I., H.M., S.V.O.), University of KwaZulu-Natal and National Health Laboratory Service, Durban (P. Moodley, K.M., T.M., P. Mpangase), and the South African Medical Research Council, Cape Town (N.M., T.K.) - all in South Africa; and the Public Health Research Institute, New Jersey Medical School-Rutgers University, Newark (E.S., B.K.)
| | - Thandi Kapwata
- From the Emory University Rollins School of Public Health and School of Medicine (N.S.S., S.C.A., S.A., A.C., N.R.G.) and the Centers for Disease Control and Prevention (N.S.S.) - both in Atlanta; Albert Einstein College of Medicine and Montefiore Medical Center (N.S.S., J.C.M.B., N.R.G.), Columbia University Mailman School of Public Health (B.M., T.S.B.), and the American Museum of Natural History (A.N.) - all in New York; the National Institute for Communicable Diseases, Johannesburg (N.I., H.M., S.V.O.), University of KwaZulu-Natal and National Health Laboratory Service, Durban (P. Moodley, K.M., T.M., P. Mpangase), and the South African Medical Research Council, Cape Town (N.M., T.K.) - all in South Africa; and the Public Health Research Institute, New Jersey Medical School-Rutgers University, Newark (E.S., B.K.)
| | - Barry Kreiswirth
- From the Emory University Rollins School of Public Health and School of Medicine (N.S.S., S.C.A., S.A., A.C., N.R.G.) and the Centers for Disease Control and Prevention (N.S.S.) - both in Atlanta; Albert Einstein College of Medicine and Montefiore Medical Center (N.S.S., J.C.M.B., N.R.G.), Columbia University Mailman School of Public Health (B.M., T.S.B.), and the American Museum of Natural History (A.N.) - all in New York; the National Institute for Communicable Diseases, Johannesburg (N.I., H.M., S.V.O.), University of KwaZulu-Natal and National Health Laboratory Service, Durban (P. Moodley, K.M., T.M., P. Mpangase), and the South African Medical Research Council, Cape Town (N.M., T.K.) - all in South Africa; and the Public Health Research Institute, New Jersey Medical School-Rutgers University, Newark (E.S., B.K.)
| | - Neel R Gandhi
- From the Emory University Rollins School of Public Health and School of Medicine (N.S.S., S.C.A., S.A., A.C., N.R.G.) and the Centers for Disease Control and Prevention (N.S.S.) - both in Atlanta; Albert Einstein College of Medicine and Montefiore Medical Center (N.S.S., J.C.M.B., N.R.G.), Columbia University Mailman School of Public Health (B.M., T.S.B.), and the American Museum of Natural History (A.N.) - all in New York; the National Institute for Communicable Diseases, Johannesburg (N.I., H.M., S.V.O.), University of KwaZulu-Natal and National Health Laboratory Service, Durban (P. Moodley, K.M., T.M., P. Mpangase), and the South African Medical Research Council, Cape Town (N.M., T.K.) - all in South Africa; and the Public Health Research Institute, New Jersey Medical School-Rutgers University, Newark (E.S., B.K.)
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