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Ryckman T, Robsky K, Cilloni L, Zawedde-Muyanja S, Ananthakrishnan R, Kendall EA, Shrestha S, Turyahabwe S, Katamba A, Dowdy DW. Ending tuberculosis in a post-COVID-19 world: a person-centred, equity-oriented approach. Lancet Infect Dis 2023; 23:e59-e66. [PMID: 35963272 PMCID: PMC9365311 DOI: 10.1016/s1473-3099(22)00500-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 02/02/2023]
Abstract
The COVID-19 pandemic has disrupted systems of care for infectious diseases-including tuberculosis-and has exposed pervasive inequities that have long marred efforts to combat these diseases. The resulting health disparities often intersect at the individual and community levels in ways that heighten vulnerability to tuberculosis. Effective responses to tuberculosis (and other infectious diseases) must respond to these realities. Unfortunately, current tuberculosis programmes are generally not designed from the perspectives of affected individuals and fail to address structural determinants of health disparities. We describe a person-centred, equity-oriented response that would identify and focus on communities affected by disparities, tailor interventions to the mechanisms by which disparities worsen tuberculosis, and address upstream determinants of those disparities. We detail four key elements of the approach (data collection, programme design, implementation, and sustainability). We then illustrate how organisations at multiple levels might partner and adapt current practices to incorporate these elements. Such an approach could generate more substantial, sustainable, and equitable reductions in tuberculosis burden at the community level, highlighting the urgency of restructuring post-COVID-19 health systems in a more person-centred, equity-oriented way.
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Affiliation(s)
- Theresa Ryckman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Katherine Robsky
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Lucia Cilloni
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stella Zawedde-Muyanja
- The Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Emily A Kendall
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda; Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sourya Shrestha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda; Clinical Epidemiology and Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda; Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Musekiwa A, Bamogo A, Shisana O, Robsky K, Zuma K, Zungu NP, Celentano DD. Prevalence of self-reported HIV testing and associated factors among adolescent girls and young women in South Africa: Results from a 2017 nationally representative population-based HIV survey. Public Health in Practice 2021; 2:100093. [PMID: 36101581 PMCID: PMC9461291 DOI: 10.1016/j.puhip.2021.100093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 01/13/2021] [Accepted: 01/25/2021] [Indexed: 11/07/2022] Open
Abstract
Objectives This article estimated the prevalence of self-reported HIV testing and identified associated factors among sexually active adolescent girls and young women (AGYW), aged 15–24 years, in South Africa. Study design This is a secondary data analysis of a nationally representative population-based cross-sectional multi-stage cluster survey of households in South Africa conducted in 2017. Methods Descriptive statistics were used to describe AGYW characteristics and the multivariable logistic regression model was used to determine factors associated with HIV testing. All analyses were adjusted for unequal sampling probabilities using survey weights. Results From the 1360 AGYW analysed (70.3% aged 20–24 years, 89.0% Black African, 95.5% unmarried, 88.7% unemployed), 1154 (estimate 85.8% (95% Confidence Interval (CI): 83.0 to 88.1)) had ever tested for HIV. In adjusted analysis, AGYW who had been pregnant in the past 24 months (adjusted Odds Ratio [aOR] 3.67, 95%CI: 1.68 to 8.02), were older (20–24 years: aOR 3.13, 95%CI: 1.86 to 5.28), or did not use condoms consistently compared to using them every time (almost every time: aOR 3.31, 95%CI: 1.07 to 10.22; sometimes: aOR 2.54, 95%CI: 1.29 to 4.98) had significantly higher odds of ever testing for HIV. Conclusions This research identified an unmet need for HIV testing among AGYW and increasing awareness of HIV counselling and testing among AGYW in South Africa is recommended. The prevalence of self-reported HIV testing among AGYW in South Africa in 2017 was 85.8% (95% CI: 83.0 to 88.1). Being pregnant in the past 24 months is associated with HIV testing among AGYW in South Africa. Being older (20–24 years) is associated with HIV testing among AGYW in South Africa. Inconsistent use of condoms is associated with HIV testing among AGYW in South Africa. There is an unmet need for HIV testing among AGYW in South Africa.
