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Cherkos AS, Cranmer LM, Njuguna I, LaCourse SM, Mugo C, Moraa H, Maleche-Obimbo E, Enquobahrie DA, Richardson BA, Wamalwa D, John-Stewart G. Effect of tuberculosis-HIV co-treatment on clinical and growth outcomes among hospitalized children newly initiating antiretroviral therapy. AIDS 2024; 38:579-588. [PMID: 38016160 PMCID: PMC10922257 DOI: 10.1097/qad.0000000000003797] [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] [Indexed: 11/30/2023]
Abstract
OBJECTIVE Evaluate effects of tuberculosis (TB)-HIV co-treatment on clinical and growth outcomes in children with HIV (CHIV). DESIGN Longitudinal study among Kenyan hospitalized ART-naive CHIV in the PUSH trial (NCT02063880). METHODS CHIV started ART within 2 weeks of enrollment; Anti-TB therapy was initiated based on clinical and TB diagnostics. Children were followed for 6 months with serial viral load, CD4%, and growth assessments [weight-for-age z -score (WAZ), height-for-age z -score (HAZ), and weight-for-height z -score (WHZ)]. TB-ART treated and ART-only groups were compared at 6 months post-ART for undetectable viral load (<40 c/ml), CD4% change, and growth using generalized linear models, linear regression, and linear mixed-effects models, respectively. RESULT Among 152 CHIV, 40.8% (62) were TB-ART treated. Pre-ART, median age was 2.0 years and growth was significantly lower, and viral load significantly higher in the TB-ART versus ART-only group. After 6 months on ART, 37.2% of CHIV had undetectable viral load and median CD4% increased by 7.2% (IQR 2.0-11.6%) with no difference between groups. The TB-ART group had lower WAZ and HAZ over 6 month follow-up [WAZ -0.81 (95% CI: -1.23 to -0.38], P < 0.001; HAZ -0.15 (95% CI: -0.29 to -0.01), P = 0.030] and greater rate of WAZ increase in analyses unadjusted and adjusted for baseline WAZ [unadjusted 0.62 (95% CI: 0.18-1.07, P = 0.006) or adjusted 0.58 (95% CI: 0.12-1.03, P = 0.013)]. CONCLUSION TB-HIV co-treatment did not adversely affect early viral suppression and CD4 + recovery post-ART. TB-ART-treated CHIV had more rapid growth reconstitution, but growth deficits persisted, suggesting need for continued growth monitoring.
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Affiliation(s)
- Ashenafi S Cherkos
- Department of Population and Community Health, School of Public Health, University of North Texas Health Science Center, Fort Worth, TX
| | - Lisa M Cranmer
- Department of Pediatrics, Emory School of Medicine
- Department of Epidemiology, Emory Rollins School of Public Health
- Children's Healthcare of Atlanta, Atlanta, GA
| | - Irene Njuguna
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
- Medical Research Department, Kenyatta National Hospital, Nairobi, Kenya
| | - Sylvia M LaCourse
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Cyrus Mugo
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
| | - Hellen Moraa
- Department of Pediatrics and Child Health, University of Nairobi, Kenya
| | | | - Daniel A Enquobahrie
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
| | - Barbra A Richardson
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
- Department of Biostatistics, School of Public Health
| | - Dalton Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Kenya
| | - Grace John-Stewart
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
- Medical Research Department, Kenyatta National Hospital, Nairobi, Kenya
- Department of Pediatrics, University of Washington, Seattle, WA, USA
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Quincer EM, Cranmer LM, Kamidani S. Prenatal Maternal Immunization for Infant Protection: A Review of the Vaccines Recommended, Infant Immunity and Future Research Directions. Pathogens 2024; 13:200. [PMID: 38535543 PMCID: PMC10975994 DOI: 10.3390/pathogens13030200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/12/2024] [Accepted: 02/17/2024] [Indexed: 04/01/2024] Open
Abstract
Prenatal maternal immunization is an effective tool to protect mothers and infants from poor health outcomes due to infectious diseases. We provide an overview of the rationale for the use of prenatal vaccines, discuss the immunologic environment of the maternal-fetal interface including the impact of maternal vaccines prenatally and subsequently on the infant's immune response, and review vaccines currently recommended in pregnancy and landscape for the future of maternal vaccination. This review aims to provide an understanding of the recent history and progress made in the field and highlight the importance of continued research and development into new vaccines for pregnant populations.
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Affiliation(s)
- Elizabeth M. Quincer
- Immunization Safety Office, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Lisa M. Cranmer
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA 30322, USA
| | - Satoshi Kamidani
- Immunization Safety Office, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
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Quincer EM, Lyland A, Onyango D, LaCourse SM, Figueroa J, John-Stewart GC, Cranmer LM. The effect of antenatal isoniazid preventive therapy on birth outcomes in Western Kenya. Int J Tuberc Lung Dis 2023; 27:906-911. [PMID: 38042967 PMCID: PMC11057228 DOI: 10.5588/ijtld.23.0134] [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] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND: Pregnant women living with HIV (WLHIV) are at high risk for TB. There are limited data to inform whether TB preventive therapy is safe in pregnancy.METHODS: We completed a retrospective study of antenatal and birth records of mother-infant dyads at two health care facilities in Kisumu, Kenya. Among pregnant WLHIV, we assessed the relationship of antenatal isoniazid preventive therapy (IPT) with birth outcomes (preterm birth, low birth weight [LBW], congenital anomalies, and perinatal death).RESULTS: Of 576 mother-infant pairs, most women were on antiretroviral therapy (574, 99.7%) with viral suppression (518, 89.9%) and one-quarter had IPT exposure during pregnancy (152, 26.4%). The prevalence of preterm birth was lower among women with antenatal IPT exposure (21% vs. 30%; P = 0.03). LBW, congenital anomaly and perinatal death were not associated with antenatal IPT; however, we observed a trend toward fewer composite poor birth outcomes among women taking antenatal IPT (26% vs 33%; P = 0.08). Controlling for maternal age and viral load, IPT use during pregnancy was associated with lower odds of preterm birth (aOR 0.62, 95% CI 0.40-0.98; P = 0.04).CONCLUSION: In a programmatic setting in Western Kenya, IPT use was not associated with adverse birth outcomes.
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Affiliation(s)
- E M Quincer
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
| | - A Lyland
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, Nell Hodgson Woodruff School of Nursing at Emory University, Atlanta, GA, USA
| | - D Onyango
- Kisumu County Department of Health, Kisumu, Kenya
| | - S M LaCourse
- Departments of Medicine, Departments of Epidemiology, Department of Global Health, and
| | - J Figueroa
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
| | - G C John-Stewart
- Departments of Medicine, Departments of Epidemiology, Department of Global Health, and, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - L M Cranmer
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
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Nelson KN, Shah NS, Cranmer LM, Vasudevan L, Bednarczyk RA. An effective vaccine is only the first step: the need to create and sustain demand for TB vaccines. Int J Tuberc Lung Dis 2023; 27:718-720. [PMID: 37749838 PMCID: PMC10519388 DOI: 10.5588/ijtld.23.0365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 08/07/2023] [Indexed: 09/27/2023] Open
Affiliation(s)
- K N Nelson
- Department of Epidemiology, Emory University Rollins School of Public Health
| | - N S Shah
- Department of Epidemiology, Emory University Rollins School of Public Health, Department of Global Health, Emory University Rollins School of Public Health, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - L M Cranmer
- Department of Epidemiology, Emory University Rollins School of Public Health, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - L Vasudevan
- Department of Global Health, Emory University Rollins School of Public Health
| | - R A Bednarczyk
- Department of Epidemiology, Emory University Rollins School of Public Health, Department of Global Health, Emory University Rollins School of Public Health
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Gunasekera KS, Marcy O, Muñoz J, Lopez-Varela E, Sekadde MP, Franke MF, Bonnet M, Ahmed S, Amanullah F, Anwar A, Augusto O, Aurilio RB, Banu S, Batool I, Brands A, Cain KP, Carratalá-Castro L, Caws M, Click ES, Cranmer LM, García-Basteiro AL, Hesseling AC, Huynh J, Kabir S, Lecca L, Mandalakas A, Mavhunga F, Myint AA, Myo K, Nampijja D, Nicol MP, Orikiriza P, Palmer M, Sant'Anna CC, Siddiqui SA, Smith JP, Song R, Thuong Thuong NT, Ung V, van der Zalm MM, Verkuijl S, Viney K, Walters EG, Warren JL, Zar HJ, Marais BJ, Graham SM, Debray TPA, Cohen T, Seddon JA. Development of treatment-decision algorithms for children evaluated for pulmonary tuberculosis: an individual participant data meta-analysis. Lancet Child Adolesc Health 2023; 7:336-346. [PMID: 36924781 PMCID: PMC10127218 DOI: 10.1016/s2352-4642(23)00004-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/06/2023] [Accepted: 01/10/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Many children with pulmonary tuberculosis remain undiagnosed and untreated with related high morbidity and mortality. Recent advances in childhood tuberculosis algorithm development have incorporated prediction modelling, but studies so far have been small and localised, with limited generalisability. We aimed to evaluate the performance of currently used diagnostic algorithms and to use prediction modelling to develop evidence-based algorithms to assist in tuberculosis treatment decision making for children presenting to primary health-care centres. METHODS For this meta-analysis, we identified individual participant data from a WHO public call for data on the management of tuberculosis in children and adolescents and referral from childhood tuberculosis experts. We included studies that prospectively recruited consecutive participants younger than 10 years attending health-care centres in countries with a high tuberculosis incidence for clinical evaluation of pulmonary tuberculosis. We collated individual participant data including clinical, bacteriological, and radiological information and a standardised reference classification of pulmonary tuberculosis. Using this dataset, we first retrospectively evaluated the performance of several existing treatment-decision algorithms. We then used the data to develop two multivariable prediction models that included features used in clinical evaluation of pulmonary tuberculosis-one with chest x-ray features and one without-and we investigated each model's generalisability using internal-external cross-validation. The parameter coefficient estimates of the two models were scaled into two scoring systems to classify tuberculosis with a prespecified sensitivity target. The two scoring systems were used to develop two pragmatic, treatment-decision algorithms for use in primary health-care settings. FINDINGS Of 4718 children from 13 studies from 12 countries, 1811 (38·4%) were classified as having pulmonary tuberculosis: 541 (29·9%) bacteriologically confirmed and 1270 (70·1%) unconfirmed. Existing treatment-decision algorithms had highly variable diagnostic performance. The scoring system derived from the prediction model that included clinical features and features from chest x-ray had a combined sensitivity of 0·86 [95% CI 0·68-0·94] and specificity of 0·37 [0·15-0·66] against a composite reference standard. The scoring system derived from the model that included only clinical features had a combined sensitivity of 0·84 [95% CI 0·66-0·93] and specificity of 0·30 [0·13-0·56] against a composite reference standard. The scoring system from each model was placed after triage steps, including assessment of illness acuity and risk of poor tuberculosis-related outcomes, to develop treatment-decision algorithms. INTERPRETATION We adopted an evidence-based approach to develop pragmatic algorithms to guide tuberculosis treatment decisions in children, irrespective of the resources locally available. This approach will empower health workers in primary health-care settings with high tuberculosis incidence and limited resources to initiate tuberculosis treatment in children to improve access to care and reduce tuberculosis-related mortality. These algorithms have been included in the operational handbook accompanying the latest WHO guidelines on the management of tuberculosis in children and adolescents. Future prospective evaluation of algorithms, including those developed in this work, is necessary to investigate clinical performance. FUNDING WHO, US National Institutes of Health.
