Dried Blood Spot Test to Assess TB in Pregnancy (DROPTB2)

Dried Blood Spot Test to Assess TB in Pregnancy in Remote and Resource Limited Areas

Despite being a key contributor to maternal mortality in high-burden regions, TB in pregnancy is a hugely neglected area of global public health. During pregnancy, the symptoms of TB are often overlooked and undiagnosed because they are vague, non-specific, and can be very similar to common complaints during pregnancy. Women with TB in pregnancy are at an increased risk of anemia and perinatal death.

The DROP-TB project aims to expand the tuberculosis (TB) detection testing in pregnancy by creating a system where blood samples are collected from women at their local healthcare clinics instead of/or at national-level TB diagnostic centres where visits can require substantial travel and cost. Blood samples collected in specific RNA stabilizing tubes and on specific storing paper filters are collected from pregnant women with presumptive TB and transported to a central TB testing facility and analyzed by real-time polymerase chain reaction (qPCR).

The DROP-TB method measures the mRNA expressions known to be markers of TB infection and disease. Based on veinous blood sampling, those signatures have showed high sensitivity (93%) and specificity (97%), can differentiate between active and latent infection, and performs well in the presence of other infections such as HIV. The DROP-TB program was specifically designed to increase the coverage of TB testing in pregnancy to improve health outcomes for women and their unborn children.

The evidence generated from this program will demonstrate the feasibility of this program in providing TB diagnosis to women in rural and remote regions of LMIC with the example of Madagascar. Evidence will be presented to policy makers as a case to support the national scale up of the program in LMICs.

Study Overview

• Status: Completed
• Conditions: Tuberculosis
• Intervention / Treatment: Diagnostic test: 3G DBS; Diagnostic test: Sputum Test; Diagnostic test: 3G Veinous Blood

Detailed Description

With this Grand Challenges Canada Transition to scale DROP-TB program, the Institut Pasteur de Madagascar will:

1. Conduct a validation trial of the DROP-TB screening program in rural Madagascar, enrolling 3,500 women with presumptive TB, of which ~1,229 will be pregnant women
2. Support the development of laboratory capacity to collect veinous, DBS and other samples for qPCR at the 101 TB testing centres participating in the trial and implement standard operating procedures for DROP-TB testing
3. Assess the implementation and cost of the shipping program to bring different type of blood samples from community-based centres to national health centres for testing.

This is a cross -sectional study conducted on pregnant women suspected of having pulmonary TB (n = 1300), pregnant women without apparent pathology (controlled pregnant women), TB indemnity and without notion of tuberculous contact ( n = 50) and non -pregnant women were also free of TB and without a notion of tuberculous contact to control for tests (n = 50).

The sample size was calculated in the hypothesis of a conservative situation by comparing confirmed tuberculous participants (positive gold standard diagnostic test) and non -tuberculous (negative gold standard diagnostic test). The blood signature measured on venous blood samples showed a sensitivity of 93% in pregnant women. If the acceptable sensitivity for the new testing method is estimated at 96% and the prevalence of pulmonary TB in pregnant women in peripheral health centers is 12% and a precision of ± 7 is desired %and an α risk of 5%, a potency of 80%, the required sample size is 1167 pregnant women of which 140 are bacteriologically confirmed as active TB and 1027 controls. Considering an enrollment or rejection rate of 20%, the total needed sample would be 1,400 pregnant women in the CDT functions in the regions of Madagascar.

1. Data collection:

   Clinical data as well as biological samples (blood and sputum samples) are collected at the inclusion, the samples are analyzed at the Pasteur Institute of Madagascar.

   The data collection is done on paper based questionnaire where the data of each patient is recorded. The results of biological tests, paraclinical investigations as well as their results are also be recorded for each participant with the help of this questionnaire.

2. Data entry:

   The data are collected and transferred to a single database (REDCap). The REDCap system is compliant with the FDA standard CRF-21 part 11 as a reliable tool that allows to improve data quality and guarantee traceability. The data is stored on an IPM's secure server.

3. Data management and quality control:

   Data management is carried out by the IPM's Epidemiology and Clinical Research Unit (EPI-RC) data management team which closely collaborate with the study coordinators.

   Access to this database is restricted and secure. The list of persons with access rights appears in the data management manual. The data manager of the study is responsible for the security and quality of the data. A list of errors and inconsistencies detected in the database are regularly sent to the field team to make corrections. This regular monitoring will allow to improve the quality of the database. The request for partial or total extraction of the database must be the subject of a manuscript request and must have the consent of the epidemiological coordinator and scientific managers of the project.

4. Statistical analyzes:

   The entire study data is grouped into a single database and cleaned prior to any statistical processing of the data. All statistical analyzes will be performed on the GraphPad PRism and R software (http://www.R-project.org/) by designated competent persons for each data category studied.

