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van Lieshout Titan A, Klaassen F, Pelissari DM, de Barros Silva JN, Alves K, Alves LC, Sanchez M, Bartholomay P, Johansen FDC, Croda J, Andrews JR, Castro MC, Cohen T, Vuik C, Menzies NA. Cost-effectiveness and health impact of screening and treatment of Mycobacterium tuberculosis infection among formerly incarcerated individuals in Brazil: a Markov modelling study. Lancet Glob Health 2024; 12:e1446-e1455. [PMID: 39151980 DOI: 10.1016/s2214-109x(24)00221-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 04/23/2024] [Accepted: 05/22/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Individuals who were formerly incarcerated have high tuberculosis incidence, but are generally not considered among the risk groups eligible for tuberculosis prevention. We investigated the potential health impact and cost-effectiveness of Mycobacterium tuberculosis infection screening and tuberculosis preventive treatment (TPT) for individuals who were formerly incarcerated in Brazil. METHODS Using published evidence for Brazil, we constructed a Markov state transition model estimating tuberculosis-related health outcomes and costs among individuals who were formerly incarcerated, by simulating transitions between health states over time. The analysis compared tuberculosis infection screening and TPT, to no screening, considering a combination of M tuberculosis infection tests and TPT regimens. We quantified health effects as reductions in tuberculosis cases, tuberculosis deaths, and disability-adjusted life-years (DALYs). We assessed costs from a tuberculosis programme perspective. We report intervention cost-effectiveness as the incremental costs per DALY averted, and tested how results changed across subgroups of the target population. FINDINGS Compared with no intervention, an intervention incorporating tuberculin skin testing and treatment with 3 months of isoniazid and rifapentine would avert 31 (95% uncertainty interval 14-56) lifetime tuberculosis cases and 4·1 (1·4-5·8) lifetime tuberculosis deaths per 1000 individuals, and cost US$242 per DALY averted. All test and regimen combinations were cost-effective compared with no screening. Younger age, longer incarceration, and more recent prison release were each associated with significantly greater health benefits and more favourable cost-effectiveness ratios, although the intervention was cost-effective for all subgroups examined. INTERPRETATION M tuberculosis infection screening and TPT for individuals who were formerly incarcerated appears cost-effective, and would provide valuable health gains. FUNDING National Institutes of Health. TRANSLATION For the Portuguese translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Ana van Lieshout Titan
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Delft Institute of Applied Mathematics, Delft University of Technology, Delft, Netherlands.
| | - Fayette Klaassen
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | | | - Kleydson Alves
- National Tuberculosis Programme, Ministry of Health, Brasilia, Brazil
| | - Layana Costa Alves
- National Tuberculosis Programme, Ministry of Health, Brasilia, Brazil; Collective Health Institute, Federal University of Bahia, Salvador, Bahia, Brazil
| | - Mauro Sanchez
- Health and Environment Surveillance Secretariat, Ministry of Health, Brasilia, Brazil
| | - Patricia Bartholomay
- Health and Environment Surveillance Secretariat, Ministry of Health, Brasilia, Brazil
| | | | - Julio Croda
- Universidade Federal de Mato Grosso do Sul, Campo Grande, Brazil; Fiocruz Mato Grosso do Sul, Fundação Oswaldo Cruz, Campo Grande, Brazil
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Marcia C Castro
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Cornelis Vuik
- Delft Institute of Applied Mathematics, Delft University of Technology, Delft, Netherlands
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Center for Health Decision Science, Harvard T H Chan School of Public Health, Boston, MA, USA
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2
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Mwatenga SA, Musa AA, Muturi MW, Musyoki AM. Prevalence and associated factors of TB and HIV coinfections among adult inmates with presumptive pulmonary TB in a Kenyan prison. Trop Med Health 2024; 52:54. [PMID: 39148132 PMCID: PMC11328499 DOI: 10.1186/s41182-024-00623-2] [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: 03/06/2024] [Accepted: 08/04/2024] [Indexed: 08/17/2024] Open
Abstract
BACKGROUND Tuberculosis (TB) is more than ten times higher in prisons compared to the general population, and HIV-infected persons are at increased risk of developing active TB and death. In the World Health Organization (WHO) African region, however, where the TB and HIV coinfections are highest, and prisons rarely factored in national disease surveillance, epidemiological data to inform TB control interventions in correctional facilities is limited. In this study, we assessed the prevalence of TB and HIV coinfections, as well as the factors associated with coinfections in our study setting. METHODS This was a prospective cross-sectional study among 157 adult (≥ 18 years) prisoners presenting with symptoms of pulmonary TB at Shimo La Tewa Prison, Kenya, between January and June 2023. The study excluded those with a history of anti-TB drugs use or on treatment follow-up and collected demographic and clinical characteristics data using a questionnaire. Sputum samples were collected and processed immediately using Xpert® MTB/RIF assay or stored at 4 °C for three (3) days in case of delay. RESULTS The overall prevalence of TB among inmates with presumptive pulmonary TB was 10.2%, 95% CI 6.37-16.91% (16/157), HIV 19.1%, 95% CI 13.73-25.97% (30/157). All the TB cases were positive for HIV (16/16, 100%), translating to TB/HIV coinfection of 10.2%, 95% CI 6.37-16.91% (16/157), and there was no rifampicin resistance. TB and HIV coinfection cases were found among underweight (100%, 16/16) prisoners. The independent factors associated with TB and HIV coinfections were education level (adjusted OR = 0.17, p = 0.007), smoking history (adjusted OR = 3.01, p = 0.009) and illegal drug use history (adjusted OR = 4.55, p = 0.044). CONCLUSION We report a high prevalence of pulmonary TB and HIV coinfections among adult inmates with presumptive pulmonary TB in Kenya, with education level, smoking status, and illegal drug use as the independent factors associated with the coinfection. The authority should take measures to protect HIV-positive prisoners from TB, focusing on education, nutrition, smoking, and illegal drug use.
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Affiliation(s)
- Suleiman Athuman Mwatenga
- Department of Medical Laboratory Sciences, Moi County Referral Hospital, P.O. Box 18-80300, Voi, Kenya
- Department of Medical Laboratory Sciences, Kenyatta University, P.O. Box 43844-00100, Nairobi, Kenya
| | - Ali A Musa
- Clinical Laboratory, Msambweni County Referral Hospital, P.O. Box 8-80404, Msambweni, Kenya
| | - Margaret W Muturi
- Department of Medical Laboratory Sciences, Moi County Referral Hospital, P.O. Box 18-80300, Voi, Kenya
| | - Abednego Moki Musyoki
- Department of Medical Laboratory Sciences, Kenyatta University, P.O. Box 43844-00100, Nairobi, Kenya.
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Pivetta de Araujo RC, Martinez L, da Silva Santos A, Ferreira Lemos E, Dias de Oliveira R, Croda M, Porto Batestin Silva D, Lemes IBG, Cunha EAT, Gonçalves TO, Pereira dos Santos PC, Oliveira da Silva B, Cavalheiro Maymone Gonçalves C, Andrews J, Croda J. Serial Mass Screening for Tuberculosis Among Incarcerated Persons in Brazil. Clin Infect Dis 2024; 78:1669-1676. [PMID: 38324908 PMCID: PMC11175667 DOI: 10.1093/cid/ciae055] [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: 05/26/2023] [Revised: 10/13/2023] [Accepted: 02/01/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND An active search for tuberculosis cases through mass screening is widely described as a tool to improve case detection in hyperendemic settings. However, its effectiveness in high-risk populations, such as incarcerated people, is debated. METHODS Between 2017 and 2021, 3 rounds of mass screening were carried out in 3 Brazilian prisons. Social and health questionnaires, chest X-rays, and Xpert MTB/RIF were performed. RESULTS More than 80% of the prison population was screened. Overall, 684 cases of pulmonary tuberculosis were diagnosed. Prevalence across screening rounds was not statistically different. Among incarcerated persons with symptoms, the overall prevalence of tuberculosis per 100 000 persons was 8497 (95% confidence interval [CI], 7346-9811), 11 115 (95% CI, 9471-13 082), and 7957 (95% CI, 6380-9882) in screening rounds 1, 2, and 3, respectively. Similar to our overall results, there were no statistical differences between screening rounds and within individual prisons. We found no statistical differences in Computer-Aided Detection for TB version 5 scores across screening rounds among people with tuberculosis-the median scores in rounds 1, 2, and 3 were 82 (interquartile range [IQR], 63-97), 77 (IQR, 60-94), and 81 (IQR, 67-92), respectively. CONCLUSIONS In this environment with hyperendemic rates of tuberculosis, 3 rounds of mass screening did not reduce the overall tuberculosis burden. In prisons, where a substantial number of tuberculosis cases is undiagnosed annually, a range of complementary interventions and more frequent tuberculosis cases screening may be required.
