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Lee YJ, Min J, Myong JP, Lee YH, Park YJ, Kim Y, Kim G, Park G, Lee SS, Park JS, Kim JS, Kim HW. Incidence of Tuberculosis Among Immigrants in Korea Who Participated in a Latent Tuberculosis Infection Screening Program. J Korean Med Sci 2024; 39:e207. [PMID: 39048302 DOI: 10.3346/jkms.2024.39.e207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 06/07/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND With a rapid decrease in tuberculosis (TB) incidence, the significance of latent tuberculosis infection (LTBI) has been underscored in South Korea. Although South Korea does not have a high proportion of immigrants compared to other countries, there is a growing argument that it should actively embrace immigrants as a solution to address issues of low birth rates and population aging. This study aimed to assess TB incidence among immigrants who participated a pilot LTBI screening program in South Korea. METHODS Records of immigrants participated in a pilot LTBI screening program in South Korea between 2018 and 2019 were linked with Korean National TB Surveillance System to determine TB development. Participants underwent interferon-gamma release assay (IGRA) and chest X-rays. Standardized incidence ratios (SIRs) stratified by age, country of origin's TB burden was calculated with a reference group of general South Korean population. RESULTS Of a total of 9,517 participants, 14 TB cases were identified. Participants with positive IGRA results who did not initiate LTBI treatment showed TB incidence of 312.5 per 100,000 person-years, whereas those with negative results showed TB incidence of 34.4 per 100,000 person-years, resulting in an incidence rate ratio of 9.08 (95% confidence interval [CI], 2.50-32.99). SIR of TB among total participants including those with negative IGRA results was 2.60 (95% CI, 1.54-4.38; P < 0.001), whereas SIR among those with positive IGRA results was 5.86 (95% CI, 3.15-10.89; P < 0.001). In the calculation of SIR among participants with positive IGRA results, those aged under 35 from high TB-burden countries or intermediate TB-burden countries showed a high SIR (18.08; 95% CI, 2.55-128.37; P = 0.004), and 11.30 (95% CI, 2.82-45.16; P < 0.001), respectively). Contrary to previous reports that suggest the majority of elderly population with a positive IGRA result were due to remote infection and had a lower TB risk compared to younger ages, SIR among those aged 65 or over from intermediate TB-burden countries was 6.15 (95% CI, 0.87-43.69; P = 0.069), which was comparable to that in younger participants aged between 35 and 49 (SIR, 4.87; 95% CI, 1.22-19.49; P = 0.025) or those aged between 50 and 64 (SIR, 4.62; 95% CI, 1.73-12.31; P = 0.002). CONCLUSION Young immigrants with positive IGRA results from countries with high or intermediate TB burden showed a relatively high TB risk compared to a general South Korea population. In addition, unexpected high TB risk was observed among elderly immigrants with positive IGRA results. In establishing future policies for LTBI in immigrants in South Korea, screenings should primarily focus on younger age group (who aged under 35). Additionally, further research is needed on the high TB risk observed in elderly immigrants.
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Affiliation(s)
- Yoo Jung Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jinsoo Min
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jun-Pyo Myong
- Department of Occupational and Environmental Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yun-Hee Lee
- Department of Occupational and Environmental Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young-Joon Park
- Division of Tuberculosis Policy, Korea Disease Control and Prevention Agency, Cheongju, Korea
| | - Yujin Kim
- Division of Tuberculosis Policy, Korea Disease Control and Prevention Agency, Cheongju, Korea
| | - Gahee Kim
- Division of Tuberculosis Policy, Korea Disease Control and Prevention Agency, Cheongju, Korea
| | - Gyuri Park
- Division of Tuberculosis Policy, Korea Disease Control and Prevention Agency, Cheongju, Korea
| | - Sung-Soon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Jae Seuk Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Ju Sang Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Hyung Woo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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Pei X, Zhong T, Yang C, Sun L, Chen M, Xu M. Cost-Effectiveness of Community-Based Active Case Finding Strategy for Tuberculosis: Evidence From Shenzhen, China. J Infect Dis 2024; 229:1866-1877. [PMID: 38262678 DOI: 10.1093/infdis/jiae024] [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: 06/09/2023] [Revised: 01/13/2024] [Accepted: 01/22/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Active case finding (ACF) is a potentially promising approach for the early identification and treatment of tuberculosis patients. However, evidence on its cost-effectiveness, particularly in low- and middle-income countries, remains limited. This study evaluates the cost-effectiveness of a community-based ACF practice in Shenzhen, China. METHODS We employed a Markov model-based decision analytic method to assess the costs and effectiveness of 3 tuberculosis detection strategies: passive case finding (PCF), basic ACF, and advanced ACF. The analysis was conducted from a societal perspective on a dynamic cohort over a 20-year horizon, focusing on active tuberculosis (ATB) prevalence and the incremental cost-effectiveness ratio (ICER). RESULTS Compared to the PCF strategy, the basic and advanced ACF strategies effectively reduced ATB cases by 6.8 and 10.2 per 100 000 population, respectively, by the final year of this 20-year period. The ICER for the basic and advanced ACF strategies were ¥14 757 and ¥8217 per quality-adjusted life-year, respectively. Both values fell below the cost-effectiveness threshold. CONCLUSIONS Our findings indicate that the community-based ACF screening strategy, which targets individuals exhibiting tuberculosis symptoms, is cost-effective. This underscores the potential benefits of adopting similar community-based ACF strategies for symptomatic populations in tuberculosis-endemic areas.
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Affiliation(s)
- Xingtong Pei
- School of Public Health (Shenzhen), Shenzhen Campus, Sun Yat-sen University, Shenzhen, China
| | - Tao Zhong
- Department of Tuberculosis Control and Prevention, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, China
| | - Chongguang Yang
- School of Public Health (Shenzhen), Shenzhen Campus, Sun Yat-sen University, Shenzhen, China
| | - Li Sun
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Meiru Chen
- School of Public Health (Shenzhen), Shenzhen Campus, Sun Yat-sen University, Shenzhen, China
| | - Mingming Xu
- School of Public Health (Shenzhen), Shenzhen Campus, Sun Yat-sen University, Shenzhen, China
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Nababan B, Triasih R, Chan G, Dwihardiani B, Hidayat A, Dewi SC, Unwanah L, Mustofa A, du Cros P. The Yield of Active Tuberculosis Disease and Latent Tuberculosis Infection in Tuberculosis Household Contacts Investigated Using Chest X-ray in Yogyakarta Province, Indonesia. Trop Med Infect Dis 2024; 9:34. [PMID: 38393123 PMCID: PMC10891579 DOI: 10.3390/tropicalmed9020034] [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: 09/27/2023] [Revised: 01/16/2024] [Accepted: 01/22/2024] [Indexed: 02/25/2024] Open
Abstract
In Indonesia, the implementation of tuberculosis (TB) contact investigation is limited, with low detection rates. We report the yield of and risk factors for TB disease and infection for household contacts (HHCs) investigated using chest X-ray (CXR) screening. We identified HHCs aged five years and above of bacteriologically confirmed index cases from 2018 to 2022 in Yogyakarta City and Kulon Progo. All HHCs were offered screening for TB symptoms; TB infection testing with either tuberculin skin testing or interferon gamma release assay; and referral for CXR. Sputum from those with symptoms or CXR suggestive of TB was tested with Xpert MTB/RIF. Risk factors for active TB disease and latent TB infection (LTBI) were identified by logistic regression models. We screened 2857 HHCs for TB between June 2020 and December 2022, with 68 (2.4%) diagnosed with active TB. Of 2621 HHCs eligible for LTBI investigation, 1083 (45.7%) were diagnosed with LTBI. The factors associated with active TB were age, being underweight, diabetes mellitus, urban living, and sleeping in the same house as an index case. Factors associated with LTBI were increasing age and male gender. Conclusions: Screening for HHC including CXR and TST/IGRA yielded a moderate prevalence of TB disease and infection.
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Affiliation(s)
- Betty Nababan
- Centre for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Sleman, Yogyakarta 55281, Indonesia
| | - Rina Triasih
- Centre for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Sleman, Yogyakarta 55281, Indonesia
- Department of Pediatric, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Dr. Sardjito Hospital, Sleman, Yogyakarta 55281, Indonesia
| | - Geoffrey Chan
- TB Elimination and Implementation Science Working Group, Burnet Institute, Melbourne, VIC 3004, Australia
| | - Bintari Dwihardiani
- Centre for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Sleman, Yogyakarta 55281, Indonesia
| | - Arif Hidayat
- Centre for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Sleman, Yogyakarta 55281, Indonesia
| | - Setyogati C. Dewi
- Yogyakarta City Health Office, Yogyakarta, Yogyakarta 55165, Indonesia
| | - Lana Unwanah
- Yogyakarta City Health Office, Yogyakarta, Yogyakarta 55165, Indonesia
| | - Arif Mustofa
- Kulon Progo District Health Office, Yogyakarta, Yogyakarta 55165, Indonesia
| | - Philipp du Cros
- TB Elimination and Implementation Science Working Group, Burnet Institute, Melbourne, VIC 3004, Australia
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Saleem UA, Karimi AS, Ehsan H. A Systematic Review on Pulmonary TB Burden and Associated Factors Among Immigrants in the UK. Infect Drug Resist 2023; 16:7835-7853. [PMID: 38162319 PMCID: PMC10757787 DOI: 10.2147/idr.s441536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/14/2023] [Indexed: 01/03/2024] Open
Abstract
Background The rapid growth of international human migration has positioned the UK in the top five countries in the world with 9.4 million immigrants in 2022. These immigrants originate from low- and middle-income countries and remain particularly at risk of developing TB. In the UK, the number of TB cases has been increasing, and the influx of immigrants could be a contributing factor. Objective This review aims to map the burden of pulmonary TB among immigrants in the UK and investigate associated factors. It also reviews the TB management approaches among immigrants in the UK. Design The study utilized PRISMA guidelines to search electronic databases (PubMed and EMBASE) for articles published from 2000 to 2022 on TB prevalence and factors in immigrants and explored government websites for TB management strategies. Results Nineteen out of 530 initially identified articles were included. The included studies reported a prevalence rate of TB among immigrants ranging from 0.04 to 52.1%, showing a decrease in the burden over time. Additionally, a higher number of TB cases were observed among immigrants from the Asian region, particularly immigrants from South Asia, followed by those from sub-Saharan Africa. Stigma, misconception about the disease, language barrier, lack of confidentiality, and unfriendly healthcare system for immigrants were the main drivers of the TB burden among immigrants. The TB management approaches in the UK include pre-entry screening for active TB, LTBI testing for a specific population group, and antibacterial therapy for 3-6 months for TB patients. Conclusion The UK's control and prevention efforts in reducing tuberculosis prevalence among immigrants show optimism, but challenges persist. Key improvements include healthcare delivery, TB improvement programs, and policies addressing stigma and patient confidentiality.
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Affiliation(s)
- Uzair Ahmad Saleem
- Faculty of Health, Medicine & Life Sciences, University of Maastricht, Maastricht, the Netherlands
| | - Ali Sina Karimi
- Medical Sciences Research Center, Ghalib University, Kabul, Afghanistan
| | - Hedayatullah Ehsan
- Medical Sciences Research Center, Ghalib University, Kabul, Afghanistan
- Kabul University of Medical Sciences, Kabul, Afghanistan
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Goscé L, Allel K, Hamada Y, Korobitsyn A, Ismail N, Bashir S, Denkinger CM, Abubakar I, White PJ, Rangaka MX. Economic evaluation of novel Mycobacterium tuberculosis specific antigen-based skin tests for detection of TB infection: A modelling study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002573. [PMID: 38117825 PMCID: PMC10732392 DOI: 10.1371/journal.pgph.0002573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 11/10/2023] [Indexed: 12/22/2023]
Abstract
Evidence on the economic impact of novel skin tests for tuberculosis infection (TBST) is scarce and limited by study quality. We used estimates on the cost-effectiveness of the use of TBST compared to current tuberculosis infection (TBI) tests to assess whether TBST are affordable and feasible to implement under different country contexts. A Markov model parametrised to Brazil, South Africa and the UK was developed to compare the cost-effectiveness of three TBI testing strategies: (1) Diaskintest (DST), (2) TST test, and (3) IGRA QFT test. Univariate and probabilistic sensitivity analyses over unit costs and main parameters were performed. Our modelling results show that Diaskintest saves $5.60 and gains 0.024 QALYs per patient and $8.40, and 0.01 QALYs per patient in Brazil, compared to TST and IGRA respectively. In South Africa, Diaskintest is also cost-saving at $4.39, with 0.015 QALYs per patient gained, compared to TST, and $64.41, and 0.007 QALYs per patient, compared to IGRA. In the UK, Diaskintest saves $73.33, and gaines 0.0351 QALYs per patient, compared to TST. However, Diaskintest, compared to IGRA, showed an incremental cost of $521.45 (95% CI (500.94-545.07)) per QALY, below the willingness-to-pay threshold of $20.223 per QALY. Diaskintest potentially saves costs and results in greater health gains than the TST and IGRA tests in Brazil and South Africa. In the UK Diaskintest would gain health but also be more costly. Our results have potential external validity because TBST remained cost-effective despite extensive sensitivity analyses.
