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Santin M, Trajman A, Goletti D, Anibarro L. Editorial: Addressing tuberculosis infection: an essential step in the fight against tuberculosis. Front Med (Lausanne) 2024; 11:1428677. [PMID: 38912341 PMCID: PMC11190313 DOI: 10.3389/fmed.2024.1428677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 05/20/2024] [Indexed: 06/25/2024] Open
Affiliation(s)
- Miguel Santin
- Tuberculosis Unit, Department of Infectious Diseases, Bellvitge University Hospital-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
- Department of Clinical Sciences, School of Medicine, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Ministerio de Ciencia Innovación y Universidades, Madrid, Spain
| | - Anete Trajman
- Department of Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- McGill TB International Centre, McGill University, Montreal, QC, Canada
- Rede Brasileira de Pesquisa em Tuberculose, REDE-TB, Rio de Janeiro, Brazil
| | - Delia Goletti
- Translational Research Unit, Department of Epidemiology, Istituto Nazionale per le Malattie Infettive L. Spallanzani-IRCCS, Rome, Italy
| | - Luis Anibarro
- Unidad de Tuberculosis, Enfermedades Infecciosas, Medicina Interna, Complexo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
- Immunology Study Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Vigo, Spain
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Liu Y, Posey DL, Weinberg MS, Phares CR. Tuberculosis in United States-Bound Follow-to-Join Asylees, 2014-2019. Am J Trop Med Hyg 2024; 110:999-1005. [PMID: 38531107 PMCID: PMC11066364 DOI: 10.4269/ajtmh.23-0233] [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: 04/19/2023] [Accepted: 11/20/2023] [Indexed: 03/28/2024] Open
Abstract
Persons may seek asylum in the United States or at a U.S. port of entry. Principal asylees are those who are granted asylum status. Their spouse and unmarried children under 21 years of age may be granted asylum if accompanying, or following to join, the principal asylees. U.S.-bound follow-to-join asylees must undergo an overseas medical examination that includes tuberculosis (TB) screening. Culture-based overseas TB screening in U.S.-bound follow-to-join asylees has not been evaluated. We evaluated data from overseas TB screening in 19,088 arrivals of follow-to-join asylees during 2014-2019 and assessed data from their postarrival evaluation, which is recommended for those at risk for TB. Of 19,088 arrivals of follow-to-join asylees, 29 (152 cases/100,000 persons) met criteria for class B0 TB (recent completion of TB treatment overseas) and 340 (1,781 cases/100,000 persons) met criteria for class B1 pulmonary TB (chest radiograph/clinical symptoms suggestive of TB but negative sputum cultures overseas). Of 6,847 persons aged 2 to 14 years from countries with a WHO-estimated TB incidence of ≥20 cases/100,000 population/year, 408 (6.0%) were classified as class B2 latent TB infection (LTBI). Postarrival evaluations were completed in 44.8%, 51.5%, and 40.4% of persons with class B0 TB, class B1 TB, and class B2 LTBI, respectively. In conclusion, culture-based overseas TB screening in U.S.-bound follow-to-join asylees is effective in identifying those with TB (class B0 TB) or those at risk for TB (class B1 TB and class B2 LTBI). Completion of postarrival evaluation for newly arrived follow-to-join asylees was less frequent than that reported for immigrants and refugees.
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Affiliation(s)
- Yecai Liu
- Division of Global Migration Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Drew L. Posey
- Division of Global Migration Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Michelle S. Weinberg
- Division of Global Migration Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Christina R. Phares
- Division of Global Migration Health, Centers for Disease Control and Prevention, Atlanta, Georgia
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Petersen E, Al-Abri S, Al-Jardani A, Memish ZA, Aklillu E, Ntoumi F, Mwaba P, Wejse C, Zumla A, Al-Yaquobi F. Screening for latent tuberculosis in migrants-status quo and future challenges. Int J Infect Dis 2024; 141S:107002. [PMID: 38479577 DOI: 10.1016/j.ijid.2024.107002] [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: 02/14/2024] [Revised: 03/05/2024] [Accepted: 03/05/2024] [Indexed: 03/25/2024] Open
Abstract
OBJECTIVES To review the evidence that migrants from tuberculosis (TB) high-incidence countries migrating to TB low-incidence countries significantly contribute to active TB cases in the counties of destination, primarily through reactivation of latent TB. METHODS This is a narrative review. The different screening programs in the countries of destination are reviewed either based on screening and preventive treatment of latent TB pre or more commonly - post arrival. RESULTS Screening can be performed using interferon-gamma release assays (IGRA) or tuberculin skin tests (TST). Preventive treatment of latent TB is using either monotherapy with isoniazid, or in combination with rifampicin or rifapentine. We discuss the ethical issues of preventive treatment in asymptomatic individuals and how these are addressed in different screening programs. CONCLUSION Screening migrants from TB high endemic countries to TB low endemic countries is beneficial. There is a lack of standardization and agreement on screening protocols, follow up and treatment.
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Affiliation(s)
- Eskild Petersen
- PandemiX Center of Excellence, Roskilde University, Roskilde, Denmark; European Society for Clinical Microbiology and Infectious Diseases Task Force for Emerging Infections, Basel, Switzerland; International Society for Infectious Diseases, Boston, MA, USA
| | - Seif Al-Abri
- Directorate General for Disease Surveillance and Control, Ministry of Health, Muscat, Oman.
| | - Amina Al-Jardani
- Central Public Health Laboratory, Ministry of Health, Muscat, Oman
| | - Ziad A Memish
- Research and Innovation Center, King Saud Medical City, Ministry of Health & College of Medicine, Al Faisal University, Riyadh, Saudi Arabia; Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Eleni Aklillu
- Department of Global Public Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Francine Ntoumi
- Fondation Congolaise pour la Recherche Médicale, Brazzaville, People's Republic of Congo; Institute for Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - Peter Mwaba
- UNZA-UCLMS Research and Training Program, UTH, Lusaka, Zambia; Lusaka Apex Medical University, Faculty of Medicine, Lusaka, Zambia
| | - Christian Wejse
- Department of Public Health, Faculty of Health Science, Aarhus University, Aarhus, Denmark
| | - Alimuddin Zumla
- Department of Infection, Centre for Clinical Microbiology, Division of Infection and Immunity, University College London, London, United Kingdom; NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, United Kingdom
| | - Fatma Al-Yaquobi
- Directorate General for Disease Surveillance and Control, Ministry of Health, Muscat, Oman
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Gray A, Surey J, Veitch M, Menezes D, Gibbons J, Leonard M, Sultan B, Esmail H, Story A. Diagnosis and management of tuberculosis infection in inclusion health populations in London. BMC Infect Dis 2024; 24:252. [PMID: 38395793 PMCID: PMC10893593 DOI: 10.1186/s12879-024-09132-3] [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: 11/28/2023] [Accepted: 02/13/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Tuberculosis in the UK is more prevalent in people with social risk factors- e.g. previous incarceration, homelessness - and in migrants from TB endemic countries. The management of TB infection is part of TB elimination strategies, but is challenging to provide to socially excluded groups and the evidence base for effective interventions is small. METHODS We evaluated a TB infection screening and treatment programme provided by a peer-led service (Find&Treat) working in inclusion health settings (e.g. homeless hostels) in London. IGRA (interferon-gamma release assay) testing and TB infection treatment were offered to eligible adults using a community-based model. The primary outcome was successful progression through the cascade of care. We also evaluated socio-demographic characteristics associated with a positive IGRA. RESULTS 42/312 (13.5%) participants had a positive IGRA and no one had evidence of active TB. 35/42 completed a medical evaluation; 22 started treatment, and 17 completed treatment. Having a positive IGRA was associated with previous incarceration and being born outside of the UK. DISCUSSION Provision of TB infection diagnosis and management to this socially excluded population has several challenges including maintaining people in care and drug-drug interactions. Peer-support workers provided this service safely and effectively with appropriate support. Further work to generate data to inform risks and benefits of treatment for TB infection in this group is needed to facilitate joint decision making.
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Affiliation(s)
- Adam Gray
- University College London Hospitals, London, UK
- Hospital for Tropical Diseases, University College London Hospitals, London, UK
- Institute for Global Health, University College London, London, UK
| | - Julian Surey
- University College London Hospitals, London, UK
- Institute for Global Health, University College London, London, UK
- Universidad Autonoma de Madrid, Madrid, Spain
| | | | - Dee Menezes
- Public Health Data Science, Institute of Health Informatics, University College London, London, UK
| | | | | | | | - Hanif Esmail
- Hospital for Tropical Diseases, University College London Hospitals, London, UK
- Institute for Global Health, University College London, London, UK
- TB Service, Whittington Hospital, London, UK
| | - Al Story
- University College London Hospitals, London, UK.
- Collaborative Centre for Inclusion Health, University College London, London, UK.
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Ortiz Laza N, Lopez Aranaga I, Toral Andres J, Toja Uriarte B, Santos Zorrozua B, Altube Urrengoechea L, Garros Garay J, Tabernero Huguet E. Latent tuberculosis infection treatment completion in Biscay: differences between regimens and monitoring approaches. Front Med (Lausanne) 2023; 10:1265057. [PMID: 38020141 PMCID: PMC10651218 DOI: 10.3389/fmed.2023.1265057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Contact tracing and treatment of latent tuberculosis infection (LTBI) is a key element of tuberculosis (TB) control in low TB incidence countries. A TB control and prevention program has been active in the Basque Country since 2003, including the development of the nurse case manager role and a unified electronic record. Three World Health Organization-approved LTBI regimens have been used: isoniazid for 6 months (6H), rifampicin for 4 months (4R), and isoniazid and rifampicin for 3 months (3HR). Centralized follow-up by a TB nurse case manager started in January 2016, with regular telephone follow-up, telemonitoring of blood test results, and monitoring of adherence by electronic review of drugs dispensed in pharmacies. Objective To estimate LTBI treatment completion and toxicity of different preventive treatment regimens in a real-world setting. Secondary objective: to investigate the adherence to different approaches to preventive treatment monitoring. Methods A multicentre retrospective cohort study was conducted using data collected prospectively on contacts of patients with TB in five hospitals in Biscay from 2003 to 2022. Results A total of 3,066 contacts with LTBI were included. The overall completion rate was 66.8%; 86.5% of patients on 3HR (n = 699) completed treatment vs. 68.3% (n = 1,260) of those on 6H (p < 0.0001). The rate of toxicity was 3.8%, without significant differences between the regimens. A total of 394 contacts were monitored by a TB nurse case manager. In these patients, the completion rate was 85% vs. 67% in those under standard care (p < 0.001). A multivariate logistic regression model identified three independent factors associated with treatment completion: being female, the 3HR regimen, and nurse telemonitoring. Conclusion 3HR was well tolerated and associated with a higher rate of treatment completion. Patients with nurse telemonitoring follow-up had better completion rates.
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Affiliation(s)
- N. Ortiz Laza
- Pulmonology Service, Cruces University Hospital, Biocruces-Bizkaia Health Research Institute, Barakaldo, Spain
| | - I. Lopez Aranaga
- Pulmonology Service, Cruces University Hospital, Biocruces-Bizkaia Health Research Institute, Barakaldo, Spain
| | - J. Toral Andres
- Pulmonology Service, Galdakao-Usansolo Hospital, Galdakao, Spain
| | | | | | | | | | - E. Tabernero Huguet
- Pulmonology Service, Cruces University Hospital, Biocruces-Bizkaia Health Research Institute, Barakaldo, Spain
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Harwood-Johnson E, Leis KS, Hanson J, Olfert J, Blonde Y, Brindamour M. Community treatment of latent tuberculosis in child and adult refugee populations: outcomes and successes. Front Public Health 2023; 11:1225217. [PMID: 37942244 PMCID: PMC10629593 DOI: 10.3389/fpubh.2023.1225217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/22/2023] [Indexed: 11/10/2023] Open
Abstract
Background Tuberculosis (TB) is the world's leading infectious cause of death, killing millions every year. In Canada, considered a low-incidence country for TB, the burden of the disease is unequally distributed, with most cases of latent tuberculosis infection (LTBI) experienced by newcomers from endemic regions. The purpose of this study was to measure LTBI treatment acceptance and completion outcomes of LTBI treatment at the REACH clinic in Saskatoon, a local refugee clinic providing primary care-based LTBI management. Methods A retrospective case series by sampling methodology was applied to review patients who visited the REACH clinic between January 2017 and June 2021 and who had an interferon-gamma release assay (IGRA) or tuberculin skin test (TST) done for LTBI screening. Those with positive results were retained for analysis. The LTBI treatment acceptance and completion groups were compared according to demographic variables, WHO regions of origin, year of arrival to Canada, and LTBI treatment regimen. Results A total of 523 patients were screened for LTBI, of whom 125 tested positive, leading to a test positivity of 23.9%. The treatment acceptance rate was 84.8%, and the treatment completion rate was 93.3%. All of those who declined treatment were more than 18 years of age (p = 0.02). Otherwise, treatment acceptance and completion rates did not vary significantly in association with gender, categories of refugees, WHO region of origin, year of arrival to Canada, or LTBI treatment regimen used. Discussion The refugee clinic acceptance and completion rates in this study are high and meet Canadian TB standards of care. The multidisciplinary clinic model and community support are important facilitators, which, in combination with shorter treatment regimens, offer a path forward for LTBI management among refugees resettling in low-incidence countries.
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Affiliation(s)
| | - Karen S. Leis
- Department of Pediatrics, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Jacelyn Hanson
- Department of Family Medicine, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Jordan Olfert
- Department of Respirology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Yvonne Blonde
- Department of Academic Family Medicine, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Mahli Brindamour
- Department of Pediatrics, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
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7
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Yang H, Lee JS, Kim Y. Healthcare workers' acceptance of and adherence to latent tuberculosis treatment. Occup Med (Lond) 2023; 73:186-192. [PMID: 36972514 DOI: 10.1093/occmed/kqad036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Healthcare workers (HCWs) with latent tuberculosis infection (LTBI) have a high risk of active tuberculosis and need systematic LTBI screening and treatment. However, acceptance and adherence rates of LTBI treatment are low. AIMS To examine the specific reasons for the loss at each LTBI treatment-cascade stage: acceptance, continuation and completion of LTBI treatment in HCWs. METHODS This retrospective descriptive study was conducted among 61 HCWs with an interferon-gamma release assay-confirmed LTBI diagnosis who were prescribed LTBI treatment at a tertiary hospital in the Republic of Korea. Data were analysed using Pearson's chi-square, Fisher's exact, independent t-test and Mann-Whitney U-test. A word cloud analysis was used to describe the perceived meaning of LTBI in HCWs. RESULTS HCWs who refused or discontinued LTBI treatment perceived LTBI as 'not a big deal', whereas HCWs who completed LTBI treatment had a high-risk perception of the LTBI prognosis, such as 'frightened about adverse prognosis'. Determinants of non-adherence to the recommended LTBI treatment included a busy work schedule, side effects of anti-tuberculosis agents and the inconvenience of regularly taking anti-tuberculosis agents. CONCLUSIONS To ensure LTBI treatment adherence in HCWs, effective interventions that are customized to each stage of the LTBI treatment should be developed, with due consideration of the stage-specific perceived facilitators and barriers in the LTBI treatment cascade.
