1
|
Li T, Du X, Jia Z, Zhao Y. A Modeling Study Recurrent Tuberculosis Towards End TB Strategy - China, 2025-2035. China CDC Wkly 2024; 6:885-890. [PMID: 39233997 PMCID: PMC11369061 DOI: 10.46234/ccdcw2024.189] [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: 02/21/2024] [Accepted: 08/01/2024] [Indexed: 09/06/2024] Open
Abstract
What is already known about this topic? The recurrence of tuberculosis (TB) following successful treatment presents a significant challenge. What is added by this report? Achieving the global End TB Strategy milestones and targets with the current strategies in China is challenging. However, interventions following recovery to prevent recurrence, in conjunction with preventive treatment for latent TB infection (LTBI), will aid in meeting these objectives. What are the implications for public health practice? Implementing interventions to mitigate recurrence is essential for improving TB control strategies both in China and worldwide. Concurrently, the development of new drugs and vaccines should focus on preventing TB recurrence.
Collapse
Affiliation(s)
- Tao Li
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
- Chinese Center for Disease Control and Prevention, Beijing, China
- National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, Chinese Center for Disease Control and Prevention, Beijing, China
- Center for Intelligent Public Health, Institute for Artificial Intelligence, Peking University, Beijing, China
| | - Xin Du
- Chinese Center for Disease Control and Prevention, Beijing, China
| | - Zhongwei Jia
- Center for Intelligent Public Health, Institute for Artificial Intelligence, Peking University, Beijing, China
- Department of Global Health, School of Public Health, Peking University, Beijing, China
- Center for Drug Abuse Control and Prevention, National Institute of Health Data Science, Peking University, Beijing, China
| | - Yanlin Zhao
- Chinese Center for Disease Control and Prevention, Beijing, China
- National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, Chinese Center for Disease Control and Prevention, Beijing, China
| |
Collapse
|
2
|
Kebede Bizuneh F, Tsegaye D, Negese Gemeda B, Kebede Bizuneh T. Proportion of active tuberculosis among HIV-infected children after antiretroviral therapy in Ethiopia: A systematic review and meta-analysis. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003528. [PMID: 39093892 PMCID: PMC11296650 DOI: 10.1371/journal.pgph.0003528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 07/03/2024] [Indexed: 08/04/2024]
Abstract
Despite effectiveness of antiretroviral therapy in reducing mortality of opportunistic infections among HIV infected children, however tuberculosis (TB) remains a significant cause for morbidity and attributed for one in every three deaths. HIV-infected children face disproportionate death risk during co-infection of TB due to their young age and miniatures immunity makes them more vulnerable. In Ethiopia, there is lack of aggregated data TB and HIV mortality in HIV infected children. We conducted an extensive systematic review of literature using Preferred Reporting of Systematic Review and Meta-Analysis (PRISMA) guideline. Five electronic databases were used mainly Scopus, PubMed, Medline, Web of Science, and Google scholar for articles searching. The pooled proportion of TB was estimated using a weighted inverse variance random-effects meta-regression using STATA version-17. Heterogeneity of the articles was evaluated using Cochran's Q test and I2 statistic. Subgroup analysis, sensitivity test, and Egger's regression were conducted for publication bias. This met-analysis is registered in Prospero-CRD42024502038. In the final met-analysis report, 13 out of 1221 articles were included and presented. During screening of 6668 HIV-infected children for active TB occurrence, 834 cases were reported after ART was initiated. The pooled proportion of active TB among HIV infected children was found 12.07% (95% CI: 10.71-13.41). In subgroup analysis, the Oromia region had 15.6% (95%CI: 10.2-20.6) TB burden, followed by southern Ethiopia 12.8% (95%CI: 10.03-15.67). During meta-regression, missed isoniazid Preventive therapy (IPT) (OR: 2.28), missed contrimoxazole preventive therapy (OR: 4.26), WHO stage III&IV (OR: 2.27), and level of Hgb ≤ 10gm/dl (OR = 3.11.7) were predictors for active TB. The systematic review found a higher proportion of active TB in HIV-infected children in Ethiopia compared to estimated rates in end TB strategy. To prevent premature death during co-infection, implement effective TB screening and cases tracing strategies in each follow up is needed.
Collapse
Affiliation(s)
| | - Dejen Tsegaye
- College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | | | | |
Collapse
|
3
|
Moges S, Lajore BA. Mortality and associated factors among patients with TB-HIV co-infection in Ethiopia: a systematic review and meta-analysis. BMC Infect Dis 2024; 24:773. [PMID: 39095740 PMCID: PMC11295522 DOI: 10.1186/s12879-024-09683-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 07/29/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND Tuberculosis (TB) and human immunodeficiency virus (HIV) co-infection is a major public health problem in Ethiopia. Patients with TB-HIV co-infection have significantly higher mortality rates compared to those with TB or HIV mono-infection. This systematic review and meta-analysis aim to summarize the evidence on mortality and associated factors among patients with TB-HIV co-infection in Ethiopia. METHODS Comprehensive searches were conducted in multiple electronic databases (PubMed/MEDLINE, Embase, CINAHL, Web of Science) for observational studies published between January 2000 and present, reporting mortality rates among TB/HIV co-infected individuals. Two reviewers performed study selection, data extraction, and quality assessment independently. Random-effects meta-analysis was used to pool mortality estimates, and heterogeneity was assessed using I² statistics. Subgroup analyses and meta-regression were performed to explore potential sources of heterogeneity. RESULTS 185 articles were retrieved with 20 studies included in the final analysis involving 8,113 participants. The pooled mortality prevalence was 16.65% (95% CI 12.57%-19.65%) with I2 : 95.98% & p-value < 0.00. Factors significantly associated with increased mortality included: older age above 44 years (HR: 1.82; 95% CI: 1.31-2.52), ambulatory(HR: 1.64; 95% CI: 1.23-2.18) and bedridden functional status(HR: 2.75; 95% CI: 2.01-3.75), extra-pulmonary Tuberculosis (ETB) (HR: 2.34; 95% CI: 1.76-3.10), advanced WHO stage III (HR: 1.76; 95% CI: 1.22-2.38) and WHO stage IV (HR: 2.17; 95% CI:1.41-3.34), opportunistic infections (HR: 1.75; 95% CI: 1.30-2.34), low CD4 count of < 50 cells/mm3 (HR: 3.37; 95% CI: 2.18-5.22) and lack of co-trimoxazole prophylaxis (HR: 2.15; 95% CI: 1.73-2.65). CONCLUSIONS TB/HIV co-infected patients in Ethiopia experience unacceptably high mortality, driven by clinical markers of advanced immunosuppression. Early screening, timely treatment initiation, optimizing preventive therapies, and comprehensive management of comorbidities are imperative to improve outcomes in this vulnerable population.
Collapse
Affiliation(s)
- Sisay Moges
- Department of Family Health, Hosanna College of Health Science, Hosanna, Ethiopia.
| | | |
Collapse
|
4
|
Bizuneh FK, Bizuneh TK, Masresha SA, Kidie AA, Arage MW, Sirage N, Abate BB. Tuberculosis-associated mortality and risk factors for HIV-infected population in Ethiopia: a systematic review and meta-analysis. Front Public Health 2024; 12:1386113. [PMID: 39104893 PMCID: PMC11298472 DOI: 10.3389/fpubh.2024.1386113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 06/24/2024] [Indexed: 08/07/2024] Open
Abstract
Background Despite the effectiveness of antiretroviral therapy in reducing mortality from opportunistic infections among people living with HIV (PLHIV), tuberculosis (TB) continues to be a significant cause of death, accounting for over one-third of all deaths in this population. In Ethiopia, there is a lack of comprehensive and aggregated data on the national level for TB-associated mortality during co-infection with HIV. Therefore, this systematic review and meta-analysis aimed to estimate TB-associated mortality and identify risk factors for PLHIV in Ethiopia. Methods We conducted an extensive systematic review of the literature using the Preferred Reporting of Systematic Review and Meta-Analysis (PRISMA) guidelines. More than seven international electronic databases were used to extract 1,196 published articles from Scopus, PubMed, MEDLINE, Web of Science, HINARY, Google Scholar, African Journal Online, and manual searching. The pooled mortality proportion of active TB was estimated using a weighted inverse variance random-effects meta-regression using STATA version-17. The heterogeneity of the articles was evaluated using Cochran's Q test and I 2 statistic test. Subgroup analysis, sensitivity analysis, and Egger's regression were conducted to investigate publication bias. This systematic review is registered in Prospero with specific No. CRD42024509131. Results Overall, 22 individual studies were included in the final meta-analysis reports. During the review, a total of 9,856 cases of TB and HIV co-infection were screened and 1,296 deaths were reported. In the final meta-analysis, the pooled TB-associated mortality for PLHIV in Ethiopia was found to be 16.2% (95% CI: 13.0-19.2, I 2 = 92.9%, p = 0.001). The subgroup analysis revealed that the Amhara region had a higher proportion of TB-associated mortality, which was reported to be 21.1% (95% CI: 18.1-28.0, I 2 = 84.4%, p = 0.001), compared to studies conducted in Harari and Addis Ababa regions, which had the proportions of 10% (95% CI: 6-13.1%, I 2 = 83.38%, p = 0.001) and 8% (95% CI: 1.1-15, I 2 = 87.6%, p = 0.001), respectively. During the random-effects meta-regression, factors associated with co-infection of mortality in TB and HIV were identified, including WHO clinical stages III & IV (OR = 3.01, 95% CI: 1.9-4.7), missed co-trimoxazole preventive therapy (CPT) (OR = 1.89, 95% CI: 1.05-3.4), and missed isoniazid preventive therapy (IPT) (OR = 1.8, 95% CI: 1.46-2.3). Conclusion In Ethiopia, the mortality rate among individuals co-infected with TB/HIV is notably high, with nearly one-fifth (16%) of individuals succumbing during co-infection; this rate is considered to be higher compared to other African countries. Risk factors for death during co-infection were identified; the included studies examined advanced WHO clinical stages IV and III, hemoglobin levels (≤10 mg/dL), missed isoniazid preventive therapy (IPT), and missed cotrimoxazole preventive therapy (CPT) as predictors. To reduce premature deaths, healthcare providers must prioritize active TB screening, ensure timely diagnosis, and provide nutritional counseling in each consecutive visit. Systematic review registration Trial registration number in Prospero =CRD42024509131 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=509131.
Collapse
Affiliation(s)
| | - Tsehay Kebede Bizuneh
- Faculties of Social Science, Geography department, Bahir Dare University, Bahir Dare, Ethiopia
| | | | | | | | - Nurye Sirage
- College of Health Sciences, Woldia University, Woldia, Ethiopia
| | | |
Collapse
|
5
|
Kim S, Can MH, Agizew TB, Auld AF, Balcells ME, Bjerrum S, Dheda K, Dorman SE, Esmail A, Fielding K, Garcia-Basteiro AL, Hanrahan CF, Kebede W, Kohli M, Luetkemeyer AF, Mita C, Reeve BWP, Silva DR, Sweeney S, Theron G, Trajman A, Vassall A, Warren JL, Yotebieng M, Cohen T, Menzies NA. Factors associated with tuberculosis treatment initiation among bacteriologically negative individuals evaluated for tuberculosis: an individual patient data meta-analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.07.24305445. [PMID: 38645191 PMCID: PMC11030305 DOI: 10.1101/2024.04.07.24305445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Background Globally, over one-third of pulmonary tuberculosis (TB) disease diagnoses are made based on clinical criteria after a negative diagnostic test result. Understanding factors associated with clinicians' decisions to initiate treatment for individuals with negative test results is critical for predicting the potential impact of new diagnostics. Methods We performed a systematic review and individual patient data meta-analysis using studies conducted between January/2010 and December/2022 (PROSPERO: CRD42022287613). We included trials or cohort studies that enrolled individuals evaluated for TB in routine settings. In these studies participants were evaluated based on clinical examination and routinely-used diagnostics, and were followed for ≥1 week after the initial test result. We used hierarchical Bayesian logistic regression to identify factors associated with treatment initiation following a negative result on an initial bacteriological test (e.g., sputum smear microscopy, Xpert MTB/RIF). Findings Multiple factors were positively associated with treatment initiation: male sex [adjusted Odds Ratio (aOR) 1.61 (1.31-1.95)], history of prior TB [aOR 1.36 (1.06-1.73)], reported cough [aOR 4.62 (3.42-6.27)], reported night sweats [aOR 1.50 (1.21-1.90)], and having HIV infection but not on ART [aOR 1.68 (1.23-2.32)]. Treatment initiation was substantially less likely for individuals testing negative with Xpert [aOR 0.77 (0.62-0.96)] compared to smear microscopy and declined in more recent years. Interpretation Multiple factors influenced decisions to initiate TB treatment despite negative test results. Clinicians were substantially less likely to treat in the absence of a positive test result when using more sensitive, PCR-based diagnostics.
Collapse
Affiliation(s)
- Sun Kim
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Melike Hazal Can
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Andrew F. Auld
- U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Maria Elvira Balcells
- Infectious Disease Department, School of Medicine, Pontificia Universidad Católica de Chile
| | - Stephanie Bjerrum
- Department of Clinical Research, University of Southern Denmark, Odense Denmark
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, Cape Town, South Africa
- South African MRC Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
- Faculty of Infectious and Tropical Diseases, Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Aliasgar Esmail
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, Cape Town, South Africa
- South African MRC Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Katherine Fielding
- TB Centre, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Alberto L. Garcia-Basteiro
- ISGlobal, Hospital Clínic – Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Barcelona, Spain
| | - Colleen F. Hanrahan
- Epidemiology Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Wakjira Kebede
- School of Medical Laboratory Sciences, Jimma University, Jimma Ethiopia
- Mycobacteriology Research Center of Jimma University, Ethiopia
| | | | | | - Carol Mita
- Countway Library of Medicine, Harvard University, Boston, MA, USA
| | - Byron W. P. Reeve
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Denise Rossato Silva
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Sedona Sweeney
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Grant Theron
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Anete Trajman
- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- McGill University, Montreal, QC, Canada
| | - Anna Vassall
- Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Joshua L. Warren
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Marcel Yotebieng
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, New York City, NY, USA
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Nicolas A. Menzies
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
6
|
Rohrig A, Morrison J, Kleinwaks G, Pugh J, McShane H, Savulescu J. Exploring the ethics of tuberculosis human challenge models. JOURNAL OF MEDICAL ETHICS 2023:jme-2023-109234. [PMID: 38159935 DOI: 10.1136/jme-2023-109234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 09/28/2023] [Indexed: 01/03/2024]
Abstract
We extend recent conversation about the ethics of human challenge trials to tuberculosis (TB). TB challenge studies could accelerate vaccine development, but ethical concerns regarding risks to trial participants and third parties have been a limiting factor. We analyse the expected social value and risks of different challenge models, concluding that if a TB challenge trial has between a 10% and a 50% chance of leading to the authorisation and near-universal delivery of a more effective vaccine 3-5 years earlier, then the trial would save between 26 400 and 1 100 000 lives over the next 10 years. We also identify five important ethical considerations that differentiate TB from recent human challenge trials: an exceptionally high disease burden with no highly effective vaccine; heightened third party risk following the trial, and, partly for that reason, uniquely stringent biosafety requirements for the trial; risks associated with best available TB treatments; and difficulties with TB disease detection. We argue that there is good reason to consider conducting challenge trials with attenuated strains like Bacillus Calmette-Guérin or attenuated Mycobacterium tuberculosis.
