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.
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