5. Management of Potential Unnecessary Events:

   All undesirable events, observed during the study will be recorded in an observation register, which is either their severity and the link with the study procedures.

   Events will be coded using the 10th International Classification of Diseases (CIM-10) http://apps.who.int/classifications/icd10/browse).

6. Quality assurance:

Project investigators ensure the internal monitoring of the project at the study sites and are directly responsible for the collection, storage and transportation of the samples. Experienced laboratory technologists are in charge of manipulating and preparing samples for qPCR and DBS techniques at IPM.

Investigators and coordinators ensure that:

• the protocol is followed
• the recruitment of participants is done according to the planned schedule;
• Biological samples are labeled appropriately and consistently;
• the data is coherent and collected, recorded and secured as indicated in the data management plan of the study

The Coordinator and supervisors, recruited by the IPM, plan to visit the study sites regularly and is authorized to inspect the study documents so that patient confidentiality is maintained, in accordance with local regulations. The investigator cooperates with the coordinator so that any problems are identified during these control visits or resolved.

IPM has specific quality controls and assurance procedures developed and maintained in its laboratories and research units.

• Study Type: Observational
• Enrollment (Actual): 1424

Contacts and Locations

Study Locations

• Madagascar
  • Amoron'i Mania
    • Ambositra, Amoron'i Mania, Madagascar
      • CHRR Ambositra, CDT Ivato
  • Analamanga
    • Antananarivo, Analamanga, Madagascar, 101
      • CSBII Ivato, AMIT Behoririka, OSTIE Behoririka, CSB II Tanjombato, CSB II Analamahitsy
    • Antananarivo, Analamanga, Madagascar
      • CSB II Isotry Central, Dispensaire SALFA 67 ha, Centre Hospitalier d'Ambohidroa
    • Antananarivo, Analamanga, Madagascar
      • CSBII Ambohimanarina, CSB II Anosipatrana, CSB II Ambohipo, CHRD Itaosy
    • Antananarivo, Analamanga, Madagascar
      • Dispensaire SALFA Ambohibao, Centre Hospitalier de Soavinandriana, Dispensaire ECAR Anatihazo Isotry,
    • Antananarivo, Analamanga, Madagascar
      • Service de Pneumo-phtisio CHU Befelatanana, CHU de Soins et Santé Publique Analakely (CHUSSPA)
    • Fenoarivo, Analamanga, Madagascar
      • CHU Fenoarivo
  • Atsimo Andrefana
    • Tulear, Atsimo Andrefana, Madagascar
      • DAT Toliara, SALFA Betela Toliara, Service Pneumo du CHU Toliara, Clinique Saint Luc
  • Atsinanana
    • Toamasina, Atsinanana, Madagascar
      • DAT Toamasina, CHU PPH Toamasina, SALFA Toamasina, CSBII Foulpointe
  • Boeny
    • Mahajanga, Boeny, Madagascar
      • DAT Mahabibo, SALFA Antanimalandy, Service de Pneumologie CHU Androva
  • Haute Matsiatra
    • Fianarantsoa, Haute Matsiatra, Madagascar
      • Service Pneumo du CHU Fianarantsoa, SALFA Ivory Atsimo, CHRD1 Ambohimahasoa, CHRD1 Ambalavao
  • Vakinankaratra
    • Antsirabe, Vakinankaratra, Madagascar
      • CHRR Antsirabe, SALFA Andranomadio, CSB II Mandoto, CSB II Ambohibary , CSB II Ambohibary

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 15 years and older (Child, Adult, Older Adult)
• Accepts Healthy Volunteers: Yes

• Sampling Method: Non-Probability Sample

Study Population

All pregnant women addressed to 101 TB diagnostic and treatment centers of Madagascar

Description

Inclusion Criteria:

1. Group cases:

   • pregnant women aged over 15 adressed to TB diagnostic and treatment centers for a bacteriological diagnosis of pulmonary TB
   • Or with one or more symptoms of presumptive TB: cough, fatigue, weight loss, fever, chills, night sweats, shortness of breath, loss of appetite
   • agreed to participate in the study with full knowledge of the facts and signed an informed consent

2. Group control:

   • pregnant women over 15 years referred to a prenatal health center,
   • without known or clinically observed pathology associated with pregnancy
   • agreed to participate in the study with full knowledge of the facts and signed an informed consent

Exclusion Criteria:

1. Group cases :

   • Patients undergoing TB treatment for more than 2 weeks
   • Treatments with immunosuppressive drugs (≥ 14 consecutive days);
   • Progressive disease which does not allow venous blood sampling and venous capillary sampling;
   • All other clinical manifestations deemed incompatible for the study

2. Group Control :

   • No clinical signs of TB, no history of previous TB
   • No other known or clinically observed pathologies

Study Plan

How is the study designed?

