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Mariner-Llicer C, Saavedra Cervera B, Mambuque E, Gomes N, Munguambe S, Villamayor L, Cancino-Muñoz I, Torres-Puente M, Nguenha D, Respeito D, Tembe G, López MG, Comas I, García-Basteiro AL. Monitoring of First-line Drug Resistance Mutations Outside the Scope of Xpert MTB/RIF Ultra is Needed for Successful Control of DR-TB in Southern Mozambique. Clin Infect Dis 2024; 78:842-845. [PMID: 38048599 PMCID: PMC11006097 DOI: 10.1093/cid/ciad684] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Indexed: 12/06/2023] Open
Abstract
Multidrug-resistant(MDR) tuberculosis in Southern Africa is of great concern, exacerbated by the spread of a clone harboring a mutation missed by Xpert Ultra. In Southern Mozambique, the presence of such mutation and rising cases of non-MDR isoniazid resistance highlights the need to ensure accurate detection of antimicrobial-resistance in the country.
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Affiliation(s)
- Carla Mariner-Llicer
- Tuberculosis Genomics Unit, Instituto de Biomedicina de Valencia (IBV), CSIC, Valencia, Spain
| | - Belén Saavedra Cervera
- ISGlobal, Hospital Clínic – Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Edson Mambuque
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Neide Gomes
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Shilzia Munguambe
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | | | - Irving Cancino-Muñoz
- FISABIO Public Health, Valencia, Spain
- I2SysBio, Universitat de València CSIC, Valencia, Spain
| | - Manuela Torres-Puente
- Tuberculosis Genomics Unit, Instituto de Biomedicina de Valencia (IBV), CSIC, Valencia, Spain
| | - Dinis Nguenha
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- Amsterdam Institute for Global Health & Development (AIGHD), Amsterdam, The Netherlands
| | - Durval Respeito
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Gustavo Tembe
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Mariana G López
- Tuberculosis Genomics Unit, Instituto de Biomedicina de Valencia (IBV), CSIC, Valencia, Spain
| | - Iñaki Comas
- Tuberculosis Genomics Unit, Instituto de Biomedicina de Valencia (IBV), CSIC, Valencia, Spain
- CIBER in Epidemiology and Public Health, Madrid, Spain
| | - Alberto L García-Basteiro
- ISGlobal, Hospital Clínic – Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Barcelona, Spain
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2
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Saavedra B, Nguenha D, de la Torre-Pérez L, Mambuque E, Tembe G, Oliveras L, Rudd M, Philimone P, Jose B, Garcia JI, Gomes N, Munguambe S, Chiconela H, Nhanommbe M, Izco S, Acacio S, García-Basteiro AL. Improving tuberculosis case detection through contact risk stratification by Xpert MTB/RIF Ultra and spatial parameters: Evaluation of an innovative active case finding strategy in Mozambique (Xpatial-TB). PLOS Glob Public Health 2024; 4:e0002789. [PMID: 38335231 PMCID: PMC10857722 DOI: 10.1371/journal.pgph.0002789] [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] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/13/2023] [Indexed: 02/12/2024]
Abstract
Prompt diagnosis is critical for tuberculosis (TB) control, as it enables early treatment which in turn, reduces transmission and improves treatment outcomes. We investigated the impact on TB diagnosis of introducing Xpert Ultra as the frontline diagnostic test, combined with an innovative active-case finding (ACF) strategy (based on Xpert Ultra semi-quantitative results and spatial parameters), in a semi-rural district of Southern Mozambique. From January-December 2018 we recruited incident TB-cases (index cases, ICs) and their household contacts (HCs). Recruitment of close community contacts (CCs) depended on IC´s Xpert Ultra results, and the population density of their area. TB-contacts, either symptomatic or people living with HIV, were asked to provide a spot sputum for lab-testing. Trends on TB case notification were compared to the previous years and to those of two districts in the south of the Maputo province (control area), using an interrupted time series analysis with and without control (CITS/ITS). A total of 1010 TB ICs (37.1% laboratory-confirmed) were recruited; 3165 HCs and 4730 CCs were screened for TB. Eighty-nine additional TB cases were identified through the ACF intervention (52.8% laboratory-confirmed). The intervention increased by 8.2% all forms of TB cases detected in 2018. Xpert Ultra trace positive results accounted for a high proportion of laboratory confirmations in the ACF cohort (51.1% vs 13.7% of those passively diagnosed). The Number Needed to Screen to find a TB case differed widely among HCs (55) and CCs (153). During the intervention period, a reversal of the previous negative trend in lab-confirmed case notifications was observed in the district. However, the CITS model did not show any statistically significant difference compared to the control area. Paediatric population benefited the most from the ACF strategy and HCs screening seemed an effective intervention to find microbiological confirmed cases in early stages of the disease.
