432 results on '"Ben J. Marais"'
Search Results
2. Critical assessment of infants born to mothers with drug resistant tuberculosisResearch in context
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Marian Loveday, Neel R. Gandhi, Palwasha Y. Khan, Grant Theron, Sindisiwe Hlangu, Kerry Holloway, Sunitha Chotoo, Nalini Singh, and Ben J. Marais
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Tuberculosis ,TB ,Transmission ,Mother-to-child ,Perinatal ,Congenital ,Medicine (General) ,R5-920 - Abstract
Summary: Background: There have been no detailed descriptions of infants born to mothers treated for drug resistant TB in pregnancy. Critical case history assessment is important to identify risks and guide clinical practice. Methods: In a cohort of pregnant women with multidrug or rifampicin resistant (MDR/RR)-TB enrolled between 1 January 2013 and 31 December 2022, we followed mother-infant pairs until the infant was 12 months old. We performed critical case history assessments to explore potential mechanisms of Mycobacterium tuberculosis transmission to the infant, and to describe the clinical presentation and disease trajectories observed in infants diagnosed with TB. Findings: Among 101 mother-infant pairs, 23 (23%) included infants diagnosed with TB disease; 16 were clinically diagnosed and seven had microbiological confirmation (five MDR/RR-TB, two drug-susceptible TB). A positive maternal sputum culture at the time of delivery was significantly associated with infant TB risk (p = 0.023). Of the 12 infants diagnosed with TB in the first three months of life, seven (58%) of the mothers were culture positive at delivery; of whom four reported poor TB treatment adherence. However, health system failures, including failing to diagnose and treat maternal MDR/RR-TB, inadequate screening of newborns at birth, not providing appropriate TB preventive therapy (TPT), and M. tuberculosis transmission from non-maternal sources also contributed to TB development in infants. Interpretation: Infants born to mothers with MDR/RR-TB are at greatest risk if maternal adherence to MDR/RR-TB treatment or antiretroviral therapy (ART) is sub-optimal. In a high TB incidence setting, infants are also at risk of non-maternal household and community transmission. Ensuring maternal TB diagnosis and appropriate treatment, together with adequate TB screening and prevention in all babies born to mothers or households with TB will minimise the risk of infant TB disease development. Funding: South African Medical Research Council.
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- 2024
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3. Disease spectrum and prognostic factors in patients treated for tuberculous meningitis in Shaanxi province, China
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Ting Wang, Meng-yan Li, Xin-shan Cai, Qiu-sheng Cheng, Ze Li, Ting-ting Liu, Lin-fu Zhou, Hong-hao Wang, Guo-dong Feng, Ben J. Marais, and Gang Zhao
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tuberculous meningitis ,prognostic factors ,disease spectrum ,diagnostic ,CSF ,Microbiology ,QR1-502 - Abstract
BackgroundTuberculous meningitis (TBM) is the most severe form of tuberculosis (TB) and can be difficult to diagnose and treat. We aimed to describe the clinical presentation, diagnosis, disease spectrum, outcome, and prognostic factors of patients treated for TBM in China.MethodsA multicenter retrospective study was conducted from 2009 to 2019 enrolling all presumptive TBM patients referred to Xijing tertiary Hospital from 27 referral centers in and around Shaanxi province, China. Patients with clinical features suggestive of TBM (abnormal CSF parameters) were included in the study if they had adequate baseline information to be classified as “confirmed,” “probable,” or “possible” TBM according to international consensus TBM criteria and remained in follow-up. Patients with a confirmed alternative diagnosis or severe immune compromise were excluded. Clinical presentation, central nervous system imaging, cerebrospinal fluid (CSF) results, TBM score, and outcome—assessed using the modified Barthel disability index—were recorded and compared.FindingsA total of 341 presumptive TBM patients met selection criteria; 63 confirmed TBM (25 culture positive, 42 Xpert-MTB/RIF positive), 66 probable TBM, 163 possible TBM, and 49 “not TBM.” Death was associated with BMRC grade III (OR = 5.172; 95%CI: 2.298–11.641), TBM score ≥ 15 (OR = 3.843; 95%CI: 1.372–10.761), age > 60 years (OR = 3.566; 95%CI: 1.022–12.442), and CSF neutrophil ratio ≥ 25% (OR = 2.298; 95%CI: 1.027–5.139). Among those with confirmed TBM, nearly one-third (17/63, 27.0%) had a TBM score 60 years) have higher TBM scores or CSF neutrophil ratios, have signs of disseminated/miliary TB, and are at greatest risk of death. In general, more effort needs to be done to improve early diagnosis and treatment outcome in TBM patients.
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- 2024
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4. Community-Wide Active Case Finding for Tuberculosis: Time to Use the Evidence We Have
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Mikaela Coleman, Chris Lowbridge, Philipp du Cros, and Ben J. Marais
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tuberculosis ,active case finding ,systematic screening ,elimination ,population-wide ,community-wide ,Medicine - Abstract
Tuberculosis, caused by the Mycobacterium tuberculosis (Mtb) bacteria, is one of the world’s deadliest infectious diseases. Despite being the world’s oldest pandemic, tuberculosis is very much a challenge of the modern era. In high-incidence settings, all people are at risk, irrespective of whether they have common vulnerabilities to the disease warranting the current WHO recommendations for community-wide tuberculosis active case finding in these settings. Despite good evidence of effectiveness in reducing tuberculosis transmission, uptake of this strategy has been lacking in the communities that would derive greatest benefit. We consider the various complexities in eliminating tuberculosis from the first principles of the disease, including diagnostic and other challenges that must be navigated under an elimination agenda. We make the case that community-wide tuberculosis active case finding is the best strategy currently available to drive elimination forward in high-incidence settings and that no time should be lost in its implementation. Recognizing that high-incidence communities vary in their epidemiology and spatiosocial characteristics, tuberculosis research and funding must now shift towards radically supporting local implementation and operational research in communities. This “preparing of the ground” for scaling up to community-wide intervention centers the local knowledge and local experience of community epidemiology to optimize implementation practices and accelerate reductions in community-level tuberculosis transmission.
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- 2024
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5. Assessing risks for bovine and zoonotic tuberculosis through spatial analysis and a questionnaire survey in Fiji – A pilot study
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Jenny-Ann L.M.L. Toribio, Keresi Lomata, Sam Fullman, Aaron Jenkins, Elva Borja, Shumaila Arif, Jarrad McKercher, David Blake, Anabel Garcia, Richard J. Whittington, Frank Underwood, and Ben J. Marais
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Extra pulmonary tuberculosis ,Bovine tuberculosis ,Mycobacterium bovis ,Zoonotic tuberculosis ,One health ,Fiji ,Science (General) ,Q1-390 ,Social sciences (General) ,H1-99 - Abstract
Mycobacterium bovis causes tuberculosis in cattle and when transmitted to humans typically causes extra-pulmonary tuberculosis (EPTB). Bovine tuberculosis (bTB) has a global distribution and is controlled in most countries to protect animal and public health. Recent studies revealed that bTB is established on dairy farms in Fiji where EPTB cases have been reported in people. The aims of this pilot investigation were to look for putative zoonotic TB (EPTB) cases in people and to evaluate practices that might contribute to the persistence and transmission of M. bovis between cattle and to humans. Existing data sets were shared between the Fiji Ministry of Agriculture and Ministry of Health and a questionnaire-based survey was implemented using One Health principles. Statistically significant co-location and close proximity of EPTB cases and bovine TB affected farms were identified. The bTB infection status of farms was significantly associated with unfenced water sources where cattle grazed. Of 247 households, 65 % shared drinking water sources with cattle and 36 % consumed raw milk without boiling, while 62 % of participants reported backyard slaughter of cattle. Several participants reported current symptoms potentially suggestive of TB (chronic cough) but the impact of smoking and history of previous TB treatment could not be evaluated. Farmers had limited understanding of the practices required to prevent bTB at farm level. Further study is recommended and should include an assessment of lifetime EPTB diagnoses, classification of farms based on more recent bTB test data and molecular typing of mycobacterial isolates from humans, cattle and the environment. A targeted awareness and education approach is required to reduce the future risk of zoonotic TB and to help ensure uptake of recommendations and practices aimed at controlling and preventing bTB.
