Estimating the long-term effects of mass screening for latent and active tuberculosis in the Marshall Islands

BACKGROUND: Ambitious population-based screening programmes for latent and active tuberculosis (TB) were implemented in the Republic of the Marshall Islands in 2017 and 2018. METHODS: We used a transmission dynamic model of TB informed by local data to capture the Marshall Islands epidemic's historical dynamics. We then used the model to project the future epidemic trajectory following the active screening interventions, as well as considering a counterfactual scenario with no intervention. We also simulated future scenarios including periodic interventions similar to those previously implemented, to assess their ability to reach the End TB Strategy targets and TB pre-elimination in the Marshall Islands. RESULTS: The screening activities conducted in 2017 and 2018 were estimated to have reduced TB incidence and mortality by around one-third in 2020, and are predicted to achieve the End TB Strategy milestone of 50% incidence reduction by 2025 compared with 2015. Screening interventions had a considerably greater impact when latent TB screening and treatment were included, compared with active case finding alone. Such combined programmes implemented at the national level could achieve TB pre-elimination around 2040 if repeated every 2 years. CONCLUSIONS: Our model suggests that it would be possible to achieve TB pre-elimination by 2040 in the Marshall Islands through frequent repetition of the same interventions as those already implemented in the country. It also highlights the importance of including latent infection testing in active screening activities

Low oxygen saturation and mortality in an adult cohort; the Tromsø Study

Published version, also available at http://dx.doi.org/10.1186/s12890-015-0003-5Background: Oxygen saturation has been shown in risk score models to predict mortality in emergency medicine. The aim of this study was to determine whether low oxygen saturation measured by a single-point measurement by pulse oximetry (SpO2) is associated with increased mortality in the general adult population. Methods: Pulse oximetry was performed in 5,152 participants in a cross-sectional survey in Tromsø, Norway, in 2001–2002 (“Tromsø 5”). Ten-year follow-up data for all-cause mortality and cause of death were obtained from the National Population and the Cause of Death Registries, respectively. Cause of death was grouped into four categories: cardiovascular disease, cancer except lung cancer, pulmonary disease, and others. SpO2 categories were assessed as predictors for all-cause mortality and death using Cox proportional-hazards regression models after correcting for age, sex, smoking history, body mass index (BMI), C-reactive protein level, self-reported diseases, respiratory symptoms, and spirometry results. Results: The mean age was 65.8 years, and 56% were women. During the follow-up, 1,046 (20.3%) participants died. The age- and sex-adjusted hazard ratios (HRs) (95% confidence intervals) for all-cause mortality were 1.99 (1.33–2.96) for SpO2 ≤ 92% and 1.36 (1.15–1.60) for SpO2 93–95%, compared with SpO2 ≥ 96%. In the multivariable Cox proportional-hazards regression models that included self-reported diseases, respiratory symptoms, smoking history, BMI, and CRP levels as the explanatory variables, SpO2 remained a significant predictor of all-cause mortality. However, after including forced expiratory volume in 1 s percent predicted (FEV1% predicted), this association was no longer significant. Mortality caused by pulmonary diseases was significantly associated with SpO2 even when FEV1% predicted was included in the model. Conclusions: Low oxygen saturation was independently associated with increased all-cause mortality and mortality caused by pulmonary diseases. When FEV1% predicted was included in the analysis, the strength of the association weakened but was still statistically significant for mortality caused by pulmonary diseases

Feasibility of achieving the 2025 WHO global tuberculosis targets in South Africa, China, and India: a combined analysis of 11 mathematical models.

BACKGROUND: The post-2015 End TB Strategy proposes targets of 50% reduction in tuberculosis incidence and 75% reduction in mortality from tuberculosis by 2025. We aimed to assess whether these targets are feasible in three high-burden countries with contrasting epidemiology and previous programmatic achievements. METHODS: 11 independently developed mathematical models of tuberculosis transmission projected the epidemiological impact of currently available tuberculosis interventions for prevention, diagnosis, and treatment in China, India, and South Africa. Models were calibrated with data on tuberculosis incidence and mortality in 2012. Representatives from national tuberculosis programmes and the advocacy community provided distinct country-specific intervention scenarios, which included screening for symptoms, active case finding, and preventive therapy. FINDINGS: Aggressive scale-up of any single intervention scenario could not achieve the post-2015 End TB Strategy targets in any country. However, the models projected that, in the South Africa national tuberculosis programme scenario, a combination of continuous isoniazid preventive therapy for individuals on antiretroviral therapy, expanded facility-based screening for symptoms of tuberculosis at health centres, and improved tuberculosis care could achieve a 55% reduction in incidence (range 31-62%) and a 72% reduction in mortality (range 64-82%) compared with 2015 levels. For India, and particularly for China, full scale-up of all interventions in tuberculosis-programme performance fell short of the 2025 targets, despite preventing a cumulative 3·4 million cases. The advocacy scenarios illustrated the high impact of detecting and treating latent tuberculosis. INTERPRETATION: Major reductions in tuberculosis burden seem possible with current interventions. However, additional interventions, adapted to country-specific tuberculosis epidemiology and health systems, are needed to reach the post-2015 End TB Strategy targets at country level. FUNDING: Bill and Melinda Gates Foundation

Cost-effectiveness and resource implications of aggressive action on tuberculosis in China, India, and South Africa: a combined analysis of nine models.