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Affiliation(s)
- Kenneth S Gunasekera
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA.
| | - Olivier Marcy
- Inserm UMR1219, Institut de Recherche pour le Développement EMR 271, GHiGS, University of Bordeaux, Bordeaux, France
| | - Johanna Muñoz
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Elisa Lopez-Varela
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique; Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | | | - Molly F Franke
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Maryline Bonnet
- University of Montpellier, TransVIHMI, Institut de Recherche pour le Développement, Inserm, Montpellier, France; Epicentre, Mbarara, Uganda
| | - Shakil Ahmed
- Department of Paediatrics, Dhaka Medical College Hospital, Dhaka, Bangladesh
| | - Farhana Amanullah
- Indus Hospital & Health Network, Karachi, Pakistan; The Aga Khan University Hospital, Karachi, Pakistan
| | - Aliya Anwar
- Indus Hospital & Health Network, Karachi, Pakistan
| | - Orvalho Augusto
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Rafaela Baroni Aurilio
- Instituto de Puericultura e Pediatria Martagao Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Sayera Banu
- Programme on Emerging Infections, Infectious Disease Division, icddr,b, Dhaka, Bangladesh
| | - Iraj Batool
- Indus Hospital & Health Network, Karachi, Pakistan
| | | | - Kevin P Cain
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lucía Carratalá-Castro
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Maxine Caws
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Birat Nepal Medical Trust, Lazmipat, Kathmandu, Nepal
| | - Eleanor S Click
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lisa M Cranmer
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA, USA; Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA, USA; Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Alberto L García-Basteiro
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Barcelona, Spain
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Julie Huynh
- Oxford University Clinical Research Unit, Centre for Tropical Diseases, Ho Chi Minh City, Viet Nam; Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Senjuti Kabir
- Programme on Emerging Infections, Infectious Disease Division, icddr,b, Dhaka, Bangladesh
| | - Leonid Lecca
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Socios En Salud Surcursal Perú, Lima, Perú
| | - Anna Mandalakas
- Global TB Program, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA; Clinical Infectious Disease Group, German Center for Infectious Research, Clinical TB Unit, Research Center Borstel, Borstel, Germany
| | | | - Aye Aye Myint
- Department of Paediatrics, University of Medicine, Mandalay, Myanmar
| | - Kyaw Myo
- Department of Paediatrics, University of Medicine, Magway, Myanmar
| | - Dorah Nampijja
- Department of Paediatrics, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mark P Nicol
- Division of Infection and Immunity, Department of Biomedical Sciences, University of Western Australia, Perth, WA, Australia
| | - Patrick Orikiriza
- Epicentre, Mbarara, Uganda; Department of Microbiology, Division of Basic Medical Sciences, School of Medicine, University of Global Health Equity, Kigali, Rwanda
| | - Megan Palmer
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | | | - Sara Ahmed Siddiqui
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Indus Hospital & Health Network, Karachi, Pakistan
| | - Jonathan P Smith
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA; US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Rinn Song
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA; Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Nguyen Thuy Thuong Thuong
- Oxford University Clinical Research Unit, Centre for Tropical Diseases, Ho Chi Minh City, Viet Nam; Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Vibol Ung
- University of Health Sciences, Phnom Penh, Cambodia; National Pediatric Hospital, Phnom Penh, Cambodia
| | - Marieke M van der Zalm
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | | | - Kerri Viney
- Global Tuberculosis Programme, WHO, Geneva, Switzerland; School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Elisabetta G Walters
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa; Directorate of Integrated Laboratory Medicine, Institute of Human Genetics, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Joshua L Warren
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross Children's Hospital, and SA-MRC Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Ben J Marais
- The Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Stephen M Graham
- Department of Paediatrics and Murdoch Children's Research Institute, Royal Children's Hospital, University of Melbourne, Melbourne, VIC, Australia; Burnet Institute, Melbourne, VIC, Australia
| | - Thomas P A Debray
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa; Department of Infectious Diseases, Imperial College London, London, UK
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LaCourse SM, Escudero JN, Mecha J, Warr AJ, Richardson BA, Carimo N, Cranmer LM, Maleche-Obimbo E, Matemo D, Kinuthia J, Hawn TR, John-Stewart G. Cumulative Mycobacterium tuberculosis Infection Incidence (Measured Primarily by Tuberculin Skin Test) Among Infants With Human Immunodeficiency Virus Exposure: Observational Follow-up of an Isoniazid Prophylaxis Trial. Clin Infect Dis 2022; 75:2253-2256. [PMID: 35607710 PMCID: PMC10200296 DOI: 10.1093/cid/ciac393] [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: 02/25/2022] [Revised: 05/05/2022] [Accepted: 05/17/2022] [Indexed: 01/19/2023] Open
Abstract
Cumulative 24-month Mycobacterium tuberculosis infection incidence (measured primarily by tuberculin skin test [TST]) was high among human immunodeficiency virus exposed but uninfected infants (8.7 [95% confidence interval, 6.3-11.9] per 100 person-years). Trend for decreased TST positivity among infants at trial end (12 months postenrollment) randomized to isoniazid at 6 weeks of age was not sustained through observational follow-up to 24 months of age. CLINICAL TRIALS REGISTRATION NCT02613169.
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Affiliation(s)
- Sylvia M LaCourse
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Jaclyn N Escudero
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Jerphason Mecha
- Medical Research Department, Kenyatta National Hospital, Nairobi, Kenya
| | - A J Warr
- Department of Pediatrics and Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Naziat Carimo
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Lisa M Cranmer
- Division of Infectious Diseases, Department of Pediatrics, Emory University, Atlanta, Georgia, USA
- Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Elizabeth Maleche-Obimbo
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Daniel Matemo
- Medical Research Department, Kenyatta National Hospital, Nairobi, Kenya
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Medical Research Department, Kenyatta National Hospital, Nairobi, Kenya
- Department of Reproductive Health, Kenyatta National Hospital, Nairobi, Kenya
| | - Thomas R Hawn
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Grace John-Stewart
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
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Malik AA, Gandhi NR, Marcy O, Walters E, Tejiokem M, Chau GD, Omer SB, Lash TL, Becerra MC, Njuguna IN, LaCourse SM, Maleche-Obimbo E, Wamalwa D, John-Stewart GC, Cranmer LM. Development of a Clinical Prediction Score Including Monocyte-to-Lymphocyte Ratio to Inform Tuberculosis Treatment Among Children With HIV: A Multicountry Study. Open Forum Infect Dis 2022; 9:ofac548. [PMID: 36381621 PMCID: PMC9645646 DOI: 10.1093/ofid/ofac548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 10/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background Clinical pediatric tuberculosis (TB) diagnosis may lead to overdiagnosis particularly among children with human immunodeficiency virus (CHIV). We assessed the performance of monocyte-lymphocyte ratio (MLR) as a diagnostic biomarker and constructed a clinical prediction score to improve specificity of TB diagnosis in CHIV with limited access to microbiologic testing. Methods We pooled data from cohorts of children aged ≤13 years from Vietnam, Cameroon, and South Africa to validate the use of MLR ≥0.378, previously found as a TB diagnostic marker among CHIV. Using multivariable logistic regression, we created an internally validated prediction score for diagnosis of TB disease in CHIV. Results The combined cohort had 601 children (median age, 1.9 [interquartile range, 0.9-5.3] years); 300 (50%) children were male, and 283 (47%) had HIV. Elevated MLR ≥0.378 had sensitivity of 36% (95% confidence interval [CI], 23%-51%) and specificity of 79% (95% CI, 71%-86%) among CHIV in the validation cohort. A model using MLR ≥0.28, age ≥4 years, tuberculin skin testing ≥5 mm, TB contact history, fever >2 weeks, and chest radiograph suggestive of TB predicted active TB disease in CHIV with an area under the receiver operating characteristic curve of 0.85. A prediction score of ≥5 points had a sensitivity of 94% and specificity of 48% to identify confirmed TB, and a sensitivity of 82% and specificity of 48% to identify confirmed and unconfirmed TB groups combined. Conclusions Our score has comparable sensitivity and specificity to algorithms including microbiological testing and should enable clinicians to rapidly initiate TB treatment among CHIV when microbiological testing is unavailable.
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Affiliation(s)
- Amyn A Malik
- Correspondence: Amyn A. Malik, PhD, Yale Institute for Global Health, 1 Church St, Suite 340, New Haven, CT 06510 ()
| | - Neel R Gandhi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Olivier Marcy
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
- Centre INSERM U1219, Bordeaux Population Health, University of Bordeaux, Bordeaux, France
| | - Elisabetta Walters
- Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- John Walton Muscular Dystrophy Research Centre, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | | | | | - Saad B Omer
- Yale Institute for Global Health, New Haven, Connecticut, USA
- Yale School of Medicine, New Haven, Connecticut, USA
- Yale School of Public Health, New Haven, Connecticut, USA
| | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Mercedes C Becerra
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Partners In Health, Boston, Massachusetts, USA
| | - Irene N Njuguna
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Sylvia M LaCourse
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | | | - Dalton Wamalwa
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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8
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Cranmer LM, Njuguna IN, LaCourse SM, Figueroa J, Gillespie S, Maleche-Obimbo E, Otieno V, Mugo C, Okinyi H, Benki-Nugent S, Pavlinac PB, Malik AA, Gandhi NR, Richardson BA, Stern J, Wamalwa DC, John-Stewart GC. Brief Report: Performance of Tuberculosis Symptom Screening Among Hospitalized ART-Naive Children With HIV in Kenya. J Acquir Immune Defic Syndr 2022; 91:280-284. [PMID: 36166517 PMCID: PMC9588620 DOI: 10.1097/qai.0000000000003060] [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: 02/03/2022] [Accepted: 06/20/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The World Health Organization (WHO) recommends tuberculosis (TB) diagnostic evaluation for children with HIV (CHIV) who have history of TB contact, poor weight gain, cough, or fever. These screening criteria were developed based on studies of symptomatic CHIV with incomplete microbiologic confirmation. We performed routine TB microbiologic evaluation of hospitalized CHIV with and without symptoms to develop a data-driven TB symptom screen. METHODS Among hospitalized antiretroviral therapy-naive Kenyan CHIV enrolled in the Pediatric Urgent Start of Highly Active Antiretroviral Therapy (PUSH) trial, we performed Xpert MTB/RIF and mycobacterial culture of respiratory and stool specimens independent of TB symptoms. We evaluated performance of WHO and other published pediatric TB screening criteria and derived optimized criteria using a combination of symptoms. RESULTS Of 168 CHIV who underwent TB microbiologic evaluation, 13 (8%) had confirmed TB. WHO TB symptom screening had 100% sensitivity and 4% specificity to detect confirmed TB. Published TB screening criteria that relied on prolonged symptoms missed cases of confirmed TB (sensitivity 85%-92%). An optimized symptom screen including weight loss, cough, anorexia, or TB contact had 100% sensitivity and improved specificity (31%) compared with the WHO pediatric TB symptom screen. CONCLUSIONS The WHO TB symptom screen was highly sensitive but resulted in a high proportion of hospitalized CHIV who would require TB diagnostic evaluation. Other published TB screening criteria missed CHIV with confirmed TB. Our optimized screening tool increased specificity while preserving sensitivity. Future multicenter studies are needed to improve TB screening tools for CHIV in both inpatient and outpatient settings.
