1
|
Gogichadze N, Sagrera A, Vicente JÁ, Millet JP, López-Seguí F, Vilaplana C. Cost-effectiveness of active tuberculosis screening among high-risk populations in low tuberculosis incidence countries: a systematic review, 2008 to 2023. Euro Surveill 2024; 29:2300614. [PMID: 38516785 PMCID: PMC11063676 DOI: 10.2807/1560-7917.es.2024.29.12.2300614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/15/2024] [Indexed: 03/23/2024] Open
Abstract
BackgroundIn countries with a low TB incidence (≤ 10 cases/100,000 population), active pulmonary tuberculosis (PTB) mostly affects vulnerable populations with limited access to healthcare. Thus, passive case-finding systems may not be successful in detecting and treating cases and preventing further transmission. Active and cost-effective search strategies can overcome this problem.AimWe aimed to review the evidence on the cost-effectiveness (C-E) of active PTB screening programmes among high-risk populations in low TB incidence countries.MethodsWe performed a systematic literature search covering 2008-2023 on PubMed, Embase, Center for Reviews and Dissemination, including Database of Abstracts of Reviews of Effects (DARE), National Health Services Economic Evaluation Database (NHS EED), Global Index Medicus and Cochrane Central Register of Controlled Trials (CENTRAL).ResultsWe retrieved 6,318 articles and included nine in this review. All included studies had an active case-finding approach and used chest X-ray, tuberculin skin test, interferon-gamma release assay and a symptoms questionnaire for screening. The results indicate that screening immigrants from countries with a TB incidence > 40 cases per 100,000 population and other vulnerable populations as individuals from isolated communities, people experiencing homelessness, those accessing drug treatment services and contacts, is cost-effective in low-incidence countries.ConclusionIn low-incidence countries, targeting high-risk groups is C-E. However, due to the data heterogenicity, we were unable to compare C-E. Harmonisation of the methods for C-E analysis is needed and would facilitate comparisons. To outline comprehensive screening and its subsequent C-E analysis, researchers should consider multiple factors influencing screening methods and outcomes.
Collapse
Affiliation(s)
- Nino Gogichadze
- Unitat de Tuberculosi Experimental, Germans Trias i Pujol Research Institute and Hospital (IGTP-HUGTIP), Badalona, Catalonia, Spain
- These authors contributed equally to the work and share the first authorship
- Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Catalonia, Spain
| | - Arnau Sagrera
- Unitat de Tuberculosi Experimental, Germans Trias i Pujol Research Institute and Hospital (IGTP-HUGTIP), Badalona, Catalonia, Spain
- These authors contributed equally to the work and share the first authorship
| | - José Ángel Vicente
- Research Group on Innovation, Health Economics and Digital Transformation (INEDIT), Institut de Recerca Germans Trias i Pujol, Badalona, Catalonia, Spain
- Fundació Lluita contra les Infeccions, Germans Trias i Pujol Research Institute and Hospital (IGTP-HUGTIP), Badalona, Catalonia, Spain
- Centre de Recerca en Economia de la Salut (CRES), Universitat Pompeu Fabra, Barcelona, Catalonia, Spain
| | - Joan-Pau Millet
- Servei d'Epidemiologia, Agència de Salut Pública Barcelona (ASPB), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Francesc López-Seguí
- Research Group on Innovation, Health Economics and Digital Transformation (INEDIT), Institut de Recerca Germans Trias i Pujol, Badalona, Catalonia, Spain
- Fundació Lluita contra les Infeccions, Germans Trias i Pujol Research Institute and Hospital (IGTP-HUGTIP), Badalona, Catalonia, Spain
- Centre de Recerca en Economia de la Salut (CRES), Universitat Pompeu Fabra, Barcelona, Catalonia, Spain
| | - Cristina Vilaplana
- Unitat de Tuberculosi Experimental, Germans Trias i Pujol Research Institute and Hospital (IGTP-HUGTIP), Badalona, Catalonia, Spain
- Microbiology Department, Northern Metropolitan Clinical Laboratory, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
- Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Catalonia, Spain
- Direcció Clínica Territorial de Malalties Infeccioses i Salut Internacional de Gerència Territorial Metropolitana Nord de l'Institut Català de la Salut, Badalona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| |
Collapse
|
2
|
