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Community engagement; Tuberculosis research Participación de la comunidad; Investigación de la tuberculosis Compromís comunitari; Recerca en tuberculosi Objectives: Community representatives are key to ensuring that tuberculosis (TB) research is relevant, culturally sensitive, and appropriate. For all trials (new drugs or treatment regimens, diagnostics, or vaccines) this can result in improvement of recruitment, retention, and adherence to the trial schedule. The early engagement of the community will, later in time, support the process of implementation of new policies designed for successful products. We aim at developing a structured protocol for the early engagement of TB community representatives developed in the context of the EU-Patient-cEntric clinicAl tRial pLatforms (EU-PEARL) project. Design: The EU-PEARL Innovative Medicine Initiative 2 (IMI2) project TB work package has developed a community engagement (CE) framework to ensure fair and efficient participation of the community in the design and implementation of TB clinical platform trials. Results: We showed that early engagement of the EU-PEARL community advisory board highly contributes to the process of development of a community-acceptable Master Protocol Trial and Intervention-Specific Appendixes. We identified capacity building and training as major gaps in advancing CE in the TB field. Conclusion: Developing strategies to address these needs can contribute to preventing tokenism and increase the acceptability and appropriateness of TB research. This work is partially supported by EU-PEARL. EU-PEARL has received funding from the InnovativeMedicines Initiative 2 Joint Undertaking under grant agreement No 853966. This Joint Undertaking receivessupport from the European Union’s Horizon 2020 research and innovation program and EFPIA and Children’sTumor Foundation, Global Alliance for TB Drug Development non-profit organization, SpringworksTherapeutics Inc. This publication reflects the authors’ views. Neither IMI nor the European Union,EFPIA,or any Associated Partners are responsible for any use that may be made of the information contained hereinDMC is the co-leader of EU-PEARL WP5. ASM is supported by a Juan Rodés (JR18/00022) postdoctoral fellowship from ISCIII. FS salary is supported by EU-PEARLgrant to UniSR.

To determine the levels and patterns of resistance to first- and second-line anti-tuberculosis (TB) drugs among new and previously treated sputum smear positive pulmonary TB (PTB) patients.We conducted a nationally representative cross-sectional facility-based survey in June 2017-July 2018 involving 45 clusters selected based on probability proportional to size. The survey aimed to determine the prevalence of anti-TB drug resistance and associated risk factors among smear positive PTB patients in Tanzania. Sputum samples were examined using smear microscopy, Xpert MTB/RIF, culture and drug susceptibility testing (DST). Logistic regression was used to account for missing data and sampling design effects on the estimates and their standard errors.We enrolled 1557 TB patients, including 1408 (90.4%) newly diagnosed and 149 (9.6%) previously treated patients. The prevalence of multidrug-resistant TB (MDR-TB) was 0.85% [95% confidence interval (CI): 0.4-1.3] among new cases and 4.6% (95% CI: 1.1-8.2) among previously treated cases. The prevalence of Mycobacterium tuberculosis strains resistant to any of the four first-line anti-TB drugs (isoniazid, rifampicin, streptomycin and ethambutol) was 1.7% among new TB patients and 6.5% among those previously treated. Drug resistance to all first-line drugs was similar (0.1%) in new and previously treated patients. None of the isolates displayed poly-resistance or extensively drug-resistant TB (XDR-TB). The only risk factor for MDR-TB was history of previous TB treatment (odds ratio = 5.7, 95% CI: 1.9-17.2).The burden of MDR-TB in the country was relatively low with no evidence of XDR-TB. Given the overall small number of MDR-TB cases in this survey, it will be beneficial focusing efforts on intensified case detection including universal DST.

Centrally necrotizing granulomas that harbor Mycobacterium tuberculosis (Mtb) are the hallmark of human tuberculosis (TB). New anti-TB therapies will need to effectively penetrate the cellular and necrotic, non-vascularized compartments of these lesions and reach sufficient concentrations to eliminate Mtb. BTZ‑043 is a novel antibiotic showing good bactericidal activity in humans in a phase IIa trial. Here, we report on the substantial efficacy of BTZ‑043 in the advanced pre-clinical model of interleukin-13-overexpressing mice, which mimic human TB pathology of pulmonary central granuloma necrosis. Accordingly, pulmonary BTZ‑043 concentrations were severalfold above the minimal inhibitory concentration in these mice. The detailed histological characterization of lung granulomas in combination with high resolution MALDI imaging revealed that BTZ‑043 diffuses and accumulates in the cellular compartment, and fully penetrates the necrotic center. In summary, this study is the first visualizing an efficient penetration, accumulation, and retention of a clinical-stage TB drug in human-like centrally necrotizing granulomas.

BackgroundTuberculosis (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.MethodsXpert 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.ResultsOut 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.ConclusionTB-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.

IntroductionArboviruses and malaria are both mosquito-borne diseases, with overlapping symptoms and geographic distribution in tropical settings. However, little information is available on the co-occurrence of arboviruses and malaria in areas highly endemic for malaria in Africa. This study was conducted with the aim to determine the frequency of recent Dengue (DENV), Chikungunya (CHIKV) and Zika (ZIKV) infections and their co-occurrence with malaria in six highly endemic districts for malaria in Mozambique.MethodsBlood samples were collected from febrile outpatients between January 2017 and December 2018 and were then tested for Malaria using RDT. Serum samples from these patients were also tested using commercially available ELISA for the presence of IgM antibodies against CHIKV, ZIKV and DENV, as well as NS1 antigen for DENV. Concurrently, a questionnaire was administered to collect socio-demographic characteristics of patients.ResultsOf the 906 participants enrolled, IgM antibodies against CHIKV, DENV and ZIKV were identified in 134 (14.8%), 64 (7.4%) and 83 (9.2%) individuals, respectively. Malaria was diagnosed in 56 (6.2%) participants, of which 16 (28.6%) were also positive for IgM anti CHIKV, 1 (1.8%) for DENV-NS1, 3 (5.4%) for IgM anti-DENV and 10 (17.8%) for IgM anti-ZIKV. There was a trend towards an increase in the frequency of IgM anti CHIKV positive samples, from 7.0% in 2014 to 14.8% in 2018 and IgM anti-ZIKV positive samples increased from 4.9% in 2015 to 9.2% in 2018.ConclusionThis study showed an increased frequency of arbovirus in Mozambique thus far, as well as a frequent occurrence of arbovirus among malaria positive patients. This highlighted the urgency for the establishment of sentinel surveillance sites for arboviruses and the need for an integrated management of febrile illnesses in places where arboviruses and malaria are both prevalent.AUTHOR SUMMARYArbovirus and malaria share clinical features, which might make the differential diagnosis of acute febrile illnesses significantly difficult, leading to frequent over diagnosis of malaria and under diagnosis of arbovirus in places where both co-occur. In Mozambique and other sub-Saharan countries, epidemiological data on the burden and temporal trend of arbovirus, as well as on co-occurrence with malaria are Chikungunya virus (CHIKV) and Dengue virus (DENV) and its co-occurrence with malaria among 609 febrile patients in six health centres located in five provinces in Mozambique. Recent CHIKV, DENV and ZIKV infection, as measured by presence of IgM antibodies, were found in 14.8%, 7.4% and 9.2% of participants and among 28.6%, 5.4% and 17.8%, of malaria positive patients. These findings suggest that arboviruses are frequent among malaria and non-malaria febrile patients, reinforcing the need for increased awareness of arbovirus in the management of acute febrile illness.