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Affiliation(s)
- Belén Saavedra
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- ISGlobal, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | - Dinis Nguenha
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Laura de la Torre-Pérez
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- ISGlobal, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | - Edson Mambuque
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Gustavo Tembe
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Laura Oliveras
- Agència de Salut Pública de Barcelona, Barcelona, Catalonia, Spain
- Institut d’Investigació Biomèdica Sant Pau (IIB Sant Pau) Barcelona, Catalonia, Spain
| | - Matthew Rudd
- Department of Mathematics and Computer Science, The University of the South, Sewanee, Tennessee, United States of America
| | - Paulo Philimone
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Benedita Jose
- National Tuberculosis Control Programme, Maputo, Mozambique
| | - Juan Ignacio Garcia
- Population Health Program Texas Biomedical Research Institute, San Antonio, Texas, United States of America
| | - Neide Gomes
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Shilzia Munguambe
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Helio Chiconela
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- National Tuberculosis Control Programme, Maputo, Mozambique
| | - Milton Nhanommbe
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Santiago Izco
- STD/HIV/Aids and Tuberculosis department, Ministry of Health and Social Welfare, Malabo, Equatorial Guinea
| | - Sozinho Acacio
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Alberto L. García-Basteiro
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- ISGlobal, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
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3
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Leukes VN, Hella J, Sabi I, Cossa M, Khosa C, Erkosar B, Mangu C, Siyame E, Mtafya B, Lwilla A, Viegas S, Madeira C, Machiana A, Ribeiro J, Garcia-Basteiro AL, Riess F, Elísio D, Sasamalo M, Mhalu G, Denkinger CM, Castro MDM, Bashir S, Schumacher SG, Tagliani E, Malhotra A, Dowdy D, Schacht C, Buech J, Nguenha D, Ntinginya N, Ruhwald M, Penn-Nicholson A, Kranzer K. Study protocol: a pragmatic, cluster-randomized controlled trial to evaluate the effect of implementation of the Truenat platform/MTB assays at primary health care clinics in Mozambique and Tanzania (TB-CAPT CORE). BMC Infect Dis 2024; 24:107. [PMID: 38243223 PMCID: PMC10797907 DOI: 10.1186/s12879-023-08876-8] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/05/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND In 2020, the WHO-approved Molbio Truenat platform and MTB assays to detect Mycobacterium tuberculosis complex (MTB) and resistance to rifampicin directly on sputum specimens. This primary health care center-based trial in Mozambique and Tanzania investigates the effect of Truenat platform/MTB assays (intervention arm) combined with rapid communication of results compared to standard of care on TB diagnosis and treatment initiation for microbiologically confirmed TB at 7 days from enrolment. METHODS The Tuberculosis Close the Gap, Increase Access, and Provide Adequate Therapy (TB-CAPT) CORE trial employs a pragmatic cluster randomized controlled design to evaluate the impact of a streamlined strategy for delivery of Truenat platform/MTB assays testing at primary health centers. Twenty-nine centers equipped with TB microscopy units were selected to participate in the trial. Among them, fifteen health centers were randomized to the intervention arm (which involves onsite molecular testing using Truenat platform/MTB assays, process process optimization to enable same-day TB diagnosis and treatment initiation, and feedback on Molbio platform performance) or the control arm (which follows routine care, including on-site sputum smear microscopy and the referral of sputum samples to off-site Xpert testing sites). The primary outcome of the study is the absolute number and proportion of participants with TB microbiological confirmation starting TB treatment within 7 days of their first visit. Secondary outcomes include time to bacteriological confirmation, health outcomes up to 60 days from first visit, as well as user preferences, direct cost, and productivity analyses. ETHICS AND DISSEMINATION TB-CAPT CORE trial has been approved by regulatory and ethical committees in Mozambique and Tanzania, as well as by each partner organization. Consent is informed and voluntary, and confidentiality of participants is maintained throughout. Study findings will be presented at scientific conferences and published in peer-reviewed international journals. TRIAL REGISTRATION US National Institutes of Health's ClinicalTrials.gov, NCT04568954. Registered 23 September 2020.
