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Menzies NA, Swartwood NA, Cohen T, Marks SM, Maloney SA, Chappelle C, Miller JW, Beeler Asay GR, Date AA, Horsburgh CR, Salomon JA. The long-term effects of domestic and international tuberculosis service improvements on tuberculosis trends within the USA: a mathematical modelling study. Lancet Public Health 2024; 9:e573-e582. [PMID: 39095134 DOI: 10.1016/s2468-2667(24)00150-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 06/11/2024] [Accepted: 06/18/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND For settings with low tuberculosis incidence, disease elimination is a long-term goal. We investigated pathways to tuberculosis pre-elimination (incidence <1·0 cases per 100 000 people) and elimination (incidence <0·1 cases per 100 000 people) in the USA, where incidence was estimated at 2·9 per 100 000 people in 2023. METHODS Using a mathematical modelling framework, we simulated how US tuberculosis incidence could be affected by changes in tuberculosis services in the countries of origin for future migrants to the USA, as well as changes in tuberculosis services inside the USA. To do so, we used a linked set of transmission dynamic models, calibrated to demographic and epidemiological data for each setting. We constructed intervention scenarios representing improvements in tuberculosis services internationally and within the USA, individually and in combination, plus a base-case scenario representing continuation of current services. We simulated health and economic outcomes until 2100, using a Bayesian approach to quantify uncertainty in these outcomes. FINDINGS Under the base-case scenario, US tuberculosis incidence was projected to decline to 1·8 cases per 100 000 (95% uncertainty interval [UI] 1·5-2·1) in the total population by 2050. Intervention scenarios produced substantial reductions in tuberculosis incidence, with the combination of all domestic and international interventions projected to achieve pre-elimination by 2033 (95% UI 2031-2037). Compared with the base-case scenario, this combination of interventions could avert 101 000 tuberculosis cases (95% UI 84 000-120 000) and 13 300 tuberculosis deaths (95% UI 10 500-16 300) in the USA from 2025 to 2050. Tuberculosis elimination was not projected before 2100. INTERPRETATION Strengthening tuberculosis services domestically, promoting the development of more effective technologies and interventions, and supporting tuberculosis programmes in countries with a high tuberculosis burden are key strategies for accelerating progress towards tuberculosis elimination in the USA. FUNDING US Centers for Disease Control and Prevention.
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Affiliation(s)
- Nicolas A Menzies
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Center for Health Decision Science, Harvard T H Chan School of Public Health, Boston, MA, USA.
| | - Nicole A Swartwood
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Suzanne M Marks
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Susan A Maloney
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Courtney Chappelle
- Division of Global Migration Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jeffrey W Miller
- Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Garrett R Beeler Asay
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Anand A Date
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - C Robert Horsburgh
- Department of Epidemiology, Department of Biostatistics, and Department of Global Health, Boston University School of Public Health, Boston, MA, USA; Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Joshua A Salomon
- Department of Health Policy, Stanford University, Palo Alto, CA, USA
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Menzies NA, Shrestha S, Parriott A, Marks SM, Hill AN, Dowdy DW, Shete PB, Cohen T, Salomon JA. The Health and Economic Benefits of Tests That Predict Future Progression to Tuberculosis Disease. Epidemiology 2022; 33:75-83. [PMID: 34669631 PMCID: PMC8633045 DOI: 10.1097/ede.0000000000001418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Effective targeting of latent tuberculosis infection (LTBI) treatment requires identifying those most likely to progress to tuberculosis (TB). We estimated the potential health and economic benefits of diagnostics with improved discrimination for LTBI that will progress to TB. METHODS A base case scenario represented current LTBI testing and treatment services in the United States in 2020, with diagnosis via. interferon-gamma release assay (IGRA). Alternative scenarios represented tests with higher positive predictive value (PPV) for future TB but similar price to IGRA, and scenarios that additionally assumed higher treatment initiation and completion. We predicted outcomes using multiple transmission-dynamic models calibrated to different geographic areas and estimated costs from a societal perspective. RESULTS In 2020, 2.1% (range across model results: 1.1%-3.4%) of individuals with LTBI were predicted to develop TB in their remaining lifetime. For IGRA, we estimated the PPV for future TB as 1.3% (0.6%-1.8%). Relative to IGRA, we estimated a test with 10% PPV would reduce treatment volume by 87% (82%-94%), reduce incremental costs by 30% (15%-52%), and increase quality-adjusted life years by 3% (2%-6%). Cost reductions and health improvements were substantially larger for scenarios in which higher PPV for future TB was associated with greater initiation and completion of treatment. CONCLUSIONS We estimated that tests with better predictive performance would substantially reduce the number of individuals treated to prevent TB but would have a modest impact on incremental costs and health impact of TB prevention services, unless accompanied by greater treatment acceptance and completion.
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Affiliation(s)
| | - Sourya Shrestha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Andrea Parriott
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA
| | - Suzanne M Marks
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, GA
| | - Andrew N Hill
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, GA
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Priya B Shete
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT
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