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Burke RM, Rickman HM, Pinto C, Ehrenkranz P, Choko A, Ford N. Reasons for disengagement from antiretroviral care in the era of "Treat All" in low- or middle-income countries: a systematic review. J Int AIDS Soc 2024; 27:e26230. [PMID: 38494657 PMCID: PMC10945039 DOI: 10.1002/jia2.26230] [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: 09/21/2023] [Accepted: 02/23/2024] [Indexed: 03/19/2024] Open
Abstract
INTRODUCTION Disengagement from antiretroviral therapy (ART) care is an important reason why people living with HIV do not achieve viral load suppression become unwell. METHODS We searched two databases and conference abstracts from January 2015 to December 2022 for studies which reported reasons for disengagement from ART care. We included quantitative (mainly surveys) and qualitative (in-depth interviews or focus groups) studies conducted after "treat all" or "Option B+" policy adoption. We used an inductive approach to categorize reasons: we report how often reasons were reported in studies and developed a conceptual framework for reasons. RESULTS We identified 21 studies which reported reasons for disengaging from ART care in the "Treat All" era, mostly in African countries: six studies in the general population of persons living with HIV, nine in pregnant or postpartum women and six in selected populations (one each in people who use drugs, isolated indigenous communities, men, women, adolescents and men who have sex with men). Reasons reported were: side effects or other antiretroviral tablet issues (15 studies); lack of perceived benefit of ART (13 studies); psychological, mental health or drug use (13 studies); concerns about stigma or confidentiality (14 studies); lack of social or family support (12 studies); socio-economic reasons (16 studies); health facility-related reasons (11 studies); and acute proximal events such as unexpected mobility (12 studies). The most common reasons for disengagement were unexpected events, socio-economic reasons, ART side effects or lack of perceived benefit of ART. Conceptually, studies described underlying vulnerability factors (individual, interpersonal, structural and healthcare) but that often unexpected proximal events (e.g. unanticipated mobility) acted as the trigger for disengagement to occur. DISCUSSION People disengage from ART care for individual, interpersonal, structural and healthcare reasons, and these reasons overlap and interact with each other. While HIV programmes cannot predict and address all events that may lead to disengagement, an approach that recognizes that such shocks will happen could help. CONCLUSIONS Health services should focus on ways to encourage clients to engage with care by making ART services welcoming, person-centred and more flexible alongside offering adherence interventions, such as counselling and peer support.
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Affiliation(s)
- Rachael M. Burke
- Clinical Research DepartmentLondon School of Hygiene and Tropical MedicineLondonUK
- Malawi Liverpool Wellcome Clinical Research ProgrammeQueen Elizabeth Central HospitalBlantyreMalawi
| | - Hannah M. Rickman
- Clinical Research DepartmentLondon School of Hygiene and Tropical MedicineLondonUK
- Malawi Liverpool Wellcome Clinical Research ProgrammeQueen Elizabeth Central HospitalBlantyreMalawi
| | - Clarice Pinto
- Global HIV, Hepatitis and STIs ProgrammeWorld Health OrganisationGenevaSwitzerland
| | - Peter Ehrenkranz
- Global Health, Bill & Melinda Gates FoundationSeattleWashingtonUSA
| | - Augustine Choko
- Malawi Liverpool Wellcome Clinical Research ProgrammeQueen Elizabeth Central HospitalBlantyreMalawi
- International Public Health DepartmentLiverpool School of Tropical MedicineLiverpoolUK
| | - Nathan Ford
- Global HIV, Hepatitis and STIs ProgrammeWorld Health OrganisationGenevaSwitzerland
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
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Nightingale ES, Feasey HRA, Khundi M, Soko RN, Burke RM, Nliwasa M, Twabi H, Mpunga JA, Fielding K, MacPherson P, Corbett EL. Community-level variation in TB testing history in Blantyre, Malawi. Int J Tuberc Lung Dis 2024; 28:99-105. [PMID: 38303035 DOI: 10.5588/ijtld.23.0213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
SETTING: Equitable access to TB testing is vital for achieving global diagnosis and treatment targets, but access to diagnostic services is often worse in poorer communities. The SCALE (Sustainable Community-wide Active case-finding for Lung hEalth) survey estimated TB prevalence in Blantyre City, Malawi, and recorded previous engagement with TB services.OBJECTIVE: To explore local variation in the prevalence of ever-testing for TB in Blantyre and investigate potential socio-economic drivers.DESIGN: We fit a mixed-effects model to self-reported prior TB testing from survey participants across 72 neighbourhood clusters, adjusted for sex, age and HIV status and with cluster-level random intercepts. We then evaluated to what extent cluster-level variation was explained by two alternate poverty indicators.RESULTS: We observed substantial variation between clusters in previous TB testing, with little correlation between neighbouring clusters. Individuals residing in less affluent households, on average, had lower odds of having undergone prior testing. However, adjusting for poverty did not explain the cluster-level variations observed.CONCLUSION: Despite a decade of increased active case-finding efforts, access to TB testing is inconsistent across the population of Blantyre. This likely reflects health inequities that also apply to TB testing in many other settings, and motivates collection and analysis of TB testing data to identify the drivers behind these inequities.
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Affiliation(s)
| | - H R A Feasey
- London School of Hygiene & Tropical Medicine, London, UK;, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre
| | - M Khundi
- African Institute for Development Policy, Lilongwe
| | - R N Soko
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre
| | - R M Burke
- London School of Hygiene & Tropical Medicine, London, UK;, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre
| | - M Nliwasa
- Kamuzu University of Health Sciences, Blantyre, Malawi
| | - H Twabi
- Kamuzu University of Health Sciences, Blantyre, Malawi;, University of Liverpool, Liverpool, UK
| | - J A Mpunga
- National TB and Leprosy Elimination Programme, Ministry of Health, Lilongwe, Malawi
| | - K Fielding
- London School of Hygiene & Tropical Medicine, London, UK
| | - P MacPherson
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, University of Glasgow, Glasgow, Scotland, UK
| | - E L Corbett
- London School of Hygiene & Tropical Medicine, London, UK
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Feasey HRA, Khundi M, Nzawa Soko R, Nightingale E, Burke RM, Henrion MYR, Phiri MD, Burchett HE, Chiume L, Nliwasa M, Twabi HH, Mpunga JA, MacPherson P, Corbett EL. Prevalence of bacteriologically-confirmed pulmonary tuberculosis in urban Blantyre, Malawi 2019-20: Substantial decline compared to 2013-14 national survey. PLOS Glob Public Health 2023; 3:e0001911. [PMID: 37862284 PMCID: PMC10588852 DOI: 10.1371/journal.pgph.0001911] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 09/21/2023] [Indexed: 10/22/2023]
Abstract
Recent evidence shows rapidly changing tuberculosis (TB) epidemiology in Southern and Eastern Africa, with need for subdistrict prevalence estimates to guide targeted interventions. We conducted a pulmonary TB prevalence survey to estimate current TB burden in Blantyre city, Malawi. From May 2019 to March 2020, 115 households in middle/high-density residential Blantyre, were randomly-selected from each of 72 clusters. Consenting eligible participants (household residents ≥ 18 years) were interviewed, including for cough (any duration), and offered HIV testing and chest X-ray; participants with cough and/or abnormal X-ray provided two sputum samples for microscopy, Xpert MTB/Rif and mycobacterial culture. TB disease prevalence and risk factors for prevalent TB were calculated using complete-case analysis, multiple imputation, and inverse probability weighting. Of 20,899 eligible adults, 15,897 (76%) were interviewed, 13,490/15,897 (85%) had X-ray, and 1,120/1,394 (80%) sputum-eligible participants produced at least one specimen, giving 15,318 complete cases (5,895, 38% men). 29/15,318 had bacteriologically-confirmed TB (189 per 100,000 complete-case (cc) / 150 per 100,000 with inverse weighting (iw)). Men had higher burden (cc: 305 [95% CI:144-645] per 100,000) than women (cc: 117 [95% CI:65-211] per 100,000): cc adjusted odds ratio (aOR) 2.70 (1.26-5.78). Other significant risk factors for prevalent TB on complete-case analysis were working age (25-49 years) and previous TB treatment, but not HIV status. Multivariable analysis of imputed data was limited by small numbers, but previous TB and age group 25-49 years remained significantly associated with higher TB prevalence. Pulmonary TB prevalence for Blantyre was considerably lower than the 1,014 per 100,000 for urban Malawi in the 2013-14 national survey, at 150-189 per 100,000 adults, but some groups, notably men, remain disproportionately affected. TB case-finding is still needed for TB elimination in Blantyre, and similar urban centres, but should focus on reaching the highest risk groups, such as older men.
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Affiliation(s)
| | - McEwen Khundi
- African Institute for Development Policy, Lilongwe, Malawi
| | - Rebecca Nzawa Soko
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Emily Nightingale
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rachael M. Burke
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Marc Y. R. Henrion
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Mphatso D. Phiri
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Helen E. Burchett
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lingstone Chiume
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Marriott Nliwasa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Hussein H. Twabi
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Peter MacPherson
- School of Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom
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Savage HR, Rickman HM, Burke RM, Odland ML, Savio M, Ringwald B, Cuevas LE, MacPherson P. Accuracy of upper respiratory tract samples to diagnose Mycobacterium tuberculosis: a systematic review and meta-analysis. Lancet Microbe 2023; 4:e811-e821. [PMID: 37714173 PMCID: PMC10547599 DOI: 10.1016/s2666-5247(23)00190-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Pulmonary tuberculosis due to Mycobacterium tuberculosis can be challenging to diagnose when sputum samples cannot be obtained, which is especially problematic in children and older people. We systematically appraised the performance characteristics and diagnostic accuracy of upper respiratory tract sampling for diagnosing active pulmonary tuberculosis. METHODS In this systematic review and meta-analysis, we searched MEDLINE, Cinahl, Web of Science, Global Health, and Global Health Archive databases for studies published between database inception and Dec 6, 2022 that reported on the accuracy of upper respiratory tract sampling for tuberculosis diagnosis compared with microbiological testing of sputum or gastric aspirate reference standard. We included studies that evaluated the accuracy of upper respiratory tract sampling (laryngeal swabs, nasopharyngeal aspirate, oral swabs, saliva, mouth wash, nasal swabs, plaque samples, and nasopharyngeal swabs) to be tested for microbiological diagnosis of tuberculous (by culture and nucleic acid amplification tests) compared with a reference standard using either sputum or gastric lavage for a microbiological test. We included cohort, case-control, cross-sectional, and randomised controlled studies that recruited participants from any community or clinical setting. We excluded post-mortem studies. We used a random-effects meta-analysis with a bivariate hierarchical model to estimate pooled sensitivity, specificity, and diagnostics odds ratio (DOR; odds of a positive test with disease relative to without), stratified by sampling method. We assessed bias using QUADAS-2 criteria. This study is registered with PROSPERO (CRD42021262392). FINDINGS We screened 10 159 titles for inclusion, reviewed 274 full texts, and included 71, comprising 119 test comparisons published between May 13, 1933, and Dec 19, 2022, in the systematic review (53 in the meta-analysis). For laryngeal swabs, pooled sensitivity was 57·8% (95% CI 50·5-65·0), specificity was 93·8% (88·4-96·8), and DOR was 20·7 (11·1-38·8). Nasopharyngeal aspirate sensitivity was 65·2% (52·0-76·4), specificity was 97·9% (96·0-99·0), and DOR was 91·0 (37·8-218·8). Oral swabs sensitivity was 56·7% (44·3-68·2), specificity was 91·3% (CI 81·0-96·3), and DOR was 13·8 (5·6-34·0). Substantial heterogeneity in diagnostic accuracy was found, probably due to differences in reference and index standards. INTERPRETATION Upper respiratory tract sampling holds promise to expand access to tuberculosis diagnosis. Exploring historical methods using modern microbiological techniques might further increase options for alternative sample types. Prospective studies are needed to optimise accuracy and utility of sampling methods in clinical practice. FUNDING UK Medical Research Council, Wellcome, and UK Foreign, Commonwealth and Development Office.
