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Felisia F, Triasih R, Nababan BWY, Sanjaya GY, Dewi SC, Rahayu ES, Unwanah L, du Cros P, Chan G. High Tuberculosis Preventive Treatment Uptake and Completion Rates Using a Person-Centered Approach among Tuberculosis Household Contact in Yogyakarta. Trop Med Infect Dis 2023; 8:520. [PMID: 38133452 PMCID: PMC10747839 DOI: 10.3390/tropicalmed8120520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 11/23/2023] [Accepted: 11/23/2023] [Indexed: 12/23/2023] Open
Abstract
Coverage of tuberculosis preventive treatment (TPT) in Indonesia is inadequate, and persons who start TPT often do not complete treatment. In 2020, Zero TB Yogyakarta implemented person-centered contact investigation and shorter TPT regimen provision in collaboration with primary health care centers. Between 1 January 2020 and 31 August 2022, we assessed eligibility for TPT among household contacts of persons with bacteriologically confirmed TB (index cases) and offered them a 3-month TPT regimen (3RH or 3HP). A dedicated nurse monitored contacts on TPT for treatment adherence and side effects every week in the first month and every two weeks in the next months. Contacts were also able to contact a nurse by phone or ask for home visits at any point if they had any concerns. A total of 1016 contacts were eligible for TPT: 772 (78.8%) started short regimen TPT with 706 (91.5%) completing their TPT. Side effects were reported in 26 (39%) of the non-completion group. We conclude that high rates of TPT uptake and completion among contacts assessed as eligible for TPT can be achieved through person-centered care and the use of shorter regimens. Side-effect monitoring and management while on TPT is vital for improving TPT completion.
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Affiliation(s)
- Felisia Felisia
- Centre for Tropical Medicine, Faculty of Medicine, Public Health, and Nursing, Gadjah Mada University, Sleman 55281, Yogyakarta, Indonesia;
| | - Rina Triasih
- Centre for Tropical Medicine, Faculty of Medicine, Public Health, and Nursing, Gadjah Mada University, Sleman 55281, Yogyakarta, Indonesia;
- Department of Pediatric, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Sleman 55281, Yogyakarta, Indonesia
| | - Betty Weri Yolanda Nababan
- Centre for Tropical Medicine, Faculty of Medicine, Public Health, and Nursing, Gadjah Mada University, Sleman 55281, Yogyakarta, Indonesia;
| | - Guardian Yoki Sanjaya
- Department of Health Policy and Management, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Sleman 55281, Yogyakarta, Indonesia;
| | - Setyogati Candra Dewi
- Yogyakarta City Health Office, Yogyakarta 55165, Yogyakarta, Indonesia; (S.C.D.); (E.S.R.); (L.U.)
| | - Endang Sri Rahayu
- Yogyakarta City Health Office, Yogyakarta 55165, Yogyakarta, Indonesia; (S.C.D.); (E.S.R.); (L.U.)
| | - Lana Unwanah
- Yogyakarta City Health Office, Yogyakarta 55165, Yogyakarta, Indonesia; (S.C.D.); (E.S.R.); (L.U.)
| | - Philipp du Cros
- Tuberculosis Elimination and Implementation Science Working Group, Burnet Institute, Melbourne, VIC 3004, Australia (G.C.)
| | - Geoffrey Chan
- Tuberculosis Elimination and Implementation Science Working Group, Burnet Institute, Melbourne, VIC 3004, Australia (G.C.)
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Marx FM, de Villiers A. Decentralising screening and preventive treatment among children exposed to tuberculosis in the household. Lancet Glob Health 2023; 11:e1836-e1837. [PMID: 37918418 DOI: 10.1016/s2214-109x(23)00503-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Florian M Marx
- Division of Infectious Disease and Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, 69120 Heidelberg, Germany; Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa.