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Affiliation(s)
- Lisa M. Cranmer
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Children’s Healthcare of Atlanta, Atlanta, GA, USA
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA, USA
| | - Irene N. Njuguna
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Sylvia M. LaCourse
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | | | | | | | - Vincent Otieno
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Cyrus Mugo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Helen Okinyi
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | | | - Amyn A. Malik
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Yale Institute for Global Health, New Haven, CT, USA
| | - Neel R. Gandhi
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA, USA
| | - Barbara A. Richardson
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Joshua Stern
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Dalton C. Wamalwa
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Grace C. John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
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9
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Miner MD, Hatherill M, Mave V, Gray GE, Nachman S, Read SW, White RG, Hesseling A, Cobelens F, Patel S, Frick M, Bailey T, Seder R, Flynn J, Rengarajan J, Kaushal D, Hanekom W, Schmidt AC, Scriba TJ, Nemes E, Andersen-Nissen E, Landay A, Dorman SE, Aldrovandi G, Cranmer LM, Day CL, Garcia-Basteiro AL, Fiore-Gartland A, Mogg R, Kublin JG, Gupta A, Churchyard G. Developing tuberculosis vaccines for people with HIV: consensus statements from an international expert panel. Lancet HIV 2022; 9:e791-e800. [PMID: 36240834 PMCID: PMC9667733 DOI: 10.1016/s2352-3018(22)00255-7] [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: 04/01/2022] [Revised: 08/16/2022] [Accepted: 08/30/2022] [Indexed: 11/06/2022]
Abstract
New tuberculosis vaccine candidates that are in the development pipeline need to be studied in people with HIV, who are at high risk of acquiring Mycobacterium tuberculosis infection and tuberculosis disease and tend to develop less robust vaccine-induced immune responses. To address the gaps in developing tuberculosis vaccines for people with HIV, a series of symposia was held that posed six framing questions to a panel of international experts: What is the use case or rationale for developing tuberculosis vaccines? What is the landscape of tuberculosis vaccines? Which vaccine candidates should be prioritised? What are the tuberculosis vaccine trial design considerations? What is the role of immunological correlates of protection? What are the gaps in preclinical models for studying tuberculosis vaccines? The international expert panel formulated consensus statements to each of the framing questions, with the intention of informing tuberculosis vaccine development and the prioritisation of clinical trials for inclusion of people with HIV.
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Affiliation(s)
| | - Mark Hatherill
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Vidya Mave
- Johns Hopkins India, Byramjee-Jeejeebhoy Government Medical College Clinical Research Site, Pune, India
| | - Glenda E Gray
- South African Medical Research Council, Cape Town, South Africa
| | - Sharon Nachman
- Department of Pediatrics, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Sarah W Read
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Richard G White
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Anneke Hesseling
- Desmond Tutu Tuberculosis Centre, Stellenbosch University, Stellenbosch, South Africa
| | - Frank Cobelens
- Department of Global Health, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Sheral Patel
- US Food and Drug Administration, Silver Spring, MD, USA
| | - Mike Frick
- Treatment Action Group, New York, NY, USA
| | | | - Robert Seder
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Joanne Flynn
- Microbiology and Molecular Genetics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Deepak Kaushal
- Texas Biomedical Research Institute, San Antonio, TX, USA
| | - Willem Hanekom
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | | | - Thomas J Scriba
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Elisa Nemes
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Erica Andersen-Nissen
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Cape Town HIV Vaccine Trials Network (HVTN) Immunology Laboratory, Cape Town, South Africa
| | | | - Susan E Dorman
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Grace Aldrovandi
- Department of Pediatrics, University of California, Los Angeles, CA, USA
| | - Lisa M Cranmer
- Emory School of Medicine, Emory University, Atlanta, GA, USA
| | - Cheryl L Day
- Emory School of Medicine, Emory University, Atlanta, GA, USA
| | - Alberto L Garcia-Basteiro
- ISGlobal, Hospital Clínic Universitat de Barcelona, Barcelona, Spain; Centro de investigação de Saúde de Manhiça, Maputo, Mozambique
| | | | - Robin Mogg
- Takeda Pharmaceutical Company, Cambridge, MA, USA
| | - James G Kublin
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Amita Gupta
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gavin Churchyard
- The Aurum Institute, Johannesburg, South Africa; School of Public Health, University of Witwatersrand, Johannesburg, South Africa; Department of Medicine, Vanderbilt University, Nashville, TN, USA.
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10
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Cranmer LM, Cotton MF, Day CL, Nemes E. What's Old and New in Tuberculosis Vaccines for Children. J Pediatric Infect Dis Soc 2022; 11:S110-S116. [PMID: 36314550 PMCID: PMC9620432 DOI: 10.1093/jpids/piac078] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Tuberculosis (TB) is a leading cause of global child mortality. Until the turn of the 21st century, Mycobacterium bovis bacille Calmette-Guerin (BCG) was the only vaccine to prevent TB. The pediatric TB vaccine pipeline has advanced in the past decade to include the evaluation of novel whole cell vaccines to replace infant BCG and investigation of subunit and whole cell vaccines to boost TB immunity during adolescence. We describe the history of BCG, current TB vaccine candidates in clinical trials, and the challenges and opportunities for future TB vaccine research in children. Children are a critical target population for TB vaccines, and expansion of the pediatric TB vaccine pipeline is urgently needed to end the TB pandemic.
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Affiliation(s)
- Lisa M Cranmer
- Department of Pediatrics, Division of Pediatric Infectious Disease, Emory School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, Georgia, USA
- Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Mark F Cotton
- Department of Pediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - Cheryl L Day
- Department of Microbiology & Immunology, Emory School of Medicine, Atlanta, Georgia, USA
- Emory Vaccine Center, Atlanta, Georgia, USA
| | - Elisa Nemes
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
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11
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Zheng W, LaCourse SM, Song B, Singh DK, Khanna M, Olivo J, Stern J, Escudero JN, Vergara C, Zhang F, Li S, Wang S, Cranmer LM, Huang Z, Bojanowski CM, Bao D, Njuguna I, Xiao Y, Wamalwa DC, Nguyen DT, Yang L, Maleche-Obimbo E, Nguyen N, Zhang L, Phan H, Fan J, Ning B, Li C, Lyon CJ, Graviss EA, John-Stewart G, Mitchell CD, Ramsay AJ, Kaushal D, Liang R, Pérez-Then E, Hu TY. Diagnosis of paediatric tuberculosis by optically detecting two virulence factors on extracellular vesicles in blood samples. Nat Biomed Eng 2022; 6:979-991. [PMID: 35986185 PMCID: PMC9391224 DOI: 10.1038/s41551-022-00922-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/01/2022] [Indexed: 11/09/2022]
Abstract
Sensitive and specific blood-based assays for the detection of pulmonary and extrapulmonary tuberculosis would reduce mortality associated with missed diagnoses, particularly in children. Here we report a nanoparticle-enhanced immunoassay read by dark-field microscopy that detects two Mycobacterium tuberculosis virulence factors (the glycolipid lipoarabinomannan and its carrier protein) on the surface of circulating extracellular vesicles. In a cohort study of 147 hospitalized and severely immunosuppressed children living with HIV, the assay detected 58 of the 78 (74%) cases of paediatric tuberculosis, 48 of the 66 (73%) cases that were missed by microbiological assays, and 8 out of 10 (80%) cases undiagnosed during the study. It also distinguished tuberculosis from latent-tuberculosis infections in non-human primates. We adapted the assay to make it portable and operable by a smartphone. With further development, the assay may facilitate the detection of tuberculosis at the point of care, particularly in resource-limited settings.
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Affiliation(s)
- Wenshu Zheng
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Sylvia M LaCourse
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Bofan Song
- James C. Wyant College of Optical Sciences, The University of Arizona, Tucson, AZ, USA
| | - Dhiraj Kumar Singh
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX, USA
| | - Mayank Khanna
- Department of Microbiology, Immunology and Parasitology, LSU Health Sciences Center, New Orleans, LA, USA
| | - Juan Olivo
- O&M Medical School (O&Med), Santo Domingo, Dominican Republic
| | - Joshua Stern
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jaclyn N Escudero
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Carlos Vergara
- O&M Medical School (O&Med), Santo Domingo, Dominican Republic
| | - Fangfang Zhang
- Virginia G. Piper Biodesign Center for Personalized Diagnostics, The Biodesign Institute, Arizona State University, Tempe, AZ, USA
| | - Shaobai Li
- James C. Wyant College of Optical Sciences, The University of Arizona, Tucson, AZ, USA
| | - Shu Wang
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Lisa M Cranmer
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Emory School of Medicine, Atlanta, GA, USA
- Children's Healthcare of Atlanta, Atlanta, GA, USA
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA, USA
| | - Zhen Huang
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Christine M Bojanowski
- Section of Pulmonary Diseases, Tulane University School of Medicine, New Orleans, LA, USA
| | - Duran Bao
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Irene Njuguna
- Department of Global Health, University of Washington, Seattle, WA, USA
- Kenyatta National Hospital, Research and Programs, Nairobi, Kenya
| | - Yating Xiao
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Dalton C Wamalwa
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist, Houston, TX, USA
| | - Li Yang
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Elizabeth Maleche-Obimbo
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | - Lili Zhang
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Ha Phan
- Center for Promotion of Advancement of Society (CPAS), Ha Noi, Vietnam
- Vietnam National Tuberculosis Program/University of California San Francisco Research Collaboration, Ha Noi, Vietnam
| | - Jia Fan
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Bo Ning
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Chenzhong Li
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Christopher J Lyon
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist, Houston, TX, USA
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, TX, USA
| | - Grace John-Stewart
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Charles D Mitchell
- Department of Pediatrics, Division of Infectious Diseases and Immunology, University of Miami Miller School of Medicine, Batchelor Children's Research Institute, Miami, FL, USA
| | - Alistair J Ramsay
- Department of Microbiology, Immunology and Parasitology, LSU Health Sciences Center, New Orleans, LA, USA
| | - Deepak Kaushal
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX, USA
| | - Rongguang Liang
- James C. Wyant College of Optical Sciences, The University of Arizona, Tucson, AZ, USA
| | - Eddy Pérez-Then
- O&M Medical School (O&Med), Santo Domingo, Dominican Republic
| | - Tony Y Hu
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA.
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA.