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Kitonsa PJ, Nalutaaya A, Mukiibi J, Nakasolya O, Isooba D, Kamoga C, Baik Y, Robsky K, Dowdy DW, Katamba A, Kendall EA. Evaluation of underweight status may improve identification of the highest-risk patients during outpatient evaluation for pulmonary tuberculosis. PLoS One 2020; 15:e0243542. [PMID: 33306710 PMCID: PMC7732099 DOI: 10.1371/journal.pone.0243542] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 11/23/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND When evaluating symptomatic patients for tuberculosis (TB) without access to same-day diagnostic test results, clinicians often make empiric decisions about starting treatment. The number of TB symptoms and/or underweight status could help identify patients at highest risk for a positive result. We sought to evaluate the usefulness of BMI assessment and a count of characteristic TB symptoms for identifying patients at highest risk for TB. METHODS We enrolled adult patients receiving pulmonary TB diagnoses and a representative sample with negative TB evaluations at four outpatient health facilities in Kampala, Uganda. We asked patients about symptoms of chronic cough, night sweats, chest pain, fever, hemoptysis, or weight loss; measured height and weight; and collected sputum for mycobacterial culture. We evaluated the diagnostic accuracy (for culture-positive TB) of two simple scoring systems: (a) number of TB symptoms, and (b) number of TB symptoms plus one or more additional points for underweight status (body mass index [BMI] ≤ 18.5 kg/m2). RESULTS We included 121 patients with culture-positive TB and 370 patients with negative culture results (44 of whom had been recommended for TB treatment by evaluating clinicians). Of the six symptoms assessed, the median number of symptoms that patients reported was two (interquartile range [IQR]: 1, 3). The median BMI was 20.9 kg/m2 (IQR: 18.6, 24.0), and 118 (24%) patients were underweight. Counting the number of symptoms provided an area under the Receiver Operating Characteristic curve (c-statistic) of 0.77 (95% confidence interval, CI: 0.72, 0.81) for identifying culture-positive TB; adding two points for underweight status increased the c-statistic to 0.81 (95%CI: 0.76, 0.85). A cutoff of ≥3 symptoms had sensitivity and specificity of 65% and 74%, whereas a score of ≥4 on the combined score (≥2 symptoms if underweight, ≥4 symptoms if not underweight) gave higher sensitivity and specificity of 69% and 81% respectively. A sensitivity analysis defining TB by Xpert MTB/RIF status produced similar results. CONCLUSION A count of patients' TB symptoms may be useful in clinical decision-making about TB diagnosis. Consideration of underweight status adds additional diagnostic value.
