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Ferrer J, Giménez E, Carretero D, Clari MÁ, Orta N, Navarro D, Albert E. Abbott realtime MTB assay for detecting Mycobacterium tuberculosis complex in respiratory specimens: a cost-benefit analysis. Eur J Clin Microbiol Infect Dis 2024:10.1007/s10096-024-04880-1. [PMID: 38958810 DOI: 10.1007/s10096-024-04880-1] [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: 09/19/2023] [Accepted: 06/19/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE Molecular screening for Mycobacterium tuberculosis (MTB) can lead to rapid empirical treatment inception and reduce hospitalization time and complementary diagnostic tests. However, in low-prevalence settings, the cost-benefit balance remains controversial due to the high cost. METHODS We used a Markov model to perform an economic analysis to evaluate the profit after implementing molecular MTB screening (Period B) compared with conventional culture testing (Period A) in respiratory samples from 7,452 consecutive subjects with presumed tuberculosis (TB). RESULTS The proportion of positivity was comparable between both periods (P > 0.05), with a total of 2.16 and 1.78 samples/patient requested in periods A and B, respectively (P < 0.001). The mean length of hospital stay was 8.66 days (95%CI: 7.63-9.70) in Period B and 11.51 days (95%CI: 10.15-12.87) in Period A (P = 0.001). The healthcare costs associated with diagnosing patients with presumed TB were reduced by €717.95 per patient with PCR screening. The probability of remaining hospitalized and the need for a greater number of outpatient specialty care visits were the variables with the most weight in the model. CONCLUSION Employing PCR as an MTB screening method in a low-prevalence setting may increase the profits to the system.
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Affiliation(s)
- Josep Ferrer
- Microbiology Service, Clinic University Hospital, INCLIVA Health Research Institute, Valencia, Spain
| | - Estela Giménez
- Microbiology Service, Clinic University Hospital, INCLIVA Health Research Institute, Valencia, Spain
| | - Diego Carretero
- Microbiology Service, Clinic University Hospital, INCLIVA Health Research Institute, Valencia, Spain
| | - Mª Ángeles Clari
- Microbiology Service, Clinic University Hospital, INCLIVA Health Research Institute, Valencia, Spain
| | - Nieves Orta
- Microbiology Unit, Hospital Francisco de Borja, Gandía, Spain
| | - David Navarro
- Microbiology Service, Clinic University Hospital, INCLIVA Health Research Institute, Valencia, Spain
- Department of Microbiology, School of Medicine, University of Valencia, Spain, Av. Blasco Ibáñez 17, Valencia, Spain
| | - Eliseo Albert
- Microbiology Service, Clinic University Hospital, INCLIVA Health Research Institute, Valencia, Spain.
- Department of Microbiology, School of Medicine, University of Valencia, Spain, Av. Blasco Ibáñez 17, Valencia, Spain.
