[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Adults with suspected tuberculosis (TB) in health facilities in Africa have a high risk of death. The risk of death for adults with suspected TB at community-level is not known but may also be high.METHODS: Adults reporting cough of 2 weeks (coughers) during a household census of 19 936 adults in a poor urban setting in Malawi were randomly sampled and age-frequency matched with adults without cough 2 weeks (controls). At 12 months, participants were traced to establish vital status, offered human immunodeficiency virus (HIV) testing and investigated for TB if symptomatic (sputum for Xpert® MTB/RIF, smear microscopy and culture).RESULTS: Of 345 individuals with cough, 245 (71%) were traced, as were 243/345 (70.4%) controls. TB was diagnosed in 8.9% (16/178) of the coughers and 3.7% (7/187) of the controls (P = 0.039). HIV prevalence among coughers was 34.6% (56/162) and 18.8% (32/170) in controls (P = 0.005); of those who were HIV-positive, respectively 26.8% and 18.8% were newly diagnosed. The 12-month risk of death was 4.1% (10/245) in coughers and 2.5% (6/243) in controls (P = 0.317).CONCLUSION: Undiagnosed HIV and TB are common among adults with chronic cough, and mortality is high in this urban setting. Interventions that promote timely seeking of HIV and TB care are needed.
Full-text · Article · Feb 2016 · The International Journal of Tuberculosis and Lung Disease
[Show abstract][Hide abstract] ABSTRACT: Vitamin D deficiency is common in African adults with tuberculosis (TB), and may be exacerbated by the metabolic effects of anti-tuberculosis drugs and antiretroviral therapy (ART). It is unclear whether vitamin D deficiency influences response to anti-tuberculosis treatment.
To describe risk factors for baseline vitamin D deficiency in Malawian adults with pulmonary TB, assess the relationship between serum 25-hydroxy vitamin D (25[OH]D) concentration and treatment response, and evaluate whether the administration of anti-tuberculosis drugs and ART is deleterious to vitamin D status during treatment.
A prospective longitudinal cohort study.
The median baseline 25(OH)D concentration of the 169 patients (58% human immunodeficiency virus [HIV] infected) recruited was 57 nmol/l; 47 (28%) had vitamin D deficiency (<50 nmol/l). Baseline 25(OH)D concentrations were lower during the cold season (P < 0.001), with food insecurity (P = 0.034) or in patients who consumed alcohol (P = 0.019). No relationship between vitamin D status and anti-tuberculosis treatment response was found. 25(OH)D concentrations increased during anti-tuberculosis treatment, irrespective of HIV status or use of ART.
Vitamin D deficiency is common among TB patients in Malawi, but this does not influence treatment response. Adverse metabolic effects of drug treatment may be compensated by the positive impact of clinical recovery preventing exacerbation of vitamin D deficiency during anti-tuberculosis treatment.
Full-text · Article · Aug 2015 · The International Journal of Tuberculosis and Lung Disease
[Show abstract][Hide abstract] ABSTRACT: Introduction Rates of upper gastrointestinal pathology requiring diagnostic and therapeutic intervention in Southern Malawi are high, resources and endoscopy services are limited, and there are very few independently practicing endoscopists. Endoscopy is recognised to be a complex cognitive and technical skill that requires a dedicated period of training to achieve proficiency. An endoscopy-training programme developed for UK trainees that includes simulation, was introduced to Malawi in 2009. This study explores the commonalities and differences in the way simulation training was experienced and made use of by endoscopy trainees in both countries. It also explores what modifications are needed to make current courses maximally beneficial in a resource limited environment.
Method Trainees and trainers from the UK and Malawi were invited to participate in semi-structured interviews. During the interview trainees were asked to describe the structure of their endoscopy training, experiences of simulation training and outline perceived benefits and drawbacks of their programme. Trainers were asked about their views on endoscopy training, experiences as course faculty and any modifications they felt were necessary to current training programmes to make them maximally beneficial in each country. Interview data was transcribed in full and analysed using a thematic analysis approach.
