How Methodologic Differences Affect Results of Economic Analyses: A Systematic Review of Interferon Gamma Release Assays for the Diagnosis of LTBI

Introduction: Cost effectiveness analyses (CEA) can provide useful information on how to invest limited funds, however they are less useful if different analysis of the same intervention provide unclear or contradictory results. The objective of our study was to conduct a systematic review of methodologic aspects of CEA that evaluate Interferon Gamma Release Assays (IGRA) for the detection of Latent Tuberculosis Infection (LTBI), in order to understand how differences affect study results. Methods: A systematic review of studies was conducted with particular focus on study quality and the variability in inputs used in models used to assess cost-effectiveness. A common decision analysis model of the IGRA versus Tuberculin Skin Test (TST) screening strategy was developed and used to quantify the impact on predicted results of observed differences of model inputs taken from the studies identified. Results: Thirteen studies were ultimately included in the review. Several specific methodologic issues were identified across studies, including how study inputs were selected, inconsistencies in the costing approach, the utility of the QALY (Quality Adjusted Life Year) as the effectiveness outcome, and how authors choose to present and interpret study results. When the IGRA versus TST test strategies were compared using our common decision analysis model predicted effectiveness largely overlapped. Implications: Many methodologic issues that contribute to inconsistent results and reduced study quality were identified in studies that assessed the cost-effectiveness of the IGRA test. More specific and relevant guidelines are needed in order to help authors standardize modelling approaches, inputs, assumptions and how results are presented and interpreted

Sociodemographic and health profile of asylum-seekers in Rio de Janeiro, 2016–2017

OBJECTIVE To analyze the sociodemographic profile and self-reported health conditions of asylum-seekers in Rio de Janeiro. METHODS A cross-sectional study of secondary data, collected from asylum claims forms completed in 2016 and 2017, at Cáritas Arquidiocesana do Rio de Janeiro (Cáritas-RJ). Descriptive analyses were performed and absolute and relative frequencies and 95% confidence intervals were calculated. RESULTS Claims completed by 818 asylum-seekers from 49 different countries were identified, of whom 126 (20.3%) were stateless, 510 (62.7%) were male, 797 (97.4%) were adults, with a mean age of 30.5 years, 551 (73.5%) were single, 340 (44.1%) had higher education, and 27 (4.0%) were unemployed in their country of origin before coming to Brazil. Fear of persecution for political opinion, violation of human rights, and risk of torture stood out among the reasons stated for requesting asylum. To reach Brazil, 629 (80.5%) traveled only by plane. Regarding health conditions, 216 (29.0%) reported having some symptom, disease or health problem, the most frequent being pain, vision problems, infectious diseases (including HIV/AIDS), and hypertension. Only 15 individuals (2.2%) reported being in some medical or psychological treatment; 42 (6.0%) reported visual impairments, 14 (2.0%) reported physical impairments and 4 (0.6%) hearing impairments. CONCLUSIONS Unlike other countries, where forced migrants with a low level of education enter clandestinely by sea or land, asylum-seekers residing in Rio de Janeiro between 2016 and 2017 were mostly adults with higher education who migrated using air transport. They had primary care-sensitive health conditions that could be treated via access to public primary health care services.OBJETIVO Analisar o perfil sociodemográfico e as condições de saúde autorrelatadas por solicitantes de refúgio no Rio de Janeiro. MÉTODOS Estudo transversal de dados secundários, coletados de formulários de solicitação de refúgio preenchidos em 2016 e 2017, na Cáritas Arquidiocesana do Rio de Janeiro (Cáritas-RJ). Foram realizadas análises descritivas e calculadas frequências absolutas, relativas e intervalos de 95% de confiança. RESULTADOS Foram identificados formulários preenchidos por 818 solicitantes de refúgio, originários de 49 países diferentes, dos quais 126 (20,3%) eram apátridas, 510 (62,7%) do sexo masculino, 797 (97,4%) adultos, com idade média de 30,5 anos, 551 (73,5%) solteiros, 340 (44,1%) com ensino superior e 27 (4,0%) desempregados no país de origem antes da vinda para o Brasil. Entre os motivos declarados para solicitação de refúgio, destacaram-se o temor de perseguição por opinião política, violação de direitos humanos e risco de tortura. Para chegar ao Brasil, 629 (80,5%) viajaram somente de avião. Em relação às condições de saúde, 216 (29,0%) afirmaram ter algum sintoma, doença ou agravo em saúde, sendo as mais frequentes dores, problemas de visão, doenças infecciosas (incluindo HIV/aids) e hipertensão. Apenas 15 indivíduos (2,2%) relataram estar em algum tratamento médico ou psicológico; 42 (6,0%) relataram deficiências visuais, 14 (2,0%) relataram deficiências físicas e 4 (0,6%) deficiências auditivas. CONCLUSÕES Diferentemente de outros países, onde migrantes forçados de baixo grau de instrução entram por vias clandestinas marítimas ou terrestres, os solicitantes de refúgio residentes no Rio de Janeiro entre 2016 e 2017, eram, em sua maioria, adultos com ensino superior que migraram usando transporte aéreo. Apresentavam condições de saúde sensíveis à atenção primária que poderiam ser tratadas via acesso aos serviços públicos da atenção primária em saúde

