TB Infection Control

No way to determine and verify the bacillary load actually. And we do
what we can. We treat , we repeat tests , schedule follow ups .And
report
In reality this is the biggest chunk of the patients - especially with
the private sector ( I mean both qualified and non certified
practitioners as well) who have really very less realisation about the
harm or the little good.....
Sorry for the grey tone!!

On 8/24/12, GHDonline (vladimir skornyakov) <> wrote:
> vladimir skornyakov added a new discussion to the TB Infection Control
> community.
>
> Title: Reliability and value Xpert/MBT/Rif for the TB patients have already
> being underwent by TB treatment
>
> Discussion contents:
> "DEAR COLLEAGUES.
> There`s one a very interesting question for me and a huge desire to learn
> your oppinion about that topic. How TB treatment already being done for
> patient influence on reliability and value Xpert/MBT/Rif. How must be
> considered results of POC test of a patient under TB treatment during a day,
> a month? a week, for example. I really understand that Xpert/MBT must be
> provided before starting of DOT, after X-Ray and so on.But unfortunatelly in
> real life we have a lot ...

No way to determine and verify the bacillary load actually. And we do
what we can. We treat , we repeat tests , schedule follow ups .And
report
In reality this is the biggest chunk of the patients - especially with
the private sector ( I mean both qualified and non certified
practitioners as well) who have really very less realisation about the
harm or the little good.....
Sorry for the grey tone!!

On 8/24/12, GHDonline (vladimir skornyakov) <> wrote:
> vladimir skornyakov added a new discussion to the TB Infection Control
> community.
>
> Title: Reliability and value Xpert/MBT/Rif for the TB patients have already
> being underwent by TB treatment
>
> Discussion contents:
> "DEAR COLLEAGUES.
> There`s one a very interesting question for me and a huge desire to learn
> your oppinion about that topic. How TB treatment already being done for
> patient influence on reliability and value Xpert/MBT/Rif. How must be
> considered results of POC test of a patient under TB treatment during a day,
> a month? a week, for example. I really understand that Xpert/MBT must be
> provided before starting of DOT, after X-Ray and so on.But unfortunatelly in
> real life we have a lot of new SS- cases where DOT has been undertaking
> before adequite micribiological and clinical diagnosis. And how do you
> think if whether there `s a sense to fulfil Xpert/MBT/Rif for the
> patients`re being treated when we`re waiting for MGIT and LI results?
> Thanks in advance"
>
> --
> View this post online:
> <http://www.ghdonline.org/ic/discussion/reliability-and-value-xpertmbtrif-for-...>
>
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> <http://www.ghdonline.org/users/dr-shanta-ghatak/edit/>
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>
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> will be shared with all community members and posted as is. Files cannot be
> added via email attachment and must be uploaded directly to GHDonline.
>
>

Perhaps the lab experts can reply as well, but I have a few comments. Although no test is perfect, even on treatment a positive test is diagnostic of TB while a negative test may not rule out TB, just as a negative culture may not rule out TB. Whereas treatment, by killing organisms, makes it difficult to culture organisms after 2 or 3 months, Xpert may remain positive for longer because it does not require viable organisms, just nucleic acid. This is both a good and bad thing. It is good because Xpert could be more useful than culture in diagnosing TB in patients already on therapy. However, it is bad for monitoring the success of treatment because, like sputum smears, it may remain positive for a while after cultures turn negative. While failure to convert sputum culture at 2 months may be a sign of treatment failure, failure to convert Xpert may not have the same significance. I am sure that there are studies on this and I hope one of the lab experts can provide some of those.

Agree.
Can be a bind when trying to diagnose TB but one gets use to it. It really works well for early identification of TB and I strongly recommend that all clinical cases of respiratory infection, in South Africa at least, should have a GeneXpert done on them. I think we miss too many TB cases by going through the respiratory tract protocol first for at least 10 days!
Regards
Shaheen

Prof Shaheen Mehtar
MBBS, FRC Path (UK), FCPath (Micro) (SA), MD (Eng)
Acting Head UIPC
Chair Infection Control Africa Network (ICAN)
Extraordinary Professor
Div Community Health, Faculty of Health Sciences
Stellenbosch Uni, Cape Town
Tel: +27 21 976 2162
Fax: + 27 21 938 5065
Mobile: +27 82 852 3697
Visit our UIPC Website
http://www.sun.ac.za/uipc

4th ICAN conference, 27th to 29th Nov, 2012.
Visit the ICAN website
http://www.ICANetwork.co.za

-----Original Message-----
From: GHDonline (Edward Nardell, MD) [mailto:]
Sent: 24 August 2012 01:40 PM
To: Mehtar, S, Prof <>
Subject: Re: [TB Infection Control] Reliability and value Xpert/MBT/Rif for the TB patients have already being underwent by TB treatment

Edward Nardell, MD replied to ...

