Detection of Mycobacterium tuberculosis Antigen in Cough Samples in Northern Ethiopia

By Dennis Camilleri | 03 May, 2018

Tuberculosis is a highly infectious disease that is spread from person to person by infected aerosols emitted by patients with respiratory forms of the disease. We describe a novel device, the TB “Breathalyser” (Rapid Biosensor Systems Ltd) that collects human cough samples and utilizes immuno- sensor and bio-optical technology to detect M. tuberculosis (MTB) Antigen (Ag85B) in them, and demonstrate its use under field conditions during a pilot study in Ethiopia. The TB Breathalyser was field tested on outpatients of three governmental Hospitals in the Tigray region, Ethiopia using a cross sectional study design. Of 427 patients tested, 192 were diagnosed as TB positive from Sputum and/or X-ray. Rapid Biosensor test results were recorded and assessed using two different thresholds for pos/neg diagnosis. Of the 192 TB positive patients 149 (at the -40 threshold) and 130 (at the -60 threshold) gave positive Breathalyser results. A further 120 (at the -40 threshold) and 106 (at the -60 threshold) were Breathalyser positive/sputum negative/X-ray negative and most were clinically positive, at an early stage of infection. The Breathalyser had sensitivities ~97-99% and specificities ~97% for early stage and actively infectious later stage patients. The Breathalyser detected 65-75% of well-established/relapsed patients. The detection of significant numbers of early stage and infectious TB patients, clearly has huge implications regarding the potential for improving the rate of detection of TB in High Burden countries where rates ~30% mostly late stage patients, are currently typical.



Edward Nardell, MD Moderator Replied at 1:34 PM, 3 May 2018

This is exciting, but like all new diagnostic tests, caution is warranted.
What is reported is one site in the hands of the company as well as local
investigators in Ethiopia. If others find similar results in a variety of
settings, AND if the cost is not prohibitive - compared to the subsidized
Xpert test (approximately $10 per test) - this may be close to the POC test
that we have been waiting for. Maintenance, stability, performance despite
heat, humidity, cold, etc are all to be determined. Hopefully, other
studies are underway.


Dennis Camilleri Replied at 2:14 PM, 3 May 2018

Dear Edward
Thank you for your constructive comments.

These results were gathered by the Ethiopian medics listed in the paper and at 3 locations in Ethiopia. We had similar results in India.

Our breathalyser and reader use low cost optical and electronic components available from well established suppliers. The disposable test target price is $5 and the reader which is roughly palm suze will have a price of $3000 but we can only achieve this economy of scale after we scale up production in volume.

We do not envisage performance issues with the final product because we are using robust compoentry that has been used for 30 years or more in industrial applications.

Challenges remain but we are very excited about this Breathalyser for use at POC for screening active TB.

Belayneh Dimah Replied at 2:15 PM, 3 May 2018

Good news sir


*Belayneh Dimah (Microbiologist )Jimma UniversityJimma,EthiopiaPo Box
:94Mobile:+251911743623Alternative E-mail:
< Name:belayneh.dimah2*

Edward Nardell, MD Moderator Replied at 2:21 PM, 3 May 2018

May I ask you to declare whether you are working for the company, or not.
It is important for our readers to understand the objectiveness or
potential biases of contributors. This is a routine request - not specific
to your post - we appreciate the information and we depend on companies to
bring us new products - but readers need to assess the information in the
context of the source.

CLAUDE RUTANGA Replied at 3:09 PM, 3 May 2018

A similar question came in my mind when I saw the repost: what's the intention of sharing this? If for any reader who may feel it can be adopted in his setting/program, there is still a huge gap of information to convince for its uptake as opposed to other WHO approved technologies which help in detecting Mtb at an earlier stage of the disease, like Xpert MTB/RIF ultra assay.
Only companies/agencies like WHO have the mandate to publicize tested and approved technologies for use at a larger/global scale.
Thanks for sharing that piece of info.
Claude Rutanga

Dennis Camilleri Replied at 3:44 PM, 3 May 2018

Thank you for your reply. We are sharing our paper as it was published under open access.

Do please contact us with your questions and we can answer as best we can.

Our Breathalyser is an antigen test and results are available in 2 minutes. It detects TB at very early stage.

Edward Nardell, MD Moderator Replied at 4:09 PM, 3 May 2018

Dear Denis,

You did not answer directly as I requested, but from the discussion, I
presume you represent the company.

