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Shah AP, Dave JD, Makwana MN, Rupani MP, Shah IA. A mixed-methods study on impact of active case finding on pulmonary tuberculosis treatment outcomes in India. Arch Public Health 2024; 82:92. [PMID: 38902803 PMCID: PMC11188491 DOI: 10.1186/s13690-024-01326-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 06/15/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND Tuberculosis (TB) remains a significant public health burden in India, with elimination targets set for 2025. Active case finding (ACF) is crucial for improving TB case detection rates, although conclusive evidence of its association with treatment outcomes is lacking. Our study aims to investigate the impact of ACF on successful TB treatment outcomes among pulmonary TB patients in Gujarat, India, and explore why ACF positively impacts these outcomes. METHODS We conducted a retrospective cohort analysis in Gujarat, India, including 1,638 pulmonary TB cases identified through ACF and 80,957 cases through passive case finding (PCF) from January 2019 to December 2020. Generalized logistic mixed-model compared treatment outcomes between the ACF and PCF groups. Additionally, in-depth interviews were conducted with 11 TB program functionaries to explore their perceptions of ACF and its impact on TB treatment outcomes. RESULTS Our analysis revealed that patients diagnosed through ACF exhibited 1.4 times higher odds of successful treatment outcomes compared to those identified through PCF. Program functionaries emphasized that ACF enhances case detection rates and enables early detection and prompt treatment initiation. This early intervention facilitates faster sputum conversion and helps reduce the infectious period, thereby improving treatment outcomes. Functionaries highlighted that ACF identifies TB cases that might otherwise be missed, ensuring timely and appropriate treatment. CONCLUSION ACF significantly improves TB treatment outcomes in Gujarat, India. The mixed-methods analysis demonstrates a positive association between ACF and successful TB treatment, with early detection and prompt treatment initiation being key factors. Insights from TB program functionaries underscore the importance of ACF in ensuring timely diagnosis and treatment, which are critical for better treatment outcomes. Expanding ACF initiatives, especially among hard-to-reach populations, can further enhance TB control efforts. Future research should focus on optimizing ACF strategies and integrating additional interventions to sustain and improve TB treatment outcomes.
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Affiliation(s)
- Akshat P Shah
- Department of Community Medicine, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Near ST Bus Stand, Jail Road, Bhavnagar, Gujarat, 364001, India
| | - Jigna D Dave
- Department of Respiratory Medicine, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Jail Road, Bhavnagar, Gujarat, 364001, India
| | - Mohit N Makwana
- Department of Community Medicine, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Near ST Bus Stand, Jail Road, Bhavnagar, Gujarat, 364001, India
- Department of Community and Family Medicine, All India Institute of Medical Sciences (AIIMS), Khanderi, Parapipaliya, Rajkot, Gujarat, 360006, India
| | - Mihir P Rupani
- Department of Community Medicine, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Near ST Bus Stand, Jail Road, Bhavnagar, Gujarat, 364001, India.
- Clinical Epidemiology (Division of Health Sciences), ICMR - National Institute of Occupational Health (NIOH), Indian Council of Medical Research (ICMR), Meghaninagar, Near Raksha Shakti University, Ahmedabad, Gujarat, 380016, India.
