Your browser doesn't support javascript.
loading
Show: 20 | 50 | 100
Results 1 - 20 de 43
Filter
Add more filters

Publication year range
1.
Bull World Health Organ ; 101(11): 730-737, 2023 Nov 01.
Article in English | MEDLINE | ID: mdl-37961060

ABSTRACT

The World Health Organization has developed target product profiles containing minimum and optimum targets for key characteristics for tests for tuberculosis treatment monitoring and optimization. Tuberculosis treatment optimization refers to initiating or switching to an effective tuberculosis treatment regimen that results in a high likelihood of a good treatment outcome. The target product profiles also cover tests of cure conducted at the end of treatment. The development of the target product profiles was informed by a stakeholder survey, a cost-effectiveness analysis and a patient-care pathway analysis. Additional feedback from stakeholders was obtained by means of a Delphi-like process, a technical consultation and a call for public comment on a draft document. A scientific development group agreed on the final targets in a consensus meeting. For characteristics rated of highest importance, the document lists: (i)Ā high diagnostic accuracy (sensitivity and specificity); (ii)Ā time to result of optimally ≤ 2Ā hours and no more than 1Ā day; (iii)Ā required sample type to be minimally invasive, easily obtainable, such as urine, breath, or capillary blood, or a respiratory sample that goes beyond sputum; (iv)Ā ideally the test could be placed at a peripheral-level health facility without a laboratory; and (v)Ā the test should be affordable to low- and middle-income countries, and allow wide and equitable access and scale-up. Use of these target product profiles should facilitate the development of new tuberculosis treatment monitoring and optimization tests that are accurate and accessible for all people being treated for tuberculosis.


L'Organisation mondiale de la santĆ© a Ć©laborĆ© des profils de produits cibles contenant des cibles minimales et optimales pour les caractĆ©ristiques principales des essais destinĆ©s au suivi et Ć  l'optimisation du traitement de la tuberculose. L'optimisation du traitement de la tuberculose fait rĆ©fĆ©rence Ć  l'instauration d'un rĆ©gime de traitement efficace de la tuberculose ou Ć  l'adoption d'un tel rĆ©gime, avec une probabilitĆ© Ć©levĆ©e d'obtenir de bons rĆ©sultats thĆ©rapeutiques. Les profils de produits cibles couvrent Ć©galement les essais de guĆ©rison effectuĆ©s Ć  l'issue du traitement. Les profils de produits cibles ont Ć©tĆ© Ć©laborĆ©s sur la base d'un sondage auprĆØs des parties prenantes, d'une analyse coĆ»t-efficacitĆ© et d'une analyse du parcours de soins du patient. Des retours supplĆ©mentaires des parties prenantes ont Ć©tĆ© obtenus au moyen d'un processus crĆ©Ć© selon la mĆ©thode Delphi, d'une consultation technique et d'un appel Ć  commentaires publics sur un projet de document. Un groupe d'Ć©laboration scientifique s'est mis d'accord sur les objectifs finaux lors d'une rĆ©union de concertation. En ce qui concerne les caractĆ©ristiques jugĆ©es les plus importantes, le document Ć©numĆØre ce qui suit: (i) une grande prĆ©cision diagnostique (sensibilitĆ© et spĆ©cificitĆ©); (ii) un dĆ©lai idĆ©al d'obtention des rĆ©sultats ≤ 2 heures et au maximum de 1 jour; (iii) le type d'Ć©chantillon requis doit ĆŖtre peu invasif et facile Ć  obtenir, comme l'urine, l'haleine ou le sang capillaire, ou bien un Ć©chantillon respiratoire au-delĆ  des expectorations; (iv) idĆ©alement, l'essai pourrait avoir lieu dans un Ć©tablissement de santĆ© pĆ©riphĆ©rique sans laboratoire ; et (v) l'essai devrait ĆŖtre abordable pour les pays Ć  revenu faible et intermĆ©diaire et permettre un accĆØs large et Ć©quitable ainsi qu'une mise Ć  l'Ć©chelle. L'utilisation de ces profils de produits cibles devrait faciliter la mise au point de nouveaux essais de surveillance et d'optimisation du traitement de la tuberculose qui soient prĆ©cis et accessibles Ć  toutes les personnes suivant un traitement pour la tuberculose.


