Newsletter: Edition 8

Dear colleagues,  

I am happy once again to greet you. As we move into summer, we’ve seen many recent successes within the TB Think Tank. Workplans for fiscal 2024/25 have been approved, and many projects are in the works. An external TB Think Tank evaluation was recently completed by colleagues at the University of the Western Cape, with results available here. To read more about the current work of the Think Tank and updates from the National Department of Health.

Read the full story here.

The updated paediatric TB guidelines have been officially released, thanks to the hard work of the Child, Adolescent and Maternal TB working group. The Optimising Treatment Outcomes Task Team have also recently developed a package of care for severely ill people living with HIV hospitalised with possible TB which is soon to be released.  

The Finding Missing People with TB Task Team has finalised a Standardised Operating Procedure for the use of dCXR for TB screening in South Africa which will be circulated shortly. They are also overseeing a dCXR optimisation project reviewing practices at several sites nationwide.  

The Epidemiology, Modelling, and Health Economics Task Team recently hosted a Modelling symposium, the report for which can be found here. The Data Systems and Innovations Task Team has commissioned an evaluation of TB data access, quality, and usage to understand the flow of data and alignment to client flow as well as assessing the integrity of the data as it is aggregated to the national level.  In addition, the evaluation will help determine what type of data is required at each health system tier for program management. The evaluation is in the works by colleagues from the Desmond Tutu TB Centre in collaboration with the Health Information Systems Program. The DSI Task Team have also struck a technical working group to support the development of a national TB dashboard.  

 The TB Prevention Task Team recently participated in a workshop for social and behavioural change communication focussed on developing a set of stories that represent the diversity of TB experiences across the country. They have also been liaising with members of the Joint Effort for Elimination of Tuberculosis (JEET) project in India to share ideas about best practices for building sustainable structures to strengthen existing systems and extend quality care to people with TB. Leaders of the TB in the Mines working group helped organise a workshop on developing computer-aided detection for silicosis, implementing CAD for TB in mining communities, and the prospect of introducing ultra-portable digital chest x-ray machines for mining communities.  

Other highlights from the National Department of Health include:  

  • The National TB Strategic Plan was presented at a special TB Think Tank webinar on 22 Aug. The implementation of the Strategic Plan is covered under TB Recovery Plan 3.0 which is currently under way.   
  • South Africa’s cycle 7 Global Fund Proposal has been submitted.  
  • A TB vaccine working group, including representation from the TB Think Tank, has been struck under the leadership of Dr Waasila Jassat and falls under the auspices of the National Advisory Group on Immunization. The working group’s mandate includes evaluating the efficacy, safety, and cost effectiveness of TB vaccine candidates, identifying priority groups for early uptake, developing recommendations for TB vaccine introduction, and informing TB vaccine service delivery strategies.

Imagine a world where cutting-edge technology helps miners breathe easier. That’s exactly what was on the table at a three-day workshop hosted by Medical Bureau for Occupational Disease-Compensation Commissioner for Occupational Diseases (MBOD/CCOD), the STOP TB Partnership, University of British Columbia (UBC) and the Southern Africa Mining Association (SAMA) from June 20th to 22nd, 2024.

Held at the Radisson Blu Hotel, the workshop brought together a powerhouse group of stakeholders – from mining companies, vendors, health regulators (SAHPRA, IAEA, etc) , advocacy organizations, non-government organisations, some SADC ministries of health (Mozambique, Malawi etc.) and international bodies like WHO, and the Global Fund. Their mission? To explore how AI and computer-aided detection (CAD) systems can change the game for detection of silicosis and tuberculosis (TB) in South Africa’s mining communities.

Why CAD Matters
CAD technology is already proving to be a game changer in screening for TB and silicosis via  chest X-rays (CXRs).

Read the full story here.

