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Leavitt SV, Rodriguez CA, Bouton TC, Horsburgh CR, Abel Zur Wiesch P, Nichols BE, White LF, Jenkins HE. Outcomes for people with TB by disease severity at presentation. Int J Tuberc Lung Dis 2024; 28:142-147. [PMID: 38454178 DOI: 10.5588/ijtld.23.0254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND There is substantial heterogeneity in disease presentation for individuals with TB disease, which may correlate with disease outcomes. We estimated disease outcomes by disease severity at presentation among individuals with TB during the pre-chemotherapy era.METHODS We extracted data on people with TB enrolled between 1917 and 1948 in the USA, stratified by three disease severity categories at presentation using the U.S. National Tuberculosis Association diagnostic criteria. These criteria were based largely on radiographic findings ("minimal", "moderately advanced", and "far advanced"). We used Bayesian parametric survival analysis to model the survival distribution overall, and by disease severity and Bayesian logistic regression to estimate the severity-level specific natural recovery odds within 3 years.RESULTS People with minimal TB at presentation had a 2% (95% CrI 0-11%) probability of TB death within 5 years vs. 40% (95% CrI 15-68) for those with far advanced disease. Individuals with minimal disease had 13.62 times the odds (95% CrI 9.87-19.10) of natural recovery within 3 years vs. those with far advanced disease.CONCLUSION Mortality and natural recovery vary by disease severity at presentation. This supports continued work to evaluate individualized (e.g., shortened or longer) regimens based on disease severity at presentation, identified using radiography..
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Affiliation(s)
| | - C A Rodriguez
- Departments of Epidemiology, Boston University School of Public Health, Boston, MA
| | - T C Bouton
- Section of Infectious Diseases, Boston Medical Center, Boston, MA, Boston University School of Medicine, Boston, MA
| | - C R Horsburgh
- Departments of Biostatistics and, Departments of Epidemiology, Boston University School of Public Health, Boston, MA, Boston University School of Medicine, Boston, MA, Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - P Abel Zur Wiesch
- Division for Infection Control and Environmental Health, Norwegian Institute of Public Health, Norway;, Center of Infectious Disease Dynamics, Pennsylvania State University, Philadelphia, PA, USA
| | - B E Nichols
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
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Yamkovoy K, Self JL, Jenkins HE, Horsburgh CR, White LF. Patterns of TB transmission in the United States, 2011-2017. Int J Tuberc Lung Dis 2024; 28:154-156. [PMID: 38454181 DOI: 10.5588/ijtld.23.0422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Affiliation(s)
- K Yamkovoy
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - J L Self
- Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - H E Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - C R Horsburgh
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, Departments of Global Health and Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - L F White
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
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Xiong Y, Millones AK, Farroñay S, Torres I, Acosta D, Jordan DR, Jimenez J, Wippel C, Jenkins HE, Lecca L, Yuen CM. Impact of the private sector on spatial accessibility to chest radiography services in Lima, Peru. IJTLD Open 2024; 1:144-146. [PMID: 38698907 PMCID: PMC11065097 DOI: 10.5588/ijtldopen.23.0460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Affiliation(s)
- Yiqi Xiong
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA
| | | | | | | | | | - Demetrice R. Jordan
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Christoph Wippel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Helen E. Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Leonid Lecca
- Socios En Salud Sucursal Peru, Lima, Peru
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Courtney M. Yuen
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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Chevalier JM, Han AX, Hansen MA, Klock E, Pandithakoralage H, Ockhuisen T, Girdwood SJ, Lekodeba NA, de Nooy A, Khan S, Johnson CC, Sacks JA, Jenkins HE, Russell CA, Nichols BE. Impact and cost-effectiveness of SARS-CoV-2 self-testing strategies in schools: a multicountry modelling analysis. BMJ Open 2024; 14:e078674. [PMID: 38417953 PMCID: PMC10900377 DOI: 10.1136/bmjopen-2023-078674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 02/13/2024] [Indexed: 03/01/2024] Open
Abstract
OBJECTIVES To determine the most epidemiologically effective and cost-effective school-based SARS-CoV-2 antigen-detection rapid diagnostic test (Ag-RDT) self-testing strategies among teachers and students. DESIGN Mathematical modelling and economic evaluation. SETTING AND PARTICIPANTS Simulated school and community populations were parameterised to Brazil, Georgia and Zambia, with SARS-CoV-2 self-testing strategies targeted to teachers and students in primary and secondary schools under varying epidemic conditions. INTERVENTIONS SARS-CoV-2 Ag-RDT self-testing strategies for only teachers or teachers and students-only symptomatically or symptomatically and asymptomatically at 5%, 10%, 40% or 100% of schools at varying frequencies. OUTCOME MEASURES Outcomes were assessed in terms of total infections and symptomatic days among teachers and students, as well as total infections and deaths within the community under the intervention compared with baseline. The incremental cost-effectiveness ratios (ICERs) were calculated for infections prevented among teachers and students. RESULTS With respect to both the reduction in infections and total cost, symptomatic testing of all teachers and students appears to be the most cost-effective strategy. Symptomatic testing can prevent up to 69·3%, 64·5% and 75·5% of school infections in Brazil, Georgia and Zambia, respectively, depending on the epidemic conditions, with additional reductions in community infections. ICERs for symptomatic testing range from US$2 to US$19 per additional school infection averted as compared with symptomatic testing of teachers alone. CONCLUSIONS Symptomatic testing of teachers and students has the potential to cost-effectively reduce a substantial number of school and community infections.
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Affiliation(s)
- Joshua M Chevalier
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Alvin X Han
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Megan A Hansen
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Ethan Klock
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Hiromi Pandithakoralage
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Tom Ockhuisen
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Nkgomeleng A Lekodeba
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alexandra de Nooy
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | | | - Jilian A Sacks
- Department of Epidemic and Pandemic Preparedness and Prevention, World Health Organization, Geneva, Switzerland
| | - Helen E Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Colin A Russell
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Brooke E Nichols
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- FIND, Geneva, Switzerland
- Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
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5
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Rodriguez CA, Horsburgh CR, Jenkins HE, White LF. Reply to 'Estimating TB survival - mind the immortal-time gap'. Int J Tuberc Lung Dis 2024; 28:66-67. [PMID: 38178287 DOI: 10.5588/ijtld.23.0485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024] Open
Affiliation(s)
- C A Rodriguez
- Departments of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - C R Horsburgh
- Departments of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - H E Jenkins
- Departments of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - L F White
- Departments of Biostatistics, Boston University School of Public Health, Boston, MA, USA
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Shapiro AN, Scott L, Moultrie H, Jacobson KR, Bor J, Fofana AM, Dor G, Ndjeka NO, da Silva P, Mlisana K, Jenkins HE, Stevens WS. Tuberculosis testing patterns in South Africa to identify groups that would benefit from increased investigation. Sci Rep 2023; 13:20875. [PMID: 38012266 PMCID: PMC10682361 DOI: 10.1038/s41598-023-47148-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 11/09/2023] [Indexed: 11/29/2023] Open
Abstract
The National Health Laboratory Service (NHLS) collects all public health laboratory test results in South Africa, providing a cohort from which to identify groups, by age, sex, HIV, and viral suppression status, that would benefit from increased tuberculosis (TB) testing. Using NHLS data (2012-2016), we assessed levels and trends over time in TB diagnostic tests performed (count and per capita) and TB test positivity. Estimates were stratified by HIV status, viral suppression, age, sex, and province. We used logistic regression to estimate the odds of testing positive for TB by viral suppression status. Nineteen million TB diagnostic tests were conducted during period 2012-2016. Testing per capita was lower among PLHIV with viral suppression than those with unsuppressed HIV (0.08 vs 0.32) but lowest among people without HIV (0.03). Test positivity was highest among young adults (aged 15-35 years), males of all age groups, and people with unsuppressed HIV. Test positivity was higher for males without laboratory evidence of HIV than those with HIV viral suppression, despite similar individual odds of TB. Our results are an important national baseline characterizing who received TB testing in South Africa. People without evidence of HIV, young adults, and males would benefit from increased TB screening given their lower testing rates and higher test positivity. These high-test positivity groups can be used to guide future expansions of TB screening.
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Affiliation(s)
- Anne N Shapiro
- Department of Biostatistics, Boston University School of Public Health, Boston, USA.
- Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.
| | - Lesley Scott
- Wits Diagnostic Innovation Hub, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Harry Moultrie
- Centre for Tuberculosis, A division of the National Health Laboratory Services, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Karen R Jacobson
- Division of Infectious Diseases, Boston Medical Center, Boston, USA
| | - Jacob Bor
- Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, USA
| | - Abdou M Fofana
- Department of Biostatistics, Boston University School of Public Health, Boston, USA
- Questrom School of Business, Institute for Health System Innovation & Policy, Boston University, Boston, USA
| | - Graeme Dor
- Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Pedro da Silva
- National Health Laboratory Service, National Priority Program, Johannesburg, South Africa
| | - Koleka Mlisana
- National Health Laboratory Service, National Priority Program, Johannesburg, South Africa
| | - Helen E Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, USA
| | - Wendy S Stevens
- Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Service, National Priority Program, Johannesburg, South Africa
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Rodriguez CA, Leavitt SV, Bouton TC, Horsburgh CR, Zur Wiesch PA, Nichols B, Jenkins HE, White LF. Survival of people with untreated TB: effects of time, geography and setting. Int J Tuberc Lung Dis 2023; 27:694-702. [PMID: 37608480 PMCID: PMC10443783 DOI: 10.5588/ijtld.22.0668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/30/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND: An estimated 40% of people who developed TB in 2021 were not diagnosed or treated. Pre-chemotherapy era data are a rich resource on survival of people with untreated TB. We aimed to identify heterogeneities in these data to inform their more precise use.METHODS: We extracted survival data from pre-chemotherapy era papers reporting TB-specific mortality and/or natural recovery data. We used Bayesian parametric survival analysis to model the survival distribution, stratifying by geography (North America vs. Europe), time (pre-1930 vs. post-1930), and setting (sanitoria vs. non-sanitoria).RESULTS: We found 12 studies with TB-specific mortality data. Ten-year survival was 69% in North America (95% CI 54-81) and 36% in Europe (95% CI 10-71). Only 38% (95% CI 18-63) of non-sanitorium individuals survived to 10 years compared to 69% (95% CI 41-87) of sanitoria/hospitalized patients. There were no significant differences between people diagnosed pre-1930 and post-1930 (5-year survival pre-1930: 65%, 95% CI 44-88 vs. post-1930: 72%, 95% CI 41-94).CONCLUSIONS: Mortality and natural recovery risks vary substantially by location and setting. These heterogeneities need to be considered when using pre-chemotherapy data to make inferences about expected survival of people with undiagnosed TB.
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Affiliation(s)
| | - S V Leavitt
- Departments of Biostatistics, Boston University School of Public Health, Boston, MA
| | - T C Bouton
- Section of Infectious Diseases, Boston Medical Center, Boston, MA, Boston University School of Medicine, Boston, MA, USA
| | - C R Horsburgh
- Departments of Epidemiology, and, Departments of Biostatistics, Boston University School of Public Health, Boston, MA
| | - P Abel Zur Wiesch
- Division for Infection Control and Environmental Health, Norwegian Institute of Public Health, Oslo, Norway, Center of Infectious Disease Dynamics, Pennsylvania State University, Philadelphia, PA
| | - B Nichols
- Department of Global Health, Boston University School of Public Health, Boston, MA USA
| | - H E Jenkins
- Departments of Biostatistics, Boston University School of Public Health, Boston, MA
| | - L F White
- Departments of Biostatistics, Boston University School of Public Health, Boston, MA
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8
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Jenkins HE, Starke J. Revealing Gaps in Our Understanding of Finding Children With TB and Our Ability to Inform Policy. Pediatrics 2023; 151:e2022059849. [PMID: 36987807 PMCID: PMC10071426 DOI: 10.1542/peds.2022-059849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2022] [Indexed: 03/30/2023] Open
Affiliation(s)
- Helen E. Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Jeffrey Starke
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, Texas
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9
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Fofana AM, Moultrie H, Scott L, Jacobson KR, Shapiro AN, Dor G, Crankshaw B, Silva PD, Jenkins HE, Bor J, Stevens WS. Cross-municipality migration and spread of tuberculosis in South Africa. Sci Rep 2023; 13:2674. [PMID: 36792792 PMCID: PMC9930008 DOI: 10.1038/s41598-023-29804-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 02/10/2023] [Indexed: 02/17/2023] Open
Abstract
Human migration facilitates the spread of infectious disease. However, little is known about the contribution of migration to the spread of tuberculosis in South Africa. We analyzed longitudinal data on all tuberculosis test results recorded by South Africa's National Health Laboratory Service (NHLS), January 2011-July 2017, alongside municipality-level migration flows estimated from the 2016 South African Community Survey. We first assessed migration patterns in people with laboratory-diagnosed tuberculosis and analyzed demographic predictors. We then quantified the impact of cross-municipality migration on tuberculosis incidence in municipality-level regression models. The NHLS database included 921,888 patients with multiple clinic visits with TB tests. Of these, 147,513 (16%) had tests in different municipalities. The median (IQR) distance travelled was 304 (163 to 536) km. Migration was most common at ages 20-39 years and rates were similar for men and women. In municipality-level regression models, each 1% increase in migration-adjusted tuberculosis prevalence was associated with a 0.47% (95% CI: 0.03% to 0.90%) increase in the incidence of drug-susceptible tuberculosis two years later, even after controlling for baseline prevalence. Similar results were found for rifampicin-resistant tuberculosis. Accounting for migration improved our ability to predict future incidence of tuberculosis.