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d’Elbée M, Harker M, Mafirakureva N, Nanfuka M, Huyen Ton Nu Nguyet M, Taguebue JV, Moh R, Khosa C, Mustapha A, Mwanga-Amumpere J, Borand L, Nolna SK, Komena E, Cumbe S, Mugisha J, Natukunda N, Mao TE, Wittwer J, Bénard A, Bernard T, Sohn H, Bonnet M, Wobudeya E, Marcy O, Dodd PJ. Cost-effectiveness and budget impact of decentralising childhood tuberculosis diagnosis in six high tuberculosis incidence countries: a mathematical modelling study. EClinicalMedicine 2024; 70:102528. [PMID: 38685930 PMCID: PMC11056392 DOI: 10.1016/j.eclinm.2024.102528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/23/2024] [Accepted: 02/21/2024] [Indexed: 05/02/2024] Open
Abstract
Background The burden of childhood tuberculosis remains high globally, largely due to under-diagnosis. Decentralising childhood tuberculosis diagnosis services to lower health system levels could improve case detection, but there is little empirically based evidence on cost-effectiveness or budget impact. Methods In this mathematical modelling study, we assessed the cost-effectiveness and budget impact of decentralising a comprehensive diagnosis package for childhood tuberculosis to district hospitals (DH-focused) or primary health centres (PHC-focused) compared to standard of care (SOC). The project was conducted in Cambodia, Cameroon, Côte d'Ivoire, Mozambique, Sierra Leone, and Uganda between August 1st, 2018 and September 30th, 2021. A mathematical model was developed to assess the health and economic outcomes of the intervention from a health system perspective. Estimated outcomes were tuberculosis cases, deaths, disability-adjusted life years (DALYs) and incremental cost-effectiveness ratios (ICERs). We also calculated the budget impact of nationwide implementation. The TB-Speed Decentralization study is registered with ClinicalTrials.gov, NCT04038632. Findings For the DH-focused strategy versus SOC, ICERs ranged between $263 (Cambodia) and $342 (Côte d'Ivoire) per DALY averted. For the PHC-focused strategy versus SOC, ICERs ranged between $477 (Cambodia) and $599 (Côte d'Ivoire) per DALY averted. Results were sensitive to TB prevalence and the discount rate used. The additional costs of implementing the DH-focused strategy ranged between $12.8 M (range 10.8-16.4) (Cambodia) and $50.4 M (36.5-74.4) (Mozambique), and between $13.9 M (12.6-15.6) (Sierra Leone) and $134.6 M (127.1-143.0) (Uganda) for the PHC-focused strategy. Interpretation The DH-focused strategy may be cost-effective in some countries, depending on the cost-effectiveness threshold used for policy making. Either intervention would require substantial early investment. Funding Unitaid.
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Affiliation(s)
- Marc d’Elbée
- University of Bordeaux, National Institute for Health and Medical Research (Inserm) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux, France
- Ceped UMR 196, Université Paris Cité, Research Institute for Sustainable Development (IRD), Inserm, Paris, France
| | - Martin Harker
- TB Modelling Group, TB Centre, and Global Centre for Health Economics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Mastula Nanfuka
- MU-JHU Care Ltd, MUJHU Research Collaboration, Kampala, Uganda
| | - Minh Huyen Ton Nu Nguyet
- University of Bordeaux, National Institute for Health and Medical Research (Inserm) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux, France
| | | | - Raoul Moh
- Teaching Unit of Dermatology and Infectiology, UFR of Medical Sciences, Félix-Houphouët Boigny University, Abidjan, Côte d’Ivoire
- Programme PAC-CI, CHU de Treichville, Abidjan, Côte d’Ivoire
| | - Celso Khosa
- Instituto Nacional de Saúde, Marracuene, Mozambique
| | | | | | - Laurence Borand
- Epidemiology and Public Health Unit, Clinical Research Group, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Eric Komena
- Programme PAC-CI, CHU de Treichville, Abidjan, Côte d’Ivoire
| | | | | | | | | | - Jérôme Wittwer
- University of Bordeaux, National Institute for Health and Medical Research UMR 1219, Bordeaux, France
| | - Antoine Bénard
- CHU Bordeaux, Service d'information Médicale, USMR & CIC-EC 14-01, Bordeaux, France
| | | | - Hojoon Sohn
- Seoul National University College of Medicine, Seoul, South Korea
| | - Maryline Bonnet
- TransVIHMI, University of Montpellier, IRD /INSERM, Montpellier, France
| | - Eric Wobudeya
- MU-JHU Care Ltd, MUJHU Research Collaboration, Kampala, Uganda
| | - Olivier Marcy