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Affiliation(s)
- Peter J. Kitonsa
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, College of Health Sciences, Kampala, Uganda
- * E-mail:
| | - Annet Nalutaaya
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, College of Health Sciences, Kampala, Uganda
| | - James Mukiibi
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Olga Nakasolya
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, College of Health Sciences, Kampala, Uganda
| | - David Isooba
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Caleb Kamoga
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Yeonsoo Baik
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States America
| | - Katherine Robsky
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States America
| | - David W. Dowdy
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, College of Health Sciences, Kampala, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States America
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, College of Health Sciences, Kampala, Uganda
- Department of Medicine, College of Health Sciences, Makerere University, Upper Mulago Hill, Kampala, Uganda
| | - Emily A. Kendall
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, College of Health Sciences, Kampala, Uganda
- Division of Infectious Diseases and Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
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Roscoe C, Lockhart C, de Klerk M, Baughman A, Agolory S, Gawanab M, Menzies H, Jonas A, Salomo N, Taffa N, Lowrance D, Robsky K, Tollefson D, Pevzner E, Hamunime N, Mavhunga F, Mungunda H. Evaluation of the uptake of tuberculosis preventative therapy for people living with HIV in Namibia: a multiple methods analysis. BMC Public Health 2020; 20:1838. [PMID: 33261569 PMCID: PMC7708912 DOI: 10.1186/s12889-020-09902-z] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 11/17/2020] [Indexed: 11/17/2022] Open
Abstract
Background In 2016, Namibia had ~ 230,000 people living with HIV (PLHIV) and 9154 new tuberculosis (TB) cases, including 3410 (38%) co-infected cases. TB preventative therapy (TPT), consisting of intensive case finding and isoniazid preventative therapy, is critical to reducing TB disease and mortality. Methods Between November 2014 and February 2015, data was abstracted from charts of PLHIV enrolled in HIV treatment. Fifty-five facilities were purposively selected based on patient volume, type and location. Charts were randomly sampled. The primary outcome was to estimate baseline TPT in PLHIV, using nationally weighted proportions. Qualitative surveys were conducted and summarized to evaluate TPT practices and quantify challenges encountered by health care workers (HCW). Results Among 861 PLHIV sampled, 96% were eligible for TPT services, of which 87.1% were screened for TB at least once. For PLHIV eligible for preventative therapy (646/810; 82.6%), 45.4% (294/646) initiated therapy and 45.7% (139/294) of those completed therapy. The proportion of eligible PLHIV completing TB screening, initiating preventative therapy and then completing preventative therapy was 20.7%. Qualitative surveys with 271 HCW identified barriers to TPT implementation including: lack of training (61.3% reported receiving training on TPT); misunderstandings about timing of TPT initiation (46.7% correctly reported TPT should be started with antiretroviral therapy); and variable screening practices and responsibilities (66.1% of HCWs screened for TB at every encounter). Though barriers were evident, 72.2% HCWs surveyed described their clinical performance as very good, often placing responsibility of difficulties on patients and downplaying challenges like staff shortages and medication stock outs. Conclusions In this study, only 1 in 5 eligible PLHIV completed the TPT cascade in Namibia. Lack of training, irregularities with TB screening and timing of TPT, unclear prescribing and recording responsibilities, and a clinical misperception may have contributed to suboptimal programmatic implementation. Addressing these challenges will be critical with continued TPT scale-up.
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Affiliation(s)
- Clay Roscoe
- U.S. Centers for Disease Control and Prevention, Windhoek, Namibia.
| | - Chris Lockhart
- U.S. Centers for Disease Control and Prevention, Windhoek, Namibia
| | - Michael de Klerk
- U.S. Centers for Disease Control and Prevention, Windhoek, Namibia
| | - Andrew Baughman
- U.S. Centers for Disease Control and Prevention, Windhoek, Namibia
| | - Simon Agolory
- U.S. Centers for Disease Control and Prevention, Windhoek, Namibia
| | - Michael Gawanab
- Ministry of Health and Social Services of Namibia, Directorate of Special Programs, Oshakati, Namibia
| | - Heather Menzies
- U.S. Centers for Disease Control and Prevention, Windhoek, Namibia
| | - Anna Jonas
- U.S. Centers for Disease Control and Prevention, Windhoek, Namibia
| | - Natanael Salomo
- Ministry of Health and Social Services of Namibia, Directorate of Special Programs, Oshakati, Namibia
| | - Negussie Taffa
- U.S. Centers for Disease Control and Prevention, Windhoek, Namibia
| | - David Lowrance
- U.S. Centers for Disease Control and Prevention, Windhoek, Namibia
| | | | | | - Eric Pevzner
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ndapewa Hamunime
- Ministry of Health and Social Services of Namibia, Directorate of Special Programs, Oshakati, Namibia
