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Brümmer LE, Thompson RR, Malhotra A, Shrestha S, Kendall EA, Andrews JR, Phillips P, Nahid P, Cattamanchi A, Marx FM, Denkinger CM, Dowdy DW. Cost-effectiveness of Low-complexity Screening Tests in Community-based Case-finding for Tuberculosis. Clin Infect Dis 2024; 78:154-163. [PMID: 37623745 PMCID: PMC10810711 DOI: 10.1093/cid/ciad501] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/18/2023] [Accepted: 08/22/2023] [Indexed: 08/26/2023] Open
Abstract
INTRODUCTION In high-burden settings, low-complexity screening tests for tuberculosis (TB) could expand the reach of community-based case-finding efforts. The potential costs and cost-effectiveness of approaches incorporating these tests are poorly understood. METHODS We developed a microsimulation model assessing 3 approaches to community-based case-finding in hypothetical populations (India-, South Africa-, The Philippines-, Uganda-, and Vietnam-like settings) with TB prevalence 4 times that of national estimates: (1) screening with a point-of-care C-reactive protein (CRP) test, (2) screening with a more sensitive "Hypothetical Screening test" (95% sensitive for Xpert Ultra-positive TB, 70% specificity; equipment/labor costs similar to Xpert Ultra, but using a $2 cartridge) followed by sputum Xpert Ultra if positive, or (3) testing all individuals with sputum Xpert Ultra. Costs are expressed in 2023 US dollars and include treatment costs. RESULTS Universal Xpert Ultra was estimated to cost a mean $4.0 million (95% uncertainty range: $3.5 to $4.6 million) and avert 3200 (2600 to 3900) TB-related disability-adjusted life years (DALYs) per 100 000 people screened ($670 [The Philippines] to $2000 [Vietnam] per DALY averted). CRP was projected to cost $550 (The Philippines) to $1500 (Vietnam) per DALY averted but with 44% fewer DALYs averted. The Hypothetical Screening test showed minimal benefit compared to universal Xpert Ultra, but if specificity were improved to 95% and per-test cost to $4.5 (all-inclusive), this strategy could cost $390 (The Philippines) to $940 (Vietnam) per DALY averted. CONCLUSIONS Screening tests can meaningfully improve the cost-effectiveness of community-based case-finding for TB but only if they are sensitive, specific, and inexpensive.
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Affiliation(s)
- Lukas E Brümmer
- Division of Infectious Disease and Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Infection Research (DZIF), partner site Heidelberg, Heidelberg University Hospital, Heidelberg, Germany
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ryan R Thompson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Akash Malhotra
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sourya Shrestha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Emily A Kendall
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, San Francisco, California, USA
| | - Patrick Phillips
- Center for Tuberculosis, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, California, USA
| | - Payam Nahid
- Center for Tuberculosis, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, California, USA
| | - Adithya Cattamanchi
- Center for Tuberculosis, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, California, USA
- Division of Pulmonary Diseases and Critical Care Medicine, University of California Irvine, Irvine, California, USA
| | - Florian M Marx
- Division of Infectious Disease and Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Infection Research (DZIF), partner site Heidelberg, Heidelberg University Hospital, Heidelberg, Germany
| | - Claudia M Denkinger
- Division of Infectious Disease and Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Infection Research (DZIF), partner site Heidelberg, Heidelberg University Hospital, Heidelberg, Germany
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Brumwell A, Tso J, Pingali V, Millones AK, Jimenez J, Calderon RI, Barreda N, Lecca L, Nicholson T, Brooks M. A costing framework to compare tuberculosis infection tests. BMJ Glob Health 2023; 8:e012297. [PMID: 38035732 PMCID: PMC10689396 DOI: 10.1136/bmjgh-2023-012297] [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: 03/14/2023] [Accepted: 10/07/2023] [Indexed: 12/02/2023] Open
Abstract
