The impact of tuberculosis on pulmonary health in Maputo, Mozambique

Background Pulmonary tuberculosis (PTB) is curable but is still a major health problem. PTB is associated to chronic lung impairment even after microbiological cure. The type, severity and risk factor for lung impairment (LI) are poorly described. The prevalence of LI and reference equations have not been established in Mozambican healthy population. Methods A cohort of PTB patients was followed for 52 weeks after TB diagnosis (2014 to 2016), spirometry and 6-Minute Walk Test was assessed at weeks 8, 26 and 52 of follow-up, in Mavalane, Maputo. Saint George Respiratory Questionnaire (SGRQ) was evaluated during treatment. In 2017, the prevalence of lung impairment and 6-Minute Walk Test were evaluated in healthy volunteers from the same neighbourhood. Results The proportion of LI is 73,3% on week 8, declining to 67,7% at week 26 and 61,3% (26% of moderate-severe) at week 52 in PTB patients. On week 52 the mean Vital Capacity (FVC) is 2.65l (66.7% of predicted) in participants with LI versus 3.68l (90% of predicted) in participants without LI. All study participants suffered from pulmonary restriction (except one). Female sex (RRR = 5), higher CD4 in HIV positives (RRR: 7.33) were significantly associated with LI. The increase of haemoglobin was protective (RRR = 0.61). The PTB patients travelled a mean distance of 442 meters on week 52 and a mean total score of 5.58 in SGRQ. The proportion of LI in the Healthy volunteers was 20%, with 19,35% of restriction (one case of obstruction) mean FVC of 3.27l (89.4% of predicted) and FEV1 of 2.7l (93.80% of predicted). Conclusion Pulmonary restriction occurs in a fifth of healthy volunteers, it develops early during TB disease or treatment affecting more than half of the PTB patients. There is a need of more studies on lung outcome in PTB and to establish reference equation in healthy volunteers

The impact of tuberculosis on pulmonary health in Maputo, Mozambique

Background Pulmonary tuberculosis (PTB) is curable but is still a major health problem. PTB is associated to chronic lung impairment even after microbiological cure. The type, severity and risk factor for lung impairment (LI) are poorly described. The prevalence of LI and reference equations have not been established in Mozambican healthy population. Methods A cohort of PTB patients was followed for 52 weeks after TB diagnosis (2014 to 2016), spirometry and 6-Minute Walk Test was assessed at weeks 8, 26 and 52 of follow-up, in Mavalane, Maputo. Saint George Respiratory Questionnaire (SGRQ) was evaluated during treatment. In 2017, the prevalence of lung impairment and 6-Minute Walk Test were evaluated in healthy volunteers from the same neighbourhood. Results The proportion of LI is 73,3% on week 8, declining to 67,7% at week 26 and 61,3% (26% of moderate-severe) at week 52 in PTB patients. On week 52 the mean Vital Capacity (FVC) is 2.65l (66.7% of predicted) in participants with LI versus 3.68l (90% of predicted) in participants without LI. All study participants suffered from pulmonary restriction (except one). Female sex (RRR = 5), higher CD4 in HIV positives (RRR: 7.33) were significantly associated with LI. The increase of haemoglobin was protective (RRR = 0.61). The PTB patients travelled a mean distance of 442 meters on week 52 and a mean total score of 5.58 in SGRQ. The proportion of LI in the Healthy volunteers was 20%, with 19,35% of restriction (one case of obstruction) mean FVC of 3.27l (89.4% of predicted) and FEV1 of 2.7l (93.80% of predicted). Conclusion Pulmonary restriction occurs in a fifth of healthy volunteers, it develops early during TB disease or treatment affecting more than half of the PTB patients. There is a need of more studies on lung outcome in PTB and to establish reference equation in healthy volunteers

Reduction of blood C-reactive protein concentration complements the resolution of sputum bacillary load in patients on anti-tuberculosis therapy