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Affiliation(s)
- Helen R Savage
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Hannah M Rickman
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK; Public Health Group, Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
| | - Rachael M Burke
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK; Public Health Group, Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
| | - Maria Lisa Odland
- Public Health Group, Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi; Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Martina Savio
- The LIGHT Consortium, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Beate Ringwald
- The LIGHT Consortium, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Luis E Cuevas
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Peter MacPherson
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK; Public Health Group, Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi; School of Health and Wellbeing, University of Glasgow, Glasgow, UK
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Burke RM, Nliwasa M, Dodd PJ, Feasey HRA, Khundi M, Choko A, Nzawa-Soko R, Mpunga J, Webb EL, Fielding K, MacPherson P, Corbett EL. Impact of Community-Wide Tuberculosis Active Case Finding and Human Immunodeficiency Virus Testing on Tuberculosis Trends in Malawi. Clin Infect Dis 2023; 77:94-100. [PMID: 37099318 PMCID: PMC10320183 DOI: 10.1093/cid/ciad238] [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: 10/21/2022] [Revised: 03/17/2023] [Accepted: 04/14/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Tuberculosis case-finding interventions are critical to meeting World Health Organization End TB strategy goals. We investigated the impact of community-wide tuberculosis active case finding (ACF) alongside scale-up of human immunodeficiency virus (HIV) testing and care on trends in adult tuberculosis case notification rates (CNRs) in Blantyre, Malawi. METHODS Five rounds of ACF for tuberculosis (1-2 weeks of leafleting, door-to-door enquiry for cough and sputum microscopy) were delivered to neighborhoods ("ACF areas") in North-West Blantyre between April 2011 and August 2014. Many of these neighborhoods also had concurrent HIV testing interventions. The remaining neighborhoods in Blantyre City ("non-ACF areas") provided a non-randomized comparator. We analyzed TB CNRs from January 2009 until December 2018. We used interrupted time series analysis to compare tuberculosis CNRs before ACF and after ACF, and between ACF and non-ACF areas. RESULTS Tuberculosis CNRs increased in Blantyre concurrently with start of ACF for tuberculosis in both ACF and non-ACF areas, with a larger magnitude in ACF areas. Compared to a counterfactual where pre-ACF CNR trends continued during ACF period, we estimated there were an additional 101 (95% confidence interval [CI] 42 to 160) microbiologically confirmed (Bac+) tuberculosis diagnoses per 100 000 person-years in the ACF areas in 3 and a half years of ACF. Compared to a counterfactual where trends in ACF area were the same as trends in non-ACF areas, we estimated an additional 63 (95% CI 38 to 90) Bac + diagnoses per 100 000 person-years in the same period. CONCLUSIONS Tuberculosis ACF was associated with a rapid increase in people diagnosed with tuberculosis in Blantyre.
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Affiliation(s)
- Rachael M Burke
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Marriott Nliwasa
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Peter J Dodd
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Helena R A Feasey
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - McEwen Khundi
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
- (MRC) International Statistics and Epidemiology Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Augustine Choko
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | | | - James Mpunga
- National Tuberculosis Programme, Government of Malawi, Lilongwe, Malawi
| | - Emily L Webb
- (MRC) International Statistics and Epidemiology Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Katherine Fielding
- (MRC) International Statistics and Epidemiology Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Peter MacPherson
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Elizabeth L Corbett
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Burke RM, Feasey N, Rangaraj A, Camps MR, Meintjes G, El-Sadr WM, Ford N. Ending AIDS deaths requires improvements in clinical care for people with advanced HIV disease who are seriously ill. Lancet HIV 2023; 10:e482-e484. [PMID: 37301220 PMCID: PMC7614731 DOI: 10.1016/s2352-3018(23)00109-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/12/2023] [Accepted: 05/04/2023] [Indexed: 06/12/2023]
Abstract
Over 4 million adults are living with advanced HIV disease with approximately 650 000 fatalities from HIV reported in 2021. People with advanced HIV disease have low immunity and can present to health services in two ways: those who are well but at high risk of developing severe disease, and those who are severely ill. These two groups require specific management approaches that place different demands on the health system. The first group can generally be supported in primary care settings but require differentiated care to meet their needs. The second group are at high risk of death and need focused diagnostics and clinical care, and possibly hospitalisation. Investments in high-quality clinical management of patients with advanced HIV disease who are seriously ill at primary care or hospital level (often only for a brief period of time during their acute illness) improves the likelihood that their condition will stabilise and that they will recover. Providing high-quality and safe clinical care that is accessible to these groups of people living with HIV who are at risk of severe illness and death is a key priority for reaching the global target of zero AIDS deaths.
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Affiliation(s)
- Rachael M Burke
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi; Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Nicholas Feasey
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, UK
| | - Ajay Rangaraj
- Global HIV, STIs and Hepatitis Programme, WHO, Geneva, Switzerland
| | | | - Graeme Meintjes
- Department of Medicine, Wellcome Centre for Infectious Diseases Research in Africa and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Wafaa M El-Sadr
- ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Nathan Ford
- Global HIV, STIs and Hepatitis Programme, WHO, Geneva, Switzerland; Centre for Infectious Disease and Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
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Wagner AD, Njuguna IN, Neary J, Lawley KA, Louden DKN, Tiwari R, Jiang W, Kalu N, Burke RM, Mangale D, Obermeyer C, Escudero JN, Bulterys MA, Waters C, Mollo B, Han H, Barr-DiChiara M, Baggaley R, Jamil MS, Shah P, Wong VJ, Drake AL, Johnson CC. Demand creation for HIV testing services: A systematic review and meta-analysis. PLoS Med 2023; 20:e1004169. [PMID: 36943831 PMCID: PMC10030044 DOI: 10.1371/journal.pmed.1004169] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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] [Received: 09/02/2022] [Accepted: 01/05/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND HIV testing services (HTS) are the first steps in reaching the UNAIDS 95-95-95 goals to achieve and maintain low HIV incidence. Evaluating the effectiveness of different demand creation interventions to increase uptake of efficient and effective HTS is useful to prioritize limited programmatic resources. This review was undertaken to inform World Health Organization (WHO) 2019 HIV testing guidelines and assessed the research question, "Which demand creation strategies are effective for enhancing uptake of HTS?" focused on populations globally. METHODS AND FINDINGS The following electronic databases were searched through September 28, 2021: PubMed, PsycInfo, Cochrane CENTRAL, CINAHL Complete, Web of Science Core Collection, EMBASE, and Global Health Database; we searched IAS and AIDS conferences. We systematically searched for randomized controlled trials (RCTs) that compared any demand creation intervention (incentives, mobilization, counseling, tailoring, and digital interventions) to either a control or other demand creation intervention and reported HTS uptake. We pooled trials to evaluate categories of demand creation interventions using random-effects models for meta-analysis and assessed study quality with Cochrane's risk of bias 1 tool. This study was funded by the WHO and registered in Prospero with ID CRD42022296947. We screened 10,583 records and 507 conference abstracts, reviewed 952 full texts, and included 124 RCTs for data extraction. The majority of studies were from the African (N = 53) and Americas (N = 54) regions. We found that mobilization (relative risk [RR]: 2.01, 95% confidence interval [CI]: [1.30, 3.09], p < 0.05; risk difference [RD]: 0.29, 95% CI [0.16, 0.43], p < 0.05, N = 4 RCTs), couple-oriented counseling (RR: 1.98, 95% CI [1.02, 3.86], p < 0.05; RD: 0.12, 95% CI [0.03, 0.21], p < 0.05, N = 4 RCTs), peer-led interventions (RR: 1.57, 95% CI [1.15, 2.15], p < 0.05; RD: 0.18, 95% CI [0.06, 0.31], p < 0.05, N = 10 RCTs), motivation-oriented counseling (RR: 1.53, 95% CI [1.07, 2.20], p < 0.05; RD: 0.17, 95% CI [0.00, 0.34], p < 0.05, N = 4 RCTs), short message service (SMS) (RR: 1.53, 95% CI [1.09, 2.16], p < 0.05; RD: 0.11, 95% CI [0.03, 0.19], p < 0.05, N = 5 RCTs), and conditional fixed value incentives (RR: 1.52, 95% CI [1.21, 1.91], p < 0.05; RD: 0.15, 95% CI [0.07, 0.22], p < 0.05, N = 11 RCTs) all significantly and importantly (≥50% relative increase) increased HTS uptake and had medium risk of bias. Lottery-based incentives and audio-based interventions less importantly (25% to 49% increase) but not significantly increased HTS uptake (medium risk of bias). Personal invitation letters and personalized message content significantly but not importantly (<25% increase) increased HTS uptake (medium risk of bias). Reduced duration counseling had comparable performance to standard duration counseling (low risk of bias) and video-based interventions were comparable or better than in-person counseling (medium risk of bias). Heterogeneity of effect among pooled studies was high. This study was limited in that we restricted to randomized trials, which may be systematically less readily available for key populations; additionally, we compare only pooled estimates for interventions with multiple studies rather than single study estimates, and there was evidence of publication bias for several interventions. CONCLUSIONS Mobilization, couple- and motivation-oriented counseling, peer-led interventions, conditional fixed value incentives, and SMS are high-impact demand creation interventions and should be prioritized for programmatic consideration. Reduced duration counseling and video-based interventions are an efficient and effective alternative to address staffing shortages. Investment in demand creation activities should prioritize those with undiagnosed HIV or ongoing HIV exposure. Selection of demand creation interventions must consider risks and benefits, context-specific factors, feasibility and sustainability, country ownership, and universal health coverage across disease areas.