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Affiliation(s)
| | - Leonardo Martinez
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Andrea da Silva Santos
- Health Sciences Research Laboratory, Federal University of Grande Dourados, Dourados, Brazil
| | - Everton Ferreira Lemos
- School of Medicine, Federal University of Mato Grosso do Sul, Campo Grande, Mato Grosso do Sul, Brazil
| | - Roberto Dias de Oliveira
- Nursing Course, State University of Mato Grosso do Sul, Dourados, Brazil
- Graduate Program in Health Sciences, Federal University of Grande Dourados, Dourados, Brazil
| | - Mariana Croda
- School of Medicine, Federal University of Mato Grosso do Sul, Campo Grande, Mato Grosso do Sul, Brazil
| | | | | | - Eunice Atsuko Totumi Cunha
- Laboratory of Bacteriology, Central Laboratory of Mato Grosso do Sul, Campo Grande, Mato Gross do Sul, Brazil
| | - Thais Oliveira Gonçalves
- Laboratory of Bacteriology, Central Laboratory of Mato Grosso do Sul, Campo Grande, Mato Gross do Sul, Brazil
| | | | - Bruna Oliveira da Silva
- Health Sciences Research Laboratory, Federal University of Grande Dourados, Dourados, Brazil
| | | | - Jason Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Julio Croda
- School of Medicine, Federal University of Mato Grosso do Sul, Campo Grande, Mato Grosso do Sul, Brazil
- Oswaldo Cruz Foundation, Campo Grande, Mato Grosso do Sul, Brazil
- Department of Epidemiology of Microbial Diseases, Yale University School of Public Health, New Haven, Connecticut, USA
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Farhat MR, Jacobson KR. For Tuberculosis, Not "To Screen or Not to Screen?" but "Who?" and "How?". Clin Infect Dis 2024; 78:1677-1679. [PMID: 38636953 PMCID: PMC11175681 DOI: 10.1093/cid/ciae058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Indexed: 04/20/2024] Open
Abstract
Active case finding leveraging new molecular diagnostics and chest X-rays with automated interpretation algorithms is increasingly being developed for high-risk populations to drive down tuberculosis incidence. We consider why such an approach did not deliver a decline in tuberculosis prevalence in Brazilian prison populations and what to consider next.
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Affiliation(s)
- Maha Reda Farhat
- Department of Biomedical Informatics, Harvard Medical School
- Pulmonary and Critical Care Medicine, Massachusetts General Hospital
| | - Karen Rita Jacobson
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
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Iúdice TNDS, da Conceição ML, de Brito AC, de Souza NM, Mesquita CR, Guimarães RJDPSE, Furlaneto IP, Saboia ADS, Lourenço MCDS, Lima KVB, Conceição EC. The Role of GeneXpert ® for Tuberculosis Diagnostics in Brazil: An Examination from a Historical and Epidemiological Perspective. Trop Med Infect Dis 2023; 8:483. [PMID: 37999602 PMCID: PMC10674801 DOI: 10.3390/tropicalmed8110483] [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: 10/01/2023] [Revised: 10/16/2023] [Accepted: 10/20/2023] [Indexed: 11/25/2023] Open
Abstract
The rapid molecular test (RMT) performed on the GeneXpert® system is widely used as a control strategy and surveillance technique for tuberculosis (TB). In the region of the Americas, TB incidence is slowly increasing owing to an upward trend in Brazil, which is among the high TB-burden countries (HBCs), ranking in the 19th position. In this context, we aimed to (i) describe the implementation and history of RMT-TB (Xpert® MTB/RIF and Xpert® MTB/RIF Ultra) in Brazil; (ii) to evaluate the national RMT laboratory distribution, TB, and resistance to RIF detection by RMT; and (iii) to correlate these data with Brazilian TB incidence. The quantitative data of Xpert® MTB/RIF and Xpert® MTB/RIF Ultra assays performed in the pulmonary TB investigation from 2014 to 2020 were provided by the Brazilian Ministry of Health. A spatial visualization using ArcGIS software was performed. The Southeast region constituted about half of the RMT laboratories-from 39.4% to 45.9% of the total value over the five regions. Regarding the federal units, the São Paulo state alone represented from 20.2% to 34.1% (5.0 to 8.5 times the value) of RMT laboratories over the years observed. There were significant differences (p < 0.0001) in the frequency of RMT laboratories between all years of the historical series. There was an unequal distribution of RMT laboratories between Brazilian regions and federal units. This alerts us for the surveillance of rapid molecular detection of TB in different parts of the country, with the possibility of improving the distribution of tests in areas of higher incidence in order to achieve the level of disease control recommended by national and worldwide authorities.
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Affiliation(s)
- Tirça Naiara da Silva Iúdice
- Programa de Pós-Graduação Biologia Parasitária na Amazônia, Universidade do Estado do Pará, Belém-Pará 66087-670, PA, Brazil; (T.N.d.S.I.); (C.R.M.)
| | | | - Artemir Coelho de Brito
- Coordenação-Geral de Vigilância da Tuberculose, Micoses Endêmicas e Micobactérias Não Tuberculosas—CGTM, Ministério da Saúde, Brasília 70000-000, DF, Brazil; (A.C.d.B.)
| | - Nicole Menezes de Souza
- Coordenação-Geral de Vigilância da Tuberculose, Micoses Endêmicas e Micobactérias Não Tuberculosas—CGTM, Ministério da Saúde, Brasília 70000-000, DF, Brazil; (A.C.d.B.)
| | - Cristal Ribeiro Mesquita
- Programa de Pós-Graduação Biologia Parasitária na Amazônia, Universidade do Estado do Pará, Belém-Pará 66087-670, PA, Brazil; (T.N.d.S.I.); (C.R.M.)
| | | | | | - Alessandra de Souza Saboia
- Laboratório de Bacteriologia e Bioensaios em Micobactérias, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil; (A.d.S.S.); (M.C.d.S.L.)
| | - Maria Cristina da Silva Lourenço
- Laboratório de Bacteriologia e Bioensaios em Micobactérias, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil; (A.d.S.S.); (M.C.d.S.L.)
| | - Karla Valéria Batista Lima
- Programa de Pós-Graduação Biologia Parasitária na Amazônia, Universidade do Estado do Pará, Belém-Pará 66087-670, PA, Brazil; (T.N.d.S.I.); (C.R.M.)
- Seção de Bacteriologia e Micologia, Instituto Evandro Chagas, Ananindeua 67030-000, PA, Brazil;
| | - Emilyn Costa Conceição
- Pós-Graduação em Pesquisa Clínica e Doenças Infecciosas, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Manguinhos, Rio de Janeiro 67030-000, RJ, Brazil
- Department of Science and Innovation–National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
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6
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Martinez L, Warren JL, Harries AD, Croda J, Espinal MA, Olarte RAL, Avedillo P, Lienhardt C, Bhatia V, Liu Q, Chakaya J, Denholm JT, Lin Y, Kawatsu L, Zhu L, Horsburgh CR, Cohen T, Andrews JR. Global, regional, and national estimates of tuberculosis incidence and case detection among incarcerated individuals from 2000 to 2019: a systematic analysis. Lancet Public Health 2023; 8:e511-e519. [PMID: 37393090 PMCID: PMC10323309 DOI: 10.1016/s2468-2667(23)00097-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/24/2023] [Accepted: 05/02/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND People who are incarcerated are at high risk of developing tuberculosis. We aimed to estimate the annual global, regional, and national incidence of tuberculosis among incarcerated populations from 2000 to 2019. METHODS We collected and aggregated data for tuberculosis incidence and prevalence estimates among incarcerated individuals in published and unpublished literature, annual tuberculosis notifications among incarcerated individuals at the country level, and the annual number of incarcerated individuals at the country level. We developed a joint hierarchical Bayesian meta-regression framework to simultaneously model tuberculosis incidence, notifications, and prevalence from 2000 to 2019. Using this model, we estimated trends in absolute tuberculosis incidence and notifications, the incidence and notification rates, and the case detection ratio by year, country, region, and globally. FINDINGS In 2019, we estimated a total of 125 105 (95% credible interval [CrI] 93 736-165 318) incident tuberculosis cases among incarcerated individuals globally. The estimated incidence rate per 100 000 person-years overall was 1148 (95% CrI 860-1517) but varied greatly by WHO region, from 793 (95% CrI 430-1342) in the Eastern Mediterranean region to 2242 (1515-3216) in the African region. Global incidence per 100 000 person-years between 2000 and 2012 among incarcerated individuals decreased from 1884 (95% CrI 1394-2616) to 1205 (910-1615); however, from 2013 onwards, tuberculosis incidence per 100 000 person-years was stable, from 1183 (95% CrI 876-1596) in 2013 to 1148 (860-1517) in 2019. In 2019, the global case detection ratio was estimated to be 53% (95% CrI 42-64), the lowest over the study period. INTERPRETATION Our estimates suggest a high tuberculosis incidence rate among incarcerated individuals globally with large gaps in tuberculosis case detection. Tuberculosis in incarcerated populations must be addressed with interventions specifically tailored to improve diagnoses and prevent transmission as a part of the broader global tuberculosis control effort. FUNDING National Institutes of Health.