Thank you for the paper and the introduction to the product, but I think
that further discussion in this impartial forum is inappropriate and might
be perceived as a product endorsement - none is intended.

Please refrain from further responses - you have made it clear that you can
be contacted directly for further questions.

EN, Moderator

Abebaw Kebede Replied at 5:31 PM, 3 May 2018

I don't think it's a publication. Can you tell us on which journal the paper published? It looks a very draft paper to be submitted for journal.
Your technology is compared against microscopy and/or Chest X-ray. However, the two TB diagnostics (your reference standard) have low sensitivity in detecting TB.
Anyhow, thanks for sharing the info!


Md jubaidul Islam Replied at 10:52 PM, 3 May 2018

I want to know about updated guideline of non tubercular mycobacterial infections 

Sent from Yahoo Mail for iPhone

Edward Nardell, MD Moderator Replied at 10:55 PM, 3 May 2018

Sorry, that is not a topic covered in this community, but the American
Thoracic Society has NTM guidelines.

Abebaw Kebede Replied at 4:41 AM, 4 May 2018

Thanks Dennis for sharing the pub.
OMICS international is a predatory or fake journal. It is not a credible journal. Journal of Biosensors & Bioelectronics is a part of OMICS (
You can see how fast the publication is: Received Date: 02 March, 2018; Accepted Date: 02 April, 2018; Published Date: 09 April, 2018. I don't think the proper reviewing process by the journal was conducted for this paper.

Criteria for Determining Predatory Open-Access Publishers (see attachment)


Attached resource:

Wessen Nega Replied at 5:00 AM, 4 May 2018

Thank you for the information. The article only showing discriptive kind of
analysis. Did you do validation for you data or did you compare with other
type of test methodes and what is the comparison result?

Edward Nardell, MD Moderator Replied at 5:50 AM, 4 May 2018

Thanks Dr. Kebede for providing the link to criteria for predatory journals
- very important. You can see commercial interests taking advantage of
these to present work that would not be published in credible places just
for paying publication costs. I wondered who used them.

That is why my first response was - caution - wait until there are many
credible publications before considering this breath test a viable, useful

I love seeing the critical response.

Dennis Camilleri Replied at 5:55 AM, 4 May 2018

Please do not hesitate to ask us questions about breath analysis for TB infection so we can answer as best we can.
Our data has been reviewed and checked by medics at Mekele in Ethiopia.

Also before this field trial we had similar results at another field trial in Ethiopia which was managed by the London School of Hygiene and Tropical Medicine and Dr Ruth McNerney. That study gave us the confidence to do this latest trial which is covered in the paper in Biosensors publication.

We have also had similar good results during a study in Bhavnagar India.

So if you are sceptical about breath analysis and our test we will be pleased to explain further.

Dennis Camilleri Replied at 6:03 AM, 4 May 2018

Good morning

I am the CEO of the company and wanted to share our results so that the TB community is aware of our field study results.
Thank you for your reply.

Dennis Camilleri Replied at 6:32 AM, 4 May 2018

Good morning

This is another paper on our TB Breathalyser that was published in BMC Infectious Disease on a small field study in Ethiopia conducted by the London School of Hygiene and Tropical Medicine.
This BMC publication gave us the encouragement we needed to pursue breath analysis for detecting TB.
Since then the TB Breathalyser has been further optimised.

Our Medical Director Dr Nicol Murray will be pleased to discuss off this platform and directly with you.

Attached resource:

Desalegn Addise Getahun Replied at 6:51 AM, 4 May 2018

Dear Dennis,

Very thanks for the information.

Wessen Nega Replied at 7:14 AM, 4 May 2018

Many thanks for the prompt response. 

Sent from my Samsung Galaxy smartphone.

Edward Nardell, MD Moderator Replied at 7:22 AM, 4 May 2018


Please stop.

I warned you that this is not a site for commercial advertising. I will
delete all further correspondence

For those who are unclear what a "predatory journal is" please read the

Ed Nardell, MD,

Steven Goodman, a dean and professor of medicine at Stanford and the editor
of the journal Clinical Trials, which has its own imitators, called this
phenomenon “the dark side of open access,” the movement to make scholarly
publications freely available.