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Affiliation(s)
- Anjuli D. Wagner
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Irene N. Njuguna
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Jillian Neary
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Kendall A. Lawley
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Diana K. N. Louden
- University Libraries, University of Washington, Seattle, Washington, United States of America
| | - Ruchi Tiwari
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Wenwen Jiang
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Ngozi Kalu
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rachael M. Burke
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Dorothy Mangale
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Chris Obermeyer
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
| | - Jaclyn N. Escudero
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Michelle A. Bulterys
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Chloe Waters
- Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Center, Seattle, Washington, United States of America
| | - Bastien Mollo
- Infectious and Tropical Diseases Department, Bichat-Claude Bernard Hospital, AP-HP, Paris, France
| | - Hannah Han
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | | | - Rachel Baggaley
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Muhammad S. Jamil
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Purvi Shah
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
- UNAIDS, Asia Pacific, Regional Support Team, Bangkok, Thailand
| | - Vincent J. Wong
- USAID, Division of HIV Prevention, Care and Treatment, Office of HIV/AIDS, Washington DC, United States of America
| | - Alison L. Drake
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Cheryl C. Johnson
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
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Burke RM, Twabi HH, Johnston C, Nliwasa M, Gupta-Wright A, Fielding K, Ford N, MacPherson P, Corbett EL. Interventions to reduce deaths in people living with HIV admitted to hospital in low- and middle-income countries: A systematic review. PLOS Glob Public Health 2023; 3:e0001557. [PMID: 36963024 PMCID: PMC10022356 DOI: 10.1371/journal.pgph.0001557] [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: 04/24/2022] [Accepted: 01/11/2023] [Indexed: 02/24/2023]
Abstract
People living with HIV (PLHIV) admitted to hospital have a high risk of death. We systematically appraised evidence for interventions to reduce mortality among hospitalised PLHIV in low- and middle-income countries (LMICs). Using a broad search strategy with terms for HIV, hospitals, and clinical trials, we searched for reports published between 1 Jan 2003 and 23 August 2021. Studies of interventions among adult HIV positive inpatients in LMICs were included if there was a comparator group and death was an outcome. We excluded studies restricted only to inpatients with a specific diagnosis (e.g. cryptococcal meningitis). Of 19,970 unique studies identified in search, ten were eligible for inclusion with 7,531 participants in total: nine randomised trials, and one before-after study. Three trials investigated systematic screening for tuberculosis; two showed survival benefit for urine TB screening vs. no urine screening, and one which compared Xpert MTB/RIF versus smear microscopy showed no difference in survival. One before-after study implemented 2007 WHO guidelines to improve management of smear negative tuberculosis in severely ill PLHIV, and showed survival benefit but with high risk of bias. Two trials evaluated complex interventions aimed at overcoming barriers to ART initiation in newly diagnosed PLHIV, one of which showed survival benefit and the other no difference. Two small trials evaluated early inpatient ART start, with no difference in survival. Two trials investigated protocol-driven fluid resuscitation for emergency-room attendees meeting case-definitions for sepsis, and showed increased mortality with use of a protocol for fluid administration. In conclusion, ten studies published since 2003 investigated interventions that aimed to reduce mortality in hospitalised adults with HIV, and weren't restricted to people with a defined disease diagnosis. Inpatient trials of diagnostics, therapeutics or a package of interventions to reduce mortality should be a research priority. Trial registration: PROSPERO Number: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019150341.
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Affiliation(s)
- Rachael M. Burke
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blanytre, Malawi
| | - Hussein H. Twabi
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Science, Blantyre, Malawi
| | - Cheryl Johnston
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Global HIV, Hepatitis, STI Programme, World Health Organisation, Geneva, Switzerland
| | - Marriott Nliwasa
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Science, Blantyre, Malawi
| | - Ankur Gupta-Wright
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nathan Ford
- Global HIV, Hepatitis, STI Programme, World Health Organisation, Geneva, Switzerland
| | - Peter MacPherson
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blanytre, Malawi
- School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Elizabeth L. Corbett
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blanytre, Malawi
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9
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McQuaid CF, Henrion MYR, Burke RM, MacPherson P, Nzawa-Soko R, Horton KC. Inequalities in the impact of COVID-19-associated disruptions on tuberculosis diagnosis by age and sex in 45 high TB burden countries. BMC Med 2022; 20:432. [PMID: 36372899 PMCID: PMC9660190 DOI: 10.1186/s12916-022-02624-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/21/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Tuberculosis remains a major public health priority and is the second leading cause of mortality from infectious disease worldwide. TB case detection rates are unacceptably low for men, the elderly and children. Disruptions in TB services due to the COVID-19 pandemic may have exacerbated these and other inequalities. METHODS We modelled trends in age- and sex- disaggregated case notifications for all forms of new and relapse TB reported to the World Health Organization for 45 high TB, TB/HIV and MDR-TB burden countries from 2013 to 2019. We compared trend predicted notifications to observed notifications in 2020 to estimate the number of people with TB likely to have missed or delayed diagnosis. We estimated the risk ratio (RR) of missed or delayed TB diagnosis for children (aged < 15 years) or the elderly (aged ≥ 65 years) compared to adults (aged 15-64 years) and women compared to men (both aged ≥ 15 years) using a random-effects meta-analysis. RESULTS An estimated 195,449 children (95% confidence interval, CI: 189,673-201,562, 37.8% of an expected 517,168), 1,126,133 adults (CI: 1,107,146-1,145,704, 21.8% of an expected 5,170,592) and 235,402 elderly (CI: 228,108-243,202, 28.5% of an expected 826,563) had a missed or delayed TB diagnosis in 2020. This included 511,546 women (CI: 499,623-523,869, 22.7%, of an expected 2,250,097) and 863,916 men (CI: 847,591-880,515, 23.0% of an expected 3,763,363). There was no evidence globally that the risk of having TB diagnosis missed or delayed was different for children and adults (RR: 1.09, CI: 0.41-2.91), the elderly and adults (RR: 1.40, CI: 0.62-3.16) or men and women (RR: 0.59, CI: 0.25-1.42). However, there was evidence of disparities in risk by age and/or sex in some WHO regions and in most countries. CONCLUSIONS There is no evidence at an aggregate global level of any difference by age or sex in the risk of disruption to TB diagnosis as a result of the COVID-19 pandemic. However, in many countries, disruptions in TB services have been greater for some groups than others. It is important to recognise these context-specific inequalities when prioritising key populations for catch-up campaigns.
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Affiliation(s)
- C Finn McQuaid
- TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.
| | - Marc Y R Henrion
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi.,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Rachael M Burke
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi.,Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Peter MacPherson
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi.,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.,Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Katherine C Horton
- TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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10
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Khundi M, Carpenter JR, Corbett EL, Feasey HRA, Soko RN, Nliwasa M, Twabi H, Chiume L, Burke RM, Horton KC, Dodd PJ, Cohen T, MacPherson P. Neighbourhood prevalence-to-notification ratios for adult bacteriologically-confirmed tuberculosis reveals hotspots of underdiagnosis in Blantyre, Malawi. PLoS One 2022; 17:e0268749. [PMID: 35605004 PMCID: PMC9126376 DOI: 10.1371/journal.pone.0268749] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 11/08/2021] [Accepted: 05/06/2022] [Indexed: 11/21/2022] Open
Abstract
Local information is needed to guide targeted interventions for respiratory infections such as tuberculosis (TB). Case notification rates (CNRs) are readily available, but systematically underestimate true disease burden in neighbourhoods with high diagnostic access barriers. We explored a novel approach, adjusting CNRs for under-notification (P:N ratio) using neighbourhood-level predictors of TB prevalence-to-notification ratios. We analysed data from 1) a citywide routine TB surveillance system including geolocation, confirmatory mycobacteriology, and clinical and demographic characteristics of all registering TB patients in Blantyre, Malawi during 2015-19, and 2) an adult TB prevalence survey done in 2019. In the prevalence survey, consenting adults from randomly selected households in 72 neighbourhoods had symptom-plus-chest X-ray screening, confirmed with sputum smear microscopy, Xpert MTB/Rif and culture. Bayesian multilevel models were used to estimate adjusted neighbourhood prevalence-to-notification ratios, based on summarised posterior draws from fitted adult bacteriologically-confirmed TB CNRs and prevalence. From 2015-19, adult bacteriologically-confirmed CNRs were 131 (479/371,834), 134 (539/415,226), 114 (519/463,707), 56 (283/517,860) and 46 (258/578,377) per 100,000 adults per annum, and 2019 bacteriologically-confirmed prevalence was 215 (29/13,490) per 100,000 adults. Lower educational achievement by household head and neighbourhood distance to TB clinic was negatively associated with CNRs. The mean neighbourhood P:N ratio was 4.49 (95% credible interval [CrI]: 0.98-11.91), consistent with underdiagnosis of TB, and was most pronounced in informal peri-urban neighbourhoods. Here we have demonstrated a method for the identification of neighbourhoods with high levels of under-diagnosis of TB without the requirement for a prevalence survey; this is important since prevalence surveys are expensive and logistically challenging. If confirmed, this approach may support more efficient and effective targeting of intensified TB and HIV case-finding interventions aiming to accelerate elimination of urban TB.
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Affiliation(s)
- McEwen Khundi
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - James R. Carpenter
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Elizabeth L. Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Helena R. A. Feasey
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rebecca Nzawa Soko
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Marriott Nliwasa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Helse Nord TB Initiative, College of Medicine, University of Malawi, Zomba, Malawi
| | - Hussein Twabi
- Helse Nord TB Initiative, College of Medicine, University of Malawi, Zomba, Malawi
| | - Lingstone Chiume
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Rachael M. Burke
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Peter J. Dodd
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Ted Cohen
- Yale School of Public Health, New Haven, CT, United States of America
| | - Peter MacPherson
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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11
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Burke RM, Nyirenda S, Twabi HH, Nliwasa M, Joekes E, Walker N, Nyirenda R, Gupta-Wright A, Fielding K, MacPherson P, Corbett EL. Design and protocol for a cluster randomised trial of enhanced diagnostics for tuberculosis screening among people living with HIV in hospital in Malawi (CASTLE study). PLoS One 2022; 17:e0261877. [PMID: 35007306 PMCID: PMC8746787 DOI: 10.1371/journal.pone.0261877] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 08/24/2021] [Accepted: 09/16/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND People living with HIV (PLHIV) have a high risk of death if hospitalised in low-income countries. Tuberculosis has long been the leading cause of admission and death, in part due to suboptimal diagnostics. Two promising new diagnostic tools are digital chest Xray with computer-aided diagnosis (DCXR-CAD) and urine testing with Fujifilm SILVAMP LAM (FujiLAM). Neither test has been rigorously evaluated among inpatients. Test characteristics may be complementary, with FujiLAM especially sensitive for disseminated tuberculosis and DCXR-CAD especially sensitive for pulmonary tuberculosis, making combined interventions of interest. DESIGN AND METHODS An exploratory unblinded, single site, two-arm cluster randomised controlled trial, with day of admission as the unit of randomisation. A third, smaller, integrated cohort arm (4:4:1 random allocation) contributes to understanding case-mix, but not trial outcomes. Participants are adults living with HIV not currently on TB treatment. The intervention (DCXR-CAD plus urine FujiLAM plus usual care) is compared to usual care alone. The primary outcome is proportion of participants started on tuberculosis treatment by day 56, with secondary outcomes of mortality (time to event) measured to to 56 days from enrolment, proportions with undiagnosed tuberculosis at death or hospital discharge and comparing proportions with enrolment-day tuberculosis treatment initiation. DISCUSSION Both DCXR-CAD and FujiLAM have potential clinical utility and may have complementary diagnostic performance. To our knowledge, this is the first randomised trial to evaluate these tests among hospitalised PLHIV.
