Presumptive Pulmonary Tuberculosis Cases Research Articles

Urinary lipoarabinomannan in individuals with sputum-negative pulmonary tuberculosis.

Tuberculosis (TB) is a major global cause of ill health. Sputum microscopy for confirmation of presumptive pulmonary TB (PTB) has a reportedly low sensitivity of 22-43 per cent for single smear and up to 60 per cent under optimal conditions. National TB Elimination Programme in India recommends the use of cartridge-based nucleic acid amplification test (CBNAAT) and culture for microbiological confirmation in presumptive PTB individuals with sputum smear negative test. The use of lateral flow urine lipoarabinomannan (LF-LAM) is usually recommended for the diagnosis of TB in HIV-positive individuals with low CD4 counts or those who are seriously ill. The objective of this study was to detect urinary LAM using cage nanotechnology that does not require a physiologic or immunologic consequence of HIV infection for LAM quantification in human urine in 50 HIV-seronegative sputum smear-negative PTB individuals. To study the diagnostic value of urinary LAM in sputum smear negative PTB individuals, a cage based nanotechnology ELISA technique was used for urinary LAM in three different groups of participants. Fifty smears negative PTB clinically diagnosed, 15 smear positive PTB and 15 post TB sequel individuals. Sputum was tested by smear, CBNAAT, and culture along with urine LAM before treatment. The results were interpreted by ROC curve in comparison to the standard tests like CBNAAT and culture. The mean urinary LAM value was 0.84 ng/ml in 37 culture-positive [Mycobacterium tuberculosis (M.tb)] and 0.49 ng/ml in 13 culture-negative (M.tb) smear-negative individuals with PTB, respectively. In 47 smear-negative PTB cases with microbiologically confirmed TB by CBNAAT, the mean urinary LAM was 0.76 ng/ml. The mean urinary LAM in post-TB sequel individuals was 0.47 ng/ml. As per the receiver operating characteristic curve, cut-off value of urinary LAM in individuals with smear-negative PTB microbiologically confirmed by: (i) CBNAAT was 0.695 ng/ml and (ii) culture was 0.615 ng/ml. The findings of this study suggest that individuals with smear-negative PTB and a urinary LAM value of >0.615 ng/ml were most likely to have microbiological confirmed TB while those with a LAM value <0.615 ng/ml >0.478 ng/ml are less likely and those with a value <0.478 ng/ml are unlikely to have microbiological confirmed TB.

Impact of the use of GeneXpert on TB diagnosis and anti-TB treatment outcome at health facilities in Addis Ababa, Ethiopia in the post-millennium development years.

GeneXpert is an effective and rapid molecular system used for tuberculosis (TB) diagnosis. It is expected to improve the detection rate and treatment outcomes needed to meet the sustainable development goals (SDG) and End TB strategy targets set for 2030. This study aimed to evaluate the impact of GeneXpert on diagnosis and anti-TB treatment outcomes in the post-millennium development goals (MDGs) in the capital city of Ethiopia. Hence, the global priority indicator based on the End TB Strategy for TB treatment success rate was met early in 2018 in Addis Ababa, Ethiopia, which was anticipated to be met by 2025. A retrospective health facilities-based study was conducted in Addis Ababa, Ethiopia. Records of all TB cases diagnosed and treated in selected health facilities from January 1st, 2015 to December 31st, 2018 were reviewed and included in the study. Data analysis of descriptive and inferential statistics was conducted using SPSS version 20. The reviewed records have shown that a total of 45,158 presumptive pulmonary TB (PTB) cases had accessed TB diagnosis services. Of which, 28.9% (13072/45158) were tested by AFB microscopy and 71.1% (32086/45158) were tested by GeneXpert. During the study period, the coverage of Xpert MTB/RIF testing increased to 94.9% in 2018 compared to 1.6% in 2015. The number of presumptive PTB cases tested with the GeneXpert system showed a significant increase compared to smear microscopy. The odds of positivity were detected in males compared to females. The odds of detecting TB cases were much higher among study participants aged 15-44 years compared to younger than 15 years. Treatment success rate showed a relative improvement each year between 2015 and 2018 with a mean of 92.6%. Reduced odds of treatment successes were observed in age categories older than 35 years, and in TB/HIV co-infected patients. Increased odds of treatment successes were reported in the years between 2016 and 2018 compared to 2015. Scaling up the Xpert MTB/RIF assay as a point-of-care test for presumptive TB cases in resource-limited settings would have a significant impact to meet the SDG and End TB strategy both in TB detection and treatment success rates.