During the workshop, experts highlighted how these AI-driven systems deliver high sensitivity and specificity, often outshining human readers. The benefits go beyond accurate diagnosis – they help chip away at the backlog of lung exams for miners’ compensation claims, ensuring workers get the care they need faster.
The discussion also zoomed in on why CAD is particularly crucial for the mining industry:

  • The high burden of TB and silicosis in miners.
  • Complex radiological challenges where traditional diagnostics might fall short.
  • Cost-effectiveness – AI isn’t just smart; it’s financially savvy.
  • Better patient outcomes – early detection leads to quicker treatment.
  • Smoother compensation – helping qualifying miners get financial support faster.

Thanks to a Global Fund initiative, the general communities with difficulties accessing health care services already uses CAD for TB screenings via mobile and fixed-Container digital x-rays. But the real buzz is the pilot program for CAD in silicosis currently underway in Mozambique, which is ripe for further development.
The Road Ahead
The consensus? CAD for TB and silicosis in mining is the future. The South African Department of Health’s MBOD/CCOD, mining companies, and other stakeholders are ready to accelerate CAD implementation. to make this happen. Here’s a peek at what’s next:

  1. Establish a research team with partners from University of British Columbia (UBC), UCT, Mozambique’s Ministry of Health, and WITS to develop CAD and mining-related research projects.
  2. Bring mining companies on board. (They’ve agreed to share data for training and validating CAD systems)
  3. The MBOD and STOP TB Partnership are drafting a Memorandum of Understanding (MOU) with vendors to facilitate CAD development, and a protocol for CAD and use of portable X-ray units in field settings in Mozambique is under review.
  4. Vendors gain access to a comprehensive dataset for training and validation, setting the stage for field implementation.
  5. Field testing in Mozambique will kick off, with real-world monitoring and evaluation scheduled for April 2025.
  6. The pilot for South African mining, peri mining and ex-mine workers will be implemented in 2025.

This workshop marks a major step toward leveraging AI and CAD to tackle the heavy burden of occupational lung diseases in mining communities. From cutting through diagnostic complexity to improving compensation for affected miners, the future of occupational health looks brighter with these advanced tools leading the way. Stay tuned as South Africa and Mozambique prepare to roll out CAD, use of portable X-ray units and give miners a breath of fresh air!

Cutting-edge solutions are shaping the fight against TB in people living with HIV! Discover the latest policy briefs highlighting the transformative potential of Urine Xpert Ultra for rapid TB diagnosis in hospitalized HIV patients, and the game-changing benefits of simultaneous initiation of TB preventive therapy and dolutegravir-based ART.

Read the full story here.

Stay informed on how these innovations are improving treatment outcomes and saving lives. 

The Optimising Treatment Outcomes Task Team endorsed the findings of recent work of Dr Bianca Sossen (UCT) and team on the use of Urine Xpert Ultra to aid in the timely TB diagnosis of hospitalised people living with HIV (PLHIV), the pre-print for which is available here. Recognising that many hospitalised PLHIV in whom TB is a concern are unable to produce sputum and urine LAM has a limited sensitivity, the use of Xpert Ultra testing on urine specimens can aid in the early diagnosis of TB, preventing unnecessary mortality is an especially vulnerable population. The figure below highlights the added advantage of urine Xpert in addition to the use of Xpert on sputum specimens and urine LAM in accordance with current guidelines.   

Findings were recently presented and endorsed at a TB Think Tank Executive Committee meeting, and steps for piloting the recommendations are underway. Watch the TB Think Tank webinar on the topic here.   

Read the full story here.

