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Shah AP, Dave JD, Makwana MN, Rupani MP, Shah IA. A mixed-methods study on impact of active case finding on pulmonary tuberculosis treatment outcomes in India. Arch Public Health 2024; 82:92. [PMID: 38902803 PMCID: PMC11188491 DOI: 10.1186/s13690-024-01326-0] [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: 04/12/2024] [Accepted: 06/15/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND Tuberculosis (TB) remains a significant public health burden in India, with elimination targets set for 2025. Active case finding (ACF) is crucial for improving TB case detection rates, although conclusive evidence of its association with treatment outcomes is lacking. Our study aims to investigate the impact of ACF on successful TB treatment outcomes among pulmonary TB patients in Gujarat, India, and explore why ACF positively impacts these outcomes. METHODS We conducted a retrospective cohort analysis in Gujarat, India, including 1,638 pulmonary TB cases identified through ACF and 80,957 cases through passive case finding (PCF) from January 2019 to December 2020. Generalized logistic mixed-model compared treatment outcomes between the ACF and PCF groups. Additionally, in-depth interviews were conducted with 11 TB program functionaries to explore their perceptions of ACF and its impact on TB treatment outcomes. RESULTS Our analysis revealed that patients diagnosed through ACF exhibited 1.4 times higher odds of successful treatment outcomes compared to those identified through PCF. Program functionaries emphasized that ACF enhances case detection rates and enables early detection and prompt treatment initiation. This early intervention facilitates faster sputum conversion and helps reduce the infectious period, thereby improving treatment outcomes. Functionaries highlighted that ACF identifies TB cases that might otherwise be missed, ensuring timely and appropriate treatment. CONCLUSION ACF significantly improves TB treatment outcomes in Gujarat, India. The mixed-methods analysis demonstrates a positive association between ACF and successful TB treatment, with early detection and prompt treatment initiation being key factors. Insights from TB program functionaries underscore the importance of ACF in ensuring timely diagnosis and treatment, which are critical for better treatment outcomes. Expanding ACF initiatives, especially among hard-to-reach populations, can further enhance TB control efforts. Future research should focus on optimizing ACF strategies and integrating additional interventions to sustain and improve TB treatment outcomes.
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Affiliation(s)
- Akshat P Shah
- Department of Community Medicine, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Near ST Bus Stand, Jail Road, Bhavnagar, Gujarat, 364001, India
| | - Jigna D Dave
- Department of Respiratory Medicine, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Jail Road, Bhavnagar, Gujarat, 364001, India
| | - Mohit N Makwana
- Department of Community Medicine, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Near ST Bus Stand, Jail Road, Bhavnagar, Gujarat, 364001, India
- Department of Community and Family Medicine, All India Institute of Medical Sciences (AIIMS), Khanderi, Parapipaliya, Rajkot, Gujarat, 360006, India
| | - Mihir P Rupani
- Department of Community Medicine, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Near ST Bus Stand, Jail Road, Bhavnagar, Gujarat, 364001, India.
- Clinical Epidemiology (Division of Health Sciences), ICMR - National Institute of Occupational Health (NIOH), Indian Council of Medical Research (ICMR), Meghaninagar, Near Raksha Shakti University, Ahmedabad, Gujarat, 380016, India.
| | - Immad A Shah
- Division of Agricultural Statistics, Sher-e-Kashmir University of Agricultural Sciences & Technology of Kashmir, Jammu & Kashmir, Srinagar, 190025, India
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Turyahabwe S, Bamuloba M, Mugenyi L, Amanya G, Byaruhanga R, Imoko JF, Nakawooya M, Walusimbi S, Nidoi J, Burua A, Sekadde M, Muttamba W, Arinaitwe M, Henry L, Kengonzi R, Mudiope M, Kirenga BJ. Community tuberculosis screening, testing and care, Uganda. Bull World Health Organ 2024; 102:400-409. [PMID: 38812802 PMCID: PMC11132162 DOI: 10.2471/blt.23.290641] [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: 08/08/2023] [Revised: 01/14/2024] [Accepted: 02/29/2024] [Indexed: 05/31/2024] Open
Abstract
Objective To assess the effectiveness of a community-based tuberculosis and leprosy intervention in which village health teams and health workers conduct door-to-door tuberculosis screening, targeted screenings and contact tracing. Methods We conducted a before-and-after implementation study in Uganda to assess the effectiveness of the community tuberculosis intervention by looking at reach, outputs, adoption and effectiveness of the intervention. Campaign 1 was conducted in March 2022 and campaign 2 in September 2022. We calculated percentages of targets achieved and compared case notification rates during the intervention with corresponding quarters in the previous year. We also assessed the leprosy screening. Findings Over 5 days, campaign 1 screened 1 289 213 people (2.9% of the general population), of whom 179 144 (13.9%) fulfilled the presumptive tuberculosis criteria, and 4043 (2.3%) were diagnosed with bacteriologically-confirmed tuberculosis; 3710 (91.8%) individuals were linked to care. In campaign 2, 5 134 056 people (11.6% of the general population) were screened, detecting 428 444 (8.3%) presumptive tuberculosis patients and 8121 (1.9%) bacteriologically-confirmed tuberculosis patients; 5942 individuals (87.1%) were linked to care. The case notification rate increased from 48.1 to 59.5 per 100 000 population in campaign 1, with a case notification rate ratio of 1.24 (95% confidence interval, CI: 1.22-1.26). In campaign 2, the case notification rate increased from 45.0 to 71.6 per 100 000 population, with a case notification rate ratio of 1.59 (95% CI: 1.56-1.62). Of the 176 patients identified with leprosy, 137 (77.8%) initiated treatment. Conclusion This community tuberculosis screening initiative is effective. However, continuous monitoring and adaptations are needed to overcome context-specific implementation challenges.
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Affiliation(s)
- Stavia Turyahabwe
- National TB and Leprosy Program, Ministry of Health, Uganda, 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Muzamiru Bamuloba
- National TB and Leprosy Program, Ministry of Health, Uganda, 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Levicatus Mugenyi
- Department of Statistics, The Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Geoffrey Amanya
- National TB and Leprosy Program, Ministry of Health, Uganda, 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Raymond Byaruhanga
- National TB and Leprosy Program, Ministry of Health, Uganda, 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Joseph Fry Imoko
- Department of Research and Innovation, Makerere University Lung Institute, Kampala, Uganda
| | - Mabel Nakawooya
- National TB and Leprosy Program, Ministry of Health, Uganda, 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Simon Walusimbi
- Department of Research and Innovation, Makerere University Lung Institute, Kampala, Uganda
| | - Jasper Nidoi
- Department of Research and Innovation, Makerere University Lung Institute, Kampala, Uganda
| | - Aldomoro Burua
- National TB and Leprosy Program, Ministry of Health, Uganda, 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Moorine Sekadde
- National TB and Leprosy Program, Ministry of Health, Uganda, 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Winters Muttamba
- Department of Research and Innovation, Makerere University Lung Institute, Kampala, Uganda
| | - Moses Arinaitwe
- National TB and Leprosy Program, Ministry of Health, Uganda, 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Luzze Henry
- National TB and Leprosy Program, Ministry of Health, Uganda, 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Rose Kengonzi
- National TB and Leprosy Program, Ministry of Health, Uganda, 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Mary Mudiope
- Department of Health Systems Strengthening, Infectious Diseases Institute, Kampala, Uganda
| | - Bruce J Kirenga
- Department of Research and Innovation, Makerere University Lung Institute, Kampala, Uganda
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Malhotra A, Ryckman TS, Johnson K, Uhlig E, Creswell J, Kendall EA, Dowdy DW, Sohn H. Active case-finding of tuberculosis compared with symptom-driven standard of care: a modelling analysis. Int J Epidemiol 2024; 53:dyae019. [PMID: 38374719 DOI: 10.1093/ije/dyae019] [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: 06/26/2023] [Accepted: 01/26/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND In settings with large case detection gaps, active case-finding (ACF) may play a critical role in the uberculosis (TB) response. However, ACF is resource intensive, and its effectiveness depends on whether people detected with TB through ACF might otherwise spontaneously resolve or be diagnosed through routine care. We analysed the potential effectiveness of ACF for TB relative to the counterfactual scenario of routine care alone. METHODS We constructed a Markov simulation model of TB natural history, diagnosis, symptoms, ACF and treatment, using a hypothetical reference setting using data from South East Asian countries. We calibrated the model to empirical data using Bayesian methods, and simulated potential 5-year outcomes with an 'aspirational' ACF intervention (reflecting maximum possible effectiveness) compared with the standard-of-care outcomes. RESULTS Under the standard of care, 51% (95% credible interval, CrI: 31%, 75%) of people with prevalent TB at baseline were estimated to be diagnosed and linked to care over 5 years. With aspirational ACF, this increased to 88% (95% CrI: 84%, 94%). Most of this difference represented people who were diagnosed and treated through ACF but experienced spontaneous resolution under standard-of-care. Aspirational ACF was projected to reduce the average duration of TB disease by 12 months (95% CrI: 6%, 18%) and TB-associated disability-adjusted life-years by 71% (95% CrI: 67%, 76%). CONCLUSION These data illustrate the importance of considering outcomes in a counterfactual standard of care scenario, as well as trade-offs between overdiagnosis and averted morbidity through earlier diagnosis-not just for TB, but for any disease in which population-based screening is recommended.
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Affiliation(s)
- Akash Malhotra
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Theresa S Ryckman
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karl Johnson
- Department of Public Health Leadership and Practice, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA
| | | | - Jacob Creswell
- Stop TB Partnership, Innovations and Grants, Geneva, Switzerland
| | - Emily A Kendall
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Hojoon Sohn
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, South Korea
- Department of Human Systems Medicine, Seoul National University College of Medicine, Seoul, South Korea
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Brümmer LE, Thompson RR, Malhotra A, Shrestha S, Kendall EA, Andrews JR, Phillips P, Nahid P, Cattamanchi A, Marx FM, Denkinger CM, Dowdy DW. Cost-effectiveness of Low-complexity Screening Tests in Community-based Case-finding for Tuberculosis. Clin Infect Dis 2024; 78:154-163. [PMID: 37623745 PMCID: PMC10810711 DOI: 10.1093/cid/ciad501] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/18/2023] [Accepted: 08/22/2023] [Indexed: 08/26/2023] Open
Abstract
INTRODUCTION In high-burden settings, low-complexity screening tests for tuberculosis (TB) could expand the reach of community-based case-finding efforts. The potential costs and cost-effectiveness of approaches incorporating these tests are poorly understood. METHODS We developed a microsimulation model assessing 3 approaches to community-based case-finding in hypothetical populations (India-, South Africa-, The Philippines-, Uganda-, and Vietnam-like settings) with TB prevalence 4 times that of national estimates: (1) screening with a point-of-care C-reactive protein (CRP) test, (2) screening with a more sensitive "Hypothetical Screening test" (95% sensitive for Xpert Ultra-positive TB, 70% specificity; equipment/labor costs similar to Xpert Ultra, but using a $2 cartridge) followed by sputum Xpert Ultra if positive, or (3) testing all individuals with sputum Xpert Ultra. Costs are expressed in 2023 US dollars and include treatment costs. RESULTS Universal Xpert Ultra was estimated to cost a mean $4.0 million (95% uncertainty range: $3.5 to $4.6 million) and avert 3200 (2600 to 3900) TB-related disability-adjusted life years (DALYs) per 100 000 people screened ($670 [The Philippines] to $2000 [Vietnam] per DALY averted). CRP was projected to cost $550 (The Philippines) to $1500 (Vietnam) per DALY averted but with 44% fewer DALYs averted. The Hypothetical Screening test showed minimal benefit compared to universal Xpert Ultra, but if specificity were improved to 95% and per-test cost to $4.5 (all-inclusive), this strategy could cost $390 (The Philippines) to $940 (Vietnam) per DALY averted. CONCLUSIONS Screening tests can meaningfully improve the cost-effectiveness of community-based case-finding for TB but only if they are sensitive, specific, and inexpensive.
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Affiliation(s)
- Lukas E Brümmer
- Division of Infectious Disease and Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Infection Research (DZIF), partner site Heidelberg, Heidelberg University Hospital, Heidelberg, Germany
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ryan R Thompson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Akash Malhotra
- 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
| | - Emily A Kendall
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, San Francisco, California, USA
| | - Patrick Phillips
- Center for Tuberculosis, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, California, USA
| | - Payam Nahid
- Center for Tuberculosis, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, California, USA
| | - Adithya Cattamanchi
- Center for Tuberculosis, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, California, USA
- Division of Pulmonary Diseases and Critical Care Medicine, University of California Irvine, Irvine, California, USA
| | - Florian M Marx
- Division of Infectious Disease and Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Infection Research (DZIF), partner site Heidelberg, Heidelberg University Hospital, Heidelberg, Germany
| | - Claudia M Denkinger
- Division of Infectious Disease and Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Infection Research (DZIF), partner site Heidelberg, Heidelberg University Hospital, Heidelberg, Germany
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Htet KKK, Phyu AN, Zayar NN, Chongsuvivatwong V. Active Tuberculosis Screening via a Mobile Health App in Myanmar: Incremental Cost-Effectiveness Evaluation. JMIR Form Res 2023; 7:e51998. [PMID: 37948119 PMCID: PMC10674145 DOI: 10.2196/51998] [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: 08/19/2023] [Revised: 10/10/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND A mobile app that calculates a tuberculosis (TB) risk score based on individual social and pathological characteristics has been shown to be a better predictor of the risk of contracting TB than conventionally used TB signs and symptoms (TBSS) in Myanmar, where the TB burden is high. Its cost-effectiveness, however, has not yet been assessed. OBJECTIVE This study aimed to determine the incremental costs of this mobile app and of chest x-rays (CXRs) in averting disability-adjusted life years (DALYs) among missed cases of active TB in the population being screened. METHODS Elements of incremental costs and effectiveness of 3 initial TB screening strategies were examined, including TBSS followed by CXR, the mobile app followed by CXR, and universal CXR. The incremental cost-effectiveness ratio (ICER; ie, the additional cost for each additional DALY averted) was compared to TBSS screening. Based on the latest 2020 gross domestic product (GDP) per capita of Myanmar (US $1477.50), the ICER was compared to willingness-to-pay (WTP) thresholds of 1, 2, and 3 times the GDP per capita. Probabilistic sensitivity analysis was conducted with a Monte Carlo simulation to compute the levels of probability that the ICER for each strategy was below each WTP threshold. RESULTS For each 100,000 population, the incremental cost compared to TBSS of active TB screening was US $345,942 for the mobile app and US $1,810,712 for universal CXR. The incremental effectiveness was 325 DALYs averted for the mobile app and 576 DALYs averted for universal CXR. For the mobile app, the estimated ICER was US $1064 (72% of GDP per capita) per 1 DALY averted. Furthermore, 100% of the simulated values were below an additional cost of 1 times the GDP per capita for 1 additional DALY averted. The universal CXR strategy has an estimated ICER of US $3143 (2.1 times the GDP per capita) per 1 DALY averted and an additional 77.2% DALYs averted compared to the app (ie, 576 - 325 / 325 DALYs); however, 0.5% of the simulated values were higher than an additional expenditure of 3 times the GDP per capita. CONCLUSIONS Based on the status of the economy in 2020, the mobile app strategy is affordable for Myanmar. The universal CXR strategy, although it could prevent an additional 77% of DALYs, is probably unaffordable. Compared to the TBSS strategy, the mobile app system based on social and pathological characteristics of TB has potential as a TB screening tool to identify missing TB cases and to reduce TB morbidity and mortality, thereby helping to achieve the global goal of "End TB" in resource-limited settings with a high TB burden.
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Affiliation(s)
- Kyaw Ko Ko Htet
- Department of Epidemiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Aye Nyein Phyu
- Department of Public Health, National Tuberculosis Programme, Ministry of Health and Sports, Mandalay, Myanmar
| | - Nyi Nyi Zayar
- Department of Epidemiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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Shrestha S, Mishra G, Hamal M, Dhital R, Shrestha S, Shrestha A, Shah NP, Khanal M, Gurung S, Caws M. Quantifying the potential epidemiological impact of a 2-year active case finding for tuberculosis in rural Nepal: a model-based analysis. BMJ Open 2023; 13:e062123. [PMID: 37914308 PMCID: PMC10626874 DOI: 10.1136/bmjopen-2022-062123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 09/22/2023] [Indexed: 11/03/2023] Open
Abstract
OBJECTIVES Active case finding (ACF) is an important tuberculosis (TB) intervention in high-burden settings. However, empirical evidence garnered from field data has been equivocal about the long-term community-level impact, and more data at a finer geographic scale and data-informed methods to quantify their impact are necessary. METHODS Using village development committee (VDC)-level data on TB notification and demography between 2016 and 2017 in four southern districts of Nepal, where ACF activities were implemented as a part of the IMPACT-TB study between 2017 and 2019, we developed VDC-level transmission models of TB and ACF. Using these models and ACF yield data collected in the study, we estimated the potential epidemiological impact of IMPACT-TB ACF and compared its efficiency across VDCs in each district. RESULTS Cases were found in the majority of VDCs during IMPACT-TB ACF, but the number of cases detected within VDCs correlated weakly with historic case notification rates. We projected that this ACF intervention would reduce the TB incidence rate by 14% (12-16) in Chitwan, 8.6% (7.3-9.7) in Dhanusha, 8.3% (7.3-9.2) in Mahottari and 3% (2.5-3.2) in Makwanpur. Over the next 10 years, we projected that this intervention would avert 987 (746-1282), 422 (304-571), 598 (450-782) and 197 (172-240) cases in Chitwan, Dhanusha, Mahottari and Makwanpur, respectively. There was substantial variation in the efficiency of ACF across VDCs: there was up to twofold difference in the number of cases averted in the 10 years per case detected. CONCLUSION ACF data confirm that TB is widely prevalent, including in VDCs with relatively low reporting rates. Although ACF is a highly efficient component of TB control, its impact can vary substantially at local levels and must be combined with other interventions to alter TB epidemiology significantly.