Association Between Cycle Threshold Value of Cartridge-Based Nucleic Acid Amplification Test and Clinical Severity of Pulmonary Tuberculosis: A Cross-sectional Study

Introduction: Tuberculosis (TB) is a major global health problem caused by Mycobacterium tuberculosis (MTB). The National Tuberculosis Elimination Programme (NTEP) emphasises early diagnosis and treatment of TB cases. The Cartridge-Based Nucleic Acid Amplification Test (CBNAAT) is a semi-automated molecular assay that rapidly detects MTB Deoxyribonucleic Acid (DNA) and Rifampicin (RIF) resistance-associated mutations using Real-Time Polymerase Chain Reaction (RT-PCR). Aim: This cross-sectional study aims to assess the association between the Cycle Threshold (Ct) value of CBNAAT and the clinical severity of Pulmonary Tuberculosis (PTB). Materials and Methods: The study was conducted at the Department of Respiratory Medicine, Navodaya Medical College Hospital and Research Centre-Raichur, from January 2020 to July 2021. A sample size of 106 participants, aged ≥18 years and meeting the NTEP guidelines for presumptive PTB cases, were enrolled. Participants underwent chest radiography, sputum smear microscopy for Acid-Fast Bacilli (AFB), and CBNAAT testing. Clinical severity of PTB was categorised as mild, moderate, or severe using the Bandim TB score. Data was entered into Microsoft Excel 2017, and statistical analysis was performed using SPSS version 23. Descriptive statistics, frequencies, percentages, means, and standard deviations were calculated, and the chi-square test was utilised to assess associations between qualitative variables. Results: Among the participants, the majority (55.7%, n=59) had moderate clinical severity. Of these, 12.3% (n=13) had high CBNAAT Ct values, 20.8% (n=22) had medium Ct values, 11.3% (n=12) had low Ct values, and 11.3% (n=12) had very low Ct values. A total of 31.1% (n=33) had severe clinical severity, with 13.2% (n=6) having high Ct values, 12.3% (n=13) having medium Ct values, and 6.6% (n=7) each having low and very low Ct values. Additionally, 13.2% (n=14) had mild clinical severity, with 0.9% (n=1) having high Ct values, 3.8% (n=4) having medium Ct values, 5.7% (n=6) having low Ct values, and 2.8% (n=3) having very low Ct values. The chi-square value was 4.697, with a p-value of 0.58. Conclusion: There is no association between the Ct value of CBNAAT and the clinical severity of PTB.

Gaps related to screening and diagnosis of tuberculosis in care cascade in selected health facilities in East Africa countries: A retrospective study