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Affiliation(s)
- H Yang
- Chonnam National University, College of Nursing, Gwangju 61469, Republic of Korea
| | - J S Lee
- Chonnam National University Hwasun Hospital, Hwasun 58128, Republic of Korea
| | - Y Kim
- Chonnam National University, College of Nursing, Gwangju 61469, Republic of Korea
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Bruxvoort KJ, Skarbinski J, Fischer H, Li Z, Eaton A, Qian L, Spence B, Wei R, Rieg G, Shaw S, Tartof SY. Latent Tuberculosis Infection Treatment Practices in Two Large Integrated Health Systems in California, 2009-2018. Open Forum Infect Dis 2023; 10:ofad219. [PMID: 37265669 PMCID: PMC10230566 DOI: 10.1093/ofid/ofad219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/19/2023] [Indexed: 06/03/2023] Open
Abstract
Background Treatment of latent tuberculosis infection (LTBI) is highly effective at preventing active tuberculosis (TB) disease. Understanding LTBI treatment practices in US health system settings is critical to identify opportunities to improve treatment prescription, initiation, and completion, and thus to prevent TB disease. Methods We assessed LTBI treatment practices among a cohort of adults after their first positive LTBI test (tuberculin skin test [TST] or interferon gamma release assay [IGRA]) between 2009 and 2018 at 2 large integrated health systems in California. We described the prescription, initiation, and completion of LTBI treatment (isoniazid [INH], rifampin, and rifamycin-INH short-course combinations) by demographic and clinical characteristics. We used multivariable robust Poisson regression to examine factors that were independently associated with treatment prescription and completion. Results Among 79 302 individuals with a positive LTBI test, 33.0% were prescribed LTBI treatment, 28.3% initiated treatment, and 18.5% completed treatment. Most individuals were prescribed INH (82.0%), but treatment completion was higher among those prescribed rifamycin-INH short-course combinations (69.6% for INH + rifapentine and 70.3% for INH + rifampin) compared with those prescribed INH (56.3%) or rifampin (56.6%). In adjusted analyses, treatment prescription and completion were associated with older age, female sex, more comorbidities, immunosuppression, not being born in a high-TB incidence country, and testing positive with IGRA vs TST. Conclusions LTBI treatment is underutilized, requiring tailored interventions to support treatment prescription and completion for patients with LTBI.
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Affiliation(s)
- Katia J Bruxvoort
- Department of Epidemiology, School of Public Health,University of Alabama at Birmingham, Birmingham, Alabama, USA
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Jacek Skarbinski
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Department of Infectious Diseases, Oakland Medical Center, Kaiser Permanente Northern California, Oakland, California, USA
| | - Heidi Fischer
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Zhuoxin Li
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Abigail Eaton
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Lei Qian
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Brigitte Spence
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Rong Wei
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Gunter Rieg
- Department of Infectious Diseases, South Bay Medical Center, Kaiser Permanente Southern California, Harbor City, California, USA
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Sally Shaw
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Sara Y Tartof
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
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Walker WL, Schmit KM, Welch EC, Vonnahme LA, Talwar A, Nguyen M, Stojanovic D, Langer AJ, Cocoros NM. Using the Food and Drug Administration´s Sentinel System for surveillance of TB infection. Int J Tuberc Lung Dis 2022; 26:1170-1176. [PMID: 36447322 PMCID: PMC9793953 DOI: 10.5588/ijtld.22.0259] [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] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND: We examined patterns in care for individuals treated for latent TB infection (LTBI) in the US Food and Drug Administration´s Sentinel System.METHODS: Using administrative claims data, we identified patients who filled standard LTBI treatment prescriptions during 2008-2019. In these cohorts, we assessed LTBI testing, clinical management, and treatment duration.RESULTS: Among 113,338 patients who filled LTBI prescriptions, 80% (90,377) received isoniazid (INH) only, 19% (21,235) rifampin (RIF) only, and 2% (1,726) INH + rifapentine (RPT). By regimen, the proportion of patients with documented prior testing for TBI was 79%, 54%, and 91%, respectively. Median therapy duration was 84 days (IQR 35-84) for the 3-month once-weekly INH + RPT regimen, 60 days (IQR 30-100) for the 6- to 9-month INH regimen, and 30 days (IQR 2-60) for the 4-month RIF regimen.CONCLUSIONS: Among the cohorts, INH-only was the most commonly prescribed LTBI treatment. Most persons who filled a prescription for LTBI treatment did not have evidence of completing recommended treatment duration. These data further support preferential use of shorter-course regimens such as INH + RPT.
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Affiliation(s)
- W L Walker
- Surveillance, Epidemiology, and Outbreak Investigations Branch, Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - K M Schmit
- Surveillance, Epidemiology, and Outbreak Investigations Branch, Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - E C Welch
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - L A Vonnahme
- Surveillance, Epidemiology, and Outbreak Investigations Branch, Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - A Talwar
- Surveillance, Epidemiology, and Outbreak Investigations Branch, Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - M Nguyen
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - D Stojanovic
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - A J Langer
- Surveillance, Epidemiology, and Outbreak Investigations Branch, Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - N M Cocoros
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
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Fornaro M, Dragioti E, De Prisco M, Billeci M, Mondin AM, Calati R, Smith L, Hatcher S, Kaluzienski M, Fiedorowicz JG, Solmi M, de Bartolomeis A, Carvalho AF. Homelessness and health-related outcomes: an umbrella review of observational studies and randomized controlled trials. BMC Med 2022; 20:224. [PMID: 35818057 PMCID: PMC9273695 DOI: 10.1186/s12916-022-02423-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/30/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Homelessness has been associated with multiple detrimental health outcomes across observational studies. However, relatively few randomized controlled trials (RCTs) have been conducted on people who experience homelessness (PEH). Thus, this umbrella review ranked the credibility of evidence derived from systematic reviews (SRs) and meta-analyses (MAs) of observational studies investigating the associations between homelessness and any health outcome as well as RCTs targeting health needs in this population. METHODS Several databases were systematically searched from inception through April 28, 2021. Any SR and/or MA reporting quantitative data and providing a control group were eligible for inclusion. The credibility of the evidence derived from observational studies was appraised by considering the significance level of the association and the largest study, the degree of heterogeneity, the presence of small-study effects as well as excess significance bias. The credibility of evidence was then ranked in five classes. For SRs and/or MAs of RCTs, we considered the level of significance and whether the prediction interval crossed the null. The AMSTAR-2 and AMSTAR-plus instruments were adopted to further assess the methodological quality of SRs and/or MAs. The Newcastle-Ottawa Scale (NOS) was employed to further appraise the methodological quality of prospective cohort studies only; a sensitivity analysis limited to higher quality studies was conducted. RESULTS Out of 1549 references, 8 MAs and 2 SRs were included. Among those considering observational studies, 23 unique associations were appraised. Twelve of them were statistically significant at the p≤0.005 level. Included cases had worst health-related outcomes than controls, but only two associations reached a priori-defined criteria for convincing (class I) evidence namely hospitalization due to any cause among PEH diagnosed with HIV infection, and the occurrence of falls within the past year among PEH. According to the AMSTAR-2 instrument, the methodological quality of all included SRs and/or MAs was "critically low." Interventional studies were scant. CONCLUSION While homelessness has been repeatedly associated with detrimental health outcomes, only two associations met the criteria for convincing evidence. Furthermore, few RCTs were appraised by SRs and/or MAs. Our umbrella review also highlights the need to standardize definitions of homelessness to be incorporated by forthcoming studies to improve the external validity of the findings in this vulnerable population.
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Affiliation(s)
- Michele Fornaro
- Section of Psychiatry, Department of Neuroscience, Reproductive Science, and Odontostomatology, Federico Ii University of Naples, Naples, Italy
| | - Elena Dragioti
- Pain and Rehabilitation Centre, and Department of Medical and Health Sciences, Linköping University, SE-581 85 Linköping, Sweden
| | - Michele De Prisco
- Section of Psychiatry, Department of Neuroscience, Reproductive Science, and Odontostomatology, Federico Ii University of Naples, Naples, Italy
| | - Martina Billeci
- Section of Psychiatry, Department of Neuroscience, Reproductive Science, and Odontostomatology, Federico Ii University of Naples, Naples, Italy
| | - Anna Maria Mondin
- Section of Psychiatry, Department of Neuroscience, Reproductive Science, and Odontostomatology, Federico Ii University of Naples, Naples, Italy
| | - Raffaella Calati
- Department of Psychology, University of Milan-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20126 Milan, Italy
- Department of Adult Psychiatry, Nimes University Hospital, 4 Rue du Professeur Robert Debré, 30029 Nimes, France
| | - Lee Smith
- Cambridge Centre for Health, Performance and Wellbeing, Anglia Ruskin University, Cambridge, UK
| | - Simon Hatcher
- Department of Psychiatry, University of Ottawa, Ottawa, ON Canada
- Department of Mental Health, The Ottawa Hospital, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Mark Kaluzienski
- Department of Psychiatry, University of Ottawa, Ottawa, ON Canada
- Department of Mental Health, The Ottawa Hospital, Ottawa, ON Canada
| | - Jess G. Fiedorowicz
- Department of Psychiatry, University of Ottawa, Ottawa, ON Canada
- Department of Mental Health, The Ottawa Hospital, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Marco Solmi
- Department of Psychiatry, University of Ottawa, Ottawa, ON Canada
- Department of Mental Health, The Ottawa Hospital, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
- Early Psychosis: Interventions and Clinical-Detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology, London, UK
- Faculty of Environmental and Life Sciences, Center for Innovation in Mental Health, School of Psychology, University of Southampton, Southampton, UK
| | - Andrea de Bartolomeis
- Section of Psychiatry, Department of Neuroscience, Reproductive Science, and Odontostomatology, Federico Ii University of Naples, Naples, Italy
- UNESCO staff, Chair - “Education for Health and Sustainable Development”, University of Naples, Federico II Naples, Naples, Italy
| | - André F. Carvalho
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Deakin University, Geelong, Australia
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Pépin J, Desjardins F, Carignan A, Lambert M, Vaillancourt I, Labrie C, Mercier D, Bourque R, LeBlanc L. Impact and benefit-cost ratio of a program for the management of latent tuberculosis infection among refugees in a region of Canada. PLoS One 2022; 17:e0267781. [PMID: 35587499 PMCID: PMC9119458 DOI: 10.1371/journal.pone.0267781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 04/14/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction
The identification and treatment of latent tuberculosis infection (LTBI) among immigrants from high-incidence regions who move to low-incidence countries is generally considered an ineffective strategy because only ≈14% of them comply with the multiple steps of the ‘cascade of care’ and complete treatment. In the Estrie region of Canada, a refugee clinic was opened in 2009. One of its goals is LTBI management.
Methods
Key components of this intervention included: close collaboration with community organizations, integration within a comprehensive package of medical care for the whole family, timely delivery following arrival, shorter treatment through preferential use of rifampin, and risk-based selection of patients to be treated. Between 2009–2020, 5131 refugees were evaluated. To determine the efficacy and benefit-cost ratio of this intervention, records of refugees seen in 2010–14 (n = 1906) and 2018–19 (n = 1638) were reviewed. Cases of tuberculosis (TB) among our foreign-born population occurring before (1997–2008) and after (2009–2020) setting up the clinic were identified. All costs associated with TB or LTBI were measured.
Results
Out of 441 patients offered LTBI treatment, 374 (85%) were compliant. Adding other losses, overall compliance was 69%. To prevent one case of TB, 95.1 individuals had to be screened and 11.9 treated, at a cost of $16,056. After discounting, each case of TB averted represented $32,631, for a benefit-cost ratio of 2.03. Among nationals of the 20 countries where refugees came from, incidence of TB decreased from 68.2 (1997–2008) to 26.3 per 100,000 person-years (2009–2020). Incidence among foreign-born persons from all other countries not targeted by the intervention did not change.
Conclusions
Among refugees settling in our region, 69% completed the LTBI cascade of care, leading to a 61% reduction in TB incidence. This intervention was cost-beneficial. Current defeatism towards LTBI management among immigrants and refugees is misguided. Compliance can be enhanced through simple measures.
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Affiliation(s)
- Jacques Pépin
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, Québec, Canada
- * E-mail:
| | - France Desjardins
- Clinique des Réfugiés, Centre Local de Services Communautaires, Sherbrooke, Québec, Canada
| | - Alex Carignan
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Michel Lambert
- Clinique des Réfugiés, Centre Local de Services Communautaires, Sherbrooke, Québec, Canada
| | - Isabelle Vaillancourt
- Clinique des Réfugiés, Centre Local de Services Communautaires, Sherbrooke, Québec, Canada
| | - Christiane Labrie
- Clinique des Réfugiés, Centre Local de Services Communautaires, Sherbrooke, Québec, Canada
| | - Dominique Mercier
- Clinique des Réfugiés, Centre Local de Services Communautaires, Sherbrooke, Québec, Canada
| | - Rachel Bourque
- Clinique des Réfugiés, Centre Local de Services Communautaires, Sherbrooke, Québec, Canada
| | - Louiselle LeBlanc
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, Québec, Canada
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12
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Marx FM, Hauer B, Menzies NA, Haas W, Perumal N. Targeting screening and treatment for latent tuberculosis infection towards asylum seekers from high-incidence countries - a model-based cost-effectiveness analysis. BMC Public Health 2021; 21:2172. [PMID: 34836526 PMCID: PMC8622109 DOI: 10.1186/s12889-021-12142-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 11/01/2021] [Indexed: 11/26/2022] Open
Abstract
Background Enhancing tuberculosis (TB) prevention and care in a post-COVID-19-pandemic phase will be essential to ensure progress towards global TB elimination. In low-burden countries, asylum seekers constitute an important high-risk group. TB frequently arises post-immigration due to the reactivation of latent TB infection (LTBI). Upon-entry screening for LTBI and TB preventive treatment (TPT) are considered worthwhile if targeted to asylum seekers from high-incidence countries who usually present with higher rates of LTBI. However, there is insufficient knowledge about optimal incidence thresholds above which introduction could be cost-effective. We aimed to estimate, among asylum seekers in Germany, the health impact and costs of upon-entry LTBI screening/TPT introduced at different thresholds of country-of-origin TB incidence. Methods We sampled hypothetical cohorts of 30–45 thousand asylum seekers aged 15 to 34 years expected to arrive in Germany in 2022 from cohorts of first-time applicants observed in 2017–2019. We modelled LTBI prevalence as a function of country-of-origin TB incidence fitted to data from observational studies. We then used a probabilistic decision-analytic model to estimate health-system costs and quality-adjusted life years (QALYs) under interferon gamma release assay (IGRA)-based screening for LTBI and rifampicin-based TPT (daily, 4 months). Incremental cost-effectiveness ratios (ICERs) were calculated for scenarios of introducing LTBI screening/TPT at different incidence thresholds. Results We estimated that among 15- to 34-year-old asylum seekers arriving in Germany in 2022, 17.5% (95% uncertainty interval: 14.2–21.6%) will be latently infected. Introducing LTBI screening/TPT above 250 per 100,000 country-of-origin TB incidence would gain 7.3 (2.7–14.8) QALYs at a cost of €51,000 (€18,000–€114,100) per QALY. Lowering the threshold to ≥200 would cost an incremental €53,300 (€19,100–€122,500) per additional QALY gained relative to the ≥250 threshold scenario; ICERs for the ≥150 and ≥ 100 thresholds were €55,900 (€20,200–€128,200) and €62,000 (€23,200–€142,000), respectively, using the next higher threshold as a reference, and considerably higher at thresholds below 100. Conclusions LTBI screening and TPT among 15- to 34-year-old asylum seekers arriving in Germany could produce health benefits at reasonable additional cost (with respect to international benchmarks) if introduced at incidence thresholds ≥100. Empirical trials are needed to investigate the feasibility and effectiveness of this approach.
