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Domínguez Á, Soldevila N, Toledo D, Parrón I, Millet JP, Barrabeig I, Godoy P. Factors Associated with Treatment Prescription to Pulmonary Tuberculosis Contacts in Catalonia (2019-2021): A Population-Based Epidemiological Study. Vaccines (Basel) 2023; 11:1800. [PMID: 38140204 PMCID: PMC10747834 DOI: 10.3390/vaccines11121800] [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: 11/13/2023] [Revised: 11/27/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
In countries with low tuberculosis (TB) incidence, the systematic testing and treatment of latent TB infection (LTBI) in contacts of pulmonary TB index cases is the standard of care. The objective of this study, conducted in Catalonia over 2019-2021, was to assess the factors associated with LTBI treatment prescription to close contacts of pulmonary TB index cases. In this population-based epidemiological study of LTBI prevalence among pulmonary TB contacts between 2019 and 2021, multiple logistic backward stepwise regression was used to identify the factors associated with treatment prescription, for which the adjusted odds ratio (aOR) and 95% confidence intervals (CI) were calculated. A total of 1487 LTBI contacts of 542 pulmonary TB index cases were studied, 80.6% of whom received a prescription. The factors associated with LTBI treatment prescription were exposure ≥6 h/day (aOR 14.20; 95% CI 5.22-38.66) and exposure <6 h/day (aOR 7.32, 95% CI 2.48-21.64), whereas the factors associated with no LTBI treatment prescription were age ≥55 years (aOR 0.22, 95% CI 0.08-0.64) and bacillus Calmette-Guerin vaccination (aOR 0.38, 95% CI 0.16-0.90). Crucial to LTBI treatment prescription is information on the contact's duration of exposure to pulmonary TB, not only for contacts exposed for ≥6 h/day, but also for contacts with lower daily exposure levels.
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Affiliation(s)
- Ángela Domínguez
- Departament de Medicina, Universitat de Barcelona, 08036 Barcelona, Spain; (Á.D.); (N.S.)
- CIBER de Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain; (J.-P.M.); (P.G.)
| | - Núria Soldevila
- Departament de Medicina, Universitat de Barcelona, 08036 Barcelona, Spain; (Á.D.); (N.S.)
- CIBER de Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain; (J.-P.M.); (P.G.)
| | - Diana Toledo
- Departament de Medicina, Universitat de Barcelona, 08036 Barcelona, Spain; (Á.D.); (N.S.)
- CIBER de Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain; (J.-P.M.); (P.G.)
| | - Ignasi Parrón
- Agència de Salut Publica de Catalunya, 08005 Barcelona, Spain;
| | - Joan-Pau Millet
- CIBER de Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain; (J.-P.M.); (P.G.)
- Agència de Salut Pública de Barcelona, 08023 Barcelona, Spain
| | - Irene Barrabeig
- CIBER de Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain; (J.-P.M.); (P.G.)
- Agència de Salut Publica de Catalunya, 08005 Barcelona, Spain;
| | - Pere Godoy
- CIBER de Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain; (J.-P.M.); (P.G.)
- Institut de Recerca Biomédica de Lleida (IRBLleida), 25198 Lleida, Spain
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Shlomi D, Galor I, More A, Oberman B, Fireman L. Latent tuberculosis infection prevalence in second generation immigrants from high to low TB burden countries. Pulmonology 2023; 29:124-129. [PMID: 33408042 DOI: 10.1016/j.pulmoe.2020.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 11/14/2020] [Accepted: 12/09/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Latent tuberculosis infection (LTBI) diagnosis in a country with a low tuberculosis burden is complicated. Since the prevalence of LTBI in second generation immigrants has not been well recognized, we conducted a cross-sectional study which aimed to explore the differences in LTBI prevalence between offspring of immigrants from high tuberculosis (TB) burden countries and those whose parents were born in countries with a low TB burden. METHODS Between May 2014 and April 2018 young native Israelis who were required to perform pre-occupational tuberculin skin tests (TST) (medical and paramedical personnel or teaching assistants of immigrants from high TB burden countries) and who had a TST result of 10mm and above were tested for QuantiFERON-TB In Tube (QFT-GIT). Statistical comparisons were made between second generation immigrants and those with both parents from a low TB burden country. RESULTS Of 102 patients, 71 were born to parents both of whom were from low-risk countries, 14 to one parent from a high-risk country and 17 to parents both of whom were from a high-risk country. The odds ratio for LTBI was 4.5 (95% CI, 1.2...17.2; p=0.03) if both parents were born in a high-risk country compared to both parents being from a low-risk country and 4.01 (95% CI, 1.12...14.3; p=0.03) higher compared to persons for whom at least one parent was born in a low-risk country. CONCLUSION The risk for latent TB is significantly higher in second generation immigrants if both parents were born in a high-risk country. IGRA should be considered before treatment to patients with a positive TST if at least one parent was born in a low-risk country in order to confirm LTBI.