This study set out to determine the occurrence of phylogenetic lineages of M.tb complex and to examine their relationship with patient demographic characteristics and multidrug-resistant TB (MDR-TB) among pulmonary TB patients enrolled during the second national anti-TB drug resistance survey in Tanzania. A cross-sectional survey was conducted involving a sample of new smear-positive pulmonary TB and previously treated individuals. Sputum samples were collected and transported to the Central TB Reference Laboratory (CTRL) in Dar es Salaam, Tanzania for smear microscopy, culture, strain identification and susceptibility testing following standard National TB and Leprosy Programme (NTLP) guidelines. For WGS, all culture positive isolates were shipped to the National TB Reference Laboratory/Supranational Tuberculosis Reference Laboratory in Uganda. The isolates were sub-cultured on selective Middlebrook 7H11 agar. High quality genomic DNA was extracted using an in-house cetyl trimethylammonium bromide (CTAB) method. Genomic libraries were sequenced using the Illumina MiSeq V3 cartridge. Tools for resistance profiling and lineage inference (Kvarq v0.12.2, Mykrobe v0.8.1 and TBprofiler v3.0.5) were ran. De novo genome assembly of all samples was done using Unicycler v0.4.8. The resulting trees were plotted, annotated and visualized using ggtree v2.0.4. &nbsp

Background Mycobacterium tuberculosis presents several lineages each with distinct characteristics of evolutionary status, transmissibility, drug resistance, host interaction, latency, and vaccine efficacy. Whole genome sequencing (WGS) has emerged as a new diagnostic tool to reliably inform the occurrence of phylogenetic lineages of Mycobacterium tuberculosis and examine their relationship with patient demographic characteristics and multidrug-resistance development. Methods 191 Mycobacterium tuberculosis isolates obtained from a 2017/2018 Tanzanian drug resistance survey were sequenced on the Illumina Miseq platform at Supranational Tuberculosis Reference Laboratory in Uganda. Obtained fast-q files were imported into tools for resistance profiling and lineage inference (Kvarq v0.12.2, Mykrobe v0.8.1 and TBprofiler v3.0.5). Additionally for phylogenetic tree construction, RaxML-NG v1.0.3(25) was used to generate a maximum likelihood phylogeny with 800 bootstrap replicates. The resulting trees were plotted, annotated and visualized using ggtree v2.0.4 Results Most [172(90.0%)] of the isolates were from newly treated Pulmonary TB patients. Coinfection with HIV was observed in 33(17.3%) TB patients. Of the 191 isolates, 22(11.5%) were resistant to one or more commonly used first line anti-TB drugs (FLD), 9(4.7%) isolates were MDR-TB while 3(1.6%) were resistant to all the drugs. Of the 24 isolates with any resistance conferring mutations, 13(54.2%) and 10(41.6%) had mutations in genes associated with resistance to INH and RIF respectively. The findings also show four major lineages i.e. Lineage 3[81 (42.4%)], followed by Lineage 4 [74 (38.7%)], the Lineage 1 [23 (12.0%)] and Lineages 2 [13 (6.8%)] circulaing in Tanzania. Conclusion The findings in this study show that Lineage 3 is the most prevalent lineage in Tanzania whereas drug resistant mutations were more frequent among isolates that belonged to Lineage 4.

Widely available tuberculosis (TB) diagnostics use sputum samples. However, many patients, particularly children and patients living with HIV (PLHIV), struggle to provide sputum. Urine diagnostics are a promising approach to circumvent this challenge while delivering reliable and timely diagnosis. This qualitative study in two high TB/HIV burden countries assesses values and preferences of end-users, along with potential barriers for the implementation of the novel Fujifilm SILVAMP TB-LAM (FujiLAM, Fujifilm, Japan) urine test. Between September 2020 and March 2021, we conducted 42 semi-structured interviews with patients, health care providers (HCPs) and decision makers (DMs) (e.g., in national TB programs) in Malawi and Zambia. Interviews were transcribed verbatim and analyzed using a framework approach supported by NVIVO. Findings aligned with the pre-existing Health Equity Implementation Framework, which guided the presentation of results. The ease and convenience of urine-based testing was described as empowering among patients and HCPs who lamented the difficulty of sputum collection, however HCPs expressed concerns that a shift in agency to the patient may affect clinic workflows (e.g., due to less control over collection). Implementation facilitators, such as shorter turnaround times, were welcomed by operators and patients alike. The decentralization of diagnostics was considered possible with FujiLAM by HCPs and DMs due to low infrastructure requirements. Finally, our findings support efforts for eliminating the CD4 count as an eligibility criterion for LAM testing, to facilitate implementation and benefit a wider range of patients. Our study identified barriers and facilitators relevant to scale-up of urine LAM tests in Malawi and Zambia. FujiLAM could positively impact health equity, as it would particularly benefit patient groups currently underserved by existing TB diagnostics. Participants view the approach as a viable, acceptable, and likely sustainable option in low- and middle-income countries, though adaptations may be required to current health care processes for deployment. Trial registration: German Clinical Trials Register, DRKS00021003. URL: https://www.drks.de/drks_web/setLocale_EN.do

Bacterial killing in TB-patients with relapse was compared to patients achieving cure, measured by TB-molecular bacterial load assay(TB-MBLA) or MGIT time to positivity(TTP). TB-MBLA in 4 relapsed patients was significantly different compared to 132 cured patients after 2 weeks of treatment; MGIT TTP showed a significant difference from week 8.

Objectives: The aim of this study was to detect the seroprevalence of Crimean–Congo haemorrhagic fever virus (CCHFV) in patients with fever of unknown origin (FUO) in endemic (Kyzylorda) and non-endemic (Almaty) oblasts of Kazakhstan. Methods: Paired serum samples from 802 patients with FUO were collected. Serum samples were investigated by ELISA to detect IgG and IgM antibodies against CCHFV. Sera with suspected acute infection were further investigated by RT-PCR to detect the viral RNA. Results: IgG antibodies were detected in 12.7% of the sera from both oblasts. Acute infection was shown by IgM ELISA in four patients from Kyzylorda, with only one developing severe CCHF. Viral RNA was found by RT-PCR in the other three patients’ sera. Phylogenetic analysis of partial L and S segments revealed CCHFV genotype Asia 2 and a possible reassortment between the genotypes Asia 1/Asia 2. Animal husbandry, such as working with cattle and horses, was significantly associated with CCHFV seropositivity. Conclusions: The antibodies and viral RNA detected in sera indicate that mild or even asymptomatic CCHFV infections are presented in Kazakhstan. This study describes the circulation of CCHFV in the so far non-endemic Almaty oblast for the first time. In conclusion, physicians treating patients with FUO in Kazakhstan should be aware of mild CCHF. Keywords: Crimean–Congo haemorrhagic fever virus, Fever of unknown origin, Reassortment, Kazakhstan

IntroductionThe WHO End-TB Strategy calls for the development of novel diagnostics to detect tuberculosis (TB) earlier and more accurately. Better diagnostics, together with tools to predict disease progression, are critical for achieving WHO End-TB targets. The Early Risk Assessment in TB Contacts by new diagnoStic tEsts (ERASE-TB) study aims to evaluate novel diagnostics and testing algorithms for early TB diagnosis and accurate prediction of disease progression among household contacts (HHCs) exposed to confirmed index cases in Mozambique, Tanzania and Zimbabwe.Methods and analysisA total of 2100 HHCs (aged ≥10 years) of adults with microbiologically-confirmed pulmonary TB will be recruited and followed up at 6-month intervals for 18–24 months. At each time point, a WHO symptom screen and digital chest radiograph (dCXR) will be performed, and blood and urine samples will be collected. Individuals screening positive (WHO symptom screen or dCXR) will be requested to provide sputum for Xpert MTB/Rif Ultra. At baseline, HHCs will also be screened for HIV, diabetes (HbA1c), chronic lung disease (spirometry), hypertension and anaemia. Study outcomes will be coprevalent TB (diagnosed at enrolment), incident TB (diagnosed during follow-up) or no TB at completion of follow-up. Novel diagnostics will be validated using fresh and biobanked samples with a nested case–control design. Cases are defined as HHCs diagnosed with TB (for early diagnosis) or with incident TB (for prediction of progression) and will be matched by age, sex and country to HHCs who remain healthy (controls). Statistical analyses will include assessment of diagnostic accuracy by constructing receiver operating curves and calculation of sensitivity and specificity.Ethics and disseminationERASE-TB has been approved by regulatory and ethical committees in each African country and by each partner organisation. Consent, with additional assent for participants Trial registration numberNCT04781257.Cite Now

