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Gutierrez J, Nsereko M, Malone LL, Mayanja-Kizza H, Kisingo H, Boom WH, Bark CM, Stein CM. Capturing Recent Mycobacterium tuberculosis Infection by Tuberculin Skin Test vs. Interferon-Gamma Release Assay. Trop Med Infect Dis 2024; 9:81. [PMID: 38668542 PMCID: PMC11053984 DOI: 10.3390/tropicalmed9040081] [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: 02/28/2024] [Revised: 03/27/2024] [Accepted: 04/09/2024] [Indexed: 04/29/2024] Open
Abstract
Reductions in tuberculosis (TB) incidence require identification of individuals at high risk of developing active disease, such as those with recent Mycobacterium tuberculosis (Mtb) infection. Using a prospective household contact (HHC) study in Kampala, Uganda, we diagnosed new Mtb infection using both the tuberculin skin test (TST) and interferon-gamma release assay (IGRA). Our study aimed to determine if the TST adds additional value to the characterization of IGRA converters. We identified 13 HHCs who only converted the IGRA (QFT-only converters), 39 HHCs who only converted their TST (TST-only converters), and 24 HHCs who converted both tests (QFT/TST converters). Univariate analysis revealed that TST-only converters were older. Additionally, increased odds of TST-only conversion were associated with older age (p = 0.02) and crowdedness (p = 0.025). QFT/TST converters had higher QFT quantitative values at conversion than QFT-only converters and a bigger change in TST quantitative values at conversion than TST-only converters. Collectively, these data indicate that TST conversion alone likely overestimates Mtb infection. Its correlation to older age suggests an "environmental" boosting response due to prolonged exposure to environmental mycobacteria. This result also suggests that QFT/TST conversion may be associated with a more robust immune response, which should be considered when planning vaccine studies.
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Affiliation(s)
- Jesús Gutierrez
- Department of Population and Quantitative Health Science, Case Western Reserve University, Cleveland, OH 44106, USA;
| | - Mary Nsereko
- Uganda-CWRU Research Collaboration and Department of Medicine, School of Medicine, Makerere University, Kampala 7062, Uganda; (M.N.); (H.M.-K.); (H.K.)
| | - LaShaunda L. Malone
- Department of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA (W.H.B.)
| | - Harriet Mayanja-Kizza
- Uganda-CWRU Research Collaboration and Department of Medicine, School of Medicine, Makerere University, Kampala 7062, Uganda; (M.N.); (H.M.-K.); (H.K.)
| | - Hussein Kisingo
- Uganda-CWRU Research Collaboration and Department of Medicine, School of Medicine, Makerere University, Kampala 7062, Uganda; (M.N.); (H.M.-K.); (H.K.)
| | - W. Henry Boom
- Department of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA (W.H.B.)
| | - Charles M. Bark
- Division of Infectious Diseases, MetroHealth Medical Center, Cleveland, OH 44109, USA;
| | - Catherine M. Stein
- Department of Population and Quantitative Health Science, Case Western Reserve University, Cleveland, OH 44106, USA;
- Department of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA (W.H.B.)
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Stein CM, Nsereko M, Malone LL, Okware B, Kisingo H, Nalukwago S, Chervenak K, Mayanja-Kizza H, Hawn TR, Boom WH. Long-term Stability of Resistance to Latent Mycobacterium tuberculosis Infection in Highly Exposed Tuberculosis Household Contacts in Kampala, Uganda. Clin Infect Dis 2019; 68:1705-1712. [PMID: 30165605 PMCID: PMC6495009 DOI: 10.1093/cid/ciy751] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [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: 05/11/2018] [Accepted: 08/24/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Resistance to latent Mycobacterium tuberculosis (M.tb) infection, identified by persistently negative tuberculin skin tests (TST) and interferon-gamma release assays (IGRA), after close contact with pulmonary tuberculosis (TB) patients has not been extensively characterized. Stability of this "resistance" beyond 2 years from exposure is unknown. METHODS 407 of 657 eligible human immunodeficiency virus (HIV)-negative adults from a TB household contact study with persistently negative TST (PTST-) or with stable latent M.tb infection (LTBI) were retraced 9.5 years (standard deviation = 3.2) later. Asymptomatic retraced contacts underwent 3 IGRAs and follow-up TST, and their M.tb infection status classified as definite/possible/probable. RESULTS Among PTST- with a definite classification, 82.7% were concordantly TST-/ quantiferon-TB Gold- (QFT-), and 16.3% converted to TST+/QFT+ LTBI. Among original LTBI contacts, 83.6% remained LTBI, and 3.9% reverted their TST and were QFT-. Although TST and QFT concordance was high (κ = 0.78), 1.0% of PTST and 12.5% of original LTBI contacts could not be classified due to discordant TST and QFT results. Epidemiological variables did not differ between retraced PTST- and LTBI contacts. CONCLUSION Resistance to LTBI, defined by repeatedly negative TST and IGRA, in adults who have had close contact with pulmonary TB patients living in TB-endemic areas, is a stable outcome of M.tb exposure. Repeated longitudinal measurements with 2 different immune assays and extended follow-up provide enhanced discriminatory power to identify this resister phenotype and avoid misclassification. Resisters may use immune mechanisms to control aerosolized M.tb that differ from those used by persons who develop "classic" LTBI.