Condições de saúde autorrelatadas por solicitantes de refúgio no Rio de Janeiro, Brasil, de 2010 a 2017

No Brasil, entre 2011 e 2022, 348.067 pessoas solicitaram o reconhecimento da condição de refugiado no país. Os motivos que resultaram na migração, os riscos durante o trajeto e a transição cultural ao chegar podem estar associados a diferentes problemas de saúde. O objetivo deste estudo foi analisar as condições de saúde autorrelatadas por solicitantes de refúgio no Município do Rio de Janeiro no período de 2010 a 2017. Trata-se de um estudo transversal de dados secundários. Foram coletadas informações preenchidas nos formulários de solicitação de refúgio do Comitê Nacional para os Refugiados (Conare) de 2010 a 2017 e da entrevista social da Cáritas Arquidiocesana do Rio de Janeiro (Cáritas/RJ). Calcularam-se as taxas de prevalência de condições de saúde e respectivos intervalos de 95% de confiança (IC95%) e a razão de chances (RC) e IC95% em um modelo de regressão logística simples segundo variáveis sociodemográficas e de migração. O estudo incluiu 1.509 indivíduos. Na chegada ao Brasil, 620 (41%) relataram ter uma ou mais condições de saúde. As chances de apresentar problemas de saúde foram maiores em pessoas oriundas do Congo (RC = 18,7) e República Democrática do Congo (RC = 9,5), nos indocumentados (RC = 4,4), nas mulheres (RC = 2,1), em pessoas com Ensino Fundamental (RC = 1,9), com idade ≥ 45 anos (RC = 1,8) e entre os que vivem/viveram maritalmente (RC = 1,8 e 2,5, respectivamente). Entre as pessoas que relataram alguma condição de saúde, mais da metade informaram sentir dores (52%). É possível que as dores físicas tenham relação com estresse pós-traumático e outros sofrimentos em saúde mental, que podem se manifestar por meio de sintomas de dores somáticas

The impact of the Brazilian family health on selected primary care sensitive conditions: A systematic review

Background Brazil has the largest public health-system in the world, with 120 million people covered by its free primary care services. The Family Health Strategy (FHS) is the main primary care model, but there is no consensus on its impact on health outcomes. We systematically reviewed published evidence regarding the impact of the Brazilian FHS on selective primary care sensitive conditions (PCSC). Methods We searched Medline, Web of Science and Lilacs in May 2016 using key words in Portuguese and English, without language restriction. We included studies if intervention was the FHS; comparison was either different levels of FHS coverage or other primary health care service models; outcomes were the selected PCSC; and results were adjusted for relevant sanitary and socioeconomic variables, including the national conditional cash transfer program (Bolsa Familia). Due to differences in methods and outcomes reported, pooling of results was not possible. Results Of 1831 records found, 31 met our inclusion criteria. Of these, 25 were ecological studies. Twenty-one employed longitudinal quasi-experimental methods, 27 compared different levels the FHS coverage, whilst four compared the FHS versus other models of primary care. Fourteen studies found an association between higher FHS coverage and lower post-neonatal and child mortality. When the effect of Bolsa Familia was accounted for, the effect of the FHS on child mortality was greater. In 13 studies about hospitalizations due to PCSC, no clear pattern of association was found. In four studies, there was no effect on child and elderly vaccination or low-birth weight. No included studies addressed breast-feeding, dengue, HIV/AIDS and other neglected infectious diseases. Conclusions Among these ecological studies with limited quality evidence, increasing coverage by the FHS was consistently associated with improvements in child mortality. Scarce evidence on other health outcomes, hospitalization and synergies with cash transfer was found