OBJECTIVE To develop a framework to estimate the practical costs incurred from, and programmatic impact related to, tuberculosis (TB) infection testing-tuberculin skin tests (TST) versus interferon gamma release assay (IGRA)-in a densely populated high-burden TB area. METHODS We developed a seven-step framework that can be tailored to individual TB programmes seeking to compare TB infection (TBI) diagnostics to inform decision-making. We present methodology to estimate (1) the prevalence of TBI, (2) true and false positives and negatives for each test, (3) the cost of test administration, (4) the cost of false negatives, (5) the cost of treating all that test positive, (6) the per-test cost incurred due to treatment and misdiagnosis and (7) the threshold at which laboratory infrastructure investments for IGRA are outweighed by system-wide savings incurred due to IGRA utilisation. We then applied this framework in a densely populated, peri-urban district in Lima, Peru with high rates of Bacillus Calmette-Guérin (BCG) vaccination. FINDINGS The lower sensitivity of TST compared with IGRA is a major cost driver, leading to health system and societal costs due to misdiagnosis. Additionally, patient and staff productivity costs were greater for TST because it requires two patient visits compared with only one for IGRA testing. When the framework was applied to the Lima setting, we estimate that IGRA-associated benefits outweigh infrastructural costs after performing 672 tests. CONCLUSIONS Given global shortages of TST and concerns about costs of IGRA testing and laboratory capacity building, this costing framework can provide public health officials and TB programmes guidance for decision-making about TBI testing locally. This framework was designed to be adaptable for use in different settings with available data. Diagnostics that increase accuracy or mitigate time to treatment should be thought of as an investment instead of an expenditure.
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Affiliation(s)
- Amanda Brumwell
- Advance Access & Delivery, Inc, Durham, North Carolina, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Jade Tso
- Advance Access & Delivery, Inc, Durham, North Carolina, USA
- School of Medicine, University of California Davis, Davis, California, USA
| | - Viswanath Pingali
- Economics, Indian Institute of Management Ahmedabad, Ahmedabad, Gujarat, India
| | | | | | - Roger I Calderon
- Socios En Salud Sucursal Peru, Lima, Peru
- Grupo de Investigación en Bioquímica y Biología Sintética, Universidad Nacional Federico Villarreal, San Miguel, Peru
| | | | - Leonid Lecca
- Socios En Salud Sucursal Peru, Lima, Peru
- Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Tom Nicholson
- Advance Access & Delivery, Inc, Durham, North Carolina, USA
- Center for International Development, Duke University Sanford School of Public Policy, Durham, North Carolina, USA
| | - Meredith Brooks
- Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
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Huang H, Qu R, Wu K, Xu J, Li J, Lu S, Sui G, Fan XY. Proteinase K-pretreated ConA-based ELISA assay: a novel urine LAM detection strategy for TB diagnosis. Front Microbiol 2023; 14:1236599. [PMID: 37692407 PMCID: PMC10485274 DOI: 10.3389/fmicb.2023.1236599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/07/2023] [Indexed: 09/12/2023] Open
Abstract
Objectives Lipoarabinomannan (LAM), an abundant cell wall glycolipid of mycobacteria including Mycobacterium tuberculosis (Mtb), is a promising TB diagnostic marker. The current commercially available urine LAM assays are not sufficiently sensitive, and more novel detection strategies are urgently needed to fill the current diagnostic gap. Methods A proteinase K-pretreated Concanavalin A (ConA)-based ELISA assay was developed. Diagnostic performance was assessed by several bacterial strains and clinical urine samples. Results The limit of detection (LoD) of the assay against ManLAM was 6 ng/ml. The assay reacted strongly to Mtb H37Rv and M. bovis BCG, intermediately to M. smegmatis mc2155, and weakly to four non-mycobacteria pathogens. This method could distinguish TB patients from healthy controls (HCs) and close contacts (CCs) in 71 urine samples treated with proteinase K, which increases urine LAM antibody reactiveness. In TB+HIV+ and TB+HIV- patients, the sensitivity was 43.8 and 37.5%, respectively, while the specificity was 100.0%. The areas under ROC curves (AUCs) were 0.74 and 0.82, respectively. Conclusion This study implies that ConA can be paired with antibodies to detect LAM. Proteinase K treatment could effectively enhance the sensitivity by restoring the reactiveness of antibodies to LAM.