Collapse
Affiliation(s)
- Abie Rohrig
- Columbia University, New York, New York, USA
- 1Day Sooner, Baltimore, Maryland, USA
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | | | | | - Jonathan Pugh
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Helen McShane
- Jenner Institute, University of Oxford Nuffield Department of Medicine, Oxford, Oxfordshire, UK
| | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Biomedical Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| |
Collapse
|
7
|
León Rubio I, Guerrero Espejo A. Osteoarticular tuberculosis mortality in Spain between 1997 and 2018. REUMATOLOGÍA CLÍNICA (ENGLISH EDITION) 2023; 19:229-231. [PMID: 37005130 DOI: 10.1016/j.reumae.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Affiliation(s)
- Isabel León Rubio
- Grupo de Investigación de Enfermedades Infecciosas, Facultad de Medicina y Odontología, Universidad Católica de Valencia «San Vicente Mártir», Valencia, Spain.
| | - Antonio Guerrero Espejo
- Grupo de Investigación de Enfermedades Infecciosas, Facultad de Medicina y Odontología, Universidad Católica de Valencia «San Vicente Mártir», Valencia, Spain
| |
Collapse
|
8
|
Otero L, Zetola N, Campos M, Zunt J, Bayer A, Curisinche M, Ochoa T, Reyes M, Vega V, Van der Stuyft P, Sterling TR. Isoniazid preventive therapy completion in children under 5 years old who are contacts of tuberculosis cases in Lima, Peru: study protocol for an open-label, cluster-randomized superiority trial. Trials 2023; 24:54. [PMID: 36694242 PMCID: PMC9871424 DOI: 10.1186/s13063-022-07062-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/30/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Children < 5 years old in contact with TB cases are at high risk for developing severe and fatal forms of TB. Contact investigation, BCG vaccination, and isoniazid preventive therapy (IPT) are the most effective strategies to prevent TB among children. However, the implementation of IPT faces challenges at several stages of the cascade of care of TB infection among children, particularly those less than 5 years old. In Peru, a large proportion of children do not complete IPT, which highlights the need to design effective interventions that enhance preventive therapy adherence and completion. Although the body of evidence for such interventions has grown, interventions in medium TB incidence settings are lacking. This study aims to test the effectiveness, acceptability, and feasibility of an intervention package to increase information and motivation to complete IPT among children < 5 who have been prescribed IPT. METHODS An open-label, cluster-randomized superiority trial will be conducted in two districts in South Lima, Peru. Thirty health facilities will be randomized as clusters, 10 to the intervention and 20 to control (standard of care). We aim to recruit 10 children from different households in each cluster. Participants will be caretakers of children aged < 5 years old who initiated IPT. The intervention consists of educational material, and short message services (SMS) reminders and motivators. The primary outcomes will be the proportion of children who picked up > 90% of the 24 weeks of IPT (22 pick-ups) and the proportion of children who picked up the 24 weeks of IPT. The standard of care is a weekly pick-up with monthly check-ups in a health facility. Feasibility and acceptability of the intervention will be assessed through an interview with the caretaker. DISCUSSION Unfavorable outcomes of TB in young children, high effectiveness of IPT, and low rates of IPT completion highlight the need to enhance adherence and completion of IPT among children < 5 years old. Testing of a context-adapted intervention is needed to improve IPT completion rates and therefore TB prevention in young children. TRIAL REGISTRATION ClinicalTrials.gov NCT03881228. Registered on March 19, 2019.
Collapse
Affiliation(s)
- L Otero
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru.
- Instituto de Medicina Tropical Alexander Von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru.
- Unit of General Epidemiology and Disease Control, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
| | - N Zetola
- Division of Pulmonary and Critical Care, Augusta University, Augusta, GA, USA
| | - M Campos
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru
- Facultad de Ciencias, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - J Zunt
- Department of Neurology, University of Washington School of Medicine, WA, Seattle, USA
| | - A Bayer
- Facultad de Salud Pública, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - M Curisinche
- Dirección de Prevención Y Control de Tuberculosis, Ministerio de Salud, Lima, Peru
- Centro Nacional de Salud Pública, Instituto Nacional de Salud, Lima, Peru
| | - T Ochoa
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru
- Instituto de Medicina Tropical Alexander Von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - M Reyes
- Instituto de Medicina Tropical Alexander Von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - V Vega
- Instituto de Medicina Tropical Alexander Von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - P Van der Stuyft
- Department of Public Health, Faculty of Medicine, Ghent University, Ghent, Belgium
| | - T R Sterling
- Vanderbilt University School of Medicine, Nashville, TN, USA
| |
Collapse
|
9
|
Shegaze M, Boda B, Ayele G, Gebremeskel F, Tariku B, Gultie T. Why people die of active tuberculosis in the era of effective chemotherapy in Southern Ethiopia: a qualitative study. J Clin Tuberc Other Mycobact Dis 2022; 29:100338. [DOI: 10.1016/j.jctube.2022.100338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
10
|
Sinha P, Lakshminarayanan SL, Cintron C, Narasimhan PB, Locks LM, Kulatilaka N, Maloomian K, Prakash Babu S, Carwile ME, Liu AF, Horsburgh CR, Acuna-Villaorduna C, Linas BP, Hochberg NS. Nutritional Supplementation Would Be Cost-Effective for Reducing Tuberculosis Incidence and Mortality in India: The Ration Optimization to Impede Tuberculosis (ROTI-TB) Model. Clin Infect Dis 2022; 75:577-585. [PMID: 34910141 PMCID: PMC9464065 DOI: 10.1093/cid/ciab1033] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Undernutrition is the leading cause of tuberculosis (TB) in India and is associated with increased TB mortality. Undernutrition also decreases quality of life and economic productivity. METHODS We assessed the cost-effectiveness of providing augmented rations to undernourished Indians through the government's Targeted Public Distribution System (TPDS). We used Markov state transition models to simulate disease progression and mortality among undernourished individuals in 3 groups: general population, household contacts (HHCs) of people living with TB, and persons living with human immunodeficiency virus (HIV). The models calculate costs and outcomes (TB cases, TB deaths, and disability-adjusted life years [DALYs]) associated with a 2600 kcal/day diet for adults with body mass index (BMI) of 16-18.4 kg/m2 until they attain a BMI of 20 kg/m2 compared to a status quo scenario wherein TPDS rations are unchanged. We employed deterministic and probabilistic sensitivity analyses to test result robustness. RESULTS Over 5 years, augmented rations could avert 81% of TB cases and 88% of TB deaths among currently undernourished Indians. Correspondingly, this intervention could forestall 78% and 48% of TB cases and prevent 88% and 70% of deaths among undernourished HHCs and persons with HIV, respectively. Augmented rations resulted in 10-fold higher resolution of undernutrition and were highly cost-effective with (incremental cost-effectiveness ratio [ICER] of $470/DALY averted). ICER was lower for HHCs ($360/DALY averted) and the HIV population ($250/DALY averted). CONCLUSIONS A robust nutritional intervention would be highly cost-effective in reducing TB incidence and mortality while reducing chronic undernutrition in India.
Collapse
Affiliation(s)
- Pranay Sinha
- Section of Infectious Diseases, Department of Internal Medicine, School of Medicine, Boston University, Boston, Massachusetts, USA
| | - Subitha L Lakshminarayanan
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Chelsie Cintron
- Section of Infectious Diseases, Department of Internal Medicine, School of Medicine, Boston University, Boston, Massachusetts, USA
| | - Prakash Babu Narasimhan
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Lindsey M Locks
- Department of Health Sciences, Boston University College of Health and Rehabilitation Sciences: Sargent College, Boston, Massachusetts, USA
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Nalin Kulatilaka
- Susilo Institute for Ethics in a Global Economy, Boston University Questrom School of Business, Boston, Massachusetts, USA
| | - Kimberly Maloomian
- Center for Bariatric Surgery, Miriam Hospital, Providence, Rhode Island, USA
- Kimba’s Kitchen, LLC, West Palm Beach, Florida, USA
| | - Senbagavalli Prakash Babu
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Madeline E Carwile
- Section of Infectious Diseases, Department of Internal Medicine, School of Medicine, Boston University, Boston, Massachusetts, USA
| | - Anne F Liu
- Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - C Robert Horsburgh
- Section of Infectious Diseases, Department of Internal Medicine, School of Medicine, Boston University, Boston, Massachusetts, USA
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Carlos Acuna-Villaorduna
- Section of Infectious Diseases, Department of Internal Medicine, School of Medicine, Boston University, Boston, Massachusetts, USA
| | - Benjamin P Linas
- Section of Infectious Diseases, Department of Internal Medicine, School of Medicine, Boston University, Boston, Massachusetts, USA
| | - Natasha S Hochberg
- Section of Infectious Diseases, Department of Internal Medicine, School of Medicine, Boston University, Boston, Massachusetts, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
11
|
Abdollahi E, Keynan Y, Foucault P, Brophy J, Sheffield H, Moghadas SM. Evaluation of TB elimination strategies in Canadian Inuit populations: Nunavut as a case study. Infect Dis Model 2022; 7:698-708. [PMID: 36313153 PMCID: PMC9583452 DOI: 10.1016/j.idm.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 07/26/2022] [Indexed: 11/26/2022] Open
Abstract
Tuberculosis (TB) continues to disproportionately affect Inuit populations in Canada with some communities having over 300 times higher rate of active TB than Canadian-born, non-Indigenous people. Inuit Tuberculosis Elimination Framework has set the goal of reducing active TB incidence by at least 50% by 2025, aiming to eliminate it by 2030. Whether these goals are achievable with available resources and treatment regimens currently in practice has not been evaluated. We developed an agent-based model of TB transmission to evaluate timelines and milestones attainable in Nunavut, Canada by including case findings, contact-tracing and testing, treatment of latent TB infection (LTBI), and the government investment on housing infrastructure to reduce the average household size. The model was calibrated to ten years of TB incidence data, and simulated for 20 years to project program outcomes. We found that, under a range of plausible scenarios with tracing and testing of 25%–100% of frequent contacts of detected active cases, the goal of 50% reduction in annual incidence by 2025 is not achievable. If active TB cases are identified rapidly within one week of becoming symptomatic, then the annual incidence would reduce below 100 per 100,000 population, with 50% reduction being met between 2025 and 2030. Eliminating TB from Inuit populations would require high rates of contact-tracing and would extend beyond 2030. The findings indicate that time-to-identification of active TB is a critical factor determining program effectiveness, suggesting that investment in resources for rapid case detection is fundamental to controlling TB. TB elimination in Inuit populations would likely extend beyond timelines outlined in action plans. Rapid case findings combined with testing of frequent contacts are fundamental to TB control. Reducing average household size has minimal effect on rates of TB incidence.
Collapse
|
12
|
Kang TG, Kwon KW, Kim K, Lee I, Kim MJ, Ha SJ, Shin SJ. Viral coinfection promotes tuberculosis immunopathogenesis by type I IFN signaling-dependent impediment of Th1 cell pulmonary influx. Nat Commun 2022; 13:3155. [PMID: 35672321 PMCID: PMC9174268 DOI: 10.1038/s41467-022-30914-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 05/06/2022] [Indexed: 01/09/2023] Open
Abstract
Tuberculosis (TB), caused by Mycobacterium tuberculosis (Mtb), is often exacerbated upon coinfection, but the underlying immunological mechanisms remain unclear. Here, to elucidate these mechanisms, we use an Mtb and lymphocytic choriomeningitis virus coinfection model. Viral coinfection significantly suppresses Mtb-specific IFN-γ production, with elevated bacterial loads and hyperinflammation in the lungs. Type I IFN signaling blockade rescues the Mtb-specific IFN-γ response and ameliorates lung immunopathology. Single-cell sequencing, tissue immunofluorescence staining, and adoptive transfer experiments indicate that viral infection-induced type I IFN signaling could inhibit CXCL9/10 production in myeloid cells, ultimately impairing pulmonary migration of Mtb-specific CD4+ T cells. Thus, our study suggests that augmented and sustained type I IFNs by virus coinfection prior to the pulmonary localization of Mtb-specific Th1 cells exacerbates TB immunopathogenesis by impeding the Mtb-specific Th1 cell influx. Our study highlights a negative function of viral coinfection-induced type I IFN responses in delaying Mtb-specific Th1 responses in the lung. Viral coinfection alongside mycobacterium tuberculosis (Mtb) infection may lead to immune complications or interference with immune responses. Here the authors show that in mice infected with Mtb and LCMV virus the specific TH1 response to MTb is reduced through a type I IFN response to the infecting virus.