IntroductionEast Africa countries (Tanzania, Kenya, and Uganda) are among tuberculosis high burdened countries globally. As we race to accelerate progress towards a world free of tuberculosis by 2035, gaps related to screening and diagnosis in the cascade care need to be addressed. MethodsWe conducted a three-year (2015–2017) retrospective study using routine program data in 21 health facilities from East Africa. Data abstraction were done at tuberculosis clinics, outpatient departments (OPD), human immunodeficiency virus (HIV) and diabetic clinics, and then complemented with structured interviews with healthcare providers to identify possible gaps related to integration, screening, and diagnosis of tuberculosis. Data were analyzed using STATA™ Version 14.1. ResultsWe extracted information from 49,454 presumptive TB patients who were registered in the 21 facilities between January 2015 and December 2017. A total of 9,565 tuberculosis cases were notified; 46.5% (4,450) were bacteriologically confirmed and 31.5% (3,013) were HIV-infected. Prevalence of tuberculosis among presumptive pulmonary tuberculosis cases was 17.4%. The outcomes observed were as follows: 79.8% (7,646) cured or completed treatment, 6.6% (634) died, 13.3% (1,270) lost to follow-up or undocumented and 0.4% (34) treatment failure. In all countries, tuberculosis screening was largely integrated at OPD and HIV clinics. High patient load, weak laboratory specimen referral system, shortage of trained personnel, and frequent interruption of laboratory supplies were the major cited challenges in screening and diagnosis of tuberculosis. ConclusionScreening and diagnostic activities were frequently affected by scarcity of human and financial resources. Tuberculosis screening was mainly integrated at OPD and HIV clinics, with less emphasis on the other health facility clinics. Closing gaps related to TB case finding and diagnosis in developing countries requires sustainable investment for both human and financial resources and strengthen the integration of TB activities within the health system.

Poor performance of the utility of the serological diagnosis of pulmonary tuberculosis in Nigeria

Introduction Pulmonary tuberculosis (PTB) is the most common form of tuberculosis. In Nigeria, PTB is diagnosed by sputum smear microscopy. The problems associated with the diagnosis of PTB using sputum smear for acid-fast bacilli and culture has provided an urgent need to assess the utility of serological tools as an adjunctive diagnostic tool in presumptive PTB cases. This study is aimed at testing the diagnostic utility of a specific immunoglobulin G (IgG) serological assay in the diagnosis of PTB. Patients and methods A utility study was conducted on 184 participants of which 92 were smear-positive PTB cases and 92 were healthy controls at the TB and Leprosy Centre and Ahmadu Bello University Teaching Hospital, Zaria. Data were collected on age and sex, and both PTB patients and controls were screened for anti-TB IgG antibodies by enzyme-linked immunosorbent assay technique. Results The mean age of the participants was 35, and the male-female ratio was 1 : 4. Twenty-one (5.7%) of the PTB patients tested positive for IgG antibodies, and 11 (1.3%) of the controls were positive. The sensitivity of the IgG antibody assay was 18.4%, with the specificity being 92.3%, while the predictive values were 70.8 and 53.1% for positive and negative results, respectively. Conclusion The IgG antibody assay is poorly sensitive; serology may not have a role in the diagnosis of PTB in resource-limited settings, but the much higher specificity suggests that it may be useful as an adjunctive diagnostic tool, or for monitoring of patients on treatment for PTB.

Weak Intra-facility Referral Linkages: Missed Opportunity for Tuberculosis Case Detection and Treatment in a Tertiary Health Facility in Benue State, Nigeria

Despite the scale up of quality-assured Tuberculosis diagnostic and treatment strategies over the years, case detection rate remains a serious challenge globally and particularly in Nigeria. Integrated service delivery is essential to addressing some of the challenges, but it's often neglected especially in low income settings. Recognizing these limitations, a 27-months retrospective review of all presumptive Pulmonary Tuberculosis cases sent to the directly observed short course treatment centre of Benue State University Teaching Hospital, a tertiary health institution in north central Nigeria was conducted to assess the source of referrals and diagnostic processes including outcome of the tests. Chi- square (χ2) test was used for test of association between the intra-facility linkages/referrals system and the tuberculosis case detection rate, with statistical significance set at p-value of ≤5%. There were 918 presumptive Tuberculosis cases with male to female ratio (M: F) of 1:1.3. The mean age of patients was 41.0.0 ±18.4 years. Majority (33.7%, n=) of the referrals were from general outpatient department of the hospital, followed by sexually transmitted infection clinic (26.0%) and Paediatrics department (1.6%, n=). The diagnostic positive rate was 145(15.8%). Overall, 295(32.2%) did not collect their results, of these 76(25.8%) were positive and 219(74.2%) were negative. The relationship between the missed cases and the weak intra-facility referral linkages was statistically significant (p=0.000). The hospital management should consider the engagement of all relevant health care providers on efficient two-way referral system towards ensuring adequate Tuberculosis case notification and prompt treatment.