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Affiliation(s)
| | - J Hella
- Ifakara Health Institute, Dar Es Salaam, Tanzania
| | - I Sabi
- Mbeya Medical Research Centre, National Institute for Medical Research (NIMR), Mbeya, Tanzania
| | - M Cossa
- Centro de Investigação Em Saúde de Manhiça (CISM), Manhica, Mozambique
| | - C Khosa
- Instituto Nacional de Saúde (INS), Marracuene, Mozambique
| | | | - C Mangu
- Mbeya Medical Research Centre, National Institute for Medical Research (NIMR), Mbeya, Tanzania
| | - E Siyame
- Mbeya Medical Research Centre, National Institute for Medical Research (NIMR), Mbeya, Tanzania
| | - B Mtafya
- Mbeya Medical Research Centre, National Institute for Medical Research (NIMR), Mbeya, Tanzania
| | - A Lwilla
- Mbeya Medical Research Centre, National Institute for Medical Research (NIMR), Mbeya, Tanzania
| | - S Viegas
- Instituto Nacional de Saúde (INS), Marracuene, Mozambique
| | - C Madeira
- Instituto Nacional de Saúde (INS), Marracuene, Mozambique
| | - A Machiana
- Instituto Nacional de Saúde (INS), Marracuene, Mozambique
| | - J Ribeiro
- Instituto Nacional de Saúde (INS), Marracuene, Mozambique
| | - A L Garcia-Basteiro
- Centro de Investigação Em Saúde de Manhiça (CISM), Manhica, Mozambique
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - F Riess
- Division of Infectious Diseases and Tropical Medicine, Ludwig Maximilian University Hospital, Munich, Germany
| | - D Elísio
- Centro de Investigação Em Saúde de Manhiça (CISM), Manhica, Mozambique
| | - M Sasamalo
- Ifakara Health Institute, Dar Es Salaam, Tanzania
| | - G Mhalu
- Ifakara Health Institute, Dar Es Salaam, Tanzania
| | - C M Denkinger
- Division of Infectious Disease and Tropical Medicine and German Centre for Infection Research, Heidelberg University Hospital, Heidelberg, Germany
| | - M D M Castro
- Division of Infectious Disease and Tropical Medicine and German Centre for Infection Research, Heidelberg University Hospital, Heidelberg, Germany
| | - S Bashir
- Division of Infectious Disease and Tropical Medicine and German Centre for Infection Research, Heidelberg University Hospital, Heidelberg, Germany
| | | | - E Tagliani
- Emerging Bacterial Pathogens Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - A Malhotra
- Johns Hopkins University (JHU), Baltimore, MD, USA
| | - D Dowdy
- Johns Hopkins University (JHU), Baltimore, MD, USA
| | | | - J Buech
- LINQ Management, Berlin, Germany
| | - D Nguenha
- Centro de Investigação Em Saúde de Manhiça (CISM), Manhica, Mozambique
| | - N Ntinginya
- Mbeya Medical Research Centre, National Institute for Medical Research (NIMR), Mbeya, Tanzania
| | | | | | - K Kranzer
- Division of Infectious Diseases and Tropical Medicine, Ludwig Maximilian University Hospital, Munich, Germany.
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK.
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Cossa M, Nguenha D, Houana A, Ehrlich J, Acácio S, Garcia-Basteiro AL. The urgent need to improve on low implementation rates for TB preventive treatment for people living with HIV. Int J Tuberc Lung Dis 2024; 28:1-2. [PMID: 38178301 DOI: 10.5588/ijtld.23.0570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024] Open
Affiliation(s)
- M Cossa
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Moçambique
| | - D Nguenha
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Moçambique
| | - A Houana
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Moçambique
| | - J Ehrlich
- ISGlobal, Hospital Clínic, Universitat de Barcelona
| | - S Acácio
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Moçambique
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5
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Mambuque E, Saavedra B, Molina-Moya B, Nguenha D, García-García E, Blanco S, Gomes N, Ehrlich J, Bulo H, Munguambe S, Chiconela H, Acacio S, Domínguez J, García-Basteiro AL. Evaluation of Omnigene-Sputum for Preservation of Sputum Samples for Diagnosis of Mycobacterium tuberculosis. Trop Med Infect Dis 2023; 8:367. [PMID: 37505663 PMCID: PMC10386065 DOI: 10.3390/tropicalmed8070367] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/06/2023] [Accepted: 07/11/2023] [Indexed: 07/29/2023] Open
Abstract
In several low-income countries, the transport of sputa could take up to one week to reach the laboratories, resulting in increased contamination rates and a loss of growth. The aim of this study was to evaluate the effect of the OMNIgene-SPUTUM in preserving Mycobacterium tuberculosis on sputum samples simulating three hypothetical scenarios for conservation and/or decontamination: (1) sputum was mixed with OMN and conserved at room temperature for five days and then processed for culture (OMN); (2) sputum cultures followed the routine standing operating procedure at day 0 (STD); and (3) sputum samples were kept at room temperature for five days and mixed with the standard decontamination reagent (SDT5) and then processed for culture. The positivity rate based on smear microscopy was 36.4%, 29.1%, and 27.3% for STD, STD5, and OMN, respectively. The proportion of positive results by liquid culture (MGIT) was 39.1% (43/110) for STD, 26.4% (29/110) for STD5, and 20.0% for OMN (22/110). The overall concordance of liquid culture results was 51.8% (57/110): 37.3% (41/110) for negative results, 11.8% (13/110) for MTBC growth, and 2.7% (3/110) for contaminated results. The OMN arm showed better performance in solid culture than in liquid culture, with a notable reduction in contaminated results.