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- 2023
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6. Exploring programmatic indicators of tuberculosis control that incorporate routine Mycobacterium tuberculosis sequencing in low incidence settings: a comprehensive (2017–2021) patient cohort analysisResearch in context
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Xiaomei Zhang, Elena Martinez, Connie Lam, Taryn Crighton, Eby Sim, Mailie Gall, Ellen J. Donnan, Ben J. Marais, and Vitali Sintchenko
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Tuberculosis ,Tuberculosis control ,Genomic surveillance ,Mycobacterium tuberculosis ,Transmission ,Drug resistance ,Public aspects of medicine ,RA1-1270 - Abstract
Summary: Background: Routine whole genome sequencing of Mycobacterium tuberculosis has been implemented with increasing frequency. However, its value for tuberculosis (TB) control programs beyond individual case management and enhanced drug resistance detection has not yet been explored. Methods: We analysed routine sequencing data of culture-confirmed TB cases notified between 1st January 2017 and 31st December 2021 in New South Wales (NSW), Australia. Genomic surveillance included evidence of local TB transmission, defined by single nucleotide polymorphism (SNP) clustering over a variable (0–25) SNP threshold, and drug resistance conferring mutations. Findings: M. tuberculosis sequences from 1831 patients were examined, representing 64.8% of all notified TB cases and 96.2% of culture-confirmed cases. Applying a traditional 5-SNP cluster threshold identified 62 transmission clusters with 183 clustered cases; 101/183 (55.2%) had 0 SNP differences. Cluster assessment over a 5-year period, using a 5-SNP threshold, provided a comprehensive overview of likely recent transmission within NSW, Australia, as an indicator of local TB control. Genotypic drug susceptibility testing (DST) was highly concordant with phenotypic DST and provided a 6.8% increase in antimycobacterial resistance detection. Importantly, it detected mutations missed by routine molecular tests. Lineage 2 strains were more likely to be drug resistant (p
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- 2023
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7. Finding and treating both tuberculosis disease and latent infection during population-wide active case finding for tuberculosis elimination
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Mikaela Coleman, Thu-Anh Nguyen, Boi Khanh Luu, Jeremy Hill, Romain Ragonnet, James M. Trauer, Greg J. Fox, Guy B. Marks, and Ben J. Marais
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Mycobacterium tuberculosis ,TB ,latent infection ,TPT ,LTBI ,active case finding ,Medicine (General) ,R5-920 - Abstract
In recognition of the high rates of undetected tuberculosis in the community, the World Health Organization (WHO) encourages targeted active case finding (ACF) among “high-risk” populations. While this strategy has led to increased case detection in these populations, the epidemic impact of these interventions has not been demonstrated. Historical data suggest that population-wide (untargeted) ACF can interrupt transmission in high-incidence settings, but implementation remains lacking, despite recent advances in screening tools. The reservoir of latent infection—affecting up to a quarter of the global population –complicates elimination efforts by acting as a pool from which future tuberculosis cases may emerge, even after all active cases have been treated. A holistic case finding strategy that addresses both active disease and latent infection is likely to be the optimal approach for rapidly achieving sustainable progress toward TB elimination in a durable way, but safety and cost effectiveness have not been demonstrated. Sensitive, symptom-agnostic community screening, combined with effective tuberculosis treatment and prevention, should eliminate all infectious cases in the community, whilst identifying and treating people with latent infection will also eliminate tomorrow’s tuberculosis cases. If real strides toward global tuberculosis elimination are to be made, bold strategies are required using the best available tools and a long horizon for cost-benefit assessment.
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- 2023
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8. Critical Review of Tuberculosis Diagnosis in Children from Papua New Guinea Presenting to Health Facilities in the Torres Strait Islands, Australia
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J’Belle Foster, Ben J. Marais, Diana Mendez, and Emma S. McBryde
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paediatric tuberculosis ,Torres Strait Islands ,tuberculosis diagnostics ,Torres Strait/PNG border ,WHO Paediatric TB Algorithm ,The Union Desk Guide ,Biology (General) ,QH301-705.5 - Abstract
Paediatric tuberculosis can be challenging to diagnose, and various approaches are used in different settings. A retrospective review was conducted on Papua New Guinea (PNG) children with presumptive TB who presented for health care in the Torres Strait Islands, Australia, between 2016 and 2019. We compared diagnostic algorithms including the modified Keith Edwards TB Score, The Union Desk Guide, and the new World Health Organization (WHO) algorithm, with diagnostic practices used in the remote Torres Strait Islands. Of the 66 children with presumptive TB, 7 had bacteriologically confirmed TB. The majority (52%) were under 5 years (median age 61 months), and 45% were malnourished. There was moderate agreement across the diagnostic methods (K = 0.34; 95% CI 0.23–0.46), with the highest concordance observed between The Union Desk Guide and the WHO’s algorithm (K = 0.61). Local TB physicians might have over-diagnosed presumed lymph node TB while under-diagnosing TB overall. Enhancing the precision and promptness of paediatric TB diagnosis using practical tools is pivotal to decrease TB-related child mortality, notably in isolated regions like the Torres Strait and the Western Province of PNG.
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- 2023
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9. The dilemma of improving rational antibiotic use in pediatric community-acquired pneumonia
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Phuong T. K. Nguyen, Paul D. Robinson, Dominic A. Fitzgerald, and Ben J. Marais
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acute respiratory infections ,lower respiratory tract infections ,pneumonia ,antibiotic ,antimicrobial resistance ,Pediatrics ,RJ1-570 - Abstract
Pneumonia is the number one cause of disease and deaths in children under five years old, outside the neonatal period, with the greatest number of cases reported from resource-limited settings. The etiology is variable, with not much information on the local etiology drug resistance profile in many countries. Recent studies suggest an increasing contribution from respiratory viruses, also in children with severe pneumonia, with an increased relative contribution in settings that have good vaccine coverage against common bacterial pathogens. Respiratory virus circulation was greatly reduced during highly restrictive measures to contain the spread of COVID-19 but rebounded once COVID-19 restrictions were relaxed. We conducted a comprehensive literature review of the disease burden, pathogens, case management and current available prevention of community acquired childhood pneumonia, with a focus on rational antibiotic use, since the treatment of respiratory infections is the leading cause of antibiotic use in children. Consistent application of revised World Health Organisation (WHO) guidance that children presenting with coryzal symptoms or wheeze can be managed without antibiotics in the absence of fever, will help to reduce unnecessary antibiotic use, as will increased availability and use of bedside inflammatory marker tests, such as C–reactive protein (CRP) in children with respiratory symptoms and fever.
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- 2023
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10. Tuberculosis mortality: quantifying agreement in clinical cause of death assessments
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Justin T. Denholm, Ben J. Marais, Ellen J. Donnan, Justin Waring, Richard Stapledon, Jemma W. Taylor, and Siddhartha Mahanty
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mortality ,tuberculosis ,policy ,public health ,Public aspects of medicine ,RA1-1270 - Abstract
Abstract Objectives: Mortality is a key statistic for public health globally, and mortality reduction is a key target of ‘End TB’ strategy. However, cause of death in relation to tuberculosis (TB) may be controversial, and we aimed to evaluate classification in Australia. Methods: We surveyed Australian clinicians and public health officers, presenting a variety of scenarios. Respondents were asked to classify each scenario with regards to whether TB was considered causative, contributory or not related to death. Results: Fifty‐nine individuals completed the survey. Respondents were experienced TB clinicians and public health officers (median 14 years of TB care experience), with a majority having recently been involved in death certification/classification. In most scenarios, there was substantial variation, particularly where death was related to TB medications, or if an alternative contributing process was recognised, such as cardiovascular complications. Variation in classification was not evidently associated with classification experience. Conclusion: We found significant variation in cause of death classification among experienced TB clinicians and public health officers, using representative TB death scenarios. Implications for public health: Consensus and transparency with regards to classification would assist in more uniform cause of death classification across jurisdictions and allow for better tracking of this critical performance measure.
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- 2022
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11. Treatment Outcomes of Childhood Tuberculous Meningitis in a Real-World Retrospective Cohort, Bandung, Indonesia
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Heda M. Nataprawira, Fajri Gafar, Nelly A. Risan, Diah A. Wulandari, Sri Sudarwati, Ben J. Marais, Jasper Stevens, Jan-Willem C. Alffenaar, and Rovina Ruslami
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tuberculosis ,tuberculous meningitis ,tuberculosis and other mycobacteria ,children ,treatment outcome ,mortality ,Medicine ,Infectious and parasitic diseases ,RC109-216 - Abstract
We retrospectively evaluated clinical features and outcomes in children treated for tuberculous meningitis (TBM) at Hasan Sadikin Hospital, Bandung, Indonesia, during 2011–2020. Among 283 patients, 153 (54.1%) were 38°C, stage III TBM, and baseline motor deficit. Despite treatment, childhood TBM in Indonesia causes substantial neurologic sequelae and death, highlighting the importance of improved early diagnosis, better tuberculosis prevention, and optimized TBM management strategies.
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- 2022
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12. Clinical and Experimental Determination of Protection Afforded by BCG Vaccination against Infection with Non-Tuberculous Mycobacteria: A Role in Cystic Fibrosis?
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Sherridan Warner, Anneliese Blaxland, Claudio Counoupas, Janine Verstraete, Marco Zampoli, Ben J. Marais, Dominic A. Fitzgerald, Paul D. Robinson, and James A. Triccas
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non-tuberculous mycobacteria ,Mycobacterium abscessus ,cystic fibrosis ,BCG vaccination ,immune response ,Medicine - Abstract
Mycobacterium abscessus is a nontuberculous mycobacterium (NTM) of particular concern in individuals with obstructive lung diseases such as cystic fibrosis (CF). Treatment requires multiple drugs and is characterised by high rates of relapse; thus, new strategies to limit infection are urgently required. This study sought to determine how Bacille Calmette-Guérin (BCG) vaccination may impact NTM infection, using a murine model of Mycobacterium abscessus infection and observational data from a non-BCG vaccinated CF cohort in Sydney, Australia and a BCG-vaccinated CF cohort in Cape Town, South Africa. In mice, BCG vaccination induced multifunctional antigen-specific CD4+ T cells circulating in the blood and was protective against dissemination of bacteria to the spleen. Prior infection with M. abscessus afforded the highest level of protection against M. abscessus challenge in the lung, and immunity was characterised by a greater frequency of pulmonary cytokine-secreting CD4+ T cells compared to BCG vaccination. In the clinical CF cohorts, the overall rates of NTM sampling during a three-year period were equivalent; however, rates of NTM colonisation were significantly lower in the BCG-vaccinated (Cape Town) cohort, which was most apparent for M. abscessus. This study provides evidence that routine BCG vaccination may reduce M. abscessus colonisation in individuals with CF, which correlates with the ability of BCG to induce multifunctional CD4+ T cells recognising M. abscessus in a murine model. Further research is needed to determine the optimal strategies for limiting NTM infections in individuals with CF.
