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Ali M, El Hafid M, Farrar DS, Kourdi H, Rea E, Waters V, Lam R, Morris SK, Kitai I. Travel-acquired paediatric tuberculosis in the Greater Toronto Area, Canada, 2002-2018. Eur Respir J 2024; 63:2301533. [PMID: 38212078 DOI: 10.1183/13993003.01533-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 01/04/2024] [Indexed: 01/13/2024]
Affiliation(s)
- Mohsin Ali
- Division of Infectious Diseases, Hospital for Sick Children, Toronto, ON, Canada
- These authors contributed equally to this work
| | - Melanie El Hafid
- Division of Infectious Diseases, Hospital for Sick Children, Toronto, ON, Canada
- These authors contributed equally to this work
| | - Daniel S Farrar
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada
| | - Haifa Kourdi
- Division of Infectious Diseases, Hospital for Sick Children, Toronto, ON, Canada
| | - Elizabeth Rea
- Tuberculosis Program, Toronto Public Health, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Valerie Waters
- Division of Infectious Diseases, Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ray Lam
- Division of Infectious Diseases, Hospital for Sick Children, Toronto, ON, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Shaun K Morris
- Division of Infectious Diseases, Hospital for Sick Children, Toronto, ON, Canada
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ian Kitai
- Division of Infectious Diseases, Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Uppal A, Nsengiyumva NP, Signor C, Jean-Louis F, Rochette M, Snowball H, Etok S, Annanack D, Ikey J, Khan FA, Schwartzman K. Active screening for tuberculosis in high-incidence Inuit communities in Canada: a cost-effectiveness analysis. CMAJ 2021; 193:E1652-E1659. [PMID: 34725112 PMCID: PMC8565977 DOI: 10.1503/cmaj.210447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Active screening for tuberculosis (TB) involves systematic detection of previously undiagnosed TB disease or latent TB infection (LTBI). It may be an important step toward elimination of TB among Inuit in Canada. We aimed to evaluate the cost-effectiveness of community-wide active screening for TB infection and disease in 2 Inuit communities in Nunavik. Methods: We incorporated screening data from the 2 communities into a decision analysis model. We predicted TB-related health outcomes over a 20-year time frame, beginning in 2019. We assessed the cost-effectiveness of active screening in the presence of varying outbreak frequency and intensity. We also considered scenarios involving variation in timing, impact and uptake of screening programs. Results: Given a single large outbreak in 2019, we estimated that 1 round of active screening reduced TB disease by 13% (95% uncertainty range −3% to 27%) and was cost saving compared with no screening, over 20 years. In the presence of simulated large outbreaks every 3 years thereafter, a single round of active screening was cost saving, as was biennial active screening. Compared with a single round, we also determined that biennial active screening reduced TB disease by 59% (95% uncertainty range 52% to 63%) and was estimated to cost Can$6430 (95% uncertainty range −$29 131 to $13 658 in 2019 Can$) per additional active TB case prevented. With smaller outbreaks or improved rates of treatment initiation and completion for people with LTBI, we determined that biennial active screening remained reasonably cost-effective compared with no active screening. Interpretation: Active screening is a potentially cost-saving approach to reducing disease burden in Inuit communities that have frequent TB outbreaks.
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Affiliation(s)
- Aashna Uppal
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que
| | - Ntwali Placide Nsengiyumva
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que
| | - Céline Signor
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que
| | - Frantz Jean-Louis
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que
| | - Marie Rochette
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que
| | - Hilda Snowball
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que
| | - Sandra Etok
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que
| | - David Annanack
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que
| | - Julie Ikey
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que
| | - Faiz Ahmad Khan
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que
| | - Kevin Schwartzman
- Montreal Chest Institute (Uppal, Khan, Schwartzman); Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation (Uppal, Nsengiyumva, Khan, Schwartzman), Research Institute of McGill University Health Centre; McGill International Tuberculosis Centre (Uppal, Nsengiyumva, Khan, Schwartzman), Montréal, Que.; Régie régionale de la santé et des services sociaux du Nunavik (Signor, Jean-Louis, Rochette); Kativik Regional Government (Snowball); Ulluriaq School (Etok), Kangiqsualujjuaq; Northern Village of Kangiqsualujjuaq (Annanack); Salluit Birth Center, Salluit (Ikey), Québec, Que.