| | - Farai Mavhunga
- Ministry of Health and Social Services of Namibia, Directorate of Special Programs, Oshakati, Namibia
| | - Helena Mungunda
- Ministry of Health and Social Services of Namibia, Directorate of Special Programs, Oshakati, Namibia
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Zhang M, Jarrett BA, Althoff KN, Burman FS, Camarata L, Coburn SB, Dickerson AS, Foti K, Kaur M, Leifheit KM, Malone J, Moore EA, Mouslim MC, Prata Menezes N, Robsky K, Tang O, Wallace AS, Dean LT. Recommendations to the Society for Epidemiologic Research for Further Promoting Diversity and Inclusion at the Annual Meeting and Beyond. Am J Epidemiol 2020; 189:1037-1041. [PMID: 32602548 PMCID: PMC7666413 DOI: 10.1093/aje/kwaa110] [Citation(s) in RCA: 4] [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: 03/14/2020] [Revised: 04/06/2020] [Accepted: 04/06/2020] [Indexed: 01/01/2023] Open
Abstract
Increasing diverse engagement in the Society for Epidemiologic Research (SER) will positively impact the field of epidemiology. As the largest and longest-running epidemiologic society in North America, SER has long been a pioneer in promoting diversity and inclusion. A recent survey of SER members, however, showed there is still room for improving diversity, inclusion, representation, and participation in the Society. In this commentary, as members of both the SER and the Johns Hopkins Bloomberg School of Public Health Department of Epidemiology's Inclusion, Diversity, Equity, Anti-Racism, and Science (Epi IDEAS) Working Group, we recommend 4 goals for the SER Annual Meeting and beyond: 1) convene epidemiologic researchers with diverse backgrounds and ideas; 2) promote an inclusive environment at the SER Annual Meeting; 3) develop, compile, and disseminate best practices to honor diversity in epidemiologic research; and 4) increase prioritization of health disparities research and methods. We also suggest strategies for achieving these goals so that SER can better include, support, and elevate members from historically disadvantaged groups. While our recommendations are tailored specifically to SER, the greater epidemiologic and academic communities could benefit from adopting these goals and strategies within their professional societies and conferences.
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Affiliation(s)
- Mingyu Zhang
- Correspondence to Mingyu Zhang, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Suite 2-200A, Baltimore, MD 21205 (e-mail: )
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Kendall EA, Kamoga C, Kitonsa PJ, Nalutaaya A, Salvatore PP, Robsky K, Nakasolya O, Mukiibi J, Isooba D, Cattamanchi A, Kato-Maeda M, Katamba A, Dowdy DW. Empiric treatment of pulmonary TB in the Xpert era: Correspondence of sputum culture, Xpert MTB/RIF, and clinical diagnoses. PLoS One 2019; 14:e0220251. [PMID: 31339935 PMCID: PMC6655770 DOI: 10.1371/journal.pone.0220251] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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: 05/14/2019] [Accepted: 07/11/2019] [Indexed: 11/19/2022] Open
Abstract
Background Clinical tuberculosis diagnosis and empiric treatment have traditionally been common among patients with negative bacteriologic test results. Increasing availability of rapid molecular diagnostic tests, including Xpert MTB/RIF and the new Xpert Ultra cartridge, may alter the role of empiric treatment. Methods We prospectively enrolled outpatients age > = 15 who were evaluated for pulmonary tuberculosis at three health facilities in Kampala, Uganda. Using sputum mycobacterial culture, interviews, and clinical record abstraction, we estimated the accuracy of clinical diagnosis relative to Xpert and sputum culture and assessed the contribution of clinical diagnosis to case detection. Results Over a period of 9 months, 99 patients were diagnosed with pulmonary tuberculosis and subsequently completed sputum culture; they were matched to 196 patients receiving negative tuberculosis evaluations in the same facilities. Xpert was included in the evaluation of 291 (99%) patients. Compared to culture, Xpert had a sensitivity of 92% (95% confidence interval 83–97%) and specificity of 95% (92–98%). Twenty patients with negative Xpert were clinically diagnosed with tuberculosis and subsequently had their culture status determined; two (10%) were culture-positive. Considering all treated patients regardless of Xpert and culture data completeness, and considering treatment initiations before a positive Xpert (N = 4) to be empiric, 26/101 (26%) tuberculosis treatment courses were started empirically. Compared to sputum smear- or Xpert-positive patients with positive cultures, empirically-treated, Xpert-negative patients with negative cultures had higher prevalence of HIV (67% versus 37%), shorter duration of cough (median 4 versus 8 weeks), and lower inflammatory markers (median CRP 7 versus 101 mg/L). Conclusion Judged against sputum culture in a routine care setting of high HIV prevalence, the accuracy of Xpert was high. Clinical judgment identified a small number of additional culture-positive cases, but with poor specificity. Although clinicians should continue to prescribe tuberculosis treatment for Xpert-negative patients whose clinical presentations strongly suggest pulmonary tuberculosis, they should also carefully consider alternative diagnoses.