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Affiliation(s)
- Edson Mambuque
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo 1929, Mozambique
| | - Belén Saavedra
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo 1929, Mozambique
- ISGlobal, Hospital Clínic, Universitat de Barcelona, 08026 Barcelona, Spain
| | - Barbara Molina-Moya
- Institut d'Investigació Germans Trias i Pujol, Universitat Autònoma de Barcelona, 08916 Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), 08916 Badalona, Spain
| | - Dinis Nguenha
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo 1929, Mozambique
| | - Esther García-García
- Institut d'Investigació Germans Trias i Pujol, Universitat Autònoma de Barcelona, 08916 Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), 08916 Badalona, Spain
| | - Silvia Blanco
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo 1929, Mozambique
| | - Neide Gomes
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo 1929, Mozambique
| | - Joanna Ehrlich
- ISGlobal, Hospital Clínic, Universitat de Barcelona, 08026 Barcelona, Spain
| | - Helder Bulo
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo 1929, Mozambique
| | - Shilzia Munguambe
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo 1929, Mozambique
| | - Helio Chiconela
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo 1929, Mozambique
- National Tuberculosis Control Program (PNCT), Maputo 1929, Mozambique
| | - Sozinho Acacio
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo 1929, Mozambique
| | - José Domínguez
- Institut d'Investigació Germans Trias i Pujol, Universitat Autònoma de Barcelona, 08916 Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), 08916 Badalona, Spain
| | - Alberto L García-Basteiro
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo 1929, Mozambique
- ISGlobal, Hospital Clínic, Universitat de Barcelona, 08026 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), 08026 Barcelona, Spain
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6
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Montoya I de Manuel-Rimbau A, Nguenha D, Mambuque E, Ehrlich J, Munguambe S, Saavedra B, Matsena T, Chiconela H, Casellas A, López-Varela E, Acacio S, Garcia-Basteiro AL. Initiation and adherence to isoniazid preventive therapy in children under 5 years of age in Manhiça, Southern Mozambique. J Trop Pediatr 2022; 69:7010560. [PMID: 36718019 DOI: 10.1093/tropej/fmad009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The WHO recommends preventive treatment for all pediatric contacts of a confirmed TB case, but coverage remains low in many high TB burden countries. We aimed to assess the coverage and adherence of the isoniazid preventive therapy (IPT) program among children under 5 years of age with household exposure to an adult pulmonary TB case in a rural district of Southern Mozambique. The estimated IPT coverage was 11.7%. A longer distance to the health center and lower age of the children hindered IPT initiation. Among patients who started IPT, 12/18 (69.9%) were adherent to the 6-month treatment.
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Affiliation(s)
| | - Dinis Nguenha
- Centro de Investigação em Saude de Manhiça, Manhiça, Maputo, Mozambique.,Amsterdam Institute for Global Health and Development (AIGHD), Amsterdam, The Netherlands
| | - Edson Mambuque
- Centro de Investigação em Saude de Manhiça, Manhiça, Maputo, Mozambique
| | - Joanna Ehrlich
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Shilzia Munguambe
- Centro de Investigação em Saude de Manhiça, Manhiça, Maputo, Mozambique
| | - Belén Saavedra
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Centro de Investigação em Saude de Manhiça, Manhiça, Maputo, Mozambique
| | - Teodimiro Matsena
- Centro de Investigação em Saude de Manhiça, Manhiça, Maputo, Mozambique
| | - Hélio Chiconela
- Centro de Investigação em Saude de Manhiça, Manhiça, Maputo, Mozambique.,National Tuberculosis Control Programme, District of Manhiça, Mozambique
| | - Aina Casellas
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Elisa López-Varela
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Centro de Investigação em Saude de Manhiça, Manhiça, Maputo, Mozambique
| | - Sozinho Acacio
- Centro de Investigação em Saude de Manhiça, Manhiça, Maputo, Mozambique
| | - Alberto L Garcia-Basteiro
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Centro de Investigação em Saude de Manhiça, Manhiça, Maputo, Mozambique.,Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Barcelona, Spain
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7
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Nguenha D, Cossa M, Acácio S, Garcia-Basteiro AL. Scaling up shorter TB preventive treatment is long overdue. Int J Tuberc Lung Dis 2022; 26:699-701. [PMID: 35898136 DOI: 10.5588/ijtld.22.0284] [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] [Indexed: 11/10/2022] Open
Affiliation(s)
- D Nguenha
- Centro de Investigação em Saúde de Manhiça, Maputo, Moçambique
| | - M Cossa
- Centro de Investigação em Saúde de Manhiça, Maputo, Moçambique
| | - S Acácio
- Centro de Investigação em Saúde de Manhiça, Maputo, Moçambique
| | - A L Garcia-Basteiro
- Centro de Investigação em Saúde de Manhiça, Maputo, Moçambique;, ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain, >Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Barcelona, Spain
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8