Funding: This study was conducted under the PanACEA Biomarkers Expansion (PanBIOME) programme and the establishment of Maputo Tuberculosis Trial Unit (MaTuTU Project) which was funded in parts through the European and Developing Countries Clinical Trials Partnership (EDCTP), PZA-study and Federal Ministry of Education and Research (BMBF), Germany.Background: Tuberculosis (TB) is a difficult-to-treat disease requiring the combination of four antibiotics for a minimum of 6 months. Rapid and quantitative biomarkers to monitor treatment response are urgently needed for individual patient management and clinical trials. C-reactive protein (CRP) is often used clinically as a rapid marker of inflammation caused by infection. We assessed the relationship of TB bacillary load and CRP as biomarkers of treatment response. Methods: Xpert MTB/RIF-confirmed pulmonary TB cases were enrolled for treatment response assessment in Mozambique. Treatment response was measured using the Tuberculosis Molecular Bacterial Load Assay (TB-MBLA) in comparison with standard-of-care Mycobacterium Growth Indicator Tube (MGIT) culture at baseline and at weeks 1, 2, 4, 8, 12, 17, and 26 of treatment. Blood CRP concentration was measured at baseline, week 8, and week 26. Treatment response was defined as increase in MGIT culture time to positivity (TTP), and reduction in TB-MBLA-measured bacillary load and blood CRP concentration. Results: Out of the 81 screened presumptive TB cases, 69 were enrolled for 6-month treatment follow-up resulting in 94% treatment completion rate. Four participants did not complete TB treatment and 22 participants had missing CRP or TB-MBLA results and were excluded from TB-MBLA-CRP analysis. The remaining 43 participants—median age, 31 years old [interquartile range (IQR): 18–56]; 70% (30/43) male; and 70% (30/43) infected with HIV—were considered for analysis. Culture TTP and bacillary load were inversely correlated, Spearman’s r = −0.67, p < 0.0001. Resolution of sputum bacillary load concurred with reduction of blood CRP, r = 0.70, p < 0.0001. At baseline, bacillary load had a median (IQR) of 6.4 (5.5–7.2), which reduced to 2.4 (0.0–2.9) and 0.0 (0.0–0.0) log10 CFU/ml at months 2 and 6 of treatment, respectively. Correspondingly, blood CRP reduced from 1.9 (1.6–2.1) at baseline to 1.3 (0.9–1.7) and 0.4 (0.1–0.8) log10 mg/dl at months 2 and 6 of treatment, respectively. CRP reduction trialed bacteriological resolution at a rate of −0.06 log10 mg/dl compared to a bacillary load of 0.23 log10 CFU/ml per week. Consequently, 14 (33%) and 37 (88%) patients had reduced CRP to normal concentration and bacillary load to zero by the end of treatment, respectively. Pre-treatment CRP concentration and bacillary load, and resolution during treatment were slightly lower in HIV co-infected patients but not significantly different from HIV-uninfected TB patients. Conclusion: TB-MBLA-measured bacillary load and blood CRP complement each other in response to anti-TB therapy. Slow CRP reduction probably reflects residual TB bacilli in the lung not expectorated in sputum. Combining both measures can improve the accuracy of these biomarkers for monitoring TB treatment response and shorten turnaround time since the results of both assays could be available in 24 h.Publisher PDFPeer reviewe

Perspectives of healthcare and social support sector policymakers on potential solutions to mitigate financial impact among people with TB in Mozambique: a qualitative study

Objective People with tuberculosis (TB) and their households face severe socioeconomic consequences, which will only be mitigated by intersectoral collaboration, especially between the health and social sectors. Evidence suggests that key factors for successful collaboration include shared goals, trust, commitment, resource allocation, efficient processes and effective communication and motivation among collaborating parties. This study aimed to understand healthcare and social support sector policymakers’ perspectives on potential solutions to mitigate financial impact among people with TB and their households in Mozambique. Design Qualitative study with primary data collection through one-to-one in-depth interviews. Setting Gaza and Inhambane provinces, Mozambique. Participants Policymakers in the health and social support sector. Results A total of 27 participants were purposefully sampled. Participants were asked about their perspectives on TB-related financial impact and potential solutions to mitigate such impact. Participants reported that people with TB are not explicitly included in existing social support policies because TB per se is not part of the eligibility criteria. People with TB and underweight or HIV were enrolled in social support schemes providing food or cash. Two themes were generated from the analysis: (1) Policymakers suggested several mitigation solutions, including food and monetary support, but perceived that their implementation would be limited by lack of resources; and (2) lack of shared views or processes related to intersectoral collaboration between health and social support sector hinders design and implementation of social support for people with TB. Conclusion Despite health and social sector policymakers reporting a willingness for intersectoral collaboration to mitigate TB-related financial impact, current approaches were perceived to be unilateral. Collaboration between health and social support sectors should focus on improving existing social support programmes

'They didn't look at me with good eyes' - experiences of the socioeconomic impact of tuberculosis and support needs among adults in a semi-rural area in Mozambique: A Qualitative Study

Tuberculosis is recognised as a disease of the economically disadvantaged people due to its association with financial vulnerability. Mozambique still faces the challenge of the high burden of TB and associated costs. We aimed to understand the social and economic impacts of TB and the need for social support among people with TB in Mozambique. We conducted a qualitative study using a phenomenological approach focusing on the lived experiences and perceptions of people with TB. A total of 52 semi-structured one-to-one in-depth interviews were conducted and data were analysed using a reflexive thematic analysis. Three themes were drawn from the analysis: (i) TB has a social and economic impact that requires adaptation and resourcefulness amongst those affected; (ii) People with TB have different preferences and needs for social support, and (iii) People with TB have different knowledge of, and experiences with, formal social support. TB affects family and community relationships mainly due to impacts on the household's finances. People with TB in Mozambique are not entitled to any form of social support, and they need to rely on help from family and the community which is often insufficient. Further investigation is needed on how social support schemes can be developed in Mozambique

Why healthcare workers are sick of TB.