Results 17 people participated in the study: 4 trainers (3 with experience of training in Europe and Malawi), 2 Endoscopy sisters and 11 trainees (4 from Malawi and 7 from the UK – two of the Malawi trainees subsequently became local trainers). Although there were considerable differences in the learning environment between the UK and Malawi, trainees recognised simulation based endoscopy-training courses as an important opportunity for intensive skill based training, which supplemented their on-going departmental endoscopy training. Factors that improved the trainee learning experience during the courses included: being taught by skilled trainers; trainees identifying a need or clinical application for their endoscopy training; and course design, specifically having access to simulation models prior to being exposed to live cases. Suggested modifications to the training programme in Malawi included; implementing robust candidate selection to prevent “drop-out” from the training programme and improving local equipment.
Conclusion UK designed simulation based endoscopy-training courses were well received by Malawian trainees and needed only minor modification to be applicable and beneficial in their new environment.
Disclosure of interest None Declared.
[Show abstract][Hide abstract] ABSTRACT: Background:
Antibiotic-tolerant bacterial persistence prevents treatment shortening in drug-susceptible tuberculosis, and accumulation of intracellular lipid bodies has been proposed to identify a persister phenotype of Mycobacterium tuberculosis cells. In Malawi, we modeled bacillary elimination rates (BERs) from sputum cultures and calculated the percentage of lipid body-positive acid-fast bacilli (%LB + AFB) on sputum smears. We assessed whether these putative measurements of persistence predict unfavorable outcomes (treatment failure/relapse).
Adults with pulmonary tuberculosis received standard 6-month therapy. Sputum samples were collected during the first 8 weeks for serial sputum colony counting (SSCC) on agar and time-to positivity (TTP) measurement in mycobacterial growth indicator tubes. BERs were extracted from nonlinear and linear mixed-effects models, respectively, fitted to these datasets. The %LB + AFB counts were assessed by fluorescence microscopy. Patients were followed until 1 year posttreatment. Individual BERs and %LB + AFB counts were related to final outcomes.
One hundred and thirty-three patients (56% HIV coinfected) participated, and 15 unfavorable outcomes were reported. These were inversely associated with faster sterilization phase bacillary elimination from the SSCC model (odds ratio [OR], 0.39; 95% confidence interval [CI], .22-.70) and a faster BER from the TTP model (OR, 0.71; 95% CI, .55-.94). Higher %LB + AFB counts on day 21-28 were recorded in patients who suffered unfavorable final outcomes compared with those who achieved stable cure (P = .008).
Modeling BERs predicts final outcome, and high %LB + AFB counts 3-4 weeks into therapy may identify a persister bacterial phenotype. These methods deserve further evaluation as surrogate endpoints for clinical trials.
Full-text · Article · Mar 2015 · Clinical Infectious Diseases
[Show abstract][Hide abstract] ABSTRACT: Antibiotic tolerant bacterial persistence prevents treatment shortening in drug susceptible tuberculosis (TB) and accumulation of intracellular lipid bodies has been proposed to identify a persister phenotype of Mycobacterium tuberculosis cells. In Malawi, we modelled Bacillary Elimination Rates (BERs) from sputum cultures and calculated the percentage of lipid body positive acid fast bacilli (%LB+AFB) on sputum smears. We assessed whether these putative measurements of persistence predict unfavourable outcomes (treatment failure/relapse).
Adults with pulmonary TB received standard 6 month therapy. Sputum samples were collected during the first 8 weeks for Serial Sputum Colony Counting (SSCC) on agar and Time to Positivity (TTP) measurement in BACTEC MGIT broth. BERs were extracted from non-linear and linear mixed effects models fitted respectively to these datasets. %LB+AFB counts were assessed by fluorescence microscopy. Patients were followed until one year post-treatment. Individual BERs and %LB+AFB counts were related to final outcomes.
133 patients (56% HIV co-infected) participated and 15 unfavourable outcomes were reported. These were inversely associated with faster sterilisation phase bacillary elimination from the SSCC model (Odds Ratio [OR]: 0.39, 95% Confidence interval [CI]: 0.22-0.70) and a faster BER from the TTP model (OR: 0.71, 95% CI: 0.55-0.94). Higher %LB+AFB counts on day 21-28 were recorded in patients who suffered unfavourable final outcomes compared to those who achieved stable cure (p=0.008).