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12
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Huang Z, LaCourse SM, Kay AW, Stern J, Escudero JN, Youngquist BM, Zheng W, Vambe D, Dlamini M, Mtetwa G, Cranmer LM, Njuguna I, Wamalwa DC, Maleche-Obimbo E, Catanzaro DG, Lyon CJ, John-Stewart G, DiNardo A, Mandalakas AM, Ning B, Hu TY. CRISPR detection of circulating cell-free Mycobacterium tuberculosis DNA in adults and children, including children with HIV: a molecular diagnostics study. Lancet Microbe 2022; 3:e482-e492. [PMID: 35659882 PMCID: PMC9300929 DOI: 10.1016/s2666-5247(22)00087-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 03/17/2022] [Accepted: 03/23/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Tuberculosis remains a leading cause of global mortality, especially for adults and children living with HIV (CLHIV) underdiagnosed by sputum-based assays. Non-sputum-based assays are needed to improve tuberculosis diagnosis and tuberculosis treatment monitoring. Our aim in this study was to determine whether ultrasensitive detection of Mycobacterium tuberculosis cell-free DNA (Mtb-cfDNA) in blood can diagnose tuberculosis and evaluate tuberculosis treatment responses. METHODS In this molecular diagnostics study we analysed archived serum from two patient populations evaluated for tuberculosis in Eswatini and Kenya to detect Mtb-cfDNA, analysing serum from all individuals who had both sufficient serum volumes and clear diagnostic results. An optimised CRISPR-mediated tuberculosis (CRISPR-TB) assay was used to detect Mtb-cfDNA in serum at enrolment from adults and children with presumptive tuberculosis and their asymptomatic household contacts, and at enrolment and during tuberculosis treatment from a cohort of symptomatic CLHIV at high risk for tuberculosis, who provided longitudinal serum at enrolment and during tuberculosis treatment. FINDINGS CRISPR-TB identified microbiologically and clinically confirmed tuberculosis cases in the predominantly HIV-negative Eswatini adult cohort with 96% sensitivity (27 [96%] of 28, 95% CI 80-100) and 94% specificity (16 [94%] of 17, 71-100), and with 83% sensitivity (5 [83%] of 6, 36-100) and 95% specificity (21 [95%] of 22, 77-100) in the paediatric cohort, including all six cases of extrapulmonary tuberculosis. In the Kenyan CLHIV cohort, CRISPR-TB detected all (13 [100%] of 13, 75-100) confirmed tuberculosis cases and 85% (39 [85%] of 46, 71-94) of unconfirmed tuberculosis cases diagnosed by non-microbiological clinical findings. CLHIV who were CRISPR-TB positive at enrolment had a 2·4-times higher risk of mortality by 6 months after enrolment. Mtb-cfDNA signal decreased after tuberculosis treatment initiation, with near or complete Mtb-cfDNA clearance by 6 months after tuberculosis treatment initiation. INTERPRETATION CRISPR-mediated detection of circulating Mtb-cfDNA shows promise to increase the identification of paediatric tuberculosis and HIV-associated tuberculosis, and potential for early diagnosis and rapid monitoring of tuberculosis treatment responses. FUNDING US Department of Defense, National Institute of Child Health and Human Development, National Institute of Allergy and Infectious Diseases, University of Washington Center for AIDS Research, and the Weatherhead Presidential Endowment fund.
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Affiliation(s)
- Zhen Huang
- Center for Cellular and Molecular Diagnostics,Department of Biochemistry and Molecular Biology,Tulane University School of Medicine, New Orleans, LA, USA; State Key Laboratory of Food Science and Technology, Nanchang University, Nanchang, Jiangxi, China
| | - Sylvia M LaCourse
- Department of Medicine, Division of Allergy and Infectious Diseases,Department of Global Health
| | - Alexander W Kay
- University of Washington, Seattle, WA, USA; Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA,Baylor Children’s Foundation-Eswatini, Mbabane, Eswatini
| | | | | | - Brady M Youngquist
- Center for Cellular and Molecular Diagnostics,Department of Biochemistry and Molecular Biology
| | - Wenshu Zheng
- Center for Cellular and Molecular Diagnostics,Department of Biochemistry and Molecular Biology
| | - Debrah Vambe
- Eswatini National Tuberculosis Control Programme, Ministry of Health, Manzini, Eswatini
| | - Muyalo Dlamini
- National TB Reference Laboratory, Eswatini Health Laboratory Services, Ministry of Health, Mbabane, Eswatini
| | - Godwin Mtetwa
- University of Washington, Seattle, WA, USA; Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA,Baylor Children’s Foundation-Eswatini, Mbabane, Eswatini
| | - Lisa M Cranmer
- Department of Pediatrics, Division of Infectious Diseases, Emory University, Atlanta, GA, USA,Children’s Healthcare of Atlanta, Atlanta, GA, USA,Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA, USA
| | - Irene Njuguna
- Research and Programmes, Kenyatta National Hospital, Nairobi, Kenya
| | - Dalton C Wamalwa
- Department of Global Health,Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Elizabeth Maleche-Obimbo
- Department of Global Health,Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Donald G Catanzaro
- Department of Biological Sciences, University of Arkansas, Fayetteville, AR, USA
| | - Christopher J Lyon
- Center for Cellular and Molecular Diagnostics,Department of Biochemistry and Molecular Biology
| | - Grace John-Stewart
- Department of Medicine, Division of Allergy and Infectious Diseases,Department of Global Health,Department of Epidemiology,Department of Pediatrics
| | - Andrew DiNardo
- University of Washington, Seattle, WA, USA; Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Anna M Mandalakas
- University of Washington, Seattle, WA, USA; Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Bo Ning
- Center for Cellular and Molecular Diagnostics,Department of Biochemistry and Molecular Biology
| | - Tony Y Hu
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA; Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA.
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13
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Warr AJ, Anterasian C, Shah JA, De Rosa SC, Nguyen FK, Maleche-Obimbo E, Cranmer LM, Matemo D, Mecha J, Kinuthia J, LaCourse SM, John-Stewart GC, Hawn TR. A CD4+ TNF+ monofunctional memory T-cell response to BCG vaccination is associated with Mycobacterium tuberculosis infection in infants exposed to HIV. EBioMedicine 2022; 80:104023. [PMID: 35533496 PMCID: PMC9092381 DOI: 10.1016/j.ebiom.2022.104023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 03/20/2022] [Accepted: 04/09/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The immunologic correlates of risk of Mycobacterium tuberculosis (Mtb) infection after BCG vaccination are unknown. The mechanism by which BCG influences the tuberculin skin test (TST) remains poorly understood. We evaluated CD4+ T-cell responses in infants exposed to HIV and uninfected (HEU) who received BCG at birth and examined their role in susceptibility to Mtb infection and influence on TST induration. METHODS HEU infants were enrolled in a randomised clinical trial of isoniazid (INH) to prevent Mtb infection in Kenya. We measured mycobacterial antigen-specific Th1 and Th17 cytokine responses at 6-10 weeks of age prior to INH randomisation and compared responses between Mtb infected and uninfected infants. Outcomes at 14 months of age included TST, QuantiFERON-Plus (QFT-Plus), and ESAT-6/CFP-10-specific non-IFN-γ cytokines measured in QFT-Plus supernatants. FINDINGS A monofunctional mycobacterial antigen-specific TNF+ CD4+ effector memory (CCR7-CD45RA-) T-cell response at 6-10 weeks of age was associated with Mtb infection at 14 months of age as measured by ESAT-6/CFP-10-specific IFN-γ and non-IFN-γ responses (Odds Ratio 2.26; Confidence Interval 1.27-4.15; P = 0.006). Mycobacterial antigen-specific polyfunctional effector memory Th1 responses at 6-10 weeks positively correlated with TST induration in infants without evidence of Mtb infection at 14 months, an association which was diminished by INH therapy. INTERPRETATION Induction of monofunctional TNF+ CD4+ effector memory T-cell responses may be detrimental in TB vaccine development. This study also provides mechanistic insight into the association of BCG-induced immune responses with TST induration and further evidence that TST-based diagnoses of Mtb infection in infants are imprecise. FUNDING Thrasher Research Fund.
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Affiliation(s)
- Alex J. Warr
- Department of Medicine, University of Washington, 750 Republican St, Seattle, WA 98109, USA,Corresponding author.
| | - Christine Anterasian
- Department of Pediatrics, University of Washington, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Javeed A Shah
- Department of Medicine, University of Washington, 750 Republican St, Seattle, WA 98109, USA,Veteran Affairs Puget Sound Healthcare System, 1660 South Columbian Way, Seattle, WA 98108, USA
| | - Stephen C. De Rosa
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave North, E4-200, Seattle, WA 98109, USA,Department of Laboratory Medicine and Pathology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Felicia K. Nguyen
- Department of Medicine, University of Washington, 750 Republican St, Seattle, WA 98109, USA
| | - Elizabeth Maleche-Obimbo
- Department of Paediatrics and Child Health, University of Nairobi, Kenyatta National Hospital, PO Box 20723-00202, Nairobi, Kenya
| | - Lisa M. Cranmer
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, 100 Woodruff Circle, Atlanta, GA 30322, USA
| | - Daniel Matemo
- Kenyatta National Hospital, PO Box 20723-00202, Nairobi, Kenya
| | - Jerphason Mecha
- Kenyatta National Hospital, PO Box 20723-00202, Nairobi, Kenya
| | - John Kinuthia
- Kenyatta National Hospital, PO Box 20723-00202, Nairobi, Kenya
| | - Sylvia M. LaCourse
- Department of Medicine, University of Washington, 750 Republican St, Seattle, WA 98109, USA,Department of Global Health, University of Washington, 325 9th Ave, Seattle, WA, 98104, USA
| | - Grace C. John-Stewart
- Department of Medicine, University of Washington, 750 Republican St, Seattle, WA 98109, USA,Department of Pediatrics, University of Washington, 4800 Sand Point Way NE, Seattle, WA 98105, USA,Department of Global Health, University of Washington, 325 9th Ave, Seattle, WA, 98104, USA
| | - Thomas R. Hawn
- Department of Medicine, University of Washington, 750 Republican St, Seattle, WA 98109, USA
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Cranmer LM, Chung MH, Chahroudi A. Support for Establishing Best Practices for Breastfeeding in the Current HIV/ART Era. J Pediatric Infect Dis Soc 2022; 11:90-91. [PMID: 34939651 DOI: 10.1093/jpids/piab128] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 12/01/2021] [Indexed: 11/14/2022]
Affiliation(s)
- Lisa M Cranmer
- Department of Pediatrics, Division of Pediatric Infectious Disease, Emory School of Medicine, Atlanta, Georgia, USA.,Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, Georgia, USA.,Children\'s Healthcare of Atlanta, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Michael H Chung
- Grady Memorial Hospital, Atlanta, Georgia, USA.,Department of Medicine, Division of Infectious Disease, Emory School of Medicine, Atlanta, Georgia, USA.,Departments of Epidemiology and Global Health, Emory Rollins School of Public Health, Atlanta, Georgia, USA
| | - Ann Chahroudi
- Department of Pediatrics, Division of Pediatric Infectious Disease, Emory School of Medicine, Atlanta, Georgia, USA.,Children\'s Healthcare of Atlanta, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
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15
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LaCourse SM, Richardson BA, Kinuthia J, Warr AJ, Maleche-Obimbo E, Matemo D, Cranmer LM, Mecha J, Escudero JN, Hawn TR, John-Stewart G. A Randomized Controlled Trial of Isoniazid to Prevent Mycobacterium tuberculosis Infection in Kenyan Human Immunodeficiency Virus-Exposed Uninfected Infants. Clin Infect Dis 2021; 73:e337-e344. [PMID: 32564076 PMCID: PMC8282257 DOI: 10.1093/cid/ciaa827] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/15/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-exposed uninfected (HEU) infants in endemic settings are at high risk of tuberculosis (TB). For infants, progression from primary Mycobacterium tuberculosis (Mtb) infection to TB disease can be rapid. We assessed whether isoniazid (INH) prevents primary Mtb infection. METHODS We conducted a randomized nonblinded controlled trial enrolling HEU infants 6 weeks of age without known TB exposure in Kenya. Participants were randomized (1:1) to 12 months of daily INH (10 mg/kg) vs no INH. Primary endpoint was Mtb infection at end of 12 months, assessed by interferon-γ release assay (QuantiFERON-TB Gold Plus) and/or tuberculin skin test (TST, added 6 months after first participant exit). RESULTS Between 15 August 2016 and 6 June 2018, 416 infants were screened, with 300 (72%) randomized to INH or no INH (150 per arm); 2 were excluded due to HIV infection. Among 298 randomized HEU infants, 12-month retention was 96.3% (287/298), and 88.9% (265/298) had primary outcome data. Mtb infection prevalence at 12-month follow-up was 10.6% (28/265); 7.6% (10/132) in the INH arm and 13.5% (18/133) in the no INH arm (7.0 vs 13.4 per 100 person-years; hazard ratio, 0.53 [95% confidence interval {CI}, .24-1.14]; P = .11]), and driven primarily by TST positivity (8.6% [8/93] in INH and 18.1% [17/94] in no INH; relative risk, 0.48 [95% CI, .22-1.05]; P = .07). Frequency of severe adverse events was similar between arms (INH, 14.0% [21/150] vs no INH, 10.7% [16/150]; P = .38), with no INH-related adverse events. CONCLUSIONS Further studies evaluating TB preventive therapy to prevent or delay primary Mtb infection in HEU and other high-risk infants are warranted. CLINICAL TRIALS REGISTRATION NCT02613169.