Record linkage under suboptimal conditions for data-intensive evaluation of primary care in Rio de Janeiro, Brazil

Background Linking Brazilian databases demands the development of algorithms and processes to deal with various challenges including the large size of the databases, the low number and poor quality of personal identifiers available to be compared (national security number not mandatory), and some characteristics of Brazilian names that make the linkage process prone to errors. This study aims to describe and evaluate the quality of the processes used to create an individual-linked database for data-intensive research on the impacts on health indicators of the expansion of primary care in Rio de Janeiro City, Brazil. Methods We created an individual-level dataset linking social benefits recipients, primary health care, hospital admission and mortality data. The databases were pre-processed, and we adopted a multiple approach strategy combining deterministic and probabilistic record linkage techniques, and an extensive clerical review of the potential matches. Relying on manual review as the gold standard, we estimated the false match (false-positive) proportion of each approach (deterministic, probabilistic, clerical review) and the missed match proportion (false-negative) of the clerical review approach. To assess the sensitivity (recall) to identifying social benefits recipients’ deaths, we used their vital status registered on the primary care database as the gold standard. Results In all linkage processes, the deterministic approach identified most of the matches. However, the proportion of matches identified in each approach varied. The false match proportion was around 1% or less in almost all approaches. The missed match proportion in the clerical review approach of all linkage processes were under 3%. We estimated a recall of 93.6% (95% CI 92.8–94.3) for the linkage between social benefits recipients and mortality data. Conclusion The adoption of a linkage strategy combining pre-processing routines, deterministic, and probabilistic strategies, as well as an extensive clerical review approach minimized linkage errors in the context of suboptimal data quality

Shortened first-line TB treatment in Brazil: potential cost savings for patients and health services.

BACKGROUND: Shortened treatment regimens for tuberculosis are under development to improve treatment outcomes and reduce costs. We estimated potential savings from a societal perspective in Brazil following the introduction of a hypothetical four-month regimen for tuberculosis treatment. METHODS: Data were gathered in ten randomly selected health facilities in Rio de Janeiro. Health service costs were estimated using an ingredient approach. Patient costs were estimated from a questionnaire administered to 126 patients. Costs per visits and per case treated were analysed according to the type of therapy: self-administered treatment (SAT), community- and facility-directly observed treatment (community-DOT, facility-DOT). RESULTS: During the last 2 months of treatment, the largest savings could be expected for community-DOT; on average USD 17,351-18,203 and USD 43,660-45,856 (bottom-up and top-down estimates) per clinic. Savings to patients could also be expected as the median (interquartile range) patient-related costs during the two last months were USD 108 (13-291), USD 93 (36-239) and USD 11 (7-126), respectively for SAT, facility-DOT and community-DOT. CONCLUSION: Introducing a four-month regimen may result in significant cost savings for both the health service and patients, especially the poorest. In particular, a community-DOT strategy, including treatment at home, could maximise health services savings while limiting patient costs. Our cost estimates are likely to be conservative because a 4-month regimen could hypothetically increase the proportion of patients cured by reducing the number of patients defaulting and we did not include the possible cost benefits from the subsequent prevention of costs due to downstream transmission averted and rapid clinical improvement with less side effects in the last two months

The need for fast-track, high-quality and low-cost studies about the role of the BCG vaccine in the fight against COVID-19.