Khan H, Gupta M, Bou-Akl T, Markel D. Tuberculosis Screening via Chest X-Ray is Financially Burdensome in Previously Independently Living Elective Total Knee Arthroplasty Patients. Spartan Med Res J 2022; 7:30158. [PMID: 35291702 PMCID: PMC8873440 DOI: 10.51894/001c.30158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/27/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In 1995, to reduce the transmission of Tuberculosis (TB) the Centers for Disease Control and Prevention recommended that all patients discharged from hospitals be required to have chest x-rays (i.e., radiography) performed before admission to long term care facilities (LTCFs). Previously independently living patients (PILPs) who undergo elective total knee replacement (TKA) surgery are a population at higher risk to end up in LTCFs for rehabilitation. By 2017, the incidence of TB was 9,105 cases compared to 22,762 in 1995. However, the recommendations that hospitals be required to perform a chest x-ray in all patients (including PILPs) being transferred to LTCF's have remained in place. The purposes of this study were to: a) determine the incidence of TB-positive chest x-rays in PILPS discharged to LTCFs after undergoing elective TKA surgery, and b) assess the cost (i.e., both financial and possible exposure to unnecessary radiation) of mandated chest x-rays before hospital discharge to LTCF for PILPs. METHODS Retrospective 2012-2017 patient chart data were collected from the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) to identify all elective TKAs for PILPs performed at two Ascension participating centers. Study data included sex, age, body mass index (BMI), length of stay, comorbidities, and chest x-ray results before discharge. Patients who underwent surgery for fracture, infection, trauma, or malignancy were excluded from the study. Categorical data were analyzed using Fisher's exact test and Student's t-test were used for continuous data. RESULTS The authors identified 4,041 total elective TKA's, from which 500 PILPs were discharged to a LTCF due to functional, medical and/or social concerns. Chest x-rays were associated with 500 (100%) negative findings for TB. Overall hospital costs for chest x-rays for patient's being discharged to an extended care facility totaled $90,848. CONCLUSIONS The mandated use of chest x-rays for TB screening of PILPs undergoing elective surgery TKA prior to discharge to LTCFs appear to place an unnecessary financial burden on the healthcare system. The mandatory use of x-rays for assessment of possible TB infection before transfer to LTCFs appears to also expose PILPs unnecessarily to radiation. Although further studies are needed to verify these results, the authors recommend that perhaps instead chest x-rays should be reserved for patients with specific comorbidities (e.g., patients on immunosuppressive therapy, with HIV, etc.) or for those patients residing in LTCFs prior to surgery.
Collapse
Affiliation(s)
- Haseeb Khan
- College of Human MedicineMichigan State University
| | - Mayank Gupta
- College of Human MedicineMichigan State University
| | | | - David Markel
- College of Human Medicine, Michigan State University; Ascension Providence Hospital; The CORE Institute
| |
Collapse
|
3
|
Han SB, Park J, Ji SK, Jang SH, Shin S, Kim MS, Kim SS, Park SH. The impact of the Xpert MTB/RIF screening among hospitalized patients with pneumonia on timely isolation of patients with pulmonary tuberculosis. Sci Rep 2021; 11:1694. [PMID: 33462255 PMCID: PMC7814080 DOI: 10.1038/s41598-020-79639-7] [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] [Received: 06/16/2020] [Accepted: 11/18/2020] [Indexed: 11/17/2022] Open
Abstract
In South Korea where the tuberculosis (TB) burden is intermediate, the risk of in-hospital transmission of TB remains high. We conducted a retrospective cohort study of 244 inpatients diagnosed with pulmonary TB (2015–2018) to evaluate the impact of the Xpert MTB/RIF assay (Xpert) screening on timely isolation. TB screening was performed with smear microscopy and a polymerase chain reaction test, and the Xpert was additionally used from November 2016. Among all patients with pulmonary TB, the median time-to-isolation was significantly reduced (22.6 vs. 69.7 h; p < 0.001) and segmented regression analysis adjusting for the time trend showed a reduction in time-to-isolation with the introduction of the Xpert (− 39.3 h; 95% CI − 85.6, 7.0; p = 0.096). Among 213 patients who were timely screened (≤ 72 h after admission), time-to-isolation decreased significantly (− 38.2 h; 95% CI − 70.6, − 5.8; p = 0.021) with the introduction of the Xpert, and its decreasing trend continued. The Xpert provided a shorter turnaround time (4.8 vs. 49.1 h; p < 0.001) and higher sensitivity (76.6% vs. 47.8%; p < 0.001) than smear microscopy. Thus, the Xpert can be a useful screening test for pulmonary TB in real-life hospital settings with an intermediate TB burden.