| | - Abigail de Villiers
- Division of Infectious Disease and Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, 69120 Heidelberg, Germany
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Mafirakureva N, Tchounga BK, Mukherjee S, Youngui BT, Ssekyanzi B, Simo L, Okello RF, Turyahabwe S, Kuate Kuate A, Cohn J, Vasiliu A, Casenghi M, Atwine D, Bonnet M, Dodd PJ. Cost-effectiveness of community-based household tuberculosis contact management for children in Cameroon and Uganda: a modelling analysis of a cluster-randomised trial. Lancet Glob Health 2023; 11:e1922-e1930. [PMID: 37918416 DOI: 10.1016/s2214-109x(23)00451-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/22/2023] [Accepted: 09/12/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND WHO recommends household contact management (HCM) including contact screening and tuberculosis-preventive treatment (TPT) for eligible children. The CONTACT trial found increased TPT initiation and completion rates when community health workers were used for HCM in Cameroon and Uganda. METHODS We did a cost-utility analysis of the CONTACT trial using a health-system perspective to estimate the health impact, health-system costs, and cost-effectiveness of community-based versus facility-based HCM models of care. A decision-analytical modelling approach was used to evaluate the cost-effectiveness of the intervention compared with the standard of care using trial data on cascade of care, intervention effects, and resource use. Health outcomes were based on modelled progression to tuberculosis, mortality, and discounted disability-adjusted life-years (DALYs) averted. Health-care resource use, outcomes, costs (2021 US$), and cost-effectiveness are presented. FINDINGS For every 1000 index patients diagnosed with tuberculosis, the intervention increased the number of TPT courses by 1110 (95% uncertainty interval 894 to 1227) in Cameroon and by 1078 (796 to 1220) in Uganda compared with the control model. The intervention prevented 15 (-3 to 49) tuberculosis deaths in Cameroon and 10 (-20 to 33) in Uganda. The incremental cost-effectiveness ratio was $620 per DALY averted in Cameroon and $970 per DALY averted in Uganda. INTERPRETATION Community-based HCM approaches can substantially reduce child tuberculosis deaths and in our case would be considered cost-effective at willingness-to-pay thresholds of $1000 per DALY averted. Their impact and cost-effectiveness are likely to be greatest where baseline HCM coverage is lowest. FUNDING Unitaid and UK Medical Research Council.
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Affiliation(s)
| | | | | | | | | | - Leonie Simo
- Elizabeth Glaser Pediatric AIDS Foundation, Yaounde, Cameroon
| | | | - Stavia Turyahabwe
- National Tuberculosis and Leprosy Program, Ministry of Health, Kampala, Uganda
| | - Albert Kuate Kuate
- National Tuberculosis Control Program, Ministry of Health, Yaounde, Cameroon
| | - Jennifer Cohn
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Anca Vasiliu
- Baylor College of Medicine, Department of Pediatrics, Global TB Program, Houston, TX, USA; University Montpellier, TransVIHMI, IRD, Inserm, Montpellier, France
| | | | - Daniel Atwine
- Epicentre, Mbarara, Uganda; Mbarara University of Science and Technology, Mbarara, Uganda
| | - Maryline Bonnet
- University Montpellier, TransVIHMI, IRD, Inserm, Montpellier, France
| | - Peter J Dodd
- Health Economics and Decision Science, University of Sheffield, Sheffield, UK
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Brough J, Martinez L, Hatherill M, Zar HJ, Lo NC, Andrews JR. Public Health Impact and Cost-Effectiveness of Screening for Active Tuberculosis Disease or Infection Among Children in South Africa. Clin Infect Dis 2023; 77:1544-1551. [PMID: 37542465 PMCID: PMC10686943 DOI: 10.1093/cid/ciad449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/20/2023] [Accepted: 07/31/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND Although tuberculosis disease is a leading cause of global childhood mortality, there remain major gaps in diagnosis, treatment, and prevention in children because tuberculosis control programs rely predominantly on presentation of symptomatic children or contact tracing. We assessed the public health impact and cost-effectiveness of age-based routine screening and contact tracing in children in South Africa. METHODS We used a deterministic mathematical model to evaluate age-based routine screening in 1-year increments from ages 0 to 5 years, with and without contact tracing and preventive treatment. Screening incorporated symptom history and tuberculin skin testing, with chest x-ray and GeneXpert Ultra for confirmatory testing. We projected tuberculosis cases, deaths, disability-adjusted life years (DALYs), and costs (in 2021 U.S. dollars) and evaluated the incremental cost-effectiveness ratios comparing each intervention. RESULTS Routine screening at age 2 years with contact tracing and preventive treatment averted 11 900 tuberculosis cases (95% confidence interval [CI]: 6160-15 730), 1360 deaths (95% CI: 260-3800), and 40 000 DALYs (95% CI: 13 000-100 000) in the South Africa pediatric population over 1 year compared with the status quo. This combined strategy was cost-effective (incremental cost-effectiveness ratio $9050 per DALY; 95% CI: 2890-22 920) and remained cost-effective above an annual risk of infection of 1.6%. For annual risk of infection between 0.8% and 1.6%, routine screening at age 2 years was the dominant strategy. CONCLUSIONS Routine screening for tuberculosis among young children combined with contact tracing and preventive treatment would have a large public health impact and be cost-effective in preventing pediatric tuberculosis deaths in high-incidence settings such as South Africa.
