The first Global Pneumonia Forum: recommendations in the time of coronavirus

For 3 days in late January, 2020, 350 government, UN and multilateral agencies, companies, non-profit organisations, and academic health leaders from more than 55 countries gathered in Barcelona, Spain, to strategise more effective ways to fight the leading infectious threat to child survival—pneumonia. The inaugural Fighting for Breath Global Forum on Childhood Pneumonia (the Global Forum) culminated in a consensus declaration outlining the steps necessary to end preventable child deaths from pneumonia in every country by 2030. The declaration is now in wider circulation and can be signed by organisations who want to join the fight against pneumonia.1 Highlights of this declaration, and of actions derived from some of the key points, are summarised in the appendix

Liquid vs Solid Culture Medium to Evaluate Proportion and Time to Change in Management of Suspects of Tuberculosis-A Pragmatic Randomized Trial in Secondary and Tertiary Health Care Units in Brazil.

BACKGROUND: The use of liquid medium (MGIT960) for tuberculosis (TB) diagnosis was recommended by WHO in 2007. However, there has been no evaluation of its effectiveness on clinically important outcomes. METHODS AND FINDINGS: A pragmatic trial was carried out in a tertiary hospital and a secondary health care unit in Rio de Janeiro City, Brazil. Participants were 16 years or older, suspected of having TB. They were excluded if only cerebral spinal fluid or blood specimens were available for analysis. MGIT960 technique was compared with the Lowenstein-Jensen (LJ) method for laboratory diagnosis of active TB. Primary outcome was the proportion of patients who had their initial medical management changed within 2 months after randomisation. Secondary outcomes were: mean time for changing the procedure, patient satisfaction with the overall treatment and adverse events. Data were analysed by intention-to-treat. Between April 2008 and September 2011, 693 patients were enrolled (348 to MGIT, 345 to LJ). Smear and culture results were positive for 10% and 15.7% of participants, respectively. Patients in the MGIT arm had their initial medical management changed more frequently than those in the LJ group (10.1% MGIT vs 3.8% LJ, RR 2.67 95% CI 1.44-.96, p = 0.002, NNT 16, 95% CI 10-39). Mean time for changing the initial procedure was greater in LJ group at both sites: 20.0 and 29.6 days in MGIT group and 52.2 and 64.3 in LJ group (MD 33.5, 95% CI 30.6-36.4, p = 0.0001). No other important differences were observed. CONCLUSIONS: This study suggests that opting for the MGIT960 system for TB diagnosis provides a promising case management model for improving the quality of care and control of TB. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN79888843

A Blueprint to Address Research Gaps in the Development of Biomarkers for Pediatric Tuberculosis

Childhood tuberculosis contributes significantly to the global tuberculosis disease burden but remains challenging to diagnose due to inadequate methods of pathogen detection in paucibacillary pediatric samples and lack of a child-specific host biomarker to identify disease. Accurately diagnosing tuberculosis in children is required to improve case detection, surveillance, healthcare delivery, and effective advocacy. In May 2014, the National Institutes of Health convened a workshop including researchers in the field to delineate priorities to address this research gap. This blueprint describes the consensus from the workshop, identifies critical research steps to advance this field, and aims to catalyze efforts toward harmonization and collaboration in this are

The impact of a line probe assay based diagnostic algorithm on time to treatment initiation and treatment outcomes for multidrug resistant TB patients in Arkhangelsk region, Russia

BACKGROUND: In the Arkhangelsk region of Northern Russia, multidrug-resistant (MDR) tuberculosis (TB) rates in new cases are amongst the highest in the world. In 2014, MDR-TB rates reached 31.7% among new cases and 56.9% among retreatment cases. The development of new diagnostic tools allows for faster detection of both TB and MDR-TB and should lead to reduced transmission by earlier initiation of anti-TB therapy. STUDY AIM: The PROVE-IT (Policy Relevant Outcomes from Validating Evidence on Impact) Russia study aimed to assess the impact of the implementation of line probe assay (LPA) as part of an LPA-based diagnostic algorithm for patients with presumptive MDR-TB focusing on time to treatment initiation with time from first-care seeking visit to the initiation of MDR-TB treatment rather than diagnostic accuracy as the primary outcome, and to assess treatment outcomes. We hypothesized that the implementation of LPA would result in faster time to treatment initiation and better treatment outcomes. METHODS: A culture-based diagnostic algorithm used prior to LPA implementation was compared to an LPA-based algorithm that replaced BacTAlert and Löwenstein Jensen (LJ) for drug sensitivity testing. A total of 295 MDR-TB patients were included in the study, 163 diagnosed with the culture-based algorithm, 132 with the LPA-based algorithm. RESULTS: Among smear positive patients, the implementation of the LPA-based algorithm was associated with a median decrease in time to MDR-TB treatment initiation of 50 and 66 days compared to the culture-based algorithm (BacTAlert and LJ respectively, p<0.001). In smear negative patients, the LPA-based algorithm was associated with a median decrease in time to MDR-TB treatment initiation of 78 days when compared to the culture-based algorithm (LJ, p<0.001). However, several weeks were still needed for treatment initiation in LPA-based algorithm, 24 days in smear positive, and 62 days in smear negative patients. Overall treatment outcomes were better in LPA-based algorithm compared to culture-based algorithm (p = 0.003). Treatment success rates at 20 months of treatment were higher in patients diagnosed with the LPA-based algorithm (65.2%) as compared to those diagnosed with the culture-based algorithm (44.8%). Mortality was also lower in the LPA-based algorithm group (7.6%) compared to the culture-based algorithm group (15.9%). There was no statistically significant difference in smear and culture conversion rates between the two algorithms. CONCLUSION: The results of the study suggest that the introduction of LPA leads to faster time to MDR diagnosis and earlier treatment initiation as well as better treatment outcomes for patients with MDR-TB. These findings also highlight the need for further improvements within the health system to reduce both patient and diagnostic delays to truly optimize the impact of new, rapid diagnostics