- University of Bordeaux, National Institute for Health and Medical Research (Inserm) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux, France
| | - Peter J. Dodd
- School of Health & Related Research, University of Sheffield, Sheffield, United Kingdom
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Gogichadze N, Sagrera A, Vicente JÁ, Millet JP, López-Seguí F, Vilaplana C. Cost-effectiveness of active tuberculosis screening among high-risk populations in low tuberculosis incidence countries: a systematic review, 2008 to 2023. Euro Surveill 2024; 29:2300614. [PMID: 38516785 PMCID: PMC11063676 DOI: 10.2807/1560-7917.es.2024.29.12.2300614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/15/2024] [Indexed: 03/23/2024] Open
Abstract
BackgroundIn countries with a low TB incidence (≤ 10 cases/100,000 population), active pulmonary tuberculosis (PTB) mostly affects vulnerable populations with limited access to healthcare. Thus, passive case-finding systems may not be successful in detecting and treating cases and preventing further transmission. Active and cost-effective search strategies can overcome this problem.AimWe aimed to review the evidence on the cost-effectiveness (C-E) of active PTB screening programmes among high-risk populations in low TB incidence countries.MethodsWe performed a systematic literature search covering 2008-2023 on PubMed, Embase, Center for Reviews and Dissemination, including Database of Abstracts of Reviews of Effects (DARE), National Health Services Economic Evaluation Database (NHS EED), Global Index Medicus and Cochrane Central Register of Controlled Trials (CENTRAL).ResultsWe retrieved 6,318 articles and included nine in this review. All included studies had an active case-finding approach and used chest X-ray, tuberculin skin test, interferon-gamma release assay and a symptoms questionnaire for screening. The results indicate that screening immigrants from countries with a TB incidence > 40 cases per 100,000 population and other vulnerable populations as individuals from isolated communities, people experiencing homelessness, those accessing drug treatment services and contacts, is cost-effective in low-incidence countries.ConclusionIn low-incidence countries, targeting high-risk groups is C-E. However, due to the data heterogenicity, we were unable to compare C-E. Harmonisation of the methods for C-E analysis is needed and would facilitate comparisons. To outline comprehensive screening and its subsequent C-E analysis, researchers should consider multiple factors influencing screening methods and outcomes.
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Affiliation(s)
- Nino Gogichadze
- Unitat de Tuberculosi Experimental, Germans Trias i Pujol Research Institute and Hospital (IGTP-HUGTIP), Badalona, Catalonia, Spain
- These authors contributed equally to the work and share the first authorship
- Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Catalonia, Spain
| | - Arnau Sagrera
- Unitat de Tuberculosi Experimental, Germans Trias i Pujol Research Institute and Hospital (IGTP-HUGTIP), Badalona, Catalonia, Spain
- These authors contributed equally to the work and share the first authorship
| | - José Ángel Vicente
- Research Group on Innovation, Health Economics and Digital Transformation (INEDIT), Institut de Recerca Germans Trias i Pujol, Badalona, Catalonia, Spain
- Fundació Lluita contra les Infeccions, Germans Trias i Pujol Research Institute and Hospital (IGTP-HUGTIP), Badalona, Catalonia, Spain
- Centre de Recerca en Economia de la Salut (CRES), Universitat Pompeu Fabra, Barcelona, Catalonia, Spain
| | - Joan-Pau Millet
- Servei d'Epidemiologia, Agència de Salut Pública Barcelona (ASPB), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Francesc López-Seguí
- Research Group on Innovation, Health Economics and Digital Transformation (INEDIT), Institut de Recerca Germans Trias i Pujol, Badalona, Catalonia, Spain
- Fundació Lluita contra les Infeccions, Germans Trias i Pujol Research Institute and Hospital (IGTP-HUGTIP), Badalona, Catalonia, Spain
- Centre de Recerca en Economia de la Salut (CRES), Universitat Pompeu Fabra, Barcelona, Catalonia, Spain
| | - Cristina Vilaplana
- Unitat de Tuberculosi Experimental, Germans Trias i Pujol Research Institute and Hospital (IGTP-HUGTIP), Badalona, Catalonia, Spain
- Microbiology Department, Northern Metropolitan Clinical Laboratory, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
- Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Catalonia, Spain
