The challenge of multisite epidemiologic studies in diverse populations: design and implementation of a 22-site study of tuberculosis in foreign-born people

Ethics Along the Continuum of Research Involving Persons with Disorders of Consciousness

Interest in disorders of consciousness (DoC) has grown substantially over the past decade and has illuminated the importance of improving understanding of DoC biology; care needs (use of monitoring, performance of interventions, and provision of emotional support); treatment options to promote recovery; and outcome prediction. Exploration of these topics requires awareness of numerous ethics considerations related to rights and resources. The Curing Coma Campaign Ethics Working Group used its expertise in neurocritical care, neuropalliative care, neuroethics, neuroscience, philosophy, and research to formulate an informal review of ethics considerations along the continuum of research involving persons with DoC related to the following: (1) study design; (2) comparison of risks versus benefits; (3) selection of inclusion and exclusion criteria; (4) screening, recruitment, and enrollment; (5) consent; (6) data protection; (7) disclosure of results to surrogates and/or legally authorized representatives; (8) translation of research into practice; (9) identification and management of conflicts of interest; (10) equity and resource availability; and (11) inclusion of minors with DoC in research. Awareness of these ethics considerations when planning and performing research involving persons with DoC will ensure that the participant rights are respected while maximizing the impact and meaningfulness of the research, interpretation of outcomes, and communication of results.

Beyond translations, perspectives for researchers to consider to enhance comprehension during consent processes for health research in sub-saharan Africa: a scoping review

BACKGROUND

Literature on issues relating to comprehension during the process of obtaining informed consent (IC) has largely focused on the challenges potential participants can face in understanding the IC documents, and the strategies used to enhance comprehension of those documents. In this review, we set out to describe the factors that have an impact on comprehension and the strategies used to enhance the IC process in sub-Saharan African countries.

METHODS

From November 2021 to January 2022, we conducted a literature search using a PRISMA tool. We searched electronic databases (PubMed, EMBASE, EBSCOHOST) to identify relevant peer reviewed studies. We then reviewed the references of these articles to find additional literature that might have been missed through the initial search. We were particularly interested in full text articles in English that focused on the IC process in SSA published between 2006 and 2020. We included systematic reviews, and studies from Western and Asian countries that included data about SSA. We excluded articles that focused on medical interventions and studies that did not require IC.

RESULTS

Out of the 50 studies included most were multi-country (n = 13) followed by single country studies in South Africa (n = 12); Kenya, Tanzania, Uganda (n = 5) each; Gambia, Ghana and Nigeria (n = 2)each ; and one each for Botswana, Malawi, Mali, Mozambique. We identified three areas of focus: (1) socio-cultural factors affecting IC; (2) gaps in the ethical and legal frameworks guiding the IC process; and (3) strategies used to improve participants' understanding of IC.

CONCLUSION

Our review showed wide recognition that the process of achieving IC in SSA is inherently challenging, and there are limitations in the strategies aimed at improving comprehension in IC. We suggest that there is a need for greater flexibility and negotiation with communities to ensure that the approach to IC is suited to the diverse socio-cultural contexts. We propose moving beyond the literal translations and technical language to understanding IC comprehension from the participants' perspectives and the researchers' views, while examining contextual factors that impact the IC process.

Cost effectiveness analysis of implementing tuberculosis screening among applicants for non-immigrant U.S. work visas

Background

While persons who receive immigrant and refugee visas are screened for active tuberculosis before admission into the United States, nonimmigrant visa applicants (NIVs) are not routinely screened and may enter the United States with infectious tuberculosis.

Objectives

We evaluated the costs and benefits of expanding pre-departure tuberculosis screening requirements to a subset of NIVs who arrive from a moderate (Mexico) or high (India) incidence tuberculosis country with temporary work visas.

Methods

We developed a decision tree model to evaluate the program costs and estimate the numbers of active tuberculosis cases that may be diagnosed in the United States in two scenarios: 1) “Screening”: screening and treatment for tuberculosis among NIVs in their home country with recommended U.S. follow-up for NIVs at elevated risk of active tuberculosis; and, 2) “No Screening” in their home country so that cases would be diagnosed passively and treatment occurs after entry into the United States. Costs were assessed from multiple perspectives, including multinational and U.S.-only perspectives.