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Nguenha D, Acacio S, Murias-Closas A, Ramanlal N, Saavedra B, Karajeanes E, Mudumane B, Mambuque E, Gomes N, Losada I, Oliveras L, Naueia E, Sterling TR, Amorim G, Moon TD, Menéndez C, Vaz P, López-Varela E, Garcia-Basteiro AL. Prevalence and clinical characteristics of pulmonary TB among pregnant and post-partum women. Int J Tuberc Lung Dis 2022; 26:641-649. [PMID: 35768920 DOI: 10.5588/ijtld.21.0567] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING: Antenatal care (ANC) and postpartum care (PPC) clinic in Manhiça District, Mozambique.OBJECTIVE: To estimate the prevalence of TB among pregnant and post-partum women and describe the clinical characteristics of the disease in a rural area of Southern Mozambique.METHODS: We conducted a cross-sectional TB prevalence study among pregnant and post-partum women recruited from September 2016 to March 2018 at the Manhiça Health Care Center (MHC). We recruited two independent cohorts of women consecutively presenting for routine pregnancy or post-partum follow-up visits.RESULTS: A total of 1,980 women from the ANC clinic and 1,010 from the PPC clinic were enrolled. We found a TB prevalence of 505/100,000 (95% CI: 242-926) among pregnant women and 297/100,000 (95% CI: 61-865) among post-partum women. Among HIV-positive pregnant women, TB prevalence was 1,626/100,000 (95% CI: 782-2,970) and among postpartum HIV-positive women, TB prevalence was 984/100,000 (95% CI: 203-2,848).CONCLUSIONS: The burden of TB was not higher in postpartum women than in pregnant women. Most TB cases were detected in HIV-positive women. TB screening and diagnostic testing among pregnant and postpartum women attending ANC and PPC clinics in Manhiça District is acceptable and feasible.
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Affiliation(s)
- D Nguenha
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - S Acacio
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - A Murias-Closas
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - N Ramanlal
- Fundação Ariel Glaser contra o SIDA Pediátrico, Maputo, Mozambique
| | - B Saavedra
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique, ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - E Karajeanes
- Fundação Ariel Glaser contra o SIDA Pediátrico, Maputo, Mozambique
| | - B Mudumane
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - E Mambuque
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - N Gomes
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - I Losada
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - L Oliveras
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain, Agència de Salut Pública de Barcelona, Barcelona, Spain, Institut d´Investigació Biomèdica Sant Pau, Barcelona, Spain
| | - E Naueia
- Fundação Ariel Glaser contra o SIDA Pediátrico, Maputo, Mozambique
| | - T R Sterling
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA, Vanderbilt Tuberculosis Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - G Amorim
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - T D Moon
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA, Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - C Menéndez
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique, ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - P Vaz
- Fundação Ariel Glaser contra o SIDA Pediátrico, Maputo, Mozambique
| | - E López-Varela
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique, ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - A L Garcia-Basteiro
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique, ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain, Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Barcelona, Spain
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9
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Churchyard G, Cárdenas V, Chihota V, Mngadi K, Sebe M, Brumskine W, Martinson N, Yimer G, Wang SH, Garcia-Basteiro AL, Nguenha D, Masilela L, Waggie Z, van den Hof S, Charalambous S, Cobelens F, Chaisson RE, Grant AD, Fielding KL. Annual Tuberculosis Preventive Therapy for Persons With HIV Infection : A Randomized Trial. Ann Intern Med 2021; 174:1367-1376. [PMID: 34424730 DOI: 10.7326/m20-7577] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Tuberculosis preventive therapy for persons with HIV infection is effective, but its durability is uncertain. OBJECTIVE To compare treatment completion rates of weekly isoniazid-rifapentine for 3 months versus daily isoniazid for 6 months as well as the effectiveness of the 3-month rifapentine-isoniazid regimen given annually for 2 years versus once. DESIGN Randomized trial. (ClinicalTrials.gov: NCT02980016). SETTING South Africa, Ethiopia, and Mozambique. PARTICIPANTS Persons with HIV infection who were receiving antiretroviral therapy, were aged 2 years or older, and did not have active tuberculosis. INTERVENTION Participants were randomly assigned to receive weekly rifapentine-isoniazid for 3 months, given either annually for 2 years or once, or daily isoniazid for 6 months. Participants were screened for tuberculosis symptoms at months 0 to 3 and 12 of each study year and at months 12 and 24 using chest radiography and sputum culture. MEASUREMENTS Treatment completion was assessed using pill counts. Tuberculosis incidence was measured over 24 months. RESULTS Between November 2016 and November 2017, 4027 participants were enrolled; 4014 were included in the analyses (median age, 41 years; 69.5% women; all using antiretroviral therapy). Treatment completion in the first year for the combined rifapentine-isoniazid groups (n = 3610) was 90.4% versus 50.5% for the isoniazid group (n = 404) (risk ratio, 1.78 [95% CI, 1.61 to 1.95]). Tuberculosis incidence among participants receiving the rifapentine-isoniazid regimen twice (n = 1808) or once (n = 1802) was similar (hazard ratio, 0.96 [CI, 0.61 to 1.50]). LIMITATION If rifapentine-isoniazid is effective in curing subclinical tuberculosis, then the intensive tuberculosis screening at month 12 may have reduced its effectiveness. CONCLUSION Treatment completion was higher with rifapentine-isoniazid for 3 months compared with isoniazid for 6 months. In settings with high tuberculosis transmission, a second round of preventive therapy did not provide additional benefit to persons receiving antiretroviral therapy. PRIMARY FUNDING SOURCE The U.S. Agency for International Development through the CHALLENGE TB grant to the KNCV Tuberculosis Foundation.