Collapse
Affiliation(s)
- Tae Gun Kang
- Department of Biochemistry, College of Life Science & Biotechnology, Yonsei University, Seoul, 03722, Republic of Korea.,Brain Korea 21 (BK21) FOUR Program, Yonsei Education & Research Center for Biosystems, Yonsei University, Seoul, 03722, Republic of Korea
| | - Kee Woong Kwon
- Department of Microbiology, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Kyungsoo Kim
- Department of Biochemistry, College of Life Science & Biotechnology, Yonsei University, Seoul, 03722, Republic of Korea.,Institute for Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Insuk Lee
- Department of Biotechnology, College of Life Science & Biotechnology, Yonsei University, Seoul, 03722, Republic of Korea
| | - Myeong Joon Kim
- Department of Biochemistry, College of Life Science & Biotechnology, Yonsei University, Seoul, 03722, Republic of Korea.,Brain Korea 21 (BK21) FOUR Program, Yonsei Education & Research Center for Biosystems, Yonsei University, Seoul, 03722, Republic of Korea
| | - Sang-Jun Ha
- Department of Biochemistry, College of Life Science & Biotechnology, Yonsei University, Seoul, 03722, Republic of Korea. .,Brain Korea 21 (BK21) FOUR Program, Yonsei Education & Research Center for Biosystems, Yonsei University, Seoul, 03722, Republic of Korea.
| | - Sung Jae Shin
- Department of Microbiology, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea. .,Institute for Immunology and Immunological Disease, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea.
| |
Collapse
|
13
|
Weerasuriya CK, Harris RC, McQuaid CF, Bozzani F, Ruan Y, Li R, Li T, Rade K, Rao R, Ginsberg AM, Gomez GB, White RG. The epidemiologic impact and cost-effectiveness of new tuberculosis vaccines on multidrug-resistant tuberculosis in India and China. BMC Med 2021; 19:60. [PMID: 33632218 PMCID: PMC7908776 DOI: 10.1186/s12916-021-01932-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/29/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Despite recent advances through the development pipeline, how novel tuberculosis (TB) vaccines might affect rifampicin-resistant and multidrug-resistant tuberculosis (RR/MDR-TB) is unknown. We investigated the epidemiologic impact, cost-effectiveness, and budget impact of hypothetical novel prophylactic prevention of disease TB vaccines on RR/MDR-TB in China and India. METHODS We constructed a deterministic, compartmental, age-, drug-resistance- and treatment history-stratified dynamic transmission model of tuberculosis. We introduced novel vaccines from 2027, with post- (PSI) or both pre- and post-infection (P&PI) efficacy, conferring 10 years of protection, with 50% efficacy. We measured vaccine cost-effectiveness over 2027-2050 as USD/DALY averted-against 1-times GDP/capita, and two healthcare opportunity cost-based (HCOC), thresholds. We carried out scenario analyses. RESULTS By 2050, the P&PI vaccine reduced RR/MDR-TB incidence rate by 71% (UI: 69-72) and 72% (UI: 70-74), and the PSI vaccine by 31% (UI: 30-32) and 44% (UI: 42-47) in China and India, respectively. In India, we found both USD 10 P&PI and PSI vaccines cost-effective at the 1-times GDP and upper HCOC thresholds and P&PI vaccines cost-effective at the lower HCOC threshold. In China, both vaccines were cost-effective at the 1-times GDP threshold. P&PI vaccine remained cost-effective at the lower HCOC threshold with 49% probability and PSI vaccines at the upper HCOC threshold with 21% probability. The P&PI vaccine was predicted to avert 0.9 million (UI: 0.8-1.1) and 1.1 million (UI: 0.9-1.4) second-line therapy regimens in China and India between 2027 and 2050, respectively. CONCLUSIONS Novel TB vaccination is likely to substantially reduce the future burden of RR/MDR-TB, while averting the need for second-line therapy. Vaccination may be cost-effective depending on vaccine characteristics and setting.
Collapse
Affiliation(s)
- Chathika K Weerasuriya
- TB Modelling Group, TB Centre and Centre for the Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK.
| | - Rebecca C Harris
- TB Modelling Group, TB Centre and Centre for the Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Currently employed at Sanofi Pasteur, Singapore, Singapore
| | - C Finn McQuaid
- TB Modelling Group, TB Centre and Centre for the Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Fiammetta Bozzani
- Department of Global Health and Development, Faculty of Public Health & Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Yunzhou Ruan
- Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Renzhong Li
- Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Tao Li
- Chinese Centre for Disease Control and Prevention, Beijing, China
| | | | - Raghuram Rao
- National Tuberculosis Elimination Programme, New Delhi, India
| | - Ann M Ginsberg
- International AIDS Vaccine Initiative, New York, USA.,Current Affiliation: Bill and Melinda Gates Foundation, Washington DC, USA
| | - Gabriela B Gomez
- Department of Global Health and Development, Faculty of Public Health & Policy, London School of Hygiene and Tropical Medicine, London, UK.,Currently employed at Sanofi Pasteur, Lyon, France
| | - Richard G White
- TB Modelling Group, TB Centre and Centre for the Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
14
|
Abstract
COVID-19 pandemic has disturbed the delivery of health care in almost all countries of the world. This has affected mostly the public health control programs. Because of lock downs, restrictions in movement, psychological fear of contacting the disease in health care facilities, diversion of health care workers for containment and management of COVID-19, utilization of diagnostic facilities like CBNAAT machines for COVID work, conversion of hospitals for care of these patients, financial diversion etc has created issues in the NTEP to focuss on TB control in India. Case notification and other areas of the program to achieve End TB by 2025 have suffered. Various ways of overcoming these difficulties have been discussed.
Collapse
Affiliation(s)
- D. Behera
- Dept. of Pulmonary Medicine, WHO Collaborating Centre for Research & Capacity Building in Chronic Respiratory Diseases, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India,National Task Force (NTEP/RNTCP),Corresponding author. Tel.: +91 172 2756822, 9815705357 (mobile)
| |
Collapse
|
15
|
Zawedde-Muyanja S, Musaazi J, Manabe YC, Katamba A, Nankabirwa JI, Castelnuovo B, Cattamanchi A. Estimating the effect of pretreatment loss to follow up on TB associated mortality at public health facilities in Uganda. PLoS One 2020; 15:e0241611. [PMID: 33206650 PMCID: PMC7673517 DOI: 10.1371/journal.pone.0241611] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 09/23/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Tuberculosis (TB) mortality estimates derived only from cohorts of patients initiated on TB treatment do not consider outcomes of patients with pretreatment loss to follow-up (LFU). We aimed to assess the effect of pretreatment LFU on TB-associated mortality in the six months following TB diagnosis at public health facilities in Uganda. METHODS At ten public health facilities, we retrospectively reviewed treatment data for all patients with a positive Xpert®MTB/RIF test result from January to June 2018. Pretreatment LFU was defined as not initiating TB treatment within two weeks of a positive test. We traced patients with pretreatment LFU to ascertain their vital status. We performed Kaplan Meier survival analysis to compare the cumulative incidence of mortality, six months after diagnosis among patients who did and did not experience pretreatment LFU. We also determined the health facility level estimates of TB associated mortality before and after incorporating deaths prior to treatment initiation among patients who experienced pretreatment LFU. RESULTS Of 510 patients with positive test, 100 (19.6%) experienced pretreatment LFU. Of these, we ascertained the vital status of 49 patients. In the six months following TB diagnosis, mortality was higher among patients who experienced pretreatment LFU 48.1/1000py vs 22.9/1000py. Hazard ratio [HR] 3.18, 95% confidence interval [CI] (1.61-6.30). After incorporating deaths prior to treatment initation among patients who experienced pretreatment LFU, health facility level estimates of TB associated mortality increased from 8.4% (95% CI 6.1%-11.6%) to 10.2% (95% CI 7.7%-13.4%). CONCLUSION Patients with confirmed TB who experience pretreatment LFU have high mortality within the first six months. Efforts should be made to prioritise linkage to treatment for this group of patients. Deaths that occur prior to treatment initation should be included when reporting TB mortality in order to more accurately reflect the health impact of TB.
Collapse
Affiliation(s)
- Stella Zawedde-Muyanja
- The Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- * E-mail:
| | - Joseph Musaazi
- The Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Yukari C. Manabe
- The Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Achilles Katamba
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joaniter I. Nankabirwa
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Barbara Castelnuovo
- The Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco, California, United States of America
| |
Collapse
|
16
|
Naidu T, Pillay SR, Ramlall S, Mthembu SS, Padayatchi N, Burns JK, Tomita A. Major Depression and Stigma among Individuals with Multidrug-Resistant Tuberculosis in South Africa. Am J Trop Med Hyg 2020; 103:1067-1071. [PMID: 32700662 DOI: 10.4269/ajtmh.19-0426] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Stigma is an important social determinant of health-seeking behavior; however, the nature and extent of its association with depression among people living with multidrug-resistant tuberculosis (MDR-TB) are not well-understood. We enrolled 200 microbiologically confirmed MDR-TB inpatients at a TB specialist hospital in KwaZulu-Natal Province, an area considered the epicenter for MDR-TB coinfection in South Africa. Four aspects of stigma and their association with major depression were assessed through individual interviews: 1) community and 2) patient perspectives toward TB, and 3) community and 4) patient perspectives toward HIV. A major depressive episode (MDE), HIV coinfection, and low income were significantly associated with greater stigma subscales. Based on an adjusted regression model, the MDE was the only factor independently associated with (all aspects of) stigma. These results indicate the potential utility of addressing stigma associated with the MDE as an important step in improving health-seeking behavior to promote adherence and retention in care.
Collapse
Affiliation(s)
- Thirusha Naidu
- Behavioural Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Suntosh R Pillay
- King DinuZulu Hospital, KwaZulu-Natal Department of Health, Durban, South Africa.,Department of Psychiatry, University of KwaZulu-Natal, Durban, South Africa
| | - Suvira Ramlall
- Department of Psychiatry, University of KwaZulu-Natal, Durban, South Africa
| | | | - Nesri Padayatchi
- MRC HIV-TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Jonathan K Burns
- Institute of Health Research, University of Exeter, Exeter, United Kingdom.,Department of Psychiatry, University of KwaZulu-Natal, Durban, South Africa
| | - Andrew Tomita
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.,Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| |
Collapse
|
17
|
Rohit A, Kumar AMV, Thekkur P, Shastri SG, Kumar RBN, Nirgude AS, Reddy MM, Ravichandra C, Somashekar N, Balu PS. Does provision of cash incentive to HIV-infected tuberculosis patients improve the treatment success in programme settings? A cohort study from South India. J Family Med Prim Care 2020; 9:3955-3964. [PMID: 33110793 PMCID: PMC7586600 DOI: 10.4103/jfmpc.jfmpc_474_20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/25/2020] [Accepted: 06/10/2020] [Indexed: 11/04/2022] Open
Abstract
Background In April 2018, the Government of India launched 'Nikshay Poshan Yojana' (NPY), a cash assistance scheme (500 Indian rupees [~8 USD] per month) intended to provide nutritional support and improve treatment outcomes among tuberculosis (TB) patients. Objective To compare the treatment outcomes of HIV-infected TB patients initiated on first-line anti-TB treatment in five selected districts of Karnataka, India before (April-September 2017) and after (April-September 2018) implementation of NPY. Methods This was a cohort study using secondary data routinely collected by the national TB and HIV programmes. Results A total of 630 patients were initiated on ATT before NPY and 591 patients after NPY implementation. Of the latter, 464 (78.5%, 95% CI: 75.0%-81.8%) received at least one installment of cash incentive. Among those received, the median (inter-quartile range) duration between treatment initiation and receipt of first installment was 74 days (41-165) and only 16% received within the first month of treatment. In 117 (25.2%) patients, the first installment was received after declaration of their treatment outcome. Treatment success (cured and treatment completed) in 'before NPY' cohort was 69.2% (95% CI: 65.6%-72.8%), while it was 65.0% (95% CI: 61.2%-68.8%) in 'after NPY' cohort. On adjusted analysis using modified Poisson regression we did not find a statistically significant association between NPY and unsuccessful treatment outcomes (adjusted relative risk-1.1, 95% CI: 0.9-1.3). Conclusion Contrary to our hypothesis and previous evidence from systematic reviews, we did not find an association between NPY and improved treatment outcomes.
Collapse
Affiliation(s)
- Amuje Rohit
- Department of Community Medicine, JJM Medical College, Davanagere, Karnataka, India
| | - Ajay M V Kumar
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France.,Centre for Operational Research, The Union South-East Asia Office, New Delhi, India.,Department of Community Medicine, Yenepoya Medical College, Yenepoya (Deemed To Be University), Mangaluru, Karnataka, India
| | - Pruthu Thekkur
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France.,Centre for Operational Research, The Union South-East Asia Office, New Delhi, India
| | - Suresh G Shastri
- Department of Health and Family Welfare Services, State Tuberculosis Cell, Bangalore, Karnataka, India
| | - Ravi B N Kumar
- Department of Health and Family Welfare Services, National AIDS Control Organization (NACO), New Delhi, India.,Department of Health and Family Welfare Services, Karnataka State AIDS Prevention Society (KSAPS), Bangalore, Karnataka, India
| | - Abhay S Nirgude
- Department of Community Medicine, Yenepoya Medical College, Yenepoya (Deemed To Be University), Mangaluru, Karnataka, India
| | - Mahendra M Reddy
- Department of Community Medicine, Sri Devaraj Urs Medical College (SDUMC), Sri Devaraj Urs Academy of Higher Education and Research (SDUAHER), Tamaka, Kolar, Karnataka, India
| | | | | | - P S Balu
- Department of Community Medicine, JJM Medical College, Davanagere, Karnataka, India
| |
Collapse
|
18
|
Rajpurkar P, O’Connell C, Schechter A, Asnani N, Li J, Kiani A, Ball RL, Mendelson M, Maartens G, van Hoving DJ, Griesel R, Ng AY, Boyles TH, Lungren MP. CheXaid: deep learning assistance for physician diagnosis of tuberculosis using chest x-rays in patients with HIV. NPJ Digit Med 2020; 3:115. [PMID: 32964138 PMCID: PMC7481246 DOI: 10.1038/s41746-020-00322-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 08/14/2020] [Indexed: 01/17/2023] Open
Abstract
Tuberculosis (TB) is the leading cause of preventable death in HIV-positive patients, and yet often remains undiagnosed and untreated. Chest x-ray is often used to assist in diagnosis, yet this presents additional challenges due to atypical radiographic presentation and radiologist shortages in regions where co-infection is most common. We developed a deep learning algorithm to diagnose TB using clinical information and chest x-ray images from 677 HIV-positive patients with suspected TB from two hospitals in South Africa. We then sought to determine whether the algorithm could assist clinicians in the diagnosis of TB in HIV-positive patients as a web-based diagnostic assistant. Use of the algorithm resulted in a modest but statistically significant improvement in clinician accuracy (p = 0.002), increasing the mean clinician accuracy from 0.60 (95% CI 0.57, 0.63) without assistance to 0.65 (95% CI 0.60, 0.70) with assistance. However, the accuracy of assisted clinicians was significantly lower (p < 0.001) than that of the stand-alone algorithm, which had an accuracy of 0.79 (95% CI 0.77, 0.82) on the same unseen test cases. These results suggest that deep learning assistance may improve clinician accuracy in TB diagnosis using chest x-rays, which would be valuable in settings with a high burden of HIV/TB co-infection. Moreover, the high accuracy of the stand-alone algorithm suggests a potential value particularly in settings with a scarcity of radiological expertise.