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Affiliation(s)
- Abdou M Fofana
- Institute for Health System Innovation & Policy, Boston University, Questrom School of Business, Boston, USA.
- Boston University School of Public Health, Boston, USA.
| | - Harry Moultrie
- Centre for Tuberculosis, National Institute for Communicable Diseases, a division of the National Health Laboratory Services, Johannesburg, South Africa
| | - Lesley Scott
- Wits Diagnostic Innovation Hub, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen R Jacobson
- Section of Infectious Diseases, Boston University School of Medicine and Boston Medical Center, Boston, USA
| | | | - Graeme Dor
- Wits Diagnostic Innovation Hub, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Beth Crankshaw
- Centre for Tuberculosis, National Institute for Communicable Diseases, a division of the National Health Laboratory Services, Johannesburg, South Africa
| | - Pedro Da Silva
- National Health Laboratory Service, Johannesburg, South Africa
| | | | - Jacob Bor
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Boston University School of Public Health, Boston, USA
| | - Wendy S Stevens
- Wits Diagnostic Innovation Hub, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Service, Johannesburg, South Africa
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10
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Horsburgh CR, Jo Y, Nichols B, Jenkins HE, Russell CA, White LF. Contribution of Reinfection to Annual Rate of Tuberculosis Infection (ARI) and Incidence of Tuberculosis Disease. Clin Infect Dis 2023; 76:e965-e972. [PMID: 35666515 PMCID: PMC10169390 DOI: 10.1093/cid/ciac451] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/24/2022] [Accepted: 06/01/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Modeling studies have concluded that 60-80% of tuberculosis (TB) infections result from reinfection of previously infected persons. The annual rate of infection (ARI), a standard measure of the risk of TB infection in a community, may not accurately reflect the true risk of infection among previously infected persons. We constructed a model of infection and reinfection with Mycobacterium tuberculosis to explore the predictive accuracy of ARI and its effect on disease incidence. METHODS We created a deterministic simulation of the progression from TB infection to disease and simulated the prevalence of TB infection at the beginning and end of a theoretical year of infection. We considered 10 disease prevalence scenarios ranging from 100/100 000 to 1000/100 000 in simulations where TB exposure probability was homogeneous across the whole simulated population or heterogeneously stratified into high-risk and low-risk groups. ARI values, rates of progression from infection to disease, and the effect of multiple reinfections were obtained from published studies. RESULTS With homogeneous exposure risk, observed ARI values produced expected numbers of infections. However, when heterogeneous risk was introduced, observed ARI was seen to underestimate true ARI by 25-58%. Of the cases of TB disease that occurred, 36% were among previously infected persons when prevalence was 100/100 000, increasing to 79% of cases when prevalence was 1000/100 000. CONCLUSIONS Measured ARI underestimates true ARI as a result of heterogeneous population mixing. The true force of infection in a community may be greater than previously appreciated. Hyperendemic communities likely contribute disproportionally to the global TB disease burden.
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Affiliation(s)
- C Robert Horsburgh
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Youngji Jo
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Brooke Nichols
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Helen E Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Colin A Russell
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Laura F White
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
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Knudsen S, Babu SP, Ramakrishnan J, Jenkins HE, Joseph N, Cintron C, Narasimhan PB, Salgame P, Hochberg NS, Hom DL, Ellner J, Horsburgh CR, Sarkar S. M. tuberculosis infection before, during and after pregnancy. Int J Tuberc Lung Dis 2023; 27:72-74. [PMID: 36853122 DOI: 10.5588/ijtld.22.0390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- S Knudsen
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Boston, MA, USA
| | - S P Babu
- Department of Preventive & Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - J Ramakrishnan
- Department of Preventive & Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - H E Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston MA, USA
| | - N Joseph
- Department of Microbiology, JIPMER, Puducherry, India
| | - C Cintron
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Boston, MA, USA
| | - P B Narasimhan
- Department of Preventive & Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - P Salgame
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - N S Hochberg
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Boston, MA, USA
| | - D L Hom
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - J Ellner
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - C R Horsburgh
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Boston, MA, USA, Department of Biostatistics, Boston University School of Public Health, Boston MA, USA, Departments of Epidemiology and Global Health, Boston University School of Public Health, Boston, MA, USA
| | - S Sarkar
- Department of Preventive & Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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12
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Yuen CM, Brooks MB, Millones AK, Acosta D, Del Águila-Rojas E, Campos H, Farroñay S, Morales G, Ramirez-Sandoval J, Nichols TC, Jimenez J, Jenkins HE, Lecca L. Geospatial analysis of reported activity locations to identify sites for tuberculosis screening. Sci Rep 2022; 12:14094. [PMID: 35982104 PMCID: PMC9387880 DOI: 10.1038/s41598-022-18456-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
Mobile screening units can help close tuberculosis case detection gaps. Placing screening units where people at high risk for undiagnosed tuberculosis preferentially spend time could make screening more resource-effective. We conducted a case–control study in Lima, Peru to identify locations where people with tuberculosis were more likely to spend time than community controls. We surveyed participants about activity locations over the past 6 months. We used density-based clustering to assess how patient and control activity locations differed, and logistic regression to compare location-based exposures. We included 109 tuberculosis patients and 79 controls. In density-based clustering analysis, the two groups had similar patterns of living locations, but their work locations clustered in distinct areas. Both groups were similarly likely to use public transit, but patients predominantly used buses and were less likely to use rapid transit (adjusted odds ratio [aOR] 0.31, 95% confidence interval [CI] 0.10–0.96) or taxis (aOR 0.42, 95% CI 0.21–0.85). Patients were more likely to have spent time in prison (aOR 11.55, 95% CI 1.48–90.13). Placing mobile screening units at bus terminals serving locations where tuberculosis patients have worked and within and around prisons could help reach people with undiagnosed tuberculosis.
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Affiliation(s)
- Courtney M Yuen
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA. .,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
| | - Meredith B Brooks
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | | | | | | - Tim C Nichols
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Helen E Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Leonid Lecca
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Socios En Salud Sucursal Peru, Lima, Peru
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13
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Leavitt SV, Jenkins HE, Sebastiani P, Lee RS, Horsburgh CR, Tibbs AM, White LF. Estimation of the generation interval using pairwise relative transmission probabilities. Biostatistics 2022; 23:807-824. [PMID: 33527996 PMCID: PMC9291635 DOI: 10.1093/biostatistics/kxaa059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 11/13/2022] Open
Abstract
The generation interval (the time between infection of primary and secondary cases) and its often used proxy, the serial interval (the time between symptom onset of primary and secondary cases) are critical parameters in understanding infectious disease dynamics. Because it is difficult to determine who infected whom, these important outbreak characteristics are not well understood for many diseases. We present a novel method for estimating transmission intervals using surveillance or outbreak investigation data that, unlike existing methods, does not require a contact tracing data or pathogen whole genome sequence data on all cases. We start with an expectation maximization algorithm and incorporate relative transmission probabilities with noise reduction. We use simulations to show that our method can accurately estimate the generation interval distribution for diseases with different reproductive numbers, generation intervals, and mutation rates. We then apply our method to routinely collected surveillance data from Massachusetts (2010-2016) to estimate the serial interval of tuberculosis in this setting.
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Affiliation(s)
- Sarah V Leavitt
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA 02118; Epidemiology Division, University of Toronto Dalla Lana School of Public Health, 155 College St Room 500, Toronto, ON M5T 3M7, Canada; Department of Epidemiology, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA 02118; and Massachusetts Department of Public Health, 250 Washington St, Boston, MA 02108
| | - Helen E Jenkins
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA 02118; Epidemiology Division, University of Toronto Dalla Lana School of Public Health, 155 College St Room 500, Toronto, ON M5T 3M7, Canada; Department of Epidemiology, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA 02118; and Massachusetts Department of Public Health, 250 Washington St, Boston, MA 02108
| | - Paola Sebastiani
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA 02118; Epidemiology Division, University of Toronto Dalla Lana School of Public Health, 155 College St Room 500, Toronto, ON M5T 3M7, Canada; Department of Epidemiology, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA 02118; and Massachusetts Department of Public Health, 250 Washington St, Boston, MA 02108
| | - Robyn S Lee
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA 02118; Epidemiology Division, University of Toronto Dalla Lana School of Public Health, 155 College St Room 500, Toronto, ON M5T 3M7, Canada; Department of Epidemiology, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA 02118; and Massachusetts Department of Public Health, 250 Washington St, Boston, MA 02108
| | - C Robert Horsburgh
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA 02118; Epidemiology Division, University of Toronto Dalla Lana School of Public Health, 155 College St Room 500, Toronto, ON M5T 3M7, Canada; Department of Epidemiology, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA 02118; and Massachusetts Department of Public Health, 250 Washington St, Boston, MA 02108
| | - Andrew M Tibbs
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA 02118; Epidemiology Division, University of Toronto Dalla Lana School of Public Health, 155 College St Room 500, Toronto, ON M5T 3M7, Canada; Department of Epidemiology, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA 02118; and Massachusetts Department of Public Health, 250 Washington St, Boston, MA 02108
| | - Laura F White
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA 02118; Epidemiology Division, University of Toronto Dalla Lana School of Public Health, 155 College St Room 500, Toronto, ON M5T 3M7, Canada; Department of Epidemiology, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA 02118; and Massachusetts Department of Public Health, 250 Washington St, Boston, MA 02108
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14
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Sy KTL, Leavitt SV, de Vos M, Dolby T, Bor J, Horsburgh CR, Warren RM, Streicher EM, Jenkins HE, Jacobson KR. Spatial heterogeneity of extensively drug resistant-tuberculosis in Western Cape Province, South Africa. Sci Rep 2022; 12:10844. [PMID: 35760977 PMCID: PMC9237070 DOI: 10.1038/s41598-022-14581-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 06/09/2022] [Indexed: 02/04/2023] Open
Abstract
Tuberculosis (TB) remains a leading infectious disease killer globally. Treatment outcomes are especially poor among people with extensively drug-resistant (XDR) TB, until recently defined as rifampicin-resistant (RR) TB with resistance to an aminoglycoside (amikacin) and a fluoroquinolone (ofloxacin). We used laboratory TB test results from Western Cape province, South Africa between 2012 and 2015 to identify XDR-TB and pre-XDR-TB (RR-TB with resistance to one second-line drug) spatial hotspots. We mapped the percentage and count of individuals with RR-TB that had XDR-TB and pre-XDR-TB across the province and in Cape Town, as well as amikacin-resistant and ofloxacin-resistant TB. We found the percentage of pre-XDR-TB and the count of XDR-TB/pre-XDR-TB highly heterogeneous with geographic hotspots within RR-TB high burden areas, and found hotspots in both percentage and count of amikacin-resistant and ofloxacin-resistant TB. The spatial distribution of percentage ofloxacin-resistant TB hotspots was similar to XDR-TB hotspots, suggesting that fluoroquinolone-resistace is often the first step to additional resistance. Our work shows that interventions used to reduce XDR-TB incidence may need to be targeted within spatial locations of RR-TB, and further research is required to understand underlying drivers of XDR-TB transmission in these locations.
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Affiliation(s)
- Karla Therese L Sy
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Sarah V Leavitt
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Margaretha de Vos
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research/South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Tania Dolby
- National Health Laboratory Service, Cape Town, South Africa
| | - Jacob Bor
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - C Robert Horsburgh
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Section of Infectious Diseases, School of Medicine and Boston Medical Center, Boston University, Boston, MA, USA
| | - Robin M Warren
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research/South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elizabeth M Streicher
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research/South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Helen E Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Karen R Jacobson
- Section of Infectious Diseases, School of Medicine and Boston Medical Center, Boston University, Boston, MA, USA.
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15
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Jenkins HE, Ayuk S, Puma D, Brooks MB, Millones AK, Jimenez J, Lecca L, Galea JT, Becerra M, Keshavjee S, Yuen CM. Geographic accessibility to health facilities predicts uptake of community-based tuberculosis screening in an urban setting. Int J Infect Dis 2022; 120:125-131. [PMID: 35470023 PMCID: PMC9176313 DOI: 10.1016/j.ijid.2022.04.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/11/2022] [Accepted: 04/15/2022] [Indexed: 01/13/2023] Open
Abstract
Objectives: Annually, more than 30% of individuals with tuberculosis (TB) remain undiagnosed. We aimed to assess whether geographic accessibility measures can identify neighborhoods that would benefit from TB screening services targeted toward closing the diagnosis gap. Methods: We used data from a community-based mobile TB screening program in Carabayllo district, Lima, Peru. We constructed four accessibility measures from the geographic center of neighborhoods to health facilities. We used logistic regression to assess the association between these measures and screening uptake in one’s residential neighborhood versus elsewhere, with quasi-information criterion values to assess the association. Results: We analyzed the screening locations for 25,000 Carabayllo residents from 49 neighborhoods. Pedestrian walk time was preferable to Euclidean distance or vehicular time in our models. For each additional 12 minutes walking time between the neighborhood and the health facility, the odds of residents using TB screening units located in their neighborhoods increased by 50% (95% CI: 26%–78%). Females had 9% (95% CI: 3%–16%) increased odds versus males of using a screening unit in their own neighborhood. Conclusion: Placing mobile TB screening units in neighborhoods with longer pedestrian time to access health facilities could benefit individuals who face more acute access barriers to health care.
