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Tuberculosis and Public Health

  • Reducing mortality
    Can Malawi reduce death from TB to 25% of 2015 per capita rates by 2025? Which combination of new diagnostic strategies could improve the timeliness and completeness of TB diagnosis in paediatric populations?

    Improving case detection
    How can screening for undiagnosed TB and HIV be used to maximize health benefits and sustainability, while minimizing harms and costs?
    Can TB interventions be more effectively targeted through better understanding of urban social and TB transmission networks?

    Optimising TB treatment
    Which novel or repurposed TB regimens could shorten TB treatment?
  • Reducing mortality

    Death from undiagnosed TB makes up a substantial fraction of TB-mortality globally, and in Malawi – with PLHIV who are not on ART at extremely high risk of death from undiagnosed TB. Early mortality soon after diagnosis with HIV and with TB remains extremely high.
    Potential components of combination strategies to reduce TB mortality include:

    • Scale-up of HIV diagnosis and treatment

    • Urine- and CXR-based TB screening in in-patients and outpatients at high risk of TB

    • Behaviour change communication around

    • Treatment of co-morbidities More adjuvant broad spectrum antibiotics/anti-infectives have a strong case for large scale implementation with research.

    Improving case detection

    Both TB and HIV Global Control strategies rely heavily on scaling up early diagnosis and treatment, without which ambitious control targets will not be met. Home & community-based screening programmes achieve much greater coverage than facility-based strategies, but need to be effective and affordable and able to achieve satisfactory linkage into the next steps of facility-based confirmation, care and prevention. Community-led and patient-delivered interventions, with greater targeting, are among the possible solutions. Chest X ray with computer-assisted diagnosis offers a high throughput low sensitivity screening approach that is incompletely explored.

    Optimising TB treatment
    Shortening and/or simplifying TB treatment remain important research goals. Activity in clinical trials of treatment for TB has increased in recent years, especially in Sub-Saharan Africa and particularly Phase II studies. Our programme of work has established our capability and reputation in participating in these trials while also advancing laboratory and statistical methods for such studies.
  • Reducing mortality

    1.1. To design and rigorously evaluate the effectiveness and cost-effectiveness of existing and novel TB diagnostic interventions in healthcare settings to increase the yield of diagnosis, reduce the time to treatment, and reduce mortality from tuberculosis.

    Improving case detection

    • 2.1. To use the public health principles of epidemiology and surveillance

    (classical and genomic) to identifying areas of Blantyre with high prevalence of undiagnosed active tuberculosis and drivers of TB transmission to better direct targeted interventions.

    • 2.2. To use innovate statistical and randomised trial methods, - including pragmatic and Bayesian trial methods – to improve TB control, mitigate risk factors for TB, and provide high-quality evidence that is relevant to national, regional and global policymakers.

    Optimising TB treatment

    3.1. With partners in the College of Medicine of Malawi TB Research Group, develop capacity for undertaking RCTs of novel and optimized TB treatment regimens for adults and children.
  • Exciting Trial Results

    • STAMP 2018: Significant and substantial increase (1.5-fold) in pre-discharge TB diagnosis, with reduced mortality at 56-days in the 61% of patients who fell into at one of 3 pre-specified “high-risk” sub-groups (CD4<100; Hb<8g/dL; Clinically suspected TB) from urine-based TB screening on admission of otherwise unselected HIV+ve medical inpatients in Zomba and Edendale (South Africa).

    • CHEPTESA 2017 (Reduction in 1 year mortality for PLHIV with advanced [WHO Stage 3/4] who are screened for TB using symptoms+Xpert MTB/RIF rather than symptoms+Fluorescent microscopy at primary care level in rural Thyolo)

    Policy Impact: Urine LAM screening of in-patients now national policy in Malawi (May 2018) and South Africa (presented at the SA TB conference 2018). Fellowships:

    • Wellcome Trust Clinical Research Career Development Fellowship (5 years, £1.1 million, 2017-2022) to Peter MacPherson

    • Titus Divala HNTI and Commonwealth PhD Scholarships (2017-21) Publications: STAMP Trial (Lancet in press)

    High Level Meetings: Titus Divala and Bertie Squire spoke at the civil society hearing at the UN, New York in preparation for the UN General Assembly (UNGA) high-level meeting on tuberculosis (May 2018)

    Conference Leaderships: Two oral abstract presentations and 1 seminar session at the Union World Conference on Tuberculosis and Lung Health, The Hague, 2018.