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Affiliation(s)
- Lara Goscé
- Institute for Global Health, University College London, London, United Kingdom
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kasim Allel
- Institute for Global Health, University College London, London, United Kingdom
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Yohhei Hamada
- Institute for Global Health, University College London, London, United Kingdom
| | - Alexei Korobitsyn
- Unit for Prevention, Diagnosis, Treatment, Care and Innovation, Global Tuberculosis Programme, World Health Organization, Genève, Switzerland
| | - Nazir Ismail
- Unit for Prevention, Diagnosis, Treatment, Care and Innovation, Global Tuberculosis Programme, World Health Organization, Genève, Switzerland
| | - Saima Bashir
- Division of Infectious Diseases and Tropical Medicine at University Hospital Heidelberg, Heidelberg, Germany
| | - Claudia M. Denkinger
- Division of Infectious Diseases and Tropical Medicine at University Hospital Heidelberg, Heidelberg, Germany
- German Center for Infection Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, United Kingdom
| | - Peter J. White
- MRC Centre for Global Infectious Disease Analysis and NIHR Health Protection Research Unit in Modelling and Health Economics, School of Public Health, Faculty of Medicine, Imperial College, London, United Kingdom
- Modelling and Economics Unit, UK Health Security Agency, London, United Kingdom
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Jordan AE, Nsengiyumva NP, Houben RMGJ, Dodd PJ, Dale KD, Trauer JM, Denholm JT, Johnston JC, Khan FA, Campbell JR, Schwartzman K. The prevalence of tuberculosis infection among foreign-born Canadians: a modelling study. CMAJ 2023; 195:E1651-E1659. [PMID: 38081633 PMCID: PMC10718277 DOI: 10.1503/cmaj.230228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND The prevalence of tuberculosis infection is critical to the design of tuberculosis prevention strategies, yet is unknown in Canada. We estimated the prevalence of tuberculosis infection among Canadian residents born abroad. METHODS We estimated the prevalence of tuberculosis infection by age and year of migration to Canada for people from each of 168 countries by constructing country-specific and calendar year-specific trends for annual risk of infection using a previously developed model. We combined country-specific prevalence estimates with Canadian Census data from 2001, 2006, 2011, 2016 and 2021 to estimate the overall prevalence of tuberculosis infection among foreign-born Canadian residents. RESULTS The estimated overall prevalence of tuberculosis infection among foreign-born people in Canada was 25% (95% uncertainty interval [UI] 20%-35%) for census year 2001, 24% (95% UI 20%-33%) for 2006, 23% (95% UI 19%-30%) for 2011, 22% (95% UI 19%-28%) for 2016 and 22% (95% UI 19%-27%) for 2021. The prevalence increased with age at migration and incidence of tuberculosis in the country of origin. In 2021, the estimated prevalence of infection among foreign-born residents was lowest in Quebec (19%, 95% UI 16%-24%) and highest in Alberta (24%, 95% UI 21%-28%) and British Columbia (24%, 95% UI 20%-30%). Among all foreign-born Canadian residents with tuberculosis infection in 2021, we estimated that only 1 in 488 (95% UI 185-1039) had become infected within the 2 preceding years. INTERPRETATION About 1 in 4 foreign-born Canadian residents has tuberculosis infection, but very few were infected within the 2 preceding years (the highest risk period for progression to tuberculosis disease). These data may inform future tuberculosis infection screening policies.
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Affiliation(s)
- Aria Ed Jordan
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que
| | - Ntwali Placide Nsengiyumva
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que
| | - Rein M G J Houben
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que
| | - Peter J Dodd
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que
| | - Katie D Dale
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que
| | - James M Trauer
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que
| | - Justin T Denholm
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que
| | - James C Johnston
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que
| | - Faiz Ahmad Khan
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que
| | - Jonathon R Campbell
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que.
| | - Kevin Schwartzman
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que.
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7
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Arinaminpathy N, Mukadi YD, Bloom A, Vincent C, Ahmedov S. Meeting the 2030 END TB goals in the wake of COVID-19: A modelling study of countries in the USAID TB portfolio. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001271. [PMID: 37870997 PMCID: PMC10593207 DOI: 10.1371/journal.pgph.0001271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 08/10/2023] [Indexed: 10/25/2023]
Abstract
Progress towards the 2030 End TB goals has seen severe setbacks due to disruptions arising from the COVID-19 pandemic. For governments and international partner organizations supporting the global TB response, there is a need to assess what level of effort is now needed to reach these goals. Using mathematical modelling, we addressed this question for the countries being supported by the United States Agency for International Development (USAID). We aggregated the 24 countries in the USAID portfolio into three geographical country groups: South Asia; sub-Saharan Africa; and Central Asian Republics/Europe (CAR/EU). From 2023 onwards we modelled a combination of interventions acting at different stages of the care cascade, including improved diagnostics; reducing the patient care seeking delay; and the rollout of a disease-preventing vaccine from 2025 onwards. We found that in all three country groups, meeting the End TB goals by 2030 will require a combination of interventions acting at stages of the TB care cascade. Specific priorities may depend on country settings, for example with public-private mix playing an important role in countries in South Asia and elsewhere. When a vaccine becomes available, its required coverage to meet the 2030 goals will vary by setting, depending on the amount of preventive therapy that has already been implemented. Monitoring the number-needed-to-test to identify 1 person with TB in community settings can provide a useful measure of progress towards the End TB goals.
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Affiliation(s)
- Nimalan Arinaminpathy
- MRC Centre for Global Infectious Disease Analysis, Imperial College, London, United Kingdom
| | - Ya Diul Mukadi
- United States Agency for International Development, Washington, DC, United States of America
| | - Amy Bloom
- United States Agency for International Development, Washington, DC, United States of America
| | - Cheri Vincent
- United States Agency for International Development, Washington, DC, United States of America
| | - Sevim Ahmedov
- United States Agency for International Development, Washington, DC, United States of America
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8
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Arvidsson Å, Lafta G, Sönnerbrandt M, Sundelin K, Paues J. The cascade of care for pregnant women with latent tuberculosis infection in a high-income country. Infect Dis (Lond) 2023; 55:635-645. [PMID: 37389825 DOI: 10.1080/23744235.2023.2228406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 06/16/2023] [Accepted: 06/16/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Pregnant women have an increased risk of developing active tuberculosis (TB). The Public Health Agency of Sweden recommends screening of active TB and latent tuberculosis infection (LTBI) among pregnant women from countries with high TB incidence at Maternal Health Care (MHC) clinics. In Östergötland County, Sweden, a screening program has been active since 2013. The aim of this study was to evaluate this screening program and the cascade of care for LTBI among pregnant women in Östergötland county. METHODS Data were obtained from pregnant women screened for TB at MHC clinics and subsequently referred to the pulmonary medicine clinic or the clinic of infectious diseases in Östergötland County between 2013 and 2018. The Public Health Agency of Sweden's national database for active TB was used to analyse if any women developed active TB up to two years after the screening process. RESULTS A total of 439 women were included. Nine cases of active TB were discovered during the screening process and two developed active TB afterward. 177 women were recommended LTBI treatment and variables significantly associated with a decreased likelihood of being recommended treatment were increasing age, time in Sweden, and parity. 137 women received and 112 (82%) completed treatment. 14 women discontinued treatment due to adverse effects. CONCLUSION Screening of pregnant women from countries with high TB incidence at MHC clinics led to the discovery of several cases of active TB. The completion rate of LTBI treatment was high and few discontinued due to adverse effects.
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Affiliation(s)
- Åsa Arvidsson
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Gihan Lafta
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | | | - Karin Sundelin
- Department for Infectious Diseases, Region Östergötland, Linköping, Sweden
| | - Jakob Paues
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
- Department for Infectious Diseases, Region Östergötland, Linköping, Sweden
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9
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Lin H, Zhang R, Wu Z, Li M, Wu J, Shen X, Yang C. Assessing the spatial heterogeneity of tuberculosis in a population with internal migration in China: a retrospective population-based study. Front Public Health 2023; 11:1155146. [PMID: 37325311 PMCID: PMC10266412 DOI: 10.3389/fpubh.2023.1155146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/11/2023] [Indexed: 06/17/2023] Open
Abstract
Background Internal migrants pose a critical threat to eliminating Tuberculosis (TB) in many high-burden countries. Understanding the influential pattern of the internal migrant population in the incidence of tuberculosis is crucial for controlling and preventing the disease. We used epidemiological and spatial data to analyze the spatial distribution of tuberculosis and identify potential risk factors for spatial heterogeneity. Methods We conducted a population-based, retrospective study and identified all incident bacterially-positive TB cases between January 1st, 2009, and December 31st, 2016, in Shanghai, China. We used Getis-Ord Gi* statistics and spatial relative risk methods to explore spatial heterogeneity and identify regions with spatial clusters of TB cases, and then used logistic regression method to estimate individual-level risk factors for notified migrant TB and spatial clusters. A hierarchical Bayesian spatial model was used to identify the attributable location-specific factors. Results Overall, 27,383 bacterially-positive tuberculosis patients were notified for analysis, with 42.54% (11,649) of them being migrants. The age-adjusted notification rate of TB among migrants was much higher than among residents. Migrants (aOR, 1.85; 95%CI, 1.65-2.08) and active screening (aOR, 3.13; 95%CI, 2.60-3.77) contributed significantly to the formation of TB high-spatial clusters. With the hierarchical Bayesian modeling, the presence of industrial parks (RR, 1.420; 95%CI, 1.023-1.974) and migrants (RR, 1.121; 95%CI, 1.007-1.247) were the risk factors for increased TB disease at the county level. Conclusion We identified a significant spatial heterogeneity of tuberculosis in Shanghai, one of the typical megacities with massive migration. Internal migrants play an essential role in the disease burden and the spatial heterogeneity of TB in urban settings. Optimized disease control and prevention strategies, including targeted interventions based on the current epidemiological heterogeneity, warrant further evaluation to fuel the TB eradication process in urban China.
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Affiliation(s)
- Honghua Lin
- School of Public Health (Shenzhen), Shenzhen Campus of Sun Yat-sen University, Shenzhen, China
| | - Rui Zhang
- School of Public Health (Shenzhen), Shenzhen Campus of Sun Yat-sen University, Shenzhen, China
| | - Zheyuan Wu
- Division of TB and HIV/AIDS Prevention, Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
- Shanghai Institutes of Preventive Medicine, Shanghai, China
| | - Minjuan Li
- School of Public Health (Shenzhen), Shenzhen Campus of Sun Yat-sen University, Shenzhen, China
| | - Jiamei Wu
- School of Public Health (Shenzhen), Shenzhen Campus of Sun Yat-sen University, Shenzhen, China
| | - Xin Shen
- Division of TB and HIV/AIDS Prevention, Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
- Shanghai Institutes of Preventive Medicine, Shanghai, China
| | - Chongguang Yang
- School of Public Health (Shenzhen), Shenzhen Campus of Sun Yat-sen University, Shenzhen, China
- School of Public Health, Yale University, New Haven, CT, United States
- Nanshan District Center for Disease Control and Prevention, Shenzhen, Guangdong Province, China
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10
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A cost-effectiveness evaluation of latent tuberculosis infection screening of a migrant population in Malaysia. Sci Rep 2023; 13:2390. [PMID: 36765258 PMCID: PMC9918505 DOI: 10.1038/s41598-023-29648-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/08/2023] [Indexed: 02/12/2023] Open
Abstract
To estimate the costs and benefits of screening for latent tuberculosis infection (LTBI) in a migrant population in Malaysia. An economic model was developed from a Malaysian healthcare perspective to compare QuantiFERON-TB Gold Plus (QuantiFERON) with the tuberculin skin test (TST). A decision tree was used to capture outcomes relating to LTBI screening followed by a Markov model that simulated the lifetime costs and benefits of the patient cohort. The Markov model did not capture the impact of secondary infections. The model included an R shiny interactive interface to allow adaptation to other scenarios and settings. QuantiFERON is both more effective and less costly than TST (dominant). Compared with QuantiFERON, the lifetime risk of developing active TB increases by approximately 40% for TST due to missed LTBI cases during screening (i.e. a higher number of false negative cases for TST). For a migrant population in Malaysia, QuantiFERON is cost-effective when compared with TST. Further research should consider targeted LTBI screening for migrants in Malaysia based on common risk factors.
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Gray AT, Surey J, Esmail H, Story A, Harris M. "It's too hard" - the management of latent TB in under-served populations in the UK: a qualitative study. BMC Health Serv Res 2022; 22:1464. [PMID: 36457026 PMCID: PMC9715280 DOI: 10.1186/s12913-022-08855-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 11/18/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND UK national guidance recommends systematic screening for latent tuberculosis infection (LTBI) in under-served populations, including people experiencing homelessness and people who use drugs. This is not routinely implemented in the UK, and the reasons for this policy-practice mismatch remain underexplored. METHODS Semi-structured qualitative interviews were conducted with 19 healthcare professionals from across the UK. Participants were recruited using purposive sampling and snowballing, identifying individuals with excellent knowledge of their regions practice and policy of LTBI management. The interviews were conducted online, and were audio recorded, with transcripts thematically analysed using a two-stage inductive coding process to explore perceived barriers and enablers to LTBI screening. RESULTS Most participants had previous experience managing LTBI in under-served populations, but none were conducting systematic screening as per national guidance. We identified service provision challenges and low prioritisation of LTBI as the key explanatory themes driving this policy-practice mismatch. Lack of resource, and the complexity of clinical decision making were two key service level barriers. System and service inertia, and lack of cost effectiveness evidence led to LTBI being deprioritised. Service integration and promotion of WHO targets for TB elimination were highlighted as potential solutions. CONCLUSION Integrating LTBI testing and treatment with existing health services for under-served populations could improve feasibility and efficacy. Promotion of UK TB elimination goals and generation of regional evidence to support commissioning for LTBI care is vital. Without such a multi-pronged approach inertia is likely to persist and the zeitgeist will remain: "it's too hard".
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Affiliation(s)
- Adam Thorburn Gray
- Find and Treat, University College London Hospitals, London, UK.
- Hospital for Tropical Diseases, University College London Hospitals, London, UK.
- Institute for Global Health, University College London, London, UK.
| | - Julian Surey
- Find and Treat, University College London Hospitals, London, UK
- Institute for Global Health, University College London, London, UK
| | - Hanif Esmail
- Hospital for Tropical Diseases, University College London Hospitals, London, UK
- Institute for Global Health, University College London, London, UK
- MRC Clinical Trials Unit, University College London, London, UK
| | - Alistair Story
- Find and Treat, University College London Hospitals, London, UK
- Collaborative Centre for Inclusion Health, University College London, London, UK
| | - Magdalena Harris
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, UK
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12
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Prevention and treatment of infectious diseases in migrants in Europe in the era of universal health coverage. THE LANCET PUBLIC HEALTH 2022; 7:e876-e884. [DOI: 10.1016/s2468-2667(22)00174-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/16/2022] [Accepted: 07/04/2022] [Indexed: 11/20/2022] Open
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Stærke NB, Fløe A, Nielsen MF, Holm M, Holm E, Hilberg O, Wejse C, Hvass AMF. The cascade of care in tuberculosis infection screening and management in newly arrived refugees in Aarhus, Denmark. Travel Med Infect Dis 2022; 49:102388. [PMID: 35753660 DOI: 10.1016/j.tmaid.2022.102388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/25/2022] [Accepted: 06/17/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Screening for tuberculosis (TB) disease and infection is often a part of health screening programs offered to refugees, but the yield of screening varies and losses along the steps from screening to treatment completion was reported. METHODS A retrospective cohort study was performed investigating a newly arrived refugee population offered a systematic refugee health assessment in Aarhus, Denmark. Data was collected on screening, referral, diagnosis and treatment for TB disease and infection. RESULTS Among both adults and children IGRA positivity was associated with origin in a high TB incidence country and increasing age. The number needed to screen (NNS) to find one case of TB infection was 7 among adult refugees and 19 among children, while NNS for TB disease was 266 and 164 respectively. The proportion of the eligible population with a valid result was 78.1% for adults and 71.3% for children, while 43.1% and 50% of adults and children with presumed TB infection completed preventive treatment. DISCUSSION Screening for TB disease and infection among refugees in Aarhus had a high yield in terms of diagnosis, however significant losses were seen during screening, follow-up and preventive treatment completion.