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Affiliation(s)
- Sourya Shrestha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Gokul Mishra
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
- Birat Nepal Medical Trust, Kathmandu, Nepal
| | - Mukesh Hamal
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | | | | | | | - Suman Gurung
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
- Birat Nepal Medical Trust, Kathmandu, Nepal
| | - Maxine Caws
- Birat Nepal Medical Trust, Kathmandu, Nepal
- Liverpool School of Tropical Medicine, Liverpool, UK
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Coleman M, Nguyen TA, Luu BK, Hill J, Ragonnet R, Trauer JM, Fox GJ, Marks GB, Marais BJ. Finding and treating both tuberculosis disease and latent infection during population-wide active case finding for tuberculosis elimination. Front Med (Lausanne) 2023; 10:1275140. [PMID: 37908846 PMCID: PMC10613897 DOI: 10.3389/fmed.2023.1275140] [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: 08/09/2023] [Accepted: 10/02/2023] [Indexed: 11/02/2023] Open
Abstract
In recognition of the high rates of undetected tuberculosis in the community, the World Health Organization (WHO) encourages targeted active case finding (ACF) among "high-risk" populations. While this strategy has led to increased case detection in these populations, the epidemic impact of these interventions has not been demonstrated. Historical data suggest that population-wide (untargeted) ACF can interrupt transmission in high-incidence settings, but implementation remains lacking, despite recent advances in screening tools. The reservoir of latent infection-affecting up to a quarter of the global population -complicates elimination efforts by acting as a pool from which future tuberculosis cases may emerge, even after all active cases have been treated. A holistic case finding strategy that addresses both active disease and latent infection is likely to be the optimal approach for rapidly achieving sustainable progress toward TB elimination in a durable way, but safety and cost effectiveness have not been demonstrated. Sensitive, symptom-agnostic community screening, combined with effective tuberculosis treatment and prevention, should eliminate all infectious cases in the community, whilst identifying and treating people with latent infection will also eliminate tomorrow's tuberculosis cases. If real strides toward global tuberculosis elimination are to be made, bold strategies are required using the best available tools and a long horizon for cost-benefit assessment.
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Affiliation(s)
- Mikaela Coleman
- WHO Collaborating Centre for Tuberculosis and the Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Sydney, NSW, Australia
- Centenary Institute, The University of Sydney, Sydney, NSW, Australia
| | - Thu-Anh Nguyen
- Woolcock Institute of Medical Research, Hanoi, Vietnam
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Boi Khanh Luu
- Woolcock Institute of Medical Research, Hanoi, Vietnam
| | - Jeremy Hill
- WHO Collaborating Centre for Tuberculosis and the Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Sydney, NSW, Australia
- Centenary Institute, The University of Sydney, Sydney, NSW, Australia
| | - Romain Ragonnet
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - James M. Trauer
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Greg J. Fox
- WHO Collaborating Centre for Tuberculosis and the Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Woolcock Institute of Medical Research, Sydney, NSW, Australia
| | - Guy B. Marks
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Woolcock Institute of Medical Research, Sydney, NSW, Australia
- Department of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Ben J. Marais
- WHO Collaborating Centre for Tuberculosis and the Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Sydney, NSW, Australia
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Quang Vo LN, Forse RJ, Tran J, Dam T, Driscoll J, Codlin AJ, Creswell J, Sidney-Annerstedt K, Van Truong V, Thi Minh HD, Huu LN, Nguyen HB, Nguyen NV. Economic evaluation of a community health worker model for tuberculosis care in Ho Chi Minh City, Viet Nam: a mixed-methods Social Return on Investment Analysis. BMC Public Health 2023; 23:945. [PMID: 37231468 DOI: 10.1186/s12889-023-15841-2] [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: 07/13/2022] [Accepted: 05/08/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND There is extensive evidence for the cost-effectiveness of programmatic and additional tuberculosis (TB) interventions, but no studies have employed the social return on investment (SROI) methodology. We conducted a SROI analysis to measure the benefits of a community health worker (CHW) model for active TB case finding and patient-centered care. METHODS This mixed-method study took place alongside a TB intervention implemented in Ho Chi Minh City, Viet Nam, between October-2017 - September-2019. The valuation encompassed beneficiary, health system and societal perspectives over a 5-year time-horizon. We conducted a rapid literature review, two focus group discussions and 14 in-depth interviews to identify and validate pertinent stakeholders and material value drivers. We compiled quantitative data from the TB program's and the intervention's surveillance systems, ecological databases, scientific publications, project accounts and 11 beneficiary surveys. We mapped, quantified and monetized value drivers to derive a crude financial benefit, which was adjusted for four counterfactuals. We calculated a SROI based on the net present value (NPV) of benefits and investments using a discounted cash flow model with a discount rate of 3.5%. A scenario analysis assessed SROI at varying discount rates of 0-10%. RESULTS The mathematical model yielded NPVs of US$235,511 in investments and US$8,497,183 in benefits. This suggested a return of US$36.08 for each dollar invested, ranging from US$31.66-US39.00 for varying discount rate scenarios. CONCLUSIONS The evaluated CHW-based TB intervention generated substantial individual and societal benefits. The SROI methodology may be an alternative for the economic evaluation of healthcare interventions.
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Affiliation(s)
- Luan Nguyen Quang Vo
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam.
| | - Rachel Jeanette Forse
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | - Jacqueline Tran
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | - Thu Dam
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | - Jenny Driscoll
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | - Andrew James Codlin
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | | | - Kristi Sidney-Annerstedt
- Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Solna, Sweden
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Esmail A, Randall P, Oelofse S, Tomasicchio M, Pooran A, Meldau R, Makambwa E, Mottay L, Jaumdally S, Calligaro G, Meier S, de Kock M, Gumbo T, Warren RM, Dheda K. Comparison of two diagnostic intervention packages for community-based active case finding for tuberculosis: an open-label randomized controlled trial. Nat Med 2023; 29:1009-1016. [PMID: 36894651 DOI: 10.1038/s41591-023-02247-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 02/01/2023] [Indexed: 03/11/2023]
Abstract
Two in every five patients with active tuberculosis (TB) remain undiagnosed or unreported. Therefore community-based, active case-finding strategies require urgent implementation. However, whether point-of-care (POC), portable battery-operated, molecular diagnostic tools deployed at a community level, compared with conventionally used POC smear microscopy, can shorten time-to-treatment initiation, thus potentially curtailing transmission, remains unclear. To clarify this issue, we performed an open-label, randomized controlled trial in periurban informal settlements of Cape Town, South Africa, where we TB symptom screened 5,274 individuals using a community-based scalable mobile clinic. Some 584 individuals with HIV infection or symptoms of TB underwent targeted diagnostic screening and were randomized (1:1) to same-day smear microscopy (n = 296) or on-site DNA-based molecular diagnosis (n = 288; GeneXpert). The primary aim was to compare time to TB treatment initiation between the arms. Secondary aims included feasibility and detection of probably infectious people. Of participants who underwent targeted screening, 9.9% (58 of 584) had culture-confirmed TB. Time-to-treatment initiation occurred significantly earlier in the Xpert versus the smear-microscopy arm (8 versus 41 d, P = 0.002). However, overall, Xpert detected only 52% of individuals with culture-positive TB. Notably, Xpert detected almost all of the probably infectious patients compared with smear microscopy (94.1% versus 23.5%, P = <0.001). Xpert was associated with a shorter median time to treatment of probably infectious patients (7 versus 24 d, P = 0.02) and a greater proportion of infectious patients were on treatment at 60 d compared with the probably noninfectious patients (76.5% versus 38.2%, P < 0.01). Overall, a greater proportion of POC Xpert-positive participants were on treatment at 60 d compared with all culture-positive participants (100% versus 46.5%, P < 0.01). These findings challenge the traditional paradigm of a passive case-finding, public health strategy and argues for the implementation of portable DNA-based diagnosis with linkage to care as a community-oriented, transmission-interruption strategy. The study was registered with the South African National Clinical Trials Registry (application ID 4367; DOH-27-0317-5367) and ClinicalTrials.gov (NCT03168945).
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Affiliation(s)
- Aliasgar Esmail
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Philippa Randall
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Suzette Oelofse
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Michele Tomasicchio
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Anil Pooran
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Richard Meldau
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Edson Makambwa
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Lynelle Mottay
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Shameem Jaumdally
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Gregory Calligaro
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Stuart Meier
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Marianna de Kock
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research/SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | | | - Robin Mark Warren
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research/SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa.
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
- Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, UK.
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Brown LK, Van Schalkwyk C, De Villiers AK, Marx FM. Impact of interventions for tuberculosis prevention and care in South Africa - a systematic review of mathematical modelling studies. S Afr Med J 2023; 113:125-134. [PMID: 36876352 DOI: 10.7196/samj.2023.v113i3.16812] [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: 03/02/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Substantial additional efforts are needed to prevent, find and successfully treat tuberculosis (TB) in South Africa (SA). In thepast decade, an increasing body of mathematical modelling research has investigated the population-level impact of TB prevention and careinterventions. To date, this evidence has not been assessed in the SA context. OBJECTIVE To systematically review mathematical modelling studies that estimated the impact of interventions towards the World HealthOrganization's End TB Strategy targets for TB incidence, TB deaths and catastrophic costs due to TB in SA. METHODS We searched the PubMed, Web of Science and Scopus databases for studies that used transmission-dynamic models of TB in SAand reported on at least one of the End TB Strategy targets at population level. We described study populations, type of interventions andtheir target groups, and estimates of impact and other key findings. For studies of country-level interventions, we estimated average annualpercentage declines (AAPDs) in TB incidence and mortality attributable to the intervention. RESULTS We identified 29 studies that met our inclusion criteria, of which 7 modelled TB preventive interventions (vaccination,antiretroviral treatment (ART) for HIV, TB preventive treatment (TPT)), 12 considered interventions along the care cascade for TB(screening/case finding, reducing initial loss to follow-up, diagnostic and treatment interventions), and 10 modelled combinationsof preventive and care-cascade interventions. Only one study focused on reducing catastrophic costs due to TB. The highest impactof a single intervention was estimated in studies of TB vaccination, TPT among people living with HIV, and scale-up of ART. Forpreventive interventions, AAPDs for TB incidence varied between 0.06% and 7.07%, and for care-cascade interventions between 0.05%and 3.27%. CONCLUSION We describe a body of mathematical modelling research with a focus on TB prevention and care in SA. We found higherestimates of impact reported in studies of preventive interventions, highlighting the need to invest in TB prevention in SA. However, studyheterogeneity and inconsistent baseline scenarios limit the ability to compare impact estimates between studies. Combinations, rather thansingle interventions, are likely needed to reach the End TB Strategy targets in SA.
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Affiliation(s)
- L K Brown
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Cape Town, South Africa.
| | - C Van Schalkwyk
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Cape Town, South Africa.
| | - A K De Villiers
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Cape Town, South Africa; Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - F M Marx
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Cape Town, South Africa; Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Division of Infectious Disease and Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany.
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Gomes I, Dong C, Vandewalle P, Khan A, Creswell J, Dowdy D, Sohn H. Comparative assessment of the cost-effectiveness of Tuberculosis (TB) active case-finding interventions: A systematic analysis of TB REACH wave 5 projects. PLoS One 2022; 17:e0270816. [PMID: 36156080 PMCID: PMC9512197 DOI: 10.1371/journal.pone.0270816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/19/2022] [Indexed: 11/18/2022] Open
Abstract
Purpose Interventions that can help streamline and reduce gaps in the tuberculosis (TB) care cascade can play crucial roles in TB prevention and care, but are often operationally complex and resource intensive, given the heterogenous settings in which they are implemented. In this study, we present a comparative analysis on cost-effectiveness of TB REACH Wave 5 projects with diverse programmatic objectives to inform future decisions regarding funding, strategic adoption, and scale-up. Methods We comprehensively reviewed project reports and financial statements from TB REACH Wave 5, a funding mechanism for interventions that aimed to strengthen the TB care cascade in diverse settings. Two independent reviewers abstracted cost (in 2017 US dollars) and key programmatic data, including project type (case-finding only; case-finding and linkage-to-care; or case-finding, linkage-to-care and patient support), operational setting (urban or rural), and project outputs (numbers of people with TB diagnosed, started on treatment, and successfully completing treatment). Cost-effectiveness ratios for each project were calculated as ratios of apportioned programmatic expenditures to corresponding project outputs. Results Of 32 case finding and patient support projects funded through TB REACH Wave 5, 29 were included for analysis (11 case-finding only; 9 case-finding and linkage-to-care; and 9 case-finding, linkage-to-care and patient support). 21 projects (72%) were implemented in either Africa or Southeast Asia, and 19 (66%) focused on serving urban areas. Average cost-effectiveness was $184 per case diagnosed (range: $30-$10,497), $332 per diagnosis and treatment initiation ($123-$10,608), and $40 per patient treatment supported ($8-$160). Cost per case diagnosed was lower for case-finding-only projects ($132) than projects including linkage-to-care ($342) or linkage-to-care and patient support ($254), and generally increased with the corresponding country’s per-capita GDP ($543 per $1000 increase, 95% confidence interval: -$53, $1138). Conclusion The costs and cost-effectiveness of interventions to strengthen the TB care cascade were heterogenous, reflecting differences in context and programmatic objective. Nevertheless, many such interventions are likely to offer good value for money. Systematic collection and analysis of cost-effectiveness data can help improve comparability, monitoring, and evaluation.
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Affiliation(s)
- Isabella Gomes
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Chaoran Dong
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Amera Khan
- Stop TB Partnership, TB REACH Initiative, Geneva, Switzerland
| | - Jacob Creswell
- Stop TB Partnership, TB REACH Initiative, Geneva, Switzerland
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Hojoon Sohn
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- * E-mail:
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Borodulina EA, Piskun VV, Uraksina MV, Shubina AT. Molecular genetic tests GeneXpert MTB/RIF and Xpert MTB/RIF (Ultra) in the diagnosis of tuberculosis (review of literature). Klin Lab Diagn 2022; 67:544-549. [PMID: 36099465 DOI: 10.51620/0869-2084-2022-67-9-544-549] [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] [Indexed: 06/15/2023]
Abstract
In recent tuberculosis years is the main cause of morbidity and death among patients with HIV infection. Modern diagnostics of tuberculosis includes mass screening of the population: digital fluorography from the age of 15 and immunodiagnostics in children and adolescents. Detection of mycobacterium tuberculosis by microscopy occurs in forms of tuberculosis with the decay of lung tissue. Such patients represent a high epidemic risk. To improve the verification of diagnosis in the practice of a phthisiologist, molecular genetic methods for the search for mycobacteria are increasingly used, based on the identification of specific fragments of the DNA chain in the diagnostic material. The most widely used method is the polymerase chain reaction (PCR), which is based on directed DNA amplification. The latest innovation is fully automated systems using cartridge technology GeneXpert. The advantages of GeneXpert are high sensitivity, speed (result in 2 hours), real-time PCR detection, exclusion of sample contamination. The technique of cartridge technology is constantly being improved, various cartridges are used on its platform, which not only detect M. tuberculosis, but also determine the sensitivity to anti-tuberculosis drugs - rifampicin (MTB / RIF cartridge) or several anti-TB drugs (MTB / XDR). Cartridges have been developed that are able to detect Mycobacterium tuberculosis (MBT) at an even lower concentration in the test material - MTB / RIF (Ultra). GeneXpert technology can be used to diagnose extrapulmonary tuberculosis by examining various biological materials, which are more effective in detecting tuberculosis in children and adolescents, in HIV-positive individuals.