Results

Under “Screening” versus “No Screening”, an estimated 179 active tuberculosis cases and 119 hospitalizations would be averted in the United States annually via predeparture treatment. From the U.S.-only perspective, this program would result in annual net cost savings of about $3.75 million. However, rom the multinational perspective, the screening program would cost $151,388 per U.S. case averted for Indian NIVs and $221,088 per U.S. case averted for Mexican NIVs.

Conclusion

From the U.S.-only perspective, the screening program would result in substantial cost savings in the form of reduced treatment and hospitalization costs. NIVs would incur increased pre-departure screening and treatment costs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41479-020-00078-z.

Challenges in Recruiting African-Born, US-Based Participants for HIV and Tuberculosis Research

Research is critical for developing HIV and tuberculosis (TB) programming for U.S. African-born communities, and depends on successful recruitment of African-born people. From January 2014 to June 2016, we recruited African-born people for HIV and TB research in King County, Washington. We compared the characteristics of study participants and the underlying populations of interest, and assessed recruitment strategies. Target enrollment for the HIV study was 167 participants; 51 participants (31%) were enrolled. Target enrollment for the TB study was 218 participants; 38 (17%) were successfully recruited. Of 249 prior TB patients we attempted to contact by phone, we reached 72 (33%). Multiple recruitment strategies were employed with variable impact. Study participants differed from the underlying populations in terms of gender, country of origin and language. Inequities in research participation and in meaningful opportunities for such participation may exacerbate existing health disparities.

Inhibition of DNA-PKcs activity re-sensitizes uveal melanoma cells to radio- and chemotherapy

Uveal melanoma (UM) is the most common primary intraocular tumor in adults. Despite of important progress in the local therapy, high radioresistance in primary tumor and chemoresistance in metastatic disease are the major obstacles for UM therapy. Therefore, strategies to overcome resistance to radiation or chemotherapy in UM are urgently needed. In this study, we found that phosphorylation of DNA-PKcs, which is the key factor of non-homologous end joining (NHEJ) pathway, was remarkably overexpressed in ionizing radiation (IR)- and Selumetinib resistant UM cells. Increased amount of NHEJ events were also observed in resistant UM cells. Inhibition of DNA-PKcs by NU7441 significantly impaired DNA repair and re-sensitized resistant UM cells to radiation and Selumetinib both in vitro and in vivo. The results demonstrate increased DNA double strand break repair as a mechanism of resistance to ionizing radiation and Selumetinib, and identify DNA-PKcs as a promising target for radio-and chemotherapy in UM patients.

High Rates of Tuberculosis and Opportunities for Prevention among International Students in the United States

RATIONALE

Foreign-born persons traveling on a student visa are not currently screened for tuberculosis on entry into the United States, despite residing in the United States for up to several years.

OBJECTIVES

To characterize the risk of tuberculosis in international students entering the United States and to identify strategies for early diagnosis and prevention in this population.

METHODS

Data were collected in 18 tuberculosis control jurisdictions in the United States. A cohort of 1,268 foreign-born patients of known visa status, diagnosed with active tuberculosis between 2004 and 2007, was used for analysis. Incidence rates were estimated on the basis of immigration data from study jurisdictions.

MEASUREMENTS AND MAIN RESULTS

Tuberculosis was diagnosed in 46 student residents, providing an annual estimate of 308 cases nationally. The estimated tuberculosis case rate in student residents was 48.1 cases per 100,000 person-years (95% confidence interval, 35.6-64.8), more than twice that of the general foreign-born population. Students identified by tuberculosis screening programs were more likely to be diagnosed within 6 months of U.S. arrival (75 vs. 6%; P < 0.001), and those with pulmonary disease were less likely to have a positive sputum smear for acid-fast bacilli compared with those not screened (18 vs. 63%; P = 0.05). In unscreened students, 71% were diagnosed more than 1 year after U.S. arrival and only 6% were previously treated for latent tuberculosis infection.