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Affiliation(s)
- Leonardo Martinez
- Department of Epidemiology, School of Public Health, Boston University, Boston, MA, USA.
| | - Joshua L Warren
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Anthony D Harries
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Julio Croda
- School of Medicine, Federal University of Mato Grosso do Sul, Campo Grande, Brazil; Oswaldo Cruz Foundation, Mato Grosso do Sul, Brazil
| | - Marcos A Espinal
- Pan American Health Organization, Communicable Diseases and Environmental Determinants of Health, Washington, DC, USA
| | - Rafael A López Olarte
- Pan American Health Organization, Communicable Diseases and Environmental Determinants of Health, Washington, DC, USA
| | - Pedro Avedillo
- Pan American Health Organization, Communicable Diseases and Environmental Determinants of Health, Washington, DC, USA
| | - Christian Lienhardt
- Unité Mixte Internationale Trans VIHMI (UMI 233 IRD-U1175 INSERM, Université de Montpellier), Institut de Recherche pour le Développement, Montpellier, France
| | - Vineet Bhatia
- Department of Communicable Diseases, World Health Organization Regional Office for South-East Asia, New Delhi, India
| | - Qiao Liu
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, China
| | - Jeremiah Chakaya
- Department of Medicine, Therapeutics, Dermatology and Psychiatry, Kenyatta University, Nairobi, Kenya; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Justin T Denholm
- Victorian Tuberculosis Program, Melbourne Health, Melbourne, VIC, Australia; Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Parkville, VIC, Australia
| | - Yan Lin
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Lisa Kawatsu
- Department of Epidemiology and Clinical Research, The Research Institute of Tuberculosis, Tokyo, Japan
| | - Limei Zhu
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, China
| | - C Robert Horsburgh
- Department of Epidemiology, School of Public Health, Boston University, Boston, MA, USA; Department of Biostatistics, School of Public Health, Boston University, Boston, MA, USA; Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Jason R Andrews
- Division of Infectious Diseases & Geographic Medicine, School of Medicine, Stanford University, Stanford, CA, USA
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Fanni SC, Marcucci A, Volpi F, Valentino S, Neri E, Romei C. Artificial Intelligence-Based Software with CE Mark for Chest X-ray Interpretation: Opportunities and Challenges. Diagnostics (Basel) 2023; 13:2020. [PMID: 37370915 DOI: 10.3390/diagnostics13122020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/26/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
Chest X-ray (CXR) is the most important technique for performing chest imaging, despite its well-known limitations in terms of scope and sensitivity. These intrinsic limitations of CXR have prompted the development of several artificial intelligence (AI)-based software packages dedicated to CXR interpretation. The online database "AI for radiology" was queried to identify CE-marked AI-based software available for CXR interpretation. The returned studies were divided according to the targeted disease. AI-powered computer-aided detection software is already widely adopted in screening and triage for pulmonary tuberculosis, especially in countries with few resources and suffering from high a burden of this disease. AI-based software has also been demonstrated to be valuable for the detection of lung nodules detection, automated flagging of positive cases, and post-processing through the development of digital bone suppression software able to produce digital bone suppressed images. Finally, the majority of available CE-marked software packages for CXR are designed to recognize several findings, with potential differences in sensitivity and specificity for each of the recognized findings.
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Affiliation(s)
- Salvatore Claudio Fanni
- Department of Translational Research, Academic Radiology, University of Pisa, 56126 Pisa, Italy
| | - Alessandro Marcucci
- Department of Translational Research, Academic Radiology, University of Pisa, 56126 Pisa, Italy
| | - Federica Volpi
- Department of Translational Research, Academic Radiology, University of Pisa, 56126 Pisa, Italy
| | | | - Emanuele Neri
- Department of Translational Research, Academic Radiology, University of Pisa, 56126 Pisa, Italy
| | - Chiara Romei
- Department of Diagnostic Imaging, 2nd Radiology Unit, Pisa University-Hospital, Via Paradisa 2, 56124 Pisa, Italy
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Charalambous S, Velen K, Rueda Z, Croda J, Herce ME, Shenoi SV, Altice FL, Muyoyeta M, Telisinghe L, Grandjean L, Keshavjee S, Andrews JR. Scaling up evidence-based approaches to tuberculosis screening in prisons. Lancet Public Health 2023; 8:e305-e310. [PMID: 36780916 DOI: 10.1016/s2468-2667(23)00002-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 12/09/2022] [Accepted: 12/20/2022] [Indexed: 02/12/2023]
Abstract
People deprived of liberty have among the highest rates of tuberculosis globally. The incidence of tuberculosis is ten times greater than the incidence of tuberculosis in the general population. In 2021, WHO updated its guidance to strongly recommend systematic screening for tuberculosis in prisons and penitentiary systems. Which case-finding strategies should be adopted, and how to effectively implement these strategies in these settings, will be crucial questions facing ministries of health and justice. In this Viewpoint, we review the evidence base for tuberculosis screening and diagnostic strategies in prisons, highlighting promising approaches and knowledge gaps. Drawing upon past experiences of implementing active case-finding and care programmes in settings with a high tuberculosis burden, we discuss challenges and opportunities for improving the tuberculosis diagnosis and treatment cascade in these settings. We argue that improved transparency in reporting of tuberculosis notifications and outcomes in prisons and renewed focus and resourcing from WHO and other stakeholders will be crucial for building the commitment and investments needed from countries to address the continued crisis of tuberculosis in prisons.
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Affiliation(s)
- Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa; School of Public Health, Wits University, Johannesburg, South Africa; Division of Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, CT, USA.
| | | | - Zulma Rueda
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MT, Canada; School of Medicine, Universidad Pontificia Bolivariana, Medellin, Colombia
| | - Julio Croda
- Division of Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, CT, USA; Departamento de Clínica Médica, Universidade Federal de Mato Grosso do Sul, Campo Grande, Brazil; Fiocruz Mato Grosso do Sul, Campo Grade, Brazil
| | - Michael E Herce
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Sheela V Shenoi
- Division of Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, CT, USA; Section of Infectious Diseases, School of Medicine, Yale University, New Haven, CT, USA; University of Malaya, Centre of Excellence on Research in AIDS, Kuala Lumpur, Malaysia
| | - Frederick L Altice
- Division of Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, CT, USA; Section of Infectious Diseases, School of Medicine, Yale University, New Haven, CT, USA; University of Malaya, Centre of Excellence on Research in AIDS, Kuala Lumpur, Malaysia
| | - Monde Muyoyeta
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Lily Telisinghe
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Louis Grandjean
- Department of Infection, Immunity and Inflammation, Institute of Child Health, University College London, UK
| | - Salmaan Keshavjee
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
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Lu P, Wu K, Zhou H, Yu H, Yuan J, Dong L, Liu Q, Ding X, Lu W, Yang H, Zhu L, Martinez L. Evaluation of ESAT6-CFP10 Skin Test for Mycobacterium tuberculosis Infection among Persons Living with HIV in China. J Clin Microbiol 2023; 61:e0181622. [PMID: 36946732 PMCID: PMC10117090 DOI: 10.1128/jcm.01816-22] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
Recent global guidelines recommend Mycobacterium tuberculosis antigen-based skin tests, such as the ESAT6-CFP10 (EC) skin test, as acceptable alternatives to the tuberculin skin test (TST) and the QuantiFERON-TB Gold In-Tube test (QFT). However, the diagnostic value of these tests among persons living with HIV (PLHIV) is unknown. We aimed to assess the diagnostic accuracy of the EC among a cohort of PLHIV in China. We recruited PLHIV in Jiangsu Province, China, to assess sensitivity and specificity of the EC test. Participants were tested with the QFT, TST, and EC skin test. Results were stratified by age, M. tuberculosis BCG vaccination, and CD4 count. The sensitivity and specificity of the EC skin test was assessed using distinct cutoffs of the QFT and TST. Of 350 PLHIV enrolled in the study, 58 (16.6%), 89 (25.4%), and 59 (16.9%) tested positive with the EC test, the QFT, and the TST, respectively. Positivity increased with CD4 count; however, these trends were similar across tests. At a 5-mm cutoff, EC skin test specificity was high (99.6%, 95% confidence interval [CI] 95% CI = 97.7 to 100.0); however, sensitivity was moderate (81.4%; 95% CI = 66.6 to 91.6). After stratifying by BCG, the sensitivity and specificity were 86.4% (95% CI = 65.1 to 97.1) and 99.1% (95% CI = 95.0 to 100.0) among vaccinated PLHIV and 76.2% (95% CI = 52.8 to 91.8) and 100.0% (95% CI = 97.2 to 100.0) among unvaccinated PLHIV, respectively. Among PLHIV, the diagnostic value of the EC skin test remained high, regardless of BCG vaccination or CD4 count. The EC skin test performed comparably to TST and may be a valid alternative diagnostic test to use in settings or populations with high HIV prevalence and BCG vaccination. To our knowledge, this is the first study to evaluate the novel ESAT6-CFP10 skin test among PLHIV. Among 350 PLHIV, the test displayed high specificity and sensitivity, a finding which did not markedly differ based on BCG vaccination and CD4 count.