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Affiliation(s)
- Catherine M Stein
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Tuberculosis Research Unit, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Mary Nsereko
- Uganda-CWRU Research Collaboration, Makerere University and Mulago Hospital, Kampala, Uganda
| | - LaShaunda L Malone
- Tuberculosis Research Unit, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Brenda Okware
- Uganda-CWRU Research Collaboration, Makerere University and Mulago Hospital, Kampala, Uganda
| | - Hussein Kisingo
- Uganda-CWRU Research Collaboration, Makerere University and Mulago Hospital, Kampala, Uganda
| | - Sophie Nalukwago
- Uganda-CWRU Research Collaboration, Makerere University and Mulago Hospital, Kampala, Uganda
| | - Keith Chervenak
- Tuberculosis Research Unit, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Harriet Mayanja-Kizza
- Department of Medicine, School of Medicine, Makerere University and Mulago Hospital, Kampala, Uganda
| | - Thomas R Hawn
- Department of Medicine, University of Washington, Seattle
| | - W Henry Boom
- Tuberculosis Research Unit, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Stein CM, Zalwango S, Malone LL, Thiel B, Mupere E, Nsereko M, Okware B, Kisingo H, Lancioni CL, Bark CM, Whalen CC, Joloba ML, Boom WH, Mayanja-Kizza H. Resistance and Susceptibility to Mycobacterium tuberculosis Infection and Disease in Tuberculosis Households in Kampala, Uganda. Am J Epidemiol 2018; 187:1477-1489. [PMID: 29304247 DOI: 10.1093/aje/kwx380] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 12/15/2017] [Indexed: 11/14/2022] Open
Abstract
Tuberculosis (TB), caused by Mycobacterium tuberculosis (Mtb), remains a major public health problem. Household contact studies identify children and adults along the spectrum from Mtb exposure to disease. In the Kawempe Community Health Study (conducted in Kampala, Uganda), 872 culture-confirmed pulmonary TB cases and their 2,585 contacts were enrolled during 2002-2012 and followed for up to 2 years each. Risk factors identified by time-to-event analysis for secondary TB differed among children, women, and men. Younger age (P = 0.0061), human immunodeficiency virus (HIV) (P = 0.0002), thinness (P = 0.01), absent bacille Calmette-Guérin vaccination (P = 0.002), and epidemiologic risk score (P < 0.0001) were risks for children. For women, risks were HIV (P < 0.0001), thinness (World Health Organization criteria; P < 0.0001), and epidemiologic risk score (P = 0.003). For men, HIV (P = 0.0007) and low body mass index (P = 0.008) resulted in faster progression to TB. Tuberculin skin testing (TST) identified contacts with Mtb infection and those with persistently negative TST. Risks for faster time to Mtb infection were identified, and included age (P = 0.0007), baseline TST induration (P < 0.0001), and epidemiologic risk score (P < 0.0001) only in children. Those with persistently negative TST comprised 10% of contacts but had no unique epidemiologic characteristics among adults. The burden of Mtb infection and disease is high in TB households, and risk factors for progression from exposure to infection and disease differ among children, women, and men.