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- 2023
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13. The impact of climate change and biodiversity loss on the health of children: An ethical perspective
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Phoebe C. M. Williams, Justin Beardsley, David Isaacs, Anne Preisz, and Ben J. Marais
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climate change ,child health ,global health ,medical ethics ,biodiversity loss ,health inequity ,Public aspects of medicine ,RA1-1270 - Abstract
The reality of human induced climate change is no longer in doubt, but the concerted global action required to address this existential crisis remains inexcusably inert. Together with climate change, biodiversity collapse is increasingly driving the emergence and spread of infectious diseases, the consequences of which are inequitable globally. Climate change is regressive in its nature, with those least responsible for destroying planetary health at greatest risk of suffering the direct and indirect health consequences. Over half a billion of the world's children live in areas vulnerable to extreme weather events. Without immediate action, the health of today's children and future generations will be compromised. We consider the impact of biodiversity collapse on the spread of infectious diseases and outline a duty of care along a continuum of three dimensions of medical ethics. From a medical perspective, the first dimension requires doctors to serve the best interests of their individual patients. The second dimension considers the public health dimension with a focus on disease control and cost-effectiveness. The neglected third dimension considers our mutual obligation to the future health and wellbeing of children and generations to come. Given the adverse impact of our ecological footprint on current and future human health, we have a collective moral obligation to act.
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- 2023
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14. Predictors of unfavourable treatment outcome in patients diagnosed with drug-resistant tuberculosis in the Torres Strait / Papua New Guinea border region
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J’Belle Foster, Diana Mendez, Ben J. Marais, Dunstan Peniyamina, and Emma S. McBryde
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Medicine ,Science - Abstract
Drug-resistant tuberculosis (DR-TB) is an ongoing challenge in the Torres Strait Islands (TSI) / Papua New Guinea (PNG) border region. Treatment success rates have historically been poor for patients diagnosed with DR-TB, leading to increased transmission. This study aimed to identify variables associated with unfavourable outcome in patients diagnosed with DR-TB to inform programmatic improvements. A retrospective study of all DR-TB cases who presented to Australian health facilities in the Torres Strait between 1 March 2000 and 31 March 2020 was performed. This time period covers four distinct TB programmatic approaches which reflect Australian and Queensland Government decisions on TB management in this remote region. Univariate and multivariate predictors of unfavourable outcome were analysed. Unfavourable outcome was defined as lost to follow up, treatment failure and death. Successful outcome was defined as cure and treatment completion. In total, 133 patients with resistance to at least one TB drug were identified. The vast majority (123/133; 92%) of DR-TB patients had pulmonary involvement; and of these, 41% (50/123) had both pulmonary and extrapulmonary TB. Unfavourable outcomes were observed in 29% (39/133) of patients. Patients living with human immunodeficiency virus, renal disease or diabetes (4/133; 4/133; 3/133) had an increased frequency of unfavourable outcome (p
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- 2022
15. Implementing tuberculosis preventive treatment in high-prevalence settings
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Greg J. Fox, Thu Anh Nguyen, Mikaela Coleman, Anete Trajman, Kavindhran Velen, and Ben J. Marais
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Mycobacterium tuberculosis ,latent tuberculosis ,preventive therapy ,prophylaxis ,patient-centered care ,Infectious and parasitic diseases ,RC109-216 - Abstract
Latent tuberculosis infection affects one quarter of the world’s population, and effective therapies are available. However, scale-up of tuberculosis preventive treatment (TPT) remains limited. We describe strategies to support scale-up of TPT in high-prevalence settings, where the potential benefit for affected individuals is considerable. Patients must be at the centre of policies to scale-up TPT. Addressing the health system requirements for scale-up will ensure that programs can deliver treatment safely, efficiently and sustainably. Further research is required to adapt TPT to local contexts, and develop new shorter treatments that will be suitable for wide-scale deployment.
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- 2021
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16. Paediatric tuberculosis – new advances to close persistent gaps
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Ben J. Marais, Sabine Verkuijl, Martina Casenghi, Rina Triasih, Anneke C. Hesseling, Anna M. Mandalakas, Olivier Marcy, James A. Seddon, Stephen M. Graham, and Farhana Amanullah
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child ,childhood ,tuberculosis ,prevention ,case finding ,gap ,Infectious and parasitic diseases ,RC109-216 - Abstract
Young children are most vulnerable to develop severe forms of tuberculosis (TB) and are over-represented among TB deaths. Almost all children estimated to have died from TB were never diagnosed or offered TB treatment.Improved access to TB preventive treatment (TPT) requires major upscaling of household contact investigation with allocation of adequate resources. Symptom-based screening is often discouraged in adults for fear of generating drug resistance, if TB cases are missed. However, the situation in vulnerable young children is different, as they present minimal risk of drug resistance generation. Further, the perceived need for additional diagnostic evaluation presents a major barrier to TPT access and underlies general reluctance to consider pragmatic decentralised models of care.Widespread roll-out of Xpert MTB/RIF Ultra® represents an opportunity for improved case detection in young children, but attaining full impact will require the use of non-sputum specimens. The new Fujifilm SILVAMP TB LAM® urine assay demonstrated good diagnostic accuracy in HIV-positive and malnourished children, but further validation is required. Given the limited accuracy of all available tests and the excellent tolerance of TB drugs in children, the global community may have to accept some over-treatment if we want to close the persistent case detection gap in young children.
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- 2021
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17. Whole genome sequencing based differentiation between re-infection and relapse in Indian patients with tuberculosis recurrence, with and without HIV co-infection
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Sivakumar Shanmugam, Nathan L. Bachmann, Elena Martinez, Ranjeeta Menon, G. Narendran, Sujatha Narayanan, Srikanth P. Tripathy, Uma Devi Ranganathan, Shailendra Sawleshwarkar, Ben J. Marais, and Vitali Sintchenko
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Mycobacterium tuberculosis ,recurrence ,HIV ,co-infection ,genome sequencing ,Antimicrobial resistance ,Infectious and parasitic diseases ,RC109-216 - Abstract
Introduction: Differentiation between relapse and reinfection in cases with tuberculosis (TB) recurrence has important implications for public health, especially in patients with human immunodeficiency virus (HIV) co-infection. We compared Mycobacterial Interspersed Repeat Unit (MIRU) typing and spoligotyping with whole genome sequencing (WGS) to differentiate between relapse and reinfection in patients (HIV-positive and HIV-negative) with TB recurrence. We also assessed the value of WGS to track acquired drug resistance in those with relapse after successful treatment. Method: Forty-one paired M. tuberculosis isolates collected from 20 HIV-positive and 21 HIV-negative patients were subjected to WGS in addition to spoligotyping and MIRU typing. Phylogenetic and Single Nucleotide Substitution (SNP) clustering analyses were performed to determine whether recurrences were due to relapse or re-infection. Results: Comparison of M. tuberculosis genomes indicated that 95% of TB recurrences in the HIV-negative cohort were due to relapse, while the majority of TB recurrences (75%) in the HIV-positive cohort was due to reinfection (P = 0.0001). New drug resistance mutations were acquired in 5/24 cases (20.8%) that experienced relapse. Conclusions: WGS provided increased resolution, but differentiation between relapse and reinfection was broadly consistent with MIRU and spoligotyping. The high contribution of reinfection among HIV infected patients experiencing TB recurrence warrants further study to explore risk factors for TB exposure.
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- 2021
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18. Value of routine whole genome sequencing for Mycobacterium tuberculosis drug resistance detection
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Connie Lam, Elena Martinez, Taryn Crighton, Catriona Furlong, Ellen Donnan, Ben J. Marais, and Vitali Sintchenko
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Whole genome sequencing ,Mycobacterium tuberculosis ,Drug Resistance ,Tuberculosis ,Lineage ,Multi-drug resistant tuberculosis ,Infectious and parasitic diseases ,RC109-216 - Abstract
Routine whole genome sequencing (WGS) of pathogens is becoming more feasible as sequencing costs decrease and access to benchtop sequencing equipment and bioinformatics pipelines increases. This study examined the added value gained from implementing routine WGS of all Mycobacterium tuberculosis isolates in New South Wales, Australia.Drug resistance markers inferred from WGS data were compared to commercial genotypic drug susceptibility testing (DST) assays and conventional phenotypic DST in all isolates sequenced between 2016 and 2019. Of the 1107 clinical M. tuberculosis isolates sequenced, 29 (2.6%) were multi-drug resistant (MDR); most belonged to Beijing (336; 30.4%) or East-African Indian (332; 30%) lineages. Compared with conventional phenotypic DST, WGS identified an additional 1% of isolates which were likely drug resistant, explained by mutations previously associated with treatment failure and mixed bacterial populations. However, WGS provided a 20% increase in drug resistance detection in comparison with commercial genotypic assays by identifying mutations outside of the classic resistance determining regions in rpoB, inhA, katG, pncA and embB genes. Gains in drug resistance detection were significant (p = 0.0137, paired t-test), but varied substantially for different phylogenetic lineages.In low incidence settings, routine WGS of M. tuberculosis provides better guidance for person-centered management of drug resistant tuberculosis than commercial genotypic assays.