Modelling BERs predicts final outcome and high %LB+AFB counts 3-4 weeks into therapy may identify a persister bacterial phenotype. These methods deserve further evaluation as surrogate endpoints for clinical trials.
[Show abstract][Hide abstract] ABSTRACT: Introduction and objectives Pre-treatment Vitamin D deficiency (VDD) is well described amongst adult TB patients in Malawi and has been associated with impaired mycobacterial immunity. Anti-TB drugs and antiretroviral therapy (ART) for HIV may induce hepatic Vitamin D metabolism, further reducing the serum concentration of active metabolites including 25-OH D3. This study identified risk factors for baseline VDD, assessed the effect of therapy on 25-OH D3 concentrations, and evaluated whether VDD deficiency has prognostic implications for treatment response.
Methods Adults with pulmonary TB were treated with standard 6 month therapy. Serum 25-OH D3 concentrations were measured at baseline, 8 weeks and end of treatment. Serial sputum samples were used to model the rate of bacterial elimination for each patient. Patients were followed until 1 year post-treatment and final outcomes were defined as favourable (stable cure) or unfavourable (failure/relapse). Linear and logistic regression analyses were used to identify risk factors for VDD and assess relationships between VDD and treatment response.
Results 133 patients were studied. 75 (56%) were HIV-infected and 24 (18%) were on ART. 118 (89%) had favourable and 15 (11%) had unfavourable outcomes. The median baseline 25-OH D3 concentration was 57.3 nmol/l. 47 (28%) patients had concentrations <50 nmol/l, representing VDD. On multivariate analysis, neither HIV status nor ART influenced baseline 25-OH D3 levels, but lower concentrations were reported in patients who were recruited during the cold months of July/August (p = 0.001), suffered food insecurity (p = 0.035) or had a lower baseline Body Mass Index (p = 0.047). Without specific supplementation, 25-OH D3 levels improved during TB therapy (see figure). There were no associations between 25-OH D3 levels at any time-point and the sputum bacillary elimination rate or final clinical outcome.
[Show abstract][Hide abstract] ABSTRACT: Background. HIV-infected persons on antiretroviral therapy (ART) remain at higher risk of pulmonary tuberculosis (TB) than HIV-uninfected individuals. This increased susceptibility may be due to impairment of alveolar macrophage (AM) function and/or mycobacteria-specific alveolar CD4+ T cell responses observed in HIV-infected ART-naive adults. Methods. Peripheral blood was drawn and bronchoalveolar lavage (BAL) performed on healthy, 35 HIV-uninfected, 25 HIV-infected ART-naive and 50 HIV-infected ART-treated asymptomatic adults. Phagosomal proteolysis of AM was assessed with fluorogenic beads. Mycobacteria-specific CD4+ T cell responses were measured by intracellular cytokine staining. Results. HIV-infected adults on ART exhibited lower plasma HIV viral load and higher blood CD4+ T cell count than ART-naïve adults. AM proteolysis and total mycobacteria-specific Th1 CD4+ T cell responses in individuals on ART for ≥4 years were similar to HIV-uninfected controls but those on ART for <4 years had impaired responses. Total Influenza-specific alveolar Th1 CD4+ T cell responses were intact in all individuals receiving ART. In contrast, BAL and blood mycobacteria-specific polyfunctional CD4+ T cell responses were impaired in adults on ART irrespective of duration. Conclusion. AM and mycobacteria-specific alveolar CD4+ T cell responses in HIV-infected adults on ART for <4 years are impaired and may partly explain the high risk of TB in HIV-infected individuals on ART. Strategies to augment ART to improve lung immune cell function and reduce the high incidence of TB in HIV-infected adults who initiate ART should be investigated.