Agree.
Can be a bind when trying to diagnose TB but one gets use to it. It really works well for early identification of TB and I strongly recommend that all clinical cases of respiratory infection, in South Africa at least, should have a GeneXpert done on them. I think we miss too many TB cases by going through the respiratory tract protocol first for at least 10 days!
Regards
Shaheen

Prof Shaheen Mehtar
MBBS, FRC Path (UK), FCPath (Micro) (SA), MD (Eng)
Acting Head UIPC
Chair Infection Control Africa Network (ICAN)
Extraordinary Professor
Div Community Health, Faculty of Health Sciences
Stellenbosch Uni, Cape Town
Tel: +27 21 976 2162
Fax: + 27 21 938 5065
Mobile: +27 82 852 3697
Visit our UIPC Website
http://www.sun.ac.za/uipc

4th ICAN conference, 27th to 29th Nov, 2012.
Visit the ICAN website
http://www.ICANetwork.co.za

-----Original Message-----
From: GHDonline (Edward Nardell, MD) [mailto:]
Sent: 24 August 2012 01:40 PM
To: Mehtar, S, Prof <>
Subject: Re: [TB Infection Control] Reliability and value Xpert/MBT/Rif for the TB patients have already being underwent by TB treatment

Edward Nardell, MD replied to the discussion "Reliability and value Xpert/MBT/Rif for the TB patients have already being underwent by TB treatment" in the TB Infection Control community.

Reply contents:
"Perhaps the lab experts can reply as well, but I have a few comments. Although no test is perfect, even on treatment a positive test is diagnostic of TB while a negative test may not rule out TB, just as a negative culture may not rule out TB. Whereas treatment, by killing organisms, makes it difficult to culture organisms after 2 or 3 months, Xpert may remain positive for longer because it does not require viable organisms, just nucleic acid. This is both a good and bad thing. It is good because Xpert could be more useful than culture in diagnosing TB in patients already on therapy. However, it is bad for monitoring the success of treatment because, like sputum smears, it may remain positive for a while after cultures turn negative. While failure to convert sputum culture at 2 months may be a sign of treatment failure, failure to convert Xpert may not have the same significance. I am sure that there are studies on this and I hope one of the lab experts can provide some of those."

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How about using Xpert as a rapid DST i.e. rapid screening for Rif resistance for non-converters on TB treatment?

Natalie

Natalie,

If you wait for non-conversion to trigger rapid DST by Xpert, you
accept weeks or months of ineffective therapy during which TB
transmission is occurring. The F-A-S-T approach to TB IC is based on
the principle that transmission stops rapidly with the institution of
EFFECTIVE therapy, that is, therapy based on DST. Therefore, ideally
(as a goal if not possible immediately) every patient needs both rapid
molecular diagnosis and rapid DST as Shaheen suggests, to be sure we
are not allowing an untreated patient to stay on a open ward for
months infecting both other patients and staff. The other parts of
F-A-S-T are FINDING cases ACTIVELY, that is by cough surveillance and
rapid diagnosis, SEPARATION and exposure reduction until effective
TREATMENT starts.

Ed

On Sat, Aug 25, 2012 at 12:44 AM, GHDonline (Natalie Lorent)
<> wrote:
> Natalie Lorent replied to the discussion "Reliability and value Xpert/MBT/Rif for the TB patients have already being underwent by TB treatment" in the TB Infection Control community.
>
> Reply contents:
> "How about using Xpert as a rapid DST i.e. rapid screening for Rif resistance for non-converters on TB treatment?
>
> Natalie"
>
> --
> View this post online:
> <http://www.ghdonline ...

Natalie,

If you wait for non-conversion to trigger rapid DST by Xpert, you
accept weeks or months of ineffective therapy during which TB
transmission is occurring. The F-A-S-T approach to TB IC is based on
the principle that transmission stops rapidly with the institution of
EFFECTIVE therapy, that is, therapy based on DST. Therefore, ideally
(as a goal if not possible immediately) every patient needs both rapid
molecular diagnosis and rapid DST as Shaheen suggests, to be sure we
are not allowing an untreated patient to stay on a open ward for
months infecting both other patients and staff. The other parts of
F-A-S-T are FINDING cases ACTIVELY, that is by cough surveillance and
rapid diagnosis, SEPARATION and exposure reduction until effective
TREATMENT starts.