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Affiliation(s)
- Florian M Marx
- Department for Infectious Disease Epidemiology, Respiratory Infections Unit, Robert Koch Institute, Berlin, Germany. .,Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa. .,DSI-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa.
| | - Barbara Hauer
- Department for Infectious Disease Epidemiology, Respiratory Infections Unit, Robert Koch Institute, Berlin, Germany
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Walter Haas
- Department for Infectious Disease Epidemiology, Respiratory Infections Unit, Robert Koch Institute, Berlin, Germany
| | - Nita Perumal
- Department for Infectious Disease Epidemiology, Respiratory Infections Unit, Robert Koch Institute, Berlin, Germany.,Immunization Unit, Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
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13
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Spruijt I, Joren C, van den Hof S, Erkens C. Tailored approaches facilitate high completion of tuberculosis infection treatment among migrants. Eur Respir J 2021; 59:13993003.02077-2021. [PMID: 34561296 DOI: 10.1183/13993003.02077-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 09/14/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Ineke Spruijt
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | - Chantal Joren
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | - Susan van den Hof
- National Institute for Public Health and the Environment (RIVM), Centre for Infectious Disease Epidemiology and Surveillance, Bilthoven, The Netherlands
| | - Connie Erkens
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
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14
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Bedingfield N, Barss L, Oxlade O, Menzies D, Fisher D. Experiences with latent TB cascade of care strengthening for household contacts in Calgary, Canada. Public Health Action 2021; 11:126-131. [PMID: 34567988 DOI: 10.5588/pha.20.0082] [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: 12/09/2020] [Accepted: 04/11/2021] [Indexed: 11/10/2022] Open
Abstract
SETTING Identification, assessment, and treatment of latent TB infection (LTBI), collectively known as the LTBI cascade of care, is critical for TB prevention. OBJECTIVE The objective of this research, conducted within the ACT4 trial, was to assess and strengthen the LTBI cascade of care for household contacts at Calgary TB Services, a clinic serving a predominately foreign-born population in Western Canada. DESIGN Baseline assessment consisted of a retrospective LTBI cascade analysis of 32 contact investigations, and questionnaires administered to patients and health care workers. Four solutions were implemented in response to identified gaps. Solution impact was measured for 6 months using descriptive statistics. RESULTS Pre-implementation, 56% of household contacts initiated treatment. Most contacts were lost to care because the tuberculin skin test (TST) was not initiated, or physicians did not recommend treatment. Evening clinics, a patient education pamphlet, a nursing workshop, and treatment recommendation guidelines were implemented. Post-implementation, losses due to LTBI treatment non-recommendation were reduced; however, the overall proportion of household contacts initiating treatment did not increase. CONCLUSION Close engagement between researchers and TB programmes can reduce losses in the LTBI cascade. To see sustained improvement in overall outcomes, long-term engagement and data collection for ongoing problem-solving are required.
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Affiliation(s)
- N Bedingfield
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary Foothills Campus, Health Sciences Centre, Calgary, AB, Canada
| | - L Barss
- Department of Medicine, Cumming School of Medicine, University of Calgary Foothills Campus, Health Sciences Centre, Calgary, AB, Canada
| | - O Oxlade
- McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - D Menzies
- McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - D Fisher
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary Foothills Campus, Health Sciences Centre, Calgary, AB, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary Foothills Campus, Health Sciences Centre, Calgary, AB, Canada
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15
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Rustage K, Lobe J, Hayward SE, Kristensen KL, Margineanu I, Stienstra Y, Goletti D, Zenner D, Noori T, Pareek M, Greenaway C, Friedland JS, Nellums LB, Hargreaves S. Initiation and completion of treatment for latent tuberculosis infection in migrants globally: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2021; 21:1701-1712. [PMID: 34363771 PMCID: PMC8612939 DOI: 10.1016/s1473-3099(21)00052-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 01/06/2021] [Accepted: 01/15/2021] [Indexed: 01/01/2023]
Abstract
Background Latent tuberculosis infection (LTBI) is one of the most prevalent infections globally and can lead to the development of active tuberculosis disease. In many low-burden countries, LTBI is concentrated within migrant populations often because of a higher disease burden in the migrant's country of origin. National programmes consequently focus on screening and treating LTBI in migrants to prevent future tuberculosis cases; however, how effective these programmes are is unclear. We aimed to assess LTBI treatment initiation and outcomes among migrants, and the factors that influence both. Methods For this systematic review and meta-analysis, we searched Embase, MEDLINE, and Global Health, and manually searched grey literature from Jan 1, 2000, to April 21, 2020. We included primary research articles reporting on LTBI treatment initiation or completion, or both, in migrants and excluded articles in which data were not stratified by migrant status, or in which the data were related to outcomes before 2000. There were no geographical or language restrictions. All included studies were quality appraised using recognised tools depending on their design, and we assessed the heterogeneity of analyses using I2. We extracted data on the numbers of migrants initiating and completing treatment. Our primary outcomes were LTBI treatment initiation and completion in migrants (defined as foreign-born). We used random-effects meta-regression to examine the influence of factors related to these outcomes. The study is registered with PROSPERO (CRD42019140338). Findings 2199 publications were retrieved screened, after which 39 publications from 13 mostly high-income, low-burden countries were included in our analyses, with treatment initiation and completion data reported for 31 598 migrants positive for LTBI, with not all articles reporting the full pathway from initiation to completion. The pooled estimate for the true proportion of migrants testing positive who initiated treatment was 69% (95% CI 51–84; I2= 99·62%; 4409 of 8764). The pooled estimate for the true proportion of migrants on treatment in datasets, who subsequently completed it was 74% (95% CI = 66–81; I2= 99·19%; 15 516 of 25 629). Where data were provided for the entire treatment pathway, the pooled estimate for the true proportion of migrants who initiated and completed treatment after a positive test was only 52% (95% CI 40–64; I2= 98·90%; 3289 of 6652). Meta-regression showed that LTBI programmes are improving, with more recent reported data (2010–20) associated with better rates of treatment initiation and completion, with multiple complex factors affecting treatment outcomes in migrants. Interpretation Although our analysis highlights that LTBI treatment initiation and completion in migrants has improved considerably from 2010–20, there is still room for improvement, with drop out reported along the entire treatment pathway. The delivery of these screening and treatment programmes will require further strengthening if the targets to eradicate tuberculosis in low-incidence countries are to be met, with greater focus needed on engaging migrants more effectively in the clinic and understanding the diverse and unique barriers and facilitators to migrants initiating and completing treatment. Funding European Society of Clinical Microbiology and Infectious Diseases, the Rosetrees Trust, the National Institute for Health Research, and the Academy of Medical Sciences.
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Affiliation(s)
- Kieran Rustage
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Jessica Lobe
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Sally E Hayward
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's University of London, London, UK; Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Kristina L Kristensen
- Research Centre for Migration, Ethnicity and Health, University of Copenhagen, Copenhagen, Denmark; International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark
| | - Ioana Margineanu
- Department of Internal Medicineand Infectious Diseases, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ymkje Stienstra
- Research Centre for Migration, Ethnicity and Health, University of Copenhagen, Copenhagen, Denmark
| | - Delia Goletti
- Saint Camillus International University of Health and Medical Sciences, Rome, Italy
| | - Dominik Zenner
- Institute for Population Health Sciences, Queen Mary University of London, London, UK
| | - Teymur Noori
- European Centre for Disease Prevention and Control, Solna, Sweden
| | - Manish Pareek
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Christina Greenaway
- Division of Infectious Diseases, Jewish General Hospital, McGill University, Montreal, QC, Canada; Center for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Jon S Friedland
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Laura B Nellums
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Sally Hargreaves
- The Migrant Health Research Group, Institute for Infection and Immunity, St George's University of London, London, UK.
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16
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Tuberculosis Screening, Testing, and Treatment of US Health Care Personnel: ACOEM and NTCA Joint Task Force on Implementation of the 2019 MMWR Recommendations. J Occup Environ Med 2021; 62:e355-e369. [PMID: 32730040 DOI: 10.1097/jom.0000000000001904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
: On May 17, 2019, the US Centers for Disease Control and Prevention and National Tuberculosis Controllers Association issued new Recommendations for Tuberculosis Screening, Testing, and Treatment of Health Care Personnel, United States, 2019, updating the health care personnel-related sections of the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. This companion document offers the collective effort and experience of occupational health, infectious disease, and public health experts from major academic and public health institutions across the United States and expands on each section of the 2019 recommendations to provide clarifications, explanations, and considerations that go beyond the 2019 recommendations to answer questions that may arise and to offer strategies for implementation.
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17
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Malik AA, Farooq S, Jaswal M, Khan H, Nasir K, Fareed U, Shahbaz S, Amanullah F, Safdar N, Khan AJ, Keshavjee S, Becerra MC, Hussain H. Safety and feasibility of 1 month of daily rifapentine plus isoniazid to prevent tuberculosis in children and adolescents: a prospective cohort study. THE LANCET CHILD & ADOLESCENT HEALTH 2021; 5:350-356. [PMID: 33770510 DOI: 10.1016/s2352-4642(21)00052-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Shorter regimens for tuberculosis prevention can improve completion rates and protection against developing active tuberculosis disease after tuberculosis exposure. We aimed to assess the safety and feasibility of 1 month of daily isoniazid and rifapentine (1HP) in children and adolescents in a low-resource setting in south Asia with low prevalence of HIV. METHODS This prospective cohort study was done in eight tuberculosis facilities in Karachi, Pakistan. Eligible participants were aged 2-19 years and were household contacts of patients with drug-susceptible tuberculosis infection. After clinical, radiological, and laboratory evaluation to rule out tuberculosis disease, participants were prescribed 1HP as a preventive regimen. Isoniazid was administered as 100 mg or 300 mg oral tablets and rifapentine was administered as 150 mg oral tablets. Dosing was according to participant bodyweight. The primary endpoints were the cumulative probability of a household contact completing all stages of the preventive care cascade, assessed in all eligible participants, and the proportion of household contacts completing 1HP, assessed among all those who initiated the regimen. Safety was assessed in all household contacts who initiated the 1HP regimen. FINDINGS Between Dec 21, 2019, and March 20, 2020, 1395 household contacts of 253 patients with tuberculosis were identified, including 678 household contacts who were eligible to participate. 628 (93%) completed evaluation, of whom ten (2%) had active tuberculosis disease. Of the 618 individuals eligible for tuberculosis prevention, 408 (66%) initiated 1HP, 385 (94%) of whom completed the regimen. The median duration of 1HP was 31 days (IQR 30-32) in those who completed the regimen. The cumulative probability of completing all steps of the tuberculosis prevention cascade was 58%. A girl aged 11 years developed tuberculosis disease within 6 months of completing 1HP. A boy aged 14 years developed a burning sensation during 1HP therapy and discontinued the regimen. No other adverse events were observed. INTERPRETATION 1HP can be safely and feasibly implemented as tuberculosis prevention in children and adolescents in programmatic settings. FUNDING The Global Fund to Fight AIDS, Tuberculosis and Malaria.
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Affiliation(s)
- Amyn A Malik
- Global Health Directorate, Indus Health Network, Karachi, Pakistan; Interactive Research and Development Global, Singapore; Yale School of Medicine and Yale Institute for Global Health, Yale University, New Haven, CT, USA.
| | - Saira Farooq
- Global Health Directorate, Indus Health Network, Karachi, Pakistan
| | - Maria Jaswal
- Global Health Directorate, Indus Health Network, Karachi, Pakistan
| | - Hiba Khan
- Global Health Directorate, Indus Health Network, Karachi, Pakistan
| | - Kumail Nasir
- Global Health Directorate, Indus Health Network, Karachi, Pakistan
| | - Usama Fareed
- Global Health Directorate, Indus Health Network, Karachi, Pakistan
| | - Shumail Shahbaz
- Global Health Directorate, Indus Health Network, Karachi, Pakistan
| | | | - Nauman Safdar
- Global Health Directorate, Indus Health Network, Karachi, Pakistan
| | - Aamir J Khan
- Interactive Research and Development Global, Singapore; Harvard Medical School, Boston, MA, USA; Harvard Medical School Center for Global Health Delivery, Boston, MA, USA
| | - Salmaan Keshavjee
- Harvard Medical School, Boston, MA, USA; Harvard Medical School Center for Global Health Delivery, Boston, MA, USA; Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Mercedes C Becerra
- Harvard Medical School, Boston, MA, USA; Harvard Medical School Center for Global Health Delivery, Boston, MA, USA; Partners In Health, Boston, MA, USA; Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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18
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Grijota-Camino MD, Montero N, Luque MJ, Díaz-Jurado M, Sabé N, Pérez-Recio S, Couceiro C, Muñoz L, Cruzado JM, Santin M. Tuberculosis prevention in patients undergoing kidney transplantation: A nurse-led program for screening and treatment. Transpl Infect Dis 2021; 23:e13603. [PMID: 33745229 DOI: 10.1111/tid.13603] [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: 01/26/2021] [Revised: 03/02/2021] [Accepted: 03/07/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Systematic screening for, and treatment of, latent tuberculosis (TB) infection is recommended prior to kidney transplant. However, little is known about patient compliance with, or the safety profile of, preventive therapies used in clinical practice. METHODS This was a retrospective observational study of patients who were eligible for kidney transplant and were evaluated for TB infection between January 2013 and June 2019 at the TB clinic of a tertiary care teaching hospital. All patient data were registered prospectively as part of our nurse-led program before kidney transplant. We assessed completion rates, tolerance with therapy, development of TB, and associated workload. RESULTS In total, 1568 patients were referred to our TB clinic for evaluation. Preventive therapy was given to 385 patients and completed by 340 (88.3%). Of these, 89 (23.1%) experienced some intolerance, with 27 requiring full discontinuation. After a median follow-up of 45 months (1426 patient-years), 206 (53.5%) of the treated patients received a kidney transplant; only one patient, who failed to complete treatment, developed post-transplant TB (7.01 cases per 10 000 patient-years; 95% confidence interval, 0.35-34.59). Extra nurse or medical visits were required by 268 (69.6%) patients. CONCLUSION Despite the complexity and workload generated by patients with ESRD awaiting kidney transplant, preventive therapy for TB is effective in most cases. Our experience provides important evidence on the feasibility of preventive therapy for TB before kidney transplant when delivered as part of a comprehensive nurse-led program.