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Kerkhoff AD, Chilukutu L, Nyangu S, Kagujje M, Mateyo K, Sanjase N, Eshun-Wilson I, Geng EH, Havlir DV, Muyoyeta M. Patient Preferences for Strategies to Improve Tuberculosis Diagnostic Services in Zambia. JAMA Netw Open 2022; 5:e2229091. [PMID: 36036933 PMCID: PMC9425150 DOI: 10.1001/jamanetworkopen.2022.29091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Delayed engagement in tuberculosis (TB) services is associated with ongoing transmission and poor clinical outcomes. OBJECTIVE To assess whether patients with TB have differential preferences for strategies to improve the public health reach of TB diagnostic services. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study was undertaken in which a discrete choice experiment (DCE) was administered between September 18, 2019, and January 17, 2020, to 401 adults (>18 years of age) with microbiologically confirmed TB in Lusaka, Zambia. The DCE had 7 attributes with 2 to 3 levels per attribute related to TB service enhancements. Latent class analysis was used to identify segments of participants with unique preferences. Multiscenario simulations were used to estimate shares of preferences for different TB service improvement strategies. MAIN OUTCOMES AND MEASURES The main outcomes were patient preference archetypes and estimated shares of preferences for different strategies to improve TB diagnostic services. Collected data were analyzed between January 3, 2022, to July 2, 2022. RESULTS Among 326 adults with TB (median [IQR] age, 34 [27-42] years; 217 [66.8%] male; 158 [48.8%] HIV positive), 3 groups with distinct preferences for TB service improvements were identified. Group 1 (192 participants [58.9%]) preferred a facility that offered same-day TB test results, shorter wait times, and financial incentives for testing. Group 2 (83 participants [25.4%]) preferred a facility that provided same-day TB results, had greater privacy, and was closer to home. Group 3 (51 participants [15.6%]) had no strong preferences for service improvements and had negative preferences for receiving telephone-based TB test results. Groups 1 and 2 were more likely to report at least a 4-week delay in seeking health care for their current TB episode compared with group 3 (29 [51.3%] in group 1, 95 [35.8%] in group 2, and 10 [19.6%] in group 3; P < .001). Strategies to improve TB diagnostic services most preferred by all participants were same-day TB test results alone (shares of preference, 69.9%) and combined with a small financial testing incentive (shares of preference, 79.3%), shortened wait times (shares of preference, 76.1%), or greater privacy (shares of preference, 75.0%). However, the most preferred service improvement strategies differed substantially by group. CONCLUSIONS AND RELEVANCE In this study, patients with TB had heterogenous preferences for TB diagnostic service improvements associated with differential health care-seeking behavior. Tailored strategies that incorporate features most valued by persons with undiagnosed TB, including same-day results, financial incentives, and greater privacy, may optimize reach by overcoming key barriers to timely TB care engagement.
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Affiliation(s)
- Andrew D. Kerkhoff
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco School of Medicine, San Francisco
| | | | - Sarah Nyangu
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Mary Kagujje
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Kondwelani Mateyo
- Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Nsala Sanjase
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri
| | - Elvin H. Geng
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco School of Medicine, San Francisco
| | - Monde Muyoyeta
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
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Shah HD, Nazli Khatib M, Syed ZQ, Gaidhane AM, Yasobant S, Narkhede K, Bhavsar P, Patel J, Sinha A, Puwar T, Saha S, Saxena D. Gaps and Interventions across the Diagnostic Care Cascade of TB Patients at the Level of Patient, Community and Health System: A Qualitative Review of the Literature. Trop Med Infect Dis 2022; 7:tropicalmed7070136. [PMID: 35878147 PMCID: PMC9315562 DOI: 10.3390/tropicalmed7070136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/03/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022] Open
Abstract
Tuberculosis (TB) continues to be one of the important public health concerns globally, and India is among the seven countries with the largest burden of TB. There has been a consistent increase in the notifications of TB cases across the globe. However, the 2018 estimates envisage a gap of about 30% between the incident and notified cases of TB, indicating a significant number of patients who remain undiagnosed or ‘missed’. It is important to understand who is ‘missed’, find this population, and provide quality care. Given these complexities, we reviewed the diagnostic gaps in the care cascade for TB. We searched Medline via PubMed and CENTRAL databases via the Cochrane Library. The search strategy for PubMed was tailored to individual databases and was as: ((((((tuberculosis[Title/Abstract]) OR (TB[Title/Abstract])) OR (koch *[Title/Abstract])) OR (“tuberculosis”[MeSH Terms]))) AND (((diagnos *) AND (“diagnosis”[MeSH Terms])))). Furthermore, we screened the references list of the potentially relevant studies to seek additional studies. Studies retrieved from these electronic searches and relevant references included in the bibliography of those studies were reviewed. Original studies in English that assessed the causes of diagnostic gaps and interventions used to address them were included. Delays in diagnosis were found to be attributable to both the individuals’ and the health system’s capacity to diagnose and promptly commence treatment. This review provides insights into the diagnostic gaps in a cascade of care for TB and different interventions adopted in studies to close this gap. The major diagnostic gaps identified in this review are as follows: people may not have access to TB diagnostic tests, individuals are at a higher risk of missed diagnosis, services are available but people may not seek care with a diagnostic facility, and patients are not diagnosed despite reaching health facilities. Therefore, reaching the goal to End TB requires putting in place models and methods to provide prompt and quality assured diagnosis to populations at par.
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Affiliation(s)
- Harsh D Shah
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar 382042, India; (S.Y.); (K.N.); (P.B.); (J.P.); (A.S.); (T.P.); (S.S.); (D.S.)
- Correspondence:
| | - Mahalaqua Nazli Khatib
- Global Evidence Synthesis Initiative, School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha 442004, India; (M.N.K.); (Z.Q.S.); (A.M.G.)
| | - Zahiruddin Quazi Syed
- Global Evidence Synthesis Initiative, School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha 442004, India; (M.N.K.); (Z.Q.S.); (A.M.G.)
| | - Abhay M. Gaidhane
- Global Evidence Synthesis Initiative, School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha 442004, India; (M.N.K.); (Z.Q.S.); (A.M.G.)
| | - Sandul Yasobant
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar 382042, India; (S.Y.); (K.N.); (P.B.); (J.P.); (A.S.); (T.P.); (S.S.); (D.S.)
- Global Evidence Synthesis Initiative, School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha 442004, India; (M.N.K.); (Z.Q.S.); (A.M.G.)
| | - Kiran Narkhede
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar 382042, India; (S.Y.); (K.N.); (P.B.); (J.P.); (A.S.); (T.P.); (S.S.); (D.S.)
| | - Priya Bhavsar
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar 382042, India; (S.Y.); (K.N.); (P.B.); (J.P.); (A.S.); (T.P.); (S.S.); (D.S.)
| | - Jay Patel
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar 382042, India; (S.Y.); (K.N.); (P.B.); (J.P.); (A.S.); (T.P.); (S.S.); (D.S.)
| | - Anish Sinha
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar 382042, India; (S.Y.); (K.N.); (P.B.); (J.P.); (A.S.); (T.P.); (S.S.); (D.S.)
| | - Tapasvi Puwar
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar 382042, India; (S.Y.); (K.N.); (P.B.); (J.P.); (A.S.); (T.P.); (S.S.); (D.S.)
| | - Somen Saha
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar 382042, India; (S.Y.); (K.N.); (P.B.); (J.P.); (A.S.); (T.P.); (S.S.); (D.S.)
- Global Evidence Synthesis Initiative, School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha 442004, India; (M.N.K.); (Z.Q.S.); (A.M.G.)
| | - Deepak Saxena
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar 382042, India; (S.Y.); (K.N.); (P.B.); (J.P.); (A.S.); (T.P.); (S.S.); (D.S.)
- Global Evidence Synthesis Initiative, School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha 442004, India; (M.N.K.); (Z.Q.S.); (A.M.G.)
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Tovar M, Aleta A, Sanz J, Moreno Y. Modeling the impact of COVID-19 on future tuberculosis burden. COMMUNICATIONS MEDICINE 2022; 2:77. [PMID: 35784445 PMCID: PMC9243113 DOI: 10.1038/s43856-022-00145-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 06/16/2022] [Indexed: 01/09/2023] Open
Abstract
Background The ongoing COVID-19 pandemic has greatly disrupted our everyday life, forcing the adoption of non-pharmaceutical interventions in many countries and putting public health services and healthcare systems worldwide under stress. These circumstances are leading to unintended effects such as the increase in the burden of other diseases. Methods Here, using a data-driven epidemiological model for tuberculosis (TB) spreading, we describe the expected rise in TB incidence and mortality if COVID-associated changes in TB notification are sustained and attributable entirely to disrupted diagnosis and treatment adherence. Results Our calculations show that the reduction in diagnosis of new TB cases due to the COVID-19 pandemic could result in 228k (CI 187-276) excess deaths in India, 111k (CI 93-134) in Indonesia, 27k (CI 21-33) in Pakistan, and 12k (CI 9-18) in Kenya. Conclusions We show that it is possible to reverse these excess deaths by increasing the pre-covid diagnosis capabilities from 15 to 50% for 2 to 4 years. This would prevent almost all TB-related excess mortality that could be caused by the COVID-19 pandemic if no additional preventative measures are introduced. Our work therefore provides guidelines for mitigating the impact of COVID-19 on tuberculosis epidemic in the years to come.
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Affiliation(s)
- Mario Tovar
- grid.11205.370000 0001 2152 8769Institute for Biocomputation and Physics of Complex Systems (BIFI), University of Zaragoza, 50009 Zaragoza, Spain ,grid.11205.370000 0001 2152 8769Department of Theoretical Physics, University of Zaragoza, 50009 Zaragoza, Spain
| | - Alberto Aleta
- grid.418750.f0000 0004 1759 3658ISI Foundation, Via Chisola 5, 10126 Torino, Italy
| | - Joaquín Sanz
- grid.11205.370000 0001 2152 8769Institute for Biocomputation and Physics of Complex Systems (BIFI), University of Zaragoza, 50009 Zaragoza, Spain ,grid.11205.370000 0001 2152 8769Department of Theoretical Physics, University of Zaragoza, 50009 Zaragoza, Spain
| | - Yamir Moreno
- grid.11205.370000 0001 2152 8769Institute for Biocomputation and Physics of Complex Systems (BIFI), University of Zaragoza, 50009 Zaragoza, Spain ,grid.11205.370000 0001 2152 8769Department of Theoretical Physics, University of Zaragoza, 50009 Zaragoza, Spain ,grid.418750.f0000 0004 1759 3658ISI Foundation, Via Chisola 5, 10126 Torino, Italy
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Berrocal-Almanza LC, Harris RJ, Collin SM, Muzyamba MC, Conroy OD, Mirza A, O'Connell AM, Altass L, Anderson SR, Thomas HL, Campbell C, Zenner D, Phin N, Kon OM, Smith EG, Lalvani A. Effectiveness of nationwide programmatic testing and treatment for latent tuberculosis infection in migrants in England: a retrospective, population-based cohort study. THE LANCET PUBLIC HEALTH 2022; 7:e305-e315. [PMID: 35338849 PMCID: PMC8967722 DOI: 10.1016/s2468-2667(22)00031-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 01/14/2022] [Accepted: 01/26/2022] [Indexed: 12/11/2022] Open
Abstract
Background In low-incidence countries, tuberculosis mainly affects migrants, mostly resulting from reactivation of latent tuberculosis infection (LTBI) acquired in high-incidence countries before migration. A nationwide primary care-based LTBI testing and treatment programme for migrants from high-incidence countries was therefore established in high tuberculosis incidence areas in England. We aimed to assess the effectiveness of this programme. Methods We did a retrospective, population-based cohort study of migrants who registered in primary care between Jan 1, 2011, and Dec 31, 2018, in 55 high-burden areas with programmatic LTBI testing and treatment. Eligible individuals were aged 16–35 years, born in a high-incidence country, and had entered England in the past 5 years. Individuals who tested interferon-γ release assay (IGRA)-negative were advised about symptoms of tuberculosis, whereas those who tested IGRA-positive were clinically assessed to rule out active tuberculosis and offered preventive therapy. The primary outcome was incident tuberculosis notified to the national Enhanced Tuberculosis Surveillance system. Findings Our cohort comprised 368 097 eligible individuals who had registered in primary care, of whom 37 268 (10·1%) were tested by the programme. 1446 incident cases of tuberculosis were identified: 166 cases in individuals who had IGRA testing (incidence 204 cases [95% CI 176–238] per 100 000 person-years) and 1280 in individuals without IGRA testing (82 cases [77–86] per 100 000 person-years). Overall, in our primary analysis including all diagnosed tuberculosis cases, a time-varying association was identified between LTBI testing and treatment and lower risk of incident tuberculosis (hazard ratio [HR] 0·76 [95% CI 0·63–0·91]) when compared with no testing. In stratified analysis by follow-up period, the intervention was associated with higher risk of tuberculosis diagnosis during the first 6 months of follow-up (9·93 [7·63–12·9) and a lower risk after 6 months (0·57 [0·41–0·79]). IGRA-positive individuals had higher risk of tuberculosis diagnosis than IGRA-negative individuals (31·9 [20·4–49·8]). Of 37 268 migrants who were tested, 6640 (17·8%) were IGRA-positive, of whom 1740 (26·2%) started preventive treatment. LTBI treatment lowered the risk of tuberculosis: of 135 incident cases in the IGRA-positive cohort, seven cases were diagnosed in the treated group (1·87 cases [95% CI 0·89–3·93] per 1000 person-years) and 128 cases were diagnosed in the untreated group (10·9 cases [9·16–12·9] per 1000 person-years; HR 0·14 [95% CI 0·06–0·32]). Interpretation A low proportion of eligible migrants were tested by the programme and a small proportion of those testing positive started treatment. Despite this, programmatic LTBI testing and treatment of individuals migrating to a low-incidence region is effective at diagnosing active tuberculosis earlier and lowers the long-term risk of progression to tuberculosis. Increasing programme participation and treatment rates for those testing positive could substantially impact national tuberculosis incidence. Funding National Institute for Health Research Health Protection Research Unit in Respiratory Infections.
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Liu C, Lee JH, Gupta AJ, Tucker A, Larkin C, Turimumahoro P, Katamba A, Davis JL, Dowdy D. Cost-effectiveness analysis of human-centred design for global health interventions: a quantitative framework. BMJ Glob Health 2022; 7:bmjgh-2021-007912. [PMID: 35346954 PMCID: PMC8961136 DOI: 10.1136/bmjgh-2021-007912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/26/2022] [Indexed: 11/04/2022] Open
Abstract
Introduction Human-centred design (HCD) is a problem-solving approach that is increasingly used to develop new global health interventions. However, there is often a large initial cost associated with HCD, and global health decision-makers would benefit from an improved understanding of the cost-effectiveness of HCD, particularly the trade-offs between the up-front costs of design and the long-term costs of delivering health interventions. Methods We developed a quantitative framework from a health systems perspective to illustrate the conditions under which HCD-informed interventions are likely to be cost-effective, taking into consideration five elements: cost of HCD, per-client intervention cost, anticipated number of clients reached, anticipated incremental per-client health benefit (ie, disability-adjusted life years (DALYs) averted) and willingness-to-pay. We evaluated several combinations of fixed and implementation cost scenarios based on the estimated costs of an HCD-informed approach to tuberculosis (TB) contact investigation in Uganda over a 2-year period to illustrate the use of this framework. Results The cost-effectiveness of HCD-informed TB contact investigation in Uganda was estimated to vary from US$8400 (2400 clients reached, lower HCD cost estimate) to US$306 000 per DALY averted (120 clients reached, baseline HCD cost estimate). In our model, cost-effectiveness was improved further when the interventions were expected to have wider reach or higher per-client health benefits. Conclusion HCD can be cost-effective when used to inform interventions that are anticipated to reach a large number of clients, or in which the cost of HCD is smaller relative to the cost of delivering the intervention itself.
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Affiliation(s)
- Chen Liu
- Department of Division of Pulmonary & Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jae Hyoung Lee
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Amanda J Gupta
- Department of Health Equity and Social Justice, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Central, Uganda
- Department of Epidemiology of Microbial Diseases, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Austin Tucker
- Department of Population Health Sciences, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Patricia Turimumahoro
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Central, Uganda
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Central, Uganda
- Clinical Epidemiology Unit, Makerere University, Kampala, Uganda
| | - J Lucian Davis
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Central, Uganda
- Department of Epidemiology of Microbial Diseases, Yale University School of Public Health, New Haven, Connecticut, USA
- Department of Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut, USA
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Central, Uganda
- Department of Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
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Uppal A, Nsengiyumva NP, Signor C, Jean-Louis F, Rochette M, Snowball H, Etok S, Annanack D, Ikey J, Khan FA, Schwartzman K. Active screening for tuberculosis in high-incidence Inuit communities in Canada: a cost-effectiveness analysis. CMAJ 2021; 193:E1652-E1659. [PMID: 34725112 PMCID: PMC8565977 DOI: 10.1503/cmaj.210447] [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] [Accepted: 09/14/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Active screening for tuberculosis (TB) involves systematic detection of previously undiagnosed TB disease or latent TB infection (LTBI). It may be an important step toward elimination of TB among Inuit in Canada. We aimed to evaluate the cost-effectiveness of community-wide active screening for TB infection and disease in 2 Inuit communities in Nunavik. Methods: We incorporated screening data from the 2 communities into a decision analysis model. We predicted TB-related health outcomes over a 20-year time frame, beginning in 2019. We assessed the cost-effectiveness of active screening in the presence of varying outbreak frequency and intensity. We also considered scenarios involving variation in timing, impact and uptake of screening programs. Results: Given a single large outbreak in 2019, we estimated that 1 round of active screening reduced TB disease by 13% (95% uncertainty range −3% to 27%) and was cost saving compared with no screening, over 20 years. In the presence of simulated large outbreaks every 3 years thereafter, a single round of active screening was cost saving, as was biennial active screening. Compared with a single round, we also determined that biennial active screening reduced TB disease by 59% (95% uncertainty range 52% to 63%) and was estimated to cost Can$6430 (95% uncertainty range −$29 131 to $13 658 in 2019 Can$) per additional active TB case prevented. With smaller outbreaks or improved rates of treatment initiation and completion for people with LTBI, we determined that biennial active screening remained reasonably cost-effective compared with no active screening. Interpretation: Active screening is a potentially cost-saving approach to reducing disease burden in Inuit communities that have frequent TB outbreaks.
