Global, regional, and national estimates of tuberculosis incidence and case detection among incarcerated individuals from 2000 to 2019: a systematic analysis.

BACKGROUND: People who are incarcerated are at high risk of developing tuberculosis. We aimed to estimate the annual global, regional, and national incidence of tuberculosis among incarcerated populations from 2000 to 2019. METHODS: We collected and aggregated data for tuberculosis incidence and prevalence estimates among incarcerated individuals in published and unpublished literature, annual tuberculosis notifications among incarcerated individuals at the country level, and the annual number of incarcerated individuals at the country level. We developed a joint hierarchical Bayesian meta-regression framework to simultaneously model tuberculosis incidence, notifications, and prevalence from 2000 to 2019. Using this model, we estimated trends in absolute tuberculosis incidence and notifications, the incidence and notification rates, and the case detection ratio by year, country, region, and globally. FINDINGS: In 2019, we estimated a total of 125 105 (95% credible interval [CrI] 93 736-165 318) incident tuberculosis cases among incarcerated individuals globally. The estimated incidence rate per 100 000 person-years overall was 1148 (95% CrI 860-1517) but varied greatly by WHO region, from 793 (95% CrI 430-1342) in the Eastern Mediterranean region to 2242 (1515-3216) in the African region. Global incidence per 100 000 person-years between 2000 and 2012 among incarcerated individuals decreased from 1884 (95% CrI 1394-2616) to 1205 (910-1615); however, from 2013 onwards, tuberculosis incidence per 100 000 person-years was stable, from 1183 (95% CrI 876-1596) in 2013 to 1148 (860-1517) in 2019. In 2019, the global case detection ratio was estimated to be 53% (95% CrI 42-64), the lowest over the study period. INTERPRETATION: Our estimates suggest a high tuberculosis incidence rate among incarcerated individuals globally with large gaps in tuberculosis case detection. Tuberculosis in incarcerated populations must be addressed with interventions specifically tailored to improve diagnoses and prevent transmission as a part of the broader global tuberculosis control effort. FUNDING: National Institutes of Health.

Infant BCG vaccination and risk of pulmonary and extrapulmonary tuberculosis throughout the life course: a systematic review and individual participant data meta-analysis.

BACKGROUND: BCG vaccines are given to more than 100 million children every year, but there is considerable debate regarding the effectiveness of BCG vaccination in preventing tuberculosis and death, particularly among older children and adults. We therefore aimed to investigate the age-specific impact of infant BCG vaccination on tuberculosis (pulmonary and extrapulmonary) development and mortality. METHODS: In this systematic review and individual participant data meta-analysis, we searched MEDLINE, Web of Science, BIOSIS, and Embase without language restrictions for case-contact cohort studies of tuberculosis contacts published between Jan 1, 1998, and April 7, 2018. Search terms included "mycobacterium tuberculosis", "TB", "tuberculosis", and "contact". We excluded cohort studies that did not provide information on BCG vaccination or were done in countries that did not recommend BCG vaccination at birth. Individual-level participant data for a prespecified list of variables, including the characteristics of the exposed participant (contact), the index case, and the environment, were requested from authors of all eligible studies. Our primary outcome was a composite of prevalent (diagnosed at or within 90 days of baseline) and incident (diagnosed more than 90 days after baseline) tuberculosis in contacts exposed to tuberculosis. Secondary outcomes were pulmonary tuberculosis, extrapulmonary tuberculosis, and mortality. We derived adjusted odds ratios (aORs) using mixed-effects, binary, multivariable logistic regression analyses with study-level random effects, adjusting for the variable of interest, baseline age, sex, previous tuberculosis, and whether data were collected prospectively or retrospectively. We stratified our results by contact age and Mycobacterium tuberculosis infection status. This study is registered with PROSPERO, CRD42020180512. FINDINGS: We identified 14 927 original records from our database searches. We included participant-level data from 26 cohort studies done in 17 countries in our meta-analysis. Among 68 552 participants, 1782 (2·6%) developed tuberculosis (1309 [2·6%] of 49 686 BCG-vaccinated participants vs 473 [2·5%] of 18 866 unvaccinated participants). The overall effectiveness of BCG vaccination against all tuberculosis was 18% (aOR 0·82, 95% CI 0·74-0·91). When stratified by age, BCG vaccination only significantly protected against all tuberculosis in children younger than 5 years (aOR 0·63, 95% CI 0·49-0·81). Among contacts with a positive tuberculin skin test or IFNγ release assay, BCG vaccination significantly protected against tuberculosis among all participants (aOR 0·81, 95% CI 0·69-0·96), participants younger than 5 years (0·68, 0·47-0·97), and participants aged 5-9 years (0·62, 0·38-0·99). There was no protective effect among those with negative tests, unless they were younger than 5 years (0·54, 0·32-0·90). 14 cohorts reported on whether tuberculosis was pulmonary or extrapulmonary (n=57 421). BCG vaccination significantly protected against pulmonary tuberculosis among all participants (916 [2·2%] in 41 119 vaccinated participants vs 334 [2·1%] in 16 161 unvaccinated participants; aOR 0·81, 0·70-0·94) but not against extrapulmonary tuberculosis (106 [0·3%] in 40 318 vaccinated participants vs 38 [0·2%] in 15 865 unvaccinated participants; 0·96, 0·65-1·41). In the four studies with mortality data, BCG vaccination was significantly protective against death (0·25, 0·13-0·49). INTERPRETATION: Our results suggest that BCG vaccination at birth is effective at preventing tuberculosis in young children but is ineffective in adolescents and adults. Immunoprotection therefore needs to be boosted in older populations. FUNDING: National Institutes of Health.