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Affiliation(s)
- Catherine M Stein
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Center for Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Tuberculosis Research Unit, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | - LaShaunda L Malone
- Tuberculosis Research Unit, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Bonnie Thiel
- Tuberculosis Research Unit, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Ezekiel Mupere
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Departments of Pediatrics and Child Health, and Medicine, School of Medicine, Makerere University and Mulago Hospital, Kampala, Uganda
| | - Mary Nsereko
- Uganda-CWRU Research Collaboration, Kampala, Uganda
| | | | | | | | - Charles M Bark
- Tuberculosis Research Unit, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher C Whalen
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia
| | - Moses L Joloba
- School for Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - W Henry Boom
- Tuberculosis Research Unit, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Harriet Mayanja-Kizza
- Departments of Pediatrics and Child Health, and Medicine, School of Medicine, Makerere University and Mulago Hospital, Kampala, Uganda
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Fluegge K, Malone LL, Nsereko M, Okware B, Wejse C, Kisingo H, Mupere E, Boom WH, Stein CM. Impact of geographic distance on appraisal delay for active TB treatment seeking in Uganda: a network analysis of the Kawempe Community Health Cohort Study. BMC Public Health 2018; 18:798. [PMID: 29940918 PMCID: PMC6019214 DOI: 10.1186/s12889-018-5648-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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: 10/25/2017] [Accepted: 05/31/2018] [Indexed: 01/22/2023] Open
Abstract
Background Appraisal delay is the time a patient takes to consider a symptom as not only noticeable, but a sign of illness. The study’s objective was to determine the association between appraisal delay in seeking tuberculosis (TB) treatment and geographic distance measured by network travel (driving and pedestrian) time (in minutes) and distance (Euclidean and self-reported) (in kilometers) and to identify other risk factors from selected covariates and how they modify the core association between delay and distance. Methods This was part of a longitudinal cohort study known as the Kawempe Community Health Study based in Kampala, Uganda. The study enrolled households from April 2002 to July 2012. Multivariable interval regression with multiplicative heteroscedasticity was used to assess the impact of time and distance on delay. The delay interval outcome was defined using a comprehensive set of 28 possible self-reported symptoms. The main independent variables were network travel time (in minutes) and Euclidean distance (in kilometers). Other covariates were organized according to the Andersen utilization conceptual framework. Results A total of 838 patients with both distance and delay data were included in the network analysis. Bivariate analyses did not reveal a significant association of any distance metric with the delay outcome. However, adjusting for patient characteristics and cavitary disease status, the multivariable model indicated that each minute of driving time to the clinic significantly (p = 0.02) and positively predicted 0.25 days’ delay. At the median distance value of 47 min, this represented an additional delay of about 12 (95% CI: [3, 21]) days to the mean of 40 days (95% CI: [25, 56]). Increasing Euclidean distance significantly predicted (p = 0.02) reduced variance in the delay outcome, thereby increasing precision of the mean delay estimate. At the median Euclidean distance of 2.8 km, the variance in the delay was reduced by more than 25%. Conclusion Of the four geographic distance measures, network travel driving time was a better and more robust predictor of mean delay in this setting. Including network travel driving time with other risk factors may be important in identifying populations especially vulnerable to delay. Electronic supplementary material The online version of this article (10.1186/s12889-018-5648-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kyle Fluegge
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106, USA. .,Present address: Office of Strategic Data Use, New York City Department of Health and Mental Hygiene, 42-09 28th Street, Long Island City, NY, 11101-4132, USA. .,Present address: Institute of Health and Environmental Research, Cleveland, OH, 44118, USA.
| | - LaShaunda L Malone
- Tuberculosis Research Unit, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Mary Nsereko
- Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Brenda Okware
- Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Christian Wejse
- Department of Infectious Diseases, Institute for Clinical Medicine / Center for Global Health, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Hussein Kisingo
- Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Ezekiel Mupere
- Department of Pediatrics and Child Health College of Health Sciences, Makerere University, Kampala, Uganda
| | - W Henry Boom
- Tuberculosis Research Unit, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106, USA.,Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Catherine M Stein
- Case Western Reserve University Research Collaboration, Kampala, Uganda.,Department of Population and Quantitative Health Sciences and Tuberculosis Research Unit, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106, USA
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Jaganath D, Zalwango S, Okware B, Nsereko M, Kisingo H, Malone L, Lancioni C, Okwera A, Joloba M, Mayanja-Kizza H, Boom WH, Stein C, Mupere E. Contact investigation for active tuberculosis among child contacts in Uganda. Clin Infect Dis 2013; 57:1685-92. [PMID: 24077055 DOI: 10.1093/cid/cit645] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Tuberculosis is a large source of morbidity and mortality among children. However, limited studies characterize childhood tuberculosis disease, and contact investigation is rarely implemented in high-burden settings. In one of the largest pediatric tuberculosis contact investigation studies in a resource-limited setting, we assessed the yield of contact tracing on childhood tuberculosis and indicators for disease progression in Uganda. METHODS Child contacts aged <15 years in Kampala, Uganda, were enrolled from July 2002 to June 2009 and evaluated for tuberculosis disease via clinical, radiographic, and laboratory methods for up to 24 months. RESULTS Seven hundred sixty-one child contacts were included in the analysis. Prevalence of tuberculosis in our child population was 10%, of which 71% were culture-confirmed positive. There were no cases of disseminated tuberculosis, and 483 of 490 children (99%) started on isoniazid preventative therapy did not develop disease. Multivariable testing suggested risk factors including human immunodeficiency virus (HIV) status (odds ratio [OR], 7.90; P < .001), and baseline positive tuberculin skin test (OR, 2.21; P = .03); BCG vaccination was particularly protective, especially among children aged ≤5 years (OR, 0.23; P < .001). Adult index characteristics such as sex, HIV status, and extent or severity of disease were not associated with childhood disease. CONCLUSIONS Contact tracing for children in high-burden settings is able to identify a large percentage of culture-confirmed positive tuberculosis cases before dissemination of disease, while suggesting factors for disease progression to identify who may benefit from targeted screening.
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Affiliation(s)
- Devan Jaganath
- David Geffen School of Medicine at the University of California, Los Angeles
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