1
|
Aguilar Ticona JP, Xiao M, Li D, Nery JN, Hitchings M, Andrade Belitardo EMM, Fofana MO, Victoriano R, Cruz JS, de Moraes L, Strobel IM, Silva JJ, Sena do Aragão Filho A, Ribeiro GS, Reis MG, Costa F, Khouri R, Ko AI, Cummings DAT. Corrigendum to "Extensive transmission of SARS-CoV-2 BQ.1* variant in a population with high levels of hybrid immunity: A prevalence survey" [International Journal of Infectious Diseases 139 (2024) 159-167]. Int J Infect Dis 2024; 141:106964. [PMID: 38452689 PMCID: PMC10927614 DOI: 10.1016/j.ijid.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Affiliation(s)
- Juan P Aguilar Ticona
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brazil; Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, United States.
| | - Meng Xiao
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, United States; Department of Laboratory Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dan Li
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, United States; Public Health Emergency Center, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Jr Nivison Nery
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brazil; Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, United States
| | - Matt Hitchings
- Department of Biostatistics, University of Florida, Gainesville, United States; Emerging Pathogens Institute, University of Florida, Gainesville, United States
| | | | - Mariam O Fofana
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, United States
| | - Renato Victoriano
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil
| | - Jaqueline S Cruz
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil
| | - Laise de Moraes
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil
| | - Icaro Morais Strobel
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil
| | - Jessica Jesus Silva
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil
| | | | - Guilherme S Ribeiro
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil; Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Brazil
| | - Mitermayer G Reis
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, United States; Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Brazil
| | - Federico Costa
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brazil; Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, United States
| | - Ricardo Khouri
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil
| | - Albert I Ko
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, United States
| | - Derek A T Cummings
- Department of Biology, University of Florida, Gainesville, United States; Emerging Pathogens Institute, University of Florida, Gainesville, United States
| |
Collapse
|
2
|
Aguilar Ticona JP, Nery N, Hitchings M, Belitardo EMMA, Fofana MO, Dorión M, Victoriano R, Cruz JS, Oliveira Santana J, de Moraes LEP, Cardoso CW, Ribeiro GS, Reis MG, Khouri R, Costa F, Ko AI, Cummings DAT. Overestimation of Severe Acute Respiratory Syndrome Coronavirus 2 Household Transmission in Settings of High Community Transmission: Insights From an Informal Settlement Community in Salvador, Brazil. Open Forum Infect Dis 2024; 11:ofae065. [PMID: 38516384 PMCID: PMC10957159 DOI: 10.1093/ofid/ofae065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/31/2024] [Indexed: 03/23/2024] Open
Abstract
Background The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron variant has spread globally. However, the contribution of community versus household transmission to the overall risk of infection remains unclear. Methods Between November 2021 and March 2022, we conducted an active case-finding study in an urban informal settlement with biweekly visits across 1174 households with 3364 residents. Individuals displaying coronavirus disease 2019 (COVID-19)-related symptoms were identified, interviewed along with household contacts, and defined as index and secondary cases based on reverse-transcription polymerase chain reaction (RT-PCR) and symptom onset. Results In 61 households, we detected a total of 94 RT-PCR-positive cases. Of 69 sequenced samples, 67 cases (97.1%) were attributed to the Omicron BA.1* variant. Among 35 of their households, the secondary attack rate was 50.0% (95% confidence interval [CI], 37.0%-63.0%). Women (relative risk [RR], 1.6 [95% CI, .9-2.7]), older individuals (median difference, 15 [95% CI, 2-21] years), and those reporting symptoms (RR, 1.73 [95% CI, 1.0-3.0]) had a significantly increased risk for SARS-CoV-2 secondary infection. Genomic analysis revealed substantial acquisition of viruses from the community even among households with other SARS-CoV-2 infections. After excluding community acquisition, we estimated a household secondary attack rate of 24.2% (95% CI, 11.9%-40.9%). Conclusions These findings underscore the ongoing risk of community acquisition of SARS-CoV-2 among households with current infections. The observed high attack rate necessitates swift booster vaccination, rapid testing availability, and therapeutic options to mitigate the severe outcomes of COVID-19.