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Affiliation(s)
- Rachael M. Burke
- Faculty of Infectious and Tropical Disease, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Saulos Nyirenda
- Zomba Central Hospital, Malawi Ministry of Health, Zomba, Malawi
| | - Hussein H. Twabi
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Marriott Nliwasa
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Elizabeth Joekes
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Naomi Walker
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Rose Nyirenda
- Department of HIV AIDS, Malawi Ministry of Health, Lilongwe, Malawi
| | - Ankur Gupta-Wright
- Faculty of Infectious and Tropical Disease, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Institute for Global Health, University College London, London, England
| | - Katherine Fielding
- Faculty of Epidemiology and Population Health, Infectious Disease Epidemiology Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Peter MacPherson
- Faculty of Infectious and Tropical Disease, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Elizabeth L. Corbett
- Faculty of Infectious and Tropical Disease, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
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12
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Burke RM, Rickman HM, Singh V, Kalua T, Labhardt ND, Hosseinipour M, Wilkinson RJ, MacPherson P. Same-day antiretroviral therapy initiation for people living with HIV who have tuberculosis symptoms: a systematic review. HIV Med 2022; 23:4-15. [PMID: 34528368 DOI: 10.1111/hiv.13169] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 08/11/2021] [Accepted: 08/13/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Tuberculosis symptoms are very common among people living with HIV (PLHIV) initiating antiretroviral therapy (ART), are not specific for tuberculosis disease and may result in delayed ART start. The risks and benefits of same-day ART initiation in PLHIV with tuberculosis symptoms are unknown. METHODS We systematically reviewed nine databases on 12 March 2020 to identify studies that investigated same-day ART initiation among PLHIV with tuberculosis symptoms and reported both their approach to TB screening and clinical outcomes. We extracted and summarized data about TB screening, numbers of people starting same-day ART and outcomes. RESULTS We included four studies. Two studies deferred ART for everyone with any tuberculosis symptoms (one or more of cough, fever, night sweats or weight loss) and substantial numbers of people had deferred ART start (28% and 39% did not start same-day ART). Two studies permitted some people with tuberculosis symptoms to start same-day ART, and fewer people deferred ART (2% and 16% did not start same-day). Two of the four studies were conducted sequentially; proven viral load suppression at 8 months was 31% when everyone with tuberculosis symptoms had ART deferred, and 44% when the algorithm was changed so that some people with tuberculosis symptoms could start same-day ART. CONCLUSIONS Although tuberculosis symptoms are very common in people starting ART, there is insufficient evidence about whether presence of tuberculosis symptoms should lead to ART start being deferred or not. Research to inform clear guidelines would help to maximise the benefits of same-day ART.
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Affiliation(s)
- Rachael M Burke
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Hannah M Rickman
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - Vindi Singh
- WHO Global HIV, Hepatitis and STI Programme, Geneva, Switzerland
- Global Fund to fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
| | - Thokozani Kalua
- Department of HIV and AIDS, Ministry of Health, Government of Malawi, Basel, Switzerland
| | - Niklaus D Labhardt
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | | | - Robert J Wilkinson
- Department of Infectious Disease, Imperial College London, UK
- Wellcome Centre for Infectious Diseases Research in Africa and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Rondebosch, South Africa
- Francis Crick Institute, London, UK
| | - Peter MacPherson
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
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13
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Feasey HRA, Burke RM, Nliwasa M, Chaisson LH, Golub JE, Naufal F, Shapiro AE, Ruperez M, Telisinghe L, Ayles H, Miller C, Burchett HED, MacPherson P, Corbett EL. Do community-based active case-finding interventions have indirect impacts on wider TB case detection and determinants of subsequent TB testing behaviour? A systematic review. PLOS Glob Public Health 2021; 1:e0000088. [PMID: 36962123 PMCID: PMC10021508 DOI: 10.1371/journal.pgph.0000088] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 11/15/2021] [Indexed: 11/18/2022]
Abstract
Community-based active case-finding (ACF) may have important impacts on routine TB case-detection and subsequent patient-initiated diagnosis pathways, contributing "indirectly" to infectious diseases prevention and care. We investigated the impact of ACF beyond directly diagnosed patients for TB, using routine case-notification rate (CNR) ratios as a measure of indirect effect. We systematically searched for publications 01-Jan-1980 to 13-Apr-2020 reporting on community-based ACF interventions compared to a comparison group, together with review of linked manuscripts reporting knowledge, attitudes, and practices (KAP) outcomes or qualitative data on TB testing behaviour. We calculated CNR ratios of routine case-notifications (i.e. excluding cases identified directly through ACF) and compared proxy behavioural outcomes for both ACF and comparator communities. Full text manuscripts from 988 of 23,883 abstracts were screened for inclusion; 36 were eligible. Of these, 12 reported routine notification rates separately from ACF intervention-attributed rates, and one reported any proxy behavioural outcomes. Two further studies were identified from screening 1121 abstracts for linked KAP/qualitative manuscripts. 8/12 case-notification studies were considered at critical or serious risk of bias. 8/11 non-randomised studies reported bacteriologically-confirmed CNR ratios between 0.47 (95% CI:0.41-0.53) and 0.96 (95% CI:0.94-0.97), with 7/11 reporting all-form CNR ratios between 0.96 (95% CI:0.88-1.05) and 1.09 (95% CI:1.02-1.16). One high-quality randomised-controlled trial reported a ratio of 1.14 (95% CI 0.91-1.43). KAP/qualitative manuscripts provided insufficient evidence to establish the impact of ACF on subsequent TB testing behaviour. ACF interventions with routine CNR ratios >1 suggest an indirect effect on wider TB case-detection, potentially due to impact on subsequent TB testing behaviour through follow-up after a negative ACF test or increased TB knowledge. However, data on this type of impact are rarely collected. Evaluation of routine case-notification, testing and proxy behavioural outcomes in intervention and comparator communities should be included as standard methodology in future ACF campaign study designs.
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Affiliation(s)
- Helena R. A. Feasey
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- TB Centre, London School of Hygiene and Tropical Medicine, London, London
| | - Rachael M. Burke
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- TB Centre, London School of Hygiene and Tropical Medicine, London, London
| | | | - Lelia H. Chaisson
- Division of Infectious Diseases, Department of Medicine, University of Illinois at Chicago, Chicago, IL, United States of America
| | - Jonathan E. Golub
- Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States of America
| | - Fahd Naufal
- Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States of America
| | - Adrienne E. Shapiro
- Department of Global Health and Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Maria Ruperez
- TB Centre, London School of Hygiene and Tropical Medicine, London, London
| | - Lily Telisinghe
- TB Centre, London School of Hygiene and Tropical Medicine, London, London
- Zambart, University of Zambia School of Public Health, Ridgeway, Zambia
| | - Helen Ayles
- TB Centre, London School of Hygiene and Tropical Medicine, London, London
- Zambart, University of Zambia School of Public Health, Ridgeway, Zambia
| | | | - Helen E. D. Burchett
- Faculty of Public Health & Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Peter MacPherson
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- TB Centre, London School of Hygiene and Tropical Medicine, London, London
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Elizabeth L. Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- TB Centre, London School of Hygiene and Tropical Medicine, London, London
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Burke RM, Henrion MYR, Mallewa J, Masamba L, Kalua T, Khundi M, Gupta-Wright A, Rylance J, Gordon SB, Masesa C, Corbett EL, Mwandumba HC, Macpherson P. Incidence of HIV-positive admission and inpatient mortality in Malawi (2012-2019). AIDS 2021; 35:2191-2199. [PMID: 34172671 PMCID: PMC7611991 DOI: 10.1097/qad.0000000000003006] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To investigate trends in population incidence of HIV-positive hospital admission and risk of in-hospital death among adults living with HIV between 2012 and 2019 in Blantyre, Malawi. DESIGN Population cohort study using an existing electronic health information system ('SPINE') at Queen Elizabeth Central Hospital and Blantyre census data. METHODS We used multiple imputation and negative binomial regression to estimate population age-specific and sex-specific admission rates over time. We used a log-binomial model to investigate trends in risk of in-hospital death. RESULTS Of 32 814 adult medical admissions during Q4 2012--Q3 2019, HIV status was recorded for 75.6%. HIV-positive admissions decreased substantially between 2012 and 2019. After imputation for missing data, HIV-positive admissions were highest in Q3 2013 (173 per 100 000 adult Blantyre residents) and lowest in Q3 2019 (53 per 100 000 residents). An estimated 10 818 fewer than expected people with HIV (PWH) [95% confidence interval (CI) 10 068-11 568] were admitted during 2012-2019 compared with the counterfactual situation where admission rates stayed the same throughout this period. Absolute reductions were greatest for women aged 25-34 years (2264 fewer HIV-positive admissions, 95% CI 2002-2526). In-hospital mortality for PWH was 23.5%, with no significant change over time in any age-sex group, and no association with antiretroviral therapy (ART) use at admission. CONCLUSION Rates of admission for adult PWH decreased substantially, likely because of large increases in community provision of HIV diagnosis, treatment and care. However, HIV-positive in-hospital deaths remain unacceptably high, despite improvements in ART coverage. A concerted research and implementation agenda is urgently needed to reduce inpatient deaths among PWH.
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Affiliation(s)
- Rachael M Burke
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine
- Malawi Liverpool Wellcome Clinical Research Programme, University of Malawi College of Medicine
| | - Marc Y R Henrion
- Malawi Liverpool Wellcome Clinical Research Programme, University of Malawi College of Medicine
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine
| | - Jane Mallewa
- Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Leo Masamba
- Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | | | - McEwan Khundi
- Malawi Liverpool Wellcome Clinical Research Programme, University of Malawi College of Medicine
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine
| | - Ankur Gupta-Wright
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine
| | - Jamie Rylance
- Malawi Liverpool Wellcome Clinical Research Programme, University of Malawi College of Medicine
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine
| | - Stephen B Gordon
- Malawi Liverpool Wellcome Clinical Research Programme, University of Malawi College of Medicine
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine
| | - Clemens Masesa
- Malawi Liverpool Wellcome Clinical Research Programme, University of Malawi College of Medicine
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine
| | - Elizabeth L Corbett
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine
- Malawi Liverpool Wellcome Clinical Research Programme, University of Malawi College of Medicine
| | - Henry C Mwandumba
- Malawi Liverpool Wellcome Clinical Research Programme, University of Malawi College of Medicine
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine
| | - Peter Macpherson
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine
- Malawi Liverpool Wellcome Clinical Research Programme, University of Malawi College of Medicine
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine
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MacPherson P, Webb EL, Kamchedzera W, Joekes E, Mjoli G, Lalloo DG, Divala TH, Choko AT, Burke RM, Maheswaran H, Pai M, Squire SB, Nliwasa M, Corbett EL. Computer-aided X-ray screening for tuberculosis and HIV testing among adults with cough in Malawi (the PROSPECT study): A randomised trial and cost-effectiveness analysis. PLoS Med 2021; 18:e1003752. [PMID: 34499665 PMCID: PMC8459969 DOI: 10.1371/journal.pmed.1003752] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 09/23/2021] [Accepted: 08/03/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Suboptimal tuberculosis (TB) diagnostics and HIV contribute to the high global burden of TB. We investigated costs and yield from systematic HIV-TB screening, including computer-aided digital chest X-ray (DCXR-CAD). METHODS AND FINDINGS In this open, three-arm randomised trial, adults (≥18 years) with cough attending acute primary services in Malawi were randomised (1:1:1) to standard of care (SOC); oral HIV testing (HIV screening) and linkage to care; or HIV testing and linkage to care plus DCXR-CAD with sputum Xpert for high CAD4TBv5 scores (HIV-TB screening). Participants and study staff were not blinded to intervention allocation, but investigator blinding was maintained until final analysis. The primary outcome was time to TB treatment. Secondary outcomes included proportion with same-day TB treatment; prevalence of undiagnosed/untreated bacteriologically confirmed TB on day 56; and undiagnosed/untreated HIV. Analysis was done on an intention-to-treat basis. Cost-effectiveness analysis used a health-provider perspective. Between 15 November 2018 and 27 November 2019, 8,236 were screened for eligibility, with 473, 492, and 497 randomly allocated to SOC, HIV, and HIV-TB screening arms; 53 (11%), 52 (9%), and 47 (9%) were lost to follow-up, respectively. At 56 days, TB treatment had been started in 5 (1.1%) SOC, 8 (1.6%) HIV screening, and 15 (3.0%) HIV-TB screening participants. Median (IQR) time to TB treatment was 11 (6.5 to 38), 6 (1 to 22), and 1 (0 to 3) days (hazard ratio for HIV-TB versus SOC: 2.86, 1.04 to 7.87), with same-day treatment of 0/5 (0%) SOC, 1/8 (12.5%) HIV, and 6/15 (40.0%) HIV-TB screening arm TB patients (p = 0.03). At day 56, 2 SOC (0.5%), 4 HIV (1.0%), and 2 HIV-TB (0.5%) participants had undiagnosed microbiologically confirmed TB. HIV screening reduced the proportion with undiagnosed or untreated HIV from 10 (2.7%) in the SOC arm to 2 (0.5%) in the HIV screening arm (risk ratio [RR]: 0.18, 0.04 to 0.83), and 1 (0.2%) in the HIV-TB screening arm (RR: 0.09, 0.01 to 0.71). Incremental costs were US$3.58 and US$19.92 per participant screened for HIV and HIV-TB; the probability of cost-effectiveness at a US$1,200/quality-adjusted life year (QALY) threshold was 83.9% and 0%. Main limitations were the lower than anticipated prevalence of TB and short participant follow-up period; cost and quality of life benefits of this screening approach may accrue over a longer time horizon. CONCLUSIONS DCXR-CAD with universal HIV screening significantly increased the timeliness and completeness of HIV and TB diagnosis. If implemented at scale, this has potential to rapidly and efficiently improve TB and HIV diagnosis and treatment. TRIAL REGISTRATION clinicaltrials.gov NCT03519425.