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Affiliation(s)
- Sylvia M LaCourse
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - John Kinuthia
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Obstetrics and Gynaecology, Kenyatta National Hospital, Nairobi, Kenya
| | - A J Warr
- Department of Pediatrics, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - Daniel Matemo
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Lisa M Cranmer
- Department of Pediatrics, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
- Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Jerphason Mecha
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Jaclyn N Escudero
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Thomas R Hawn
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Grace John-Stewart
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
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16
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Malik AA, Gandhi NR, Lash TL, Cranmer LM, Omer SB, Ahmed JF, Siddiqui S, Amanullah F, Khan AJ, Keshavjee S, Hussain H, Becerra MC. Effectiveness of Preventive Therapy for Persons Exposed at Home to Drug-Resistant Tuberculosis, Karachi, Pakistan. Emerg Infect Dis 2021; 27:805-812. [PMID: 33624580 PMCID: PMC7920671 DOI: 10.3201/eid2703.203916] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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
Fluoroquinolone-based preventive therapy reduced risk for tuberculosis disease by 65%. In Karachi, Pakistan, a South Asian megacity with a high prevalence of tuberculosis (TB) and low HIV prevalence, we assessed the effectiveness of fluoroquinolone-based preventive therapy for drug-resistant (DR) TB exposure. During February 2016–March 2017, high-risk household contacts of DR TB patients began a 6-month course of preventive therapy with a fluoroquinolone-based, 2-drug regimen. We assessed effectiveness in this cohort by comparing the rate and risk for TB disease over 2 years to the rates and risks reported in the literature. Of 172 participants, TB occurred in 2 persons over 336 person-years of observation. TB disease incidence rate observed in the cohort was 6.0/1,000 person-years. The incidence rate ratio ranged from 0.29 (95% CI 0.04–1.3) to 0.50 (95% CI 0.06–2.8), with a pooled estimate of 0.35 (95% CI 0.14–0.87). Overall, fluoroquinolone-based preventive therapy for DR TB exposure reduced risk for TB disease by 65%.
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17
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Malik AA, Becerra MC, Lash TL, Cranmer LM, Omer SB, Fuad J, Siddiqui S, Amanullah F, Jaswal M, Salahuddin N, Keshavjee S, Hussain H, Gandhi NR. Risk Factors for Adverse Events in Household Contacts Prescribed Preventive Treatment for Drug-resistant Tuberculosis Exposure. Clin Infect Dis 2021; 72:1709-1715. [PMID: 32266942 PMCID: PMC8315482 DOI: 10.1093/cid/ciaa327] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 12/31/2019] [Accepted: 03/24/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Completion of tuberculosis (TB) preventive treatment is important to optimize efficacy; treatment-related adverse events (AEs) sometimes result in discontinuation. This study describes the occurrence of AEs and their risk factors during a 6-month, 2-drug, fluoroquinolone-based preventive treatment for household contacts of patients with drug-resistant TB in Karachi, Pakistan. METHODS The primary outcome was development of any clinical AE during preventive treatment. Adverse events were categorized using the AE grading tables of the National Institutes of Health. Time-to-event analysis with Kaplan-Meier curves and Cox proportional hazards models accounting for recurrence were used to analyze associated risk factors. RESULTS Of the 172 household contacts on preventive treatment, 36 (21%) developed 64 AEs during 813 months of treatment. The incidence of AEs over 6 months of treatment was 7.9 per 100 person-months; 16 per 100 person-months with a fluoroquinolone and ethionamide, and 4.4 per 100 person-months with a fluoroquinolone and ethambutol. There were 53 (83%) grade 1 and 11 grade 2 AEs, with no grade 3 or 4 AEs. In multivariable analysis, the risk of AEs was higher in contacts prescribed ethionamide as compared to ethambutol adjusting for age, sex, and body mass index (adjusted hazard ratio, 2.1 [95% confidence interval {CI}, 1.2-3.6]). Overall, there was no notable difference in treatment completion among the contacts who experienced an AE and those who did not (crude odds ratio, 1.1 [95% CI, .52-2.5]). CONCLUSIONS A fluoroquinolone-based preventive treatment regimen for drug-resistant TB exposure is well tolerated. Regimens with ethionamide are more likely to result in AEs.
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Affiliation(s)
- Amyn A Malik
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA
- Global Health Directorate, Indus Health Network, Karachi, Pakistan
- Interactive Research and Development Global, Singapore
| | - Mercedes C Becerra
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Partners In Health, Boston, Massachusetts, USA
| | - Timothy L Lash
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Lisa M Cranmer
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Saad B Omer
- Yale Institute for Global Health, New Haven, Connecticut, USA
- Yale School of Medicine, New Haven, Connecticut, USA
- Yale School of Public Health, New Haven, Connecticut, USA
| | - Junaid Fuad
- Global Health Directorate, Indus Health Network, Karachi, Pakistan
| | - Sara Siddiqui
- Global Health Directorate, Indus Health Network, Karachi, Pakistan
| | | | - Maria Jaswal
- Global Health Directorate, Indus Health Network, Karachi, Pakistan
| | | | - Salmaan Keshavjee
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Partners In Health, Boston, Massachusetts, USA
| | | | - Neel R Gandhi
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA
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18
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Neary J, Njuguna IN, Cranmer LM, Otieno VO, Mugo C, Okinyi HM, Benki-Nugent S, Richardson BA, Stern J, Maleche-Obimbo E, Wamalwa DC, John-Stewart GC, Wagner AD. Newly diagnosed HIV positive children: a unique index case to improve HIV diagnosis and linkage to care of parents. AIDS Care 2020; 32:1400-1405. [PMID: 32019333 DOI: 10.1080/09540121.2020.1719027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Newly diagnosed HIV positive children may be unique index cases to identify undiagnosed parents. Data was used from the Pediatric Urgent Start of HAART (NCT02063880) trial, which enrolled hospitalized, ART-naïve, HIV positive children ages 0-12 years in Kenya. Exact McNemar's tests were used to compare proportions of mothers and fathers tested for HIV, linked to care, and on ART at baseline and 6 months. This analysis included 87 newly diagnosed children with HIV who completed 6 months of follow-up. Among 83 children with living mothers, there were improvements in maternal linkage to care and treatment comparing baseline to 6 months (36% vs. 78%; p < 0.0001 and 22% vs. 52%; p < 0.0001). Among 80 children with living fathers, there were increases from baseline to 6 months in the number of fathers who knew the child's HIV status (34% vs. 78%; p < 0.0001), fathers ever tested for HIV (43% vs. 65%; p < 0.0001), fathers ever tested HIV positive (21% vs. 43%; p < 0.0001), fathers ever linked to care (15% vs. 35%; p < 0.0001), and fathers ever initiated on ART (11% vs. 23%; p = 0.0039). Newly diagnosed HIV positive children can be important index cases to identify parents with undiagnosed HIV or poor engagement in care.
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Affiliation(s)
- Jillian Neary
- Departments of Global Health, University of Washington, Seattle, WA, USA
| | - Irene N Njuguna
- Departments of Epidemiology, University of Washington, Seattle, WA, USA.,Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Lisa M Cranmer
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | - Cyrus Mugo
- Departments of Global Health, University of Washington, Seattle, WA, USA.,Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Hellen M Okinyi
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Sarah Benki-Nugent
- Departments of Global Health, University of Washington, Seattle, WA, USA
| | - Barbra A Richardson
- Departments of Global Health, University of Washington, Seattle, WA, USA.,Departments of Biostatistics, University of Washington, Seattle, WA, USA
| | - Joshua Stern
- Departments of Biostatistics, University of Washington, Seattle, WA, USA
| | | | - Dalton C Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Grace C John-Stewart
- Departments of Global Health, University of Washington, Seattle, WA, USA.,Departments of Epidemiology, University of Washington, Seattle, WA, USA.,Departments of Medicine, University of Washington, Seattle, WA, USA.,Departments of Pediatrics, University of Washington, Seattle, WA, USA
| | - Anjuli D Wagner
- Departments of Global Health, University of Washington, Seattle, WA, USA
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19
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LaCourse SM, Richardson BA, Kinuthia J, Warr AJ, Maleche-Obimbo E, Matemo D, Cranmer LM, Escudero JN, Hawn TR, John-Stewart GC. Infant TB Infection Prevention Study (iTIPS): a randomised trial protocol evaluating isoniazid to prevent M. tuberculosis infection in HIV-exposed uninfected children. BMJ Open 2020; 10:e034308. [PMID: 31969368 PMCID: PMC7045242 DOI: 10.1136/bmjopen-2019-034308] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 12/05/2019] [Accepted: 01/07/2020] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION HIV-exposed uninfected (HEU) infants in tuberculosis (TB) endemic settings are at high risk of Mycobacterium tuberculosis (Mtb) infection and TB disease, even in the absence of known Mtb exposure. Because infancy is a time of rapid progression from primary infection to active TB disease, it is important to define when and how TB preventive interventions exert their effect in order to develop effective prevention strategies in this high-risk population. METHODS AND ANALYSIS We designed a non-blinded randomised controlled trial to determine efficacy of isoniazid (INH) to prevent primary Mtb infection among HEU children. Target sample size is 300 (150 infants in each arm). Children are enrolled at 6 weeks of age from maternal and child health clinics in Kenya and are randomised to receive 12 months of daily INH ~10 mg/kg plus pyridoxine or no INH. The primary endpoint is Mtb infection, assessed by interferon-gamma release assay QuantiFERON-TB Gold Plus (QFT-Plus) or tuberculin skin test after 12 months post-enrolment. Secondary outcomes include severe adverse events, expanded Mtb infection definition using additional QFT-Plus supernatant markers and determining correlates of Mtb infection. Exploratory analyses include a combined outcome of TB infection, disease and mortality, and sensitivity analyses excluding infants with baseline TB-specific responses on flow cytometry. ETHICS AND DISSEMINATION An external and independent Data and Safety Monitoring Board monitors adverse events. Results will be disseminated through peer-reviewed journals, presentations at local and international conferences to national and global policy-makers, the local community and participants. TRIAL REGISTRATION NUMBER NCT02613169; Pre-results.