Bacillus Calmette-Guérin (BCG) vaccination is routine and near-universal in many low- and middle-income countries (LMIC). It has been suggested that BCG can have a protective effect on COVID-19 morbidity and mortality. This commentary discusses the limitations of the evidence around BCG and COVID-19. We argue that higher-quality evidence is necessary to understand the protective effect of the BCG vaccine from existing, secondary data, while we await results from clinical trials currently conducted in different settings

Proposta de vigilância de óbitos por tuberculose em sistemas de informação

OBJECTIVE: To propose a tuberculosis-related death surveillance strategy based on the Brazilian Mortality Information System. METHODS: Data on 55 tuberculosis-related deaths, which occurred in two large hospitals in Rio de Janeiro, Southeastern Brazil, between September 2005 and August 2006, were obtained from the SIM. These cases were searched and compared with cases in the National Notification System (Sinan). The increment in the number of notifications and completeness of data were evaluated, as well as entry type and outcome in Sinan. RESULTS: Of the 55 deaths, 28 were registered in Sinan. Comparison between systems allowed for the following corrections: 27 new cases were notified, 14 new notifications performed by the hospitals where death occurred and ten outcomes corrected. This represented an increment of 41/144 (28%) notifications by these two hospitals in 2006. Nine cases, previously classified as unconfirmed tuberculosis were reclassified as bacteriologically confirmed, and another five cases were reclassified from tuberculosis to AIDS as the primary cause of death. CONCLUSIONS: The proposed surveillance system for tuberculosis-related death was useful to increase data completeness, decrease under-notification and cases with unknown outcome, to evaluate epidemiological surveillance and death certificate quality and to trace previously unidentified contacts.OBJETIVO: Proponer estrategia de vigilancia de óbitos relacionados con tuberculosis con base en el Sistema de Información de Mortalidad. MÉTODOS: Datos sobre 55 óbitos relacionados con tuberculosis, ocurridos en dos hospitales de grande porte en Rio de Janeiro (Sureste de Brasil) entre septiembre de 2005 y agosto de 2006, fueron obtenidos en el Sistema de Información de Mortalidad. En seguida, tales casos fueron confrontados con los registros en el Sistema de Información de Agravios de Notificación (SINAN). El incremento en el número de notificaciones y en la completitud de los datos fue evaluado, así como el tipo de entrada y resultado en el SINAN. RESULTADOS: De los 55 óbitos, 28 estaban notificados en el SINAN. La relación entre los sistemas posibilitó las siguientes correcciones: 27 nuevos casos notificados, 14 nuevas notificaciones realizadas por la unidad donde ocurrió el óbito y el encerramiento de diez notificaciones. Esto representó incremento de 41(28%) notificaciones de las 144 realizadas por los dos hospitales en 2006. Nueve casos fueron reclasificados para la condición de tuberculosis sin confirmación para tuberculosis con confirmación diagnóstica, y cinco casos fueron reclasificados de tuberculosis para Aids como causa básica de muerte. CONCLUSIÓN: La vigilancia de óbitos por tuberculosis propuesta permitió aumentar la completitud de los sistemas de información, disminuir la subnotificación y el número de casos no encerrados, supervisar la Vigilancia Epidemiológica de las unidades y la calidad del llenado de las Declaraciones de Óbito y buscar contactos no evaluados por el equipo de salud.OBJETIVO: Propor estratégia de vigilância de óbitos relacionados à tuberculose com base no Sistema de Informação de Mortalidade. MÉTODOS: Dados sobre os 55 óbitos relacionados à tuberculose, ocorridos em dois hospitais de grande porte do Rio de Janeiro entre setembro de 2005 e agosto de 2006, foram obtidos no Sistema de Informação de Mortalidade. Esses casos foram confrontados com os registros no Sistema de Informação de Agravos de Notificação (Sinan). O incremento no número de notificações e na completitude dos dados foi avaliado, bem como o tipo de entrada e desfecho no Sinan. RESULTADOS: Dos 55 óbitos, 28 estavam notificados no Sinan. O relacionamento dos sistemas possibilitou as seguintes correções: 27 casos novos notificados, 14 novas notificações realizadas pela unidade em que ocorreu o óbito e o encerramento de dez notificações. Isso representou incremento de 41 (28%) notificações às 144 realizadas pelos dois hospitais em 2006. Nove casos foram reclassificados da condição de tuberculose sem confirmação para tuberculose com confirmação diagnóstica, e cinco casos foram reclassificados de tuberculose para Aids como causa básica de morte. CONCLUSÕES: A vigilância de óbitos por tuberculose proposta permitiu aumentar a completitude dos sistemas de informação, diminuir a subnotificação e o número de casos não encerrados, supervisionar a vigilância epidemiológica das unidades e a qualidade do preenchimento das declarações de óbito, além de buscar contatos não avaliados pela equipe de saúde