Tuberculosis screening among ambulatory people living with HIV: a systematic review and individual participant data meta-analysis.
Tuberculosis screening among ambulatory people living with HIV: a systematic review and individual participant data meta-analysis.
复制标题
DOI：
10.1016/s1473-3099(21)00387-x
复制
发表时间：
2022-04
期刊：
影响因子：
--
通讯作者：
Maartens G
中科院分区：
文献类型：
--
作者：
Dhana A;Hamada Y;Kengne AP;Kerkhoff AD;Rangaka MX;Kredo T;Baddeley A;Miller C;Singh S;Hanifa Y;Grant AD;Fielding K;Affolabi D;Merle CS;Wachinou AP;Yoon C;Cattamanchi A;Hoffmann CJ;Martinson N;Mbu ET;Sander MS;Balcha TT;Skogmar S;Reeve BWP;Theron G;Ndlangalavu G;Modi S;Cavanaugh J;Swindells S;Chaisson RE;Ahmad Khan F;Howard AA;Wood R;Thit SS;Kyi MM;Hanson J;Drain PK;Shapiro AE;Kufa T;Churchyard G;Nguyen DT;Graviss EA;Bjerrum S;Johansen IS;Gersh JK;Horne DJ;LaCourse SM;Al-Darraji HAA;Kamarulzaman A;Kempker RR;Tukvadze N;Barr DA;Meintjes G;Maartens G
世卫组织推荐的流动艾滋病毒感染者结核病筛查和诊断流程是四症状筛查（称为世卫组织推荐的四症状筛查 [W4SS]），如果 W4SS 呈阳性，则随后进行世卫组织推荐的分子快速诊断测试（例如 Xpert MTB/RIF [以下简称 Xpert]）。为了向更新的世界卫生组织指南提供信息，我们旨在评估替代筛查测试和结核病策略在该人群中的诊断准确性。在本次系统综述和个体参与者数据荟萃分析中，我们更新了对 PubMed (MEDLINE)、Embase、Cochrane 图书馆和 2011 年 1 月 1 日至 2018 年 3 月 12 日期间出版物的会议摘要的检索，这在之前的系统综述中完成，涵盖了截至 2019 年 8 月 2 日的时期。我们筛选了已识别文章的参考文献列表，并联系了该领域的专家。我们纳入了成人和青少年（年龄≥10岁）流动艾滋病毒感染者的前瞻性横断面、观察性研究和随机试验，无论结核病的体征和症状如何。我们使用标准化数据提取表格提取研究级别的数据，并向研究作者请求个人参与者数据。我们的目的是将 W4SS 与替代筛查测试和策略以及 WHO 推荐的算法（即 W4SS 后接 Xpert）与 Xpert 在整体和关键亚组（例如抗逆转录病毒治疗 [ART] 状态）的诊断准确性（敏感性和特异性）方面进行比较。参考标准是文化。本研究已在 PROSPERO 注册，CRD42020155895。我们确定了 25 项研究，并从 22 项研究中获取了数据（包括 15 666 名参与者；15 663 名参与者中有 4347 名 [27·7%] 接受了 ART 数据）。 W4SS 敏感性为 82% (95% CI 72–89)，特异性为 42% (29–57)。 C 反应蛋白 (≥10 mg/L) 与 W4SS 具有相似的敏感性 (77% [61–88])，但特异性较高 (74% [61–83]；n=3571)。咳嗽（持续≥2周）、血红蛋白（<10 g/dL）、体重指数（<18·5 kg/m2）和淋巴结肿大的特异性较高（80-90%），但敏感性较低（29-43%）。 WHO推荐的算法的敏感性为58%（50-66），特异性为99%（98-100）； Xpert for all 的敏感性为 68% (57–76)，特异性为 99% (98–99)。在一项对两者进行评估的研究中，sputum Xpert Ultra 的敏感性高于 sputum Xpert（73% [62–81] vs 57% [47–67]），并且特异性相似（98% [96–98] vs 99% [98–100]）。在接受 ART 的门诊患者中（接受 ART 的 4347 人中的 4309 人 [99·1%]），W4SS 敏感性为 53% (35–71)，特异性为 71% (51–85)。在该人群中，与单独使用 W4SS 相比，对任何胸部 X 射线异常进行 W4SS 的并行策略（同时进行两项测试）具有较高的敏感性 (89% [70–97]) 和较低的特异性 (33% [17–54]；n=2670)；在结核病患病率为 5% 的情况下，与 W4SS 相比，该策略每 1000 名艾滋病毒感染者需要进行 379 次快速诊断检测，但会多发现 18 例结核病例。在未接受 ART 的门诊患者中（15–541 名门诊患者中的 11–160 [71·8%]），W4SS 敏感性为 85% (76–91)，特异性为 37% (25–51)。单独的 C 反应蛋白 (≥10 mg/L) 与 (83% [79–86]) 具有相似的敏感性 (83% [79–86])，但比 W4SS 具有更高的特异性 (67% [60–73]；n=3187)，并且 W4SS 的序贯策略（均为阳性）然后 C 反应蛋白 (≥5 mg/L) 具有与 (84% [75–90]) 相似的敏感性，但比 (64%) 更高的特异性[57–71]；n=3187)，仅 W4SS；在结核病患病率为 10% 的情况下，与 W4SS 相比，这些策略每 1000 名 HIV 感染者需要的快速诊断检测次数将减少 272 次和 244 次，但会分别多漏掉 2 例和 1 例结核病例。 C反应蛋白减少了进一步快速诊断检测的需要，同时又不影响敏感性，并已被纳入更新的世界卫生组织结核病筛查指南中。然而，ART 门诊患者的 C 反应蛋白数据很少，因此需要进一步研究 C 反应蛋白在该组中的效用。与 W4SS 结合使用时，胸部 X 光检查对于接受 ART 的门诊患者非常有用。 WHO推荐的算法灵敏度不理想； Xpert for all 提供了轻微的灵敏度增益，但会产生重大的资源影响。世界卫生组织。
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. 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. We identified 25 studies, and obtained data from 22 studies (including 15 666 participants; 4347 [27·7%] 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 (<18·5 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 [99·1%] 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 [71·8%] 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. 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. World Health Organization.
影响因子：
3.1
作者：
Drain PK;Losina E;Coleman SM;Giddy J;Ross D;Katz JN;Bassett IV
通讯作者：
Bassett IV