No preview · Article · Sep 2014 · American Journal of Respiratory and Critical Care Medicine
[Show abstract][Hide abstract] ABSTRACT: HIV-1-infected persons are at higher risk of lower respiratory tract infections than HIV-1-uninfected individuals. This suggests strongly that HIV-infected persons have specific impairment of pulmonary immune responses, but current understanding of how HIV alters pulmonary immunity is incomplete. Alveolar macrophages (AMs), comprising small and large macrophages, are major effectors of innate immunity in the lung. We postulated that HIV-1 impairs pulmonary innate immunity through impairment of AM physiological functions. AMs were obtained by bronchoalveolar lavage from healthy, asymptomatic, antiretroviral therapy-naive HIV-1-infected and HIV-1-uninfected adults. We used novel assays to detect in vivo HIV-infected AMs and to assess AM functions based on the HIV infection status of individual cells. We show that HIV has differential effects on key AM physiological functions, whereby small AMs are infected preferentially by the virus, resulting in selective impairment of phagocytic function. In contrast, HIV has a more generalized effect on AM proteolysis, which does not require direct viral infection. These findings provide new insights into how HIV alters pulmonary innate immunity and the phenotype of AMs that harbors the virus. They underscore the need to clear this HIV reservoir to improve pulmonary immunity and reduce the high incidence of lower respiratory tract infections in HIV-1-infected individuals.Mucosal Immunology advance online publication, 29 January 2014; doi:10.1038/mi.2013.127.
Full-text · Article · Jan 2014 · Mucosal Immunology
[Show abstract][Hide abstract] ABSTRACT: Introduction Sustainable endoscopy services could improve management of upper gastrointestinal malignancy and haemorrhage, both common in Malawi. Since 2008 we have committed to improving endoscopy training through an International Health Link (IHL) partnership with Malawi. We aimed to (1) develop a sustainable training “hub” with locally-trained Trainers in Blantyre (2) develop locally-relevant training courses, (3) extend training support to regional hospital “spokes”.
Methods We partnered in five training visits to Malawi, funded by the Tropical Health Education Trust and the British Society of Gastroenterology. We ran 14 courses (Basic Skills, Skills Enhancement, Training the Gastroscopy Trainers (TGT) and Endoscopy Nurses) involving 52 delegate-training-episodes (29 local doctors, 12 clinical officers (COs), three expatriate doctors, eight nurses). Outcomes were monitored by JAG-format DOPS and course evaluations. Progress over time towards the three aims was assessed.
Results Aim 1) Training models and audit, reporting and assessment tools were introduced in Blantyre. The mean number of delegate-episodes increased from 6.3 during the first four visits, to 20 during the last two visits. During the first four visits the local faculty was four expatriate doctors and one CO, increasing to seven local doctors, five COs, two nurses and one expatriate doctor during the last two visits. In the first four visits, 16/21 delegate-episodes involved only skills learning and 5/21 (24%) were as mentored or local faculty, while in the last two visits, 25/40 involved only skills learning and 15/40 (38%) were as mentored or local faculty. In 2011 we ran and evaluated the first TGT within Malawi. Aim 2) We developed a Basic Skills in Gastroscopy course appropriate to local circumstances, which was delivered, evaluated and modified over each visit, and ultimately delivered by two locally-trained Trainers. Aim 3) The delegates' region of origin for the first four visits was 18/19 from Blantyre, and for the last two visits was 15/40 Blantyre, 13/40 Lilongwe, 7/40 Zomba, 3/40 Mzuzu and 2/40 Zambia. The origin of UK external faculty increased from 1 to 3 sites, and two new IHLs were established with Lilongwe and Zomba.
Conclusion IHL partnerships represent a sustainable means of improving GI endoscopy training. Modified JAG-format courses, assessments and evaluations were useful even in a resource-limited setting. A hub-and-spoke model helped to support other regions. Future training priorities include training in therapy and further development of local trainers. Local reporting tools should allow audit of outcomes across regions.
Competing interests None declared.