Clinical Impact of the Line Probe Assay and Xpert® MTB/RIF Assay in the Presumptive Diagnosis of Drug-Resistant Tuberculosis in Brazil: A Pragmatic Clinical Trial

Background: Rapid molecular methods such as the line probe assay (LPA) and Xpert® MTB/RIF assay (Xpert) have been recommended by the World Health Organization for drug-resistant tuberculosis (DR-TB) diagnosis. We conducted an interventional trial in DR-TB reference centers in Brazil to evaluate the impact of the use of LPA and Xpert. Methods: Patients with DR-TB were eligible if their drug susceptibility testing results were available to the treating physician at the time of consultation. The standard reference MGITTM 960 was compared with Xpert (arm 1) and LPA (arm 2). Effectiveness was considered as the start of the appropriate TB regimen that matched drug susceptibility testing (DST) and the proportions of culture conversion and favorable treatment outcomes after 6 months. Results: A higher rate of empirical treatment was observed with MGIT alone than with the Xpert assay (97.0% vs. 45.0%) and LPA (98.2% vs. 67.5%). Patients started appropriate TB treatment more quickly than those in the MGIT group (median 15.0 vs. 40.5 days; p<0.01) in arm 1. Compared to the MGIT group, culture conversion after 6 months was higher for Xpert in arm 1 (90.9% vs. 79.3%, p=0.39) and LPA in arm 2 (80.0% vs. 83.0%, p=0.81). Conclusions: In the Xpert arm, there was a significant reduction in days to the start of appropriate anti-TB treatment and a trend towards greater culture conversion in the sixth month

Untersuchung des Einflusses mitochondrialer Polymorphismen auf die phänotypische Ausprägung der Neurofibromatose Typ 1 bei monozygoten Zwillingen