CONCLUSIONS

The tuberculosis case rate in foreign-born students is significantly higher than in other foreign-born individuals. Screening this group after arrival to the United States is an effective strategy for earlier diagnosis of active tuberculosis.

A workplace tuberculosis case investigation in the presence of immigrant contacts from high prevalence countries

The highest prevalence of tuberculosis (TB) occurs in foreign born immigrants in the United States. Contact investigations at work sites with mostly immigrant workers present multiple practical problems. Recently 402 contacts were investigated at a meat packing plant in rural Texas by the Texas Department of State Health Services (DSHS). Our objective was to study the approach and effectiveness of this intensive investigation. We reviewed information, including symptoms, BCG status, TB history, X-rays, and treatment, on the sentinel case and 47 contacts managed by the Texas DSHS TB Division in Lubbock, TX. We used a gamma interferon release assay (T-SPOT.TB) to identify contacts with TB infection. The sentinel case was foreign born and had cavitary TB with acid-fast positive smears. Forty-two work site contacts were foreign born, and five were US born. The foreign born contacts were from Sudan, Somalia, Mexico, Burma, and Haiti; 18 contacts had a history of BCG vaccination. T-SPOT.TB tests were positive in 20 contacts, borderline in four, and negative in 23. Contacts with borderline results had negative repeat tests. Twenty-three contacts with negative T-SPOT.TB tests were scheduled for repeat tests in 4 weeks, but only four returned for this testing. Chest X-rays were abnormal in two contacts who were started on treatment. Sputum was collected in three individuals; one was culture positive for pan-sensitive Mycobacterium tuberculosis. Twelve contacts were treated for latent TB. Our investigation established an infection rate of 42.5% in this work site contact cohort, which is similar to the 39% prevalence reported by the Center for Disease Control. The use of T-SPOT.TB assays simplified testing in immigrants with high rates of BCG vaccination. Our investigation was complicated by language barriers, varying and uncertain levels of exposure, and a high rate of drop outs in the negative T-SPOT.TB contacts. This concerted effort provides a model for investigating work site contacts, especially with numerous immigrants, and illustrates the problems associated with these investigations.

Transnational Record Linkage for Tuberculosis Surveillance and Program Evaluation

OBJECTIVE

Pre-immigration tuberculosis (TB) screening, followed by post-arrival rescreening during the first year, is critical to reducing TB among foreign-born people in the United States. However, existing U.S. public health surveillance is inadequate to monitor TB among immigrants during subsequent years. We developed and tested a novel method for ascertaining post-U.S.-arrival TB outcomes among high-TB-risk immigrant cohorts to improve surveillance.

METHODS

We used a probabilistic record linkage program to link pre-immigration screening records from U.S.-bound immigrants from the Philippines (n=422,593) and Vietnam (n=214,401) with the California TB registry during 2000-2010. We estimated sensitivity using Monte Carlo simulations to account for uncertainty in key inputs. Specificity was evaluated by using a time-stratified approach, which defined false-positives as TB records linked to pre-immigration screening records dated after the person had arrived in the United States.

RESULTS

TB was reported in 4,382 and 2,830 people born in the Philippines and Vietnam, respectively, in California during the study period. Of these TB cases, records for 973 and 452 cases of people born in the Philippines and Vietnam, respectively, were linked to pre-immigration screening records. Sensitivity and specificity of linkage were 89% (90% credible interval [CrI] 83, 97) and 100%, respectively, for the Philippines, and 90% (90% CrI 83, 98) and 99.9%, respectively, for Vietnam.

CONCLUSION

Electronic linkage of pre-immigration screening records to a domestic TB registry was feasible, sensitive, and highly specific in two high-priority immigrant cohorts. Transnational record linkage can be used for program evaluation and routine monitoring of post-U.S.-arrival TB risk among immigrants, but requires interagency data sharing and collaboration.

Preventing Infectious Pulmonary Tuberculosis Among Foreign-Born Residents of the United States

OBJECTIVES

We described risk factors associated with infectious tuberculosis (TB) and missed TB-prevention opportunities in foreign-born US residents, who account for almost two thirds of the nation's TB patients.