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Affiliation(s)
- Peter MacPherson
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Emily L. Webb
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Wala Kamchedzera
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Elizabeth Joekes
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Gugu Mjoli
- Department of Radiology, Chris Hani Baragwanath Hospital, Soweto, South Africa
| | - David G. Lalloo
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Titus H. Divala
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Helse Nord TB Initiative, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Augustine T. Choko
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Rachael M. Burke
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal, Canada
| | - S. Bertel Squire
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Marriott Nliwasa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Helse Nord TB Initiative, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Elizabeth L. Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Soko RN, Burke RM, Feasey HRA, Sibande W, Nliwasa M, Henrion MYR, Khundi M, Dodd PJ, Ku CC, Kawalazira G, Choko AT, Divala TH, Corbett EL, MacPherson P. Effects of Coronavirus Disease Pandemic on Tuberculosis Notifications, Malawi. Emerg Infect Dis 2021; 27:1831-1839. [PMID: 34152962 PMCID: PMC8237899 DOI: 10.3201/eid2707.210557] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The coronavirus disease (COVID-19) pandemic might affect tuberculosis (TB) diagnosis and patient care. We analyzed a citywide electronic TB register in Blantyre, Malawi and interviewed TB officers. Malawi did not have an official COVID-19 lockdown but closed schools and borders on March 23, 2020. In an interrupted time series analysis, we noted an immediate 35.9% reduction in TB notifications in April 2020; notifications recovered to near prepandemic numbers by December 2020. However, 333 fewer cumulative TB notifications were received than anticipated. Women and girls were affected more (30.7% fewer cases) than men and boys (20.9% fewer cases). Fear of COVID-19 infection, temporary facility closures, inadequate personal protective equipment, and COVID-19 stigma because of similar symptoms to TB were mentioned as reasons for fewer people being diagnosed with TB. Public health measures could benefit control of both TB and COVID-19, but only if TB diagnostic services remain accessible and are considered safe to attend.
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Burke RM, Rickman HM, Singh V, Corbett EL, Ayles H, Jahn A, Hosseinipour MC, Wilkinson RJ, MacPherson P. What is the optimum time to start antiretroviral therapy in people with HIV and tuberculosis coinfection? A systematic review and meta-analysis. J Int AIDS Soc 2021; 24:e25772. [PMID: 34289243 PMCID: PMC8294654 DOI: 10.1002/jia2.25772] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 06/07/2021] [Accepted: 06/24/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND HIV and tuberculosis are frequently diagnosed concurrently. In March 2021, World Health Organization recommended that antiretroviral therapy (ART) should be started within two weeks of tuberculosis treatment start, at any CD4 count. We assessed whether earlier ART improved outcomes in people with newly diagnosed HIV and tuberculosis. METHODS We did a systematic review by searching nine databases for trials that compared earlier ART to later ART initiation in people with HIV and tuberculosis. We included studies published from database inception to 12 March 2021. We compared ART within four weeks versus ART more than four weeks after TB treatment, and ART within two weeks versus ART between two and eight weeks, and stratified analysis by CD4 count. The main outcome was death; secondary outcomes included IRIS and AIDS-defining events. We pooled effect estimates using random effects meta-analysis. RESULTS AND DISCUSSION We screened 2468 abstracts, and identified nine trials. Among people with all CD4 counts, there was no difference in mortality by earlier ART (≤4 week) versus later ART (>4 week) (risk difference [RD] 0%, 95% confidence interval [CI] -2% to +1%). Among people with CD4 count ≤50 cells/mm3 , earlier ART (≤4 weeks) reduced risk of death (RD -6%, -10% to -1%). Among people with all CD4 counts earlier ART (≤4 weeks) increased the risk of IRIS (RD +6%, 95% CI +2% to +10%) and reduced the incidence of AIDS-defining events (RD -2%, 95% CI -4% to 0%). Results were similar when trials were restricted to the four trials which permitted comparison of ART within two weeks to ART between two and eight weeks. Trials were conducted between 2004 and 2014, before recommendations to treat HIV at any CD4 count or to rapidly start ART in people without TB. No trials included children or pregnant women. No trials included integrase inhibitors in ART regimens. DISCUSSION Earlier ART did not alter risk of death overall among people living with HIV who had TB disease. For logistical and patient preference reasons, earlier ART initiation for everyone with TB and HIV may be preferred to later ART.
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Affiliation(s)
- Rachael M Burke
- Malawi‐Liverpool‐Wellcome Clinical Research ProgrammeBlantyreMalawi
- Clinical Research DepartmentFaculty of Infectious and Tropical DiseaseLondon School of Hygiene and Tropical MedicineLondonUK
| | - Hannah M Rickman
- Malawi‐Liverpool‐Wellcome Clinical Research ProgrammeBlantyreMalawi
| | - Vindi Singh
- Department HIV, Hepatitis and STIsWorld Health OrganisationGenevaSwitzerland
| | - Elizabeth L Corbett
- Malawi‐Liverpool‐Wellcome Clinical Research ProgrammeBlantyreMalawi
- Clinical Research DepartmentFaculty of Infectious and Tropical DiseaseLondon School of Hygiene and Tropical MedicineLondonUK
| | - Helen Ayles
- Malawi‐Liverpool‐Wellcome Clinical Research ProgrammeBlantyreMalawi
- ZambartLusakaZambia
| | - Andreas Jahn
- Department of HIV and AIDSMinistry of Health MalawiLilongweMalawi
- International Training and Education Center for HealthDepartment of Global HealthUniversity of WashingtonSeattleWAUSA
| | | | - Robert J Wilkinson
- Dept Infectious DiseaseImperial College LondonLondonUK
- Wellcome Centre for Infectious Diseases Research in Africa and Institute of Infectious Disease and Molecular MedicineUniversity of Cape TownObservatoryRepublic of South Africa
- Francis Crick InstituteLondonUK
| | - Peter MacPherson
- Malawi‐Liverpool‐Wellcome Clinical Research ProgrammeBlantyreMalawi
- Clinical Research DepartmentFaculty of Infectious and Tropical DiseaseLondon School of Hygiene and Tropical MedicineLondonUK
- Department of Clinical SciencesLiverpool School of Tropical MedicineLiverpoolUK
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Burke RM, Nliwasa M, Feasey HRA, Chaisson LH, Golub JE, Naufal F, Shapiro AE, Ruperez M, Telisinghe L, Ayles H, Corbett EL, MacPherson P. Community-based active case-finding interventions for tuberculosis: a systematic review. Lancet Public Health 2021; 6:e283-e299. [PMID: 33765456 PMCID: PMC8082281 DOI: 10.1016/s2468-2667(21)00033-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/03/2021] [Accepted: 02/08/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Community-based active case-finding interventions might identify and treat more people with tuberculosis disease than standard case detection. We aimed to assess whether active case-finding interventions can affect tuberculosis epidemiology in the wider community. METHODS We did a systematic review by searching PubMed, Embase, Scopus, and Cochrane Library for studies that compared tuberculosis case notification rates, tuberculosis disease prevalence, or tuberculosis infection prevalence or incidence in children, between populations exposed and unexposed to active case-finding interventions. We included studies published in English between Jan 1, 1980, and April 13, 2020. Studies of active case-finding in the general population, in populations perceived to be at high risk for tuberculosis, and in closed settings were included, whereas studies of tuberculosis screening at health-care facilities, among household contacts, or among children only, and studies that screened fewer than 1000 people were excluded. To estimate effectiveness, we extracted or calculated case notification rates, prevalence of tuberculosis disease, and incidence or prevalence of tuberculosis infection in children, and compared ratios of these outcomes between groups that were exposed or not exposed to active case-finding interventions. RESULTS 27 883 abstracts were screened and 988 articles underwent full text review. 28 studies contributed data for analysis of tuberculosis case notifications, nine for prevalence of tuberculosis disease, and two for incidence or prevalence of tuberculosis infection in children. In one cluster-randomised trial in South Africa and Zambia, an active case-finding intervention based on community mobilisation and sputum drop-off did not affect tuberculosis prevalence, whereas, in a cluster-randomised trial in Vietnam, an active case-finding intervention based on sputum tuberculosis tests for everyone reduced tuberculosis prevalence in the community. We found inconsistent, low-quality evidence that active case-finding might increase the number of cases of tuberculosis notified in populations with structural risk factors for tuberculosis. INTERPRETATION Community-based active case-finding for tuberculosis might be effective in changing tuberculosis epidemiology and thereby improving population health if delivered with high coverage and intensity. If possible, active case-finding projects should incorporate a well designed, robust evaluation to contribute to the evidence base and help elucidate which delivery methods and diagnostic strategies are most effective. FUNDING WHO Global TB Programme.