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Affiliation(s)
- Aashna Uppal
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que
| | - Ntwali Placide Nsengiyumva
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que
| | - Céline Signor
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que
| | - Frantz Jean-Louis
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que
| | - Marie Rochette
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que
| | - Hilda Snowball
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que
| | - Sandra Etok
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que
| | - David Annanack
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que
| | - Julie Ikey
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que
| | - Faiz Ahmad Khan
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que
| | - Kevin Schwartzman
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que.
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Costs and cost-effectiveness of a comprehensive tuberculosis case finding strategy in Zambia. PLoS One 2021; 16:e0256531. [PMID: 34499668 PMCID: PMC8428570 DOI: 10.1371/journal.pone.0256531] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 08/09/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction Active-case finding (ACF) programs have an important role in addressing case detection gaps and halting tuberculosis (TB) transmission. Evidence is limited on the cost-effectiveness of ACF interventions, particularly on how their value is impacted by different operational, epidemiological and patient care-seeking patterns. Methods We evaluated the costs and cost-effectiveness of a combined facility and community-based ACF intervention in Zambia that utilized mobile chest X-ray with computer-aided reading/interpretation software and laboratory-based Xpert MTB/RIF testing. Programmatic costs (in 2018 US dollars) were assessed from the health system perspective using prospectively collected cost and operational data. Cost-effectiveness of the ACF intervention was assessed as the incremental cost per TB death averted over a five-year time horizon using a multi-stage Markov state-transition model reflecting patient symptom-associated care-seeking and TB care under ACF compared to passive care. Results Over 18 months of field operations, the ACF intervention costed $435 to diagnose and initiate treatment for one person with TB. After accounting for patient symptom-associated care-seeking patterns in Zambia, we estimate that this one-time ACF intervention would incrementally diagnose 407 (7,207 versus 6,800) TB patients and avert 502 (611 versus 1,113) TB-associated deaths compared to the status quo (passive case finding), at an incremental cost of $2,284 per death averted over the next five-year period. HIV/TB mortality rate, patient symptom-associated care-seeking probabilities in the absence of ACF, and the costs of ACF patient screening were key drivers of cost-effectiveness. Conclusions A one-time comprehensive ACF intervention simultaneously operating in public health clinics and corresponding catchment communities can have important medium-term impact on case-finding and be cost-effective in Zambia. The value of such interventions increases if targeted to populations with high HIV/TB mortality, substantial barriers (both behavioral and physical) to care-seeking exist, and when ACF interventions can optimize screening by achieving operational efficiency.
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20
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Yuen CM, Puma D, Millones AK, Galea JT, Tzelios C, Calderon RI, Brooks MB, Jimenez J, Contreras C, Nichols TC, Nicholson T, Lecca L, Becerra MC, Keshavjee S. Identifying barriers and facilitators to implementation of community-based tuberculosis active case finding with mobile X-ray units in Lima, Peru: a RE-AIM evaluation. BMJ Open 2021; 11:e050314. [PMID: 34234000 PMCID: PMC8264873 DOI: 10.1136/bmjopen-2021-050314] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Identify barriers and facilitators to integrating community tuberculosis screening with mobile X-ray units into a health system. METHODS Reach, effectiveness, adoption, implementation and maintenance evaluation. SETTING 3-district region of Lima, Peru. PARTICIPANTS 63 899 people attended the mobile units from 7 February 2019 to 6 February 2020. INTERVENTIONS Participants were screened by chest radiography, which was scored for abnormality by computer-aided detection. People with abnormal X-rays were evaluated clinically and by GeneXpert MTB/RIF (Xpert) sputum testing. People diagnosed with tuberculosis at the mobile unit were accompanied to health facilities for treatment initiation. PRIMARY AND SECONDARY OUTCOME MEASURES Reach was defined as the percentage of the population of the three-district region that attended the mobile units. Effectiveness was defined as the change in tuberculosis case notifications over a historical baseline. Key implementation fidelity indicators were the percentages of people who had chest radiography performed, were evaluated clinically, had sputum samples collected, had valid Xpert results and initiated treatment. RESULTS The intervention reached 6% of the target population and was associated with an 11% (95% CI 6 to 16) increase in quarterly case notifications, adjusting for the increasing trend in notifications over the previous 3 years. Implementation indicators for screening, sputum collection and Xpert testing procedures all exceeded 85%. Only 82% of people diagnosed with tuberculosis at the mobile units received treatment; people with negative or trace Xpert results were less likely to receive treatment. Suboptimal treatment initiation was driven by health facility doctors' lack of familiarity with Xpert and lack of confidence in diagnoses made at the mobile unit. CONCLUSION Mobile X-ray units were a feasible and effective strategy to extend tuberculosis diagnostic services into communities and improve early case detection. Effective deployment however requires advance coordination among stakeholders and targeted provider training to ensure that people diagnosed with tuberculosis by new modalities receive prompt treatment.
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Affiliation(s)
- Courtney M Yuen
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Jerome T Galea
- School of Social Work, University of South Florida, Tampa, Florida, USA
- College of Public Health, University of South Florida, Tampa, Florida, USA
| | | | - Roger I Calderon
- Socios En Salud Sucursal Peru, Lima, Peru
- Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Meredith B Brooks
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Tim C Nichols
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Tom Nicholson
- Center for International Development, Duke University Sanford School of Public Policy, Durham, North Carolina, USA
- Advance Access & Delivery, Durham, North Carolina, USA
| | | | - Mercedes C Becerra
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Center for Global Health Delivery, Harvard Medical School, Boston, Massachusetts, USA
| | - Salmaan Keshavjee
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Center for Global Health Delivery, Harvard Medical School, Boston, Massachusetts, USA
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21
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Shewade HD, Satyanarayana S, Kumar AM. Does active case finding for tuberculosis generate more false-positives compared to passive case finding in India? Indian J Tuberc 2021; 68:396-399. [PMID: 34099207 DOI: 10.1016/j.ijtb.2020.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 09/15/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Hemant Deepak Shewade
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France; The Union South-East Asia (USEA) Office, New Delhi, India.
| | - Srinath Satyanarayana
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France; The Union South-East Asia (USEA) Office, New Delhi, India
| | - Ajay Mv Kumar
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France; The Union South-East Asia (USEA) Office, New Delhi, India; Yenepoya Medical College, Mangaluru, India
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22
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Sohn H, Sweeney S, Mudzengi D, Creswell J, Menzies NA, Fox GJ, MacPherson P, Dowdy DW. Determining the value of TB active case-finding: current evidence and methodological considerations. Int J Tuberc Lung Dis 2021; 25:171-181. [PMID: 33688805 PMCID: PMC8647907 DOI: 10.5588/ijtld.20.0565] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Active case-finding (ACF) is an important component of the End TB Strategy. However, ACF is resource-intensive, and the economics of ACF are not well-understood. Data on the costs of ACF are limited, with little consistency in the units and methods used to estimate and report costs. Mathematical models to forecast the long-term effects of ACF require empirical measurements of the yield, timing and costs of case detection. Pragmatic trials offer an opportunity to assess the cost-effectiveness of ACF interventions within a 'real-world´ context. However, such analyses generally require early introduction of economic evaluations to enable prospective data collection on resource requirements. Closing the global case-detection gap will require substantial additional resources, including continued investment in innovative technologies. Research is essential to the optimal implementation, cost-effectiveness, and affordability of ACF in high-burden settings. To assess the value of ACF, we must prioritize the collection of high-quality data regarding costs and effectiveness, and link those data to analytical models that are adapted to local settings.
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Affiliation(s)
- H Sohn
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - S Sweeney
- London School of Hygiene & Tropical Medicine, London, UK
| | - D Mudzengi
- The Aurum Institute, Johannesburg, South Africa
| | - J Creswell
- The Stop TB Partnership, UNOPS, Geneva, Switzerland
| | - N A Menzies
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - G J Fox
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Woolcock Institute of Medical Research, Glebe, NSW, Australia
| | - P MacPherson
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Malawi, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - D W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Case finding strategies under National Tuberculosis Elimination Programme (NTEP). Indian J Tuberc 2020; 67:S101-S106. [PMID: 33308653 PMCID: PMC7526527 DOI: 10.1016/j.ijtb.2020.09.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/24/2020] [Indexed: 11/23/2022]
Abstract
Case finding, an important parameter in fight against Tuberculosis (TB) has always remained a challenge despite advances in diagnostic modalities, access to health care and administrative commitment. We are still far from reaching the goals so set as per End TB Strategy and National Strategic Plan 2017–2025, and case finding is of paramount importance for achieving the said targets. This article, after identifying the obstacles faced in case finding, explores the various case finding strategies in the perspective of diagnostics, feasibility, resource utilization and current recommendations. Need for prioritization of case finding in different settings with involvement and active participation of one and all has been discussed. Role of health education in an individual, general public and health care worker in the context of case finding has been highlighted. Research areas to strengthen case finding have been enumerated. The review concludes by bringing out the need for heightened efforts for case finding in TB as the resources are significantly diverted as the world is facing the corona virus disease 2019 (COVID-19) pandemic. Early case finding and prompt treatment is very important for eliminating Tuberculosis but has always remained a challenge. Ongoing passive case finding needs to be strictly complemented with active case finding especially in vulnerable population. Efforts for case finding in TB should not be neglected despite the present corona virus disease 2019 (COVID-19) pandemic.
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Cilloni L, Kranzer K, Stagg HR, Arinaminpathy N. Trade-offs between cost and accuracy in active case finding for tuberculosis: A dynamic modelling analysis. PLoS Med 2020; 17:e1003456. [PMID: 33264288 PMCID: PMC7710036 DOI: 10.1371/journal.pmed.1003456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/02/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Active case finding (ACF) may be valuable in tuberculosis (TB) control, but questions remain about its optimum implementation in different settings. For example, smear microscopy misses up to half of TB cases, yet is cheap and detects the most infectious TB cases. What, then, is the incremental value of using more sensitive and specific, yet more costly, tests such as Xpert MTB/RIF in ACF in a high-burden setting? METHODS AND FINDINGS We constructed a dynamic transmission model of TB, calibrated to be consistent with an urban slum population in India. We applied this model to compare the potential cost and impact of 2 hypothetical approaches following initial symptom screening: (i) 'moderate accuracy' testing employing a microscopy-like test (i.e., lower cost but also lower accuracy) for bacteriological confirmation and (ii) 'high accuracy' testing employing an Xpert-like test (higher cost but also higher accuracy, while also detecting rifampicin resistance). Results suggest that ACF using a moderate-accuracy test could in fact cost more overall than using a high-accuracy test. Under an illustrative budget of US$20 million in a slum population of 2 million, high-accuracy testing would avert 1.14 (95% credible interval 0.75-1.99, with p = 0.28) cases relative to each case averted by moderate-accuracy testing. Test specificity is a key driver: High-accuracy testing would be significantly more impactful at the 5% significance level, as long as the high-accuracy test has specificity at least 3 percentage points greater than the moderate-accuracy test. Additional factors promoting the impact of high-accuracy testing are that (i) its ability to detect rifampicin resistance can lead to long-term cost savings in second-line treatment and (ii) its higher sensitivity contributes to the overall cases averted by ACF. Amongst the limitations of this study, our cost model has a narrow focus on the commodity costs of testing and treatment; our estimates should not be taken as indicative of the overall cost of ACF. There remains uncertainty about the true specificity of tests such as smear and Xpert-like tests in ACF, relating to the accuracy of the reference standard under such conditions. CONCLUSIONS Our results suggest that cheaper diagnostics do not necessarily translate to less costly ACF, as any savings from the test cost can be strongly outweighed by factors including false-positive TB treatment, reduced sensitivity, and foregone savings in second-line treatment. In resource-limited settings, it is therefore important to take all of these factors into account when designing cost-effective strategies for ACF.
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Affiliation(s)
- Lucia Cilloni
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
- * E-mail:
| | - Katharina Kranzer
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Biomedical Research and Training Institute, Harare, Zimbabwe
- Research Centre Borstel, Sülfeld, Germany
| | - Helen R. Stagg
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Nimalan Arinaminpathy
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
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Cilloni L, Fu H, Vesga JF, Dowdy D, Pretorius C, Ahmedov S, Nair SA, Mosneaga A, Masini E, Sahu S, Arinaminpathy N. The potential impact of the COVID-19 pandemic on the tuberculosis epidemic a modelling analysis. EClinicalMedicine 2020; 28:100603. [PMID: 33134905 PMCID: PMC7584493 DOI: 10.1016/j.eclinm.2020.100603] [Citation(s) in RCA: 164] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/25/2020] [Accepted: 10/05/2020] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Routine services for tuberculosis (TB) are being disrupted by stringent lockdowns against the novel SARS-CoV-2 virus. We sought to estimate the potential long-term epidemiological impact of such disruptions on TB burden in high-burden countries, and how this negative impact could be mitigated. METHODS We adapted mathematical models of TB transmission in three high-burden countries (India, Kenya and Ukraine) to incorporate lockdown-associated disruptions in the TB care cascade. The anticipated level of disruption reflected consensus from a rapid expert consultation. We modelled the impact of these disruptions on TB incidence and mortality over the next five years, and also considered potential interventions to curtail this impact. FINDINGS Even temporary disruptions can cause long-term increases in TB incidence and mortality. If lockdown-related disruptions cause a temporary 50% reduction in TB transmission, we estimated that a 3-month suspension of TB services, followed by 10 months to restore to normal, would cause, over the next 5 years, an additional 1⋅19 million TB cases (Crl 1⋅06-1⋅33) and 361,000 TB deaths (CrI 333-394 thousand) in India, 24,700 (16,100-44,700) TB cases and 12,500 deaths (8.8-17.8 thousand) in Kenya, and 4,350 (826-6,540) cases and 1,340 deaths (815-1,980) in Ukraine. The principal driver of these adverse impacts is the accumulation of undetected TB during a lockdown. We demonstrate how long term increases in TB burden could be averted in the short term through supplementary "catch-up" TB case detection and treatment, once restrictions are eased. INTERPRETATION Lockdown-related disruptions can cause long-lasting increases in TB burden, but these negative effects can be mitigated with rapid restoration of TB services, and targeted interventions that are implemented as soon as restrictions are lifted. FUNDING USAID and Stop TB Partnership.
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Affiliation(s)
- Lucia Cilloni
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, United Kingdom
| | - Han Fu
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, United Kingdom
| | - Juan F Vesga
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, United Kingdom
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Sevim Ahmedov
- Bureau for Global Health, Infectious Diseases Division, United States Agency for International Development, Washington, DC, USA
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Ajudua FI, Mash RJ. Implementing active surveillance for TB-The views of managers in a resource limited setting, South Africa. PLoS One 2020; 15:e0239430. [PMID: 33006993 PMCID: PMC7531829 DOI: 10.1371/journal.pone.0239430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 09/07/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The achievement of the World Health Organization's END TB goals will depend on the successful implementation of strategies for early diagnosis and retention of patients on effective therapy until cure. An estimated 150,000 cases are missed annually in South Africa. It is necessary to look at means for identifying these missed cases. This requires the implementation of active surveillance for TB, a policy adopted by the National Department of Health. AIM To explore the views of managers of the TB program on the implementation of active surveillance for TB in the resource constrained setting of the Eastern Cape, South Africa. METHODS A descriptive, explorative, thematically analysed qualitative study based on 10 semi-structured interviews of managers of the TB program. Interviews were transcribed verbatim and analysed using the framework method and Atlas-ti. RESULTS Active case finding of people attending health facilities was the dominant approach, although screening by community health workers (CHWs) was available. Both government and non-government organisations employed CHWs to screen door to door and sometimes as part of campaigns or community events. Some CHWs focused only on contact tracing or people that were non-adherent to TB treatment. Challenges for CHWs included poor coordination and duplication of services, failure to investigate those identified in the community, lack of transport and supportive supervision as well as security issues. Successes included expanding coverage by government CHW teams, innovations to improve screening, strategies to improve CHW capability and attention to social determinants. CONCLUSION A multifaceted facility- and community-based approach was seen as ideal for active surveillance. More resources should be targeted at strengthening teams of CHWs, for whom this would be part of a comprehensive and integrated service in a community-orientated primary care framework, and community engagement to strengthen community level interventions.