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Affiliation(s)
- Joseph Brough
- National Capital Consortium, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Leonardo Martinez
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Mark Hatherill
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Heather J Zar
- Department of Pediatrics and Child Health, Red Cross War Memorial Children's Hospital and SA-MRC Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Nathan C Lo
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA
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Mafirakureva N, Mukherjee S, de Souza M, Kelly-Cirino C, Songane MJP, Cohn J, Lemaire JF, Casenghi M, Dodd PJ. Cost-effectiveness analysis of interventions to improve diagnosis and preventive therapy for paediatric tuberculosis in 9 sub-Saharan African countries: A modelling study. PLoS Med 2023; 20:e1004285. [PMID: 37672524 PMCID: PMC10511115 DOI: 10.1371/journal.pmed.1004285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 09/20/2023] [Accepted: 08/22/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Over 1 million children aged 0 to 14 years were estimated to develop tuberculosis in 2021, resulting in over 200,000 deaths. Practical interventions are urgently needed to improve diagnosis and antituberculosis treatment (ATT) initiation in children aged 0 to 14 years and to increase coverage of tuberculosis preventive therapy (TPT) in children at high risk of developing tuberculosis disease. The multicountry CaP-TB intervention scaled up facility-based intensified case finding and strengthened household contact management and TPT provision at HIV clinics. To add to the limited health-economic evidence on interventions to improve ATT and TPT in children, we evaluated the cost-effectiveness of the CaP-TB intervention. METHODS AND FINDINGS We analysed clinic-level pre/post data to quantify the impact of the CaP-TB intervention on ATT and TPT initiation across 9 sub-Saharan African countries. Data on tuberculosis diagnosis and ATT/TPT initiation counts with corresponding follow-up time were available for 146 sites across the 9 countries prior to and post project implementation, stratified by 0 to 4 and 5 to 14 year age-groups. Preintervention data were retrospectively collected from facility registers for a 12-month period, and intervention data were prospectively collected from December 2018 to June 2021 using project-specific forms. Bayesian generalised linear mixed-effects models were used to estimate country-level rate ratios for tuberculosis diagnosis and ATT/TPT initiation. We analysed project expenditure and cascade data to determine unit costs of intervention components and used mathematical modelling to project health impact, health system costs, and cost-effectiveness. Overall, ATT and TPT initiation increased, with country-level incidence rate ratios varying between 0.8 (95% uncertainty interval [UI], 0.7 to 1.0) and 2.9 (95% UI, 2.3 to 3.6) for ATT and between 1.6 (95% UI, 1.5 to 1.8) and 9.8 (95% UI, 8.1 to 11.8) for TPT. We projected that for every 100 children starting either ATT or TPT at baseline, the intervention package translated to between 1 (95% UI, -1 to 3) and 38 (95% UI, 24 to 58) deaths averted, with a median incremental cost-effectiveness ratio (ICER) of US$634 per disability-adjusted life year (DALY) averted. ICERs ranged between US$135/DALY averted in Democratic of the Congo and US$6,804/DALY averted in Cameroon. The main limitation of our study is that the impact is based on pre/post comparisons, which could be confounded. CONCLUSIONS In most countries, the CaP-TB intervention package improved tuberculosis treatment and prevention services for children aged under 15 years, but large variation in estimated impact and ICERs highlights the importance of local context. TRIAL REGISTRATION This evaluation is part of the TIPPI study, registered with ClinicalTrials.gov (NCT03948698).