Collapse
Affiliation(s)
- Seung Beom Han
- Infection Prevention and Control Unit, The Catholic University of Korea, Daejeon St. Mary's Hospital, Daejeon, Korea.,Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joonhong Park
- Infection Prevention and Control Unit, The Catholic University of Korea, Daejeon St. Mary's Hospital, Daejeon, Korea.,Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seul Ki Ji
- Infection Prevention and Control Unit, The Catholic University of Korea, Daejeon St. Mary's Hospital, Daejeon, Korea
| | - So Hee Jang
- Infection Prevention and Control Unit, The Catholic University of Korea, Daejeon St. Mary's Hospital, Daejeon, Korea
| | - Soyoung Shin
- Infection Prevention and Control Unit, The Catholic University of Korea, Daejeon St. Mary's Hospital, Daejeon, Korea.,Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Myung Sook Kim
- Division of Pulmonology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Soo Kim
- Division of Pulmonology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sun Hee Park
- Infection Prevention and Control Unit, The Catholic University of Korea, Daejeon St. Mary's Hospital, Daejeon, Korea. .,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| |
Collapse
|
4
|
Herrera Diaz M, Haworth-Brockman M, Keynan Y. Review of Evidence for Using Chest X-Rays for Active Tuberculosis Screening in Long-Term Care in Canada. Front Public Health 2020; 8:16. [PMID: 32117851 PMCID: PMC7025450 DOI: 10.3389/fpubh.2020.00016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 01/17/2020] [Indexed: 12/16/2022] Open
Abstract
Background: People living in long-term care facilities (LTCF) are at high risk to develop active tuberculosis primarily as a result of reactivation of a latent TB infection, or endemic transmission between residents. Current national guidelines in Canada are to use a posterior-anterior and lateral chest X-ray to screen for TB for those over 65 years old, upon admission to a LTCF. Objective: To assess the available evidence for cost benefits of universal chest X-ray screening for new LTCF residents. Methodology: We conducted a search for all articles published until September 2018, in PubMed and WorlCat databases, in English, using a combination of key words: chest X-ray, chest radiography or CXR, long-term care, elderly, screening, and tuberculosis. We also reviewed publicly available guidelines for screening new residents to LTCF from across Canada. We report on a qualitative synthesis of the evidence in the documents retrieved. Results: The final review yielded four cost-effectiveness studies (2 of 4 conducted in countries with low incidence), one systematic review, one recommendation/editorial, and one cohort study. We found that in a tuberculosis low-incidence country the CXR cost per identified case was $672,298 CAD. Enacting a more targeted screening program, perhaps one that tests only those who previously had TB, or other high-risk medical conditions may enhance the cost-effectiveness. Recommendations: We suggest reviewing the screening policy for active TB in people entering LTCF, which is based on a CXR. The results indicate that a targeted search for active TB in people with symptoms or other high-risk medical conditions may be more cost-effective.