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Affiliation(s)
- Peng Lu
- Department of Chronic Communicable Disease, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, Jiangsu, People's Republic of China
| | - Kai Wu
- Central Hospital, Jiangsu Prison Administration, Changzhou, Jiangsu, People's Republic of China
| | - Hongxi Zhou
- Central Hospital, Jiangsu Prison Administration, Changzhou, Jiangsu, People's Republic of China
| | - Haibing Yu
- Central Hospital, Jiangsu Prison Administration, Changzhou, Jiangsu, People's Republic of China
| | - Ju Yuan
- Central Hospital, Jiangsu Prison Administration, Changzhou, Jiangsu, People's Republic of China
| | - Lang Dong
- Central Hospital, Jiangsu Prison Administration, Changzhou, Jiangsu, People's Republic of China
| | - Qiao Liu
- Department of Chronic Communicable Disease, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, Jiangsu, People's Republic of China
| | - Xiaoyan Ding
- Department of Chronic Communicable Disease, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, Jiangsu, People's Republic of China
| | - Wei Lu
- Department of Chronic Communicable Disease, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, Jiangsu, People's Republic of China
| | - Haitao Yang
- Jiangsu Provincial Health Development Research Center, Nanjing, Jiangsu, People's Republic of China
| | - Limei Zhu
- Department of Chronic Communicable Disease, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, Jiangsu, People's Republic of China
| | - Leonardo Martinez
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts, USA
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10
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Placeres AF, de Almeida Soares D, Delpino FM, Moura HSD, Scholze AR, dos Santos MS, Arcêncio RA, Fronteira I. Epidemiology of TB in prisoners: a metanalysis of the prevalence of active and latent TB. BMC Infect Dis 2023; 23:20. [PMID: 36631770 PMCID: PMC9835258 DOI: 10.1186/s12879-022-07961-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 12/20/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) in prisons usually occurs at higher rates than in the general population, especially in developing countries. TB has been reported as the most common cause of death among prisoners. Studies have shown limitations for early detection of TB in prisons that seem to result from mistaken concepts about TB, delayed diagnosis mainly due to the naturalization of lack of healthcare for this population METHODS: A scoping review was performed using the methodology of the Joanna Briggs Institute to assess "What are the scientific evidences on the epidemiology of TB in the prison system?". Then, a meta-analysis was performed to assess the prevalence of TB (active and latent) TB in prisoners. The results are presented as prevalence, in percentage, through random effects models, with a confidence interval of 95%. RESULTS Regarding active TB, the results of the metanalysis showed that countries with a high burden of TB had a prevalence of 3.54% [2.71; 4.63], countries not considered to be high burden TB countries had a prevalence of 1.43% [0.86; 2.37]. Latent TB had a prevalence of 51.61% [39.46; 63.58] in high TB burden countries and a prevalence of 40.24% [23.51; 59.61] in countries with low TB burden. In terms of development, in low- and lower-middle-income countries, the prevalence of active TB was 3.13% [1.84; 5.29] and in high- and upper-middle income countries the prevalence was 2.25% [1.70; 2.99]. The prevalence of latent TB in high- and middle-income countries was 43.77% [28.61; 60.18] and of 49.42% [45.91; 52.94] in low and lower middle-income countries. CONCLUSION Our analysis suggests that TB, and probably other infectious diseases, find fertile ground in prisons where previous acquire social disadvantages seem to thrive-therefore, TB in prisons is a global public health problem and effective strategies are needed to control the disease are needed targeting the prison environment, including rapid health assessments to understand each context and to implement tailored and precision interventions.
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Affiliation(s)
- Aline Ferreira Placeres
- grid.10772.330000000121511713Instituto de Higiene e Medicina Tropical (IHMT), Universidade Nova de Lisboa, Rua da Junqueira 100, 1349-008 Lisbon, Portugal
| | - Débora de Almeida Soares
- grid.10772.330000000121511713Instituto de Higiene e Medicina Tropical (IHMT), Universidade Nova de Lisboa, Rua da Junqueira 100, 1349-008 Lisbon, Portugal
| | - Felipe Mendes Delpino
- grid.411221.50000 0001 2134 6519Programa de Pós Graduação em Enfermagem, Universidade Federal de Pelotas, Pelotas, Brazil
| | - Heriederson Sávio Dias Moura
- grid.11899.380000 0004 1937 0722Escola de Enfermagem de Ribeirão Preto (EERP/USP), Universidade de São Paulo, São Paulo, Brazil
| | - Alessandro Rolim Scholze
- grid.441795.aUniversidade Estadual do Norte do Paraná, Campus Luiz Meneguel de Bandeirantes, Bandeirantes, Brazil
| | - Márcio Souza dos Santos
- grid.11899.380000 0004 1937 0722Escola de Enfermagem de Ribeirão Preto (EERP/USP), Universidade de São Paulo, São Paulo, Brazil
| | - Ricardo Alexandre Arcêncio
- grid.11899.380000 0004 1937 0722Escola de Enfermagem de Ribeirão Preto (EERP/USP), Universidade de São Paulo, São Paulo, Brazil
| | - Inês Fronteira
- grid.10772.330000000121511713Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade NOVA de Lisboa, Lisbon, Portugal
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11
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Soares TR, Oliveira RDD, Liu YE, Santos ADS, Santos PCPD, Monte LRS, Oliveira LMD, Park CM, Hwang EJ, Andrews JR, Croda J. Evaluation of chest X-ray with automated interpretation algorithms for mass tuberculosis screening in prisons: a cross-sectional study. LANCET REGIONAL HEALTH. AMERICAS 2023; 17:100388. [PMID: 36776567 PMCID: PMC9904090 DOI: 10.1016/j.lana.2022.100388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 09/28/2022] [Accepted: 10/18/2022] [Indexed: 06/18/2023]
Abstract
Background The World Health Organization (WHO) recommends systematic tuberculosis (TB) screening in prisons. Evidence is lacking for accurate and scalable screening approaches in this setting. We aimed to assess the accuracy of artificial intelligence-based chest x-ray interpretation algorithms for TB screening in prisons. Methods We performed prospective TB screening in three male prisons in Brazil from October 2017 to December 2019. We administered a standardized questionnaire, performed a chest x-ray in a mobile unit, and collected sputum for confirmatory testing using Xpert MTB/RIF and culture. We evaluated x-ray images using three algorithms (CAD4TB version 6, Lunit version 3.1.0.0 and qXR version 3) and compared their accuracy. We utilized multivariable logistic regression to assess the effect of demographic and clinical characteristics on algorithm accuracy. Finally, we investigated the relationship between abnormality scores and Xpert semi-quantitative results. Findings Among 2075 incarcerated individuals, 259 (12.5%) had confirmed TB. All three algorithms performed similarly overall with area under the receiver operating characteristic curve (AUC) of 0.88-0.91. At 90% sensitivity, only LunitTB and qXR met the WHO Target Product Profile requirements for a triage test, with specificity of 84% and 74%, respectively. All algorithms had variable performance by age, prior TB, smoking, and presence of TB symptoms. LunitTB was the most robust to this heterogeneity but nonetheless failed to meet the TPP for individuals with previous TB. Abnormality scores of all three algorithms were significantly correlated with sputum bacillary load. Interpretation Automated x-ray interpretation algorithms can be an effective triage tool for TB screening in prisons. However, their specificity is insufficient in individuals with previous TB. Funding This study was supported by the US National Institutes of Health (grant numbers R01 AI130058 and R01 AI149620) and the State Secretary of Health of Mato Grosso do Sul.