METHODS

In a cross-sectional study at 20 US sites of foreign-born persons diagnosed with TB in 2005 through 2006, we collected results of sputum smear microscopy for acid-fast bacilli (a marker for infectiousness) and data on visa status, sociodemographics, TB-related care seeking, and latent TB infection (LTBI) diagnosis opportunities.

RESULTS

Among 980 persons with pulmonary TB who reported their visa status, 601 (61%) were legal permanent residents, 131 (13.4%) had temporary visas, and 248 (25.3%) were undocumented. Undocumented persons were more likely than permanent residents to have acid-fast bacilli-positive smears at diagnosis (risk ratio = 1.3; 95% confidence interval = 1.2, 1.4). Of those diagnosed 1 year or more after arrival, 57.3% reported LTBI screening opportunities; fewer than 25% actually were. Undocumented persons reported fewer LTBI screening opportunities and were less likely to be tested.

CONCLUSIONS

Progress toward TB elimination in the United States depends upon expanding opportunities for regular medical care and promotion of LTBI screening and treatment among foreign-born persons.

Examining the impact of patient characteristics and symptomatology on knowledge, attitudes, and beliefs among foreign-born tuberculosis cases in the US and Canada

Foreign-born individuals represent the majority of TB cases in the US/Canada. Little is known about their TB knowledge, attitudes, and beliefs (KAB). Cross-sectional survey was conducted in 22 sites in the US/Canada among foreign-born adults with active TB. Multiple regression was used to examine KAB factors against covariates. Of 1,475 participants interviewed, most answered the six knowledge items correctly. Significant predictors of correct knowledge included region of origin, education, income, age, visa status, place of diagnosis, BCG vaccination, and TB symptoms. Significant predictors of higher perceived risk/stigma scores included region of origin, age, place of diagnosis, English fluency, time in the US/Canada, TB symptoms, and household rooms. This study examines associations between TB KAB and patient and disease characteristics in foreign-born individuals in the US/Canada. The findings call for improved health education, along with efforts to reduce stigma and enhance realistic risk assessments.

Tuberculosis treatment managed by providers outside the Public Health Department: lessons for the Affordable Care Act

INTRODUCTION

Tuberculosis (TB) requires at least six months of multidrug treatment and necessitates monitoring for response to treatment. Historically, public health departments (HDs) have cared for most TB patients in the United States. The Affordable Care Act (ACA) provides coverage for uninsured persons and may increase the proportion of TB patients cared for by private medical providers and other providers outside HDs (PMPs). We sought to determine whether there were differences in care provided by HDs and PMPs to inform public health planning under the ACA.

METHODS

We conducted a retrospective, cross-sectional analysis of California TB registry data. We included adult TB patients with culture-positive, pulmonary TB reported in California during 2007-2011. We examined trends, described case characteristics, and created multivariate models measuring two standards of TB care in PMP- and HD-managed patients: documented culture conversion within 60 days, and use of directly observed therapy (DOT).

RESULTS

The proportion of PMP-managed TB patients increased during 2007-2011 (p = 0.002). On univariable analysis (N = 4,606), older age, white, black or Asian/Pacific Islander race, and birth in the United States were significantly associated with PMP care (p<0.05). Younger age, Hispanic ethnicity, homelessness, drug or alcohol use, and cavitary and/or smear-positive TB disease, were associated with HD care. Multivariable analysis showed PMP care was associated with lack of documented culture conversion (adjusted relative risk [aRR] = 1.37, confidence interval [CI] 1.25-1.51) and lack of DOT (aRR = 8.56, CI 6.59-11.1).

CONCLUSION

While HDs cared for TB cases with more social and clinical complexities, patients under PMP care were less likely to receive DOT and have documented culture conversion. This indicates a need for close collaboration between PMPs and HDs to ensure that optimal care is provided to all TB patients and TB transmission is halted. Strategies to enhance collaboration between HDs and PMPs should be included in ACA implementation.

Epidemiology of tuberculosis in young children in the United States

OBJECTIVES

To estimate tuberculosis (TB) rates among young children in the United States by children's and parents' birth origins and describe the epidemiology of TB among young children who are foreign-born or have at least 1 foreign-born parent.

