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Background Emerging evidence suggests that shortened, simplified treatment regimens for rifampicin-resistant tuberculosis (RR-TB) can achieve comparable end-of-treatment (EOT) outcomes to longer regimens. We compared a 6-month regimen containing bedaquiline, pretomanid, linezolid, and moxifloxacin (BPaLM) to a standard of care strategy using a 9- or 18-month regimen depending on whether fluoroquinolone resistance (FQ-R) was detected on drug susceptibility testing (DST). Methods and findings The primary objective was to determine whether 6 months of BPaLM is a cost-effective treatment strategy for RR-TB. We used genomic and demographic data to parameterize a mathematical model estimating long-term health outcomes measured in quality-adjusted life years (QALYs) and lifetime costs in 2022 USD ($) for each treatment strategy for patients 15 years and older diagnosed with pulmonary RR-TB in Moldova, a country with a high burden of TB drug resistance. For each individual, we simulated the natural history of TB and associated treatment outcomes, as well as the process of acquiring resistance to each of 12 anti-TB drugs. Compared to the standard of care, 6 months of BPaLM was cost-effective. This strategy was estimated to reduce lifetime costs by $3,366 (95% UI: [1,465, 5,742] p < 0.001) per individual, with a nonsignificant change in QALYs (-0.06; 95% UI: [-0.49, 0.03] p = 0.790). For those stopping moxifloxacin under the BPaLM regimen, continuing with BPaL plus clofazimine (BPaLC) provided more QALYs at lower cost than continuing with BPaL alone. Strategies based on 6 months of BPaLM had at least a 93% chance of being cost-effective, so long as BPaLC was continued in the event of stopping moxifloxacin. BPaLM for 6 months also reduced the average time spent with TB resistant to amikacin, bedaquiline, clofazimine, cycloserine, moxifloxacin, and pyrazinamide, while it increased the average time spent with TB resistant to delamanid and pretomanid. Sensitivity analyses showed 6 months of BPaLM to be cost-effective across a broad range of values for the relative effectiveness of BPaLM, and the proportion of the cohort with FQ-R. Compared to the standard of care, 6 months of BPaLM would be expected to save Moldova's national TB program budget $7.1 million (95% UI: [1.3 million, 15.4 million] p = 0.002) over the 5-year period from implementation. Our analysis did not account for all possible interactions between specific drugs with regard to treatment outcomes, resistance acquisition, or the consequences of specific types of severe adverse events, nor did we model how the intervention may affect TB transmission dynamics. Conclusions Compared to standard of care, longer regimens, the implementation of the 6-month BPaLM regimen could improve the cost-effectiveness of care for individuals diagnosed with RR-TB, particularly in settings with a high burden of drug-resistant TB. Further research may be warranted to explore the impact and cost-effectiveness of shorter RR-TB regimens across settings with varied drug-resistant TB burdens and national income levels., Author(s): Lyndon P. James 1,2,*, Fayette Klaassen 3, Sedona Sweeney 4, Jennifer Furin 5, Molly F. Franke 5, Reza Yaesoubi 6, Dumitru Chesov 7,8, Nelly Ciobanu 9, Alexandru Codreanu 9, [...]

In 2010, cholera, caused by the bacterium Vibrio cholerae, was introduced into Haiti, resulting in >800,000 cases and >10,000 deaths (1,2). Case incidence peaked in 2012, then decreased, and the [...]