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Affiliation(s)
- Maria D Grijota-Camino
- Tuberculosis Unit, Service of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute of Biomedical Research (IDIBELL), L'Hospitalet de Llobregat, Spain
| | - Núria Montero
- Service of Nephrology, Bellvitge University Hospital-Bellvitge Institute of Biomedical Research (IDIBELL), L'Hospitalet de Llobregat, Spain.,Department of Clinical Sciences, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Maria J Luque
- Tuberculosis Unit, Service of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute of Biomedical Research (IDIBELL), L'Hospitalet de Llobregat, Spain
| | - Maria Díaz-Jurado
- Service of Nephrology, Bellvitge University Hospital-Bellvitge Institute of Biomedical Research (IDIBELL), L'Hospitalet de Llobregat, Spain
| | - Núria Sabé
- Tuberculosis Unit, Service of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute of Biomedical Research (IDIBELL), L'Hospitalet de Llobregat, Spain.,Department of Clinical Sciences, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Sandra Pérez-Recio
- Tuberculosis Unit, Service of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute of Biomedical Research (IDIBELL), L'Hospitalet de Llobregat, Spain
| | - Carlos Couceiro
- Service of Nephrology, Bellvitge University Hospital-Bellvitge Institute of Biomedical Research (IDIBELL), L'Hospitalet de Llobregat, Spain.,Department of Clinical Sciences, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Laura Muñoz
- Department of Clinical Sciences, University of Barcelona, L'Hospitalet de Llobregat, Spain.,Service of Internal Medicine, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain
| | - Josep M Cruzado
- Service of Nephrology, Bellvitge University Hospital-Bellvitge Institute of Biomedical Research (IDIBELL), L'Hospitalet de Llobregat, Spain.,Department of Clinical Sciences, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Miguel Santin
- Tuberculosis Unit, Service of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute of Biomedical Research (IDIBELL), L'Hospitalet de Llobregat, Spain.,Department of Clinical Sciences, University of Barcelona, L'Hospitalet de Llobregat, Spain
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19
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Swift MD, Molella RG, Vaughn AIS, Breeher LE, Newcomb RD, Abdellatif S, Murad MH. Determinants of Latent Tuberculosis Treatment Acceptance and Completion in Healthcare Personnel. Clin Infect Dis 2021; 71:284-290. [PMID: 31552416 DOI: 10.1093/cid/ciz817] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 08/16/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND US public health strategy for eliminating tuberculosis (TB) prioritizes treatment of latent TB infection (LTBI). Healthcare personnel (HCP) are less willing to accept treatment than other populations. Little is known about factors associated with HCP LTBI therapy acceptance and completion. METHODS We conducted a retrospective chart review to identify all employees with LTBI at time of hire at a large academic medical center during a 10-year period. Personal demographics, occupational factors, and clinic visit variables were correlated with LTBI treatment acceptance and completion rates using multivariate logistic regression. RESULTS Of 470 HCP with LTBI for whom treatment was recommended, 193 (41.1%) accepted treatment, while 137 (29.1%) completed treatment. Treatment adherence was better with 4 months of rifampin than 9 months of isoniazid (95% vs 68%, P < .005). Increased age of the healthcare worker was independently associated with lower rates of treatment acceptance (odds ratio [95% confidence interval]: 0.97 [0.94-0.99] per year), as was having an occupation of clinician (0.47 [0.26-0.85]) or researcher (0.34 [0.19-0.64]). Male gender was associated with higher treatment acceptance (1.90 [1.21-2.99]). Treatment completion was associated with being from a low- (9.49 [2.06-43.73]) or medium- (8.51 [3.93-18.44]) TB-burden country. CONCLUSIONS Geographic and occupational factors affect acceptance and completion of LTBI therapy. Short-course regimens may improve adherence. Physicians, researchers, and HCP from high-TB-burden countries have lower treatment rates than other HCP. Improving LTBI treatment in HCP will require attending to cultural and occupational differences.
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Affiliation(s)
| | | | | | | | | | | | - M Hassan Murad
- Department of Medicine, Mayo Clinic, Rochester, Minnesota
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Kawatsu L, Uchimura K, Ohkado A. Trend and treatment outcomes of latent tuberculosis infection among migrant persons in Japan: retrospective analysis of Japan tuberculosis surveillance data. BMC Infect Dis 2021; 21:42. [PMID: 33422003 PMCID: PMC7796533 DOI: 10.1186/s12879-020-05712-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 12/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Screening for latent tuberculosis infection (LTBI) among migrant population has become a critical issue for many low tuberculosis (TB) burden countries. Evidence regarding effectiveness of LTBI programs are limited, however, partly because of paucity of national data on treatment outcomes for LTBI. In Japan, notification of LTBI is mandatory, and its treatment outcome is reported as part of Japan's national TB surveillance system. We thus conducted a detailed analysis of LTBI among foreign-born persons, to update the epidemiological trend of newly notified LTBI between 2007 and 2018, and to examine the treatment regimen and outcome of those notified in 2016 and 2017, focusing specifically on the potential risk factors for lost to follow-up. METHODS We extracted and analyzed the data of newly notified LTBI patients from the Japan Tuberculosis Surveillance System to examine the overall trend of notification and by age groups and modes of detection between 2007 and 2018, and the cohort data for treatment regimen and outcomes of foreign-born persons notified with LTBI in 2016 and 2017. Trends and proportions were summarized descriptively, and logistic regression analysis was conducted to identify potential risk factors for lost to follow-up. Comparisons were made with the Japan-born patients where appropriate, using chi-squared tests. RESULTS Both the number and proportion of LTBI among foreign-born persons have been constantly increasing, reaching 963 cases in 2018. Cohort analysis of the surveillance data indicated that the proportion of those on shorter regimen was higher among the foreign- than Japan-born patients (5.5% vs. 1.8%, p < 0.001). The proportion of those who have been lost to follow-up and transferred outside of Japan combined was higher among the foreign- than Japan-born patients (12.0% vs, 8.2%, p < 0.001). Risk factors for lost to follow-up were being employed on a temporal basis, and job status unknown (adjusted odds ratios 3.11 and 4.09, 95% confidence intervals 1.34-7.26 and 1.60-10.48, respectively). CONCLUSIONS Migrant population face greater risk of interrupting LTBI treatment, and interventions to improve adherence are a critical component of programmatic management of LTBI. Further studies are needed to explore the cultural and socioeconomic situation in which foreign-born persons undergo LTBI treatment in Japan.
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Affiliation(s)
- Lisa Kawatsu
- Department of Epidemiology and Clinical Research, The Research Institute of Tuberculosis, 3-1-24, Matsuyama Kiyose, Tokyo, Japan.
| | - Kazuhiro Uchimura
- Department of Epidemiology and Clinical Research, The Research Institute of Tuberculosis, 3-1-24, Matsuyama Kiyose, Tokyo, Japan
| | - Akihiro Ohkado
- Department of Epidemiology and Clinical Research, The Research Institute of Tuberculosis, 3-1-24, Matsuyama Kiyose, Tokyo, Japan
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21
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Stockbridge EL, Loethen AD, Annan E, Miller TL. Interferon gamma release assay tests are associated with persistence and completion of latent tuberculosis infection treatment in the United States: Evidence from commercial insurance data. PLoS One 2020; 15:e0243102. [PMID: 33270737 PMCID: PMC7714216 DOI: 10.1371/journal.pone.0243102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 11/13/2020] [Indexed: 11/29/2022] Open
Abstract
Background Risk-targeted testing and treatment of latent tuberculosis infection (LTBI) is a critical component of the United States’ (US) tuberculosis (TB) elimination strategy, but relatively low treatment completion rates remain a challenge. Both treatment persistence and completion may be facilitated by diagnosing LTBI using interferon gamma release assays (IGRA) rather than tuberculin skin tests (TST). Methods We used a national sample of administrative claims data to explore associations diagnostic test choice (TST, IGRA, TST with subsequent IGRA) and treatment persistence and completion in persons initiating a daily dose isoniazid LTBI treatment regimen in the US private healthcare sector between July 2011 and March 2014. Associations were analyzed with a generalized ordered logit model (completion) and a negative binomial regression model (persistence). Results Of 662 persons initiating treatment, 327 (49.4%) completed at least the 6-month regimen and 173 (26.1%) completed the 9-month regimen; 129 (19.5%) persisted in treatment one month or less. Six-month completion was least likely in persons receiving a TST (42.2%) relative to persons receiving an IGRA (55.0%) or TST then IGRA (67.2%; p = 0.001). Those receiving an IGRA or a TST followed by an IGRA had higher odds of completion compared to those receiving a TST (aOR = 1.59 and 2.50; p = 0.017 and 0.001, respectively). Receiving an IGRA or a TST and subsequent IGRA was associated with increased treatment persistence relative to TST (aIRR = 1.14 and 1.25; p = 0.027 and 0.009, respectively). Conclusions IGRA use is significantly associated with both higher levels of LTBI treatment completion and treatment persistence. These differences are apparent both when IGRAs alone were administered and when IGRAs were administered subsequent to a TST. Our results suggest that IGRAs contribute to more effective LTBI treatment and consequently individual and population protections against TB.
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Affiliation(s)
- Erica L Stockbridge
- Department of Advanced Health Analytics and Solutions, Magellan Health, Inc., Scottsdale, Arizona, United States of America.,Department of Health Behavior & Health Systems, School of Public Health, University of North Texas Health Science Center, Fort Worth, Texas, United States of America
| | - Abiah D Loethen
- Department of Advanced Health Analytics and Solutions, Magellan Health, Inc., Scottsdale, Arizona, United States of America
| | - Esther Annan
- Department of Biostatistics and Epidemiology, School of Public Health, University of North Texas Health Science Center, Fort Worth, Texas, United States of America
| | - Thaddeus L Miller
- Department of Health Behavior & Health Systems, School of Public Health, University of North Texas Health Science Center, Fort Worth, Texas, United States of America
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Stagg HR, Flook M, Martinecz A, Kielmann K, Abel Zur Wiesch P, Karat AS, Lipman MCI, Sloan DJ, Walker EF, Fielding KL. All nonadherence is equal but is some more equal than others? Tuberculosis in the digital era. ERJ Open Res 2020; 6:00315-2020. [PMID: 33263043 PMCID: PMC7682676 DOI: 10.1183/23120541.00315-2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/16/2020] [Indexed: 12/20/2022] Open
Abstract
Adherence to treatment for tuberculosis (TB) has been a concern for many decades, resulting in the World Health Organization's recommendation of the direct observation of treatment in the 1990s. Recent advances in digital adherence technologies (DATs) have renewed discussion on how to best address nonadherence, as well as offering important information on dose-by-dose adherence patterns and their variability between countries and settings. Previous studies have largely focussed on percentage thresholds to delineate sufficient adherence, but this is misleading and limited, given the complex and dynamic nature of adherence over the treatment course. Instead, we apply a standardised taxonomy - as adopted by the international adherence community - to dose-by-dose medication-taking data, which divides missed doses into 1) late/noninitiation (starting treatment later than expected/not starting), 2) discontinuation (ending treatment early), and 3) suboptimal implementation (intermittent missed doses). Using this taxonomy, we can consider the implications of different forms of nonadherence for intervention and regimen design. For example, can treatment regimens be adapted to increase the "forgiveness" of common patterns of suboptimal implementation to protect against treatment failure and the development of drug resistance? Is it reasonable to treat all missed doses of treatment as equally problematic and equally common when deploying DATs? Can DAT data be used to indicate the patients that need enhanced levels of support during their treatment course? Critically, we pinpoint key areas where knowledge regarding treatment adherence is sparse and impeding scientific progress.
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Affiliation(s)
- Helen R Stagg
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Mary Flook
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Antal Martinecz
- Department of Biology, Pennsylvania State University, University Park, PA, USA.,Center for Infectious Disease Dynamics, Huck Institutes of the Life Sciences, Pennsylvania State University, University Park, PA, USA.,Department of Pharmacy, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Karina Kielmann
- The Institute for Global Health and Development, Queen Margaret University, Musselburgh, UK
| | - Pia Abel Zur Wiesch
- Department of Biology, Pennsylvania State University, University Park, PA, USA.,Center for Infectious Disease Dynamics, Huck Institutes of the Life Sciences, Pennsylvania State University, University Park, PA, USA.,These authors contributed equally
| | - Aaron S Karat
- The Institute for Global Health and Development, Queen Margaret University, Musselburgh, UK.,TB Centre, London School of Hygiene & Tropical Medicine, London, UK.,These authors contributed equally
| | - Marc C I Lipman
- UCL Respiratory, Division of Medicine, University College London, London, UK.,Department of Respiratory Medicine, Royal Free London NHS Foundation Trust, London, UK.,These authors contributed equally
| | - Derek J Sloan
- School of Medicine, University of St Andrews, St Andrews, UK.,These authors contributed equally
| | | | - Katherine L Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Shimabuco AY, de Medeiros-Ribeiro AC, Miossi R, Bonfiglioli KR, de Moraes JCB, Gonçalves CR, Sampaio-Barros PD, Goldenstein-Schainberg C, de Souza FHC, do Prado LL, Ugolini-Lopes MR, Yuki EFVN, Bonfa E, Saad CGS. Ankylosing spondylitis and psoriatic arthritis: revisiting screening of latent tuberculosis infection and its follow-up during anti-tumor necrosis factor therapy in an endemic area. Clinics (Sao Paulo) 2020; 75:e1870. [PMID: 33146355 PMCID: PMC7561058 DOI: 10.6061/clinics/2020/e1870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 07/08/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To retrospectively evaluate the performance and distinctive pattern of latent tuberculosis (TB) infection (LTBI) screening and treatment in patients with ankylosing spondylitis (AS) and psoriatic arthritis (PsA) under anti-tumor necrosis factor (TNF) therapy and determine the relevance of re-exposure and other risk factors for TB development. METHODS A total of 135 and 83 patients with AS and PsA, respectively, were evaluated for LTBI treatment before receiving anti-TNF drugs via the tuberculin skin test (TST), chest radiography, and TB exposure history assessment. All subjects were evaluated for TB infection at 3-month intervals. RESULTS The patients with AS were more often treated for LTBI than were those with PsA (42% versus 30%, p=0.043). The former also presented a higher frequency of TST positivity (93% versus 64%, p=0.002), although they had a lower frequency of exposure history (18% versus 52%, p=0.027) and previous TB (0.7% versus 6%, p=0.03). During follow-up [median, 5.8 years; interquartile range (1QR), 2.2-9.0 years], 11/218 (5%) patients developed active TB (AS, n=7; PsA, n=4). TB re-exposure was the main cause in seven patients (64%) after 12 months of therapy (median, 21.9 months; IQR, 14.2-42.8 months) and five LTBI-negative patients. TB was identified within the first year in four patients (36.3%) (median, 5.3 months; IQR, 1.2-8.8 months), two of whom were LTBI-positive. There was no difference in the TB-free survival according to the anti-TNF drug type/class; neither synthetic drug nor prednisone use was related to TB occurrence (p>0.05). CONCLUSION Known re-exposure is the most critical factor for incident TB cases in spondyloarthritis. There are also some distinct features in AS and PsA LTBI screening, considering the higher frequency of LTBI and TST positivities in patients with AS. Annual risk reassessment taking into consideration these peculiar features and including the TST should be recommended for patients in endemic countries.