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Affiliation(s)
- Sylvia M LaCourse
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Barbra A Richardson
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - John Kinuthia
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Reproductive Health, Kenyatta National Hospital, Nairobi, Kenya
| | - A J Warr
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - Daniel Matemo
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Lisa M Cranmer
- Department of Pediatrics, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta Inc, Atlanta, Georgia, USA
| | - Jaclyn N Escudero
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Thomas R Hawn
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Grace C John-Stewart
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
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20
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LaCourse SM, Wagner AD, Cranmer LM, Copeland A, Maleche-Obimbo E, Richardson BA, Matemo D, Kinuthia J, John-Stewart G. Brief Report: High Programmatic Isoniazid Preventive Therapy (IPT) Use in Pregnancy Among HIV-Infected Women. J Acquir Immune Defic Syndr 2019; 82:41-45. [PMID: 31408031 PMCID: PMC6697133 DOI: 10.1097/qai.0000000000002086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND The World Health Organization recommends isoniazid preventive therapy (IPT) for people living with HIV (PLHIV) to prevent tuberculosis (TB), including pregnant women. Recent trial results suggest increased adverse pregnancy outcomes associated with IPT during pregnancy. Data are limited regarding programmatic IPT use in pregnant PLHIV. METHODS We assessed previous programmatic IPT during pregnancy among HIV-infected mothers on enrollment to an infant TB prevention trial in Kenya. Pregnancy IPT use was assessed by the estimated conception date assuming 38 weeks of gestation. Correlates of initiation and completion were analyzed by relative risk regression, using generalized linear models with log link and Poisson family adjusted for IPT initiation year. RESULTS Between August 15, 2016, to June 6, 2018, 300 HIV-infected women enrolled at 6 weeks postpartum. Two hundred twenty-four (74.7%) women reported previous IPT, of whom 155/224 (69.2%) had any pregnancy IPT use. Forty-five (29.0%) initiated preconception extending into early pregnancy, 41 (26.5%) initiated and completed during pregnancy, and 69 (44.5%) initiated in pregnancy and extended into early postpartum. The median gestational age at IPT pregnancy initiation was 15.1 weeks (interquartile range 8.3-28.4). Pregnancy/early postpartum IPT initiation was associated with new pregnancy HIV diagnosis [adjusted relative risk 1.9 95% confidence interval (CI): 1.6 to 2.2, P < 0.001]. Six-month IPT completion rates were high [147/160 (91.9%)] among women with sufficient time to complete before trial enrollment and similar among preconception or during pregnancy initiators [adjusted relative risk 0.93 (95% confidence interval: 0.83 to 1.04, P = 0.19)]. CONCLUSIONS Programmatic IPT use was high in pregnant PLHIV, with frequent periconception and early pregnancy initiation. Programmatic surveillance could provide further insights on pregnancy IPT implementation and maternal and infant safety outcomes.
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Affiliation(s)
- Sylvia M LaCourse
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA
| | | | - Lisa M Cranmer
- Department of Pediatrics, Division of Infectious Diseases, Emory University, Atlanta, GA
- Children's Healthcare of Atlanta, Atlanta, GA
| | - Audrey Copeland
- Schools of Nursing, Emory University, Atlanta, GA
- Public Health, Emory University, Atlanta, GA
| | | | - Barbra A Richardson
- Global Health, University of Washington, Seattle, WA
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Daniel Matemo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - John Kinuthia
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Reproductive Health, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA
- Global Health, University of Washington, Seattle, WA
- Pediatrics, University of Washington, Seattle, WA
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21
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Njuguna IN, Cranmer LM, Wagner AD, LaCourse SM, Mugo C, Benki-Nugent S, Richardson BA, Stern J, Maleche-Obimbo E, Wamalwa DC, John-Stewart G. Brief Report: Cofactors of Mortality Among Hospitalized HIV-Infected Children Initiating Antiretroviral Therapy in Kenya. J Acquir Immune Defic Syndr 2019; 81:138-144. [PMID: 31095004 PMCID: PMC6609091 DOI: 10.1097/qai.0000000000002012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Identifying factors associated with mortality among acutely ill HIV-infected children presenting with advanced HIV disease may help clinicians optimize care for those at highest risk of death. DESIGN Using data from a randomized controlled trial (NCT02063880), we determined baseline sociodemographic, clinical, and laboratory cofactors of mortality among HIV-infected children in Kenya. METHODS We enrolled hospitalized, HIV-infected, antiretroviral therapy-naive children (0-12 years), initiated antiretroviral therapy, and followed up them for 6 months. We used Cox proportional hazards regression to estimate hazard ratios (HRs) for death and 95% confidence intervals (CIs). RESULTS Of 181 enrolled children, 39 (22%) died. Common diagnoses at death were pneumonia or suspected pulmonary tuberculosis [23 (59%)] and gastroenteritis [7 (18%)]. Factors associated with mortality in univariate analysis included age <2 years [HR 3.08 (95% CI: 1.50 to 6.33)], orphaned or vulnerable child (OVC) [HR 2.05 (95% CI: 1.09 to 3.84)], weight-for-age Z score <-2 [HR 2.29 (95% CI: 1.05 to 5.00)], diagnosis of pneumonia with hypoxia [HR 5.25 (95% CI: 2.00 to 13.84)], oral thrush [HR 2.17 (95% CI: 1.15 to 4.09)], persistent diarrhea [HR 3.81 (95% CI: 1.89 to 7.69)], and higher log10 HIV-1 viral load [HR 2.16 (95% CI: 1.35 to 3.46)] (all P < 0.05). In multivariable analysis, age <2 years and OVC status remained significantly associated with mortality. CONCLUSIONS Young age and OVC status independently predicted mortality. Hypoxic pneumonia, oral thrush, and persistent diarrhea are important clinical features that predict mortality. Strategies to enhance early diagnosis in children and improve hospital management of critically ill HIV-infected children are needed.
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Affiliation(s)
- Irene N Njuguna
- Kenyatta National Hospital, Nairobi, Kenya
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Lisa M Cranmer
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
| | | | | | - Cyrus Mugo
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | | | | | | | - Dalton C Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Epidemiology, University of Washington, Seattle, WA
- Medicine, University of Washington, Seattle, WA
- Pediatrics, University of Washington, Seattle, WA
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22
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Gómez LA, Crowell CS, Njuguna I, Cranmer LM, Wamalwa D, Chebet D, Otieno V, Maleche-Obimbo E, Gladstone M, John-Stewart G, Benki-Nugent S. Improved Neurodevelopment After Initiation of Antiretroviral Therapy in Human Immunodeficiency Virus-infected Children. Pediatr Infect Dis J 2018; 37:916-922. [PMID: 29438131 PMCID: PMC6087680 DOI: 10.1097/inf.0000000000001942] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Late human immunodeficiency virus (HIV) diagnosis after severe co-morbidity remains common in resource-limited settings. Neurodevelopmental recovery during antiretroviral therapy (ART) for late-diagnosed children is understudied. We determined 6-month neurodevelopmental trajectories in HIV-infected children initiating ART during hospitalization. METHODS HIV-infected children initiated ART after HIV diagnosis during hospitalization in Kenya. The Malawi Developmental Assessment Tool was administered after clinical stabilization within 1 month and at 6 months post-ART initiation. Baseline versus 6-month Z scores for each developmental domain were compared; cofactors for change in Z scores were evaluated using linear regression. RESULTS Among 74 children, median age was 1.7 years (interquartile range, 0.8-2.4) and median Z scores for gross motor, fine motor, social and language domains were -1.34, -1.04, -0.53 and -0.95, respectively. At baseline, children with higher plasma viremia had lower social Z scores (P = 0.008). Better nourished (weight-for-age Z score [WAZ] ≥-2) children had higher Z scores in all developmental domains (all P values ≤0.05). After 6 months on ART (n = 58), gross and fine motor Z scores improved significantly (mean change 0.39; P = 0.007 and 0.43; P = 0.001, respectively), but social and language did not. Children with better immune and growth response to ART had higher gains in gross motor (0.05 per unit-gain CD4%; P = 0.04; 0.34 per unit-gain WAZ; P = 0.006 and 0.44 per unit-gain height-for-age Z score; P = 0.005), social (0.37 per unit-gain WAZ; P = 0.002) and language (0.25 per unit-gain height-for-age Z score; P = 0.01). CONCLUSIONS Children had significant neurodevelopmental gains during 6 months of ART, and children with better growth and immune recovery had greater improvement. Prompt commencement of ART may improve neurodevelopment in addition to immunity and growth.
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Affiliation(s)
- Laurén A. Gómez
- Dept. of Global Health, Univ. of Washington, Seattle, WA, USA
| | - Claudia S. Crowell
- Dept. of Pediatrics, Div. of Pediatric Infectious Diseases, Univ. of Washington and Seattle Children’s Hospital, Seattle, WA, USA
| | - Irene Njuguna
- Dept. of Paediatrics & Child Health, Univ. of Nairobi, Nairobi, Kenya
| | - Lisa M. Cranmer
- Dept. of Pediatrics, Emory Univ. and Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Dalton Wamalwa
- Dept. of Paediatrics & Child Health, Univ. of Nairobi, Nairobi, Kenya
| | - Daisy Chebet
- Dept. of Paediatrics & Child Health, Univ. of Nairobi, Nairobi, Kenya
| | - Vincent Otieno
- Dept. of Paediatrics & Child Health, Univ. of Nairobi, Nairobi, Kenya
| | | | - Melissa Gladstone
- Dept. Of Women’s and Children’s Health, University of Liverpool, Liverpool, UK
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LaCourse SM, Cranmer LM, Njuguna IN, Gatimu J, Stern J, Maleche-Obimbo E, Walson JL, Wamalwa D, John-Stewart GC, Pavlinac PB. Urine Tuberculosis Lipoarabinomannan Predicts Mortality in Hospitalized Human Immunodeficiency Virus-Infected Children. Clin Infect Dis 2018; 66:1798-1801. [PMID: 29324985 PMCID: PMC5961239 DOI: 10.1093/cid/ciy011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 01/05/2018] [Indexed: 12/21/2022] Open
Abstract
Clinical Trials Registration NCT02063880.
