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Coleman M, Nguyen TA, Luu BK, Hill J, Ragonnet R, Trauer JM, Fox GJ, Marks GB, Marais BJ. Finding and treating both tuberculosis disease and latent infection during population-wide active case finding for tuberculosis elimination. Front Med (Lausanne) 2023; 10:1275140. [PMID: 37908846 PMCID: PMC10613897 DOI: 10.3389/fmed.2023.1275140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/02/2023] [Indexed: 11/02/2023] Open
Abstract
In recognition of the high rates of undetected tuberculosis in the community, the World Health Organization (WHO) encourages targeted active case finding (ACF) among "high-risk" populations. While this strategy has led to increased case detection in these populations, the epidemic impact of these interventions has not been demonstrated. Historical data suggest that population-wide (untargeted) ACF can interrupt transmission in high-incidence settings, but implementation remains lacking, despite recent advances in screening tools. The reservoir of latent infection-affecting up to a quarter of the global population -complicates elimination efforts by acting as a pool from which future tuberculosis cases may emerge, even after all active cases have been treated. A holistic case finding strategy that addresses both active disease and latent infection is likely to be the optimal approach for rapidly achieving sustainable progress toward TB elimination in a durable way, but safety and cost effectiveness have not been demonstrated. Sensitive, symptom-agnostic community screening, combined with effective tuberculosis treatment and prevention, should eliminate all infectious cases in the community, whilst identifying and treating people with latent infection will also eliminate tomorrow's tuberculosis cases. If real strides toward global tuberculosis elimination are to be made, bold strategies are required using the best available tools and a long horizon for cost-benefit assessment.
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Affiliation(s)
- Mikaela Coleman
- WHO Collaborating Centre for Tuberculosis and the Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Sydney, NSW, Australia
- Centenary Institute, The University of Sydney, Sydney, NSW, Australia
| | - Thu-Anh Nguyen
- Woolcock Institute of Medical Research, Hanoi, Vietnam
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Boi Khanh Luu
- Woolcock Institute of Medical Research, Hanoi, Vietnam
| | - Jeremy Hill
- WHO Collaborating Centre for Tuberculosis and the Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Sydney, NSW, Australia
- Centenary Institute, The University of Sydney, Sydney, NSW, Australia
| | - Romain Ragonnet
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - James M. Trauer
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Greg J. Fox
- WHO Collaborating Centre for Tuberculosis and the Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Woolcock Institute of Medical Research, Sydney, NSW, Australia
| | - Guy B. Marks
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Woolcock Institute of Medical Research, Sydney, NSW, Australia
- Department of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Ben J. Marais
- WHO Collaborating Centre for Tuberculosis and the Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Sydney, NSW, Australia
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Van't Hoog A, Viney K, Biermann O, Yang B, Leeflang MM, Langendam MW. Symptom- and chest-radiography screening for active pulmonary tuberculosis in HIV-negative adults and adults with unknown HIV status. Cochrane Database Syst Rev 2022; 3:CD010890. [PMID: 35320584 PMCID: PMC9109771 DOI: 10.1002/14651858.cd010890.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Systematic screening in high-burden settings is recommended as a strategy for early detection of pulmonary tuberculosis disease, reducing mortality, morbidity and transmission, and improving equity in access to care. Questioning for symptoms and chest radiography (CXR) have historically been the most widely available tools to screen for tuberculosis disease. Their accuracy is important for the design of tuberculosis screening programmes and determines, in combination with the accuracy of confirmatory diagnostic tests, the yield of a screening programme and the burden on individuals and the health service. OBJECTIVES To assess the sensitivity and specificity of questioning for the presence of one or more tuberculosis symptoms or symptom combinations, CXR, and combinations of these as screening tools for detecting bacteriologically confirmed pulmonary tuberculosis disease in HIV-negative adults and adults with unknown HIV status who are considered eligible for systematic screening for tuberculosis disease. Second, to investigate sources of heterogeneity, especially in relation to regional, epidemiological, and demographic characteristics of the study populations. SEARCH METHODS We