Collapse
Affiliation(s)
- Pranav Rajpurkar
- Stanford University Department of Computer Science, Stanford, CA USA
| | - Chloe O’Connell
- Massachusetts General Hospital Department of Anesthesia, Boston, MA USA
| | - Amit Schechter
- Stanford University Department of Computer Science, Stanford, CA USA
| | - Nishit Asnani
- Stanford University Department of Computer Science, Stanford, CA USA
| | - Jason Li
- Stanford University Department of Computer Science, Stanford, CA USA
| | - Amirhossein Kiani
- Stanford University Department of Computer Science, Stanford, CA USA
| | | | - Marc Mendelson
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Rulan Griesel
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew Y. Ng
- Stanford University Department of Computer Science, Stanford, CA USA
| | - Tom H. Boyles
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | |
Collapse
|
19
|
Danielsen AS, Elstrøm P, Arnesen TM, Gopinathan U, Kacelnik O. Targeting TB or MRSA in Norwegian municipalities during 'the refugee crisis' of 2015: a framework for priority setting in screening. ACTA ACUST UNITED AC 2020; 24. [PMID: 31552819 PMCID: PMC6761574 DOI: 10.2807/1560-7917.es.2019.24.38.1800676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction In 2015, there was an increase in the number of asylum seekers arriving in Europe. Like in other countries, deciding screening priorities for tuberculosis (TB) and meticillin-resistant Staphylococcus aureus (MRSA) was a challenge. At least five of 428 municipalities chose to screen asylum seekers for MRSA before TB; the Norwegian Institute for Public Health advised against this. Aim To evaluate the MRSA/TB screening results from 2014 to 2016 and create a generalised framework for screening prioritisation in Norway through simulation modelling. Methods This is a register-based cohort study of asylum seekers using data from the Norwegian Surveillance System for Communicable Diseases from 2014 to 2016. We used survey data from municipalities that screened all asylum seekers for MRSA and denominator data from the Directorate of Immigration. A comparative risk assessment model was built to investigate the outcomes of prioritising between TB and MRSA in screening regimes. Results Of 46,090 asylum seekers, 137 (0.30%) were diagnosed with active TB (notification rate: 300/100,000 person-years). In the municipalities that screened all asylum seekers for MRSA, 13 of 1,768 (0.74%) were found to be infected with MRSA. The model estimated that screening for MRSA would prevent eight MRSA infections while prioritising TB screening would prevent 24 cases of active TB and one death. Conclusion Our findings support the decision to advise against screening for MRSA before TB among newly arrived asylum seekers. The model was an effective tool for comparing screening priorities and can be applied to other scenarios in other countries.
Collapse
Affiliation(s)
- Anders Skyrud Danielsen
- Department of Antibiotic Resistance and Infection Prevention, Norwegian Institute of Public Health, Oslo, Norway
| | - Petter Elstrøm
- Department of Antibiotic Resistance and Infection Prevention, Norwegian Institute of Public Health, Oslo, Norway
| | - Trude Margrete Arnesen
- Department of Tuberculosis, Blood Borne and Sexually Transmitted Infections, Norwegian Institute of Public Health, Oslo, Norway
| | - Unni Gopinathan
- Cluster for Global Health, Norwegian Institute of Public Health & Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Oliver Kacelnik
- Department of Antibiotic Resistance and Infection Prevention, Norwegian Institute of Public Health, Oslo, Norway
| |
Collapse
|
20
|
Jo Y, Shrestha S, Gomes I, Marks S, Hill A, Asay G, Dowdy D. Model-Based Cost-Effectiveness of State-level Latent Tuberculosis Interventions in California, Florida, New York and Texas. Clin Infect Dis 2020; 73:e3476-e3482. [PMID: 32584968 DOI: 10.1093/cid/ciaa857] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 06/19/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Targeted testing and treatment (TTT) for latent tuberculosis infection (LTBI) is a recommended strategy to accelerate TB reductions and further tuberculosis elimination in the United States (US). Evidence on cost-effectiveness of TTT for key populations can help advance this goal. METHODS We used a model of TB transmission to estimate the numbers of individuals who could be tested by interferon-γ release assay (IGRA) and treated for LTBI with three months of self-administered rifapentine and isoniazid (3HP) under various TTT scenarios. Specifically, we considered rapidly scaling up TTT among people who are non-US-born, diabetic, HIV-positive, homeless or incarcerated in California, Florida, New York, and Texas - states where more than half of US TB cases occur. We projected costs (from the healthcare system perspective, in 2018 dollars), thirty-year reductions in TB incidence, and incremental cost effectiveness (cost per quality-adjusted life year [QALY] gained) for TTT in each modeled population. RESULTS The projected cost effectiveness of TTT differed substantially by state and population, while the health impact (number of TB cases averted) was consistently greatest among the non-US-born. TTT was most cost-effective among persons living with HIV (from $2,828/QALY gained in Florida to $11,265/QALY gained in New York) and least cost-effective among people with diabetes (from $223,041/QALY gained in California to $817,753 /QALY in New York). CONCLUSIONS The modeled cost-effectiveness of TTT for LTBI varies across states but was consistently greatest among people living with HIV, moderate among people who are non-US-born, incarcerated, or homeless, and least cost-effective among people living with diabetes.
Collapse
Affiliation(s)
- Youngji Jo
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sourya Shrestha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Isabella Gomes
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Suzanne Marks
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Andrew Hill
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Garrett Asay
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| |
Collapse
|
21
|
Abstract
Does prosocial behavior promote happiness? We test this longstanding hypothesis in a behavioral experiment that extends the scope of previous research. In our Saving a Life paradigm, every participant either saved one human life in expectation by triggering a targeted donation of 350 euros or received an amount of 100 euros. Using a choice paradigm between two binary lotteries with different chances of saving a life, we observed subjects' intentions at the same time as creating random variation in prosocial outcomes. We repeatedly measured happiness at various delays. Our data weakly replicate the positive effect identified in previous research but only for the very short run. One month later, the sign of the effect reversed, and prosocial behavior led to significantly lower happiness than obtaining the money. Notably, even those subjects who chose prosocially were ultimately happier if they ended up getting the money for themselves. Our findings revealed a more nuanced causal relationship than previously suggested, providing an explanation for the apparent absence of universal prosocial behavior.
Collapse
Affiliation(s)
- Armin Falk
- Department of Economics, University of Bonn, 53113 Bonn, Germany;
- Institute on Behavior and Inequality, 53113 Bonn, Germany
| | - Thomas Graeber
- Department of Economics, Harvard University, Cambridge, MA 02138
| |
Collapse
|
22
|
Commentary: Why Has Uptake of Pneumococcal Vaccines for Children Been So Slow? The Perils of Undervaluation. Pediatr Infect Dis J 2020; 39:145-156. [PMID: 31725554 DOI: 10.1097/inf.0000000000002521] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Pediatric pneumococcal disease exacts a substantial burden on global health, much of which is vaccine-preventable. Despite this considerable burden and the demonstrably high efficacy of pneumococcal conjugate vaccines (PCVs), the overall level of PCV uptake remains concerningly low, especially compared with that of other childhood-recommended vaccines, such as tuberculosis and polio. A broad set of plausible explanations exists for this low uptake, including logistical challenges, psychosocial factors and affordability. One additional and systematic cause of low uptake, which is the focus of our discussion, is economists' and policymakers' tendency to undervalue vaccination in general by adopting a narrow health sector perspective when performing economic evaluations of vaccines. We present an alternative, societal framework for economic evaluations that encompasses a broader set of socioeconomic benefits in addition to health benefits. Quantifying a more comprehensive taxonomy of PCV's benefits will help to address potential undervaluation and may be sufficient not only to justify recommendation and reimbursement but also to stimulate efforts and investment toward closing coverage gaps.
Collapse
|
23
|
Huddart S, Svadzian A, Nafade V, Satyanarayana S, Pai M. Tuberculosis case fatality in India: a systematic review and meta-analysis. BMJ Glob Health 2020; 5:e002080. [PMID: 32133176 PMCID: PMC7042607 DOI: 10.1136/bmjgh-2019-002080] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/09/2019] [Accepted: 12/23/2019] [Indexed: 11/03/2022] Open
Abstract
Introduction The WHO End TB Strategy calls for a global reduction in the case fatality ratio (CFR) below 5%. India accounts for a third of global tuberculosis (TB) deaths. This systematic review estimated CFRs among Indian patients with TB both during and after treatment. Methods We systematically searched Medline, Embase and Global Health for eligible studies published between 1 January 2006 and 8 January 2019, including both cohort studies and intervention study control arms that followed Indian patients with TB for fatality either during treatment or post-treatment. From relevant studies we extracted CFRs in addition to study demographics. Study quality was assessed using modified Scottish Intercollegiate Guidelines Network cohort criteria. Sufficiently homogenous studies were pooled using a random effect generalised linear mixed model. A meta-regression was performed to associate study characteristics with resulting CFRs. Results 218 relevant studies were identified, of which 211 provided treatment phase CFRs. Most patients (92.4%) were treated in the public sector. Quality concerns were identified in 74% of papers. We estimated a pooled treatment phase CFR of 5.16% (95% CI 4.20% to 6.34%) which fell to 3.78% (2.77% to 5.16%) when restricted to 52 high-quality studies. Treatment phase CFRs were higher for paediatric (n=27, 6.50% (2.65% to 10.36%)), drug-resistant (n=43, 14.06% (10.15% to 19.49%)) and HIV-infected (n=35, 10.91% (7.68% to 15.50%)) patients. Nineteen post-treatment CFR studies were too heterogeneous to pool except when restricting to three high-quality studies (2.69% (-0.79% to 6.18%)). Poor study quality (OR=2.27 (2.01 to 2.57)) and tertiary centres patients (OR=1.15 (1.03 to 1.28)) were significantly associated with increased treatment phase case fatality. Conclusions Case fatality is a critical measure of the quality of TB care. While India's treatment CFRs are in line with WHO targets, several key patient groups remain understudied and most studies suffer from methodological issues. Increased high-quality reporting on patient outcomes will help improve the evidence base on this topic.
Collapse
Affiliation(s)
- Sophie Huddart
- Epidemiology & Biostatistics, McGill University, Montreal, Quebec, Canada.,McGill International TB Centre, Montreal, Quebec, Canada
| | - Anita Svadzian
- Epidemiology & Biostatistics, McGill University, Montreal, Quebec, Canada.,McGill International TB Centre, Montreal, Quebec, Canada
| | - Vaidehi Nafade
- Epidemiology & Biostatistics, McGill University, Montreal, Quebec, Canada.,McGill International TB Centre, Montreal, Quebec, Canada
| | | | - Madhukar Pai
- Epidemiology & Biostatistics, McGill University, Montreal, Quebec, Canada.,McGill International TB Centre, Montreal, Quebec, Canada
| |
Collapse
|
24
|
Pedrazzoli D, Kranzer K, Thomas HL, Lalor MK. Trends and risk factors for death and excess all-cause mortality among notified tuberculosis patients in the UK: an analysis of surveillance data. ERJ Open Res 2019; 5:00125-2019. [PMID: 31857993 PMCID: PMC6911924 DOI: 10.1183/23120541.00125-2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 09/24/2019] [Indexed: 11/05/2022] Open
Abstract
Introduction In the UK, several hundred patients notified with tuberculosis (TB) die every year. The aim of this article is to describe trends in deaths among notified TB patients, explore risk factors associated with death and compare all-cause mortality in TB patients with age-specific mortality rates in the general UK population. Methods We used 2001–2014 data from UK national TB surveillance to explore trends and risk factors for death, and population mortality data to compare age-specific death rates among notified TB patients with annual death rates in the UK general population. Results The proportion of TB patients in the UK who died each year declined steadily from 7.1% in 2002 to 5.5% in 2014. One in five patients (21.3%) was diagnosed with TB post-mortem. Where information was available, almost half of the deaths occurred within 2 months of starting treatment. Risk factors for death included demographic, disease-specific and social risk factors. Age had by far the largest effect, with patients aged ≥80 years having a 70 times increased risk of death compared with those aged <15 years. In contrast, excess mortality determined by incidence ratios comparing all-cause mortality among TB patients with that of the general population was highest among children and the working-age population (15–64 years old). Conclusions Efforts to control TB and improve diagnosis and treatment outcomes in the UK need to be sustained. Control efforts need to focus on socially deprived and vulnerable groups. There is a need for further in-depth analysis of deaths of TB patients in the UK to identify potentially preventable factors. Despite an overall decline in death among TB patients in the UK, patients with TB are still 6 times more likely to die during follow-up than the annual death rate in the general populationhttp://bit.ly/2MqDw9Q
Collapse
Affiliation(s)
- Debora Pedrazzoli
- Dept of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.,These authors contributed equally to this work
| | - Katharina Kranzer
- Dept of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK.,These authors contributed equally to this work
| | - H Lucy Thomas
- TB Unit, Tuberculosis, Acute Respiratory, Gastrointestinal, Emerging/Zoonotic Infections and Travel Migrant Health Division (TARGETS), National Infection Service, Public Health England, London, UK
| | - Maeve K Lalor
- TB Unit, Tuberculosis, Acute Respiratory, Gastrointestinal, Emerging/Zoonotic Infections and Travel Migrant Health Division (TARGETS), National Infection Service, Public Health England, London, UK.,Institute for Global Health, University College London, London, UK
| |
Collapse
|
25
|
García-Basteiro AL, Brew J, Williams B, Borgdorff M, Cobelens F. What is the true tuberculosis mortality burden? Differences in estimates by the World Health Organization and the Global Burden of Disease study. Int J Epidemiol 2019; 47:1549-1560. [PMID: 30010785 DOI: 10.1093/ije/dyy144] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2018] [Indexed: 11/14/2022] Open
Abstract
Background The World Health Organization (WHO) and the Global Burden of Disease (GBD) study at the Institute for Health Metrics and Evaluation (IHME) periodically provide global estimates of tuberculosis (TB) mortality. We compared the 2015 WHO and GBD TB mortality estimates and explored which factors might drive the differences. Methods We extracted the number of estimated TB-attributable deaths, disaggregated by age, HIV status, sex and country from publicly available WHO and GBD datasets for the year 2015. We 'standardized' differences between sources by adjusting each country's difference in absolute number of deaths by the average number of deaths estimated by both sources. Results For 195 countries with estimates from both institutions, WHO estimated 1 768 482 deaths attributable to TB, whereas GBD estimated 1 322 916 deaths, a difference of 445 566 deaths or 29% of the average of the two estimates. The countries with the largest absolute differences in deaths were Nigeria (216 621), Bangladesh (49 863) and Tanzania (38 272). The standardized difference was not associated with HIV prevalence, prevalence of multidrug resistance or global region, but did show correlation with the case detection rate as estimated by WHO [r = -0.37, 95% confidence interval (CI): -049; -0.24] or, inversely, with case detection rate based on GBD data (r = 0.44, 95% CI: 0.31; 0.54). Countries with a recent national prevalence survey had higher standardized differences (higher estimates by WHO) than those without (P = 0.006). After exclusion of countries with recent prevalence surveys, the overall correlation between both estimates was r = 0.991. Conclusions A few countries account for the large global discrepancy in TB mortality estimates. The differences are due to the methodological approaches used by WHO and GBD. The use and interpretation of prevalence survey data and case detection rates seem to play a role in the observed differences.