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Affiliation(s)
- Andrea Yukie Shimabuco
- Divisao de Reumatologia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, SP, BR
| | | | - Renata Miossi
- Divisao de Reumatologia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, SP, BR
| | | | | | | | | | | | | | - Leandro Lara do Prado
- Divisao de Reumatologia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, SP, BR
| | | | | | - Eloisa Bonfa
- Divisao de Reumatologia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, SP, BR
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24
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Manful A, Waller L, Katz B, Cummins J, Warkentin J, Reagon B, Shaw-Kaikai J, Zhu Y, van der Heijden YF. Gaps in the care cascade for screening and treatment of refugees with tuberculosis infection in Middle Tennessee: a retrospective cohort study. BMC Infect Dis 2020; 20:592. [PMID: 32778060 PMCID: PMC7418421 DOI: 10.1186/s12879-020-05311-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 07/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treatment of tuberculosis infection (TBI) in individuals at high risk for tuberculosis (TB) disease is a priority for TB elimination in the US. Newly arrived refugees in Middle Tennessee are screened for TBI, but factors associated with gaps in the TBI care cascade are not well characterized. METHODS We assessed the TBI care cascade from US entry to completion of treatment for refugees who resettled in Middle Tennessee from 2012 through 2016. We assessed factors associated with treatment initiation and completion using logistic regression models. RESULTS Of 6776 refugees who completed initial health screening, 1681 (25%) screened positive for TBI, 1208 were eligible for treatment, 690 started treatment, and 432 completed treatment. Male sex (Odds Ratio [OR]: 1.42; 95% Confidence Interval [CI]: 1.06, 1.89) and screening with interferon gamma release assay compared to tuberculin skin test (OR: 2.89; 95% CI: 1.59, 5.27) were associated with increased treatment initiation; living farther away from TB clinic was associated with decreased treatment initiation (OR: 0.91; 95% CI: 0.83, 0.99). Existing diabetes (OR: 7.27; 95% CI: 1.93, 27.30), receipt of influenza vaccination (OR: 1.65; 95% CI: 1.14, 2.40) and region of origin from South-Eastern or Southern Asia (ORSEAsia: 2.30; 95% CI: 1.43, 3.70; ORSAsia: 1.64; 95% CI: 1.02, 2.64) were associated with increased treatment completion. Six refugees developed TB disease after declining (n = 4) or partially completing (n = 2) TBI treatment; none who completed treatment developed TB disease. CONCLUSIONS We determined gaps in the TBI care cascade among refugees in Middle Tennessee. Further assessment of barriers to treatment initiation and completion and interventions to assist refugees are warranted to improve these gaps and prevent TB disease.
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Affiliation(s)
- Adoma Manful
- Vanderbilt University School of Medicine, Nashville, USA
| | - Leslie Waller
- Tuberculosis Elimination Program, Metro Public Health Department, Nashville, USA
| | - Ben Katz
- Tuberculosis Elimination Program, Tennessee Department of Health, Nashville, USA
| | - Jason Cummins
- Tuberculosis Elimination Program, Tennessee Department of Health, Nashville, USA
| | - Jon Warkentin
- Tuberculosis Elimination Program, Tennessee Department of Health, Nashville, USA
| | - Billy Reagon
- Tuberculosis Elimination Program, Metro Public Health Department, Nashville, USA
| | - Joanna Shaw-Kaikai
- Tuberculosis Elimination Program, Metro Public Health Department, Nashville, USA
- Vanderbilt Tuberculosis Center, Vanderbilt University School of Medicine, Nashville, USA
| | - Yuwei Zhu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, USA
| | - Yuri F van der Heijden
- Vanderbilt Tuberculosis Center, Vanderbilt University School of Medicine, Nashville, USA.
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, A2200 Medical Center North, 1161 21st Avenue South, Nashville, TN, 37232, USA.
- The Aurum Institute, Johannesburg, South Africa.
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25
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Abstract
Rationale: U.S. health departments routinely conduct post-arrival evaluation of immigrants and refugees at risk for tuberculosis (TB), but this important intervention has not been thoroughly studied.Objectives: To assess outcomes of the post-arrival evaluation intervention.Methods: We categorized at-risk immigrants and refugees as having had recent completion of treatment for pulmonary TB disease overseas (including in Mexico and Canada); as having suspected TB disease (chest radiograph/clinical symptoms suggestive of TB) but negative culture results overseas; or as having latent TB infection (LTBI) diagnosed overseas. Among 2.1 million U.S.-bound immigrants and refugees screened for TB overseas during 2013-2016, 90,737 were identified as at risk for TB. We analyzed a national data set of these at-risk immigrants and refugees and calculated rates of TB disease for those who completed post-arrival evaluation.Results: Among 4,225 persons with recent completion of treatment for pulmonary TB disease overseas, 3,005 (71.1%) completed post-arrival evaluation within 1 year of arrival; of these, TB disease was diagnosed in 22 (732 cases/100,000 persons), including 4 sputum culture-positive cases (133 cases/100,000 persons), 13 sputum culture-negative cases (433 cases/100,000 persons), and 5 cases with no reported sputum-culture results (166 cases/100,000 persons). Among 55,938 with suspected TB disease but negative culture results overseas, 37,089 (66.3%) completed post-arrival evaluation; of these, TB disease was diagnosed in 597 (1,610 cases/100,000 persons), including 262 sputum culture-positive cases (706 cases/100,000 persons), 281 sputum culture-negative cases (758 cases/100,000 persons), and 54 cases with no reported sputum-culture results (146 cases/100,000 persons). Among 30,574 with LTBI diagnosed overseas, 18,466 (60.4%) completed post-arrival evaluation; of these, TB disease was diagnosed in 48 (260 cases/100,000 persons), including 11 sputum culture-positive cases (60 cases/100,000 persons), 22 sputum culture-negative cases (119 cases/100,000 persons), and 15 cases with no reported sputum-culture results (81 cases/100,000 persons). Of 21,714 persons for whom treatment for LTBI was recommended at post-arrival evaluation, 14,977 (69.0%) initiated treatment and 8,695 (40.0%) completed treatment.Conclusions: Post-arrival evaluation of at-risk immigrants and refugees can be highly effective. To optimize the yield and impact of this intervention, strategies are needed to improve completion rates of post-arrival evaluation and treatment for LTBI.
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26
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Jo Y, Shrestha S, Gomes I, Marks S, Hill A, Asay G, Dowdy D. Model-Based Cost-Effectiveness of State-level Latent Tuberculosis Interventions in California, Florida, New York and Texas. Clin Infect Dis 2020; 73:e3476-e3482. [PMID: 32584968 DOI: 10.1093/cid/ciaa857] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 06/19/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Targeted testing and treatment (TTT) for latent tuberculosis infection (LTBI) is a recommended strategy to accelerate TB reductions and further tuberculosis elimination in the United States (US). Evidence on cost-effectiveness of TTT for key populations can help advance this goal. METHODS We used a model of TB transmission to estimate the numbers of individuals who could be tested by interferon-γ release assay (IGRA) and treated for LTBI with three months of self-administered rifapentine and isoniazid (3HP) under various TTT scenarios. Specifically, we considered rapidly scaling up TTT among people who are non-US-born, diabetic, HIV-positive, homeless or incarcerated in California, Florida, New York, and Texas - states where more than half of US TB cases occur. We projected costs (from the healthcare system perspective, in 2018 dollars), thirty-year reductions in TB incidence, and incremental cost effectiveness (cost per quality-adjusted life year [QALY] gained) for TTT in each modeled population. RESULTS The projected cost effectiveness of TTT differed substantially by state and population, while the health impact (number of TB cases averted) was consistently greatest among the non-US-born. TTT was most cost-effective among persons living with HIV (from $2,828/QALY gained in Florida to $11,265/QALY gained in New York) and least cost-effective among people with diabetes (from $223,041/QALY gained in California to $817,753 /QALY in New York). CONCLUSIONS The modeled cost-effectiveness of TTT for LTBI varies across states but was consistently greatest among people living with HIV, moderate among people who are non-US-born, incarcerated, or homeless, and least cost-effective among people living with diabetes.
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Affiliation(s)
- Youngji Jo
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sourya Shrestha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Isabella Gomes
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Suzanne Marks
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Andrew Hill
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Garrett Asay
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Serum proteomics of active tuberculosis patients and contacts reveals unique processes activated during Mycobacterium tuberculosis infection. Sci Rep 2020; 10:3844. [PMID: 32123229 PMCID: PMC7052228 DOI: 10.1038/s41598-020-60753-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 02/17/2020] [Indexed: 01/24/2023] Open
Abstract
Tuberculosis (TB) is the most lethal infection among infectious diseases. The specific aim of this study was to establish panels of serum protein biomarkers representative of active TB patients and their household contacts who were either infected (LTBI) or uninfected (EMI-TB Discovery Cohort, Pontevedra Region, Spain). A TMT (Tamdem mass tags) 10plex-based quantitative proteomics study was performed in quintuplicate containing a total of 15 individual serum samples per group. Peptides were analyzed in an LC-Orbitrap Elite platform, and raw data were processed using Proteome Discoverer 2.1. A total of 418 proteins were quantified. The specific protein signature of active TB patients was characterized by an accumulation of proteins related to complement activation, inflammation and modulation of immune response and also by a decrease of a small subset of proteins, including apolipoprotein A and serotransferrin, indicating the importance of lipid transport and iron assimilation in the progression of the disease. This signature was verified by the targeted measurement of selected candidates in a second cohort (EMI-TB Verification Cohort, Maputo Region, Mozambique) by ELISA and nephelometry techniques. These findings will aid our understanding of the complex metabolic processes associated with TB progression from LTBI to active disease.
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28
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Sentís A, Vasconcelos P, Machado RS, Caylà JA, Guxens M, Peixoto V, Duarte R, Carvalho I, Carvalho C. Failure to complete treatment for latent tuberculosis infection in Portugal, 2013-2017: geographic-, sociodemographic-, and medical-associated factors. Eur J Clin Microbiol Infect Dis 2019; 39:647-656. [PMID: 31797155 DOI: 10.1007/s10096-019-03765-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 11/07/2019] [Indexed: 10/25/2022]
Abstract
There is conflicting evidence about factors associated with failure to complete treatment (FCT) for latent tuberculosis infection (LTBI). We aim to identify the geographic, sociodemographic, and medical factors associated with FCT in Portugal, highlighting the two main metropolitan areas of Porto and Lisbon. We performed a retrospective cohort study including LTBI patients that started treatment in Portugal between 2013 and 2017. We calculated adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) using multivariable logistic regression to identify geographic, sociodemographic, and medical factors associated with FCT. Data on completion of treatment were available for 15,478 of 17,144 patients (90.3%). Of those, 2132 (13.8%) failed to complete treatment. Factors associated with FCT were being older than 15 years (aOR, 1.65 (95% CI = 1.34-2.05) for those aged 16 to 29), being born abroad (aOR, 2.04 (95% CI = 1.19-3.50) for Asia; aOR, 1.57 (95% CI = 1.24-1.98) for Africa), having a chronic disease (aOR, 1.29 (95% CI = 1.04-1.60)), alcohol abuse (aOR, 2.24 (95% CI = 1.73-2.90)), and being intravenous drug user (aOR, 1.68 (95% CI = 1.05-2.68)). Three-month course treatment with isoniazid plus rifampicin was associated with decreased FCT when compared with 6- or 9-month courses of isoniazid-only (aOR, 0.59 (95% CI = 0.45-0.77)). In Lisbon metropolitan area, being born in Africa, and in Porto metropolitan area, alcohol abusing and being intravenous drug user were distinctive factors associated with FCT. Sociodemographic and medical factors associated with FCT may vary by geographical area and should be taken into account when planning interventions to improve LTBI treatment outcomes. This study reinforces that shorter course treatment for LTBI might reduce FCT.
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Affiliation(s)
- Alexis Sentís
- Directorate-General of Health, Lisbon, Portugal.,European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control, (ECDC), Stockholm, Sweden.,ISGlobal, Barcelona, Spain.,Pompeu Fabra University (UPF), Barcelona, Spain.,Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Paula Vasconcelos
- Directorate-General of Health, Lisbon, Portugal.,European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control, (ECDC), Stockholm, Sweden
| | - Rita Sá Machado
- Directorate-General of Health, Lisbon, Portugal.,European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control, (ECDC), Stockholm, Sweden
| | - Joan A Caylà
- Foundation of Tuberculosis Research Unit of Barcelona, Barcelona, Spain
| | - Mònica Guxens
- ISGlobal, Barcelona, Spain.,Pompeu Fabra University (UPF), Barcelona, Spain.,Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain.,Department of Child and Adolescent Psychiatry/Psychology, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Vasco Peixoto
- Directorate-General of Health, Lisbon, Portugal.,European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control, (ECDC), Stockholm, Sweden
| | - Raquel Duarte
- Directorate-General of Health, Lisbon, Portugal.,Public Health Science and Medical Education Department, Faculty of Medicine, University of Porto, Porto, Portugal.,EPIUnit, Institute of Public Health, University of Porto, Porto, Portugal.,Pulmonology Department, Hospital Centre of Vila Nova de Gaia/Espinho EPE, Vila Nova de Gaia, Portugal
| | | | - Carlos Carvalho
- Directorate-General of Health, Lisbon, Portugal. .,Department of Public Health, Northern Regional Health Administration, Porto, Portugal. .,Multidisciplinary Unit for Biomedical Research (UMIB), Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal.
