Improved diagnosis of tuberculosis by antigen detection from sputum and extrapulmonary samples by immunochemistry-based assays
The main objective of the project is to improve the diagnosis of extrapulmonary tuberculosis by implementation of a novel diagnostic test in the routine laboratory in a resource-limited setting. The test was implemented at Mnazi Mmoja Hospital, Zanzibar, in July 2014, and patients were included for one year from August 2014. Diagnosing extrapulmonary tuberculosis (EPTB) is challenging. We have developed a new immunochemistry-based test for diagnosing EPTB. The test has previously been validated in several studies. The results from these studies show that the test could potentially improve the diagnosis of EPTB, and warrants the testing of the diagnostic accuracy and feasibility of implementation in a routine diagnostic setting. The main objective of this study was to evaluate if we could improve the diagnosis of EPTB by implementation and validation of the new test in routine diagnostics in a resource-limited setting. Further, to evaluate the feasibility of implementation. This is the first study to implement the new test in a routine diagnostic setting, and we have gained valuable knowledge which could facilitate implementation in other settings. We implemented the test at Mnazi Mmoja Hospital (MMH) in Zanzibar. The study had a cohort design and the patients were prospectively enrolled at MMH for 13 months from August 2014. The inclusion criterion was patients with presumptive EPTB identified using clinical diagnostic algorithms. Patients starting antituberculous therapy were followed until end of treatment and the last follow-up was in April 2016. A total of 132 patients have been included and the patients were categorized based on a composite reference standard as confirmed, probable or possible TB cases or not TB cases. The final diagnoses will be used to calculate the sensitivity and specificity of the new immunochemistry test. Further, we are evaluating the feasibility of implementation of a new laboratory-based diagnostic test in a resource-limited setting, and assessing facilitators and challenges to the implementation process. In this part of the study the PhD-fellow will use her experience and field notes during her time implementing the new test and working at MMH. In addition, local medical personnel working in the TB programme and different departments at MMH were interviewed. A total of 9 study participants have been interviewed in this part of the project At the time of inclusion patients were asked questions related to patient history, symptoms, diagnostic delay and socioeconomic status in a structured interview. Data from the interviews and medical records will be used to assess the health-seeking behaviour and diagnostic delay in EPTB at MMH, Zanzibar. Patients receiving EPTB as a final diagnosis in the cohort study are included in the data analysis of this study. Adult patients starting antituberculous therapy were asked to donate blood samples before, during and after treatment for the study of Interferon-gamma-inducible protein 10 (IP-10) as a biomarker for response to treatment in EPTB. Forty-two patients have been included in this study. Quantification of IP-10 in dried blood/plasma spots will be performed using an ELISA-based assay. We included patients with pulmonary TB form September 2014 till November 2016. Sputum samples were collected and will be used for development of a sensitive method for detection of mycobacterial antigens directly from sputum to improve and expedite the diagnosis of pulmonary TB. The PhD-fellow have spent altogether 16 months doing field work and data collection at MMH in Zanzibar. This included 14 months from July 2014 to September 2015, and several follow-up visits during 2016. All data to be analysed and included in the articles and PhD-thesis have been collected and manuscripts are in progress.