Collapse
Affiliation(s)
- Juan P Aguilar Ticona
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Bahia, Brazil
- Fundação Oswaldo Cruz, Instituto Gonçalo Moniz, Ministério da Saúde, Salvador, Bahia, Brazil
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Nivison Nery
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Bahia, Brazil
- Fundação Oswaldo Cruz, Instituto Gonçalo Moniz, Ministério da Saúde, Salvador, Bahia, Brazil
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Matt Hitchings
- Department of Biostatistics, University of Florida, Gainesville, Florida, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
| | | | - Mariam O Fofana
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Murilo Dorión
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Renato Victoriano
- Fundação Oswaldo Cruz, Instituto Gonçalo Moniz, Ministério da Saúde, Salvador, Bahia, Brazil
| | - Jaqueline S Cruz
- Fundação Oswaldo Cruz, Instituto Gonçalo Moniz, Ministério da Saúde, Salvador, Bahia, Brazil
| | - Juliet Oliveira Santana
- Fundação Oswaldo Cruz, Instituto Gonçalo Moniz, Ministério da Saúde, Salvador, Bahia, Brazil
| | | | - Cristiane W Cardoso
- Fundação Oswaldo Cruz, Instituto Gonçalo Moniz, Ministério da Saúde, Salvador, Bahia, Brazil
- Centro de Informações Estratégicas de Vigilância em Saúde (CIEVS), Secretaria Municipal de Saúde de Salvador, Salvador, Brazil
| | - Guilherme S Ribeiro
- Fundação Oswaldo Cruz, Instituto Gonçalo Moniz, Ministério da Saúde, Salvador, Bahia, Brazil
- Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Bahia, Brazil
| | - Mitermayer G Reis
- Fundação Oswaldo Cruz, Instituto Gonçalo Moniz, Ministério da Saúde, Salvador, Bahia, Brazil
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
- Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Bahia, Brazil
| | - Ricardo Khouri
- Fundação Oswaldo Cruz, Instituto Gonçalo Moniz, Ministério da Saúde, Salvador, Bahia, Brazil
| | - Federico Costa
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Bahia, Brazil
- Fundação Oswaldo Cruz, Instituto Gonçalo Moniz, Ministério da Saúde, Salvador, Bahia, Brazil
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Albert I Ko
- Fundação Oswaldo Cruz, Instituto Gonçalo Moniz, Ministério da Saúde, Salvador, Bahia, Brazil
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Derek A T Cummings
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
- Department of Biology, University of Florida, Gainesville, Florida, USA
| |
Collapse
|
3
|
Aguilar Ticona JP, Xiao M, Li D, Nery N, Hitchings M, Belitardo EMMA, Fofana MO, Victoriano R, Cruz JS, de Moraes L, Strobel IM, Silva JJ, Sena do Aragão Filho A, Ribeiro GS, Reis MG, Costa F, Khouri R, Ko AI, Cummings DAT. Extensive transmission of SARS-CoV-2 BQ.1* variant in a population with high levels of hybrid immunity: A prevalence survey. Int J Infect Dis 2024; 139:159-167. [PMID: 38070701 PMCID: PMC10784150 DOI: 10.1016/j.ijid.2023.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 01/01/2024] Open
Abstract
OBJECTIVES The SARS-CoV-2 BQ.1* variant rapidly spread globally in late 2022, posing a challenge due to its increased immune evasion. METHODS We conducted a prevalence survey in Brazil from November 16 to December 22, 2022, as part of a cohort study. We conducted interviews and collected nasal samples for reverse transcription-polymerase chain reaction (RT-PCR) testing and whole-genome sequencing. Cumulative incidence was estimated using RT-PCR positivity, cycle threshold values, and external data on the dynamics of RT-PCR positivity following infection. RESULTS Among 535 participants, 54% had documented SARS-CoV-2 exposure before this outbreak and 74% had received COVID-19 vaccination. In this study, 14.8% tested positive for SARS-CoV-2, with BQ.1* identified in 90.7% of cases. Using case data and cycle threshold values, cumulative incidence was estimated at 56% (95% confidence interval, 36-88%). Of the 79 positive participants, 48.1% had a symptomatic illness, with a lower proportion fulfilling the World Health Organization COVID-19 case definition compared to prior Omicron waves. No participants required medical attention. CONCLUSIONS Despite high population-level hybrid immunity, the BQ.1* variant attacked 56% of our population. Lower disease severity was associated with BQ.1* compared to prior Omicron variants. Hybrid immunity may provide protection against future SARS-CoV-2 variants but in this case was not able to prevent widespread transmission.
Collapse
Affiliation(s)
- Juan P Aguilar Ticona
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brazil; Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, United States.