BACKGROUND: The post-2015 End TB Strategy sets global targets of reducing tuberculosis incidence by 50% and mortality by 75% by 2025. We aimed to assess resource requirements and cost-effectiveness of strategies to achieve these targets in China, India, and South Africa. METHODS: We examined intervention scenarios developed in consultation with country stakeholders, which scaled up existing interventions to high but feasible coverage by 2025. Nine independent modelling groups collaborated to estimate policy outcomes, and we estimated the cost of each scenario by synthesising service use estimates, empirical cost data, and expert opinion on implementation strategies. We estimated health effects (ie, disability-adjusted life-years averted) and resource implications for 2016-35, including patient-incurred costs. To assess resource requirements and cost-effectiveness, we compared scenarios with a base case representing continued current practice. FINDINGS: Incremental tuberculosis service costs differed by scenario and country, and in some cases they more than doubled existing funding needs. In general, expansion of tuberculosis services substantially reduced patient-incurred costs and, in India and China, produced net cost savings for most interventions under a societal perspective. In all three countries, expansion of access to care produced substantial health gains. Compared with current practice and conventional cost-effectiveness thresholds, most intervention approaches seemed highly cost-effective. INTERPRETATION: Expansion of tuberculosis services seems cost-effective for high-burden countries and could generate substantial health and economic benefits for patients, although substantial new funding would be required. Further work to determine the optimal intervention mix for each country is necessary. FUNDING: Bill & Melinda Gates Foundation

Outcome measurements with indigenous consumers

[Extract] The need to monitor outcomes is nowhere more pressing than in those areas where systems appear to be least effective. For Indigenous! peoples of Australia there has been delayed recognition of the dire mental health consequences of many aspects of colonization and development (Human Rights and Equal Opportunity Commission, 1997, Calma, 2007). High suicide rates and community concern have begun to attract national attention and intervention after decades of procrastination (Zubrick et al., 1995, Australian Bureau of Statistics, 2005, Brown and Brown, 2007). 'While some have argued that it is necessary to develop Indigenous-specific tools to assess status and outcomes with sufficient validity, others recognize the potential loss to Indigenous consumers if they are not included in the national datasets. However, comparability in the use of mainstream measures with Indigenous consumers is highly under-researched' (Haswell-Elkins et al., 2007)

Attitudes of mental health staff to routine outcome measurement

Background: Routine outcome measurement is mandated in public mental health services in Australia, but uptake and compliance are variable. This may be because of uncertainties and resistances among clinicians.Aims: To survey attitudes and practices to routine outcome measurement among staff in adult area mental health services and to elucidate their correlates.Method: As part of a larger study, a specifically designed questionnaire was distributed to all staff.Results: A high return rate was achieved. A wide range of opinion was found. Staff who had attended training reported the measures as easier to use than those who had not. Staff who had recently seen feedback rated outcome measures as more valuable but less easy to use than those who had not seen feedback. Compared to other disciplines, medical staff and psychologists tended to rate outcome measures as less useful.Conclusions: The results have implications for the implementation and sustainability of routine outcome measurement. They highlight the need for staff to receive targeted training and usable reports, and to have access to resources to extract meaning and value from outcome measures.<br /

Outcome measurement in adult Indigenous mental health consumers

Little is known about the performance of outcome instruments with consumers of different cultural backgrounds. We report a study of using routine outcome measures with Indigenous adult mental health consumers, whereby mental health clinicians used two leading Australian measures with consumers who self-identified as Indigenous. Mean scores on most items were different from the predominantly non-Indigenous national averages; some, particularly those assessing accommodation and occupation, were worse while others (those assessing depression) were better. Scores were consistently worse when more informants were involved in the assessment. A set of good practice principles for the use of standardized measures with Indigenous consumers was developed. They recommend using informants whenever possible, ratings should objectively reflect underlying disadvantage and behaviours that are not sanctioned or accepted within the local culture, but not phenomena that are socially or culturally accepted. Despite the advice and training, most assessments did not involve additional informants. The (mainly non-Indigenous) clinicians mostly indicated no additional difficulty in using the outcome measures with the Indigenous consumers, although clinicians reported greater difficulty in completing them when additional informants were present. In 52% of assessments, clinicians felt that the scales reflected the consumer's problems reasonably, and in 22%, well. Perceived validity was positively associated with consumer engagement. The study provides qualified support for the practice of using the HoNOS and LSP for routine outcome assessment with Indigenous consumers. The main provisos are that clinicians need to maximize the engagement of consumers and try to ensure involvement of additional informants to reduce the chances of invalid assessments

Objections to routine clinical outcomes measurement in mental health services: any evidence so far?

Aims: To examine whether criticisms published in advance of the development of RCOM have been borne out by data now available from such a programme. Method: This was an observational study of routine ratings using HoNOS65+ at inception/admission and again at discharge in an old age psychiatry service from 1997 to 2008. Testable hypotheses were generated from each criticism amenable to empirical examination. Inter-rater reliability estimates were applied to observed differences between scores between community and ward patients using resampling. Results: Five thousand one hundred eighty community inceptions and 862 admissions had HoNOS65+ ratings at referral/admission and discharge. We could find no evidence of gaming (artificially worse scores at inception and better at discharge), selection, attrition or detection bias, and ratings were consistent with diagnosis and level of service. Anticipated low levels of inter-rater reliability did not vitiate differences between levels of service. Conclusions: Although only hypotheses testable from within RCOM data were examined, and only 46% of eligible episodes had complete outcomes data, no evidence of the alleged biases were found. RCOM seems valid and practical in mental health services