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Affiliation(s)
| | - Sushant Mukherjee
- Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), Washington, DC, United States of America
| | - Mikhael de Souza
- Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), Washington, DC, United States of America
| | - Cassandra Kelly-Cirino
- Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), Washington, DC, United States of America
| | - Mario J. P. Songane
- Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), Washington, DC, United States of America
| | - Jennifer Cohn
- Division of Infectious Diseases, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Jean-François Lemaire
- Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), Washington, DC, United States of America
| | - Martina Casenghi
- Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), Washington, DC, United States of America
| | - Peter J. Dodd
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom
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Ryckman T, Weiser J, Gombe M, Turner K, Soni P, Tarlton D, Mazhidova N, Churchyard G, Chaisson RE, Dowdy DW. Impact and cost-effectiveness of short-course tuberculosis preventive treatment for household contacts and people with HIV in 29 high-incidence countries: a modelling analysis. Lancet Glob Health 2023; 11:e1205-e1216. [PMID: 37474228 PMCID: PMC10369017 DOI: 10.1016/s2214-109x(23)00251-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Guidelines and implementation of tuberculosis preventive treatment (TPT) vary by age and HIV status. Specifically, TPT is strongly recommended for people living with HIV/AIDS (PLWHA) and household contacts younger than 5 years but only conditionally recommended for older contacts. Cost remains a major barrier to implementation. The aim of this study was to evaluate the cost-effectiveness of TPT for household contacts and PLWHA. METHODS We developed a state-transition model to simulate short-course TPT for household contacts and PLWHA in 29 high-incidence countries based on data from previous studies and public databases. Our primary outcome was the incremental cost-effectiveness ratio, expressed as incremental discounted costs (2020 US$, including contact investigation costs) per incremental discounted disability-adjusted life year (DALY) averted, compared with a scenario without any TPT or contact investigation. We propagated uncertainty in all model parameters using probabilistic sensitivity analysis and also evaluated the sensitivity of results to the screening algorithm used to rule out active disease, the choice of TPT regimen, the modelling time horizon, assumptions about TPT coverage, antiretroviral therapy discontinuation, and secondary transmission. FINDINGS Between 2023 and 2035, scaling up TPT prevented 0·9 (95% uncertainty interval 0·4-1·6) people from developing tuberculosis and 0·13 (0·05-0·27) tuberculosis deaths per 100 PLWHA, at an incremental cost of $15 (9-21) per PLWHA. For household contacts, TPT (with contact investigation) averted 1·1 (0·5-2·0) cases and 0·7 (0·4-1·0) deaths per 100 contacts, at a cost of $21 (17-25) per contact. Cost-effectiveness was most favourable for household contacts younger than 5 years ($22 per DALY averted) and contacts aged 5-14 years ($104 per DALY averted) but also fell within conservative cost-effectiveness thresholds in many countries for PLWHA ($722 per DALY averted) and adult contacts ($309 per DALY averted). Costs per DALY averted tended to be lower when compared with a scenario with contact investigation but no TPT. The cost-effectiveness of TPT was not substantially altered in sensitivity analyses, except that TPT was more favourable in analysis that considered a longer time horizon or included secondary transmission benefits. INTERPRETATION In many high-incidence countries, short-course TPT is likely to be cost-effective for PLWHA and household contacts of all ages, regardless of whether contact investigation is already in place. Failing to implement tuberculosis contact investigation and TPT will incur a large burden of avertable illness and mortality in the next decade. FUNDING Unitaid.