Improving the diagnosis of pulmonary tuberculosis using line probe assay and determining the factors associated with the disease in children in Jos, Nigeria

Diagnosing tuberculosis (TB), including pulmonary tuberculosis (PTB), in children remains a challenge, partly due to its paucibacillary nature in young children. Data on the use of line probe assay (LPA), on gastric and sputum samples, for diagnosing PTB in children are scarce. We determined the proportion of samples positive for Mycobacterium tuberculosis (MTB) by smear microscopy (SM) and LPA in presumptive PTB cases as well as the factors associated with PTB confirmed by LPA, in children in Jos, Nigeria. An observational study in children aged 6 months-16 years. Gastric and sputum samples were examined by SM and by LPA for MTB using GenoType MTBDRplus Ver 2.0 (Hain Lifescience). Multivariate logistic regression was performed to determine the factors associated with PTB. Out of 103 children with presumptive PTB, 47 had confirmed PTB, 26 unconfirmed PTB and 30 unlikely PTB by LPA. In 67 gastric samples, MTB was identified by SM in 2 (3.0%) compared to 28 (41.8%) by LPA while in 31 sputum samples, MTB was identified by SM in 5 (16.1%) compared to 18 (58.1%) by LPA. The factors associated with pulmonary tuberculosis were an abnormal chest X-ray (adjusted odds ratio (AOR))=12.39 [3.75-40.90], p<0.001), sleeping in the same room with more than three persons (AOR=3.30 [1.23-8.85], p=0.018) and sleeping in a room with none or one window (AOR=2.86 [1.03-7.95], p=0.044). Line probe assay improves the diagnosis of pulmonary TB in children, especially with gastric samples, while an abnormal chest X-ray is a useful adjunct in PTB diagnosis. Avoiding overcrowding and having windows in sleeping rooms are a necessary part of TB prevention.

Barriers of community pharmacists in identification and referral of presumptive tuberculosis cases in Tiruvallur district of Tamil Nadu

BackgroundTuberculosis (TB) still continues to be a major public health threat. Early diagnosis is the cornerstone in combating TB. Community pharmacists are the front line health care providers among the health care system. The present study aimed to identify the barriers of community pharmacists in the identification and referral of presumptive pulmonary tuberculosis cases. MethodsProspective, cross-sectional study was conducted among the community pharmacists in Tiruvallur district of Tamil Nadu. One pharmacist from each pharmacy was interviewed using semi-structured questionnaire. Knowledge component, practice and barriers of identification and referral in presumptive TB cases were captured. ResultsA total of 143 pharmacists were included in the study. Barriers in identification and referral by pharmacists’ perception were patient volume (32%), pharmacy workload (22%), difficulty in identifying the cases (16%), etc. Research team also identified few barriers such as pharmacists do not have adequate knowledge about TB (34%), pharmacists are not trained enough to identify and refer presumptive TB cases (26%), etc. All the pharmacists (100%) refer the presumptive TB cases, if they come across for OTC medications. Pharmacists also provided health education to their community (45.7%). ConclusionAdequate training of community pharmacists and a follow-up system for the presumptive TB cases identified by the community pharmacist are essential in reducing the barriers of pharmacists in TB case detection.