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Pregnant women suspected TB; This group enrolled as cases	Diagnostic test: 3G DBS; Collection of capillary blood samples for the 3G q-PCR test; Other Names: 3G qPCR test with Dried Blot Spot Samples; Diagnostic test: Sputum Test; Collection of sputum for test culture, microscopy, GeneXpert; Other Names: Culture sputum; GeneXpert Sputum; Microscopy Sputum; Diagnostic test: 3G Veinous Blood; Collection liquid veinous blood for the 3G q-PCR test
Pregnant women without signs suspected TB; This group enrolled as controls	Diagnostic test: 3G DBS; Collection of capillary blood samples for the 3G q-PCR test; Other Names: 3G qPCR test with Dried Blot Spot Samples; Diagnostic test: 3G Veinous Blood; Collection liquid veinous blood for the 3G q-PCR test

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
diagnostic feature of test 3 G q-PCR capillary blood compared to gold stantard test	The diagnostic performance are estimated by the sensitivity and specificity of the 3G q-PCR test with capillary blood compared to the sputum test as gold standard	at inclusion
diagnostic feature of test 3 G q-PCR capillary blood compared to 3 G q-PCR veinous blood	The diagnostic performance are estimated by the sensitivity and specificity of the 3G q-PCR test with capillary blood compared to the 3 G q-PCR veinous blood as a reference test	at inclusion

Collaborators and Investigators

• Sponsor: Institut Pasteur de Madagascar
• Collaborators: Johns Hopkins Bloomberg School of Public Health; National Tuberculosis Program, Madagascar; Analakely Hospital University Care and Public Health, Madagascar; Virginia-Maryland College Veterinary Medecine, Blacksburg
• Investigators: Principal Investigator: Niaina RAKOTOSAMIMANANA, PhD, Institut Pasteur Madagascar

Publications and helpful links

General Publications

• Sweeney TE, Braviak L, Tato CM, Khatri P. Genome-wide expression for diagnosis of pulmonary tuberculosis: a multicohort analysis. Lancet Respir Med. 2016 Mar;4(3):213-24. doi: 10.1016/S2213-2600(16)00048-5. Epub 2016 Feb 20.
• Sharma A, Jaiswal S, Shukla M, Lal J. Dried blood spots: concepts, present status, and future perspectives in bioanalysis. Drug Test Anal. 2014 May;6(5):399-414. doi: 10.1002/dta.1646. Epub 2014 Apr 1.
• McAllister G, Shepherd S, Templeton K, Aitken C, Gunson R. Long term stability of HBsAg, anti-HBc and anti-HCV in dried blood spot samples and eluates. J Clin Virol. 2015 Oct;71:10-7. doi: 10.1016/j.jcv.2015.07.303. Epub 2015 Jul 29.
• Rakotosamimanana N, Raharimanga V, Andriamandimby SF, Soares JL, Doherty TM, Ratsitorahina M, Ramarokoto H, Zumla A, Huggett J, Rook G, Richard V, Gicquel B, Rasolofo-Razanamparany V; VACSEL/VACSIS Study Group. Variation in gamma interferon responses to different infecting strains of Mycobacterium tuberculosis in acid-fast bacillus smear-positive patients and household contacts in Antananarivo, Madagascar. Clin Vaccine Immunol. 2010 Jul;17(7):1094-103. doi: 10.1128/CVI.00049-10. Epub 2010 May 12.
• Ostler MW, Porter JH, Buxton OM. Dried blood spot collection of health biomarkers to maximize participation in population studies. J Vis Exp. 2014 Jan 28;(83):e50973. doi: 10.3791/50973.
• Gruner N, Stambouli O, Ross RS. Dried blood spots--preparing and processing for use in immunoassays and in molecular techniques. J Vis Exp. 2015 Mar 13;(97):52619. doi: 10.3791/52619.

Study record dates

Study Major Dates

• Study Start (Actual): October 27, 2021
• Primary Completion (Actual): September 30, 2022
• Study Completion (Actual): September 30, 2022

Study Registration Dates

• First Submitted: April 29, 2021
• First Submitted That Met QC Criteria: April 29, 2021
• First Posted (Actual): May 4, 2021

Study Record Updates

• Last Update Posted (Actual): September 28, 2023
• Last Update Submitted That Met QC Criteria: September 26, 2023
• Last Verified: September 1, 2023

More Information

Terms related to this study

• Keywords: Tuberculosis; Diagnostic; Pregnant women; Dried Blood Spot; Genes signature
• Additional Relevant MeSH Terms: Infections; Bacterial Infections; Bacterial Infections and Mycoses; Gram-Positive Bacterial Infections; Actinomycetales Infections; Mycobacterium Infections; Tuberculosis
• Other Study ID Numbers: 2021-01; TTS-2008-25933 (Other Grant/Funding Number: Grand Challenges Canada)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED
• IPD Plan Description: At the time of submission to the ethics committee, it will be decided to make a plan a share IPD

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No