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Affiliation(s)
- Theresa Ryckman
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Jeff Weiser
- The Aurum Institute, Parktown, Johannesburg, South Africa
| | - Makaita Gombe
- The Aurum Institute, Parktown, Johannesburg, South Africa
| | - Karin Turner
- The Aurum Institute, Parktown, Johannesburg, South Africa
| | | | | | | | | | - Richard E Chaisson
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David W Dowdy
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Safdar N, Malik AA. Prioritising health: cost and tuberculosis elimination in high-burden, resource-limited settings. Lancet Glob Health 2023; 11:e1142-e1143. [PMID: 37474210 DOI: 10.1016/s2214-109x(23)00301-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 07/22/2023]
Affiliation(s)
- Nauman Safdar
- Interactive Research and Development Global, Singapore 049145.
| | - Amyn A Malik
- Interactive Research and Development Global, Singapore 049145; Analysis Group, Boston, MA, USA
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Abstract
PURPOSE OF REVIEW The current review identifies recent advances in the prevention, diagnosis, and treatment of childhood tuberculosis (TB) with a focus on the WHO's updated TB management guidelines released in 2022. RECENT FINDINGS The COVID-19 pandemic negatively affected global TB control due to the diversion of healthcare resources and decreased patient care-seeking behaviour. Despite this, key advances in childhood TB management have continued. The WHO now recommends shorter rifamycin-based regimens for TB preventive treatment as well as shorter regimens for the treatment of both drug-susceptible and drug-resistant TB. The Xpert Ultra assay is now recommended as the initial diagnostic test for TB in children with presumed TB and can also be used on stool samples. Point-of-care urinary lipoarabinomannan assays are promising as 'rule-in' tests for children with presumed TB living with HIV. Treatment decision algorithms can be used to diagnose TB in symptomatic children in settings with and without access to chest X-rays; bacteriological confirmation should always be attempted. SUMMARY Recent guideline updates are a key milestone in the management of childhood TB, and the paediatric TB community should now prioritize their efficient implementation in high TB burden countries while generating evidence to close current evidence gaps.
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Affiliation(s)
- Heather Finlayson
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences
| | - Juanita Lishman
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences
| | - Megan Palmer
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
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Kota NT, Shrestha S, Kashkary A, Samina P, Zwerling A. The Global Expansion of LTBI Screening and Treatment Programs: Exploring Gaps in the Supporting Economic Evidence. Pathogens 2023; 12:pathogens12030500. [PMID: 36986422 PMCID: PMC10054594 DOI: 10.3390/pathogens12030500] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/03/2023] [Accepted: 03/14/2023] [Indexed: 03/30/2023] Open
Abstract
The global burden of latent TB infection (LTBI) and the progression of LTBI to active TB disease are important drivers of ongoing TB incidence. Addressing LTBI through screening and TB preventive treatment (TPT) is critical in order to end the TB epidemic by 2035. Given the limited resources available to health ministries around the world in the fight against TB, we must consider economic evidence for LTBI screening and treatment strategies to ensure that limited resources are used to achieve the biggest health impact. In this narrative review, we explore key economic evidence around LTBI screening and TPT strategies in different populations to summarize our current understanding and highlight gaps in existing knowledge. When considering economic evidence supporting LTBI screening or evaluating different testing approaches, a disproportionate number of economic studies have been conducted in high-income countries (HICs), despite the vast majority of TB burden being borne in low- and middle-income countries (LMICs). Recent years have seen a temporal shift, with increasing data from low- and middle-income countries (LMICs), particularly with regard to targeting high-risk groups for TB prevention. While LTBI screening and prevention programs can come with extensive costs, targeting LTBI screening among high-risk populations, such as people living with HIV (PLHIV), children, household contacts (HHC) and immigrants from high-TB-burden countries, has been shown to consistently improve the cost effectiveness of screening programs. Further, the cost effectiveness of different LTBI screening algorithms and diagnostic approaches varies widely across settings, leading to different national TB screening policies. Novel shortened regimens for TPT have also consistently been shown to be cost effective across a range of settings. These economic evaluations highlight key implementation considerations such as the critical nature of ensuring high rates of adherence and completion, despite the costs associated with adherence programs not being routinely assessed and included. Digital and other adherence support approaches are now being assessed for their utility and cost effectiveness in conjunction with novel shortened TPT regimens, but more economic evidence is needed to understand the potential cost savings, particularly in settings where directly observed preventive therapy (DOPT) is routinely conducted. Despite the growth of the economic evidence base for LTBI screening and TPT recently, there are still significant gaps in the economic evidence around the scale-up and implementation of expanded LTBI screening and treatment programs, particularly among traditionally hard-to-reach populations.