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Affiliation(s)
- Huan Huang
- Shanghai Key Laboratory of Atmospheric Particle Pollution Prevention (LAP3), Department of Environmental Science and Engineering, Fudan University, Shanghai, China
- Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Rong Qu
- Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
- School of Laboratory Medicine and Life Science, Wenzhou Medical University, Wenzhou, China
| | - Kang Wu
- Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Jinchuan Xu
- Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Jianhui Li
- Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Shuihua Lu
- Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
- National Clinical Research Center for Infectious Disease, Shenzhen Third People's Hospital, Shenzhen, China
| | - Guodong Sui
- Shanghai Key Laboratory of Atmospheric Particle Pollution Prevention (LAP3), Department of Environmental Science and Engineering, Fudan University, Shanghai, China
- Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai, China
| | - Xiao-Yong Fan
- Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
- School of Laboratory Medicine and Life Science, Wenzhou Medical University, Wenzhou, China
- Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai, China
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Widoyo R, Djafri D, Putri ASE, Yani FF, Kusumawati RL, Wongsirichot T, Chongsuvivatwong V. Missing Cases of Bacteriologically Confirmed TB/DR-TB from the National Treatment Registers in West and North Sumatra Provinces, Indonesia. Trop Med Infect Dis 2023; 8:31. [PMID: 36668938 PMCID: PMC9861403 DOI: 10.3390/tropicalmed8010031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/15/2022] [Accepted: 12/30/2022] [Indexed: 01/04/2023] Open
Abstract
This study aimed to assess the percentage of confirmed drug-sensitive (DS) TB and drug-resistant (DR) TB patients who were missing in the national treatment registration in North Sumatra and West Sumatra, where treatment services for DR-TB in North Sumatra are relatively well established compared with West Sumatra, where the system recently started. Confirmed DS/DR-TB records in the laboratory register at 40 government health facilities in 2017 and 2018 were traced to determine whether they were in the treatment register databases. A Jaro-Winkler soundexed string distance analysis enhanced by socio-demographic information matching had sensitivity and specificity over 98% in identifying the same person in the same or different databases. The laboratory data contained 5885 newly diagnosed records of bacteriologically confirmed TB cases. Of the 5885 cases, 1424 of 5353 (26.6%) DS-TB cases and 133 of 532 (25.0%) DR-TB cases were missing in the treatment notification database. The odds of missing treatment for DS-TB was similar for both provinces (AOR = 1.0 (0.9, 1.2), but for DR-TB, North Sumatra had a significantly lower missing odds ratio (AOR = 0.4 (0.2, 0.7). The system must be improved to reduce this missing rate, especially for DR-TB in West Sumatra.
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Affiliation(s)
- Ratno Widoyo
- Epidemiology Unit, Faculty of Medicine, Prince Songkla University, Hat Yai 90110, Thailand
- Department of Epidemiology and Biostatistics, Faculty of Public Health, Universitas Andalas, Padang 25128, Indonesia
| | - Defriman Djafri
- Department of Epidemiology and Biostatistics, Faculty of Public Health, Universitas Andalas, Padang 25128, Indonesia
| | - Ade Suzana Eka Putri
- Department of Epidemiology and Biostatistics, Faculty of Public Health, Universitas Andalas, Padang 25128, Indonesia
| | - Finny Fitry Yani
- Department of Child Health, Faculty of Medicine, Universitas Andalas, Dr. M. Djamil General Hospital, Padang 25128, Indonesia
| | - R Lia Kusumawati
- Department of Microbiology, Faculty of Medicine, Universitas Sumatra Utara, H. Adam Malik Hospital, Medan 20136, Indonesia
| | - Thakerng Wongsirichot
- Division of Computational Science, Faculty of Science, Prince of Songkla University, Hat Yai 90110, Thailand
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