| | - Immad A Shah
- Division of Agricultural Statistics, Sher-e-Kashmir University of Agricultural Sciences & Technology of Kashmir, Jammu & Kashmir, Srinagar, 190025, India
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Jhaveri TA, Jhaveri D, Galivanche A, Lubeck-Schricker M, Voehler D, Chung M, Thekkur P, Chadha V, Nathavitharana R, Kumar AMV, Shewade HD, Powers K, Mayer KH, Haberer JE, Bain P, Pai M, Satyanarayana S, Subbaraman R. Barriers to engagement in the care cascade for tuberculosis disease in India: A systematic review of quantitative studies. PLoS Med 2024; 21:e1004409. [PMID: 38805509 PMCID: PMC11166313 DOI: 10.1371/journal.pmed.1004409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/11/2024] [Accepted: 04/29/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND India accounts for about one-quarter of people contracting tuberculosis (TB) disease annually and nearly one-third of TB deaths globally. Many Indians do not navigate all care cascade stages to receive TB treatment and achieve recurrence-free survival. Guided by a population/exposure/comparison/outcomes (PECO) framework, we report findings of a systematic review to identify factors contributing to unfavorable outcomes across each care cascade gap for TB disease in India. METHODS AND FINDINGS We defined care cascade gaps as comprising people with confirmed or presumptive TB who did not: start the TB diagnostic workup (Gap 1), complete the workup (Gap 2), start treatment (Gap 3), achieve treatment success (Gap 4), or achieve TB recurrence-free survival (Gap 5). Three systematic searches of PubMed, Embase, and Web of Science from January 1, 2000 to August 14, 2023 were conducted. We identified articles evaluating factors associated with unfavorable outcomes for each gap (reported as adjusted odds, relative risk, or hazard ratios) and, among people experiencing unfavorable outcomes, reasons for these outcomes (reported as proportions), with specific quality or risk of bias criteria for each gap. Findings were organized into person-, family-, and society-, or health system-related factors, using a social-ecological framework. Factors associated with unfavorable outcomes across multiple cascade stages included: male sex, older age, poverty-related factors, lower symptom severity or duration, undernutrition, alcohol use, smoking, and distrust of (or dissatisfaction with) health services. People previously treated for TB were more likely to seek care and engage in the diagnostic workup (Gaps 1 and 2) but more likely to suffer pretreatment loss to follow-up (Gap 3) and unfavorable treatment outcomes (Gap 4), especially those who were lost to follow-up during their prior treatment. For individual care cascade gaps, multiple studies highlighted lack of TB knowledge and structural barriers (e.g., transportation challenges) as contributing to lack of care-seeking for TB symptoms (Gap 1, 14 studies); lack of access to diagnostics (e.g., X-ray), non-identification of eligible people for testing, and failure of providers to communicate concern for TB as contributing to non-completion of the diagnostic workup (Gap 2, 17 studies); stigma, poor recording of patient contact information by providers, and early death from diagnostic delays as contributing to pretreatment loss to follow-up (Gap 3, 15 studies); and lack of TB knowledge, stigma, depression, and medication adverse effects as contributing to unfavorable treatment outcomes (Gap 4, 86 studies). Medication nonadherence contributed to unfavorable treatment outcomes (Gap 4) and TB recurrence (Gap 5, 14 studies). Limitations include lack of meta-analyses due to the heterogeneity of findings and limited generalizability to some Indian regions, given the country's diverse population. CONCLUSIONS This systematic review illuminates common patterns of risk that shape outcomes for Indians with TB, while highlighting knowledge gaps-particularly regarding TB care for children or in the private sector-to guide future research. Findings may inform targeting of support services to people with TB who have higher risk of poor outcomes and inform multicomponent interventions to close gaps in the care cascade.