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Affiliation(s)
- Rachael M Burke
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
| | - Marriott Nliwasa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi; Helse Nord Tuberculosis Initiative, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Helena R A Feasey
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Lelia H Chaisson
- Division of Infectious Diseases, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Jonathan E Golub
- Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Fahd Naufal
- Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Adrienne E Shapiro
- Department of Global Health and Department of Medicine, University of Washington, Seattle, WA, USA
| | - Maria Ruperez
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Lily Telisinghe
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Zambart, University of Zambia School of Public Health, Ridgeway, Zambia
| | - Helen Ayles
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Zambart, University of Zambia School of Public Health, Ridgeway, Zambia
| | - Elizabeth L Corbett
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Peter MacPherson
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, UK
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19
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Burke RM, Gupta Wright A. Diagnosing Tuberculosis in People With Advanced Human Immunodeficiency Virus: More Is Needed. Clin Infect Dis 2021; 73:e878-e879. [PMID: 34398959 DOI: 10.1093/cid/ciab184] [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: 02/12/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Rachael M Burke
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Malawi Liverpool Wellcome Clinical Research Programme, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Ankur Gupta Wright
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Institute for Global Health, University College London, London, United Kingdom
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20
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Kirolos A, Thindwa D, Khundi M, Burke RM, Henrion MYR, Nakamura I, Divala TH, Nliwasa M, Corbett EL, MacPherson P. Tuberculosis case notifications in Malawi have strong seasonal and weather-related trends. Sci Rep 2021; 11:4621. [PMID: 33633272 PMCID: PMC7907065 DOI: 10.1038/s41598-021-84124-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 09/30/2020] [Accepted: 02/02/2021] [Indexed: 12/30/2022] Open
Abstract
Seasonal trends in tuberculosis (TB) notifications have been observed in several countries but are poorly understood. Explanatory factors may include weather, indoor crowding, seasonal respiratory infections and migration. Using enhanced citywide TB surveillance data collected over nine years in Blantyre, Malawi, we set out to investigate how weather and seasonality affect temporal trends in TB case notification rates (CNRs) across different demographic groups. We used data from prospective enhanced surveillance between April 2011 and December 2018, which systematically collected age, HIV status, sex and case notification dates for all registering TB cases in Blantyre. We retrieved temperature and rainfall data from the Global Surface Summary of the Day weather station database. We calculated weekly trends in TB CNRs, rainfall and temperature, and calculated 10-week moving averages. To investigate the associations between rainfall, temperature and TB CNRs, we fitted generalized linear models using a distributed lag nonlinear framework. The estimated Blantyre population increased from 1,068,151 in April 2011 to 1,264,304 in December 2018, with 15,908 TB cases recorded. Overall annual TB CNRs declined from 222 to 145 per 100,000 between 2012 and 2018, with the largest declines seen in HIV-positive people and adults aged over 20 years old. TB CNRs peaks occurred with increasing temperature in September and October before the onset of increased rainfall, and later in the rainy season during January-March, after sustained rainfall. When lag between a change in weather and TB case notifications was accounted for, higher average rainfall was associated with an equivalent six weeks of relatively lower TB notification rates, whereas there were no changes in TB CNR associated with change in average temperatures. TB CNRs in Blantyre have a seasonal pattern of two cyclical peaks per year, coinciding with the start and end of the rainy season. These trends may be explained by increased transmission at certain times of the year, by limited healthcare access, by patterns of seasonal respiratory infections precipitating cough and care-seeking, or by migratory patterns related to planting and harvesting during the rainy season.
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Affiliation(s)
- Amir Kirolos
- grid.10025.360000 0004 1936 8470Department of Clinical Infection, Microbiology & Immunology, Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Deus Thindwa
- grid.8991.90000 0004 0425 469XDepartment of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - McEwen Khundi
- grid.8991.90000 0004 0425 469XDepartment of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK ,grid.415487.b0000 0004 0598 3456Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Queen Elizabeth Central Hospital, PO30096, Blantyre, Malawi
| | - Rachael M. Burke
- grid.415487.b0000 0004 0598 3456Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Queen Elizabeth Central Hospital, PO30096, Blantyre, Malawi ,grid.8991.90000 0004 0425 469XClinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Marc Y. R. Henrion
- grid.415487.b0000 0004 0598 3456Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Queen Elizabeth Central Hospital, PO30096, Blantyre, Malawi ,grid.48004.380000 0004 1936 9764Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Itaru Nakamura
- grid.412781.90000 0004 1775 2495Department of Infectious Diseases, Tokyo Medical University Hospital, Tokyo, Japan
| | - Titus H. Divala
- grid.8991.90000 0004 0425 469XDepartment of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK ,grid.10595.380000 0001 2113 2211Helse Nord TB Initiative, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Marriott Nliwasa
- grid.415487.b0000 0004 0598 3456Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Queen Elizabeth Central Hospital, PO30096, Blantyre, Malawi ,grid.10595.380000 0001 2113 2211Helse Nord TB Initiative, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Elizabeth L. Corbett
- grid.415487.b0000 0004 0598 3456Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Queen Elizabeth Central Hospital, PO30096, Blantyre, Malawi ,grid.8991.90000 0004 0425 469XClinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter MacPherson
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Queen Elizabeth Central Hospital, PO30096, Blantyre, Malawi. .,Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK. .,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
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MacPherson P, Williams CM, Burke RM, Barer MR, Esmail H. Before the whistle blows: developing new paradigms in tuberculosis screening to maximise benefit and minimise harm. Wellcome Open Res 2021. [DOI: 10.12688/wellcomeopenres.16506.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We summarise recent emerging evidence around tuberculosis (TB) transmission and its role in tuberculosis epidemiology, and in novel TB screening and diagnostic tests that will likely become available in low-resource settings in the near future. Little consideration has been paid to how these novel new tests will be implemented, nor what the consequences for individuals, communities and health systems will be. In particular, because of low specificity and consequent false-positive diagnoses, and the low percentage of people who “screen positive” that will go onto develop active pulmonary disease, there is significant potential for inappropriate initiation of TB treatment, as well as stigmatisation, loss of livelihoods and in some setting institutionalisation, with uncertain benefit for individual health or community transmission. We use analogy to prompt consideration of how and where new TB screening tests could be implemented in TB screening programmes in low-resource settings. Acceptance and confidence in TB screening programmes depends on well-functioning public health programmes that use screening algorithms that minimise harms and balance population benefits with autonomy and respect for individuals. Before new TB screening tests and algorithms are introduced, more evidence for their effectiveness, costs, benefits and harms under real-world conditions are required.
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Affiliation(s)
- Titus Divala
- University of Malawi College of Medicine, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
| | - Rachael M Burke
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK; Faculty of Infectious and Tropical Disease, London School of Hygiene & Tropical Medicine, London, UK.
| | - Latif Ndeketa
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
| | - Elizabeth L Corbett
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK; Faculty of Infectious and Tropical Disease, London School of Hygiene & Tropical Medicine, London, UK
| | - Peter MacPherson
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
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Massaquoi TA, Burke RM, Yang G, Lakoh S, Sevalie S, Li B, Jia H, Huang L, Deen GF, Beynon F, Sahr F. Cross sectional study of chronic hepatitis B prevalence among healthcare workers in an urban setting, Sierra Leone. PLoS One 2018; 13:e0201820. [PMID: 30096162 PMCID: PMC6086405 DOI: 10.1371/journal.pone.0201820] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 07/23/2018] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Hepatitis B is a serious public health problem across sub-Saharan Africa. Sierra Leone has no national hepatitis B strategy plan or high quality estimates of prevalence. Healthcare workers are perceived as an at-risk group for hepatitis B. We assessed the prevalence of hepatitis B among healthcare workers at two hospital sites in Freetown, Sierra Leone. METHODS In October 2017, healthcare workers were offered voluntary testing for hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), hepatitis B core antibody (anti-HBc), hepatitis B e antigen (HBeAg) and hepatitis B e antibody (anti-HBe) using rapid lateral flow assay for all samples, followed by Enzyme Immunosorbent Assay to confirm positive results. Participants completed a questionnaire about knowledge, attitudes and practices concerning hepatitis B. HBsAg positive participants were invited to a clinic for further assessment. RESULTS Overall, 447 participants were tested for hepatitis B. Most (90.6%, 405/447) participants were nurses, 72.3% (323/447) were female and 71.6% (320/447) were 30 years or older. The prevalence of chronic hepatitis B (HBsAg positivity) was 8.7% (39 / 447, 95% CI 6.3-11.7%). There was no significant difference in prevalence by sex, age group, site of work or type of job. None of the 66.7% (26 / 39) of participants with chronic hepatitis B who attended the clinic met the 2015 WHO criteria to start treatment for hepatitis B on the basis of cirrhosis. Most participants (96.9% 432 / 446) stated that they were worried about their risk of hepatitis B at work. CONCLUSIONS Hepatitis B is highly prevalent among healthcare workers in Sierra Leone. It is unclear whether this reflects high community prevalence or is due to occupational risk. No participants with chronic hepatitis B needed to start treatment. In order to achieve the WHO target of elimination of viral hepatitis by 2030, introduction of birth dose vaccine for infants and catch-up vaccines for healthcare workers and healthcare students, together with a national hepatitis B screen and treat programme is advisable for Sierra Leone.
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Affiliation(s)
- Thomas A. Massaquoi
- 34 Military Hospital, Wilberforce Barracks, Freetown, Sierra Leone
- * E-mail: (TAM); (LH)
| | - Rachael M. Burke
- Centre for Global Health and Health Partnerships, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
- Kings Sierra Leone Partnership, Connaught Hospital, Freetown, Sierra Leone
| | - Guang Yang
- Chinese Military Medical Expert Group in Sierra Leone, 302 Military Hospital, Beijing, China
| | - Suliaman Lakoh
- University Sierra Leone Teaching Hospital Complex, Connaught Hospital, Freetown, Sierra Leone
| | - Stephen Sevalie
- 34 Military Hospital, Wilberforce Barracks, Freetown, Sierra Leone
| | - Bo Li
- Chinese Military Medical Expert Group in Sierra Leone, 302 Military Hospital, Beijing, China
| | - Hongjun Jia
- Chinese Military Medical Expert Group in Sierra Leone, 302 Military Hospital, Beijing, China
| | - Lei Huang
- Chinese Military Medical Expert Group in Sierra Leone, 302 Military Hospital, Beijing, China
- * E-mail: (TAM); (LH)
| | - Gibrilla F. Deen
- University Sierra Leone Teaching Hospital Complex, Connaught Hospital, Freetown, Sierra Leone
| | - Fenella Beynon
- Centre for Global Health and Health Partnerships, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
- Kings Sierra Leone Partnership, Connaught Hospital, Freetown, Sierra Leone
| | - Foday Sahr
- 34 Military Hospital, Wilberforce Barracks, Freetown, Sierra Leone
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Burke RM, Coronel J, Moore D. Minimum inhibitory concentration distributions for first- and second-line antimicrobials against Mycobacterium tuberculosis. J Med Microbiol 2017; 66:1023-1026. [PMID: 28759352 DOI: 10.1099/jmm.0.000534] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We report the range of minimum inhibitory concentrations for six antimicrobial drugs in 228 clinical Mycobacterium tuberculosis (MTB) isolates from three distinct groups of patients (unselected patients, patients at high risk of drug-resistant TB and HIV-positive patients) in Lima, Peru. These data highlight the challenges of and discriminatory characteristics required for MTB drug susceptibility testing.