La OrganizaciĆ³n Mundial de la Salud ha elaborado perfiles de productos objetivo que contienen objetivos mĆ­nimos y Ć³ptimos para las caracterĆ­sticas principales de las pruebas de seguimiento y optimizaciĆ³n del tratamiento de la tuberculosis. La optimizaciĆ³n del tratamiento de la tuberculosis consiste en iniciar o cambiar a un rĆ©gimen eficaz de tratamiento de la tuberculosis que ofrezca una alta probabilidad de un buen resultado terapĆ©utico. Los perfiles de productos objetivo tambiĆ©n abarcan las pruebas de curaciĆ³n realizadas al final del tratamiento. La elaboraciĆ³n de los perfiles de los productos objetivo se basĆ³ en una encuesta a las partes interesadas, un anĆ”lisis de rentabilidad y un anĆ”lisis de la vĆ­a de atenciĆ³n al paciente. Se obtuvo informaciĆ³n adicional de las partes interesadas mediante un proceso tipo Delphi, una consulta tĆ©cnica y una convocatoria de comentarios pĆŗblicos sobre un borrador del documento. Un grupo de desarrollo cientĆ­fico acordĆ³ los objetivos finales en una reuniĆ³n de consenso. Para las caracterĆ­sticas clasificadas de mayor importancia, el documento enumera:Ā (i)Ā alta precisiĆ³n diagnĆ³stica (sensibilidad y especificidad); (ii)Ā tiempo hasta el resultado de Ć³ptimamente ≤Ā 2Ā horas y no mĆ”s de 1Ā dĆ­a; (iii)Ā el tipo de muestra requerida debe ser mĆ­nimamente invasiva, fĆ”cil de obtener, como orina, aliento o sangre capilar, o una muestra respiratoria que vaya mĆ”s allĆ” del esputo; (iv)Ā idealmente la prueba podrĆ­a realizarse en un centro sanitario perifĆ©rico sin laboratorio; y (v)Ā la prueba debe ser asequible para los paĆ­ses de ingresos bajos y medios y permitir un acceso amplio y equitativo y su expansiĆ³n. El uso de estos perfiles de producto objetivo deberĆ­a facilitar el desarrollo de pruebas nuevas de seguimiento y optimizaciĆ³n del tratamiento de la tuberculosis que sean precisas y accesibles para todas las personas que reciben tratamiento antituberculoso.


Subject(s)
Body Fluids , Tuberculosis , Humans , Tuberculosis/diagnosis , Tuberculosis/drug therapy , Sensitivity and Specificity , World Health Organization , Sputum
2.
BMC Health Serv Res ; 23(1): 1284, 2023 Nov 22.
Article in English | MEDLINE | ID: mdl-37993890

ABSTRACT

Introducing new vaccines within national immunization programs requires careful consideration of disease- and vaccine-related issues as well as of the strength of the program and the affected health system. Economic evaluations play an essential role in this process. In this editorial, we set the context and invite contributions for a BMC Health Services Research Collection of articles titled 'Economic Evaluations of Vaccine Programs'.


Subject(s)
Vaccination , Vaccines , Humans , Cost-Benefit Analysis , Immunization Programs , Health Services Research , Immunization
3.
PLoS Med ; 19(6): e1004032, 2022 06.
Article in English | MEDLINE | ID: mdl-35696431