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Affiliation(s)
- Nina Breinholt Stærke
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark; Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Andreas Fløe
- Department of Respiratory Diseases, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Mie Fryd Nielsen
- Department of Respiratory Diseases, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Mette Holm
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Emma Holm
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Ole Hilberg
- Department of Internal Medicine, Sygehus Lillebælt, Beriderbakken 4, 7100, Vejle, Denmark; Department of Regional Health Research, University of Southern Denmark, Campusvej 55, 5230, Odense, Denmark
| | - Christian Wejse
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark; Center for Global Health (GloHAU), Aarhus University, Bartholins allé 2, 8000, Aarhus C, Denmark
| | - Anne Mette Fløe Hvass
- Center for Global Health (GloHAU), Aarhus University, Bartholins allé 2, 8000, Aarhus C, Denmark; Department of Social Medicine, Aarhus Municipality, Fredens torv 6, 8000, Aarhus N, Denmark
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Berrocal-Almanza LC, Harris RJ, Collin SM, Muzyamba MC, Conroy OD, Mirza A, O'Connell AM, Altass L, Anderson SR, Thomas HL, Campbell C, Zenner D, Phin N, Kon OM, Smith EG, Lalvani A. Effectiveness of nationwide programmatic testing and treatment for latent tuberculosis infection in migrants in England: a retrospective, population-based cohort study. THE LANCET PUBLIC HEALTH 2022; 7:e305-e315. [PMID: 35338849 PMCID: PMC8967722 DOI: 10.1016/s2468-2667(22)00031-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 01/14/2022] [Accepted: 01/26/2022] [Indexed: 12/11/2022] Open
Abstract
Background In low-incidence countries, tuberculosis mainly affects migrants, mostly resulting from reactivation of latent tuberculosis infection (LTBI) acquired in high-incidence countries before migration. A nationwide primary care-based LTBI testing and treatment programme for migrants from high-incidence countries was therefore established in high tuberculosis incidence areas in England. We aimed to assess the effectiveness of this programme. Methods We did a retrospective, population-based cohort study of migrants who registered in primary care between Jan 1, 2011, and Dec 31, 2018, in 55 high-burden areas with programmatic LTBI testing and treatment. Eligible individuals were aged 16–35 years, born in a high-incidence country, and had entered England in the past 5 years. Individuals who tested interferon-γ release assay (IGRA)-negative were advised about symptoms of tuberculosis, whereas those who tested IGRA-positive were clinically assessed to rule out active tuberculosis and offered preventive therapy. The primary outcome was incident tuberculosis notified to the national Enhanced Tuberculosis Surveillance system. Findings Our cohort comprised 368 097 eligible individuals who had registered in primary care, of whom 37 268 (10·1%) were tested by the programme. 1446 incident cases of tuberculosis were identified: 166 cases in individuals who had IGRA testing (incidence 204 cases [95% CI 176–238] per 100 000 person-years) and 1280 in individuals without IGRA testing (82 cases [77–86] per 100 000 person-years). Overall, in our primary analysis including all diagnosed tuberculosis cases, a time-varying association was identified between LTBI testing and treatment and lower risk of incident tuberculosis (hazard ratio [HR] 0·76 [95% CI 0·63–0·91]) when compared with no testing. In stratified analysis by follow-up period, the intervention was associated with higher risk of tuberculosis diagnosis during the first 6 months of follow-up (9·93 [7·63–12·9) and a lower risk after 6 months (0·57 [0·41–0·79]). IGRA-positive individuals had higher risk of tuberculosis diagnosis than IGRA-negative individuals (31·9 [20·4–49·8]). Of 37 268 migrants who were tested, 6640 (17·8%) were IGRA-positive, of whom 1740 (26·2%) started preventive treatment. LTBI treatment lowered the risk of tuberculosis: of 135 incident cases in the IGRA-positive cohort, seven cases were diagnosed in the treated group (1·87 cases [95% CI 0·89–3·93] per 1000 person-years) and 128 cases were diagnosed in the untreated group (10·9 cases [9·16–12·9] per 1000 person-years; HR 0·14 [95% CI 0·06–0·32]). Interpretation A low proportion of eligible migrants were tested by the programme and a small proportion of those testing positive started treatment. Despite this, programmatic LTBI testing and treatment of individuals migrating to a low-incidence region is effective at diagnosing active tuberculosis earlier and lowers the long-term risk of progression to tuberculosis. Increasing programme participation and treatment rates for those testing positive could substantially impact national tuberculosis incidence. Funding National Institute for Health Research Health Protection Research Unit in Respiratory Infections.
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15
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Pareek M, Greenaway C. Programmatic screening for latent tuberculosis in migrants. THE LANCET PUBLIC HEALTH 2022; 7:e292-e293. [DOI: 10.1016/s2468-2667(22)00064-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/09/2022] [Indexed: 10/18/2022] Open
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Margineanu I, Rustage K, Noori T, Zenner D, Greenaway C, Pareek M, Akkerman O, Hayward S, Friedland JS, Goletti D, Stienstra Y, Hargreaves S. Country-specific approaches to latent tuberculosis screening targeting migrants in EU/EEA* countries: A survey of national experts, September 2019 to February 2020. EURO SURVEILLANCE : BULLETIN EUROPEEN SUR LES MALADIES TRANSMISSIBLES = EUROPEAN COMMUNICABLE DISEASE BULLETIN 2022; 27. [PMID: 35332865 PMCID: PMC8950856 DOI: 10.2807/1560-7917.es.2022.27.12.2002070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Migrants in low tuberculosis (TB) incidence countries in the European Union (EU)/European Economic Area (EEA) are an at-risk group for latent tuberculosis infection (LTBI) and are increasingly included in LTBI screening programmes. Aim To investigate current approaches and implement LTBI screening in recently arrived migrants in the EU/EEA and Switzerland. Methods At least one TB expert working at a national level from the EU/EEA and one TB expert from Switzerland completed an electronic questionnaire. We used descriptive analyses to calculate percentages, and framework analysis to synthesise free-text responses. Results Experts from 32 countries were invited to participate (30 countries responded): 15 experts reported an LTBI screening programme targeting migrants in their country; five reported plans to implement one in the near future; and 10 reported having no programme. LTBI screening was predominantly for asylum seekers (n = 12) and refugees (n = 11). Twelve countries use ‘country of origin’ as the main eligibility criteria. The countries took similar approaches to diagnosis and treatment but different approaches to follow-up. Six experts reported that drop-out rates in migrants were higher compared with non-migrant groups. Most of the experts (n = 22) called for a renewed focus on expanding efforts to screen for LTBI in migrants arriving in low-incidence countries. Conclusion We found a range of approaches to LTBI screening of migrants in the EU/EEA and Switzerland. Findings suggest a renewed focus is needed to expand and strengthen efforts to meaningfully include migrants in these programmes, in order to meet regional and global elimination targets for TB.
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Affiliation(s)
- Ioana Margineanu
- University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Kieran Rustage
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Teymur Noori
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | | | | | | | - Onno Akkerman
- University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Sally Hayward
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom.,The Migrant Health Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Jon S Friedland
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Delia Goletti
- Translational Research Unit, Department of Epidemiology and Preclinical Research, National Institute for Infectious Diseases L. Spallanzani, Rome Italy
| | - Ymkje Stienstra
- University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Sally Hargreaves
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
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- The ESGITM/ESGMYC Study Groups are acknowledged at the end of the article
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Dale KD, Abayawardana MJ, McBryde ES, Trauer JM, Carvalho N. Modeling the Cost-Effectiveness of Latent Tuberculosis Screening and Treatment Strategies in Recent Migrants to a Low-Incidence Setting. Am J Epidemiol 2022; 191:255-270. [PMID: 34017976 DOI: 10.1093/aje/kwab150] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 05/02/2021] [Accepted: 05/13/2021] [Indexed: 11/12/2022] Open
Abstract
Many tuberculosis (TB) cases in low-incidence settings are attributed to reactivation of latent TB infection (LTBI) acquired overseas. We assessed the cost-effectiveness of community-based LTBI screening and treatment strategies in recent migrants to a low-incidence setting (Australia). A decision-analytical Markov model was developed that cycled 1 migrant cohort (≥11-year-olds) annually over a lifetime from 2020. Postmigration/onshore and offshore (screening during visa application) strategies were compared with existing policy (chest x-ray during visa application). Outcomes included TB cases averted and discounted cost per quality-adjusted life-year (QALY) gained from a health-sector perspective. Most recent migrants are young adults and cost-effectiveness is limited by their relatively low LTBI prevalence, low TB mortality risks, and high emigration probability. Onshore strategies cost at least $203,188 (Australian) per QALY gained, preventing approximately 2.3%-7.0% of TB cases in the cohort. Offshore strategies (screening costs incurred by migrants) cost at least $13,907 per QALY gained, preventing 5.5%-16.9% of cases. Findings were most sensitive to the LTBI treatment quality-of-life decrement (further to severe adverse events); with a minimal decrement, all strategies caused more ill health than they prevented. Additional LTBI strategies in recent migrants could only marginally contribute to TB elimination and are unlikely to be cost-effective unless screening costs are borne by migrants and potential LTBI treatment quality-of-life decrements are ignored.
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Cinardo P, Farrant O, Gunn K, Ward A, Eisen S, Longley N. Screening for neglected tropical diseases and other infections in refugee and asylum-seeker populations in the United Kingdom. Ther Adv Infect Dis 2022; 9:20499361221116680. [PMID: 35958977 PMCID: PMC9358592 DOI: 10.1177/20499361221116680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/13/2022] [Indexed: 11/24/2022] Open
Abstract
Asylum-seekers and refugees have an increased burden of infections compared with the general population. This has been widely recognised by countries welcoming those fleeing conflict and persecution; however, there are no screening standardised guidelines and regulatory processes. Identification of certain neglected tropical diseases (NTDs) and other infections is important for the health and well-being of the individual in addition to public health and biosecurity. In the United Kingdom, screening for infections at port of entry or after arrival is not mandatory. Those on refugee resettlement programmes will have infection screening as part of their pre-entry health assessment, but no such system exists for those claiming asylum in the United Kingdom. In this article, we have reviewed published, peer-reviewed articles looking at the approaches to screening for NTDs and infectious diseases in the United Kingdom. In addition to this, we have reviewed the literature looking at the acceptability, barriers and facilitators of these screening practices. We found that there is a heterogeneous approach to screening practices in the United Kingdom and a paucity of data to support a single ‘best practice’ approach. Based on our findings, we have made recommendations and consideration for NTD screening strategies and highlighted important areas for future research.
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Affiliation(s)
- Paola Cinardo
- Clinical Research Fellow, Acute Medicine, University College Hospital, 235 Euston Road, London, NW1 2BU, London, UK
| | - Olivia Farrant
- Infectious Diseases, Hospital for Tropical Diseases, London, UK; Acute Medicine, University College Hospital, London, UK
| | - Kimberlee Gunn
- Division of Infection and Immunity, University College Hospital, London, UK
| | - Allison Ward
- Children's & Adolescent Services, Royal Free London NHS Foundation Trust, London, UK
| | - Sarah Eisen
- Children and Young People's Services, University College Hospital, London, UK
| | - Nicky Longley
- Infectious Diseases and Travel Medicine, Hospital for Tropical Diseases, London, UK
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19
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Marx FM, Hauer B, Menzies NA, Haas W, Perumal N. Targeting screening and treatment for latent tuberculosis infection towards asylum seekers from high-incidence countries - a model-based cost-effectiveness analysis. BMC Public Health 2021; 21:2172. [PMID: 34836526 PMCID: PMC8622109 DOI: 10.1186/s12889-021-12142-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 11/01/2021] [Indexed: 11/26/2022] Open
Abstract
Background Enhancing tuberculosis (TB) prevention and care in a post-COVID-19-pandemic phase will be essential to ensure progress towards global TB elimination. In low-burden countries, asylum seekers constitute an important high-risk group. TB frequently arises post-immigration due to the reactivation of latent TB infection (LTBI). Upon-entry screening for LTBI and TB preventive treatment (TPT) are considered worthwhile if targeted to asylum seekers from high-incidence countries who usually present with higher rates of LTBI. However, there is insufficient knowledge about optimal incidence thresholds above which introduction could be cost-effective. We aimed to estimate, among asylum seekers in Germany, the health impact and costs of upon-entry LTBI screening/TPT introduced at different thresholds of country-of-origin TB incidence. Methods We sampled hypothetical cohorts of 30–45 thousand asylum seekers aged 15 to 34 years expected to arrive in Germany in 2022 from cohorts of first-time applicants observed in 2017–2019. We modelled LTBI prevalence as a function of country-of-origin TB incidence fitted to data from observational studies. We then used a probabilistic decision-analytic model to estimate health-system costs and quality-adjusted life years (QALYs) under interferon gamma release assay (IGRA)-based screening for LTBI and rifampicin-based TPT (daily, 4 months). Incremental cost-effectiveness ratios (ICERs) were calculated for scenarios of introducing LTBI screening/TPT at different incidence thresholds. Results We estimated that among 15- to 34-year-old asylum seekers arriving in Germany in 2022, 17.5% (95% uncertainty interval: 14.2–21.6%) will be latently infected. Introducing LTBI screening/TPT above 250 per 100,000 country-of-origin TB incidence would gain 7.3 (2.7–14.8) QALYs at a cost of €51,000 (€18,000–€114,100) per QALY. Lowering the threshold to ≥200 would cost an incremental €53,300 (€19,100–€122,500) per additional QALY gained relative to the ≥250 threshold scenario; ICERs for the ≥150 and ≥ 100 thresholds were €55,900 (€20,200–€128,200) and €62,000 (€23,200–€142,000), respectively, using the next higher threshold as a reference, and considerably higher at thresholds below 100. Conclusions LTBI screening and TPT among 15- to 34-year-old asylum seekers arriving in Germany could produce health benefits at reasonable additional cost (with respect to international benchmarks) if introduced at incidence thresholds ≥100. Empirical trials are needed to investigate the feasibility and effectiveness of this approach.