The number of these journals and conferences has exploded in recent years
as scientific publishing has shifted from a traditional business model for
professional societies and organizations built almost entirely on
subscription revenues to open access, which relies on authors or their
backers to pay for the publication of papers online, where anyone can read

Open access got its start about a decade ago and quickly won widespread
acclaim with the advent of well-regarded, peer-reviewed journals like those
published by the Public Library of Science, known as PLoS
<>. Such articles were listed in databases like PubMed
<>, which is maintained
by the National Library of Medicine, and selected for their quality.

But some researchers are now raising the alarm about what they see as the
proliferation of online journals that will print seemingly anything for a
fee. They warn that nonexperts doing online research will have trouble
distinguishing credible research from junk. “Most people don’t know the
journal universe,” Dr. Goodman said. “They will not know from a journal’s
title if it is for real or not.”

Researchers also say that universities are facing new challenges in
assessing the résumés of academics. Are the publications they list in
highly competitive journals or ones masquerading as such? And some
academics themselves say they have found it difficult to disentangle
themselves from these journals once they mistakenly agree to serve on their
editorial boards.

The phenomenon has caught the attention of Nature, one of the most
competitive and well-regarded scientific journals. In a news report
<> published
recently, the journal noted “the rise of questionable operators” and
explored whether it was better to blacklist them or to create a “white
list” of those open-access journals that meet certain standards. Nature
included a checklist on “how to perform due diligence before submitting to
a journal or a publisher.”

Jeffrey Beall, a research librarian at the University of Colorado in
Denver, has developed his own blacklist
<>of what he calls “predatory
open-access journals.” There were 20 publishers on his list in 2010, and
now there are more than 300. He estimates that there are as many as 4,000
predatory journals today, at least 25 percent of the total number of
open-access journals.

“It’s almost like the word is out,” he said. “This is easy money, very
little work, a low barrier start-up.”

dr.hanifa mbithe Replied at 10:00 AM, 5 May 2018

I think this is something very helpful especially in our tb endemic counties,as the disease burden seems to be worsening with immune compromised patients,I do hope I will seeing this soon in tanzani

dr.hanifa mbithe Replied at 10:04 AM, 5 May 2018

Oh I think I am lost in here,sorry moderator I hadn't read most of the messages up there,so this is not an article from ghd,OK now I understand after reading in detail.

Belayneh Dimah Replied at 3:25 AM, 10 May 2018

Dear all can it process 0.5 ml purulent sputum sample???

Belayneh Dimah Replied at 3:28 AM, 10 May 2018

With gene Xpert.....can we process less than 1ml....0.5 ml purulent sputum

Edward Nardell, MD Moderator Replied at 7:14 AM, 10 May 2018

Because our only source of information is the company, and the paper was
not detailed, we decided not to discuss this technology further until there
are more independent published results.

I worry that more unsubstantiated responses from the company could be

Ed Nardell, moderator.

Cristina Russo Replied at 10:42 AM, 10 May 2018

I use to process 0.5 of decontaminated sample

Cristina Russo MD
Responsabile Struttura Semplice
Dipartimento dei Laboratori
Tel. +39.06.6859.2219- 2599
Fax +39.06.6859.2218
Ospedale Pediatrico Bambino Gesù - IRCCS
Piazza Sant'Onofrio, 4 - 00165 Roma
Da: <> per conto di Edward Nardell, MD via GHDonline <>
Inviato: giovedì 10 maggio 2018 13:18:06
A: Russo Cristina
Oggetto: Re: Detection of Mycobacterium tuberculosis Antigen in Cough Samples in Northern Ethiopia

Edward Nardell, MD< replied to a discussion< in TB Infection Control<

Because our only source of information is the company, and the paper was
not detailed, we decided not to discuss this technology further until there
are more independent published results.

I worry that more unsubstantiated responses from the company could be

Ed Nardell, moderator.


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Marlon L. Bayot Replied at 7:43 PM, 10 May 2018

Hi, Belayne.

Based on the Global Laboratory Initiative (GLI) standards, the optimum sputum specimen volume and quality for Xpert MTB/Rif is 1-4 mL of mucopurulent sputum. Though the GeneXpert technology has high sensitivity and specificity, good and accurate results still largely depend on proper and adequate specimen collection.

(Hi, Dr. Edward. I am not sure if it still appropriate to answer this question under this discussion thread, however, I just wanted to share an answer to Belayne’s concern.)