Sustaining communicable disease elimination efforts in the Americas in the wake of COVID-19.

The COVID-19 pandemic has disrupted implementation of health interventions and set back priority programs aiming to control and eliminate communicable diseases. At the same time, the pandemic has opened up opportunities to expedite innovations in health service delivery to increase effectiveness and position health on the development and political agendas of leaders and policy makers. In this context, we present an integrated, sustainable approach to accelerate elimination of more than 35 communicable diseases and related conditions in the region of the Americas. The Elimination Initiative promotes a life-course, person-centred approach based on four dimensions - preventing new infections, ending mortality and morbidity, and preventing disability - and four critical lines of action including strengthening health systems integration and service delivery, strengthening health surveillance and information systems, addressing environmental and social determinants of health, and furthering governance, stewardship, and finance. We present key actions and operational considerations according to each line of action that countries can take advantage of to further advance disease elimination in the region.

The escalating tuberculosis crisis in central and South American prisons.

In the past decade, tuberculosis incidence has declined in much of the world, but has risen in central and South America. It is not yet clear what is driving this reversal of progress in tuberculosis control. Since 2000, the incarcerated population in central and South America has grown by 206%, the greatest increase in the world. Over the same period, notified tuberculosis cases among the incarcerated population (hereinafter termed persons deprived of their liberty [PDL], following the Inter-American Commission on Human Rights) have risen by 269%. In both central and South America, the rise of disease among PDL more than offsets tuberculosis control gains in the general population. Tuberculosis is increasingly concentrated among PDL; currently, 11% of all notified tuberculosis cases in central and South America occur among PDL who comprise less than 1% of the population. The extraordinarily high risk of acquiring tuberculosis within prisons creates a health and human rights crisis for PDL that also undermines wider tuberculosis control efforts. Controlling tuberculosis in this region will require countries to take urgent measures to prioritise the health of PDL.

Considerations for a sustainability framework for neglected tropical diseases programming.

Addressing neglected tropical diseases (NTDs) is critical to achieving universal healthcare and the Sustainable Development Goals. Significant strides are being made to expand NTD programs, but these programs still need to be fully incorporated into national governance, financing, planning and service delivery structures. The World Health Organization has developed a sustainability framework that calls for governments to create a vision and a multisector plan to achieving sustainability. Several critical factors need to be considered to avoid undermining progress toward disease elimination and control targets, while merging program components into national systems.

Resistencia a los antimicrobianos: tiempo para la acción

El año 2020 será recordado por la pandemia ocasionada por el coronavirus SARS-CoV-2, responsable de más de 10 millones de casos y más de 500 000 muertes solo en la primera mitad del año, que recibió una atención política y social sin precedentes. Esta crisis global de salud pública debe servir para llamar la atención también sobre otras epidemias silenciosas, como la resistencia a los antimicrobianos (RAM), que se considera responsable de 700 000 muertes en todo el mundo anualmente, 230 000 de ellas por tuberculosis multirresistente. En la Región de las Américas, los microorganismos multirresistentes son la causa principal de las infecciones asociadas a la atención de la salud. Los datos de la vigilancia procedentes de la Red de Vigilancia de la Resistencia a los Antimicrobianos (RELAVRA) demuestran una tendencia creciente de la resistencia de patógenos hospitalarios como Klebsiella pneumoniae, cuyo porcentaje de no sensibilidad a los antibióticos carbapenémicos está aumentando significativamente en Latinoamérica desde 2014, hasta alcanzar el 21% en promedio. Las consecuencias en términos de mortalidad, discapacidad y costos económicos son significativas para los sistemas de salud. Por ejemplo, Staphylococcus aureus ocasiona un amplio rango de infecciones y es uno de los microorganismos aislado con mayor frecuencia en infecciones asociadas a la atención de la salud; en Latinoamérica, más del 25% de los aislamientos de S. aureus son resistentes a la meticilina. Las consecuencias son un exceso de mortalidad —atribuible a la resistencia a la meticilina— del 45,2% en comparación con las cepas sensibles, y el aumento de los costos del tratamiento antibiótico y de la hospitalización en veces y en casi 3 veces, respectivamente...