Collapse
Affiliation(s)
- Mariana Herrera Diaz
- Grupo de Investigación en Salud Pública, Universidad Pontificia Bolivariana, Medellín, Colombia.,Facultad Nacional de Salud Pública, Universidad de Antioquia, Medellín, Colombia
| | - Margaret Haworth-Brockman
- National Collaborating Centre for Infectious Diseases, Winnipeg, MB, Canada.,Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Yoav Keynan
- National Collaborating Centre for Infectious Diseases, Winnipeg, MB, Canada.,Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Internal Medicine, Medical Microbiology & Infectious Diseases, University of Manitoba, Winnipeg, MB, Canada
| |
Collapse
|
5
|
Campbell JR, Dowdy D, Schwartzman K. Treatment of latent infection to achieve tuberculosis elimination in low-incidence countries. PLoS Med 2019; 16:e1002824. [PMID: 31170161 PMCID: PMC6553715 DOI: 10.1371/journal.pmed.1002824] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
In a Perspective for the Tuberculosis Special Issue, Kevin Schwartzman and colleagues discuss the choices and implications for personal versus public health benefits when pursuing tuberculosis elimination in low-incidence countries.
Collapse
Affiliation(s)
- Jonathon R. Campbell
- McGill International TB Centre, McGill University, Montréal, Québec, Canada
- Respiratory Epidemiology and Clinical Research Unit, Montréal Chest Institute, McGill University Health Centre, Montréal, Québec, Canada
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Kevin Schwartzman
- McGill International TB Centre, McGill University, Montréal, Québec, Canada
- Respiratory Epidemiology and Clinical Research Unit, Montréal Chest Institute, McGill University Health Centre, Montréal, Québec, Canada
- * E-mail:
| |
Collapse
|
6
|
Faust L, McCarthy A, Schreiber Y. Recommendations for the screening of paediatric latent tuberculosis infection in indigenous communities: a systematic review of screening strategies among high-risk groups in low-incidence countries. BMC Public Health 2018; 18:979. [PMID: 30081879 PMCID: PMC6090746 DOI: 10.1186/s12889-018-5886-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 07/25/2018] [Indexed: 11/13/2022] Open
Abstract
Background Tuberculosis (TB) continues to be a global public health concern. Due to the presence of multiple risk factors such as poor housing conditions and food insecurity in Canadian Indigenous communities, this population is at particularly high risk of TB infection. Given the challenges of screening for latent TB infection (LTBI) in remote communities, a synthesis of the existing literature regarding current screening strategies among high-risk groups in low-incidence countries is warranted, in order to provide an evidence base for the optimization of paediatric LTBI screening practices in the Canadian Indigenous context. Methods A literature search of the Embase and Medline databases was conducted, and studies pertaining the evaluation of screening strategies or screening tools for LTBI in paediatric high-risk groups in low-incidence countries were included. Studies focusing on LTBI screening in Indigenous communities were also included, regardless of whether they focused on a paediatric population. Their results were summarized and discussed in the context of their relevance to screening strategies suitable to the Canadian Indigenous setting. Grey literature sources such as government reports or policy briefs were also consulted. Results The initial literature search returned 327 studies, with 266 being excluded after abstract screening, and 36 studies being included in the final review (original research studies: n = 25, review papers or policy recommendations: n = 11). In the examined studies, case identification and cost-effectiveness of universal screening were low in low-incidence countries. Therefore, studies generally recommended targeted screening of high-risk groups in low-incidence countries, however, there remains a lack of consensus regarding cut-offs for the incidence-based screening of high-risk communities, as well as regarding the utility and prioritization of individual risk-factor-based screening of high-risk groups. The utility of the TST compared to IGRAs for LTBI detection in the pediatric population also remains contested. Conclusions Relevant strategies for targeted screening in the Canadian Indigenous context include community-level incidence-based screening (screening based on geographic location within high-incidence communities), as well as individual risk-factor-based screening, taking into account pertinent risk factors in Indigenous settings, such as poor housing conditions, malnutrition, contact with an active case, or the presence of relevant co-morbidities, such as renal disease.