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Affiliation(s)
- Florian M Marx
- Department for Infectious Disease Epidemiology, Respiratory Infections Unit, Robert Koch Institute, Berlin, Germany. .,Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa. .,DSI-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa.
| | - Barbara Hauer
- Department for Infectious Disease Epidemiology, Respiratory Infections Unit, Robert Koch Institute, Berlin, Germany
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Walter Haas
- Department for Infectious Disease Epidemiology, Respiratory Infections Unit, Robert Koch Institute, Berlin, Germany
| | - Nita Perumal
- Department for Infectious Disease Epidemiology, Respiratory Infections Unit, Robert Koch Institute, Berlin, Germany.,Immunization Unit, Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
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20
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O'Connell J, de Barra E, McConkey S. Systematic review of latent tuberculosis infection research to inform programmatic management in Ireland. Ir J Med Sci 2021; 191:1485-1504. [PMID: 34595689 PMCID: PMC9308571 DOI: 10.1007/s11845-021-02779-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 09/08/2021] [Indexed: 11/11/2022]
Abstract
The World Health Organisation (WHO) End Tuberculosis (TB) Strategy and the WHO Framework Towards Tuberculosis Elimination in Low Incidence Countries state that latent tuberculosis infection (LTBI) screening and treatment in selected high-risk groups is a priority action to eliminate TB. The European Centre for Disease Prevention and Control (ECDC) advises that this should be done through high-quality programmatic management, which they describe as having six key components. The research aim was to systematically review the literature to identify what is known about the epidemiology of LTBI and the uptake and completion of LTBI screening and treatment in Ireland to inform the programmatic management of LTBI nationally. A systematic literature review was performed according to a review protocol and reported in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Twenty-eight studies were eligible for inclusion and described LTBI screening or treatment performed in one of five contexts, pre-biologic or other immunosuppression screening, people living with HIV, TB case contacts, other vulnerable populations, or healthcare workers. The risk of bias across studies with regard to prevalence of LTBI was generally high. One study reported a complete cascade of LTBI care from screening initiation to treatment completion. This systematic review has described what published research there is on the epidemiology and cascade of LTBI care in Ireland and identified knowledge gaps. A strategy for addressing these knowledge gaps has been proposed.
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Affiliation(s)
- James O'Connell
- School of Postgraduate Studies, Royal College of Surgeons in Ireland, Dublin 2, Dublin, Ireland.
| | - Eoghan de Barra
- Department of International Health and Tropical Medicine, Royal College of Surgeons in Ireland, Dublin 2, Dublin, Ireland.,Department of Infectious Diseases Medicine, Beaumont University Hospital, Dublin 5, Dublin, Ireland
| | - Samuel McConkey
- Department of International Health and Tropical Medicine, Royal College of Surgeons in Ireland, Dublin 2, Dublin, Ireland.,Department of Infectious Diseases Medicine, Beaumont University Hospital, Dublin 5, Dublin, Ireland
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21
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Lim VW, Wee HL, Lee P, Lin Y, Tan YR, Tan MX, Lin LW, Yap P, Chee CB, Barkham T, Lee V, Chen M, Ong RTH. Cross-sectional study of prevalence and risk factors, and a cost-effectiveness evaluation of screening and preventive treatment strategies for latent tuberculosis among migrants in Singapore. BMJ Open 2021; 11:e050629. [PMID: 34266845 PMCID: PMC8286773 DOI: 10.1136/bmjopen-2021-050629] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES WHO recommends that low burden countries consider systematic screening and treatment of latent tuberculosis infection (LTBI) in migrants from high incidence countries. We aimed to determine LTBI prevalence and risk factors and evaluate cost-effectiveness of screening and treating LTBI in migrants to Singapore from a government payer perspective. DESIGN Cross-sectional study and cost-effectiveness analysis. SETTING Migrants in Singapore. PARTICIPANTS 3618 migrants who were between 20 and 50 years old, have not worked in Singapore previously and stayed in Singapore for less than a year were recruited. PRIMARY AND SECONDARY OUTCOME MEASURES Costs, quality-adjusted life-years (QALYs), threshold length of stay, incremental cost-effectiveness ratios (ICERs), cost per active TB case averted. RESULTS Of 3584 migrants surveyed, 20.4% had positive interferon-gamma release assay (IGRA) results, with the highest positivity in Filipinos (33.2%). Higher LTBI prevalence was significantly associated with age, marital status and past TB exposure. The cost-effectiveness model projected an ICER of S$57 116 per QALY and S$12 422 per active TB case averted for screening and treating LTBI with 3 months once weekly isoniazid and rifapentine combination regimen treatment compared with no screening over a 50-year time horizon. ICER was most sensitive to the cohort's length of stay in Singapore, yearly disease progression rates from LTBI to active TB, followed by the cost of IGRA testing. CONCLUSIONS For LTBI screening and treatment of migrants to be cost-effective, migrants from high burden countries would have to stay in Singapore for ~50 years. Risk-stratified approaches based on projected length of stay and country of origin and/or age group can be considered.
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Affiliation(s)
- Vanessa W Lim
- Infectious Disease Research and Training Office, National Centre for Infectious Diseases, Singapore
| | - Hwee Lin Wee
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Phoebe Lee
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
- Communicable Diseases Division, Ministry of Health Singapore, Singapore
| | - Yijun Lin
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
- Communicable Diseases Division, Ministry of Health Singapore, Singapore
| | - Yi Roe Tan
- Infectious Disease Research and Training Office, National Centre for Infectious Diseases, Singapore
| | - Mei Xuan Tan
- Infectious Disease Research and Training Office, National Centre for Infectious Diseases, Singapore
| | - Lydia Wenxin Lin
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Peiling Yap
- Infectious Disease Research and Training Office, National Centre for Infectious Diseases, Singapore
| | - Cynthia Be Chee
- Tuberculosis Control Unit, Singapore TB Elimination Programme, Singapore
| | - Timothy Barkham
- Department of Laboratory Medicine, Tan Tock Seng Hospital, Singapore
| | - Vernon Lee
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
- Communicable Diseases Division, Ministry of Health Singapore, Singapore
| | - Mark Chen
- Infectious Disease Research and Training Office, National Centre for Infectious Diseases, Singapore
| | - Rick Twee-Hee Ong
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
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22
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Shedrawy J, Deogan C, Öhd JN, Hergens MP, Bruchfeld J, Jonsson J, Siroka A, Lönnroth K. Cost-effectiveness of the latent tuberculosis screening program for migrants in Stockholm Region. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2021; 22:445-454. [PMID: 33559787 PMCID: PMC7954754 DOI: 10.1007/s10198-021-01265-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 01/13/2021] [Indexed: 06/07/2023]
Abstract
INTRODUCTION The majority of tuberculosis (TB) cases in Sweden occur among migrants from endemic countries through activation of latent tuberculosis infection (LTBI). Sweden has LTBI-screening policies for migrants that have not been previously evaluated. This study aimed to assess the cost-effectiveness of the current screening strategy in Stockholm. METHODS A Markov model was developed to predict the costs and effects of the current LTBI-screening program compared to a scenario of no LTBI screening over a 50-year time horizon. Epidemiological and cost data were obtained from local sources when available. The primary outcomes were incremental cost-effectiveness ratio (ICER) in terms of societal cost per quality-adjusted life year (QALY). RESULTS Screening migrants in the age group 13-19 years had the lowest ICER, 300,082 Swedish Kronor (SEK)/QALY, which is considered cost-effective in Sweden. In the age group 20-34, ICER was 714,527 SEK/QALY (moderately cost-effectives) and in all age groups above 34 ICERs were above 1,000,000 SEK/QALY (not cost-effective). ICER decreased with increasing TB incidence in country of origin. CONCLUSION Screening is cost-effective for young cohorts, mainly between 13 and 19, while cost-effectiveness in age group 20-34 years could be enhanced by focusing on migrants from highest incidence countries and/or by increasing the LTBI treatment initiation rate. Screening is not cost-effective in older cohorts regardless of the country of origin.
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Affiliation(s)
- Jad Shedrawy
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
| | - Charlotte Deogan
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- The Public Health Agency of Sweden, Stockholm, Sweden
| | - Joanna Nederby Öhd
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Communicable Disease Control and Prevention, Stockholm County Council, Stockholm, Sweden
| | - Maria-Pia Hergens
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Communicable Disease Control and Prevention, Stockholm County Council, Stockholm, Sweden
| | - Judith Bruchfeld
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Knut Lönnroth
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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23
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Kristensen KL, Ravn P, Petersen JH, Hargreaves S, Nellums LB, Friedland JS, Andersen PH, Norredam M, Lillebaek T. Long-term risk of tuberculosis among migrants according to migrant status: a cohort study. Int J Epidemiol 2021; 49:776-785. [PMID: 32380550 DOI: 10.1093/ije/dyaa063] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The majority of tuberculosis (TB) cases in low-incidence countries occur in migrants. Only few studies have assessed the long-term TB risk in migrants after immigration, and datasets have not considered this across a range of diverse migrant groups. This nationwide study aimed to investigate long-term TB risk among migrants according to migrant status and region of origin. METHODS This cohort study included all migrants aged ≥ 18 years who obtained residence in Denmark from 1993 to 2015, with a mean follow-up of 10.8 years [standard deviation (SD) 7.3]. Migrants were categorized based on legal status of residence and region of origin. Incidence rates (IR) and rate ratios (IRR) were estimated by Poisson regression. RESULTS A total of 142 314 migrants were included. Across all migrants, the TB risk was highest during year 1 of residence (IR 275/100 000 person-years; 95% CI 249-305) followed by a gradual decline, though TB risk remained high for over a decade. Compared with the Danish-born population, the IRRs after 7-8 years were particularly higher among former asylum seekers (IRR 31; 95% CI 20-46), quota refugees (IRR 31; 95% CI 16-71), and family-reunified with refugees (IRR 22; 95% CI 12-44). Sub-Saharan African migrants also experienced elevated risk (IRR 75; 95% CI 51-109). The proportion of migrants with pulmonary TB was 52.4%. CONCLUSION All migrant groups experienced an initial high TB risk, but long-term risk remained high in key migrant groups. Most European countries focus TB screening on or soon after arrival. Our study suggests that approaches to TB screening should be adapted, with migrant populations benefiting from long-term access to preventive health services.
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Affiliation(s)
- Kristina Langholz Kristensen
- International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark.,Department of Pulmonary and Infectious Diseases, Nordsjaellands Hospital, Hilleroed, Denmark
| | - Pernille Ravn
- Department of Medicine, Section of Infectious Diseases, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | | | - Sally Hargreaves
- Institute for Infection & Immunity, St George's University of London, London, UK
| | - Laura B Nellums
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jon S Friedland
- Institute for Infection & Immunity, St George's University of London, London, UK
| | - Peter Henrik Andersen
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark
| | - Marie Norredam
- Research Centre for Migration, Ethnicity and Health, University of Copenhagen, Copenhagen, Denmark.,Department of Infectious Diseases, Section of Immigrant Medicine, University Hospital Hvidovre, Hvidovre, Denmark
| | - Troels Lillebaek
- International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark.,Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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24
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Kumar DS, Ronald LA, Romanowski K, Rose C, Shulha HP, Cook VJ, Johnston JC. Risk of active tuberculosis in migrants diagnosed with cancer: a retrospective cohort study in British Columbia, Canada. BMJ Open 2021; 11:e037827. [PMID: 33653739 PMCID: PMC7929860 DOI: 10.1136/bmjopen-2020-037827] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To describe the association between types of cancer and active tuberculosis (TB) risk in migrants. Additionally, in order to better inform latent TB infection (LTBI) screening protocols, we assessed proportion of active TB cases potentially preventable through LTBI screening and treatment in migrants with cancer. DESIGN Population-based, retrospective cohort study. SETTING British Columbia (BC), Canada. PARTICIPANTS 1 000 764 individuals who immigrated to Canada from 1985 to 2012 and established residency in BC at any point up to 2015. PRIMARY AND SECONDARY OUTCOME MEASURES Using linked health administrative databases and disease registries, data on demographics, comorbidities, cancer type, TB exposure and active TB diagnosis were extracted. Primary outcomes included: time to first active TB diagnoses, and risks of active TB following cancer diagnoses which were estimated using Cox extended hazard regression models. Potentially preventable TB was defined as active TB diagnosed >6 months postcancer diagnoses. RESULTS Active TB risk was increased in migrants with cancer ((HR (95% CI)) 2.5 (2.0 to 3.1)), after adjustment for age, sex, TB incidence in country of origin, immigration classification, contact status and comorbidities. Highest risk was observed with lung cancer (HR 11.2 (7.4 to 16.9)) and sarcoma (HR 8.1 (3.3 to 19.5)), followed by leukaemia (HR 5.6 (3.1 to 10.2)), lymphoma (HR 4.9 (2.7 to 8.7)) and gastrointestinal cancers (HR 2.7 (1.7 to 4.4)). The majority (65.9%) of active TB cases were diagnosed >6 months postcancer diagnosis. CONCLUSION Specific cancers increase active TB risk to varying degrees in the migrant population of BC, with approximately two-thirds of active TB cases identified as potentially preventable.
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Affiliation(s)
- Divjot S Kumar
- Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa A Ronald
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Kamila Romanowski
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Caren Rose
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Hennady P Shulha
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Victoria J Cook
- Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - James C Johnston
- Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
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25
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Mugwagwa T, Abubakar I, White PJ. Using molecular testing and whole-genome sequencing for tuberculosis diagnosis in a low-burden setting: a cost-effectiveness analysis using transmission-dynamic modelling. Thorax 2021; 76:281-291. [PMID: 33542086 DOI: 10.1136/thoraxjnl-2019-214004] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 10/08/2020] [Accepted: 10/26/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Despite progress in TB control in low-burden countries like England and Wales, there are still diagnostic delays. Molecular testing and/or whole-genome sequencing (WGS) provide more rapid diagnosis but their cost-effectiveness is relatively unexplored in low-burden settings. METHODS An integrated transmission-dynamic health economic model is used to assess the cost-effectiveness of using WGS to replace culture-based drug-sensitivity testing, versus using molecular testing versus combined use of WGS and molecular testing, for routine TB diagnosis. The model accounts for the effects of faster appropriate treatment in reducing transmission, benefiting health and reducing future treatment costs. Cost-effectiveness is assessed using incremental net benefit (INB) over a 10-year horizon with a quality-adjusted life-year valued at £20 000, and discounting at 3.5% per year. RESULTS WGS shortens the time to drug sensitivity testing and treatment modification where necessary, reducing treatment and hospitalisation costs, with an INB of £7.1 million. Molecular testing shortens the time to TB diagnosis and treatment. Initially, this causes an increase in annual costs of treatment, but averting transmissions and future active TB disease subsequently, resulting in cost savings and health benefits to achieve an INB of £8.6 million (GeneXpert MTB/RIF) or £11.1 million (Xpert-Ultra). Combined use of Xpert-Ultra and WGS is the optimal strategy we consider, with an INB of £16.5 million. CONCLUSION Routine use of WGS or molecular testing is cost-effective in a low-burden setting, and combined use is the most cost-effective option. Adoption of these technologies can help low-burden countries meet the WHO End TB Strategy milestones, particularly the UK, which still has relatively high TB rates.