searched the MEDLINE, Embase, LILACS, and HTA (Health Technology Assessment) databases using pre-specified search terms and consulted experts for unpublished reports, for the period 1992 to 2018. The search date was 10 December 2018. This search was repeated on 2 July 2021. SELECTION CRITERIA Studies were eligible if participants were screened for tuberculosis disease using symptom questions, or abnormalities on CXR, or both, and were offered confirmatory testing with a reference standard. We included studies if diagnostic two-by-two tables could be generated for one or more index tests, even if not all participants were subjected to a microbacteriological reference standard. We excluded studies evaluating self-reporting of symptoms. DATA COLLECTION AND ANALYSIS We categorized symptom and CXR index tests according to commonly used definitions. We assessed the methodological quality of included studies using the QUADAS-2 instrument. We examined the forest plots and receiver operating characteristic plots visually for heterogeneity. We estimated summary sensitivities and specificities (and 95% confidence intervals (CI)) for each index test using bivariate random-effects methods. We analyzed potential sources of heterogeneity in a hierarchical mixed-model. MAIN RESULTS The electronic database search identified 9473 titles and abstracts. Through expert consultation, we identified 31 reports on national tuberculosis prevalence surveys as eligible (of which eight were already captured in the search of the electronic databases), and we identified 957 potentially relevant articles through reference checking. After removal of duplicates, we assessed 10,415 titles and abstracts, of which we identified 430 (4%) for full text review, whereafter we excluded 364 articles. In total, 66 articles provided data on 59 studies. We assessed the 2 July 2021 search results; seven studies were potentially eligible but would make no material difference to the review findings or grading of the evidence, and were not added in this edition of the review. We judged most studies at high risk of bias in one or more domains, most commonly because of incorporation bias and verification bias. We judged applicability concerns low in more than 80% of studies in all three domains. The three most common symptom index tests, cough for two or more weeks (41 studies), any cough (21 studies), and any tuberculosis symptom (29 studies), showed a summary sensitivity of 42.1% (95% CI 36.6% to 47.7%), 51.3% (95% CI 42.8% to 59.7%), and 70.6% (95% CI 61.7% to 78.2%, all very low-certainty evidence), and a specificity of 94.4% (95% CI 92.6% to 95.8%, high-certainty evidence), 87.6% (95% CI 81.6% to 91.8%, low-certainty evidence), and 65.1% (95% CI 53.3% to 75.4%, low-certainty evidence), respectively. The data on symptom index tests were more heterogenous than those for CXR. The studies on any tuberculosis symptom were the most heterogeneous, but had the lowest number of variables explaining this variation. Symptom index tests also showed regional variation. The summary sensitivity of any CXR abnormality (23 studies) was 94.7% (95% CI 92.2% to 96.4%, very low-certainty evidence) and 84.8% (95% CI 76.7% to 90.4%, low-certainty evidence) for CXR abnormalities suggestive of tuberculosis (19 studies), and specificity was 89.1% (95% CI 85.6% to 91.8%, low-certainty evidence) and 95.6% (95% CI 92.6% to 97.4%, high-certainty evidence), respectively. Sensitivity was more heterogenous than specificity, and could be explained by regional variation. The addition of cough for two or more weeks, whether to any (pulmonary) CXR abnormality or to CXR abnormalities suggestive of tuberculosis, resulted in a summary sensitivity and specificity of 99.2% (95% CI 96.8% to 99.8%) and 84.9% (95% CI 81.2% to 88.1%) (15 studies; certainty of evidence not assessed). AUTHORS' CONCLUSIONS The summary estimates of the symptom and CXR index tests may inform the choice of screening and diagnostic algorithms in any given setting or country where screening for tuberculosis is being implemented. The high sensitivity of CXR index tests, with or without symptom questions in parallel, suggests a high yield of persons with tuberculosis disease. However, additional considerations will determine the design of screening and diagnostic algorithms, such as the availability and accessibility of CXR facilities or the resources to fund them, and the need for more or fewer diagnostic tests to confirm the diagnosis (depending on screening test specificity), which also has resource implications. These review findings should be interpreted with caution due to methodological limitations in the included studies and regional variation in sensitivity and specificity. The sensitivity and specificity of an index test in a specific setting cannot be predicted with great precision due to heterogeneity. This should be borne in mind when planning for and implementing tuberculosis screening programmes.