Does mobile phone instructional video demonstrating sputum expectoration improve the sputum sample quality and quantity in presumptive pulmonary TB cases? Protocol for a prospective pragmatic non-randomised controlled trial in Karnataka state, India

IntroductionSputum smear microscopy is the cornerstone of tuberculosis (TB) diagnosis under the Revised National Tuberculosis Control Programme (RNTCP) in India. Instructions on how to produce a good sputum sample are...

Comparison of Conventional versus Molecular Semi-Quantitative Assay in Presumptive Pulmonary Tuberculosis Cases: A Study from Eastern India.

Comparison of Conventional versus Molecular Semi-Quantitative Assay in Presumptive Pulmonary Tuberculosis Cases: A Study from Eastern India.

Rifampicin resistant tuberculosis in presumptive pulmonary tuberculosis cases in Dubti Hospital, Afar, Ethiopia.

Ethiopia stood third in drug-resistant tuberculosis (TB) in Africa, and more than 5,000 MDR-TB patients are reported each year. Greater than 90% of rifampicin (RIF) resistant strains are resistant to isoniazid (INH) and hence the objective of this study was to determine the prevalence and risk factors of RIF resistant MTB among presumptive TB cases at Dubti General Hospital, Afar, Ethiopia. In this cross-sectional study, 384 presumptive TB cases were recruited and a structured questionnaire was used to collect socio-demographic and clinical data. Sputum samples were collected and examined using X-pertMTB/RIF assay. Bivariate, multivariate logistic regressions, and fishers' exact analysis were done to assess the associations between the prevalence of TB and MDR-TB with different socio-demographic and clinical variables. In the present study, the overall prevalence of pulmonary TB was 24.5% (94/384), of this 4 (4.3%) isolates were resistant to RIF. History of anti-TB treatment (AOR = 2.4, 95% CI: 1.3-4.4 and TB contact (AOR = 3.6, 95% CI: 2.1-6.2 were significantly associated with gene X-pert MTB/RIF positive TB. Moreover, resistance to rifampicin was statistically associated with the history of TB contact with multi-drug resistant TB (P = 0.027) and khat chewer cases (P = 0.04). The overall prevalence of TB and its drug-resistant were relatively higher than that of in the general population in Ethiopia. History of anti-TB treatment and TB contact were significantly associated with X-pert MTB/RIF positive MDR-TB.

Demography and the dual epidemics of tuberculosis and HIV: Analysis of cross-sectional data from Sub-Saharan Africa.

BackgroundConvergence of tuberculosis (TB) and HIV epidemics is associated with higher morbidity and mortality risks and understanding their distribution across key demographic factors is essential for prevention and control. This analysis examines the prevalence of TB, HIV and TB-HIV coinfection across age and gender in patients with presumptive TB seeking care at the National TB and Leprosy Training Center in Nigeria.MethodsSamples from 1603 presumptive pulmonary TB cases who provided informed consent were evaluated with a sequential testing algorithm that included a smear microscopy, cultures in liquid and broth media and then genotyping by Hain line probe assays. HIV was serially tested with two HIV rapid assays and retested with a third assay in non-conclusive samples.ResultsTwenty-three percent (375/1603) had confirmed pulmonary TB infection, 23.6% (378/1603) were positive for HIV infection and 26.9% (101/375) of the confirmed TB cases were HIV co-infected. Males had a higher prevalence of TB: 27.6% vs. 18.0%, p < .0001; and a lower prevalence of HIV: 19.0% vs. 29.6%, p < .0001. In the age range of 25–29 years, males were twice as likely to have TB (OR = 2.2; 95% confidence interval [CI]: 1.3–3.9, p = 0.0032) while females were five times more likely to have HIV (OR = 4.8; 95% CI: 2.6–8.9, p < .0001). Persons with TB-HIV coinfection were more likely to be young, female and less likely to be married.ConclusionYounger females with a high burden of HIV may be under-diagnosed and under-reported for TB in Nigeria. Community programs for intensified and early detection of TB and HIV targeting younger females are needed in this setting.