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MESH Headings
- Adult
- Antibiotics, Antitubercular/classification
- Antibiotics, Antitubercular/therapeutic use
- Case-Control Studies
- Diagnostic Tests, Routine/methods
- Diagnostic Tests, Routine/trends
- Drug Resistance, Bacterial/genetics
- Female
- Humans
- Male
- Microbiological Techniques/methods
- Molecular Diagnostic Techniques/methods
- Mycobacterium tuberculosis/genetics
- Mycobacterium tuberculosis/isolation & purification
- Polymerase Chain Reaction/methods
- Polymerase Chain Reaction/trends
- Reproducibility of Results
- Sensitivity and Specificity
- Sputum/microbiology
- Time-to-Treatment/statistics & numerical data
- Tuberculosis, Multidrug-Resistant/diagnosis
- Tuberculosis, Multidrug-Resistant/genetics
- Tuberculosis, Multidrug-Resistant/prevention & control
- Tuberculosis, Pulmonary/diagnosis
- Tuberculosis, Pulmonary/drug therapy
- Tuberculosis, Pulmonary/epidemiology
- Tuberculosis, Pulmonary/microbiology
- Uganda/epidemiology
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Affiliation(s)
- Emily A. Kendall
- Division of Infectious Diseases and Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States America
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
- * E-mail:
| | - Caleb Kamoga
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Peter J. Kitonsa
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Annet Nalutaaya
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Phillip P. Salvatore
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States America
| | - Katherine Robsky
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States America
| | - Olga Nakasolya
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - James Mukiibi
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - David Isooba
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Adithya Cattamanchi
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States America
| | - Midori Kato-Maeda
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States America
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David W. Dowdy
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States America
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Abstract
OBJECTIVES To describe the epidemiology and factors associated with pediatric central nervous system (CNS) tuberculosis (TB) in California from 1993 to 2011. METHODS We analyzed California TB registry data for persons aged ≤18 years, comparing CNS TB cases versus non-CNS TB cases reported from 1993 to 2011. Factors associated with CNS TB and TB deaths were identified by using multivariate logistic regression. RESULTS A total of 200 CNS TB cases were reported. Compared with non-CNS TB case patients, CNS TB case patients were more likely to be aged <5 years (72.0% vs 43.6%; odds ratio [OR]: 3.8 [95% confidence interval (CI): 2.4-5.9]), US-born (82.0% vs 58.2%; OR: 3.3 [CI: 2.3-4.7]), and Hispanic (75.0% vs 63.2%; OR: 1.7 [CI: 1.3-2.4]). Among US-born CNS TB case patients (during 2010-2011), 76.5% had a foreign-born parent. Tuberculin skin test results were negative in 38.2% of 170 CNS TB cases tested. In multivariate analysis, age <5 years (adjusted odds ratio [aOR]: 3.3 [CI: 2.0-5.4]), US birth (aOR: 1.8 [CI 1.2-2.7]), and Hispanic ethnicity (aOR: 1.5 [CI: 1.1-2.1]) were associated with an increased risk of developing CNS TB. For deaths, CNS TB (aOR: 3.8 [CI: 1.4-9.9]) and culture positivity (aOR: 6.2 [CI: 2.2-17.3]) were associated with increased risk of death, whereas tuberculin skin test positivity (aOR: 0.1 [CI: 0.04-0.2]) was associated with decreased risk. CONCLUSIONS Subsets of children are at increased risk for CNS TB in California and may benefit from additional prevention efforts.