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Affiliation(s)
- Anja Van't Hoog
- Anja van't Hoog, Health Research & Training Consultancy, Utrecht, Netherlands
| | - Kerri Viney
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- School of Public Health, The University of Sydney, Sydney, Australia
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Olivia Biermann
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Bada Yang
- Epidemiology and Data Science, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Mariska Mg Leeflang
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Miranda W Langendam
- Epidemiology and Data Science, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
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Robsky KO, Kitonsa PJ, Mukiibi J, Nakasolya O, Isooba D, Nalutaaya A, Salvatore PP, Kendall EA, Katamba A, Dowdy D. Spatial distribution of people diagnosed with tuberculosis through routine and active case finding: a community-based study in Kampala, Uganda. Infect Dis Poverty 2020; 9:73. [PMID: 32571435 PMCID: PMC7310105 DOI: 10.1186/s40249-020-00687-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 06/01/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Routine tuberculosis (TB) notifications are geographically heterogeneous, but their utility in predicting the location of undiagnosed TB cases is unclear. We aimed to identify small-scale geographic areas with high TB notification rates based on routinely collected data and to evaluate whether these areas have a correspondingly high rate of undiagnosed prevalent TB. METHODS We used routinely collected data to identify geographic areas with high TB notification rates and evaluated the extent to which these areas correlated with the location of undiagnosed cases during a subsequent community-wide active case finding intervention in Kampala, Uganda. We first enrolled all adults who lived within 35 contiguous zones and were diagnosed through routine care at four local TB Diagnosis and Treatment Units. We calculated average monthly TB notification rates in each zone and defined geographic areas of "high risk" as zones that constituted the 20% of the population with highest notification rates. We compared the observed proportion of TB notifications among residents of these high-risk zones to the expected proportion, using simulated estimates based on population size and random variation alone. We then evaluated the extent to which these high-risk zones identified areas with high burdens of undiagnosed TB during a subsequent community-based active case finding campaign using a chi-square test. RESULTS We enrolled 45 adults diagnosed with TB through routine practices and who lived within the study area (estimated population of 49 527). Eighteen zones reported no TB cases in the 9-month period; among the remaining zones, monthly TB notification rates ranged from 3.9 to 39.4 per 100 000 population. The five zones with the highest notification rates constituted 62% (95% CI: 47-75%) of TB cases and 22% of the population-significantly higher than would be expected if population size and random chance were the only determinants of zone-to-zone variation (48%, 95% simulation interval: 40-59%). These five high-risk zones accounted for 42% (95% CI: 34-51%) of the 128 cases detected during the subsequent community-based case finding intervention, which was significantly higher than the 22% expected by chance (P < 0.001) but lower than the 62% of cases notified from those zones during the pre-intervention period (P = 0.02). CONCLUSIONS There is substantial heterogeneity in routine TB notification rates at the zone level. Using facility-based TB notification rates to prioritize high-yield areas for active case finding could double the yield of such case-finding interventions.
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Affiliation(s)
- Katherine O Robsky
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda.