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Affiliation(s)
- Tendai Mugwagwa
- Modelling and Economics Unit, National Infection Service, Public Health England, London, UK.,MRC Centre for Global Infectious Disease Analysis and NIHR Health Protection Research Unit in Modelling and Health Economics, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK
| | - Peter J White
- Modelling and Economics Unit, National Infection Service, Public Health England, London, UK .,MRC Centre for Global Infectious Disease Analysis and NIHR Health Protection Research Unit in Modelling and Health Economics, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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26
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BCG Vaccine Protection against TB Infection among Children Older than 5 Years in Close Contact with an Infectious Adult TB Case. J Clin Med 2020; 9:jcm9103224. [PMID: 33050061 PMCID: PMC7601378 DOI: 10.3390/jcm9103224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/01/2020] [Accepted: 10/05/2020] [Indexed: 11/23/2022] Open
Abstract
The Bacille Calmette–Guérin (BCG) vaccine has been shown to provide considerable protection against miliary or meningeal tuberculosis (TB), but whether it prevents other forms of disease remains controversial. Recent evidence has shown that the BCG vaccine also provides protection against latent TB infection (LTBI). The aim of the current study was to examine whether BCG has a protective role against LTBI among children in close contact with an adult index case in a low TB endemicity setting with the use of the QuantiFERON-TB Gold In-Tube test (QFT-GIT). A cross-sectional study was conducted over a 10-year period among children referred to our outpatient TB clinic with a history of close contact with an adult with pulmonary TB. All subjects had a QFT-GIT performed. In total, 207 children > 5 to 16 years of age with known recent exposure were enrolled. BCG-vaccinated subjects had a 59% lower risk of presenting with LTBI after close contact with an adult index case compared with unvaccinated subjects (OR = 0.41, 95% CI: 0.23–0.73, p = 0.002). After adjustment for possible confounders, the protective effect of prior BCG immunization was estimated at 68% (OR = 0.32, 95% CI: 0.15–0.66, p = 0.002). Other risk factors for LTBI included a history of migration (OR = 2.27, 95% CI: 1.13–4.53, p = 0.021) and transmission of infection to other exposed child contacts (OR = 4.62, 95% CI: 2.27–9.39, p = 0.001). We were able to determine a strong protective role of BCG vaccination among children older than 5 years, immunized at school entry, who had close contact with an adult infectious TB case.
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27
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Guillén-Nepita AL, Vázquez-Marrufo G, Cruz-Hernández A, García-Oliva F, Zepeda-Gurrola RC, Vázquez-Garcidueñas MS. Detailed epidemiological analysis as a strategy for evaluating the actual behavior of tuberculosis in an apparently low-incidence region. Pathog Glob Health 2020; 114:393-404. [PMID: 32924885 DOI: 10.1080/20477724.2020.1813488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Tuberculosis control in developing regions with apparent low incidence, like the low-income Mexican state of Michoacán, with mean annual incidence rates below 10/100,000 inhabitants, requires knowledge of the actual behavior of the disease. This can be determined using an epidemiological profile at sub-regional level, allowing disclosure of the clinical and social factors that may be hampering efforts to control tuberculosis. In this work, a detailed epidemiological profile was outlined using data of all new monthly cases registered in the National System of Epidemiological Surveillance Database for Michoacán municipalities from 2000 to 2012. Cases were grouped by gender and age, and sociodemographic data were obtained both from the National Institute of Statistics and Geography and from the United Nations Development Programme. Correlations were calculated by Chi-square, Mann-Whitney U, and Kruskal-Wallis H tests. We observed no statistically significant differences between notification rates for the years 2000, 2005 and 2010 (χ2 = 0.222, p = 0.895). The percentage of cases is similar between all age groups older than 15, while some regions had low notification rates but high proportions of pediatric cases. Higher proportions of cases of extrapulmonary tuberculosis were observed in municipalities in northern Michoacán. No correlation was found between municipal Human Development Index values and municipal notification rates. Michoacán is undergoing an epidemiological transition with three regions having different epidemiological profiles and particular needs for effective prevention and containment of tuberculosis. Our work shows the importance of the spatial scale of epidemiological profiles for determining specific regional needs of surveillance and containment.
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28
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Hargreaves S, Nellums LB, Johnson C, Goldberg J, Pantelidis P, Rahman A, Friedland FMedSci JS. Delivering multi-disease screening to migrants for latent TB and blood-borne viruses in an emergency department setting: A feasibility study. Travel Med Infect Dis 2020; 36:101611. [PMID: 32126293 PMCID: PMC7493708 DOI: 10.1016/j.tmaid.2020.101611] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 11/06/2019] [Accepted: 02/26/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Screening for latent tuberculosis infection (LTBI) in migrants is important for elimination of tuberculosis in low-incidence countries, alongside the need to detect blood-borne infections to align with new guidelines on migrant screening for multiple infections in European countries. However, feasibility needs to be better understood. METHODS We did a feasibility study to test an innovative screening model offering combined testing for LTBI (QuantiFERON), HIV, hepatitis B/C in a UK emergency department, with two year follow-up. RESULTS 96 economic migrants, asylum seekers and refugees from 43 countries were screened (46 [47.9%] women; mean age 35.2 years [SD 11.7; range 18-73]; mean time in the UK 4.8 years [SD 3.2; range 0-10]). 14 migrants (14.6%) tested positive for LTBI alongside HIV [1], hepatitis B [2], and hepatitis C [1] Of migrants with LTBI, 5 (35.7%) were successfully engaged in treatment. 74 (77.1%) migrants reported no previous screening since migrating to the UK. CONCLUSION Multi-disease screening in this setting is feasible and merits being further tested in larger-scale studies. However, greater emphasis must be placed on ensuring successful treatment outcomes. We identified major gaps in current screening provision; most migrants had been offered no prior screening despite several years since migration, which holds relevance to policy and practice in the UK and other European countries.
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Affiliation(s)
- Sally Hargreaves
- Institute for Infection & Immunity, St. George's, University of London, United Kingdom.
| | - Laura B Nellums
- Institute for Infection & Immunity, St. George's, University of London, United Kingdom; Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Catherine Johnson
- Section of Infectious Diseases & Immunity, Imperial College London, United Kingdom
| | - Jacob Goldberg
- Section of Infectious Diseases & Immunity, Imperial College London, United Kingdom
| | | | - Asif Rahman
- Imperial College Healthcare NHS Trust, London, United Kingdom
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Zammarchi L, Tilli M, Botta A, Buonfrate D, Bartoloni A, Boccalini S. Strategies for management of strongyloidiasis in migrants from Sub-Saharan Africa recently arrived in Italy: A cost-effectiveness analysis. Travel Med Infect Dis 2020; 36:101561. [PMID: 31982632 DOI: 10.1016/j.tmaid.2020.101561] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 01/18/2020] [Accepted: 01/20/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Italian and the European Centre for Disease Control and Prevention guidelines both recommend a systematic serological screening for strongyloidiasis in sub-Saharan migrants (SSA), however, studies on clinical and economic impact of this strategy in the Italian and European settings are lacking. METHODS A population of 100,000 migrants from SSA to Italy was considered and a Markov decision tree model was developed to assess the clinical and economic impact of two interventions for strongyloidiasis compared with the current practice (passive diagnosis of symptomatic cases): a) universal serological screening and treatment with ivermectin in case of positive test b) universal presumptive treatment with ivermectin. One and 10-year time horizon in the health-care perspective were considered. RESULTS In the one and 10-year time horizon respectively the costs for passive diagnosis was €1,164,169 and €9,735,908, those for screening option was € 2,856,011 and € 4,959,638 and those for presumptive treatment was €3,538,474 and € 4,883,272. Considering the cost per cured subject in the one-year time horizon, screening appears more favorable (€209.53), than the other two options (€232.55 per presumptive treatment and €10,197.29 per current strategy). Incremental cost-effectiveness ratio (ICERs) of screening strategy and presumptive treatment were respectively 265.27 and 333.19. The sensitivity analysis identified strongyloidiasis' prevalence as the main driver of ICER. CONCLUSIONS Compared to the current practice (passive diagnosis) both screening and presumptive treatment strategies are more favorable from a cost-effectiveness point of view, with a slight advantage of the screening strategy in a one-year time horizon.
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Affiliation(s)
- Lorenzo Zammarchi
- Department of Experimental and Clinical Medicine, University of Florence, Italy; Referral Center for Tropical Diseases of Tuscany, Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy.
| | - Marta Tilli
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Annarita Botta
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Dora Buonfrate
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | - Alessandro Bartoloni
- Department of Experimental and Clinical Medicine, University of Florence, Italy; Referral Center for Tropical Diseases of Tuscany, Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
| | - Sara Boccalini
- Department of Health Sciences, University of Florence, Italy
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Bracchi M, van Halsema C, Post F, Awosusi F, Barbour A, Bradley S, Coyne K, Dixon-Williams E, Freedman A, Jelliman P, Khoo S, Leen C, Lipman M, Lucas S, Miller R, Seden K, Pozniak A. British HIV Association guidelines for the management of tuberculosis in adults living with HIV 2019. HIV Med 2020; 20 Suppl 6:s2-s83. [PMID: 31152481 DOI: 10.1111/hiv.12748] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
| | - Clare van Halsema
- North Manchester General Hospital, Liverpool School of Tropical Medicine
| | - Frank Post
- King's College Hospital NHS Foundation Trust
| | | | | | | | | | | | | | - Pauline Jelliman
- Royal Liverpool and Broadgreen University Hospital Trust, NHIVNA
| | | | | | | | | | | | | | - Anton Pozniak
- Chelsea and Westminster Hospital NHS Foundation Trust, London School of Hygiene and Tropical Medicine
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Villa S, Codecasa LR, Faccini M, Pontello MM, Ferrarese M, Castellotti PF, Senatore S, Lamberti A, Mazzola E, Perno CF, Campisi D, Saporiti M, Raviglione MC. Latent tuberculosis screening and treatment among asylum seekers: a mixed-methods study. Eur Respir J 2020; 55:55/4/2000052. [DOI: 10.1183/13993003.00052-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 02/20/2020] [Indexed: 02/03/2023]
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Eborall H, Wobi F, Ellis K, Willars J, Abubakar I, Griffiths C, Pareek M. Integrated screening of migrants for multiple infectious diseases: Qualitative study of a city-wide programme. EClinicalMedicine 2020; 21:100315. [PMID: 32322806 PMCID: PMC7170938 DOI: 10.1016/j.eclinm.2020.100315] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/04/2020] [Accepted: 02/27/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Migrants from certain regions are at increased risk of key infectious diseases (including HIV, tuberculosis (TB), hepatitis B and hepatitis C). Although guidelines increasingly recommend integrated screening for multiple infections to reduce morbidity little is known about what migrants and healthcare professionals think about this approach. METHODS Prospective qualitative study in Leicester, United Kingdom within a novel city-wide integrated screening programme in three iterative phases to understand views about infections and integrated screening. Phase 1 focus groups (nine) with migrants from diverse communities (n = 74); phase 2 semi-structured interviews with healthcare professionals involved in the screening pathway (n = 32); phase 3 semi-structured interviews (n = 23) with individuals having tested positive for one/more infections through the programme. Analysis was informed by the constant comparative process and iterative across phases 1-3. FINDINGS Migrants' awareness of TB, HIV and hepatitis B/C varied, with greater awareness of TB and HIV than hepatitis B/C; perceived susceptibility to the infections was low. The integrated screening programme was well-received by migrants and professionals; concerns were limited to data-sharing. As anticipated, given the target group, language was cited as a challenge but mitigated by various interpretation strategies. INTERPRETATION This large qualitative analysis is the first to confirm that integrated screening for key infectious diseases is feasible, positively viewed by, and acceptable to, migrants and healthcare professionals. These findings support recent guideline recommendations and therefore have important implications for policy-makers and clinicians as programmes of this type are more widely implemented in diverse settings. FUNDING National Institute for Health Research.
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Affiliation(s)
- Helen Eborall
- Department of Health Sciences, University of Leicester, United Kingdom
| | - Fatimah Wobi
- Department of Health Sciences, University of Leicester, United Kingdom
- Department of Respiratory Sciences, University of Leicester, United Kingdom
| | - Kate Ellis
- Department of Infection and HIV Medicine, University Hospitals Leicester NHS Trust, United Kingdom
| | - Janet Willars
- Department of Health Sciences, University of Leicester, United Kingdom
| | - Ibrahim Abubakar
- Institute of Global Health, University College London, London, United Kingdom
| | - Chris Griffiths
- Institute of Population Health Sciences, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Manish Pareek
- Department of Respiratory Sciences, University of Leicester, United Kingdom
- Department of Infection and HIV Medicine, University Hospitals Leicester NHS Trust, United Kingdom
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Al Abri S, Kowada A, Yaqoubi F, Al Khalili S, Ndunda N, Petersen E. Cost-effectiveness of IGRA/QFT-Plus for TB screening of migrants in Oman. Int J Infect Dis 2020; 92S:S72-S77. [DOI: 10.1016/j.ijid.2020.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/03/2020] [Accepted: 03/04/2020] [Indexed: 11/25/2022] Open
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Al Abri S, Kasaeva T, Migliori GB, Goletti D, Zenner D, Denholm J, Al Maani A, Cirillo DM, Schön T, Lillebæk T, Al-Jardani A, Go UY, Dias HM, Tiberi S, Al Yaquobi F, Khamis FA, Kurup P, Wilson M, Memish Z, Al Maqbali A, Akhtar M, Wejse C, Petersen E. Tools to implement the World Health Organization End TB Strategy: Addressing common challenges in high and low endemic countries. Int J Infect Dis 2020; 92S:S60-S68. [PMID: 32114195 DOI: 10.1016/j.ijid.2020.02.042] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/21/2020] [Accepted: 02/21/2020] [Indexed: 02/07/2023] Open
Abstract
AIM The purpose of this viewpoint is to summarize the advantages and constraints of the tools and strategies available for reducing the annual incidence of tuberculosis (TB) by implementing the World Health Organization (WHO) End TB Strategy and the linked WHO TB Elimination Framework, with special reference to Oman. METHODS The case-study was built based on the presentations and discussions at an international workshop on TB elimination in low incidence countries organized by the Ministry of Health, Oman, which took place from September 5 to September 7, 2019, and supported by the WHO and European Society of Clinical Microbiology and Infectious Diseases (ESCMID). RESULTS Existing tools were reviewed, including the screening of migrants for latent TB infection (LTBI) with interferon-gamma release assays, clinical examination for active pulmonary TB (APTB) including chest X-rays, organization of laboratory services, and the existing centres for mandatory health examination of pre-arrival or arriving migrants, including examination for APTB. The need for public-private partnerships to handle the burden of screening arriving migrants for active TB was discussed at length and different models for financing were reviewed. CONCLUSIONS In a country with a high proportion of migrants from high endemic countries, screening for LTBI is of high priority. Molecular typing and the development of public-private partnerships are needed.