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Affiliation(s)
- Sylvia M LaCourse
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle
| | - Lisa M Cranmer
- Department of Pediatrics, Division of Infectious Diseases, Emory University School of Medicine
- Children’s Healthcare of Atlanta, Georgia
| | - Irene N Njuguna
- Department of Epidemiology, University of Washington, Seattle
- Kenyatta National Hospital, Nairobi, Kenya
| | - John Gatimu
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Joshua Stern
- Department of Global Health, University of Washington, Seattle
| | | | - Judd L Walson
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
- Department of Global Health, University of Washington, Seattle
- Department of Pediatrics, University of Washington, Seattle
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | - Dalton Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Grace C John-Stewart
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
- Department of Global Health, University of Washington, Seattle
- Department of Pediatrics, University of Washington, Seattle
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Cranmer LM, Langat A, Ronen K, McGrath CJ, LaCourse S, Pintye J, Odeny B, Singa B, Katana A, Nganga L, Kinuthia J, John-Stewart G. Integrating tuberculosis screening in Kenyan Prevention of Mother-To-Child Transmission programs. Int J Tuberc Lung Dis 2018; 21:256-262. [PMID: 28225335 DOI: 10.5588/ijtld.16.0478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) screening in Prevention of Mother-To-Child Transmission (PMTCT) programs is important to improve TB detection, prevention and treatment. METHODS As part of a national PMTCT program evaluation, mother-infant pairs attending 6-week and 9-month immunization visits were enrolled at 141 maternal and child health clinics throughout Kenya. Clinics were selected using population-proportion-to-size sampling with oversampling in a high human immunodeficiency virus (HIV) prevalence region. The World Health Organization (WHO) TB symptom screen was administered to HIV-infected mothers, and associations with infant cofactors were determined. RESULTS Among 498 HIV-infected mothers, 165 (33%) had a positive TB symptom screen. Positive maternal TB symptom screen was associated with prior TB (P = 0.04). Women with a positive TB symptom screen were more likely to have an infant with HIV infection (P = 0.02) and non-specific TB symptoms, including cough (P = 0.003), fever (P = 0.05), and difficulty breathing (P = 0.01). TB exposure was reported by 11% of the women, and 15% of the TB-exposed women received isoniazid preventive therapy. CONCLUSIONS Postpartum HIV-infected mothers frequently had a positive TB symptom screen. Mothers with a positive TB symptom screen were more likely to have infants with HIV or non-specific TB symptoms. Integration of maternal TB screening and prevention into PMTCT programs may improve maternal and infant outcomes.
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Affiliation(s)
- L M Cranmer
- Emory University School of Medicine and Children's Hospital of Atlanta, Atlanta, Georgia, USA
| | - A Langat
- Centers for Disease Control and Prevention, Nairobi, Kenya
| | - K Ronen
- University of Washington, Seattle, Washington
| | - C J McGrath
- University of Texas Medical Branch, Galveston, Texas, USA
| | - S LaCourse
- University of Washington, Seattle, Washington
| | - J Pintye
- University of Washington, Seattle, Washington
| | - B Odeny
- University of Washington, Seattle, Washington
| | - B Singa
- Kenya Medical Research Institute, Nairobi
| | - A Katana
- Centers for Disease Control and Prevention, Nairobi, Kenya
| | - L Nganga
- Centers for Disease Control and Prevention, Nairobi, Kenya
| | - J Kinuthia
- Kenyatta National Hospital, Nairobi, Kenya
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LaCourse SM, Cranmer LM, Bekker A, Steingart KR, Black D, Horne DJ, Oren E, Pals S, Modi S, Mathad J. Symptom screening for active tuberculosis in pregnant women living with HIV. Cochrane Database Syst Rev 2018; 2018:CD012934. [PMID: 29910691 PMCID: PMC5997280 DOI: 10.1002/14651858.cd012934] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This is a protocol for a Cochrane Review (Diagnostic test accuracy). The objectives are as follows: To assess the accuracy of the four-symptom screen (cough, fever, night sweats, or weight loss) for identifying active TB in pregnant PLHIV who are screened in an outpatient or community setting. To investigate potential sources of heterogeneity of the accuracy of the four-symptom screen between studies including: ART status, CD4 cell count, gestational age, pregnancy stage (pregnancy vs. postpartum), screening test definition of cough (any cough vs. cough greater than 2 weeks).To describe the accuracy of single symptoms included within the four-symptom screen, additioal symptoms or symptom combinations, for identifying active TB in pregnant PLHIV. For example, additional symptoms may include failure to gain weight or fatigue.
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Affiliation(s)
- Sylvia M LaCourse
- University of WashingtonDepartment of Medicine, Division of Allergy and Infectious Diseases325 9th Avenue, Box 359931SeattleUSAWA 98104
| | - Lisa M Cranmer
- Emory University School of Medicine and Children's Healthcare of AtlantaDepartment of PediatricsAtlantaUSA
| | - Adrie Bekker
- Stellenbosch UniversityDepartment of PaediatricsCape TownSouth Africa
| | - Karen R Steingart
- Liverpool School of Tropical MedicineCochrane Infectious Diseases GroupPembroke PlaceLiverpoolUK
| | - Danae Black
- University of WashingtonDepartment of EpidemiologySeattleUSA
| | - David J Horne
- University of WashingtonDepartment of Medicine, Division of Pulmonary and Critical Care Medicine, and Firland Northwest TB CenterSeattleUSA
| | - Eyal Oren
- San Diego State UniversityDivision of Epidemiology and BiostatisticsSan DiegoUSA
| | - Sherri Pals
- US Centers for Disease Control and Prevention (CDC)Division of Global HIV and Tuberculosis, Center for Global HealthAtlantaUSA
| | - Surbhi Modi
- US Centers for Disease Control and Prevention (CDC)Division of Global HIV and Tuberculosis, Center for Global HealthAtlantaUSA
| | - Jyoti Mathad
- Center for Global Health, Weill Cornell Medical CollegeDepartment of Medicine, Division of Infectious DiseasesNew YorkUSA
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Njuguna IN, Cranmer LM, Otieno VO, Mugo C, Okinyi HM, Benki-Nugent S, Richardson B, Stern J, Maleche-Obimbo E, Wamalwa DC, John-Stewart GC. Urgent versus post-stabilisation antiretroviral treatment in hospitalised HIV-infected children in Kenya (PUSH): a randomised controlled trial. Lancet HIV 2018; 5:e12-e22. [PMID: 29150377 PMCID: PMC5777310 DOI: 10.1016/s2352-3018(17)30167-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 08/30/2017] [Accepted: 09/04/2017] [Indexed: 12/03/2022]
Abstract
BACKGROUND Urgent antiretroviral therapy (ART) among hospitalised HIV-infected children might accelerate recovery or worsen outcomes associated with immune reconstitution. We aimed to compare urgent versus post-stabilisation ART among hospitalised HIV-infected children in Kenya. METHODS In this unmasked randomised controlled trial, we randomly assigned (1:1) HIV-infected, ART-naive children aged 0-12 years who were eligible for treatment to receive ART within 48 h (urgent group) or in 7-14 days (post-stabilisation group) at four hospitals in Kenya (two in Nairobi and two in western Kenya). We excluded children with suspected or confirmed CNS infection. A statistician not involved in study procedures did block randomisation with variable block sizes generated using STATA version 12. We followed children for 6 months for primary outcomes: mortality, drug toxicity, and immune reconstitution inflammatory syndrome (IRIS). We did all analyses in a modified intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT02063880. FINDINGS We began enrolment on April 24, 2013, and completed follow-up on Nov 17, 2015. We enrolled 191 (76%) of 250 hospitalised HIV-infected children. Of these, 183 children were randomly assigned: 90 to urgent ART and 93 to post-stabilisation ART. 181 (99%) of 183 children were included in the modified intention-to-treat analysis. Median age was 1·9 years (IQR 0·8-4·8). Baseline sociodemographic, clinical, and virological characteristics did not differ between groups except median CD4 cell percentage, which was lower in the urgent group (13% [IQR 9-18] vs 17% [IQR 9-24]; p=0·052). Of 181 admission diagnoses, 118 (65%) were pneumonia, 58 (32%) malnutrition, and 27 (15%) suspected tuberculosis. Median time to ART was 1 day (IQR 1-1) in the urgent group and 8 days (IQR 7-11) in the post-stabilisation group. Overall, mortality risk at 6 months was 61 per 100 person-years. Mortality risk did not differ by group (70 per 100 person-years in the urgent group vs 54 per 100 person-years in the post-stabilisation group; hazard ratio [HR] 1·26, 95% CI 0·67-2·37) p=0.47, even after adjusting for baseline CD4 cell percentage (adjusted HR 1·30, 95% CI 0·69-2·45; p=0·41). The incidence of IRIS, and drug toxicity was not significantly different between trial arms. There were no differences between treatment groups in the proportion of grade 3 or 4 adverse events (34 [38%] of 90 children in the urgent group vs 40 [44%] of 91 children in the post-stabilisation group; p=0·40) or the proportion of any change in ART regimen (five [7%] vs six [8%]; p=0·79). We discontinued randomisation at interim review when the futility boundary was crossed. INTERPRETATION Early mortality risk was extremely high among hospitalised HIV-infected children. Urgent ART did not improve survival. FUNDING National Institute of Child Health and Human Development, National Institutes of Health, USA.
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Affiliation(s)
- Irene N Njuguna
- Kenyatta National Hospital, Nairobi, Kenya; Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | - Lisa M Cranmer
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | - Cyrus Mugo
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Hellen M Okinyi
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | - Barbra Richardson
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Joshua Stern
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | - Dalton C Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Grace C John-Stewart
- Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA
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Wagner AD, Njuguna IN, Andere RA, Cranmer LM, Okinyi HM, Benki-Nugent S, Chohan BH, Maleche-Obimbo E, Wamalwa DC, John-Stewart GC. Infant/child rapid serology tests fail to reliably assess HIV exposure among sick hospitalized infants. AIDS 2017; 31:F1-F7. [PMID: 28609404 PMCID: PMC5540651 DOI: 10.1097/qad.0000000000001562] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The WHO guidelines for infant and child HIV diagnosis recommend the use of maternal serology to determine child exposure status in ages 0-18 months, but suggest that infant serology can reliably be used to determine exposure for those less than 4 months. There is little evidence about the performance of these recommendations among hospitalized sick infants and children. METHODS Within a clinical trial (NCT02063880) in Kenya, among children 18 months or younger, maternal and child rapid serologic HIV tests were performed in tandem. Dried blood spots were tested using HIV DNA PCR for all children whose mothers were seropositive, irrespective of child serostatus. We characterized the performance of infant/child serology results to detect HIV exposure in three age groups: 0-3, 4-8, and 9-18 months. RESULTS Among 65 maternal serology positive infants age 0-3 months, 48 (74%), 1 (2%) and 16 (25%) had positive, indeterminate and negative infant serology results, respectively. Twelve (25%), 0 and 4 (25%) of those with positive, indeterminate and negative infant serology results, respectively, were HIV-infected by DNA PCR. Among 71 maternal serology positive infants age 4-8 months, 31 (44%), 8 (11%) and 32 (45%) had positive, indeterminate and negative infant serology results, respectively. Fourteen (45%), 2 (25%) and 7 (22%) infants with positive, indeterminate and negative infant serology results, respectively, were HIV-infected. Among 67 maternal serology positive infants/children age 9-18 months, 40 (60%), 2 (3%) and 25 (37%) had positive, indeterminate and negative infant serology results, respectively. Thirty-six (90%), 2 (100%) and 2 (8%) infants with positive, indeterminate and negative infant serology results, respectively, were HIV-infected. In the 0-3, 4-8 and 9-18 month age groups, use of maternal serology to define HIV exposure identified 33% [95% confidence interval (CI) 10-65%], 44% (95% CI 20-70%) and 5% (95% CI 0.1-18%) more HIV infections, respectively. CONCLUSION Maternal serology should preferentially be used for screening among hospitalized infants of all ages to improve early diagnosis of children with HIV.