ABSTRACT

BACKGROUND: Shorter, safer, and cheaper tuberculosis (TB) preventive treatment (TPT) regimens will enhance uptake and effectiveness. WHO developed target product profiles describing minimum requirements and optimal targets for key attributes of novel TPT regimens. We performed a cost-effectiveness analysis addressing the scale-up of regimens meeting these criteria in Brazil, a setting with relatively low transmission and low HIV and rifampicin-resistant TB (RR-TB) prevalence, and South Africa, a setting with higher transmission and higher HIV and RR-TB prevalence. METHODS AND FINDINGS: We used outputs from a model simulating scale-up of TPT regimens meeting minimal and optimal criteria. We assumed that drug costs for minimal and optimal regimens were identical to 6 months of daily isoniazid (6H). The minimal regimen lasted 3 months, with 70% completion and 80% efficacy; the optimal regimen lasted 1 month, with 90% completion and 100% efficacy. Target groups were people living with HIV (PLHIV) on antiretroviral treatment and household contacts (HHCs) of identified TB patients. The status quo was 6H at 2019 coverage levels for PLHIV and HHCs. We projected TB cases and deaths, TB-associated disability-adjusted life years (DALYs), and costs (in 2020 US dollars) associated with TB from a TB services perspective from 2020 to 2035, with 3% annual discounting. We estimated the expected costs and outcomes of scaling up 6H, the minimal TPT regimen, or the optimal TPT regimen to reach all eligible PLHIV and HHCs by 2023, compared to the status quo. Maintaining current 6H coverage in Brazil (0% of HHCs and 30% of PLHIV treated) would be associated with 1.1 (95% uncertainty range [UR] 1.1-1.2) million TB cases, 123,000 (115,000-132,000) deaths, and 2.5 (2.1-3.1) million DALYs and would cost $1.1 ($1.0-$1.3) billion during 2020-2035. Expanding the 6H, minimal, or optimal regimen to 100% coverage among eligible groups would reduce DALYs by 0.5% (95% UR 1.2% reduction, 0.4% increase), 2.5% (1.8%-3.0%), and 9.0% (6.5%-11.0%), respectively, with additional costs of $107 ($95-$117) million and $51 ($41-$60) million and savings of $36 ($14-$58) million, respectively. Compared to the status quo, costs per DALY averted were $7,608 and $808 for scaling up the 6H and minimal regimens, respectively, while the optimal regimen was dominant (cost savings, reduced DALYs). In South Africa, maintaining current 6H coverage (0% of HHCs and 69% of PLHIV treated) would be associated with 3.6 (95% UR 3.0-4.3) million TB cases, 843,000 (598,000-1,201,000) deaths, and 36.7 (19.5-58.0) million DALYs and would cost $2.5 ($1.8-$3.6) billion. Expanding coverage with the 6H, minimal, or optimal regimen would reduce DALYs by 6.9% (95% UR 4.3%-95%), 15.5% (11.8%-18.9%), and 38.0% (32.7%-43.0%), respectively, with additional costs of $79 (-$7, $151) million and $40 (-$52, $140) million and savings of $608 ($443-$832) million, respectively. Compared to the status quo, estimated costs per DALY averted were $31 and $7 for scaling up the 6H and minimal regimens, while the optimal regimen was dominant. Study limitations included the focus on 2 countries, and no explicit consideration of costs incurred before the decision to prescribe TPT. CONCLUSIONS: Our findings suggest that scale-up of TPT regimens meeting minimum or optimal requirements would likely have important impacts on TB-associated outcomes and would likely be cost-effective or cost saving.


Subject(s)
HIV Infections , Tuberculosis, Multidrug-Resistant , Antitubercular Agents/therapeutic use , Brazil/epidemiology , Cost-Benefit Analysis , HIV Infections/drug therapy , HIV Infections/epidemiology , HIV Infections/prevention & control , Humans , South Africa/epidemiology , Tuberculosis, Multidrug-Resistant/drug therapy
4.
BMC Med ; 20(1): 182, 2022 05 18.
Article in English | MEDLINE | ID: mdl-35581650

ABSTRACT

BACKGROUND: Recent years have seen important improvements in available preventive treatment regimens for tuberculosis (TB), and research is ongoing to develop these further. To assist with the formulation of target product profiles for future regimens, we examined which regimen properties would be most influential in the epidemiological impact of preventive treatment. METHODS: Following expert consultation, we identified 5 regimen properties relevant to the incidence-reducing impact of a future preventive treatment regimen: regimen duration, efficacy, ease-of-adherence (treatment completion rates in programmatic conditions), forgiveness to non-completion and the barrier to developing rifampicin resistance during treatment. For each regimen property, we elicited expert input for minimally acceptable and optimal (ideal-but-feasible) performance scenarios for future regimens. Using mathematical modelling, we then examined how each regimen property would influence the TB incidence reduction arising from full uptake of future regimens according to current WHO guidelines, in four countries: South Africa, Kenya, India and Brazil. RESULTS: Of all regimen properties, efficacy is the single most important predictor of epidemiological impact, while ease-of-adherence plays an important secondary role. These results are qualitatively consistent across country settings; sensitivity analyses show that these results are also qualitatively robust to a range of model assumptions, including the mechanism of action of future preventive regimens. CONCLUSIONS: As preventive treatment regimens against TB continue to improve, understanding the key drivers of epidemiological impact can assist in guiding further development. By meeting these key targets, future preventive treatment regimens could play a critical role in global efforts to end TB.


Subject(s)
Tuberculosis , Antitubercular Agents/therapeutic use , Clinical Protocols , Humans , Incidence , India , Rifampin , Tuberculosis/drug therapy , Tuberculosis/epidemiology , Tuberculosis/prevention & control
5.
Eur Respir J ; 58(2)2021 08.
Article in English | MEDLINE | ID: mdl-33479110

ABSTRACT

The scale-up of tuberculosis (TB) preventive treatment (TPT) must be accelerated to achieve the targets set by the United Nations High-level Meeting on TB and the End TB Strategy. The scale-up of effective TPT is hampered by concerns about operational challenges to implement the existing tests for TB infection. New simpler tests could facilitate the scale-up of testing for TB infection. We present a framework for evaluation of new immunodiagnostic tests for the detection of TB infection, with an aim to facilitate their standardised evaluation and accelerate adoption into global and national policies and subsequent scale-up. The framework describes the principles to be considered when evaluating new tests for TB infection and provides guidance to manufacturers, researchers, regulators and other users on study designs, populations, reference standards, sample size calculation and data analysis and it is also aligned with the Global Strategy for TB Research and Innovation adopted by the World Health Assembly in 2020. In addition, we briefly describe technical issues that should be considered when evaluating new tests, including the safety for skin tests, costs incurred by patients and the health system, and operational characteristics.


