Reasons for missed opportunities to screen and test for TB in healthcare facilities.

Missed opportunities for TB screening and/or passive testing in clinics continues to contribute to the number of missed cases. To understand reasons for these missed opportunities, we conducted focus group discussions with clinic-based nurses. Nurses described low indices of suspicion, prioritization of seemingly more urgent ailments and clinic operational challenges as barriers to TB screening and testing. To improve TB screening and testing in clinics, standard patients should be used to identify real-time factors that impact nurses' clinical decision-making and engage in real-time feedback and discussion with nurses to help optimize opportunities for TB screening and testing.

Les occasions manquées de dépistage de la TB et/ou de tests passifs dans les cliniques continuent de contribuer au nombre de cas manqués. Pour comprendre les raisons de ces occasions manquées, nous avons organisé des discussions de groupe avec des infirmières travaillant dans des cliniques. Les infirmières ont décrit les faibles indices de suspicion, la priorité accordée à des affections apparemment plus urgentes et les défis opérationnels des cliniques comme des obstacles au dépistage de la TB. Pour améliorer le dépistage et le test de la TB dans les cliniques, il faudrait utiliser des patients standard pour identifier les facteurs en temps réel qui influent sur la prise de décision clinique des infirmières et engager une rétroaction et une discussion en temps réel avec les infirmières pour aider à optimiser les occasions de dépistage et de test de la TB.

Aetiological testing compared with syndromic management for sexually transmitted infections in HIV-infected pregnant women in South Africa: a non-randomised prospective cohort study.

OBJECTIVE: To measure the frequencies of sexually transmitted infections (STIs) and adverse pregnancy outcomes among women receiving either aetiological testing or syndromic management for STIs. DESIGN: Non-randomised prospective cohort study. SETTING: Primary healthcare facilities in Tshwane, South Africa. POPULATION: HIV-infected pregnant women attending antenatal care services. METHODS: Participants were enrolled to receive aetiological testing using Xpert® CT/NG and Xpert® TV assays or standard syndromic management. Outcome data were collected at the postnatal care visit (≤30 days from delivery) and from maternity records. Enrolment gestational age-adjusted relative risk (aRR) was calculated. MAIN OUTCOME MEASURES: STI prevalence at postnatal visit, and frequency of adverse pregnancy outcomes (preterm birth, low birthweight). RESULTS: We enrolled 841 women. The prevalence of any STI at baseline was 40%; Chlamydia trachomatis 30%, Neisseria gonorrhoeae 5.6%, Trichomonas vaginalis 20%. The prevalence of STIs at postnatal care was lower among those receiving aetiological testing compared with those receiving syndromic management (14% versus 23%; aRR 0.61; 95% CI 0.35-1.05). No difference was observed between study groups for frequency of preterm birth (23% versus 23%; aRR 1.2, 95% CI 0.81-1.8) and low birth weight (15% versus 13%; aRR 1.1, 95% CI 0.66-1.7). CONCLUSIONS: Aetiological testing provides an effective intervention to reduce the high burden of STIs in pregnant women in South Africa; however, the optimal implementation strategy remains to be determined. TWEETABLE ABSTRACT: Aetiological testing effectively reduces the burden of sexually transmitted infections in pregnancy.

Acceptability and Feasibility of Integrating Point-of-Care Diagnostic Testing of Sexually Transmitted Infections into a South African Antenatal Care Program for HIV-Infected Pregnant Women.

