tuberculosis screening among ambulatory people living with hiv a systematic review CORD-Papers-2022-06-02 (Version 1)
| Title: | Tuberculosis screening among ambulatory people living with HIV: a systematic review and individual participant data meta-analysis |
|---|---|
| Abstract: | BACKGROUND: The WHO-recommended tuberculosis screening and diagnostic algorithm in ambulatory people living with HIV is a four-symptom screen (known as the WHO-recommended four symptom screen [W4SS]) followed by a WHO-recommended molecular rapid diagnostic test (eg Xpert MTB/RIF [hereafter referred to as Xpert]) if W4SS is positive. To inform updated WHO guidelines we aimed to assess the diagnostic accuracy of alternative screening tests and strategies for tuberculosis in this population. METHODS: In this systematic review and individual participant data meta-analysis we updated a search of PubMed (MEDLINE) Embase the Cochrane Library and conference abstracts for publications from Jan 1 2011 to March 12 2018 done in a previous systematic review to include the period up to Aug 2 2019. We screened the reference lists of identified pieces and contacted experts in the field. We included prospective cross-sectional observational studies and randomised trials among adult and adolescent (age 10 years) ambulatory people living with HIV irrespective of signs and symptoms of tuberculosis. We extracted study-level data using a standardised data extraction form and we requested individual participant data from study authors. We aimed to compare the W4SS with alternative screening tests and strategies and the WHO-recommended algorithm (ie W4SS followed by Xpert) with Xpert for all in terms of diagnostic accuracy (sensitivity and specificity) overall and in key subgroups (eg by antiretroviral therapy [ART] status). The reference standard was culture. This study is registered with PROSPERO CRD42020155895. FINDINGS: We identified 25 studies and obtained data from 22 studies (including 15 666 participants; 4347 [277%] of 15 663 participants with data were on ART). W4SS sensitivity was 82% (95% CI 72-89) and specificity was 42% (29-57). C-reactive protein (10 mg/L) had similar sensitivity to (77% [61-88]) but higher specificity (74% [61-83]; n=3571) than W4SS. Cough (lasting 2 weeks) haemoglobin (<10 g/dL) body-mass index (<185 kg/m2) and lymphadenopathy had high specificities (80-90%) but low sensitivities (29-43%). The WHO-recommended algorithm had a sensitivity of 58% (50-66) and a specificity of 99% (98-100); Xpert for all had a sensitivity of 68% (57-76) and a specificity of 99% (98-99). In the one study that assessed both the sensitivity of sputum Xpert Ultra was higher than sputum Xpert (73% [62-81] vs 57% [47-67]) and specificities were similar (98% [96-98] vs 99% [98-100]). Among outpatients on ART (4309 [991%] of 4347 people on ART) W4SS sensitivity was 53% (35-71) and specificity was 71% (51-85). In this population a parallel strategy (two tests done at the same time) of W4SS with any chest x-ray abnormality had higher sensitivity (89% [70-97]) and lower specificity (33% [17-54]; n=2670) than W4SS alone; at a tuberculosis prevalence of 5% this strategy would require 379 more rapid diagnostic tests per 1000 people living with HIV than W4SS but detect 18 more tuberculosis cases. Among outpatients not on ART (11 160 [718%] of 15 541 outpatients) W4SS sensitivity was 85% (76-91) and specificity was 37% (25-51). C-reactive protein (10 mg/L) alone had a similar sensitivity to (83% [79-86]) but higher specificity (67% [60-73]; n=3187) than W4SS and a sequential strategy (both test positive) of W4SS then C-reactive protein (5 mg/L) had a similar sensitivity to (84% [75-90]) but higher specificity than (64% [57-71]; n=3187) W4SS alone; at 10% tuberculosis prevalence these strategies would require 272 and 244 fewer rapid diagnostic tests per 1000 people living with HIV than W4SS but miss two and one more tuberculosis cases respectively. INTERPRETATION: C-reactive protein reduces the need for further rapid diagnostic tests without compromising sensitivity and has been included in the updated WHO tuberculosis screening guidelines. However C-reactive protein data were scarce for outpatients on ART necessitating future research regarding the utility of C-reactive protein in this group. Chest x-ray can be useful in outpatients on ART when combined with W4SS. The WHO-recommended algorithm has suboptimal sensitivity; Xpert for all offers slight sensitivity gains and would have major resource implications. FUNDING: World Health Organization. |
| Published: | 2022 |
| Journal: | Lancet Infect Dis |
| DOI: | 10.1016/s1473-3099(21)00387-x |
| DOI_URL: | http://doi.org/10.1016/s1473-3099(21)00387-x |
| Author Name: | Dhana Ashar |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/dhana_ashar |
| Author Name: | Hamada Yohhei |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/hamada_yohhei |
| Author Name: | Kengne Andre P |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/kengne_andre_p |
| Author Name: | Kerkhoff Andrew D |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/kerkhoff_andrew_d |
| Author Name: | Rangaka Molebogeng X |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/rangaka_molebogeng_x |