The TB Prevention Task Team has endorsed the findings of the Dolphin Too Study, a Phase I/II comparative trial of TB preventive treatment in the form of 3 months of once-weekly isoniazid and rifapentine (3HP) versus 6 months isoniazid (6H) among antiretroviral-naïve people living with HIV initiating a dolutegravir-containing (DTG) regimen in South Africa. Although the World Health Organisation and South African National Department of Health already recommend the use of 3HP for people living with HIV, its use for antiretroviral-naïve individuals starting DTG-based regimens had not been rigorously studied, and thus its use in this population was omitted from current guidelines. The Dolphin Too Study was conceived to address this gap, considering the safety and DTG pharmacokinetics during coadministration of DTG and 3HP versus 6H as well as HIV viral load. The study found the simultaneous start of 3HP and DTG-based antiretroviral therapy was safe, well-tolerated, and achieved rapid and maintained viral suppression. Pharmacokinetic results were also favourable, with robust DTG troughs observed. A 72% induction effect of rifapentine on DTG clearance was observed, and DTG troughs were significantly lower in the 3HP group than the 6H group at weeks 3 and 8, but still sufficient to achieve and maintain HIV viral load. More detail on the findings can be found in a Union World Conference 2023 abstract (abstract no. LB01-100-15, page S616) and in September’s TB Think Tank webinar. The Prevention Task Team is currently working with the National Department of Health to suggest updates in TPT guidance to reflect the study findings.  

Updated guidance on the use of Isoniazid Preventive Therapy in pregnant women  

Last year, the TB Think Tank worked with the National Department of Health to resolve a discrepancy between South Africa’s 2023 Guidelines for the Treatment of Latent TB Infection and the 2023 ART Clinical Guidelines concerning the timing of TB preventive treatment (TPT) in pregnant women living with HIV (WLHIV). The guidelines for the treatment of latent TB infection recommended 12 months isoniazid (12H) be initiated in WLHIV during pregnancy regardless of CD4 cell count, while an early draft of the ART clinical guidelines recommended deferral until 6 weeks post-partum for WLHIV with CD4 cell counts above 350µm/L. The matter was taken up be the National Essential Medicines List Committee (NEMLC) in 2024, and a decision was published in NEMLC’s March 2024 Bulletin (see page 4), indicating that isoniazid preventive treatment should be deferred until 6-weeks post-partum in all pregnant women to mitigate risk of harm and simplify clinical guidance. The TB Prevention Task Team will work with the National Department of Health to update the Guidelines for the treatment of latent TB infection accordingly.   

In this edition, we feature Dr. Barry Kistnasamy, a public health medicine specialist with over 25 years of impactful contributions in health policy, research, and advocacy. 

Read the full story here.

Barry Kistnasamy is a public health medicine specialist, and he obtained his Bachelor of Medicine and Bachelor of Surgery (MBChB) and MMed (Community Health) from the then University of Natal in South Africa (now University of KwaZulu-Natal). He later furthered his studies in complementary pillars, which includes; i) education and training in health economics at the University of York in the United Kingdom, ii) occupational and environmental health at the University of Michigan in the United States, iii) advanced epidemiology at Tufts University in the United States, and iv) health leadership at the University of Cambridge in the United Kingdom. 

He has over 25 years of experience in health policy development, health planning, research, national and international collaboration, public health advocacy, public health surveillance, outbreak preparedness and response, healthcare innovations, leadership and management in both public and private sectors and non-government organisations. 

The key aspects of his career and expertise spans across the provision of occupational health, HIV/AIDS and tuberculosis interventions in occupational health settings. He has worked with the World Health Organization, the International Labour Organization, and the World Bank and has served on many national and international boards, committees, and commissions. He served in the South African Department of Defence during the integration of the armed forces; was the Deputy Director-General and head of health, welfare, and environment in the Northern Cape province during the first term of the democratic government; and served as the Dean of the Nelson Mandela School of Medicine in Durban. He also served as the Executive Director of the National Institute for Occupational Health and the National Cancer Registry and led the initial discussions on the development of the National Public Health Institutes of South Africa. 

He currently serves as Compensation Commissioner for occupational diseases covering compensation for occupational diseases in the mines and works sector in South Africa. His work emphasizes addressing historical injustices faced by migrant miners regarding prevention, care and compensation for occupational lung diseases. He played a crucial role in the preparedness for the Ebola outbreak response and recently in the workplace programme for the COVID-19 pandemic. Dr Kistnasamy has co-authored numerous publications on occupational health, with a focus on silicosis and tuberculosis. His recent work explores the use of artificial intelligence and computer-aided detection for screening of occupational lung diseases and climate change and health. He takes pride in mentoring, supporting and coaching the upcoming public health specialists, epidemiologists and other junior health professionals. 