Collapse
Affiliation(s)
- Alberto L García-Basteiro
- Amsterdam Institute for Global Health and Development (AIGHD), Amsterdam, The Netherlands.,Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique.,ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.,Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, The Netherlands
| | - Joe Brew
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique.,ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Brian Williams
- South African Centre for Epidemiological Modelling and Analysis (SACEMA), Stellenbosch, South Africa
| | - Martien Borgdorff
- Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, The Netherlands
| | - Frank Cobelens
- Amsterdam Institute for Global Health and Development (AIGHD), Amsterdam, The Netherlands.,Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
26
|
Tomita A, Ramlall S, Naidu T, Mthembu SS, Padayatchi N, Burns JK. Major depression and household food insecurity among individuals with multidrug-resistant tuberculosis (MDR-TB) in South Africa. Soc Psychiatry Psychiatr Epidemiol 2019; 54:387-393. [PMID: 30758540 PMCID: PMC6439252 DOI: 10.1007/s00127-019-01669-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 02/04/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Household food insecurity in South Africa is a pervasive public health challenge. Although its link to chronic health conditions is well established, its relationship to mental illness, particularly major depression, is not well-understood. Despite KwaZulu-Natal Province being the epicenter of the drug-resistant tuberculosis (MDR-TB) epidemic, and having the largest share of poverty in South Africa, this relationship remains unexamined. This study investigated the association between major depressive episode (MDE) and household food insecurity among individuals with MDR-TB. METHODS We enrolled and interviewed 141 newly admitted microbiologically confirmed MDR-TB inpatients at a specialized TB hospital in KwaZulu-Natal Province, South Africa. Logistic regression models were fitted to assess the relationship between MDE and household food insecurity, while accounting for socio-demographic status (e.g., age, gender, education, marital status, social grant status, income, and preference for living in one's community). RESULTS The prevalence of MDE and household food insecurity was 11.35% and 21.01%, respectively. MDE was significantly associated with household food insecurity (aOR 4.63, 95% CI 1.17-18.38). Individuals who are female (aOR 6.29, 95% CI 1.13-35.03), young (aOR 8.86, 95% CI 1.69-46.34), have low educational attainment (aOR 6.19, 95% CI 1.70-22.59) and receive social grants (aOR 7.60, 95% CI 2.36-24.48) were most at risk of household food insecurity. CONCLUSIONS MDE in individuals with MDR-TB was significantly associated with household food insecurity, independent of socio-economic status. Although MDR-TB is not exclusively a disease of the poor, individuals from socio-economically disadvantaged backgrounds (e.g., female, young adults, low education, and social grant recipients) were more likely to experience household food insecurity. Our study underscores the need to address the co-occurring cycles of food insecurity and untreated MDE in South Africa.
Collapse
Affiliation(s)
- Andrew Tomita
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Private Bag X7, Congella, Durban, 4013, South Africa.
| | - Suvira Ramlall
- Department of Psychiatry, University of KwaZulu-Natal, Durban, South Africa
| | - Thirusha Naidu
- Department of Behavioural Medicine, University of KwaZulu-Natal, Durban, South Africa
| | | | - Nesri Padayatchi
- MRC HIV-TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Jonathan K Burns
- Department of Psychiatry, University of KwaZulu-Natal, Durban, South Africa
- Institute of Health Research, University of Exeter, Exeter, UK
| |
Collapse
|
27
|
Kendall EA, Azman AS, Maartens G, Boulle A, Wilkinson RJ, Dowdy DW, Rangaka MX. Projected population-wide impact of antiretroviral therapy-linked isoniazid preventive therapy in a high-burden setting. AIDS 2019; 33:525-536. [PMID: 30325773 PMCID: PMC6355370 DOI: 10.1097/qad.0000000000002053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Both isoniazid preventive therapy (IPT) and antiretroviral therapy (ART) reduce tuberculosis risk in individuals living with HIV. We sought to estimate the broader, population-wide impact of providing a pragmatically implemented 12-month IPT regimen to ART recipients in a high-burden community. DESIGN Dynamic transmission model of a tuberculosis (TB)-HIV epidemic, calibrated to site-specific, historical epidemiologic and clinical trial data from Khayelitsha, South Africa. METHODS We projected the 5-year impact of delivering a 12-month IPT regimen community-wide to 85% of new ART initiators and 15%/year of those already on ART, accounting for IPT-attributable reductions in TB infection, progression, and transmission. We also evaluated scenarios of continuously-delivered IPT, ongoing ART scale-up, and lower tuberculosis incidence. RESULTS Under historical (early 2010) ART coverage, this ART-linked IPT intervention prevented one tuberculosis case per 18 [95% credible interval (CrI) 11-29] people treated. It lowered TB incidence by a projected 23% (95% CrI 14-30%) among people receiving ART, and by 5.2% (95% CrI 2.9-8.7%) in the total population. Continuous IPT reduced the number needed to treat to prevent one case of TB to 10 (95% CrI 7-16), though it required 74% more person-years of therapy (95% CrI 64-94%) to prevent one TB case, relative to 12-month therapy. Under expanding ART coverage, the tuberculosis incidence reduction achieved by 12-month IPT grew to 7.6% (95% CrI 4.3-12.6%). Effect sizes were similar in a simulated setting of lower TB incidence. CONCLUSIONS IPT in conjunction with ART reduces tuberculosis incidence among those who receive therapy and has additional impact on tuberculosis transmission in the population.
Collapse
Affiliation(s)
- Emily A Kendall
- Division of Infectious Diseases, Johns Hopkins University School of Medicine
| | - Andrew S Azman
- Division of Infectious Disease Epidemiology, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, Department of Public Health and Family Medicine, University of Cape Town
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Imperial College
- Francis Crick Institute
| | - David W Dowdy
- Division of Infectious Disease Epidemiology, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Molebogeng X Rangaka
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Institute for Global Health, University College London, London, UK
| |
Collapse
|
28
|
Wilson D, Moosa MYS, Cohen T, Cudahy P, Aldous C, Maartens G. Evaluation of Tuberculosis Treatment Response With Serial C-Reactive Protein Measurements. Open Forum Infect Dis 2018; 5:ofy253. [PMID: 30474046 PMCID: PMC6240901 DOI: 10.1093/ofid/ofy253] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 10/05/2018] [Indexed: 12/21/2022] Open
Abstract
Background Novel biomarkers are needed to assess response to antituberculosis therapy in smear-negative patients. Methods To evaluate the utility of C-reactive protein (CRP) in monitoring response to antituberculosis therapy, we conducted a post hoc analysis on a cohort of adults with symptoms of tuberculosis and negative sputum smears in a high–tuberculosis and HIV prevalence setting in KwaZulu-Natal, South Africa. Serial changes in CRP, weight, and hemoglobin were evaluated over 8 weeks. Results Four hundred twenty-one participants being evaluated for smear-negative tuberculosis were enrolled, and 33 were excluded. Two hundred ninety-five were treated for tuberculosis (137 confirmed, 158 possible), and 93 did not have tuberculosis. One hundred and eighty-three of 213 (86%) participants who agreed to HIV testing were HIV positive. At week 8, the on-treatment median CRP reduction in the tuberculosis group (interquartile range [IQR]) was 79.5% (25.4% to 91.7%), the median weight gain was 2.3% (−1.0% to 5.6%), and the median hemoglobin increase was 7.0% (0.8% to 18.9%); P < .0001 for baseline to week 8 comparison of absolute median values. Only CRP changed significantly at week 2 (median reduction [IQR], 75.1% [46.9% to 89.2%]) in the group with confirmed tuberculosis and in the possible tuberculosis group (median reduction [IQR], 49.0% [−0.4% to 80.9%]). Failure of CRP to reduce to ≤55% of the baseline value at week 2 predicted hospitalization or death in both tuberculosis groups, with 99% negative predictive value. Conclusions Change in CRP may have utility in early evaluation of response to antituberculosis treatment and to identify those at increased risk of adverse outcomes.
Collapse
Affiliation(s)
- Douglas Wilson
- Department of Internal Medicine, Edendale Hospital, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Mahomed-Yunus S Moosa
- Division of Medicine, Department of Infectious Diseases, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
| | - Patrick Cudahy
- Section of Infectious Disease, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Collen Aldous
- School of Clinical Medicine, Nelson R Mandela (NRMSM) Campus, University of Durban, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
29
|
Nliwasa M, MacPherson P, Gupta‐Wright A, Mwapasa M, Horton K, Odland JØ, Flach C, Corbett EL. High HIV and active tuberculosis prevalence and increased mortality risk in adults with symptoms of TB: a systematic review and meta-analyses. J Int AIDS Soc 2018; 21:e25162. [PMID: 30063287 PMCID: PMC6067081 DOI: 10.1002/jia2.25162] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 06/21/2018] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION HIV and tuberculosis (TB) remain leading causes of preventable death in low- and middle-income countries (LMICs). The World Health Organization (WHO) recommends HIV testing for all individuals with TB symptoms, but implementation has been suboptimal. We conducted a systematic literature review and meta-analyses to estimate HIV and TB prevalence, and short-term (two to six months) mortality, among adults with TB symptoms at community- and facility level. METHODS We searched Embase, Global Health and MEDLINE databases, and reviewed conference abstracts for studies reporting simultaneous HIV and TB screening of adults in LMICs published between January 2003 and December 2017. Meta-analyses were performed to estimate prevalence of HIV, undiagnosed TB and mortality risk at different health system levels. RESULTS Sixty-two studies including 260,792 symptomatic adults were identified, mostly from Africa and Asia. Median HIV prevalence was 19.2% (IQR: 8.3% to 40.4%) at community level, 55.7% (IQR: 20.9% to 71.2%) at primary care level and 80.7% (IQR: 73.8% to 84.6%) at hospital level. Median TB prevalence was 6.9% (IQR: 3.3% to 8.4%) at community, 20.5% (IQR: 11.7% to 46.4%) at primary care and 36.4% (IQR: 22.9% to 40.9%) at hospital level. Median short-term mortality was 22.6% (IQR: 15.6% to 27.7%) among inpatients, 3.1% (IQR: 1.2% to 4.2%) at primary care and 1.6% (95% CI: 0.45 to 4.13, n = 1 study) at community level. CONCLUSIONS Adults with TB symptoms have extremely high prevalence of HIV infection, even when identified through community surveys. TB prevalence and mortality increased substantially at primary care and inpatient level respectively. Strategies to expand symptom-based TB screening combined with HIV and TB testing for all symptomatic individuals should be of the highest priority for both disease programmes in LMICs with generalized HIV epidemics. Interventions to reduce short-term mortality are urgently needed.
Collapse
Affiliation(s)
- Marriott Nliwasa
- Helse Nord Tuberculosis InitiativeDepartment of PathologyCollege of MedicineBlantyreMalawi
- Malawi‐Liverpool‐Welcome Trust Clinical Research ProgrammeBlantyreMalawi
- Clinical Research DepartmentLondon School of Hygiene & Tropical Medicine (LSHTM)LondonUK
| | - Peter MacPherson
- Department of Clinical SciencesLiverpool School of Tropical MedicineLiverpoolUK
| | - Ankur Gupta‐Wright
- Malawi‐Liverpool‐Welcome Trust Clinical Research ProgrammeBlantyreMalawi
- Clinical Research DepartmentLondon School of Hygiene & Tropical Medicine (LSHTM)LondonUK
| | - Mphatso Mwapasa
- Helse Nord Tuberculosis InitiativeDepartment of PathologyCollege of MedicineBlantyreMalawi
| | - Katherine Horton
- Clinical Research DepartmentLondon School of Hygiene & Tropical Medicine (LSHTM)LondonUK
| | - Jon Ø Odland
- Department of Community MedicineFaculty of Health SciencesUiT The Arctic University of NorwayTromsøNorway
- School of Public HealthUniversity of PretoriaPretoriaSouth Africa
| | - Clare Flach
- Department of Primary Care & Public Health SciencesKing's College LondonLondonUK
| | - Elizabeth L. Corbett
- Helse Nord Tuberculosis InitiativeDepartment of PathologyCollege of MedicineBlantyreMalawi
- Malawi‐Liverpool‐Welcome Trust Clinical Research ProgrammeBlantyreMalawi
- Clinical Research DepartmentLondon School of Hygiene & Tropical Medicine (LSHTM)LondonUK
| |
Collapse
|
30
|
Chawla KS, Kanyama C, Mbewe A, Matoga M, Hoffman I, Ngoma J, Hosseinipour MC. Policy to practice: impact of GeneXpert MTB/RIF implementation on the TB spectrum of care in Lilongwe, Malawi. Trans R Soc Trop Med Hyg 2017; 110:305-11. [PMID: 27198215 DOI: 10.1093/trstmh/trw030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 04/05/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND While previous research has provided evidence of the diagnostic accuracy of the GeneXpert MTB/RIF (GeneXpert), further information is needed about implementation in the real-world. This study evaluated the impact of the introduction of GeneXpert testing in a tertiary medical center according to the testing algorithm proposed by the National TB Control Program (NTP) guidelines. METHODS All adult medicine inpatient persons with presumptive TB admitted between November 2013 and March 2014 were eligible for GeneXpert sputum testing and followed to TB treatment initiation status. RESULTS We identified 932 persons with presumptive TB, of which 307 (32.9%) were GeneXpert tested. Those tested had an average age of 40 years, 49.2% (151) were male, 34.5% (106) were HIV positive, and 84.1% (249) presented with a cough. Of those GeneXpert tested, 28/307 (9.1%) tested positive, a 55.5% increase in detection compared to smear microscopy. However, the majority (44/72, 61%) of TB diagnoses were made by other modalities and not confirmed microbiologically. Of the 58 patients recommended to start treatment and discharged from the hospital, only 23 (40%) were documented to have started treatment at regional directly observed treatment short (DOTS) centers. CONCLUSIONS GeneXpert contributed minimally to overall TB diagnosis and the cascade of care due to implementation challenges of sputum collection, empiric treatment, and weak linkage to care between inpatient and outpatient settings.