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Affiliation(s)
| | - Sally Ayuk
- University of Texas at Arlington, Arlington, Texas, USA
| | | | | | | | | | - Leonid Lecca
- Socios en Salud Sucursal Peru, Lima, Peru; Harvard Medical School, Boston, MA, USA
| | - Jerome T Galea
- School of Social Work, University of South Florida, Tampa, FL, USA; College of Public Health, University of South Florida, Tampa, FL, USA
| | | | - Salmaan Keshavjee
- Harvard Medical School, Boston, MA, USA; Brigham and Women's Hospital, Boston, MA, USA
| | - Courtney M Yuen
- Harvard Medical School, Boston, MA, USA; Brigham and Women's Hospital, Boston, MA, USA.
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16
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Kuzyk PV, Padilla R, Rybak NR, Hoshovska II, Kitov VO, Savchyna MO, Jenkins HE, Chiang SS, Horsburgh CR, Dolynska M, Petrenko V, Gychka SG. Missed Tuberculosis Diagnoses: Analysis of Pediatric Autopsy Data From General Hospitals in Lviv, Ukraine. J Pediatric Infect Dis Soc 2022; 11:300-302. [PMID: 35395086 PMCID: PMC9214781 DOI: 10.1093/jpids/piac016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 03/04/2022] [Indexed: 11/13/2022]
Abstract
We reviewed autopsy data from general hospitals in Lviv, Ukraine to understand pediatric mortality due to tuberculosis (TB). We identified 14 (0.6%) of 2345 autopsied children with unrecognized or untreated TB. More sensitive TB diagnostics for children and improved strategies for identifying which children require TB evaluation are urgently needed.
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Affiliation(s)
- Petro V Kuzyk
- Department of Pathological Anatomy, Bogomolets National Medical University, Kyiv, Ukraine
| | - Rachel Padilla
- School of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Natasha R Rybak
- Infectious Diseases and Immunology, Miriam Hospital, Providence, Rhode Island, USA
| | | | | | - Mariia O Savchyna
- Department of Paediatric and Adolescent Diseases, Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine
| | - Helen E Jenkins
- Corresponding Author: Helen E. Jenkins, PhD, MSc, Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118, USA. E-mail:
| | - Silvia S Chiang
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island, USA,Center for International Health Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Charles Robert Horsburgh
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Maria Dolynska
- Department of Tuberculosis and Pulmonology, Bogomolets National Medical University, Kyiv, Ukraine
| | - Vasyl Petrenko
- Department of Tuberculosis and Pulmonology, Bogomolets National Medical University, Kyiv, Ukraine
| | - Sergiy G Gychka
- Department of Pathological Anatomy, Bogomolets National Medical University, Kyiv, Ukraine
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17
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Brooks MB, Jenkins HE, Puma D, Tzelios C, Millones AK, Jimenez J, Galea JT, Lecca L, Becerra MC, Keshavjee S, Yuen CM. A role for community-level socioeconomic indicators in targeting tuberculosis screening interventions. Sci Rep 2022; 12:781. [PMID: 35039612 PMCID: PMC8764089 DOI: 10.1038/s41598-022-04834-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 12/30/2021] [Indexed: 11/29/2022] Open
Abstract
Tuberculosis screening programs commonly target areas with high case notification rates. However, this may exacerbate disparities by excluding areas that already face barriers to accessing diagnostic services. We compared historic case notification rates, demographic, and socioeconomic indicators as predictors of neighborhood-level tuberculosis screening yield during a mobile screening program in 74 neighborhoods in Lima, Peru. We used logistic regression and Classification and Regression Tree (CART) analysis to identify predictors of screening yield. During February 7, 2019-February 6, 2020, the program screened 29,619 people and diagnosed 147 tuberculosis cases. Historic case notification rate was not associated with screening yield in any analysis. In regression analysis, screening yield decreased as the percent of vehicle ownership increased (odds ratio [OR]: 0.76 per 10% increase in vehicle ownership; 95% confidence interval [CI]: 0.58-0.99). CART analysis identified the percent of blender ownership (≤ 83.1% vs > 83.1%; OR: 1.7; 95% CI: 1.2-2.6) and the percent of TB patients with a prior tuberculosis episode (> 10.6% vs ≤ 10.6%; OR: 3.6; 95% CI: 1.0-12.7) as optimal predictors of screening yield. Overall, socioeconomic indicators were better predictors of tuberculosis screening yield than historic case notification rates. Considering community-level socioeconomic characteristics could help identify high-yield locations for screening interventions.
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Affiliation(s)
- Meredith B Brooks
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA.
- Harvard Medical School Center for Global Health Delivery, Boston, MA, USA.
| | - Helen E Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | | | - Christine Tzelios
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
- Socios En Salud Sucursal Peru, Lima, Peru
| | | | | | - Jerome T Galea
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
- School of Social Work, University of South Florida, Tampa, FL, USA
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Leonid Lecca
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
- Socios En Salud Sucursal Peru, Lima, Peru
| | - Mercedes C Becerra
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
- Harvard Medical School Center for Global Health Delivery, Boston, MA, USA
| | - Salmaan Keshavjee
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
- Harvard Medical School Center for Global Health Delivery, Boston, MA, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Courtney M Yuen
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
- Harvard Medical School Center for Global Health Delivery, Boston, MA, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
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18
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Abstract
BACKGROUND To stop tuberculosis (TB), the leading infectious cause of death globally, we need to better understand transmission risk factors. Although many studies have identified associations between individual-level covariates and pathogen genetic relatedness, few have identified characteristics of transmission pairs or explored how closely covariates associated with genetic relatedness mirror those associated with transmission. METHODS We simulated a TB-like outbreak with pathogen genetic data and estimated odds ratios (ORs) to correlate each covariate and genetic relatedness. We used a naive Bayes approach to modify the genetic links and nonlinks to resemble the true links and nonlinks more closely and estimated modified ORs with this approach. We compared these two sets of ORs with the true ORs for transmission. Finally, we applied this method to TB data in Hamburg, Germany, and Massachusetts, USA, to find pair-level covariates associated with transmission. RESULTS Using simulations, we found that associations between covariates and genetic relatedness had the same relative magnitudes and directions as the true associations with transmission, but biased absolute magnitudes. Modifying the genetic links and nonlinks reduced the bias and increased the confidence interval widths, more accurately capturing error. In Hamburg and Massachusetts, pairs were more likely to be probable transmission links if they lived in closer proximity, had a shorter time between observations, or had shared ethnicity, social risk factors, drug resistance, or genotypes. CONCLUSIONS We developed a method to improve the use of genetic relatedness as a proxy for transmission, and aid in understanding TB transmission dynamics in low-burden settings.
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Affiliation(s)
- Sarah V Leavitt
- From the Boston University School of Public Health, Department of Biostatistics, Boston, MA
| | - C Robert Horsburgh
- Boston University School of Public Health, Department of Epidemiology, Boston, MA
| | - Robyn S Lee
- University of Toronto, Dalla Lana School of Public Health, Epidemiology Division, Toronto, ON, Canada
| | | | - Laura F White
- From the Boston University School of Public Health, Department of Biostatistics, Boston, MA
| | - Helen E Jenkins
- From the Boston University School of Public Health, Department of Biostatistics, Boston, MA
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19
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du Preez K, Jenkins HE, Donald PR, Solomons RS, Graham SM, Schaaf HS, Starke JR, Hesseling AC, Seddon JA. Tuberculous Meningitis in Children: A Forgotten Public Health Emergency. Front Neurol 2022; 13:751133. [PMID: 35370901 PMCID: PMC8970690 DOI: 10.3389/fneur.2022.751133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 02/18/2022] [Indexed: 11/13/2022] Open
Abstract
Tuberculous meningitis (TBM) remains a major cause of morbidity and mortality in children with tuberculosis (TB), yet there are currently no estimates of the global burden of pediatric TBM. Due to frequent non-specific clinical presentation and limited and inadequate diagnostic tests, children with TBM are often diagnosed late or die undiagnosed. Even when diagnosed and treated, 20% of children with TBM die. Of survivors, the majority have substantial neurological disability with significant negative impact on children and their families. Surveillance data on this devastating form of TB can help to quantify the contribution of TBM to the overall burden, morbidity and mortality of TB in children and the epidemiology of TB more broadly. Pediatric TBM usually occurs shortly after primary infection with Mycobacterium tuberculosis and reflects ongoing TB transmission to children. In this article we explain the public health importance of pediatric TBM, discuss the epidemiology within the context of overall TB control and health system functioning and the limitations of current surveillance strategies. We provide a clear rationale for the benefit of improved surveillance of pediatric TBM using a TB care cascade framework to support monitoring and evaluation of pediatric TB, and TB control more broadly. Considering the public health implications of a diagnosis of TBM in children, we provide recommendations to strengthen pediatric TBM surveillance and outline how improved surveillance can help us identify opportunities for prevention, earlier diagnosis and improved care to minimize the impact of TBM on children globally.
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Affiliation(s)
- Karen du Preez
- 1Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- *Correspondence: Karen du Preez
| | - Helen E. Jenkins
- 2Department of Biostatistics, School of Public Health, Boston University, Boston, MA, United States
| | - Peter R. Donald
- 1Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Regan S. Solomons
- 3Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Stephen M. Graham
- 4Department of Paediatrics and Murdoch Children's Research Institute, Centre for International Child Health, University of Melbourne Royal Children's Hospital, Melbourne, VIC, Australia
- 5International Union Against Tuberculosis and Lung Disease, Paris, France
| | - H. Simon Schaaf
- 1Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- 3Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Jeffrey R. Starke
- 6Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Anneke C. Hesseling
- 1Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - James A. Seddon
- 1Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- 7Department of Infectious Diseases, Imperial College London, London, United Kingdom
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20
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Khalife S, Jenkins HE, Dolynska M, Terleieva I, Varchenko I, Liu T, Carter EJ, Horsburgh CR, Rybak NR, Petrenko V, Chiang SS. Incidence and Mortality of Extrapulmonary Tuberculosis in Ukraine: Analysis of National Surveillance Data. Clin Infect Dis 2021; 75:604-612. [PMID: 34929028 DOI: 10.1093/cid/ciab1018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Improved understanding of the epidemiology and mortality risk factors of extrapulmonary tuberculosis (EPTB) may facilitate successful diagnosis and management. METHODS We analyzed national surveillance data from Ukraine to characterize EPTB subtypes (i.e., localized in different anatomic sites). We calculated annual reported incidence, stratified by age, sex, and HIV status. Using Cox regression, we estimated mortality risk factors. RESULTS Between January 2015-November 2018, 14,062 adults/adolescents (≥15 years old) and 417 children (<15 years old) had extrapulmonary TB with or without concomitant pulmonary TB. The most commonly reported EPTB subtypes were pleural, peripheral lymph node, and osteoarticular. Most EPTB subtype notifications peaked at age 30-39 years and were higher in males. In adults/adolescents, most peripheral TB lymphadenitis, central nervous system (CNS) TB, and abdominal TB occurred in those with untreated HIV. CNS TB notifications in people without HIV peaked before age five years. Adults/adolescents with CNS TB (adjusted hazard ratio (aHR) 3.22, 95% CI: 2.89-3.60) and abdominal TB (aHR 1.83, 95% CI: 1.59-2.11) were more likely to die than those with pulmonary TB. Children with CNS TB were more likely to die (aHR 88.25, 95% CI: 43.49-179.10) than those with non-CNS TB. Among adults/adolescents, older age and HIV were associated with death. Rifampicin resistance was associated with mortality in pleural, peripheral lymph node, and CNS TB. CONCLUSION We have identified the most common EPTB subtypes by age and sex; patterns of EPTB disease by HIV status; and mortality risk factors. These findings can inform diagnosis and care for people with EPTB.
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Affiliation(s)
- Sara Khalife
- Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Helen E Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Mariia Dolynska
- Department of Tuberculosis and Pulmonology, Bogomolets National Medical University, Kyiv City, Ukraine
| | - Iana Terleieva
- Public Health Center of the Ministry of Health, Kyiv City, Ukraine
| | - Iurii Varchenko
- Public Health Center of the Ministry of Health, Kyiv City, Ukraine
| | - Tao Liu
- Department of Biostatistics, Brown University School of Public Health, Providence, RI, USA
| | - E Jane Carter
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - C Robert Horsburgh
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA.,Department of Medicine, Boston University School of Medicine, Boston, MA, USA.,Department of Epidemiology and Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Natasha R Rybak
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Vasyl Petrenko
- Department of Tuberculosis and Pulmonology, Bogomolets National Medical University, Kyiv City, Ukraine
| | - Silvia S Chiang
- Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI, USA.,Center for International Health Research, Rhode Island Hospital, Providence, RI, USA
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21
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Weng CH, Butt WWW, Brooks MB, Clarke C, Jenkins HE, Holland SD, Chiang SS. Diagnostic value of symptoms for pediatric SARS-CoV-2 infection in a primary care setting. PLoS One 2021; 16:e0249980. [PMID: 34898635 PMCID: PMC8668089 DOI: 10.1371/journal.pone.0249980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 11/03/2021] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To evaluate the diagnostic value of symptoms used by daycares and schools to screen children and adolescents for SARS-CoV-2 infection, we analyzed data from a primary care setting. METHODS This cohort study included all patients ≤17 years old who were evaluated at Providence Community Health Centers (PCHC; Providence, U.S.), for COVID-19 symptoms and/or exposure, and received SARS-CoV-2 polymerase chain reaction (PCR) testing between March-June 2020. Participants were identified from PCHC electronic medical records. For three age groups- 0-4, 5-11, and 12-17 years-we estimated the sensitivity, specificity, and area under the receiver operating curve (AUC) of individual symptoms and three symptom combinations: a case definition published by the Rhode Island Department of Health (RIDOH), and two novel combinations generated by different statistical approaches to maximize sensitivity, specificity, and AUC. We evaluated symptom combinations both with and without consideration of COVID-19 exposure. Myalgia, headache, sore throat, abdominal pain, nausea, anosmia, and ageusia were not assessed in 0-4 year-olds due to the lower reliability of these symptoms in this group. RESULTS Of 555 participants, 217 (39.1%) were SARS-CoV-2-infected. Fever was more common among 0-4 years-olds (p = 0.002); older children more frequently reported fatigue (p = 0.02). In children ≥5 years old, anosmia or ageusia had 94-98% specificity. In all ages, exposure history most accurately predicted infection. With respect to individual symptoms, cough most accurately predicted infection in <5 year-olds (AUC 0.69) and 12-17 year-olds (AUC 0.62), while headache was most accurate in 5-11 year-olds (AUC 0.62). In combination with exposure history, the novel symptom combinations generated statistically to maximize test characteristics had sensitivity >95% but specificity <30%. No symptom or symptom combination had AUC ≥0.70. CONCLUSIONS Anosmia or ageusia in children ≥5 years old should raise providers' index of suspicion for COVID-19. However, our overall findings underscore the limited diagnostic value of symptoms.
