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Ammerman NC, Nuermberger EL, Owen A, Rannard SP, Meyers CF, Swindells S. Potential Impact of Long-Acting Products on the Control of Tuberculosis: Preclinical Advancements and Translational Tools in Preventive Treatment. Clin Infect Dis 2022; 75:S510-S516. [PMID: 36410384 PMCID: PMC10200320 DOI: 10.1093/cid/ciac672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A key component of global tuberculosis (TB) control is the treatment of latent TB infection. The use of long-acting technologies to administer TB preventive treatment has the potential to significantly improve the delivery and impact of this important public health intervention. For example, an ideal long-acting treatment could consist of a single dose that could be administered in the clinic (ie, a "1-shot cure" for latent TB). Interest in long-acting formulations for TB preventive therapy has gained considerable traction in recent years. This article presents an overview of the specific considerations and current preclinical advancements relevant for the development of long-acting technologies of TB drugs for treatment of latent infection, including attributes of target product profiles, suitability of drugs for long-acting formulations, ongoing research efforts, and translation to clinical studies.
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Affiliation(s)
- Nicole C Ammerman
- Department of Medical Microbiology and Infectious Diseases, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands
- Center for Tuberculosis Research, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eric L Nuermberger
- Center for Tuberculosis Research, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrew Owen
- Centre of Excellence for Long-acting Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - Steve P Rannard
- Centre of Excellence for Long-acting Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - Caren Freel Meyers
- Department of Pharmacology and Molecular Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Susan Swindells
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Nsengiyumva NP, Campbell JR, Oxlade O, Vesga JF, Lienhardt C, Trajman A, Falzon D, Den Boon S, Arinaminpathy N, Schwartzman K. Scaling up target regimens for tuberculosis preventive treatment in Brazil and South Africa: An analysis of costs and cost-effectiveness. PLoS Med 2022; 19:e1004032. [PMID: 35696431 PMCID: PMC9239450 DOI: 10.1371/journal.pmed.1004032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/28/2022] [Accepted: 05/26/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Shorter, safer, and cheaper tuberculosis (TB) preventive treatment (TPT) regimens will enhance uptake and effectiveness. WHO developed target product profiles describing minimum requirements and optimal targets for key attributes of novel TPT regimens. We performed a cost-effectiveness analysis addressing the scale-up of regimens meeting these criteria in Brazil, a setting with relatively low transmission and low HIV and rifampicin-resistant TB (RR-TB) prevalence, and South Africa, a setting with higher transmission and higher HIV and RR-TB prevalence. METHODS AND FINDINGS We used outputs from a model simulating scale-up of TPT regimens meeting minimal and optimal criteria. We assumed that drug costs for minimal and optimal regimens were identical to 6 months of daily isoniazid (6H). The minimal regimen lasted 3 months, with 70% completion and 80% efficacy; the optimal regimen lasted 1 month, with 90% completion and 100% efficacy. Target groups were people living with HIV (PLHIV) on antiretroviral treatment and household contacts (HHCs) of identified TB patients. The status quo was 6H at 2019 coverage levels for PLHIV and HHCs. We projected TB cases and deaths, TB-associated disability-adjusted life years (DALYs), and costs (in 2020 US dollars) associated with TB from a TB services perspective from 2020 to 2035, with 3% annual discounting. We estimated the expected costs and outcomes of scaling up 6H, the minimal TPT regimen, or the optimal TPT regimen to reach all eligible PLHIV and HHCs by 2023, compared to the status quo. Maintaining current 6H coverage in Brazil (0% of HHCs and 30% of PLHIV treated) would be associated with 1.1 (95% uncertainty range [UR] 1.1-1.2) million TB cases, 123,000 (115,000-132,000) deaths, and 2.5 (2.1-3.1) million DALYs and would cost $1.1 ($1.0-$1.3) billion during 2020-2035. Expanding the 6H, minimal, or optimal regimen to 100% coverage among eligible groups would reduce DALYs by 0.5% (95% UR 1.2% reduction, 0.4% increase), 2.5% (1.8%-3.0%), and 9.0% (6.5%-11.0%), respectively, with additional costs of $107 ($95-$117) million and $51 ($41-$60) million and savings of $36 ($14-$58) million, respectively. Compared to the status quo, costs per DALY averted were $7,608 and $808 for scaling up the 6H and minimal regimens, respectively, while the optimal regimen was dominant (cost savings, reduced DALYs). In South Africa, maintaining current 6H coverage (0% of HHCs and 69% of PLHIV treated) would be associated with 3.6 (95% UR 3.0-4.3) million TB cases, 843,000 (598,000-1,201,000) deaths, and 36.7 (19.5-58.0) million DALYs and would cost $2.5 ($1.8-$3.6) billion. Expanding coverage with the 6H, minimal, or optimal regimen would reduce DALYs by 6.9% (95% UR 4.3%-95%), 15.5% (11.8%-18.9%), and 38.0% (32.7%-43.0%), respectively, with additional costs of $79 (-$7, $151) million and $40 (-$52, $140) million and savings of $608 ($443-$832) million, respectively. Compared to the status quo, estimated costs per DALY averted were $31 and $7 for scaling up the 6H and minimal regimens, while the optimal regimen was dominant. Study limitations included the focus on 2 countries, and no explicit consideration of costs incurred before the decision to prescribe TPT. CONCLUSIONS Our findings suggest that scale-up of TPT regimens meeting minimum or optimal requirements would likely have important impacts on TB-associated outcomes and would likely be cost-effective or cost saving.