- Direcció Clínica Territorial de Malalties Infeccioses i Salut Internacional de Gerència Territorial Metropolitana Nord de l'Institut Català de la Salut, Badalona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
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Goscé L, Allel K, Hamada Y, Korobitsyn A, Ismail N, Bashir S, Denkinger CM, Abubakar I, White PJ, Rangaka MX. Economic evaluation of novel Mycobacterium tuberculosis specific antigen-based skin tests for detection of TB infection: A modelling study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002573. [PMID: 38117825 PMCID: PMC10732392 DOI: 10.1371/journal.pgph.0002573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 11/10/2023] [Indexed: 12/22/2023]
Abstract
Evidence on the economic impact of novel skin tests for tuberculosis infection (TBST) is scarce and limited by study quality. We used estimates on the cost-effectiveness of the use of TBST compared to current tuberculosis infection (TBI) tests to assess whether TBST are affordable and feasible to implement under different country contexts. A Markov model parametrised to Brazil, South Africa and the UK was developed to compare the cost-effectiveness of three TBI testing strategies: (1) Diaskintest (DST), (2) TST test, and (3) IGRA QFT test. Univariate and probabilistic sensitivity analyses over unit costs and main parameters were performed. Our modelling results show that Diaskintest saves $5.60 and gains 0.024 QALYs per patient and $8.40, and 0.01 QALYs per patient in Brazil, compared to TST and IGRA respectively. In South Africa, Diaskintest is also cost-saving at $4.39, with 0.015 QALYs per patient gained, compared to TST, and $64.41, and 0.007 QALYs per patient, compared to IGRA. In the UK, Diaskintest saves $73.33, and gaines 0.0351 QALYs per patient, compared to TST. However, Diaskintest, compared to IGRA, showed an incremental cost of $521.45 (95% CI (500.94-545.07)) per QALY, below the willingness-to-pay threshold of $20.223 per QALY. Diaskintest potentially saves costs and results in greater health gains than the TST and IGRA tests in Brazil and South Africa. In the UK Diaskintest would gain health but also be more costly. Our results have potential external validity because TBST remained cost-effective despite extensive sensitivity analyses.
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Affiliation(s)
- Lara Goscé
- Institute for Global Health, University College London, London, United Kingdom
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kasim Allel
- Institute for Global Health, University College London, London, United Kingdom
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Yohhei Hamada
- Institute for Global Health, University College London, London, United Kingdom
| | - Alexei Korobitsyn
- Unit for Prevention, Diagnosis, Treatment, Care and Innovation, Global Tuberculosis Programme, World Health Organization, Genève, Switzerland
| | - Nazir Ismail
- Unit for Prevention, Diagnosis, Treatment, Care and Innovation, Global Tuberculosis Programme, World Health Organization, Genève, Switzerland
| | - Saima Bashir
- Division of Infectious Diseases and Tropical Medicine at University Hospital Heidelberg, Heidelberg, Germany
| | - Claudia M. Denkinger
- Division of Infectious Diseases and Tropical Medicine at University Hospital Heidelberg, Heidelberg, Germany
- German Center for Infection Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, United Kingdom
| | - Peter J. White
- MRC Centre for Global Infectious Disease Analysis and NIHR Health Protection Research Unit in Modelling and Health Economics, School of Public Health, Faculty of Medicine, Imperial College, London, United Kingdom
- Modelling and Economics Unit, UK Health Security Agency, London, United Kingdom
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5
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Cao X, Song Z, He W, Yang Z, Sun Q, Wang Y, He P, Zhao B, Zhang Z, Zhao Y. Tuberculosis screening characteristics amongst freshmen in Changping District, Beijing, China. BMC Infect Dis 2023; 23:869. [PMID: 38082230 PMCID: PMC10714516 DOI: 10.1186/s12879-023-08802-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/07/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Screening for Tuberculosis (TB) is a critical tactic for minimizing the prevalence of illness within schools. Tuberculosis Preventive Therapy (TPT), in turn, effectively staves off the development of TB from latent tuberculosis infection (LTBI). Unfortunately, there is limited research on LTBI and