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Affiliation(s)
- Gavin Churchyard
- The Aurum Institute, Parktown, South Africa, Vanderbilt University, Nashville, Tennessee, and University of the Witwatersrand, Johannesburg, South Africa (G.C.)
| | - Vicky Cárdenas
- The Aurum Institute, Parktown, South Africa (V.C., K.M., M.S., W.B., L.M., Z.W.)
| | - Violet Chihota
- The Aurum Institute, Parktown, South Africa, and University of the Witwatersrand, Johannesburg, South Africa (V.C., S.C.)
| | - Kathy Mngadi
- The Aurum Institute, Parktown, South Africa (V.C., K.M., M.S., W.B., L.M., Z.W.)
| | - Modulakgotla Sebe
- The Aurum Institute, Parktown, South Africa (V.C., K.M., M.S., W.B., L.M., Z.W.)
| | - William Brumskine
- The Aurum Institute, Parktown, South Africa (V.C., K.M., M.S., W.B., L.M., Z.W.)
| | - Neil Martinson
- University of the Witwatersrand, Johannesburg, South Africa, and Amsterdam University Medical Centres, Amsterdam, the Netherlands (N.M.)
| | - Getnet Yimer
- The Ohio State University, Addis Ababa, Ethiopia (G.Y., S.W.)
| | - Shu-Hua Wang
- The Ohio State University, Addis Ababa, Ethiopia (G.Y., S.W.)
| | | | - Dinis Nguenha
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique (A.L.G., D.N.)
| | - LeeAnne Masilela
- The Aurum Institute, Parktown, South Africa (V.C., K.M., M.S., W.B., L.M., Z.W.)
| | - Zainab Waggie
- The Aurum Institute, Parktown, South Africa (V.C., K.M., M.S., W.B., L.M., Z.W.)
| | - Susan van den Hof
- KNCV Tuberculosis Foundation, Den Haag, the Netherlands, and National Institute for Public Health and the Environment, Bilthoven, the Netherlands (S.V.)
| | - Salome Charalambous
- The Aurum Institute, Parktown, South Africa, and University of the Witwatersrand, Johannesburg, South Africa (V.C., S.C.)
| | - Frank Cobelens
- Amsterdam University Medical Centres, Amsterdam, the Netherlands (F.C.)
| | | | - Alison D Grant
- London School of Hygiene & Tropical Medicine, London, United Kingdom, University of the Witwatersrand, Johannesburg, South Africa, and University of KwaZulu-Natal, Durban, South Africa (A.D.G.)
| | - Katherine L Fielding
- London School of Hygiene & Tropical Medicine, London, United Kingdom, and University of the Witwatersrand, Johannesburg, South Africa (K.L.F.)