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Affiliation(s)
- Febisola I. Ajudua
- Department of Family and Emergency Medicine, Division of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
- Department of Family Medicine and Rural Health, Faculty of Health Sciences, Walter Sisulu University, Mthatha, Eastern Cape, South Africa
| | - Robert J. Mash
- Department of Family and Emergency Medicine, Division of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
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Garg T, Bhardwaj M, Deo S. Role of community health workers in improving cost efficiency in an active case finding tuberculosis programme: an operational research study from rural Bihar, India. BMJ Open 2020; 10:e036625. [PMID: 33004390 PMCID: PMC7536783 DOI: 10.1136/bmjopen-2019-036625] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Cost-efficient active case finding (ACF) approaches are needed for their large-scale adoption in national tuberculosis (TB) programmes. Our aim was to assess if community health workers' (CHW) knowledge about families' health status can improve the cost efficiency of the ACF programme without adversely affecting the delivery of other health services for which they are responsible. DESIGN Quasi-experimental design. INTERVENTIONS We evaluated an ACF programme in the Samastipur district in Bihar, India, between July 2017 and June 2018. CHWs called Accredited Social Health Activists generated referrals of individuals at risk of TB and conducted symptom-based screening to identify patients with presumptive TB. They also helped them undergo testing and provided treatment support for confirmed TB cases. PRIMARY AND SECONDARY OUTCOME MEASURES We compared the notification rate from the intervention region with that from a control region in the same district with similar characteristics. We analysed operational data to calculate the cost per TB case diagnosed. We used routine programmatic data from the public health system to estimate the impact on other services provided by CHWs. FINDINGS CHWs identified 9895 patients with presumptive TB. Of these, 5864 patients were tested for TB, and 1236 were confirmed as TB cases. Annual public case notification rate increased sharply in the intervention region from 45.8 to 105.8 per 100 000 population, whereas it decreased from 50.7 to 45.3 in the control region. There was no practically or statistically significant impact on other output indicators of the CHWs, such as institutional deliveries (-0.04%). The overall cost of the intervention was about US$134 per diagnosed case. Main cost drivers were human resources, and commodities (drugs and diagnostics), which contributed 37.4% and 32.5% of the cost, respectively. CONCLUSIONS ACF programmes that use existing CHWs in the health system are feasible, cost efficient and do not adversely affect other healthcare services delivered by CHWs.
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Affiliation(s)
- Tushar Garg
- Research, Innovators In Health, Patna, Bihar, India
| | | | - Sarang Deo
- Operations Management, Indian School of Business, Hyderabad, Telangana, India
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Enhanced Private Sector Engagement for Tuberculosis Diagnosis and Reporting through an Intermediary Agency in Ho Chi Minh City, Viet Nam. Trop Med Infect Dis 2020; 5:tropicalmed5030143. [PMID: 32937757 PMCID: PMC7558378 DOI: 10.3390/tropicalmed5030143] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/31/2020] [Accepted: 09/01/2020] [Indexed: 11/28/2022] Open
Abstract
Under-detection and -reporting in the private sector constitute a major barrier in Viet Nam’s fight to end tuberculosis (TB). Effective private-sector engagement requires innovative approaches. We established an intermediary agency that incentivized private providers in two districts of Ho Chi Minh City to refer persons with presumptive TB and share data of unreported TB treatment from July 2017 to March 2019. We subsidized chest x-ray screening and Xpert MTB/RIF testing, and supported test logistics, recording, and reporting. Among 393 participating private providers, 32.1% (126/393) referred at least one symptomatic person, and 3.6% (14/393) reported TB patients treated in their practice. In total, the study identified 1203 people with TB through private provider engagement. Of these, 7.6% (91/1203) were referred for treatment in government facilities. The referrals led to a post-intervention increase of +8.5% in All Forms TB notifications in the intervention districts. The remaining 92.4% (1112/1203) of identified people with TB elected private-sector treatment and were not notified to the NTP. Had this private TB treatment been included in official notifications, the increase in All Forms TB notifications would have been +68.3%. Our evaluation showed that an intermediary agency model can potentially engage private providers in Viet Nam to notify many people with TB who are not being captured by the current system. This could have a substantial impact on transparency into disease burden and contribute significantly to the progress towards ending TB.
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Trauer JM, Dodd PJ, Gomes MGM, Gomez GB, Houben RMGJ, McBryde ES, Melsew YA, Menzies NA, Arinaminpathy N, Shrestha S, Dowdy DW. The Importance of Heterogeneity to the Epidemiology of Tuberculosis. Clin Infect Dis 2020; 69:159-166. [PMID: 30383204 PMCID: PMC6579955 DOI: 10.1093/cid/ciy938] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/31/2018] [Indexed: 12/23/2022] Open
Abstract
Although less well-recognized than for other infectious diseases, heterogeneity is a defining feature of tuberculosis (TB) epidemiology. To advance toward TB elimination, this heterogeneity must be better understood and addressed. Drivers of heterogeneity in TB epidemiology act at the level of the infectious host, organism, susceptible host, environment, and distal determinants. These effects may be amplified by social mixing patterns, while the variable latent period between infection and disease may mask heterogeneity in transmission. Reliance on notified cases may lead to misidentification of the most affected groups, as case detection is often poorest where prevalence is highest. Assuming that average rates apply across diverse groups and ignoring the effects of cohort selection may result in misunderstanding of the epidemic and the anticipated effects of control measures. Given this substantial heterogeneity, interventions targeting high-risk groups based on location, social determinants, or comorbidities could improve efficiency, but raise ethical and equity considerations.
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Affiliation(s)
- James M Trauer
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter J Dodd
- Health Economic and Decision Science, University of Sheffield, United Kingdom
| | - M Gabriela M Gomes
- Liverpool School of Tropical Medicine, United Kingdom.,CIBIO-InBIO, Centro de Investigação em Biodiversidade e Recursos Genéticos, Universidade do Porto, Portugal
| | - Gabriela B Gomez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Rein M G J Houben
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, United Kingdom.,Infectious Disease Epidemiology Department, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Emma S McBryde
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland
| | - Yayehirad A Melsew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Nimalan Arinaminpathy
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, United Kingdom
| | - Sourya Shrestha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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30
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Robsky KO, Kitonsa PJ, Mukiibi J, Nakasolya O, Isooba D, Nalutaaya A, Salvatore PP, Kendall EA, Katamba A, Dowdy D. Spatial distribution of people diagnosed with tuberculosis through routine and active case finding: a community-based study in Kampala, Uganda. Infect Dis Poverty 2020; 9:73. [PMID: 32571435 PMCID: PMC7310105 DOI: 10.1186/s40249-020-00687-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 06/01/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Routine tuberculosis (TB) notifications are geographically heterogeneous, but their utility in predicting the location of undiagnosed TB cases is unclear. We aimed to identify small-scale geographic areas with high TB notification rates based on routinely collected data and to evaluate whether these areas have a correspondingly high rate of undiagnosed prevalent TB. METHODS We used routinely collected data to identify geographic areas with high TB notification rates and evaluated the extent to which these areas correlated with the location of undiagnosed cases during a subsequent community-wide active case finding intervention in Kampala, Uganda. We first enrolled all adults who lived within 35 contiguous zones and were diagnosed through routine care at four local TB Diagnosis and Treatment Units. We calculated average monthly TB notification rates in each zone and defined geographic areas of "high risk" as zones that constituted the 20% of the population with highest notification rates. We compared the observed proportion of TB notifications among residents of these high-risk zones to the expected proportion, using simulated estimates based on population size and random variation alone. We then evaluated the extent to which these high-risk zones identified areas with high burdens of undiagnosed TB during a subsequent community-based active case finding campaign using a chi-square test. RESULTS We enrolled 45 adults diagnosed with TB through routine practices and who lived within the study area (estimated population of 49 527). Eighteen zones reported no TB cases in the 9-month period; among the remaining zones, monthly TB notification rates ranged from 3.9 to 39.4 per 100 000 population. The five zones with the highest notification rates constituted 62% (95% CI: 47-75%) of TB cases and 22% of the population-significantly higher than would be expected if population size and random chance were the only determinants of zone-to-zone variation (48%, 95% simulation interval: 40-59%). These five high-risk zones accounted for 42% (95% CI: 34-51%) of the 128 cases detected during the subsequent community-based case finding intervention, which was significantly higher than the 22% expected by chance (P < 0.001) but lower than the 62% of cases notified from those zones during the pre-intervention period (P = 0.02). CONCLUSIONS There is substantial heterogeneity in routine TB notification rates at the zone level. Using facility-based TB notification rates to prioritize high-yield areas for active case finding could double the yield of such case-finding interventions.
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Affiliation(s)
- Katherine O Robsky
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda.
| | - Peter J Kitonsa
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - James Mukiibi
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Olga Nakasolya
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - David Isooba
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Annet Nalutaaya
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Phillip P Salvatore
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Emily A Kendall
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda.,Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda.,Department of Medicine, Clinical Epidemiology and Biostatistics Unit, Makerere University, College of Health Sciences, Kampala, Uganda
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda.,Johns Hopkins School of Medicine, Baltimore, MD, USA
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Lung T, Marks GB, Nhung NV, Anh NT, Hoa NLP, Anh LTN, Hoa NB, Britton WJ, Bestrashniy J, Jan S, Fox GJ. Household contact investigation for the detection of tuberculosis in Vietnam: economic evaluation of a cluster-randomised trial. LANCET GLOBAL HEALTH 2020; 7:e376-e384. [PMID: 30784638 DOI: 10.1016/s2214-109x(18)30520-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 10/18/2018] [Accepted: 11/07/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Active case finding is recommended as an important strategy to control tuberculosis, particularly in low-income and middle-income countries with a high prevalence of the disease. However, the costs and cost-effectiveness of active case finding are unclear due to the absence of evidence from randomised trials. We assessed the costs and cost-effectiveness of an active case finding strategy in Vietnam, where there is a high prevalence of tuberculosis. METHODS We conducted an economic evaluation alongside the Active Case Finding in Tuberculosis (ACT2) trial-a pragmatic cluster-randomised controlled trial in 70 districts across eight provinces of Vietnam. Patients aged 15 years and older with smear-positive pulmonary tuberculosis were recruited to the trial if they lived with one or more other household members. Household contacts were verbally invited to the clinic by the index patient with tuberculosis. ACT2 compared a combination of active and passive case finding with usual care (passive case finding) of household contacts of patients with tuberculosis from a health system perspective. Clustering occurred at the district and household level. Districts were the unit of randomisation, and we used minimisation to ensure balance of intervention and control districts within each province. In the intervention group, participants were invited to attend screening at baseline, 6 months, 12 months, and 24 months. We determined health-care costs with a standardised national costing survey and reported results in 2017 $US. The primary outcome of our study was disability-adjusted life years (DALYs) averted over a 24-month period. ACT2 was registered prospectively with the Australian and New Zealand Clinical Trials Registry, number ACTRN126.100.00600044. FINDINGS Between Aug 11, 2010, and Aug 11, 2015, 10 964 index patients and 25 707 household contacts completed the ACT2 study. There were 10 069 household contacts in the intervention group and 15 638 household contacts in the control group. The incremental cost-effectiveness ratio per DALY averted was $544 (330-1375). INTERPRETATION Active case finding was shown to be highly cost-effective in a setting with a high prevalence of tuberculosis. Investment in the wide-scale implementation of this programme in Vietnam should be strongly supported. FUNDING Australian National Health and Medical Research Council.
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Affiliation(s)
- Thomas Lung
- The George Institute for Global Health, The University of New South Wales, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, NSW, Australia.
| | - Guy B Marks
- South Western Sydney Clinical School, University of New South Wales, Kensington, NSW, Australia; Woolcock Institute of Medical Research, Glebe, NSW, Australia
| | - Nguyen Viet Nhung
- National Lung Hospital, Ba Dinh, Hanoi, Vietnam; Hanoi Medical University, Hanoi, Vietnam
| | - Nguyen Thu Anh
- Woolcock Institute of Medical Research, Glebe, NSW, Australia
| | | | - Le Thi Ngoc Anh
- Woolcock Institute of Medical Research, Glebe, NSW, Australia
| | - Nguyen Binh Hoa
- National Lung Hospital, Ba Dinh, Hanoi, Vietnam; Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Warwick John Britton
- Faculty of Medicine and Health, University of Sydney, NSW, Australia; Centenary Institute of Cancer Medicine and Cell Biology, University of Sydney, Camperdown, NSW, Australia
| | | | - Stephen Jan
- The George Institute for Global Health, The University of New South Wales, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Gregory J Fox
- Faculty of Medicine and Health, University of Sydney, NSW, Australia; Woolcock Institute of Medical Research, Glebe, NSW, Australia
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Imsanguan W, Bupachat S, Wanchaithanawong V, Luangjina S, Thawtheong S, Nedsuwan S, Pungrassami P, Mahasirimongkol S, Wiriyaprasobchok A, Kaewmamuang K, Kamolwat P, Ngamvithayapong-Yanai J. Contact tracing for tuberculosis, Thailand. Bull World Health Organ 2020; 98:212-218. [PMID: 32132756 PMCID: PMC7047024 DOI: 10.2471/blt.19.239293] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 11/22/2019] [Accepted: 01/03/2020] [Indexed: 12/03/2022] Open
Abstract
Problem Despite implementation of universal health coverage in Thailand, gaps remain in the system for screening contacts of tuberculosis patients. Approach We designed broader criteria for contact investigation and new screening practices and assessed the approach in a programme-based operational research study in 2017–2018. Clinic staff interviewed 100 index patients and asked them to give household and non-household contacts an invitation for a free screening and chest X-ray. Contact persons who attended received 250 Thai baht (about 8 United States dollars) allowance for transport. Local setting Chiang Rai province, Thailand, has high rates of tuberculosis notification and a high number of people living in poverty. The coverage of contact investigation in under 5-year-olds was only 33.2% (222 screened out of 668 contacts) over 2011–2015. Relevant changes Index patients identified 440 contacts in total and gave invitation cards to 227 of them. The contact investigation coverage was 81.1% (184/227) and tuberculosis detection among contacts screened was 6.0% (11/184). Of the 11 contacts with active tuberculosis, three did not have tuberculosis symptoms, three were non-household contacts and three were contacts of non-smear-positive tuberculosis patients. The contact investigation coverage of the contacts younger than 5 years was 100% (14/14) and the yield of tuberculosis detection in this age group was 21.4% (3/14). Lessons learnt High coverage of contact investigation with a high yield of tuberculosis detection among contacts can be achieved by applying broader criteria for contact investigation and providing financial support for transportation.
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Affiliation(s)
| | - Surasit Bupachat
- TB/HIV Research Foundation, 1050/1 Satarnpayabarn Rd., Muang District, Chiang Rai 57000, Thailand
| | | | - Sarmwai Luangjina
- TB/HIV Research Foundation, 1050/1 Satarnpayabarn Rd., Muang District, Chiang Rai 57000, Thailand
| | - Sureerat Thawtheong
- TB/HIV Research Foundation, 1050/1 Satarnpayabarn Rd., Muang District, Chiang Rai 57000, Thailand
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López L, Keynan Y, Marin D, Ríos-Hincapie CY, Montes F, Escudero-Atehortua AC, Rueda ZV. Is tuberculosis elimination a feasible goal in Colombia by 2050? Health Policy Plan 2020; 35:47-57. [PMID: 31665295 DOI: 10.1093/heapol/czz122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2019] [Indexed: 11/13/2022] Open
Abstract
Colombia has an underreporting of 30% of the total cases, according to World Health Organization (WHO) estimations. In 2016, successful tuberculosis (TB) treatment rate was 70%, and the mortality rate ranged between 3.5% and 10%. In 2015, Colombia adopted and adapted the End TB strategy and set a target of 50% reduction in incidence and mortality by 2035 compared with 2015. The aims of this study were: To evaluate whether Colombia will be able to achieve the goals of TB incidence and mortality by 2050, using the current strategies; and whether the implementation of new screening, diagnosis and TB treatment strategies will allow to achieve those WHO targets. An ecological study was conducted using TB case-notification, successful treatment and mortality rates from the last 8 years (2009-17). System dynamics analysis was performed using simulated scenarios: (1) continuation with the same trends following the trajectory of the last 8 years (Status quo) and (2) modification of the targets between 2017 through 2050, assuming the implementation of multimodal strategies to increase the screening, to improve the early diagnosis and to improve the treatment adherence. Following the current strategies, it is projected that Colombia will not achieve the End TB strategy targets. Achieving the goal of TB incidence of 10/100 000 by 2050 will only be possible by implementing combined strategies for increasing screening of people with respiratory symptoms, improving access to rapid diagnostic tests and improving treatment adherence. Therefore, it is necessary to design and implement simultaneous strategies according to the population needs and resources, in order to stride towards the End TB targets.