Antimicrobial resistance: time for action

The year 2020 will be remembered for the SARS-CoV-2 coronavirus pandemic, responsible for more than 10 million cases and more than 500 000 deaths in the first half of the year alone, and receiving unprecedented political and social attention. This global public health crisis should draw attention to other silent epidemics, such as antimicrobial resistance (AMR), responsible for 700 000 annual deaths worldwide, 230 000 of them from multi-drug-resistant tuberculosis.2 In the Region of the Americas, multidrug-resistant microorganisms are the leading cause of health care-associated infections. Surveillance data from the Latin American Network for Antimicrobial Resistance Surveillance (RELAVRA) show an increasing trend in the resistance of hospital pathogens such as Klebsiella pneumoniae, whose non-susceptibility to carbapenem antibiotics has been increasing significantly in Latin America since 2014, reaching an average of 21%.3 There are significant consequences for health systems in terms of mortality, disability, and economic costs. For example, Staphylococcus aureus causes a wide range of infections and is one of the most commonly isolated microorganisms in health care-associated infections; in Latin America, more than 25% of S. aureus isolates are resistant to methicillin. The result is 45.2% excess mortality attributable to methicillin resistance, compared to susceptible strains, and increased antibiotic treatment costs (6.7 times greater) and hospitalization (almost 3 times greater).

Trachoma elimination in Latin America: prioritization of municipalities for surveillance activities

[ABSTRACT]. Objective. To identify and prioritize municipalities in 22 countries of Latin America for trachoma surveillance activities, to measure the absence or prevalence of trachoma, and to support validation and trachoma elimination efforts in the Region of the Americas. Methods. A prioritization scale was developed in 2017 to rank each municipality by considering a combination of three characteristics: (a) its trachoma vulnerability index, derived from three socioeconomic factors known to be risks for trachoma—lack of access to improved sanitation, to clean drinking water, and to adequate education, according to housing census data from early 2017; (b) its history of trachoma in countries where the disease was not a known public health problem in 2016; and (c) whether or not it shares a border with a municipality where trachoma was a known public health problem in 2016. Municipalities in 22 countries were classified as either very high, high, medium, or low priority for trachoma surveillance. From the Caribbean, only Trinidad and Tobago met inclusion criteria. Results. The prioritization scale identified 1 053 municipalities in Brazil, Colombia, and Guatemala as very high priority for trachoma surveillance. In Ecuador, El Salvador, Guyana, Paraguay, Peru, Suriname, and Venezuela, 183 municipalities were ranked as high priority, and in Argentina, Belize, Bolivia, Chile, Dominican Republic, Honduras, Nicaragua, Panama, and Uruguay, 677 municipalities were designated a medium priority for trachoma surveillance. Conclusions. This prioritization scale will be useful to countries in Latin America that still need to ascertain their current trachoma situation. The absence or prevalence of trachoma in countries designated as very high and high priority for trachoma surveillance activities must be studied to determine the extent of the disease in Latin America.