Pyrazinamide is a potent sterilising agent that shortens the treatment duration needed to cure tuberculosis. It is synergistic with novel and existing drugs for tuberculosis. The dose of pyrazinamide that optimises efficacy while remaining safe is uncertain, as is its potential role in shortening treatment duration further.Pharmacokinetic data, sputum culture, and safety laboratory results were compiled from Tuberculosis Trials Consortium (TBTC) studies 27 and 28 and Pan-African Consortium for the Evaluation of Antituberculosis Antibiotics (PanACEA) multi-arm multi-stage tuberculosis (MAMS-TB), multi-centre phase 2 trials in which participants received rifampicin (range 10–35 mg·kg−1), pyrazinamide (range 20–30 mg·kg−1), plus two companion drugs. Pyrazinamide pharmacokinetic–pharmacodynamic (PK–PD) and pharmacokinetic-toxicity analyses were performed.In TBTC studies (n=77), higher pyrazinamide maximum concentration (Cmax) was associated with shorter time to culture conversion (TTCC) and higher probability of 2-month culture conversion (p-valuemax increased and varied by rifampicin area under the curve (p-value4500 mg) or increasing both pyrazinamide and rifampicin would be required to reach targets associated with treatment shortening. Combining all trials, liver toxicity was rare (3.9% with grade 3 or higher liver function tests (LFT)), and no relationship was seen between pyrazinamide Cmax and LFT levels.Pyrazinamide's microbiological efficacy increases with increasing drug concentrations. Optimising pyrazinamide alone, though, is unlikely to be sufficient to allow tuberculosis treatment shortening; rather, rifampicin dose would need to be increased in parallel.

Objectives This study investigated the molecular epidemiology of respiratory syncytial virus (RSV) among febrile children with acute respiratory tract infection in Ghana, Gabon, Tanzania and Burkina Faso between 2014 and 2017 as well as the evolution and diversification of RSV strains from other sub-Saharan countries. Methods Pharyngeal swabs were collected at four study sites (Agogo, Ghana: n = 490; Lambarene, Gabon: n = 182; Mbeya, Tanzania: n = 293; Nouna, Burkina Faso: n = 115) and analysed for RSV and other respiratory viruses using rtPCR. For RSV-positive samples, sequence analysis of the second hypervariable region of the G gene was performed. A dataset of RSV strains from sub-Saharan Africa (2011-2017) currently available in GenBank was compiled. Phylogenetic analysis was conducted to identify the diversity of circulating RSV genotypes. Results In total, 46 samples were tested RSV positive (Ghana n = 31 (6.3%), Gabon n = 4 (2.2%), Tanzania n = 9 (3.1%) and Burkina Faso n = 2 (1.7%)). The most common RSV co-infection was with rhinovirus. All RSV A strains clustered with genotype ON1 strains with a 72-nucleotide duplication and all RSV B strains belonged to genotype BAIX. Phylogenetic analysis of amino acid sequences from sub-Saharan Africa revealed the diversification into 11 different ON1 and 22 different BAIX lineages and differentiation of ON1 and BAIX strains into potential new sub-genotypes, provisionally named ON1-NGR, BAIX-KEN1, BAIX-KEN2 and BAIX-KEN3. Conclusion The study contributes to an improved understanding of the molecular epidemiology of RSV infection in sub-Saharan Africa. It provides the first phylogenetic data for RSV from Tanzania, Gabon and Burkina Faso and combines it with RSV strains from all other sub-Saharan countries currently available in GenBank.

Background: Antimicrobial resistance (AMR) thwarts the curative power of drugs and is a present-time global problem. We present data on antimicrobial susceptibility and resistance determinants of bacteria the WHO has highlighted as being key antimicrobial resistance concerns in Africa, to strengthen knowledge of AMR patterns in the region. Methods: Blood, stool, and urine specimens of febrile patients, aged between ≥ 30 days and ≤ 15 years and hospitalized in Burkina Faso, Gabon, Ghana, and Tanzania were cultured from November 2013 to March 2017 (Patients > 15 years were included in Tanzania). Antimicrobial susceptibility testing was performed for all Enterobacterales and Staphylococcus aureus isolates using disk diffusion method. Extended-spectrum beta-lactamase (ESBL) production was confirmed by double-disk diffusion test and the detection of blaCTX–M, blaTEM and blaSHV. Multilocus sequence typing was conducted for ESBL-producing Escherichia coli and Klebsiella pneumoniae, ciprofloxacin-resistant Salmonella enterica and S. aureus. Ciprofloxacin-resistant Salmonella enterica were screened for plasmid-mediated resistance genes and mutations in gyrA, gyrB, parC, and parE. S. aureus isolates were tested for the presence of mecA and Panton-Valentine Leukocidin (PVL) and further genotyped by spa typing. Results: Among 4,052 specimens from 3,012 patients, 219 cultures were positive of which 88.1% (n = 193) were Enterobacterales and 7.3% (n = 16) S. aureus. The prevalence of ESBL-producing Enterobacterales (all CTX-M15 genotype) was 45.2% (14/31; 95% CI: 27.3, 64.0) in Burkina Faso, 25.8% (8/31; 95% CI: 11.9, 44.6) in Gabon, 15.1% (18/119; 95% CI: 9.2, 22.8) in Ghana and 0.0% (0/12; 95% CI: 0.0, 26.5) in Tanzania. ESBL positive non-typhoid Salmonella (n = 3) were detected in Burkina Faso only and methicillin-resistant S. aureus (n = 2) were detected in Ghana only. While sequence type (ST)131 predominated among ESBL E. coli (39.1%;9/23), STs among ESBL K. pneumoniae were highly heterogenous. Ciprofloxacin resistant nt Salmonella were commonest in Burkina Faso (50.0%; 6/12) and all harbored qnrB genes. PVL were found in 81.3% S. aureus. Conclusion: Our findings reveal a distinct susceptibility pattern across the various study regions in Africa, with notably high rates of ESBL-producing Enterobacterales and ciprofloxacin-resistant nt Salmonella in Burkina Faso. This highlights the need for local AMR surveillance and reporting of resistances to support appropriate action.

Background Accumulating data indicate that higher rifampicin doses are more effective and shorten tuberculosis (TB) treatment duration. This study evaluated the safety, tolerability, pharmacokinetics, and 7- and 14-day early bactericidal activity (EBA) of increasing doses of rifampicin. Here we report the results of the final cohorts of PanACEA HIGHRIF1, a dose escalation study in treatment-naive adult smear-positive patients with TB. Methods Patients received, in consecutive cohorts, 40 or 50 mg·kg−1 rifampicin once daily in monotherapy (day 1–7), supplemented with standard dose isoniazid, pyrazinamide and ethambutol between days 8 and 14. Results In the 40 mg·kg−1 cohort (n=15), 13 patients experienced a total of 36 adverse events during monotherapy, resulting in one treatment discontinuation. In the 50 mg·kg−1 cohort (n=17), all patients experienced adverse events during monotherapy, 93 in total; 11 patients withdrew or stopped study medication. Adverse events were mostly mild/moderate and tolerability rather than safety related, i.e. gastrointestinal disorders, pruritis, hyperbilirubinaemia and jaundice. There was a more than proportional increase in the rifampicin geometric mean area under the plasma concentration–time curve from time 0 to 12 h (AUC0–24 h) for 50 mg·kg−1 compared with 40 mg·kg−1; 571 (range 320–995) versus 387 (range 201–847) mg·L−1·h, while peak exposures saw proportional increases. Protein-unbound exposure after 50 mg·kg−1 (11% (range 8–17%)) was comparable with lower rifampicin doses. Rifampicin exposures and bilirubin concentrations were correlated (Spearman's ρ=0.670 on day 3, p, While bactericidal activity continues to increase with dose, for the first time we identified dose-limiting intolerability for rifampicin dosed at 50 mg·kg−1; 40 mg·kg−1 seems the optimal tolerable dose for evaluation in TB treatment-shortening trials https://bit.ly/37dUIuB