Collapse
Affiliation(s)
- Lena Faust
- Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Anne McCarthy
- Department of Medicine, University of Ottawa, Ottawa, Canada.,Ottawa Hospital Research Institute, Ottawa, Canada
| | - Yoko Schreiber
- Department of Medicine, University of Ottawa, Ottawa, Canada. .,Ottawa Hospital Research Institute, Ottawa, Canada.
| |
Collapse
|
7
|
Li J, Yip BHK, Leung C, Chung W, Kwok KO, Chan EYY, Yeoh E, Chung P. Screening for latent and active tuberculosis infection in the elderly at admission to residential care homes: A cost-effectiveness analysis in an intermediate disease burden area. PLoS One 2018; 13:e0189531. [PMID: 29293514 PMCID: PMC5749681 DOI: 10.1371/journal.pone.0189531] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 11/27/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) in the elderly remains a challenge in intermediate disease burden areas like Hong Kong. Given a higher TB burden in the elderly and limited impact of current case-finding strategy by patient-initiated pathway, proactive screening approaches for the high-risk group could be optimal and increasingly need targeted economic evaluations. In this study, we examined whether and under what circumstance the screening strategies are cost-effective compared with no screening strategy for the elderly at admission to residential care homes. METHODS A decision analytic process based on Markov model was adopted to evaluate the cost-effectiveness of four strategies: (i) no screening, (ii) TB screening (CXR) and (iii) TB screening (Xpert) represent screening for TB in symptomatic elderly by chest X-ray and Xpert® MTB/RIF respectively, and (iv) LTBI/TB screening represents screening for latent and active TB infection by QuantiFERON®-TB Gold In-Tube and chest X-ray. The target population was a hypothetical cohort of 65-year-old people, using a health service provider perspective and a time horizon of 20 years. The outcomes were direct medical costs, life-years and quality-adjusted life-years (QALYs) measured by incremental cost-effectiveness ratio (ICER). RESULTS In the base-case analysis, no screening was the most cost-saving; TB screening (CXR) was dominated by TB screening (Xpert); LTBI/TB screening resulted in more life-years and QALYs accrued. The ICERs of LTBI/TB screening were US$19,712 and US$29,951 per QALY gained compared with no screening and TB screening (Xpert), respectively. At the willingness-to-pay threshold of US$50,000 per QALY gained, LTBI/TB screening was the most cost-effective when the probability of annual LTBI reactivation was greater than 0.155% and acceptability of LTBI/TB screening was greater than 38%. In 1,000 iterations of Monte Carlo simulation, the probabilities of no screening, TB screening (CXR), TB screening (Xpert), and LTBI/TB screening to be cost-effective were 0, 1.3%, 20.1%, and 78.6% respectively. CONCLUSIONS Screening for latent and active TB infection in Hong Kong elderly people at admission to residential care homes appears to be highly effective and cost-effective. The key findings may be the next key factor to bring down TB endemic in the elderly population among intermediate TB burden areas.