| | - Meng Xiao
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, United States; Department of Laboratory Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dan Li
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, United States; Public Health Emergency Center, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Nivison Nery
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brazil; Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, United States
| | - Matt Hitchings
- Department of Biostatistics, University of Florida, Gainesville, United States; Emerging Pathogens Institute, University of Florida, Gainesville, United States
| | | | - Mariam O Fofana
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, United States
| | - Renato Victoriano
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil
| | - Jaqueline S Cruz
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil
| | - Laise de Moraes
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil
| | - Icaro Morais Strobel
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil
| | - Jessica Jesus Silva
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil
| | | | - Guilherme S Ribeiro
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil; Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Brazil
| | - Mitermayer G Reis
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, United States; Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Brazil
| | - Federico Costa
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brazil; Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, United States
| | - Ricardo Khouri
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil
| | - Albert I Ko
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, United States
| | - Derek A T Cummings
- Department of Biology, University of Florida, Gainesville, United States; Emerging Pathogens Institute, University of Florida, Gainesville, United States
| |
Collapse
|
4
|
Lind ML, Robertson AJ, Silva J, Warner F, Coppi AC, Price N, Duckwall C, Sosensky P, Di Giuseppe EC, Borg R, Fofana MO, Ranzani OT, Dean NE, Andrews JR, Croda J, Iwasaki A, Cummings DAT, Ko AI, Hitchings MDT, Schulz WL. Association between primary or booster COVID-19 mRNA vaccination and Omicron lineage BA.1 SARS-CoV-2 infection in people with a prior SARS-CoV-2 infection: A test-negative case-control analysis. PLoS Med 2022; 19:e1004136. [PMID: 36454733 PMCID: PMC9714718 DOI: 10.1371/journal.pmed.1004136] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 10/26/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The benefit of primary and booster vaccination in people who experienced a prior Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection remains unclear. The objective of this study was to estimate the effectiveness of primary (two-dose series) and booster (third dose) mRNA vaccination against Omicron (lineage BA.1) infection among people with a prior documented infection. METHODS AND FINDINGS We conducted a test-negative case-control study of reverse transcription PCRs (RT-PCRs) analyzed with the TaqPath (Thermo Fisher Scientific) assay and recorded in the Yale New Haven Health system from November 1, 2021, to April 30, 2022. Overall, 11,307 cases (positive TaqPath analyzed RT-PCRs with S-gene target failure [SGTF]) and 130,041 controls (negative TaqPath analyzed RT-PCRs) were included (median age: cases: 35 years, controls: 39 years). Among cases and controls, 5.9% and 8.1% had a documented prior infection (positive SARS-CoV-2 test record ≥90 days prior to the included test), respectively. We estimated the effectiveness of primary and booster vaccination relative to SGTF-defined Omicron (lineage BA.1) variant infection using a logistic regression adjusted for date of test, age, sex, race/ethnicity, insurance, comorbidities, social venerability index, municipality, and healthcare utilization. The effectiveness of primary vaccination 14 to 149 days after the second dose was 41.0% (95% confidence interval (CI): 14.1% to 59.4%, p 0.006) and 27.1% (95% CI: 18.7% to 34.6%, p < 0.001) for people with and without a documented prior infection, respectively. The effectiveness of booster vaccination (≥14 days after booster dose) was 47.1% (95% CI: 22.4% to 63.9%, p 0.001) and 54.1% (95% CI: 49.2% to 58.4%, p < 0.001) in people with and without a documented prior infection, respectively. To test whether booster vaccination reduced the risk of infection beyond that of the primary series, we compared the odds of infection among boosted (≥14 days after booster dose) and booster-eligible people (≥150 days after second dose). The odds ratio (OR) comparing boosted and booster-eligible people with a documented prior infection was 0.79 (95% CI: 0.54 to 1.16, p 0.222), whereas the OR comparing boosted and booster-eligible people without a documented prior infection was 0.54 (95% CI: 0.49 to 0.59, p < 0.001). This study's limitations include the risk of residual confounding, the use of data from a single system, and the reliance on TaqPath analyzed RT-PCR results. CONCLUSIONS In this study, we observed that primary vaccination provided significant but limited protection against Omicron (lineage BA.1) infection among people with and without a documented prior infection. While booster vaccination was associated with additional protection against Omicron BA.1 infection in people without a documented prior infection, it was not found to be associated with additional protection among people with a documented prior infection. These findings support primary vaccination in people regardless of documented prior infection status but suggest that infection history may impact the relative benefit of booster doses.
Collapse
Affiliation(s)
- Margaret L. Lind
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Alexander J. Robertson
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Julio Silva
- Department of Immunobiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Frederick Warner
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, United States of America
| | - Andreas C. Coppi
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, United States of America
| | - Nathan Price
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, United States of America
| | - Chelsea Duckwall
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Peri Sosensky
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Erendira C. Di Giuseppe
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Ryan Borg
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Mariam O. Fofana
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Otavio T. Ranzani
- Barcelona Institute for Global Health, ISGlobal, Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Pulmonary Division, Heart Institute, Hospital das Clínicas, Faculdade de Medicina, São Paulo, Brazil
| | - Natalie E. Dean
- Department of Biostatistics & Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Jason R. Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, California, United States of America
| | - Julio Croda
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
- Fiocruz Mato Grosso do Sul, Fundação Oswaldo Cruz, Campo Grande, Brazil
- Universidade Federal de Mato Grosso do Sul, Campo Grande, Brazil
| | - Akiko Iwasaki
- Department of Immunobiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
- Howard Hughes Medical Institute, Chevy Chase, Maryland, United States of America
| | - Derek A. T. Cummings
- Department of Biology, University of Florida, Gainesville, Florida, United States of America
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, United States of America
| | - Albert I. Ko
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
| | - Matt D. T. Hitchings
- Department of Biostatistics, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Wade L. Schulz
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America
| |
Collapse
|
5
|
Andrade Belitardo EMM, Nery N, Aguilar Ticona JP, Portilho MM, Mello IO, Ribeiro GS, Reis MG, Costa F, Cummings DAT, Ko AI, Fofana MO. Reliable estimation of SARS-CoV-2 anti-spike protein IgG titers from single dilution optical density values in serologic surveys. Diagn Microbiol Infect Dis 2022; 104:115807. [PMID: 36162285 PMCID: PMC9428330 DOI: 10.1016/j.diagmicrobio.2022.115807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 07/25/2022] [Accepted: 08/28/2022] [Indexed: 11/28/2022]
Abstract
Reliable and scalable seroepidemiology methods are needed to estimate SARS-CoV-2 incidence and monitor the dynamics of population-level immunity as the pandemic evolves. We aimed to evaluate the reliability of SARS-CoV-2 normalized ELISA optical density (nOD) at a single dilution compared to titers derived from serial dilutions. We conducted serial serosurveys within a community-based cohort in Salvador, Brazil. Anti-S IgG ELISA (Euroimmun AG) was performed with 5 serial 3-fold dilutions of paired sera from 54 participants. Changes in nOD reliably predicted increases and decreases in titers (98.1% agreement, κ = 95.8%). Fitting the relationship between nOD and interpolated titers to a log-log curve yields highly accurate predictions of titers (r2 = 0.995) and changes in titers (r2 = 0.975), using only 1 to 2 dilutions. This approach can significantly reduce the time, labor and resources needed for large-scale serosurveys to ascertain population-level changes in exposure and immunity.