[Show abstract][Hide abstract] ABSTRACT: Serial Sputum Colony Counting (SSCC) is an important technique in clinical trials of new treatments for tuberculosis (TB). Quantitative cultures on selective Middlebrook agar are used to calculate the rate of bacillary elimination from sputum collected from patients at different time points during the first 2 months of therapy. However, the procedure can be complicated by high sample contamination rates. This study, conducted in a resource-poor setting in Malawi, assessed the ability of different antifungal drugs in selective agar to reduce contamination. Overall, 229 samples were studied and 15% to 27% were contaminated. Fungal organisms were particularly implicated, and samples collected later in treatment were at particular risk (P < 0.001). Amphotericin B (AmB) is the standard antifungal drug used on SSCC plates at a concentration of 10 mg/ml. On selective Middlebrook 7H10 plates, AmB at 30 mg/ml reduced sample contamination by 17% compared with AmB at 10 mg/ml. The relative risk of contamination using AmB at 10 mg/ml was 1.79 (95% confidence interval [CI], 1.25 to 3.55). On Middlebrook 7H11 plates, a combination of AmB at 10 mg/ml and carbendazim at 50 mg/ml was associated with 10% less contamination than AmB at 30 mg/ml. The relative risk of contamination with AmB at 30 mg/ml was 1.79 (95% CI, 1.01 to 3.17). Improved antifungal activity was accompanied by a small reduction in bacillary counts, but this did not affect modeling of bacillary elimination. In conclusion, a combination of AmB and carbendazim optimized the antifungal activity of selective media for growth of TB. We recommend this method to reduce contamination rates and improve SSCC studies in African countries where the burden of TB is highest.
Full-text · Article · May 2012 · Journal of clinical microbiology
[Show abstract][Hide abstract] ABSTRACT: Professional phagocytes ingest particulate material to fulfil a diverse array of functions in a multicellular organism. The ancestral function of phagosomes is digestion; however, through evolution this degradative capacity has become pivotal to the adaptive immune response by processing antigens to be presented to lymphocytes. Moreover, phagocytes have also acquired an active role in microbial killing. This Innovation article describes new assays that probe the biological activities which occur within phagosomes. These assays provide functional insights into how the phagosome fulfils its diverse roles in homeostasis and in innate and adaptive immune responses.
[Show abstract][Hide abstract] ABSTRACT: Malawi is one of many developing countries conducting research in collaboration with developed countries. These partnerships have facilitated the sharing of ideas, knowledge, technology and resources, as well as developing and strengthening the country's research capacity. Professor Malcolm Molyneux, who recently retired as director of the Malawi-Liverpool-Wellcome Trust (MLW) clinical research programme, the Wellcome Trust's major overseas programme in Malawi, played a substantial role in developing Malawi's capacity to conduct relevant and competitive clinical research by encouraging and promoting collaboration between clinicians, researchers and sponsors from within Malawi and abroad. Not only have these developments resulted in better patient care in Malawi and beyond, they have also advanced understanding of the epidemiology, pathogenesis and treatment of important communicable diseases. This paper discusses Malcolm Molyneux's remarkable contribution to research capacity development in Malawi.
No preview · Article · Mar 2009 · Transactions of the Royal Society of Tropical Medicine and Hygiene
[Show abstract][Hide abstract] ABSTRACT: Nucleic acid amplification tests (NAAT) based on PCR provide rapid identification of Mycobacterium tuberculosis and the detection of rifampicin resistance. Indications for their use in clinical samples are now included in British tuberculosis guidelines.
A retrospective audit of patients with suspected mycobacterial infection in a Liverpool hospital between 2002 and 2006. Documentation of the impact of NAAT usage in acid fast bacillus (AFB) microscopy positive samples on clinical practice and the influence of a multidisciplinary group on their appropriate use, compared with British guidelines.
Mycobacteria were seen or isolated from 282 patients and identified as M tuberculosis in 181 (64%). NAAT were indicated in 87/123 AFB positive samples and performed in 51 (59%). M tuberculosis was confirmed or excluded by this method in 86% of tested samples within 2 weeks, compared with 7% identified using standard methods. The appropriate use of NAAT increased significantly over the study period. The NAAT result had a clinical impact in 20/51 (39%) tested patients. Culture results suggest the potential for a direct clinical impact in 8/36 (22%) patients in which it was indicated but not sent and 5/36 (14%) patients for whom it was not indicated. Patients managed by the multidisciplinary group had a higher rate of HIV testing and appropriate use of NAAT.
There were significant clinical benefits from the use of nucleic acid amplification tests in this low prevalence setting. Our data suggest that there would be additional benefit from their use with all AFB smear positive clinical samples.