Collapse
Affiliation(s)
- Jun Li
- Jockey School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Benjamin H. K. Yip
- Jockey School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Chichiu Leung
- Tuberculosis and Chest Service, Department of Health, Hong Kong, China
| | - Wankyo Chung
- Department of Public Health Science, Graduate School of Public Health, Seoul National University, Seoul, South Korea
| | - Kin On Kwok
- Jockey School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Emily Y. Y. Chan
- Jockey School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Engkiong Yeoh
- Jockey School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Puihong Chung
- Jockey School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
- * E-mail:
| |
Collapse
|
8
|
Battling Tuberculosis beyond antibiotics. Value Health Reg Issues 2017; 13:79-81. [DOI: 10.1016/j.vhri.2017.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 07/30/2017] [Accepted: 08/03/2017] [Indexed: 11/21/2022]
|
9
|
Li J, Chung PH, Leung CLK, Nishikiori N, Chan EYY, Yeoh EK. The strategic framework of tuberculosis control and prevention in the elderly: a scoping review towards End TB targets. Infect Dis Poverty 2017; 6:70. [PMID: 28569191 PMCID: PMC5452345 DOI: 10.1186/s40249-017-0284-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 03/13/2017] [Indexed: 11/10/2022] Open
Abstract
With the rapid pace of population ageing, tuberculosis (TB) in the elderly increasingly becomes a public health challenge. Despite the increasing burden and high risks for TB in the elderly, targeted strategy has not been well understood and evaluated. We undertook a scoping review to identify current TB strategies, research and policy gaps in the elderly and summarized the results within a strategic framework towards End TB targets. Databases of Embase, MEDLINE, Global health and EBM reviews were searched for original studies, review articles, and policy papers published in English between January 1990 and December 2015. Articles examining TB strategy, program, guideline or intervention in the elderly from public health perspective were included.Nineteen articles met the inclusion criteria. Most of them were qualitative studies, issued in high- and middle-income countries and after 2000. To break the chain of TB transmission and reactivation in the elderly, infection control, interventions of avoiding delay in diagnosis and containment are essential for preventing transmission, especially in elderly institutions and aged immigrants; screening of latent TB infection and preventive therapy had effective impacts on reducing the risk of reactivation and should be used less reluctantly in older people; optimizing early case-finding with a high index of suspicion, systematic screening for prioritized high-risk groups, initial empirical and adequate follow-up treatment with close monitoring and evaluation, as well as enhanced programmatic management are fundamental pillars for active TB elimination. Evaluation of TB epidemiology, risk factors, impacts and cost-effectiveness of interventions, adopting accurate and rapid diagnostic tools, shorter and less toxic preventive therapy, are critical issues for developing strategy in the elderly towards End TB targets.TB control strategies in the elderly were comprehensively mapped in a causal link pathway. The framework and principals identified in this study will help to evaluate and improve current program, develop targeted strategy, as well as raise more discussions on the research priority settings and policy transitions. Given the scarceness of policy and evaluated interventions, as well as the unawareness of shifting TB epidemiology and strategy especially in developing countries, the increasing need of a ready TB program for the elderly warrants further research.
Collapse
Affiliation(s)
- Jun Li
- JC School of Public Health and Primary Care, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - Pui-Hong Chung
- JC School of Public Health and Primary Care, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China.
| | - Cyrus L K Leung
- JC School of Public Health and Primary Care, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - Nobuyuki Nishikiori
- World Health Organization Regional Office for the Western Pacific, Manila, Philippines
| | - Emily Y Y Chan
- JC School of Public Health and Primary Care, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - Eng-Kiong Yeoh
- JC School of Public Health and Primary Care, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| |
Collapse
|
10
|
KOWADA A. Cost-effectiveness of interferon-gamma release assays for tuberculosis screening in nursing homes. Epidemiol Infect 2016; 144:3215-3225. [PMID: 27412626 PMCID: PMC9150199 DOI: 10.1017/s0950268816001382] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 05/13/2016] [Accepted: 06/09/2016] [Indexed: 11/07/2022] Open
Abstract
Tuberculosis (TB) in older people is a significant public health problem in low TB-incidence countries. Older persons have increased TB incidence, higher reactivation and mortality. A delay in diagnosis and initiation of TB treatment in patients with atypical clinical and radiological features is a significant factor of widespread transmission. This study aimed to evaluate the cost-effectiveness of interferon-gamma release assays [IGRAs; QuantiFERON®-TB Gold In-Tube (QFT) and T-SPOT®.TB (T-SPOT)] compared to the tuberculin skin test (TST) and chest X-ray (CXR) examination for TB screening for nursing homes. Decision trees and Markov models were constructed using a societal perspective on a lifetime horizon. Seven strategies: no screening, TST, QFT, T-SPOT, TST followed by QFT, TST followed by T-SPOT, and CXR were considered. QFT [US$ 401·9, 4·36 707 QALY (year 2014 values)] was the most cost-effective at the willingness-to-pay level of US$ 50 000/QALY gained. TST followed by QFT was the most cost-effective in residents with comorbidities. CXR was less cost-effective. Cost-effectiveness was sensitive to latent TB infection (LTBI) rate and bacillus Calmette-Guérin vaccination rate. Effective LTBI screening using IGRA is recommended to prevent TB transmission not only in nursing homes but also in local communities in low-incidence countries.
