High Prevalence of Pulmonary Tuberculosis but Low Sensitivity of Symptom Screening among HIV-Infected Pregnant Women in South Africa

Hoffmann, Christopher J.; Variava, Ebrahim; Rakgokong, Modiehi; Masonoke, Katlego; Watt, Martin van der; Chaisson, Richard E.; Martinson, Neil

doi:10.1371/journal.pone.0062211

Cited by 70 publications

(83 citation statements)

References 24 publications

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“…7,9,10,12,[19][20][21][22][23][24][25][26][27][28][29][30][31] Variation between countries is marked and predates the HIV epidemic. 1,32,33 Lengthy delays in diagnosis and missed diagnosis are still reported by many HIV-positive and HIV-negative TB patients, despite major investment in strengthening health systems and TB services during the last decade.…”

Section: Epidemiology Of Undiagnosed Tuberculosis Diseasementioning

confidence: 99%

Tuberculosis screening in high human immunodeficiency virus prevalence settings: turning promise into reality [State of the art series. Active case finding/screening. Number 5 in the series]

Corbett

MacPherson²

2013

int j tuberc lung dis

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SUMMARYTwenty years of sky-high tuberculosis (TB) incidence rates and high TB mortality in high human immunodeficiency virus (HIV) prevalence countries have so far not been matched by the same magnitude or breadth of responses as seen in malaria or HIV programmes. Instead, recommendations have been narrowly focused on people presenting to health facilities for investigation of TB symptoms, or for HIV testing and care. However, despite the recent major investment and scale-up of TB and HIV services, undiagnosed TB remains highly prevalent at community level, implying that diagnosis of TB remains slow and incomplete. This maintains high transmission rates and exposes people living with HIV to high rates of morbidity and mortality.More intensive use of TB screening, with broader definitions of target populations, expanded indications for screening both inside and outside of health facilities, and appropriate selection of new diagnostic tools, offers the prospect of rapidly improving population-level control of TB. Diagnostic accuracy of suitable (high throughput) algorithms remains the major barrier to realising this goal.In the present study, we review the evidence available to guide expanded TB screening in HIVprevalent settings, ideally through combined TB-HIV interventions that provide screening for both TB and HIV, and maximise entry to HIV and TB care and prevention. Ideally, we would systematically test, treat and prevent TB and HIV comprehensively, offering both TB and HIV screening to all health facility attendees, TB households and all adults in the highest risk communities. However, we are still held back by inadequate diagnostics, financing and paucity of population-impact data. Relevant contemporary research showing the high need for potential gains, and pitfalls from expanded and intensified TB screening in high HIV prevalence settings are discussed in this review. In high human immunodeficiency virus (HIV) prevalence settings, population-level tuberculosis (TB) incidence increased in parallel with adult HIV prevalence in the 1990s and remains extremely high, with over 1% of adults diagnosed with TB each year in many Southern African towns. 1 Outbreaks of multi-and extensively drug-resistant TB (XDR-TB) have been generated in HIV care clinics, and then spread into general communities. 2,3 Autopsy studies show that TB is the single biggest killer of people living with HIV (PLHIV), being the cause in 32% to 45% of HIV-related deaths 4 and with a high proportion of fatal cases undiagnosed in life. 4,5 Of the estimated 430 000 TB-related deaths among PLHIV during 2011, 79% were in Africa. These stark facts demonstrate the urgent need to strengthen TB prevention and care services using all available approaches, including more ambitious TB screening strategies.TB screening is the first step in both anti-tuberculosis treatment and TB prevention pathways, and has an integral place in routine HIV care and infection control. Key potential entry points for TB screening are illustrated in Figure 1. TB screening c...

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Section: Epidemiology Of Undiagnosed Tuberculosis Diseasementioning

confidence: 99%

Tuberculosis screening in high human immunodeficiency virus prevalence settings: turning promise into reality [State of the art series. Active case finding/screening. Number 5 in the series]

Corbett

MacPherson²

2013

int j tuberc lung dis

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“…In a study in South Africa that documented a high prevalence of TB among HIV-infected women (47/1415, 3.3%), the majority (73%) did not report any TB symptoms. 23 2) Symptoms may be attenuated in people living with HIV, often yielding negative results on smear microscopy. 24 Participants in this study who were treated for TB had a lower CD4 count than those who were not treated for TB (256 cells/μl, IQR 106-302 vs. 377 cells/μl, IQR 244-530).…”

Section: Public Health Action Screening For Tb In Pregnancy 297mentioning

confidence: 99%

“…3) Physiological changes associated with pregnancy may mask the symptoms of TB. 23 4) There may a low prevalence of TB in pregnancy-this is less plausible considering TB is a major cause of non-obstetrical maternal deaths. 3 5) A combination of all of the above.…”

Section: Public Health Action Screening For Tb In Pregnancy 297mentioning

confidence: 99%

Screening for tuberculosis in pregnancy: do we need more than a symptom screen? Experience from western Kenya