TPT among students. This study aimed to assess LTBI among freshmen in Changping District and advocate for the implementation of TPT. METHODS The prospective study collected data from 12 educational institutions within the Changping District of Beijing. The Kolmogorov - Smirnov test and other statistical methods were used for statistical analysis, [Formula: see text] was obtained using the formula [Formula: see text] nΣA2/nRnC-1, df = (C-1) (R-1). We analyzed potential factors impacting the LTBI rate, and scrutinized the possible causes behind the low application of TPT and its efficacy for LTBI treatment, China. RESULTS Among 19,872 freshmen included in this study, 18 active TB cases (91 per 10,0000) and 2236 LTBI cases (11.6% of 19,223) were identified, respectively. Furthermore, of those with LTBI, 1045 (5.4% of 19,223) showed a strong positive for purified protein derivative (PPD), but only 312 opted for TB preventive treatment. There appeared to be no significant difference in the prevalence of LTBI and TPT rate between male and female students. Concurrently, 11 (71 per 100,000) and 7 (158 per 100,000) cases of active tuberculosis were identified in 6 universities and 6 higher vocational colleges, respectively. Interestingly, almost all freshmen who underwent TPT came from universities, suggesting a statistically significant disparity in TPT rate (χ2 = 139.829, P < 0.001) between these two types of educational institutions. Meanwhile, as for the age-wise distribution of latent infection among 17-20 years old freshmen, the LTBI rate exhibited 10.5%, 11.6%, 12.1% and 13.5%, respectively. Correlation between LTBI rate, the strong positive rate was statistically significant among different ages (χ2 = 34.559, P < 0.001). Over a follow-up period of 2 years, three students were diagnosed with active tuberculosis, one of which was resistant to rifampicin. All three students manifested a strong positive for PPD and declined preventive treatment during TB screening. CONCLUSIONS The data indicates a high rate of LTBI amongst students in areas with a heavy TB burden, potentially leading to cross-regional TB transmission due to the migration of students. Education level might contribute to the limited uptake of TPT. Therefore, improving the implementation of TB preventive treatments is crucial in controlling and preventing TB across schools.
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Affiliation(s)
- Xiaolong Cao
- Chinese Center for Disease Control and Prevention, National Tuberculosis Reference Laboratory, No. 155 Chang Bai Road, Changping District, Beijing, 102206, People's Republic of China
- Beijing Changping Institute for Tuberculosis Prevention and Treatment, No. 4 He Ping Street, Changping District, Beijing, 102200, People's Republic of China
| | - Zexuan Song
- Chinese Center for Disease Control and Prevention, National Tuberculosis Reference Laboratory, No. 155 Chang Bai Road, Changping District, Beijing, 102206, People's Republic of China
| | - Wencong He
- Chinese Center for Disease Control and Prevention, National Tuberculosis Reference Laboratory, No. 155 Chang Bai Road, Changping District, Beijing, 102206, People's Republic of China
| | - Zhen Yang
- Beijing Changping Institute for Tuberculosis Prevention and Treatment, No. 4 He Ping Street, Changping District, Beijing, 102200, People's Republic of China
| | - Qian Sun
- Beijing Changping Institute for Tuberculosis Prevention and Treatment, No. 4 He Ping Street, Changping District, Beijing, 102200, People's Republic of China
| | - Yiting Wang
- Chinese Center for Disease Control and Prevention, National Tuberculosis Reference Laboratory, No. 155 Chang Bai Road, Changping District, Beijing, 102206, People's Republic of China
| | - Ping He
- Chinese Center for Disease Control and Prevention, National Tuberculosis Reference Laboratory, No. 155 Chang Bai Road, Changping District, Beijing, 102206, People's Republic of China
| | - Bing Zhao
- Chinese Center for Disease Control and Prevention, National Tuberculosis Reference Laboratory, No. 155 Chang Bai Road, Changping District, Beijing, 102206, People's Republic of China
| | - Zhiguo Zhang
- Beijing Changping Institute for Tuberculosis Prevention and Treatment, No. 4 He Ping Street, Changping District, Beijing, 102200, People's Republic of China.
| | - Yanlin Zhao
- Chinese Center for Disease Control and Prevention, National Tuberculosis Reference Laboratory, No. 155 Chang Bai Road, Changping District, Beijing, 102206, People's Republic of China.