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Affiliation(s)
- Lucelly López
- Research Department Facultad de Medicina, Universidad Pontificia Bolivariana, Calle 78B # 72A-109, Medellín, Colombia
| | - Yoav Keynan
- Department of Medical Microbiology and Infectious Disease, University of Manitoba, Winnipeg, Canada.,Department of Internal Medicine, University of Manitoba, Winnipeg, Canada.,Department of Community Health Science, University of Manitoba, Winnipeg, Canada
| | - Diana Marin
- Research Department Facultad de Medicina, Universidad Pontificia Bolivariana, Calle 78B # 72A-109, Medellín, Colombia
| | | | | | | | - Zulma Vanessa Rueda
- Research Department Facultad de Medicina, Universidad Pontificia Bolivariana, Calle 78B # 72A-109, Medellín, Colombia
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Shewade HD, Gupta V, Satyanarayana S, Kumar S, Pandey P, Bajpai UN, Tripathy JP, Kathirvel S, Pandurangan S, Mohanty S, Ghule VH, Sagili KD, Prasad BM, Singh P, Singh K, Jayaraman G, Rajeswaran P, Biswas M, Mallick G, Naqvi AJ, Bharadwaj AK, Sathiyanarayanan K, Pathak A, Mohan N, Rao R, Kumar AMV, Chadha SS. Active versus passive case finding for tuberculosis in marginalised and vulnerable populations in India: comparison of treatment outcomes. Glob Health Action 2020; 12:1656451. [PMID: 31475635 PMCID: PMC6735288 DOI: 10.1080/16549716.2019.1656451] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Community-based active case finding (ACF) for tuberculosis (TB) implemented among marginalised and vulnerable populations in 285 districts of India resulted in reduction of diagnosis delay and prevalence of catastrophic costs due to TB diagnosis. We were interested to know whether this translated into improved treatment outcomes. Globally, there is limited published literature from marginalised and vulnerable populations on the independent effect of community-based ACF on treatment outcomes when compared to passive case finding (PCF). Objectives: To determine the relative differences in unfavourable treatment outcomes (death, loss-to-follow-up, failure, not evaluated) of ACF and PCF-diagnosed people. Methods: Cohort study involving record reviews and interviews in 18 randomly selected districts. We enrolled all ACF-diagnosed people with new smear-positive pulmonary TB, registered under the national TB programme between March 2016 and February 2017, and an equal number of randomly selected PCF-diagnosed people in the same settings. We used log binomial models to adjust for confounders. Results: Of 572 enrolled, 275 belonged to the ACF and 297 to the PCF group. The proportion of unfavourable outcomes were 10.2% (95% CI: 7.1%, 14.3%) in the ACF and 12.5% (95% CI: 9.2%, 16.7%) in the PCF group (p = 0.468). The association between ACF and unfavourable outcomes remained non-significant after adjusting for confounders available from records [aRR: 0.83 (95% CI: 0.56, 1.21)]. Due to patient non-availability at their residence, interviews were conducted for 465 (81.3%). In the 465 cohort too, there was no association after adjusting for confounders from records and interviews [aRR: 1.05 (95% CI: 0.62, 1.77)]. Conclusion: We did not find significant differences in the treatment outcomes. Due to the wide CIs, studies with larger sample sizes are urgently required. Studies are required to understand how to translate the benefits of ACF to improved treatment outcomes.
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Affiliation(s)
- Hemant Deepak Shewade
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union) , Paris , France.,Department of Operational Research , The Union South-East Asia (USEA) , New Delhi, India.,Karuna Trust , Bengaluru , India
| | - Vivek Gupta
- Dr RP Centre for Ophthalmic Sciences, All India Institute of Medical Sciences (AIIMS) , New Delhi , India
| | - Srinath Satyanarayana
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union) , Paris , France
| | - Sunil Kumar
- State TB Cell , Department of Health & Family Welfare, Government of Kerala, Thiruvananthapuram , India
| | - Prabhat Pandey
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | - U N Bajpai
- Voluntary Health Association of India (VHAI) , New Delhi , India
| | - Jaya Prasad Tripathy
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union) , Paris , France.,Department of Operational Research , The Union South-East Asia (USEA) , New Delhi, India
| | - Soundappan Kathirvel
- Department of Operational Research , The Union South-East Asia (USEA) , New Delhi, India.,Department of Community Medicine and School of Public Health , Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh , India
| | - Sripriya Pandurangan
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | - Subrat Mohanty
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | - Vaibhav Haribhau Ghule
- Joint Efforts for Elimination of TB (JEET) Project , Foundation for Innovate New Diagnostics (FIND), New Delhi , India
| | - Karuna D Sagili
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | | | - Priyanka Singh
- MAMTA Health Institute for Mother and Child , New Delhi , India
| | - Kamlesh Singh
- Catholic Health Association of India (CHAI) , Telangana , India
| | - Gurukartick Jayaraman
- Resource Group for Education & Advocacy for Community Health (REACH) , Chennai , India
| | - P Rajeswaran
- Resource Group for Education & Advocacy for Community Health (REACH) , Chennai , India
| | - Moumita Biswas
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | - Gayadhar Mallick
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | - Ali Jafar Naqvi
- MAMTA Health Institute for Mother and Child , New Delhi , India
| | | | - K Sathiyanarayanan
- Resource Group for Education & Advocacy for Community Health (REACH) , Chennai , India
| | - Aniruddha Pathak
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | - Nisha Mohan
- Karuna Trust , Bengaluru , India.,IIHMR University, Jaipur , India
| | - Raghuram Rao
- Central TB Division, Revised National Tuberculosis Control Programme, Ministry of Health and Family Welfare , Government of India , New Delhi, India
| | - Ajay M V Kumar
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union) , Paris , France.,Department of Operational Research , The Union South-East Asia (USEA) , New Delhi, India.,Yenepoya Medical College, Yenepoya (Deemed to be University), Mangaluru , India
| | - Sarabjit Singh Chadha
- Infectious Diseases, Foundation for Innovate New Diagnostics (FIND), New Delhi , India
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Biermann O, Lönnroth K, Caws M, Viney K. Factors influencing active tuberculosis case-finding policy development and implementation: a scoping review. BMJ Open 2019; 9:e031284. [PMID: 31831535 PMCID: PMC6924749 DOI: 10.1136/bmjopen-2019-031284] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 11/04/2019] [Accepted: 11/20/2019] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE To explore antecedents, components and influencing factors on active case-finding (ACF) policy development and implementation. DESIGN Scoping review, searching MEDLINE, Web of Science, the Cochrane Database of Systematic Reviews and the World Health Organization (WHO) Library from January 1968 to January 2018. We excluded studies focusing on latent tuberculosis (TB) infection, passive case-finding, childhood TB and studies about effectiveness, yield, accuracy and impact without descriptions of how this evidence has/could influence ACF policy or implementation. We included any type of study written in English, and conducted frequency and thematic analyses. RESULTS Seventy-three articles fulfilled our eligibility criteria. Most (67%) were published after 2010. The studies were conducted in all WHO regions, but primarily in Africa (22%), Europe (23%) and the Western-Pacific region (12%). Forty-one percent of the studies were classified as quantitative, followed by reviews (22%) and qualitative studies (12%). Most articles focused on ACF for tuberculosis contacts (25%) or migrants (32%). Fourteen percent of the articles described community-based screening of high-risk populations. Fifty-nine percent of studies reported influencing factors for ACF implementation; mostly linked to the health system (eg, resources) and the community/individual (eg, social determinants of health). Only two articles highlighted factors influencing ACF policy development (eg, politics). Six articles described WHO's ACF-related recommendations as important antecedent for ACF. Key components of successful ACF implementation include health system capacity, mechanisms for integration, education and collaboration for ACF. CONCLUSION We identified some main themes regarding the antecedents, components and influencing factors for ACF policy development and implementation. While we know much about facilitators and barriers for ACF policy implementation, we know less about how to strengthen those facilitators and how to overcome those barriers. A major knowledge gap remains when it comes to understanding which contextual factors influence ACF policy development. Research is required to understand, inform and improve ACF policy development and implementation.
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Affiliation(s)
- Olivia Biermann
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Knut Lönnroth
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Maxine Caws
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
- Birat Nepal Medical Trust, Kathmandu, Lazimpat, Nepal
| | - Kerri Viney
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Research School of Population Health, College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
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Li L, Yao Y, Liang J, Zhan X, Wang F, Yue C, Wu BQ, Hu S, Liu M, Wan J, Luo J. Serum human epididymis protein 4 concentrations are associated with severity of patients with pulmonary tuberculosis. Clin Chim Acta 2019; 502:255-260. [PMID: 31730821 DOI: 10.1016/j.cca.2019.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 10/02/2019] [Accepted: 11/05/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Human epididymis protein 4 (HE4) has been recognized as a biomarker which elevated in various diseases. The aim of this study was to evaluate the value of serum HE4 in pulmonary tuberculosis (PTB). METHODS Serum HE4 concentrations were determined in 127 PTB, 88 chronic bronchitis (CHB), and 105 healthy control subjects by chemiluminescent microparticle immunoassay. Receiver operating characteristic (ROC) curves and Spearman's correlation analysis were performed for investigating value of HE4. RESULTS Serum HE4 concentrations were significantly increased in PTB (62.8 pmol/L, IQR 45.8-90.7), compared with that of CHB (50.2 pmol/L, IQR 42.3-64.3, P = 0.0002) and normal control (35.4 pmol/L, IQR 31.1-42.9, P < 0.0001). ROC curve suggested that the AUC of HE4 used to discriminate PTB from CHB was 0.647 (95% CI, 0.574-0.719), with the cutoff value, sensitivity, specificity, PPV, and NPV at 71.9 pmol/L, 0.417, 0.852, 0.672 and 0.543, respectively. Meanwhile, compared with mild to moderated PTB, the levels of HE4 in advanced PTB were significantly elevated (75.8 vs. 57.7 pmol/L, P = 0.0052). What's more, the levels of HE4 in PTB were found to be significantly associated with the albumin, CRP, and cavity (r = -0.2996, P = 0.0006, r = 0.265, P = 0.0026, r = 0.4699, P < 0.0001, respectively). CONCLUSIONS Elevated serum HE4 concentration could be used as a biomarker for the diagnosis and assessment of disease severity in PTB.
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Affiliation(s)
- Laisheng Li
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, People's Republic of China
| | - Yingsheng Yao
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, People's Republic of China; Department of Laboratory Medicine, Shantou Central Hospital, Affiliated Shantou Hospital of Sun Yat-sen University, Shantou, Guangdong 515041, People's Republic of China
| | - Jianbo Liang
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, People's Republic of China
| | - Xiaoxia Zhan
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, People's Republic of China
| | - Fen Wang
- Department of Pathology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, People's Republic of China
| | - Caifeng Yue
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, People's Republic of China
| | - Ben-Quan Wu
- Department of Internal Medicine, Medical Intensive Care Unit and Division of Respiratory Diseases, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, People's Republic of China
| | - Shengfeng Hu
- Institute of Molecular Immunology, School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou 510515, People's Republic of China
| | - Min Liu
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, People's Republic of China
| | - Jianxin Wan
- Department of Laboratory Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, People's Republic of China.
| | - Jinmei Luo
- Department of Internal Medicine, Medical Intensive Care Unit and Division of Respiratory Diseases, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, People's Republic of China.
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Hussain H, Mori AT, Khan AJ, Khowaja S, Creswell J, Tylleskar T, Robberstad B. The cost-effectiveness of incentive-based active case finding for tuberculosis (TB) control in the private sector Karachi, Pakistan. BMC Health Serv Res 2019; 19:690. [PMID: 31606031 PMCID: PMC6790051 DOI: 10.1186/s12913-019-4444-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 08/20/2019] [Indexed: 11/26/2022] Open
Abstract
Background In Asia, over 50% of patients with symptoms of tuberculosis (TB) access health care from private providers. These patients are usually not notified to the National TB Control Programs, which contributes to low notification rates in many countries. Methods From January 1, 2011 to December 31, 2012, Karachi’s Indus Hospital - a private sector partner to the National TB Programme - engaged 80 private family clinics in its catchment area in active case finding using health worker incentives to increase notification of TB disease. The costs incurred were estimated from the perspective of patients, health facility and the program providing TB services. A Markov decision tree model was developed to calculate the cost-effectiveness of the active case finding as compared to case detection through the routine passive TB centers. Pakistan has a large private health sector, which can be mobilized for TB screening using an incentivized active case finding strategy. Currently, TB screening is largely performed in specialist public TB centers through passive case finding. Active and passive case finding strategies are assumed to operate independently from each other. Results The incentive-based active case finding program costed USD 223 per patient treated. In contrast, the center based non-incentive arm was 23.4% cheaper, costing USD 171 per patient treated. Cost-effectiveness analysis showed that the incentive-based active case finding program was more effective and less expensive per DALY averted when compared to the baseline passive case finding as it averts an additional 0.01966 DALYs and saved 15.74 US$ per patient treated. Conclusion Both screening strategies appear to be cost-effective in an urban Pakistan context. Incentive driven active case findings of TB in the private sector costs less and averts more DALYs per health seeker than passive case finding, when both alternatives are compared to a common baseline situation of no screening. Electronic supplementary material The online version of this article (10.1186/s12913-019-4444-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hamidah Hussain
- Interactive Research and Development, Global, Singapore, Singapore. .,Centre for International Health, Bergen, Norway. .,Department of Global Public Health and Primary Care,
- University of Bergen, Bergen, Norway.
| | - Amani Thomas Mori
- Centre for International Health, Bergen, Norway.,Department of Global Public Health and Primary Care,
- University of Bergen, Bergen, Norway
| | - Aamir J Khan
- Interactive Research and Development, Global, Singapore, Singapore
| | - Saira Khowaja
- Interactive Research and Development, Global, Singapore, Singapore
| | | | - Thorkild Tylleskar
- Centre for International Health, Bergen, Norway.,Department of Global Public Health and Primary Care,
- University of Bergen, Bergen, Norway
| | - Bjarne Robberstad
- Department of Global Public Health and Primary Care,
- University of Bergen, Bergen, Norway.,Section for Ethics and Health Economics, Bergen, Norway
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38
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Silva SYBE, Pinto ESG, Medeiros ERD, Rebouças DGDC, Paiva ACDS, Nascimento CPAD, Souza NLD. Strategies for the evaluation of interventions for the control of tuberculosis: integrative review. Rev Bras Enferm 2019; 72:1370-1377. [DOI: 10.1590/0034-7167-2017-0922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 03/05/2018] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Objective: Identifying the available evidence in the scientific literature about the strategies used in the evaluations of interventions for the control of tuberculosis. Method: Integrative review with searches in databases Lilacs, CINAHL and PubMed in August 2017. Thirty-three articles were selected and the theoretical referential of health assessment was used for analysis. Results: The prevalent interventions were health programs (60.7%), 69.7% focusing on results and 81.9% having quantitative character (81.9%). Final considerations: The evaluation of interventions for the control of tuberculosis is beneficial for the health services’ users and aids in the decision making of managers and health professionals.
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Kigozi NG, Heunis JC, Engelbrecht MC. Yield of systematic household contact investigation for tuberculosis in a high-burden metropolitan district of South Africa. BMC Public Health 2019; 19:867. [PMID: 31269950 PMCID: PMC6609408 DOI: 10.1186/s12889-019-7194-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 06/18/2019] [Indexed: 01/21/2023] Open
Abstract
Background Systematic household contact investigation (SHCI) is recommended as an active-case-finding (ACF) strategy to identify individuals at high risk of tuberculosis (TB) infection, in order to enable early detection and treatment. Reluctance to implement SHCI in sub-Saharan African and South African high-burden contexts may stem from uncertainty about the potential yield of this strategy when targeting specific categories of TB index cases. In order to inform and motivate scale-up, this pilot study investigated the effectiveness of SHCI when targeting the World Health Organization’s (WHO) recommended categories of infectious index cases. Method Data were gathered in September and October 2016. Household contacts of infectious TB cases who attended 40 primary health care facilities in Mangaung Metropolitan District were recruited. The categories of TB index cases included 1) children <5 years, 2) HIV co-infected pulmonary TB (PTB) cases (≥5 years), 3) HIV-negative PTB cases (≥5 years), and 4) multidrug-resistant (MDR) TB cases. Contacts were screened for TB symptoms and symptomatic individuals and all children <5 years were referred for clinical evaluation. Data were analysed to establish the yield and factors associated with new TB diagnosis. Results Of 259 contacts screened, just under half (47.1%) underwent TB clinical investigation, during which 17 (6.6%) new TB cases were diagnosed, which represents a prevalence rate of 6564 per 100,000 population. Fifteen contacts needed to be screened to detect one new TB case. The proportion of new TB cases was the highest among contacts of HIV-negative PTB index cases (47.9%). The likelihood of TB diagnosis was higher among male contacts (odds ratio [OR]: 4.8; 95% confidence interval [CI]: 1.54–14.97) and those reporting coughing (OR: 4.3; 95% CI: 1.11–16.43). Conclusion The high yield of new TB observed in this pilot study demonstrates that targeted SHCI may be an effective ACF strategy in Mangaung and similar high-burden settings in South Africa. Targeting different index case categories produced variable yield – the highest among contacts of HIV-negative TB index cases. SHCI among household contacts of all four the WHO-recommended categories of infectious TB index cases – and male and coughing contacts, in particular – should be maximised.