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Affiliation(s)
| | - Suvesh Shrestha
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON K1G 5Z3, Canada
| | - Abdulhameed Kashkary
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON K1G 5Z3, Canada
- Public Health Authority, Riyadh 13351, Saudi Arabia
| | - Pushpita Samina
- Center for Health Economics and Policy Analysis, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Alice Zwerling
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON K1G 5Z3, Canada
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Preventive Treatment for Household Contacts of Drug-Susceptible Tuberculosis Patients. Pathogens 2022; 11:pathogens11111258. [DOI: 10.3390/pathogens11111258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/16/2022] Open
Abstract
People who live in the household of someone with infectious pulmonary tuberculosis are at a high risk of tuberculosis infection and subsequent progression to tuberculosis disease. These individuals are prioritized for contact investigation and tuberculosis preventive treatment (TPT). The treatment of TB infection is critical to prevent the progression of infection to disease and is prioritized in household contacts. Despite the availability of TPT, uptake in household contacts is poor. Multiple barriers prevent the optimal implementation of these policies. This manuscript lays out potential next steps for closing the policy-to-implementation gap in household contacts of all ages.
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Nsengiyumva NP, Campbell JR, Oxlade O, Vesga JF, Lienhardt C, Trajman A, Falzon D, Den Boon S, Arinaminpathy N, Schwartzman K. Scaling up target regimens for tuberculosis preventive treatment in Brazil and South Africa: An analysis of costs and cost-effectiveness. PLoS Med 2022; 19:e1004032. [PMID: 35696431 PMCID: PMC9239450 DOI: 10.1371/journal.pmed.1004032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/28/2022] [Accepted: 05/26/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Shorter, safer, and cheaper tuberculosis (TB) preventive treatment (TPT) regimens will enhance uptake and effectiveness. WHO developed target product profiles describing minimum requirements and optimal targets for key attributes of novel TPT regimens. We performed a cost-effectiveness analysis addressing the scale-up of regimens meeting these criteria in Brazil, a setting with relatively low transmission and low HIV and rifampicin-resistant TB (RR-TB) prevalence, and South Africa, a setting with higher transmission and higher HIV and RR-TB prevalence. METHODS AND FINDINGS We used outputs from a model simulating scale-up of TPT regimens meeting minimal and optimal criteria. We assumed that drug costs for minimal and optimal regimens were identical to 6 months of daily isoniazid (6H). The minimal regimen lasted 3 months, with 70% completion and 80% efficacy; the optimal regimen lasted 1 month, with 90% completion and 100% efficacy. Target groups were people living with HIV (PLHIV) on antiretroviral treatment and household contacts (HHCs) of identified TB patients. The status quo was 6H at 2019 coverage levels for PLHIV and HHCs. We projected TB cases and deaths, TB-associated disability-adjusted life years (DALYs), and costs (in 2020 US dollars) associated with TB from a TB services perspective from 2020 to 2035, with 3% annual discounting. We estimated the expected costs and outcomes of scaling up 6H, the minimal TPT regimen, or the optimal TPT regimen to reach all eligible PLHIV and HHCs by 2023, compared to the status quo. Maintaining current 6H coverage in Brazil (0% of HHCs and 30% of PLHIV treated) would be associated with 1.1 (95% uncertainty range [UR] 1.1-1.2) million TB cases, 123,000 (115,000-132,000) deaths, and 2.5 (2.1-3.1) million DALYs and would cost $1.1 ($1.0-$1.3) billion during 2020-2035. Expanding the 6H, minimal, or optimal regimen to 100% coverage among eligible groups would reduce DALYs by 0.5% (95% UR 1.2% reduction, 0.4% increase), 2.5% (1.8%-3.0%), and 9.0% (6.5%-11.0%), respectively, with additional costs of $107 ($95-$117) million and $51 ($41-$60) million and savings of $36 ($14-$58) million, respectively. Compared to the status quo, costs per DALY averted were $7,608 and $808 for scaling up the 6H and minimal regimens, respectively, while the optimal regimen was dominant (cost savings, reduced DALYs). In South Africa, maintaining current 6H coverage (0% of HHCs and 69% of PLHIV treated) would be associated with 3.6 (95% UR 3.0-4.3) million TB cases, 