Subject(s)
Latent Tuberculosis , Tuberculosis , Global Health , Humans , Reference Standards , Tuberculosis/diagnosis
6.
Emerg Infect Dis ; 25(2): 249-255, 2019 02.
Article in English | MEDLINE | ID: mdl-30500321

ABSTRACT

Ebola virus (EBOV) can persist in immunologically protected body sites in survivors of Ebola virus disease, creating the potential to initiate new chains of transmission. From the outbreak in West Africa during 2014-2016, we identified 13 possible events of viral persistence-derived transmission of EBOV (VPDTe) and applied predefined criteria to classify transmission events based on the strength of evidence for VPDTe and source and route of transmission. For 8 events, a recipient case was identified; possible source cases were identified for 5 of these 8. For 5 events, a recipient case or chain of transmission could not be confidently determined. Five events met our criteria for sexual transmission (male-to-female). One VPDTe event led to at least 4 generations of cases; transmission was limited after the other events. VPDTe has increased the importance of Ebola survivor services and sustained surveillance and response capacity in regions with previously widespread transmission.


Subject(s)
Disease Outbreaks , Ebolavirus , Hemorrhagic Fever, Ebola/epidemiology , Hemorrhagic Fever, Ebola/transmission , Survivors , Adolescent , Adult , Africa, Western/epidemiology , Ebolavirus/classification , Ebolavirus/genetics , Ebolavirus/isolation & purification , Female , Hemorrhagic Fever, Ebola/virology , Humans , Male , Middle Aged , Public Health Surveillance , Young Adult
7.
BMC Med ; 17(1): 163, 2019 08 19.
Article in English | MEDLINE | ID: mdl-31422772

ABSTRACT

BACKGROUND: Despite the increasing popularity of multi-model comparison studies and their ability to inform policy recommendations, clear guidance on how to conduct multi-model comparisons is not available. Herein, we present guidelines to provide a structured approach to comparisons of multiple models of interventions against infectious diseases. The primary target audience for these guidelines are researchers carrying out model comparison studies and policy-makers using model comparison studies to inform policy decisions. METHODS: The consensus process used for the development of the guidelines included a systematic review of existing model comparison studies on effectiveness and cost-effectiveness of vaccination, a 2-day meeting and guideline development workshop during which mathematical modellers from different disease areas critically discussed and debated the guideline content and wording, and several rounds of comments on sequential versions of the guidelines by all authors. RESULTS: The guidelines provide principles for multi-model comparisons, with specific practice statements on what modellers should do for six domains. The guidelines provide explanation and elaboration of the principles and practice statements as well as some examples to illustrate these. The principles are (1) the policy and research question - the model comparison should address a relevant, clearly defined policy question; (2) model identification and selection - the identification and selection of models for inclusion in the model comparison should be transparent and minimise selection bias; (3) harmonisation - standardisation of input data and outputs should be determined by the research question and value of the effort needed for this step; (4) exploring variability - between- and within-model variability and uncertainty should be explored; (5) presenting and pooling results - results should be presented in an appropriate way to support decision-making; and (6) interpretation - results should be interpreted to inform the policy question. CONCLUSION: These guidelines should help researchers plan, conduct and report model comparisons of infectious diseases and related interventions in a systematic and structured manner for the purpose of supporting health policy decisions. Adherence to these guidelines will contribute to greater consistency and objectivity in the approach and methods used in multi-model comparisons, and as such improve the quality of modelled evidence for policy.


Subject(s)
Communicable Diseases/therapy , Health Policy , Models, Theoretical , Cost-Benefit Analysis , Decision Making , Humans
11.
Eur Respir J ; 46(6): 1563-76, 2015 Dec.
Article in English | MEDLINE | ID: mdl-26405286