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Affiliation(s)
- Tulip A. Jhaveri
- Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, United States of America
| | - Disha Jhaveri
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Amith Galivanche
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Maya Lubeck-Schricker
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Dominic Voehler
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Mei Chung
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, United States of America
| | - Pruthu Thekkur
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | | | - Ruvandhi Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ajay M. V. Kumar
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
- Department of Community Medicine, Yenepoya Medical College, Yenepoya (deemed to be university), Mangalore, India
| | - Hemant Deepak Shewade
- Division of Health Systems Research, ICMR-National Institute of Epidemiology, Chennai, India
| | - Katherine Powers
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Kenneth H. Mayer
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
- The Fenway Institute, Boston, Massachusetts, United States of America
| | - Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Paul Bain
- Countway Library of Medicine, Boston, Massachusetts, United States of America
| | - Madhukar Pai
- Department of Global and Public Health and McGill International TB Centre, McGill University, Montreal, Canada
| | - Srinath Satyanarayana
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | - Ramnath Subbaraman
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, United States of America
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
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Ghazy RM, El Saeh HM, Abdulaziz S, Hammouda EA, Elzorkany AM, Khidr H, Zarif N, Elrewany E, Abd ElHafeez S. A systematic review and meta-analysis of the catastrophic costs incurred by tuberculosis patients. Sci Rep 2022; 12:558. [PMID: 35017604 PMCID: PMC8752613 DOI: 10.1038/s41598-021-04345-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 12/13/2021] [Indexed: 12/20/2022] Open
Abstract
One of the strategies of the World Health Organization End Tuberculosis (TB) was to reduce the catastrophic costs incurred by TB-affected families to 0% by 2020.Catastrophic cost is defined by the total cost related to TB management exceeding 20% of the annual pre-TB household income. This study aimed to estimate the pooled proportion of TB affected households who incurred catastrophic costs. We searched PubMed, SciELO, Scopus, Embase, Google Scholar, ProQuest, SAGE, and Web of Science databases according to Preferred Reporting Items of the Systematic Reviews and Meta-Analysis (PRISMA) guidelines till November 20, 2020. Eligible studies were identified and data on catastrophic costs due to TB were extracted. We performed a meta-analysis to generate the pooled proportion of patients with TB facing catastrophic costs. From 5114 studies identified, 29 articles were included in the final analysis. The pooled proportion of patients faced catastrophic costs was (43%, 95% CI [34-51]). Meta-regression revealed that country, drug sensitivity, and Human immune-deficiency Virus (HIV) co-infection were the main predictors of such costs. Catastrophic costs incurred by drug sensitive, drug resistant, and HIV co-infection were 32%, 81%, and 81%, respectively. The catastrophic costs incurred were lower among active than passive case findings (12% vs. 30%). Half (50%) of TB-affected households faced catastrophic health expenditure at 10% cut-off point. The financial burden of patients seeking TB diagnosis and treatment continues to be a worldwide impediment. Therefore, the End TB approach should rely on socioeconomic support and cost-cutting initiatives.PROSPERO registration: CRD42020221283.
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Affiliation(s)
- Ramy Mohamed Ghazy
- Tropical Health Department, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Haider M El Saeh
- Community Medicine Department, Faculty of Medicine, University of Tripoli, Tripoli, Libya
| | | | | | | | - Heba Khidr
- Ministry of Health and Population, Alexandria, Egypt
| | - Nardine Zarif
- Ministry of Health and Population, Alexandria, Egypt
| | - Ehab Elrewany
- Tropical Health Department, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Samar Abd ElHafeez
- Epidemiology Department, High Institute of Public Health, Alexandria University, Alexandria, Egypt
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Alsdurf H, Empringham B, Miller C, Zwerling A. Tuberculosis screening costs and cost-effectiveness in high-risk groups: a systematic review. BMC Infect Dis 2021; 21:935. [PMID: 34496804 PMCID: PMC8425319 DOI: 10.1186/s12879-021-06633-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 08/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Systematic screening for active tuberculosis (TB) is a strategy which requires the health system to seek out individuals, rather than waiting for individuals to self-present with symptoms (i.e., passive case finding). Our review aimed to summarize the current economic evidence and understand the costs and cost-effectiveness of systematic screening approaches among high-risk groups and settings. METHODS We conducted a systematic review on economic evaluations of screening for TB disease targeting persons with clinical and/or structural risk factors, such as persons living with HIV (PLHIV) or persons experiencing homelessness. We searched three databases for studies published between January 1, 2010 and February 1, 2020. Studies were included if they reported cost and a key outcome measure. Owing to considerable heterogeneity in settings and type of screening strategy, we synthesized data descriptively. RESULTS A total of 27 articles were included in our review; 19/27 (70%) took place in high TB burden countries. Seventeen studies took place among persons with clinical risk factors, including 14 among PLHIV, while 13 studies were among persons with structural risk factors. Nine studies reported incremental cost-effectiveness ratios (ICERs) ranging from US$51 to $1980 per disability-adjusted life year (DALY) averted. Screening was most cost-effective among PLHIV. Among persons with clinical and structural risk factors there was limited evidence, but screening was generally not shown to be cost-effective. CONCLUSIONS Studies showed that screening is most likely to be cost-effective in a high TB prevalence population. Our review highlights that to reach the "missing millions" TB programmes should focus on simple, cheaper initial screening tools (i.e., symptom screen and CXR) followed by molecular diagnostic tools (i.e., Xpert®) among the highest risk groups in the local setting (i.e., PLHIV, urban slums). Programmatic costs greatly impact cost-effectiveness thus future research should provide both fixed and variable costs of screening interventions to improve comparability.