Contains fulltext : 220733.pdf (Publisher’s version ) (Open Access) In this comparative biomarker study, we analysed 1768 serial sputum samples from 178 patients at 4 sites in Southeast Africa. We show that tuberculosis Molecular Bacterial Load Assay (TB-MBLA) reduces time-to-TB-bacillary-load-result from days/weeks by culture to hours and detects early patient treatment response. By day 14 of treatment, 5% of patients had cleared bacillary load to zero, rising to 58% by 12th week of treatment. Fall in bacillary load correlated with mycobacterial growth indicator tube culture time-to-positivity (Spearmans r=-0.51, 95% CI (-0.56 to -0.46), p

Background: Accumulating data indicate that higher rifampicin doses may be more effective and shorten tuberculosis treatment duration. This study evaluated the safety, tolerability, pharmacokinetics, and 14-day early bactericidal activity (EBA) of increasing doses of rifampicin. Methods: We performed a dose-escalation study in treatment-naive adult smear-positive tuberculosis patients. Patients received, in consecutive cohorts, 40 or 50mg/kg rifampicin once daily in monotherapy (day 1-7), supplemented with standard doses of isoniazid, pyrazinamide and ethambutol between day 8-14. Safety, tolerability, pharmacokinetics, and EBA were assessed. Findings: In the 40mg/kg cohort (n=15), 13 patients experienced adverse events (AEs) during monotherapy (n=36), resulting in one treatment discontinuation in the combination phase. In the 50mg/kg group (n=17), all patients experienced AEs during monotherapy. There were more AEs in total (n=93) compared to 40mg/kg, and eleven patients withdrew or stopped study medication. AEs were mostly mild or moderate (≤grade 3) and tolerability related, i.e. gastrointestinal disorders, pruritis, hyperbilirubinemia and jaundice. A more than proportional increase in rifampicin exposure with dose was observed, in line with previous cohorts. EBA increased considerably with dose; with the highest seen in the 50mg/kg cohort. Interpretation: Our research concludes a journey that started in the 1960s. Rifampicin up to 40mg/kg was well tolerated. Although associated with an increased bactericidal effect, the tolerability of a 50mg/kg dose was poor. Rifampicin at 40mg/kg appears to be the optimal dose for evaluation in a phase IIB/C treatment shortening trial. Trial Registration: Here we report the results of the final cohorts of the PanACEA HIGHRIF1 trial (clinicaltrials.gov NCT01392911). Funding Statement: This publication was produced by PanACEA, which is part of the European and Developing Countries Clinical Trials Partnership (EDCTP) 1 programme [project code IP.2007.32011.012 (HIGHRIF)] and the EDCTP2 programme supported by the European Union (grant number TRIA2015-1102-PanACEA). Declaration of Interests: We declare no competing interests. Ethics Approval Statement: The study protocol was approved by the applicable ethical review boards and by the South African Health Products Regulatory Authority and was conducted according to international and South African Good Clinical Practice guidelines.

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.

Greater Banjul Area of the Gambia.To identify co-prevalent tuberculosis (TB) among child contacts of adults with smear-positive TB.Child contacts aged

The study was supported by the German Ministry of Education and Research (BMBF, Grant No. 01KA0901 ) and the European and Developing Countries Clinical Trials Partnership (EDCTP, Project-ID: IP.2007.32011.011 ). The Xpert MTB/RIF assay detects Mycobacterium tuberculosis in unprocessed or NALC/NaOH- decontaminated sputum. The effect of repeated NALC/NaOH-decontamination on several Xpert performance parameters was assessed in this study. A second NALC/NaOH-decontamination had no effect on the binary Xpert-outcome but increased the value for the quantitative readout (CTmin). Repeated decontamination was not associated with PCR-inhibition or invalid results. The CTmin of M.tb positive samples was higher in inhibited Xpert runs. Our data indicate that NALC/NaOH-decontamination has an effect on the performance of the Xpert assay, and that CTmin readouts of decontaminated sputum samples should be interpreted with caution. Postprint

ObjectivesBetter outcomes in tuberculosis require new diagnostic and treatment monitoring tools. In this paper we evaluated the utility of a marker ofM. tuberculosisviable count, the Molecular Bacterial Load assay (MBLA) for diagnosis and treatment monitoring of tuberculosis in a high burden setting.MethodsPatients with smear positive pulmonary tuberculosis from two sites in Tanzania and one each in Malawi and Mozambique. Sputum samples were taken weekly for the first 12 weeks of treatment and evaluated by MBLA and mycobacterial growth indicator tube method (MGIT).ResultsThe results of high and low positive control samples confirmed inter site reproducibility. Over the 12 weeks of treatment there was a steady decline in the viable bacterial load as measured by the MBLA that corresponds to rise in time to a positive result (TTP) in the Mycobacterial Growth Indicator Tube. Both MBLA and MGIT provided similar time to test negativity. Importantly, as treatment progressed samples in MGIT were increasingly likely to be contaminated, which compromised the acquisition of results but did not affect MBLA samples.ConclusionsMBLA produces a reproducible measure ofMtbviable count comparable to that of MGIT that is not compromised by contamination in a real-world setting. As a molecular test, the results can be available in as little as four hours and could allow health care professionals to identify rapidly patients who are failing therapy.

BackgroundAccumulating data indicate that higher rifampicin doses are more effective and shorten tuberculosis (TB) treatment duration. This study evaluated the safety, tolerability, pharmacokinetics, and 7- and 14-day early bactericidal activity (EBA) of increasing doses of rifampicin. Here we report the results of the final cohorts of PanACEA HIGHRIF1, a dose escalation study in treatment-naive adult smear-positive patients with TB.MethodsPatients received, in consecutive cohorts, 40 or 50 mg·kg−1 rifampicin once daily in monotherapy (day 1–7), supplemented with standard dose isoniazid, pyrazinamide and ethambutol between days 8 and 14.ResultsIn the 40 mg·kg−1 cohort (n=15), 13 patients experienced a total of 36 adverse events during monotherapy, resulting in one treatment discontinuation. In the 50 mg·kg−1 cohort (n=17), all patients experienced adverse events during monotherapy, 93 in total; 11 patients withdrew or stopped study medication. Adverse events were mostly mild/moderate and tolerability rather than safety related, i.e. gastrointestinal disorders, pruritis, hyperbilirubinaemia and jaundice. There was a more than proportional increase in the rifampicin geometric mean area under the plasma concentration–time curve from time 0 to 12 h (AUC0–24 h) for 50 mg·kg−1 compared with 40 mg·kg−1; 571 (range 320–995) versus 387 (range 201–847) mg·L−1·h, while peak exposures saw proportional increases. Protein-unbound exposure after 50 mg·kg−1 (11% (range 8–17%)) was comparable with lower rifampicin doses. Rifampicin exposures and bilirubin concentrations were correlated (Spearman's ρ=0.670 on day 3, p−1: 14-day EBA −0.427 (95% CI −0.500– −0.355) log10CFU·mL−1·day−1.ConclusionAlthough associated with an increased bactericidal effect, the 50 mg·kg−1 dose was not well tolerated. Rifampicin at 40 mg·kg−1 was well tolerated and therefore selected for evaluation in a phase IIc treatment-shortening trial.