ABSTRACT

Latent tuberculosis infection (LTBI) is characterised by the presence of immune responses to previously acquired Mycobacterium tuberculosis infection without clinical evidence of active tuberculosis (TB). Here we report evidence-based guidelines from the World Health Organization for a public health approach to the management of LTBI in high risk individuals in countries with high or middle upper income and TB incidence of <100 per 100Ć¢Ā€ĀŠ000 per year. The guidelines strongly recommend systematic testing and treatment of LTBI in people living with HIV, adult and child contacts of pulmonary TB cases, patients initiating anti-tumour necrosis factor treatment, patients receiving dialysis, patients preparing for organ or haematological transplantation, and patients with silicosis. In prisoners, healthcare workers, immigrants from high TB burden countries, homeless persons and illicit drug users, systematic testing and treatment of LTBI is conditionally recommended, according to TB epidemiology and resource availability. Either commercial interferon-gamma release assays or Mantoux tuberculin skin testing could be used to test for LTBI. Chest radiography should be performed before LTBI treatment to rule out active TB disease. Recommended treatment regimens for LTBI include: 6 or 9Ć¢Ā€Ā…month isoniazid; 12Ć¢Ā€Ā…week rifapentine plus isoniazid; 3-4Ć¢Ā€Ā…month isoniazid plus rifampicin; or 3-4Ć¢Ā€Ā…month rifampicin alone.


Subject(s)
Antitubercular Agents/therapeutic use , Isoniazid/therapeutic use , Latent Tuberculosis/drug therapy , Rifampin/analogs & derivatives , Rifampin/therapeutic use , Antirheumatic Agents/therapeutic use , Coinfection/epidemiology , Comorbidity , Disease Management , Drug Users , Emigrants and Immigrants , Evidence-Based Medicine , HIV Infections/epidemiology , Health Personnel , Ill-Housed Persons , Humans , Interferon-gamma Release Tests , Kidney Failure, Chronic/epidemiology , Kidney Failure, Chronic/therapy , Latent Tuberculosis/diagnosis , Latent Tuberculosis/epidemiology , Mass Screening , Practice Guidelines as Topic , Prisoners , Public Health , Radiography, Thoracic , Renal Dialysis , Risk Assessment , Silicosis/epidemiology , Substance-Related Disorders/epidemiology , Transplant Recipients , Tuberculin Test , Tumor Necrosis Factor-alpha/antagonists & inhibitors , World Health Organization
12.
Respirology ; 19(3): 382-8, 2014 Apr.
Article in English | MEDLINE | ID: mdl-24460728

ABSTRACT

BACKGROUND AND OBJECTIVE: In low and middle-income countries where HIV infection is prevalent, identifying patients at high risk of dying from lower respiratory tract infections is challenging and validated prognostic models are lacking. Serum procalcitonin may be a useful prognostic tool in these settings. We sought to determine if elevated serum procalcitonin is associated with increased in-hospital mortality and to combine serum procalcitonin with available clinical characteristics to create a clinically useful prognostic model. METHODS: We conducted a prospective, nested case-control study of 241 HIV-infected adults admitted to Mulago Hospital in Kampala, Uganda with cough ≥2 weeks in duration. We collected demographic and clinical information, baseline serum for procalcitonin analysis, and followed patients to determine in-hospital mortality. RESULTS: Serum procalcitonin was a strong and independent predictor of inpatient mortality (aOR = 7.69, p = 0.01, sensitivity = 93%, negative predictive value = 97%). Best subset multivariate analysis identified 3 variables that were combined into a prognostic model to risk stratify patients; these variables included respiratory rate ≥30 breaths/minute (aOR = 2.07, p = 0.11), oxygen saturation <90% (aOR = 3.07, p = 0.02), and serum procalcitonin >0.5 ng/ml (aOR = 7.69, p = 0.01). The predicted probability of inpatient mortality ranged from 1% when no variables were present, to 42% when all variables were present. CONCLUSIONS: Elevated serum procalcitonin >0.5 ng/ml is an independent predictor of in-hospital mortality. Elevated serum procalcitonin, tachypnea, and hypoxemia may be combined into a prognostic model to identify patients at high risk of dying in the hospital. This model may be used to estimate the probability of death and to guide triage and treatment decisions.


Subject(s)
Biomarkers/blood , Calcitonin/blood , HIV Infections/mortality , Protein Precursors/blood , Respiratory Tract Infections/mortality , Adult , Aged , Calcitonin Gene-Related Peptide , Case-Control Studies , False Negative Reactions , Female , HIV Infections/blood , Hospital Mortality , Humans , Male , Middle Aged , Predictive Value of Tests , Prevalence , Prospective Studies , Respiratory Tract Infections/blood , Risk Assessment , Sensitivity and Specificity , Uganda/epidemiology
13.
Int J Infect Dis ; 141S: 106980, 2024 Apr.
Article in English | MEDLINE | ID: mdl-38403111

ABSTRACT

OBJECTIVES: Outline the objectives, methods, and initial stages of the Prevention and Systematic Screening (PASS) initiative, a complimentary element of the innovative new approach of technical assistance mechanisms of WHO and its partners to countries aligned to the Regional TB Action Plan to End TB in the European Region by 2030. DESIGN: To provide an objective and critical overview of the existing landscape on TB epidemic in the WHO European Region (the European Region) and ii) identify the strategic significance of proactive measures aimed at approaching TB pre-elimination in the Region. RESULTS: Interventions primarily include systematic screening for TB disease and treatment for TB infection (TBI). CONCLUSIONS: PASS to End TB is an exemplary initiative of how technical and funding partners are joining hands to support national health programmes to work towards global commitments to curb major public health challenges like TB.