[RESUMEN]. Objetivo. Establecer y priorizar los municipios en 22 países de América Latina para desempeñar actividades de vigilancia del tracoma, medir la ausencia o la prevalencia del tracoma, y brindar apoyo a la validación y las iniciativas de eliminación del tracoma en la Región de las Américas. Métodos. En el 2017, se creó una escala de asignación de prioridades con el fin de clasificar cada municipio teniendo presente una combinación de tres características: a) el índice de vulnerabilidad al tracoma, derivado de los tres factores socioeconómicos conocidos por ser factores de riesgos para el tracoma (falta de acceso del municipio a mejores instalaciones sanitarias, agua potable limpia y educación adecuada), según los datos del censo de vivienda de principios del 2017; b) los antecedentes de tracoma en los países en que la enfermedad no se conocía como problema de salud pública en el año 2016, y c) si el municipio comparte frontera con otro donde el tracoma supuso un problema de salud pública en el 2016. Se clasificaron municipios de 22 países según un criterio de prioridad muy alta, alta, media o baja de vigilancia del tracoma. En el Caribe, únicamente Trinidad y Tabago cumplieron los criterios de inclusión. Resultados. Mediante la escala de asignación de prioridades se establecieron 1 053 municipios en Brasil, Colombia y Guatemala con prioridad muy alta de vigilancia del tracoma. En Ecuador, El Salvador, Guyana, Paraguay, Perú, Suriname y Venezuela, 183 municipios se clasificaron con prioridad alta y en Argentina, Belice, Bolivia, Chile, República Dominicana, Honduras, Nicaragua, Panamá y Uruguay, se asignó a 677 municipios una prioridad media de vigilancia del tracoma. Conclusiones. Esta escala de asignación de prioridades será una herramienta útil para los países en América Latina que todavía necesitan evaluar su actual situación de tracoma. Debe estudiarse la ausencia o prevalencia del tracoma en los países designados con prioridades muy alta y alta para las actividades de vigilancia de tracoma con el fin de determinar la magnitud de la enfermedad en América Latina.

[RESUMO]. Objetivo. Identificar e priorizar os municípios em 22 países da América Latina para realizar atividades de vigilância epidemiológica do tracoma, determinar a ausência ou a prevalência do tracoma e dar apoio à validação e aos esforços de eliminação da doença na Região das Américas. Métodos. Uma escala de priorização foi elaborada em 2017 para classificar cada município segundo três critérios combinados: (a) índice de vulnerabilidade ao tracoma, estimado com base em três fatores socioeconômicos conhecidos como riscos à doença – falta de acesso a um melhor saneamento básico, à água para consumo e a uma educação adequada, segundo dados do censo habitacional realizado no início de 2017; (b) antecedentes do tracoma nos países onde a doença não era um problema conhecido de saúde pública em 2016 e (c) fazer divisa ou não com um município onde o tracoma era um problema conhecido de saúde pública em 2016. Os municípios de 22 países foram classificados como de prioridade muito alta, alta, média ou baixa para a vigilância do tracoma. No Caribe, apenas Trinidad e Tobago satisfez os critérios de inclusão. Resultados. De acordo com a escala de priorização, 1.053 municípios no Brasil, Colômbia e Guatemala foram classificados como de prioridade muito alta; 183 municípios no Equador, El Salvador, Guiana, Paraguai, Peru, Suriname e Venezuela como de prioridade alta, e 677 municípios na Argentina, Belize, Bolívia, Chile, República Dominicana, Honduras, Nicarágua, Panamá e Uruguai foram qualificados como de prioridade média para a vigilância do tracoma. Conclusões. A escala de priorização será um instrumento útil aos países na América Latina que ainda precisam determinar sua situação atual em relação ao tracoma. A ausência ou a prevalência da doença deve ser pesquisada nos países classificados como de prioridade muito alta e alta para as atividades de vigilância para que se possa conhecer a extensão do tracoma na América Latina.

Characterizing Shigella species distribution and antimicrobial susceptibility to ciprofloxacin and nalidixic acid in Latin America between 2000-2015.

BACKGROUND: Shigellosis is the second leading cause of diarrheal death globally. The global burden has been complicated by the emergence of Shigella strains resistant to first line antibiotic treatments such as ciprofloxacin. This study aims to describe the epidemiologic distribution of the most common Shigella species, and their antimicrobial susceptibility patterns to ciprofloxacin and nalidixic acid (NA) in Latin America. METHODS: Laboratory data from 19 countries were obtained through the Latin American Network for Antimicrobial Resistance Surveillance (ReLAVRA) from 2000-2015. The Clinical Laboratory Standards Institute reduced susceptibility breakpoints for Enterobacteriaceae was used to interpret the disc diffusion tests for Shigella susceptibility to ciprofloxacin and NA. Negative binominal regression was used to analyze longitudinal trends of Shigella isolates antimicrobial susceptibility. RESULTS: 79,548 Shigella isolates were tested and reported between 2000-2015. The most common isolated species were S. flexneri (49%), and S. sonnei (28%). There was a steady increase in the proportion of S. sonnei isolates within the region(p<0.001). The average annual percentage increase (AAPI) in nonsusceptibility was 18.4% (p<0.001) for ciprofloxacin (baseline = 0.3); and 13.2%(p<0.001) for NA (baseline = 3). AAPI nonsusceptibility to ciprofloxacin was 13.3% for S. flexneri (p<0.04); and 39.9% for S. sonnei (p<0.001). Honduras, Dominican Republic, Venezuela, and Chile reported the highest increase in nonsusceptibility to ciprofloxacin among all Shigella isolates. CONCLUSION: There is an increasing trend in Shigella nonsusceptibility to ciprofloxacin and NA, including among the most common shigella species, in Latin America. This rise of nonsusceptibility among Shigella species to commonly used treatments such as ciprofloxacin is alarming and threatens the control and management of this currently treatable infection. Improved data quality, collection and reporting is needed in Latin America to respond effectively to the rising trends observed. This includes the need for quality isolate level epidemiological data; molecular data, and data on antibiotic consumption and use.