Ed

On Sat, Aug 25, 2012 at 12:44 AM, GHDonline (Natalie Lorent)
<> wrote:
> Natalie Lorent replied to the discussion "Reliability and value Xpert/MBT/Rif for the TB patients have already being underwent by TB treatment" in the TB Infection Control community.
>
> Reply contents:
> "How about using Xpert as a rapid DST i.e. rapid screening for Rif resistance for non-converters on TB treatment?
>
> Natalie"
>
> --
> View this post online:
> <http://www.ghdonline.org/ic/discussion/reliability-and-value-xpertmbtrif-for-...>
>
> Unsubscribe or change your email notification settings:
> <http://www.ghdonline.org/users/edward-nardell-md/edit/>
>
> Contact the GHDonline team:
> <http://www.ghdonline.org/contact/>
>
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Dear Ed,
I completely agree with your statement. In Cambodia we are trying our best to identify and treat TB patients asap. However, the country cannot afford to do DST for all cases. Therefore certain criteria are used in line with WHO recommendations. Xpert was introduced less than a year. Despite a lot of effort, many TB patients who should have (had) a DST did not have it yet because of the huge backlog of cases. Although Xpert cannot be used to follow-up treatment (as it cannot identify dead from viable bacili), we currently use it in patients on treatment i.e. non-converters at mo 2, 3, 5 or 7, to evaluate for possible drug-resistance. Does that make sense?
Natalie

Hi Natalie,

It may be the best that you can do, but it does not make sense for the
reasons that I stated, and in my opinion, really isn't good enough. I
don't think that current WHO guidelines were written with an
appreciation of the rapid impact that a rapid DST followed by
effective treatment can have on TB transmission. Using the procedure
outlined below, a patient can go two months coughing on the ward with
MDR or XDR TB before his failure to convert sputum smear will trigger
a Xpert test. Can we afford to generate that many more MDR or XDR
patients on the ward, or among staff, which will then have to be
treated - further adding to the backlog? I don't think we can if we
want to turn around this epidemic. One of the problems of TB Control
at the highest level is acceptance of standards for poor settings that
would never be acceptable in resource-rich settings. In my opinion,
programs need to demand funding sufficient to stop the transmission
cycle, that is, actively identify active cases and get them onto
effective treatment in a matter of a few days, not months. This ...

Hi Natalie,

It may be the best that you can do, but it does not make sense for the
reasons that I stated, and in my opinion, really isn't good enough. I
don't think that current WHO guidelines were written with an
appreciation of the rapid impact that a rapid DST followed by
effective treatment can have on TB transmission. Using the procedure
outlined below, a patient can go two months coughing on the ward with
MDR or XDR TB before his failure to convert sputum smear will trigger
a Xpert test. Can we afford to generate that many more MDR or XDR
patients on the ward, or among staff, which will then have to be
treated - further adding to the backlog? I don't think we can if we
want to turn around this epidemic. One of the problems of TB Control
at the highest level is acceptance of standards for poor settings that
would never be acceptable in resource-rich settings. In my opinion,
programs need to demand funding sufficient to stop the transmission
cycle, that is, actively identify active cases and get them onto
effective treatment in a matter of a few days, not months. This is
technically possible. It is also likely to be cost effective if the
price of delayed treatment and treating subsequent additional
transmitted cases is calculated into the cost of NOT doing a rapid DST
up front at the time of diagnosis.

Sorry, but I can't agree with the plan as outlined. We must aim
higher if we are ever to turn around the MDR/XDR epidemic. It may take
time and will certainly take money to get there, but we should not
settle for less.

Ed

On Sun, Aug 26, 2012 at 9:39 PM, GHDonline (Natalie Lorent)
<> wrote:
> Natalie Lorent replied to the discussion "Reliability and value Xpert/MBT/Rif for the TB patients have already being underwent by TB treatment" in the TB Infection Control community.
>
> Reply contents:
> "Dear Ed,
> I completely agree with your statement. In Cambodia we are trying our best to identify and treat TB patients asap. However, the country cannot afford to do DST for all cases. Therefore certain criteria are used in line with WHO recommendations. Xpert was introduced less than a year. Despite a lot of effort, many TB patients who should have (had) a DST did not have it yet because of the huge backlog of cases. Although Xpert cannot be used to follow-up treatment (as it cannot identify dead from viable bacili), we currently use it in patients on treatment i.e. non-converters at mo 2, 3, 5 or 7, to evaluate for possible drug-resistance. Does that make sense?
> Natalie"
>
> --
> View this post online:
> <http://www.ghdonline.org/ic/discussion/reliability-and-value-xpertmbtrif-for-...>
>
> Unsubscribe or change your email notification settings:
> <http://www.ghdonline.org/users/edward-nardell-md/edit/>
>
> Contact the GHDonline team:
> <http://www.ghdonline.org/contact/>
>
> You can reply to this discussion by responding directly to this e-mail; it will be shared with all community members and posted as is. Files cannot be added via email attachment and must be uploaded directly to GHDonline.