Subject(s)
Tuberculosis , Humans , Tuberculosis/diagnosis , Tuberculosis/epidemiology , Tuberculosis/prevention & control , Europe/epidemiology , Public Health , World Health Organization
14.
PLOS Glob Public Health ; 4(7): e0003306, 2024.
Article in English | MEDLINE | ID: mdl-38954723

ABSTRACT

The provision of tuberculosis preventive treatment is one of the critical interventions to reduce tuberculosis incidence and ultimately eliminate the disease, yet we still miss appropriate tools for an impactful intervention and treatment coverage remains low. We used recent data, epidemiological estimates, and research findings to analyze the challenges of each step of the cascade of tuberculosis prevention that currently delay the strategy implementation. We addressed research gaps and implementation bottlenecks that withhold key actions in tuberculosis case finding, testing for tuberculosis infection, provision of preventive treatment with safer, shorter regimens and supporting people to complete their treatment. Empowering communities to generate demand for preventive therapy and other prevention services in a holistic manner and providing adequate financial support to sustain implementation are essential requirements. The adoption of an effective, universal monitoring and evaluation system is a prerequisite to provide general and granular insight, and to steer progress of the tuberculosis infection strategy at global and local level.

15.
Clin Microbiol Infect ; 30(4): 481-488, 2024 Apr.
Article in English | MEDLINE | ID: mdl-38182047

ABSTRACT

SCOPE: The current tools for tuberculosis (TB) treatment monitoring, smear microscopy and culture, cannot accurately predict poor treatment outcomes. Research into new TB treatment monitoring tools (TMTs) is growing, but data are unreliable. In this article, we aim to provide guidance for studies investigating and evaluating TB TMT for use during routine clinical care. Here, a TB TMT would guide treatment during the course of therapy, rather than testing for a cure at the regimen's end. This article does not cover the use of TB TMTs as surrogate endpoints in the clinical trial context. METHODS: Guidelines were initially informed by experiences during a systematic review of TB TMTs. Subsequently, a small content expert group was consulted for feedback on initial recommendations. After revision, feedback from substantive experts across sectors was sought. QUESTIONS ADDRESSED BY THE GUIDELINE AND RECOMMENDATIONS: The proposed considerations and recommendations for studies evaluating TB TMTs for use during the treatment in routine clinical care fall into eight domains. We provide specific recommendations regarding study design and recruitment, outcome definitions, reference standards, participant follow-up, clinical setting, study population, treatment regimen reporting, and index tests and data presentation. Overall, TB TMTs should be evaluated in a manner similar to diagnostic tests, but TB TMT accuracy must be assessed at multiple timepoints throughout the treatment course, and TB TMTs should be evaluated in study populations who have already received a diagnosis of TB. Study design and outcome definitions must be aligned with the developmental phase of the TB TMT under evaluation. There is no reference standard for TB treatment response, so different reference standards and comparator tests have been proposed, the selection of which will vary depending on the developmental phase of the TMT under assessment. The use of comparator tests can assist in generating evidence. Clarity is required when reporting of timepoints, TMT read-outs, and analysis results. Implementing these recommendations will lead to higher quality TB TMT studies that will allow data to be meaningfully compared, thereby facilitating the development of novel tools to guide individual TB therapy and improve treatment outcomes.


Subject(s)
Antitubercular Agents , Tuberculosis , Humans , Tuberculosis/diagnosis , Tuberculosis/drug therapy , Antitubercular Agents/therapeutic use , Research Design , Treatment Outcome , Practice Guidelines as Topic
16.
Trop Med Infect Dis ; 8(4)2023 Apr 01.
Article in English | MEDLINE | ID: mdl-37104339