Collapse
Affiliation(s)
| | - Nivison Nery
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil
| | | | | | - Iago O Mello
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil
| | - Guilherme S Ribeiro
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil; Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Bahia, Brazil
| | - Mitermayer G Reis
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil; Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Bahia, Brazil; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Federico Costa
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil; Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Bahia, Brazil; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Derek A T Cummings
- Department of Biology, University of Florida, Gainesville, FL, USA; Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Albert I Ko
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Mariam O Fofana
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA.
| |
Collapse
|
6
|
Abstract
The recently reported cases of coerced sterilisation of women at a privately operated immigration detention facility in the USA are egregious in their disregard for human dignity and professional ethics, but sadly not surprising. These abuses represent a continuation of efforts to control the reproductive capacity of women, fueled by racist and xenophobic motives. Physicians helped create and legitimise the pseudoscientific framework for the eugenics movement, which would implement forceful sterilisation as its tool of choice to eliminate undesirable traits that were thought to be biologically inherited and predominant among racial and ethnic minorities. Although state-endorsed forcible sterilisation programs have ended, incarcerated women have remained particularly vulnerable to sterilisation abuse. The intersectional vulnerabilities of racism, xenophobia and carcerality must be addressed to prevent such abuses from recurring.
Collapse
Affiliation(s)
- Mariam O Fofana
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| |
Collapse
|
7
|
Fofana MO, Nery N, Aguilar Ticona JP, de Andrade Belitardo EMM, Victoriano R, Anjos RO, Portilho MM, de Santana MC, dos Santos LL, de Oliveira D, Cruz JS, Muenker MC, Khouri R, Wunder EA, Hitchings MDT, Johnson O, Reis MG, Ribeiro GS, Cummings DAT, Costa F, Ko AI. Structural factors associated with SARS-CoV-2 infection risk in an urban slum setting in Salvador, Brazil: A cross-sectional survey. PLoS Med 2022; 19:e1004093. [PMID: 36074784 PMCID: PMC9499230 DOI: 10.1371/journal.pmed.1004093] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 09/22/2022] [Accepted: 08/17/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The structural environment of urban slums, including physical, demographic, and socioeconomic attributes, renders inhabitants more vulnerable to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection. Yet, little is known about the specific determinants that contribute to high transmission within these communities. We therefore aimed to investigate SARS-CoV-2 seroprevalence in an urban slum in Brazil. METHODS AND FINDINGS We performed a cross-sectional serosurvey of an established cohort of 2,041 urban slum residents from the city of Salvador, Brazil between November 2020 and February 2021, following the first Coronavirus Disease 2019 (COVID-19) pandemic wave in the country and during the onset of the second wave. The median age in this population was 29 years (interquartile range [IQR] 16 to 44); most participants reported their ethnicity as Black (51.5%) or Brown (41.7%), and 58.5% were female. The median size of participating households was 3 (IQR 2 to 4), with a median daily per capita income of 2.32 (IQR 0.33-5.15) US Dollars. The main outcome measure was presence of IgG against the SARS-CoV-2 spike protein. We implemented multilevel models with random intercepts for each household to estimate seroprevalence and associated risk factors, adjusting for the sensitivity and specificity of the assay, and the age and gender distribution of our study population. We identified high seroprevalence (47.9%, 95% confidence interval [CI] 44.2% to 52.1%), particularly among female residents (50.3% [95% CI 46.3% to 54.8%] versus 44.6% [95% CI 40.1% to 49.4%] among male residents, p < 0.01) and among children (54.4% [95% CI 49.6% to 59.3%] versus 45.4% [95% CI 41.5% to 49.7%] among adults, p < 0.01). Adults residing in households with children were more likely to be seropositive (48.6% [95% CI 44.8% to 52.3%] versus 40.7% [95% CI 37.2% to 44.3%], p < 0.01). Women who were unemployed and living below the poverty threshold (daily per capita household income <$1.25) were more likely to be seropositive compared to men with the same employment and income status (53.9% [95% CI 47.0% to 60.6%] versus 32.9% [95% CI 23.2% to 44.3%], p < 0.01). Participation in the study was voluntary, which may limit the generalizability of our findings. CONCLUSIONS Prior to the peak of the second wave of the COVID-19 pandemic, cumulative incidence as assessed by serology approached 50% in a Brazilian urban slum population. In contrast to observations from industrialized countries, SARS-CoV-2 incidence was highest among children, as well as women living in extreme poverty. These findings emphasize the need for targeted interventions that provide safe environments for children and mitigate the structural risks posed by crowding and poverty for the most vulnerable residents of urban slum communities.