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Affiliation(s)
- Chien-Hsiang Weng
- Department of Family Medicine, Brown University Warren Alpert Medical School, Providence, RI, United States of America
- Providence Community Health Centers, Providence, RI, United States of America
| | - Wesley Wing Wah Butt
- Department of Family Medicine, Brown University Warren Alpert Medical School, Providence, RI, United States of America
- Providence Community Health Centers, Providence, RI, United States of America
| | - Meredith B. Brooks
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Claudia Clarke
- Providence Community Health Centers, Providence, RI, United States of America
| | - Helen E. Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States of America
| | - Sabina D. Holland
- Department of Pediatrics, Brown University Warren Alpert Medical School, Providence, RI, United States of America
| | - Silvia S. Chiang
- Department of Pediatrics, Brown University Warren Alpert Medical School, Providence, RI, United States of America
- Center for International Health Research, Rhode Island Hospital, Providence, RI, United States of America
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Chiang SS, Brooks MB, Jenkins HE, Rubenstein D, Seddon JA, van de Water BJ, Lindeborg MM, Becerra MC, Yuen CM. Concordance of Drug-resistance Profiles Between Persons With Drug-resistant Tuberculosis and Their Household Contacts: A Systematic Review and Meta-analysis. Clin Infect Dis 2021; 73:250-263. [PMID: 32448887 DOI: 10.1093/cid/ciaa613] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/18/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Household contacts of patients with drug-resistant tuberculosis (TB) are at high risk for being infected with Mycobacterium tuberculosis and for developing TB disease. To guide regimen composition for the empirical treatment of TB infection and disease in these household contacts, we estimated drug-resistance profile concordance between index patients with drug-resistant TB and their household contacts. METHODS We performed a systematic review and meta-analysis of studies published through 24 July 2018 that reported resistance profiles of drug-resistant TB index cases and secondary cases within their households. Using a random-effects meta-analysis, we estimated resistance profile concordance, defined as the percentage of secondary cases whose M. tuberculosis strains were resistant to the same drugs as strains from their index cases. We also estimated isoniazid/rifampin concordance, defined as whether index and secondary cases had identical susceptibilities for isoniazid and rifampin only. RESULTS We identified 33 eligible studies that evaluated resistance profile concordance between 484 secondary cases and their household index cases. Pooled resistance profile concordance was 54.3% (95% confidence interval [CI], 40.7-67.6%; I2 = 85%). Pooled isoniazid/rifampin concordance was 82.6% (95% CI, 72.3-90.9%; I2 = 73%). Concordance estimates were similar in a subanalysis of 16 studies from high-TB-burden countries. There were insufficient data to perform a subanalysis among pediatric secondary cases. CONCLUSIONS Household contacts of patients with drug-resistant TB should receive treatment for TB infection and disease that assumes that they, too, are infected with a drug-resistant M. tuberculosis strain. Whenever possible, drug susceptibility testing should be performed for secondary cases to optimize regimen composition.
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Affiliation(s)
- Silvia S Chiang
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Center for International Health Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Meredith B Brooks
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Helen E Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Dana Rubenstein
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - James A Seddon
- Department of Infectious Diseases, Imperial College London, London, United Kingdom.,Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Brittney J van de Water
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael M Lindeborg
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Mercedes C Becerra
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Courtney M Yuen
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
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23
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Hamer DH, White LF, Jenkins HE, Gill CJ, Landsberg HE, Klapperich C, Bulekova K, Platt J, Decarie L, Gilmore W, Pilkington M, MacDowell TL, Faria MA, Densmore D, Landaverde L, Li W, Rose T, Burgay SP, Miller C, Doucette-Stamm L, Lockard K, Elmore K, Schroeder T, Zaia AM, Kolaczyk ED, Waters G, Brown RA. Assessment of a COVID-19 Control Plan on an Urban University Campus During a Second Wave of the Pandemic. JAMA Netw Open 2021; 4:e2116425. [PMID: 34170303 PMCID: PMC8233704 DOI: 10.1001/jamanetworkopen.2021.16425] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/03/2021] [Indexed: 01/15/2023] Open
Abstract
Importance The COVID-19 pandemic has severely disrupted US educational institutions. Given potential adverse financial and psychosocial effects of campus closures, many institutions developed strategies to reopen campuses in the fall 2020 semester despite the ongoing threat of COVID-19. However, many institutions opted to have limited campus reopening to minimize potential risk of spread of SARS-CoV-2. Objective To analyze how Boston University (BU) fully reopened its campus in the fall of 2020 and controlled COVID-19 transmission despite worsening transmission in Boston, Massachusetts. Design, Setting, and Participants This multifaceted intervention case series was conducted at a large urban university campus in Boston, Massachusetts, during the fall 2020 semester. The BU response included a high-throughput SARS-CoV-2 polymerase chain reaction testing facility with capacity to deliver results in less than 24 hours; routine asymptomatic screening for COVID-19; daily health attestations; adherence monitoring and feedback; robust contact tracing, quarantine, and isolation in on-campus facilities; face mask use; enhanced hand hygiene; social distancing recommendations; dedensification of classrooms and public places; and enhancement of all building air systems. Data were analyzed from December 20, 2020, to January 31, 2021. Main Outcomes and Measures SARS-CoV-2 diagnosis confirmed by reverse transcription-polymerase chain reaction of anterior nares specimens and sources of transmission, as determined through contact tracing. Results Between August and December 2020, BU conducted more than 500 000 COVID-19 tests and identified 719 individuals with COVID-19, including 496 students (69.0%), 11 faculty (1.5%), and 212 staff (29.5%). Overall, 718 individuals, or 1.8% of the BU community, had test results positive for SARS-CoV-2. Of 837 close contacts traced, 86 individuals (10.3%) had test results positive for COVID-19. BU contact tracers identified a source of transmission for 370 individuals (51.5%), with 206 individuals (55.7%) identifying a non-BU source. Among 5 faculty and 84 staff with SARS-CoV-2 with a known source of infection, most reported a transmission source outside of BU (all 5 faculty members [100%] and 67 staff members [79.8%]). A BU source was identified by 108 of 183 undergraduate students with SARS-CoV-2 (59.0%) and 39 of 98 graduate students with SARS-CoV-2 (39.8%); notably, no transmission was traced to a classroom setting. Conclusions and Relevance In this case series of COVID-19 transmission, BU used a coordinated strategy of testing, contact tracing, isolation, and quarantine, with robust management and oversight, to control COVID-19 transmission in an urban university setting.
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Affiliation(s)
- Davidson H. Hamer
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
- Section of Infectious Disease, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- National Emerging Infectious Disease Laboratory, Boston, Massachusetts
- Precision Diagnostics Center, Boston University, Boston, Massachusetts
| | - Laura F. White
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Helen E. Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Christopher J. Gill
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
| | - Hannah E. Landsberg
- Student Health Services, Healthway, Boston University, Boston, Massachusetts
| | - Catherine Klapperich
- Precision Diagnostics Center, Boston University, Boston, Massachusetts
- Department of Biomedical Engineering, Boston University, Boston, Massachusetts
| | - Katia Bulekova
- Information Services and Technology, Boston University, Boston, Massachusetts
| | - Judy Platt
- Student Health Services, Healthway, Boston University, Boston, Massachusetts
| | - Linette Decarie
- Boston University Analytical Services & Institutional Research, Boston, Massachusetts
| | - Wayne Gilmore
- Information Services and Technology, Boston University, Boston, Massachusetts
| | - Megan Pilkington
- Boston University Analytical Services & Institutional Research, Boston, Massachusetts
| | - Trevor L. MacDowell
- Information Services and Technology, Boston University, Boston, Massachusetts
| | - Mark A. Faria
- Information Services and Technology, Boston University, Boston, Massachusetts
| | - Douglas Densmore
- Electrical and Computer Engineering, Boston University, Boston, Massachusetts
- Biological Design Center, Boston University, Boston, Massachusetts
| | - Lena Landaverde
- Student Health Services, Healthway, Boston University, Boston, Massachusetts
- Department of Biomedical Engineering, Boston University, Boston, Massachusetts
| | - Wenrui Li
- Department of Mathematics and Statistics, Boston University, Boston, Massachusetts
| | - Tom Rose
- Human Resources, Boston University, Boston, Massachusetts
| | - Stephen P. Burgay
- Office of External Affairs, Boston University, Boston, Massachusetts
| | - Candice Miller
- BU Clinical Testing Laboratory, Research Department, Boston University, Boston, Massachusetts
| | - Lynn Doucette-Stamm
- BU Clinical Testing Laboratory, Research Department, Boston University, Boston, Massachusetts
| | - Kelly Lockard
- Continuous Improvement & Data Analytics, Boston University, Boston, Massachusetts
| | - Kenneth Elmore
- Office of the Provost, Boston University, Boston, Massachusetts
| | - Tracy Schroeder
- Information Services and Technology, Boston University, Boston, Massachusetts
| | - Ann M. Zaia
- Occupational Health Center, Boston University, Boston Massachusetts
| | - Eric D. Kolaczyk
- Department of Mathematics and Statistics, Boston University, Boston, Massachusetts
- Hariri Institute for Computing, Boston University, Boston, Massachusetts
| | - Gloria Waters
- Office of the Provost, Boston University, Boston, Massachusetts
- College of Health and Rehabilitation Services, Sargent College, Boston University, Boston, Massachusetts
| | - Robert A. Brown
- College of Engineering, Boston University, Boston, Massachusetts
- Office of the President, Boston University, Boston, Massachusetts
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24
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Affiliation(s)
- Silvia S Chiang
- Department of Pediatrics, Warren Alpert Medical School, Brown University, Providence, Rhode Island;
- Division of Pediatric Infectious Diseases, Hasbro Children's Hospital, Providence, Rhode Island
- Center for International Health Research, Rhode Island Hospital, Providence, Rhode Island; and
| | - Helen E Jenkins
- Department of Biostatistics, School of Public Health, Boston University, Boston, Massachusetts
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25
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Leavitt SV, Lee RS, Sebastiani P, Horsburgh CR, Jenkins HE, White LF. Estimating the relative probability of direct transmission between infectious disease patients. Int J Epidemiol 2021; 49:764-775. [PMID: 32211747 DOI: 10.1093/ije/dyaa031] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 02/07/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Estimating infectious disease parameters such as the serial interval (time between symptom onset in primary and secondary cases) and reproductive number (average number of secondary cases produced by a primary case) are important in understanding infectious disease dynamics. Many estimation methods require linking cases by direct transmission, a difficult task for most diseases. METHODS Using a subset of cases with detailed genetic and/or contact investigation data to develop a training set of probable transmission events, we build a model to estimate the relative transmission probability for all case-pairs from demographic, spatial and clinical data. Our method is based on naive Bayes, a machine learning classification algorithm which uses the observed frequencies in the training dataset to estimate the probability that a pair is linked given a set of covariates. RESULTS In simulations, we find that the probabilities estimated using genetic distance between cases to define training transmission events are able to distinguish between truly linked and unlinked pairs with high accuracy (area under the receiver operating curve value of 95%). Additionally, only a subset of the cases, 10-50% depending on sample size, need to have detailed genetic data for our method to perform well. We show how these probabilities can be used to estimate the average effective reproductive number and apply our method to a tuberculosis outbreak in Hamburg, Germany. CONCLUSIONS Our method is a novel way to infer transmission dynamics in any dataset when only a subset of cases has rich contact investigation and/or genetic data.
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Affiliation(s)
- Sarah V Leavitt
- School of Public Health, Department of Biostatistics, Boston University, Boston, MA, USA
| | - Robyn S Lee
- Harvard T.H. Chan School of Public Health, Boston, MA, USA.,University of Toronto Dalla Lana School of Public Health Epidemiology Division, Toronto, ON, Canada
| | - Paola Sebastiani
- School of Public Health, Department of Biostatistics, Boston University, Boston, MA, USA
| | - C Robert Horsburgh
- School of Public Health, Department of Epidemiology, Boston University, Boston, MA, USA
| | - Helen E Jenkins
- School of Public Health, Department of Biostatistics, Boston University, Boston, MA, USA
| | - Laura F White
- School of Public Health, Department of Biostatistics, Boston University, Boston, MA, USA
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26
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Leavitt SV, Jacobson KR, Ragan EJ, Bor J, Hughes J, Bouton TC, Dolby T, Warren RM, Jenkins HE. Decentralized Care for Rifampin-Resistant Tuberculosis, Western Cape, South Africa. Emerg Infect Dis 2021; 27:728-739. [PMID: 33622466 PMCID: PMC7920662 DOI: 10.3201/eid2703.203204] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
In 2011, South Africa implemented a policy to decentralize treatment for rifampin-resistant tuberculosis (TB) to reduce durations of hospitalization and enable local treatment. We assessed policy implementation in Western Cape Province, where services expanded from 6 specialized TB hospitals to 406 facilities, by analyzing National Health Laboratory Service data on TB during 2012-2015. We calculated the percentage of patients who visited a TB hospital <1 year after rifampin-resistant TB diagnosis, the median duration of their hospitalizations, and the total distance between facilities visited. We assessed temporal changes with linear regression and stratified results by location. Of 2,878 patients, 65% were from Cape Town. In Cape Town, 29% visited a TB hospital; elsewhere, 68% visited a TB hospital. We found that hospitalizations and travel distances were shorter in Cape Town than in the surrounding areas.
