1
|
Jhaveri TA, Jhaveri D, Galivanche A, Lubeck-Schricker M, Voehler D, Chung M, Thekkur P, Chadha V, Nathavitharana R, Kumar AMV, Shewade HD, Powers K, Mayer KH, Haberer JE, Bain P, Pai M, Satyanarayana S, Subbaraman R. Barriers to engagement in the care cascade for tuberculosis disease in India: A systematic review of quantitative studies. PLoS Med 2024; 21:e1004409. [PMID: 38805509 PMCID: PMC11166313 DOI: 10.1371/journal.pmed.1004409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/11/2024] [Accepted: 04/29/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND India accounts for about one-quarter of people contracting tuberculosis (TB) disease annually and nearly one-third of TB deaths globally. Many Indians do not navigate all care cascade stages to receive TB treatment and achieve recurrence-free survival. Guided by a population/exposure/comparison/outcomes (PECO) framework, we report findings of a systematic review to identify factors contributing to unfavorable outcomes across each care cascade gap for TB disease in India. METHODS AND FINDINGS We defined care cascade gaps as comprising people with confirmed or presumptive TB who did not: start the TB diagnostic workup (Gap 1), complete the workup (Gap 2), start treatment (Gap 3), achieve treatment success (Gap 4), or achieve TB recurrence-free survival (Gap 5). Three systematic searches of PubMed, Embase, and Web of Science from January 1, 2000 to August 14, 2023 were conducted. We identified articles evaluating factors associated with unfavorable outcomes for each gap (reported as adjusted odds, relative risk, or hazard ratios) and, among people experiencing unfavorable outcomes, reasons for these outcomes (reported as proportions), with specific quality or risk of bias criteria for each gap. Findings were organized into person-, family-, and society-, or health system-related factors, using a social-ecological framework. Factors associated with unfavorable outcomes across multiple cascade stages included: male sex, older age, poverty-related factors, lower symptom severity or duration, undernutrition, alcohol use, smoking, and distrust of (or dissatisfaction with) health services. People previously treated for TB were more likely to seek care and engage in the diagnostic workup (Gaps 1 and 2) but more likely to suffer pretreatment loss to follow-up (Gap 3) and unfavorable treatment outcomes (Gap 4), especially those who were lost to follow-up during their prior treatment. For individual care cascade gaps, multiple studies highlighted lack of TB knowledge and structural barriers (e.g., transportation challenges) as contributing to lack of care-seeking for TB symptoms (Gap 1, 14 studies); lack of access to diagnostics (e.g., X-ray), non-identification of eligible people for testing, and failure of providers to communicate concern for TB as contributing to non-completion of the diagnostic workup (Gap 2, 17 studies); stigma, poor recording of patient contact information by providers, and early death from diagnostic delays as contributing to pretreatment loss to follow-up (Gap 3, 15 studies); and lack of TB knowledge, stigma, depression, and medication adverse effects as contributing to unfavorable treatment outcomes (Gap 4, 86 studies). Medication nonadherence contributed to unfavorable treatment outcomes (Gap 4) and TB recurrence (Gap 5, 14 studies). Limitations include lack of meta-analyses due to the heterogeneity of findings and limited generalizability to some Indian regions, given the country's diverse population. CONCLUSIONS This systematic review illuminates common patterns of risk that shape outcomes for Indians with TB, while highlighting knowledge gaps-particularly regarding TB care for children or in the private sector-to guide future research. Findings may inform targeting of support services to people with TB who have higher risk of poor outcomes and inform multicomponent interventions to close gaps in the care cascade.
Collapse
Affiliation(s)
- Tulip A. Jhaveri
- Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, United States of America
| | - Disha Jhaveri
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Amith Galivanche
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Maya Lubeck-Schricker
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Dominic Voehler
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Mei Chung
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, United States of America
| | - Pruthu Thekkur
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | | | - Ruvandhi Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ajay M. V. Kumar
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
- Department of Community Medicine, Yenepoya Medical College, Yenepoya (deemed to be university), Mangalore, India
| | - Hemant Deepak Shewade
- Division of Health Systems Research, ICMR-National Institute of Epidemiology, Chennai, India
| | - Katherine Powers
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Kenneth H. Mayer
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
- The Fenway Institute, Boston, Massachusetts, United States of America
| | - Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Paul Bain
- Countway Library of Medicine, Boston, Massachusetts, United States of America
| | - Madhukar Pai
- Department of Global and Public Health and McGill International TB Centre, McGill University, Montreal, Canada
| | - Srinath Satyanarayana
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | - Ramnath Subbaraman
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, United States of America
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
| |
Collapse
|
2
|
Giridharan P, Selvaraju S, Rao R, Rade K, Thiruvengadam K, Asthana S, Balachandar R, Dipak Bangar S, Bansal AK, Bhat J, Chakraborty D, Chopra V, Das D, Dutta S, Rekha Devi K, Kumar S, Laxmaiah A, Madhukar M, Mahapatra A, Mohanty SS, Rangaraju C, Turuk J, Zaman K, Krishnan R, Shanmugam S, Kumar N, Panduranga Joshi R, Narasimhaiah S, Chandrasekaran P, Gangakhedkar RR, Bhargava B. Recurrence of pulmonary tuberculosis in India: Findings from the 2019-2021 nationwide community-based TB prevalence survey. PLoS One 2023; 18:e0294254. [PMID: 38127931 PMCID: PMC10734941 DOI: 10.1371/journal.pone.0294254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 10/30/2023] [Indexed: 12/23/2023] Open
Abstract
Recurrent Tuberculosis patients contribute to a significant proportion of TB burden in India. A nationwide survey was conducted during 2019-2021 across India among adults to estimate the prevalence of TB. A total of 322480 individuals were screened and 1402 were having TB. Of this, 381 (27.1%) had recurrent TB. The crude prevalence (95% CI) of recurrent TB was 118 (107-131) per 100,000 population. The median duration between episodes of TB was 24 months. The proportion of drug resistant TB was 11.3% and 3.6% in the recurrent group and new TB patients respectively. Higher prevalence of recurrent TB was observed in elderly, males, malnourished, known diabetics, smokers, and alcohol users. (p<0.001). To prevent TB recurrence, all treated tuberculosis patients must be followed at least for 24 months, with screening for Chest X-ray, liquid culture every 6 months, smoking cessation, alcohol cessation, nutritional interventions and good diabetic management.
