The RATIONS (Reducing Activation of Tuberculosis by Improvement of Nutritional Status) study: a cluster randomised trial of nutritional support (food rations) to reduce TB incidence in household contacts of patients with microbiologically confirmed pulmonary tuberculosis in communities with a high prevalence of undernutrition, Jharkhand, India

Bhargava, Anurag; Bhargava, Madhavi; Velayutham, Banurekha; Thiruvengadam, Kannan; Watson, Basilea; Kulkarni, Bharati; Singh, Manjula; Dayal, R. S.; Pathak, Rajeev Ranjan; Mitra, Anindya; Rade, Kiran; Sachdeva, Kuldeep Singh

doi:10.1136/bmjopen-2020-047210

Cited by 20 publications

(12 citation statements)

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“…The copyright holder for this preprint this version posted March 21, 2024. ; https://doi.org/10.1101/2024.03.20.24304585 doi: medRxiv preprint barriers to care, improving housing and living conditions, and addressing under-nutrition all provide further avenues for reaching TB goals, in addition to the strategies examined in this analysis. 50,51 Achieving TB elimination represents a major challenge, even for low incidence settings like the United States. Strategies that combine a range of approaches are likely needed to achieve this goal, involving strengthening of services within the United States, promoting technological advancements, and supporting action against TB in high-burden countries.…”

Section: Discussionmentioning

confidence: 99%

The long-term impacts of domestic and international TB service improvements on TB trends within the United States: a mathematical modelling study

Menzies,

Swartwood,

Cohen

et al. 2024

Preprint

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BackgroundFor low TB incidence settings, disease elimination is a long-term goal. We investigated pathways to TB pre-elimination and elimination (incidence <1.0 and <0.1 per 100,000, respectively) in the United States.MethodsUsing a mathematical modelling framework, we simulated how U.S. TB incidence could be affected by changes in TB services in the countries of origin for future migrants to the United States, as well as changes in TB services inside the United States. We constructed intervention scenarios representing improvements in TB services internationally and within the United States, individually and in combination, plus a base-case scenario representing continuation of current services. We simulated health and economic outcomes until 2100.FindingsUnder the base-case, U.S. TB incidence rates were projected to decline to 1.8 (95% uncertainty interval: 1.5, 2.1) per 100,000 by 2050. Intervention scenarios produced substantial reductions in TB incidence, with the combination of all domestic and international interventions projected to achieve pre-elimination by 2033 (2031, 2037). Compared to the base-case, this combination could avert 101 (84, 120) thousand U.S. TB cases and 13 (11, 16) thousand U.S. TB deaths over 2025-2050; the total economic value of these TB incidence reductions was estimated as US$68 (33, 112) billion. TB elimination was not projected before 2100.InterpretationStrengthening TB services domestically, promoting the development of more effective technologies and interventions, and supporting TB programs in high-burden countries are key strategies for accelerating progress towards TB elimination in the United States.FundingU.S. Centers for Disease Control and Prevention.Research in ContextEvidence before this studyA number of studies have investigated the potential health impacts of tuberculosis intervention options in individual countries, across high incidence and low incidence settings. Studies in high incidence settings have generally emphasized TB case detection as a high-impact strategy, while studies in low incidence settings have focused on preventive treatment among individuals with TB infection. Few studies have examined the combined effect of interventions choices in both high- and low-incidence settings, and how these choices can contribute to progress towards TB elimination goals in individual countries.Added value of this studyUsing a mathematical modelling approach, this study assessed how interventions in high burden countries and interventions used within the United States could affect future TB trends within the United States. Dependencies between different TB epidemics were modelled explicitly through migration. The analysis examined the extent to which different intervention combinations could accelerate progress towards TB pre-elimination and elimination goals (incidence <1.0 and <0.1 per 100,000, respectively).Implications of all the available evidenceIn this low-burden setting, actions to strengthen TB services domestically, promote the development of more effective technologies and interventions, and support TB programs in high-burden countries were all found to be complementary and impactful strategies for accelerating progress towards TB elimination.

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Section: Discussionmentioning

confidence: 99%

The long-term impacts of domestic and international TB service improvements on TB trends within the United States: a mathematical modelling study

Menzies,

Swartwood,

Cohen

et al. 2024

Preprint

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“…In the RATIONS intervention, HHCs of PWTB receive a food basket that contains a daily multi-micronutrient tablet, rice, and lentils for 6 months. (4) The food basket provides 23g of protein and a total of 750 Kcal calories daily.…”

Section: Intervention Strategiesmentioning

confidence: 99%

In-kind nutritional supplementation for household contacts of persons with tuberculosis would be cost-effective for reducing tuberculosis incidence and mortality in India: a modeling study

Sinha,

Dauphinais,

Carwile

et al. 2024

Preprint

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Background: Undernutrition is the leading cause of tuberculosis (TB) globally, but nutritional interventions are often considered cost prohibitive. The RATIONS study demonstrated that nutritional support provided to household contacts of persons with TB can reduce TB incidence. However, the long-term cost-effectiveness of this intervention is unclear. Methods: We assessed the cost-effectiveness of a RATIONS-style intervention (daily 750 kcal dietary supplementation and multi-micronutrient tablet). Using a Markov state transition model we simulated TB incidence, treatment, and TB-attributable mortality among household contacts receiving the RATIONS intervention, as compared to no nutritional support. We calculated health outcomes (TB cases, TB deaths, and disability-adjusted life years [DALYs]) over the lifetime of intervention recipients and assessed costs from government and societal perspectives. We tested the robustness of results to parameter changes via deterministic and probabilistic sensitivity analysis. Findings: Over two years, household contacts receiving the RATIONS intervention would experience 39% (95% uncertainty interval (UI): 23, 52) fewer TB cases and 59% (95% UI: 44, 69) fewer TB deaths. The intervention was estimated to avert 13,775 (95% UI: 9036, 20,199) TB DALYs over the lifetime of the study cohort comprising 100,000 household contacts and was cost-effective from both government (incremental cost-effectiveness ratio: $229 per DALY averted [95% UI: 133, 387]) and societal perspectives ($184 per DALY averted [95% UI: 83, 344]). The results were most sensitive to the cost of the nutritional supplement. Interpretation Prompt nutritional support for household contacts of persons with TB disease would be cost-effective in reducing TB incidence and mortality in India.

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“…Two upcoming studies from India will shed greater light on the impact of robust nutritional supplementation on TB incidence among household contacts as well as TB treatment outcomes [52] , [53] . These studies aim to address potential reasons for lack of success in previous nutritional interventions, which include the studies being underpowered, providing insufficient or inadequate interventions, and poor accounting of caloric intake.…”

Section: Effect Of Nutritional Interventionsmentioning

confidence: 99%