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Affiliation(s)
- Rachael M Burke
- Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London, UK
| | - Jorge Coronel
- Laboratorio de Investigación de Enfermedades Infecciosas, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - David Moore
- TB Centre, London School of Hygiene and Tropical Medicine, London, UK.,Laboratorio de Investigación de Enfermedades Infecciosas, Universidad Peruana Cayetano Heredia, Lima, Peru.,Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London, UK
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25
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Burke RM, Maxwell B, Hunter C, Graham D, O'Donoghue D, Shields MD. Night-to-night variation of pulse oximetry in children with sleep-disordered breathing. Arch Dis Child 2016; 101:1095-1099. [PMID: 26969584 DOI: 10.1136/archdischild-2015-308981] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [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] [Received: 05/14/2015] [Revised: 02/15/2016] [Accepted: 02/21/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Sleep-disordered breathing is a common and serious feature of many paediatric conditions and is particularly a problem in children with Down syndrome. Overnight pulse oximetry is recommended as an initial screening test, but it is unclear how overnight oximetry results should be interpreted and how many nights should be recorded. METHODS This retrospective observational study evaluated night-to-night variation using statistical measures of repeatability for 214 children referred to a paediatric respiratory clinic, who required overnight oximetry measurements. This included 30 children with Down syndrome. We measured length of adequate trace, basal SpO2, number of desaturations (>4% SpO2 drop for >10 s) per hour ('adjusted index') and time with SpO2<90%. We classified oximetry traces into normal or abnormal based on physiology. RESULTS 132 out of 214 (62%) children had three technically adequate nights' oximetry, including 13 out of 30 (43%) children with Down syndrome. Intraclass correlation coefficient for adjusted index was 0.54 (95% CI 0.20 to 0.81) among children with Down syndrome and 0.88 (95% CI 0.84 to 0.91) for children with other diagnoses. Negative predictor value of a negative first night predicting two subsequent negative nights was 0.2 in children with Down syndrome and 0.55 in children with other diagnoses. CONCLUSIONS There is substantial night-to-night variation in overnight oximetry readings among children in all clinical groups undergoing overnight oximetry. This is a more pronounced problem in children with Down syndrome. Increasing the number of attempted nights' recording from one to three provides useful additional clinical information.
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Affiliation(s)
- Rachael M Burke
- Centre for Infection and Immunity, Queen's University Belfast, Belfast, UK.,Royal Belfast Hospital for Sick Children, Belfast Health & Social Care Trust, Belfast, UK
| | - Barbara Maxwell
- Royal Belfast Hospital for Sick Children, Belfast Health & Social Care Trust, Belfast, UK
| | - Carolyn Hunter
- Royal Belfast Hospital for Sick Children, Belfast Health & Social Care Trust, Belfast, UK
| | - David Graham
- Royal Belfast Hospital for Sick Children, Belfast Health & Social Care Trust, Belfast, UK
| | - Dara O'Donoghue
- Royal Belfast Hospital for Sick Children, Belfast Health & Social Care Trust, Belfast, UK
| | - Michael D Shields
- Centre for Infection and Immunity, Queen's University Belfast, Belfast, UK.,Royal Belfast Hospital for Sick Children, Belfast Health & Social Care Trust, Belfast, UK
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26
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Burke RM, McKenna JP, Cox C, Coyle PV, Shields MD, Fairley DJ. A comparison of different pre-lysis methods and extraction kits for recovery of Streptococcus agalacticae (Lancefield group B Streptococcus) DNA from whole blood. J Microbiol Methods 2016; 129:103-108. [DOI: 10.1016/j.mimet.2016.08.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 08/15/2016] [Accepted: 08/18/2016] [Indexed: 10/21/2022]
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27
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Affiliation(s)
- R M Burke
- Hospital for Tropical Diseases, Infection Division, University College London Hospitals FT, London, UK
| | - S Candfield
- Hospital for Tropical Diseases, Infection Division, University College London Hospitals FT, London, UK
| | - P Gothard
- Hospital for Tropical Diseases, Infection Division, University College London Hospitals FT, London, UK
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28
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Henry KE, Elfers CT, Burke RM, Chepurny OG, Holz GG, Blevins JE, Roth CL, Doyle RP. Vitamin B12 conjugation of peptide-YY(3-36) decreases food intake compared to native peptide-YY(3-36) upon subcutaneous administration in male rats. Endocrinology 2015; 156:1739-49. [PMID: 25658456 PMCID: PMC4398759 DOI: 10.1210/en.2014-1825] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [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: 02/07/2023]
Abstract
Challenges to peptide-based therapies include rapid clearance, ready degradation by hydrolysis/proteolysis, and poor intestinal uptake and/or a need for blood brain barrier transport. This work evaluates the efficacy of conjugation of vitamin B12 (B12) on sc administered peptide tyrosine tyrosine (PYY)(3-36) function. In the current experiments, a B12-PYY(3-36) conjugate was tested against native PYY(3-36), and an inactive conjugate B12-PYYC36 (null control) in vitro and in vivo. In vitro experiments demonstrated similar agonism for the neuropeptide Y2 receptor by the B12-PYY(3-36) conjugate (EC50 26.5 nM) compared with native PYY(3-36) (EC50 16.0 nM), with the null control having an EC50 of 1.8 μM. In vivo experiments were performed in young adult male Sprague Dawley rats (9 wk). Daily treatments were delivered sc in five 1-hour pulses, each pulse delivering 5-10 nmol/kg, by implanted microinfusion pumps. Increases in hindbrain Fos expression were comparable 90 minutes after B12-PYY(3-36) or PYY3-36 injection relative to saline or B12-PYYC36. Food intake was reduced during a 5-day treatment for both B12-PYY(3-36)- (24%, P = .001) and PYY(3-36)-(13%, P = .008) treated groups relative to baseline. In addition, reduction of food intake after the three dark cycle treatment pulses was more consistent with B12-PYY(3-36) treatment (-26%, -29%, -27%) compared with the PYY(3-36) treatment (-3%, -21%, -16%), and B12-PYY(3-36) generated a significantly longer inhibition of food intake vs. PYY(3-36) treatment after the first two pulses (P = .041 and P = .036, respectively). These findings demonstrate a stronger, more consistent, and longer inhibition of food intake after the pulses of B12-PYY(3-36) conjugate compared with the native PYY(3-36).
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Affiliation(s)
- Kelly E Henry
- Department of Chemistry (K.E.H., R.M.B., R.P.D.), Center for Science and Technology, Syracuse University, Syracuse, New York 13244; Center for Integrative Brain Research (C.T.E., C.L.R.), Division of Endocrinology, Seattle Children's Research Institute, Seattle, Washington 98101; Departments of Medicine (O.G.C., G.G.H., R.P.D.) and Pharmacology (G.G.H.), State University of New York, Upstate Medical University, Syracuse, New York 13210; Research and Development Service (J.E.B.), Veterans Affairs Puget Sound Health Care System, Seattle, Washington 98108; Department of Medicine (J.E.B.), Division of Metabolism, Endocrinology, and Nutrition, University of Washington, Seattle, Washington 98195; and Division of Endocrinology (C.L.R.), Department of Pediatrics, University of Washington, Seattle, Washington 98105
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29
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Mina MJ, Burke RM, Klugman KP. Estimating the prevalence of coinfection with influenza virus and the atypical bacteria Bordetella pertussis, Chlamydophila pneumoniae, and Mycoplasma pneumoniae. Eur J Clin Microbiol Infect Dis 2014; 33:1585-9. [PMID: 24789653 DOI: 10.1007/s10096-014-2120-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 04/09/2014] [Indexed: 01/22/2023]
Abstract
Coinfections with common bacterial respiratory pathogens and influenza viruses are well-known causes of disease, often via synergistic interactions between the influenza virus, the bacteria, and the human host. However, relatively little is known about interactions between atypical bacteria and influenza viruses. A recent report by Reinton et al. explored this issue by analyzing data from 3,661 patients seeking medical assistance for the presence of Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Bordetella pertussis, as well as influenza A or B virus in nasal swab specimens. The report, however, did not accurately assess the epidemiologic interactions of these pathogens. We aimed to describe the interactions between these bacterial species and influenza infections. Strong and highly statistically significant antagonistic interspecies interactions were detected between C. pneumoniae and influenza virus [odds ratio (OR): 0.09; p < 0.0001) and M. pneumoniae and influenza virus infections (OR: 0.29; p = 0.003). No association was detected between B. pertussis and influenza infection (p = 0.34), contrary to the initial report, and coinfection was not detected at a higher-than-by-chance frequency within the population. Further support of these results is supplied by the analysis of two earlier investigations reporting data on influenza virus and these atypical bacteria. Our results supplement the large body of literature regarding interactions between influenza virus and typical respiratory pathogens, providing a fuller picture of the spectrum of interactions between influenza viruses and respiratory bacteria. Further, we demonstrate the importance of choosing the most appropriate reference populations for the analysis being performed and describe the pitfalls that may occur when care is not taken in this regard.
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Affiliation(s)
- M J Mina
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, 08544, USA,
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30
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Doig AJ, Hughes E, Burke RM, Su TJ, Heenan RK, Lu J. Inhibition of toxicity and protofibril formation in the amyloid-beta peptide beta(25-35) using N-methylated derivatives. Biochem Soc Trans 2002; 30:537-42. [PMID: 12196132 DOI: 10.1042/bst0300537] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Beta (25-35) is a fragment of beta-amyloid that retains its wild-type properties. N-methylated derivatives of beta(25-35) can block hydrogen bonding on the outer edge of the assembling amyloid, so preventing the aggregation and inhibiting the toxicity of the wild-type peptide. The effects are assayed by Congo Red and thioflavin T binding, electron microscopy and an MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] toxicity assay. N-methyl-Gly-25 has similar properties to the wild- type, while five other methylation sites have varying effects on prefolded fibrils and fibril assembly. In particular, N-methyl-Gly-33 is able to completely prevent fibril assembly and reduces the toxicity of prefolded amyloid. With N-methyl-Leu-34 the fibril morphology is altered and toxicity reduced. A preliminary study of beta(25-35) structure in aqueous solution was made by small-angle neutron scattering (SANS). The protofibrillar aggregates are best described as a disc of radius 140 A and height 53 A (1 A = 0.1 nm), though the possibility of polydisperse aggregates cannot be ruled out. No aggregates form in the presence of N-methyl-Gly-33. We suggest that the use of N-methylated derivatives of amyloidogenic peptides and proteins could provide a general solution to the problem of amyloid deposition and toxicity and that SANS is an important technique for the direct observation of protofibril formation and destruction in solution.
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Affiliation(s)
- A J Doig
- Department of Biomolecular Sciences, UMIST, P.O. Box 88, Manchester M60 1QD, UK.
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31
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Burke RM, Cairney JWG. Laccases and other polyphenol oxidases in ecto- and ericoid mycorrhizal fungi. Mycorrhiza 2002; 12:105-116. [PMID: 12072980 DOI: 10.1007/s00572-002-0162-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2001] [Accepted: 02/12/2002] [Indexed: 05/23/2023]
Abstract
Polyphenol oxidases are known to be produced by a range of ectomycorrhizal (ECM) and ericoid mycorrhizal fungi. These enzymes include laccase (EC 1.10.3.2), catechol oxidase (EC 1.10.3.1) and tyrosinase (EC 1.14.18.1), between which there exists considerable overlap in substrate affinities. In this review we consider the nature and function of these enzymes, along with the difficulties associated with assigning precise enzymatic descriptions. The evidence for production of laccase and other polyphenol oxidases by ECM and ericoid mycorrhizal fungi is critically assessed and their potential significance to the mycorrhizal symbioses discussed.