Collapse
Affiliation(s)
| | - Sriram Selvaraju
- ICMR- National Institute for Research in Tuberculosis, Chetpet, Chennai, India
| | - Raghuram Rao
- Central TB Division, Ministry of Health and Family Welfare, New Delhi, India
| | - Kiran Rade
- National Professional Officer, WHO Country Office, New Delhi, India
| | | | - Smita Asthana
- ICMR- National Institute for Cancer Prevention and Research, Noida, Uttar Pradesh, India
| | - Rakesh Balachandar
- ICMR- National Institute for Occupational Health, Ahmedabad, Gujarat, India
| | | | - Avi Kumar Bansal
- ICMR- National JALMA Institute of Leprosy and other Mycobacterial diseases, Agra, Uttar Pradesh, India
| | - Jyothi Bhat
- ICMR- National Institute for research in Tribal Health, Jabalpur, Madhya Pradesh, India
| | - Debjit Chakraborty
- ICMR- National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Vishal Chopra
- State TB Training and Demonstration Centre (STDC), TB Hospital, Lahori, Punjab, India
| | - Dasarathi Das
- ICMR- Regional Medical Research Centre, Bhubaneshwar, Odisha, India
| | - Shanta Dutta
- ICMR- National Institute of Cholera and Enteric Diseases, Kolkata, India
| | | | | | - Avula Laxmaiah
- ICMR- National Institute for Research in Nutrition, Hyderabad, Telangana, India
| | - Major Madhukar
- ICMR- Rajendra Memorial Research Institute of Medical Sciences Agamkuan, Patna, India
| | | | - Suman Sundar Mohanty
- ICMR- ICMR-National Institute for Implementation Research on Non-Communicable Diseases, Jodhpur, India
| | | | | | - Kamran Zaman
- ICMR- Regional Medical Research Centre, Gorakhpur
| | - Rajendran Krishnan
- ICMR- National Institute for Research in Tuberculosis, Chetpet, Chennai, India
| | - Sivakumar Shanmugam
- ICMR- National Institute for Research in Tuberculosis, Chetpet, Chennai, India
| | - Nishant Kumar
- Central TB Division, Ministry of Health and Family Welfare, New Delhi, India
| | | | | | | | | | | |
Collapse
|
3
|
Faust L, Naidoo P, Caceres-Cardenas G, Ugarte-Gil C, Muyoyeta M, Kerkhoff AD, Nagarajan K, Satyanarayana S, Rakotosamimanana N, Grandjean Lapierre S, Adejumo OA, Kuye J, Oga-Omenka C, Pai M, Subbaraman R. Improving measurement of tuberculosis care cascades to enhance people-centred care. THE LANCET. INFECTIOUS DISEASES 2023; 23:e547-e557. [PMID: 37652066 DOI: 10.1016/s1473-3099(23)00375-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/01/2023] [Accepted: 06/08/2023] [Indexed: 09/02/2023]
Abstract
Care cascades represent the proportion of people reaching milestones in care for a disease and are widely used to track progress towards global targets for HIV and other diseases. Despite recent progress in estimating care cascades for tuberculosis (TB) disease, they have not been routinely applied at national and subnational levels, representing a lost opportunity for public health impact. As researchers who have estimated TB care cascades in high-incidence countries (India, Madagascar, Nigeria, Peru, South Africa, and Zambia), we describe the utility of care cascades and identify measurement challenges, including the lack of population-based disease burden data and electronic data capture, the under-reporting of people with TB navigating fragmented and privatised health systems, the heterogeneity of TB tests, and the lack of post-treatment follow-up. We outline an agenda for rectifying these gaps and argue that improving care cascade measurement is crucial to enhancing people-centred care and achieving the End TB goals.
Collapse
Affiliation(s)
- Lena Faust
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, QC, Canada; McGill International TB Centre, Montréal, QC, Canada
| | - Pren Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - César Ugarte-Gil
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru; School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru; TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Monde Muyoyeta
- Tuberculosis Department, Center for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, USA
| | - Karikalan Nagarajan
- Department of Social and Behavioural Research, ICMR-National Institute for Research in Tuberculosis, Chennai, Tamil Nadu, India
| | - Srinath Satyanarayana
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France; South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | | | - Simon Grandjean Lapierre
- McGill International TB Centre, Montréal, QC, Canada; Mycobacteriology Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar; Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada; Department of Microbiology, Infectious Diseases and Immunology, Université de Montréal, Montréal, QC, Canada
| | | | - Joseph Kuye
- National Tuberculosis and Leprosy Control Program, Abuja, Nigeria
| | - Charity Oga-Omenka
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, QC, Canada; McGill International TB Centre, Montréal, QC, Canada
| | - Ramnath Subbaraman
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, MA, USA; Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, MA, USA.
| |
Collapse
|
4
|
Bhargava A, Bhargava M, Meher A, Teja GS, Velayutham B, Watson B, Benedetti A, Barik G, Singh VP, Singh D, Madhukeshwar AK, Prasad R, Pathak RR, Chadha V, Joshi R. Nutritional support for adult patients with microbiologically confirmed pulmonary tuberculosis: outcomes in a programmatic cohort nested within the RATIONS trial in Jharkhand, India. Lancet Glob Health 2023; 11:e1402-e1411. [PMID: 37567210 DOI: 10.1016/s2214-109x(23)00324-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 06/27/2023] [Accepted: 07/04/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND Undernutrition is a common comorbidity of tuberculosis in countries with a high tuberculosis burden, such as India. RATIONS is a field-based, cluster-randomised controlled trial evaluating the effect of providing nutritional support to household contacts of adult patients with microbiologically confirmed pulmonary tuberculosis in Jharkhand, India, on tuberculosis incidence. The patient cohort in both groups of the trial was provided with nutritional support. In this study, we assessed the effects of nutritional support on tuberculosis mortality, treatment success, and other outcomes in the RATIONS patient cohort. METHODS We enrolled patients (aged 18 years or older) with microbiologically confirmed pulmonary tuberculosis across 28 tuberculosis units. Patients received nutritional support in the form of food rations (1200 kcal and 52 g of protein per day) and micronutrient pills. Nutritional support was for 6 months for drug-susceptible tuberculosis and 12 months for multidrug-resistant tuberculosis; patients with drug-susceptible tuberculosis could receive an extension of up to 6 months if their BMI was less than 18·5 kg/m2 at the end of treatment. We recorded BMI, diabetes status, and modified Eastern Cooperative Oncology Group (ECOG) performance status at baseline. Clinical outcomes (treatment success, tuberculosis mortality, loss to follow-up, and change in performance status) and weight gain were recorded at 6 months. We assessed the predictors of tuberculosis mortality with Poisson and Cox regression using adjusted incidence rate ratios (IRRs) and adjusted hazard ratios (HRs). The RATIONS trial is registered with the Clinical Trials Registry of India (CTRI/2019/08/020490). FINDINGS Between Aug 16, 2019, and Jan 31, 2021, 2800 patients (mean age 41·5 years [SD 14·5]; 1979 [70·7%] men and 821 [29·3%] women) were enrolled. At enrolment, 2291 (82·4%) patients were underweight (BMI <18·5 kg/m2), and 480 (17·3%) had a BMI of less than 14 kg/m2. The mean weight and BMI were 42·6 kg (SD 7·8) and 16·4 kg/m2 (2·6) in men and 36·1 kg (7·3) and 16·2 kg/m2 (2·9) in women. During the 6-month follow-up, treatment was successful in 2623 (93·7%) patients, 108 (3·9%) tuberculosis deaths occurred, 28 (1·0%) patients were lost to follow-up, and treatment failure was experienced by five (0·2%) patients. The median weight gain was 4·6 kg (IQR 2·8-6·8), but 1441 (54·8%) of 2630 patients remained underweight. At 2 months, 1444 (54·0%) of 2676 patients gained at least 5% of baseline weight. Baseline weight (adjusted IRR 0·95, 95% CI 0·90-0·99), BMI (0·88, 0·76-1·01), poor performance status (ECOG categories 3-4; 5·33, 2·90-9·79), diabetes (3·30, 1·65-6·72), and haemoglobin (0·85, 0·71-1·00) were predictors of tuberculosis mortality. A reduced hazard of death (adjusted HR 0·39, 95% CI 0·18-0·86) was associated with a 5% weight gain at 2 months. INTERPRETATION In this study, nutritional support was provided to a cohort with a high prevalence of severe undernutrition. Weight gain, particularly in the first 2 months, was associated with a substantially decreased hazard of tuberculosis mortality. Nutritional support needs to be an integral component of patient-centred care to improve treatment outcomes in such settings. FUNDING India Tuberculosis Research Consortium, Indian Council of Medical Research.