| Author Name: | Kredo Tamara |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/kredo_tamara |
| Author Name: | Baddeley Annabel |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/baddeley_annabel |
| Author Name: | Miller Cecily |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/miller_cecily |
| Author Name: | Singh Satvinder |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/singh_satvinder |
| Author Name: | Hanifa Yasmeen |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/hanifa_yasmeen |
| Author Name: | Grant Alison D |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/grant_alison_d |
| Author Name: | Fielding Katherine |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/fielding_katherine |
| Author Name: | Affolabi Dissou |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/affolabi_dissou |
| Author Name: | Merle Corinne S |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/merle_corinne_s |
| Author Name: | Wachinou Ablo Prudence |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/wachinou_ablo_prudence |
| Author Name: | Yoon Christina |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/yoon_christina |
| Author Name: | Cattamanchi Adithya |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/cattamanchi_adithya |
| Author Name: | Hoffmann Christopher J |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/hoffmann_christopher_j |
| Author Name: | Martinson Neil |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/martinson_neil |
| Author Name: | Mbu Eyongetah Tabenyang |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/mbu_eyongetah_tabenyang |
| Author Name: | Sander Melissa S |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/sander_melissa_s |
| Author Name: | Balcha Taye T |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/balcha_taye_t |
| Author Name: | Skogmar Sten |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/skogmar_sten |
| Author Name: | Reeve Byron W P |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/reeve_byron_w_p |
| Author Name: | Theron Grant |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/theron_grant |
| Author Name: | Ndlangalavu Gcobisa |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/ndlangalavu_gcobisa |
| Author Name: | Modi Surbhi |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/modi_surbhi |
| Author Name: | Cavanaugh Joseph |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/cavanaugh_joseph |
| Author Name: | Swindells Susan |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/swindells_susan |
| Author Name: | Chaisson Richard E |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/chaisson_richard_e |
| Author Name: | Ahmad Khan Faiz |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/ahmad_khan_faiz |
| Author Name: | Howard Andrea A |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/howard_andrea_a |
| Author Name: | Wood Robin |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/wood_robin |
| Author Name: | Thit Swe Swe |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/thit_swe_swe |
| Author Name: | Kyi Mar Mar |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/kyi_mar_mar |
| Author Name: | Hanson Josh |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/hanson_josh |
| Author Name: | Drain Paul K |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/drain_paul_k |
| Author Name: | Shapiro Adrienne E |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/shapiro_adrienne_e |
| Author Name: | Kufa Tendesayi |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/kufa_tendesayi |
| Author Name: | Churchyard Gavin |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/churchyard_gavin |
| Author Name: | Nguyen Duc T |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/nguyen_duc_t |
| Author Name: | Graviss Edward A |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/graviss_edward_a |
| Author Name: | Bjerrum Stephanie |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/bjerrum_stephanie |
| Author Name: | Johansen Isik S |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/johansen_isik_s |
| Author Name: | Gersh Jill K |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/gersh_jill_k |
| Author Name: | Horne David J |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/horne_david_j |
| Author Name: | LaCourse Sylvia M |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/lacourse_sylvia_m |
| Author Name: | Al Darraji Haider Abdulrazzaq Abed |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/al_darraji_haider_abdulrazzaq_abed |
| Author Name: | Kamarulzaman Adeeba |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/kamarulzaman_adeeba |
| Author Name: | Kempker Russell R |
| Author link: | https://covid19-data.nist.gov/pid/rest/local/author/kempker_russell_r |
| license: | unk |
| license_url: | [unknown license] |
| source_x: | Medline; WHO |
| source_x_url: | https://www.medline.com/https://www.who.int/ |
| pubmed_id: | 34800394 |
| pubmed_id_url: | https://www.ncbi.nlm.nih.gov/pubmed/34800394 |
| who_covidence_id: | #covidwho-1839425 |
| url: | https://doi.org/10.1016/s1473-3099(21)00387-x https://www.ncbi.nlm.nih.gov/pubmed/34800394/ |
| has_full_text: | FALSE |
| G_ID: | tuberculosis_screening_among_ambulatory_people_living_with_hiv_a_systematic_review |
