Evaluation of the Latent Tuberculosis Care Cascade Among Public Health Clinics in the United States.

BACKGROUND: Tuberculosis (TB) elimination within the United States will require scaling up TB preventive services. Many public health departments offer care for latent tuberculosis infection (LTBI), although gaps in the LTBI care cascade are not well quantified. An understanding of these gaps will be required to design targeted public health interventions. METHODS: We conducted a cohort study through the Tuberculosis Epidemiologic Studies Consortium (TBESC) within 15 local health department (LHD) TB clinics across the United States. Data were abstracted on individuals receiving LTBI care during 2016-2017 through chart review. Our primary objective was to quantify the LTBI care cascade, beginning with LTBI testing and extending through treatment completion. RESULTS: Among 23 885 participants tested by LHDs, 46% (11 009) were male with a median age of 31 (interquartile range [IQR] 20-46). A median of 35% of participants were US-born at each site (IQR 11-78). Overall, 16 689 (70%) received a tuberculin skin test (TST), 6993 (29%) received a Quantiferon (QFT), and 1934 (8%) received a T-SPOT.TB; 5% (1190) had more than one test. Among those tested, 2877 (12%) had at least one positive test result (3% among US-born, and 23% among non-US-born, P < .01). Of 2515 (11%) of the total participants diagnosed with LTBI, 1073 (42%) initiated therapy, of whom 817 (76%) completed treatment (32% of those with LTBI diagnosis). CONCLUSIONS: Significant gaps were identified along the LTBI care cascade, with less than half of individuals diagnosed with LTBI initiating therapy. Further research is needed to better characterize the factors impeding LTBI diagnosis, treatment initiation, and treatment completion.

Programmatic Effectiveness of Latent Tuberculosis Care Cascade in a Community Health Center.

Our aim was to quantify successful completion of steps of the latent tuberculosis (LTBI) care cascade in a community health center (CHC) with a large foreign-born population. We conducted a retrospective cohort study of individuals with a positive test for tuberculosis (TB) infection from 2015 to 2017 at Baltimore Medical Systems (BMS). During the study period, 3,984 individuals were tested for TB. Of the 418 individuals with positive tests, 152 (36%) were referred elsewhere for care, whereas 266 (64%) were retained in care at BMS. Treatment was prescribed for 157 of the 214 (73%) diagnosed with LTBI and retained in care at BMS (125/157 [80%] four months of rifampin; 32/157 [20%] nine months of isoniazid). One hundred forty-one patients (141/157, 90%) initiated treatment, of which 119 completed therapy (119/141, 84%). Our study identified several gaps in the LTBI care cascade in a CHC. Nonetheless, a large proportion of those treated for LTBI at the CHC completed therapy.

Geographic Information Systems, spatial analysis, and HIV in Africa: A scoping review.

INTRODUCTION: Geographic Information Systems (GIS) and spatial analysis are emerging tools for global health, but it is unclear to what extent they have been applied to HIV research in Africa. To help inform researchers and program implementers, this scoping review documents the range and depth of published HIV-related GIS and spatial analysis research studies conducted in Africa. METHODS: A systematic literature search for articles related to GIS and spatial analysis was conducted through PubMed, EMBASE, and Web of Science databases. Using pre-specified inclusion criteria, articles were screened and key data were abstracted. Grounded, inductive analysis was conducted to organize studies into meaningful thematic areas. RESULTS AND DISCUSSION: The search returned 773 unique articles, of which 65 were included in the final review. 15 different countries were represented. Over half of the included studies were published after 2014. Articles were categorized into the following non-mutually exclusive themes: (a) HIV geography, (b) HIV risk factors, and (c) HIV service implementation. Studies demonstrated a broad range of GIS and spatial analysis applications including characterizing geographic distribution of HIV, evaluating risk factors for HIV, and assessing and improving access to HIV care services. CONCLUSIONS: GIS and spatial analysis have been widely applied to HIV-related research in Africa. The current literature reveals a diversity of themes and methodologies and a relatively young, but rapidly growing, evidence base.