Tuberculosis diagnostic and treatment practices in private sector: Implementation study in an Indian city

SettingImplementation study in private health facilities in an Indian metropolis. ObjectivesImprove Tuberculosis (TB) care by private practitioners (PPs). MethodsPPs from a defined city area were imparted short training in TB care and linkages made with public facilities; subsequent practices were recorded. ResultsOf 364 presumptive TB patient records, 70 (19.3%) did not conform to its definition. Of the conforming, 174 (59.2%) had presumptive pulmonary TB (PTB), 53 (18%) presumptive extra-pulmonary (EPTB) and 67 (24%) had both. Of conforming presumptive PTB, most underwent Chest X-ray and sputum examination in private laboratories. Tissue based diagnostics were not advised for most presumptive EPTB patients. Of 101 cases diagnosed with TB, 82% were new, 23% known diabetic and 4.7% human immune deficiency virus (HIV) reactive out of 64 tested. Most were notified and initiated treatment within 15 days of diagnosis. One-fourth was prescribed standard treatment regimen and treatment was not directly observed for most. One third was initial defaulters or lost during treatment; 62% of PTB and 46% EPTB cases initiated on treatment in private were successfully treated. Of successfully treated PTB cases, 61% had undergone follow-up sputum examination. ConclusionMuch intensified support mechanisms are needed to improve TB care in private sector.

Molecular detection of sputum Mycobacterium tuberculosis/rifampicin resistance among presumptive pulmonary tuberculosis cases in Borno state, North-Eastern Nigeria

Background: Drug resistance to anti-tuberculosis (anti-TB) medication and human immunodeficiency virus (HIV) infection undermines global control of TB.Aim: The aim of this study is to determine sputum mycobacteria/rifampicin resistance obtained from Xpert MTB/RIF molecular assay in five health facilities in Borno state.Methods: Records of 5518 presumptive TB cases that presented for care from September 2014 to December 2017 were retrieved from TB registers in this multicentre descriptive study.Results: A total of 5518 pulmonary TB presumptive cases, out of which 5484 were drug-sensitive TB (DSTB) and 34 drug-resistant TB (DRTB). The MTB detection rate was 19.1% and it was higher among DRTB with rate of 41.2% than DSTB of 19.0%. The prevalence of rifampicin resistance was 6.1%, with higher preponderance rate of 78.6% among DRTB cases than 5.1% among DSTB cases. Only 2566 (46.5%) had HIV counselling and testing. The MTB detection rate of 22.1% in HIV-negative patients was significantly higher than 16.5% in HIV patients, P = 0.001, 95% confidence interval (CI) = 2.27–8.93. Conversely, RIF resistance of 7.0% obtained in HIV patients was significantly higher than 4.8% in HIV-negative patients, P = 0.03, 95% CI = 0.06–4.34. Previous TB treatment was significantly associated with RIF resistance, P = 0.000, odd ratio = 1318.1, 95% CI = 302.1–6318.3.Conclusion: GeneXpert is a valuable tool for the detection of both MTB and RIF resistance. It is therefore useful for both management and TB infection prevention and control. Given the observed strong association between previous exposure to anti-TB medication and RIF resistance in this report, we advocate mandatory resistance test for TB patients with previous exposure to TB medication in addition to good adherence to TB medication.

Improved performance of Xpert MTB/RIF assay on sputum sediment samples obtained from presumptive pulmonary tuberculosis cases at Kibong\u2019oto infectious diseases hospital in\xa0Tanzania