| | - Peter J Kitonsa
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - James Mukiibi
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Olga Nakasolya
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - David Isooba
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Annet Nalutaaya
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Phillip P Salvatore
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Emily A Kendall
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda.,Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda.,Department of Medicine, Clinical Epidemiology and Biostatistics Unit, Makerere University, College of Health Sciences, Kampala, Uganda
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda.,Johns Hopkins School of Medicine, Baltimore, MD, USA
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Piatek AS, Wells WA, Shen KC, Colvin CE. Realizing the "40 by 2022" Commitment from the United Nations High-Level Meeting on the Fight to End Tuberculosis: What Will It Take to Meet Rapid Diagnostic Testing Needs? GLOBAL HEALTH, SCIENCE AND PRACTICE 2019; 7:551-563. [PMID: 31818871 PMCID: PMC6927833 DOI: 10.9745/ghsp-d-19-00244] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 09/17/2019] [Indexed: 11/23/2022]
Abstract
Existing rapid diagnostics offer faster and more sensitive diagnosis of tuberculosis (TB) and simultaneous detection of multidrug-resistant TB. A 5-fold increase in investment in these tools is needed to meet the needs of the TB community and the United Nations’ ambitious 40 million by 2022 diagnosis and treatment target. The potential gains from full adoption of World Health Organization (WHO)-recommended rapid diagnostics (WRDs) for tuberculosis (TB) are significant, but there is no current analysis of the additional investment needed to reach this goal. We sought to estimate the necessary investment in instruments, tests, and money, using Xpert MTB/RIF (Xpert), which detects Mycobacterium tuberculosis (MTB) and tests for resistance to rifampicin (RIF), as an example. An existing calculator for TB diagnostic needs was adapted to estimate the Xpert needs for a group of 24 countries with high TB burdens. This analysis assumed that countries will achieve the case-finding commitments agreed to at the recent United Nations High-Level Meeting on the Fight to End Tuberculosis, and that countries would adopt the WHO-recommended algorithm in which all people with signs and symptoms of TB receive an Xpert test. When compared to the current investments in these countries, this baseline model revealed that countries would require a 4-fold increase in the number of Xpert modules and a 6-fold increase in the number of Xpert test cartridges per year to meet their full testing needs. The incremental cost of the additional instruments for these countries would total approximately US$474 million, plus an incremental cost each year of cartridges of approximately $586 million, or a 5-fold increase over current investments. A sensitivity analysis revealed a variety of possible changes under alternative scenarios, but most of these changes either do not meet the global goals, are unrealistic, or would result in even greater investment needs. These findings suggest that a major investment is needed in WRD capacity to implement the recommended diagnostic algorithm for TB and reach the case-finding commitments by 2022.
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Affiliation(s)
- Amy S Piatek
- United States Agency for International Development, Washington, DC, USA
| | - William A Wells
- United States Agency for International Development, Washington, DC, USA.
| | - Kaiser C Shen
- United States Agency for International Development, Washington, DC, USA
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Sander MS, Laah SN, Titahong CN, Lele C, Kinge T, de Jong BC, Abena JLF, Codlin AJ, Creswell J. Systematic screening for tuberculosis among hospital outpatients in Cameroon: The role of screening and testing algorithms to improve case detection. J Clin Tuberc Other Mycobact Dis 2019; 15:100095. [PMID: 31720422 PMCID: PMC6830146 DOI: 10.1016/j.jctube.2019.100095] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Better screening and testing approaches are needed to improve TB case finding, particularly in health facilities where many people with TB seek care but are not diagnosed using the existing approaches. OBJECTIVE We aimed to evaluate the performance of various TB screening and testing approaches among hospital outpatients in a setting with a high prevalence of HIV/TB. METHODS We screened outpatients at a large hospital in Cameroon using both chest X-ray and a symptom questionnaire including current cough, fever, night sweats and/or weight loss. Participants with a positive screen were tested for TB using smear microscopy, the Xpert MTB/RIF assay, and culture. RESULTS Among 2051 people screened, 1137 (55%) reported one or more TB symptom and 389 (19%) had an abnormal chest X-ray. In total, 1255 people (61%) had a positive screen and 31 of those screened (1.5%) had bacteriologically confirmed TB. To detect TB, screening with cough >2 weeks had a sensitivity of 61% (95% CI, 44-78%). Screening for a combination of cough >2 -weeks and/or abnormal chest X-ray had a sensitivity of 81% (95% CI, 67-95%) and specificity of 71% (95% CI, 69-73%), while screening for a combination of cough >2 weeks or any of 2 or more symptoms had a similar performance. Smear microscopy and Xpert MTB/RIF detected 32% (10/31) and 55% (17/31), respectively, of people who had bacteriologically-confirmed TB. CONCLUSIONS Screening hospital outpatients for cough >2 weeks or for at least 2 of current cough, fever, night sweats or weight loss is a feasible strategy that had a high relative yield to detect bacteriologically-confirmed TB in this population. Clinical diagnosis of TB is still an important need, even where Xpert MTB/RIF testing is available.