Kosgei¹,

Szkwarko²,

Callens³

et al. 2013

public health action

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underdiagnosis of active TB disease during the antenatal and postnatal periods. HIV and TB co-infection during pregnancy have a multiplier effect on maternal morbidity and mortality, and result in poorer pregnancy outcomes. 1,11 In Pune, India, TB increased the probability of death by 2.2-fold among HIV-infected women who developed TB and by 3.4-fold for their infants compared to women who did not develop TB. 11 In Johannesburg, South Africa, 70% of obstetric deaths in HIV-infected women were mainly attributed to TB. 12 These fi gures suggest that routine screening of pregnant women for TB in endemic settings would be helpful, particularly those who are HIV-infected.The World Health Organization (WHO) recommends ruling out active TB and identifying those in need of further testing among HIV-infected adults using specifi c symptoms (current cough of any duration, fever, weight loss or night sweats). 13 Although these recommendations were not specifi c for pregnancy, Gupta et al. used this recommendation and found a 1.4% (11/799) prevalence of active TB among HIVi nfected pregnant women who were part of a clinical trial in India. 14 Another study of cough of >2 weeks, performed in Kenya by the same clinical team and by the same fi rst author in a routine setting similar to the target population for this study, failed to identify those with TB disease (n = 187). 15 The current study differs from the earlier one in its larger sample size and because it compares HIV-infected and non-infected pregnant women.Data on the utilization of symptom screening among pregnant women in routine settings are scarce. This has been attributed to signifi cant fi nancial and logistical challenges in the implementation of screening in this group of patients. 1 The objectives of the present study were 1) to explore the utility of TB symptom screening using symptoms of ⩾2 weeks' duration in a routine setting, and 2) to compare differences in diagnosis of TB among HIV-infected and non-infected pregnant women in western Kenya. METHODS Study designThis was a descriptive cohort study among HIV-infected and non-infected pregnant women. R eduction of tuberculosis (TB) transmission, morbidity and mortality relies largely on intensifi ed case fi nding, with consequent early initiation of adequate treatment. 1,2 This is particularly important among pregnant women in resource-limited settings where TB is a cause of non-obstetrical (indirect) maternal deaths. 3,4 This burden is higher in settings with a high prevalence of human immunodefi ciency virus (HIV) infection. 5,6 Kenya has an adult HIV prevalence of 6.2%, 7 with an unacceptably high maternal mortality ratio of 488 per 100 000 live births; 25% of these deaths are attributed to indirect causes such as TB, anaemia, HIV and malaria. 8 TB case notifi cation data are not stratifi ed for pregnancy, but women of reproductive age bear a higher burden of TB in sub-Saharan Africa than their male counterparts. 1,9 Data from Western Cape, South Africa, indicate that there is a 24.2-fold higher incidenc...

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“…Pregnant women with HIV infection are at especially high risk of progression from latent TB infection (LTBI) to TB disease, and immunologic changes related to pregnancy may enhance the risk (10,11). In addition, TB is a significant cause of infant and maternal morbidity and mortality, especially in settings where the HIV incidence is high (12,13).…”

mentioning

confidence: 99%

Population Pharmacokinetics of Rifampin in Pregnant Women with Tuberculosis and HIV Coinfection in Soweto, South Africa

Denti

Martinson

Cohn

et al. 2016

Antimicrob Agents Chemother

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Effective treatment of tuberculosis during pregnancy is essential for preventing maternal and fetal mortality, but little is known about the effects of pregnancy on the disposition of antituberculosis drugs. We explored the effects of pregnancy on the pharmacokinetics of rifampin, the key sterilizing drug in tuberculosis treatment, in Tshepiso, a prospective cohort study involving pregnant HIV-infected women with or without tuberculosis in Soweto, South Africa. Participants receiving standard first-line tuberculosis treatment underwent sparse sampling for rifampin at 37 weeks' gestation or delivery and then postpartum. Cord blood was collected when possible. A population pharmacokinetic model was developed to investigate the effects of pregnancy on rifampin pharmacokinetics. Among the 48 participants, median age and weight were 28 years and 67 kg, respectively. A one-compartment model with first-order elimination, transit compartment absorption, and allometric scaling described the data well.

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High Prevalence of Pulmonary Tuberculosis but Low Sensitivity of Symptom Screening among HIV-Infected Pregnant Women in South Africa

Cited by 70 publications

References 24 publications

Tuberculosis screening in high human immunodeficiency virus prevalence settings: turning promise into reality [State of the art series. Active case finding/screening. Number 5 in the series]

Tuberculosis screening in high human immunodeficiency virus prevalence settings: turning promise into reality [State of the art series. Active case finding/screening. Number 5 in the series]

Screening for tuberculosis in pregnancy: do we need more than a symptom screen? Experience from western Kenya

Population Pharmacokinetics of Rifampin in Pregnant Women with Tuberculosis and HIV Coinfection in Soweto, South Africa

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