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Affiliation(s)
- Thiego Ramon Soares
- Faculty of Health Sciences of Federal University of Grande Dourados, Dourados, MS, Brazil
| | - Roberto Dias de Oliveira
- Faculty of Health Sciences of Federal University of Grande Dourados, Dourados, MS, Brazil
- Nursing School, State University of Mato Grosso do Sul, Dourados, MS, Brazil
| | - Yiran E. Liu
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Andrea da Silva Santos
- Faculty of Health Sciences of Federal University of Grande Dourados, Dourados, MS, Brazil
| | | | | | | | - Chang Min Park
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Eui Jin Hwang
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Jason R. Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Julio Croda
- Oswaldo Cruz Foundation, Campo Grande, MS, Brazil
- Department of Epidemiology of Microbial Diseases, Yale University School of Public Health, New Haven, CT, United States of America
- School of Medicine, Federal University of Mato Grosso do Sul, Campo Grande, MS, Brazil
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12
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Bashir S, Kik SV, Ruhwald M, Khan A, Tariq M, Hussain H, Denkinger CM. Economic analysis of different throughput scenarios and implementation strategies of computer-aided detection software as a screening and triage test for pulmonary TB. PLoS One 2022; 17:e0277393. [PMID: 36584194 PMCID: PMC9803287 DOI: 10.1371/journal.pone.0277393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 10/26/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Artificial Intelligence (AI) systems have demonstrated potential in detecting tuberculosis (TB) associated abnormalities from chest X-ray (CXR) images. Thus, they might provide a solution to radiologist shortages in high TB burden countries. However, the cost of implementing computer-aided detection (CAD) software has thus far been understudied. In this study, we performed a costing analysis of CAD software when used as a screening or triage test for pulmonary TB, estimated the incremental cost compared to a radiologist reading of different throughput scenarios, and predicted the cost for the national scale-up plan in Pakistan. METHODS For the study, we focused on CAD software reviewed by the World Health Organization (CAD4TB, Lunit INSIGHT CXR, qXR) or listed in the Global Drug Facility diagnostics catalogue (CAD4TB, InferRead). Costing information was obtained from the CAD software developers. CAD4TB and InferRead use a perpetual license pricing model, while Lunit and qXR are priced per license for restricted number of scans. A major implementer in Pakistan provided costing information for human resource and software training. The per-screen cost was estimated for each CAD software and for radiologist for 1) active case finding, and 2) facility based CXR testing scenarios with throughputs ranging from 50,000-100,000 scans. Moreover, we estimated the scale-up cost for CAD or radiologist CXR reading in Pakistan based on the National Strategic Plan, considering that to reach 80% diagnostic coverage, 50% of TB patients would need to be found through facility-based triage and 30% through active case finding (ACF). RESULTS The per-screen cost for CAD4TB (0.25 USD- 2.33 USD) and InferRead (0.19 USD- 2.78 USD) was lower than that of a radiologist (0.70 USD- 0.93 USD) for high throughput scenarios studied. In comparison, the per-screen cost for Lunit (0.94 USD- 1.69 USD) and qXR (0.95 USD-1.9 USD) were only comparable with that of the radiologists in the highest throughput scenario in ACF. To achieve 80 percent diagnostic coverage at scale in Pakistan, the projected additional cost of deploying CAD software to complement the current infrastructure over a four-year period were estimated at 2.65-19.23 million USD, whereas Human readers, would cost an additional 23.97 million USD. CONCLUSIONS Our findings suggest that using CAD software could enable large-scale screening programs in high TB-burden countries and be less costly than radiologist. To achieve minimum cost, the target number of screens in a specific screening strategy should be carefully considered when selecting CAD software, along with the offered pricing structure and other aspects such as performance and operational features. Integrating CAD software in implementation strategies for case finding could be an economical way to attain the intended programmatic goals.
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Affiliation(s)
- Saima Bashir
- Division of Tropical Medicine, Center of Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
- * E-mail:
| | - Sandra V. Kik
- FIND, The Global Alliance for Diagnostics, Geneva, Switzerland
| | - Morten Ruhwald
- FIND, The Global Alliance for Diagnostics, Geneva, Switzerland
| | - Amir Khan
- Interactive Research and Development, Global, Singapore
| | | | | | - Claudia M. Denkinger
- Division of Tropical Medicine, Center of Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
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13
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Verma R, Moreira FMF, do Prado Morais AO, Walter KS, Dos Santos PCP, Kim E, Soares TR, de Araujo RCP, da Silva BO, da Silva Santos A, Croda J, Andrews JR. Detection of M. tuberculosis in the environment as a tool for identifying high-risk locations for tuberculosis transmission. THE SCIENCE OF THE TOTAL ENVIRONMENT 2022; 843:156970. [PMID: 35760168 DOI: 10.1016/j.scitotenv.2022.156970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 06/15/2023]
Abstract
Tuberculosis (TB) remains a leading cause of infectious mortality globally, yet most cases cannot be epidemiologically linked even with extensive contact investigations and whole genome sequencing. Consequently, there remain major gaps in our understanding of where and when M. tuberculosis (Mtb) exposures occur. We aimed to investigate whether Mtb can be detected in environments where TB patients were recently present, which could serve as a tool for characterizing exposure risk. We collected 389 environment surface (ES) swabs from two high TB burden prisons in Brazil, sampling 41 (n = 340) cells occupied by individuals with active TB and 7 (n = 49) cells from individuals without TB. In a subset of pooled swabs (n = 6) and a swab from a cigarette lighter from the cell with active TB patients, we enriched Mtb DNA using RNA-bait hybrid capture assays and performed whole genome sequencing. In prison cells, Mtb DNA was detected in 55/340 (16 %) of ES swabs from cells occupied by active TB patients and none (0/49) from cells in which no active TB patients were present. Mtb was detected in 13/16 (81 %) prison cells occupied by the individuals with high/medium sputum Xpert Mtb load and 8/25 (32 %) with low/very low sputum Mtb load (p = 0.003). Seven hybrid capture samples had a median genomic coverage of 140×. rpoB mutations conferring high-level rifampin resistance were detected in 3/7 ES swabs. Mtb was frequently detectable in environments recently occupied by individuals with active TB. This approach could be applied in congregate environments to identify and characterize high-risk settings for Mtb exposure.
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Affiliation(s)
- Renu Verma
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | | | - Agne Oliveira do Prado Morais
- Postgraduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Mato Grosso do Sul, Brazil
| | - Katharine S Walter
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Paulo César Pereira Dos Santos
- Postgraduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Mato Grosso do Sul, Brazil
| | - Eugene Kim
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Thiego Ramon Soares
- Faculty of Health Sciences, Federal University of Grande Dourados, Dourados, MS, Brazil
| | | | | | | | - Julio Croda
- Oswaldo Cruz Foundation Mato Grosso do Sul, Mato Grosso do Sul, Brazil; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, USA; Federal University of Mato Grosso do Sul - UFMS, Campo Grande, MS, Brazil
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
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14
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Naufal F, Chaisson LH, Robsky KO, Delgado-Barroso P, Alvarez-Manzo HS, Miller CR, Shapiro AE, Golub JE. Number needed to screen for TB in clinical, structural or occupational risk groups. Int J Tuberc Lung Dis 2022; 26:500-508. [PMID: 35650693 DOI: 10.5588/ijtld.21.0749] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND: Screening for active TB using active case-finding (ACF) may reduce TB incidence, prevalence, and mortality; however, yield of ACF interventions varies substantially across populations. We systematically reviewed studies reporting on ACF to calculate the number needed to screen (NNS) for groups at high risk for TB.METHODS: We conducted a literature search for studies reporting ACF for adults published between November 2010 and February 2020. We determined active TB prevalence detected through various screening strategies and calculated crude NNS for - TB confirmed using culture or Xpert® MTB/RIF, and weighted mean NNS stratified by screening strategy, risk group, and country-level TB incidence.RESULTS: We screened 27,223 abstracts; 90 studies were included (41 in low/moderate and 49 in medium/high TB incidence settings). High-risk groups included inpatients, outpatients, people living with diabetes (PLWD), migrants, prison inmates, persons experiencing homelessness (PEH), healthcare workers, and miners. Screening strategies included symptom-based screening, chest X-ray and Xpert testing. NNS varied widely across and within incidence settings based on risk groups and screening methods. Screening tools with higher sensitivity (e.g., Xpert, CXR) were associated with lower NNS estimates.CONCLUSIONS: NNS for ACF strategies varies substantially between adult risk groups. Specific interventions should be tailored based on local epidemiology and costs.