Background The population structure and drug resistance pattern of Mycobacterium tuberculosis complex (MTBC) isolates in Ethiopian prisons and some communities is still unknown. Methods A comparative cross sectional study was conducted on 126 MTBC strains isolated from prisons and communities in southwestern, southern and eastern Ethiopia. Phenotypic drug susceptibility testing was performed with the MGIT960 system. Combined 24-loci Mycobacterium interspersed repetitive unit-variable number tandem repeat and spacer oligonucleotide typing methods were used to study the MTBC population structure. The obtained data from prisons and communities were compared using statistical tests and regression analysis. Results A diverse population structure with 11 different lineages and sub-lineages was identified. The predominant strains were the recently described Ethiopia_H37Rv like (27.52%) and Ethiopia_3 (16.51%) with equal lineage distribution between prisons and communities. 28.57% of prison strains and 31.82% of community strains shared the identical genotype with at least one other strain. The multidrug-resistance (MDR) prevalence of the community was 2.27% whereas that of prisons was 9.52%. The highest mono resistance was seen against streptomycin (15.89%). Conclusion Tuberculosis in communities and prisons is caused by a variety of MTBC lineages with predominance of local Ethiopian lineages. The increasing prevalence of MDR MTBC strains is alarming. These findings suggest the need for new approaches for control of MDR tuberculosis in Ethiopia. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-2041-x) contains supplementary material, which is available to authorized users.

A conference called "Outbreaks in Tanzania-Are We Prepared?" was held in Mbeya, Tanzania, on September 14 and 15, 2015, accompanied by a training workshop on infection prevention and control for local stakeholders from September 16 to 18, 2015. The objective of the conference was to revisit past disease epidemics and to reflect on the current status of surveillance and outbreak preparedness in Tanzania, including an overview of agents relevant to biosecurity. The conference brought together national authorities of Tanzania, regional public health representatives, people from research and academic institutions, and international stakeholders. Key findings of the event were: (1) although national frameworks for surveillance and preparedness exist, their implementation presents challenges, and local health structures need support in implementation; (2) the ability to identify and properly manage infectious diseases of public health concern is crucial in empowering the local health workforce to contribute to surveillance measures, which in turn allows for realistic risk assessments and management algorithms; and (3) in settings of limited resources, research activities acquire an additional responsibility toward national surveillance and capacity building and should be integrated into national epidemic preparedness plans. This event was the first of its kind in Tanzania, facilitating direct discussion among regional, zonal, national, and international stakeholders on surveillance and outbreak preparedness. The conference's conclusions are relevant to strengthening health systems in other low- and middle-income countries.

Background: The analysis of phenotypic characteristics on Mycobacterium tuberculosis (MTB)-specific T cells is a promising approach for the diagnosis of active tuberculosis (aTB) and for monitoring treatment success. We therefore studied phenotypic changes on MTB-specific CD4 T cells upon anti-tuberculosis treatment initiation in relation to the treatment response as determined by sputum culture. Methods: Peripheral blood mononuclear cells from subjects with latent MTB infection (n = 16) and aTB (n = 39) at baseline, weeks 9, 12, and 26 (end of treatment) were analyzed after intracellular interferon gamma staining and overnight stimulation with tuberculin. Liquid sputum cultures were performed weekly until week 12 and during 4 visits until week 26. Results: T cell activation marker expression on MTB-specific CD4 T cells differed significantly between subjects with aTB and latent MTB infection with no overlap for the frequencies of CD38pos and Ki67pos cells (both p < 0.0001). At 9 weeks after anti-TB treatment initiation the frequencies of activation marker (CD38, HLA-DR, Ki67) positive MTB-specific, but not total CD4 T cells, were significantly reduced (p < 0.0001). Treatment induced phenotypic changes from baseline until week 9 and until week 12 differed substantially between individual aTB patients and correlated with an individual's time to stable sputum culture conversion for expression of CD38 and HLA-DR (both p < 0.05). In contrast, the frequencies of maturation marker CD27 positive MTB-specific CD4 T cells remained largely unchanged until week 26 and significantly differed between subjects with treated TB disease and latent MTB infection (p = 0.0003). Discussion: Phenotypic changes of MTB-specific T cells are potential surrogate markers for tuberculosis treatment efficacy and can help to discriminate between aTB (profile: CD38pos, CD27low), treated TB (CD38neg, CD27low), and latent MTB infection (CD38neg, CD27high).

Background: The analysis of phenotypic characteristics on Mycobacterium tuberculosis (MTB)-specific T cells is a promising approach for the diagnosis of active tuberculosis (aTB) and for monitoring treatment success. We therefore studied phenotypic changes on MTB-specific CD4 T cells upon anti-tuberculosis treatment initiation in relation to the treatment response as determined by sputum culture.Methods: Peripheral blood mononuclear cells from subjects with latent MTB infection (n = 16) and aTB (n = 39) at baseline, weeks 9, 12, and 26 (end of treatment) were analyzed after intracellular interferon gamma staining and overnight stimulation with tuberculin. Liquid sputum cultures were performed weekly until week 12 and during 4 visits until week 26.Results: T cell activation marker expression on MTB-specific CD4 T cells differed significantly between subjects with aTB and latent MTB infection with no overlap for the frequencies of CD38pos and Ki67pos cells (both p < 0.0001). At 9 weeks after anti-TB treatment initiation the frequencies of activation marker (CD38, HLA-DR, Ki67) positive MTB-specific, but not total CD4 T cells, were significantly reduced (p < 0.0001). Treatment induced phenotypic changes from baseline until week 9 and until week 12 differed substantially between individual aTB patients and correlated with an individual's time to stable sputum culture conversion for expression of CD38 and HLA-DR (both p < 0.05). In contrast, the frequencies of maturation marker CD27 positive MTB-specific CD4 T cells remained largely unchanged until week 26 and significantly differed between subjects with treated TB disease and latent MTB infection (p = 0.0003).Discussion: Phenotypic changes of MTB-specific T cells are potential surrogate markers for tuberculosis treatment efficacy and can help to discriminate between aTB (profile: CD38pos, CD27low), treated TB (CD38neg, CD27low), and latent MTB infection (CD38neg, CD27high).

This work was supported by the European and Developing Countries Clinical Trials partnership (grants IP.2007.32011.011, IP.2007.32011.012, and IP.2007.32011.013) and the German Ministry for Education and Research (grant 01KA0901). The original study conducted within the PanACEA consortium. Background: Tuberculosis remains a huge public health problem and the prolonged treatment duration obstructs effective tuberculosis control. Higher rifampicin doses have been associated with better bactericidal activity, but optimal dosing is uncertain. This analysis aimed to characterize the relationship between rifampicin plasma exposure and treatment response over 6 months in a recent study investigating the potential for treatment shortening with high-dose rifampicin. Methods: Data were analyzed from 336 patients with pulmonary tuberculosis (97 with pharmacokinetic data) treated with rifampicin doses of 10, 20, or 35 mg/kg. The response measure was time to stable sputum culture conversion (TSCC). We derived individual exposure metrics with a previously developed population pharmacokinetic model of rifampicin. TSCC was modeled using a parametric time-to-event approach, and a sequential exposure-response analysis was performed. Results: Higher rifampicin exposures increased the probability of early culture conversion. No maximal limit of the effect was detected within the observed range. The expected proportion of patients with stable culture conversion on liquid medium at week 8 was predicted to increase from 39% (95% confidence interval, 37%-41%) to 55% (49%-61%), with the rifampicin area under the curve increasing from 20 to 175 mg/L·h (representative for 10 and 35 mg/kg, respectively). Other predictors of TSCC were baseline bacterial load, proportion of culture results unavailable, and substitution of ethambutol for either moxifloxacin or SQ109. Conclusions: Increasing rifampicin exposure shortened TSCC, and the effect did not plateau, indicating that doses >35 mg/kg could be yet more effective. Optimizing rifampicin dosage while preventing toxicity is a clinical priority. Publisher PDF

We evaluated the diagnostic performance of two tests based on the release of lipoarabinomannan (LAM) into the urine, the MTB-LAM-ELISA assay and the Determine TB-LAM-strip assay, in children with suspected tuberculosis (TB) in a high TB/HIV-prevalence setting.In a prospective study, 132 children with suspected active TB were assigned to diagnostic subgroups. Urine samples were subjected to testing by both assays to ascertain sensitivity and specificity. Host factors associated with positive LAM results were investigated and LAM excretion monitored after antituberculous treatment initiation.18 (13.6%) children had culture-confirmed pulmonary TB. The assays' sensitivity was higher in HIV-positiveversusHIV-negative children: 70% (95% confidence interval 35–93%)versus13% (0–53%) for MTB-LAM-ELISA and 50% (19–81%)versus0% (0–37%) for Determine TB-LAM. In 35 (27%) children with excluded active TB, both assays showed a specificity of 97.1% (85–100%). Proteinuria and low body mass index were independently associated with LAM positivity. In most patients, LAM excretion declined to zero during or at conclusion of antituberculous treatment.HIV/TB co-infected children might benefit from LAM-based tests to aid early TB diagnosis and subsequent positive impact on morbidity and mortality. Using LAM as a rule-in and treatment-monitoring tool may also show further potential.