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Affiliation(s)
- N Gladys Kigozi
- Centre for Health Systems Research & Development, University of the Free State, P.O. Box 399, Bloemfontein, 9300, South Africa.
| | - J Christo Heunis
- Centre for Health Systems Research & Development, University of the Free State, P.O. Box 399, Bloemfontein, 9300, South Africa
| | - Michelle C Engelbrecht
- Centre for Health Systems Research & Development, University of the Free State, P.O. Box 399, Bloemfontein, 9300, South Africa
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Machekera SM, Wilkinson E, Hinderaker SG, Mabhala M, Zishiri C, Ncube RT, Timire C, Takarinda KC, Sengai T, Sandy C. A comparison of the yield and relative cost of active tuberculosis case-finding algorithms in Zimbabwe. Public Health Action 2019; 9:63-68. [PMID: 31417855 DOI: 10.5588/pha.18.0098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/09/2019] [Indexed: 11/10/2022] Open
Abstract
Setting Ten districts and three cities in Zimbabwe. Objective To compare the yield and relative cost of identifying a case of tuberculosis (TB) using the three WHO-recommended algorithms (WHO2b, symptom inquiry only; WHO2d, chest X-ray [CXR] after a positive symptom inquiry; WHO3b, CXR only) and the Zimbabwe active case finding (ZimACF) algorithm (symptom inquiry plus CXR) to everyone. Design Cross-sectional study using data from the ZimACF project. Results A total of 38 574 people were screened from April to December 2017; 488 (1.3%) were diagnosed with TB using the ZimACF algorithm. Fewer TB cases would have been diagnosed with the WHO-recommended algorithms. This ranged from 7% fewer (34 cases) with WHO3b, 18% fewer (88 cases) with WHO2b and 25% fewer (122 cases) with WHO2d. The need for CXR ranged from 36% (WHO2d) to 100% (WHO3b). The need for bacteriological confirmation ranged from 7% (WHO2d) to 40% (ZimACF). The relative cost per case of TB diagnosed ranged from US$180 with WHO3b to US$565 for the ZimACF algorithm. Conclusion The ZimACF algorithm had the highest case yield, but at a much higher cost per case than the WHO algorithms. It is possible to switch to algorithm WHO3b, but the trade-off between cost and yield needs to be reviewed by the Zimbabwean National TB Programme.
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Affiliation(s)
- S M Machekera
- International Union Against Tuberculosis and Lung Diseases, Harare, Zimbabwe
| | - E Wilkinson
- Institute of Medicine, University of Chester, Chester, UK
| | - S G Hinderaker
- Centre of International Health, University of Bergen, Bergen, Norway
| | - M Mabhala
- Department of Public Health and Wellbeing, University of Chester, Chester, UK
| | - C Zishiri
- International Union Against Tuberculosis and Lung Diseases, Harare, Zimbabwe
| | - R T Ncube
- International Union Against Tuberculosis and Lung Diseases, Harare, Zimbabwe
| | - C Timire
- International Union Against Tuberculosis and Lung Diseases, Harare, Zimbabwe.,Ministry of Health and Child Care, Harare, Zimbabwe
| | - K C Takarinda
- International Union Against Tuberculosis and Lung Diseases, Harare, Zimbabwe.,Ministry of Health and Child Care, Harare, Zimbabwe
| | - T Sengai
- Family AIDS Caring Trust, Mutare, Zimbabwe
| | - C Sandy
- Ministry of Health and Child Care, Harare, Zimbabwe
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Daftary A, Satyanarayana S, Jha N, Singh M, Mondal S, Vadnais C, Pai M. Can community pharmacists improve tuberculosis case finding? A mixed methods intervention study in India. BMJ Glob Health 2019; 4:e001417. [PMID: 31179037 PMCID: PMC6528751 DOI: 10.1136/bmjgh-2019-001417] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/13/2019] [Accepted: 04/06/2019] [Indexed: 11/16/2022] Open
Abstract
Introduction India has the world’s highest burden of tuberculosis (TB). Private retail pharmacies are the preferred provider for 40% of patients with TB symptoms and up to 25% of diagnosed patients. Engaging pharmacies in TB screening services could improve case detection. Methods A novel TB screening and referral intervention was piloted over 18 months, under the pragmatic staggered recruitment of 105 pharmacies in Patna, India. The intervention was integrated into an ongoing public–private mix (PPM) programme, with five added components: pharmacy training in TB screening, referral of patients with TB symptoms for a chest radiograph (CXR) followed by a doctor consultation, incentives for referral completion and TB diagnosis, short message service (SMS) reminders and field support. The intervention was evaluated using mixed methods. Results 81% of pharmacies actively participated in the intervention. Over 132.49 pharmacy person-years of observation in the intervention group, 1674 referrals were made and 255 cases of TB were diagnosed. The rate of registration of symptomatic patients was 62 times higher in the intervention group compared with the control group (95% CI: 54 to 72). TB diagnosis was 25 times higher (95% CI: 20 to 32). Microbiological testing and test confirmation were also significantly higher among patients diagnosed in the intervention group (p<0.001). Perceived professional credibility, patient trust, symptom severity and providing access to a free screening test were seen to improve pharmacists’ engagement in the intervention. Workload, patient demand for over-the-counter medicines, doctor consultation fees and programme documentation impeded engagement. An additional 240 cases of TB were attributed to the intervention, and the approximate cost incurred per case detected due to the intervention was US$100. Conclusions It is feasible and impactful to engage pharmacies in TB screening and referral activities, especially if working within existing public-private mix (PPM) programmes, appealing to pharmacies’ business mindset and among pharmacies with strong community ties.
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Affiliation(s)
- Amrita Daftary
- McGill International TB Centre and Department of Epidemiology & Biostatistics, McGill University, Montreal, Québec, Canada.,Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Srinath Satyanarayana
- The International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | - Nita Jha
- World Health Partners, Patna, Bihar, India
| | | | - Shinjini Mondal
- Department of Family Medicine, McGill University, Montreal, Québec, Canada
| | - Caroline Vadnais
- Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
| | - Madhukar Pai
- McGill International TB Centre and Department of Epidemiology & Biostatistics, McGill University, Montreal, Québec, Canada.,Manipal McGill Centre for Infectious Diseases, Manipal, Karnataka, India
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42
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Emerson J, Panzer A, Cohen JT, Chalkidou K, Teerawattananon Y, Sculpher M, Wilkinson T, Walker D, Neumann PJ, Kim DD. Adherence to the iDSI reference case among published cost-per-DALY averted studies. PLoS One 2019; 14:e0205633. [PMID: 31042714 PMCID: PMC6493721 DOI: 10.1371/journal.pone.0205633] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 03/28/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The iDSI reference case, originally published in 2014, aims to improve the quality and comparability of cost-effectiveness analyses (CEA). This study assesses whether the development of the guideline is associated with an improvement in methodological and reporting practices for CEAs using disability-adjusted life-years (DALYs). METHODS We analyzed the Tufts Medical Center Global Health CEA Registry to identify cost-per-DALY averted studies published from 2011 to 2017. Among each of 11 principles in the iDSI reference case, we translated all methodological specifications and reporting standards into a series of binary questions (satisfied or not satisfied) and awarded articles one point for each item satisfied. We then calculated methodological and reporting adherence scores separately as a percentage of total possible points, measured as normalized adherence score (0% = no adherence; 100% = full adherence). Using the year 2014 as the dissemination period, we conducted a pre-post analysis. We also conducted sensitivity analyses using: 1) optional criteria in scoring, 2) alternate dissemination period (2014-2015), and 3) alternative comparator classification. RESULTS Articles averaged 60% adherence to methodological specifications and 74% adherence to reporting standards. While methodological adherence scores did not significantly improve (59% pre-2014 vs. 60% post-2014, p = 0.53), reporting adherence scores increased slightly over time (72% pre-2014 vs. 75% post-2014, p<0.01). Overall, reporting adherence scores exceeded methodological adherence scores (74% vs. 60%, p<0.001). Articles seldom addressed budget impact (9% reporting, 10% methodological) or equity (7% reporting, 7% methodological). CONCLUSIONS The iDSI reference case has substantial potential to serve as a useful resource for researchers and policy-makers in global health settings, but greater effort to promote adherence and awareness is needed to achieve its potential.
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Affiliation(s)
- Joanna Emerson
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, United States of America
| | - Ari Panzer
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, United States of America
| | - Joshua T. Cohen
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, United States of America
| | - Kalipso Chalkidou
- Institute of Global Health Innovation, Imperial College London, London, United Kingdom
| | - Yot Teerawattananon
- The Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Mark Sculpher
- Centre for Health Economics, University of York, York, United Kingdom
| | - Thomas Wilkinson
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Damian Walker
- Bill & Melinda Gates Foundation, Seattle, WA, United States of America
| | - Peter J. Neumann
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, United States of America
| | - David D. Kim
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, United States of America
- * E-mail:
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Saunders MJ, Tovar MA, Collier D, Baldwin MR, Montoya R, Valencia TR, Gilman RH, Evans CA. Active and passive case-finding in tuberculosis-affected households in Peru: a 10-year prospective cohort study. THE LANCET. INFECTIOUS DISEASES 2019; 19:519-528. [PMID: 30910427 PMCID: PMC6483977 DOI: 10.1016/s1473-3099(18)30753-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 11/06/2018] [Accepted: 11/29/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Active case-finding among contacts of patients with tuberculosis is a global health priority, but the effects of active versus passive case-finding are poorly characterised. We assessed the contribution of active versus passive case-finding to tuberculosis detection among contacts and compared sex and disease characteristics between contacts diagnosed through these strategies. METHODS In shanty towns in Callao, Peru, we identified index patients with tuberculosis and followed up contacts aged 15 years or older for tuberculosis. All patients and contacts were offered free programmatic active case-finding entailing sputum smear microscopy and clinical assessment. Additionally, all contacts were offered intensified active case-finding with sputum smear and culture testing monthly for 6 months and then once every 4 years. Passive case-finding at local health facilities was ongoing throughout follow-up. FINDINGS Between Oct 23, 2002, and May 26, 2006, we identified 2666 contacts, who were followed up until March 1, 2016. Median follow-up was 10·0 years (IQR 7·5-11·0). 232 (9%) of 2666 contacts were diagnosed with tuberculosis. The 2-year cumulative risk of tuberculosis was 4·6% (95% CI 3·5-5·5), and overall incidence was 0·98 cases (95% CI 0·86-1·10) per 100 person-years. 53 (23%) of 232 contacts with tuberculosis were diagnosed through active case-finding and 179 (77%) were identified through passive case-finding. During the first 6 months of the study, 23 (45%) of 51 contacts were diagnosed through active case-finding and 28 (55%) were identified through passive case-finding. Contacts diagnosed through active versus passive case-finding were more frequently female (36 [68%] of 53 vs 85 [47%] of 179; p=0·009), had a symptom duration of less than 15 days (nine [25%] of 36 vs ten [8%] of 127; p=0·03), and were more likely to be sputum smear-negative (33 [62%] of 53 vs 62 [35%] of 179; p=0·0003). INTERPRETATION Although active case-finding made an important contribution to tuberculosis detection among contacts, passive case-finding detected most of the tuberculosis burden. Compared with passive case-finding, active case-finding was equitable, helped to diagnose tuberculosis earlier and usually before a positive result on sputum smear microscopy, and showed a high burden of undetected tuberculosis among women. FUNDING Wellcome Trust, Department for International Development Civil Society Challenge Fund, Joint Global Health Trials consortium, Bill & Melinda Gates Foundation, Imperial College National Institutes of Health Research Biomedical Research Centre, Foundation for Innovative New Diagnostics, Sir Halley Stewart Trust, WHO, TB REACH, and IFHAD: Innovation for Health and Development.
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Affiliation(s)
- Matthew J Saunders
- Infectious Diseases and Immunity, Imperial College London, and Wellcome Trust Imperial College Centre for Global Health Research, London, UK; Innovation for Health and Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru; Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru.
| | - Marco A Tovar
- Infectious Diseases and Immunity, Imperial College London, and Wellcome Trust Imperial College Centre for Global Health Research, London, UK; Innovation for Health and Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru; Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru
| | - Dami Collier
- Innovation for Health and Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru; Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru
| | - Matthew R Baldwin
- Innovation for Health and Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru; Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru; Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Rosario Montoya
- Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru
| | - Teresa R Valencia
- Innovation for Health and Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Robert H Gilman
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Carlton A Evans
- Infectious Diseases and Immunity, Imperial College London, and Wellcome Trust Imperial College Centre for Global Health Research, London, UK; Innovation for Health and Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru; Innovación Por la Salud Y Desarrollo (IPSYD), Asociación Benéfica PRISMA, Lima, Peru
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Reid MJA, Arinaminpathy N, Bloom A, Bloom BR, Boehme C, Chaisson R, Chin DP, Churchyard G, Cox H, Ditiu L, Dybul M, Farrar J, Fauci AS, Fekadu E, Fujiwara PI, Hallett TB, Hanson CL, Harrington M, Herbert N, Hopewell PC, Ikeda C, Jamison DT, Khan AJ, Koek I, Krishnan N, Motsoaledi A, Pai M, Raviglione MC, Sharman A, Small PM, Swaminathan S, Temesgen Z, Vassall A, Venkatesan N, van Weezenbeek K, Yamey G, Agins BD, Alexandru S, Andrews JR, Beyeler N, Bivol S, Brigden G, Cattamanchi A, Cazabon D, Crudu V, Daftary A, Dewan P, Doepel LK, Eisinger RW, Fan V, Fewer S, Furin J, Goldhaber-Fiebert JD, Gomez GB, Graham SM, Gupta D, Kamene M, Khaparde S, Mailu EW, Masini EO, McHugh L, Mitchell E, Moon S, Osberg M, Pande T, Prince L, Rade K, Rao R, Remme M, Seddon JA, Selwyn C, Shete P, Sachdeva KS, Stallworthy G, Vesga JF, Vilc V, Goosby EP. Building a tuberculosis-free world: The Lancet Commission on tuberculosis. Lancet 2019; 393:1331-1384. [PMID: 30904263 DOI: 10.1016/s0140-6736(19)30024-8] [Citation(s) in RCA: 216] [Impact Index Per Article: 43.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 12/20/2018] [Accepted: 12/25/2018] [Indexed: 11/22/2022]
Affiliation(s)
- Michael J A Reid
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA.