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Affiliation(s)
- Melissa S. Sander
- Tuberculosis Reference Laboratory Bamenda, PO Box 586, Bamenda, Cameroon
| | | | | | | | | | - Bouke C. de Jong
- Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium
| | | | - Andrew J. Codlin
- Stop TB Partnership, Chemin du Pommier 40, 1218 Le Grand-Saconnex, Geneva, Switzerland
| | - Jacob Creswell
- Stop TB Partnership, Chemin du Pommier 40, 1218 Le Grand-Saconnex, Geneva, Switzerland
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Tiemersma EW, Huong NT, Yen PH, Tinh BT, Thuy TTB, Van Hung N, Mai NT, Verver S, Gebhard A, Nhung NV. Infection control and tuberculosis among health care workers in Viet Nam, 2009-2013: a cross-sectional survey. BMC Infect Dis 2016; 16:664. [PMID: 27832744 PMCID: PMC5103393 DOI: 10.1186/s12879-016-1993-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 10/29/2016] [Indexed: 11/10/2022] Open
Abstract
Background Data on tuberculosis (TB) among health care workers (HCW) and TB infection control (TBIC) indicators are rarely available at national level. We assessed multi-year trends in notification data of TB among HCW and explored possible associations with TBIC indicators. Methods Notified TB incidence among HCW and 3 other TBIC indicators were collected annually from all 64 provincial and 3 national TB facilities in Vietnam. Time trends in TB notification between 2009 and 2013 were assessed using linear regression analysis. Multivariate regression models were applied to assess associations between the facility-specific 5-year notification rate and TBIC indicators. Results Forty-seven (70 %) of 67 facilities contributed data annually over five years; 15 reported at least one HCW with TB in 2009 compared to six in 2013. The TB notification rate dropped from 593 to 197 per 100,000 HCW (ptrend = 0.02). Among 104 TB cases reported, 30 were employed at TB wards, 24 at other clinical wards, ten in the microbiology laboratory, six at the MDR-TB ward, and 34 in other positions. The proportion of facilities with a TBIC plan and focal person remained relatively stable between 70 % and 84 %. The proportion of facilities providing personal protective equipment (PPE) to their staff increased over time. Facilities with a TBIC focal person were 7.6 times more likely to report any TB cases than facilities without a focal person. Conclusions The TB notification rates among HCW seemed to decrease over time. Availability of PPE increased over the same period. Appointing a TBIC focal person was associated with reporting of TB cases among HCW. It remains unclear whether TBIC measures helped in reduction of the TB notification rates in HCW.
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Affiliation(s)
- Edine W Tiemersma
- KNCV Tuberculosis Foundation, Benoordenhoutseweg 46, 2596 BC, The Hague, The Netherlands.
| | - Nguyen Thien Huong
- KNCV Tuberculosis Foundation Vietnam Country Office, 130 Mai Anh Tuan Street, Hanoi, Vietnam
| | - Pham Hoang Yen
- National Tuberculosis Control Program of Vietnam, 463 Hoang Hoa Tham, Hanoi, Vietnam
| | - Bui Thi Tinh
- KNCV Tuberculosis Foundation Vietnam Country Office, 130 Mai Anh Tuan Street, Hanoi, Vietnam
| | - Tran Thi Bich Thuy
- National Tuberculosis Control Program of Vietnam, 463 Hoang Hoa Tham, Hanoi, Vietnam
| | - Nguyen Van Hung
- National Tuberculosis Control Program of Vietnam, 463 Hoang Hoa Tham, Hanoi, Vietnam
| | - Nguyen Thanh Mai
- Pham Ngoc Thach Hospital, 120 Hong Bang, Ho Chi Minh City, Vietnam
| | - Suzanne Verver
- KNCV Tuberculosis Foundation, Benoordenhoutseweg 46, 2596 BC, The Hague, The Netherlands
| | - Agnes Gebhard
- KNCV Tuberculosis Foundation, Benoordenhoutseweg 46, 2596 BC, The Hague, The Netherlands
| | - Nguyen Viet Nhung
- National Tuberculosis Control Program of Vietnam, 463 Hoang Hoa Tham, Hanoi, Vietnam
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Comparative meta-analysis of tuberculosis contact investigation interventions in eleven high burden countries. PLoS One 2015; 10:e0119822. [PMID: 25812013 PMCID: PMC4374904 DOI: 10.1371/journal.pone.0119822] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 01/16/2015] [Indexed: 11/30/2022] Open
Abstract
