Cost-effectiveness of anti-SARS-CoV-2 antibody diagnostic tests in Brazil.

BACKGROUND: Although serologic tests for COVID-19 diagnosis are rarely indicated nowadays, they remain commercially available and widely used in Brazil. The objective of this study was to evaluate the cost-effectiveness of anti-SARS-CoV-2antibody diagnostic tests for COVID-19 in Brazil. METHODS: Eleven commercially available diagnostic tests, comprising five lateral-flow immunochromatographic assays (LFAs) and six immunoenzymatic assays (ELISA) were analyzed from the perspective of the Brazilian Unified Health System. RESULTS: The direct costs of LFAs ranged from US$ 11.42 to US$ 17.41and of ELISAs, from US$ 6.59 to US$ 10.31. Considering an estimated disease prevalence between 5% and 10%, the anti-SARS-CoV-2 ELISA (IgG) was the most cost-effective test, followed by the rapid One Step COVID-19 Test, at an incremental cost-effectiveness ratio of US$ 2.52 and US$ 1.26 per properly diagnosed case, respectively. Considering only the LFAs, at the same prevalence estimates, two tests, the COVID-19 IgG/IgM and the One Step COVID-19 Test, showed high effectiveness at similar costs. For situations where the estimated probability of disease is 50%, the LFAs are more costly and less effective alternatives. CONCLUSIONS: Nowadays there are few indications for the use of serologic tests in the diagnosis of COVID-19 and numerous commercially available tests, with marked differences are observed among them. In general, LFA tests are more cost-effective for estimated low-COVID-19-prevalences, while ELISAs are more cost-effective for high-pretest-probability scenarios.

Exploring prognosis in chronic relapsing visceral leishmaniasis among HIV-infected patients: Circulating Leishmania DNA.

BACKGROUND: Visceral leishmaniasis (VL) affecting HIV-infected patients is considered a challenging condition because of its high mortality and relapse rates. The approach of this condition is still surrounded by many uncertainties, especially regarding the criteria to institute and discontinue secondary prophylaxis for VL. The aim of this study was to evaluate the Leishmania parasitism kinetic assessed by polymerase chain reaction (PCR) as a possible tool in the prognostic assessment in a context in which patients are receiving highly active antiretroviral therapy and secondary prophylaxis. METHODS: A prospective observation of Leishmania-HIV-co infected patients was performed and two groups with distinct clinical prognosis unpredicted by their CD4 count at the moment of VL diagnosis and not related to their HIV load control were confirmed. RESULTS: Relapsing (R) and non-relapsing (NR) patients had similar antiviral therapy use rates, CD4 lymphocyte count medians and HIV load levels at VL-diagnosis. At the 12-month follow-up, R-patients presented a significantly lower CD4 lymphocyte count than NR-patients, without difference in HIV load control. The time between HIV and VL diagnoses was longer in the R than NR-group. Comparison between Kaplan-Meier relapse-free survival curves (time to relapse) using a log rank test showed that patients presenting circulating Leishmania DNA had a significantly higher risk of clinical VL relapse within 4 months after a positive test (p=0.001). CONCLUSIONS: These results reinforce that a negative PCR could be a useful tool to support prophylaxis interruption among patients with CD4 counts above 200cells/mm3 and that a positive PCR suggests imminent VL relapse.

Prevalence of Leishmania infection in adult HIV/AIDS patients treated in a tertiary-level care center in Brasilia, Federal District, Brazil.

In order to estimate the magnitude of Leishmania/HIV co-infection, patients with HIV/AIDS at the Brasilia University Hospital, DF, Brazil were used as subjects in a cross-sectional study. One hundred and sixty-three patients were enrolled, seven of whom had visceral leishmaniasis (VL). One hundred and twelve patients (68.7%) were men; 155 (95.1%) had been exposed to HIV infection through unprotected sex. The median age was 37 years (range: 20-74) and the median CD4+ lymphocyte count was 314 cells/microl (range: 2-1600). Symptomatic patients underwent bone marrow evaluations through direct examination of Giemsa-stained films, parasite culture and PCR assay. Blood samples were evaluated by means of an indirect immunofluorescent antibody test (IFAT), an ELISA using a soluble antigen of L. chagasi (ELISA), an ELISA with the rK39 antigen (ELISA-rK39) and a PCR targeted to the kDNA region and to the internal transcribed spacer 1 of the rDNA gene. The proportion of positive results was 2.4% for the IFAT, 12.3% for the ELISA and 4.9% for the rK39 tests. The estimated prevalence was 16%. The PCR in the blood was positive in three patients (1.8%). The prevalence of Leishmania spp. infection is high among HIV patients attending this Brazilian center suggesting that they should be routinely investigated for VL infection.

Detection of Leishmania kDNA in human serum samples for the diagnosis of visceral leishmaniasis.

The performance of PCR to detect Leishmania kDNA in serum for the diagnosis of visceral leishmaniasis (VL) was assessed in serum samples from 65 patients with VL, 17 non-infected individuals and 17 patients with other febrile hepatosplenic diseases. Serum PCR showed a sensitivity of 85%, specificity of 100% and efficiency of 90%. The sensitivity values obtained for blood PCR (97%) and rK39 ELISA (95%) were significantly higher (P=0.01) than the values observed for L. chagasi ELISA (88%) and serum PCR (85%), whilst no difference was observed among the specificity rates obtained with rK39 ELISA (94%; P=0.47) and L. chagasi ELISA (85%; P=0.06). This work suggests that the use of serum samples may be an alternative for the diagnosis of VL when peripheral blood samples are not available or require significant operational efforts.

Combined diagnostic methods identify a remarkable proportion of asymptomatic Leishmania (Leishmania) chagasi carriers who present modulated cytokine profiles.

Peripheral blood samples of 138 co-habitants from 25 families with recently diagnosed cases of visceral leishmaniasis in the Metropolitan Region of Belo Horizonte, Minas Gerais, Brazil, were analyzed by indirect fluorescent antibody test (IFAT), rK39 and Leishmania chagasi Enzyme Linked Immunosorbent Assay (ELISA), intradermal skin-test and Polymerase Chain Reaction (PCR) over a 12-month period. The cumulative positivity was significantly higher by PCR (29.7%) than by IFAT, rK39 ELISA, L. chagasi ELISA and intradermal skin-test (5.1%, 6.5%, 14.5% and 2.9%, respectively). In addition, the cytokine profile was measured in 16 of the 138 volunteers, of whom eight were asymptomatic carriers and eight were non-infected co-habitants. The innate immunity cells from asymptomatic carriers displayed, upon in vitro antigenic stimulation, a modulated increase in cytokine synthesis that was distinct from that observed in non-infected volunteers. This study suggests that the identification of a large proportion of asymptomatic carriers is facilitated when more than one diagnostic method is applied and that a mixed pattern of immune response is correlated with clinical status of asymptomatic individuals. These observations suggest also that asymptomatic infection by L. chagasi is a frequent event and that control programs could benefit by including this indicator in their interventions.