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- 2021
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19. Critical Consideration of Tuberculosis Management of Papua New Guinea Nationals and Cross-Border Health Issues in the Remote Torres Strait Islands, Australia
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J’Belle Foster, Diana Mendez, Ben J. Marais, Justin T. Denholm, Dunstan Peniyamina, and Emma S. McBryde
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tuberculosis ,Torres Strait ,medical evacuation ,cross-border ,Medicine - Abstract
The international border between Australia and Papua New Guinea (PNG) serves as a gateway for the delivery of primary and tertiary healthcare for PNG patients presenting to Australian health facilities with presumptive tuberculosis (TB). An audit of all PNG nationals with presumptive TB who presented to clinics in the Torres Strait between 2016 and 2019 was conducted to evaluate outcomes for PNG patients and to consider the consistency and equity of decision-making regarding aeromedical evacuation. We also reviewed the current aeromedical retrieval policy and the outcomes of patients referred back to Daru General Hospital in PNG. During the study period, 213 PNG nationals presented with presumptive TB to primary health centres (PHC) in the Torres Strait. In total, 44 (21%) patients were medically evacuated to Australian hospitals; 26 met the evacuation criteria of whom 3 died, and 18 did not meet the criteria of whom 1 died. A further 22 patients who met the medical evacuation criteria into Australia were referred to Daru General Hospital of whom 2 died and 10 were lost to follow-up. The cross-border movement of people from PNG into Australia is associated with an emergent duty of care. Ongoing monitoring and evaluation of patient outcomes are necessary for transparency and justice.
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- 2022
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20. Cross-Border Movement of Highly Drug-Resistant Mycobacterium tuberculosis from Papua New Guinea to Australia through Torres Strait Protected Zone, 2010–2015
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Arnold Bainomugisa, Sushil Pandey, Ellen Donnan, Graham Simpson, J’Belle Foster, Evelyn Lavu, Stenard Hiasihri, Emma S. McBryde, Rendi Moke, Steven Vincent, Vitali Sintchenko, Ben J. Marais, Lachlan J.M. Coin, and Christopher Coulter
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whole-genome sequencing ,tuberculosis ,MDR-TB ,Torres Strait ,Papua New Guinea ,Australia ,Medicine ,Infectious and parasitic diseases ,RC109-216 - Abstract
In this retrospective study, we used whole-genome sequencing (WGS) to delineate transmission dynamics, characterize drug-resistance markers, and identify risk factors of transmission among Papua New Guinea residents of the Torres Strait Protected Zone (TSPZ) who had tuberculosis diagnoses during 2010–2015. Of 117 isolates collected, we could acquire WGS data for 100; 79 were Beijing sublineage 2.2.1.1, which was associated with active transmission (odds ratio 6.190, 95% CI 2.221–18.077). Strains were distributed widely throughout the TSPZ. Clustering occurred more often within than between villages (p = 0.0013). Including 4 multidrug-resistant tuberculosis isolates from Australia citizens epidemiologically linked to the TSPZ into the transmission network analysis revealed 2 probable cross-border transmission events. All multidrug-resistant isolates (33/104) belonged to Beijing sublineage 2.2.1.1 and had high-level isoniazid and ethionamide co-resistance; 2 isolates were extensively drug resistant. Including WGS in regional surveillance could improve tuberculosis transmission tracking and control strategies within the TSPZ.
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- 2019
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21. Asthma and atopy prevalence are not reduced among former tuberculosis patients compared with controls in Lima, Peru
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Anthony L. Byrne, Ben J. Marais, Carole D. Mitnick, Frances L. Garden, Leonid Lecca, Carmen Contreras, Yaninna Yauri, Fanny Garcia, and Guy B. Marks
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Tuberculosis ,Atopy ,Allergy ,Immune response ,Asthma ,Peru ,Diseases of the respiratory system ,RC705-779 - Abstract
Abstract Background Although there are theoretical reasons for believing that asthma and atopy may be negatively correlated with tuberculosis, epidemiological studies have had conflicting findings. Objective To determine if people with confirmed tuberculosis were less likely to be atopic and less likely to have atopic disease including asthma compared to those with no previous tuberculosis. Methods Patients in Lima, Peru with a prior history of tuberculosis were identified from clinic records in this cohort study. A representative sample of individuals without a prior tuberculosis diagnosis was recruited from the same community. Allergen skin prick testing was performed to classify atopic status. Allergic rhinitis was identified by history. Asthma was defined by symptoms and spirometry. Eosinophilic airway inflammation was measured using exhaled nitric oxide levels. Results We evaluated 177 patients with, and 161 individuals without, previous tuberculosis. There was a lower prevalence of atopy among people with prior tuberculosis on univariate analysis (odds ratio 0.57; 95% confidence interval 0.37–0.88) but, after adjustment for potential confounders, this was no longer statistically significant (aOR 0.64, 95% CI 0.41–1.01). The prevalence of allergic rhinitis (aOR 0.76, 95% CI 0.47 to 1.24 and asthma (aOR 1.18, 95% CI 0.69 to 2.00) did not differ significantly between the two groups. We also found no significant difference in the prevalence of elevated exhaled nitric oxide (aOR 1.30, 95% CI 0.78 to 2.17) or a combined index of atopic disease (aOR 0.86, 95% CI 0.54 to 1.36). Conclusion In this urban environment in a middle-income country, prior tuberculosis may be associated with a reduced risk of atopy but does not protect against asthma and atopic disease.
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- 2019
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22. Surgery in nontuberculous mycobacteria pulmonary disease
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Mimi Lu, Dominic Fitzgerald, Jonathan Karpelowsky, Hiran Selvadurai, Chetan Pandit, Paul Robinson, and Ben J. Marais
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Diseases of the respiratory system ,RC705-779 - Abstract
Medical treatment of pulmonary nontuberculous mycobacteria (NTM) disease has highly variable outcomes. Despite the use of multiple antibiotics, sputum clearance is often difficult to achieve, especially in cases with macrolide resistant NTM infection. Immunocompromised patients and those with structural lung disease are at increased risk, although occurrence in immunocompetent patients without structural lung disease is well recognised. Most pulmonary NTM disease involves Mycobacterium avium complex (MAC), but with enhanced identification multiple species have now been recognised as opportunistic pathogens. The observed increase in NTM disease, especially infection with multidrug-resistant Mycobacterium abscessus complex, is probably multifactorial. Surgery has been used as adjuvant treatment in patients with 1) focal disease that can be removed or 2) bothersome symptoms despite medical treatment that can be ameliorated. Early post-surgical mortality is low, but long-term morbidity and mortality are highly dependent on the degree of lung involvement and the residual lung function, the potency of medical treatment and the type of surgical intervention. In conjunction with antibiotic therapy, reported post-surgical sputum clearance was excellent, although publication bias should be considered. Bronchopleural fistulae were problematic, especially in pneumonectomy cases. Study results support the use of minimal resection surgery, in a carefully selected subgroup of patients with focal disease or persistent symptoms. Educational aims To critically review the literature describing the use of surgery in the treatment of pulmonary disease caused by nontuberculous mycobacteria (NTM). To assess the outcomes and complications observed with different surgical approaches used in the treatment of pulmonary NTM disease.
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- 2018
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23. Tuberculosis in Children and Adolescents: Progress and Perseverance
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Stephen M. Graham, Ben J. Marais, and Farhana Amanullah
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n/a ,Medicine - Abstract
Although it is an ancient pathogen, tuberculosis (TB) remains a major infectious cause of death globally, transiently displaced by COVID-19 [...]
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- 2022
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24. Diagnostic Challenges in Childhood Pulmonary Tuberculosis—Optimizing the Clinical Approach
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Kenneth S. Gunasekera, Bryan Vonasek, Jacquie Oliwa, Rina Triasih, Christina Lancioni, Stephen M. Graham, James A. Seddon, and Ben J. Marais
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tuberculosis ,children ,paediatric ,diagnosis ,symptom-based ,Medicine - Abstract
The management of childhood tuberculosis (TB) is hampered by the low sensitivity and limited accessibility of microbiological testing. Optimizing clinical approaches is therefore critical to close the persistent gaps in TB case detection and prevention necessary to realize the child mortality targets of the End TB Strategy. In this review, we provide practical guidance summarizing the evidence and guidelines describing the use of symptoms and signs in decision making for children being evaluated for either TB preventive treatment (TPT) or TB disease treatment in high-TB incidence settings. Among at-risk children being evaluated for TPT, a symptom screen may be used to differentiate children who require further investigation for TB disease before receiving TPT. For symptomatic children being investigated for TB disease, an algorithmic approach can inform which children should receive TB treatment, even in the absence of imaging or microbiological confirmation. Though clinical approaches have limitations in accuracy, they are readily available and can provide valuable guidance for decision making in resource-limited settings to increase treatment access. We discuss the trade-offs in using them to make TB treatment decisions.