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3
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Uppal A, Oxlade O, Nsengiyumva NP, N'Diaye DS, Alvarez GG, Schwartzman K. Social and behavioral risk reduction strategies for tuberculosis prevention in Canadian Inuit communities: a cost-effectiveness analysis. BMC Public Health 2021; 21:280. [PMID: 33536003 PMCID: PMC7860224 DOI: 10.1186/s12889-021-10187-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 01/06/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) is an important public health problem in Inuit communities across Canada, with an annual incidence rate in 2017 that was nearly 300 times higher than in Canadian-born non-Indigenous individuals. Social and behavioral factors that are prevalent in the North, such as commercial tobacco use, excessive alcohol use, food insecurity and overcrowded housing put individuals at higher risk for TB morbidity and mortality. We examined the potential impact of mitigation strategies for these risk factors, in reducing TB burden in this setting. METHODS We created a transmission model to simulate the epidemiology of TB in Nunavut, Canada. We then used a decision analysis model to assess the potential impact of several evidence-based strategies targeting tobacco use, excessive alcohol use, food insecurity and overcrowded housing. We predicted TB incidence, TB-related deaths, quality adjusted life years (QALYs), and associated costs and cost-effectiveness over 20 years. All costs were expressed in 2018 Canadian dollars. RESULTS Compared to a status quo scenario with no new interventions for these risk factors, the reduction strategy for tobacco use was most effective and cost-effective, reducing TB incidence by 5.5% (95% uncertainty range: 2.7-11%) over 20 years, with an estimated cost of $95,835 per TB case prevented and $49,671 per QALY gained. The addition of the food insecurity reduction strategy reduced incidence by a further 2% (0.5-3%) compared to the tobacco cessation strategy alone, but at significant cost. CONCLUSIONS Strategies that aim to reduce commercial tobacco use and improve food security will likely lead to modest reductions in TB morbidity and mortality. Although important for the communities, strategies that address excess alcohol use and overcrowding will likely have a more limited impact on TB-related outcomes at current scale, and are associated with much higher cost. Their benefits will be more substantial with scale up, which will also likely have important downstream impacts such as improved mental health, educational attainment and food security.
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Affiliation(s)
- Aashna Uppal
- Montreal Chest Institute, Montreal, Quebec, Canada
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada
- McGill International Tuberculosis Centre, 1001 boulevard Décarie, Room D05.2511, Montréal, Québec, H4A 3J1, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Olivia Oxlade
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada
- McGill International Tuberculosis Centre, 1001 boulevard Décarie, Room D05.2511, Montréal, Québec, H4A 3J1, Canada
| | - Ntwali Placide Nsengiyumva
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada
- McGill International Tuberculosis Centre, 1001 boulevard Décarie, Room D05.2511, Montréal, Québec, H4A 3J1, Canada
| | - Dieynaba S N'Diaye
- Montreal Chest Institute, Montreal, Quebec, Canada
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada
- McGill International Tuberculosis Centre, 1001 boulevard Décarie, Room D05.2511, Montréal, Québec, H4A 3J1, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Gonzalo G Alvarez
- The Ottawa Hospital Research Institute, Department of Medicine, Division of Respirology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Kevin Schwartzman
- Montreal Chest Institute, Montreal, Quebec, Canada.
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada.
- McGill International Tuberculosis Centre, 1001 boulevard Décarie, Room D05.2511, Montréal, Québec, H4A 3J1, Canada.
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.