| | - Nimalan Arinaminpathy
- School of Public Health, Imperial College London, London, UK; Faculty of Medicine, Imperial College London, London, UK
| | - Amy Bloom
- Tuberculosis Division, United States Agency for International Development, Washington, DC, USA
| | - Barry R Bloom
- Department of Global Health and Population, Harvard University, Cambridge, MA, USA
| | | | - Richard Chaisson
- Departments of Medicine, Epidemiology, and International Health, Johns Hopkins School of Medicine, Baltimore, MA, USA
| | | | | | - Helen Cox
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Mark Dybul
- Department of Medicine, Centre for Global Health and Quality, Georgetown University, Washington, DC, USA
| | | | - Anthony S Fauci
- National Institute of Allergy and Infectious Diseases, US National Institutes of Health, Maryland, MA, USA
| | | | - Paula I Fujiwara
- Department of Tuberculosis and HIV, The International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Timothy B Hallett
- School of Public Health, Imperial College London, London, UK; Faculty of Medicine, Imperial College London, London, UK
| | | | | | - Nick Herbert
- Global TB Caucus, Houses of Parliament, London, UK
| | - Philip C Hopewell
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Chieko Ikeda
- Department of GLobal Health, Ministry of Heath, Labor and Welfare, Tokyo, Japan
| | - Dean T Jamison
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Aamir J Khan
- Interactive Research & Development, Karachi, Pakistan
| | - Irene Koek
- Global Health Bureau, United States Agency for International Development, Washington, DC, USA
| | - Nalini Krishnan
- Resource Group for Education and Advocacy for Community Health, Chennai, India
| | - Aaron Motsoaledi
- South African National Department of Health, Pretoria, South Africa
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada; McGill International TB Center, McGill University, Montreal, QC, Canada
| | - Mario C Raviglione
- University of Milan, Milan, Italy; Global Studies Institute, University of Geneva, Geneva, Switzerland
| | - Almaz Sharman
- Academy of Preventive Medicine of Kazakhstan, Almaty, Kazakhstan
| | - Peter M Small
- Global Health Institute, School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | | | - Zelalem Temesgen
- Department of Infectious Diseases, Mayo Clinic, Rochester, MI, USA
| | - Anna Vassall
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK; Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, Netherlands
| | | | | | - Gavin Yamey
- Center for Policy Impact in Global Health, Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Bruce D Agins
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Sofia Alexandru
- Institutul de Ftiziopneumologie Chiril Draganiuc, Chisinau, Moldova
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Naomi Beyeler
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Stela Bivol
- Center for Health Policies and Studies, Chisinau, Moldova
| | - Grania Brigden
- Department of Tuberculosis and HIV, The International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Adithya Cattamanchi
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Danielle Cazabon
- McGill International TB Center, McGill University, Montreal, QC, Canada
| | - Valeriu Crudu
- Center for Health Policies and Studies, Chisinau, Moldova
| | - Amrita Daftary
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada; McGill International TB Center, McGill University, Montreal, QC, Canada
| | - Puneet Dewan
- Bill & Melinda Gates Foundation, New Delhi, India
| | - Laurie K Doepel
- National Institute of Allergy and Infectious Diseases, US National Institutes of Health, Maryland, MA, USA
| | - Robert W Eisinger
- National Institute of Allergy and Infectious Diseases, US National Institutes of Health, Maryland, MA, USA
| | - Victoria Fan
- T H Chan School of Public Health, Harvard University, Cambridge, MA, USA; Office of Public Health Studies, University of Hawaii, Mānoa, HI, USA
| | - Sara Fewer
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Jennifer Furin
- Division of Infectious Diseases & HIV Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Jeremy D Goldhaber-Fiebert
- Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
| | - Gabriela B Gomez
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Stephen M Graham
- Department of Tuberculosis and HIV, The International Union Against Tuberculosis and Lung Disease, Paris, France; Department of Paediatrics, Center for International Child Health, University of Melbourne, Melbourne, VIC, Australia; Burnet Institute, Melbourne, VIC, Australia
| | - Devesh Gupta
- Revised National TB Control Program, New Delhi, India
| | - Maureen Kamene
- National Tuberculosis, Leprosy and Lung Disease Program, Ministry of Health, Nairobi, Kenya
| | | | - Eunice W Mailu
- National Tuberculosis, Leprosy and Lung Disease Program, Ministry of Health, Nairobi, Kenya
| | | | - Lorrie McHugh
- Office of the Secretary-General's Special Envoy on Tuberculosis, United Nations, Geneva, Switzerland
| | - Ellen Mitchell
- International Institute of Social Studies, Erasmus University Rotterdam, The Hague, Netherland
| | - Suerie Moon
- Department of Global Health and Population, Harvard University, Cambridge, MA, USA; Global Health Centre, The Graduate Institute Geneva, Geneva, Switzerland
| | | | - Tripti Pande
- McGill International TB Center, McGill University, Montreal, QC, Canada
| | - Lea Prince
- Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
| | | | - Raghuram Rao
- Ministry of Health and Family Welfare, New Delhi, India
| | - Michelle Remme
- International Institute for Global Health, United Nations University, Kuala Lumpur, Malaysia
| | - James A Seddon
- Department of Medicine, Imperial College London, London, UK; Faculty of Medicine, Imperial College London, London, UK; Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Casey Selwyn
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Priya Shete
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Juan F Vesga
- School of Public Health, Imperial College London, London, UK; Faculty of Medicine, Imperial College London, London, UK
| | | | - Eric P Goosby
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
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Vesga JF, Hallett TB, Reid MJA, Sachdeva KS, Rao R, Khaparde S, Dave P, Rade K, Kamene M, Omesa E, Masini E, Omale N, Onyango E, Owiti P, Karanja M, Kiplimo R, Alexandru S, Vilc V, Crudu V, Bivol S, Celan C, Arinaminpathy N. Assessing tuberculosis control priorities in high-burden settings: a modelling approach. LANCET GLOBAL HEALTH 2019; 7:e585-e595. [PMID: 30904521 DOI: 10.1016/s2214-109x(19)30037-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 10/22/2018] [Accepted: 01/11/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND In the context of WHO's End TB strategy, there is a need to focus future control efforts on those interventions and innovations that would be most effective in accelerating declines in tuberculosis burden. Using a modelling approach to link the tuberculosis care cascade to transmission, we aimed to identify which improvements in the cascade would yield the greatest effect on incidence and mortality. METHODS We engaged with national tuberculosis programmes in three country settings (India, Kenya, and Moldova) as illustrative examples of settings with a large private sector (India), a high HIV burden (Kenya), and a high burden of multidrug resistance (Moldova). We collated WHO country burden estimates, routine surveillance data, and tuberculosis prevalence surveys from 2011 (for India) and 2016 (for Kenya). Linking the tuberculosis care cascade to tuberculosis transmission using a mathematical model with Bayesian melding in each setting, we examined which cascade shortfalls would have the greatest effect on incidence and mortality, and how the cascade could be used to monitor future control efforts. FINDINGS Modelling suggests that combined measures to strengthen the care cascade could reduce cumulative tuberculosis incidence by 38% (95% Bayesian credible intervals 27-43) in India, 31% (25-41) in Kenya, and 27% (17-41) in Moldova between 2018 and 2035. For both incidence and mortality, modelling suggests that the most important cascade losses are the proportion of patients visiting the private health-care sector in India, missed diagnosis in health-care settings in Kenya, and drug sensitivity testing in Moldova. In all settings, the most influential delay is the interval before a patient's first presentation for care. In future interventions, the proportion of individuals with tuberculosis who are on high-quality treatment could offer a more robust monitoring tool than routine notifications of tuberculosis. INTERPRETATION Linked to transmission, the care cascade can be valuable, not only for improving patient outcomes but also in identifying and monitoring programmatic priorities to reduce tuberculosis incidence and mortality. FUNDING US Agency for International Development, Stop TB Partnership, UK Medical Research Council, and Department for International Development.
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Affiliation(s)
- Juan F Vesga
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK.
| | - Timothy B Hallett
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
| | - Michael J A Reid
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - Raghuram Rao
- Central TB Division, New Delhi, India; Central TB Division, New Delhi, India
| | | | | | - Kiran Rade
- WHO India Country Office, New Delhi, India
| | - Maureen Kamene
- National Tuberculosis, Leprosy and Lung Disease Programme, Nairobi, Kenya
| | - Eunice Omesa
- National Tuberculosis, Leprosy and Lung Disease Programme, Nairobi, Kenya
| | | | - Newton Omale
- National Tuberculosis, Leprosy and Lung Disease Programme, Nairobi, Kenya
| | - Elizabeth Onyango
- National Tuberculosis, Leprosy and Lung Disease Programme, Nairobi, Kenya
| | - Philip Owiti
- National Tuberculosis, Leprosy and Lung Disease Programme, Nairobi, Kenya
| | | | - Richard Kiplimo
- National Tuberculosis, Leprosy and Lung Disease Programme, Nairobi, Kenya
| | - Sofia Alexandru
- National Tuberculosis Programme, 'Chiril Draganiuc' Institute of Phthisiopneumology, Chisinau, Moldova
| | - Valentina Vilc
- National Tuberculosis Programme, 'Chiril Draganiuc' Institute of Phthisiopneumology, Chisinau, Moldova
| | - Valeriu Crudu
- National Tuberculosis Programme, 'Chiril Draganiuc' Institute of Phthisiopneumology, Chisinau, Moldova
| | - Stela Bivol
- Centre for Health Policies and Studies, Chisinau, Moldova
| | - Cristina Celan
- Centre for Health Policies and Studies, Chisinau, Moldova
| | - Nimalan Arinaminpathy
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
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The performance and yield of tuberculosis testing algorithms using microscopy, chest x-ray, and Xpert MTB/RIF. J Clin Tuberc Other Mycobact Dis 2018; 14:1-6. [PMID: 31720409 PMCID: PMC6830149 DOI: 10.1016/j.jctube.2018.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 11/19/2018] [Accepted: 11/26/2018] [Indexed: 12/14/2022] Open
Abstract
Setting The introduction of Xpert MTB/RIF (Xpert) and renewed interest in chest x-ray (CXR) for tuberculosis testing has provided additional choices to the smear-based diagnostic algorithms used by TB programs previously. More programmatic data is needed to better understand the implications of possible approaches. Objective We sought to evaluate how different testing algorithms using microscopy, Xpert and CXR impacted the number of people detected with TB in a district hospital in Nepal. Design Consecutively recruited patients with TB-related symptoms were offered smear microscopy, CXR and Xpert. We tested six hypothetical algorithms and compared yield, bacteriologically positive (Bac+) cases missed, and tests conducted. Results Among 929 patients, Bac+ prevalence was 17.3% (n = 161). Smear microscopy detected 121 (75.2% of Bac+). Depending on the radiologists' interpretation of CXR, Xpert testing could be reduced by (31%-60%). Smear microscopy reduced Xpert cartridge need slightly, but increased the overall diagnostic tests performed. Conclusion Xpert detected a large proportion of Bac+ TB cases missed by microscopy. CXR was useful in greatly reducing the number of diagnostic tests needed even among presumptive TB patients. Loose CXR readings should be used to identify more people for TB testing. More analysis of costs and standardized CXR reading should be considered.
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Mburu JW, Kingwara L, Ester M, Andrew N. Use of classification and regression tree (CART), to identify hemoglobin A1C (HbA 1C) cut-off thresholds predictive of poor tuberculosis treatment outcomes and associated risk factors. J Clin Tuberc Other Mycobact Dis 2018; 11:10-16. [PMID: 31720385 PMCID: PMC6830151 DOI: 10.1016/j.jctube.2018.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 01/18/2018] [Accepted: 01/23/2018] [Indexed: 11/23/2022] Open
Abstract
Background Rifampin-based therapy potentially exacerbates glycemic control among TB patients who are already at high risk of hyperglycemia. This impacts negatively to the optimal care of TB- diabetes mellitus co-affected patients. Classification and regression tree (CART), a machine-learning algorithm impervious to statistical assumptions is one of the ideal tools for clinical decision-making that can be used to identify hemoglobin A1C (HbA1C) cut-off thresholds predictive of poor TB treatment outcomes in such populations. Methods 340TB smear positive patients attending two peri-urban clinics were recruited and prospectively followed up for six months. Baseline HbA1C and random blood glucose (RBG) levels were determined. CART was then used to identify cut-off thresholds and rank outcome predictors at end of therapy by determining Risk ratios (RR) and 95% confidence interval (CI) of each predictor threshold. Fractal geometry law explained effect of weight, while U-shaped curve explained effect of HbA1C on these clinical outcomes. Results Of the 340 patients enrolled: 84%were cured, 7% completed therapy and 9% had unfavorable outcomes out of which 4% (n = 32) had microbiologic failure. Using CART HbA1C identified thresholds were >2.95%, 2.95–4.55% and >4.55%, containing 8/11 (73%), 111/114 (97%) and 189/215 (88%) of patients who experienced favorable outcomes. RR for favorable outcome in patients with weight <53.25 Kg compared to >53.25 Kg was 0.61 (95% CI, 0.45–0.88) among patients with HbA1C >4.55%. Simulation of the CART model with 13 patients data failed therapy revealed that 8/11 (73%) of patients with HbA1C <2.95%, 111/114 (97%) with HbA1C between 2.95% and 4.55% and 189/215 (88%) of patients with HbA1c >4.55% experienced microbiologic failure. Conclusion Using fractal geometry relationships to drug pharmacokinetics, low weight has profound influence on failure of anti-tuberculosis treatment among patients at risk for diabetes mellitus.
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Affiliation(s)
- Josephine W Mburu
- National Reference Tuberculosis Laboratory, MOH, Kenya.,Jomo Kenyatta University of Agriculture and Technology (JKUAT), Kenya
| | | | - Magiri Ester
- Jomo Kenyatta University of Agriculture and Technology (JKUAT), Kenya
| | - Nyerere Andrew
- Jomo Kenyatta University of Agriculture and Technology (JKUAT), Kenya
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Kigozi G, Engelbrecht M, Heunis C, Janse van Rensburg A. Household contact non-attendance of clinical evaluation for tuberculosis: a pilot study in a high burden district in South Africa. BMC Infect Dis 2018; 18:106. [PMID: 29506488 PMCID: PMC5838997 DOI: 10.1186/s12879-018-3010-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 02/22/2018] [Indexed: 11/21/2022] Open
Abstract
Background In 2012, the World Health Organization launched guidelines for systematically investigating contacts of persons with infectious tuberculosis (TB) in low- and middle-income countries. As such, it is necessary to understand factors that would influence successful scale-up. This study targeted household contacts of newly-diagnosed infectious TB patients in the Mangaung Metropolitan district to explore factors associated with non-attendance of clinical evaluation. Method In September–October 2016, a pilot study of household contacts was conducted. At each of the 40 primary health care (PHC) facilities in the district, at least one out of four types of TB index cases were purposefully selected. These included children <5 years, smear-positive cases, HIV co-infected cases, and multidrug-resistant TB (MDR-TB) cases. Trained fieldworkers administered questionnaires and screened contacts for TB symptoms. Those with TB symptoms as well as children <5 years were referred for clinical evaluation at the nearest PHC facility. Contacts’ socio-demographic and clinical characteristics, TB knowledge and perception about TB-related discrimination are described. Logistic regression analysis was used to investigate factors associated with non-attendance of clinical evaluation. Results Out of the 259 participants, approximately three in every five (59.5%) were female. The median age was 20 (interquartile range: 8–41) years. While the large majority (87.3%) of adult contacts correctly described TB aetiology, almost three in every five (59.9%) thought that it was hereditary, and almost two-thirds (65.5%) believed that it could be cured by herbal medicine. About one-fifth (22.9%) of contacts believed that TB patients were subjected to discrimination. Two in every five (39.4%) contacts were referred for clinical evaluation of whom more than half (52.9%) did not attend the clinic. Non-attendance was significantly associated with inter alia male gender (AOR: 3.4; CI: 1.11–10.24), prior TB diagnosis (AOR: 5.6; CI: 1.13–27.90) and sharing of a bedroom with the index case (AOR: 3.4: CI: 1.07–10.59). Conclusion The pilot study identified gaps in household contacts’ knowledge of TB. Further research on important individual, clinical and structural factors that can influence and should be considered in the planning, implementation and scale-up of household contact TB investigation is warranted.
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Affiliation(s)
- Gladys Kigozi
- Centre for Health Systems Research & Development, University of the Free State, P. O. Box 339, Bloemfontein, 9300, South Africa.
| | - Michelle Engelbrecht
- Centre for Health Systems Research & Development, University of the Free State, P. O. Box 339, Bloemfontein, 9300, South Africa
| | - Christo Heunis
- Centre for Health Systems Research & Development, University of the Free State, P. O. Box 339, Bloemfontein, 9300, South Africa
| | - André Janse van Rensburg
- Centre for Health Systems Research & Development, University of the Free State, P. O. Box 339, Bloemfontein, 9300, South Africa
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Yang C, Gao Q. Recent transmission of Mycobacterium tuberculosis in China: the implication of molecular epidemiology for tuberculosis control. Front Med 2018; 12:76-83. [PMID: 29357036 DOI: 10.1007/s11684-017-0609-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/31/2017] [Indexed: 11/28/2022]
Abstract
Tuberculosis (TB) has remained an ongoing concern in China. The national scale-up of the Directly Observed Treatment, Short Course (DOTS) program has accelerated the fight against TB in China. Nevertheless, many challenges still remain, including the spread of drug-resistant strains, high disease burden in rural areas, and enormous rural-to-urban migrations. Whether incident active TB represents recent transmission or endogenous reactivation has helped to prioritize the strategies for TB control. Evidence from molecular epidemiology studies has delineated the recent transmission of Mycobacterium tuberculosis (M. tuberculosis) strains in many settings. However, the transmission patterns of TB in most areas of China are still not clear. Studies carried out to date could not capture the real burden of recent transmission of the disease in China because of the retrospective study design, incomplete sampling, and use of low-resolution genotyping methods. We reviewed the implementations of molecular epidemiology of TB in China, the estimated disease burden due to recent transmission of M. tuberculosis strains, the primary transmission of drug-resistant TB, and the evaluation of a feasible genotyping method of M. tuberculosis strains in circulation.
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Affiliation(s)
- Chongguang Yang
- Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, School of Basic Medical Science, Fudan University, Shanghai, 200032, China.,Department of Epidemiology of Microbial Diseases, School of Public Health, Yale University, 60 College Street, New Haven, CT, 06510, USA
| | - Qian Gao
- Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, School of Basic Medical Science, Fudan University, Shanghai, 200032, China.
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Epidemiological paradigm: Tuberculosis in HIV, diabetes, and smoking in North East India: An impact greater than sum of its parts. Indian J Tuberc 2017; 65:1-3. [PMID: 29332641 DOI: 10.1016/j.ijtb.2017.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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