Collapse
Affiliation(s)
- Anurag Bhargava
- Department of Medicine, Yenepoya Medical College, Mangalore, India; Center for Nutrition Studies, Yenepoya (Deemed to be University), Mangalore, India; Department of Medicine, McGill University, Montreal, QC, Canada.
| | - Madhavi Bhargava
- Department of Community Medicine, Yenepoya Medical College, Mangalore, India; Center for Nutrition Studies, Yenepoya (Deemed to be University), Mangalore, India
| | - Ajay Meher
- Indian Council of Medical Research-National Institute for Research in Tuberculosis, Chennai, India
| | - G Sai Teja
- Center for Nutrition Studies, Yenepoya (Deemed to be University), Mangalore, India
| | - Banurekha Velayutham
- Indian Council of Medical Research-National Institute for Research in Tuberculosis, Chennai, India
| | - Basilea Watson
- Indian Council of Medical Research-National Institute for Research in Tuberculosis, Chennai, India
| | - Andrea Benedetti
- Center for Nutrition Studies, Yenepoya (Deemed to be University), Mangalore, India; Department of Medicine, McGill University, Montreal, QC, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Ganesh Barik
- Indian Council of Medical Research-National Institute for Research in Tuberculosis, Chennai, India
| | - Vivek Pratap Singh
- Indian Council of Medical Research-National Institute for Research in Tuberculosis, Chennai, India
| | - Dhananjay Singh
- Indian Council of Medical Research-National Institute for Research in Tuberculosis, Chennai, India
| | | | - Ranjit Prasad
- State TB Cell, National Tuberculosis Elimination Programme, Ranchi, India
| | | | | | - Rajendra Joshi
- National Tuberculosis Elimination Programme, Ministry of Health and Family Welfare, New Delhi, India
| |
Collapse
|
5
|
Anaam MS, Alrasheedy AA. Recurrence Rate of Pulmonary Tuberculosis in Patients Treated with the Standard 6-Month Regimen: Findings and Implications from a Prospective Observational Multicenter Study. Trop Med Infect Dis 2023; 8:tropicalmed8020110. [PMID: 36828526 PMCID: PMC9963147 DOI: 10.3390/tropicalmed8020110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 01/27/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023] Open
Abstract
Tuberculosis (TB) recurrence following successful treatment is a significant challenge in TB control programs. However, the rate of TB recurrence varies among studies. It depends on several factors, including the country/region where the investigation occurs, the study design, sample characteristics, and the anti-TB regimen used. In Yemen, a few previous studies examined the rate of TB recurrence and reported high recurrence rates, with a 5-year recurrence rate of approximately 9.5%. However, they were conducted before 2010 using the previous anti-TB regimen which was phased out and replaced with the World Health Organization's (WHO) standard 6-month TB regimen. Consequently, this study aimed to examine the rate of TB recurrence after the implementation of the WHO standard 6-month regimen in Yemen. A prospective observational study was conducted with patients diagnosed with drug-susceptible pulmonary TB. The patients were recruited from five health centers with TB units in five governorates from January to December 2011. All the patients were followed up for five years after treatment completion. A total of 439 patients who completed the anti-TB regimen met the inclusion criteria and were included in the study. During the 5-year follow-up period, 8 patients (1.8%) died, and 13 patients (2.96%) were lost to follow-up, resulting in a final cohort of 418 patients. Of the cohort, 50.5% (n = 211) were male, while 49.5% (n = 207) were female patients. Of the patients, 129 patients (30.9%) were illiterate, 56 (13.4%) had cavitary pulmonary disease, and 6.2% (n = 26) had diabetes. The overall 5-year rate of TB recurrence in this study for the patients receiving the standard 6-month regimen was 2.9% (12/418). Moreover, almost half of the recurrent cases (41.7%; n = 5) were seen during the first year of the follow-up period. Some patient groups with risk factors recorded a higher recurrence rate, including patients with diabetes (15.4%), non-compliant patients (14.3%), pre-treatment lung cavitation patients (8.9%), illiterate patients (7.8%), and underweight patients (5.1%). In conclusion, the overall TB recurrence rate with the standard 6-month regimen was lower than that with the previous TB regimens. However, more efforts are needed to decrease TB recurrence rates further and achieve a durable cure for TB. In addition, healthcare professionals and TB control programs should consider potential risk factors of recurrence and address them to provide optimal care.
Collapse
Affiliation(s)
- Mohammed Saif Anaam
- Department of Pharmacy Practice, Unaizah College of Pharmacy, Qassim University, Qassim 51911, Saudi Arabia
| | - Alian A. Alrasheedy
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Buraidah 51452, Saudi Arabia
- Correspondence:
| |
Collapse
|
6
|
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
|
7
|
Cox SR, Kadam A, Atre S, Gupte AN, Sohn H, Gupte N, Sawant T, Mhadeshwar V, Thompson R, Kendall E, Hoffmann C, Suryavanshi N, Kerrigan D, Tripathy S, Kakrani A, Barthwal MS, Mave V, Golub JE. Tuberculosis (TB) Aftermath: study protocol for a hybrid type I effectiveness-implementation non-inferiority randomized trial in India comparing two active case finding (ACF) strategies among individuals treated for TB and their household contacts. Trials 2022; 23:635. [PMID: 35932062 PMCID: PMC9354295 DOI: 10.1186/s13063-022-06503-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/01/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Approximately 7% of all reported tuberculosis (TB) cases each year are recurrent, occurring among people who have had TB in the recent or distant past. TB recurrence is particularly common in India, which has the largest TB burden worldwide. Although patients recently treated for TB are at high risk of developing TB again, evidence around effective active case finding (ACF) strategies in this population is scarce. We will conduct a hybrid type I effectiveness-implementation non-inferiority randomized trial to compare the effectiveness, cost-effectiveness, and feasibility of two ACF strategies among individuals who have completed TB treatment and their household contacts (HHCs). METHODS We will enroll 1076 adults (≥ 18 years) who have completed TB treatment at a public TB unit (TU) in Pune, India, along with their HHCs (averaging two per patient, n = 2152). Participants will undergo symptom-based ACF by existing healthcare workers (HCWs) at 6-month intervals and will be randomized to either home-based ACF (HACF) or telephonic ACF (TACF). Symptomatic participants will undergo microbiologic testing through the program. Asymptomatic HHCs will be referred for TB preventive treatment (TPT) per national guidelines. The primary outcome is rate per 100 person-years of people diagnosed with new or recurrent TB by study arm, within 12 months following treatment completion. The secondary outcome is proportion of HHCs < 6 years, by study arm, initiated on TPT after ruling out TB disease. Study staff will collect socio-demographic and clinical data to identify risk factors for TB recurrence and will measure post-TB lung impairment. In both arms, an 18-month "mop-up" visit will be conducted to ascertain outcomes. We will use the RE-AIM framework to characterize implementation processes and explore acceptability through in-depth interviews with index patients, HHCs and HCWs (n = 100). Cost-effectiveness will be assessed by calculating the incremental cost per TB case detected within 12 months and projected for disability-adjusted life years averted based on modeled estimates of morbidity, mortality, and time with infectious TB. DISCUSSION This novel trial will guide India's scale-up of post-treatment ACF and provide an evidence base for designing strategies to detect recurrent and new TB in other high burden settings. TRIAL REGISTRATION NCT04333485 , registered April 3, 2020. CTRI/2020/05/025059 [Clinical Trials Registry of India], registered May 6 2020.
Collapse
Affiliation(s)
- Samyra R Cox
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA.
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA.
| | - Abhay Kadam
- Johns Hopkins India, G-4 & G-5, PHOENIX Building, OPP. to Residency Club, Pune, Maharashtra, 411001, India
| | - Sachin Atre
- Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Maharashtra, 411018, India
| | - Akshay N Gupte
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Hojoon Sohn
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Nikhil Gupte
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
- Johns Hopkins India, G-4 & G-5, PHOENIX Building, OPP. to Residency Club, Pune, Maharashtra, 411001, India
| | - Trupti Sawant
- Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Maharashtra, 411018, India
| | - Vishal Mhadeshwar
- Johns Hopkins India, G-4 & G-5, PHOENIX Building, OPP. to Residency Club, Pune, Maharashtra, 411001, India
| | - Ryan Thompson
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | - Emily Kendall
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Christopher Hoffmann
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Nishi Suryavanshi
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
- Johns Hopkins India, G-4 & G-5, PHOENIX Building, OPP. to Residency Club, Pune, Maharashtra, 411001, India
| | - Deanna Kerrigan
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- George Washington University, 2121 I St NW, Washington, D.C., 20052, USA
| | - Srikanth Tripathy
- Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Maharashtra, 411018, India
| | - Arjunlal Kakrani
- Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Maharashtra, 411018, India
| | - Madhusudan S Barthwal
- Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Maharashtra, 411018, India
| | - Vidya Mave
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
- Johns Hopkins India, G-4 & G-5, PHOENIX Building, OPP. to Residency Club, Pune, Maharashtra, 411001, India
| | - Jonathan E Golub
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
| |
Collapse
|
8
|
Abstract
Cough assessment is central to the clinical management of respiratory diseases, including tuberculosis (TB), but strategies to objectively and unobtrusively measure cough are lacking. Acoustic epidemiology is an emerging field that uses technology to detect cough sounds and analyze cough patterns to improve health outcomes among people with respiratory conditions linked to cough. This field is increasingly exploring the potential of artificial intelligence (AI) for more advanced applications, such as analyzing cough sounds as a biomarker for disease screening. While much of the data are preliminary, objective cough assessment could potentially transform disease control programs, including TB, and support individual patient management. Here, we present an overview of recent advances in this field and describe how cough assessment, if validated, could support public health programs at various stages of the TB care cascade. Zimmer et al. discuss the importance of cough assessment in clinical management of tuberculosis (TB). They describe how acoustic epidemiology, which uses recording devices and artificial intelligence to detect, record and analyze cough, can be used in TB control and individual patient management.