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- 2022
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25. Extensive Homoplasy but No Evidence of Convergent Evolution of Repeat Numbers at MIRU Loci in Modern Mycobacterium tuberculosis Lineages
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Alexander C. Outhred, Ulziijargal Gurjav, Peter Jelfs, Nadine McCallum, Qinning Wang, Grant A. Hill-Cawthorne, Ben J. Marais, and Vitali Sintchenko
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Mycobacterium tuberculosis ,homoplasy ,convergent evolution ,MIRU ,VNTR ,phylogeny ,Public aspects of medicine ,RA1-1270 - Abstract
More human deaths have been attributable to Mycobacterium tuberculosis than any other pathogen, and the epidemic is sustained by ongoing transmission. Various typing schemes have been developed to identify strain-specific differences and track transmission dynamics in affected communities, with recent introduction of whole genome sequencing providing the most accurate assessment. Mycobacterial interspersed repetitive unit (MIRU) typing is a family of variable number tandem repeat schemes that have been widely used to study the molecular epidemiology of M. tuberculosis. MIRU typing was used in most well-resourced settings to perform routine molecular epidemiology. Instances of MIRU homoplasy have been observed in comparison with sequence-based phylogenies, limiting its discriminatory value. A fundamental question is whether the observed homoplasy arises purely through stochastic processes, or whether there is evidence of natural selection. We compared repeat numbers at 24 MIRU loci with a whole genome sequence-based phylogeny of 245 isolates representing three modern M. tuberculosis lineages. This analysis demonstrated extensive homoplasy of repeat numbers, but did not detect any evidence of natural selection of repeat numbers, at least since the ancestral branching of the three modern lineages of M. tuberculosis. In addition, we observed good sensitivity but poor specificity and positive predictive values of MIRU-24 to detect clusters of recent transmission, as defined by whole-genome single nucleotide polymorphism analysis. These findings provide mechanistic insight, and support a transition away from VNTR-based typing toward sequence-based typing schemes for both research and public health purposes.
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- 2020
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26. MDR/XDR-TB management of patients and contacts: Challenges facing the new decade. The 2020 clinical update by the Global Tuberculosis Network
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Giovanni Battista Migliori, Simon Tiberi, Alimuddin Zumla, Eskild Petersen, Jeremiah Muhwa Chakaya, Christian Wejse, Marcela Muñoz Torrico, Raquel Duarte, Jan Willem Alffenaar, H. Simon Schaaf, Ben J. Marais, Daniela Maria Cirillo, Riccardo Alagna, Adrian Rendon, Emanuele Pontali, Alberto Piubello, José Figueroa, Gabriella Ferlazzo, Alberto García-Basteiro, Rosella Centis, Dina Visca, Lia D’Ambrosio, Giovanni Sotgiu, T. Abu Arkub, O.W. Akkerman, A. Aleksa, E. Belilovski, E. Bernal, F-X. Blanc, M. Boeree, S. Borisov, J. Bruchfeld, J. Cadiñanos Loidi, J.A. Caminero, A.C. Carvalho, J.J. Cebrian Gallardo, Charalampos, E. Danila, L. Davies Forsman, J. Denholm, K. Dheda, R. Diel, S. Diktanas, C. Dobler, M. Enwerem, S. Esposito, N. Escobar Salinas, A. Filippov, B. Formenti, J.M. García García, D. Goletti, R. Gomez Rosso, G. Gualano, P. Isaakidis, A. Kaluzhenina, S. Koirala, L. Kuksa, H. Kunst, Y. Li, C. Magis-Escurra, V. Manfrin, S. Manga, K. Manika, V. Marchese, E. Martínez Robles, A. Maryandyshev, A. Matteelli, A. Mariani, J. Mazza-Stalder, F. Mello, L. Mendoza, A. Mesi, S. Miliauskas, H. Mustafa Hamdan, N. Ndjeka, M. Nieto Marcos, T.H.M. Ottenhoff, D.J. Palmero, F. Palmieri, A. Papavasileiou, M.C. Payen, A. Pontarelli, M. Pretti Dalcolmo, S. Quirós Fernandez, R. Romero, D. Rossato Silva, A.P. Santos, B. Seaworth, M. Sinitsyn, A. Skrahina, I. Solovic, A. Spanevello, M. Tadolini, C. Torres, Z. Udwadia, M. van den Boom, G.V. Volchenkov, A. Yedilbayev, R. Zaleskis, and J.P. Zellweger
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Infectious and parasitic diseases ,RC109-216 - Abstract
The continuous flow of new research articles on MDR-TB diagnosis, treatment, prevention and rehabilitation requires frequent update of existing guidelines. This review is aimed at providing clinicians and public health staff with an updated and easy-to-consult document arising from consensus of Global Tuberculosis Network (GTN) experts.The core published documents and guidelines have been reviewed, including the recently published MDR-TB WHO rapid advice and ATS/CDC/ERS/IDSA guidelines.After a rapid review of epidemiology and risk factors, the clinical priorities on MDR-TB diagnosis (including whole genome sequencing and drug-susceptibility testing interpretations) and treatment (treatment design and management, TB in children) are discussed. Furthermore, the review comprehensively describes the latest information on contact tracing and LTBI management in MDR-TB contacts, while providing guidance on post-treatment functional evaluation and rehabilitation of TB sequelae, infection control and other public health priorities. Keywords: MDR-TB, XDR-TB, Diagnosis, Treatment, Prevention, Rehabilitation of sequelae
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- 2020
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27. Key Transitions in the Evolution of Rapid and Slow Growing Mycobacteria Identified by Comparative Genomics
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Nathan L. Bachmann, Rauf Salamzade, Abigail L. Manson, Richard Whittington, Vitali Sintchenko, Ashlee M. Earl, and Ben J. Marais
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Mycobacterium species ,growth phenotype ,evolution ,comparative genomics ,phylogenetic analysis ,Microbiology ,QR1-502 - Abstract
Mycobacteria have been classified into rapid and slow growing phenotypes, but the genetic factors that underlie these growth rate differences are not well understood. We compared the genomes of 157 mycobacterial species, representing all major branches of the mycobacterial phylogenetic tree to identify genes and operons enriched among rapid and slow growing mycobacteria. Overlaying growth phenotype on a phylogenetic tree based on 304 core genes suggested that ancestral mycobacteria had a rapid growth phenotype with a single major evolutionary separation into rapid and slow growing sub-genera. We identified 293 genes enriched among rapid growing sub-genera, including genes encoding for amino acid transport/metabolism (e.g., livFGMH operon) and transcription, as well as novel ABC transporters. Loss of the livFGMH and ABC transporter operons among slow growing species suggests that reduced cellular amino acid transport may be growth limiting. Comparative genomic analysis suggests that horizontal gene transfer, from non-mycobacterial genera, may have contributed to niche adaptation and pathogenicity, especially among slow growing species. Interestingly, the mammalian cell entry (mce) operon was found to be ubiquitous, irrespective of growth phenotype or pathogenicity, although protein sequence homology between rapid and slow growing species was low (
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- 2020
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28. Factors associated with breastfeeding intent among mothers of newborn babies in Da Nang, Viet Nam
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Phuong Thi Kim Nguyen, Hoang Thi Tran, Thuy Thi Thanh Thai, Kirsty Foster, Christine L. Roberts, and Ben J. Marais
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Essential newborn care package ,Breastfeeding ,Viet Nam ,Breastfeed ,Pediatrics ,RJ1-570 ,Public aspects of medicine ,RA1-1270 - Abstract
Abstract Background Breastfeeding is recognized as the single most cost-effective intervention to reduce child morbidity and mortality. However, few studies have explored perceived barriers to breastfeeding and factors associated with breastfeeding intent among mothers of newborn babies in Viet Nam. We conducted a study to assess breastfeeding initiation rates, intent to breastfeed exclusively for 6 months or more and perceived barriers to breastfeed among mothers of newborn babies in Da Nang, Viet Nam. Methods We conducted a cross-sectional questionnaire survey of mothers in the postnatal wards of Da Nang Hospital for Women and Children in central Viet Nam from 10 February 2017 to 24 February 2017, following implementation of the World Health Organization (WHO) Essential Newborn Care (ENC) package. Results Of 286 mothers surveyed, 259 (90.6%) initiated breastfeeding; 203/258 (78.7%) within 1 hour (h) of birth. Most (207, 72.4%) mothers indicated intent to breastfeed exclusively for 6 months or more, but this was lower among mothers of preterm babies (82.2% versus 20.0%, p
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- 2018
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29. Tuberculosis among older adults in Zambia: burden and characteristics among a neglected group
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Jenna Coffman, Pascalina Chanda-Kapata, Ben J. Marais, Nathan Kapata, Alimuddin Zumla, and Joel Negin
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Tuberculosis ,Older adults ,Zambia ,Public aspects of medicine ,RA1-1270 - Abstract
Abstract Background The 2010 Global Burden of Disease estimates show that 57% of all TB deaths globally occurred among adults older than 50 years of age. Few studies document the TB burden among older adults in Southern Africa. We focused on adults older than 55 years to assess the relative TB burden and associated demographic factors. Methods A cross sectional nationally representative TB prevalence survey conducted of Zambian residents aged 15 years and above from 66 clusters across all the 10 provinces of Zambia. Evaluation included testing for TB as well as an in-depth questionnaire. We compared survey data for those aged 55 and older to those aged 15–54 years. Survey results were also compared with 2013 routinely collected programmatic notification data to generate future hypotheses regarding active and passive case finding. Results Among older adults with TB, 30/ 54 (55.6%) were male, 3/27 (11.1%) were HIV infected and 35/54 (64.8%) lived in rural areas. TB prevalence was higher in those aged ≥55 (0.7%) than in the 15–54 age group (0.5%). Males had higher rates of TB across both age groups with 0.7% (15–54) and 1.0% (≥55) compared with females 0.4% (15–54) and 0.6% (≥55). In rural areas, the prevalence of TB was significantly higher among older than younger adults (0.7% vs 0.3%), while the HIV infection rate was among TB patients was lower (11.1% vs 30.8%). The prevalence survey detected TB in 54/7484 (0.7%) of older adults compared to 3619/723,000 (0.5%) reported in 2013 programmatic data. Conclusion High TB rates among older adults in TB endemic areas justify consideration of active TB case finding and prevention strategies.