METHODS

Study subjects were children <5 years old diagnosed with TB in 20 US jurisdictions during 2005-2006. TB rates were calculated from jurisdictions' TB case counts and American Community Survey population estimates. An observational study collected demographics, immigration and travel histories, and clinical and source case details from parental interviews and health department and TB surveillance records.

RESULTS

Compared with TB rates among US-born children with US-born parents, rates were 32 times higher in foreign-born children and 6 times higher in US-born children with foreign-born parents. Most TB cases (53%) were among the 29% of children who were US born with foreign-born parents. In the observational study, US-born children with foreign-born parents were more likely than foreign-born children to be infants (30% vs. 7%), Hispanic (73% vs. 37%), diagnosed through contact tracing (40% vs. 7%), and have an identified source case (61% vs. 19%); two-thirds of children were exposed in the United States.

CONCLUSIONS

Young children who are US born of foreign-born parents have relatively high rates of TB and account for most cases in this age group. Prompt diagnosis and treatment of adult source cases, effective contact investigations prioritizing young contacts, and targeted testing and treatment of latent TB infection are necessary to reduce TB morbidity in this population.

Optimizing the protection of research participants and personnel in HIV-related research where TB is prevalent: practical solutions for improving infection control

Tuberculosis (TB) is a leading cause of death among persons with HIV globally. HIV-related research in TB endemic areas raises some unique and important ethical issues in infection control related to protecting both research participants and personnel. To address such concerns, this article provides practical guidance to help research teams develop strategies to prevent TB transmission in studies involving persons with HIV in TB endemic settings.

The ethics of clinical research in low- and middle-income countries

The increasing conduct of clinical research in low- and middle-income countries (LMIC) is motivated by the desire to promote host country access to biomedical research, to enhance LMIC access to modern clinical care, and opportunities to conduct research with simpler regulatory requirements and at lower cost. Yet clinical research in LMIC is associated with ethical risks beyond those of clinical research conducted in high-income countries (HIC). Ethical challenges particular to clinical research in LMIC include the conduct of placebo-controlled clinical trials in LMIC despite HIC availability of effective comparator interventions, obtaining informed consent despite power inequities, and the obligation of HIC researchers to redress health disparities in LMIC. This chapter covers these and additional ethical challenges of clinical research in LMIC, and proposes ways to navigate these challenges through awareness, regulatory oversight, consultation, and collaboration with LMIC investigators and community representatives. With its ethical challenges properly managed, clinical research in LMIC provides historic opportunities to bring biomedical research and better healthcare infrastructure to countries previously left behind in the modern rush to biomedical innovation.

Socioeconomic determinants associated with willingness to participate in medical research among a diverse population

INTRODUCTION

Although it is federally-mandated that racial/ethnic minorities be included in research studies, recruiting diverse populations remains a challenge. This is particularly difficult when research involves children. The purpose of this study was to assess attitudes and beliefs toward medical research among a racially and socioeconomically diverse population of parents of school children.

METHODS

A cross-sectional parent-report survey was conducted in New York City public elementary schools using stratified random selection to obtain a diverse population. Fear of medical research and likelihood to participate in medical research were assessed using a validated questionnaire. Differences in fear/likelihood to participate in research across race/ethnicity and socioeconomic characteristics were evaluated.

RESULTS

In general, parents were afraid of their child "being treated as a guinea pig", but were willing to allow their child to participate in research if asked by their own doctor. Factors associated with a lower score on fear toward research were; primary language other than English (OR=0.59), access to an interpreter (OR=0.73) and access to medical service within a day (OR=0.51). Latinos had the highest fear score (OR=1.87) compared to Whites. Asians were the ethnic group most likely to participate in research (OR=1.71). Low education level (OR=2.18) and public health insurance (OR=1.37) were associated with a higher score for likelihood of allowing one's child to participate in medical research.

CONCLUSION

Minority parents reported more fear of allowing their children to participate in medical research, but were as likely to consent their children's participation, especially if asked by their own physician.