[Show abstract][Hide abstract] ABSTRACT: In the developing world, early mortality within 1 month of commencing tuberculosis (TB) treatment is high, particularly with human immunodeficiency virus (HIV) co-infection. In Malawi, 40% of those who die do so in the first month of treatment. Reasons remain unclear and may include delayed diagnosis, opportunistic infections, immune restoration inflammatory syndrome (IRIS) or malnutrition. One possible contributing factor is underlying hypoadrenalism associated with TB-HIV, exacerbated by rifampicin (RMP) induction of P450 and glucocorticoid metabolism.
To assess the prevalence of hypoadrenalism in TB patients before and after commencement of TB treatment, and relationship with early mortality.
Prospective descriptive study assessing hypoadrenalism before and after anti-tuberculosis treatment, HIV status and outcome up to 3 months post-treatment.
Of 51 patients enrolled, 29 (56.9%) were female (median age 32 years, range 18-62). Of 43 patients HIV-tested, 38 (88.3%) were HIV-positive and 15.7% died within the first month. At 3 months, 11 (21.6%) were known to have died. Adequate cortisol levels were found in 49/51 (95.9%) before commencing RMP. Neither of the two with reduced response died. All 34 patients revealed adequate cortisol responses at 2 weeks.
No evidence of hypoadrenalism was found in this first study to assess adrenal function and outcome of anti-tuberculosis treatment.
No preview · Article · Apr 2008 · The International Journal of Tuberculosis and Lung Disease
[Show abstract][Hide abstract] ABSTRACT: Infection with human immunodeficiency virus (HIV) may affect the clinical presentation of pulmonary tuberculosis (TB). To investigate the association between sputum smear status at presentation and local pulmonary immune responses in HIV-infected patients with pulmonary TB, we compared the cellular and cytokine profiles in bronchoalveolar lavage (BAL) fluid obtained from the site of lung disease in 22 sputum smear- and culture-positive, and 17 sputum smear-negative but culture-positive pulmonary TB patients. Smear-positive patients had significantly higher BAL fluid concentrations of IL-6 (p=0.007), IL-8 (p=0.02), IL-10 (p=0.03) and IFN-gamma (p=0.008) than smear-negative patients. No significant differences in the proportions of examined BAL cells were found. We concluded that sputum smear-positive TB was associated with greater pro-inflammatory and immunomodulatory cytokine responses at the site of lung disease than sputum smear-negative disease. The local immune responses may affect the clinical presentation of active pulmonary TB in HIV-infected patients.
[Show abstract][Hide abstract] ABSTRACT: The functional capacity of alveolar macrophages (AM) in human immunodeficiency virus (HIV)-infected patients with pulmonary tuberculosis (TB) is not completely understood. To investigate the capacity of AM to mediate inflammatory responses, we obtained AM from human subjects by bronchoalveolar lavage (BAL) and studied the cells ex vivo. We compared AM from HIV-infected patients with suspected pulmonary TB to AM from healthy, HIV-negative controls for their capacity to produce TNF-alpha or IL-6 spontaneously and upon stimulation with lipopolysaccharide (LPS). Cytokine-producing cells were identified by macrophage markers and intracellular cytokine staining and flow cytometry. A higher proportion of AM from patients with microbiologically confirmed pulmonary TB than patients with probable TB or controls spontaneously expressed TNF-alpha shortly after isolation (geometric means: 38.5%, 23.7% and 15.8%, respectively), suggesting endogenous cytokine production. The proportions of AM spontaneously expressing TNF-alpha positively correlated with peripheral blood CD4(+) T-lymphocyte counts in patients (partial r=0.60, p=0.003) but not controls. Stimulation with LPS resulted in a significant increase in the proportions of TNF-alpha- and IL-6-positive AM from patients and controls (p<0.01). Bronchoalveolar lavage fluid (BALF) from confirmed TB patients also contained higher concentrations of the inflammatory cytokines predominantly produced by macrophages, IL-6 and IL-8, than controls (geometric mean cytokine concentrations per gram of BALF albumin were 1291 pg/g vs. 115 pg/g, p=0.03 for IL-6 and 4739 pg/g vs. 704 pg/g, p=0.03 for IL-8). We concluded that AM from HIV-infected patients with pulmonary TB produced and released inflammatory cytokines in vivo and retained their innate ability to respond to stimulation by LPS.
No preview · Article · Aug 2007 · Microbes and Infection