Collapse
Affiliation(s)
- Mariam O. Fofana
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
- * E-mail: (MOF); (AIK)
| | - Nivison Nery
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Bahia, Brazil
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil
| | - Juan P. Aguilar Ticona
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Bahia, Brazil
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil
| | | | - Renato Victoriano
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil
| | | | - Moyra M. Portilho
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil
| | | | | | | | - Jaqueline S. Cruz
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil
| | | | - Ricardo Khouri
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil
| | - Elsio A. Wunder
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil
| | - Matt D. T. Hitchings
- Department of Biostatistics, University of Florida, Gainesville, Florida, United States of America
| | - Olatunji Johnson
- Department of Mathematics, University of Manchester, Manchester, United Kingdom
| | - Mitermayer G. Reis
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil
- Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Bahia, Brazil
| | - Guilherme S. Ribeiro
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil
- Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Bahia, Brazil
| | - Derek A. T. Cummings
- Department of Biology, University of Florida, Gainesville, Florida, United States of America
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, United States of America
| | - Federico Costa
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Bahia, Brazil
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil
| | - Albert I. Ko
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil
- * E-mail: (MOF); (AIK)
| |
Collapse
|
8
|
Fofana MO, Nery N, Aguilar Ticona JP, Belitardo EM, Victoriano R, Anjos RO, Portilho MM, de Santana MC, dos Santos LL, de Oliveira D, Cruz JS, Muencker MC, Khouri R, Wunder EA, Hitchings MD, Johnson O, Reis MG, Ribeiro GS, Cummings DA, Costa F, Ko AI. Structural factors contributing to SARS-CoV-2 infection risk in the urban slum setting.. [PMID: 35194620 PMCID: PMC8863166 DOI: 10.1101/2022.02.13.22270856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background The structural environment of urban slums, including physical, demographic and socioeconomic attributes, renders inhabitants more vulnerable to SARS-CoV-2 infection. Yet, little is known about the specific determinants that contribute to high transmission within these communities. Methods and findings We performed a serosurvey of an established cohort of 2,035 urban slum residents from the city of Salvador, Brazil between November 2020 and February 2021, following the first COVID-19 pandemic wave in the country. We identified high SARS-CoV-2 seroprevalence (46.4%, 95% confidence interval [CI] 44.3–48.6%), particularly among female residents (48.7% [95% CI 45.9–51.6%] vs. 43.2% [95% CI 39.8–46.6%] among male residents), and among children (56.5% [95% CI 52.3–60.5%] vs. 42.4% [95% CI 39.9–45.0%] among adults). In multivariable models that accounted for household-level clustering, the odds ratio for SARS-CoV-2 seropositivity among children was 1.96 (95% CI 1.42–2.72) compared to adults aged 30–44 years. Adults residing in households with children were more likely to be seropositive; this effect was particularly prominent among individuals with age 30–44 and 60 years or more. Women living below the poverty threshold (daily per capita household income <$1.25) and those who were unemployed were more likely to be seropositive. Conclusions During a single wave of the COVID-19 pandemic, cumulative incidence as assessed by serology approached 50% in a Brazilian urban slum population. In contrast to observations from industrialized countries, SARS-CoV-2 incidence was highest among children, as well as women living in extreme poverty. These findings emphasize the need for targeted interventions that provide safe environments for children and mitigate the structural risks posed by crowding and poverty for the most vulnerable residents of urban slum communities.
Collapse
|
9
|
Affiliation(s)
- Mariam O Fofana
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
| |
Collapse
|
10
|
Abstract
The persistent influence of coloniality both from external actors and from within threatens the response to COVID-19 in Africa. This essay presents historical context for the colonial inheritance of modern global health and analyses two controversies related to COVID-19 that illustrate facets of coloniality: comments made by French researchers regarding the testing of BCG vaccine in Africa, and the claims by Madagascar's president Andry Rajoelina that the country had developed an effective traditional remedy named Covid-Organics. Leveraging both historical sources and contemporary documentary sources, I demonstrate how the currents of exploitation, marginalisation, pathologisation and saviourism rooted in coloniality are manifested via these events. I also discuss responses to coloniality, focussing on the misuse and co-optation of pan-Africanist rhetoric. In particular, I argue that the scandal surrounding Covid-Organics is a reflection of endogenised coloniality, whereby local elites entrench and benefit from inequitable power structures at the intersubjective (rather than trans-national) scale. I conclude with a reflection on the need for equity as a guiding principle to dismantle global health colonialism.