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27
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Kan CK, Ragan EJ, Sarkar S, Knudsen S, Forsyth M, Muthuraj M, Vinod K, Jenkins HE, Horsburgh CR, Salgame P, Roy G, Ellner JJ, Jacobson KR, Sahu S, Hochberg NS. Alcohol use and tuberculosis clinical presentation at the time of diagnosis in Puducherry and Tamil Nadu, India. PLoS One 2020; 15:e0240595. [PMID: 33332367 PMCID: PMC7746146 DOI: 10.1371/journal.pone.0240595] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/30/2020] [Indexed: 02/07/2023] Open
Abstract
SETTING Alcohol use increases the risk of tuberculosis (TB) disease and is associated with worse outcomes. OBJECTIVE To determine whether alcohol use affects TB severity at diagnosis in a high-burden setting. DESIGN Participants were smear-positive people living with TB (PLWTB) in India. Disease severity was assessed as 1) high versus low smear grade, 2) time to positivity (TTP) on liquid culture, 3) chest radiograph cavitation, and 4) percent lung affected. Alcohol use and being at-risk for alcohol use disorders (AUD) were assessed using the AUDIT-C. Univariable and multivariable analyses were conducted. RESULTS Of 1166 PLWTB, 691 (59.3%) were drinkers; of those, 518/691 (75.0%) were at-risk for AUD. Drinkers had more lung affected than non-drinkers (adjusted mean difference 10.8%, p<0.0001); this was not significant for those at-risk for AUD (adjusted mean difference 3.7%, p = 0.11). High smear grade (aOR 1.0, 95%CI: 0.7-1.4), cavitation (aOR 0.8, 95%CI 0.4-1.8), and TTP (mean difference 5.2 hours, p = 0.51) did not differ between drinkers and non-drinkers, nor between those at-risk and not at-risk for AUD. CONCLUSIONS A large proportion of PLWTB were drinkers and were at-risk for AUD. Alcohol drinkers had more lung affected than non-drinkers. Studies are needed to explore mechanisms of this association.
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Affiliation(s)
- Carolyn K Kan
- Section of Infectious Diseases, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America
| | - Elizabeth J Ragan
- Section of Infectious Diseases, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America
| | - Sonali Sarkar
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Gorimedu, Puducherry, India
| | - Selby Knudsen
- Section of Infectious Diseases, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America
| | - Megan Forsyth
- Section of Infectious Diseases, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America
| | - Muthaiah Muthuraj
- Intermediate Reference Laboratory, Government Hospital for Chest Diseases, Gorimedu, Puducherry, India
| | - Kumar Vinod
- Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Gorimedu, Puducherry, India
| | - Helen E Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - C Robert Horsburgh
- Section of Infectious Diseases, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America.,Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America.,Departments of Epidemiology and Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Padmini Salgame
- Division of Infectious Diseases, Department of Medicine, New Jersey Medical School, Rutgers University, Newark, New Jersey, United States of America
| | - Gautam Roy
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Gorimedu, Puducherry, India
| | - Jerrold J Ellner
- Division of Infectious Diseases, Department of Medicine, New Jersey Medical School, Rutgers University, Newark, New Jersey, United States of America
| | - Karen R Jacobson
- Section of Infectious Diseases, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America
| | - Swaroop Sahu
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Gorimedu, Puducherry, India
| | - Natasha S Hochberg
- Section of Infectious Diseases, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America
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28
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Zhou TJ, Lakshminarayanan S, Sarkar S, Knudsen S, Horsburgh CR, Muthaiah M, Kan CK, Salgame P, Ellner JJ, Roy G, Jenkins HE, Hochberg NS. Predictors of Loss to Follow-Up among Men with Tuberculosis in Puducherry and Tamil Nadu, India. Am J Trop Med Hyg 2020; 103:1050-1056. [PMID: 32618243 PMCID: PMC7470548 DOI: 10.4269/ajtmh.19-0415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Identifying predictors of loss to follow-up (LTFU; treatment lapse ≥ 2 months) among people with tuberculosis (TB) may assist programmatic efforts in controlling the spread of TB. Newly diagnosed smear-positive TB patients were enrolled in the Regional Prospective Observational Research for TB study in Puducherry and Tamil Nadu, India. Treatment records were used to identify LTFU of those who were enrolled from May 2014 through December 2017. This nested case–control study evaluated male TB patients. Predictors were assessed using multivariable logistic regression. Of 425 men with TB, 82 (19%) were LTFU. In the adjusted analyses of males, divorced/separated marital status (adjusted odds ratio [aOR] 3.80; 95% CI: 1.39–10.38) and at-risk alcohol use (aOR 1.92; 95% CI: 1.12–3.27) were significant predictors for increased risk of LTFU, and diabetes was a significant predictor for decreased risk of LTFU (aOR 0.52; 95% CI: 0.29–0.92). Of 53 men with recorded date of last treatment visit, 23 (43%) and 43 (81%) had LTFU within the first 2 and first 4 months of treatment, respectively. Addressing at-risk alcohol use and providing more intensive follow-up could lead to improved treatment completion.
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Affiliation(s)
- Thomas J Zhou
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Subitha Lakshminarayanan
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Sonali Sarkar
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Selby Knudsen
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts
| | - C Robert Horsburgh
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts.,Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts.,Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Muthuraj Muthaiah
- Intermediate Reference Laboratory, Government Hospital for Chest Diseases, Puducherry, India
| | - Carolyn K Kan
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Padmini Salgame
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Jerrold J Ellner
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Gautam Roy
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Helen E Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Natasha S Hochberg
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts.,Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
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29
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Ma Y, Jenkins HE, Sebastiani P, Ellner JJ, Jones-López EC, Dietze R, Horsburgh, Jr. CR, White LF. Using Cure Models to Estimate the Serial Interval of Tuberculosis With Limited Follow-up. Am J Epidemiol 2020; 189:1421-1426. [PMID: 32458995 PMCID: PMC7731991 DOI: 10.1093/aje/kwaa090] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 12/26/2022] Open
Abstract
Serial interval (SI), defined as the time between symptom onset in an infector and infectee pair, is commonly used to understand infectious diseases transmission. Slow progression to active disease, as well as the small percentage of individuals who will eventually develop active disease, complicate the estimation of the SI for tuberculosis (TB). In this paper, we showed via simulation studies that when there is credible information on the percentage of those who will develop TB disease following infection, a cure model, first introduced by Boag in 1949, should be used to estimate the SI for TB. This model includes a parameter in the likelihood function to account for the study population being composed of those who will have the event of interest and those who will never have the event. We estimated the SI for TB to be approximately 0.5 years for the United States and Canada (January 2002 to December 2006) and approximately 2.0 years for Brazil (March 2008 to June 2012), which might imply a higher occurrence of reinfection TB in a developing country like Brazil.
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Affiliation(s)
- Yicheng Ma
- Correspondence to Dr. Yicheng Ma, Department of Biostatistics, 801 Massachusetts Avenue, Boston, MA 02118 (e-mail: )
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30
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Benedum CM, Shea KM, Jenkins HE, Kim LY, Markuzon N. Weekly dengue forecasts in Iquitos, Peru; San Juan, Puerto Rico; and Singapore. PLoS Negl Trop Dis 2020; 14:e0008710. [PMID: 33064770 PMCID: PMC7567393 DOI: 10.1371/journal.pntd.0008710] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 08/13/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Predictive models can serve as early warning systems and can be used to forecast future risk of various infectious diseases. Conventionally, regression and time series models are used to forecast dengue incidence, using dengue surveillance (e.g., case counts) and weather data. However, these models may be limited in terms of model assumptions and the number of predictors that can be included. Machine learning (ML) methods are designed to work with a large number of predictors and thus offer an appealing alternative. Here, we compared the performance of ML algorithms with that of regression models in predicting dengue cases and outbreaks from 4 to up to 12 weeks in advance. Many countries lack sufficient health surveillance infrastructure, as such we evaluated the contribution of dengue surveillance and weather data on the predictive power of these models. METHODS We developed ML, regression, and time series models to forecast weekly dengue case counts and outbreaks in Iquitos, Peru; San Juan, Puerto Rico; and Singapore from 1990-2016. Forecasts were generated using available weekly dengue surveillance, and weather data. We evaluated the agreement between model forecasts and actual dengue observations using Mean Absolute Error and Matthew's Correlation Coefficient (MCC). RESULTS For near term predictions of weekly case counts and when using surveillance data, ML models had 21% and 33% less error than regression and time series models respectively. However, using weather data only, ML models did not demonstrate a practical advantage. When forecasting weekly dengue outbreaks 12 weeks in advance, ML models achieved a maximum MCC of 0.61. CONCLUSIONS Our results identified 2 scenarios when ML models are advantageous over regression model: 1) predicting dengue weekly case counts 4 weeks ahead when dengue surveillance data are available and 2) predicting weekly dengue outbreaks 12 weeks ahead when dengue surveillance data are unavailable. Given the advantages of ML models, dengue early warning systems may be improved by the inclusion of these models.
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Affiliation(s)
- Corey M. Benedum
- Draper, Cambridge, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Kimberly M. Shea
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Helen E. Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Louis Y. Kim
- Draper, Cambridge, Massachusetts, United States of America
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31
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Chiang SS, Dolynska M, Rybak NR, Cruz AT, Aibana O, Sheremeta Y, Petrenko V, Mamotenko A, Terleieva I, Horsburgh CR, Jenkins HE. Clinical manifestations and epidemiology of adolescent tuberculosis in Ukraine. ERJ Open Res 2020; 6:00308-2020. [PMID: 32964003 PMCID: PMC7487357 DOI: 10.1183/23120541.00308-2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 05/26/2020] [Indexed: 11/18/2022] Open
Abstract
Background During adolescence, childhood and adult forms of tuberculosis (TB) overlap, resulting in diverse disease manifestations. Knowing which patient characteristics are associated with which manifestations may facilitate diagnosis and enhance understanding of TB pathophysiology. Methods In this cross-sectional study, we included 10–19-year-olds in Ukraine's national TB registry who started TB treatment between 2015 and 2018. Using multivariable regression, we estimated associations between patient characteristics and four presentations of TB: pleural, extrathoracic, cavitary and rifampicin-resistant (RR). We also described the epidemiology of adolescent TB in Ukraine. Results Among 2491 adolescent TB cases, 88.4% were microbiologically confirmed. RR-TB was confirmed in 16.9% of new and 29.7% of recurrent cases. Of 88 HIV-infected adolescents, 59.1% were not on antiretroviral therapy at TB diagnosis. Among 10–14-year-olds, boys had more pleural disease (adjusted OR (aOR) 2.12, 95% CI: 1.08–4.37). Extrathoracic TB was associated with age 15–19 years (aOR 0.26, 95% CI: 0.18–0.37) and HIV (aOR 3.25, 95% CI: 1.55–6.61 in 10–14-year-olds; aOR 8.18, 95% CI: 3.58–17.31 in 15–19-year-olds). Cavitary TB was more common in migrants (aOR 3.53, 95% CI: 1.66–7.61) and 15–19-year-olds (aOR 4.10, 95% CI: 3.00–5.73); among 15–19-year-olds, it was inversely associated with HIV (aOR 0.32, 95% CI: 0.13–0.70). RR-TB was associated with recurrent disease (aOR 1.87, 95% CI: 1.08–3.13), urban residence (aOR 1.27, 95% CI: 1.01–1.62) and cavitation (aOR 2.98, 95% CI: 2.35–3.78). Conclusions Age, sex, HIV and social factors impact the presentation of adolescent TB. Preventive, diagnostic and treatment activities should take these factors into consideration. Analysing 2491 cases of adolescent tuberculosis in Ukraine, associations were observed between four clinical presentations – cavitary, pleural, extrathoracic and rifampicin-resistant TB – and age, sex, HIV status, prior treatment and social factors.https://bit.ly/2XplZFt
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Affiliation(s)
- Silvia S Chiang
- Dept of Pediatrics, Alpert Medical School of Brown University, Providence, RI, USA.,Center for International Health Research, Rhode Island Hospital, Providence, RI, USA
| | - Maria Dolynska
- Dept of Tuberculosis and Pulmonology, Bogomolets National Medical University, Kyiv, Ukraine
| | - Natasha R Rybak
- Dept of Medicine, Alpert Medical School of Brown University, Providence, RI, USA.,Dept of Medicine, The Miriam Hospital, Providence, RI, USA
| | - Andrea T Cruz
- Dept of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Omowunmi Aibana
- Dept of Medicine, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Yana Sheremeta
- All-Ukrainian Network of People Living with HIV/AIDS, Kyiv, Ukraine
| | - Vasyl Petrenko
- Dept of Tuberculosis and Pulmonology, Bogomolets National Medical University, Kyiv, Ukraine
| | | | - Iana Terleieva
- Public Health Center of the Ministry of Health, Kyiv, Ukraine
| | - C Robert Horsburgh
- Dept of Medicine, Boston University School of Medicine, Boston, MA, USA.,Dept of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Helen E Jenkins
- Dept of Biostatistics, Boston University School of Public Health, Boston, MA, USA
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McIntosh AI, Jenkins HE, Horsburgh CR, Jones-López EC, Whalen CC, Gaeddert M, Marques-Rodrigues P, Ellner JJ, Dietze R, White LF. Partitioning the risk of tuberculosis transmission in household contact studies. PLoS One 2019; 14:e0223966. [PMID: 31639145 PMCID: PMC6804987 DOI: 10.1371/journal.pone.0223966] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 10/02/2019] [Indexed: 01/25/2023] Open
Abstract
Household contact studies of tuberculosis (TB) are a common way to study disease transmission dynamics. However these studies lack a mechanism for accounting for community transmission, which is known to be significant, particularly in high burden settings. We illustrate a statistical approach for estimating both the correlates with transmission of TB in a household setting and the probability of community transmission using a modified Bayesian mixed-effects model. This is applied to two household contact studies in Vitória, Brazil from 2008-2013 and Kampala, Uganda from 1995-2004 that enrolled households with an individual that was recently diagnosed with pulmonary TB. We estimate the probability of community transmission to be higher in Uganda (ranging from 0.21 to 0.69, depending on HHC age and HIV status of the index case) than in Brazil (ranging from 0.13 for young children to 0.50 in adults). These estimates are consistent with a higher overall burden of disease in Uganda compared to Brazil. Our method also estimates an increasing risk of community-acquired TB with age of the household contact, consistent with existing literature. This approach is a useful way to integrate the role of the community in understanding TB disease transmission dynamics in household contact studies.