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10
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Saavedra B, Mambuque E, Gomes N, Nguenha D, Mabunda R, Faife L, Langa R, Munguambe S, Manjate F, Cossa A, Scott L, García-Basteiro AL. Diagnostic performance of the Abbott RealTime MTB assay for tuberculosis diagnosis in people living with HIV. Sci Rep 2021; 11:19271. [PMID: 34588508 PMCID: PMC8481474 DOI: 10.1038/s41598-021-96922-3] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/02/2021] [Indexed: 11/09/2022] Open
Abstract
Strengthening tuberculosis diagnosis is an international priority and the advocacy for multi-disease testing devices raises the possibility of improving laboratory efficiency. However, the advantages of centralized platforms might not translate into real improvements under operational conditions. This study aimed to evaluate the field use of the Abbott RealTime MTB (RT-MTB) and Xpert MTB/RIF assays, in a large cohort of HIV-positive and TB presumptive cases in Southern Mozambique. Over a 6-month period, 255 HIV-positive TB presumptive cases were consecutively recruited in the high TB/HIV burden district of Manhiça. The diagnostic performance of both assays was evaluated against two different reference standards: a microbiological gold standard (MGS) and a composite reference standard (CRS). Results from the primary analysis (MGS) showed improved sensitivity (Se) and reduced specificity (Sp) for the Abbott RT-MTB assay compared to the Xpert MTB/RIF (RT-MTB Se: 0.92 (95% CI: 0.75;0.99) vs Xpert Se: 0.73 (95% CI: 0.52;0.88) p value = 0.06; RT-MTB Sp: 0.80 (0.72;0.86) vs Xpert Sp: 0.96 (0.92;0.99) p value < 0.001). The lower specificity may be due to cross-reactivity with non-tuberculous mycobacteria (NTMs), the detection of non-viable MTBC, or the identification of true TB cases missed by the gold standard.
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Affiliation(s)
- Belén Saavedra
- PhD Program in Medicine and Translational Research, Universitat de Barcelona, Barcelona, Spain.
- Centro de Investigação Em Saude de Manhiça (CISM), Maputo, Mozambique.
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.
| | - Edson Mambuque
- Centro de Investigação Em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Neide Gomes
- Centro de Investigação Em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Dinis Nguenha
- Centro de Investigação Em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Rita Mabunda
- Centro de Investigação Em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Luis Faife
- Manhiça Health Research Hospital, Ministry of Health, National Tuberculosis Control Program, Maputo, Mozambique
| | - Ruben Langa
- Manhiça Health Research Hospital, Ministry of Health, National Tuberculosis Control Program, Maputo, Mozambique
| | - Shilzia Munguambe
- Centro de Investigação Em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Filomena Manjate
- Centro de Investigação Em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Anelsio Cossa
- Centro de Investigação Em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Lesley Scott
- Department of Molecular Medicine and Haematology, School of Pathology, and iLEAD, Faculty of Health Sciences, Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa
| | - Alberto L García-Basteiro
- Centro de Investigação Em Saude de Manhiça (CISM), Maputo, Mozambique
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
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11
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Saavedra B, Mambuque E, Nguenha D, Gomes N, Munguane S, García JI, Izco S, Acacio S, Murias-Closas A, Cossa M, Losada I, Pernas H, Oliveras L, Theron G, García-Basteiro AL. Performance of Xpert MTB/RIF Ultra for tuberculosis diagnosis in the context of passive and active case finding. Eur Respir J 2021; 58:13993003.00257-2021. [PMID: 34140293 DOI: 10.1183/13993003.00257-2021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/11/2021] [Indexed: 11/05/2022]
Abstract
We present a field evaluation of the diagnostic accuracy of Xpert MTB/RIF (Xpert) and Xpert MTB/RIF Ultra (Ultra), using two cohorts in a high TB/HIV burden setting in Southern Mozambique. Single respiratory specimens from symptomatic adults accessing health care services (passive case finding (PCF) cohort), and from household and community close contacts (active case finding (ACF) cohort), were tested by smear microscopy, culture, Xpert and Ultra. Liquid and solid culture served as a composite reference standard. We explored trace results' impact on specificity via their recategorisation to negative (in all and just among those previously treated individuals) A total of 1419 and 252 participants were enrolled in the PCF and ACF cohorts, respectively. For the PCF cohort, Ultra showed higher sensitivity than Xpert overall (0.95 (95% CI: 0.90, 0.98) versus 0.88 (0.82, 0.93); p<0.001) and among smear negative patients (0.63 (0.48, 0.76) and 0.84 (0.71, 0.93). Ultra's specificity was lower than Xpert's (0.98 (0.97, 0.99) versus 0.96 (0.95, 0.97); p=0.008). For ACF, sensitivities were the same (0.67 (95% CI: 0.22,0.96) for both tests), although Ultra detected a higher number of microbiologically confirmed samples than Xpert (4.7% (12/252) versus 2.7% (7/252)). Conditional recategorisation of trace results among previously treated participants maintained differences in specificity in the PCF cohort. These results add evidence on the improved sensitivity of Ultra and support its use in different case finding scenarios.