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Affiliation(s)
- Alexandra Duque-Silva
- UCSF Benioff Children's Hospital Oakland, Oakland, California; and Tuberculosis Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health, Richmond, California
| | - Katherine Robsky
- Tuberculosis Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health, Richmond, California
| | - Jennifer Flood
- Tuberculosis Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health, Richmond, California
| | - Pennan M Barry
- Tuberculosis Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health, Richmond, California
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Chitnis AS, Robsky K, Schecter GF, Westenhouse J, Barry PM. Trends in Tuberculosis Cases Among Nursing Home Residents, California, 2000 to 2009. J Am Geriatr Soc 2015; 63:1098-104. [PMID: 26096384 DOI: 10.1111/jgs.13437] [Citation(s) in RCA: 9] [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] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine trends in tuberculosis (TB) incidence and to compare demographic and clinical characteristics of nursing home (NH) residents and community-dwelling older adults. DESIGN Prospective TB surveillance. SETTING TB cases reported in California from 2000 to 2009. PARTICIPANTS TB patients aged 65 and older. MEASUREMENTS Trends in TB incidence per 100,000 population were assessed using Poisson regression. Demographic and clinical characteristics were compared using the chi-square or Wilcoxon rank-sum test. Among NH residents, risk factors for death during TB treatment were identified using logistic regression. RESULTS From 2000 to 2009, TB incidence rates decreased significantly, from 15.9/100,000 to 8.4/100,000 (-44%, 95% confidence interval (CI) = -66% to -7%) for NH residents and from 21.2/100,000 to 15.0/100,000 (-27%, 95% CI = -29% to -24%) for community-dwelling older adults. Overall, 211 TB cases among NH residents and 6,518 cases among community-dwelling older adults were reported. NH residents were more likely than community-dwelling older adults to be older (median age 81 vs 75, P < .001), have a negative acid-fast bacilli sputum smear and positive culture (37% vs 28%, P < .001), and die while undergoing TB treatment (44% vs 14%, P < .001), and were less likely to have a positive tuberculin skin test (TST) (28% vs 44%, P < .001) and have TB care provided by a health department (20% vs 59%, P < .001). In multivariable analysis, NH residents who had a positive TST were less likely to die while undergoing TB treatment (odds ratio = 0.39, 95% CI = 0.16-0.96). CONCLUSION TB incidence rates were lower, and reductions in incidence were greater among NH residents; community-dwelling older adults had higher TB rates and smaller reductions in incidence. Interventions that promote timely detection and treatment of TB infection and disease may be needed to reduce morbidity and mortality among NH residents.