BackgroundThe introduction of Xpert MTB/RIF assay (Xpert) has significantly improved diagnosis of Tuberculosis (TB) in resource limited human immunodeficiency virus (HIV) endemic settings. We aimed to modify the Xpert protocol to improve the detection of Mycobacterium tuberculosis (MTB).MethodsThis cross sectional study was conducted among presumptive pulmonary tuberculosis (PTB) patients at Kibong’oto Infectious Diseases Hospital between August and November 2015. Each patient consented to provide 2 samples of raw sputa. One-sputum sample was sedimented using the Petroff’s method and divided into two portions. One portion of sediment was inoculated on Lowenstein-Jensen culture media and observed for any growth for up to 8 weeks. Both, raw sputum and the portions of sediments were tested separately using Xpert with a sample reagent ratio of 1:2. Mean age of patients, prevalence of MTB, Xpert sensitivity, specificity, positive and negative predictive value were calculated. An incremental sensitivity was determined. Pearson chi-square and either an independent T or Mann-Whitney U-test were used to compared categorical and continuous variables respectively. A p- value of ≤0.05 was considered significant.ResultsOf the 270 presumptive PTB cases, 262 were eligible for analysis. Eight (3%) were excluded due to contaminated culture. Patients’ mean age was 42.9 (±SD 15.1) years of which 173 (66%) were female. The overall prevalence of PTB was 112 (43%), of which the Xpert detected 105 (40%) in sediments and 98 (37%) in raw sputa as compared to culture which detected 85 (32%) cases of PTB. Sensitivity, specificity, positive and negative predictive values of Xpert on sputum sediments were 92%, 85%, 74% and 96% respectively. Overall, the incremental sensitivity of Xpert on sediment over raw sputum was 6%. In HIV infected Presumptive PTB, the incremental sensitivity was 12%.ConclusionLowering the sample reagent to sediment dilution ratio increases sensitivity of Xpert on MTB detection among presumptive PTB cases, especially in HIV infected individuals.

Front-loaded sputum microscopy in the diagnosis of pulmonary tuberculosis

Objective/background: The objectives of this study are to describe the acid-fast bacilli (AFB) yield of a front-loaded scheme in which an additional on-the-spot specimen (Xspot [Xs]) was collected 1h after the first spot specimen and to compare the default rate between the front-loaded and standard schemes. The performance of the front-loaded sputum microscopy was also compared with the standard World Health Organization (WHO) method for the diagnosis of pulmonary tuberculosis (PTB) in Anambra State, Nigeria. Methods: A total of 1487 individuals with presumptive pulmonary TB participated. Participants’ age ranged from 15years and above. Three sputum specimens were submitted as spot–early morning–spot. An additional specimen (Xs) was submitted 1h after the first spot. The sputum smears were stained using the Ziehl–Neelsen technique. Results: A total of 183 (12.3%) patients were AFB positive. The front-loaded scheme identified 182 (99%) TB patients, whereas the standard scheme identified 183 (100%) TB patients. The difference was not statistically significant (p>.05). The first two specimens of each scheme (S–Xs vs. S–M) identified 176 (96.2%) and 181 (98.9%) of PTB patients, respectively. Neither difference was statistically significant (p>.05). Default during the diagnostic process was 11% in the standard but only 0.7% in the front-load scheme. The difference was significant (p<.05). Conclusion: Front-loaded smear microscopy has similar performance compared with the standard scheme. More presumptive PTB cases defaulted in the standard than in the front-loaded scheme. Front-loaded smear microscopy could therefore be used in the diagnosis in PTB in Anambra State.

Increased detection of smear-negative pulmonary tuberculosis by GeneXpert MTB/RIF® assay after bleach concentration