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Affiliation(s)
- Belén Saavedra
- Universitat de Barcelona, Barcelona, Spain.,Centro de Investigação em Sade de Manhiça (CISM), Maputo, Mozambique.,ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Edson Mambuque
- Centro de Investigação em Sade de Manhiça (CISM), Maputo, Mozambique
| | - Dinis Nguenha
- Centro de Investigação em Sade de Manhiça (CISM), Maputo, Mozambique
| | - Neide Gomes
- Centro de Investigação em Sade de Manhiça (CISM), Maputo, Mozambique
| | - Shilzia Munguane
- Centro de Investigação em Sade de Manhiça (CISM), Maputo, Mozambique
| | - Juan Ignacio García
- TB Group, Population Health Programme, Texas Biomedical Research Institute, San Antonio, TX, USA
| | - Santiago Izco
- Centro de Investigação em Sade de Manhiça (CISM), Maputo, Mozambique.,ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Sozinho Acacio
- Centro de Investigação em Sade de Manhiça (CISM), Maputo, Mozambique
| | | | - Marta Cossa
- Centro de Investigação em Sade de Manhiça (CISM), Maputo, Mozambique
| | - Irene Losada
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Hadrián Pernas
- MD Internal Medicine - Infectious Diseases Complexo Hospitalario Universitario de Santiago
| | - Laura Oliveras
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.,Agència de Salut Pública de Barcelona, Barcelona, Catalonia, Spain.,Institut D'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Catalonia, Spain
| | - Grant Theron
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, and SAMRC Centre for Tuberculosis Research, Stellenbosch University, Tygerberg, Cape Town, South Africa
| | - Alberto L García-Basteiro
- Centro de Investigação em Sade de Manhiça (CISM), Maputo, Mozambique .,ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
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12
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García JI, Mambuque E, Nguenha D, Vilanculo F, Sacoor C, Sequera VG, Fernández-Quevedo M, Pierre MLL, Chiconela H, Faife LA, Respeito D, Saavedra B, Nhampossa T, López-Varela E, Garcia-Basteiro AL. Mortality and risk of tuberculosis among people living with HIV in whom TB was initially ruled out. Sci Rep 2020; 10:15442. [PMID: 32963296 PMCID: PMC7509810 DOI: 10.1038/s41598-020-71784-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 07/31/2020] [Indexed: 12/12/2022] Open
Abstract
Tuberculosis (TB) misdiagnosis remains a public health concern, especially among people living with HIV (PLHIV), given the high mortality associated with missed TB diagnoses. The main objective of this study was to describe the all-cause mortality, TB incidence rates and their associated risk factors in a cohort of PLHIV with presumptive TB in whom TB was initially ruled out. We retrospectively followed a cohort of PLHIV with presumptive TB over a 2 year-period in a rural district in Southern Mozambique. During the study period 382 PLHIV were followed-up. Mortality rate was 6.8/100 person-years (PYs) (95% CI 5.2-9.2) and TB incidence rate was 5.4/100 PYs (95% CI 3.9-7.5). Thirty-six percent of deaths and 43% of TB incident cases occurred in the first 12 months of the follow up. Mortality and TB incidence rates in the 2-year period after TB was initially ruled out was very high. The TB diagnostic work-up and linkage to HIV care should be strengthened to decrease TB burden and all-cause mortality among PLHIV with presumptive TB.
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Affiliation(s)
- Juan Ignacio García
- TB Group, Population Health Program, Texas Biomedical Research Institute, San Antonio, TX, USA
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Edson Mambuque
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Dinis Nguenha
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | | | - Charfudin Sacoor
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | | | | | | | - Helio Chiconela
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- Manhiça District Hospital, Ministry of Health, National Tuberculosis Control Program, Maputo, Mozambique
| | - Luis A Faife
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- Manhiça District Hospital, Ministry of Health, National Tuberculosis Control Program, Maputo, Mozambique
| | - Durval Respeito
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- Manhiça District Hospital, Ministry of Health, National Tuberculosis Control Program, Maputo, Mozambique
| | - Belén Saavedra
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Tacilta Nhampossa
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Mozambique
| | - Elisa López-Varela
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Desmond Tutu TB center, Stellenbosch University, Cape Town, South Africa
| | - Alberto L Garcia-Basteiro
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique.
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.
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13
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Nguenha D, Garcia JI, Cowan JF, Garcia-Basteiro AL. Spatial epidemiology for tuberculosis surveillance: a relevant add-on to routine surveillance. Int J Tuberc Lung Dis 2019; 23:278-279. [DOI: 10.5588/ijtld.19.0104] [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] [Indexed: 11/10/2022] Open
Affiliation(s)
- D. Nguenha
- Centro de Investigação em Saude de Manhiça, Vila da Manhiça, Maputo Province, Mozambique
| | - J. I. Garcia
- Centro de Investigação em Saude de Manhiça, Vila da Manhiça, Maputo Province, Mozambique, ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - J. F. Cowan
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - A. L. Garcia-Basteiro
- Centro de Investigação em Saude de Manhiça, Vila da Manhiça, Maputo Province, Mozambique, ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain, Amsterdam Institute for Global Health
and Development, Academic Medical Center, Amsterdam, The Netherlands
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