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Affiliation(s)
- H Alsdurf
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Cresent, Ottawa, Canada
| | - B Empringham
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Cresent, Ottawa, Canada.,Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - C Miller
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - A Zwerling
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Cresent, Ottawa, Canada.
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Ghazy RM, Saeh HME, Abdulaziz S, Hammouda EA, Elzorkany A, Kheder H, Zarif N, Elrewany E, Elhafeez SA. A Systematic Review and Meta-Analysis on Catastrophic Cost incurred by Tuberculosis Patients and their Households.. [DOI: 10.1101/2021.02.27.21252453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
AbstractBackgroundAs one of the World Health Organization (WHO) End Tuberculosis (TB) Strategy is to reduce the proportion of TB affected families that face catastrophic costs to 0% by 2020. This systematic review and meta-analysis aimed to estimate the pooled proportion of TB affected households who face catastrophic cost.MethodA search of the online database through September 2020 was performed. A total of 5114 articles were found, of which 29 articles got included in quantitative synthesis. Catastrophic cost is defined if total cost related to TB exceeded 20% of annual pre-TB household income. R software was used to estimate the pooled proportion at 95% confidence intervals (CIs) using the fixed/random-effect models.ResultThe proportion of patients faced catastrophic cost was 43% (95% CI 34-52, I2= 99%); 32% (95% CI 29 – 35, I2= 70%) among drug sensitive, and 80% (95% CI 74-85, I2= 54%) among drug resistant, and 81% (95%CI 78-84%, I2= 0%) among HIV patients. Regarding active versus passive case finding the pooled proportion of catastrophic cost was 12% (95% CI 9-16, I2= 95%) versus 42% (95% CI 35-50, I2= 94%). The pooled proportion of direct cost to the total cost was 45% (95% CI 39-51, I2= 91%). The pooled proportion of patients facing catastrophic health expenditure (CHE) at cut of point of 10% of their yearly income was 45% (95% CI 35-56, I2= 93%) while at 40% of their capacity to pay was 63% (95% CI 40-80, I2= 96%).ConclusionDespite the ongoing efforts, there is a significant proportion of patients facing catastrophic cost, which represent a main obstacle against TB control.PROSPERO registrationCRD42020221283
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Kendall EA, Shrestha S, Dowdy DW. The Epidemiological Importance of Subclinical Tuberculosis. A Critical Reappraisal. Am J Respir Crit Care Med 2021; 203:168-174. [PMID: 33197210 DOI: 10.1164/rccm.202006-2394pp] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Emily A Kendall
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Sourya Shrestha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Singh AA, Creswell J, Bhatia V. Framework for planning and monitoring active TB case finding interventions to meet the global targets in the COVID-19 era and beyond: South-East Asia perspective. PLOS GLOBAL PUBLIC HEALTH 2021; 1:e0000073. [PMID: 36962114 PMCID: PMC10021227 DOI: 10.1371/journal.pgph.0000073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There was an estimated 20-40% decline in tuberculosis (TB) case detection in the South-East Asia Region (SEA Region) during 2020 due to COVID-19 outbreak. This is over and above a million people with TB who were missed each year, prior to the pandemic. Active case finding (ACF) for TB has been gaining considerable interest and investment in the SEA Region and will be even more essential for finding people with TB missed due to the COVID-19 pandemic. Many countries in the Region have incorporated ACF activities into national strategic plans and are conducting large scale activities with varying results. ACF can reach people with TB earlier than routine approaches, can lead to increases in the numbers