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Affiliation(s)
- Anjuli D Wagner
- aDepartment of Global Health, University of Washington, Seattle, Washington, USA bKenyatta National Hospital, Nairobi, Kenya cDepartment of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA dDepartment of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya eDepartment of Medicine, University of Washington, Seattle, Washington, USA fKenya Medical Research Institute, Nairobi, Nairobi, Kenya gDepartment of Epidemiology hDepartment of Pediatrics, University of Washington, Seattle, Washington, USA. *Anjuli D. Wagner and Irene N. Njuguna are co-first authors
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Jonnalagadda S, LaCourse SM, Otieno P, Lohman-Payne B, Maleche-Obimbo E, Cranmer LM, John-Stewart GC. Incidence and correlates of tuberculosis IGRA conversion among HIV-infected postpartum women. Int J Tuberc Lung Dis 2016; 19:792-8. [PMID: 26056103 DOI: 10.5588/ijtld.14.0878] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Prevention of maternal-to-child transmission program at a tertiary care hospital in Nairobi, Kenya. The risk of acquiring Mycobacterium tuberculosis infection among peripartum human immunodeficiency virus (HIV) infected women is poorly defined. OBJECTIVE To determine the incidence of and co-factors for interferon-gamma release assay (IGRA) conversion among postpartum HIV-infected women using T-SPOT.TB. DESIGN We used data and cryopreserved peripheral blood mononuclear cells from a historical cohort of HIV-infected women enrolled at 32 weeks' gestation and followed for 1 year postpartum between 1999 and 2005. RESULTS Of 89 women initially IGRA-negative during pregnancy, 11 (12.4%) became positive, 53 (59.5%) remained negative and 25 (28.1%) were indeterminate at 1 year postpartum. Mean interferon-gamma (IFN-γ) response among converters increased from ~1 to >50 spot-forming cells/well (P = 0.015). IGRA conversion was significantly associated with partner HIV infection, flush toilets, maternal illness and cough during follow-up, but not maternal CD4 count or HIV viral load. CONCLUSION The high rates of IGRA conversion seen among HIV-infected postpartum women in our study are similar to those of other groups at high risk for M. tuberculosis infection. This has important implications for M. tuberculosis infection screening strategies and provision of preventive therapy for the health of women and their infants.
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Affiliation(s)
- S Jonnalagadda
- Department of Epidemiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - S M LaCourse
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - P Otieno
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - B Lohman-Payne
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA; Department of Paediatrics & Child Health, University of Nairobi, Nairobi, Kenya; Institute for Immunology and Informatics and Department of Cell and Molecular Biology, University of Rhode Island, Providence, Rhode Island, USA
| | | | - L M Cranmer
- Emory School of Medicine and Children's Healthcare of Atlanta, Division of Pediatric Infectious Disease, Atlanta, Georgia, USA
| | - G C John-Stewart
- Department of Epidemiology, Department of Medicine, University of Washington, Seattle, Washington, USA; Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA; Department of Global Health, University of Washington, Seattle, USA; Department of Global Health, University of Washington, Seattle, USA
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Njuguna IN, Wagner AD, Cranmer LM, Otieno VO, Onyango JA, Chebet DJ, Okinyi HM, Benki-Nugent S, Maleche-Obimbo E, Slyker JA, John-Stewart GC, Wamalwa DC. Hospitalized Children Reveal Health Systems Gaps in the Mother-Child HIV Care Cascade in Kenya. AIDS Patient Care STDS 2016; 30:119-24. [PMID: 27308805 DOI: 10.1089/apc.2015.0239] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
To identify missed opportunities in HIV prevention, diagnosis, and linkage to care, we enrolled 183 hospitalized, HIV-infected, ART-naïve Kenyan children 0-12 years from four hospitals in Nairobi and Kisumu, and reviewed prevention of mother-to-child transmission of HIV (PMTCT), hospitalization, and HIV testing history. Median age was 1.8 years (IQR = 0.8, 4.5). Most mothers received HIV testing during pregnancy (77%). Among mothers tested, 60% and 40% reported HIV-negative and positive results, respectively; 33% of HIV-diagnosed mothers did not receive PMTCT antiretrovirals. First missed opportunities for pediatric diagnosis and linkage were due to failure to test mothers (23.1%), maternal HIV acquisition following initial negative test (45.7%), no early infant diagnosis (EID) or provider-initiated testing (PITC) (12.7%), late breastfeeding transmission (8.7%), failure to collect child HIV test results (1.2%), and no linkage to care following HIV diagnosis (8.7%). Among previously hospitalized children, 38% never received an HIV test. Strengthening initial and repeat maternal HIV testing and PITC are key interventions to prevent, detect, and treat pediatric HIV infections.
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Affiliation(s)
- Irene N. Njuguna
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Anjuli D. Wagner
- Department of Global Health, University of Washington, Seattle, Washington
| | - Lisa M. Cranmer
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Vincent O. Otieno
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Judith A. Onyango
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Daisy J. Chebet
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Helen M. Okinyi
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | | | - Jennifer A. Slyker
- Department of Global Health, University of Washington, Seattle, Washington
| | - Grace C. John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology and Pediatrics, University of Washington, Seattle, Washington
| | - Dalton C. Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Cranmer LM, Kanyugo M, Lohman-Payne B, Tapia K, John-Stewart GC. Tuberculosis interferon-gamma responses in the breast milk of human immunodeficiency virus infected mothers. Int J Tuberc Lung Dis 2015; 19:141-3. [PMID: 25574910 DOI: 10.5588/ijtld.14.0384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Tuberculosis (TB) cellular immune responses were examined in the breast milk of human immunodeficiency virus infected mothers using the T-SPOT. TB interferon-gamma release assay (IGRA). Positive TB interferon-gamma (IFN-γ) responses were detected in 6 of 8 (75%) valid breast milk assays. Among 7 mothers with paired breast milk and blood assays, TB IFN-γ responses were higher in breast milk than in blood (P = 0.02). The magnitude of TB IFN-γ responses in maternal breast milk and blood were correlated. Elucidating the influence of TB immune responses in breast milk on infant TB susceptibility and immunity may inform future maternal TB vaccine strategies.
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Affiliation(s)
- L M Cranmer
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA; Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya; Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - M Kanyugo
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - B Lohman-Payne
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya; Department of Cell and Molecular Biology, University of Rhode Island, Providence, Rhode Island, USA
| | - K Tapia
- Department of Biostatistics, University of Washington, Seattle, Washington, USA; Department of Global Health, University of Washington, Seattle, Washington, USA
| | - G C John-Stewart
- Department of Pediatrics, University of Washington, Seattle, Washington, USA; Department of Global Health, University of Washington, Seattle, Washington, USA; Department of Medicine, University of Washington, Seattle, Washington, USA; Department of Epidemiology, University of Washington, Seattle, Washington, USA
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31
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Pavlinac PB, Naulikha JM, John-Stewart GC, Onchiri FM, Okumu AO, Sitati RR, Cranmer LM, Lokken EM, Singa BO, Walson JL. Mycobacterium tuberculosis Bacteremia Among Acutely Febrile Children in Western Kenya. Am J Trop Med Hyg 2015; 93:1087-91. [PMID: 26324730 DOI: 10.4269/ajtmh.15-0365] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 07/13/2015] [Indexed: 12/28/2022] Open
Abstract
In children, Mycobacterium tuberculosis (M. tuberculosis) frequently disseminates systemically, presenting with nonspecific signs including fever. We determined prevalence of M. tuberculosis bacteremia among febrile children presenting to hospitals in Nyanza, Kenya (a region with high human immunodeficiency virus (HIV) and M. tuberculosis prevalence). Between March 2013 and February 2014, we enrolled children aged 6 months to 5 years presenting with fever (axillary temperature ≥ 37.5°C) and no recent antibiotic use. Blood samples were collected for bacterial and mycobacterial culture using standard methods. Among 148 children enrolled, median age was 3.1 years (interquartile range: 1.8-4.1 years); 10.3% of children were living with a household member diagnosed with M. tuberculosis in the last year. Seventeen percent of children were stunted (height-for-age z-score < -2), 18.6% wasted (weight-for-height z-score < -2), 2.7% were HIV-infected, and 14.2% were HIV-exposed uninfected. Seventeen children (11.5%) had one or more signs of tuberculosis (TB). All children had a Bacille Calmette-Guerin vaccination scar. Among 134 viable blood cultures, none (95% confidence interval: 0-2.7%) had Mycobacterium isolated. Despite exposure to household TB contacts, HIV exposure, and malnutrition, M. tuberculosis bacteremia was not detected in this pediatric febrile cohort, a finding consistent with other pediatric studies.
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Affiliation(s)
- Patricia B Pavlinac
- Department of Global Health, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/CGHR Centre for Global Health Research, Kisumu, Kenya; Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Jaqueline M Naulikha
- Department of Global Health, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/CGHR Centre for Global Health Research, Kisumu, Kenya; Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Grace C John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/CGHR Centre for Global Health Research, Kisumu, Kenya; Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Frankline M Onchiri
- Department of Global Health, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/CGHR Centre for Global Health Research, Kisumu, Kenya; Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Albert O Okumu
- Department of Global Health, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/CGHR Centre for Global Health Research, Kisumu, Kenya; Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Ruth R Sitati
- Department of Global Health, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/CGHR Centre for Global Health Research, Kisumu, Kenya; Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Lisa M Cranmer
- Department of Global Health, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/CGHR Centre for Global Health Research, Kisumu, Kenya; Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Erica M Lokken
- Department of Global Health, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/CGHR Centre for Global Health Research, Kisumu, Kenya; Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Benson O Singa
- Department of Global Health, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/CGHR Centre for Global Health Research, Kisumu, Kenya; Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Kenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/CGHR Centre for Global Health Research, Kisumu, Kenya; Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
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