Background Screening of household contacts of tuberculosis (TB) patients is a recommended strategy to improve early case detection. While it has been widely implemented in low prevalence countries, the most optimal protocols for contact investigation in high prevalence, low resource settings is yet to be determined. This study evaluated contact investigation interventions in eleven lower and middle income countries and reviewed the association between context or program-related factors and the yield of cases among contacts. Methods We reviewed data from nineteen first wave TB REACH funded projects piloting innovations to improve case detection. These nineteen had fulfilled the eligibility criteria: contact investigation implementation and complete data reporting. We performed a cross-sectional analysis of the percentage yield and case notifications for each project. Implementation strategies were delineated and the association between independent variables and yield was analyzed by fitting a random effects logistic regression. Findings Overall, the nineteen interventions screened 139,052 household contacts, showing great heterogeneity in the percentage yield of microscopy confirmed cases (SS+), ranging from 0.1% to 6.2%). Compared to the most restrictive testing criteria (at least two weeks of cough) the aOR’s for lesser (any TB related symptom) and least (all contacts) restrictive testing criteria were 1.71 (95%CI 0.94−3.13) and 6.90 (95% CI 3.42−13.93) respectively. The aOR for inclusion of SS- and extra-pulmonary TB was 0.31 (95% CI 0.15−0.62) compared to restricting index cases to SS+ TB. Contact investigation contributed between <1% and 14% to all SS+ cases diagnosed in the intervention areas. Conclusions This study confirms that high numbers of active TB cases can be identified through contact investigation in a variety of contexts. However, design and program implementation factors appear to influence the yield of contact investigation and its concomitant contribution to TB case detection.
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Lin YH, Chen CP, Chen PY, Huang JC, Ho C, Weng HH, Tsai YH, Peng YS. Screening for pulmonary tuberculosis in type 2 diabetes elderly: a cross-sectional study in a community hospital. BMC Public Health 2015; 15:3. [PMID: 25572102 PMCID: PMC4324855 DOI: 10.1186/1471-2458-15-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 12/09/2014] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Tuberculosis is one of the major infectious diseases in Taiwan. It has an especially high prevalence in diabetes patients, in whom it is usually asymptomatic and are more likely to result in drug-resistant tuberculosis. The aim of the study was to aggressively screen high risk diabetic elderly, identify the prevalence of tuberculosis and its determinants. METHODS Type 2 diabetes patients aged over 65 years were enrolled. They received chest X-rays, blood tests and the questionnaires to assess their medical history and symptoms. Suspicious cases were referred to the pulmonary or infectious disease outpatient clinics. Pulmonary tuberculosis was confirmed by sputum culture. Variables between groups were analyzed by Student t test, Chi-square test or Fisher's exact test. Risk factors were assessed using univariate logistic regression and multiple logistic regression. RESULTS A total of 3,087 patients participated this screening program and 7 patients screened positive for pulmonary tuberculosis. Another 5 patients were being under treatment when participating screening program. The prevalence rate was 3.89 per thousand people. The patients with male gender, smoking, liver cirrhosis or subjective body weight loss were associated with an increased risk of tuberculosis significantly. Subjective body weight loss (OR: 6.635 [95% CI: 2.096-21.007]), liver cirrhosis (OR: 10.307 [95% CI: 2.108-50.395]) and history of smoking (OR: 3.981 [95% CI: 1.246-12.718]) are independent risk factors. Among all 73 patients with active tuberculosis or tuberculosis history, they tended to be male, lower body mass index (BMI), more smoking history, more alcohol consumption, more family history of tuberculosis, higher low density lipoprotein (LDL), and less hypertension. However, there was no significant difference in the glycated hemoglobin (HbA1c) levels between the tuberculosis group and non-tuberculosis group. CONCLUSIONS Active screening program is helpful in detecting pulmonary tuberculosis in elderly diabetes patients. Subjective body weight loss, smoking and liver cirrhosis are independent risk factors.