of people diagnosed, and is often needed for certain key populations who face stigma, social, and economic barriers. However, ACF is not a one size fits all approach, and has higher costs than routine care. So, planning interventions in consultation with relevant stakeholders including the affected communities is critical. Furthermore, continuous monitoring during the intervention and after completion is crucial as national TB programmes review progress and decide on the effective utilization of limited resources. Planning and monitoring become more relevant in the COVID-19 era because of constraints posed by resource diversion towards pandemic control. Here, we summarize different aspects of planning and monitoring of ACF approaches to inform national TB programmes and partners based on experiences in the SEA Region, as programmes look to reach those who are missed and catch-up on progress towards ending TB.
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Affiliation(s)
| | | | - Vineet Bhatia
- South-East Asia Regional Office, World Health Organization, New Delhi, India
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Case finding strategies under National Tuberculosis Elimination Programme (NTEP). Indian J Tuberc 2020; 67:S101-S106. [PMID: 33308653 PMCID: PMC7526527 DOI: 10.1016/j.ijtb.2020.09.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/24/2020] [Indexed: 11/23/2022]
Abstract
Case finding, an important parameter in fight against Tuberculosis (TB) has always remained a challenge despite advances in diagnostic modalities, access to health care and administrative commitment. We are still far from reaching the goals so set as per End TB Strategy and National Strategic Plan 2017–2025, and case finding is of paramount importance for achieving the said targets. This article, after identifying the obstacles faced in case finding, explores the various case finding strategies in the perspective of diagnostics, feasibility, resource utilization and current recommendations. Need for prioritization of case finding in different settings with involvement and active participation of one and all has been discussed. Role of health education in an individual, general public and health care worker in the context of case finding has been highlighted. Research areas to strengthen case finding have been enumerated. The review concludes by bringing out the need for heightened efforts for case finding in TB as the resources are significantly diverted as the world is facing the corona virus disease 2019 (COVID-19) pandemic. Early case finding and prompt treatment is very important for eliminating Tuberculosis but has always remained a challenge. Ongoing passive case finding needs to be strictly complemented with active case finding especially in vulnerable population. Efforts for case finding in TB should not be neglected despite the present corona virus disease 2019 (COVID-19) pandemic.
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Raina SK. Active Case Finding in Tuberculosis: Need for a Cautious Approach. J Glob Infect Dis 2020; 12:3-4. [PMID: 32165794 PMCID: PMC7045762 DOI: 10.4103/jgid.jgid_139_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 10/28/2019] [Indexed: 11/20/2022] Open
Affiliation(s)
- Sunil Kumar Raina
- Department of Community Medicine, Dr. R.P. Government Medical College, Tanda, Himachal Pradesh, India
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Bahurupi Y, Singh M, Sharma A, Kishore S, Aggarwal P, Jain B, Bhadoria A, Kumar Reddy N. Treatment outcomes of tuberculosis patients detected by active case finding under the Revised National Tuberculosis Control Programme during 2018 in Haridwar district of Uttarakhand. J Family Med Prim Care 2020; 9:5132-5135. [PMID: 33409176 PMCID: PMC7773101 DOI: 10.4103/jfmpc.jfmpc_623_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/10/2020] [Accepted: 07/21/2020] [Indexed: 11/04/2022] Open
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