Background: Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV) infections may increase the risk of vertical transmission of the human immunodeficiency virus (HIV). In resource-limited settings, symptomatic screening, and syndromic management of sexually transmitted infections (STIs) during pregnancy continue to be the standard of care. In the absence of diagnostic testing, asymptomatic infections in pregnant women go untreated. Objective: To describe the acceptability and feasibility of integrating diagnostic STI screening into first antenatal care visits for HIV-infected pregnant women. Methods: HIV-infected pregnant women were recruited during their first antenatal care visit from three antenatal care clinics in Tshwane District, South Africa, between June 2016 and October 2017. Self-collected vaginal swabs were used to screen for CT, NG, and TV with a diagnostic point-of-care (POC) nucleic acid amplification test. Those with STIs were provided treatment per South African national guidelines. Results: Of 442 eligible women, 430 (97.3%) agreed to participate and were tested. Of those with a positive STI test result (n = 173; 40.2%), 159 (91.9%) received same-day results and treatment; 100% of STI-infected women were treated within seven days. Conclusions: Integration of POC diagnostic STI screening into first-visit antenatal care services was feasible and highly acceptable for HIV-infected pregnant women.

Estimating the magnitude of pulmonary tuberculosis patients missed by primary health care clinics in South Africa.

SETTING: The present study was conducted at 20 randomly selected primary health clinics across Buffalo City Metropolitan Health District, a high TB burden district in South Africa. OBJECTIVE: To estimate the proportion of TB patients missed by primary health clinics. DESIGN: We enrolled 1255 TB-symptomatic individuals exiting primary health clinics between March and December 2015. Participants were interviewed and asked to provide sputum for Xpert® MTB/RIF testing. RESULTS: Clinic staff screened 79.1% of participants seeking care for TB-related symptoms and 21.9% of those attending a clinic for other reasons (P < 0.001). Of those screened by clinic staff, 21.5% reported submitting sputum, although only 9.8% had available results. Study staff tested sputum from 779 participants not tested by clinic staff. Of these, 39 (5.0%) individuals tested positive for TB, three of whom were rifampicin-resistant; 15/39 (38.5%) were never screened and 24/39 (61.5%) were screened but not tested by clinic staff. We estimate that the health system missed 62.9-78.5% of TB patients attending primary health clinics for TB-related symptoms and 89.5-100% of those attending a clinic for other reasons. CONCLUSION: Low rates of TB screening and testing by the health system resulted in missed TB patients. Universal TB screening and testing of symptomatic individuals should be instituted in high TB burden communities in South Africa.

Several carcinoembryonic antigens (CD66) serve as receptors for gonococcal opacity proteins.

Neisseria gonorrhoeae (GC) is a human pathogen that adheres to and invades genital surfaces. Although pili are required for the initial adherence, the interaction of GC with epithelial cells is also promoted by a family of outer membrane proteins, the opacity (Opa) proteins such as OpaA protein from strain MS11. Studies have demonstrated that the interaction of the OpaA GC with epithelial cells involves binding to heparan sulfate attached to syndecan receptors. However, other Opa proteins interact with CEA gene family member 1 (CGM1) or biliary glycoprotein (BGP), members of the CD66 antigen family. In this study, we demonstrate that, in addition, the 180-kD carcinoembryonic antigen (CEA) is a receptor for Opa proteins. This conclusion was based on the following observations. First, transfected HeLa cells expressing CEA (HeLa-CEA) and the CEA-expressing colon cancer cell line (LS 174T) bound and subsequently engulfed the Opa+ bacteria. These interactions were inhibited by anti-CEA antibody, but could not be inhibited by addition of heparin. Furthermore, OpaI E. coli directly bound purified CEA. We also compared the adherence and invasion by Opa+ bacteria of CD66 transfected HeLa cells: HeLa-BGPa, HeLa-CGM6, HeLa-NCA, HeLa-CGM1a, HeLa-CEA, and HeLa-Neo serving as negative control. Using OpaI as the prototype, the relative ability of the transfected HeLa cell lines to support adherence was (CEA = BGPa >CGM1a >NCA >>CGM6 = Neo). The ability to mediate invasion of the transfectant cells was (CGM1a >CEA >BGPa >NCA >CGM6 = Neo). Among the Opa proteins tested, OpaC proved to be bifunctional, able to mediate adherence to both syndecan receptors and to CD66 antigens.