Collapse
Affiliation(s)
- A. KOWADA
- General Affairs Department, Ota City Office, Tokyo, Japan
| |
Collapse
|
11
|
Lönnroth K, Migliori GB, Abubakar I, D'Ambrosio L, de Vries G, Diel R, Douglas P, Falzon D, Gaudreau MA, Goletti D, González Ochoa ER, LoBue P, Matteelli A, Njoo H, Solovic I, Story A, Tayeb T, van der Werf MJ, Weil D, Zellweger JP, Abdel Aziz M, Al Lawati MR, Aliberti S, Arrazola de Oñate W, Barreira D, Bhatia V, Blasi F, Bloom A, Bruchfeld J, Castelli F, Centis R, Chemtob D, Cirillo DM, Colorado A, Dadu A, Dahle UR, De Paoli L, Dias HM, Duarte R, Fattorini L, Gaga M, Getahun H, Glaziou P, Goguadze L, del Granado M, Haas W, Järvinen A, Kwon GY, Mosca D, Nahid P, Nishikiori N, Noguer I, O'Donnell J, Pace-Asciak A, Pompa MG, Popescu GG, Robalo Cordeiro C, Rønning K, Ruhwald M, Sculier JP, Simunović A, Smith-Palmer A, Sotgiu G, Sulis G, Torres-Duque CA, Umeki K, Uplekar M, van Weezenbeek C, Vasankari T, Vitillo RJ, Voniatis C, Wanlin M, Raviglione MC. Towards tuberculosis elimination: an action framework for low-incidence countries. Eur Respir J 2015; 45:928-52. [PMID: 25792630 PMCID: PMC4391660 DOI: 10.1183/09031936.00214014] [Citation(s) in RCA: 530] [Impact Index Per Article: 58.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 01/02/2015] [Indexed: 12/31/2022]
Abstract
This paper describes an action framework for countries with low tuberculosis (TB) incidence (<100 TB cases per million population) that are striving for TB elimination. The framework sets out priority interventions required for these countries to progress first towards "pre-elimination" (<10 cases per million) and eventually the elimination of TB as a public health problem (less than one case per million). TB epidemiology in most low-incidence countries is characterised by a low rate of transmission in the general population, occasional outbreaks, a majority of TB cases generated from progression of latent TB infection (LTBI) rather than local transmission, concentration to certain vulnerable and hard-to-reach risk groups, and challenges posed by cross-border migration. Common health system challenges are that political commitment, funding, clinical expertise and general awareness of TB diminishes as TB incidence falls. The framework presents a tailored response to these challenges, grouped into eight priority action areas: 1) ensure political commitment, funding and stewardship for planning and essential services; 2) address the most vulnerable and hard-to-reach groups; 3) address special needs of migrants and cross-border issues; 4) undertake screening for active TB and LTBI in TB contacts and selected high-risk groups, and provide appropriate treatment; 5) optimise the prevention and care of drug-resistant TB; 6) ensure continued surveillance, programme monitoring and evaluation and case-based data management; 7) invest in research and new tools; and 8) support global TB prevention, care and control. The overall approach needs to be multisectorial, focusing on equitable access to high-quality diagnosis and care, and on addressing the social determinants of TB. Because of increasing globalisation and population mobility, the response needs to have both national and global dimensions.