BackgroundMobile health (mHealth) technologies provide many potential benefits to the delivery of health care. Medical decision support tools have shown particular promise in improving quality of care and provider workflow. Frontline health workers such as Community Health Workers (CHWs) have been shown to be effective in extending the reach of care, yet only a few medicine dosing tools are available to them. ObjectiveWe developed an mHealth medicine dosing tool tailored to the skill level of CHWs to assist in the delivery of care. The mHealth tool was created for CHWs with primary school education working in rural Mexico and Guatemala. Perceptions and impressions of this tool were collected and compared to an existing paper-based medicine dosing tool. MethodsSeventeen Partners In Health CHWs in rural Mexico and Guatemala completed a one-day training in the mHealth medicine dosing tool. Following the training, a prescription dosing test was administered, and CHWs were given the choice to use the mHealth or paper-based tool to answer 7 questions. Subsequently, demographic and qualitative data was collected using a questionnaire and an in-person interview conducted in Spanish, then translated into English. The qualitative questions captured data on 4 categories: comfort, acceptability, preference, and accuracy. Qualitative responses were analyzed for major themes and quantitative variables were analyzed using SAS. Results82% of the 17 CHWs chose the mHealth tool for at least 1 of 7 questions compared to 53% (9/17) who chose to use the paper-based tool. 93% (13/14) rated the phone as being easy or very easy to use, and 56% (5/9) who used the paper-based tool rated it as easy or very easy. Dosing accuracy was generally higher among questions answered using the mHealth tool relative to questions answered using the paper-based tool. Analysis of major qualitative themes indicated that the mHealth tool was perceived as being quick, easy to use, and as having complete information. The mHealth tool was seen as an acceptable dosing tool to use and as a way for CHWs to gain credibility within the community. ConclusionsA tailored cell phone-based mHealth medicine dosing tool was found to be useful and acceptable by CHWs in rural Mexico and Guatemala. The streamlined workflow of the mHealth tool and benefits such as the speed and self-lighting were found to be particularly useful features. Well designed and positioned tools such as this may improve effective task shifting by reinforcing the tasks that different cadres of workers are asked to perform. Further studies can explore how to best implement this mHealth tool in real-world settings, including how to incorporate the best elements of the paper-based tool that were also found to be helpful.

Background Few studies have evaluated the association between preexisting vitamin D deficiency and incident tuberculosis (TB). We assessed the impact of baseline vitamins D levels on TB disease risk. Methods and findings We assessed the association between baseline vitamin D and incident TB in a prospective cohort of 6,751 HIV-negative household contacts of TB patients enrolled between September 1, 2009, and August 29, 2012, in Lima, Peru. We screened for TB disease at 2, 6, and 12 months after enrollment. We defined cases as household contacts who developed TB disease at least 15 days after enrollment of the index patient. For each case, we randomly selected four controls from among contacts who did not develop TB disease, matching on gender and year of age. We also conducted a one-stage individual-participant data (IPD) meta-analysis searching PubMed and Embase to identify prospective studies of vitamin D and TB disease until June 8, 2019. We included studies that assessed vitamin D before TB diagnosis. In the primary analysis, we defined vitamin D deficiency as 25-(OH)D 75nmol/L. We estimated the association between baseline vitamin D status and incident TB using conditional logistic regression in the Lima cohort and generalized linear mixed models in the meta-analysis. We further defined severe vitamin D deficiency as 25-(OH)D < 25 nmol/L and performed stratified analyses by HIV status in the IPD meta-analysis. In the Lima cohort, we analyzed 180 cases and 709 matched controls. The adjusted odds ratio (aOR) for TB risk among participants with baseline vitamin D deficiency compared to sufficient vitamin D was 1.63 (95% CI 0.75-3.52; p = 0.22). We included seven published studies in the meta-analysis and analyzed 3,544 participants. In the pooled analysis, the aOR was 1.48 (95% CI 1.04-2.10; p = 0.03). The aOR for severe vitamin D deficiency was 2.05 (95% CI 0.87-4.87; p trend for decreasing 25-(OH)D levels from sufficient vitamin D to severe deficiency = 0.02). Among 1,576 HIV-positive patients, vitamin D deficiency conferred a 2-fold (aOR 2.18, 95% CI 1.22-3.90; p = 0.01) increased risk of TB, and the aOR for severe vitamin D deficiency compared to sufficient vitamin D was 4.28 (95% CI 0.85-21.45; p = 0.08). Our Lima cohort study is limited by the short duration of follow-up, and the IPD meta-analysis is limited by the number of possible confounding covariates available across all studies. Conclusion Our findings suggest vitamin D predicts TB disease risk in a dose-dependent manner and that the risk of TB disease is highest among HIV-positive individuals with severe vitamin D deficiency. Randomized control trials are needed to evaluate the possible role of vitamin D supplementation on reducing TB disease risk., Author(s): Omowunmi Aibana 1, Chuan-Chin Huang 2, Said Aboud 3, Alberto Arnedo-Pena 4, Mercedes C. Becerra 2, Juan Bautista Bellido-Blasco 4, Ramesh Bhosale 5, Roger Calderon 6, Silvia Chiang 7, [...]

The discovery and use of discriminating genetic markers such as IS6110 restriction fragment length polymorphisms (RFLPs), spacer oligonucleotides (spoligotyping), and mycobacterial interspersed repetitive unit--variable number tandem repeats (MIRU-VNTRs) (1) have [...]