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6
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Dinh LV, Wiemers AMC, Forse RJ, Phan YTH, Codlin AJ, Annerstedt KS, Dong TTT, Nguyen L, Pham TH, Nguyen LH, Dang HMT, Tuan MH, Le PT, Lonnroth K, Creswell J, Khan A, Kirubi B, Nguyen HB, Nguyen NV, Vo LNQ. Comparing Catastrophic Costs: Active vs. Passive Tuberculosis Case Finding in Urban Vietnam. Trop Med Infect Dis 2023; 8:423. [PMID: 37755885 PMCID: PMC10535862 DOI: 10.3390/tropicalmed8090423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/11/2023] [Accepted: 08/14/2023] [Indexed: 09/28/2023] Open
Abstract
Active case finding (ACF) is a strategy that aims to identify people with tuberculosis (TB) earlier in their disease. This outreach approach may lead to a reduction in catastrophic cost incurrence (costs exceeding 20% of annual household income), a main target of WHO's End TB Strategy. Our study assessed the socio-economic impact of ACF by comparing patient costs in actively and passively detected people with TB. Longitudinal patient cost surveys were prospectively fielded for people with drug-sensitive pulmonary TB, with 105 detected through ACF and 107 passively detected. Data were collected in four Vietnamese cities between October 2020 and March 2022. ACF reduced pre-treatment (USD 10 vs. 101, p < 0.001) and treatment costs (USD 888 vs. 1213, p < 0.001) in TB-affected individuals. Furthermore, it reduced the occurrence of job loss (15.2% vs. 35.5%, p = 0.001) and use of coping strategies (28.6% vs. 45.7%, p = 0.004). However, catastrophic cost incurrence was high at 52.8% and did not differ between cohorts. ACF did not significantly decrease indirect costs, the largest contributor to catastrophic costs. ACF reduces costs but cannot sufficiently reduce the risk of catastrophic costs. As income loss is the largest driver of costs during TB treatment, social protection schemes need to be expanded.
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Affiliation(s)
| | | | - Rachel J. Forse
- Friends for International TB Relief, Ha Noi 10000, Vietnam
- WHO Collaboration Centre on Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Yen T. H. Phan
- Center for Development of Community Health Initiatives, Ha Noi 10000, Vietnam
| | - Andrew J. Codlin
- Friends for International TB Relief, Ha Noi 10000, Vietnam
- WHO Collaboration Centre on Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Kristi Sidney Annerstedt
- WHO Collaboration Centre on Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, 171 76 Stockholm, Sweden
| | | | - Lan Nguyen
- IRD VN, Ho Chi Minh City 700000, Vietnam
| | | | - Lan H. Nguyen
- Pham Ngoc Thach Hospital, Ho Chi Minh City 700000, Vietnam
| | - Ha M. T. Dang
- Pham Ngoc Thach Hospital, Ho Chi Minh City 700000, Vietnam
| | - Mac H. Tuan
- Hai Phong Lung Hospital, Hai Phong 188140, Vietnam
| | | | - Knut Lonnroth
- WHO Collaboration Centre on Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Jacob Creswell
- Stop TB Partnership, Le Grand-Saconnex, 1218 Geneva, Switzerland
| | - Amera Khan
- Stop TB Partnership, Le Grand-Saconnex, 1218 Geneva, Switzerland
| | - Beatrice Kirubi
- Stop TB Partnership, Le Grand-Saconnex, 1218 Geneva, Switzerland
| | | | | | - Luan N. Q. Vo
- Friends for International TB Relief, Ha Noi 10000, Vietnam
- WHO Collaboration Centre on Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, 171 76 Stockholm, Sweden