Objectives SQ109, an asymmetrical diamine, is a novel anti-TB drug candidate. This first study in patients was done to determine safety, tolerability, pharmacokinetics and bacteriological effect of different doses of SQ109 alone and in combination with rifampicin when administered over 14 days. Patients and methods Smear-positive pulmonary TB patients were randomized into six groups of 15 to receive once-daily oral treatment with 75, 150 or 300 mg of SQ109, rifampicin (10 mg/kg body weight), rifampicin plus 150 mg of SQ109, or rifampicin plus 300 mg of SQ109 for 14 days. Patients were hospitalized for supervised treatment, regular clinical, biochemical and electrocardiographic safety assessments, pharmacokinetic profiling and daily overnight sputum collection. Results SQ109 was safe and generally well tolerated. Mild to moderate dose-dependent gastrointestinal complaints were the most frequent adverse events. No relevant QT prolongation was noted. Maximum SQ109 plasma concentrations were lower than MICs. Exposure to SQ109 (AUC0–24) increased by drug accumulation upon repeated administration in the SQ109 monotherapy groups. Co-administration of SQ109 150 mg with rifampicin resulted in decreasing SQ109 exposures from day 1 to day 14. A higher (300 mg) dose of SQ109 largely outweighed the evolving inductive effect of rifampicin. The daily fall in log cfu/mL of sputum (95% CI) was 0.093 (0.126–0.059) with rifampicin, 0.133 (0.166–0.100) with rifampicin plus 150 mg of SQ109 and 0.089 (0.121–0.057) with rifampicin plus 300 mg of SQ109. Treatments with SQ109 alone showed no significant activity. Conclusions SQ109 alone or with rifampicin was safe over 14 days. Upon co-administration with rifampicin, 300 mg of SQ109 yielded a higher exposure than the 150 mg dose. SQ109 did not appear to be active alone or to enhance the activity of rifampicin during the 14 days of treatment.

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.

Setting: Greater Banjul area of The Gambia. Objectives: To evaluate uptake, adherence and completion of treatment among tuberculosis (TB) exposed children in The Gambia when isoniazid preventive treatment (IPT) is delivered at home Design: Child (age

BackgroundChildren account for an estimated 1 million new cases of TB every year, representing roughly 7% of the total disease burden. Every year, around 2 09 000 children die from TB, half of those cases are in Africa. The main issue continues to be timely and accurate diagnosis, as treatment outcomes – even in the case of drug resistance – are significantly better than in adults.Clinical diagnosis in the absence of laboratory confirmation is hampered by non-specificity of symptoms. Diagnostics validation studies in children are difficult – in most studies, very few of the symptomatic children achieved microbiological disease confirmation, resulting in imprecise estimates for test sensitivity.Design/methodsWith the RaPaed TB study funded by EDCTP, we are preparing an improved diagnostic validation study design to improve on the traditional approach of a single-gate, double diagnostic study in the target population. The project will evaluate multiple new tests on the same patients, to determine algorithms of screening and confirmatory tests. Most novel tests in this study use non-sputum samples and are therefore more suitable for children.Allocation of patients to standardised groups will follow the recommendations of the NIH-convened consensus panel on case definitions of paediatric TB diagnostic studies. Using an endpoint review committee will allow blinded review of those new-positive cases, plus matched controls, and determine their likelihood of disease based on clinical data including follow-up, and X-ray. This will improve the quality of evaluation of false positive vs. true positive results of new tests and therefore improve the assessment of specificity.To improve on sensitivity assessment, the study includes partners with a high number of confirmed cases in past studies and plans to draw in cases of confirmed disease from other diagnostic facilities.ConclusionThis improved methodology will lead to more meaningful and applicable results of diagnostic validation studies.

SETTING Mbeya, Tanzania. OBJECTIVE To develop a new liquid culture method to detect Mycobacterium tuberculosis complex (MTC) in sputum using 2,3-diphenyl-5-thienyl-(2)-tetrazolium (STC), the nitrate reductase assay (NRA) and p-nitrobenzoic acid (PNB). DESIGN Ninety-three sputum samples collected from 18 tuberculosis patients were decontaminated with N-acetyl-L-cysteine-sodium hydroxide using MGIT™ 960 and in STC-NRA cultures, both in the presence and in the absence of PNB, an inhibitor of MTC growth. The reduction of STC by colour change indicated mycobacterial growth; NRA was then performed to confirm MTC. RESULTS STC-NRA culture was positive for acid-fast bacilli in 66/93 (71%) samples, of which 60/93 (64.5%) were identified as MTC-positive and 6/93 (6.5%) as indeterminate mycobacteria. MGIT indicated MTC in 59/93 (63.4%) cultures. Contamination was detected in 12/93 (13%) STC-NRA cultures vs. 29/93 (31.2%) MGIT cultures. The mean time to detection (TTD) of MTC using STC-NRA was 14 days and 7 days using MGIT. CONCLUSION The STC-NRA method is sensitive for the detection of MTC in sputum. TTD increased with duration of anti-tuberculosis treatment, highlighting the value of this method in monitoring treatment success. The method is simple and inexpensive and, unlike MGIT, does not require technical equipment. The preliminary performance characteristics of the method should be further evaluated in larger studies.

SummaryBackgroundAn accurate biomarker is urgently needed to monitor the response to treatment in patients with pulmonary tuberculosis. The Xpert MTB/RIF assay is a commercially available real-time PCR that can be used to detect Mycobacterium-tuberculosis-specific DNA sequences in sputum samples. We therefore evaluated this assay with serial sputum samples obtained over 26 weeks from patients undergoing treatment for tuberculosis.MethodsWe analysed sputum samples from 221 patients with smear-positive tuberculosis enrolled at two sites (Cape Town, South Africa, and Mbeya, Tanzania) of a multicentre randomised clinical trial REMoxTB of antituberculosis treatment on a weekly basis (weeks 0 to 8), then at weeks 12, 17, 22, and 26 after treatment initiation. The Xpert MTB/RIF results over time were compared with the results of standard smear microscopy and culture methods.FindingsWe obtained and analysed 2741 sputum samples from 221 patients. The reduction in positivity rates with Xpert MTB/RIF were slower than those with the standard methods. At week 8, positive results were obtained for 62 (29%) of 212 sputum samples with smear microscopy, 46 (26%) of 175 with solid culture (Löwenstein-Jensen medium), 77 (42%) of 183 with liquid culture (Bactec MGIT960 system), and 174 (84%) of 207 with Xpert MTB/RIF; at 26 weeks, positive results were obtained for ten (5%) of 199, four (3%) of 157, seven (4%) of 169, and 22 (27%) of 83 sputum samples, respectively. The reduction in detection of quantitative M tuberculosis DNA with Xpert MTB/RIF correlated with smear grades (ρ=–0·74; p

Rickettsioses caused by typhus group rickettsiae have been reported in various African regions. We conducted a cross-sectional survey of 1,227 participants from 9 different sites in the Mbeya region, Tanzania; overall seroprevalence of typhus group rickettsiae was 9.3%. Risk factors identified in multivariable analysis included low vegetation density and highway proximity.