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Affiliation(s)
- Seif Al Abri
- Directorate General for Diseases Surveillance and Control, Ministry of Health, Muscat, Oman.
| | | | - Giovanni Battista Migliori
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy
| | - Delia Goletti
- Translational Research Unit, National Institute for Infectious Diseases "Lazzaro Spallanzani" - IRCCS, Rome, Italy; ESCMID Study Group on Mycobacteria, Basel, Switzerland
| | - Dominik Zenner
- Regional Office of the European Economic Area, EU and NATO and International Organization for Migration, IOM, Brussels, Belgium
| | - Justin Denholm
- Department of Infectious Diseases, Royal Melbourne Hospital and Victorian TB Programme, Melbourne, Australia
| | - Amal Al Maani
- Paediatric Infectious Diseases, The Royal Hospital and Central Department of Infection Prevention and Control, Directorate General for Diseases Surveillance and Control, Ministry of Health, Muscat, Oman
| | - Daniela Maria Cirillo
- Emerging Bacterial Pathogen Research Unit, Italian Reference Centre for Molecular Typing of Mycobacteria, San Rafaele Scientific Institute, Milan, Italy
| | - Thomas Schön
- Department of Clinical Microbiology and Infectious Diseases, Kalmar Hospital and University of Linköping, Sweden
| | - Troels Lillebæk
- International Reference Laboratory of Mycobacteriology, WHO TB Supranational Reference Laboratory Copenhagen, Infectious Disease Preparedness Area, Statens Serum Institute and Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Amina Al-Jardani
- Central Public Health Laboratory, Directorate General for Disease Surveillance and Control, Ministry of Health, Muscat, Oman
| | - Un-Yeong Go
- International Tuberculosis Research Centre, Seoul, Republic of Korea
| | - Hannah Monica Dias
- WHO Global TB Programme Unit on Policy, Strategy and Innovations, Geneva, Switzerland
| | - Simon Tiberi
- Infectious Diseases, Barts Health NHS Trust, London, United Kingdom; Queen Mary University of London, London, United Kingdom
| | - Fatma Al Yaquobi
- Tuberculosis and Acute Respiratory Diseases Surveillance, Directorate General for Disease Surveillance and Control, Ministry of Health, Muscat, Oman
| | - Faryal Ali Khamis
- Department of Infectious Diseases, The Royal Hospital, Ministry of Health, Muscat, Oman
| | - Padmamohan Kurup
- Department of Disease Surveillance and Control, Muscat Governorate, Muscat, Oman
| | | | - Ziad Memish
- Prince Mohammed bin Abdulaziz Hospital, Ministry of Health and College of Medicine, Alfaisal University, Riyadh, Saudi Arabia; Rollings School of Public Health, Emory University, Atlanta, GA, USA
| | - Ali Al Maqbali
- Disease Surveillance and Control, North Bathinah Governorate, Sohar, Oman
| | | | - Christian Wejse
- Department of Infectious Disease, Aarhus University Hospital and School of Public Health, Faculty of Health Sciences, University of Aarhus, Denmark; ESCMID Study Group for Travel and Migration, Basel, Switzerland
| | - Eskild Petersen
- Directorate General for Disease Surveillance and Control, Ministry of Health, Muscat, Oman; Institute for Clinical Medicine, Faculty of Health Science, University of Aarhus, Denmark; ESCMID Emerging Infections Task Force, Basel, Switzerland
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Berrocal-Almanza LC, Harris R, Lalor MK, Muzyamba MC, Were J, O'Connell AM, Mirza A, Kon OM, Lalvani A, Zenner D. Effectiveness of pre-entry active tuberculosis and post-entry latent tuberculosis screening in new entrants to the UK: a retrospective, population-based cohort study. THE LANCET. INFECTIOUS DISEASES 2019; 19:1191-1201. [DOI: 10.1016/s1473-3099(19)30260-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/28/2019] [Accepted: 05/10/2019] [Indexed: 10/26/2022]
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Greenaway C, Pareek M, Abou Chakra CN, Walji M, Makarenko I, Alabdulkarim B, Hogan C, McConnell T, Scarfo B, Christensen R, Tran A, Rowbotham N, van der Werf MJ, Noori T, Pottie K, Matteelli A, Zenner D, Morton RL. The effectiveness and cost-effectiveness of screening for latent tuberculosis among migrants in the EU/EEA: a systematic review. ACTA ACUST UNITED AC 2019; 23. [PMID: 29637889 PMCID: PMC5894253 DOI: 10.2807/1560-7917.es.2018.23.14.17-00543] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Migrants account for a large and growing proportion of tuberculosis (TB) cases in low-incidence countries in the European Union/European Economic Area (EU/EEA) which are primarily due to reactivation of latent TB infection (LTBI). Addressing LTBI among migrants will be critical to achieve TB elimination. Methods: We conducted a systematic review to determine effectiveness (performance of diagnostic tests, efficacy of treatment, uptake and completion of screening and treatment) and a second systematic review on cost-effectiveness of LTBI screening programmes for migrants living in the EU/EEA. Results: We identified seven systematic reviews and 16 individual studies that addressed our aims. Tuberculin skin tests and interferon gamma release assays had high sensitivity (79%) but when positive, both tests poorly predicted the development of active TB (incidence rate ratio: 2.07 and 2.40, respectively). Different LTBI treatment regimens had low to moderate efficacy but were equivalent in preventing active TB. Rifampicin-based regimens may be preferred because of lower hepatotoxicity (risk ratio = 0.15) and higher completion rates (82% vs 69%) compared with isoniazid. Only 14.3% of migrants eligible for screening completed treatment because of losses along all steps of the LTBI care cascade. Limited economic analyses suggest that the most cost-effective approach may be targeting young migrants from high TB incidence countries. Discussion: The effectiveness of LTBI programmes is limited by the large pool of migrants with LTBI, poorly predictive tests, long treatments and a weak care cascade. Targeted LTBI programmes that ensure high screening uptake and treatment completion will have greatest individual and public health benefit.
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Affiliation(s)
- Christina Greenaway
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada.,Division of Infectious Diseases, Jewish General Hospital, McGill University, Montreal, Canada
| | - Manish Pareek
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, United Kingdom
| | | | - Moneeza Walji
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | - Iuliia Makarenko
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | - Balqis Alabdulkarim
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | - Catherine Hogan
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada.,Division of Infectious Diseases, Jewish General Hospital, McGill University, Montreal, Canada
| | - Ted McConnell
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | - Brittany Scarfo
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | - Robin Christensen
- Department of Rheumatology, Odense University Hospital, Denmark.,Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Anh Tran
- National Health and Medical Research Council, NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Nick Rowbotham
- National Health and Medical Research Council, NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | | | - Teymur Noori
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - Kevin Pottie
- Bruyere Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Alberto Matteelli
- Clinic of Infectious and Tropical Diseases, University of Brescia and Brescia Spedali Civili General Hospital, World Health Organization Collaborating Centre for TB/HIV and TB Elimination, Brescia, Italy
| | - Dominik Zenner
- Department of Infection and Population Health, University College London, London, United Kingdom.,Respiratory Diseases Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom
| | - Rachael L Morton
- National Health and Medical Research Council, NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
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Spruijt I, Tesfay Haile D, Suurmond J, van den Hof S, Koenders M, Kouw P, van Noort N, Toumanian S, Cobelens F, Goosen S, Erkens C. Latent tuberculosis screening and treatment among asylum seekers: a mixed-methods study. Eur Respir J 2019; 54:13993003.00861-2019. [DOI: 10.1183/13993003.00861-2019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 08/26/2019] [Indexed: 11/05/2022]
Abstract
IntroductionEvidence on conditions for implementation of latent tuberculosis infection (LTBI) screening and treatment among asylum seekers is needed to inform tuberculosis (TB) control policies. We used mixed-methods to evaluate the implementation of an LTBI screening and treatment programme among asylum seekers in the Netherlands.MethodsWe offered voluntary LTBI screening to asylum seekers aged ≥12 years living in asylum seeker centres from countries with a TB incidence >200 per 10 000 population. We calculated LTBI screening and treatment cascade coverage, and assessed associated factors with Poisson regression using robust variance estimators. We interviewed TB care staff (seven group interviews) and Eritrean clients (21 group and 21 individual interviews) to identify programme enhancers and barriers.ResultsWe screened 719 (63% of 1136) clients for LTBI. LTBI was diagnosed among 178 (25%) clients; 149 (84%) initiated LTBI treatment, of whom 129 (87%) completed treatment. In-person TB and LTBI education, the use of professional interpreters, and collaboration with partner organisations were enhancers for LTBI screening uptake. Demand-driven LTBI treatment support by TB nurses enhanced treatment completion. Factors complicating LTBI screening and treatment were having to travel to public health services, language barriers and moving from asylum seeker centres to the community during treatment.ConclusionLTBI screening and treatment of asylum seekers is feasible and effective when high quality of care is provided, including culture-sensitive TB education throughout the care cascade. Additionally, collaboration with partner organisations, such as agencies responsible for reception and support of asylum seekers, should be in place.
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Rafiei N, Williams J, Mulley WR, Trauer JM, Jenkin GA, Rogers BA. Mycobacterium tuberculosis: Active disease and latent infection in a renal transplant cohort. Nephrology (Carlton) 2019; 24:569-574. [PMID: 29660203 DOI: 10.1111/nep.13386] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2018] [Indexed: 01/09/2023]
Abstract
AIM Our aim was threefold: first, to determine the incidence of active TB in our cohort, second to investigate the risk factors for active TB and third, to understand current screening practices. The ultimate goal was to use our findings to inform development of local and national guidelines. METHODS The records of all adult patients who underwent renal transplantation at our centre from 2005 to 2014 were retrospectively reviewed to assess current screening practices, the risks for and burden of active TB. RESULTS A total of 660 individuals underwent renal transplantation during this period, totalling 3647 person years of follow up. Two patients were diagnosed with active TB after renal transplant, resulting in an incidence of 55 per 100 000 person-years. Of 656 transplant recipients, 102 (15.5%) were born in high TB incidence countries and 89 (13.5%) had an interferon gamma release assay (IGRA) at any point. Individuals born in high TB risk countries had a much higher incidence of active TB (353 per 100 000 person-years). Ten individuals had positive IGRA tests, of whom two were treated for active TB, two received chemoprophylaxis and six were not treated. CONCLUSIONS In the absence of formal guidelines, IGRA-based screening for LTBI was infrequently performed. Our data suggest that screening and treatment of renal transplant recipients born in high incidence countries is an important preventive measure.
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Affiliation(s)
- Nastaran Rafiei
- Monash Infectious Diseases, Monash Health, Melbourne, Victoria, Australia
| | - Jackie Williams
- Monash Infectious Diseases, Monash Health, Melbourne, Victoria, Australia
| | - William R Mulley
- Department of Nephrology, Monash Medical Centre, Melbourne, Victoria, Australia.,Department of Medicine, Centre for Inflammatory Diseases, Monash University, Melbourne, Victoria, Australia
| | - James M Trauer
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Grant A Jenkin
- Monash Infectious Diseases, Monash Health, Melbourne, Victoria, Australia
| | - Benjamin A Rogers
- Monash Infectious Diseases, Monash Health, Melbourne, Victoria, Australia.,Department of Medicine, Centre for Inflammatory Diseases, Monash University, Melbourne, Victoria, Australia
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Ronald LA, Campbell JR, Balshaw RF, Romanowski K, Roth DZ, Marra F, Cook VJ, Johnston JC. Demographic predictors of active tuberculosis in people migrating to British Columbia, Canada: a retrospective cohort study. CMAJ 2019; 190:E209-E216. [PMID: 29483329 DOI: 10.1503/cmaj.170817] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2017] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Canadian tuberculosis (TB) guidelines recommend targeting postlanding screening for and treatment of latent tuberculosis infection (LTBI) in people migrating to Canada who are at increased risk for TB reactivation. Our objectives were to calculate robust longitudinal estimates of TB incidence in a cohort of people migrating to British Columbia, Canada, over a 29-year period, and to identify groups at highest risk of developing TB based on demographic characteristics at time of landing. METHODS We included all individuals (n = 1 080 908) who became permanent residents of Canada between Jan. 1, 1985, and Dec. 31, 2012, and were resident in BC at any time between 1985 and 2013. Multiple administrative databases were linked to the provincial TB registry. We used recursive partitioning models to identify populations with high TB yield. RESULTS Active TB was diagnosed in 2814 individuals (incidence rate 24.2/100 000 person-years). Demographic factors (live-in caregiver, family, refugee immigration classes; higher TB incidence in country of birth; and older age) were strong predictors of TB incidence in BC, with elevated rates continuing many years after entry into the cohort. Recursive partitioning identified refugees 18-64 years of age from countries with a TB incidence greater than 224/100 000 population as a high-yield group, with 1% developing TB within the first 10 years. INTERPRETATION These findings support recommendations in Canadian guidelines to target postlanding screening for and treatment of LTBI in adult refugees from high-incidence countries. Because high-yield populations can be identified at entry via demographic data, screening at this point may be practical and high-impact, particularly if the LTBI care cascade can be optimized.