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Tuberculosis Prevention in the Private Sector: Using Claims-Based Methods to Identify and Evaluate Latent Tuberculosis Infection Treatment With Isoniazid Among the Commercially Insured. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2019; 24:E25-E33. [PMID: 29084120 DOI: 10.1097/phh.0000000000000628] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
CONTEXT Targeted identification and treatment of people with latent tuberculosis infection (LTBI) are key components of the US tuberculosis elimination strategy. Because of recent policy changes, some LTBI treatment may shift from public health departments to the private sector. OBJECTIVES To (1) develop methodology to estimate initiation and completion of treatment with isoniazid for LTBI using claims data, and (2) estimate treatment completion rates for isoniazid regimens from commercial insurance claims. METHODS Medical and pharmacy claims data representing insurance-paid services rendered and prescriptions filled between January 2011 and March 2015 were analyzed. PARTICIPANTS Four million commercially insured individuals 0 to 64 years of age. MAIN OUTCOME MEASURES Six-month and 9-month treatment completion rates for isoniazid LTBI regimens. RESULTS There was an annual isoniazid LTBI treatment initiation rate of 12.5/100 000 insured persons. Of 1074 unique courses of treatment with isoniazid for which treatment completion could be assessed, almost half (46.3%; confidence interval, 43.3-49.3) completed 6 or more months of therapy. Of those, approximately half (48.9%; confidence interval, 44.5-53.3) completed 9 months or more. CONCLUSIONS Claims data can be used to identify and evaluate LTBI treatment with isoniazid occurring in the commercial sector. Completion rates were in the range of those found in public health settings. These findings suggest that the commercial sector may be a valuable adjunct to more traditional venues for tuberculosis prevention. In addition, these newly developed claims-based methods offer a means to gain important insights and open new avenues to monitor, evaluate, and coordinate tuberculosis prevention.
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Lal A, Al Hammadi A, Rapose A. Latent Tuberculosis Infection: Treatment Initiation and Completion Rates in Persons Seeking Immigration and Health Care Workers. Am J Med 2019; 132:1353-1355. [PMID: 31153865 DOI: 10.1016/j.amjmed.2019.04.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/02/2019] [Accepted: 04/20/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND We assessed the factors associated with initiation and completion rates of latent tuberculosis (TB) infection treatment in persons evaluated at an infectious diseases outpatient clinic in central Massachusetts. The Centers for Disease Control and Prevention (CDC) estimates that there may be up to 14 million persons in the United States with a latent TB infection. The risk of developing active TB in these persons can range from 5% to 15%. Hence, treatment of latent TB infection is an important aspect of any plan attempting to eradicate TB from the United States. METHODS We performed a retrospective chart review of patients referred to our outpatient infectious diseases clinic from December 2006 to October 2010. RESULTS Overall treatment initiation and completion rates were 76% and 68%, respectively, in our cohort. Two factors that were statistically significant for higher rates of treatment completion were 4 or more follow-up visits during the course of treatment (P < 0.001) and persons seeking immigration (PSI) to the United States (P < 0.02). Rate of treatment refusal was higher in health care workers as compared to workers not in health care (35% vs 13%, P = 0.004, 95% confidence interval [CI]: 1.38-4.91). CONCLUSION Our study reveals findings not previously reported in the US literature. We noted a high rate of treatment completion in persons seeking immigration to the United States. The second unique observation is the higher treatment completion rates in persons with 4 or more follow-up visits. We suggest that an emphasis on at least 4 follow-up visits can be an intervention that could improve the overall rates of treatment completion.
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Affiliation(s)
- Amos Lal
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, Mass.
| | - Ahmed Al Hammadi
- University of Texas Health Science Center, Houston-McGovern Medical School, Houston
| | - Alwyn Rapose
- Division of Infectious Diseases, Reliant Medical Group, Worcester, Mass; Assistant Professor of Clinical Medicine, University of Massachusetts, Worcester
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Godoy P, Alsedà M. Vigilancia de los contactos en la tuberculosis: ¿cómo podemos mejorar la estrategia? Enferm Infecc Microbiol Clin 2019; 37:493-495. [DOI: 10.1016/j.eimc.2019.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 04/30/2019] [Indexed: 10/25/2022]
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Greenaway C, Pareek M, Abou Chakra CN, Walji M, Makarenko I, Alabdulkarim B, Hogan C, McConnell T, Scarfo B, Christensen R, Tran A, Rowbotham N, van der Werf MJ, Noori T, Pottie K, Matteelli A, Zenner D, Morton RL. The effectiveness and cost-effectiveness of screening for latent tuberculosis among migrants in the EU/EEA: a systematic review. ACTA ACUST UNITED AC 2019; 23. [PMID: 29637889 PMCID: PMC5894253 DOI: 10.2807/1560-7917.es.2018.23.14.17-00543] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Migrants account for a large and growing proportion of tuberculosis (TB) cases in low-incidence countries in the European Union/European Economic Area (EU/EEA) which are primarily due to reactivation of latent TB infection (LTBI). Addressing LTBI among migrants will be critical to achieve TB elimination. Methods: We conducted a systematic review to determine effectiveness (performance of diagnostic tests, efficacy of treatment, uptake and completion of screening and treatment) and a second systematic review on cost-effectiveness of LTBI screening programmes for migrants living in the EU/EEA. Results: We identified seven systematic reviews and 16 individual studies that addressed our aims. Tuberculin skin tests and interferon gamma release assays had high sensitivity (79%) but when positive, both tests poorly predicted the development of active TB (incidence rate ratio: 2.07 and 2.40, respectively). Different LTBI treatment regimens had low to moderate efficacy but were equivalent in preventing active TB. Rifampicin-based regimens may be preferred because of lower hepatotoxicity (risk ratio = 0.15) and higher completion rates (82% vs 69%) compared with isoniazid. Only 14.3% of migrants eligible for screening completed treatment because of losses along all steps of the LTBI care cascade. Limited economic analyses suggest that the most cost-effective approach may be targeting young migrants from high TB incidence countries. Discussion: The effectiveness of LTBI programmes is limited by the large pool of migrants with LTBI, poorly predictive tests, long treatments and a weak care cascade. Targeted LTBI programmes that ensure high screening uptake and treatment completion will have greatest individual and public health benefit.
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Affiliation(s)
- Christina Greenaway
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada.,Division of Infectious Diseases, Jewish General Hospital, McGill University, Montreal, Canada
| | - Manish Pareek
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, United Kingdom
| | | | - Moneeza Walji
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | - Iuliia Makarenko
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | - Balqis Alabdulkarim
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | - Catherine Hogan
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada.,Division of Infectious Diseases, Jewish General Hospital, McGill University, Montreal, Canada
| | - Ted McConnell
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | - Brittany Scarfo
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | - Robin Christensen
- Department of Rheumatology, Odense University Hospital, Denmark.,Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Anh Tran
- National Health and Medical Research Council, NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Nick Rowbotham
- National Health and Medical Research Council, NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | | | - Teymur Noori
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - Kevin Pottie
- Bruyere Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Alberto Matteelli
- Clinic of Infectious and Tropical Diseases, University of Brescia and Brescia Spedali Civili General Hospital, World Health Organization Collaborating Centre for TB/HIV and TB Elimination, Brescia, Italy
| | - Dominik Zenner
- Department of Infection and Population Health, University College London, London, United Kingdom.,Respiratory Diseases Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom
| | - Rachael L Morton
- National Health and Medical Research Council, NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
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Villa S, Codecasa LR, Faccini M, Pontello MM, Ferrarese M, Castellotti PF, Senatore S, Lamberti A, Mazzola E, Perno CF, Campisi D, Saporiti M, Raviglione MC. Tuberculosis among asylum seekers in Milan, Italy: epidemiological analysis and evaluation of interventions. Eur Respir J 2019; 54:13993003.00896-2019. [DOI: 10.1183/13993003.00896-2019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 07/25/2019] [Indexed: 12/13/2022]
Abstract
In countries of the European Union, tuberculosis (TB) mainly affects marginalised people, including asylum seekers. Migratory flows from high-incidence countries to Italy have increased up to 2017, posing challenges to the national health system. This study sought to assess TB and latent TB infection (LTBI) prevalence among asylum seekers in Milan during the biennium 2016–2017 and to evaluate interventions in place.A two-level active surveillance and screening system was developed for both TB and LTBI. Asylum seekers underwent an initial screening with a tuberculin skin test (TST) and a questionnaire at the receiving sites. At the Regional TB Reference Centre, those with a positive result underwent chest radiography. People aged <35 years with negative chest radiography results underwent further testing by interferon-γ release assay. If results of the assay were positive, LTBI treatment was offered. TB and LTBI prevalence were compared with literature data.A total of 5324 asylum seekers, mostly young (10–39 years; 98%), male (84%) and from sub-Saharan Africa (69%), were enrolled in the study. 69 active TB cases were diagnosed and 863 LTBI-positive individuals were detected. TB prevalence was high (1236 per 100 000 population) and LTBI prevalence was 28%. Despite losses (41%) during the transition from initial screening sites and the diagnostic centre, a good TB cure rate (84%) and optimal LTBI treatment completion (94%) were achieved.Our study shows that TB incidence is high among asylum seekers in Milan and that well-coordinated screening measures are critical for early diagnosis and treatment. It also proves that rolling out successful at-scale interventions for both prophylaxis and disease management is feasible.
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Sumner T, Scriba TJ, Penn-Nicholson A, Hatherill M, White RG. Potential population level impact on tuberculosis incidence of using an mRNA expression signature correlate-of-risk test to target tuberculosis preventive therapy. Sci Rep 2019; 9:11126. [PMID: 31366947 PMCID: PMC6668474 DOI: 10.1038/s41598-019-47645-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 07/02/2019] [Indexed: 01/16/2023] Open
Abstract
Achieving the WHO End-Tuberculosis (TB) targets requires approaches to prevent progression to TB among individuals with Mycobacterium tuberculosis (M.tb) infection. Effective preventive therapy (PT) exists, but current tests have low specificity for identifying who, among those infected, is at risk of developing TB. Using mathematical models, we assessed the potential population-level impact on TB incidence of using a new more specific mRNA expression signature (COR) to target PT among HIV-uninfected adults in South Africa. We compared the results to the use of the existing interferon-γ release assay (IGRA). With annual screening coverage of 30% COR-targeted PT could reduce TB incidence in 2035 by 20% (95% CI 15-27). With the same coverage, IGRA-targeted PT could reduce TB incidence by 39% (31-48) but would require greater use of PT resulting in a higher number needed to treat per TB case averted (COR: 49 (29-77); IGRA: 84 (59-123)). The relative differences between COR and IGRA were not sensitive to screening coverage. COR-targeted PT could contribute to reducing total TB burden in high incidence countries like South Africa by allowing more efficient targeting of treatment. To maximise impact, COR-like tests may be best utilised in the highest burden regions, or sub-populations, within these countries.
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Affiliation(s)
- Tom Sumner
- TB Modelling Group, TB Centre, Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom.
| | - Thomas J Scriba
- South African Tuberculosis Vaccine Initiative, Division of Immunology, Department of Pathology and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Adam Penn-Nicholson
- South African Tuberculosis Vaccine Initiative, Division of Immunology, Department of Pathology and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Mark Hatherill
- South African Tuberculosis Vaccine Initiative, Division of Immunology, Department of Pathology and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Richard G White
- TB Modelling Group, TB Centre, Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Spruijt I, Erkens C, Suurmond J, Huisman E, Koenders M, Kouw P, Toumanian S, Cobelens F, van den Hof S. Implementation of latent tuberculosis infection screening and treatment among newly arriving immigrants in the Netherlands: A mixed methods pilot evaluation. PLoS One 2019; 14:e0219252. [PMID: 31260502 PMCID: PMC6602457 DOI: 10.1371/journal.pone.0219252] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 06/19/2019] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION To reach pre-elimination levels of tuberculosis (TB) incidence in the Netherlands, prevention of TB among immigrants through diagnosis and treatment of latent TB infection (LTBI) is needed. We studied the feasibility of a LTBI screening and treatment program among newly arriving immigrants for national implementation. METHODS We used mixed methods to evaluate the implementation of LTBI screening and treatment in five Public Health Services (PHS) among immigrants from countries with a TB incidence >50/100,000 population. We used Poisson regression models with robust variance estimators to assess factors associated with LTBI diagnosis and LTBI treatment initiation and reported reasons for not initiating or completing LTBI treatment. We interviewed five PHS teams using a semi-structured method to identify enhancing and impeding factors for LTBI screening and treatment. RESULTS We screened 566 immigrants; 94 (17%) were diagnosed with LTBI, of whom 49 (52%) initiated and 34 (69%) completed LTBI treatment. LTBI diagnosis was associated with male gender, higher age group, higher TB incidence in the country of origin and lower level of education. Treatment initiation was associated with PHS (ranging from 29% to 86%), lower age group, longer intended duration of stay in the Netherlands, and lower level of education. According to TB physicians, clients and their consulted physicians in the home country lacked awareness about benefits of LTBI treatment. Furthermore, TB physicians questioned the individual and public health benefit of clients who return to their country of origin within the foreseeable future. CONCLUSIONS Doubt of physicians in both host country and country of origin about individual and public health benefits of LTBI screening and treatment of immigrants hampered treatment initiation: the high initiation proportion in one PHS shows that if TB physicians are committed, the LTBI treatment uptake can be higher.