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Affiliation(s)
- F Naufal
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - L H Chaisson
- Division of Infectious Diseases, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - K O Robsky
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - P Delgado-Barroso
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - H S Alvarez-Manzo
- Department of Molecular Microbiology and Immunology, Johns Hopkins University, Baltimore, MD, USA
| | - C R Miller
- World Health Organization, Geneva, Switzerland
| | - A E Shapiro
- Departments of Global Health and Medicine, University of Washington, Seattle, WA
| | - J E Golub
- Division of Infectious Diseases, Department of Medicine, University of Illinois at Chicago, Chicago, IL, Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA, Department of International Health, Johns Hopkins University, Baltimore, MD, USA
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15
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Walter KS, Dos Santos PCP, Gonçalves TO, da Silva BO, da Silva Santos A, de Cássia Leite A, da Silva AM, Figueira Moreira FM, de Oliveira RD, Lemos EF, Cunha E, Liu YE, Ko AI, Colijn C, Cohen T, Mathema B, Croda J, Andrews JR. The role of prisons in disseminating tuberculosis in Brazil: A genomic epidemiology study. LANCET REGIONAL HEALTH. AMERICAS 2022; 9. [PMID: 35647574 PMCID: PMC9140320 DOI: 10.1016/j.lana.2022.100186] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Globally, prisons are high-incidence settings for tuberculosis. Yet the role of prisons as reservoirs of M. tuberculosis, propagating epidemics through spillover to surrounding communities, has been difficult to measure directly. Methods To quantify the role of prisons in driving wider community M. tuberculosis transmission, we conducted prospective genomic surveillance in Central West Brazil from 2014 to 2019. We whole genome sequenced 1152 M. tuberculosis isolates collected during active and passive surveillance inside and outside prisons and linked genomes to detailed incarceration histories. We applied multiple phylogenetic and genomic clustering approaches and inferred timed transmission trees. Findings M. tuberculosis sequences from incarcerated and non-incarcerated people were closely related in a maximum likelihood phylogeny. The majority (70.8%; 46/65) of genomic clusters including people with no incarceration history also included individuals with a recent history of incarceration. Among cases in individuals with no incarceration history, 50.6% (162/320) were in clusters that included individuals with recent incarceration history, suggesting that transmission chains often span prisons and communities. We identified a minimum of 18 highly probable spillover events, M. tuberculosis transmission from people with a recent incarceration history to people with no prior history of incarceration, occurring in the state’s four largest cities and across sampling years. We additionally found that frequent transfers of people between the state’s prisons creates a highly connected prison network that likely disseminates M. tuberculosis across the state. Interpretation We developed a framework for measuring spillover from high-incidence environments to surrounding communities by integrating genomic and spatial information. Our findings indicate that, in this setting, prisons serve not only as disease reservoirs, but also disseminate M. tuberculosis across highly connected prison networks, both amplifying and propagating M. tuberculosis risk in surrounding communities. Funding Brazil’s National Council for Scientific and Technological Development and US National Institutes of Health.
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Affiliation(s)
- Katharine S Walter
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA 94305, United States
| | | | | | - Bruna Oliveira da Silva
- Health Sciences Research Laboratory, Federal University of Grande Dourados, Dourados, Brazil
| | - Andrea da Silva Santos
- Health Sciences Research Laboratory, Federal University of Grande Dourados, Dourados, Brazil
| | | | - Alessandra Moura da Silva
- School of Medicine, Federal University of Mato Grosso do Sul, School of Medicine, Campo Grande, Brazil
| | | | | | - Everton Ferreira Lemos
- School of Medicine, Federal University of Mato Grosso do Sul, School of Medicine, Campo Grande, Brazil
| | - Eunice Cunha
- Laboratory of Bacteriology, Central Laboratory of Mato Grosso do Sul, Campo Grande, Brazil
| | - Yiran E Liu
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA 94305, United States.,Cancer Biology Graduate Program, Stanford University School of Medicine, Stanford, United States
| | - Albert I Ko
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, United States.,Instituto Gonçalo¸ Moniz, Fundação Oswaldo Cruz, Salvador, BA, Brazil
| | - Caroline Colijn
- Department of Mathematics, Simon Fraser University, Burnaby, Canada
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, United States
| | - Barun Mathema
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, United States
| | - Julio Croda
- School of Medicine, Federal University of Mato Grosso do Sul, School of Medicine, Campo Grande, Brazil.,Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, United States.,Mato Grosso do Sul Office, Oswaldo Cruz Foundation, Campo Grande, Brazil
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA 94305, United States
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16
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Digital Chest X-ray with Computer-aided Detection for TB Screening within Correctional Facilities. Ann Am Thorac Soc 2021; 19:1313-1319. [PMID: 34914539 DOI: 10.1513/annalsats.202103-380oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Realizing the Global Plan to End TB will require reaching at least 90% of people in key populations such as inmates through optimizing case-finding approaches. OBJECTIVES To evaluate the addition of digital chest x-ray (d-CXR) with computer-aided detection (CAD) to symptoms on TB yield among inmates. METHODS Consecutive adult inmates from four correctional facilities in South Africa were screened for TB using symptoms and d-CXR. Any person with >1 symptom or CAD>50 provided two sputa for liquid culture and GeneXpert MTB/RIF Ultra (Xpert Ultra) testing. In a sample of 800 symptom-negative inmates with CAD<50, Xpert Ultra testing was also conducted. TB yield was defined as the proportion of new bacteriologically-confirmed TB patients identified. RESULTS We enrolled 3,576 participants; 99.6% male, median age of 34 years (IQR: 28-41), and 584 (16.3%) HIV-positive. Of those screened, 867 (24.2%) participants required investigation [394 (11.2%) symptomatic, 685 (19.1%) on abnormal CAD and 867 (24.2%) with either]. Sputum was taken in 747 (86.2%) participants, with 28 (7.8 per 1000 population) new TB cases diagnosed. Based on hypothesized screening modalities, yield would have been 3.6 per 1,000 population on symptoms alone and 7.0 per 1,000 population on d-CXR alone. Amongst an additional 800 inmates tested whom initially screened symptom-negative and CAD<50, five TB cases were diagnosed. No difference in TB yield when comparing Xpert Ultra against culture (5.6 vs. 4.8 per 1,000 population; p=0.21). CONCLUSIONS The addition of d-CXR identified two times more undiagnosed TB than patients investigated on symptoms alone. Complimentary use of d-CXR may potentially overcome subjectivity inherent in symptom screening alone for identifying TB in this population.
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17
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Dos Santos PCP, da Silva Santos A, de Oliveira RD, da Silva BO, Soares TR, Martinez L, Andrews JR, Croda J. Pooling Sputum Samples for Efficient Mass Tuberculosis Screening in Prisons. Clin Infect Dis 2021; 74:2115-2121. [PMID: 34718459 DOI: 10.1093/cid/ciab847] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Although systematic tuberculosis screening in high-risk groups is recommended by WHO, implementation in prisons has been limited due to resource constraints. Whether Xpert Ultra sputum pooling could be a sensitive and efficient approach to mass screening in prisons is unknown. METHODS 1,280 sputum samples were collected from inmates in Brazil during mass screening and tested using Xpert G4. We selected samples for mixing in pools of 4, 8, 12, and 16, which were then tested using Ultra. In each pool, a single positive sample of differing Xpert mycobacterial loads was used. Additionally, 10 pools of 16 negative samples each were analyzed as controls. We then simulated tuberculosis screening at prevalences of 0.5-5% and calculated the cost per tuberculosis case detected at different sputum pooling sizes. RESULTS The sensitivity and specificity of sputum pooling were high (sensitivity: 94%; 95% CI: 88-98; specificity: 100%, 95% CI: 84-100). Sensitivity was greater in pools in which the positive sample had a high mycobacterial load compared to those that were very low (100% vs 88%). In settings with a higher tuberculosis prevalence, pools of 4 and 8 were more efficient than larger pool sizes. Larger pools decreased the costs by 87% at low prevalences whereas smaller pools fitted greater at higher prevalences (57%). CONCLUSIONS Sputum pooling using Ultra was a sensitive strategy for tuberculosis screening. This approach was more efficient than individual testing across a broad range of simulated tuberculosis prevalence settings and could enable active case finding to be scaled while containing costs.
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Affiliation(s)
| | | | | | | | - Thiego Ramon Soares
- Faculty of Health Sciences, Federal University of Grande Dourados, Dourados, MS, Brazil
| | - Leonardo Martinez
- Boston University, School of Public Health, Department of Epidemiology, Boston, MA, United States of America
| | - Jason R Andrews
- Stanford University School of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford, CA, United States of America
| | - Julio Croda
- Oswaldo Cruz Foundation, Mato Grosso do Sul, Campo Grande, MS, Brazil
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18
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Walter KS, Tatara MB, Esther da Silva K, Moreira FMF, dos Santos PCP, de Melo Ferrari DD, Cunha EA, Andrews JR, Croda J. Local and Travel-Associated Transmission of Tuberculosis at Central Western Border of Brazil, 2014-2017. Emerg Infect Dis 2021; 27:905-914. [PMID: 33622493 PMCID: PMC7920644 DOI: 10.3201/eid2703.203839] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
International migrants are at heightened risk for tuberculosis (TB) disease. Intensified incarceration at international borders may compound population-wide TB risk. However, few studies have investigated the contributions of migration, local transmission, or prisons in driving incident TB at international borders. We conducted prospective population-based genomic surveillance in 3 cities along Brazil’s central western border from 2014–2017. Although most isolates (89/132; 67%) fell within genomic transmission clusters, genetically unique isolates disproportionately occurred among participants with recent international travel (17/42; 40.5%), suggesting that both local transmission and migration contribute to incident TB. Isolates from 40 participants with and 76 without an incarceration history clustered together throughout a maximum-likelihood phylogeny, indicating the close interrelatedness of prison and community epidemics. Our findings highlight the need for ongoing surveillance to control continued introductions of TB and reduce the disproportionate burden of TB in prisons at Brazil’s international borders.