Objective/backgroundThe GeneXpert MTB/RIF assay (Xpert) was endorsed as the initial diagnostic tool in people suspected of human immunodeficiency virus-associated or drug-resistant tuberculosis (TB). However, information regarding the performance of Xpert for diagnosing smear-negative TB in high burden settings remains limited. We evaluated the diagnostic accuracy of Xpert and the impact of bleach concentration on the performance of Xpert using smear-negative sputum samples from human immunodeficiency virus-negative patients. MethodsOne spot and one morning smear-negative sputum samples per patient were examined using Xpert and culture at the Mycobacteriology Research Center of Jimma University, Ethiopia. The sputum culture on both Löwenstein–Jensen and/or Mycobacteria Growth Indicator Tube was the gold-standard. ResultsOf 185 smear-negative presumptive pulmonary TB cases, 19 (10.3%) had culture-proven TB. The sensitivity of Xpert on spot and morning sputum was similar (63.2%). Testing two specimens per patient insignificantly increased the sensitivity of Xpert. Bleach concentration and pelleting improved the sensitivity of Xpert over unprocessed sputum in paired samples (73.8% vs. 63.2%) without affecting the specificity (95%). Bleach concentration and pelleting allowed an additional seven cases of TB (missed on the first and second direct Xperts) to be detected, five of which were from culture-negative cases. ConclusionTesting of a single sputum sample by Xpert can reach reasonable sensitivity and results would be available on the same day, avoiding loss of patients and treatment delay. The sensitivity of Xpert was improved after bleach concentration and pelleting, although its added value needs further study on a larger scale.

Experience of active tuberculosis case finding in nearly 5 million households in India.

In India, to increase tuberculosis (TB) case detection under the National Tuberculosis Programme, active case finding (ACF) was implemented by the Global Fund-supported Project Axshya, among high-risk groups in 300 districts. Between April 2013 and December 2014, 4.9 million households covering ~20 million people were visited. Of 350 047 presumptive pulmonary TB cases (cough of ⩾2 weeks) identified, 187 586 (54%) underwent sputum smear examination and 14 447 (8%) were found to be smear-positive. ACF resulted in the detection of a large number of persons with presumptive pulmonary TB and smear-positive TB. Ensuring sputum examination of all those with presumptive TB was a major challenge.

Enhancing TB case detection: experience in offering upfront Xpert MTB/RIF testing to pediatric presumptive TB and DR TB cases for early rapid diagnosis of drug sensitive and drug resistant TB.

BackgroundDiagnosis of pulmonary tuberculosis (PTB) in children is challenging due to difficulties in obtaining good quality sputum specimens as well as the paucibacillary nature of disease. Globally a large proportion of pediatric tuberculosis (TB) cases are diagnosed based only on clinical findings. Xpert MTB/RIF, a highly sensitive and specific rapid tool, offers a promising solution in addressing these challenges. This study presents the results from pediatric groups taking part in a large demonstration study wherein Xpert MTB/RIF testing replaced smear microscopy for all presumptive PTB cases in public health facilities across India.MethodsThe study covered a population of 8.8 million across 18 programmatic sub-district level tuberculosis units (TU), with one Xpert MTB/RIF platform established at each study TU. Pediatric presumptive PTB cases (both TB and Drug Resistant TB (DR-TB)) accessing any public health facilities in study area were prospectively enrolled and tested on Xpert MTB/RIF following a standardized diagnostic algorithm.Results4,600 pediatric presumptive pulmonary TB cases were enrolled. 590 (12.8%, CI 11.8–13.8) pediatric PTB were diagnosed. Overall 10.4% (CI 9.5–11.2) of presumptive PTB cases had positive results by Xpert MTB/RIF, compared with 4.8% (CI 4.2–5.4) who had smear-positive results. Upfront Xpert MTB/RIF testing of presumptive PTB and presumptive DR-TB cases resulted in diagnosis of 79 and 12 rifampicin resistance cases, respectively. Positive predictive value (PPV) for rifampicin resistance detection was high (98%, CI 90.1–99.9), with no statistically significant variation with respect to past history of treatment.ConclusionUpfront access to Xpert MTB/RIF testing in pediatric presumptive PTB cases was associated with a two-fold increase in bacteriologically-confirmed PTB, and increased detection of rifampicin-resistant TB cases under routine operational conditions across India. These results suggest that routine Xpert MTB/RIF testing is a promising solution to present-day challenges in the diagnosis of PTB in pediatric patients.