Collapse
Affiliation(s)
- Knut Lönnroth
- Global TB Programme, World Health Organization, Geneva, Switzerland
- Both authors contributed equally
| | - Giovanni Battista Migliori
- WHO Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, IRCCS, Tradate, Italy
- Both authors contributed equally
| | - Ibrahim Abubakar
- TB Section, University College London and Public Health England, London, UK
| | - Lia D'Ambrosio
- WHO Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, IRCCS, Tradate, Italy
| | | | - Roland Diel
- University Hospital Schleswig Holstein, Institute for Epidemiology, Kiel, Germany
| | - Paul Douglas
- Global Health Borders Refugee and Onshore Services, Dept of Immigration and Border Protection, Sydney, Australia
| | - Dennis Falzon
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Marc-Andre Gaudreau
- Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Montreal, QC, Canada
| | - Delia Goletti
- National Institute for Infectious Diseases, Rome, Italy
| | - Edilberto R. González Ochoa
- Research and Surveillance Group on TB, Leprosy and ARI, Epidemiology Board, Institute of Tropical Medicine “Pedro Kourí”, Havana, Cuba
| | - Philip LoBue
- Division of TB Elimination, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Howard Njoo
- Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Montreal, QC, Canada
| | - Ivan Solovic
- TB Dept, National Institute for TB, Respiratory Diseases and Thoracic Surgery, Vysne Hagy, Catholic University, Ružomberok, Slovakia
| | | | - Tamara Tayeb
- National TB Control Programme, Ministry of Health, Riyadh, Saudi Arabia
| | | | - Diana Weil
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | | | | | | | - Stefano Aliberti
- Università degli Studi di Milano – Bicocca, UO Clinica Pneumologica, AO San Gerardo, Monza, Italy
| | | | | | - Vineet Bhatia
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Francesco Blasi
- Dipartimento Fisiopatologia Medico-Chirurgica e dei Trapianti, University of Milan, IRCCS Fondazione Cà Granda, Milan, Italy
| | - Amy Bloom
- US Agency for International Development, Washington, DC, USA
| | - Judith Bruchfeld
- Unit of Infectious Diseases, Institution of Medicine, Karolinska Institute Solna and Karolinska University Hospital, Stockholm, Sweden
| | | | - Rosella Centis
- WHO Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, IRCCS, Tradate, Italy
| | | | | | | | - Andrei Dadu
- TB and M/XDR-TB Control Programme, WHO Regional Office for Europe, Copenhagen, Denmark
| | - Ulf R. Dahle
- Norwegian Institute of Public Health, Oslo, Norway
| | | | - Hannah M. Dias
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | | | | | - Mina Gaga
- National Referral Centre for Mycobacteria, Athens Chest Hospital, Ministry of Health, Athens, Greece
| | | | - Philippe Glaziou
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Lasha Goguadze
- International Federation of Red Cross and Red Crescent Societies, Geneva, Switzerland
| | | | - Walter Haas
- Dept of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Asko Järvinen
- Finnish Lung Health Association, Helsinki, Finland
- Helsinki University Central Hospital, Division of Infectious Diseases, Helsinki, Finland
| | - Geun-Yong Kwon
- Korea Centers for Disease Control and Prevention (KCDC), Ministry of Health and Welfare, Seoul, Republic of Korea
| | - Davide Mosca
- International Organization for Migration, Geneva, Switzerland
| | - Payam Nahid
- University of California, San Francisco, CA, USA
- American Thoracic Society (ATS), New York, NY, USA
| | - Nobuyuki Nishikiori
- Stop TB and Leprosy Elimination, WHO Regional Office for the Western Pacific, Manila, Philippines
| | | | - Joan O'Donnell
- HSE Health Protection Surveillance Centre, Dublin, Ireland
| | | | | | | | | | | | | | | | | | | | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Dept of Biomedical Sciences, University of Sassari, Research, Medical Education and Professional Development Unit, AOU Sassari, Sassari, Italy
| | - Giorgia Sulis
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Carlos A. Torres-Duque
- Asociacion Latinoamericana de Torax (ALAT) - Fundacion Neumologica Colombiana, Bogota, Colombia
| | | | - Mukund Uplekar
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | | | | | | | | | - Maryse Wanlin
- Fonds des Affections Respiratoires (FARES), Brussels, Belgium
| | | |
Collapse
|