Collapse
Affiliation(s)
- Mariam O Fofana
- Harvard-Affiliated Emergency Medicine Residency (HAEMR), Boston, MA, USA
| |
Collapse
|
11
|
Kendall EA, Fofana MO, Dowdy DW. Burden of transmitted multidrug resistance in epidemics of tuberculosis: a transmission modelling analysis. Lancet Respir Med 2015; 3:963-72. [PMID: 26597127 PMCID: PMC4684734 DOI: 10.1016/s2213-2600(15)00458-0] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 10/22/2015] [Accepted: 10/25/2015] [Indexed: 11/26/2022]
Abstract
Background Multidrug-resistant tuberculosis (MDR-TB) can be acquired through de novo mutation during TB treatment or through transmission from other individuals with active MDR-TB. Understanding the balance between these two mechanisms is essential when allocating resources for MDR-TB. Methods We constructed a dynamic transmission model of an MDR-TB epidemic, allowing for both treatment-related acquisition and person-to-person transmission of resistance. We used national TB notification data to inform Bayesian estimates of the fraction of each country’s 2013 MDR-TB incidence that resulted from MDR transmission rather than treatment-related MDR acquisition. Findings Global estimates of 3·5% MDR-TB prevalence among new TB notifications and 20·5% among retreatment notifications translate into an estimate that resistance transmission rather than acquisition accounts for a median 96% (95% UR: 68–100%) of all incident MDR-TB, and 61% (16–95%) of incident MDR-TB in previously-treated individuals. The estimated percentage of MDR-TB resulting from transmission varied substantially with different countries’ notification data; for example, we estimated this percentage at 48% (30–75%) of MDR-TB in Bangladesh, versus 99% (91–100%) in Uzbekistan. Estimates were most sensitive to estimates of the transmissibility of MDR strains, the probability of acquiring MDR during tuberculosis treatment, and the responsiveness of MDR TB to first-line treatment. Interpretation Notifications of MDR prevalence from most high-burden settings are most consistent with the vast majority of incident MDR-TB resulting from transmission rather than new treatment-related acquisition of resistance. Merely improving the treatment of drug-susceptible TB is unlikely to greatly reduce future MDR-TB incidence. Improved diagnosis and treatment of MDR-TB – including new tests and drug regimens – should be highly prioritized.
Collapse
Affiliation(s)
- Emily A Kendall
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Mariam O Fofana
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
12
|
Fofana MO. Hazardous intersections: race, ethnicity, and medicine. Virtual Mentor 2014; 16:419-422. [PMID: 25090665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
|
13
|
Fofana MO, Knight GM, Gomez GB, White RG, Dowdy DW. Population-level impact of shorter-course regimens for tuberculosis: a model-based analysis. PLoS One 2014; 9:e96389. [PMID: 24816692 PMCID: PMC4015982 DOI: 10.1371/journal.pone.0096389] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 04/07/2014] [Indexed: 11/19/2022] Open
Abstract
Despite current control efforts, global tuberculosis (TB) incidence is decreasing slowly. New regimens that can shorten treatment hold promise for improving treatment completion and success, but their impact on population-level transmission remains unclear. Earlier models projected that a four-month regimen could reduce TB incidence by 10% but assumed that an entire course of therapy must be completed to derive any benefit. We constructed a dynamic transmission model of TB disease calibrated to global estimates of incidence, prevalence, mortality, and treatment success. To account for the efficacy of partial treatment, we used data from clinical trials of early short-course regimens to estimate relapse rates among TB patients who completed one-third, one-half, two-thirds, and all of their first-line treatment regimens. We projected population-level incidence and mortality over 10 years, comparing standard six-month therapy to hypothetical shorter-course regimens with equivalent treatment success but fewer defaults. The impact of hypothetical four-month regimens on TB incidence after 10 years was smaller than estimated in previous modeling analyses (1.9% [95% uncertainty range 0.6-3.1%] vs. 10%). Impact on TB mortality was larger (3.5% at 10 years) but still modest. Transmission impact was most sensitive to the proportion of patients completing therapy: four-month therapy led to greater incidence reductions in settings where 25% of patients leave care ("default") over six months. Our findings remained robust under one-way variation of model parameters. These findings suggest that novel regimens that shorten treatment duration may have only a modest effect on TB transmission except in settings of very low treatment completion.