Collapse
Affiliation(s)
| | | | | | | | - Irving Hoffman
- UNC Project Malawi, Lilongwe, Malawi Division of Infectious Diseases, Department of Medicine, University of North Carolina Chapel Hill, NC USA
| | - Jonathan Ngoma
- Department of Medicine, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Mina C Hosseinipour
- UNC Project Malawi, Lilongwe, Malawi Division of Infectious Diseases, Department of Medicine, University of North Carolina Chapel Hill, NC USA
| |
Collapse
|
31
|
Dheda K, Cox H, Esmail A, Wasserman S, Chang KC, Lange C. Recent controversies about MDR and XDR-TB: Global implementation of the WHO shorter MDR-TB regimen and bedaquiline for all with MDR-TB? Respirology 2017; 23:36-45. [PMID: 28850767 DOI: 10.1111/resp.13143] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/26/2017] [Accepted: 07/10/2017] [Indexed: 12/29/2022]
Abstract
Tuberculosis (TB) is now the biggest infectious disease killer worldwide. Although the estimated incidence of TB has marginally declined over several years, it is out of control in some regions including in Africa. The advent of multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) threatens to further destabilize control in several regions of the world. Drug-resistant TB constitutes a significant threat because it underpins almost 25% of global TB mortality, is associated with high morbidity, is a threat to healthcare workers and is unsustainably costly to treat. The advent of highly resistant TB with emerging bacillary resistance to newer drugs has raised further concern. Encouragingly, in addition to preventative strategies, several interventions have recently been introduced to curb the drug-resistant TB epidemic, including newer molecular diagnostic tools, new (bedaquiline and delamanid) and repurposed (linezolid and clofazimine) drugs and shorter and individualized treatment regimens. However, there are several controversies that surround the use of new drugs and regimens, including whether, how and to what extent they should be used, and who specifically should be treated so that outcomes are optimally improved without amplifying the burden of drug resistance, and other potential drawbacks, thus sustaining effectiveness of the new drugs. The equipoise surrounding these controversies is discussed and some recommendations are provided.
Collapse
Affiliation(s)
- Keertan Dheda
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Helen Cox
- Division of Medical Microbiology, and the Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Aliasgar Esmail
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Sean Wasserman
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kwok Chiu Chang
- Department of Health, Tuberculosis and Chest Service, Centre for Health Protection, Hong Kong, China
| | - Christoph Lange
- Division of Clinical Infectious Diseases, German Center for Infection Research (DZIF), Research Center Borstel, Borstel, Germany
| |
Collapse
|
32
|
Adamu AL, Gadanya MA, Abubakar IS, Jibo AM, Bello MM, Gajida AU, Babashani MM, Abubakar I. High mortality among tuberculosis patients on treatment in Nigeria: a retrospective cohort study. BMC Infect Dis 2017; 17:170. [PMID: 28231851 PMCID: PMC5324260 DOI: 10.1186/s12879-017-2249-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 02/07/2017] [Indexed: 12/02/2022] Open
Abstract
Background Tuberculosis (TB) remains a leading cause of death in much of sub-Saharan Africa despite available effective treatment. Prompt initiation of TB treatment and access to antiretroviral therapy (ART) remains vital to the success of TB control. We assessed time to mortality after treatment onset using data from a large treatment centre in Nigeria. Methods We analysed a retrospective cohort of TB patients that commenced treatment between January 2010 and December 2014 in Aminu Kano Teaching Hospital. We estimated mortality rates per person-months at risk (pm). Cox proportional hazards model was used to determine risk factors for mortality. Results Among 1,424 patients with a median age of 36.6 years, 237 patients (16.6%) died after commencing TB treatment giving a mortality rate of 3.68 per 100 pm of treatment in this cohort. Most deaths occurred soon after treatment onset with a mortality rate of 37.6 per 100 pm in the 1st week of treatment. Risk factors for death were being HIV-positive but not on anti-retroviral treatment (ART) (aHR 1.39(1 · 04–1 · 85)), residence outside the city (aHR 3 · 18(2.28–4.45)), previous TB treatment (aHR 3.48(2.54–4.77)), no microbiological confirmation (aHR 4.96(2.69–9.17)), having both pulmonary and extra-pulmonary TB (aHR 1.45(1.03–2.02), and referral from a non-programme linked clinic/centre (aHR 3.02(2.01–4.53)). Conclusions We attribute early deaths in this relatively young cohort to delay in diagnosis and treatment of TB, inadequate treatment of drug-resistant TB, and poor ART access. Considerable expansion and improvement in quality of diagnosis and treatment services for TB and HIV are needed to achieve the sustainable development goal of reducing TB deaths by 95% by 2035.
Collapse
Affiliation(s)
- Aishatu L Adamu
- Department of Community Medicine, College of Health Sciences, Bayero University Kano, Kano, Nigeria.,Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Muktar A Gadanya
- Department of Community Medicine, College of Health Sciences, Bayero University Kano, Kano, Nigeria.,Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Isa S Abubakar
- Department of Community Medicine, College of Health Sciences, Bayero University Kano, Kano, Nigeria.,Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Abubakar M Jibo
- Department of Community Medicine, College of Health Sciences, Bayero University Kano, Kano, Nigeria.,Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Musa M Bello
- Department of Community Medicine, College of Health Sciences, Bayero University Kano, Kano, Nigeria.,Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Auwalu U Gajida
- Department of Community Medicine, College of Health Sciences, Bayero University Kano, Kano, Nigeria.,Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Musa M Babashani
- Department of Medicine, College of Health Sciences, Bayero University Kano, Kano, Nigeria.,Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK.
| |
Collapse
|
33
|
Ouedraogo E, Lurton G, Mohamadou S, Dillé I, Diallo I, Mamadou S, Adehossi E, Hanki Y, Tchousso O, Arzika M, Gazeré O, Amadou F, Illo N, Abdourahmane Y, Idé M, Alhousseini Z, Lamontagne F, Deze C, D'Ortenzio E, Diallo S. [Evaluation of the benefit of different complementary exams in the search for a TB diagnosis algorithm for HIV patients put on ART in Niamey, Niger]. ACTA ACUST UNITED AC 2016; 109:368-375. [PMID: 27848101 DOI: 10.1007/s13149-016-0532-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 06/30/2016] [Indexed: 11/25/2022]
Abstract
In Niger, the tuberculosis (TB) screening among people living with human immunodeficiency virus (HIV) (PLHIV) is nonsystematic and the use of additional tests is very often limited. The objective of this research is to evaluate the performance and the cost-effectiveness of various paraclinical testing strategies of TB among adult patients with HIV, using available tests in routine for patients cared in Niamey. This is a multicentric prospective intervention study performed in Niamey between 2010 and 2013. TB screening has been sought in newly diagnosed PLHIV, before ART treatment, performing consistently: a sputum examination by MZN (Ziehl-Nielsen staining) and microscopy fluorescence (MIF), chest radiography (CR), and abdominal ultrasound. The performance of these different tests was calculated using sputum culture as a gold standard. The various examinations were then combined in different algorithms. The cost-effectiveness of different algorithms was assessed by calculating the money needed to prevent a patient, put on ART, dying of TB. Between November 2010 and November 2012, 509 PLHIV were included. TB was diagnosed in 78 patients (15.3%), including 35 pulmonary forms, 24 ganglion, and 19 multifocal. The sensitivity of the evaluated algorithms varied between 0.35 and 0.85. The specificity ranged from 0.85 to 0.97. The most costeffective algorithm was the one involving MIF and CR. We recommend implementing a systematic and free direct examination of sputum by MIF and a CR for the detection of TB among newly diagnosed PLHIV in Niger.
Collapse
Affiliation(s)
| | | | | | - I Dillé
- Ministère de la Santé publique du Niger, Niamey, Niger
| | | | - S Mamadou
- Ministère de la Santé publique du Niger, Niamey, Niger.,Université de Niamey, Niamey, Niger
| | - E Adehossi
- Ministère de la Santé publique du Niger, Niamey, Niger.,Université de Niamey, Niamey, Niger
| | - Y Hanki
- Ministère de la Santé publique du Niger, Niamey, Niger
| | - O Tchousso
- Ministère de la Santé publique du Niger, Niamey, Niger
| | - M Arzika
- Ministère de la Santé publique du Niger, Niamey, Niger
| | - O Gazeré
- Ministère de la Santé publique du Niger, Niamey, Niger
| | - F Amadou
- Ministère de la Santé publique du Niger, Niamey, Niger
| | - N Illo
- Ministère de la Santé publique du Niger, Niamey, Niger
| | | | - M Idé
- Ministère de la Santé publique du Niger, Niamey, Niger
| | - Z Alhousseini
- Coordination intersectorielle de lutte contre les IST/VIH/sida de Niamey, Niamey, Niger
| | | | - C Deze
- Solthis, 75013, Paris, France
| | | | | |
Collapse
|
34
|
Benefits of continuous isoniazid preventive therapy may outweigh resistance risks in a declining tuberculosis/HIV coepidemic. AIDS 2016; 30:2715-2723. [PMID: 27782966 DOI: 10.1097/qad.0000000000001235] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Extending the duration of isoniazid preventive therapy (IPT) among people living with HIV (PLHIV) may improve its effectiveness at both individual and population levels, but could also increase selective pressure in favor of isoniazid-resistant tuberculosis (TB) strains. The objective of this study was to determine the relative importance of these two effects. METHODS Transmission dynamic model. DESIGN We created a mathematical model of TB transmission incorporating HIV incidence and treatment, mixed strain latent TB infections, and four different phenotypes of TB drug resistance (pan-susceptible, isoniazid monoresistant, rifampicin monoresistant, and multidrug resistant). We used this model to project the effects of IPT duration on the incidence of isoniazid-sensitive and isoniazid-resistant TB as well as mortality among PLHIV. We evaluated the sensitivity of our baseline model, which was calibrated to data from Botswana, to different assumptions about the future trajectory of the TB epidemic. RESULTS Our model suggests that, in the context of a declining TB epidemic such as that currently observed in Botswana, the incidence and mortality benefits of continuous IPT for PLHIV are likely to outweigh the potential resistance risks associated with long-duration IPT. However, should TB epidemics fail to remain in control, as was observed during the initial emergence of HIV, the selective pressure imposed by widespread use of continuous IPT on isoniazid-resistant TB incidence may erode its initial benefits. CONCLUSION Resistance concerns are likely insufficient to rule out use of continuous IPT when coupled with effective TB treatment, case finding, and HIV control.
Collapse
|
35
|
Wasserman S, Engel ME, Griesel R, Mendelson M. Burden of pneumocystis pneumonia in HIV-infected adults in sub-Saharan Africa: a systematic review and meta-analysis. BMC Infect Dis 2016; 16:482. [PMID: 27612639 PMCID: PMC5018169 DOI: 10.1186/s12879-016-1809-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 08/26/2016] [Indexed: 11/16/2022] Open
Abstract
Background Seroprevalence data and clinical studies in children suggest that the burden of pneumocystis pneumonia (PCP) in Africa may be underestimated. We performed a systematic review to determine the prevalence and attributable mortality of PCP amongst HIV-infected adults in sub-Saharan Africa. Methods We searched Pubmed, Web of Science, Africa-Wide: NiPAD and CINAHL, from Jan 1 1995 to June 1 2015, for studies that reported the prevalence, mortality or case fatality of PCP in HIV-infected adults living in sub-Saharan African countries. Prevalence data from individual studies were combined by random-effects meta-analysis according to the Mantel-Haenszel method. Data were stratified by clinical setting, diagnostic method, and study year. Results We included 48 unique study populations comprising 6884 individuals from 18 countries in sub-Saharan Africa. The pooled prevalence of PCP among 6018 patients from all clinical settings was 15 · 4 % (95 % CI 12 · 9–18 · 0), and was highest amongst inpatients, 22 · 4 % (95 % CI 17 · 2–27 · 7). More cases were identified by bronchoalveolar lavage, 21 · 0 % (15 · 0–27 · 0), compared with expectorated, 7 · 7 % (4 · 4–11 · 1), or induced sputum, 11 · 7 % (4 · 9–18 · 4). Polymerase chain reaction (PCR) was used in 14 studies (n = 1686). There was a trend of decreasing PCP prevalence amongst inpatients over time, from 28 % (21–34) in the 1990s to 9 % (8–10) after 2005. The case fatality rate was 18 · 8 % (11 · 0–26 · 5), and PCP accounted for 6 · 5 % (3 · 7–9 · 3) of study deaths. Conclusions PCP is an important opportunistic infection amongst HIV-infected adults in sub-Saharan Africa, particularly amongst patients admitted to hospital. Although prevalence appears to be decreasing, improved access to antiretroviral therapy and non-invasive diagnostics, such as PCR, are needed. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1809-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Sean Wasserman
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - Mark E Engel
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rulan Griesel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
36
|
Rodrigo T, Casals M, Caminero JA, García-García JM, Jiménez-Fuentes MA, Medina JF, Millet JP, Ruiz-Manzano J, Caylá J. Factors Associated with Fatality during the Intensive Phase of Anti-Tuberculosis Treatment. PLoS One 2016; 11:e0159925. [PMID: 27487189 PMCID: PMC4972388 DOI: 10.1371/journal.pone.0159925] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 07/11/2016] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To determine the case-fatality rate (CFR) at the end of the intensive phase of tuberculosis (TB) treatment, and factors associated with fatality. METHODS TB patients diagnosed between 2006 and 2013 were followed-up during treatment. We computed the CFR at the end of the intensive phase of TB treatment, and the incidence of death per 100 person-days (pd) of follow-up. We performed survival analysis using the Kaplan-Meier method and Cox regression, and calculate hazard ratios (HR) and 95% confidence intervals (CI). RESULTS A total of 5,182 patients were included, of whom 180 (3.5%) died; 87 of these deaths (48.3%) occurred during the intensive phase of treatment, with a CFR of 1.7%. The incidence of death was 0.028/100 pd. The following factors were associated with death during the intensive phase: being >50 years (HR = 36.9;CI:4.8-283.4); being retired (HR = 2.4;CI:1.1-5.1); having visited the emergency department (HR = 3.1;CI:1.2-7.7); HIV infection (HR = 3.4;CI:1.6-7.2); initial standard treatment with 3 drugs (HR = 2.0;CI:1.2-3.3) or non-standard treatments (HR = 2.68;CI:1.36-5.25); comprehension difficulties (HR = 2.8;CI:1.3-6.1); and smear-positive sputum (HR = 2.3-CI:1.0-4.8). CONCLUSION There is a non-negligible CFR during the intensive phase of TB, whose reduction should be prioritised. The CFR could be a useful indicator for evaluating TB programs.