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Affiliation(s)
- Yung-Hsiang Lin
- />Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, No.6, W. Sec., Jiapu Rd, Puzih City, Chiayi County 613 Taiwan
| | - Chia-Pei Chen
- />Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, No.6, W. Sec., Jiapu Rd, Puzih City, Chiayi County 613 Taiwan
| | - Pao-Ying Chen
- />Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, No.6, W. Sec., Jiapu Rd, Puzih City, Chiayi County 613 Taiwan
| | - Jui-Chu Huang
- />Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, No.6, W. Sec., Jiapu Rd, Puzih City, Chiayi County 613 Taiwan
| | - Cheng Ho
- />Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, No.6, W. Sec., Jiapu Rd, Puzih City, Chiayi County 613 Taiwan
| | - Hsu-Huei Weng
- />Department of Diagnostic Radiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
- />Chang Gung University, College of Medicine, Tao-Yuan, Taiwan
| | - Ying-Huang Tsai
- />Division of Thoracic and Critical Care Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
- />Chang Gung University, College of Medicine, Tao-Yuan, Taiwan
| | - Yun-Shing Peng
- />Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, No.6, W. Sec., Jiapu Rd, Puzih City, Chiayi County 613 Taiwan
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Wei X, Zhang X, Yin J, Walley J, Beanland R, Zou G, Zhang H, Li F, Liu Z, Zee BCY, Griffiths SM. Changes in pulmonary tuberculosis prevalence: evidence from the 2010 population survey in a populous province of China. BMC Infect Dis 2014; 14:21. [PMID: 24410932 PMCID: PMC3890533 DOI: 10.1186/1471-2334-14-21] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 01/08/2014] [Indexed: 11/10/2022] Open
Abstract
Background This paper reports findings from the prevalence survey conducted in Shandong China in 2010, a province with a population of 94 million. This study aimed to estimate TB prevalence of the province in 2010 in comparison with the 2000 survey; and to compare yields of TB cases from different case finding approaches. Methods A population based, cross-sectional survey was conducted using multi-stage random cluster sampling. 54,279 adults participated in the survey with a response rate of 96%. Doctors interviewed and classified participants as suspected TB cases if they presented with persistent cough, abnormal chest X-ray (CXRAY), or both. Three sputum specimens of all suspected cases were collected and sent for smear microscopy and culture. Results Adjusted prevalence rate of bacteriologically confirmed cases was 34 per 100,000 for adults in Shandong in 2010. Compared to the 2000 survey, TB prevalence has declined by 80%. 53% of bacteriologically confirmed cases did not present persistent cough. The yield of bacteriologically confirmed cases was 47% by symptom screening and 95% by CXRAY. Over 50% of TB cases were among over 65’s. Conclusions The prevalence rate of bacteriologically confirmed cases was significantly reduced compared with 2000. The survey raised challenges to identify TB cases without clear symptoms.
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Affiliation(s)
| | - Xiulei Zhang
- Center for Tuberculosis Control, Shandong Provincial Chest Hospital, 12 Lieshishan Dong Lu, Jinan 250101, China.