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Affiliation(s)
- Amit S Chitnis
- Tuberculosis Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health, Richmond, California
| | - Katherine Robsky
- Tuberculosis Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health, Richmond, California
| | - Gisela F Schecter
- Tuberculosis Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health, Richmond, California
| | - Janice Westenhouse
- Tuberculosis Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health, Richmond, California
| | - Pennan M Barry
- Tuberculosis Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health, Richmond, California
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9
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Chitnis AS, Schecter GF, Cilnis M, Robsky K, Flood JM, Barry PM. Epidemiology of tuberculosis cases with end-stage renal disease, California, 2010. Am J Nephrol 2014; 39:314-21. [PMID: 24751696 DOI: 10.1159/000360183] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 01/30/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Few studies have compared population-based tuberculosis (TB) incidence rates by end-stage renal disease (ESRD) status. No studies have compared TB genotypes by ESRD status to determine whether TB disease resulted from recent transmission or reactivation of latent TB infection (LTBI). We calculated TB incidence rates and compared demographic and clinical characteristics and genotypes among TB cases by ESRD status. METHODS This analysis was based on prospective surveillance for TB cases during 2010 in California. Clustered genotype was defined as ≥2 culture-positive TB cases with matching genotypes in the same county. The χ(2) or Wilcoxon rank-sum test was used to compare variables. RESULTS During 2010, 83 TB cases with ESRD and 2,244 cases without ESRD were reported in California; TB incidence rates were 110.3/100,000 and 6.0/100,000, respectively. ESRD case patients versus patients without ESRD were more likely to be older (median age 66 vs. 49 years; p < 0.001), foreign-born persons who had arrived in the USA >5 years before TB diagnosis (97 vs. 75%; p < 0.001) and dead at TB diagnosis (7 vs. 2%; p = 0.01). ESRD patients were less likely to have a positive tuberculin skin test (50 vs. 80%; p < 0.001), positive acid-fast bacilli sputum smears (33 vs. 53%; p = 0.01) and cavities on chest radiography (6 vs. 21%; p = 0.01). No differences in proportions of clustered TB genotypes were detected (20 vs. 23%; p = 0.54). CONCLUSIONS Rates of TB are 18 times higher in California's ESRD population, and TB disease likely occurred due to LTBI reactivation because few patients had clustered genotypes. Efforts to prevent TB among ESRD patients may require the use of newer diagnostic tests and promotion of LTBI treatment.
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Affiliation(s)
- Amit S Chitnis
- Tuberculosis Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health, Richmond, Calif., USA
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Steingart KR, Jotblad S, Robsky K, Deck D, Hopewell PC, Huang D, Nahid P. Higher-dose rifampin for the treatment of pulmonary tuberculosis: a systematic review. Int J Tuberc Lung Dis 2011; 15:305-316. [PMID: 21333096] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
OBJECTIVE To provide a descriptive synthesis of the evidence assessing the efficacy and safety of higher doses of rifampin (RMP) for the treatment of pulmonary tuberculosis (TB). METHODS Systematic review of randomized controlled trials that evaluate a range of RMP doses, including doses higher than standard (>10 mg/kg or >600 mg), used as part of combination drug therapies for pulmonary TB. Two reviewers applied inclusion criteria, assessed trial quality and extracted data. Inclusion criteria were smear- or culture-confirmed pulmonary TB, and English and French language articles. Exclusion criteria were RMP monotherapy and smear-negative TB. Outcomes included were sputum culture conversion, treatment failure, recurrence and adverse events, including hepatotoxicity and flu-like syndrome. RESULTS Of 14 trials (4256 participants) identified, 12 were conducted before 1980. Four trials were considered high quality according to published guidelines. Study characteristics, including history of prior TB treatment, dose of RMP, duration of treatment, timing of introduction of intervention treatment, concomitant drugs, and duration of follow-up, varied, making synthesis of efficacy data challenging. Several trials suggested an advantage in terms of likelihood of culture conversion among patients receiving at least 900 mg RMP. However, an increased incidence of flu-like syndrome was seen when RMP doses of 900 mg and higher were given intermittently. CONCLUSION Historical trials suggest that higher than standard RMP dosing results in improved culture conversion rates. Phase 2 and 3 clinical trials evaluating higher doses of RMP and other rifamycins are needed to confirm efficacy and assure tolerability. Pharmacokinetic studies will be needed to inform the development of such trials.
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Affiliation(s)
- K R Steingart
- Curry International Tuberculosis Center, University of California, San Francisco, California, USA.
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