The PanACEA consortium was funded by the European Developing Country Partnership through grants IP.2007.32011.011, IP.2007.32011.012, and IP.2007.32011.013. PN is supported by the NIAID of the National Institutes of Health (R01AI104589) and the TBTC. KED is supported by NIAID/NID (R01AI111992) and the TBTC. Background The standard 6-month four-drug regimen for the treatment of drug-sensitive tuberculosis has remained unchanged for decades and is inadequate to control the epidemic. Shorter, simpler regimens are urgently needed to defeat what is now the world’s greatest infectious disease killer. Methods We describe the Phase IIC Selection Trial with Extended Post-treatment follow-up (STEP) as a novel hybrid phase II/III trial design to accelerate regimen development. In the Phase IIC STEP trial, the experimental regimen is given for the duration for which it will be studied in phase III (presently 3 or 4 months) and patients are followed for clinical outcomes of treatment failure and relapse for a total of 12 months from randomisation. Operating characteristics of the trial design are explored assuming a classical frequentist framework as well as a Bayesian framework with flat and sceptical priors. A simulation study is conducted using data from the RIFAQUIN phase III trial to illustrate how such a design could be used in practice. Results With 80 patients per arm, and two (2.5 %) unfavourable outcomes in the STEP trial, there is a probability of 0.99 that the proportion of unfavourable outcomes in a potential phase III trial would be less than 12 % and a probability of 0.91 that the proportion of unfavourable outcomes would be less than 8 %. With six (7.5 %) unfavourable outcomes, there is a probability of 0.82 that the proportion of unfavourable outcomes in a potential phase III trial would be less than 12 % and a probability of 0.41 that it would be less than 8 %. Simulations using data from the RIFAQUIN trial show that a STEP trial with 80 patients per arm would have correctly shown that the Inferior Regimen should not proceed to phase III and would have had a high chance (0.88) of either showing that the Successful Regimen could proceed to phase III or that it might require further optimisation. Conclusions Collection of definitive clinical outcome data in a relatively small number of participants over only 12 months provides valuable information about the likelihood of success in a future phase III trial. We strongly believe that the STEP trial design described herein is an important tool that would allow for more informed decision-making and accelerate regimen development. Publisher PDF

Acute fever is one of the most common presenting symptoms globally. In order to reduce the empiric use of antimicrobial drugs and improve outcomes, it is essential to improve diagnostic capabilities. In the absence of microbiology facilities in low-income settings, an assay to distinguish bacterial from non-bacterial causes would be a critical first step. To ensure that patient and market needs are met, the requirements of such a test should be specified in a target product profile (TPP). To identify minimal/optimal characteristics for a bacterial vs. non-bacterial fever test, experts from academia and international organizations with expertise in infectious diseases, diagnostic test development, laboratory medicine, global health, and health economics were convened. Proposed TPPs were reviewed by this working group, and consensus characteristics were defined. The working group defined non-severely ill, non-malaria infected children as the target population for the desired assay. To provide access to the most patients, the test should be deployable to community health centers and informal health settings, and staff should require 90% and >80% for sensitivity and specificity, respectively. Other key characteristics, to account for the challenging environment at which the test is targeted, included: i) time-to-result

Confirming the diagnosis of childhood tuberculosis is a major challenge. However, research on childhood tuberculosis as it relates to better diagnostics is often neglected because of technical difficulties, such as the slow growth in culture, the difficulty of obtaining specimens, and the diverse and relatively nonspecific clinical presentation of tuberculosis in this age group. Researchers often use individually designed criteria for enrollment, diagnostic classifications, and reference standards, thereby hindering the interpretation and comparability of their findings. The development of standardized research approaches and definitions is therefore needed to strengthen the evaluation of new diagnostics for detection and confirmation of tuberculosis in children. In this article we present consensus statements on methodological issues for conducting research of Tuberculosis diagnostics among children, with a focus on intrathoracic tuberculosis. The statements are complementary to a clinical research case definition presented in an accompanying publication and suggest a phased approach to diagnostics evaluation; entry criteria for enrollment; methods for classification of disease certainty, including the rational use of culture within the case definition; age categories and comorbidities for reporting results; and the need to use standard operating procedures. Special consideration is given to the performance of microbiological culture in children and we also recommend for alternative methodological approaches to report findings in a standardized manner to overcome these limitations are made. This consensus statement is an important step toward ensuring greater rigor and comparability of pediatric tuberculosis diagnostic research, with the aim of realizing the full potential of better tests for children.

Item does not contain fulltext A growing number of new drugs for the treatment of tuberculosis are in clinical development. Confirmatory phase 3 trials are expensive and time-consuming and the question of whether one particular drug combination can be used to treat tuberculosis is less important from a public health perspective than the question of which are the shortest, simplest, most effective, and safest regimens. While preclinical and phase 1 studies provide some guidance in the selection of combinations for clinical evaluation, a large number of combinations will require phase 2 testing to ensure that only the best regimens advance to phase 3. The multi-arm multi-stage trial design is an example of a treatment selection-adaptive design where multiple experimental arms are each simultaneously compared with a common control and interim analyses allow for poor performing arms to be dropped early. Such designs, if designed and implemented correctly, require fewer patients, can be completed in a shorter time frame, and answer more relevant questions without any loss in statistical validity or scientific integrity. There are, however, practical issues that must be considered in applying this in tuberculosis treatment trials. More innovative trials designs should be considered to speed drug and regimen development for the treatment of tuberculosis.

International audience; We report an MRSA outbreak in our 25-bed tertiary neonatal intensive care unit (NICU), which was successfully contained. Methods include a retrospective review of patient files, microbiology records and meeting protocols. During the seven months of outbreak, 27 patients and seven health care workers (HCWs) had positive cultures for MRSA. The outbreak was caused by the epidemic Rhine-Hessen strain; cultured isolates were monoclonal. After a sharp increase of the number of new MRSA-cases the installation of an outbreak management team (OMT) and implementation of comprehensive measures (extensive screening and decolonization strategy including orally applied vancomycin, isolation wards, intensive disinfection regimen) successfully terminated the outbreak within one month. Ten (53%) of 19 patients with completed follow-up and all of the HCWs were decolonized successfully. Gastrointestinal colonization was present in 15 of 27 (56%) neonates, and was associated with poor decolonization success (30% vs. 78% in absence of gastrointestinal colonization). A comprehensive outbreak management can terminate an outbreak in a NICU setting within a short time. Thorough screening of nares, throat and especially stool is necessary for correct cohorting. Gastrointestinal decolonization in neonates seems difficult.

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In this pilot study, we evaluated the Xpert® MTB/RIF assay in an active case-finding strategy, using two spot sputum samples collected within a 1-hour interval from household contacts of smear-positive TB index cases. Tuberculosis (TB) confirmed by culture served as the reference standard. Among 219 enrolled contacts, the yield of active TB was 2.3%. While the sensitivity of smear microscopy was 60% (95%CI 14.7–94.7), Xpert MTB/RIF achieved a sensitivity of 100% (95%CI 47.81–100.0). All culture-confirmed cases tested positive by Xpert MTB/RIF on the first submitted sample, suggesting that the evaluation of only one sample could be sufficient for TB diagnosis in this context.