Collapse
|
9
|
Bargaje M, Bharaswadkar S, Lohidasan S, Panda BK. Plasma drug concentrations of 4-drug fixed-dose combination regimen and its efficacy for treatment of pulmonary tuberculosis under National Tuberculosis Elimination Programme: A prospective pilot study. Indian J Tuberc 2022; 69:311-319. [PMID: 35760480 DOI: 10.1016/j.ijtb.2021.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The thrice weekly dosing regimen of DOTS has shown low rifampicin plasma concentrations as an independent risk factor for unfavourable tuberculosis (TB) outcome. With introduction of daily regimen using fixed dose combinations (FDC) under National Tuberculosis Elimination Programme (NTEP) the existence of suboptimal plasma levels of first-line antitubercular drugs and its clinical significance remain poorly understood. METHOD We included a prospective cohort of newly diagnosed pulmonary tuberculosis (PTB) patients receiving 4-FDC daily regimen under NTEP. Plasma concentration at 2 hours (C2h) of each drug was determined after two weeks of treatment using liquid chromatography (LCMS/MS) developed by us. TB card and laboratory reports were reviewed for baseline characteristics and clinical status at 2, 4 and 6 months after the initiation of treatment. At a 1 year follow-up, therapy failure was defined as death or a relapse of tuberculosis. RESULTS Among 40 PTB patients, the C2h post dose plasma concentrations of H, R and E were suboptimal in 25%, 60% and 10% respectively. The C2h of H, R, Z and E were respectively 4.2 ± 2.0, 7.3 ± 2.8, 39.2 ± 8.8 and 3.5 ± 1.2 μg/ml; 60% of the patients had suboptimal plasma concentrations and commonly it was observed with H and R. C2h were lower than expected for at least two drugs i.e. H and R in 25% (10/40) of the patients. Plasma concentration of isoniazid and rifampicin has always been considered important for microbiological response and treatment outcome and low concentrations has been associated with poor treatment response. These patients may require a two year follow up and critical evaluation for prevention of MDR-TB. However, all the TB patients were cured and none of them had recurrence within one year follow up. CONCLUSIONS All the pulmonary TB patients administering 4-FDC daily regimen under programmatic settings were cured despite the suboptimal levels of isoniaizd and rifampicin. All the patients achieved pyrazinamide plasma levels and probably this could be the reason behind favourable outcome. Further study is required on large sample size with various subset of population to understand the need of therapeutic drug monitoring.
Collapse
Affiliation(s)
- Medha Bargaje
- Department of Pulmonary Medicine, Bharati Vidyapeeth (Deemed to be University) Medical College and Hospital, Pune, Maharashtra, 411043, India
| | - Sandeep Bharaswadkar
- Regional Team Lead, World Health Organization Country Office for India, WHO NTEP Technical Support Network, Pune, India
| | - Sathiyanarayanan Lohidasan
- Department of Pharmaceutical Chemistry, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University), Pune, Maharashtra, 411038, India
| | - Bijoy Kumar Panda
- Department of Clinical Pharmacy, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University), Pune, Maharashtra, 411038, India.
| |
Collapse
|
10
|
Jorwal P, Bharath BG, Ray A, Vyas S, Soneja M, Biswas A, Sinha S, Khan M. Diagnostic utility of chest computerized tomography in the diagnosis of recurrence among sputum scarce and sputum negative previously treated pulmonary tuberculosis suspects. Lung India 2022; 39:145-151. [PMID: 35259797 PMCID: PMC9053920 DOI: 10.4103/lungindia.lungindia_103_21] [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] [Indexed: 11/28/2022] Open
Abstract
Objective: The objective was to study the sensitivity, specificity, and diagnostic accuracy of various computed tomography (CT) chest findings in diagnosing recurrence among pulmonary tuberculosis (PTB) suspects. Materials and Methods: A prospective observational study was conducted in a tertiary care hospital in New Delhi. A total of 130 suspects with a past history of treatment for PTB, who presented with any of the symptoms suggestive of recurrence were included. Sputum-positive, HIV-positive patients, pregnant females, and patients aged <18 years were excluded. Patients underwent CT chest followed by bronchoalveolar lavage (BAL). Results: A total of 62 patients were there in the final analysis. The median age of the patients with recurrent PTB was 27.5 years. Cough was the universal symptom in all these patients (>90%). Hemoptysis was the predominant symptom among patients with chronic pulmonary aspergillosis (66.6%). Necrotic mediastinal lymph nodes had good diagnostic accuracy of 88.71% with area under the curve of 0.806, P < 0.001 in diagnosing recurrent TB. BAL GeneXpert and mycobacteria growth indicator tube had good sensitivity (83.33% and 84.62%, respectively), specificity (100% for both), and excellent diagnostic accuracy (95.16% and 96.36%, respectively) for diagnosing recurrence in sputum negative and sputum scarce patient, (P < 0.001) when compared with composite reference standard. For culture-positive cases, BAL GeneXpert MTB/RIF had 100% sensitivity and 97.73% specificity in diagnosing recurrent PTB patients. Conclusion: The presence of mediastinal necrotic lymph node is the most accurate CT finding that can differentiate recurrent TB from post-TB sequelae. No other single chest CT scan finding had reliable diagnostic accuracy in comparison to microbiological tools in diagnosing recurrence among sputum negative or scarce previously treated PTB suspects.
Collapse
|
11
|
Qiu B, Tao B, Liu Q, Li Z, Song H, Tian D, Wu J, Wu Z, Zhan M, Lu W, Wang J. A Prospective Cohort Study on the Prevalent and Recurrent Tuberculosis Isolates Using the MIRU-VNTR Typing. Front Med (Lausanne) 2021; 8:685368. [PMID: 34595184 PMCID: PMC8476766 DOI: 10.3389/fmed.2021.685368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 08/23/2021] [Indexed: 11/30/2022] Open
Abstract
The study aims to describe the clustering characteristics of Mycobacterium tuberculosis (M.tb) strains circulating in eastern China and determine the ratio of relapse and reinfection in recurrent patients. We recruited sputum smear-positive pulmonary tuberculosis cases from five cities of Jiangsu Province, China, during August 2013 and December 2015. Patients were followed for the treatment outcomes and recurrence based on a cohort design. M.tb strains were isolated and genotyped using the 12-locus MIRU-VNTR. The Beijing family was identified by the extended Region of Difference (RD) analysis. The Hunter-Gaston Discriminatory Index (HGDI) was used to judge the resolution ability of MIRU-VNTR. The odds ratio (OR) together with 95% confidence interval (CI) were used to estimate the strength of association. We performed a cluster analysis on 2098 M.tb isolates and classified them into 545 genotypes and five categories (I, 0.19%; II, 0.43%; III, 3.34%; IV, 77.46%; V, 18.59%). After adjusting for potential confounders, the Beijing family genotype (OR = 118.63, 95% CI: 79.61–176.79, P = 0.001) was significantly related to the dominant strain infections. Patients infected with non-dominant strains had a higher risk of the pulmonary cavity (OR = 1.39, 95% CI: 1.01–1.91, P = 0.046). Among 37 paired recurrent cases, 22 (59.46%) were determined as endogenous reactivation, and 15 (40.54%) were exogenous reinfection. The type of M.tb strains prevalent in Jiangsu Province is relatively single. Beijing family strains infection is dominant in local tuberculosis cases. Endogenous reactivation appears to be a major cause of recurrent tuberculosis in Eastern China. This finding emphasizes the importance of case follow-up and monitoring after the completion of antituberculosis treatment.