The overall aim of the project is to improve the diagnosis of extrapulmonary tuberculosis by implementation of a novel diagnostic test in the routine laboratory in a low-resource setting. The test was implemented at Mnazi Mmoja Hospital, Zanzibar, in July 2014, and patients have been included for one year from September 2014. I have been collecting data for my PhD-thesis at Mnazi Mmoja Hospital (MMH), Zanzibar, from July 2014 until September 2015. I will continue to travel to Zanzibar for shorter periods during my PhD-period, for follow-up of patients and further evaluation of the feasibility of the new diagnostic assay in the routine diagnostics at MMH. The routines and protocols for the implementation of the assay was established in the summer 2014, and after this there has been a continuous evaluation of what is working and what routines and protocols that should be changed. Technologists at the histopathology laboratory have continuously been trained and supervised, and are currently running the new assay independently as part of routine diagnostic activity. I have been supervising the technologist throughout and evaluated all the assay results together with the local pathologist. The inclusion of suspected extrapulmonary tuberculosis patients at MMH was continued for one year from September 2014, and a total of 132 patients have been included in this part of the study. My work with the patients included collection of relevant samples, investigations of the samples, collection and storage of biological material (biobank), as described in the project protocol, and follow-up of study participants during treatment. I have also collected sputum samples from pulmonary tuberculosis suspects and control groups, for development of a mycobacterial antigen detection assay directly in sputum samples. We are still including pulmonary tuberculosis suspects. All samples from the participants in the healthy control group have been collected. I have presented the study at two other local hospitals at Zanzibar, because the project got approval to include also from these hospitals in November 2014. I received educational visit from supervisor Dr Tehmina Mustafa and co-supervisor Dr Lisbet Sviland one week in June 2015. The time was spent doing quality assurance of the routine evaluation of the slides stained with immunochemistry, evaluation of the project and discussions regarding the new immunochemical assay in routine diagnostics after completion of the study. In addition, we visited Muhimbili University Hospital (Dar es Salaam), where I presented the study and study data, in the prospect of future collaboration. I had a poster presentation at The World Conference on Lung Health in December, and a presentation at “Vestnorsk Lungeforum” in November. I am currently writing the draft for my first article. In 2015 I had a three months leave, from March to May, from my PhD programme. During this period I was working as a clinician at Mnazi Mmoja Hospital at Zanzibar, employed at the Department of Thoracic Medicine, Haukeland University Hospital, and financed through Department of International Collaboration, Haukeland University Hospital. This will delay the completion of my PhD thesis from March 2017 until June 2017. This will not have any negative consequences for the project.
Tuberculosis (TB) is still a major threat to public health. The overall goal of the project is to improve the diagnosis of extrapulmonary TB by implementation of a novel diagnostic test. The test has been implemented at Mnazi Mmoja Hospital, Zanzibar. 53 patients suspected of having extrapulmonary TB have been included in the study so far. I started my PhD-scholarship 15th of March 2014. When I started, all the study questionnaires, consent forms and most of the research protocols were already developed. All questionnaires, information letters and consent forms are both in English and Kiswahili. The English versions were translated to Kiswahili, and then the Kiswahili versions were translated back to English. The study got ethical clearance from REK Vest in February. In April I attended the course INT 914 “Applied economic evaluation in health care”, UoB, at PhD-level. I travelled for two weeks to Mnazi Mmoja Hospital (MMH) at Zanzibar in May to start the local planning of the study and networking with the collaborating health personnel at MMH. Pre-testing and adaption of the questionnaire according to the local situation at Zanzibar was also done during this visit. In June, I planned the study further, got laboratory training in the required methods and training in different procedures as pleuratapping and tapping of joint fluid at different departments at Haukeland University Hospital. The study obtained ethical clearance from the Research Ethics Committee of Zanzibar (ZAMREC) in July and the project was started. I expect to stay for 12 months at MMH for data collection. In July I developed laboratory protocols for implementation of the new diagnostic test and trained the laboratory personnel at MMH, who has had no prior training in the new diagnostic test. In addition to two laboratory technologists, one local medical doctor, working with inclusion and interviewing of patients, and a pathologist reading the test results, were hired in part-time positions in the project. Study participants are enrolled from every ward and outpatient departments at MMH. In August I started working at the tuberculosis clinic at MMH, to enroll patients and work with competence building of local health personnel. The inclusion of study participants started in September. From every patient we obtain a detailed clinical history. They also go through a physical examination and interview relevant for the evaluation of the diagnostic delay and cost-effectiveness analysis for comparison of the new diagnostic test with routinely used tests. The suspected extrapulmonary patients are followed throughout the treatment period of 6 (or more) months. 53 patients suspected of having extrapulmonary tuberculosis and 21 pulmonary tuberculosis suspects are included so far. Collection and storage of material for biobank has also been done as described in the project description. Delays from the planned activities: The logistics of this project is massive. Our project involves collaboration between several departments, and the development of routines and logistics has taken longer time than what was anticipated at the time of project planning. The inclusion of patients at Zanzibar has been slower than expected. Many patients are not referred to Mnazi Mmoja Hospital and treated outside this hospital. Our survey during the project planning did not reveal this situation. This challenge has been overcome by obtaining permission from ZAMREC to include patients from four peripheral hospitals, which is expected to expedite the process of patient inclusion. This may have consequence in delaying the completion of the PhD thesis within the planned 3 years. This would only postpone the planned activities without any negative consequences for the project in general.