ABSTRACT

The 2018 United Nations High-Level Meeting on Tuberculosis (UNHLM) set targets for case detection and TB preventive treatment (TPT) by 2022. However, by the start of 2022, about 13.7 million TB patients still needed to be detected and treated, and 21.8 million household contacts needed to be given TPT globally. To inform future target setting, we examined how the 2018 UNHLM targets could have been achieved using WHO-recommended interventions for TB detection and TPT in 33 high-TB burden countries in the final year of the period covered by the UNHLM targets. We used OneHealth-TIME model outputs combined with the unit cost of interventions to derive the total costs of health services. Our model estimated that, in order to achieve UNHLM targets, >45 million people attending health facilities with symptoms would have needed to be evaluated for TB. An additional 23.1 million people with HIV, 19.4 million household TB contacts, and 303 million individuals from high-risk groups would have required systematic screening for TB. The estimated total costs amounted to ~USD 6.7 billion, of which ~15% was required for passive case finding, ~10% for screening people with HIV, ~4% for screening household contacts, ~65% for screening other risk groups, and ~6% for providing TPT to household contacts. Significant mobilization of additional domestic and international investments in TB healthcare services will be needed to reach such targets in the future.

17.
PLOS Digit Health ; 2(2): e0000182, 2023 Feb.
Article in English | MEDLINE | ID: mdl-36812644

ABSTRACT

Digital technologies are playing an increasing role in the global response to tuberculosis (TB), however their effectiveness and impact are often shaped in the context in which they are implemented. Implementation research can help facilitate the effective introduction of digital health technologies in TB programmes. In 2020, the Implementation Research for Digital Technologies and TB online toolkit (IR4DTB) was developed and launched by the Special Programme for Research and Training in Tropical Diseases, and the Global TB Programme at the World Health Organization (WHO), to build local capacity for IR and promote the effective use of digital technologies within TB programmes. This paper describes the development and piloting of the IR4DTB toolkit, a self-learning tool designed for TB programme implementers. The toolkit comprises six modules reflecting key steps of the IR process, practical instructions and guidance on how to complete these steps, and real-word case studies to illustrate key learning points. This paper also describes the launch of the IR4DTB during a five-day training workshop with TB staff from China, Uzbekistan, Pakistan, Malaysia. The workshop included facilitated sessions on the IR4DTB modules, and provided an opportunity for participants to work with facilitators to develop a comprehensive IR proposal addressing an identified challenge related to the implementation and/or scale-up of digital health technologies for TB care in their home country. Post-workshop evaluation revealed high level of satisfaction among participants with the workshop content and format. The IR4DTB toolkit is a replicable model which can be used to strengthen the TB staff capacity to innovate within a culture of continuous collection of evidence. Through continued trainings and adaptation of the toolkit alongside the integration of digital technologies within TB prevention and care, this model has the potential to contribute directly to all components of the End TB Strategy.

18.
Am J Respir Crit Care Med ; 184(3): 362-7, 2011 Aug 01.
Article in English | MEDLINE | ID: mdl-21471088

ABSTRACT

RATIONALE: Tuberculosis case-detection rates are below internationally established targets in high-burden countries. Real-time monitoring and evaluation of adherence to widely endorsed standards of tuberculosis care might facilitate improved case finding. OBJECTIVES: To monitor and evaluate the quality of tuberculosis case-detection and management services in a low-income country with a high incidence of tuberculosis. METHODS: We prospectively evaluated tuberculosis diagnostic services at five primary health-care facilities in Uganda for 1 year, after introducing a real-time, electronic performance-monitoring system. We collected data on every clinical encounter, and measured quality using indicators derived from the International Standards of Tuberculosis Care. MEASUREMENTS AND MAIN RESULTS: In 2009, there were 62,909 adult primary-care visits. During the first quarter of 2009, clinicians referred only 21% of patients with cough greater than or equal to 2 weeks for sputum smear microscopy and only 71% of patients with a positive sputum examination for tuberculosis treatment. These proportions increased to 53% and 84%, respectively, in the fourth quarter of 2009. The cumulative probability that a smear-positive patient with cough greater than or equal to 2 weeks would be appropriately evaluated and referred for treatment rose from 11% to 34% (P = 0.005). The quarterly number of tuberculosis cases identified and prescribed treatment also increased four-fold, from 5 to 21. CONCLUSIONS: Poor adherence to internationally accepted standards of tuberculosis care improved after introduction of real-time performance monitoring and was associated with increased tuberculosis case detection. Real-time monitoring and evaluation can strengthen health systems in low-income countries and facilitate operational research on the effectiveness and sustainability of interventions to improve tuberculosis case detection.