Hi Ed,
According to Russian State Regulations of TB care in every new revealed case of TB we at once must refer a patient to SS+ or SS- category after microscopy ( before MGIT and LJ will be received ) in order to provide proper treatment and epidemiological measures. How do you think what category should be referred the patients with SS- (microscopy) but their POC test turns out positive.
Vladimir Skornyakov, Vladimir-city, Russia

-----Original Message-----
From: GHDonline (Edward Nardell, MD) [mailto:]
Sent: Wednesday, August 29, 2012 12:11 AM
To: vladimir skornyakov
Subject: Re: [TB Infection Control] Reliability and value Xpert/MBT/Rif for the TB patients have already being underwent by TB treatment

Edward Nardell, MD replied to the discussion "Reliability and value Xpert/MBT/Rif for the TB patients have already being underwent by TB treatment" in the TB Infection Control community.

Reply contents:
"Hi Natalie,

It may be the best that you can do, but it does not make sense for the reasons that I stated, and in my opinion, really isn't good enough. I don't think that current WHO guidelines were written with an appreciation of the rapid impact that a rapid ...

Hi Ed,
According to Russian State Regulations of TB care in every new revealed case of TB we at once must refer a patient to SS+ or SS- category after microscopy ( before MGIT and LJ will be received ) in order to provide proper treatment and epidemiological measures. How do you think what category should be referred the patients with SS- (microscopy) but their POC test turns out positive.
Vladimir Skornyakov, Vladimir-city, Russia

-----Original Message-----
From: GHDonline (Edward Nardell, MD) [mailto:]
Sent: Wednesday, August 29, 2012 12:11 AM
To: vladimir skornyakov
Subject: Re: [TB Infection Control] Reliability and value Xpert/MBT/Rif for the TB patients have already being underwent by TB treatment

Edward Nardell, MD replied to the discussion "Reliability and value Xpert/MBT/Rif for the TB patients have already being underwent by TB treatment" in the TB Infection Control community.

Reply contents:
"Hi Natalie,

It may be the best that you can do, but it does not make sense for the reasons that I stated, and in my opinion, really isn't good enough. I don't think that current WHO guidelines were written with an appreciation of the rapid impact that a rapid DST followed by effective treatment can have on TB transmission. Using the procedure outlined below, a patient can go two months coughing on the ward with MDR or XDR TB before his failure to convert sputum smear will trigger a Xpert test. Can we afford to generate that many more MDR or XDR patients on the ward, or among staff, which will then have to be treated - further adding to the backlog? I don't think we can if we want to turn around this epidemic. One of the problems of TB Control at the highest level is acceptance of standards for poor settings that would never be acceptable in resource-rich settings. In my opinion, programs need to demand funding sufficient to stop the transmission cycle, that is, actively identify active cases and get them onto effective treatment in a matter of a few days, not months. This is technically possible. It is also likely to be cost effective if the price of delayed treatment and treating subsequent additional transmitted cases is calculated into the cost of NOT doing a rapid DST up front at the time of diagnosis.

Sorry, but I can't agree with the plan as outlined. We must aim higher if we are ever to turn around the MDR/XDR epidemic. It may take time and will certainly take money to get there, but we should not settle for less.

Ed

On Sun, Aug 26, 2012 at 9:39 PM, GHDonline (Natalie Lorent) <> wrote:
> Natalie Lorent replied to the discussion "Reliability and value Xpert/MBT/Rif for the TB patients have already being underwent by TB treatment" in the TB Infection Control community.
>
> Reply contents:
> "Dear Ed,
> I completely agree with your statement. In Cambodia we are trying our best to identify and treat TB patients asap. However, the country cannot afford to do DST for all cases. Therefore certain criteria are used in line with WHO recommendations. Xpert was introduced less than a year. Despite a lot of effort, many TB patients who should have (had) a DST did not have it yet because of the huge backlog of cases. Although Xpert cannot be used to follow-up treatment (as it cannot identify dead from viable bacili), we currently use it in patients on treatment i.e. non-converters at mo 2, 3, 5 or 7, to evaluate for possible drug-resistance. Does that make sense?
> Natalie"
>
> --
> View this post online:
> <http://www.ghdonline.org/ic/discussion/reliability-and-value-xpertmbt
> rif-for-the-tb-patie/#reply-5492-2?id=10004&format=text&type=instant>
>
> Unsubscribe or change your email notification settings:
> <http://www.ghdonline.org/users/edward-nardell-md/edit/>
>
> Contact the GHDonline team:
> <http://www.ghdonline.org/contact/>
>
> You can reply to this discussion by responding directly to this e-mail; it will be shared with all community members and posted as is. Files cannot be added via email attachment and must be uploaded directly to GHDonline."

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Dear Ed,
I understand and of course share your concerns. I just wanted to outline the realities on the field. But, we will continue the fight!
Best,
Natalie