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4
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N’Diaye DS, Nsengiyumva NP, Uppal A, Oxlade O, Alvarez GG, Schwartzman K. The potential impact and cost-effectiveness of tobacco reduction strategies for tuberculosis prevention in Canadian Inuit communities. BMC Med 2019; 17:26. [PMID: 30712513 PMCID: PMC6360759 DOI: 10.1186/s12916-019-1261-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 01/15/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) remains a significant public health problem in Canadian Inuit communities. In 2016, Canadian Inuit had an incidence rate 35 times the Canadian average. Tobacco use is an important risk factor for TB, and over 60% of Inuit adults smoke. We aimed to estimate changes in TB-related outcomes and costs from reducing tobacco use in Inuit communities. METHODS Using a transmission model to estimate the initial prevalence of latent TB infection (LTBI), followed by decision analysis modelling, we conducted a cost-effectiveness analysis that compared the current standard of care for management of TB and LTBI without additional tobacco reduction intervention (Status Quo) with (1) increased tobacco taxation, (2) pharmacotherapy and counselling for smoking cessation, (3) pharmacotherapy, counselling plus mass media campaign, and (4) the combination of all these. Projected outcomes included the following: TB cases, TB-related deaths, quality-adjusted life years (QALYs), and health system costs, all over 20 years. RESULTS The combined strategy was projected to reduce active TB cases by 6.1% (95% uncertainty range 4.9-7.0%) and TB deaths by 10.4% (9.5-11.4%) over 20 years, relative to the status quo. Increased taxation was the only cost-saving strategy. CONCLUSIONS Currently available strategies to reduce commercial tobacco use will likely have a modest impact on TB-related outcomes in the medium term, but some may be cost saving.
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Affiliation(s)
- Dieynaba S. N’Diaye
- Montreal Chest Institute, Montreal, Quebec Canada
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, 1001 boulevard Décarie, Room D05.2511, Montreal, Quebec H4A 3J1 Canada
- McGill International Tuberculosis Centre, Montreal, Quebec Canada
| | - Ntwali Placide Nsengiyumva
- Montreal Chest Institute, Montreal, Quebec Canada
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, 1001 boulevard Décarie, Room D05.2511, Montreal, Quebec H4A 3J1 Canada
- McGill International Tuberculosis Centre, Montreal, Quebec Canada
| | - Aashna Uppal
- Montreal Chest Institute, Montreal, Quebec Canada
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, 1001 boulevard Décarie, Room D05.2511, Montreal, Quebec H4A 3J1 Canada
- McGill International Tuberculosis Centre, Montreal, Quebec Canada
| | - Olivia Oxlade
- Montreal Chest Institute, Montreal, Quebec Canada
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, 1001 boulevard Décarie, Room D05.2511, Montreal, Quebec H4A 3J1 Canada
- McGill International Tuberculosis Centre, Montreal, Quebec Canada
| | - Gonzalo G. Alvarez
- The Ottawa Hospital Research Institute, Ottawa, Ontario Canada
- Department of Medicine, Division of Respirology, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario Canada
| | - Kevin Schwartzman
- Montreal Chest Institute, Montreal, Quebec Canada
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, 1001 boulevard Décarie, Room D05.2511, Montreal, Quebec H4A 3J1 Canada
- McGill International Tuberculosis Centre, Montreal, Quebec Canada
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5
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Kowada A. Cost effectiveness of interferon-gamma release assay for tuberculosis screening using three months of rifapentine and isoniazid among long-term expatriates from low to high incidence countries. Travel Med Infect Dis 2016; 14:489-498. [DOI: 10.1016/j.tmaid.2016.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 04/10/2016] [Accepted: 05/06/2016] [Indexed: 10/21/2022]
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Getahun H, Matteelli A, Abubakar I, Aziz MA, Baddeley A, Barreira D, Den Boon S, Borroto Gutierrez SM, Bruchfeld J, Burhan E, Cavalcante S, Cedillos R, Chaisson R, Chee CBE, Chesire L, Corbett E, Dara M, Denholm J, de Vries G, Falzon D, Ford N, Gale-Rowe M, Gilpin C, Girardi E, Go UY, Govindasamy D, D Grant A, Grzemska M, Harris R, Horsburgh CR, Ismayilov A, Jaramillo E, Kik S, Kranzer K, Lienhardt C, LoBue P, Lönnroth K, Marks G, Menzies D, Migliori GB, Mosca D, Mukadi YD, Mwinga A, Nelson L, Nishikiori N, Oordt-Speets A, Rangaka MX, Reis A, Rotz L, Sandgren A, Sañé Schepisi M, Schünemann HJ, Sharma SK, Sotgiu G, Stagg HR, Sterling TR, Tayeb T, Uplekar M, van der Werf MJ, Vandevelde W, van Kessel F, van't Hoog A, Varma JK, Vezhnina N, Voniatis C, Vonk Noordegraaf-Schouten M, Weil D, Weyer K, Wilkinson RJ, Yoshiyama T, Zellweger JP, Raviglione M. Management of latent Mycobacterium tuberculosis infection: WHO guidelines for low tuberculosis burden countries. Eur Respir J 2015; 46:1563-76. [PMID: 26405286 PMCID: PMC4664608 DOI: 10.1183/13993003.01245-2015] [Citation(s) in RCA: 377] [Impact Index Per Article: 41.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 08/26/2015] [Indexed: 12/21/2022]