Einleitung: Die Entdeckung somatischer homoplasmischer Mutationen der mitochondrialen DNA (mtDNA) in Tumoren gab Anlass zu der Frage, ob Mutationen der mtDNA einen Einfluss auf Entstehung und Wachstum von Tumoren haben könnten. Die Neurofibromatose Typ 1 (NF1, von Recklinghausen) ist eine der häufigsten erblichen Tumorerkrankungen mit einer Penetranz von 100%, aber hoher phänotypischer Variabilität. Selbst eineiige Zwillinge können sich erheblich in ihrem Phänotyp unterscheiden. Durch die ungleiche Verteilung der Mitochondriengenome auf die Embryonen könnten heteroplasmische mtDNA-Polymorphismen den Phänotyp der Neurofibromatose Typ 1 unterschiedlich beeinflussen. Ziel dieser Arbeit war es herauszufinden, ob es interindividuelle Unterschiede in der mtDNA-Sequenz monozygoter Zwillinge gibt, die an Neurofibromatose Typ 1 erkrankt sind, sich jedoch im Phänotyp unterscheiden. Des Weiteren habe ich nach intraindividuellen Unterschieden der mtDNA-Sequenz zwischen Blut und Tumorgewebe gesucht. Die Frage war, ob es somatische mtDNA-Mutationen gibt, die einen Einfluss auf das Entstehen der Tumore haben könnten. Innerhalb der mtDNA gibt es hypervariable Regionen (HVR), von denen der oft in heteroplamischer Form vorkommende D310-Trakt im D-loop als Marker für klonales Wachstum in Tumoren empfohlen wurde. Ich habe versucht, durch Analyse des D-loops der mtDNA aus Neurofibromen klonales Wachstum nachzuweisen. Methoden: Ich habe die mitochondriale DNA vier monozygoter Zwillingspaare untersucht. Die DNA wurde sowohl aus Blutleukozyten als auch aus Neurofibromen extrahiert. Ich habe zunächst mit mtDNA-spezifischen Primern eine Long-range PCR durchgeführt. Mit dem Long-range PCR-Produkt als Matrize habe ich in 17 verschachtelten PCR Reaktionen Fragmente generiert und diese sequenziert. Den relativen Anteil heteroplasmischer Längenvarianten des D310-Traktes ermittelte ich mittels Genotypisierung. Ergebnisse: Beim Vergleich der mtDNA-Sequenzen mit der mtDNA Standardsequenz (Genbank, NC_001807) habe ich insgesamt 88 Abweichungen gefunden. Die meisten waren in der Datenbank Mitomap verzeichnet. Es fanden sich keine interindividuellen Unterschiede innerhalb der einzelnen Paare. Beim Vergleich der mtDNA-Sequenzen aus Blut- mit denen aus Tumorzellen eines Zwillingspaares fand ich keinen intraindividuellen Unterschied. Der D310-Trakt innerhalb der HVR2 kam bei allen Zwillingspaaren in heteroplasmischer Form vor. Bei den Zwillingen A1 und A2 sowie deren Mutter MA konnte ich annähernd die gleiche Verteilung der Löngenvarianten in Blutzellen sowie in Neurofibromen von A1 und A2 zeigen. Schlussfolgerungen: Ich konnte keinen Hinweis dafür finden, dass Veränderungen in der mtDNA die phänotypische Ausprägung der NF1 beeinflussen. In Neurofibromen konnte ich durch Untersuchung des D310-Traktes keinen Hinweis auf klonales Wachstum finden.Introduction: The discovery of homoplasmic somatic mutations of the mitochondrial DNA (mtDNA) led to the question whether mutations of mtDNA could influence tumor development and growth. Neurofibromatosis Type 1 (NF1) is one of the most common inherited disorders. Penetrance of the disease is 100%, but phenotypic variability is high, even amongst identical twins. I wanted to test the hypothesis, whether the unequal distribution of heteroplasmic mtDNA variants between the embryos might influence NF1 phenotype. The aim of this study was to look for interindividual differences of the mtDNA sequence between identical twins. In order to detect somatic mutation that could possibly influence tumor development I searched for intraindividual differences between blood- and tumor-mtDNA. The hypervariable D310-tract within the D-loop is heteroplasmic in most individuals, but shows a tendency towards homoplasmy in tumors. Therefore, it has been proposed as marker for clonal tumor growth. I tried to identify clonal growth in cutaneous neurofibromas by examination of the D310-tract. Methods: I examined the mtDNA from four pairs of identical twins. MtDNA was extracted from blood-leucocytes as well as from neurofibromas. With DNA-specific primers I first performed a long-range PCR. The product was then reamplified as 17 nested PCR fragments and sequenced afterwards. The relative amount of heteroplasmic D310-tract length variants was analyzed by genotyping. Results: Taken together, I identified 88 deviations from the mtDNA standard sequence (Genbank NC_001807). Most of these variants were already known as polymorphisms in the database MITOMAP. I could neither find any interindividual differences between the individuals of a twin pair nor intraindividual differences between blood- and tumor-mtDNA. The D310-tract was heteroplasmic in all twin pairs. Twins A1 and A2 as well as their mother showed almost the same distribution of length variants in blood and tumor. Conclusion: I could not show that mtDNA polymorphisms play a role in phenotypic variability of NF1. Examination of the D310 tract in cutaneous neurofibromas did not show signs of clonal growth

Xpert MTB/RIF and Xpert MTB/RIF Ultra assays for active tuberculosis and rifampicin resistance in children

This is a protocol for a Cochrane Review (Diagnostic test accuracy). The objectives are as follows: Primary objectives To determine the diagnostic accuracy of Xpert MTB/RIF and Xpert Ultra for a) PTB in children presumed to have tuberculosis; b) lymph node tuberculosis in children presumed to have tuberculosis; c) tuberculous meningitis in children presumed to have tuberculosis; and d) rifampicin resistance in children presumed to have tuberculosis. For tuberculosis detection, the role of the index tests would be a replacement for standard practice. For rifampicin resistance detection, the role of the index tests would be an initial replacement test for culture‐based drug susceptibility testing

Utility of host markers detected in Quantiferon supernatants for the diagnosis of tuberculosis in children in a high-burden setting