Dr Thato Mosidi never expected to be diagnosed with tuberculosis (TB), despite widely prevalent exposure and very limited infection control measures. The life-threatening diagnosis of primary extensively drug-resistant TB (XDR-TB) came as an even greater shock. The inconvenient truth is that, rather than being protected, Dr Mosidi and thousands of her healthcare colleagues are at an increased risk of TB and especially drug-resistant TB. In this viewpoint paper we debunk the widely held false belief that healthcare workers are somehow immune to TB disease (TB-proof) and explore some of the key factors contributing to the pervasive stigmatization and subsequent non-disclosure of occupational TB. Our front-line workers are some of the first to suffer the consequences of a progressively more resistant and fatal TB epidemic, and urgent interventions are needed to ensure the safety and continued availability of these precious healthcare resources. These include the rapid development and scale-up of improved diagnostic and treatment options, strengthened infection control measures, and focused interventions to tackle stigma and discrimination in all its forms. We call our colleagues to action to protect themselves and those they care for

Why healthcare workers are sick of TB

Dr Thato Mosidi never expected to be diagnosed with tuberculosis (TB), despite widely prevalent exposure and very limited infection control measures. The life-threatening diagnosis of primary extensively drug-resistant TB (XDR-TB) came as an even greater shock. The inconvenient truth is that, rather than being protected, Dr Mosidi and thousands of her healthcare colleagues are at an increased risk of TB and especially drug-resistant TB. In this viewpoint paper we debunk the widely held false belief that healthcare workers are somehow immune to TB disease (TB-proof) and explore some of the key factors contributing to the pervasive stigmatization and subsequent non-disclosure of occupational TB. Our front-line workers are some of the first to suffer the consequences of a progressively more resistant and fatal TB epidemic, and urgent interventions are needed to ensure the safety and continued availability of these precious healthcare resources. These include the rapid development and scale-up of improved diagnostic and treatment options, strengthened infection control measures, and focused interventions to tackle stigma and discrimination in all its forms. We call our colleagues to action to protect themselves and those they care for

Rapid and Accurate Diagnosis of Pediatric Tuberculosis Disease (RaPaed-TB): A Diagnostic Accuracy Study for Pediatric Tuberculosis.

Introduction: An estimated 1.2 million children develop tuberculosis (TB) every year with 240,000 dying because of missed diagnosis. Existing tools suffer from lack of accuracy and are often unavailable. Here, we describe the scientific and clinical methodology applied in RaPaed-TB, a diagnostic accuracy study. Methods: This prospective diagnostic accuracy study evaluating several candidate tests for TB was set out to recruit 1000 children <15 years with presumptive TB in 5 countries (Malawi, Mozambique, South Africa, Tanzania, India). Assessments at baseline included documentation of TB signs and symptoms, TB history, radiography, tuberculin skin test, HIV testing and spirometry. Respiratory samples for reference standard testing (culture, Xpert Ultra) included sputum (induced/spontaneous) or gastric aspirate, and nasopharyngeal aspirate (if <5 years). For novel tests, blood, urine and stool were collected. All participants were followed up at months 1 and 3, and month 6 if on TB treatment or unwell. The primary endpoint followed NIH-consensus statements on categorization of TB disease status for each participant. The study was approved by the sponsor's and all relevant local ethics committees. As a diagnostic accuracy study for a disease with an imperfect reference standard, RaPaed-TB was designed following a rigorous and complex methodology. This allows for the determination of diagnostic accuracy of novel assays and combination of testing strategies for optimal care for children, including high-risk groups (ie, very young, malnourished, children living with HIV). Being one of the largest of its kind, RaPaed-TB will inform the development of improved diagnostic approaches to increase case detection in pediatric TB

Proceedings from the CIHLMU 5th Infectious Diseases Symposium 2016 “Drug Resistant Tuberculosis: Old Disease - New Challenge”

Abstract The 5th CIHLMU Infectious Disease Symposium, Munich, Germany, March 12, 2016 brought together Tuberculosis Experts from developed and low middle-income countries to discuss the control of drug resistance Tuberculosis. The meeting featured 9 presentations: Tuberculosis history and current scenario, Tuberculosis and migration - current scenario in Germany, Mechanism of Tuberculosis resistance development, Epidemiology of resistance – transmission vs. new generation of resistance, The impact of diagnostic in patients beyond – sensitivity and specificity, The Bangladesh regimen – new hope trough old drugs, New drugs and regimens – an overview on studies and Multi and Extensively Drug Resistant Tuberculosis from Europe. The presentations were followed by a panel discussion. Serious Multidrug Resistance epidemic in some countries may jeopardize the progress in Tuberculosis control. In this meeting epidemiology, mechanism, immigration and screening, diagnosis, research and treatment of drug resistant tuberculosis were discussed