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Affiliation(s)
- Ineke Spruijt
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | - Connie Erkens
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | - Jeanine Suurmond
- Department of Public Health, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Erik Huisman
- Department tuberculosis control, Public Health Service Haaglanden, The Hague, The Netherlands
| | - Marga Koenders
- Department tuberculosis control, Public Health Service Gelderland Zuid, Nijmegen, The Netherlands
| | - Peter Kouw
- Department tuberculosis control, Public Health Service Amsterdam, Amsterdam, The Netherlands
| | - Sophie Toumanian
- Department tuberculosis control, Public Health Service Twente, Enschede, The Netherlands
| | - Frank Cobelens
- Department of Global Health and Amsterdam Institute for Global Health and Development, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Onwubiko U, Wall K, Sales RM, Holland DP. Using Directly Observed Therapy (DOT) for latent tuberculosis treatment - A hit or a miss? A propensity score analysis of treatment completion among 274 homeless adults in Fulton County, GA. PLoS One 2019; 14:e0218373. [PMID: 31226132 PMCID: PMC6588273 DOI: 10.1371/journal.pone.0218373] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 06/02/2019] [Indexed: 01/06/2023] Open
Abstract
Latent tuberculosis infection (LTBI) treatment in persons at increased risk of disease progression is a key strategy with the strong potential to increase rate of tuberculosis (TB) decline in the United States. However, LTBI treatment in homeless persons, a population at high-risk of active TB disease, is usually associated with poor adherence. We describe the impact of using directly observed treatment (DOT) versus self-administered treatments (SAT) as an adherence-improving intervention to administer four months of daily rifampin regimen for LTBI treatment among homeless adults in Atlanta. Retrospective analysis of clinical care data on 274 homeless persons who initiated daily rifampin treatment for LTBI treatment at a county health department between January 2014 and December 2016 was performed. To reduce bias from non-random assignment of treatment, an inverse probability of treatment weighted (IPTW) logistic regression model was used to assess the effect of treatment type on treatment completion. Subgroup analyses were performed to assess heterogeneity of treatment effect on LTBI completion. Of 274 LTBI treatment initiators, 177 (65%) completed treatment [DOT 118/181 (65%), SAT 59/93 (63%)]. In the fully adjusted and weighted analysis, the odds of completing LTBI treatment on DOT was 40% higher than the odds of completing treatment by SAT [adjusted odds ratio (95% CI), aOR: 1.40 (1.07, 1.82), p = 0.014]. The unstable nature of homeless persons’ lifestyle makes LTBI treatment difficult for many reasons. Our study lends support to the use of DOT to improve LTBI treatment completion among subgroups of homeless persons on treatment with daily rifampin.
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Affiliation(s)
- Udodirim Onwubiko
- Medical and Preventive Services, Fulton County Board of Health, Atlanta, Georgia, United States of America
- * E-mail:
| | - Kristin Wall
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Rose-Marie Sales
- Tuberculosis Program, Georgia Department of Public Health, Atlanta, Georgia, United States of America
| | - David P. Holland
- Medical and Preventive Services, Fulton County Board of Health, Atlanta, Georgia, United States of America
- Division of Infectious Diseases, School of Medicine, Emory University, Atlanta, Georgia, United States of America
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Collins JM, Onwubiko U, Holland DP. QuantiFERON-TB Gold Versus Tuberculin Screening and Care Retention Among Persons Experiencing Homelessness: Georgia, 2015-2017. Am J Public Health 2019; 109:1028-1033. [PMID: 31095412 DOI: 10.2105/ajph.2019.305069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To characterize the cascade of care for latent tuberculosis infection (LTBI) in persons experiencing homelessness (PEH) and evaluate the effect of screening by QuantiFERON-TB Gold (QFT) versus tuberculin skin test (TST). Methods. We performed a retrospective cohort study of all PEH screened for LTBI by QFT and TST from May 2015 to April 2017 in Fulton County, Georgia. Results. There were 3504 PEH screened by QFT and 5509 by TST, with 2925 TSTs administered on site at community shelters and 2584 at the health department. More valid test results were obtained in those screened by QFT (99.0% vs 69.0%; P < .001) because of low return rates for reading in both TST arms. For tests administered on site, testing by QFT versus TST improved retention in care with significantly more estimated LTBI cases following up for a medical examination (67.8% vs 51.0%; P < .001) and starting LTBI treatment (58.4% vs 39.8%; P < .001). Conclusions. A QFT-based screening strategy in PEH improved diagnosis and retention in care for new LTBI cases compared with TST and may be an effective strategy to limit progression to active tuberculosis.
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Affiliation(s)
- Jeffrey M Collins
- Jeffrey M. Collins and David P. Holland are with the School of Medicine, Emory University, Atlanta, GA. Udodirim Onwubiko and David P. Holland are with the Fulton County Board of Health, Atlanta
| | - Udodirim Onwubiko
- Jeffrey M. Collins and David P. Holland are with the School of Medicine, Emory University, Atlanta, GA. Udodirim Onwubiko and David P. Holland are with the Fulton County Board of Health, Atlanta
| | - David P Holland
- Jeffrey M. Collins and David P. Holland are with the School of Medicine, Emory University, Atlanta, GA. Udodirim Onwubiko and David P. Holland are with the Fulton County Board of Health, Atlanta
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Nwana N, Marks SM, Lan E, Chang AH, Holcombe M, Morris SB. Treatment of latent Mycobacterium tuberculosis infection with 12 once weekly directly-observed doses of isoniazid and rifapentine among persons experiencing homelessness. PLoS One 2019; 14:e0213524. [PMID: 30865724 PMCID: PMC6415837 DOI: 10.1371/journal.pone.0213524] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 02/24/2019] [Indexed: 12/22/2022] Open
Abstract
Objectives To investigate treatment outcomes and associated characteristics of persons experiencing homelessness who received 12-weekly doses of directly observed isoniazid and rifapentine (3HP/DOT) treatment for latent TB infection (LTBI). Methods Among homeless persons treated with 3HP/DOT during July 2011 –June 2015 in 11 U.S. TB programs, we conducted descriptive analyses of observational data, and identified associations between sociodemographic factors and treatment outcomes. Qualitative interviews were conducted to understand programmatic experiences. Results Of 393 persons experiencing homelessness (median age: 50 years; range: 13–74 years), 301 (76.6%) completed treatment, 55 (14.0%) were lost to follow-up, 18 (4.6%) stopped because of an adverse event (AE), and 19 (4.8%) stopped after relocations or refusing treatment. Eighty-one (20.6%) had at least one AE. Persons aged ≥65 were more likely to discontinue treatment than persons aged 31–44 years. Programs reported difficulty in following up with persons experiencing homelessness because of relocations, mistrust, and alcohol or drug use. Conclusions This study demonstrates the feasibility of administering the 3HP/DOT LTBI regimen to persons experiencing homelessness, a high-risk population.
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Affiliation(s)
- Nwabunie Nwana
- ORISE Research Participation Program at Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Suzanne M Marks
- Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Edward Lan
- Los Angeles County Department of Public Health Tuberculosis Control Program, Los Angeles, California, United States of America
| | - Alicia H Chang
- Los Angeles County Department of Public Health Tuberculosis Control Program, Los Angeles, California, United States of America
| | - Michael Holcombe
- Mississippi State Department of Health Tuberculosis Program, Jackson, Mississippi, United States of America
| | - Sapna Bamrah Morris
- Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Mateos J, Estévez O, González-Fernández Á, Anibarro L, Pallarés Á, Reljic R, Gallardo JM, Medina I, Carrera M. High-resolution quantitative proteomics applied to the study of the specific protein signature in the sputum and saliva of active tuberculosis patients and their infected and uninfected contacts. J Proteomics 2019; 195:41-52. [PMID: 30660769 DOI: 10.1016/j.jprot.2019.01.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/05/2018] [Accepted: 01/13/2019] [Indexed: 12/11/2022]
Abstract
Our goal was to establish panels of protein biomarkers that are characteristic of patients with microbiologically confirmed pulmonary tuberculosis (TB) and their contacts, including latent TB-infected (LTBI) and uninfected patients. Since the first pathogen-host contact occurs in the oral and nasal passages the saliva and sputum were chosen as the biological fluids to be studied. Quantitative shotgun proteomics was performed using a LTQ-Orbitrap-Elite platform. For active TB patients, both fluids exhibited a specific accumulation of proteins that were related to complement activation, inflammation and modulation of immune response. In the saliva of TB patients, a decrease of in proteins related to glucose and lipid metabolism was detected. In contrast, the sputum of uninfected contacts presented a specific proteomic signature that was composed of proteins involved in the perception of bitter taste, defense against pathogens and innate immune response, suggesting that those are key events during the initial entry of the pathogen in the host. SIGNIFICANCE: This is the first study to compare the saliva and sputum from active TB patients and their contacts. Our findings strongly suggest that TB patients show not only an activation of processes that are related to complement activation and modulation of inflammation but also an imbalance in carbohydrate and lipid metabolism. In addition, those individuals who do not get infected after direct exposure to the pathogen display a typical proteomic signature in the sputum, which is a reflection of the secretion from the nasal and oral mucosa, the first immunological barriers that M. tuberculosis encounters in the host. Thus, this result indicates the importance of the processes related to the innate immune response in fighting the initial events of the infection.
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Affiliation(s)
- Jesús Mateos
- Spanish National Research Council (CSIC), Vigo, Pontevedra, Spain.
| | - Olivia Estévez
- Biomedical Research Centre (CINBIO), Galician Singular Center of Research, Galicia Sur Health Research Institute (IIS-GS), University of Vigo, Vigo, Pontevedra, Spain
| | - África González-Fernández
- Biomedical Research Centre (CINBIO), Galician Singular Center of Research, Galicia Sur Health Research Institute (IIS-GS), University of Vigo, Vigo, Pontevedra, Spain
| | - Luis Anibarro
- Biomedical Research Centre (CINBIO), Galician Singular Center of Research, Galicia Sur Health Research Institute (IIS-GS), University of Vigo, Vigo, Pontevedra, Spain; Tuberculosis Unit, Infectious Diseases, Internal Medicine Service, Complexo Hospitalario Universitario de Pontevedra, Galicia Sur Health Research Institute (IIS-GS), Pontevedra, Spain; Mycobacterial Infections Study Group (GEIM) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), Madrid, Spain
| | - Ángeles Pallarés
- Tuberculosis Unit, Infectious Diseases, Internal Medicine Service, Complexo Hospitalario Universitario de Pontevedra, Galicia Sur Health Research Institute (IIS-GS), Pontevedra, Spain
| | | | - José M Gallardo
- Spanish National Research Council (CSIC), Vigo, Pontevedra, Spain
| | - Isabel Medina
- Spanish National Research Council (CSIC), Vigo, Pontevedra, Spain
| | - Mónica Carrera
- Spanish National Research Council (CSIC), Vigo, Pontevedra, Spain.
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Rosales-Klintz S, Bruchfeld J, Haas W, Heldal E, Houben RM, van Kessel F, Mandelbaum M, Matteelli A, Migliori GB, Oordt-Speets A, Solovic I, Vašáková M, Verver S, de Vlas SJ, Vonk Noordegraaf-Schouten MJ, de Vries G, Zenner D, van der Werf MJ. Guidance for programmatic management of latent tuberculosis infection in the European Union/European Economic Area. Eur Respir J 2019; 53:53/1/1802077. [DOI: 10.1183/13993003.02077-2018] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 11/09/2018] [Indexed: 11/05/2022]
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Lambert LA, Katz D, Feng PJ, Djojonegoro BM, Fair E, Jasuja S, Marantz S, Horsburgh CR, Ho C. Impact of Choice of Test for Latent Tuberculosis Infection on Treatment Acceptance and Completion. Microbiol Insights 2018; 11:1178636118811311. [PMID: 30505150 PMCID: PMC6259069 DOI: 10.1177/1178636118811311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 10/14/2018] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The aim of this study is to assess whether choice of test for tuberculosis (TB) infection affects decisions to accept and complete treatment among contacts to TB cases. METHODS Retrospective study is conducted in which TB contacts, ⩾15 years old during 2005 and 2009, were tested for infection with either a tuberculin skin test (TST) or an interferon-gamma release assay test, the QuantiFERON-TB Gold In-Tube (QFT-GIT). RESULTS Of 658 persons with valid test results, 185 (28%) had positive results, including 128 of 406 (32%) who had TST and 57 of 252 (23%) who received QFT-GIT. Treatment acceptance was 43 of 57 (75%) among QFT-GIT-positive and 97 of 128 (76%) among TST-positive persons (risk ratio [RR] = 1.0, 95% confidence interval [CI], 0.83-1.2). Treatment completion was 56% among QFT-GIT-positive (32 of 57) and 59% (75 of 128) among TST-positive persons (RR = 0.96, 95% CI, 0.73-1.26). DISCUSSION Our study showed no difference in proportions of TB contacts ⩾15 years old with positive TST results who accepted or completed LTBI treatment compared with those with positive QFT-GIT results. Future studies should include high-risk persons with no known TB exposure, who constitute the main reservoir for TB cases in the United States.
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Affiliation(s)
- Lauren A Lambert
- Centers for Disease Control and Prevention, Division of TB Elimination Atlanta, GA, USA
| | - Dolly Katz
- Centers for Disease Control and Prevention, Division of TB Elimination Atlanta, GA, USA
| | - Pei-Jean Feng
- Centers for Disease Control and Prevention, Division of TB Elimination Atlanta, GA, USA
| | | | - Elizabeth Fair
- Francis J. Curry National TB Center, San Francisco, CA, USA
| | - Supriya Jasuja
- Respiratory Health Association, Cook County Department of Public Health, Chicago, IL, USA
| | - Susan Marantz
- Respiratory Health Association, Cook County Department of Public Health, Chicago, IL, USA
| | | | - Christine Ho
- Centers for Disease Control and Prevention, Division of TB Elimination Atlanta, GA, USA
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42
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Milinkovic DA, Birch S, Scott F, Newbold KB, Hopkins J, Saffie M, Essue BM. Low prioritization of latent tuberculosis infection-A systemic barrier to tuberculosis control: A qualitative study in Ontario, Canada. Int J Health Plann Manage 2018; 34:384-395. [PMID: 30402949 DOI: 10.1002/hpm.2670] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/28/2018] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Eliminating tuberculosis (TB) in low-incidence countries is an important global health priority, and Canada has committed to achieve this goal. The elimination of TB in low-incidence countries requires effective management and treatment of latent tuberculosis infection (LTBI). This study aimed to understand and describe the system-level barriers to LTBI treatment for immigrant populations in the Greater Toronto and Hamilton Area, Ontario, Canada. METHODS A qualitative study that used purposive sampling to recruit and interview health system advisors and planners (n = 10), providers (n = 13), and clients of LTBI health services (n = 9). Data were recorded, transcribed verbatim, and analyzed using content analysis. RESULTS Low prioritization of LTBI was an overarching theme that impacted four dimensions of LTBI care: management, service delivery, health literacy, and health care access. These factors explained, in part, inequities in the system that were linked to variations in health care quality and health care access. While some planners and providers at the local level were attempting to prioritize LTBI care, there was no clear pathway for information sharing. CONCLUSIONS This multiperspective study identified barriers beyond the typical socioeconomic determinants and highlighted important upstream factors that hinder treatment initiation and adherence. Addressing these factors is critical if Canada is to meet the WHO's global call to eradicate TB in all low incidence settings.