Background Early bactericidal activity (EBA) during the first two weeks of TB treatment is an important method for early efficacy evaluation of new anti-tuberculosis agents. Methods We performed an observational; two-site clinical study in Tanzania in patients with newly diagnosed pulmonary TB during the first eight weeks of standard HRZE treatment. Baseline and treatment-related covariates including X-ray, baseline bacterial load and rifampicin pharmacokinetics were analysed for their correlation to treatment success. Results From Nov 2011 to July 2013 we enrolled 74 pulmonary TB patients from Moshi (41) and Mbeya (33). Mbeya participants had a higher baseline bacterial load measured by log time to positivity (TTP) in the MGIT culture system (median 1.29; IQR 1.09–1.46 vs 1.58; IQR 1.44–1.87; p Conclusions This observation EBA study using standard HZRE was successfully implemented with methodologies thus far established for the first time at the two Tanzanian sites. Baseline bacterial load was confirmed as an important predictive parameter.

This work was supported by EDCTP who fund the PanACEA consortium (IP.2007.32011.011, IP.2007.32011.012, IP.2007.32011.013) and PreDiCT-TB consortium [IMI Joint undertaking grant agreement number 115337, resources of which are composed of financial contribution from the European Union’s Seventh Framework Programme (FP7/2007-2013) and EFPIA companies’ in kind contribution]. Objectives The relationship between cfu and Mycobacterial Growth Indicator Tube (MGIT) time to positivity (TTP) is uncertain. We attempted to understand this relationship and create a mathematical model to relate these two methods of determining mycobacterial load. Methods Sequential bacteriological load data from clinical trials determined by MGIT and cfu were collected and mathematical models derived. All model fittings were conducted in the R statistical software environment (version 3.0.2), using the lm and nls functions. Results TTP showed a negative correlation with log10 cfu on all 14 days of the study. There was an increasing gradient of the regression line and y-intercept as treatment progressed. There was also a trend towards an increasing gradient with higher doses of rifampicin. Conclusions These data suggest that there is a population of mycobacterial cells that are more numerous when detected in liquid than on solid medium. Increasing doses of rifampicin differentially kill this group of organisms. These findings support the idea that increased doses of rifampicin are more effective. Postprint Postprint

After cisplatin / 5-fluorouracil chemotherapy for nasopharyngeal carcinoma, an 18-year female patient developed aortobifemoral embolism. Besides chemotherapy, additional risk factors for arterial thromboembolic events were smoking, contraceptive medication and adjuvant antiemetic treatment with dexamethasone. Thrombophilia screening was negative. Thromboembolic complications during or after cisplatin have been reported in a frequency of 17.6 % in lung cancer patients, and in 8.4 % of patients with germ cell tumors. The incidence of arterial thromboembolic events was 9.3 % and 1.7 %, respectively. The pathogenesis of cisplatin induced thromboembolism is thought to be caused by endothelial damage leading to endothelial cell dysfunction, increased von Willebrand factor plasma levels, and hypomagnesaemia.

Identification and evaluation of diagnostic biomarkers that predict TB disease progression are elaborate and complicated undertakings, since the number of incident cases even in high risk study populations is usually low and the definition of latent M.tb infection through a positive TST or IGRA test result is inaccurate. Using a retrospective case–control study approach embedded in the Amsterdam Cohort Studies on HIV infection and AIDS (van den Hoek et al., 1988), Sloot et al. (in press) identify a transcriptional signature within Peripheral Blood Mononuclear Cells, which identifies HIV-positive subjects who are later diagnosed with active TB disease. 55 to 250 days prior to TB diagnosis, IL13 transcription was detected in six out of 14 TB progressors and linked to differential expression of 50 additional genes, including type I IFN signature genes, while no subject in the control group expressed IL13. It can be assumed that this signature is part of an early host immune response to mycobacterial replication in vivo. Whether it is a hallmark of deficient immunological control of the pathogen invariably linked to progressive disease or rather reflective of pathogen activity independent of subsequent disease progression remains unclear. The study by Sloot et al. supports the concept that a diagnostic approach based on host biomarkers cannot only improve the diagnosis of active TB in populations where a conventional sputum-based diagnosis is difficult (e.g. in children, HIV-positives, extra-pulmonary TB), but might further allow identification of subjects with sub-clinically active M.tb replication. Other recent articles also highlighted the potential of host biomarkers based on transcriptional (Anderson et al., 2014, Joosten et al., 2012) or novel T cell signatures (Portevin et al., 2014, Harari et al., 2011, Schuetz et al., 2011) to improve diagnosis of active TB and possibly also allow early detection of TB disease progression. It is widely accepted that often a substantial time interval exists between infection with M.tb, and diagnosis of symptomatic disease. Individuals who develop active TB disease after primary infection frequently do so within the first two years (Marais et al., 2004). This specific characteristic of M.tb infection provides a window of opportunity for more accurate identification of individuals currently progressing to active TB using such novel biomarkers and to target them for early therapeutic intervention. Particularly in high risk populations such as HIV-positives, TB-contacts or IFN-gamma release assay converters (or TST skin-test converters) this approach might be more attractive than the current suboptimal algorithms with very limited specificity to trigger isoniazid preventive treatment, which likely result in overtreatment (American Thoracic Society, 2000). The use of novel host biomarkers in such a strategy would not only help to significantly reduce TB disease morbidity by detection of those subjects with the highest risk of active TB development in a “pre-clinical” stadium and motivating them and the treating medical staff to adhere to preventive treatment, but could also help to abrogate the MTB transmission chain and hence contribute to the EndTB Strategy by WHO and to the vision of a world free of TB in 2050 (WHO, 2014). Future research in the field of host biomarkers predictive of TB disease should be aiming at simplifying current diagnostic approaches into affordable products applicable on a large scale. Simultaneously, prospective large scale studies on early detection of progressive TB disease will be necessary (even though complicated to conduct) to further confirm the diagnostic accuracy and feasibility of these novel biomarkers in the field. Especially, the specificity for progressive versus non-progressive/latent M.tb infection needs to be assessed, as well as the biomarkers ability to distinguish between TB and other inflammatory diseases. An assessment of host biomarkers would require validation work in patient populations with different genetic backgrounds, as ethnicity can influence the composition of the host response, making such studies even larger. Significant effort is still required until the application of such novel diagnostic strategies on a large scale could be achieved. Nonetheless, new diagnostic host markers for early identification of progressive TB disease might herald a new era in TB diagnosis and early treatment.

Several studies showed that assessing levels of specific circulating microRNAs (miRNAs) is a non-invasive, rapid, and accurate method for diagnosing diseases or detecting alterations in physiological conditions. We aimed to identify a serum miRNA signature to be used for the diagnosis of tuberculosis (TB). To account for variations due to the genetic makeup, we enrolled adults from two study settings in Europe and Africa. The following categories of subjects were considered: healthy (H), active pulmonary TB (PTB), active pulmonary TB, HIV co-infected (PTB/HIV), latent TB infection (LTBI), other pulmonary infections (OPI), and active extra-pulmonary TB (EPTB). Sera from 10 subjects of the same category were pooled and, after total RNA extraction, screened for miRNA levels by TaqMan low-density arrays. After identification of “relevant miRNAs”, we refined the serum miRNA signature discriminating between H and PTB on individual subjects. Signatures were analyzed for their diagnostic performances using a multivariate logistic model and a Relevance Vector Machine (RVM) model. A leave-one-out-cross-validation (LOOCV) approach was adopted for assessing how both models could perform in practice. The analysis on pooled specimens identified selected miRNAs as discriminatory for the categories analyzed. On individual serum samples, we showed that 15 miRNAs serve as signature for H and PTB categories with a diagnostic accuracy of 82% (CI 70.2–90.0), and 77% (CI 64.2–85.9) in a RVM and a logistic classification model, respectively. Considering the different ethnicity, by selecting the specific signature for the European group (10 miRNAs) the diagnostic accuracy increased up to 83% (CI 68.1–92.1), and 81% (65.0–90.3), respectively. The African-specific signature (12 miRNAs) increased the diagnostic accuracy up to 95% (CI 76.4–99.1), and 100% (83.9–100.0), respectively. Serum miRNA signatures represent an interesting source of biomarkers for TB disease with the potential to discriminate between PTB and LTBI, but also among the other categories.