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- 2017
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30. A user-friendly mathematical modelling web interface to assist local decision making in the fight against drug-resistant tuberculosis
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Romain Ragonnet, James M. Trauer, Justin T. Denholm, Ben J. Marais, and Emma S. McBryde
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User Interface ,Decision making ,Tuberculosis ,Multidrug-resistant tuberculosis ,Re-treatment ,Causal pathway ,Infectious and parasitic diseases ,RC109-216 - Abstract
Abstract Multidrug-resistant and rifampicin-resistant tuberculosis (MDR/RR-TB) represent an important challenge for global tuberculosis (TB) control. The high rates of MDR/RR-TB observed among re-treatment cases can arise from diverse pathways: de novo amplification during initial treatment, inappropriate treatment of undiagnosed MDR/RR-TB, relapse despite appropriate treatment, or reinfection with MDR/RR-TB. Mathematical modelling allows quantification of the contribution made by these pathways in different settings. This information provides valuable insights for TB policy-makers, allowing better contextualised solutions. However, mathematical modelling outputs need to consider local data and be easily accessible to decision makers in order to improve their usefulness. We present a user-friendly web-based modelling interface, which can be used by people without technical knowledge. Users can input their own parameter values and produce estimates for their specific setting. This innovative tool provides easy access to mathematical modelling outputs that are highly relevant to national TB control programs. In future, the same approach could be applied to a variety of modelling applications, enhancing local decision making.
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- 2017
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31. Encouraging rational antibiotic use in childhood pneumonia: a focus on Vietnam and the Western Pacific Region
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Nguyen T. K. Phuong, Tran T. Hoang, Pham H. Van, Lolyta Tu, Stephen M. Graham, and Ben J. Marais
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Antibiotic Prescription ,Cefaclor ,Pneumococcal Conjugate Vaccine ,Vaccine Uptake ,Macrolide Resistance ,Diseases of the respiratory system ,RC705-779 - Abstract
Abstract Globally, pneumonia is considered to be the biggest killer of infants and young children (aged
- Published
- 2017
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32. Improving access to tuberculosis preventive therapy and treatment for children
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Ben J. Marais
- Subjects
Tuberculosis ,Children ,Drug-resistant ,Infectious and parasitic diseases ,RC109-216 - Abstract
Children suffer a huge burden of disease in tuberculosis (TB) endemic countries. This disease burden was largely invisible when TB control programmes focused exclusively on adults with sputum smear-positive disease. High-level advocacy and better data have improved visibility, but the establishment of functional paediatric TB programmes remains challenging. The key issues that limit children's access to TB preventive therapy and treatment in endemic areas are briefly discussed. Barriers to preventive therapy include (1) the perceived inability to rule out active disease, (2) fear of creating drug resistance, (3) non-implementation of existing guidelines in the absence of adequate monitoring, and (4) poor adherence with long preventive therapy courses. Barriers to TB treatment include (1) perceived diagnostic difficulties, (2) non-availability of chest radiography, (3) young children presenting to unprepared maternal and child health (MCH) services, and (4) the absence of child-friendly formulations. With drug-resistant disease there is currently no guidance on the use of preventive therapy and treatment is usually restricted to cases with bacteriologically confirmed disease, which excludes most young children from care, even if their likely source case has documented drug-resistant TB.
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- 2017
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33. The risk of global epidemic replacement with drug-resistant Mycobacterium tuberculosis strains
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Emma S. McBryde, Michael T. Meehan, Tan N. Doan, Romain Ragonnet, Ben J. Marais, Vanina Guernier, and James M. Trauer
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Antibiotic resistance ,Mathematical modelling ,Communicable disease control ,Tuberculosis ,Infectious and parasitic diseases ,RC109-216 - Abstract
Objectives: Multidrug-resistant tuberculosis (MDR-TB) is a threat to tuberculosis (TB) control. To guide TB control, it is essential to understand the extent to which and the circumstances in which MDR-TB will replace drug-susceptible TB (DS-TB) as the dominant phenotype. The issue was examined by assessing evidence from genomics, pharmacokinetics, and epidemiology studies. This evidence was then synthesized into a mathematical model. Methods: This model considers two TB strains, one with and one without an MDR phenotype. It was considered that intrinsic transmissibility may be different between the two strains, as may the control response including the detection, treatment failure, and default rates. The outcomes were explored in terms of the incidence of MDR-TB and time until MDR-TB surpasses DS-TB as the dominant strain. Results and conclusions: The ability of MDR-TB to dominate DS-TB was highly sensitive to the relative transmissibility of the resistant strain; however, MDR-TB could dominate even when its transmissibility was modestly reduced (to between 50% and 100% as transmissible as the DS-TB strain). This model suggests that it may take decades or more for strain replacement to occur. It was also found that while the amplification of resistance is the early cause of MDR-TB, this will rapidly give way to person-to-person transmission.
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- 2017
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34. Detailed characterisation of the tuberculosis epidemic in Western Sydney: a descriptive epidemiological study
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Sophie Norton, Shopna K. Bag, Jin-Gun Cho, Neil Heron, Hassan Assareh, Laila Pavaresh, Stephen Corbett, and Ben J. Marais
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Medicine - Abstract
Traditional tuberculosis (TB) epidemiology reports rarely provide a detailed analysis of TB incidence in particular geographic locations and among diverse population groups. Western Sydney Local Health District (WSLHD) has one of the highest TB incidence rates in Australia, and we explored whether more detailed epidemiological analysis could provide a better overview of the local disease dynamics. Using multiple relevant data sources, we performed a retrospective descriptive study of TB cases diagnosed within the WSLHD from 2006 to 2015 with a specific focus on geographic hotspots and the population structure within these hotspots. Over the study period nearly 90% of Western Sydney TB cases were born in a high TB incidence country. The TB disease burden was geographically concentrated in particular areas, with variable ethnic profiles in these different hotspots. The most common countries of birth were India (33.0%), the Philippines (11.4%) and China (8.8%). Among the local government areas in Western Sydney, Auburn had the highest average TB incidence (29.4 per 100 000) with exceptionally high population-specific TB incidence rates among people born in Nepal (average 223 per 100 000 population), Afghanistan (average 154 per 100 000 population) and India (average 143 per 100 000 population). Similar to other highly cosmopolitan cities around the world, the TB burden in Sydney showed strong geographic concentration. Detailed analysis of TB patient and population profiles in Western Sydney should guide better contextualised and culturally appropriate public health strategies.
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- 2019
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35. Multidrug-resistant tuberculosis infection and disease in children: a review of new and repurposed drugs
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Julie Huynh and Ben J. Marais
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Infectious and parasitic diseases ,RC109-216 - Abstract
The World Health Organization estimates that 10 million new cases of tuberculosis (TB) occurred worldwide in 2017, of which 600,000 were rifampicin or multidrug-resistant (RR/MDR) TB. Modelling estimates suggest that 32,000 new cases of MDR-TB occur in children annually, but only a fraction of these are correctly diagnosed and treated. Accurately diagnosing TB in children, who usually have paucibacillary disease, and implementing effective TB prevention and treatment programmes in resource-limited settings remain major challenges. In light of the underappreciated RR/MDR-TB burden in children, and the lack of paediatric data on newer drugs for TB prevention and treatment, we present an overview of new and repurposed TB drugs, describing the available evidence for safety and efficacy in children to assist clinical care and decision-making.
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- 2019
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36. The Implementation of Mass-Vaccination against SARS-CoV-2: A Systematic Review of Existing Strategies and Guidelines
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Tasnim Hasan, Justin Beardsley, Ben J. Marais, Thu Anh Nguyen, and Greg J. Fox
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covid ,vaccination ,national policy data ,implementation ,Medicine - Abstract
The global drive to vaccinate against severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) began in December 2020 with countries in Europe, Middle East, and North America leading the roll out of a mass-vaccination program. This systematic review synthesised all available English-language guidelines and research regarding mass-vaccination for COVID-19 until 1 March 2021—the first three months of the global mass-vaccination effort. Data were extracted from national websites, PubMed, Embase, Medline and medRxiv, including peer and non-peer review research findings. A total of 15 national policy documents were included. Policies were summarised according to the World Health Organisation (WHO) framework for mass vaccination. All included policies prioritised front-line health care workers and the elderly. Limited information was available regarding staffing, cold chain, communication strategies and infrastructure requirements for effective vaccine delivery. A total of 26 research studies were identified, reporting roll-out strategies, vaccine uptake and reasons for refusal, adverse effects, and real-life estimates of efficacy. Early data showed a reduction in SARS-CoV-2 cases, hospitalisation and deaths in settings with good coverage. Very low rates of vaccine-related serious adverse events were observed. These findings provide an overview of current practice and early outcomes of COVID-19 mass-vaccination, guiding countries where roll-out is yet to commence.
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- 2021
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37. Multidrug-Resistant Tuberculosis in Patients for Whom First-Line Treatment Failed, Mongolia, 2010–2011
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Claudia C. Dobler, Sarah Korver, Ochirbat Batbayar, Batiargal Nyamdulam, Sodnomdarjaa Oyuntsetseg, Bold Tsolmon, Bazarragchaa Surmaajav, Byambaa Bayarjargal, and Ben J. Marais
- Subjects
tuberculosis ,multidrug-resistant tuberculosis ,treatment failure ,category I treatment ,drug susceptibility testing ,new sputum smear-positive patients ,Medicine ,Infectious and parasitic diseases ,RC109-216 - Abstract
In Ulaanbaatar, Mongolia, multidrug-resistant tuberculosis (MDR TB) was diagnosed for more than a third of new sputum smear–positive tuberculosis patients for whom treatment had failed. This finding suggests a significant risk for community-acquired MDR TB and a need to make rapid molecular drug susceptibility testing available to more people.