Abstract
Latent tuberculosis infection (LTBI) is characterised by the presence of immune responses to previously acquired Mycobacterium tuberculosis infection without clinical evidence of active tuberculosis (TB). Here we report evidence-based guidelines from the World Health Organization for a public health approach to the management of LTBI in high risk individuals in countries with high or middle upper income and TB incidence of <100 per 100 000 per year. The guidelines strongly recommend systematic testing and treatment of LTBI in people living with HIV, adult and child contacts of pulmonary TB cases, patients initiating anti-tumour necrosis factor treatment, patients receiving dialysis, patients preparing for organ or haematological transplantation, and patients with silicosis. In prisoners, healthcare workers, immigrants from high TB burden countries, homeless persons and illicit drug users, systematic testing and treatment of LTBI is conditionally recommended, according to TB epidemiology and resource availability. Either commercial interferon-gamma release assays or Mantoux tuberculin skin testing could be used to test for LTBI. Chest radiography should be performed before LTBI treatment to rule out active TB disease. Recommended treatment regimens for LTBI include: 6 or 9 month isoniazid; 12 week rifapentine plus isoniazid; 3-4 month isoniazid plus rifampicin; or 3-4 month rifampicin alone.
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Affiliation(s)
| | - Alberto Matteelli
- The Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Ibrahim Abubakar
- Dept of Infection and Population Health, University College London, London, UK Public Health England, London, UK
| | - Mohamed Abdel Aziz
- World Health Organization, Regional Office for Eastern Mediterranean, Egypt
| | - Annabel Baddeley
- The Global TB Programme, World Health Organization, Geneva, Switzerland
| | | | | | | | - Judith Bruchfeld
- Unit of Infectious Diseases, Dept of Medicine, Karolinska Institute Solna and Karolinska University Hospital, Stockholm, Sweden
| | - Erlina Burhan
- Dept of Pulmonology and Respiratory Medicine, Faculty of Medicine, University of Indonesia and Persahabatan Hospital, Jakarta, Indonesia
| | - Solange Cavalcante
- Evandro Chagas National Institute of Infectious Diseases, FIOCRUZ, Rio de Janeiro, Brazil
| | | | - Richard Chaisson
- Center for TB Research, John Hopkins University, Baltimore, MD, USA
| | | | | | | | - Masoud Dara
- World Health Organization, Regional Office for Europe, Denmark
| | | | | | - Dennis Falzon
- The Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Nathan Ford
- Dept of HIV and Global Hepatitis Programme, World Health Organization, Switzerland
| | | | - Chris Gilpin
- The Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Enrico Girardi
- Istituto Nazionale Malattie Infettive L. Spallanzani, Rome, Italy
| | - Un-Yeong Go
- Dept of HIV/AIDS and TB Control Korea, Korea Centers for Disease Control and Prevention, Republic of Korea
| | - Darshini Govindasamy
- Health Systems Research Unit, South African Medical Research Council, South Africa
| | - Alison D Grant
- Dept of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - C Robert Horsburgh
- Dept of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | | | - Ernesto Jaramillo
- The Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Sandra Kik
- McGill International TB Centre, and Dept of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
| | - Katharina Kranzer
- Dept of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Knut Lönnroth
- The Global TB Programme, World Health Organization, Geneva, Switzerland Dept of Public Health Sciences, Karolinska Institute, Solna, Sweden
| | - Guy Marks
- Woolcock Institute of Medical Research University of Sydney and UNSW Australia, Sydney, Australia
| | - Dick Menzies
- McGill International TB Centre, and Dept of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
| | | | - Davide Mosca
- Migration Health Department, International Organization of Migration, Geneva, Switzerland
| | - Ya Diul Mukadi
- Infectious Disease Division, Bureau for Global Health, US Agency for International Development, Washington, DC, USA
| | | | - Lisa Nelson