Use of Smartphone-Based Video Directly Observed Therapy (vDOT) in Tuberculosis Care: Single-Arm, Prospective Feasibility Study.

BACKGROUND: India accounts for nearly one-quarter of the global tuberculosis (TB) burden. Directly observed treatment (DOT) through in-person observation is recommended in India, although implementation has been heterogeneous due largely to resource limitations. Video DOT (vDOT) is a novel, smartphone-based approach that allows for remote treatment monitoring through patient-recorded videos. Prior studies in high-income, low disease burden settings, such as the United States, have shown vDOT to be feasible, although little is known about the role it may play in resource-limited, high-burden settings. OBJECTIVE: The goal of the research was to assess the feasibility and acceptability of vDOT for adherence monitoring within a resource-limited, high TB burden setting of India. METHODS: We conducted a prospective, single-arm, pilot implementation of vDOT in Pune, India. Outcome measures included adherence (proportion of prescribed doses observed by video) and verifiable fraction (proportion of prescribed doses observed by video or verbally confirmed with the patient following an incomplete/unverifiable video submission). vDOT acceptability among patients was assessed using a posttreatment survey. RESULTS: A total of 25 patients enrolled. The median number of weeks on vDOT was 13 (interquartile range [IQR] 11-16). Median adherence was 74% (IQR 62%-84%), and median verifiable fraction was 86% (IQR 74%-98%). More than 90% of patients reported recording and uploading videos without difficulty. CONCLUSIONS: We have demonstrated that vDOT may be a feasible and acceptable approach to TB treatment monitoring in India. Our work expands the evidence base around vDOT by being one of the first efforts to evaluate vDOT within a resource-limited, high TB burden setting. To our knowledge, this is the first reported use of vDOT in India.

Advancing Patient-Centered Care in Tuberculosis Management: A Mixed-Methods Appraisal of Video Directly Observed Therapy.

BACKGROUND: Directly observed therapy (DOT) remains an integral component of treatment support and adherence monitoring in tuberculosis care. In-person DOT is resource intensive and often burdensome for patients. Video DOT (vDOT) has been proposed as an alternative to increase treatment flexibility and better meet patient-specific needs. METHODS: We conducted a pragmatic, prospective pilot implementation of vDOT at 3 TB clinics in Maryland. A mixed-methods approach was implemented to assess (1) effectiveness, (2) acceptability, and (3) cost. Medication adherence on vDOT was compared with that of in-person DOT. Interviews and surveys were conducted with patients and providers before and after implementation, with framework analysis utilized to extract salient themes. Last, a cost analysis assessed the economic impacts of vDOT implementation across heterogeneous clinic structures. RESULTS: Medication adherence on vDOT was comparable to that of in-person DOT (94% vs 98%, P = .17), with a higher percentage of total treatment doses (inclusive of weekend/holiday self-administration) ultimately observed during the vDOT period (72% vs 66%, P = .03). Video DOT was well received by staff and patients alike, who cited increased treatment flexibility, convenience, and patient privacy. Our cost analysis estimated a savings with vDOT of $1391 per patient for a standard 6-month treatment course. CONCLUSIONS: Video DOT is an acceptable and important option for measurement of TB treatment adherence and may allow a higher proportion of prescribed treatment doses to be observed, compared with in-person DOT. Video DOT may be cost-saving and should be considered as a component of individualized, patient-centered case management plans.

Gonococcal Conjunctivitis: A Case Report of an Unusual Mode of Transmission.

BACKGROUND: Outside of the newborn period, development of gonococcal conjunctivitis is rare and predominantly occurs through autoinoculation. We report an unusual case of gonococcal conjunctivitis in a young woman exposed through direct inoculation. CASE: A 19-year-old woman presented with purulent ocular discharge, severe pain, and decreased vision unresponsive to topical antibiotics or ganciclovir approximately 3 weeks after accidental ocular exposure to seminal fluid during unprotected oral sex. Cultured ocular drainage grew Neisseria gonorrhea; vaginal and throat cultures were negative. She was successfully treated with ceftriaxone and doxycycline for 10 days. SUMMARY AND CONCLUSION: Clinicians should be aware of the potential for vision-threatening gonococcal conjunctivitis from exposure during sexual contact.