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- 2015
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38. Tuberculosis and chronic respiratory disease: a systematic review
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Anthony L. Byrne, Ben J. Marais, Carole D. Mitnick, Leonid Lecca, and Guy B. Marks
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Tuberculosis ,Chronic Respiratory Disease ,Chronic Obstructive Pulmonary Disease ,Bronchiectasis ,Systematic Review ,Infectious and parasitic diseases ,RC109-216 - Abstract
Background: Chronic respiratory disease causes substantial global morbidity and mortality. The contribution of pulmonary tuberculosis to the aetiology of chronic respiratory disease is rarely considered, but may be important in tuberculosis-endemic areas. Methods: We performed a systematic literature review to assess the association between a history of tuberculosis and the presence of chronic obstructive pulmonary disease (COPD) or chronic suppurative lung disease (bronchiectasis). Study quality was evaluated using the National Heart Lung and Blood Institute quality assessment tool. Meta-analysis was performed using the DerSimonian and Laird random effects model. Results: We identified 9 eligible studies for COPD and 2 for bronchiectasis. Overall, there was a significant association between a history of tuberculosis and the presence of COPD in adults aged over 40 years (pooled odds ratio 3.05 (95% confidence interval 2.42, 3.85). Among individual COPD studies the strongest associations were found in countries with a high incidence of tuberculosis, as well as among never smokers and younger people. Conclusion: In tuberculosis endemic areas, tuberculosis is strongly associated with the presence of chronic respiratory disease in adults. Efforts to improve long-term lung health should be part of tuberculosis care.
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- 2015
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39. Why healthcare workers are sick of TB
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Arne von Delft, Angela Dramowski, Celso Khosa, Koot Kotze, Philip Lederer, Thato Mosidi, Jurgens A. Peters, Jonathan Smith, Helene-Mari van der Westhuizen, Dalene von Delft, Bart Willems, Matthew Bates, Gill Craig, Markus Maeurer, Ben J. Marais, Peter Mwaba, Elizabete A. Nunes, Thomas Nyirenda, Matt Oliver, and Alimuddin Zumla
- Subjects
Tuberculosis (TB) ,Multidrug- & Extensively Drug-Resistant TB (MDR-TB & XDR-TB) ,Healthcare worker (occupational) ,Infection control ,Prevention ,Stigma ,Infectious and parasitic diseases ,RC109-216 - Abstract
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.
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- 2015
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40. Chronic airflow obstruction after successful treatment of multidrug-resistant tuberculosis
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Anthony L. Byrne, Ben J. Marais, Carole D. Mitnick, Frances L. Garden, Leonid Lecca, Carmen Contreras, Yaninna Yauri, Fanny Garcia, and Guy B. Marks
- Subjects
Medicine - Abstract
Cross-sectional studies reveal an association between tuberculosis (TB) and chronic airflow obstruction, but cannot adequately address confounding. We hypothesised that treated pulmonary TB is an independent risk factor for chronic airflow obstruction. The Pulmones Post TB cohort study enrolled participants from Lima, Peru, aged 10–70 years with a history of drug-susceptible (DS)- or multidrug-resistant (MDR)-TB who had completed treatment and were clinically cured. Unexposed participants without TB were randomly selected from the same districts. We assessed respiratory symptoms, relevant environmental exposures, and spirometric lung function pre- and post-bronchodilator. In total, 144 participants with DS-TB, 33 with MDR-TB and 161 unexposed participants were fully evaluated. Compared with unexposed participants, MDR-TB patients had lower lung volumes (adjusted mean difference in forced vital capacity −370 mL, 95% CI −644– −97) and post-bronchodilator airflow obstruction (adjusted OR 4.89, 95% CI 1.27–18.78). Participants who had recovered from DS-TB did not have lower lung volumes than unexposed participants, but were more likely to have a reduced forced expiratory volume in 1 s/forced vital capacity ratio
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- 2017
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41. Tuberculosis among older adults – time to take notice
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Joel Negin, Seye Abimbola, and Ben J. Marais
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Tuberculosis ,older adults ,Infectious and parasitic diseases ,RC109-216 - Abstract
Knowledge that older people are vulnerable to develop tuberculosis is rarely considered in developing country settings. According to 2010 Global Burden of Disease estimates, the majority of tuberculosis-related deaths occurred among people older than 50; most in those aged 65 and above. Older people also contribute a large proportion of Disability-Adjusted Life Years (DALYs); 51% of tuberculosis DALYs occurred in patients aged 50 years and older in East Asia. Tuberculosis age distributions in Africa have been severely skewed by the human immunodeficiency virus (HIV) epidemic, but emerging data suggest increasing disease burdens among older people. Older adults are more likely to develop extra-pulmonary and atypical forms of disease that are often harder to diagnose than conventional sputum smear-positive pulmonary tuberculosis. Their care is complicated by more frequent drug-related adverse events and increased co-morbidity, which may prove difficult to manage in regions where health resources are already constrained. Health systems will have to confront the challenge of an ageing global population and the integrated services required to address their health needs.
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- 2015
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42. Response to: Socio-political prescriptions for latent tuberculosis infection are required to prevent reactivation of tuberculosis
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Greg J. Fox, Claudia C. Dobler, Ben J. Marais, and Justin T. Denholm
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Latent tuberculosis infection ,Tuberculosis ,Prevention ,Therapy ,Infectious and parasitic diseases ,RC109-216 - Abstract
The importance of addressing the conditions that predispose individuals and populations to develop tuberculosis is increasingly being recognized. Accurate quantification of the protective effect of preventive therapy and the provision of pragmatic guidance for clinical care and public health interventions is important. However, this approach must be nested within a socio-political context that addresses associated disadvantage and inequality.
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- 2017
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43. Immune Vulnerability of Infants to Tuberculosis
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Koen Vanden Driessche, Alexander Persson, Ben J. Marais, Pamela J. Fink, and Kevin B. Urdahl
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Immunologic diseases. Allergy ,RC581-607 - Abstract
One of the challenges faced by the infant immune system is learning to distinguish the myriad of foreign but nonthreatening antigens encountered from those expressed by true pathogens. This balance is reflected in the diminished production of proinflammatory cytokines by both innate and adaptive immune cells in the infant. A downside of this bias is that several factors critical for controlling Mycobacterium tuberculosis infection are significantly restricted in infants, including TNF, IL-1, and IL-12. Furthermore, infant T cells are inherently less capable of differentiating into IFN-γ-producing T cells. As a result, infected infants are 5–10 times more likely than adults to develop active tuberculosis (TB) and have higher rates of severe disseminated disease, including miliary TB and meningitis. Infant TB is a fundamentally different disease than TB in immune competent adults. Immunotherapeutics, therefore, should be specifically evaluated in infants before they are routinely employed to treat TB in this age group. Modalities aimed at reducing inflammation, which may be beneficial for adjunctive therapy of some forms of TB in older children and adults, may be of no benefit or even harmful in infants who manifest much less inflammatory disease.
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- 2013
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44. Genomic markers of drug resistance inMycobacterium tuberculosispopulations with minority variants
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Xiaomei Zhang, Connie Lam, Elena Martinez, Eby Sim, Taryn Crighton, Ben J Marais, and Vitali Sintchenko
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Minority variants ofMycobacterium tuberculosisharbouring mutations conferring resistance can become dominant populations during tuberculosis (TB) treatment, leading to treatment failure. Our understanding of drug resistant within-host sub-populations and the frequency of resistance conferring mutations in minority variants remains limited.M. tuberculosissequences recovered from liquid cultures of culture-confirmed TB cases notified between January 2017 and December 2021 in New South Wales, Australia were examined. Potential drug resistance conferring minority variants were identified using LoFreq, and mixed populations of differentM. tuberculosisstrains (≥100 SNPs apart) were examined using QuantTB.A total of 1831 routinely sequencedM. tuberculosisstrains were included in the analysis. Drug resistance conferring minority variants were detected in 3.5% (65/1831) of sequenced cultures; 84.6% (55/65) had majority strains that were drug susceptible and 15.4% (10/65) had majority strains that were drug resistant. Minority variants with high confidence drug resistance conferring mutations were 1.5 times more common when the majority strains were drug resistant. MixedM. tuberculosisstrain populations were documented in 10.0% (183/1831) of specimens. Minority variants with high confidence drug resistance conferring mutations were more frequently detected in mixedM. tuberculosisstrain populations (2.7%, 5/183) than in single strain populations (0.6%, 10/1648; p=0.01).Drug resistant minority variants require careful monitoring in settings that implement routineM. tuberculosissequencing. The frequency with which drug resistant minority variants are detected is influenced by selective culture methods and culture-independent sequencing should provide a more accurate picture.