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Affiliation(s)
- Avery I. McIntosh
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Helen E. Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - C. Robert Horsburgh
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Edward C. Jones-López
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Christopher C. Whalen
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia, United States of America
| | - Mary Gaeddert
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, United States of America
| | | | - Jerrold J. Ellner
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, United States of America
| | | | - Laura F. White
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
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Abstract
BACKGROUND Childhood tuberculosis (TB) has historically been neglected, although in recent years there has been increased focus on this problem. In particular, there have been two efforts to estimate the burden of pediatric multidrug-resistant TB (MDR-TB). METHODS We review current estimates of the global incidence of pediatric MDR-TB disease. We then combine pediatric MDR-TB treatment data from the World Health Organization and recently published case fatality ratio estimates for children with TB to produce mortality estimates for children with MDR-TB. Finally, we combine treatment data and estimates of household size and disease risk to estimate how many children could be treated for probable or confirmed MDR-TB by carrying out household contact investigations around adult MDR-TB patients. RESULTS Between 25 000 and 32 000 children develop MDR-TB disease annually, accounting for around 3% of all pediatric TB cases. Only 3-4% of these children are likely to receive MDR-TB treatment. We estimate that around 21% of children who develop MDR-TB disease will die. Carrying out household contact investigations around adult MDR-TB patients could find an estimated 12 times as many pediatric MDR-TB cases as are currently being identified. DISCUSSION The diagnosis and treatment of children with MDR-TB needs to be prioritized by TB programs.
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Affiliation(s)
- H E Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston
| | - C M Yuen
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Dodd PJ, Yuen CM, Becerra MC, Revill P, Jenkins HE, Seddon JA. Potential effect of household contact management on childhood tuberculosis: a mathematical modelling study. Lancet Glob Health 2018; 6:e1329-e1338. [PMID: 30266570 PMCID: PMC6227381 DOI: 10.1016/s2214-109x(18)30401-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/26/2018] [Accepted: 08/17/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Tuberculosis is recognised as a major cause of morbidity and mortality in children, with most cases in children going undiagnosed and resulting in poor outcomes. Household contact management, which aims to identify children with active tuberculosis and to provide preventive therapy for those with HIV or those younger than 5 years, has long been recommended but has very poor coverage globally. New guidelines include widespread provision of preventive therapy to children with a positive tuberculin skin test (TST) who are older than 5 years. METHODS In this mathematical modelling study, we provide the first global and national estimates of the impact of moving from zero to full coverage of household contact management (with and without preventive therapy for TST-positive children older than 5 years). We assembled data on tuberculosis notifications, household structure, household contact co-prevalence of tuberculosis disease and infection, the efficacy of preventive therapy, and the natural history of childhood tuberculosis. We used a model to estimate households visited, children screened, and treatment courses given for active and latent tuberculosis. We calculated the numbers of tuberculosis cases, deaths, and life-years lost because of tuberculosis for each intervention scenario and country. FINDINGS We estimated that full implementation of household contact management would prevent 159 500 (75% uncertainty interval [UI] 147 000-170 900) cases of tuberculosis and 108 400 (75% UI 98 800-116 700) deaths in children younger than 15 years (representing the loss of 7 305 000 [75% UI 6 663 000-7 874 000] life-years). We estimated that preventing one child death from tuberculosis would require visiting 48 households, screening 77 children, giving 48 preventive therapy courses, and giving two tuberculosis treatments versus no household contact management. INTERPRETATION Household contact management could substantially reduce childhood disease and death caused by tuberculosis globally. Funding and research to optimise its implementation should be prioritised. FUNDING UK Medical Research Council, US National Institutes of Health, Fulbright Commission, Janssen Global Public Health.
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Affiliation(s)
- Peter J Dodd
- School of Health and Related Research, University of Sheffield, Sheffield, UK.
| | - Courtney M Yuen
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Mercedes C Becerra
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Partners In Health, Boston, MA, USA
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Helen E Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - James A Seddon
- Centre for International Child Health, Department of Paediatrics, Imperial College London, London, UK; Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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McIntosh AI, Jenkins HE, White LF, Barnard M, Thomson DR, Dolby T, Simpson J, Streicher EM, Kleinman MB, Ragan EJ, van Helden PD, Murray MB, Warren RM, Jacobson KR. Using routinely collected laboratory data to identify high rifampicin-resistant tuberculosis burden communities in the Western Cape Province, South Africa: A retrospective spatiotemporal analysis. PLoS Med 2018; 15:e1002638. [PMID: 30130377 PMCID: PMC6103505 DOI: 10.1371/journal.pmed.1002638] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 07/13/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND South Africa has the highest tuberculosis incidence globally (781/100,000), with an estimated 4.3% of cases being rifampicin resistant (RR). Control and elimination strategies will require detailed spatial information to understand where drug-resistant tuberculosis exists and why it persists in those communities. We demonstrate a method to enable drug-resistant tuberculosis monitoring by identifying high-burden communities in the Western Cape Province using routinely collected laboratory data. METHODS AND FINDINGS We retrospectively identified cases of microbiologically confirmed tuberculosis and RR-tuberculosis from all biological samples submitted for tuberculosis testing (n = 2,219,891) to the Western Cape National Health Laboratory Services (NHLS) between January 1, 2008, and June 30, 2013. Because the NHLS database lacks unique patient identifiers, we performed a series of record-linking processes to match specimen records to individual patients. We counted an individual as having a single disease episode if their positive samples came from within two years of each other. Cases were aggregated by clinic location (n = 302) to estimate the percentage of tuberculosis cases with rifampicin resistance per clinic. We used inverse distance weighting (IDW) to produce heatmaps of the RR-tuberculosis percentage across the province. Regression was used to estimate annual changes in the RR-tuberculosis percentage by clinic, and estimated average size and direction of change was mapped. We identified 799,779 individuals who had specimens submitted from mappable clinics for testing, of whom 222,735 (27.8%) had microbiologically confirmed tuberculosis. The study population was 43% female, the median age was 36 years (IQR 27-44), and 10,255 (4.6%, 95% CI: 4.6-4.7) cases had documented rifampicin resistance. Among individuals with microbiologically confirmed tuberculosis, 8,947 (4.0%) had more than one disease episode during the study period. The percentage of tuberculosis cases with rifampicin resistance documented among these individuals was 11.4% (95% CI: 10.7-12.0). Overall, the percentage of tuberculosis cases that were RR-tuberculosis was spatially heterogeneous, ranging from 0% to 25% across the province. Our maps reveal significant yearly fluctuations in RR-tuberculosis percentages at several locations. Additionally, the directions of change over time in RR-tuberculosis percentage were not uniform. The main limitation of this study is the lack of unique patient identifiers in the NHLS database, rendering findings to be estimates reliant on the accuracy of the person-matching algorithm. CONCLUSIONS Our maps reveal striking spatial and temporal heterogeneity in RR-tuberculosis percentages across this province. We demonstrate the potential to monitor RR-tuberculosis spatially and temporally with routinely collected laboratory data, enabling improved resource targeting and more rapid locally appropriate interventions.
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Affiliation(s)
- Avery I. McIntosh
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Helen E. Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Laura F. White
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | | | - Dana R. Thomson
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Tania Dolby
- National Health Laboratory Service, Cape Town, South Africa
| | - John Simpson
- National Health Laboratory Service, Cape Town, South Africa
| | - Elizabeth M. Streicher
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research/SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Mary B. Kleinman
- Section of Infectious Diseases, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America
| | - Elizabeth J. Ragan
- Section of Infectious Diseases, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America
| | - Paul D. van Helden
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research/SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Megan B. Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Robin M. Warren
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research/SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Karen R. Jacobson
- Section of Infectious Diseases, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America
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Nguyen DT, Jenkins HE, Graviss EA. Prognostic score to predict mortality during TB treatment in TB/HIV co-infected patients. PLoS One 2018; 13:e0196022. [PMID: 29659636 PMCID: PMC5901929 DOI: 10.1371/journal.pone.0196022] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 04/04/2018] [Indexed: 11/19/2022] Open
Abstract
Background Estimating mortality risk during TB treatment in HIV co-infected patients is challenging for health professionals, especially in a low TB prevalence population, due to the lack of a standardized prognostic system. The current study aimed to develop and validate a simple mortality prognostic scoring system for TB/HIV co-infected patients. Methods Using data from the CDC’s Tuberculosis Genotyping Information Management System of TB patients in Texas reported from 01/2010 through 12/2016, age ≥15 years, HIV(+), and outcome being “completed” or “died”, we developed and internally validated a mortality prognostic score using multiple logistic regression. Model discrimination was determined by the area under the receiver operating characteristic (ROC) curve (AUC). The model’s good calibration was determined by a non-significant Hosmer-Lemeshow’s goodness of fit test. Results Among the 450 patients included in the analysis, 57 (12.7%) died during TB treatment. The final prognostic score used six characteristics (age, residence in long-term care facility, meningeal TB, chest x-ray, culture positive, and culture not converted/unknown), which are routinely collected by TB programs. Prognostic scores were categorized into three groups that predicted mortality: low-risk (<20 points), medium-risk (20–25 points) and high-risk (>25 points). The model had good discrimination and calibration (AUC = 0.82; 0.80 in bootstrap validation), and a non-significant Hosmer-Lemeshow test p = 0.71. Conclusion Our simple validated mortality prognostic scoring system can be a practical tool for health professionals in identifying TB/HIV co-infected patients with high mortality risk.
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Affiliation(s)
- Duc T. Nguyen
- Houston Methodist Hospital Institute, Houston, Texas, United States of America
| | - Helen E. Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Edward A. Graviss
- Houston Methodist Hospital Institute, Houston, Texas, United States of America
- * E-mail:
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Nourzad S, Jenkins HE, Milstein M, Mitnick CD. Estimating the global burden of multidrug-resistant tuberculosis among prevalent cases of tuberculosis. Int J Tuberc Lung Dis 2018; 21:6-11. [PMID: 28157458 DOI: 10.5588/ijtld.16.0110] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Estimates of the multidrug-resistant tuberculosis (MDR-TB) burden are based on incomplete, infrequently updated data among a limited pool of notified or incident pulmonary TB cases. METHODS Using World Health Organization data reported by 217 countries/territories in 2014, we calculated the MDR-TB burden among prevalent TB cases and compared these with estimates among incident and notified TB patients. We also compared treatment coverage across estimates. RESULTS Among prevalent TB patients worldwide in 2014, we estimate that 555 545 (95% credible bounds 499 340-617 391) MDR-TB cases occurred. This is 85% more than the 300 000 estimated among notified cases, and 16% more than the 480 000 among incident cases. Only 20% of MDR-TB cases among prevalent-compared to 37% of MDR-TB among notified-TB patients had access to MDR-TB treatment. Applying prior estimates, only 10% of MDR-TB cases will have successful outcomes. CONCLUSION Estimates based on likely-to-be-diagnosed cases of MDR-TB overlook a significant proportion of morbidity, mortality, and transmission that occur in undiagnosed, untreated, prevalent TB patients. Even though it may still likely underestimate the true disease burden, MDR-TB among patients with prevalent TB represents a closer approximation of disease burden than currently reported indicators. Progress toward elimination or control depends on policies guided by a more complete representation of the disease burden.