Collapse
Affiliation(s)
- Beibei Qiu
- Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Bilin Tao
- Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Qiao Liu
- Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China.,Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, China
| | - Zhongqi Li
- Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Huan Song
- Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Dan Tian
- Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Jizhou Wu
- Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Zhuchao Wu
- Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Mengyao Zhan
- Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Wei Lu
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, China
| | - Jianming Wang
- Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| |
Collapse
|
12
|
Asare P, Asante-Poku A, Osei-Wusu S, Otchere ID, Yeboah-Manu D. The Relevance of Genomic Epidemiology for Control of Tuberculosis in West Africa. Front Public Health 2021; 9:706651. [PMID: 34368069 PMCID: PMC8342769 DOI: 10.3389/fpubh.2021.706651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/29/2021] [Indexed: 12/30/2022] Open
Abstract
Tuberculosis (TB), an airborne infectious disease caused by Mycobacterium tuberculosis complex (MTBC), remains a global health problem. West Africa has a unique epidemiology of TB that is characterized by medium- to high-prevalence. Moreover, the geographical restriction of M. africanum to the sub-region makes West Africa have an extra burden to deal with a two-in-one pathogen. The region is also burdened with low case detection, late reporting, poor treatment adherence leading to development of drug resistance and relapse. Sporadic studies conducted within the subregion report higher burden of drug resistant TB (DRTB) than previously thought. The need for more sensitive and robust tools for routine surveillance as well as to understand the mechanisms of DRTB and transmission dynamics for the design of effective control tools, cannot be overemphasized. The advancement in molecular biology tools including traditional fingerprinting and next generation sequencing (NGS) technologies offer reliable tools for genomic epidemiology. Genomic epidemiology provides in-depth insight of the nature of pathogens, circulating strains and their spread as well as prompt detection of the emergence of new strains. It also offers the opportunity to monitor treatment and evaluate interventions. Furthermore, genomic epidemiology can be used to understand potential emergence and spread of drug resistant strains and resistance mechanisms allowing the design of simple but rapid tools. In this review, we will describe the local epidemiology of MTBC, highlight past and current investigations toward understanding their biology and spread as well as discuss the relevance of genomic epidemiology studies to TB control in West Africa.
Collapse
Affiliation(s)
- Prince Asare
- College of Health Sciences, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Adwoa Asante-Poku
- College of Health Sciences, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Stephen Osei-Wusu
- College of Health Sciences, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Isaac Darko Otchere
- College of Health Sciences, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Dorothy Yeboah-Manu
- College of Health Sciences, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| |
Collapse
|
13
|
Huddart S, Singh M, Jha N, Benedetti A, Pai M. Case fatality and recurrent tuberculosis among patients managed in the private sector: A cohort study in Patna, India. PLoS One 2021; 16:e0249225. [PMID: 33770134 PMCID: PMC7996982 DOI: 10.1371/journal.pone.0249225] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/14/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND A key component of the WHO End TB Strategy is quality of care, for which case fatality is a critical marker. Half of India's nearly 3 million TB patients are treated in the highly unregulated private sector, yet little is known about the outcomes of these patients. Using a retrospective cohort design, we estimated the case fatality ratio (CFR) and rate of recurrent TB among patients managed in the private healthcare sector in Patna, India. METHODS World Health Partners' Private Provider Interface Agencies (PPIA) pilot project in Patna has treated 89,906 private sector TB patients since 2013. A random sample of 4,000 patients treated from 2014 to 2016 were surveyed in 2018 for case fatality and recurrent TB. CFR is defined as the proportion of patients who die during the period of interest. Treatment CFRs, post-treatment CFRs and rates of recurrent TB were estimated. Predictors for fatality and recurrence were identified using Cox proportional hazards modelling. Survey non-response was adjusted for using inverse probability selection weighting. RESULTS The survey response rate was 56.0%. The weighted average follow-up times were 8.7 months in the treatment phase and 26.4 months in the post-treatment phase. Unobserved patients were more likely to have less than one month of treatment adherence (32.0% vs. 13.5%) and were more likely to live in rural Patna (21.9% vs. 15.0%). The adjusted treatment phase CFR was 7.27% (5.97%, 8.49%) and at 24 months post-treatment was 3.32% (2.36%, 4.42%). The adjusted 24 month post-treatment phase recurrent TB rate was 3.56% (2.54%, 4.79%). CONCLUSIONS Our cohort study provides critical estimates of TB patient outcomes in the Indian private sector, and accounts for selection bias. Patients in the private sector in Patna experienced a moderate treatment CFR but rates of recurrent TB and post-treatment fatality were low.
Collapse
Affiliation(s)
- Sophie Huddart
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
- Faculty of Medicine, University of California–San Francisco, San Francisco, CA, United States of America
| | | | - Nita Jha
- World Health Partners, Patna, India
| | - Andrea Benedetti
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
- Manipal McGill Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, India
| |
Collapse
|
14
|
Shao Y, Song H, Li G, Li Y, Li Y, Zhu L, Lu W, Chen C. Relapse or Re-Infection, the Situation of Recurrent Tuberculosis in Eastern China. Front Cell Infect Microbiol 2021; 11:638990. [PMID: 33816342 PMCID: PMC8010194 DOI: 10.3389/fcimb.2021.638990] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 03/01/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose Recurrent tuberculosis (TB) is defined by more than one TB episode per patient and is caused by re-infection with a new Mycobacterium tuberculosis (Mtb) strain or relapse with the previous strain. Recurrence of TB is one important obstacle for End TB strategy in the world and elucidating the triggers of recurrence is important for the current TB control strategy in China. This study aimed to analyze the sources of recurrent TB by the molecular genotyping method. Method A population-based surveillance was undertaking on all culture-positive TB cases in Jiangsu province, China from 2013 to 2019. Phenotypic drug susceptibility test (DST) by proportion method and mycobacterial interspersed repetitive units-variable number of tandem repeat (MIRU-VNTR) were adopted for drug resistance and genotype detection. Results A total of 1451 culture-positive TB patients were collected and 30 (2.06%, 30/1451) TB cases had recurrent TB episodes. Except 7 isolates were failed during subculture, 23 paired isolates were assessed. After genotyping by MIRU-VNTR, 12 (52.17%, 12/23) paired recurrence TB were demonstrated as relapse and 11 (47.83%,11/23) paired cases were identified as re-infection. The average interval time for recurrence was 24.04 (95%CI: 19.37-28.71) months, and there was no significant difference between relapse and re-infection. For the relapsed cases, two paired isolates exhibited drug resistance shifting, while four paired isolates revealed inconsistent drug resistance among the re-infection group including two multidrug-resistant tuberculosis (MDR-TB) at the second episode. Conclusion Relapse and re-infection contributed equally to the current situation of recurrence TB in Jiangsu, China. Besides, more efficient treatment assessment, specific and vigorous interventions are urgently needed for MDR-TB patients, considering obvious performance among re-infection cases.
Collapse
Affiliation(s)
- Yan Shao
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, China
| | - Honghuan Song
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, China
| | - Guoli Li
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, China
| | - Yan Li
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, China
| | - Yishu Li
- Department of Epidemiology and Statistics, School of Public Health, Southeast University, Nanjing, China
| | - Limei Zhu
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, China
| | - Wei Lu
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, China
| | - Cheng Chen
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, China
| |
Collapse
|
15
|
Asare P, Osei-Wusu S, Baddoo NA, Bedeley E, Otchere ID, Brites D, Loiseau C, Asante-Poku A, Prah DA, Borrell S, Reinhard M, Omari MA, Forson A, Koram KA, Gagneux S, Yeboah-Manu D. Genomic epidemiological analysis identifies high relapse among individuals with recurring tuberculosis and provides evidence of recent household-related transmission of tuberculosis in Ghana. Int J Infect Dis 2021; 106:13-22. [PMID: 33667696 PMCID: PMC8134059 DOI: 10.1016/j.ijid.2021.02.110] [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] [Received: 12/09/2020] [Revised: 02/25/2021] [Accepted: 02/25/2021] [Indexed: 11/29/2022] Open
Abstract
Unresolved previous infection as major cause of recurring tuberculosis (TB) in Ghana. Genomic epidemiology identifies high relapse among recurrent TB cases in Ghana. 15-locus MIRU-VNTR typing is sufficient to predict the cause of TB recurrence. Evidence of recent household-related TB transmission in Ghana. Need for increased education by national TB control program.