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7
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Martinson NA, Nonyane BAS, Genade LP, Berhanu RH, Naidoo P, Brey Z, Kinghorn A, Nyathi S, Young K, Hausler H, Connell L, Lutchminarain K, Swe Swe-Han K, Vreede H, Said M, von Knorring N, Moulton LH, Lebina L. Evaluating systematic targeted universal testing for tuberculosis in primary care clinics of South Africa: A cluster-randomized trial (The TUTT Trial). PLoS Med 2023; 20:e1004237. [PMID: 37216385 DOI: 10.1371/journal.pmed.1004237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 04/21/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND The World Health Organization (WHO) recommends systematic symptom screening for tuberculosis (TB). However, TB prevalence surveys suggest that this strategy does not identify millions of TB patients, globally. Undiagnosed or delayed diagnosis of TB contribute to TB transmission and exacerbate morbidity and mortality. We conducted a cluster-randomized trial of large urban and rural primary healthcare clinics in 3 provinces of South Africa to evaluate whether a novel intervention of targeted universal testing for TB (TUTT) in high-risk groups diagnosed more patients with TB per month compared to current standard of care (SoC) symptom-directed TB testing. METHODS AND FINDINGS Sixty-two clinics were randomized; with initiation of the intervention clinics over 6 months from March 2019. The study was prematurely stopped in March 2020 due to clinics restricting access to patients, and then a week later due to the Coronavirus Disease 2019 (COVID-19) national lockdown; by then, we had accrued a similar number of TB diagnoses to that of the power estimates and permanently stopped the trial. In intervention clinics, attendees living with HIV, those self-reporting a recent close contact with TB, or a prior episode of TB were all offered a sputum test for TB, irrespective of whether they reported symptoms of TB. We analyzed data abstracted from the national public sector laboratory database using Poisson regression models and compared the mean number of TB patients diagnosed per clinic per month between the study arms. Intervention clinics diagnosed 6,777 patients with TB, 20.7 patients with TB per clinic month (95% CI 16.7, 24.8) versus 6,750, 18.8 patients with TB per clinic month (95% CI 15.3, 22.2) in control clinics during study months. A direct comparison, adjusting for province and clinic TB case volume strata, did not show a significant difference in the number of TB cases between the 2 arms, incidence rate ratio (IRR) 1.14 (95% CI 0.94, 1.38, p = 0.46). However, prespecified difference-in-differences analyses showed that while the rate of TB diagnoses in control clinics decreased over time, intervention clinics had a 17% relative increase in TB patients diagnosed per month compared to the prior year, interaction IRR 1.17 (95% CI 1.14, 1.19, p < 0.001). Trial limitations were the premature stop due to COVID-19 lockdowns and the absence of between-arm comparisons of initiation and outcomes of TB treatment in those diagnosed with TB. CONCLUSIONS Our trial suggests that the implementation of TUTT in these 3 groups at extreme risk of TB identified more TB patients than SoC and could assist in reducing undiagnosed TB patients in settings of high TB prevalence. TRIAL REGISTRATION South African National Clinical Trials Registry DOH-27-092021-4901.