Dr Kistnasamy’s work continues to significantly impact public health in South Africa and the region, particularly in the areas of occupational health, workers’ compensation, and the intersection of technology with healthcare delivery. He currently serves as the co-chair of the TB Think Tank for TB in the Mines Working Group.

Don’t miss our upcoming webinar series, scheduled for every third Monday of the month, unless otherwise noted! Mark your calendar for October 21st as we dive into Levofloxacin for MDR-TB prevention in child contacts, featuring insights from the TB-CHAMP trial.

If you’ve missed any recent sessions, don’t worry! Catch up on key discussions from our past webinars using the links below. Join the conversation, stay informed, and be part of the movement driving TB innovation forward!

Our TB Think Tank members and associates have been actively contributing to the global TB research landscape with a host of impactful new publications! These studies address critical issues such as health-seeking behaviours, TB treatment initiation delays, and the effects of the COVID-19 pandemic on TB diagnosis and care. Explore groundbreaking work ranging from drug-resistant TB in infants to mHealth technologies for TB case finding, as well as innovative TB diagnostics like tongue swabs and the flex Xpert MTB/XDR testing. Catch up on these cutting-edge insights and stay informed on the latest advancements driving TB care forward!

  1. Sathar F, Charalambous S, Velen K, et al. Health-seeking behaviour and patient-related factors associated with the time to TB treatment initiation in four African countries: a cross-sectional survey.
    https://doi.org/10.1136/bmjph-2024-001002  DOI: https://bmjpublichealth.bmj.com/content/2/2/e001002
     
  2. Loveday M, Gandhi R, Khan P, Theron G, Hlangu, S, Holloway K, et alCritical assessment of infants born to mothers with drug resistant tuberculosis
    DOI: https://doi.org/10.1016/j.eclinm.2024.102821
    https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(24)00400-0/fulltext
     
  3.  Jennings K,  Lembani M, Hesseling A, Mbula N, Mohr-Holland E,  Mudaly V, Smith M, Osman M, Meehan S
    A decline in tuberculosis diagnosis, treatment initiation and success during the COVID-19 pandemic, using routine health data in Cape Town, South Africa
    DOI: https://doi.org/10.1371/journal.pone.0310383
    https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0310383 
     
  4. Holtgrewe LML, Johnson A, Nyhan K, Boffa J, Shenoi SV, Karat AS, Davis JL,
    Charalambous S
    Burden of tuberculosis in underserved populations in South Africa: A systematic review and meta-analysis
    DOI: https://doi.org/10.1371/journal.pgph.0003753 
    Burden of tuberculosis in underserved populations in South Africa: A systematic review and meta-analysis | PLOS Global Public Health
     
  5.  Baloyi DP,  Myburgh H,  Bester D, Anthony GM, Switala J, Schaaf HS, Naidoo L, Solomons R, Nuttall J, Murray J, Rohlwink U, Figaji A, Hoddinott G, Du Preez K
    Navigating complex care pathways–healthcare workers’ perspectives on health system barriers for children with tuberculous meningitis in Cape Town, South Africa
    DOI: https://doi.org/10.1371/journal.pgph.0003518
    https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-024-00934-9  
     
  6. Steinhaus, M.C., Nicholson, T.J., Pliakas, T. et al.
    Prevalence and risk of burnout among HIV service providers in South Africa and Zambia: findings from the HPTN 071 (PopART) trial.
    https://doi.org/10.1186/s12960-024-00934-9
    https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-024-00934-9  
     