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Affiliation(s)
- Deborah A Milinkovic
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Canada
| | - Stephen Birch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Centre for the Business and Economics of Health, University of Queensland, Brisbane, Australia.,Centre for Health Economics, University of Manchester, Manchester, UK
| | - Fran Scott
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Canada
| | - K Bruce Newbold
- School of Geography and Earth Sciences (SGES), McMaster University, Hamilton, Canada
| | - Jessica Hopkins
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Region of Peel Public Health, Mississauga, Canada
| | - Muntasir Saffie
- Division of Respirology, McMaster University, Hamilton, Canada
| | - Beverley M Essue
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Canada.,Menzies Centre for Health Policy, University of Sydney, Sydney, Australia
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43
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Jiménez-Fuentes MÁ, Milà Augé C, Solsona Peiró J, de Souza-Galvão ML. Tratamiento de la infección tuberculosa latente en una unidad clínica de tuberculosis. Arch Bronconeumol 2018; 54:484-486. [DOI: 10.1016/j.arbres.2018.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 01/10/2018] [Accepted: 01/11/2018] [Indexed: 10/17/2022]
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44
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Cho KS. Tuberculosis control in the Republic of Korea. Epidemiol Health 2018; 40:e2018036. [PMID: 30081621 PMCID: PMC6335497 DOI: 10.4178/epih.e2018036] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 08/02/2018] [Indexed: 11/09/2022] Open
Abstract
The incidence and mortality rates of tuberculosis (TB) in the Republic of Korea are 77 and 5.2 per 100,000 people, respectively (2016), which are the highest among the member countries of the Organization for Economic Cooperation and Development. Recently, the incidence of TB among teens and individuals in their 20s in the Republic of Korea decreased significantly. The decrease is largely attributed to the TB screening and contact investigation efforts targeting schools over the past few years. However, the incidence of TB among elderly individuals remains high, and it is even increasing compared to that in the past 10 years. Older individuals account for 42% of all TB cases and 82% of TB-related deaths. The success rate of TB treatment in the Republic of Korea has gradually increased due to various programs, such as control of non-compliance, insurance coverage for TB diagnosis and treatment, and TB public-private mix models. This study suggests that policy makers should focus their efforts on policies that prioritize a significant reduction in the incidence of TB based on the 2nd National Strategic Plan for Tuberculosis Control (2018-2022).
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Affiliation(s)
- Kyung Sook Cho
- Division of Social Services Projects, Office of Social Welfare Policy, Ministry of Health and Welfare, Sejong, Korea
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45
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Incipient and Subclinical Tuberculosis: a Clinical Review of Early Stages and Progression of Infection. Clin Microbiol Rev 2018; 31:31/4/e00021-18. [PMID: 30021818 DOI: 10.1128/cmr.00021-18] [Citation(s) in RCA: 293] [Impact Index Per Article: 48.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Tuberculosis (TB) is the leading infectious cause of mortality worldwide, due in part to a limited understanding of its clinical pathogenic spectrum of infection and disease. Historically, scientific research, diagnostic testing, and drug treatment have focused on addressing one of two disease states: latent TB infection or active TB disease. Recent research has clearly demonstrated that human TB infection, from latent infection to active disease, exists within a continuous spectrum of metabolic bacterial activity and antagonistic immunological responses. This revised understanding leads us to propose two additional clinical states: incipient and subclinical TB. The recognition of incipient and subclinical TB, which helps divide latent and active TB along the clinical disease spectrum, provides opportunities for the development of diagnostic and therapeutic interventions to prevent progression to active TB disease and transmission of TB bacilli. In this report, we review the current understanding of the pathogenesis, immunology, clinical epidemiology, diagnosis, treatment, and prevention of both incipient and subclinical TB, two emerging clinical states of an ancient bacterium.
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Dobler CC, Fox GJ, Douglas P, Viney KA, Ahmad Khan F, Temesgen Z, Marais BJ. Screening for tuberculosis in migrants and visitors from high-incidence settings: present and future perspectives. Eur Respir J 2018; 52:13993003.00591-2018. [PMID: 29794133 DOI: 10.1183/13993003.00591-2018] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 05/17/2018] [Indexed: 12/26/2022]
Abstract
In most settings with a low incidence of tuberculosis (TB), foreign-born people make up the majority of TB cases, but the distribution of the TB risk among different migrant populations is often poorly quantified. In addition, screening practices for TB disease and latent TB infection (LTBI) vary widely. Addressing the risk of TB in international migrants is an essential component of TB prevention and care efforts in low-incidence countries, and strategies to systematically screen for, diagnose, treat and prevent TB among this group contribute to national and global TB elimination goals.This review provides an overview and critical assessment of TB screening practices that are focused on migrants and visitors from high to low TB incidence countries, including pre-migration screening and post-migration follow-up of those deemed to be at an increased risk of developing TB. We focus mainly on migrants who enter the destination country via application for a long-stay visa, as well as asylum seekers and refugees, but briefly consider issues related to short-term visitors and those with long-duration multiple-entry visas. Issues related to the screening of children and screening for LTBI are also explored.
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Affiliation(s)
- Claudia C Dobler
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.,Mayo Clinic Center for Tuberculosis, Rochester, MN, USA
| | - Greg J Fox
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.,Central Clinical School, Faculty of Medicine and Health Sciences, University of Sydney, Sydney, Australia
| | - Paul Douglas
- International Organization for Migration (IOM), Geneva, Switzerland
| | - Kerri A Viney
- Dept of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.,Research School of Population Health, Australian National University, Canberra, Australia
| | - Faiz Ahmad Khan
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada.,Depts of Medicine and Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | | | - Ben J Marais
- The Children's Hospital at Westmead and the Marie Bashir Institute for Infectious Diseases and Biosecurity (MBI), University of Sydney, Sydney, Australia
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47
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do Valle Leone de Oliveira SM, Ferreira da Silva E, Coimbra Motta-Castro AR, de Oliveira Landgraf de Castro V, Stábile AC, Mello Miranda Paniago A, Trajman A. Tuberculosis infection among cocaine crack users in Brazil. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 59:24-27. [PMID: 29966805 DOI: 10.1016/j.drugpo.2018.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 04/14/2018] [Accepted: 06/11/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND WHO recommends treatment for latent tuberculosis infection (LTBI) in the homeless and people who use drugs (PWUD). The optimal test for LTBI screening is uncertain. METHODS A cross-sectional study was conducted among the homeless and drug-rehabilitation clinic clients chronically using crack in Western Brazil. Participants were interviewed and offered HIV testing plus tuberculin skin testing (TST) and QuantiFeron®-Gold-in-Tube (QFT). We considered LTBI when either TST or QFT were positive. Factors associated with LTBI were adjusted in a multivariate model. RESULTS Among 372 subjects with at least one valid test, 216 (58%) had LTBI. TST was not read in 18.4%; QFT was indeterminate in 2.5%. TST detected 27 (26%) extra LTBI cases among 75 QFT-negative individuals. PWUD had over three-fold odds for LTBI. TST was 4.5 times more likely to be positive in BCG-vaccinated individuals. CONCLUSION Given the high risk of progression to disease in this population, the high rates of loss to TST reading and the possibility of false-positive TST results from BCG vaccination, we endorse current CDC recommendations to use QFT for LTBI screening among the homeless and PWUD. However, because adding TST to a negative QFT increased LTBI detection considerably, TST should be considered in QFT-negative individuals.
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Affiliation(s)
| | | | - Ana Rita Coimbra Motta-Castro
- Federal University of Mato Grosso do Sul, Campo Grande, Mato Grosso do Sul, Brazil; Oswaldo Cruz Foundation, Campo Grande, Mato Grosso do Sul, Brazil.
| | | | | | | | - Anete Trajman
- Instituto de Medicina Social, State University of Rio de Janeiro, Rio de Janeiro, Brazil; McGill University, Montreal, Quebec, Canada.
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48
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Stockbridge EL, Miller TL, Carlson EK, Ho C. Predictors of latent tuberculosis infection treatment completion in the US private sector: an analysis of administrative claims data. BMC Public Health 2018; 18:662. [PMID: 29843664 PMCID: PMC5975486 DOI: 10.1186/s12889-018-5578-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 05/21/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Factors that affect latent tuberculosis infection (LTBI) treatment completion in the US have not been well studied beyond public health settings. This gap was highlighted by recent health insurance-related regulatory changes that are likely to increase LTBI treatment by private sector healthcare providers. We analyzed LTBI treatment completion in the private healthcare setting to facilitate planning around this important opportunity for tuberculosis (TB) control in the US. METHODS We analyzed a national sample of commercial insurance medical and pharmacy claims data for people ages 0 to 64 years who initiated daily dose isoniazid treatment between July 2011 and March 2014 and who had complete data. All individuals resided in the US. Factors associated with treatment completion were examined using multivariable generalized ordered logit models and bivariate Kruskal-Wallis tests or Spearman correlations. RESULTS We identified 1072 individuals with complete data who initiated isoniazid LTBI treatment. Treatment completion was significantly associated with less restrictive health insurance, age < 15 years, patient location, use of interferon-gamma release assays, non-poverty, HIV diagnosis, immunosuppressive drug therapy, and higher cumulative counts of clinical risk factors. CONCLUSIONS Private sector healthcare claims data provide insights into LTBI treatment completion patterns and patient/provider behaviors. Such information is critical to understanding the opportunities and limitations of private healthcare in the US to support treatment completion as this sector's role in protecting against and eliminating TB grows.
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Affiliation(s)
- Erica L. Stockbridge
- Department of Health Behavior and Health Systems, University of North Texas Health Science Center School of Public Health, 3500 Camp Bowie Blvd, Fort Worth, TX 76107 USA
- Department of Advanced Health Analytics and Solutions, Magellan Health, Inc., 4800 N Scottsdale Rd #4400, Scottsdale, AZ 85251 USA
- Institute for Patient Safety, University of North Texas Health Science Center, 3500 Camp Bowie Blvd, Fort Worth, TX 76107 USA
| | - Thaddeus L. Miller
- Department of Health Behavior and Health Systems, University of North Texas Health Science Center School of Public Health, 3500 Camp Bowie Blvd, Fort Worth, TX 76107 USA
| | - Erin K. Carlson
- College of Nursing and Health Innovation, University of Texas at Arlington, 411 S. Nedderman Drive, Arlington, TX 76019-0407 USA
| | - Christine Ho
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333 USA
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49
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Olsson O, Winqvist N, Olsson M, Olsson P, Björkman P. High rate of latent tuberculosis treatment completion in immigrants seeking asylum in Sweden. Infect Dis (Lond) 2018; 50:678-686. [PMID: 29620426 DOI: 10.1080/23744235.2018.1459046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND/AIM Treatment of latently infected individuals at increased risk of reactivation is a cornerstone in tuberculosis control. Although asylum seekers without residence permit in Sweden are offered screening for both active tuberculosis and latent tuberculosis infection (LTBI), treatment for LTBI is often not initiated due to anticipated low rates of treatment completion. We aimed to compare completion rates for LTBI treatment between asylum seekers and other patients, and between asylum seekers with and without residence permit. METHODS Data were collected retrospectively from tuberculosis clinic registers and medical records. For comparison of treatment completion rates, relative risks (RR) and confidence intervals (CI) were calculated. Predictors of completion were assessed by logistic regression multivariate analysis. RESULTS Treatment completion was achieved in 506/606 subjects (83%). RR of non-completion for asylum seekers (n = 297) compared to other subjects (n = 309) was 1.13 (95% CI: 0.79-1.61; p = .51), and 0.91 (95% CI: 0.53-1.56; p = .72) for asylum seekers without residence permit (n = 217) compared to asylum seekers with residence permit (n = 80). Completion rates increased from 53% in 2008 to 92% in 2015-2016. The following factors were associated with completion: scheduled interpreter-assisted appointments throughout the course of therapy, shorter treatment duration (6 vs. 9 months), and being treated in connection with immunosuppressive therapy. CONCLUSION Treatment completion rates were similar between asylum seekers and other subjects, supporting initiation of latent tuberculosis treatment in immigrants with recent arrival to low-endemic countries.
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Affiliation(s)
- O Olsson
- a Department of Translational Medicine, Clinical Infection Medicine , Lund University , Sweden
| | - N Winqvist
- a Department of Translational Medicine, Clinical Infection Medicine , Lund University , Sweden.,b Skane Regional Office for Infectious Disease Control , Malmö , Sweden
| | - M Olsson
- c Department of Infectious Diseases , Skane University Hospital , Malmö , Sweden
| | - P Olsson
- c Department of Infectious Diseases , Skane University Hospital , Malmö , Sweden
| | - P Björkman
- a Department of Translational Medicine, Clinical Infection Medicine , Lund University , Sweden
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50
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Loutet MG, Burman M, Jayasekera N, Trathen D, Dart S, Kunst H, Zenner D. National roll-out of latent tuberculosis testing and treatment for new migrants in England: a retrospective evaluation in a high-incidence area. Eur Respir J 2018; 51:51/1/1701226. [PMID: 29326327 PMCID: PMC5898937 DOI: 10.1183/13993003.01226-2017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 10/06/2017] [Indexed: 12/18/2022]
Abstract
Latent tuberculosis infection (LTBI) screening is an important intervention for tuberculosis (TB) elimination in low-incidence countries and is, therefore, a key component of England's TB control strategy. This study describes outcomes from a LTBI screening programme in a high-incidence area to inform national LTBI screening in England and other low-incidence countries.We conducted a retrospective cohort study of LTBI screening among eligible migrants (from high-incidence countries and entered the UK within the last 5 years), who were identified at primary-care clinics in Newham, London between August 2014 and August 2015. Multivariable logistic regression was used to identify factors associated with LTBI testing uptake, interferon-γ release assay (IGRA) positivity and treatment uptake.40% of individuals offered LTBI screening received an IGRA test. The majority of individuals tested were 16-35 years old, male and born in India, Bangladesh or Pakistan. Country of birth, smoking status and co-morbidities were associated with LTBI testing uptake. IGRA positivity was 32% among those tested and was significantly associated with country of birth, age, sex and co-morbidities.This study identifies factors associated with screening uptake, IGRA positivity and treatment uptake, and improves understanding of groups that should be supported to increase acceptability of LTBI testing and treatment in the community.
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Affiliation(s)
| | - Matthew Burman
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University, London, UK.,Dept of Respiratory Medicine, Barts Health NHS Trust, London, UK
| | | | | | - Susan Dart
- Dept of Respiratory Medicine, Barts Health NHS Trust, London, UK
| | - Heinke Kunst
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University, London, UK.,Dept of Respiratory Medicine, Barts Health NHS Trust, London, UK
| | - Dominik Zenner
- National Infection Service, Public Health England, London, UK.,Institute for Global Health, University College London, London, UK.,National Institute for Health Research Health Protection Research Unit in Respiratory Infections, Imperial College London, London, UK
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