Subject(s)
Diagnostic Services/statistics & numerical data , Primary Health Care/statistics & numerical data , Tuberculosis, Pulmonary/diagnosis , Adult , Diagnostic Services/standards , Global Health , Guideline Adherence/statistics & numerical data , Humans , Incidence , Population Surveillance/methods , Practice Guidelines as Topic , Primary Health Care/methods , Primary Health Care/standards , Prospective Studies , Sputum/microbiology , Tuberculosis, Pulmonary/epidemiology , Uganda/epidemiology
19.
Am J Respir Crit Care Med ; 183(4): 547-51, 2011 Feb 15.
Article in English | MEDLINE | ID: mdl-20851925

ABSTRACT

RATIONALE: Smear-positive tuberculosis (TB) case detection rates are far below targets in most low-income countries. The standard approach to smear microscopy involves sputum collection over multiple days and examination of sputum smears by light microscopy (LM), an insensitive and time-consuming technique. OBJECTIVE: To determine whether two alternative approaches can increase smear-positive case detection by increasing the efficiency (single-specimen microscopy) or sensitivity (light-emitting diode [LED] fluorescence microscopy [FM]) of TB suspect evaluation. METHODS: We enrolled patients with cough of 2 weeks or more admitted to Mulago Hospital in Kampala, Uganda and collected spot and early morning sputum specimens. We compared the diagnostic accuracy of four prespecified strategies based on the number of sputum specimens collected (one specimen versus two specimens) and the type of microscopy (LM versus LED FM) using mycobacterial culture as a reference standard. MEASUREMENTS AND MAIN RESULTS: Two hundred thirty-three of 464 (50%) patients had culture-positive TB. There was no difference in sensitivity between single-specimen and two-specimen strategies when smears were examined with LM (55 vs. 56%; difference, -1%; 95% confidence interval [CI], -5 to +2%) or LED FM (61 vs. 64%; difference, -3%; 95% CI, -7 to +1%). LED FM was more sensitive than LM with both the single-specimen (61 vs. 55%; difference, 6%; 95% CI, 2-10%) and two-specimen strategies (64 vs. 56%; difference, 8%; 95% CI, 3-12%). Findings were similar among the HIV-infected patient subset (n = 321 patients). CONCLUSIONS: In low-income, high TB burden settings, single-specimen microscopy and LED FM, either alone or in combination, could considerably increase identification of smear-positive TB cases.


Subject(s)
Sputum/microbiology , Tuberculosis, Pulmonary/diagnosis , Tuberculosis, Pulmonary/microbiology , Adult , Humans , Male , Microscopy, Fluorescence/methods , Microscopy, Polarization/methods , Prospective Studies , Reproducibility of Results , Sensitivity and Specificity , Specimen Handling , Uganda
20.
PLoS Med ; 8(11): e1001120, 2011 Nov.
Article in English | MEDLINE | ID: mdl-22087078

ABSTRACT

BACKGROUND: Xpert MTB/RIF (Xpert) is a promising new rapid diagnostic technology for tuberculosis (TB) that has characteristics that suggest large-scale roll-out. However, because the test is expensive, there are concerns among TB program managers and policy makers regarding its affordability for low- and middle-income settings. METHODS AND FINDINGS: We estimate the impact of the introduction of Xpert on the costs and cost-effectiveness of TB care using decision analytic modelling, comparing the introduction of Xpert to a base case of smear microscopy and clinical diagnosis in India, South Africa, and Uganda. The introduction of Xpert increases TB case finding in all three settings; from 72%-85% to 95%-99% of the cohort of individuals with suspected TB, compared to the base case. Diagnostic costs (including the costs of testing all individuals with suspected TB) also increase: from US$28-US$49 to US$133-US$146 and US$137-US$151 per TB case detected when Xpert is used "in addition to" and "as a replacement of" smear microscopy, respectively. The incremental cost effectiveness ratios (ICERs) for using Xpert "in addition to" smear microscopy, compared to the base case, range from US$41-$110 per disability adjusted life year (DALY) averted. Likewise the ICERS for using Xpert "as a replacement of" smear microscopy range from US$52-$138 per DALY averted. These ICERs are below the World Health Organization (WHO) willingness to pay threshold. CONCLUSIONS: Our results suggest that Xpert is a cost-effective method of TB diagnosis, compared to a base case of smear microscopy and clinical diagnosis of smear-negative TB in low- and middle-income settings where, with its ability to substantially increase case finding, it has important potential for improving TB diagnosis and control. The extent of cost-effectiveness gain to TB programmes from deploying Xpert is primarily dependent on current TB diagnostic practices. Further work is required during scale-up to validate these findings.


Subject(s)
Clinical Laboratory Techniques/economics , Tuberculosis, Pulmonary/diagnosis , Clinical Laboratory Techniques/methods , Cohort Studies , Cost-Benefit Analysis , Humans , India , South Africa , Tuberculosis, Pulmonary/economics , Uganda
SELECTION OF CITATIONS
SEARCH DETAIL