Collapse
Affiliation(s)
- T. Rodrigo
- Programa Integrado de Investigación en Tuberculosis (PII TB), Fundación Respira de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Ministerio de Economía y Competitividad, Madrid, Spain
- Unidad de Investigación de Tuberculosis, Servicio de Epidemiologia, Agencia de Salud Pública de Barcelona, Barcelona, Spain
| | - M. Casals
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Ministerio de Economía y Competitividad, Madrid, Spain
- Unidad de Investigación de Tuberculosis, Servicio de Epidemiologia, Agencia de Salud Pública de Barcelona, Barcelona, Spain
| | - J. A. Caminero
- Programa Integrado de Investigación en Tuberculosis (PII TB), Fundación Respira de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Barcelona, Spain
- Servicio de Neumología. Hospital General Universitario de Gran Canaria Dr, Negrín, Canary Islands, Spain
- International Union Against Tuberculosis and Lung Disease, París, France
| | - J. M. García-García
- Programa Integrado de Investigación en Tuberculosis (PII TB), Fundación Respira de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Barcelona, Spain
- Servicio de Neumología, Hospital San Agustín de Avilés, Asturias, Spain
| | - M. A. Jiménez-Fuentes
- Programa Integrado de Investigación en Tuberculosis (PII TB), Fundación Respira de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Barcelona, Spain
- Unidad de Tuberculosis, Hospital Universitario Valle de Hebrón, Barcelona, Spain
| | - J. F. Medina
- Programa Integrado de Investigación en Tuberculosis (PII TB), Fundación Respira de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Barcelona, Spain
- Servicio de Neumología, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - J. P. Millet
- Programa Integrado de Investigación en Tuberculosis (PII TB), Fundación Respira de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Barcelona, Spain
- Unidad de Investigación de Tuberculosis, Servicio de Epidemiologia, Agencia de Salud Pública de Barcelona, Barcelona, Spain
| | - J. Ruiz-Manzano
- Programa Integrado de Investigación en Tuberculosis (PII TB), Fundación Respira de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Barcelona, Spain
- Servicio de Neumología, Hospital Universitario Germans Trías y Pujol de Badalona, Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Ministerio de Economía y Competitividad, Madrid, Spain
| | - J. Caylá
- Programa Integrado de Investigación en Tuberculosis (PII TB), Fundación Respira de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Ministerio de Economía y Competitividad, Madrid, Spain
- Unidad de Investigación de Tuberculosis, Servicio de Epidemiologia, Agencia de Salud Pública de Barcelona, Barcelona, Spain
| | | |
Collapse
|
37
|
van der Walt M, Lancaster J, Shean K. Tuberculosis Case Fatality and Other Causes of Death among Multidrug-Resistant Tuberculosis Patients in a High HIV Prevalence Setting, 2000-2008, South Africa. PLoS One 2016; 11:e0144249. [PMID: 26950554 PMCID: PMC4780825 DOI: 10.1371/journal.pone.0144249] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 11/16/2015] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION South Africa has the highest reported rates of multi-drug resistant TB in Africa, typified by poor treatment outcomes, attributable mainly to high default and death rates. Concomitant HIV has become the strongest predictor of death among MDR-TB patients, while anti-retroviral therapy (ART) has dramatically reduced mortality. TB Case fatality rate (CFR) is an indicator that specifically reports on deaths due to TB. AIM The aim of this paper was to investigate causes of death amongst MDR-TB patients, the contribution of conditions other than TB to deaths, and to determine if causes differ between HIV-uninfected patients, HIV-infected patients receiving ART and those without ART. METHODS We carried out a retrospective review of data captured from the register of the MDR-TB programme of the North West Province, South Africa. We included 671 patients treated between 2000-2008; 59% of the cohort was HIV-infected and 33% had received ART during MDR treatment. The register contained data on treatment outcomes and causes of death. RESULTS Treatment outcomes between HIV-uninfected cases, HIV-infected cases receiving ART and HIV-infected without ART differed significantly (p<0.000). The cohort death rate was 24%, 13% for HIV-uninfected cases and 31% for HIV-infected cases. TB caused most of the deaths, resulting in a cohort CFR of 15%, 9% for HIV-uninfected cases and 20% for HIV-infected cases. Cohort mortality rate due to other conditions was 2%. AIDS-conditions rather than TB caused significantly more deaths among HIV-infected cases receiving ART than those not (p = 0.02). CONCLUSIONS The deaths among HIV-infected individuals contribute substantially to the high death rate. ART co-therapy protected HIV-infected cases from death due to TB and AIDS-conditions. Mechanisms need to be in place to ensure that HIV-infected individuals are retained in care upon completion of their MDR-TB treatment.
Collapse
Affiliation(s)
- Martie van der Walt
- Tuberculosis Platform, South African Medical Research Council, Pretoria, South Africa
| | - Joey Lancaster
- Tuberculosis Platform, South African Medical Research Council, Pretoria, South Africa
| | - Karen Shean
- Tuberculosis Platform, South African Medical Research Council, Pretoria, South Africa
| |
Collapse
|
38
|
Affiliation(s)
- Jennifer Furin
- Tuberculosis Research Unit, Case Western Reserve University, Cleveland, OH 44106, USA.
| | | | - Lucica Ditiu
- Stop TB Partnership Secretariat, World Health Organization, Geneva, Switzerland
| | - Glenda Gray
- South African Medical Research Council and Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Domingo Palmero
- Hospital de Infecciosas Dr F J Muñiz, Buenos Aires, Argentina
| | | |
Collapse
|
39
|
Wang W, Zhao Q, Yuan Z, Zheng Y, Zhang Y, Lu L, Hou Y, Zhang Y, Xu B. Tuberculosis-associated mortality in Shanghai, China: a longitudinal study. Bull World Health Organ 2015; 93:826-33. [PMID: 26668434 PMCID: PMC4669732 DOI: 10.2471/blt.15.154161] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 07/18/2015] [Accepted: 07/28/2015] [Indexed: 11/27/2022] Open
Abstract
Objective To determine excess mortality in a cohort of people with tuberculosis in Shanghai. Methods Participants were local residents in 4 (of 19) districts in Shanghai, registered in one of four tuberculosis clinics between January 1, 2004 and December 31, 2008. Baseline data were collected at the most recent diagnosis of tuberculosis and mortality was assessed between March and May of 2014. We calculated standardized mortality ratios (SMR) and case-fatality rates for all participants and for subgroups. Univariate and multivariate Cox regression models were used to quantify associations between co-morbidities and mortality from all causes and from tuberculosis. Findings We registered 4569 subjects in the cohort. Overall, the cohort had an SMR for deaths from all causes of 5.2 (95% confidence interval, CI: 4.8–5.6). Males had a higher SMR than females (6.1 versus 3.0). After adjustment for age and sex, hazard ratios (HR) for deaths from all causes were significantly greater in previously treated people (HR: 1.26; 95% CI: 1.08–1.49) and sputum smear-test positive people (HR: 1.55; 95% CI: 1.35–1.78). The risk of death from tuberculosis was also significantly greater for previously treated people (HR: 1.88; 95% CI: 1.24–2.86) and smear positive people (HR: 3.16; 95% CI: 2.06–4.87). Conclusion People with tuberculosis in Shanghai have an increased risk of mortality. Earlier diagnosis and more vigilant follow-up may help to reduce mortality in this group.
Collapse
Affiliation(s)
- Weibing Wang
- Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety (Ministry of Education), Fudan University, 138 Yi Xue Yuan Road, Shanghai 200032, China
| | - Qi Zhao
- Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety (Ministry of Education), Fudan University, 138 Yi Xue Yuan Road, Shanghai 200032, China
| | - Zhengan Yuan
- Shanghai Center for Disease Control and Prevention, Shanghai, China
| | - Yihui Zheng
- Putuo District Center for Disease Control and Prevention, Shanghai, China
| | - Yixing Zhang
- Pudong District Center for Disease Control and Prevention, Shanghai, China
| | - Liping Lu
- Songjiang District Center for Disease Control and Prevention, Shanghai, China
| | - Yun Hou
- Yangpu District Center for Disease Control and Prevention, Shanghai, China
| | - Yue Zhang
- Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety (Ministry of Education), Fudan University, 138 Yi Xue Yuan Road, Shanghai 200032, China
| | - Biao Xu
- Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety (Ministry of Education), Fudan University, 138 Yi Xue Yuan Road, Shanghai 200032, China
| |
Collapse
|
40
|
Dobler CC, Martin A, Marks GB. Benefit of treatment of latent tuberculosis infection in individual patients. Eur Respir J 2015; 46:1397-406. [DOI: 10.1183/13993003.00577-2015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 06/24/2015] [Indexed: 11/05/2022]
Abstract
We aimed to develop a decision aid that estimates whether treatment of latent tuberculosis infection (LTBI) is likely to have a net gain in quality-adjusted life-years for an individual.A Markov model was developed which incorporated personalised estimates for risk of tuberculosis (TB) reactivation, TB death, quality-of-life impairments and treatment side-effects. The net effect of LTBI treatment was quantified in terms of quality-adjusted life-years gained or lost. Analyses were conducted for a representative set of hypothetical patients.LTBI treatment was estimated to be beneficial when the annual risk of TB reactivation exceeded 13/100 000 to 93/100 000 for females aged 10–75 years and 15/100 000 to 119/100 000 for males aged 10–75 years; the numbers needed to treat to avoid one case of TB were 93, 77, 85 and 72, respectively, at these threshold levels.LTBI treatment was estimated to confer a positive net benefit across a broad range of patients with characteristics typically seen in a low incidence setting for TB. Use of the decision aid has the potential to facilitate and increase confidence with LTBI treatment decisions by providing clinicians and patients with personalised estimates of likely net benefit.
Collapse
|
41
|
Kim H, Kim Y, Lee KY, Lee BJ. Backbone assignments of 1H, 15N and 13C resonances and secondary structure prediction of MRA1997 from Mycobacterium tuberculosis H37Rv. JOURNAL OF THE KOREAN MAGNETIC RESONANCE SOCIETY 2015. [DOI: 10.6564/jkmrs.2015.19.1.049] [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]
|
42
|
Amogne W, Aderaye G, Habtewold A, Yimer G, Makonnen E, Worku A, Sonnerborg A, Aklillu E, Lindquist L. Efficacy and Safety of Antiretroviral Therapy Initiated One Week after Tuberculosis Therapy in Patients with CD4 Counts < 200 Cells/μL: TB-HAART Study, a Randomized Clinical Trial. PLoS One 2015; 10:e0122587. [PMID: 25966339 PMCID: PMC4429073 DOI: 10.1371/journal.pone.0122587] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 01/10/2015] [Indexed: 11/24/2022] Open
Abstract
Background Given the high death rate the first two months of tuberculosis (TB) therapy in HIV patients, it is critical defining the optimal time to initiate combination antiretroviral therapy (cART). Methods A randomized, open-label, clinical trial comparing efficacy and safety of efavirenz-based cART initiated one week, four weeks, and eight weeks after TB therapy in patients with baseline CD4 count < 200 cells/μL was conducted. The primary endpoint was all-cause mortality rate at 48 weeks. The secondary endpoints were hepatotoxicity-requiring interruption of TB therapy, TB-associated immune reconstitution inflammatory syndrome, new AIDS defining illnesses, CD4 counts, HIV RNA levels, and AFB smear conversion rates. All analyses were intention-to-treat. Results We studied 478 patients with median CD4 count of 73 cells/μL and 5.2 logs HIV RNA randomized to week one (n = 163), week four (n = 160), and week eight (n = 155). Sixty-four deaths (13.4%) occurred in 339.2 person-years. All-cause mortality rates at 48 weeks were 25 per 100 person-years in week one, 18 per 100 person-years in week four and 15 per 100 person-years in week eight (P = 0.2 by the log-rank test). All-cause mortality incidence rate ratios in subgroups with CD4 count below 50 cells/μL versus above were 2.8 in week one (95% CI 1.2–6.7), 3.1 in week four (95% CI 1.2–8.6) and 5.1 in week eight (95% CI 1.8–16). Serum albumin < 3gms/dL (adjusted HR, aHR = 2.3) and CD4 < 50 cells/μL (aHR = 2.7) were independent predictors of mortality. Compared with similar subgroups from weeks four and eight, first-line TB treatment interruption was high in week one deaths (P = 0.03) and in the CD4 subgroup <50 cells/μL (P = 0.02). Conclusions Antiretroviral therapy one week after TB therapy doesn’t improve overall survival. Despite increased mortality with CD4 < 50 cells/μL, we recommend cART later than the first week of TB therapy to avoid serious hepatotoxicity and treatment interruption. Trial Registration ClinicalTrials.gov NCT 01315301
Collapse
Affiliation(s)
- Wondwossen Amogne
- Department of Medicine, Division of Infectious Diseases, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden; Department of Internal Medicine, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Getachew Aderaye
- Department of Internal Medicine, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abiy Habtewold
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska University Hospital, Huddinge C1: 68, Karolinska Institute, Stockholm, Sweden; Department of Pharmacology, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Getnet Yimer
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska University Hospital, Huddinge C1: 68, Karolinska Institute, Stockholm, Sweden; Department of Pharmacology, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Eyasu Makonnen
- Department of Pharmacology, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alemayhu Worku
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Anders Sonnerborg
- Department of Medicine, Division of Infectious Diseases, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Eleni Aklillu
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska University Hospital, Huddinge C1: 68, Karolinska Institute, Stockholm, Sweden
| | - Lars Lindquist
- Department of Medicine, Division of Infectious Diseases, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| |
Collapse
|
43
|
Houben RMGJ, Dowdy DW, Vassall A, Cohen T, Nicol MP, Granich RM, Shea JE, Eckhoff P, Dye C, Kimerling ME, White RG. How can mathematical models advance tuberculosis control in high HIV prevalence settings? Int J Tuberc Lung Dis 2015; 18:509-14. [PMID: 24903784 PMCID: PMC4436821 DOI: 10.5588/ijtld.13.0773] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Existing approaches to tuberculosis (TB) control have been no more than partially successful in areas with high human immunodeficiency virus (HIV) prevalence. In the context of increasingly constrained resources, mathematical modelling can augment understanding and support policy for implementing those strategies that are most likely to bring public health and economic benefits. In this paper, we present an overview of past and recent contributions of TB modelling in this key area, and suggest a way forward through a modelling research agenda that supports a more effective response to the TB-HIV epidemic, based on expert discussions at a meeting convened by the TB Modelling and Analysis Consortium. The research agenda identified high-priority areas for future modelling efforts, including 1) the difficult diagnosis and high mortality of TB-HIV; 2) the high risk of disease progression; 3) TB health systems in high HIV prevalence settings; 4) uncertainty in the natural progression of TB-HIV; and 5) combined interventions for TB-HIV. Efficient and rapid progress towards completion of this modelling agenda will require co-ordination between the modelling community and key stakeholders, including advocates, health policy makers, donors and national or regional finance officials. A continuing dialogue will ensure that new results are effectively communicated and new policy-relevant questions are addressed swiftly.