843,000 (598,000-1,201,000) deaths, and 36.7 (19.5-58.0) million DALYs and would cost $2.5 ($1.8-$3.6) billion. Expanding coverage with the 6H, minimal, or optimal regimen would reduce DALYs by 6.9% (95% UR 4.3%-95%), 15.5% (11.8%-18.9%), and 38.0% (32.7%-43.0%), respectively, with additional costs of $79 (-$7, $151) million and $40 (-$52, $140) million and savings of $608 ($443-$832) million, respectively. Compared to the status quo, estimated costs per DALY averted were $31 and $7 for scaling up the 6H and minimal regimens, while the optimal regimen was dominant. Study limitations included the focus on 2 countries, and no explicit consideration of costs incurred before the decision to prescribe TPT. CONCLUSIONS Our findings suggest that scale-up of TPT regimens meeting minimum or optimal requirements would likely have important impacts on TB-associated outcomes and would likely be cost-effective or cost saving.
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Affiliation(s)
- Ntwali Placide Nsengiyumva
- McGill International Tuberculosis Centre, McGill University, Montreal, Quebec, Canada
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Jonathon R. Campbell
- McGill International Tuberculosis Centre, McGill University, Montreal, Quebec, Canada
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Olivia Oxlade
- McGill International Tuberculosis Centre, McGill University, Montreal, Quebec, Canada
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Juan F. Vesga
- Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, London, United Kingdom
| | | | - Anete Trajman
- McGill International Tuberculosis Centre, McGill University, Montreal, Quebec, Canada
- Programa de Pós-graduação em Clínica Médica, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Dennis Falzon
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Saskia Den Boon
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Nimalan Arinaminpathy
- Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Kevin Schwartzman
- McGill International Tuberculosis Centre, McGill University, Montreal, Quebec, Canada
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Respiratory Division, Department of Medicine, McGill University, Montreal, Quebec, Canada
- * E-mail:
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Sumner T, Mendelsohn SC, Scriba TJ, Hatherill M, White RG. The impact of blood transcriptomic biomarker targeted tuberculosis preventive therapy in people living with HIV: a mathematical modelling study. BMC Med 2021; 19:252. [PMID: 34711213 PMCID: PMC8555196 DOI: 10.1186/s12916-021-02127-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 09/14/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) preventive therapy is recommended for all people living with HIV (PLHIV). Despite the elevated risk of TB amongst PLHIV, most of those eligible for preventive therapy would never develop TB. Tests which can identify individuals at greatest risk of disease would allow more efficient targeting of preventive therapy. METHODS We used mathematical modelling to estimate the potential impact of using a blood transcriptomic biomarker (RISK11) to target preventive therapy amongst PLHIV. We compared universal treatment to RISK11 targeted treatment and explored the effect of repeat screening of the population with RISK11. RESULTS Annual RISK11 screening, with preventive therapy provided to those testing positive, could avert 26% (95% CI 13-34) more cases over 10 years compared to one round of universal treatment. For the cost per case averted to be lower than universal treatment, the maximum cost of the RISK11 test was approximately 10% of the cost of preventive therapy. The benefit of RISK11 screening may be greatest amongst PLHIV on ART (compared to ART naïve individuals) due to the increased specificity of the test in this group. CONCLUSIONS Biomarker targeted preventive therapy may be more effective than universal treatment amongst PLHIV in high incidence settings but would require repeat screening.
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Affiliation(s)
- Tom Sumner
- TB Modelling Group, TB Centre, Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
| | - Simon C Mendelsohn
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Thomas J Scriba
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Mark Hatherill
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Richard G White
- TB Modelling Group, TB Centre, Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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