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Affiliation(s)
- Lisa A Ronald
- Division of Respiratory Medicine, Faculty of Medicine (Ronald, Cook, Johnston), University of British Columbia; BC Centre for Disease Control (Ronald, Balshaw, Romanowski, Roth, Cook, Johnston); Faculty of Pharmaceutical Sciences (Campbell, Marra), University of British Columbia, Vancouver, BC
| | - Jonathon R Campbell
- Division of Respiratory Medicine, Faculty of Medicine (Ronald, Cook, Johnston), University of British Columbia; BC Centre for Disease Control (Ronald, Balshaw, Romanowski, Roth, Cook, Johnston); Faculty of Pharmaceutical Sciences (Campbell, Marra), University of British Columbia, Vancouver, BC
| | - Robert F Balshaw
- Division of Respiratory Medicine, Faculty of Medicine (Ronald, Cook, Johnston), University of British Columbia; BC Centre for Disease Control (Ronald, Balshaw, Romanowski, Roth, Cook, Johnston); Faculty of Pharmaceutical Sciences (Campbell, Marra), University of British Columbia, Vancouver, BC
| | - Kamila Romanowski
- Division of Respiratory Medicine, Faculty of Medicine (Ronald, Cook, Johnston), University of British Columbia; BC Centre for Disease Control (Ronald, Balshaw, Romanowski, Roth, Cook, Johnston); Faculty of Pharmaceutical Sciences (Campbell, Marra), University of British Columbia, Vancouver, BC
| | - David Z Roth
- Division of Respiratory Medicine, Faculty of Medicine (Ronald, Cook, Johnston), University of British Columbia; BC Centre for Disease Control (Ronald, Balshaw, Romanowski, Roth, Cook, Johnston); Faculty of Pharmaceutical Sciences (Campbell, Marra), University of British Columbia, Vancouver, BC
| | - Fawziah Marra
- Division of Respiratory Medicine, Faculty of Medicine (Ronald, Cook, Johnston), University of British Columbia; BC Centre for Disease Control (Ronald, Balshaw, Romanowski, Roth, Cook, Johnston); Faculty of Pharmaceutical Sciences (Campbell, Marra), University of British Columbia, Vancouver, BC
| | - Victoria J Cook
- Division of Respiratory Medicine, Faculty of Medicine (Ronald, Cook, Johnston), University of British Columbia; BC Centre for Disease Control (Ronald, Balshaw, Romanowski, Roth, Cook, Johnston); Faculty of Pharmaceutical Sciences (Campbell, Marra), University of British Columbia, Vancouver, BC
| | - James C Johnston
- Division of Respiratory Medicine, Faculty of Medicine (Ronald, Cook, Johnston), University of British Columbia; BC Centre for Disease Control (Ronald, Balshaw, Romanowski, Roth, Cook, Johnston); Faculty of Pharmaceutical Sciences (Campbell, Marra), University of British Columbia, Vancouver, BC
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Tam G, Lai SW. Is Singapore on track to eliminate tuberculosis by 2030? A policy case study. SAGE Open Med 2019; 7:2050312119851331. [PMID: 31205699 PMCID: PMC6537069 DOI: 10.1177/2050312119851331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 04/25/2019] [Indexed: 01/15/2023] Open
Abstract
Tuberculosis remains the top 10 causes of death worldwide in 2015, with the largest number of new tuberculosis cases occurring in Asia. Singapore, a high-income Asian country, still has an intermediate tuberculosis burden. This study is to determine Singapore's tuberculosis policy with regard to achieving tuberculosis elimination goals. This is a case study of tuberculosis elimination policy in Singapore. Data were collected by policy review and literature review. Policy documents and reports were gathered from the websites of the Ministry of Health and the World Health Organization for policy review. The literature review was carried out through PubMed and Google Scholar to identify articles on epidemiology, treatment, and prevention of tuberculosis in Singapore. Data analysis of policy reports revealed that despite the overall downwards trend in the tuberculosis incidence rates between 2000 and 2015, the tuberculosis incidence rates reversed in 2008. Singapore tuberculosis policies are mostly consistent with the World Health Organization Stop TB Strategy, although over half of the performance indicators were not achieved by 2015. After screening 1014 articles, 18 studies were included in the literature review. The rapidly ageing population, great population mobility, and continuous community transmission were found to be major obstacles to achieving Millennium Development Goals in Singapore. Singapore is lagging in achieving the targets. Scaling up the existing tuberculosis programme to accelerate the tuberculosis decline is required to meet Sustainable Development Goals 2030. Unlike other high-income countries with an intermediate tuberculosis burden in Asia, Singapore has increasing tuberculosis incidence rates. While other countries face the burden of an ageing population, Singapore faces an additional burden of an influx of migrants from high-incidence countries. Singapore will need to control tuberculosis in both these demographic groups to reverse the increasing incidence trend.
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Affiliation(s)
- Greta Tam
- The Jockey Club School of Public Health and Primary
Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Shuk Wun Lai
- The Jockey Club School of Public Health and Primary
Care, The Chinese University of Hong Kong, Shatin, Hong Kong
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Bozorgmehr K, Preussler S, Wagner U, Joggerst B, Szecsenyi J, Razum O, Stock C. Using country of origin to inform targeted tuberculosis screening in asylum seekers: a modelling study of screening data in a German federal state, 2002-2015. BMC Infect Dis 2019; 19:304. [PMID: 30943917 PMCID: PMC6448304 DOI: 10.1186/s12879-019-3902-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/13/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Screening programmes for tuberculosis (TB) among immigrants rarely consider the heterogeneity of risk related to migrants' country of origin. We assess the performance of a large screening programme in asylum seekers by analysing (i) the difference in yield and numbers needed to screen (NNS) by country and WHO-reported TB burden, (ii) the possible impact of screening thresholds on sensitivity, and (iii) the value of WHO-estimated TB burden to improve the prediction accuracy of screening yield. METHODS We combined individual data of 119,037 asylum seekers screened for TB in Germany (2002-2015) with TB estimates of the World Health Organization (WHO) (1990-2014) for their 81 countries of origin. Adjusted rate ratios (aRR) and 95% credible intervals (CrI) of the observed yield of screening were calculated in Bayesian Poisson regression models by categories of WHO-estimated TB incidence. We assessed changes in sensitivity depending on screening thresholds, used WHO TB estimates as prior information to predict TB in asylum seekers, and modelled country-specific probabilities of numbers needed to screen (NNS) conditional on different screening thresholds. RESULTS The overall yield was 82 per 100,000 and the annual yield ranged from 44.1 to 279.7 per 100,000. Country-specific yields ranged from 10 (95%- CrI: 1-47) to 683 (95%-CrI: 306-1336) per 100,000 in Iraqi and Somali asylum seekers, respectively. The observed yield was higher in asylum seekers from countries with a WHO-estimated TB incidence > 50 relative to those from countries ≤50 per 100,000 (aRR: 4.17, 95%-CrI: 2.86-6.59). Introducing a threshold in the range of a WHO-estimated TB incidence of 50 and 100 per 100,000 resulted in the lowest "loss" in sensitivity. WHO's TB prevalence estimates improved prediction accuracy for eight of the 11 countries, and allowed modelling country-specific probabilities of NNS. CONCLUSIONS WHO's TB data can inform the estimation of screening yield and thus be used to improve screening efficiency in asylum seekers. This may help to develop more targeted screening strategies by reducing uncertainty in estimates of expected country-specific yield, and identify thresholds with lowest loss in sensitivity. Further modelling studies are needed which combine clinical, diagnostic and country-specific parameters.
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Affiliation(s)
- Kayvan Bozorgmehr
- Department of General Practice and Health Services Research, University Hospital Heidelberg, INF 130.3, 69120 Heidelberg, Germany
- Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Stella Preussler
- Institute of Medical Biometry and Informatics (IMBI), University Hospital Heidelberg, Heidelberg, Germany
| | - Ulrich Wagner
- Public health authority, Section for Disease Control, Landkreis Karlsruhe, Karlsruhe, Germany
| | | | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital Heidelberg, INF 130.3, 69120 Heidelberg, Germany
| | - Oliver Razum
- Department of Epidemiology and International Public Health, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Christian Stock
- Institute of Medical Biometry and Informatics (IMBI), University Hospital Heidelberg, Heidelberg, Germany
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, DKFZ, Heidelberg, Germany
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Pareek M, Eborall HC, Wobi F, Ellis KS, Kontopantelis E, Zhang F, Baggaley R, Hollingsworth TD, Baines D, Patel H, Haldar P, Patel M, Stephenson I, Browne I, Gill P, Kapur R, Farooqi A, Abubakar I, Griffiths C. Community-based testing of migrants for infectious diseases (COMBAT-ID): impact, acceptability and cost-effectiveness of identifying infectious diseases among migrants in primary care: protocol for an interrupted time-series, qualitative and health economic analysis. BMJ Open 2019; 9:e029188. [PMID: 30850420 PMCID: PMC6429847 DOI: 10.1136/bmjopen-2019-029188] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 01/24/2019] [Accepted: 01/28/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Migration is a major global driver of population change. Certain migrants may be at increased risk of infectious diseases, including tuberculosis (TB), HIV, hepatitis B and hepatitis C, and have poorer outcomes. Early diagnosis and management of these infections can reduce morbidity, mortality and onward transmission and is supported by national guidelines. To date, screening initiatives have been sporadic and focused on individual diseases; systematic routine testing of migrant groups for multiple infections is rarely undertaken and its impact is unknown. We describe the protocol for the evaluation of acceptability, effectiveness and cost-effectiveness of an integrated approach to screening migrants for a range of infectious diseases in primary care. METHODS AND ANALYSIS We will conduct a mixed-methods study which includes an observational cohort with interrupted time-series analysis before and after the introduction of routine screening of migrants for infectious diseases (latent TB, HIV, hepatitis B and hepatitis C) when first registering with primary care within Leicester, UK. We will assess trends in the monthly number and rate of testing and diagnosis for latent TB, HIV, hepatitis B and hepatitis C to determine the effect of the policy change using segmented regression analyses at monthly time-points. Concurrently, we will undertake an integrated qualitative sub-study to understand the views of migrants and healthcare professionals to the new testing policy in primary care. Finally, we will evaluate the cost-effectiveness of combined infection testing for migrants in primary care. ETHICS AND DISSEMINATION The study has received HRA and NHS approvals for both the interrupted time-series analysis (16/SC/0127) and the qualitative sub-study (16/EM/0159). For the interrupted time-series analysis we will only use fully anonymised data. For the qualitative sub-study, we will gain written, informed, consent. Dissemination of the results will be through local and national meetings/conferences as well as publications in peer-reviewed journals.
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Affiliation(s)
- Manish Pareek
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
- Department of Infection and HIV Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Helen C Eborall
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Fatimah Wobi
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Kate S Ellis
- Department of Infection and HIV Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Evangelos Kontopantelis
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Centre for Primary Care, NIHR School for Primary Care Research, Manchester, UK
| | - Fang Zhang
- Department of Population Medicine, Harvard Pilgrim Health Care, Wellesley, Massachusetts, USA
| | - Rebecca Baggaley
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
- Department of Global Health and Development, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Darrin Baines
- Department of Accounting, Finance & Economics, Bournemouth University, Poole, UK
| | - Hemu Patel
- Department of Clinical Microbiology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Pranabashis Haldar
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
- Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Mayur Patel
- NHS Leicester City Clinical Commissioning Group, NHS Leicester City Clinical Commissioning Group, Leicester, UK
| | - Iain Stephenson
- Department of Infection and HIV Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ivan Browne
- Department of Public Health, Leicester City Council, Leicester, UK
| | - Paramjit Gill
- Academic Unit of Primary Care, University of Warwick, Warwick, UK
| | - Rajesh Kapur
- NHS Leicester City Clinical Commissioning Group, NHS Leicester City Clinical Commissioning Group, Leicester, UK
| | - Azhar Farooqi
- NHS Leicester City Clinical Commissioning Group, NHS Leicester City Clinical Commissioning Group, Leicester, UK
| | - Ibrahim Abubakar
- Institute of Global Health, University College London, London, UK
| | - Chris Griffiths
- Barts Institute of Population Health Sciences, Barts and The London School of Medicine and Dentistry, London, UK
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Winje BA, Grøneng GM, White RA, Akre P, Aavitsland P, Heldal E. Immigrant screening for latent tuberculosis infection: numbers needed to test and treat, a Norwegian population-based cohort study. BMJ Open 2019; 9:e023412. [PMID: 30782706 PMCID: PMC6340421 DOI: 10.1136/bmjopen-2018-023412] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To estimate the number needed to screen (NNS) and the number needed to treat (NNT) to prevent one tuberculosis (TB) case in the Norwegian immigrant latent tuberculosis infection (LTBI) screening programme and to explore the effect of delay of LTBI treatment initiation. DESIGN Population-based, prospective cohort study. PARTICIPANTS Immigrants to Norway. OUTCOME Incident TB. METHODS We obtained aggregated data on immigration to Norway in 2008-2011 and used data from the Norwegian Surveillance System for Infectious Diseases to assess the number of TB cases arising in this cohort within 5 years after arrival. We calculated the average NNS and NNT for immigrants from the top 10 source countries for TB in Norway and by estimated TB incidence rates in source countries. We explored the sensitivity of these estimates with regard to test performance, treatment efficacy and treatment adherence using an extreme value approach, and assessed the effects of emigration, time to TB diagnosis (to define incident TB) and intervention timing. RESULTS NNS and NNT were overall high, with substantial variation. NNT showed numerically stronger negative correlation with TB notification rate in Norway (-0.75 [95% CI -1.00 to -0.44]) than with the WHO incidence rate (IR) (-0.32 [95% CI -0.93 to 0.29]). NNT was affected substantially by emigration and the definition of incident TB. Estimates were lowest for Somali (NNS 99 [70-150], NNT 27 [19-41]) and highest for Thai immigrants (NNS 585 [413-887], NNT 111 [79-116]). Implementing LTBI treatment in immigrants sooner after arrival may improve the effectiveness of the programme. CONCLUSION Using TB notifications in Norway, rather than IR in source countries, would improve targeting of immigrants for LTBI management. However, the overall high NNT is a concern and challenges the scale-up of preventive LTBI treatment for significant public health impact. Better data are urgently needed to monitor and evaluate NNS and NNT in countries implementing LTBI screening.