Ellen Baron Replied at 3:38 PM, 11 May 2018

Hello colleagues: I thought I would reply on behalf of Cepheid regarding volume of sputum to process in Xpert Mtb/Rif and Mtb/RIF Ultra tests. As for any commercial product, always follow the instructions given in the Product Insert.
The Xpert Mtb/RIF (or Ultra) Product Insert says to estimate the volume of fresh, unconcentrated sputum, and then add an amount of Sample Reagent two times the volume of the specimen. However, the cartridge requires at least 2 ml of sample + reagent volume total liquid to run correctly. The included pipette has a line at the 2.0 mL mark to help you determine if you have sufficient volume to run the test.
If you had 0.5 mL sputum, added 1.0 mL of Sample Reagent, you would only have 1.5 mL total, which is not sufficient to test. So really, you need at least 0.7 mL of fresh sputum so if you add 1.4 mL of Sample Reagent (twice the volume of the sample), you now have 2.1 mL and you can pipette that complete amount into the cartridge and run the test.
If you choose to run a specimen with only 0.5 mL volume, and you add sufficient Sample Reagent (or 2 times volume Sample Reagent and then dilute the suspension with water or saline) to reach at least 2.0 mL total "treated" sample, then you have diluted the sample more than recommended, and you are running the test in an "off-label" manner. Now it becomes a "laboratory-developed test" and Cepheid cannot support the results or help you with discrepant results (false negative vs culture, for example).
That said, it is your choice. If there are sufficient organisms in that sample to yield a positive test result, that will of course be correct. The problem is for patients with low bacillary load, and the test result may be negative due to low volume of the actual sputum specimen getting processed. One issue with "Mtb VERY LOW" results is that they have a rare probability of reporting false-resistance to rifampin, as reported by Ocheratina, for example. We recommend confirming all Rifampin resistance results, but particularly when you have "very low" results for numbers of organisms in the sample. If you are also performing a microscopic exam along with Xpert and you see acid fast bacilli (smear-positive), then you would know that you have sufficient bacterial load to run a sample of 0.5 mL and dilute it a bit to bring the final test volume up to 2.0 mL. It is still considered off-label, but the chances of getting a false-negative result or a false rifampin resistant result due to "MTB VERY LOW" are much lower.

I hope this is clear and you can always send me private question to help with clarification.

Ellen Jo Baron, Ph.D., D(ABMM)
Consultant, Medical Affairs
MOBILE 650.380.6430

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Belayneh Dimah Replied at 2:18 AM, 12 May 2018

Many thanks Dr Ellen.... Your best explanation.


*Belayneh Dimah (MSc ,Med. Microbiology )Jimma UniversityJimma,EthiopiaPo
Box :94Mobile:+251911743623Alternative E-mail:
< Name:belayneh.dimah2*

Paco Trinchan Replied at 5:25 AM, 12 May 2018

Many thanks Dr E Baron for your time clariflying this issue, your
explanations about the GeneXpert test are always very clear and easy to

Eva Wakuganda Replied at 6:10 AM, 18 May 2018

Thank you for sharing this paper,it can be helpfull in Tb diagnosis in
children with a lot of false negatives due paucibacillary nature in sputum
and gastgastric aspirates.

Eva Wakuganda Replied at 6:18 AM, 18 May 2018

Sorry I did not other previous comments regarding the paper.

Joven Jebio Ongole Replied at 6:50 AM, 18 May 2018

In our program in rural South Africa, we have adopted compulsory education
of patients prior to sputum collection and since we started, the positive
yield have increased by 18 % in first three months and stabilized at 24%
Dr JJ Ongole

Edward Nardell, MD Moderator Replied at 8:38 PM, 18 May 2018

Eva, caution! Please wait for independent confirmation published in
reputable journals.

Lots of tests look good but don't pan out.

Ed Nardell

Eva Wakuganda Replied at 6:18 AM, 19 May 2018

Thank you Edward for the information its noted,I sent my comment before
reading previous comments regarding the paper,

Zea Rahim Replied at 11:48 PM, 19 May 2018

Dear Colleague,
It is a very encouraging news to increase case detection. May I know the tool you used for compulsory educaton.

Appreciate hearing your feedback.

Best wishes.

Dr. Md. Zeaur Rahim

Zeaur Rahim M. Phil, DRSU, Ph.D
Mycobacteriology Laboratory
International Centre for Diarrhoeal Disease
Research, Bangladesh
GPO Box 128, Dhaka 1000, Bangladesh
Telephone: 880 2 9827001-10 extn 2439, Cell phone: +8801712701920
Fax: 880 2 8812529, 880 2 8812530,
Email: <mailto:>, <mailto:>