Objective To retrospectively investigate the cause of recurring tuberculosis (rcTB) among participants with pulmonary TB recruited from a prospective population-based study conducted between July 2012 and December 2015. Methods Mycobacterium tuberculosis complex isolates obtained from rcTB cases were characterized by standard mycobacterial genotyping tools, whole-genome sequencing, and phylogenetic analysis carried out to assess strain relatedness. Results The majority (58.3%, 21/36) of study participants with rcTB episodes had TB recurrence within 12 months post treatment. TB strains with isoniazid (INH) resistance were found in 19.4% (7/36) of participants at the primary episode, of which 29% (2/7) were also rifampicin-resistant. On TB recurrence, an INH-resistant strain was found in a larger proportion of participants, 27.8% (10/36), of which 40% (4/10) were MDR-TB strains. rcTB was attributed to relapse (same strain) in 75.0% (27/36) of participants and 25.0% (9/36) to re-infection. Conclusion Our findings indicate that previous unresolved infectiondue to inadequate treatment, may be the major cause of rcTB.
Collapse
Affiliation(s)
- Prince Asare
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana (UG), Ghana; West African Centre for Cell Biology of Infectious Pathogens, UG, Ghana; Department of Biochemistry, Cell and Molecular Biology, UG, Ghana.
| | - Stephen Osei-Wusu
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana (UG), Ghana
| | | | - Edmund Bedeley
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana (UG), Ghana
| | - Isaac Darko Otchere
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana (UG), Ghana
| | - Daniela Brites
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Chloé Loiseau
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Adwoa Asante-Poku
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana (UG), Ghana
| | - Diana Ahu Prah
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana (UG), Ghana
| | - Sonia Borrell
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Miriam Reinhard
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Michael Amo Omari
- Department of Chest Diseases, Korle-Bu Teaching Hospital, Korle-Bu, Accra, Ghana
| | - Audrey Forson
- Department of Chest Diseases, Korle-Bu Teaching Hospital, Korle-Bu, Accra, Ghana
| | - Kwadwo Ansah Koram
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana (UG), Ghana
| | - Sebastien Gagneux
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Dorothy Yeboah-Manu
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana (UG), Ghana; West African Centre for Cell Biology of Infectious Pathogens, UG, Ghana
| |
Collapse
|
16
|
Vega V, Rodríguez S, Van der Stuyft P, Seas C, Otero L. Recurrent TB: a systematic review and meta-analysis of the incidence rates and the proportions of relapses and reinfections. Thorax 2021; 76:494-502. [PMID: 33547088 DOI: 10.1136/thoraxjnl-2020-215449] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 12/07/2020] [Accepted: 12/09/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND A recurrent tuberculosis (TB) episode results from exogenous reinfection or relapse after cure. The use of genotyping allows the distinction between both. METHODS We did a systematic review and meta-analysis, using four databases to search for studies in English, French and Spanish published between 1 January 1980 and 30 September 2020 that assessed recurrences after TB treatment success and/or differentiated relapses from reinfections using genotyping. We calculated person years of follow-up and performed random-effects model meta-analysis for estimating pooled recurrent TB incidence rates and proportions of relapses and reinfections. We performed subgroup analyses by clinical-epidemiological factors and by methodological study characteristics. FINDINGS The pooled recurrent TB incidence rate was 2.26 per 100 person years at risk (95% CI 1.87 to 2.73; 145 studies). Heterogeneity was high (I2=98%). Stratified pooled recurrence rates increased from 1.47 (95% CI 0.87 to 2.46) to 4.10 (95% CI 2.67 to 6.28) per 100 person years for studies conducted in low versus high TB incidence settings. Background HIV prevalence, treatment drug regimen, sample size and duration of follow-up contributed too. The pooled proportion of relapses was 70% (95% CI 63% to 77%; I²=85%; 48 studies). Heterogeneity was determined by background TB incidence, as demonstrated by pooled proportions of 83% (95% CI 75% to 89%) versus 59% (95% CI 42% to 74%) relapse for studies from settings with low versus high TB incidence, respectively. INTERPRETATION The risk of recurrent TB is substantial and relapse is consistently the most frequent form of recurrence. Notwithstanding, with increasing background TB incidence the proportion of reinfections increases and the predominance of relapses among recurrences decreases. PROSPERO REGISTRATION NUMBER CRD42018077867.
Collapse
Affiliation(s)
- Victor Vega
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Sharon Rodríguez
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Patrick Van der Stuyft
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
| | - Carlos Seas
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Larissa Otero
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| |
Collapse
|
17
|
Gautam S, Shrestha N, Mahato S, Nguyen TPA, Mishra SR, Berg-Beckhoff G. Diabetes among tuberculosis patients and its impact on tuberculosis treatment in South Asia: a systematic review and meta-analysis. Sci Rep 2021; 11:2113. [PMID: 33483542 PMCID: PMC7822911 DOI: 10.1038/s41598-021-81057-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/18/2020] [Indexed: 01/30/2023] Open
Abstract
The escalating burden of diabetes is increasing the risk of contracting tuberculosis (TB) and has a pervasive impact on TB treatment outcomes. Therefore, we conducted this systematic review and meta-analysis to examine the burden of diabetes among TB patients and assess its impact on TB treatment in South Asia (Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, India, Pakistan, and Sri Lanka). PubMed, Excerpta Medica Database (EMBASE), and CINAHL databases were systematically searched for observational (cross-sectional, case-control and cohort) studies that reported prevalence of diabetes in TB patients and published between 1 January 1980 and 30 July 2020. A random-effect model for computing the pooled prevalence of diabetes and a fixed-effect model for assessing its impact on TB treatment were used. The review was registered with PROSPERO number CRD42020167896. Of the 3463 identified studies, a total of 74 studies (47 studies from India, 10 from Pakistan, four from Nepal and two from both Bangladesh and Sri-Lanka) were included in this systematic review: 65 studies for the prevalence of diabetes among TB patients and nine studies for the impact of diabetes on TB treatment outcomes. The pooled prevalence of diabetes in TB patients was 21% (95% CI 18.0, 23.0; I2 98.3%), varying from 11% in Bangladesh to 24% in Sri-Lanka. The prevalence was higher in studies having a sample size less than 300 (23%, 95% CI 18.0, 27.0), studies conducted in adults (21%, 95% CI 18.0, 23.0) and countries with high TB burden (21%, 95% CI 19.0, 24.0). Publication bias was detected based on the graphic asymmetry of the funnel plot and Egger's test (p < 0.001). Compared with non-diabetic TB patients, patients with TB and diabetes were associated with higher odds of mortality (Odds Ratio (OR) 1.7; 95% CI 1.2, 2.51; I2 19.4%) and treatment failure (OR 1.7; 95% CI 1.1, 2.4; I2 49.6%), but not associated with Multi-drug resistant TB (OR 1.0; 95% CI 0.6, 1.7; I2 40.7%). This study found a high burden of diabetes among TB patients in South Asia. Patients with TB-diabetes were at higher risk of treatment failure and mortality compared to TB alone. Screening for diabetes among TB patients along with planning and implementation of preventive and curative strategies for both TB and diabetes are urgently needed.