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Affiliation(s)
- Neil A Martinson
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa
- Johns Hopkins University Center for TB Research, Baltimore, Maryland, United States of America
| | - Bareng A S Nonyane
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, United States of America
| | - Leisha P Genade
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa
| | - Rebecca H Berhanu
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Pren Naidoo
- Public Health Management Consultant, South Africa, Johannesburg, South Africa
| | - Zameer Brey
- Bill and Melinda Gates Foundation, South Africa, Johannesburg, South Africa
| | - Anthony Kinghorn
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | | | - Keeren Lutchminarain
- National Health Laboratory Service Department of Microbiology, Inkosi Albert Luthuli Central Hospital, eThekwini, South Africa
- University of Kwa Zulu Natal, Durban, South Africa
| | - Khine Swe Swe-Han
- National Health Laboratory Service Department of Microbiology, Inkosi Albert Luthuli Central Hospital, eThekwini, South Africa
- University of Kwa Zulu Natal, Durban, South Africa
| | - Helena Vreede
- National Health Laboratory Service, Chemical Pathology, Groote Schuur Hospital, Cape Town, South Africa
| | - Mohamed Said
- National Health Laboratory Service, Microbiology and Academic Division, Tshwane, South Africa
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| | - Nina von Knorring
- National Health Laboratory Service, Clinical Microbiology, Johannesburg, South Africa
- Division of Clinical Microbiology and Infectious Diseases, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence H Moulton
- Johns Hopkins University Center for TB Research, Baltimore, Maryland, United States of America
| | - Limakatso Lebina
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa
- Africa Health Research Institute, KwaZulu Natal, South Africa
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8
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Sachdeva KS, Kumar N. Closing the gaps in tuberculosis detection-considerations for policy makers. Lancet Glob Health 2023; 11:e185-e186. [PMID: 36669799 DOI: 10.1016/s2214-109x(23)00008-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 12/23/2022] [Indexed: 01/20/2023]
Affiliation(s)
- Kuldeep Singh Sachdeva
- South East Asia International Union Against Tuberculosis and Lung Disease, New Delhi, 110016 India.
| | - Nishant Kumar
- Ministry of Health, Government of India, New Delhi, India
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9
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Naufal F, Chaisson LH, Robsky KO, Delgado-Barroso P, Alvarez-Manzo HS, Miller CR, Shapiro AE, Golub JE. Number needed to screen for TB in clinical, structural or occupational risk groups. Int J Tuberc Lung Dis 2022; 26:500-508. [PMID: 35650693 DOI: 10.5588/ijtld.21.0749] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND: Screening for active TB using active case-finding (ACF) may reduce TB incidence, prevalence, and mortality; however, yield of ACF interventions varies substantially across populations. We systematically reviewed studies reporting on ACF to calculate the number needed to screen (NNS) for groups at high risk for TB.METHODS: We conducted a literature search for studies reporting ACF for adults published between November 2010 and February 2020. We determined active TB prevalence detected through various screening strategies and calculated crude NNS for - TB confirmed using culture or Xpert® MTB/RIF, and weighted mean NNS stratified by screening strategy, risk group, and country-level TB incidence.RESULTS: We screened 27,223 abstracts; 90 studies were included (41 in low/moderate and 49 in medium/high TB incidence settings). High-risk groups included inpatients, outpatients, people living with diabetes (PLWD), migrants, prison inmates, persons experiencing homelessness (PEH), healthcare workers, and miners. Screening strategies included symptom-based screening, chest X-ray and Xpert testing. NNS varied widely across and within incidence settings based on risk groups and screening methods. Screening tools with higher sensitivity (e.g., Xpert, CXR) were associated with lower NNS estimates.CONCLUSIONS: NNS for ACF strategies varies substantially between adult risk groups. Specific interventions should be tailored based on local epidemiology and costs.
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Affiliation(s)
- F Naufal
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - L H Chaisson
- Division of Infectious Diseases, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - K O Robsky
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - P Delgado-Barroso
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - H S Alvarez-Manzo
- Department of Molecular Microbiology and Immunology, Johns Hopkins University, Baltimore, MD, USA
| | - C R Miller
- World Health Organization, Geneva, Switzerland
| | - A E Shapiro
- Departments of Global Health and Medicine, University of Washington, Seattle, WA
| | - J E Golub
- Division of Infectious Diseases, Department of Medicine, University of Illinois at Chicago, Chicago, IL, Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA, Department of International Health, Johns Hopkins University, Baltimore, MD, USA
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