  7. Purchase SE, Wademan DT, Tshetu NL, Rafique M, Hoddinott G, Seddon J,
    Schaaf SH, Hesseling A
    Holistic acceptability of an adult levofloxacin formulation in children and adolescents on a tuberculosis preventive treatment trial
    DOI: https://doi.org/10.1186/s12960-024-00934-9
    https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0003381
     
  8. Andama A, Steadman AE, Ahls C, Cangelosi G, David A, de Vos M, Heichman K, Kato-Maeda K, Penn-Nicholson A, Scott L, Turnbull K, Wood R, Weigel K, Cattamanchi A,
    Consensus standard operating procedure for collection of tongue swabs for TB diagnostics v1. Protocols.io.
    DOI: https://dx.doi.org/10.17504/protocols.io.kxygxyw54l8j/v1
    https://www.protocols.io/view/consensus-standard-operating-procedure-for-collect-dfhy3j7w.html
     
  9. Ahls, C., David, A., Chilambi, G.S., Cattamanchi, A., de Vos, M., Heard, K., Heichman. K., Penn-Nicholson. A., Scott, L., Steadman, A.E., Turnbull, K., Alland, A.
    Xpert MTB/RIF Ultra testing from tongue swabs – Diluted SR method. Protocols.io.
    DOI: https://dx.doi.org/10.17504/protocols.io.14egn69nyl5d/v1
    https://www.protocols.io/view/xpert-mtb-rif-ultra-testing-from-tongue-swabs-dilu-dfjf3kjn.html 
     
  10. Centner CM, Munir R, Tagliani E, Rieß F, Brown P, Hayes C, Dolby T, Zemanay W, Cirillo DM, David A, Schumacher SG, Denkinger CM, Ruhwald M, Leukes VN, Nicol MP, Van der Walt I, Kisten G, Gumede M, Mace A, Brink A, Stevens W, Scott L, Penn-Nicholson A, Cox H, on behalf of the TB-CAPT Consortium
    flex Xpert MTB/XDR testing of residual rifampicin resistant specimens: a clinical laboratory-based diagnostic accuracy and feasibility study in South Africa
    DOI: https://doi.org/10.1093/ofid/ofae437
    https://pubmed.ncbi.nlm.nih.gov/39165581/
     
  11. Mudzengi DL, Chomutare H, Nagudi J, Ntshiqa T, Davis JL, Charalambous S, Velen K.
    Using mHealth Technologies for Case Finding in Tuberculosis and Other Infectious Diseases in Africa: Systematic Review.
    DOI: https://doi.org/10.2196/53211
    http://www.ncbi.nlm.nih.gov/pmc/articles/pmc11384173/
     
  12. Charalambous S, Maraba N, Jennings L, Rabothata I, Cogill D, Mukora R, Hippner P, Naidoo P, Xaba N, Mchunu L, Velen K, Orrell C, Fielding KL.
    Treatment adherence and clinical outcomes amongst in people with drug-susceptible tuberculosis using medication monitor and differentiated care approach compared with standard of care in South Africa: a cluster randomized trial.
    DOI: https://doi.org/10.1016/j.eclinm.2024.102745 http://www.ncbi.nlm.nih.gov/pmc/articles/pmc11338121/
     
  13. Hamada Y, Quartagno M, Malik F, Ntshamane K, Tisler A, Gaikwad S, Acuna-Villaorduna C, Bhavani PK, Alisjahbana B, Ronacher K, Apriani L, Becerra M, Chu AL, Creswell J, Diaz G, Ferro BE, Galea JT, Grandjean L, Grewal HMS, Gupta A, Jones-López EC, Kleynhans L, Lecca L, MacPherson P, Murray M, Marín D, Restrepo BI, Shivakumar S, Shu E, Sivakumaran D, Vo LNQ, Webb EL, Copas A, Abubakar I, Rangaka MX. Prevalence of non-communicable diseases among household contacts of people with tuberculosis: A systematic review and individual participant data meta-analysis.
    DOI: https://doi.org/10.1111/tmi.14038
    https://pubmed.ncbi.nlm.nih.gov/39073229/

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