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Affiliation(s)
- S Nourzad
- Department of Global Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - H E Jenkins
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Department of Biostatistics, Boston University School of Public Health, Boston, USA
| | - M Milstein
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Bouvé College of Health Sciences, Northeastern University, Boston, USA
| | - C D Mitnick
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, USA; Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA; Partners In Health, Boston, Massachusetts, USA
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Abstract
The drug isoniazid (INH) is a key component of global tuberculosis (TB) control programmes. It is estimated, however, that 16.1% of TB disease cases in the former Soviet Union countries and 7.5% of cases outside of these settings have non-multidrug-resistant (MDR) INH resistance. Resistance has been linked to poorer treatment outcomes, post-treatment relapse and death, at least for specific sites of disease. Multiple genetic loci are associated with phenotypic resistance; however, the relationship between genotype and phenotype is complex, and restricts the use of rapid sequencing techniques as part of the diagnostic process to determine the most appropriate treatment regimens for patients. The burden of resistance also influences the usefulness of INH preventive therapy. Despite seven decades of INH use, our knowledge in key areas such as the epidemiology of resistant strains, their clinical consequences, whether tailored treatment regimens are required and the role of INH resistance in fuelling the MDR-TB epidemic is limited. The importance of non-MDR INH resistance needs to be re-evaluated both globally and by national TB control programmes.
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Affiliation(s)
- H R Stagg
- Institute of Global Health, UCL, London, UK
| | - M C Lipman
- University College London (UCL) Respiratory, Division of Medicine, UCL, London, UK;, Royal Free London National Health Service Foundation Trust, London, UK
| | - T D McHugh
- Centre for Clinical Microbiology, UCL, London, UK
| | - H E Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
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Dodd PJ, Yuen CM, Sismanidis C, Seddon JA, Jenkins HE. The global burden of tuberculosis mortality in children: a mathematical modelling study. Lancet Glob Health 2018; 5:e898-e906. [PMID: 28807188 PMCID: PMC5556253 DOI: 10.1016/s2214-109x(17)30289-9] [Citation(s) in RCA: 234] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 06/16/2017] [Accepted: 06/29/2017] [Indexed: 12/22/2022]
Abstract
Background Tuberculosis in children is increasingly recognised as an important component of the global tuberculosis burden, with an estimated 1 million cases in 2015. Although younger children are vulnerable to severe forms of tuberculosis disease, no age-disaggregated estimates of paediatric tuberculosis mortality exist, and tuberculosis has never been included in official estimates of under-5 child mortality. We aimed to produce a global mortality burden estimate in children using a complementary approach not dependent on vital registration data. Methods In this mathematical modelling study, we estimated deaths in children younger than 5 years and those aged 5–14 years for 217 countries and territories using a case-fatality-based approach. We used paediatric tuberculosis notification data and HIV and antiretroviral treatment estimates to disaggregate the WHO paediatric tuberculosis incidence estimates by age, HIV, and treatment status. We then applied systematic review evidence on corresponding case-fatality ratios. Findings We estimated that 239 000 (95% uncertainty interval [UI] 194 000–298 000) children younger than 15 years died from tuberculosis worldwide in 2015; 80% (191 000, 95% UI 132 000–257 000) of these deaths were in children younger than 5 years. More than 70% (182 000, 140 000–239 000) of deaths occurred in the WHO southeast Asia and Africa regions. We estimated that 39 000 (17%, 23 000–73 000) paediatric tuberculosis deaths worldwide were in children with HIV infections, with 31 000 (36%, 19 000–59 000) in the WHO Africa region. More than 96% (230 000, 185 000–289 000) of all tuberculosis deaths occurred in children not receiving tuberculosis treatment. Interpretation Tuberculosis is a top ten cause of death in children worldwide and a key omission from previous analyses of under-5 mortality. Almost all these deaths occur in children not on tuberculosis treatment, implying substantial scope to reduce this burden. Funding UNITAID, National Institutes of Health, and National Institute for Health Research.
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Affiliation(s)
- Peter J Dodd
- School of Health and Related Research, University of Sheffield, Sheffield, UK.
| | - Courtney M Yuen
- Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | | | - James A Seddon
- Centre for International Child Health, Department of Paediatrics, Imperial College London, London, UK
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Van Ness SE, Chandra A, Sarkar S, Pleskunas J, Ellner JJ, Roy G, Lakshminarayanan S, Sahu S, Horsburgh CR, Jenkins HE, Hochberg NS. Predictors of delayed care seeking for tuberculosis in southern India: an observational study. BMC Infect Dis 2017; 17:567. [PMID: 28806911 PMCID: PMC5557420 DOI: 10.1186/s12879-017-2629-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/24/2017] [Indexed: 12/02/2022] Open
Abstract
Background Reducing delay to accessing care is necessary to reduce the Tuberculosis (TB) burden in high incidence countries such as India. This study aimed to identify factors associated with delays in seeking care for TB in Southern India. Methods We analyzed data from newly diagnosed, smear-positive, culture-confirmed, pulmonary TB patients in the Regional Prospective Observational Research for TB (RePORT) cohort in Puducherry and Tamil Nadu, India. Data were collected on demographic characteristics, symptom duration, and TB knowledge, among other factors. Delay was defined as cough ≥4 weeks before treatment initiation. Risky alcohol use was defined by the AUDIT-C score which incorporates information about regular alcohol use and binge drinking. TB knowledge was assessed by knowing transmission mode or potential curability. Results Of 501 TB patients, 369 (73.7%) subjects delayed seeking care. In multivariable analysis, risky alcohol use was significantly associated with delay (aOR 2.20, 95% CI: 1.31, 3.68). Delay was less likely in lower versus higher income groups (<3000 versus >10,000 rupees/month, aOR 0.31, 95% CI: 0.12, 0.78). TB knowledge was not significantly associated with delay. Conclusions Local TB programs should consider that risky alcohol users may delay seeking care for TB. Further studies will be needed to determine why patients with higher income delay in seeking care. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2629-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah E Van Ness
- Department of Biostatistics, Boston University, Crosstown Building, 801 Massachusetts Avenue, 3rd Floor, Boston, MA, 02118, USA.
| | - Ankit Chandra
- Department of Preventive and Social Medicine, JIPMER, Puducherry, India
| | - Sonali Sarkar
- Department of Preventive and Social Medicine, JIPMER, Puducherry, India
| | | | - Jerrold J Ellner
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Boston, MA, USA
| | - Gautam Roy
- Department of Preventive and Social Medicine, JIPMER, Puducherry, India
| | | | - Swaroop Sahu
- Department of Preventive and Social Medicine, JIPMER, Puducherry, India
| | - C Robert Horsburgh
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Helen E Jenkins
- Department of Biostatistics, Boston University, Crosstown Building, 801 Massachusetts Avenue, 3rd Floor, Boston, MA, 02118, USA
| | - Natasha S Hochberg
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Boston, MA, USA.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
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McIntosh AI, Doros G, Jones-López EC, Gaeddert M, Jenkins HE, Marques-Rodrigues P, Ellner JJ, Dietze R, White LF. Extensions to Bayesian generalized linear mixed effects models for household tuberculosis transmission. Stat Med 2017; 36:2522-2532. [PMID: 28370491 DOI: 10.1002/sim.7303] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 03/15/2017] [Indexed: 02/01/2023]
Abstract
Household contact studies, a mainstay of tuberculosis transmission research, often assume that tuberculosis-infected household contacts of an index case were infected within the household. However, strain genotyping has provided evidence against this assumption. Understanding the household versus community infection dynamic is essential for designing interventions. The misattribution of infection sources can also bias household transmission predictor estimates. We present a household-community transmission model that estimates the probability of community infection, that is, the probability that a household contact of an index case was actually infected from a source outside the home and simultaneously estimates transmission predictors. We show through simulation that our method accurately predicts the probability of community infection in several scenarios and that not accounting for community-acquired infection in household contact studies can bias risk factor estimates. Applying the model to data from Vitória, Brazil, produced household risk factor estimates similar to two other standard methods for age and sex. However, our model gave different estimates for sleeping proximity to index case and disease severity score. These results show that estimating both the probability of community infection and household transmission predictors is feasible and that standard tuberculosis transmission models likely underestimate the risk for two important transmission predictors. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Avery I McIntosh
- Department of Biostatistics, Boston University, Boston, Massachusetts, U.S.A.,Section of Infectious Diseases, Department of Medicine, Boston Medical Center, School of Medicine, Boston University, Boston, Massachusetts, U.S.A
| | - Gheorghe Doros
- Department of Biostatistics, Boston University, Boston, Massachusetts, U.S.A
| | - Edward C Jones-López
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, School of Medicine, Boston University, Boston, Massachusetts, U.S.A
| | - Mary Gaeddert
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, School of Medicine, Boston University, Boston, Massachusetts, U.S.A
| | - Helen E Jenkins
- Department of Biostatistics, Boston University, Boston, Massachusetts, U.S.A
| | | | - Jerrold J Ellner
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, School of Medicine, Boston University, Boston, Massachusetts, U.S.A
| | - Reynaldo Dietze
- Núcleo de Doenças Infecciosas, Universidade Federal do Espírito Santo (UFES), Vitória, Brazil
| | - Laura F White
- Department of Biostatistics, Boston University, Boston, Massachusetts, U.S.A
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McAnaw SE, Hesseling AC, Seddon JA, Dooley KE, Garcia-Prats AJ, Kim S, Jenkins HE, Schaaf HS, Sterling TR, Horsburgh CR. Pediatric multidrug-resistant tuberculosis clinical trials: challenges and opportunities. Int J Infect Dis 2017; 56:194-199. [PMID: 27955992 PMCID: PMC5606236 DOI: 10.1016/j.ijid.2016.11.423] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 11/23/2016] [Accepted: 11/30/2016] [Indexed: 10/20/2022] Open
Abstract
On June 17, 2016, RESIST-TB, IMPAACT, Vital Strategies, and New Ventures jointly hosted the Pediatric Multidrug Resistant Tuberculosis Clinical Trials Landscape Meeting in Arlington, Virginia, USA. The meeting provided updates on current multidrug-resistant tuberculosis (MDR-TB) trials targeting pediatric populations and adult trials that have included pediatric patients. A series of presentations were given that discussed site capacity needs, community engagement, and additional interventions necessary for clinical trials to improve the treatment of pediatric MDR-TB. This article presents a summary of topics discussed, including the following: current trials ongoing and planned; the global burden of MDR-TB in children; current regimens for MDR-TB treatment in children; pharmacokinetics of second-line anti-tuberculosis medications in children; design, sample size, and statistical considerations for MDR-TB trials in children; selection of study population, design, and treatment arms for a trial of novel pediatric MDR-TB regimens; practical aspects of pediatric MDR-TB treatment trials; and strategies for integrating children into adult tuberculosis trials. These discussions elucidated barriers to pediatric MDR-TB clinical trials and provided insight into necessary next steps for progress in this field. Investigators and funding agencies need to respond to these recommendations so that important studies can be implemented, leading to improved treatment for children with MDR-TB.
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Affiliation(s)
- S E McAnaw
- RESIST TB, 801 Massachusetts Avenue, suite 389, Boston, MA 202118, USA.
| | - A C Hesseling
- RESIST TB, 801 Massachusetts Avenue, suite 389, Boston, MA 202118, USA
| | - J A Seddon
- RESIST TB, 801 Massachusetts Avenue, suite 389, Boston, MA 202118, USA
| | - K E Dooley
- RESIST TB, 801 Massachusetts Avenue, suite 389, Boston, MA 202118, USA
| | - A J Garcia-Prats
- RESIST TB, 801 Massachusetts Avenue, suite 389, Boston, MA 202118, USA
| | - S Kim
- RESIST TB, 801 Massachusetts Avenue, suite 389, Boston, MA 202118, USA
| | - H E Jenkins
- RESIST TB, 801 Massachusetts Avenue, suite 389, Boston, MA 202118, USA
| | - H S Schaaf
- RESIST TB, 801 Massachusetts Avenue, suite 389, Boston, MA 202118, USA
| | - T R Sterling
- RESIST TB, 801 Massachusetts Avenue, suite 389, Boston, MA 202118, USA
| | - C R Horsburgh
- RESIST TB, 801 Massachusetts Avenue, suite 389, Boston, MA 202118, USA
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Jenkins HE, Yuen CM, Rodriguez CA, Nathavitharana RR, McLaughlin MM, Donald P, Marais BJ, Becerra MC. Mortality in children diagnosed with tuberculosis: a systematic review and meta-analysis. Lancet Infect Dis 2016; 17:285-295. [PMID: 27964822 DOI: 10.1016/s1473-3099(16)30474-1] [Citation(s) in RCA: 151] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 10/03/2016] [Accepted: 10/10/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Case fatality ratios in children with tuberculosis are poorly understood-particularly those among children with HIV and children not receiving tuberculosis treatment. We did a systematic review of published work to identify studies of population-representative samples of paediatric (ie, <15 years) tuberculosis cases. METHODS We searched PubMed and Embase for reports published in English, French, Portuguese, or Spanish before Aug 12, 2016, that included terms related to tuberculosis, children, mortality, and population representativeness. We also reviewed our own files and reference lists of articles identified by this search. We screened titles and abstracts for inclusion, excluding studies in which outcomes were unknown for 10% or more of the children and publications detailing non-representative samples. We used random-effects meta-analysis to produce pooled estimates of case fatality ratios from the included studies, which we divided into three eras: the pre-treatment era (ie, studies before 1946), the middle era (1946-80), and the recent era (after 1980). We stratified our analyses by whether or not children received tuberculosis treatment, age (0-4 years, 5-14 years), and HIV status. FINDINGS We identified 31 papers comprising 35 datasets representing 82 436 children with tuberculosis disease, of whom 9274 died. Among children with tuberculosis included in studies in the pre-treatment era, the pooled case fatality ratio was 21·9% (95% CI 18·1-26·4) overall. The pooled case fatality ratio was significantly higher in children aged 0-4 years (43·6%, 95% CI 36·8-50·6) than in those aged 5-14 years (14·9%, 11·5-19·1). In studies in the recent era, when most children had tuberculosis treatment, the pooled case fatality ratio was 0·9% (95% CI 0·5-1·6). US surveillance data suggest that the case fatality ratio is substantially higher in children with HIV receiving treatment for tuberculosis (especially without antiretroviral therapy) than in those without HIV. INTERPRETATION Without adequate treatment, children with tuberculosis, especially those younger than 5 years, are at high risk of death. Children with HIV have an increased mortality risk, even when receiving tuberculosis treatment. FUNDING US National Institutes of Health, Janssen Global Public Health.