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Sanchez A, Massari V, Gerhardt G, Espinola AB, Siriwardana M, Camacho LAB, Larouzé B. X ray screening at entry and systematic screening for the control of tuberculosis in a highly endemic prison. BMC Public Health 2013; 13:983. [PMID: 24139204 PMCID: PMC4015746 DOI: 10.1186/1471-2458-13-983] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 10/11/2013] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) is a major issue in prisons of low and middle income countries where TB incidence rates are much higher in prison populations as compared with the general population. In the Rio de Janeiro (RJ) State prison system, the TB control program is limited to passive case-finding and supervised short duration treatment. The aim of this study was to measure the impact of X-ray screening at entry associated with systematic screening on the prevalence and incidence of active TB. METHODS We followed up for 2 years a RJ State prison for adult males (1429 inmates at the beginning of the study) and performed, in addition to passive case-finding, 1) two "cross-sectional" X-ray systematic screenings: the first at the beginning of the study period and the second 13 months later; 2) X-ray screening of inmates entering the prison during the 2 year study period. Bacteriological examinations were performed in inmates presenting any pulmonary, pleural or mediastinal X-ray abnormality or spontaneously attending the prison clinic for symptoms suggestive of TB. RESULTS Overall, 4326 X-rays were performed and 246 TB cases were identified. Prevalence among entering inmates remained similar during 1st and the 2nd year of the study: 2.8% (21/754) and 2.9% (28/954) respectively, whereas prevalence decreased from 6.0% (83/1374) to 2.8% (35/1244) between 1st and 2nd systematic screenings (p < 0.0001). Incidence rates of cases identified by passive case-finding decreased from 42 to 19 per 1000 person-years between the 1st and the 2nd year (p < 0.0001). Cases identified by screenings were less likely to be bacteriologically confirmed as compared with cases identified by passive-case finding. CONCLUSIONS The strategy investigated, which seems highly effective, should be considered in highly endemic confined settings such as prisons.
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Affiliation(s)
- Alexandra Sanchez
- Programa de Controle de Tuberculose e, Coordenação de Gestão em Saúde Penitenciária, Secretaria de Estado de Administração Penitenciária, Rio de Janeiro, Brasil
| | - Veronique Massari
- INSERM U707, F-75012, Paris, France
- UPMC UMR-S707, F-75012, Paris, France
| | | | - Ana Beatriz Espinola
- Programa de Controle de Tuberculose e, Coordenação de Gestão em Saúde Penitenciária, Secretaria de Estado de Administração Penitenciária, Rio de Janeiro, Brasil
| | | | - Luiz Antonio B Camacho
- Departamento de Epidemiologia e Metodos Quantitativos em Saúde, Escola Nacional de Saude Publica, Fiocruz, Rio de Janeiro, Brasil
| | - Bernard Larouzé
- INSERM U707, F-75012, Paris, France
- UPMC UMR-S707, F-75012, Paris, France
- Departamento de Epidemiologia e Metodos Quantitativos em Saúde, Escola Nacional de Saude Publica, Fiocruz, Rio de Janeiro, Brasil
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Dowdy DW, Basu S, Andrews JR. Is passive diagnosis enough? The impact of subclinical disease on diagnostic strategies for tuberculosis. Am J Respir Crit Care Med 2012; 187:543-51. [PMID: 23262515 DOI: 10.1164/rccm.201207-1217oc] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Tuberculosis (TB) is characterized by a subclinical phase (symptoms absent or not considered abnormal); prediagnostic phase (symptoms noticed but diagnosis not pursued); and clinical phase (care actively sought). Diagnostic capacity during these phases is limited. OBJECTIVES To estimate the population-level impact of TB case-finding strategies in the presence of subclinical and prediagnostic disease. METHODS We created a mathematical epidemic model of TB, calibrated to global incidence. We then introduced three prototypical diagnostic interventions: increased sensitivity of diagnosis in the clinical phase by 20% ("passive"); early diagnosis during the prediagnostic phase at a rate of 10% per year ("enhanced"); and population-based diagnosis of 5% of undiagnosed prevalent cases per year ("active"). MEASUREMENTS AND MAIN RESULTS If the subclinical phase was ignored, as in most models, the passive strategy was projected to reduce TB incidence by 18% (90% uncertainty range [UR], 11-32%) by year 10, compared with 23% (90% UR, 14-35%) for the enhanced strategy and 18% (90% UR, 11-28%) for the active strategy. After incorporating a subclinical phase into the model, consistent with population-based prevalence surveys, the active strategy still reduced 10-year TB incidence by 16% (90% UR, 11-28%), but the passive and enhanced strategies' impact was attenuated to 11% (90% UR, 8-25%) and 6% (90% UR, 4-13%), respectively. The degree of attenuation depended strongly on the transmission rate during the subclinical phase. CONCLUSIONS Subclinical disease may limit the impact of current diagnostic strategies for TB. Active detection of undiagnosed prevalent cases may achieve greater population-level TB control than increasing passive case detection.
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Affiliation(s)
- David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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