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- 2023
45. Evolving role of chest radiographs for diagnosis of pediatric pulmonary tuberculosis
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Monica Miranda-Schaeubinger, Shyam Sunder B. Venkatakrishna, Hansel J. Otero, Ben J. Marais, Pierre Goussard, Lisa J. Frigati, Heather J. Zar, and Savvas Andronikou
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Pediatrics, Perinatology and Child Health ,Radiology, Nuclear Medicine and imaging - Published
- 2023
46. Mortality and Cause of Death in Children With Presumptive Disseminated Tuberculosis
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Maryline Bonnet, Anne-Christine Nordholm, Bob Ssekyanzi, Onesmus Byamukama, Patrick Orikiriza, Tobias Tusabe, Dan Nyehangane, Ivan Mugisha Taremwa, Esther Turyashemererwa, Eric Wobudeya, Juliet Mwanga-Amumpaire, Ben J Marais, and Dorah Nampijja
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Pediatrics, Perinatology and Child Health - Abstract
BACKGROUND AND OBJECTIVES Children experience high tuberculosis (TB)-related mortality but causes of death among those with presumptive TB are poorly documented. We describe the mortality, likely causes of death, and associated risk factors among vulnerable children admitted with presumptive TB in rural Uganda. METHODS We conducted a prospective study of vulnerable children, defined as RESULTS Of the 219 children included, 157 (71.7%) were CONCLUSIONS Vulnerable children hospitalized with presumptive TB experienced high mortality. A better understanding of the likely causes of death in this group is important to guide empirical management.
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- 2023
47. Caring for Adolescents and Young Adults with Tuberculosis or at Risk of Tuberculosis: Consensus Statement from an International Expert Panel
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Silvia S. Chiang, Patricia M. Waterous, Vivian Faith Atieno, Sarah Bernays, Yaroslava Bondarenko, Andrea T. Cruz, Márcia C.B. de Oliveira, Hernán Del Castillo Barrientos, Anthony Enimil, Gabriella Ferlazzo, Rashida Abbas Ferrand, Jennifer Furin, Graeme Hoddinott, Petros Isaakidis, Katharina Kranzer, Elizabeth Maleche-Obimbo, Homa Mansoor, Ben J. Marais, Erika Mohr-Holland, Mabel Morales, Anh Phuong Nguyen, Joshua Ochieng Oliyo, Clemax Couto Sant’Anna, Susan M. Sawyer, H. Simon Schaaf, James A. Seddon, Sangeeta Sharma, Alena Skrahina, Jeffrey R. Starke, Rina Triasih, Bazarragchaa Tsogt, Henry Welch, and Leslie A. Enane
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Psychiatry and Mental health ,Pediatrics, Perinatology and Child Health ,Public Health, Environmental and Occupational Health ,Article - Abstract
BACKGROUND: Despite being a preventable and treatable disease, tuberculosis (TB) is a leading cause of death among young people globally. Each year, an estimated 1.8 million adolescents and young adults (AYAs; 10–24 years old) develop TB. In 2019, an estimated 161,000 AYAs died of the disease. AYAs have unique developmental, psychosocial, and healthcare needs, but these needs have been neglected in both TB care and research agendas. In order to improve outcomes in this age group, the specific needs of AYAs must be considered and addressed. METHODS: Through a consensus process, an international panel of 34 clinicians, researchers, TB survivors, and advocates with expertise in child/adolescent TB and/or adolescent health proposed interventions for optimizing AYA engagement in TB care. The process consisted of reviewing the literature on TB in AYAs; identifying and discussing priority areas; and drafting and revising proposed interventions until consensus, defined a priori, was reached. RESULTS: The panel acknowledged the dearth of evidence on best practices for identifying and managing AYAs with TB. The final consensus statement, based on expert opinion, proposes nine interventions to reform current practices that may harm AYA health and well-being, and nine interventions to establish high-quality AYA-centered TB services. CONCLUSION: AYA-specific interventions for TB care and research are critical for improving outcomes in this age group. In the absence of evidence on best practices, this consensus statement from an international group of experts can help address the needs of AYA with TB or at risk for TB.
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- 2023
48. The use of whole genome sequencing for tuberculosis public health activities in Australia: a joint statement of the National Tuberculosis Advisory Committee and Communicable Diseases Genomics Network
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Ellen J Donnan, Ben J Marais, Chris Coulter, Justin Waring, Ivan Bastian, Deborah A Williamson, Norelle L Sherry, Katherine Bond, Vitali Sintchenko, Ella M Meumann, Kristy Horan, Louise Cooley, and Justin T Denholm
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General Medicine - Published
- 2023
49. The Value of Chest Radiography in Tuberculosis Preventive Treatment Screening in Children and Adolescents
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Ben J. Marais and Stephen M. Graham
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Radiography ,Pulmonary and Respiratory Medicine ,Adolescent ,Humans ,Mass Screening ,Tuberculosis ,Child ,Critical Care and Intensive Care Medicine - Published
- 2022
50. Development and validation of treatment-decision algorithms for children evaluated for pulmonary tuberculosis: an individual participant data meta-analysis
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Kenneth S Gunasekera, Olivier Marcy, Johanna Muñoz, Elisa Lopez-Varela, Moorine P Sekadde, Molly F Franke, Maryline Bonnet, Shakil Ahmed, Farhana Amanullah, Aliya Anwar, Orvalho Augusto, Rafaela Baroni Aurilio, Sayera Banu, Iraj Batool, Annemieke Brands, Kevin P Cain, Lucía Carratalá-Castro, Maxine Caws, Eleanor S Click, Lisa M Cranmer, Alberto L García-Basteiro, Anneke C Hesseling, Julie Huynh, Senjuti Kabir, Leonid Lecca, Anna Mandalakas, Farai Mavhunga, Aye Aye Myint, Kyaw Myo, Dorah Nampijja, Mark P Nicol, Patrick Orikiriza, Megan Palmer, Clemax Couto Sant'Anna, Sara Ahmed Siddiqui, Jonathan P Smith, Rinn Song, Nguyen Thuy Thuong Thuong, Vibol Ung, Marieke M van der Zalm, Sabine Verkuijl, Kerri Viney, Elisabetta G Walters, Joshua L Warren, Heather J Zar, Ben J Marais, Stephen M Graham, Thomas P A Debray, Ted Cohen, James A Seddon, Bordeaux population health (BPH), Université de Bordeaux (UB)-Institut de Santé Publique, d'Épidémiologie et de Développement (ISPED)-Institut National de la Santé et de la Recherche Médicale (INSERM), Global Health in the Global South (GHiGS), Institut de Recherche pour le Développement (IRD)- Bordeaux population health (BPH), and Université de Bordeaux (UB)-Institut de Santé Publique, d'Épidémiologie et de Développement (ISPED)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Bordeaux (UB)-Institut de Santé Publique, d'Épidémiologie et de Développement (ISPED)-Institut National de la Santé et de la Recherche Médicale (INSERM)
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Pediatrics, Perinatology and Child Health ,Developmental and Educational Psychology ,[SDV.SPEE]Life Sciences [q-bio]/Santé publique et épidémiologie - Abstract
BACKGROUND: Many children with pulmonary tuberculosis remain undiagnosed and untreated with related high morbidity and mortality. Recent advances in childhood tuberculosis algorithm development have incorporated prediction modelling, but studies so far have been small and localised, with limited generalisability. We aimed to evaluate the performance of currently used diagnostic algorithms and to use prediction modelling to develop evidence-based algorithms to assist in tuberculosis treatment decision making for children presenting to primary health-care centres. METHODS: For this meta-analysis, we identified individual participant data from a WHO public call for data on the management of tuberculosis in children and adolescents and referral from childhood tuberculosis experts. We included studies that prospectively recruited consecutive participants younger than 10 years attending health-care centres in countries with a high tuberculosis incidence for clinical evaluation of pulmonary tuberculosis. We collated individual participant data including clinical, bacteriological, and radiological information and a standardised reference classification of pulmonary tuberculosis. Using this dataset, we first retrospectively evaluated the performance of several existing treatment-decision algorithms. We then used the data to develop two multivariable prediction models that included features used in clinical evaluation of pulmonary tuberculosis-one with chest x-ray features and one without-and we investigated each model's generalisability using internal-external cross-validation. The parameter coefficient estimates of the two models were scaled into two scoring systems to classify tuberculosis with a prespecified sensitivity target. The two scoring systems were used to develop two pragmatic, treatment-decision algorithms for use in primary health-care settings. FINDINGS: Of 4718 children from 13 studies from 12 countries, 1811 (38·4%) were classified as having pulmonary tuberculosis: 541 (29·9%) bacteriologically confirmed and 1270 (70·1%) unconfirmed. Existing treatment-decision algorithms had highly variable diagnostic performance. The scoring system derived from the prediction model that included clinical features and features from chest x-ray had a combined sensitivity of 0·86 [95% CI 0·68-0·94] and specificity of 0·37 [0·15-0·66] against a composite reference standard. The scoring system derived from the model that included only clinical features had a combined sensitivity of 0·84 [95% CI 0·66-0·93] and specificity of 0·30 [0·13-0·56] against a composite reference standard. The scoring system from each model was placed after triage steps, including assessment of illness acuity and risk of poor tuberculosis-related outcomes, to develop treatment-decision algorithms. INTERPRETATION: We adopted an evidence-based approach to develop pragmatic algorithms to guide tuberculosis treatment decisions in children, irrespective of the resources locally available. This approach will empower health workers in primary health-care settings with high tuberculosis incidence and limited resources to initiate tuberculosis treatment in children to improve access to care and reduce tuberculosis-related mortality. These algorithms have been included in the operational handbook accompanying the latest WHO guidelines on the management of tuberculosis in children and adolescents. Future prospective evaluation of algorithms, including those developed in this work, is necessary to investigate clinical performance. FUNDING: WHO, US National Institutes of Health.
- Published
- 2023
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