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Affiliation(s)
- R M Burke
- Department of Biomolecular Sciences, UMIST, PO Box 88, Manchester, M60 1QD, UK
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32
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Lobashevsky AL, Senkbeil RW, Shoaf JL, Stephenson AK, Skelton SB, Burke RM, Deierhoi MH, Thomas JM. The number of amino acid residues mismatches correlates with flow cytometry crossmatching results in high PRA renal patients. Hum Immunol 2002; 63:364-74. [PMID: 11975980 DOI: 10.1016/s0198-8859(02)00371-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Highly sensitized renal transplant candidates present a group at high risk for acute and chronic rejection. The probability of finding compatible donors for these recipients is significantly lower in comparison to those who have low PRA values. As a consequence, these patients spend longer time on the waiting list and become tethered to dialysis. The results of final cross match (XM) are critical for making a decision about whether such a candidate receives an organ or not. The degree of donor and recipient HLA compatibility predicts the results of XM. The goal of this study was to expand a variety of acceptable HLA-AB mismatches (MM) for high PRA kidney recipients using the HLAMATCHMAKER algorithm. This strategy focuses on the fine structural features of HLA polymorphism comprising amino acid residues or triplets (AAT), which are located in alpha-helical coils of HLA molecules and are available to antibodies. We analyzed serum samples from thirty-nine highly alloimmunized recipients (PRA > or = 85%). The level of sensitization was detected using FlowPRA Class I Screening Test. This group of transplant candidates included thirteen recipients who demonstrated negative results of final T/B FCXM and twenty-six, who were FCXM positive. The application of the HLAMATCHMAKER algorithm based on the HLA class I donor and recipient typing allowed us to detect the total number of AATMM as well as the number of immunogenic AAT in both FCXM negative and FCXM positive groups of recipients. Significantly greater numbers of both total and highly immunogenic AATMM have been emerged in the group of FCXM positive patients. Furthermore, the results of this analysis have shown a high degree of probability of positive FCXM if the number of highly immunogenic AATMM was > or = 1 (chi(2) = 22.9 Yate's correction; p = 0.000001). We did not observe overlapping between antibody specificity and permissible HLA-AB MM detected using the HLAMATCHMAKER strategy. Thus, the number of highly immunogenic AATMM can serve as a reliable predictive value for final FCXM results in highly sensitized renal transplant candidates. The HLAMATCHMAKER algorithm appears to be the proper strategy to find donors for high PRA recipients.
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Affiliation(s)
- A L Lobashevsky
- Tissue Typing Laboratory, University of Alabama Hospitals, Birmingham, AL 35294, USA.
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33
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Hughes E, Burke RM, Doig AJ. Inhibition of toxicity in the beta-amyloid peptide fragment beta -(25-35) using N-methylated derivatives: a general strategy to prevent amyloid formation. J Biol Chem 2000; 275:25109-15. [PMID: 10825171 DOI: 10.1074/jbc.m003554200] [Citation(s) in RCA: 177] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
beta-(25-35) is a synthetic derivative of beta-amyloid, the peptide that is believed to cause Alzheimer's disease. As it is highly toxic and forms fibrillar aggregates typical of beta-amyloid, it is suitable as a model for testing inhibitors of aggregation and toxicity. We demonstrate that N-methylated derivatives of beta-(25-35), which in isolation are soluble and non-toxic, can prevent the aggregation and inhibit the resulting toxicity of the wild type peptide. N-Methylation can block hydrogen bonding on the outer edge of the assembling amyloid. The peptides are assayed by Congo red and thioflavin T binding, electron microscopy, and a 3-(4, 5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) toxicity assay on PC12 cells. One peptide (Gly(25) N-methylated) has properties similar to the wild type, whereas five have varying effects on prefolded fibrils and fibril assembly. In particular, beta-(25-35) with Gly(33) N-methylated is able to completely prevent fibril assembly and to reduce the toxicity of prefolded amyloid. With Leu(34) N-methylated, the fibril morphology is altered and the toxicity reduced. We suggest that the use of N-methylated derivatives of amyloidogenic peptides and proteins could provide a general solution to the problem of amyloid deposition and toxicity.
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Affiliation(s)
- E Hughes
- Department of Biomolecular Sciences, University of Manchester Institute of Science and Technology, United Kingdom
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34
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Clegg PD, Burke RM, Coughlan AR, Riggs CM, Carter SD. Characterisation of equine matrix metalloproteinase 2 and 9; and identification of the cellular sources of these enzymes in joints. Equine Vet J 1997; 29:335-42. [PMID: 9306058 DOI: 10.1111/j.2042-3306.1997.tb03136.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The cellular production by resident articular cells and infiltrating inflammatory cells of the gelatinase matrix metalloproteinases (MMP) was investigated by tissue culture methods and analysis of cell supernatants by gelatin zymography. Peripheral blood neutrophils in short term culture produced MMP-9, as did peripheral blood monocytes in culture. Isolated articular chondrocytes in monolayer culture produced both MMP-2 and MMP-9, although articular cartilage maintained as explant culture produced MMP-2 alone. Synovial fibroblasts grown in monolayer culture produced MMP-2 alone, although synovial membrane in explant culture produced both MMP-2 and the active form of MMP-2. Lysis of blood polymorph neutrophils produced large quantities of MMP-9, but lysis of blood monocytes, synovial fibroblasts and articular chondrocytes produced little enzyme indicating that, unlike the other cell types, polymorph neutrophils store MMPs intracellularly. Equine MMP-2 was purified from synovial fibroblast cell culture supernatant, and equine MMP-9 from polymorph neutrophil cell culture supernatant, by gelatin-sepharose affinity chromatography. The 2 enzymes were identified from their molecular weights and by their respective N-terminal amino acid sequences which showed homology with the enzymes from other species. The demonstration that invasive cells and resident articular cells can produce enzymes which are capable of digestion of certain component molecules of the articular cartilage matrix, shows that therapeutic targeting of these enzymes could be a valid proposition in the prevention of cartilage destruction in osteoarthritis.
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Affiliation(s)
- P D Clegg
- Department of Veterinary Clinical Science and Animal Husbandry, University Veterinary Teaching Hospital, University of Liverpool, Leahurst, UK
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35
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Cairney JWG, Burke RM. Physiological heterogeneity within fungal mycelia: an important concept for a functional understanding of the ectomycorrhizal symbiosis. New Phytol 1996; 134:685-695. [PMID: 33863201 DOI: 10.1111/j.1469-8137.1996.tb04934.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Individual mycelia of filamentous fungi display considerable heterogeneity at the physiological level. Important physiological processes such as nutrient absorption, extracellular enzyme secretion and solute translocation occur differentially within an individual mycelium, and vary according to spatio-temporal changes in patterns of gene expression as the mycelium develops and senesces. In ectomycorrhizal (ECM) fungi, gene expression appears to be strongly influenced by interaction with the soil environment and the host root. The ECM mycelium is thus a complex and dynamic entity wherein discrete regions display particular physiological attributes. Physiological heterogeneity is important in the overall functioning of the symbiosis. In the particular case of movement of phosphorus from soil to host root in the ECM symbiosis, heterogeneity might provide the driving force for the integrated processes of absorption, translocation and transfer. It is suggested that it is only by considering the sum of the seemingly disparate physiological processes within the heterogeneous mycelium that mycorrhizal functioning can be fully understood.
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Affiliation(s)
- J W G Cairney
- Department of Biological Sciences, University of Western Sydney (Nepean), PO Box 10, Kingswood, NSW 2747, Australia
| | - R M Burke
- Department of Biochemistry & Applied Molecular Biology, UMIST, PO Box 88, Manchester M60 1QD, UK
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Abstract
The role of ischemia in the development of reversible late potentials was assessed in 19 patients undergoing percutaneous transluminal coronary angioplasty. Signal-averaged electrocardiograms were performed before angioplasty, during ischemia caused by balloon inflation and after angioplasty. Five of 19 patients developed late potentials that reverted to normal after angioplasty. Age, sex, ejection fraction, left ventricular end diastolic pressure, vessels involved, and extent of myocardium in jeopardy did not predict the development of late potentials. Patients with a prior history of myocardial infarction were more likely to develop late potentials. Therefore, patients with prior myocardial infarction appear more likely to develop the substrate for reentrant ventricular tachycardia during periods of ischemia.
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Affiliation(s)
- D A Rubin
- Division of Cardiology, Westchester County Medical Center, New York Medical College, Valhalla 10595
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Abstract
Bacillus stearothermophilus grew readily on glycerol in carbon-limited chemostat culture and expressed a high carbon conversion efficiency. However, the strain of organism used (probably B. stearothermophilus var. nondiastaticus) proved particularly sensitive to glycerol, both respiration and growth being severely impeded by any surfeit of this compound. Sensitivity was found to correlate with an exceptionally high level of expression of glycerol kinase [activities of more than 80 mumol min-1 (mg protein)-1 were manifest in crude cell-free extracts], coupled with low activities of methylglyoxal synthase and of glyoxylase (enzymes of the methylglyoxal bypass). It is proposed that metabolic dysfunction results from an uncontrolled gross accumulation of glycerol phosphate (and early products of its metabolism) within the cells, coupled with depletion of the intracellular phosphate pool.
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Affiliation(s)
- R M Burke
- Department of Molecular Biology and Biotechnology, University of Sheffield, UK
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Burke RM, Schwartz LP, Snider DE. The Ottawa County project: a report of a tuberculosis screening project in a small mining community. Am J Public Health 1979; 69:340-7. [PMID: 426159 PMCID: PMC1619039 DOI: 10.2105/ajph.69.4.340] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Following a retrospective review of tuberculosis cases reported from Ottawa County, Oklahoma, from 1969 through 1973, a selective tuberculosis screening project was implemented. Screening of a "target group" of the population, 519 former miners, greater than or equal to 50 years of age, resulted in the discovery of abnormal chest X-rays in 182; (103 with silicosis, 36 with silicotuberculosis, 12 with inactive tuberculosis, and 31 with other abnormalities). Eighty-five of these persons had positive tuberculin skin tests. Preventive therapy was recommended for 50, and 36 completed the prescribed course of treatment. Eight new bacteriologically confirmed cases of tuberculosis were found and treated. A large number of persons (1,904) residing in the same area who were not part of the target group were also screened for tuberculosis. This group contained a large number of positive tuberculin reactors but very few were candidates for isoniazid preventive therapy. Thirteen persons in this group had abnormal chest X-rays consistent with inactive tuberculosis but 12 had been identified and given preventive therapy before the project began. These data suggest that selective approaches to screening for tuberculosis in a community which are based on an in-depth retrospective review of the tuberculosis case register can be highly successful.
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Fogan L, Burke RM. Review of patients readmitted to Oklahoma State Tuberculosis Sanatoria. J Okla State Med Assoc 1968; 61:212-216. [PMID: 5653489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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