Inclusion of non-medical interventions in model-based economic evaluations for tuberculosis: A scoping review.

BACKGROUND: The economic evaluation of health interventions is important in priority setting. Several guidance documents exist to support the conduct of economic evaluations, however, there is limited guidance for the evaluation of non-medical interventions. For tuberculosis (TB), where equity-deserving groups are disproportionately impacted, assessing interventions aimed at addressing social risk factors is necessary to effectively reduce TB burden. OBJECTIVE: This scoping review seeks to assess the existing literature on model-based economic evaluations of TB interventions to gauge the extent to which non-medical interventions have been evaluated in low-TB-incidence jurisdictions. As a secondary objective, this review aims to characterize key features of existing economic evaluations of medical and non-medical interventions. METHODS: A literature search was conducted in the grey literature and MEDLINE, Embase, EconLit, and PsychINFO databases to September 6, 2022 following the Arksey and O'Malley framework. Eligible articles were those that used decision-analytic modeling for economic evaluation of TB interventions in low-TB-incidence jurisdictions. RESULTS: This review identified 127 studies that met the inclusion criteria; 11 focused on prevention, 73 on detection, and 43 on treatment of TB. Only three studies (2%) evaluated non-medical interventions, including smoking reduction strategies, improving housing conditions, and providing food vouchers. All three non-medical intervention evaluations incorporated TB transmission and robust uncertainty analysis into the evaluation. The remainder of the studies evaluated direct medical interventions, eight of which were focused on specific implementation components (e.g., video observed therapy) which shared similar methodological challenges as the non-medical interventions. The majority of remaining evaluated medical interventions were focused on comparing various screening programs (e.g., immigrant screening program) and treatment regimens. CONCLUSIONS: This scoping review identified a gap in literature in the evaluation of non-medical TB interventions. However, the identified articles provided useful examples of how economic modeling can be used to explore non-traditional interventions using existing economic evaluation methods.

Diagnostic and public health investigation of Mycobacterium tuberculosis infection in a dog in Ontario, Canada.

A 4-y-old, female mixed-breed dog was presented to the Ontario Veterinary College for further evaluation of multiple pulmonary and hepatic masses, intrathoracic lymphadenitis, and recent development of a pyogranulomatous pleural effusion. Along with other comprehensive tests, a thoracic lymph node biopsy was performed, and Mycobacterium tuberculosis complex infection was confirmed by real-time PCR. The dog's condition declined post-operatively, and euthanasia was elected. Postmortem examination confirmed severe granulomatous pneumonia, hepatitis, intrathoracic and intraabdominal lymphadenitis, omentitis, and nephritis. Line-probe assays performed on samples collected postmortem confirmed the species as M. tuberculosis. 24-loci MIRU-VNTR genotyping, spoligotyping, and whole-genome sequencing revealed relations to known human isolates, but no epidemiologic link to these cases was investigated. Given the concern for potential human exposure during this animal's disease course, a public health investigation was initiated; 45 individuals were tested for M. tuberculosis exposure, and no subsequent human infections related to this animal were identified. Our case highlights the need for more readily available, minimally invasive testing for the diagnosis of canine mycobacteriosis, and highlights the ability of canid species to act as potential contributors to the epidemiology of M. tuberculosis infections.

Domestic impact of tuberculosis screening among new immigrants to Ontario, Canada.

BACKGROUND: All Canadian immigrants undergo screening for tuberculosis (TB) before immigration, and selected immigrants must undergo postimmigration surveillance for the disease. We sought to quantify the domestic health impact of screening for TB in all new immigrants and to identify mechanisms to enhance effectiveness and efficiency of this screening. METHODS: We linked preimmigration medical examination records from 944,375 immigrants who settled in Ontario between 2002 and 2011 to active TB reporting data in Ontario between 2002 and 2011. Using a retrospective cohort study design, we measured birth country-specific rates of active TB detected through preimmigration screening and postimmigration surveillance. We then quantified the proportion of active TB cases among residents of Ontario born abroad that were detected through postimmigration surveillance. Using Cox regression, we identified independent predictors of active TB postimmigration. RESULTS: Immigrants from 6 countries accounted for 87.3% of active TB cases detected through preimmigration screening, and 10 countries accounted for 80.4% of cases detected through postimmigration surveillance. Immigrants from countries with a TB (all-sites) incidence rate of less than 30 cases per 100 000 persons resulted in pre- and postimmigration detection of 2.4 and 0.9 cases per 100 000 immigrants, respectively. Postimmigration surveillance detected 2.6% of active TB cases in Ontario residents born abroad, and TB was detected a median of 18 days earlier in those undergoing surveillance than in those who were not referred to surveillance or who did not comply. Predictors of active TB postimmigration included radiographic markers of old TB, birth country, immigration category, location of application for residency, immune status and age. INTERPRETATION: Universal screening for TB in new immigrants has a modest impact on the domestic burden of active TB and is highly inefficient. Focusing preimmigration screening in countries with high incidence rates and revising criteria for postimmigration surveillance could increase the effectiveness and efficiency of screening.

The impact of infection on population health: results of the Ontario burden of infectious diseases study.

BACKGROUND: Evidence-based priority setting is increasingly important for rationally distributing scarce health resources and for guiding future health research. We sought to quantify the contribution of a wide range of infectious diseases to the overall infectious disease burden in a high-income setting. METHODOLOGY/PRINCIPAL FINDINGS: We used health-adjusted life years (HALYs), a composite measure comprising premature mortality and reduced functioning due to disease, to estimate the burden of 51 infectious diseases and associated syndromes in Ontario using 2005-2007 data. Deaths were estimated from vital statistics data and disease incidence was estimated from reportable disease, healthcare utilization, and cancer registry data, supplemented by local modeling studies and national and international epidemiologic studies. The 51 infectious agents and associated syndromes accounted for 729 lost HALYs, 44.2 deaths, and 58,987 incident cases per 100,000 population annually. The most burdensome infectious agents were: hepatitis C virus, Streptococcus pneumoniae, Escherichia coli, human papillomavirus, hepatitis B virus, human immunodeficiency virus, Staphylococcus aureus, influenza virus, Clostridium difficile, and rhinovirus. The top five, ten, and 20 pathogens accounted for 46%, 67%, and 75% of the total infectious disease burden, respectively. Marked sex-specific differences in disease burden were observed for some pathogens. The main limitations of this study were the exclusion of certain infectious diseases due to data availability issues, not considering the impact of co-infections and co-morbidity, and the inability to assess the burden of milder infections that do not result in healthcare utilization. CONCLUSIONS/SIGNIFICANCE: Infectious diseases continue to cause a substantial health burden in high-income settings such as Ontario. Most of this burden is attributable to a relatively small number of infectious agents, for which many effective interventions have been previously identified. Therefore, these findings should be used to guide public health policy, planning, and research.

Detecting random responding using the Assessment of Depression Inventory: a brief screening measure of depression.

BACKGROUND: Traditionally, the assessment of random responding in psychological assessment tools has been the primary domain of large multi-scale inventories. However, the ability of clinicians to assess random responding when using short symptom inventories is also an important facet of reliably assessing psychopathology and psychological distress. METHODS: This study assesses the effectiveness of a short symptom inventory, the Assessment of Depression Inventory (ADI), to assess random responding. RESULTS: The responses of 335 clinical patients, 150 responses from a feigning population, and 1,000 generated random profiles were compared to determine if the Random and Reliability scales of the ADI could detect adequately random responses. CONCLUSIONS: Findings indicate that even scales as short as four items can be used to detect random responses in symptom inventories at levels equivalent to or better than longer multi-scale inventories.