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Affiliation(s)
- Ntwali Placide Nsengiyumva
- McGill International Tuberculosis Centre, McGill University, Montreal, Quebec, Canada
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Jonathon R. Campbell
- McGill International Tuberculosis Centre, McGill University, Montreal, Quebec, Canada
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Olivia Oxlade
- McGill International Tuberculosis Centre, McGill University, Montreal, Quebec, Canada
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Juan F. Vesga
- Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, London, United Kingdom
| | | | - Anete Trajman
- McGill International Tuberculosis Centre, McGill University, Montreal, Quebec, Canada
- Programa de Pós-graduação em Clínica Médica, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Dennis Falzon
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Saskia Den Boon
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Nimalan Arinaminpathy
- Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Kevin Schwartzman
- McGill International Tuberculosis Centre, McGill University, Montreal, Quebec, Canada
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Respiratory Division, Department of Medicine, McGill University, Montreal, Quebec, Canada
- * E-mail:
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Vesga JF, Lienhardt C, Nsengiyumva P, Campbell JR, Oxlade O, den Boon S, Falzon D, Schwartzman K, Churchyard G, Arinaminpathy N. Prioritising attributes for tuberculosis preventive treatment regimens: a modelling analysis. BMC Med 2022; 20:182. [PMID: 35581650 PMCID: PMC9115962 DOI: 10.1186/s12916-022-02378-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/19/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Recent years have seen important improvements in available preventive treatment regimens for tuberculosis (TB), and research is ongoing to develop these further. To assist with the formulation of target product profiles for future regimens, we examined which regimen properties would be most influential in the epidemiological impact of preventive treatment. METHODS Following expert consultation, we identified 5 regimen properties relevant to the incidence-reducing impact of a future preventive treatment regimen: regimen duration, efficacy, ease-of-adherence (treatment completion rates in programmatic conditions), forgiveness to non-completion and the barrier to developing rifampicin resistance during treatment. For each regimen property, we elicited expert input for minimally acceptable and optimal (ideal-but-feasible) performance scenarios for future regimens. Using mathematical modelling, we then examined how each regimen property would influence the TB incidence reduction arising from full uptake of future regimens according to current WHO guidelines, in four countries: South Africa, Kenya, India and Brazil. RESULTS Of all regimen properties, efficacy is the single most important predictor of epidemiological impact, while ease-of-adherence plays an important secondary role. These results are qualitatively consistent across country settings; sensitivity analyses show that these results are also qualitatively robust to a range of model assumptions, including the mechanism of action of future preventive regimens. CONCLUSIONS As preventive treatment regimens against TB continue to improve, understanding the key drivers of epidemiological impact can assist in guiding further development. By meeting these key targets, future preventive treatment regimens could play a critical role in global efforts to end TB.
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Affiliation(s)
- Juan F Vesga
- Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, London, UK.
| | | | - Placide Nsengiyumva
- McGill International Tuberculosis Centre, McGill University, Montreal, Canada
| | - Jonathon R Campbell
- McGill International Tuberculosis Centre, McGill University, Montreal, Canada
| | - Olivia Oxlade
- McGill International Tuberculosis Centre, McGill University, Montreal, Canada
| | - Saskia den Boon
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Dennis Falzon
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Kevin Schwartzman
- McGill International Tuberculosis Centre, McGill University, Montreal, Canada
| | - Gavin Churchyard
- The Aurum Institute, Parktown, South Africa.,School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Nimalan Arinaminpathy
- Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, London, UK
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