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Bouton TC, Jacobson KR. Symptom Screens Are Not Sufficient: The Fight Against Tuberculosis Needs Better Weapons. Clin Infect Dis 2021; 73:121-123. [PMID: 32296819 PMCID: PMC8246807 DOI: 10.1093/cid/ciaa440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/14/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Tara C Bouton
- Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Karen R Jacobson
- Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts, USA
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20
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Shapiro AE, Ross JM, Yao M, Schiller I, Kohli M, Dendukuri N, Steingart KR, Horne DJ. Xpert MTB/RIF and Xpert Ultra assays for screening for pulmonary tuberculosis and rifampicin resistance in adults, irrespective of signs or symptoms. Cochrane Database Syst Rev 2021; 3:CD013694. [PMID: 33755189 PMCID: PMC8437892 DOI: 10.1002/14651858.cd013694.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Tuberculosis is a leading cause of infectious disease-related death and is one of the top 10 causes of death worldwide. The World Health Organization (WHO) recommends the use of specific rapid molecular tests, including Xpert MTB/RIF or Xpert Ultra, as initial diagnostic tests for the detection of tuberculosis and rifampicin resistance in people with signs and symptoms of tuberculosis. However, the WHO estimates that nearly one-third of all active tuberculosis cases go undiagnosed and unreported. We were interested in whether a single test, Xpert MTB/RIF or Xpert Ultra, could be useful as a screening test to close this diagnostic gap and improve tuberculosis case detection. OBJECTIVES To estimate the accuracy of Xpert MTB/RIF and Xpert Ultra for screening for pulmonary tuberculosis in adults, irrespective of signs or symptoms of pulmonary tuberculosis in high-risk groups and in the general population. Screening "irrespective of signs or symptoms" refers to screening of people who have not been assessed for the presence of tuberculosis symptoms (e.g. cough). To estimate the accuracy of Xpert MTB/RIF and Xpert Ultra for detecting rifampicin resistance in adults screened for tuberculosis, irrespective of signs and symptoms of pulmonary tuberculosis in high-risk groups and in the general population. SEARCH METHODS We searched 12 databases including the Cochrane Infectious Diseases Group Specialized Register, MEDLINE and Embase, on 19 March 2020 without language restrictions. We also reviewed reference lists of included articles and related Cochrane Reviews, and contacted researchers in the field to identify additional studies. SELECTION CRITERIA Cross-sectional and cohort studies in which adults (15 years and older) in high-risk groups (e.g. people living with HIV, household contacts of people with tuberculosis) or in the general population were screened for pulmonary tuberculosis using Xpert MTB/RIF or Xpert Ultra. For tuberculosis detection, the reference standard was culture. For rifampicin resistance detection, the reference standards were culture-based drug susceptibility testing and line probe assays. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data using a standardized form and assessed risk of bias and applicability using QUADAS-2. We used a bivariate random-effects model to estimate pooled sensitivity and specificity with 95% credible intervals (CrIs) separately for tuberculosis detection and rifampicin resistance detection. We estimated all models using a Bayesian approach. For tuberculosis detection, we first estimated screening accuracy in distinct high-risk groups, including people living with HIV, household contacts, people residing in prisons, and miners, and then in several high-risk groups combined. MAIN RESULTS We included a total of 21 studies: 18 studies (13,114 participants) evaluated Xpert MTB/RIF as a screening test for pulmonary tuberculosis and one study (571 participants) evaluated both Xpert MTB/RIF and Xpert Ultra. Three studies (159 participants) evaluated Xpert MTB/RIF for rifampicin resistance. Fifteen studies (75%) were conducted in high tuberculosis burden and 16 (80%) in high TB/HIV-burden countries. We judged most studies to have low risk of bias in all four QUADAS-2 domains and low concern for applicability. Xpert MTB/RIF and Xpert Ultra as screening tests for pulmonary tuberculosis In people living with HIV (12 studies), Xpert MTB/RIF pooled sensitivity and specificity (95% CrI) were 61.8% (53.6 to 69.9) (602 participants; moderate-certainty evidence) and 98.8% (98.0 to 99.4) (4173 participants; high-certainty evidence). Of 1000 people where 50 have tuberculosis on culture, 40 would be Xpert MTB/RIF-positive; of these, 9 (22%) would not have tuberculosis (false-positives); and 960 would be Xpert MTB/RIF-negative; of these, 19 (2%) would have tuberculosis (false-negatives). In people living with HIV (1 study), Xpert Ultra sensitivity and specificity (95% CI) were 69% (57 to 80) (68 participants; very low-certainty evidence) and 98% (97 to 99) (503 participants; moderate-certainty evidence). Of 1000 people where 50 have tuberculosis on culture, 53 would be Xpert Ultra-positive; of these, 19 (36%) would not have tuberculosis (false-positives); and 947 would be Xpert Ultra-negative; of these, 16 (2%) would have tuberculosis (false-negatives). In non-hospitalized people in high-risk groups (5 studies), Xpert MTB/RIF pooled sensitivity and specificity were 69.4% (47.7 to 86.2) (337 participants, low-certainty evidence) and 98.8% (97.2 to 99.5) (8619 participants, moderate-certainty evidence). Of 1000 people where 10 have tuberculosis on culture, 19 would be Xpert MTB/RIF-positive; of these, 12 (63%) would not have tuberculosis (false-positives); and 981 would be Xpert MTB/RIF-negative; of these, 3 (0%) would have tuberculosis (false-negatives). We did not identify any studies using Xpert MTB/RIF or Xpert Ultra for screening in the general population. Xpert MTB/RIF as a screening test for rifampicin resistance Xpert MTB/RIF sensitivity was 81% and 100% (2 studies, 20 participants; very low-certainty evidence), and specificity was 94% to 100%, (3 studies, 139 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS Of the high-risks groups evaluated, Xpert MTB/RIF applied as a screening test was accurate for tuberculosis in high tuberculosis burden settings. Sensitivity and specificity were similar in people living with HIV and non-hospitalized people in high-risk groups. In people living with HIV, Xpert Ultra sensitivity was slightly higher than that of Xpert MTB/RIF and specificity similar. As there was only one study of Xpert Ultra in this analysis, results should be interpreted with caution. There were no studies that evaluated the tests in people with diabetes mellitus and other groups considered at high-risk for tuberculosis, or in the general population.