Collapse
Affiliation(s)
- Mariam O. Fofana
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Medical Scientist Training Program, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Gwenan M. Knight
- TB Modelling Group, TB Centre and Centre for the Mathematical Modelling of Infectious Diseases, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Gabriela B. Gomez
- Department of Global Health, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Richard G. White
- TB Modelling Group, TB Centre and Centre for the Mathematical Modelling of Infectious Diseases, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David W. Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| |
Collapse
|
14
|
Abstract
Controversies and debates surrounding race have long been a fixture in American medicine. In the past, the biological concept of race-the idea that race is biologically determined and meaningful-has served to justify the institution of slavery and the conduct of unethical research trials. Although these days may seem far behind, contemporary debates over the race-specific approval of drugs and the significance of genetic differences are evidence that race still yields tremendous influence on medical research and clinical practice. In many ways, the use of race in medicine today reflects the internalisation of racial hierarchies borne out of the history of slavery and state-mandated segregation, and there is still much uncertainty over its benefits and harms. Although using race in research can help elucidate disparities, the reflexive use of race as a variable runs the risk of reifying the biological concept of race and blinding researchers to important underlying factors such as socioeconomic status. Similarly, in clinical practice, the use of race in assessing a patient's risk of certain conditions (eg, sickle cell) turns harmful when the heuristic becomes a rule. Through selected historical and contemporary examples, I aim to show how the biological concept of race that gave rise to past abuses remains alive and harmful, and propose changes in medical education as a potential solution. By learning from the past, today's physicians will be better armed to discern-and correct-the ways in which contemporary medicine perpetuates historical injustices.
Collapse
Affiliation(s)
- Mariam O Fofana
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, , Baltimore, Maryland, USA
| |
Collapse
|
15
|
Abstract
OBJECTIVE To evaluate the cost-effectiveness of novel first-line treatment regimens for tuberculosis (TB). DESIGN Using decision analysis, we projected the costs and effectiveness, from the health care perspective, of treating a patient cohort in the public sector for active TB without known or suspected resistance to first-line drugs. We compared standard (6-month) treatment to hypothetical regimens of equal efficacy, higher cost and shorter duration. RESULTS For every 100 TB patients treated, replacing standard treatment with shorter-course regimens would avert an estimated 2-4 failures/relapses, 0.2-0.4 deaths and 8-14 disability-adjusted life years (DALYs), or 6-11% of all DALYs suffered. We identified three primary determinants of cost-effectiveness: drug price, continuation phase treatment delivery costs and deaths averted through fewer relapses. In a high treatment cost scenario (similar to Brazil), averted delivery costs outweighed higher drug costs, making novel regimens cost-saving. In a low treatment cost scenario (similar to the Philippines), a 4-month regimen with a drug price of $1/day cost $66 per patient, or $840 per DALY averted, and became cost-saving if the drug price dropped below $0.37/day. CONCLUSION Although they avert a small proportion of total DALYs, novel, shorter-course first-line regimens for TB are likely to be cost-effective or cost-saving in most settings.
Collapse
Affiliation(s)
- J P Owens
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | |
Collapse
|
16
|
Fofana MO. 2012 winning essay. Joey knows best? Balancing conflicts and defending a child’s best interest in difficult clinical decisions. Virtual Mentor 2013; 15:653-9. [PMID: 23937779 DOI: 10.1001/virtualmentor.2013.15.8.conl1-1308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mariam O Fofana
- Mariam O. Fofana is a fourth-year medical student at Johns Hopkins University School of Medicine in Baltimore
| |
Collapse
|
17
|
Walensky RP, Wood R, Fofana MO, Martinson NA, Losina E, April MD, Bassett IV, Morris BL, Freedberg KA, Paltiel AD. The clinical impact and cost-effectiveness of routine, voluntary HIV screening in South Africa. J Acquir Immune Defic Syndr 2011; 56:26-35. [PMID: 21068674 PMCID: PMC3005842 DOI: 10.1097/qai.0b013e3181fb8f24] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although 900,000 HIV-infected South Africans receive antiretroviral therapy, the majority of South Africans with HIV remain undiagnosed. METHODS We use a published simulation model of HIV case detection and treatment to examine 3 HIV screening scenarios, in addition to current practice as follows: (1) one-time; (2) every 5 years; and (3) annually. South African model input data include the following: 16.9% HIV prevalence, 1.3% annual incidence, 49% test acceptance rate, HIV testing costs of $6.49/patient, and a 47% linkage-to-care rate (including 2 sequential antiretroviral therapy regimens) for identified cases. Outcomes include life expectancy, direct medical costs, and incremental cost-effectiveness. RESULTS HIV screening one-time, every 5 years, and annually increase HIV-infected quality-adjusted life expectancy (mean age 33 years) from 180.6 months (current practice) to 184.9, 187.6, and 197.2 months. The incremental cost-effectiveness of one-time screening is dominated by screening every 5 years. Screening every 5 years and annually each have incremental cost-effectiveness ratios of $1570/quality-adjusted life year and $1720/quality-adjusted life year. Screening annually is very cost-effective even in settings with the lowest incidence/prevalence, with test acceptance and linkage rates both as low as 20%, or when accounting for a stigma impact at least four-fold that of the base case. CONCLUSIONS In South Africa, annual voluntary HIV screening offers substantial clinical benefit and is very cost-effective, even with highly constrained access to care and treatment.