Collapse
Affiliation(s)
- Sanju Gautam
- Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | | | - Sweta Mahato
- Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | - Tuan P A Nguyen
- Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | | | | |
Collapse
|
18
|
Rakesh PS, Balakrishnan S, Mathew ME, Mrithunjayan S, Manu MS. Population Attributable Risk of Tuberculosis Vulnerabilities in Kerala, India. Indian J Community Med 2020; 45:367-370. [PMID: 33354021 PMCID: PMC7745824 DOI: 10.4103/ijcm.ijcm_336_19] [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] [Received: 08/13/2019] [Accepted: 06/15/2020] [Indexed: 11/04/2022] Open
Abstract
Background A robust disaggregated understanding of the determinants of tuberculosis (TB) in each local setting is essential for effective health system and policy action to control TB. Objectives The objective of the study was to identify population attributable risk (PAR) for TB disease based on the locally available evidences for Kerala, India. Methods Systematic review was done for risk factors of TB in the state. The second set of searches was done to understand the prevalence of the identified risk factors in general population in Kerala. With all available studies and reports, an expert group consensus was made to finalize state-specific prevalence of risk factors. Population attributable fractions were calculated for identified risk factors. Results PAR for TB disease in Kerala obtained was 24% for undernutrition, 15% for diabetes, 15% for tobacco use, and 1% for HIV. Conclusion Kerala state's PAR for TB was comparatively lower for HIV but higher for diabetes mellitus. Similar exercises for summarizing population risk factors need to happen at all states for making plans to effectively combat TB.
Collapse
Affiliation(s)
- P S Rakesh
- WHO RNTCP Technical Support Network, State TB Cell, Thiruvananthapuram, Kerala, India
| | - Shibu Balakrishnan
- WHO RNTCP Technical Support Network, State TB Cell, Thiruvananthapuram, Kerala, India
| | - Manu E Mathew
- WHO RNTCP Technical Support Network, State TB Cell, Thiruvananthapuram, Kerala, India
| | | | - M S Manu
- State TB Training and Demonstration Centre, Thiruvananthapuram, Kerala, India
| |
Collapse
|
19
|
Subbaraman R, Jhaveri T, Nathavitharana RR. Closing gaps in the tuberculosis care cascade: an action-oriented research agenda. J Clin Tuberc Other Mycobact Dis 2020; 19:100144. [PMID: 32072022 PMCID: PMC7015982 DOI: 10.1016/j.jctube.2020.100144] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The care cascade-which evaluates outcomes across stages of patient engagement in a health system-is an important framework for assessing quality of tuberculosis (TB) care. In recent years, there has been progress in measuring care cascades in high TB burden countries; however, there are still shortcomings in our knowledge of how to reduce poor patient outcomes. In this paper, we outline a research agenda for understanding why patients fall through the cracks in the care cascade. The pathway for evidence generation will require new systematic reviews, observational cohort studies, intervention development and testing, and continuous quality improvement initiatives embedded within national TB programs. Certain gaps, such as pretreatment loss to follow-up and post-treatment disease recurrence, should be a priority given a relative paucity of high-quality research to understand and address poor outcomes. Research on interventions to reduce death and loss to follow-up during treatment should move beyond a focus on monitoring (or observation) strategies, to address patient needs including psychosocial and nutritional support. While key research questions vary for each gap, some patient populations may experience disparities across multiple stages of care and should be a priority for research, including men, individuals with a prior treatment history, and individuals with drug-resistant TB. Closing gaps in the care cascade will require investments in a bold and innovative action-oriented research agenda.
Collapse
Affiliation(s)
- Ramnath Subbaraman
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, USA
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, USA
| | - Tulip Jhaveri
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, USA
| | - Ruvandhi R. Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| |
Collapse
|
20
|
Ramachandran G, Chandrasekaran P, Gaikwad S, Agibothu Kupparam HK, Thiruvengadam K, Gupte N, Paradkar M, Dhanasekaran K, Sivaramakrishnan GN, Kagal A, Thomas B, Pradhan N, Kadam D, Hanna LE, Balasubramanian U, Kulkarni V, Murali L, Golub J, Gupte A, Shivakumar SVBY, Swaminathan S, Dooley KE, Gupta A, Mave V. Subtherapeutic Rifampicin Concentration Is Associated With Unfavorable Tuberculosis Treatment Outcomes. Clin Infect Dis 2020; 70:1463-1470. [PMID: 31075166 PMCID: PMC7931830 DOI: 10.1093/cid/ciz380] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 05/09/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The relationships between first-line drug concentrations and clinically important outcomes among patients with tuberculosis (TB) remain poorly understood. METHODS We enrolled a prospective cohort of patients with new pulmonary TB receiving thrice-weekly treatment in India. The maximum plasma concentration of each drug was determined at months 1 and 5 using blood samples drawn 2 hours postdose. Subtherapeutic cutoffs were: rifampicin <8 µg/mL, isoniazid <3 µg/mL, and pyrazinamide <20 µg/mL. Factors associated with lower log-transformed drug concentrations, unfavorable outcomes (composite of treatment failure, all-cause mortality, and recurrence), and individual outcomes were examined using Poisson regression models. RESULTS Among 404 participants, rifampicin, isoniazid, and pyrazinamide concentrations were subtherapeutic in 85%, 29%, and 13%, respectively, at month 1 (with similar results for rifampicin and isoniazid at month 5). Rifampicin concentrations were lower with human immunodeficiency virus coinfection (median, 1.6 vs 4.6 µg/mL; P = .015). Unfavorable outcome was observed in 19%; a 1-μg/mL decrease in rifampicin concentration was independently associated with unfavorable outcome (adjusted incidence rate ratio [aIRR], 1.21 [95% confidence interval {CI}, 1.01-1.47]) and treatment failure (aIRR, 1.16 [95% CI, 1.05-1.28]). A 1-μg/mL decrease in pyrazinamide concentration was associated with recurrence (aIRR, 1.05 [95% CI, 1.01-1.11]). CONCLUSIONS Rifampicin concentrations were subtherapeutic in most Indian patients taking a thrice-weekly TB regimen, and low rifampicin and pyrazinamide concentrations were associated with poor outcomes. Higher or more frequent dosing is needed to improve TB treatment outcomes in India.
Collapse
Affiliation(s)
| | | | - Sanjay Gaikwad
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | | | | | - Nikhil Gupte
- Johns Hopkins School of Medicine, Baltimore, Maryland
- Byramjee Jeejeebhoy Government Medical College–Johns Hopkins University Clinical Research Site, Pune
| | - Mandar Paradkar
- Byramjee Jeejeebhoy Government Medical College–Johns Hopkins University Clinical Research Site, Pune
| | | | | | - Anju Kagal
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Beena Thomas
- National Institute for Research in Tuberculosis, Chennai
| | - Neeta Pradhan
- Byramjee Jeejeebhoy Government Medical College–Johns Hopkins University Clinical Research Site, Pune
| | - Dileep Kadam
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | | | - Usha Balasubramanian
- Byramjee Jeejeebhoy Government Medical College–Johns Hopkins University Clinical Research Site, Pune
| | - Vandana Kulkarni
- Byramjee Jeejeebhoy Government Medical College–Johns Hopkins University Clinical Research Site, Pune
| | | | - Jonathan Golub
- Johns Hopkins School of Medicine, Baltimore, Maryland
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Akshay Gupte
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | | | | | - Amita Gupta
- Johns Hopkins School of Medicine, Baltimore, Maryland
- Byramjee Jeejeebhoy Government Medical College–Johns Hopkins University Clinical Research Site, Pune
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Vidya Mave
- Johns Hopkins School of Medicine, Baltimore, Maryland
- Byramjee Jeejeebhoy Government Medical College–Johns Hopkins University Clinical Research Site, Pune
| |
Collapse
|
21
|
Daniels B, Kwan A, Satyanarayana S, Subbaraman R, Das RK, Das V, Das J, Pai M. Use of standardised patients to assess gender differences in quality of tuberculosis care in urban India: a two-city, cross-sectional study. Lancet Glob Health 2019; 7:e633-e643. [PMID: 30928341 PMCID: PMC6465957 DOI: 10.1016/s2214-109x(19)30031-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 01/09/2019] [Accepted: 01/11/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND In India, men are more likely than women to have active tuberculosis but are less likely to be diagnosed and notified to national tuberculosis programmes. We used data from standardised patient visits to assess whether these gender differences occur because of provider practice. METHODS We sent standardised patients (people recruited from local populations and trained to portray a scripted medical condition to health-care providers) to present four tuberculosis case scenarios to private health-care providers in the cities of Mumbai and Patna. Sampling and weighting allowed for city representative interpretation. Because standardised patients were assigned to providers by a field team blinded to this study, we did balance and placebo regression tests to confirm standardised patients were assigned by gender as good as randomly. Then, by use of linear and logistic regression, we assessed correct case management, our primary outcome, and other dimensions of care by standardised patient gender. FINDINGS Between Nov 21, 2014, and Aug 21, 2015, 2602 clinical interactions at 1203 private facilities were completed by 24 standardised patients (16 men, eight women). We found standardised patients were assigned to providers as good as randomly. We found no differences in correct management by patient gender (odds ratio 1·05; 95% CI 0·76-1·45; p=0·77) and no differences across gender within any case scenario, setting, provider gender, or provider qualification. INTERPRETATION Systematic differences in quality of care are unlikely to be a cause of the observed under-representation of men in tuberculosis notifications in the private sector in urban India. FUNDING Grand Challenges Canada, Bill & Melinda Gates Foundation, World Bank Knowledge for Change Program.