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Affiliation(s)
- Adrienne E Shapiro
- Division of Allergy & Infectious Diseases, Global Health & Medicine, University of Washington, Seattle, USA
| | - Jennifer M Ross
- Division of Allergy & Infectious Diseases, Global Health & Medicine, University of Washington, Seattle, USA
| | - Mandy Yao
- Centre for Outcomes Research, McGill University Health Centre - Research Institute, Montreal, Canada
| | - Ian Schiller
- Centre for Outcomes Research, McGill University Health Centre - Research Institute, Montreal, Canada
| | - Mikashmi Kohli
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Nandini Dendukuri
- Centre for Outcomes Research, McGill University Health Centre - Research Institute, Montreal, Canada
| | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - David J Horne
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, and Firland Northwest TB Center, University of Washington, Seattle, WA, USA
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21
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Cords O, Martinez L, Warren JL, O'Marr JM, Walter KS, Cohen T, Zheng J, Ko AI, Croda J, Andrews JR. Incidence and prevalence of tuberculosis in incarcerated populations: a systematic review and meta-analysis. LANCET PUBLIC HEALTH 2021; 6:e300-e308. [PMID: 33765455 PMCID: PMC8168455 DOI: 10.1016/s2468-2667(21)00025-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/17/2020] [Accepted: 01/25/2021] [Indexed: 12/24/2022]
Abstract
Background Prisons are recognised as high-risk environments for tuberculosis, but there has been little systematic investigation of the global and regional incidence and prevalence of tuberculosis, and its determinants, in prisons. We did a systematic review and meta-analysis to assess the incidence and prevalence of tuberculosis in incarcerated populations by geographical region. Methods In this systematic review and meta-analysis, we searched MEDLINE, Embase, Web of Knowledge, and the LILACS electronic database from Jan 1, 1980, to Nov 15, 2020, for cross-sectional and cohort studies reporting the incidence of Mycobacterium tuberculosis infection, incidence of tuberculosis, or prevalence of tuberculosis among incarcerated individuals in all geographical regions. We extracted data from individual studies, and calculated pooled estimates of incidence and prevalence through hierarchical Bayesian meta-regression modelling. We also did subgroup analyses by region. Incidence rate ratios between prisons and the general population were calculated by dividing the incidence of tuberculosis in prisons by WHO estimates of the national population-level incidence. Findings We identified 159 relevant studies; 11 investigated the incidence of M tuberculosis infection (n=16 318), 51 investigated the incidence of tuberculosis (n=1 858 323), and 106 investigated the prevalence of tuberculosis (n=6 727 513) in incarcerated populations. The overall pooled incidence of M tuberculosis infection among prisoners was 15·0 (95% credible interval [CrI] 3·8–41·6) per 100 person-years. The incidence of tuberculosis (per 100 000 person-years) among prisoners was highest in studies from the WHO African (2190 [95% CrI 810–4840] cases) and South-East Asia (1550 [240–5300] cases) regions and in South America (970 [460–1860] cases), and lowest in North America (30 [20–50] cases) and the WHO Eastern Mediterranean region (270 [50–880] cases). The prevalence of tuberculosis was greater than 1000 per 100 000 prisoners in all global regions except for North America and the Western Pacific, and highest in the WHO South-East Asia region (1810 [95% CrI 670–4000] cases per 100 000 prisoners). The incidence rate ratio between prisons and the general population was much higher in South America (26·9; 95% CrI 17·1–40·1) than in other regions, but was nevertheless higher than ten in the WHO African (12·6; 6·2–22·3), Eastern Mediterranean (15·6; 6·5–32·5), and South-East Asia (11·7; 4·1–27·1) regions. Interpretation Globally, people in prison are at high risk of contracting M tuberculosis infection and developing tuberculosis, with consistent disparities between prisons and the general population across regions. Tuberculosis control programmes should prioritise preventive interventions among incarcerated populations. Funding US National Institutes of Health.
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Affiliation(s)
- Olivia Cords
- Division of Infectious Diseases and Geographic Medicine, Stanford, CA, USA
| | - Leonardo Martinez
- Division of Infectious Diseases and Geographic Medicine, Stanford, CA, USA; Department of Epidemiology, School of Public Health, Boston University, Boston, MA, USA.
| | - Joshua L Warren
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Jamieson Michael O'Marr
- Division of Infectious Diseases and Geographic Medicine, Stanford, CA, USA; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Katharine S Walter
- Division of Infectious Diseases and Geographic Medicine, Stanford, CA, USA
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Jimmy Zheng
- Stanford University School of Medicine, Stanford, CA, USA
| | - Albert I Ko
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA; Oswaldo Cruz Foundation, Salvador, Brazil
| | - Julio Croda
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA; Universidade Federal de Mato Grosso do Sul, Faculdade de Medicina, Campo Grande, Mato Grosso do Sul, Brazil; Fundação Oswaldo Cruz, Campo Grande, Mato Grosso do Sul, Brazil
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford, CA, USA
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22
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Moreira FMF, Verma R, Pereira dos Santos PC, Leite A, da Silva Santos A, de Araujo RCP, da Silva BO, de Sá Queiroz JHF, Persing DH, Södersten E, Gnanashanmugam D, Khatri P, Croda J, Andrews JR. Blood-based host biomarker diagnostics in active case finding for pulmonary tuberculosis: A diagnostic case-control study. EClinicalMedicine 2021; 33:100776. [PMID: 33842866 PMCID: PMC8020164 DOI: 10.1016/j.eclinm.2021.100776] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND There is a need to identify scalable tuberculosis screening strategies among high burden populations. The WHO has identified a non-sputum-based triage test as a development priority. METHODS We performed a diagnostic case-control study of point-of-care C-reactive protein (CRP) and Prototype-Xpert-MTB-Host-Response (Xpert-MTB-HR) assays in the context of a mass screening program for tuberculosis in two prisons in Brazil. All incarcerated individuals irrespective of symptoms were screened by sputum Xpert MTB/RIF and sputum culture. Among consecutive, Xpert MTB/RIF or culture-confirmed cases and Xpert MTB/RIF and culture-negative controls, CRP was quantified in serum by a point-of-care assay (iChroma-II) and a 3-gene expression score was quantified from whole blood using the Xpert-MTB-HR cartridge. We evaluated receiver operating characteristic area under the curve (AUC) and assessed specificity at 90% sensitivity and sensitivity at 70% specificity, consistent with WHO target product profile (TPP) benchmarks. FINDINGS Two hundred controls (no TB) and 100 culture- or Xpert MTB/RIF-positive tuberculosis cases were included. Half of tuberculosis cases and 11% of controls reported any tuberculosis symptoms. AUC for CRP was 0·79 (95% CI: 0·73-0·84) and for Xpert-MTB-HR was 0·84 (95% CI: 0·79-0·89). At 90% sensitivity, Xpert-MTB-HR had significantly higher specificity (53·0%, 95% CI: 45·0-69·0%) than CRP (28·1%, 95% CI: 20·2-41·8%) (p = 0·003), both well below the TPP benchmark of 70%. Among individuals with medium or high sputum Xpert MTB/RIF semi-quantitative load, sensitivity (at 70% specificity) of CRP (90·3%, 95% CI: 74·2-98·0) and Xpert-MTB-HR (96·8%, 95% CI: 83·3-99·9%) was higher. INTERPRETATION For active case finding in this high tuberculosis-burden setting, CRP and Xpert-MTB-HR did not meet TPP benchmarks for a triage test. However, Xpert-MTB-HR was highly sensitive in detecting individuals with medium or high sputum bacillary burden. FUNDING National Institutes of Health (R01 AI130058 and R01 AI149620) and Brazilian National Council for Scientific and Technological Development (CNPq-404182/2019-4).
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Affiliation(s)
| | - Renu Verma
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Alessandra Leite
- Faculty of Health Sciences, Federal University of Grande Dourados, Dourados, MS, Brazil
| | | | | | | | | | | | | | | | - Purvesh Khatri
- Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford, CA, USA
| | - Julio Croda
- Oswaldo Cruz Foundation, Campo Grande, MS, Brazil
- School of Medicine, Federal University of Mato Grosso do Sul, Campo Grande, MS, Brazil
- Yale School of Public Health, New Haven, CT, USA
| | - Jason R. Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
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23
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Increased incarceration rates drive growing tuberculosis burden in prisons and jeopardize overall tuberculosis control in Paraguay. Sci Rep 2020; 10:21247. [PMID: 33277515 PMCID: PMC7718226 DOI: 10.1038/s41598-020-77504-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 10/28/2020] [Indexed: 02/06/2023] Open
Abstract
Incarcerated populations are at high-risk to develop tuberculosis (TB), however their impact on the population-level tuberculosis epidemic has been scarcely studied. We aimed to describe the burden and trends of TB among incarcerated populations over time in Paraguay, its clinical and epidemiological differences and the population attributable fraction. This is an observational, descriptive study including all TB cases notified to the National TB control Program in Paraguay during the period 2009–2018. We also used case registries of prisoners diagnosed with tuberculosis from the Minister of Justice. The population attributable fraction of TB in the community due to incarcerated cases was estimated through Levin’s formula. The characteristics of TB cases in and outside of prison were compared as well as the characteristics of TB in prisons were modified over time. During 2009–2018, 2764 (9.7%) of the 28,534 TB reported cases in Paraguay occurred in prisons. The number of prisoners in Paraguay increased from 6258 in 2009 to 14,627 in 2018 (incarceration rate, 101 to 207 per 100,000 persons) while the number of TB cases among prisoners increased by 250% (n = 192 in 2009 versus n = 480 in 2018). The annual TB notification rate among male prisoners was 3218 and 3459 per 100,000 inmates in 2009 and 2018, respectively. The percentage of all TB cases occurring among prisoners increased from 7.1% in 2009 to 14.5% in 2018. The relative risk of TB in prisons compared to community was 70.3 (95% CI, 67.7–73.1); the overall population attributable risk was 9.5%. Among the 16 penitentiary centers in the country, two of them—Tacumbú (39.0%) and Ciudad del Este (23.3%)—represent two thirds of all TB cases in prisons. TB among inmates is predominantly concentrated in those 20–34 years old (77.3% of all), twice the percentage of cases for the same age group outside of prison. Our findings show that the TB epidemic in prisons represents one of the most important challenges for TB control in Paraguay, especially in the country’s largest cities. Appropriate TB control measures among incarcerated populations are needed and may have substantial impact on the overall TB burden in the country.
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