Implementation of 3HP in 2 NYC Health Department tuberculosis clinics increased TBI treatment completion by 31 percentage points compared with historical estimates. More flexible DOT options may improve acceptance of 3HP. Wider use of 3HP may substantially improve TBI treatment completion in NYC and advance progress toward tuberculosis elimination.

SUMMARYThe dominant approach to decision-making in public health policy for infectious diseases relies heavily on expert opinion, which often applies empirical evidence to policy questions in a manner that is neither systematic nor transparent. Although systematic reviews are frequently commissioned to inform specific components of policy (such as efficacy), the same process is rarely applied to the full decision-making process. Mathematical models provide a mechanism through which empirical evidence can be methodically and transparently integrated to address such questions. However, such models are often considered difficult to interpret. In addition, models provide estimates that need to be iteratively reevaluated as new data or considerations arise. Using the case study of a novel diagnostic for tuberculosis, a framework for improved collaboration between public health decision-makers and mathematical modellers that could lead to more transparent and evidence-driven policy decisions for infectious diseases in the future is proposed. The framework proposes that policymakers should establish long-term collaborations with modellers to address key questions, and that modellers should strive to provide clear explanations of the uncertainty of model structure and outputs. Doing so will improve the applicability of models and clarify their limitations when used to inform real-world public health policy decisions.

Literature surrounding the burden of and factors associated with hepatitis B virus (HBV) and hepatitis C virus (HCV) infection in persons with tuberculosis (TB) disease remains limited and focused on populations outside the USA. Cross-matched New York City (NYC) TB and viral hepatitis surveillance data were used to estimate the proportion of NYC adults diagnosed with TB from 2000 to 2010 with a report of viral hepatitis infection and to describe the impact of viral hepatitis infection on TB treatment completion and death. For 9512 TB patients, HCV infection was reported in 4.2% and HBV infection in 3.7%; <1% of TB patients had both HCV and HBV infection. The proportion of TB patients with HCV infection to die before TB treatment completion was larger than in TB patients without a viral hepatitis report (21% vs. 9%); this association remained when stratified by HIV status. There was no significant difference in death before treatment completion for TB patients with HBV infection compared to TB patients without a viral hepatitis report when stratified by HIV status. These findings reinforce the importance of hepatitis testing and providing additional support to TB patients with viral hepatitis infection.

Using QuantiFERON®-Gold In-Tube (QFT-GIT) data, the prevalence of tuberculosis infection in New York City was estimated. Patient characteristics associated with a positive result were consistent with known tuberculosis risk factors. Results suggest that blood-based tests for tuberculosis infection are reliable.

Background After steady decline since the 1990s, tuberculosis (TB) incidence in New York City (NYC) and the United States (US) has flattened. The reasons for this trend and the implications for the future trajectory of TB in the US remain unclear. Methods We developed a compartmental model of TB in NYC, parameterized with detailed epidemiological data. We ran the model under five alternative scenarios representing different explanations for recent declines in TB incidence. We evaluated each scenario’s relative likelihood by comparing its output to available data. We used the most likely scenarios to explore drivers of TB incidence and predict future trajectories of the TB epidemic in NYC. Findings Demographic changes and declining TB transmission alone were insufficient to explain recent trends in NYC TB incidence. Only scenarios that assumed contemporary changes in TB dynamics among the foreign-born – a declining rate of reactivation or a decrease in imported subclinical TB – could accurately describe the trajectory of TB incidence since 2007. In those scenarios, the projected decline in TB incidence from 2015 to 2025 varied from minimal [2·0%/year (95% credible interval 0·4–3·5%)] to similar to 2005 to 2009 trends [4·4%/year (2·5–6·4%)]. The primary factor differentiating optimistic from pessimistic projections was the degree to which improvements in TB dynamics among the foreign-born continued into the coming decade. Interpretation Further progress against TB in NYC requires additional focus on the foreign-born population. Absent additional intervention in this group, TB incidence may not decline further.

Matching infectious disease surveillance data has become a routine activity for many health departments. With the increasing focus on chronic disease, it is also useful to explore opportunities to match infectious and chronic disease surveillance data. To understand the burden of diabetes in New York City (NYC), adults with select infectious diseases (tuberculosis, HIV infection, hepatitis B, hepatitis C, chlamydial infection, gonorrhea, and syphilis) reported between 2006 and 2010 were matched with hemoglobin A1c results reported in the same period. Persons were considered to have diabetes with 2 or more hemoglobin A1c test results of 6.5% or higher. The analysis was restricted to persons who were 18 years or older at the time of first report, either A1c or infectious disease. Overall age-adjusted diabetes prevalence was 8.1%, and diabetes prevalence was associated with increasing age; among NYC residents, prevalence ranged from 0.6% among 18- to 29-year-olds to 22.4% among those 65 years and older. This association was also observed in each infectious disease. Diabetes prevalence was significantly higher among persons with tuberculosis born in Mexico, Jamaica, Honduras, Guyana, Bangladesh, Dominican Republic, the Philippines, and Haiti compared with those born in the United States after adjusting for age and sex. Hepatitis C virus-infected women had higher age-adjusted prevalence of diabetes compared with the NYC population as a whole. Recognizing associations between diabetes and infectious diseases can assist early diagnosis and management of these conditions. Matching chronic disease and infectious disease surveillance data has important implications for local health departments and large health system practices, including increasing opportunities for integrated work both internal to systems and with the local community. Large health systems may consider opportunities for increased collaboration across infectious and chronic disease programs facilitated through data linkages of routinely collected surveillance data.

The majority of South Asians were likely infected with TB abroad. South Asians represent a meaningful foreign-born subpopulation for targeted detection and treatment of TB infection in NYC.

Background: Drug-resistant tuberculosis is a high priority threat to global public health. There are still critical gaps in understanding how novel drug-resistant M. tuberculosis strains emerge and, once emergent, what drives the differential propagation of certain epidemiologically-successful strains over others. This study sought to describe the joint evolutionary and epidemiological histories of a novel multidrug-resistant M. tuberculosis strain recently identified in the capital city of the Republic of Moldova (MDR Ural/4.2). Methods: Using whole genome sequence data and Bayesian phylogenomic methods, we reconstruct the stepwise acquisition of drug-resistance mutations in the MDR Ural/4.2 strain, estimate its historical bacterial population size over time, and infer the migration history of this strain between Eastern European countries. Results: We infer that MDR Ural/4.2 likely evolved (via acquisition of rpoB S450L, which confers resistance to rifampin) in the early 1990s, during a period of social turmoil following Moldovan independence from the Soviet Union. This strain subsequently underwent substantial population size expansion in the early 2000s, at a time when national guidelines encouraged in hospital treatment of TB patients. We infer exportation of this strain and its INH-resistant ancestral precursor from Moldova to neighboring countries starting as early as 1985. Conclusions: Our findings underscore how public health practice and social determinants of health shape the conditions under which M. tuberculosis evolves, and demonstrates how historical changes in these conditions shape present-day challenges in TB control. These findings underscore the need for regional coordination in TB control across Eastern Europe.