Arbovirosis emergentes y reemergentes transmitidas por Aedes en la Región de las Américas: implicaciones en materia de políticas de salud / Emerging and reemerging Aedes-transmitted arbovirus infections in the Region of the Americas: implications for health policy

[RESUMEN]. El aumento en la incidencia y distribución geográfica de las arbovirosis constituye uno de los principales problemas de salud pública en la Región de las Américas. La incidencia del dengue ha experimentado una tendencia creciente en los últimos decenios en la Región, donde se ha pasado de una endemicidad baja a hiperendemicidad. También, la incidencia de la fiebre amarilla se ha intensificado en este período, y ha pasado de una actividad restringida a zonas selváticas a presentar brotes urbanos. El chikunguña comenzó a propagarse de forma pandémica en el 2005 a un ritmo sin precedentes y llegó al continente americano en el 2013. Al año siguiente, la infección por el virus del Zika irrumpió también en la Región con un brote explosivo acompañado de gravísimas anomalías congénitas y trastornos neurológicos, hasta convertirse en una de las mayores crisis de salud en los últimos años. La inadecuada vigilancia de las arbovirosis en la Región y la carencia de pruebas serológicas para diferenciar entre los distintos virus plantean retos considerables. Sigue habiendo pocas evidencias científicas en respaldo de las intervenciones de control de vectores. El manejo clínico sigue siendo la piedra angular del control de estas enfermedades. En la actualidad, solo están autorizadas en la Región de las Américas las vacunas contra la fiebre amarilla y contra el dengue, si bien hay varias vacunas experimentales en fase de investigación en ensayos clínicos. El Grupo Mundial de Expertos en Arbovirus ofrece en este artículo un panorama de los progresos, los retos y las recomendaciones sobre prevención y control de las arbovirosis en los países de la Región de las Américas.

[ABSTRACT]. The increasing geographical spread and disease incidence of arboviral infections are among the greatest public health concerns in the Americas. The region has observed an increasing trend in dengue incidence in the last decades, evolving from low to hyperendemicity. Yellow fever incidence has also intensified in this period, expanding from sylvatic-restricted activity to urban outbreaks. Chikungunya started spreading pandemically in 2005 at an unprecedented pace, reaching the Americas in 2013. The following year, Zika also emerged in the region with an explosive outbreak, carrying devastating congenital abnormalities and neurologic disorders and becoming one of the greatest global health crises in years. The inadequate arbovirus surveillance in the region and the lack of serologic tests to differentiate among viruses poses substantial challenges. The evidence for vector control interventions remains weak. Clinical management remains the mainstay of arboviral disease control. Currently, only yellow fever and dengue vaccines are licensed in the Americas, with several candidate vaccines in clinical trials. The Global Arbovirus Group of Experts provides in this article an overview of progress, challenges, and recommendations on arboviral prevention and control for countries of the Americas.

Emerging and Reemerging Aedes-Transmitted Arbovirus Infections in the Region of the Americas: Implications for Health Policy.

The increasing geographical spread and disease incidence of arboviral infections are among the greatest public health concerns in the Americas. The region has observed an increasing trend in dengue incidence in the last decades, evolving from low to hyperendemicity. Yellow fever incidence has also intensified in this period, expanding from sylvatic-restricted activity to urban outbreaks. Chikungunya started spreading pandemically in 2005 at an unprecedented pace, reaching the Americas in 2013. The following year, Zika also emerged in the region with an explosive outbreak, carrying devastating congenital abnormalities and neurologic disorders and becoming one of the greatest global health crises in years. The inadequate arbovirus surveillance in the region and the lack of serologic tests to differentiate among viruses poses substantial challenges. The evidence for vector control interventions remains weak. Clinical management remains the mainstay of arboviral disease control. Currently, only yellow fever and dengue vaccines are licensed in the Americas, with several candidate vaccines in clinical trials. The Global Arbovirus Group of Experts provides in this article an overview of progress, challenges, and recommendations on arboviral prevention and control for countries of the Americas.