Collapse
Affiliation(s)
| | - Ada Kwan
- Development Research Group, The World Bank, Washington, DC, USA; University of California at Berkeley, Berkeley, CA, USA
| | - Srinath Satyanarayana
- Center for Operational Research, International Union Against TB and Lung Diseases, Paris, France
| | - Ramnath Subbaraman
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Ranendra K Das
- Institute for Socio-Economic Research on Development and Democracy, Delhi, India
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, MD, USA
| | - Jishnu Das
- Development Research Group, The World Bank, Washington, DC, USA; Center for Policy Research, New Delhi, India
| | - Madhukar Pai
- McGill International TB Centre and Department of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada; Manipal McGill Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, India.
| |
Collapse
|
22
|
Subbaraman R, Nathavitharana RR, Mayer KH, Satyanarayana S, Chadha VK, Arinaminpathy N, Pai M. Constructing care cascades for active tuberculosis: A strategy for program monitoring and identifying gaps in quality of care. PLoS Med 2019; 16:e1002754. [PMID: 30811385 PMCID: PMC6392267 DOI: 10.1371/journal.pmed.1002754] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The cascade of care is a model for evaluating patient retention across sequential stages of care required to achieve a successful treatment outcome. This approach was first used to evaluate HIV care and has since been applied to other diseases. The tuberculosis (TB) community has only recently started using care cascade analyses to quantify gaps in quality of care. In this article, we describe methods for estimating gaps (patient losses) and steps (patients retained) in the care cascade for active TB disease. We highlight approaches for overcoming challenges in constructing the TB care cascade, which include difficulties in estimating the population-level burden of disease and the diagnostic gap due to the limited sensitivity of TB diagnostic tests. We also describe potential uses of this model for evaluating the impact of interventions to improve case finding, diagnosis, linkage to care, retention in care, and post-treatment monitoring of TB patients.
Collapse
Affiliation(s)
- Ramnath Subbaraman
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, United States of America
| | - Ruvandhi R. Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kenneth H. Mayer
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
- The Fenway Institute, Boston, Massachusetts, United States of America
| | - Srinath Satyanarayana
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Vineet K. Chadha
- Central Leprosy Teaching and Research Institute, Chengalpattu, India
| | - Nimalan Arinaminpathy
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health and McGill International TB Centre, McGill University, Montreal, Canada
| |
Collapse
|
23
|
Horton KC, White RG, Houben RMGJ. Systematic neglect of men as a key population in tuberculosis. Tuberculosis (Edinb) 2018; 113:249-253. [PMID: 30287201 DOI: 10.1016/j.tube.2018.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/21/2018] [Accepted: 09/24/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Katherine C Horton
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom; Tuberculosis Modelling Group, Tuberculosis Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom.
| | - Richard G White
- Tuberculosis Modelling Group, Tuberculosis Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom; Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom.
| | - Rein M G J Houben
- Tuberculosis Modelling Group, Tuberculosis Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom; Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom.
| |
Collapse
|
24
|
Zong Z, Huo F, Shi J, Jing W, Ma Y, Liang Q, Jiang G, Dai G, Huang H, Pang Y. Relapse Versus Reinfection of Recurrent Tuberculosis Patients in a National Tuberculosis Specialized Hospital in Beijing, China. Front Microbiol 2018; 9:1858. [PMID: 30154770 PMCID: PMC6102324 DOI: 10.3389/fmicb.2018.01858] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 07/24/2018] [Indexed: 02/02/2023] Open
Abstract
Tuberculosis (TB) recurrence can result from either relapse of an original infection or exogenous reinfection with a new strain of Mycobacterium tuberculosis (MTB). The aim of this study was to assess the roles of relapse and reinfection among recurrent TB cases characterized by a high prevalence rate of drug-resistant TB within a hospital setting. After 58 paired recurrent TB cases were genotyped to distinguish relapse from reinfection, 37 (63.8%) were demonstrated to be relapse cases, while the remaining 21 were classified as reinfection cases. Statistical analysis revealed that male gender was a risk factor for TB reinfection, odds ratios and 95% confidence interval (OR [95% CI]: 4.188[1.012–17.392], P = 0.049). Of MTB isolates obtained from the 37 relapse cases, 11 exhibited conversion from susceptible to resistance to at least one antibiotic, with the most frequent emergence of drug resistance observed to be levofloxacin. For reinfection cases, reemergence of rifampicin-resistant isolates harboring double gene mutations, of codon 531 of rpoB and codon 306 of embB, were observed. In conclusion, our data demonstrate that relapse is a major mechanism leading to TB recurrence in Beijing Chest Hospital, a national hospital specialized in TB treatment. Moreover, male patients are at higher risk for reinfection. The extremely high rate of multidrug-resistant tuberculosis (MDR-TB) among reinfection cases reflects more successful transmission of MDR-TB strains versus non-resistant strains overall.
Collapse
Affiliation(s)
- Zhaojing Zong
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory of Drug Resistance Tuberculosis Research, Beijing Chest Hospital, Beijing Tuberculosis and Thoracic Tumor Research Institute, Capital Medical University, Beijing, China
| | - Fengmin Huo
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory of Drug Resistance Tuberculosis Research, Beijing Chest Hospital, Beijing Tuberculosis and Thoracic Tumor Research Institute, Capital Medical University, Beijing, China
| | - Jin Shi
- Beijing Pediatric Institute, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Wei Jing
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory of Drug Resistance Tuberculosis Research, Beijing Chest Hospital, Beijing Tuberculosis and Thoracic Tumor Research Institute, Capital Medical University, Beijing, China
| | - Yifeng Ma
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory of Drug Resistance Tuberculosis Research, Beijing Chest Hospital, Beijing Tuberculosis and Thoracic Tumor Research Institute, Capital Medical University, Beijing, China
| | - Qian Liang
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory of Drug Resistance Tuberculosis Research, Beijing Chest Hospital, Beijing Tuberculosis and Thoracic Tumor Research Institute, Capital Medical University, Beijing, China
| | - Guanglu Jiang
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory of Drug Resistance Tuberculosis Research, Beijing Chest Hospital, Beijing Tuberculosis and Thoracic Tumor Research Institute, Capital Medical University, Beijing, China
| | - Guangming Dai
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory of Drug Resistance Tuberculosis Research, Beijing Chest Hospital, Beijing Tuberculosis and Thoracic Tumor Research Institute, Capital Medical University, Beijing, China
| | - Hairong Huang
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory of Drug Resistance Tuberculosis Research, Beijing Chest Hospital, Beijing Tuberculosis and Thoracic Tumor Research Institute, Capital Medical University, Beijing, China
| | - Yu Pang
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory of Drug Resistance Tuberculosis Research, Beijing Chest Hospital, Beijing Tuberculosis and Thoracic Tumor Research Institute, Capital Medical University, Beijing, China
| |
Collapse
|