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Affiliation(s)
- Brita Askeland Winje
- Department of Vaccine-Preventable Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - Gry Marysol Grøneng
- Department of Infectious Disease Epidemiology and Modelling, Norwegian Institute of Public Health, Oslo, Norway
| | - Richard Aubrey White
- Department of Infectious Disease Epidemiology and Modelling, Norwegian Institute of Public Health, Oslo, Norway
| | - Peter Akre
- Statistics and Analysis Division, Norwegian Directorate of Immigration, Oslo, Norway
| | - Preben Aavitsland
- Division of Infectious Diseases and Environmental Health, Norwegian Institute of Public Health, Oslo, Norway
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Einar Heldal
- Department of Tuberculosis, Blood-Borne and Sexually Transmitted Infections, Norwegian Institute of Public Health, Oslo, Norway
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Rosales-Klintz S, Bruchfeld J, Haas W, Heldal E, Houben RM, van Kessel F, Mandelbaum M, Matteelli A, Migliori GB, Oordt-Speets A, Solovic I, Vašáková M, Verver S, de Vlas SJ, Vonk Noordegraaf-Schouten MJ, de Vries G, Zenner D, van der Werf MJ. Guidance for programmatic management of latent tuberculosis infection in the European Union/European Economic Area. Eur Respir J 2019; 53:53/1/1802077. [DOI: 10.1183/13993003.02077-2018] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 11/09/2018] [Indexed: 11/05/2022]
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Dale KD, Trauer JM, Dodd PJ, Houben R, Denholm JT. Estimating the prevalence of latent tuberculosis in a low-incidence setting: Australia. Eur Respir J 2018; 52:13993003.01218-2018. [DOI: 10.1183/13993003.01218-2018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 10/12/2018] [Indexed: 11/05/2022]
Abstract
Migration is a key driver of tuberculosis (TB) in many low-incidence settings, with the majority of TB cases attributed to reactivation of latent TB (LTBI) acquired overseas. A greater understanding of LTBI risk in heterogeneous migrant populations would aid health planning. We aimed to estimate the LTBI prevalence and distribution among locally born and overseas-born Australians.Annual risks of TB infection estimates were applied to population cohorts (by country of birth, year of arrival and age) in Australian census data in 2006, 2011 and 2016.Both the absolute number and proportion of Australian residents with LTBI increased from 4.6% (interquartile range (IQR) 4.2–5.2%) in 2006 to 5.1% (IQR 4.7–5.5%) in 2016, due to the increasing proportion of the population born overseas (23.8% in 2006 to 28.3% in 2016). Of all residents estimated to have LTBI in 2016; 93.2% were overseas born, 21.6% were aged <35 years and 34.4% had migrated to Australia since 2007.The overall prevalence of LTBI in Australia is low. Some residents, particularly migrants from high-incidence settings, may have considerably higher risk of LTBI, and these findings allow for tailored public health interventions to reduce the risk and impact of future TB disease.
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46
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Williams B, Pickard L, Grandjean L, Pope S, Anderson SR, Morgan G, Williams A. The need to implement effective new entrant tuberculosis screening in children: evidence from school 'outbreak'. J Public Health (Oxf) 2018; 38:e511-e515. [PMID: 28158852 DOI: 10.1093/pubmed/fdv186] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Bhanu Williams
- Department of Paediatrics, LNWH NHS Trust, Watford Road, Harrow, HA1 3UJ, Ealing, UK
| | - Lucy Pickard
- Department of Paediatrics, LNWH NHS Trust, Watford Road, Harrow, HA1 3UJ, Ealing, UK
| | - Louis Grandjean
- Department of Paediatrics, LNWH NHS Trust, Watford Road, Harrow, HA1 3UJ, Ealing, UK
| | - Sue Pope
- Department of Paediatrics, LNWH NHS Trust, Watford Road, Harrow, HA1 3UJ, Ealing, UK
| | - Sarah R Anderson
- NW London Health Protection Team, Public Health England, London, UK
| | - Gail Morgan
- NW London Health Protection Team, Public Health England, London, UK
| | - Amanda Williams
- Department of Paediatrics, LNWH NHS Trust, Watford Road, Harrow, HA1 3UJ, Ealing, UK
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47
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Cavany SM, Vynnycky E, Anderson CS, Maguire H, Sandmann F, Thomas HL, White RG, Sumner T. Should NICE reconsider the 2016 UK guidelines on TB contact tracing? A cost-effectiveness analysis of contact investigations in London. Thorax 2018; 74:185-193. [PMID: 30121574 DOI: 10.1136/thoraxjnl-2018-211662] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 07/08/2018] [Accepted: 07/30/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND In January 2016, clinical TB guidance in the UK changed to no longer recommend screening contacts of non-pulmonary, non-laryngeal (ETB) index cases. However, no new evidence was cited for this change, and there is evidence that screening these contacts may be worthwhile. The objective of this study was to estimate the cost-effectiveness of screening contacts of adult ETB cases and adult pulmonary or laryngeal TB (PTB) cases in London, UK. METHODS We carried out a cross-sectional analysis of data collected on TB index cases and contacts in the London TB register and an economic evaluation using a static model describing contact tracing outcomes. Incremental cost-effectiveness ratios (ICERs) were calculated using no screening as the baseline comparator. All adult TB cases (≥15 years old) in London from 2012 to 2015, and their contacts, were eligible (2465/5084 PTB and 2559/6090 ETB index cases were included). RESULTS Assuming each contact with PTB infects one person/month, the ICER of screening contacts of ETB cases was £78 000/quality-adjusted life-years (QALY) (95% CI 39 000 to 140 000), and screening contacts of PTB cases was £30 000/QALY (95% CI 18 000 to 50 000). The ICER of screening contacts of ETB cases was £30 000/QALY if each contact with PTB infects 3.4 people/month. Limitations of this study include the use of self-reported symptomatic periods and lack of knowledge about onward transmission from PTB contacts. CONCLUSIONS Screening contacts of ETB cases in London was almost certainly not cost-effective at any conventional willingness-to-pay threshold in England, supporting recent changes to National Institute for Health and Care Excellence national guidelines.
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Affiliation(s)
- Sean M Cavany
- TB Modelling Group, TB Centre and CMMID, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.,Statistics, Modelling and Economics Department, Public Health England, London, UK.,Department of Biological Sciences, University of Notre Dame, South Bend, IN, United States
| | - Emilia Vynnycky
- TB Modelling Group, TB Centre and CMMID, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.,Statistics, Modelling and Economics Department, Public Health England, London, UK
| | | | - Helen Maguire
- Field Epidemiology Service, Public Health England, London, UK.,Institute for Global Health, University College London, London, UK
| | - Frank Sandmann
- Statistics, Modelling and Economics Department, Public Health England, London, UK.,CMMID, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - H Lucy Thomas
- Respiratory Diseases Department, Public Health England, London, UK
| | - Richard G White
- TB Modelling Group, TB Centre and CMMID, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Tom Sumner
- TB Modelling Group, TB Centre and CMMID, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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48
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Faust L, McCarthy A, Schreiber Y. Recommendations for the screening of paediatric latent tuberculosis infection in indigenous communities: a systematic review of screening strategies among high-risk groups in low-incidence countries. BMC Public Health 2018; 18:979. [PMID: 30081879 PMCID: PMC6090746 DOI: 10.1186/s12889-018-5886-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 07/25/2018] [Indexed: 11/13/2022] Open
Abstract
Background Tuberculosis (TB) continues to be a global public health concern. Due to the presence of multiple risk factors such as poor housing conditions and food insecurity in Canadian Indigenous communities, this population is at particularly high risk of TB infection. Given the challenges of screening for latent TB infection (LTBI) in remote communities, a synthesis of the existing literature regarding current screening strategies among high-risk groups in low-incidence countries is warranted, in order to provide an evidence base for the optimization of paediatric LTBI screening practices in the Canadian Indigenous context. Methods A literature search of the Embase and Medline databases was conducted, and studies pertaining the evaluation of screening strategies or screening tools for LTBI in paediatric high-risk groups in low-incidence countries were included. Studies focusing on LTBI screening in Indigenous communities were also included, regardless of whether they focused on a paediatric population. Their results were summarized and discussed in the context of their relevance to screening strategies suitable to the Canadian Indigenous setting. Grey literature sources such as government reports or policy briefs were also consulted. Results The initial literature search returned 327 studies, with 266 being excluded after abstract screening, and 36 studies being included in the final review (original research studies: n = 25, review papers or policy recommendations: n = 11). In the examined studies, case identification and cost-effectiveness of universal screening were low in low-incidence countries. Therefore, studies generally recommended targeted screening of high-risk groups in low-incidence countries, however, there remains a lack of consensus regarding cut-offs for the incidence-based screening of high-risk communities, as well as regarding the utility and prioritization of individual risk-factor-based screening of high-risk groups. The utility of the TST compared to IGRAs for LTBI detection in the pediatric population also remains contested. Conclusions Relevant strategies for targeted screening in the Canadian Indigenous context include community-level incidence-based screening (screening based on geographic location within high-incidence communities), as well as individual risk-factor-based screening, taking into account pertinent risk factors in Indigenous settings, such as poor housing conditions, malnutrition, contact with an active case, or the presence of relevant co-morbidities, such as renal disease.
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Affiliation(s)
- Lena Faust
- Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Anne McCarthy
- Department of Medicine, University of Ottawa, Ottawa, Canada.,Ottawa Hospital Research Institute, Ottawa, Canada
| | - Yoko Schreiber
- Department of Medicine, University of Ottawa, Ottawa, Canada. .,Ottawa Hospital Research Institute, Ottawa, Canada.
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Dobler CC, Fox GJ, Douglas P, Viney KA, Ahmad Khan F, Temesgen Z, Marais BJ. Screening for tuberculosis in migrants and visitors from high-incidence settings: present and future perspectives. Eur Respir J 2018; 52:13993003.00591-2018. [PMID: 29794133 DOI: 10.1183/13993003.00591-2018] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 05/17/2018] [Indexed: 12/26/2022]
Abstract
In most settings with a low incidence of tuberculosis (TB), foreign-born people make up the majority of TB cases, but the distribution of the TB risk among different migrant populations is often poorly quantified. In addition, screening practices for TB disease and latent TB infection (LTBI) vary widely. Addressing the risk of TB in international migrants is an essential component of TB prevention and care efforts in low-incidence countries, and strategies to systematically screen for, diagnose, treat and prevent TB among this group contribute to national and global TB elimination goals.This review provides an overview and critical assessment of TB screening practices that are focused on migrants and visitors from high to low TB incidence countries, including pre-migration screening and post-migration follow-up of those deemed to be at an increased risk of developing TB. We focus mainly on migrants who enter the destination country via application for a long-stay visa, as well as asylum seekers and refugees, but briefly consider issues related to short-term visitors and those with long-duration multiple-entry visas. Issues related to the screening of children and screening for LTBI are also explored.
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Affiliation(s)
- Claudia C Dobler
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.,Mayo Clinic Center for Tuberculosis, Rochester, MN, USA
| | - Greg J Fox
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.,Central Clinical School, Faculty of Medicine and Health Sciences, University of Sydney, Sydney, Australia
| | - Paul Douglas
- International Organization for Migration (IOM), Geneva, Switzerland
| | - Kerri A Viney
- Dept of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.,Research School of Population Health, Australian National University, Canberra, Australia
| | - Faiz Ahmad Khan
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada.,Depts of Medicine and Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | | | - Ben J Marais
- The Children's Hospital at Westmead and the Marie Bashir Institute for Infectious Diseases and Biosecurity (MBI), University of Sydney, Sydney, Australia
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50
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How effective are approaches to migrant screening for infectious diseases in Europe? A systematic review. THE LANCET. INFECTIOUS DISEASES 2018; 18:e259-e271. [PMID: 29778396 DOI: 10.1016/s1473-3099(18)30117-8] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 01/26/2018] [Accepted: 02/06/2018] [Indexed: 12/20/2022]
Abstract
Rates of migration to Europe, and within Europe, have increased in recent years, with considerable implications for health systems. Migrants in Europe face a disproportionate burden of tuberculosis, HIV, and hepatitis B and C, yet experience a large number of barriers to accessing statutory health care on arrival. A better understanding of how to deliver effective and cost-effective screening, vaccination, and health services to this group is now crucial. We did a systematic review to document and assess the effectiveness and cost-effectiveness of approaches used for infectious diseases screening, and to explore facilitators and barriers experienced by migrants to accessing screening programmes. Following PRISMA guidelines, we searched Embase, PubMed, PsychINFO, the Cochrane Library, and Web of Science (1989 to July 1, 2015, updated on Jan 1, 2018), with no language restrictions, and systematically approached experts across the European Union (EU) for grey literature. Inclusion criteria were primary research studies assessing screening interventions for any infectious disease in the migrant (foreign-born) population residing in EU or European Economic Area (EEA) countries. Primary outcomes were the following effectiveness indicators: uptake of screening, coverage, infections detected, and treatment outcomes. Of 4112 unique records, 47 studies met our inclusion criteria, from ten European countries (Belgium, Denmark, France, Italy, the Netherlands, Norway, Spain, Sweden, Switzerland, and the UK) encompassing 248 402 migrants. We found that most European countries screening migrants focus on single diseases only-predominantly active or latent tuberculosis infection-and specifically target asylum seekers and refugees, with 22 studies reporting on other infections (including HIV and hepatitis B and C). An infection was detected in 3·74% (range 0·00-95·16) of migrants. Latent tuberculosis had the highest prevalence across all infections (median 15·02% [0·35-31·81]). Uptake of screening by migrants was high (median 79·50% [18·62-100·00]), particularly in primary health-care settings (uptake 96·77% [76·00-100·00]). However, in 24·62% (0·12-78·99) of migrants screening was not completed and a final diagnosis was not made. Pooled data highlight high treatment completion in migrants (83·79%, range 0·00-100·00), yet data were highly heterogeneous for this outcome, masking important disparities between studies and infections, with only 54·45% (35·71-72·27) of migrants with latent tuberculosis ultimately completing treatment after screening. Coverage of the migrant population in Europe is low (39·29% [14·53-92·50]). Data on cost-effectiveness were scarce, but suggest moderate to high cost-effectiveness of migrant screening programmes depending on migrant group and disease targeted. European countries have adopted a variety of approaches to screening migrants for infections; however, these are limited in scope to single diseases and a narrow subset of migrants, with low coverage. More emphasis must be placed on developing innovative and sustainable strategies to facilitate screening and treatment completion and improve health outcomes, encompassing multiple key infections with consideration given to a wider group of high-risk migrants. Policy makers and researchers involved with global migration need to ensure a longer-term view on improving health outcomes in migrant populations as they integrate into health systems in host countries.
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