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Affiliation(s)
- D Shlomi
- Adelson School of Medicine, Ariel University, Ariel, Israel; Clalit Health Services, Dan- Petah-Tiqwa District, Israel.
| | - I Galor
- Israel Defense Forces Medical Corps, Israel
| | - A More
- The Obstetric and Gynecology Division, Delivery Room Department, Assaf Harofeh Medical Center, Israel
| | - B Oberman
- The Gertner Institute for Epidemiology and Health Policy Research, Tel-HaShomer, Israel
| | - L Fireman
- The Laboratory of Pulmonary and Allergic Diseases,Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
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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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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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Dale KD, Karmakar M, Snow KJ, Menzies D, Trauer JM, Denholm JT. Quantifying the rates of late reactivation tuberculosis: a systematic review. THE LANCET. INFECTIOUS DISEASES 2021; 21:e303-e317. [PMID: 33891908 DOI: 10.1016/s1473-3099(20)30728-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 08/12/2020] [Accepted: 08/29/2020] [Indexed: 11/17/2022]
Abstract
The risk of tuberculosis is greatest soon after infection, but Mycobacterium tuberculosis can remain in the body latently, and individuals can develop disease in the future, sometimes years later. However, there is uncertainty about how often reactivation of latent tuberculosis infection (LTBI) occurs. We searched eight databases (inception to June 25, 2019) to identify studies that quantified tuberculosis reactivation rates occurring more than 2 years after infection (late reactivation), with a focus on identifying untreated study cohorts with defined timing of LTBI acquisition (PROSPERO registered: CRD42017070594). We included 110 studies, divided into four methodological groups. Group 1 included studies that documented late reactivation rates from conversion (n=14) and group 2 documented late reactivation rates in LTBI cohorts from exposure (n=11). Group 3 included 86 studies in LTBI cohorts with an unknown exposure history, and group 4 included seven ecological studies. Since antibiotics have been used to treat tuberculosis, only 11 studies have documented late reactivation rates in infected, untreated cohorts from either conversion (group 1) or exposure (group 2); six of these studies lasted at least 4 years and none lasted longer than 10 years. These studies found that tuberculosis rates declined over time, reaching approximately 200 cases per 100 000 person-years or less by the fifth year, and possibly declining further after 5 years but interpretation was limited by decreasing or unspecified cohort sizes. In cohorts with latent tuberculosis and an unknown exposure history (group 3), tuberculosis rates were generally lower than those seen in groups 1 and 2, and beyond 10 years after screening, rates had declined to less than 100 per 100 000 person-years. Reinfection risks limit interpretation in all studies and the effect of age is unclear. Late reactivation rates are commonly estimated or modelled to prioritise tuberculosis control strategies towards tubuculosis elimination, but significant gaps remain in our understanding that must be acknowledged; the relative importance of late reactivation versus early progression to the global burden of tuberculosis remains unknown.
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Affiliation(s)
- Katie D Dale
- Victorian Tuberculosis Program, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia; Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia.
| | - Malancha Karmakar
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia; Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Kathryn J Snow
- Centre for International Child Health, Department of Paediatrics, Royal Children's Hospital, University of Melbourne, Parkville, VIC, Australia; Australia Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Dick Menzies
- Respiratory Epidemiology and Clinical Research Unit, McGill International TB Centre, Montreal, QC, Canada
| | - James M Trauer
- Victorian Tuberculosis Program, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Justin T Denholm
- Victorian Tuberculosis Program, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia; Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
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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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Nordstoga I, Drage M, Steen TW, Winje BA. Wanting to or having to - a qualitative study of experiences and attitudes towards migrant screening for tuberculosis in Norway. BMC Public Health 2019; 19:796. [PMID: 31226971 PMCID: PMC6588894 DOI: 10.1186/s12889-019-7128-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 06/09/2019] [Indexed: 11/26/2022] Open
Abstract
Background This study assesses how tuberculosis (TB) screening is perceived by immigrants in Norway. Screening is mandatory for people arriving from high incidence countries. To attend screening, immigrants have to contact the health system after receiving an invitation by letter. The proportion of non-attenders is not known, and there are no sanctions for not attending. Generally, only persons who test positive receive test results. The study explores users’ experiences, attitudes and motivations for attending or not attending TB screening, and perceived barriers and enablers. Methods We conducted six focus group discussions and three individual interviews with 34 people from 16 countries in Africa, Asia and Europe. Interviews were recorded and transcribed, and data was coded following a general inductive approach: All transcribed text data was closely read through, salient themes were identified and categories were created and labelled. The data was read through several times and the category system was subsequently revised. Results Most appreciated the opportunity to be tested for a severe disease and were generally positive towards the healthcare system. At the same time, many were uncomfortable with screening, particularly due to the fear and stigma attached to TB. All experienced practical problems related to language, information, and accessing facilities. Having to ask others for help made them feel dependent and vulnerable. Positive and negative attitudes simultaneously created ambivalence. Many wanted “structuring measures” like sanctions to help attendance. Many said that not receiving results left them feeling anxious. Conclusions In order to adapt the system and improve trust and patient uptake, all aspects of the screening should be taken into account. Ambivalence towards screening probably has a negative impact on screening uptake and should be sought reduced. A combination of ambivalence and a wish for “structuring measures” leads the authors to conclude that mandatory screening is a reasonable measure. However, since mandatory screening negatively impacts patient autonomy, and because of fear, stigma and practical problems, the health system should empower users by improving communication and access to services. In addition, it is recommended that negative test results are also communicated to the users. Electronic supplementary material The online version of this article (10.1186/s12889-019-7128-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Mona Drage
- LHL International Tuberculosis Foundation, Oslo, Norway
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