CITATION: Chegou, N. N. et al. 2013. Utility of host markers detected in Quantiferon supernatants for the diagnosis of tuberculosis in children in a high-burden setting. PLoS ONE, 8(5):e64226, doi:10.1371/journal.pone.0064226.The original publication is available at http://journals.plos.org/plosoneBackground: The diagnosis of childhood tuberculosis (TB) disease remains a challenge especially in young and HIV-infected children. Recent studies have identified potential host markers which, when measured in Quantiferon (QFT-IT) supernatants, show promise in discriminating between Mycobacterium tuberculosis (M.tb) infection states. In this study, the utility of such markers was investigated in children screened for TB in a setting with high TB incidence. Methodology and Principal Findings: 76 children (29% HIV-infected) with or without active TB provided blood specimens collected directly into QFT-IT tubes. After overnight incubation, culture supernatants were harvested, aliquoted and frozen for future immunological research purposes. Subsequently, the levels of 12 host markers previously identified as potential TB diagnostic markers were evaluated in these supernatants for their ability to discriminate between M.tb infection and disease states using the Luminex platform. Of the 76 children included, 19 (25%) had culture confirmed TB disease; 26 (46%) of the 57 without TB had positive markers of M.tb infection defined by a positive QFT-IT test. The potentially most useful analytes for diagnosing TB disease included IFN-a2, IL-1Ra, sCD40L and VEGF and the most useful markers for discriminating between QFT-IT positive children as TB or latent infection included IL-1Ra, IP-10 and VEGF. When markers were used in combinations of four, 84% of all children were accurately classified into their respective groups (TB disease or no TB), after leave-one-out cross validation. Conclusions: Measurement of the levels of IFN-a2, IL-1Ra, sCD40L, IP-10 and VEGF in QFT-IT supernatants may be a useful method for diagnosing TB disease and differentiating between active TB disease and M.tb infection in children. Our observations warrant further investigation in larger well-characterized clinical cohorts.http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0064226Publisher's versio

Xpert MTB/RIF assay for the diagnosis of pulmonary tuberculosis in children: a systematic review and meta-analysis

Background Microbiological confirmation of childhood tuberculosis is rare because of the difficulty of collection of specimens, low sensitivity of smear microscopy, and poor access to culture. We aimed to establish summary estimates for sensitivity and specificity of of the Xpert MTB/RIF assay compared with microscopy in the diagnosis of pulmonary tuberculosis in children. Methods We searched for studies published up to Jan 6, 2015, that used Xpert in any setting in children with and without HIV infection. We systematically reviewed studies that compared the diagnostic accuracy of Xpert MTB/RIF (Xpert) with microscopy for detection of pulmonary tuberculosis and rifampicin resistance in children younger than 16 years against two reference standards—culture results and culture-negative children who were started on anti-tuberculosis therapy. We did meta-analyses using a bivariate random-effects model. Findings We identified 15 studies including 4768 respiratory specimens in 3640 children investigated for pulmonary tuberculosis. Culture tests were positive for tuberculosis in 12% (420 of 3640) of all children assessed and Xpert was positive in 11% (406 of 3640). Compared with culture, the pooled sensitivities and specificities of Xpert for tuberculosis detection were 62% (95% credible interval 51–73) and 98% (97–99), respectively, with use of expectorated or induced sputum samples and 66% (51–81) and 98% (96–99), respectively, with use of samples from gastric lavage. Xpert sensitivity was 36–44% higher than was sensitivity for microscopy. Xpert sensitivity in culture-negative children started on antituberculosis therapy was 2% (1–3) for expectorated or induced sputum. Xpert's pooled sensitivity and specificity to detect rifampicin resistance was 86% (95% credible interval 53–98) and 98% (94–100), respectively. Interpretation Compared with microscopy, Xpert offers better sensitivity for the diagnosis of pulmonary tuberculosis in children and its scale-up will improve access to tuberculosis diagnostics for children. Although Xpert helps to provide rapid confirmation of disease, its sensitivity remains suboptimum compared with culture tests. A negative Xpert result does not rule out tuberculosis. Good clinical acumen is still needed to decide when to start antituberculosis therapy and continued research for better diagnostics is crucial

Provision of Decentralized TB Care Services: A Detect&ndash;Treat&ndash;Prevent Strategy for Children and Adolescents Affected by TB

In this review, we discuss considerations and successful models for providing decentralized diagnosis, treatment, and prevention services for children and adolescents. Key approaches to building decentralized capacity for childhood TB diagnosis in primary care facilities include provider training and increased access to child-focused diagnostic tools and techniques. Treatment of TB disease should be managed close to where patients live; pediatric formulations of both first- and second-line drugs should be widely available; and any hospitalization should be for as brief a period as medically indicated. TB preventive treatment for child and adolescent contacts must be greatly expanded, which will require home visits to identify contacts, building capacity to rule out TB, and adoption of shorter preventive regimens. Decentralization of TB services should involve the private sector, with collaborations outside the TB program in order to reach children and adolescents where they first enter the health care system. The impact of decentralization will be maximized if programs are family-centered and designed around responding to the needs of children and adolescents affected by TB, as well as their families