- Dept of HIV and Global Hepatitis Programme, World Health Organization, Switzerland
| | - Nobuyuki Nishikiori
- World Health Organization, Regional Office for the Western Pacific, Philippines
| | | | - Molebogeng Xheedha Rangaka
- Dept of Infection and Population Health, University College London, London, UK Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Andreas Reis
- Knowledge, Ethics and Research Department, World Health Organization, Switzerland
| | - Lisa Rotz
- Centers for Disease Control and Prevention, USA
| | - Andreas Sandgren
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | | | - Holger J Schünemann
- Dept of Clinical Epidemiology and Biostatistics and Dept of Medicine, GRADE Center, McMaster University, Hamilton, ON, Canada
| | | | - Giovanni Sotgiu
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - Helen R Stagg
- Dept of Infection and Population Health, University College London, London, UK
| | | | - Tamara Tayeb
- National TB Programme, Ministry of Health, Riyadh, Saudi Arabia
| | - Mukund Uplekar
- The Global TB Programme, World Health Organization, Geneva, Switzerland
| | | | | | - Femke van Kessel
- Pallas Health Research and Consultancy BV, Rotterdam, The Netherlands
| | - Anna van't Hoog
- Academic Medical Centre, University of Amsterdam, Dept of Global Health, Amsterdam, The Netherlands
| | - Jay K Varma
- Centers for Disease Control and Prevention, USA
| | | | | | | | - Diana Weil
- The Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Karin Weyer
- The Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Robert John Wilkinson
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa Francis Crick Institute Mill Hill Laboratory, Dept of Medicine, Imperial College London, London, UK
| | - Takashi Yoshiyama
- Fukujuji Hospital, Japan Anti Tuberculosis Association, Tokyo, Japan
| | | | - Mario Raviglione
- The Global TB Programme, World Health Organization, Geneva, Switzerland
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Feldman I, Hellström L, Johansson P. Heterogeneity in cost-effectiveness of lifestyle counseling for metabolic syndrome risk groups -primary care patients in Sweden. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2013; 11:19. [PMID: 23984906 PMCID: PMC3765778 DOI: 10.1186/1478-7547-11-19] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 08/09/2013] [Indexed: 12/18/2022] Open
Abstract
Background Clinical trials have indicated that lifestyle interventions for patients with lifestyle-related cardiovascular and diabetes risk factors (the metabolic syndrome) are cost-effective. However, patient characteristics in primary care practice vary considerably, i.e. they exhibit heterogeneity in risk factors. The cost-effectiveness of lifestyle interventions is likely to differ over heterogeneous patient groups. Methods Patients (62 men, 80 women) in the Kalmar Metabolic Syndrome Program (KMSP) in primary care (Kalmar regional healthcare area, Sweden) were divided into three groups reflecting different profiles of metabolic risk factors (low, middle and high risk) and gender. A Markov model was used to predict future cardiovascular disease and diabetes, including complications (until age 85 years or death), with health effects measured as QALYs and costs from a societal perspective in Euro (EUR) 2012, discounted 3%. Simulations with risk factor levels at start and at 12 months follow-up were performed for each group, with an assumed 4-year sustainability of intervention effects. Results The program was estimated cost-saving for middle and high risk men, while the incremental cost vs. do-nothing varied between EUR 3,500 – 18,000 per QALY for other groups. There is heterogeneity in the cost-effectiveness over the risk groups but this does not affect the overall conclusion on the cost-effectiveness of the KMSP. Even the highest ICER (for high risk women) is considered moderately cost-effective in Sweden. The base case result was not sensitive to alternative data and methodology but considerably affected by sustainability assumptions. Alternative risk stratifications did not change the overall conclusion that KMSP is cost-effective. However, simple grouping with average risk factor levels over gender groups overestimate the cost-effectiveness. Conclusions Lifestyle counseling to prevent metabolic diseases is cost-effective in Swedish standard primary care settings. The use of risk stratification in the cost-effectiveness analysis established that the program was cost-effective for all patient groups, even for those with very high levels of lifestyle-related risk factors for the metabolic syndrome diseases. Heterogeneity in the cost-effectiveness of lifestyle interventions in primary care patients is expected, and should be considered in health policy decisions.