Collapse
Affiliation(s)
- Rochelle P Walensky
- Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Walensky RP, Wolf LL, Wood R, Fofana MO, Freedberg KA, Martinson NA, Paltiel AD, Anglaret X, Weinstein MC, Losina E. When to start antiretroviral therapy in resource-limited settings. Ann Intern Med 2009; 151:157-66. [PMID: 19620143 PMCID: PMC3092478 DOI: 10.7326/0003-4819-151-3-200908040-00138] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The results of international clinical trials that are assessing when to initiate antiretroviral therapy (ART) will not be available for several years. OBJECTIVE To inform HIV treatment decisions about the optimal CD4 threshold at which to initiate ART in South Africa while awaiting the results of these trials. DESIGN Cost-effectiveness analysis by using a computer simulation model of HIV disease. DATA SOURCES Published data from randomized trials and observational cohorts in South Africa. TARGET POPULATION HIV-infected patients in South Africa. TIME HORIZON 5-year and lifetime. PERSPECTIVE Modified societal. INTERVENTION No treatment, ART initiated at a CD4 count less than 0.250 x 10(9) cells/L, and ART initiated at a CD4 count less than 0.350 x 10(9) cells/L. OUTCOME MEASURES Morbidity, mortality, life expectancy, medical costs, and cost-effectiveness. RESULTS OF BASE-CASE ANALYSIS If 10% to 100% of HIV-infected patients are identified and linked to care, a CD4 count threshold for ART initiation of 0.350 x 10(9) cells/L would reduce severe opportunistic diseases by 22,000 to 221,000 and deaths by 25,000 to 253,000 during the next 5 years compared with ART initiation at 0.250 x 10(9) cells/L; cost increases would range from $142 million (10%) to $1.4 billion (100%). Either ART initiation strategy would increase long-term survival by at least 7.9 years, with a mean per-person life expectancy of 3.8 years with no ART and 12.5 years with an initiation threshold of 0.350 x 10(9) cells/L. Compared with an initiation threshold of 0.250 x 10(9) cells/L, a threshold of 0.350 x 10(9) cells/L has an incremental cost-effectiveness ratio of $1200 per year of life saved. RESULTS OF SENSITIVITY ANALYSIS Initiating ART at a CD4 count less than 0.350 x 10(9) cells/L would remain cost-effective over the next 5 years even if the probability that the trial would demonstrate the superiority of earlier therapy is as low as 17%. LIMITATION This model does not consider the possible benefits of initiating ART at a CD4 count greater than 0.350 x 10(9) cells/L or of reduced HIV transmission. CONCLUSION Earlier initiation of ART in South Africa will probably reduce morbidity and mortality, improve long-term survival, and be cost-effective. While awaiting trial results, treatment guidelines should be liberalized to allow initiation at CD4 counts less than 0.350 x 10(9) cells/L, earlier than is currently recommended. PRIMARY FUNDING SOURCE National Institute of Allergy and Infectious Diseases and the Doris Duke Charitable Foundation.
Collapse
Affiliation(s)
- Rochelle P Walensky
- Massachusetts General Hospital, Brigham and Women's Hospital, Harvard University Medical School, Harvard School of Public Health, and Boston University School of Public Health, Boston, Massachusetts 02114, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Walensky RP, Wood R, Weinstein MC, Martinson NA, Losina E, Fofana MO, Goldie SJ, Divi N, Yazdanpanah Y, Wang B, Paltiel AD, Freedberg KA. Scaling up antiretroviral therapy in South Africa: the impact of speed on survival. J Infect Dis 2008; 197:1324-32. [PMID: 18422445 DOI: 10.1086/587184] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Only 33% of eligible human immunodeficiency virus (HIV)-infected patients in South Africa receive antiretroviral therapy (ART). We sought to estimate the impact of alternative ART scale-up scenarios on patient outcomes from 2007-2012. METHODS Using a simulation model of HIV infection with South African data, we projected HIV-associated mortality with and without effective ART for an adult cohort in need of therapy (2007) and for adults who became eligible for treatment (2008-2012). We compared 5 scale-up scenarios: (1) zero growth, with a total of 100,000 new treatment slots; (2) constant growth, with 600,000; (3) moderate growth, with 2.1 million; (4) rapid growth, with 2.4 million); and (5) full capacity, with 3.2 million. RESULTS Our projections showed that by 2011, the rapid growth scenario fully met the South African need for ART; by 2012, the moderate scenario met 97% of the need, but the zero and constant growth scenarios met only 28% and 52% of the need, respectively. The latter scenarios resulted in 364,000 and 831,000 people alive and on ART in 2012. From 2007 to 2012, cumulative deaths in South Africa ranged from 2.5 million under the zero growth scenario to 1.2 million under the rapid growth scenario. CONCLUSIONS Alternative ART scale-up scenarios in South Africa will lead to differences in the death rate that amount to more than 1.2 million deaths by 2012. More rapid scale-up remains critically important.
Collapse
Affiliation(s)
- Rochelle P Walensky
- The Divisions of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|