Collapse
Affiliation(s)
- R M G J Houben
- TB Modelling Group, TB Centre, and Centre for the Mathematical Modelling of Infectious Diseases, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - D W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - A Vassall
- Department of Global Health and Development, LSHTM, London, UK
| | - T Cohen
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA
| | - M P Nicol
- Division of Medical Microbiology and Institute of Infectious Diseases and Molecular Medicine, University of Cape Town and National Health Laboratory Service, South Africa
| | - R M Granich
- Joint United Nations Programme on HIV/AIDS, World Health Organization (WHO), Geneva, Switzerland
| | - J E Shea
- Oxford-Emergent Tuberculosis Consortium, Wokingham, UK
| | - P Eckhoff
- Intellectual Ventures Laboratory, Bellevue, Washington, USA
| | - C Dye
- HIV, TB Malaria and Neglected Tropical Diseases Cluster, WHO, Geneva, Switzerland
| | - M E Kimerling
- Bill and Melinda Gates Foundation, Seattle, Washington, USA
| | - R G White
- TB Modelling Group, TB Centre, and Centre for the Mathematical Modelling of Infectious Diseases, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | | |
Collapse
|
44
|
Christensen ASH, Roed C, Andersen PH, Andersen AB, Obel N. Long-term mortality in patients with pulmonary and extrapulmonary tuberculosis: a Danish nationwide cohort study. Clin Epidemiol 2014; 6:405-21. [PMID: 25419160 PMCID: PMC4235508 DOI: 10.2147/clep.s65331] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Long-term mortality and causes of death in patients with pulmonary tuberculosis (PTB) and extrapulmonary tuberculosis (EPTB) are poorly documented. In this study, long-term mortality and causes of death in PTB and EPTB patients were compared with the background population and it was investigated whether mortality was associated with family-related risk factors. METHODS A NATIONWIDE COHORT STUDY WAS CONDUCTED INCLUDING: all adult Danes notified with PTB or EPTB from 1977 to 2008 and alive 1 year after diagnosis; a randomly selected comparison cohort matched on birth date and sex; adult siblings of PTB patients; and population controls. Data were extracted from national registries. All-cause and cause-specific mortality rate ratios were calculated for patients and siblings and compared with their respective control cohorts. A total of 8,291 patients (6,402 PTB and 1,889 EPTB), 24,873 population controls, 1,990 siblings of PTB patients and 11,679 siblings of PTB population controls were included. RESULTS Overall, the mortality rate ratio was 1.86 (95% confidence interval [CI] 1.77-1.96) for PTB patients and 1.24 (95% CI 1.12-1.37) for EPTB patients. Both patient cohorts had significantly increased risk of death due to infectious diseases and diabetes. Further, the PTB patients had increased mortality due to cancers (mainly respiratory and gastrointestinal tract), liver and respiratory system diseases, and alcohol and drug abuse. The PTB patients had increased mortality compared with their siblings (mortality rate ratio 3.55; 95% CI 2.57-4.91) as did the siblings of the PTB patients compared with the siblings of population controls (mortality rate ratio 2.16; 95% CI 1.62-2.87). CONCLUSION We conclude that adult PTB patients have an almost two-fold increased long-term mortality whereas EPTB patients have a slightly increased long-term mortality compared with the background population. The increased long-term mortality in PTB patients stems from diseases associated with alcohol, tobacco, and drug abuse as well as immune suppression, and family-related factors.
Collapse
Affiliation(s)
| | - Casper Roed
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter H Andersen
- Department of Infectious Disease Epidemiology, Statens Serum Institut, Copenhagen, Denmark
| | | | - Niels Obel
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| |
Collapse
|
45
|
The impact of antiretroviral therapy on mortality in HIV positive people during tuberculosis treatment: a systematic review and meta-analysis. PLoS One 2014; 9:e112017. [PMID: 25391135 PMCID: PMC4229142 DOI: 10.1371/journal.pone.0112017] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 10/11/2014] [Indexed: 01/25/2023] Open
Abstract
Objective To quantify the impact of antiretroviral therapy (ART) on mortality in HIV-positive people during tuberculosis (TB) treatment. Design We conducted a systematic literature review and meta-analysis. Studies published from 1996 through February 15, 2013, were identified by searching electronic resources (Pubmed and Embase) and conference books, manual searches of references, and expert consultation. Pooled estimates for the outcome of interest were acquired using random effects meta-analysis. Subjects The study population included individuals receiving ART before or during TB treatment. Main Outcome Measures Main outcome measures were: (i) TB-case fatality ratio (CFR), defined as the proportion of individuals dying during TB treatment and, if mortality in HIV-positive people not on ART was also reported, (ii) the relative risk of death during TB treatment by ART status. Results Twenty-one studies were included in the systematic review. Random effects pooled meta-analysis estimated the CFR between 8% and 14% (pooled estimate 11%). Among HIV-positive TB cases, those receiving ART had a reduction in mortality during TB treatment of between 44% and 71% (RR = 0.42, 95%CI: 0.29–0.56). Conclusion Starting ART before or during TB therapy reduces the risk of death during TB treatment by around three-fifths in clinical settings. National programmes should continue to expand coverage of ART for HIV positive in order to control the dual epidemic.
Collapse
|
46
|
Abstract
Objectives: Reliable estimates of the joint burden of HIV and tuberculosis epidemics are crucial to planning strategic global and national tuberculosis responses. Prior to the Global Tuberculosis Report 2013, the Global Tuberculosis Programme (GTB) released estimates for tuberculosis–HIV incidence at the global level only. Neither GTB nor United Nations Programme on HIV/AIDS (UNAIDS) published country specific estimates for tuberculosis–HIV mortality. We used a regression approach that combined all available data from GTB and UNAIDS in order to estimate tuberculosis–HIV incidence and mortality at country level. Methods: A regression method was devised to relate CD4 dynamics (based on national Spectrum files) to an increased relative risk (RR) of tuberculosis disease. The objective function is based on least squares and incorporates all available country-level estimates of tuberculosis–HIV incidence. Global regression parameters, obtained from averaging results over countries with population survey estimates for tuberculosis–HIV burden, were applied to countries with no survey tuberculosis–HIV incidence estimates. Results: The method produced results that are in reasonably close agreement with existing GTB estimates for global tuberculosis–HIV burden. It estimated that tuberculosis–HIV accounts for 12.6% of global tuberculosis incidence, 21.3% of all tuberculosis deaths, and 20% of all HIV deaths as estimated by the Spectrum AIDS Impact Module (AIM). Regional estimates show the highest absolute incidence burden in East and Southeast Asia, and the highest per capita burden in sub-Saharan Africa, where between 12.5% (Central sub-Saharan Africa) and 60.6% (Southern sub-Saharan Africa) of all tuberculosis disease occurs in people living with HIV (PLWH). Tuberculosis mortality follows a similar pattern, except that a disproportionate percentage of global tuberculosis deaths (12.1%) relative to global incidence (8.7%) occurred in Southern sub-Saharan Africa. Conclusion: The disaggregation of tuberculosis incidence using a regression method on RR of tuberculosis disease and all available data on HIV burden (from UNAIDS) and tuberculosis–HIV testing (survey, sentinel and routine surveillance data) produces results that closely match GTB estimates for 2011. The tuberculosis–HIV incidence and mortality results were published in the Global Tuberculosis Report 2013. Several limitations of and potential improvements to the process are suggested.
Collapse
|
47
|
Glaziou P, Sismanidis C, Floyd K, Raviglione M. Global epidemiology of tuberculosis. Cold Spring Harb Perspect Med 2014; 5:a017798. [PMID: 25359550 DOI: 10.1101/cshperspect.a017798] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Despite the availability of effective chemotherapy, tuberculosis (TB) killed 1.3 million people in 2012. Alongside HIV, it remains a top cause of death from an infectious disease. Global targets for reductions in the epidemiological burden of TB have been set for 2015 and 2050 within the context of the Millennium Development Goals (MDGs) and by the Stop TB Partnership. Achieving these targets is the focus of national and international efforts in TB control, and showing whether or not they are achieved is of major importance to guide future and sustainable investments. This article provides a short overview of sources of data to estimate TB disease burden; presents estimates of TB incidence, prevalence, and mortality in 2012 and an assessment of progress toward the 2015 targets for reductions in these indicators based on trends since 1990 and projections up to 2015; analyzes trends in TB notifications and in the implementation of the Stop TB Strategy; and considers prospects for elimination of TB after 2015.
Collapse
Affiliation(s)
- Philippe Glaziou
- HIV/AIDS, Tuberculosis & Malaria, World Health Organization, 1211 Geneva 27, Switzerland
| | - Charalambos Sismanidis
- HIV/AIDS, Tuberculosis & Malaria, World Health Organization, 1211 Geneva 27, Switzerland
| | - Katherine Floyd
- HIV/AIDS, Tuberculosis & Malaria, World Health Organization, 1211 Geneva 27, Switzerland
| | - Mario Raviglione
- HIV/AIDS, Tuberculosis & Malaria, World Health Organization, 1211 Geneva 27, Switzerland
| |
Collapse
|
48
|
Rudolf F. The Bandim TBscore--reliability, further development, and evaluation of potential uses. Glob Health Action 2014; 7:24303. [PMID: 24857613 PMCID: PMC4032506 DOI: 10.3402/gha.v7.24303] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 04/20/2014] [Accepted: 04/28/2014] [Indexed: 12/12/2022] Open
Abstract
Background The tuberculosis (TB) case detection rate has stagnated at 60% due to disorganized case finding and insensitivity of sputum smear microscopy. Of the identified TB cases, 4% die while being treated, monitored with tools that insufficiently predict failure/mortality. Objective To explore the TBscore, a recently proposed clinical severity measure for pulmonary TB (PTB) patients, and to refine, validate, and investigate its place in case finding. Design The TBscore’s inter-observer agreement was assessed and compared to the Karnofsky Performance Score (KPS) (paper I). The TBscore’s variables underlying constructs were assessed, sorting out unrelated items, proposing a more easily assessable TBscoreII, which was validated internally and externally (paper II). Finally, TBscore and TBscoreII’s place in PTB-screening was examined in paper III. Results The inter-observer variability when grading PTB patients into severity classes was moderate for both TBscore (κW=0.52, 95% CI 0.46–0.56) and KPS (κW=0.49, 95% CI 0.33–0.65). KPS was influenced by HIV status, whereas TBscore was unaffected by it. In paper II, proposed TBscoreII was validated internally, in Guinea-Bissau, and externally, in Ethiopia. In both settings, a failure to bring down the score by ≥25% from baseline to 2 months of treatment predicted subsequent failure (p=0.007). Finally, in paper III, TBscore and TBscoreII were assessed in health-care-seeking adults and found to be higher in PTB-diagnosed patients, 4.9 (95% CI 4.6–5.2) and 3.9 (95% CI 3.8–4.0), respectively, versus patients not diagnosed with PTB, 3.0 (95% CI 2.7–3.2) and 2.4 (95% CI 2.3–2.5), respectively. Had we referred only patients with cough >2 weeks to sputum smear, we would have missed 32.1% of the smear confirmed cases in our cohort. A TBscoreII>=2 missed 8.6%. Conclusions TBscore and TBscoreII are useful monitoring tools for PTB patients on treatment, as they could fill the void which currently exists in risk grading of patients. They may also have a role in PTB screening; however, this requires our findings to be repeated elsewhere.
Collapse
Affiliation(s)
- Frauke Rudolf
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark;
| |
Collapse
|
49
|
Schwartz AB, Tamuhla N, Steenhoff AP, Nkakana K, Letlhogile R, Chadborn TR, Kestler M, Zetola NM, Ravimohan S, Bisson GP. Outcomes in HIV-infected adults with tuberculosis at clinics with and without co-located HIV clinics in Botswana. Int J Tuberc Lung Dis 2014; 17:1298-303. [PMID: 24025381 DOI: 10.5588/ijtld.12.0861] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Gaborone, Botswana. OBJECTIVE To determine if starting anti-tuberculosis treatment at clinics in Gaborone without co-located human immunodeficiency virus (HIV) clinics would delay time to highly active antiretroviral therapy (HAART) initiation and be associated with lower survival compared to starting anti-tuberculosis treatment at clinics with on-site HIV clinics. DESIGN Retrospective cohort study. Subjects were HAART-naïve, aged ≥ 21 years with pulmonary tuberculosis (TB), HIV and CD4 counts ≤ 250 cells/mm(3) initiating anti-tuberculosis treatment between 2005 and 2010. Survival at completion of anti-tuberculosis treatment or at 6 months post-treatment initiation and time to HAART after anti-tuberculosis treatment initiation were compared by clinic type. RESULTS Respectively 259 and 80 patients from clinics without and with on-site HIV facilities qualified for the study. Age, sex, CD4, baseline sputum smears and loss to follow-up rate were similar by clinic type. Mortality did not differ between clinics without or with on-site HIV clinics (20/250, 8.0% vs. 8/79, 10.1%, relative risk 0.79, 95%CI 0.36-1.72), nor did median time to HAART initiation (respectively 63 and 66 days, P = 0.53). CONCLUSION In urban areas where TB and HIV programs are separate, geographic co-location alone without further integration may not reduce mortality or time to HAART initiation among co-infected patients.
Collapse
Affiliation(s)
- A B Schwartz
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Yadav RP, Nishikiori N, Satha P, Eang MT, Lubell Y. Cost-effectiveness of a tuberculosis active case finding program targeting household and neighborhood contacts in Cambodia. Am J Trop Med Hyg 2014; 90:866-872. [PMID: 24615134 PMCID: PMC4015580 DOI: 10.4269/ajtmh.13-0419] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
In many high-risk populations, access to tuberculosis (TB) diagnosis and treatment is limited and pockets of high prevalence persist. We estimated the cost-effectiveness of an extensive active case finding program in areas of Cambodia where TB notifications and household poverty rates are highest and access to care is restricted. Thirty operational health districts with high TB incidence and household poverty were randomized into intervention and control groups. In intervention operational health districts, all household and symptomatic neighborhood contacts of registered TB patients of the past two years were encouraged to attend screening at mobile centers. In control districts, routine passive case finding activities continued. The program screened more than 35,000 household and neighborhood contacts and identified 810 bacteriologically confirmed cases. The cost-effectiveness analysis estimated that in these cases the reduction in mortality from 14% to 2% would result in a cost per daily adjusted life year averted of $330, suggesting that active case finding was highly cost-effective.
Collapse
Affiliation(s)
| | | | | | | | - Yoel Lubell
- *Address correspondence to Yoel Lubell, Mahidol–Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok 10400, Thailand. E-mail:
| |
Collapse
|