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Affiliation(s)
- Helen E Jenkins
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA; Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA.
| | - Courtney M Yuen
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Carly A Rodriguez
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Megan M McLaughlin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Peter Donald
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Ben J Marais
- The Children's Hospital at Westmead, University of Sydney, Sydney, NSW, Australia
| | - Mercedes C Becerra
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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Skrahin A, Jenkins HE, Hurevich H, Solodovnikova V, Isaikina Y, Klimuk D, Rohava Z, Skrahina A. Effectiveness of a novel cellular therapy to treat multidrug-resistant tuberculosis. Int J Mycobacteriol 2016; 5 Suppl 1:S23. [PMID: 28043573 DOI: 10.1016/j.ijmyco.2016.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 11/06/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND/OBJECTIVE We urgently need novel treatments for multidrug-resistant tuberculosis (MDR-TB). Autologous mesenchymal stromal cell (MSC) infusion is one such possibility due to its potential to repair damaged lung tissue and boost immune responses. We aimed to assess the safety and effectiveness of MSC to improve treatment outcomes among MDR-TB patients. METHODS We analyzed treatment outcomes for 108 Belarusian MDR-TB patients receiving chemotherapy. Thirty-six patients (cases) also had MSCs collected, extracted, cultured, and reinfused (average time from chemotherapy start to infusion was 49days) in optimal dose; another 36 patients (without MSC treatment) were "study controls". We identified another control group: 36 patients from the Belarusian national surveillance database (surveillance controls) 1:1 matched to cases. RESULTS Successful outcomes were observed in 81% of cases, 42% of surveillance controls, and 39% of study controls. After adjusting for age, odds of a successful outcome were 6.5 (95% confidence interval, 1.2-36.2, p=0.032) times greater for cases than surveillance controls. Adjusting for other potential confounders increased the effect estimate while maintaining statistical significance. Cases were less likely (p=0.01) to be culture negative at 2months than surveillance controls, indicating a poorer initial prognosis in cases before (or shortly after) infusion. Radiological improvement was more likely in cases than in study controls. CONCLUSION MSC treatment could vastly improve treatment outcomes for MDR-TB patients. Our findings could revolutionize therapy options and have strong implications for future directions of MDR-TB therapy research.
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Affiliation(s)
- Aliaksandr Skrahin
- Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus; Belarus State Medical University, Minsk, Belarus
| | - Helen E Jenkins
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Henadz Hurevich
- Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus
| | | | - Yanina Isaikina
- Research Centre for Paediatric Oncology, Haematology and Immunology, Minsk, Belarus
| | - Dzmitri Klimuk
- Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus
| | - Zoya Rohava
- Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus
| | - Alena Skrahina
- Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus.
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Abstract
In 2015, the World Health Organization (WHO) declared tuberculosis (TB) to be responsible for more deaths than any other single infectious disease. The burden of TB among children has frequently been dismissed as relatively low with resulting deaths contributing very little to global under-five all-cause mortality, although without rigorous estimates of these statistics, the burden of childhood TB was, in reality, unknown. Recent work in the area has resulted in a WHO estimate of 1 million new cases of childhood TB in 2014 resulting in 136,000 deaths. Around 3% of these cases likely have multidrug-resistant TB and at least 40,000 are in HIV-infected children. TB is now thought to be a major or contributory cause of many deaths in children under five years old, despite not being recorded as such, and is likely in the top ten causes of global mortality in this age group. In particular, recent work has shown that TB is an under-lying cause of a substantial proportion of pneumonia deaths in TB-endemic countries. Childhood TB should be given higher priority: we need to identify children at greatest risk of TB disease and death and make more use of tools such as active case-finding and preventive therapy. TB is a preventable and treatable disease from which no child should die.
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Affiliation(s)
- Helen E. Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, MA 02118 USA
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46
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Seddon JA, Jenkins HE, Liu L, Cohen T, Black RE, Vos T, Becerra MC, Graham SM, Sismanidis C, Dodd PJ. Counting children with tuberculosis: why numbers matter. Int J Tuberc Lung Dis 2016; 19 Suppl 1:9-16. [PMID: 26564535 DOI: 10.5588/ijtld.15.0471] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
In the last 5 years, childhood tuberculosis (TB) has received increasing attention from international organisations, national TB programmes and academics. For the first time, a number of different groups are developing techniques to estimate the burden of childhood TB. We review the challenges in diagnosing TB in children and the reasons why cases in children can go unreported. We discuss the importance of an accurate understanding of burden for identifying problems in programme delivery, targeting interventions, monitoring trends, setting targets, allocating resources appropriately and providing strong advocacy. We briefly review the estimates produced by new analytical methods, and outline the reasons for recent improvements in our understanding and potential future directions. We conclude that while innovation, collaboration and better data have improved our understanding of the childhood TB burden, it remains substantially incomplete.
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Affiliation(s)
- J A Seddon
- Department of Paediatrics, Imperial College London, London, UK
| | - H E Jenkins
- Department of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts
| | - L Liu
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - T Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
| | - R E Black
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - T Vos
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington
| | - M C Becerra
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - S M Graham
- Centre for International Child Health, University of Melbourne Department of Paediatrics and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - C Sismanidis
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - P J Dodd
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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47
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Skrahin A, Jenkins HE, Hurevich H, Solodovnikova V, Isaikina Y, Klimuk D, Rohava Z, Skrahina A. Effectiveness of a novel cellular therapy to treat multidrug-resistant tuberculosis. J Clin Tuberc Other Mycobact Dis 2016; 4:21-27. [PMID: 27284577 PMCID: PMC4894747 DOI: 10.1016/j.jctube.2016.05.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Introduction We urgently need novel treatments for multidrug-resistant tuberculosis (MDR-TB). Autologous mesenchymal stromal cell (MSC) infusion is one such possibility due to its potential to repair damaged lung tissue and boost immune responses. We aimed to assess the effectiveness of MSC to improve outcomes among MDR-TB patients. Methods We analyzed outcomes for 108 Belarussian MDR-TB patients receiving chemotherapy. Thirty-six patients (“cases”) also had MSCs extracted, cultured and re-infused (average time from chemotherapy start to infusion was 49 days); another 36 patients were “study controls”. We identified another control group: 36 patients from the Belarussian surveillance database (“surveillance controls”) 1:1 matched to cases. Results Of the cases, 81% had successful outcomes versus 42% of surveillance controls and 39% of study controls. Successful outcome odds were 6.5 (95% Confidence Interval: 1.2–36.2, p = 0.032) times greater for cases than surveillance controls (age-adjusted). Radiological improvement was more likely in cases than study controls. Culture analysis prior to infusion demonstrated a poorer initial prognosis in cases, yet despite this they had better outcomes than the control groups. Conclusion MSC treatment could vastly improve outcomes for MDR-TB patients. Our findings could revolutionize therapy options and have strong implications for future directions of MDR-TB therapy research.
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Affiliation(s)
- Aliaksandr Skrahin
- Clinical Department, Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus
- Department of Intensive Care and Anesthesiology, Belarus State Medical University, Minsk, Belarus
| | - Helen E. Jenkins
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, USA
- Harvard Medical School, Boston, USA
- Corresponding author at: Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118, USA
| | - Henadz Hurevich
- Clinical Department, Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus
| | - Varvara Solodovnikova
- Clinical Department, Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus
| | - Yanina Isaikina
- Laboratory of Cellular Biotechnology and Cytotherapy, Belarussian Research Centre for Paediatric Oncology, Haematology and Immunology, Minsk, Belarus
| | - Dzmitri Klimuk
- Department of Monitoring and Evaluation, Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus
| | - Zoya Rohava
- Laboratory Department, Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus
| | - Alena Skrahina
- Clinical Department, Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus
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Yuen CM, Jenkins HE, Chang R, Mpunga J, Becerra MC. Two methods for setting child-focused tuberculosis care targets. Public Health Action 2016; 6:83-96. [PMID: 27358801 DOI: 10.5588/pha.16.0022] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 04/28/2016] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To allocate resources for household contact investigations, tuberculosis (TB) programs need estimates of the numbers of child contacts requiring care. DESIGN We developed two methods to estimate annual numbers of child contacts aged 0-14 years requiring evaluation and treatment. Method 1 combines local data using simple formulas. Using publicly available data, Method 2 uses a linear regression model based on Demographic and Health Survey and World Bank data to estimate the number of children per household, then combines these results with case notifications and risk estimates of disease and infection. RESULTS Applying Method 1 to data from Malawi indicated that every year ~21 000 child contacts require evaluation and ~1900 should be diagnosed with TB. Applying Method 2 to all countries suggested that, globally, 2.41 million (95% uncertainty interval [UI] 2.36-2.46) children aged <5 years, and 5.07 million (95%UI 4.81-5.34) children aged 5-14 years live in households of adult patients with known TB. Of these, 239 014 (95%UI 118 649-478581) and 419 816 (95%UI 140600-1 268805), respectively, will have TB. An additional 848 453 (95%UI 705838-1 017551) and 2660 885 (95%UI 2080517-3 413 189), respectively, will be infected. CONCLUSION It is feasible to use available data to set programmatic evaluation and treatment targets to improve care for child contacts of patients with TB.
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Affiliation(s)
- C M Yuen
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA ; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - H E Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - R Chang
- Clinton Health Access Initiative, Kigali, Rwanda
| | - J Mpunga
- National Tuberculosis Control Programme, Lilongwe, Malawi
| | - M C Becerra
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA ; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA ; Partners in Health, Boston, Massachusetts, USA
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Kunkel A, Abel Zur Wiesch P, Nathavitharana RR, Marx FM, Jenkins HE, Cohen T. Smear positivity in paediatric and adult tuberculosis: systematic review and meta-analysis. BMC Infect Dis 2016; 16:282. [PMID: 27296716 PMCID: PMC4906576 DOI: 10.1186/s12879-016-1617-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 06/03/2016] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) diagnosis continues to rely on sputum smear microscopy in many settings. We conducted a meta-analysis to estimate the percentage of children and adults with tuberculosis that are sputum smear positive. METHODS We searched PubMed, MEDLINE, Embase, and Global Health databases for studies that included both children and adults with all forms of active TB. The pooled percentages of children and adults with smear positive TB were estimated using the inverse variance heterogeneity model. This review was registered in the PROSPERO database under registration number CRD42015015331. RESULTS We identified 20 studies meeting our inclusion criteria that reported smear positivity for a total of 18,316 children and 162,574 adults from 14 countries. The pooled percentage of paediatric TB cases that were sputum smear positive was 6.8 % (95 % Confidence Interval (CI) 2.2-12.2 %), compared with 52.0 % (95 % CI 40.0-64.0 %) among adult cases. Eight studies reported data separately for children aged 0-4 and 5-14. The percentage of children aged 0-4 that were smear positive was 0.5 % (95 % CI 0.0-1.9 %), compared with 14.0 % (95 % CI 8.9-19.4 %) among children aged 5-14. CONCLUSIONS Children, especially those aged 0-4, are much less likely to be sputum smear positive than adults. National TB programs relying on sputum smear for diagnosis are at risk of under-diagnosing and underestimating the burden of TB in children.
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Affiliation(s)
- Amber Kunkel
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, USA.,Department of Epidemiology, Harvard School of Public Health, Boston, USA
| | - Pia Abel Zur Wiesch
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, USA.,Centre for Molecular Medicine Norway, Nordic EMBL Partnership, Oslo, Norway.,Department of Pharmacy, University of Tromso, Tromso, Norway
| | | | - Florian M Marx
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, USA.,Division of Global Health Equity, Brigham and Women's Hospital and Harvard Medical School, Boston, USA
| | - Helen E Jenkins
- Division of Global Health Equity, Brigham and Women's Hospital and Harvard Medical School, Boston, USA
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, USA.
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Abstract
Accelerating progress in the fight against tuberculosis will require a drastic shift from a strategy focused on control to one focused on elimination. Successful disease elimination campaigns are characterised by locally tailored responses that are informed by appropriate data. To develop such a response to tuberculosis, we suggest a three-step process that includes improved collection and use of existing programmatic data, collection of additional data (eg, geographic information, drug resistance, and risk factors) to inform tailored responses, and targeted collection of novel data (eg, sequencing data, targeted surveys, and contact investigations) to improve understanding of tuberculosis transmission dynamics. Development of a locally targeted response for tuberculosis will require substantial investment to reconfigure existing systems, coupled with additional empirical data to evaluate the effectiveness of specific approaches. Without adoption of an elimination strategy that uses local data to target hotspots of transmission, ambitious targets to end tuberculosis will almost certainly remain unmet.
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Affiliation(s)
- Grant Theron
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, and South African Medical Research Council Centre for Molecular and Cellular Biology, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa; Lung Infection and Immunity Unit, Department of Medicine, University of Cape Town, Observatory, Cape Town, South Africa
| | - Helen E Jenkins
- Department of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Frank Cobelens
- KNCV Tuberculosis Foundation, The Hague, Netherlands; Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, Netherlands
| | | | - Aamir J Khan
- Interactive Research & Development, Karachi, Pakistan
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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