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Affiliation(s)
- Inna Feldman
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
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Mahomed H, Ehrlich R, Hawkridge T, Hatherill M, Geiter L, Kafaar F, Abrahams DA, Mulenga H, Tameris M, Geldenhuys H, Hanekom WA, Verver S, Hussey GD. Screening for TB in high school adolescents in a high burden setting in South Africa. Tuberculosis (Edinb) 2013; 93:357-62. [PMID: 23477938 DOI: 10.1016/j.tube.2013.02.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Revised: 01/24/2013] [Accepted: 02/04/2013] [Indexed: 10/27/2022]
Abstract
Screening for tuberculosis (TB) disease is important for TB control and TB vaccine efficacy trials but this has not been evaluated in adolescents. We conducted a study to determine the prevalence of active TB and performance of specific screening tests for TB in adolescents in a high burden setting. Adolescents aged 12-18 years were recruited from high schools in a rural town in South Africa. Participants were screened for active TB using symptoms, household TB contact, positive interferon gamma release assay (IGRA) and positive tuberculin skin test (TST). Of 6363 adolescents recruited, 21 were newly diagnosed with TB of whom 19 were culture positive. After exclusions, the derived prevalence of smear positive TB was 16/5682 = 3/1000 (95% confidence interval (CI) 1-4/1000). The sensitivity of TST and IGRA for active TB were 85% (95% CI 62-100%) and 94% (95% CI 79-100%) respectively. None of the methods alone or in combination had positive predictive values greater than 2%. The screening tools evaluated in this study may not be practical for routine use owing to low positive predictive values but may be useful in TB vaccine clinical trials.
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Affiliation(s)
- Hassan Mahomed
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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Kadambi A, Leipold RJ, Kansal AR, Sorensen S, Getsios D. Inclusion of compliance and persistence in economic models: past, present and future. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2012; 10:365-379. [PMID: 23030640 DOI: 10.1007/bf03261872] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Economic models are developed to provide decision makers with information related to the real-world effectiveness of therapeutics, screening and diagnostic regimens. Although compliance with these regimens often has a significant impact on real-world clinical outcomes and costs, compliance and persistence have historically been addressed in a relatively superficial fashion in economic models. In this review, we present a discussion of the current state of economic modelling as it relates to the consideration of compliance and persistence. We discuss the challenges associated with the inclusion of compliance and persistence in economic models and provide an in-depth review of recent modelling literature that considers compliance or persistence, including a brief summary of previous reviews on this topic and a survey of published models from 2005 to 2012. We review the recent literature in detail, providing a therapeutic-area-specific discussion of the approaches and conclusions drawn from the inclusion of compliance or persistence in economic models. In virtually all publications, variation of model parameters related to compliance and persistence was shown to have a significant impact on predictions of economic outcomes. Growing recognition of the importance of compliance and persistence in the context of economic evaluations has led to an increasing number of economic models that consider these factors, as well as the use of more sophisticated modelling techniques such as individual simulations that provide an avenue for more rigorous consideration of compliance and persistence than is possible with more traditional methods. However, we note areas of continuing concern cited by previous reviews, including inconsistent definitions, documentation and tenuous assumptions required to estimate the effect of compliance and persistence. Finally, we discuss potential means to surmount these challenges via more focused efforts to collect compliance and persistence data.
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