Larval tolerance, gene flow, and the northern geographic range limit of fiddler crabs.

Despite growing interest in species' range shifts, little is known about the ecological and evolutionary factors that control geographic range boundaries. We investigated the processes that maintain the northern range limit of the mud fiddler crab (Uca pugnax) at North Scituate, Massachusetts, USA (42 degrees 14' N), located approximately 60 km north of Cape Cod. Larvae from five populations in Massachusetts were reared under controlled temperatures to test whether cooler water near the edge of this species' range inhibits planktonic development. Few larvae completed development at temperatures < 18 degrees C, a threshold that larvae would regularly encounter north of Cape Cod. Extensive salt marshes are present north of the current range boundary, and a transplant experiment using field enclosures confirmed that benthic fiddler crabs can survive severe winter conditions in this northern habitat. Taken with oceanographic data, these results suggest that the range boundary of fiddler crabs is likely maintained by the influence of cooler water temperatures on the larval phase. Analyses of mitochondrial DNA sequences from a neutral marker (COI) indicate high gene flow among U. pugnax populations in Massachusetts with little differentiation across Cape Cod. Consistent with predictions regarding the homogenizing influence of gene flow, larvae from source populations north and south of Cape Cod shared a common lower threshold for development. However, larvae produced near the range edge had faster growth rates than those from the south side of Cape Cod (typically reaching the final megalopal stage 1.0-5.5 d faster at 18 degrees C). Additional studies are needed to determine the mechanism underlying this counter-gradient variation in development time. We hypothesize that dispersal into cooler water on the north side of Cape Cod may act as a selection filter that sieves out slow developers from the larval pool by increasing planktonic duration and exposure to associated sources of mortality. Thus while high gene flow may prevent the evolution of greater cold tolerance in northern populations, recurrent selection on existing variation may lead to an unexpected concentration of favorable adaptations at the edge of the range. Such a pattern could permit edge populations to play a dominant and unrecognized role in future range extensions.

AST: A Simplified 3-item Tool for Managing Alcohol Withdrawal.

AIMS: This study compared the Glasgow Modified Alcohol Withdrawal Scale (GMAWS) and a newly devised 3-item "Anxiety Sweats Tremor" Scale (AST) to the Revised Clinical Institute Withdrawal Assessment Scale (CIWA-Ar)-the standard of care for symptom-triggered management of alcohol withdrawal syndrome. METHODS: Our study took place over 2 separate 1-week observational periods, and included 332 serial evaluations from 85 unique patients. All study participants were treated per hospital protocol based on CIWA-Ar, with supplemental scoring initially by GMAWS and later by AST in tandem. Internal consistency, interitem correlation, and operational characteristics were explored. RESULTS: Median CIWA-Ar score across both phases was 6 (range 0-13), with a median GMAWS score of 2 (range 0-5) and an AST score of 3 (range 0-7). The internal consistency of CIWA-Ar and GMAWS were both poor, with Cronbach alpha scores of 0.46 (n = 156) and 0.41 (n = 156), respectively. The internal consistency of the AST scale was significantly better, with a Cronbach alpha of 0.68 (n = 176). AST identified individuals with CIWA-Ar ≥8 with an area under the receiver-operating characteristic curve of 0.83 (95% confidence interval 0.77-0.89), compared with 0.81 (95% confidence interval 0.74-0.88) for GMAWS. An AST score of ≥3 (out of a possible 9) predicted CIWA-Ar ≥8, with a sensitivity of 93% and a specificity of 63%, whereas the GMAWS had a sensitivity and specificity of 100% and 12%, respectively, based on previously defined cut-offs. CONCLUSIONS: A simple 3-item scale demonstrated good internal consistency and reliably identified individuals experiencing significant alcohol withdrawal. This scale needs to be tested in other settings and among patients with a broader spectrum of withdrawal severity.