Publications
115 results found
Ricks S, Denkinger CM, Schumacher SG, et al., 2020, The potential impact of urine-LAM diagnostics on tuberculosis incidence and mortality: a modelling analysis, PLoS Medicine, Vol: 17, ISSN: 1549-1277
BackgroundLateral flow urine lipoarabinomannan (LAM) tests could offer important new opportunities for the early detection of tuberculosis (TB). The currently licensed LAM test, Alere Determine TB LAM Ag (‘LF-LAM’), performs best in the sickest people living with HIV (PLHIV). However, the technology continues to improve, with newer LAM tests, such as Fujifilm SILVAMP TB LAM (‘SILVAMP-LAM’) showing improved sensitivity, including amongst HIV-negative patients. It is important to anticipate the epidemiological impact that current and future LAM tests may have on TB incidence and mortality.Methods and findingsConcentrating on South Africa, we examined the impact that widening LAM test eligibility would have on TB incidence and mortality. We developed a mathematical model of TB transmission to project the impact of LAM tests, distinguishing ‘current’ tests (with sensitivity consistent with LF-LAM), from hypothetical ‘future’ tests (having sensitivity consistent with SILVAMP-LAM). We modelled the impact of both tests, assuming full adoption of the 2019 WHO guidelines for the use of these tests amongst those receiving HIV care. We also simulated the hypothetical deployment of future LAM tests for all people presenting to care with TB symptoms, not restricted to PLHIV. Our model projects that 2,700,000 (95% credible interval [CrI] 2,000,000–3,600,000) and 420,000 (95% CrI 350,000–520,000) cumulative TB incident cases and deaths, respectively, would occur between 2020 and 2035 if the status quo is maintained. Relative to this comparator, current and future LAM tests would respectively avert 54 (95% CrI 33–86) and 90 (95% CrI 55–145) TB deaths amongst inpatients between 2020 and 2035, i.e., reductions of 5% (95% CrI 4%–6%) and 9% (95% CrI 7%–11%) in inpatient TB mortality. This impact in absolute deaths averted doubles if testing is expanded to include outpatients, yet remains <1% of count
Cilloni L, Arinaminpathy N, Stagg H, et al., 2020, Trade-offs between cost and accuracy in active case-finding for tuberculosis: a dynamic modelling analysis, PLoS Medicine, Vol: 17, Pages: 1-20, ISSN: 1549-1277
BackgroundActive case-finding (ACF) may be valuable in tuberculosis (TB) control, but questions remain about its optimum implementation in different settings. For example, smear microscopy misses up to half of TB cases, yet is cheap, and detects the most infectious TB cases. What, then, is the incremental value of using more sensitive and specific, yet more costly, tests such as Xpert MTB/RIF, in ACF in a high burden setting?Methods and FindingsWe constructed a dynamic transmission model of TB, calibrated to be consistent with an urban slum population in India. We applied this model to compare the potential cost and impact of two hypothetical approaches, following initial symptom screening: (i) ‘moderate accuracy’ testing employing a microscopy-like test (that is, lower cost but also lower accuracy) for bacteriological confirmation and (ii) ‘high accuracy’ testing employing an Xpert-like test (higher-cost but also higher accuracy, while also detecting rifampicin resistance).Results suggest that ACF using a moderate-accuracy test could in fact cost more overall than using a high-accuracy test. Under an illustrative budget of USD 20 million in a slum population of 2 million, high-accuracy testing would avert 1·14 (95% Bayesian credible intervals 0·75 – 1·99, with p = 0.28) cases relative to each case averted by moderate-accuracy testing. Test specificity is a key driver: high-accuracy testing would be significantly more impactful at the 5% significance level, as long as the high-accuracy test has specificity at least 3 percentage points greater than the moderate-accuracy test. Additional factors promoting the impact of a high-accuracy are that: its ability to detect rifampicin resistance can lead to long-term cost savings in second-line treatment; and its higher sensitivity contributes to the overall cases averted by ACF.Amongst limitations of this study, our cost model has a narrow focus on the commodity costs of tes
Cilloni L, Fu H, Vesga JF, et al., 2020, The potential impact of the COVID-19 pandemic on the tuberculosis epidemic a modelling analysis, EClinicalMedicine, Vol: 28, ISSN: 2589-5370
Background: Routine services for tuberculosis (TB) are being disrupted by stringent lockdowns against the novel SARS-CoV-2 virus. We sought to estimate the potential long-term epidemiological impact of such disruptions on TB burden in high-burden countries, and how this negative impact could be mitigated. Methods: We adapted mathematical models of TB transmission in three high-burden countries (India, Kenya and Ukraine) to incorporate lockdown-associated disruptions in the TB care cascade. The anticipated level of disruption reflected consensus from a rapid expert consultation. We modelled the impact of these disruptions on TB incidence and mortality over the next five years, and also considered potential interventions to curtail this impact. Findings: Even temporary disruptions can cause long-term increases in TB incidence and mortality. If lockdown-related disruptions cause a temporary 50% reduction in TB transmission, we estimated that a 3-month suspension of TB services, followed by 10 months to restore to normal, would cause, over the next 5 years, an additional 1⋅19 million TB cases (Crl 1⋅06-1⋅33) and 361,000 TB deaths (CrI 333-394 thousand) in India, 24,700 (16,100-44,700) TB cases and 12,500 deaths (8.8-17.8 thousand) in Kenya, and 4,350 (826-6,540) cases and 1,340 deaths (815-1,980) in Ukraine. The principal driver of these adverse impacts is the accumulation of undetected TB during a lockdown. We demonstrate how long term increases in TB burden could be averted in the short term through supplementary "catch-up" TB case detection and treatment, once restrictions are eased. Interpretation: Lockdown-related disruptions can cause long-lasting increases in TB burden, but these negative effects can be mitigated with rapid restoration of TB services, and targeted interventions that are implemented as soon as restrictions are lifted. Funding: USAID and Stop TB Partnership.
Reid MJA, Silva S, Arinaminpathy N, et al., 2020, Building a tuberculosis-free world while responding to the COVID-19 pandemic, LANCET, Vol: 396, Pages: 1312-1313, ISSN: 0140-6736
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- Citations: 10
Arinaminpathy N, Das J, McCormick TH, et al., 2020, Quantifying heterogeneity in SARS-CoV-2 transmission during the lockdown in India.
The novel SARS-CoV-2 virus shows marked heterogeneity in its transmission. Here, we used data collected from contact tracing during the lockdown in Punjab, a major state in India, to quantify this heterogeneity, and to examine implications for transmission dynamics. We found evidence of heterogeneity acting at multiple levels: in the number of potentially infectious contacts per index case, and in the per-contact risk of infection. Incorporating these findings in simple mathematical models of disease transmission reveals that these heterogeneities act in combination to strongly influence transmission dynamics. Standard approaches, such as representing heterogeneity through secondary case distributions, could be biased by neglecting these underlying interactions between heterogeneities. We discuss implications for policy, and for more efficient contact tracing in resource-constrained settings such as India. Our results highlight how contact tracing, an important public health measure, can also provide important insights into epidemic spread and control.
Hogan A, Jewell B, Sherrard-Smith E, et al., 2020, Potential impact of the COVID-19 pandemic on HIV, TB and malaria in low- and middle-income countries: a modelling study, The Lancet Global Health, Vol: 8, Pages: e1132-e1141, ISSN: 2214-109X
Background: COVID-19 has the potential to cause substantial disruptions to health services, including by cases overburdening the health system or response measures limiting usual programmatic activities. We aimed to quantify the extent to which disruptions in services for human immunodeficiency virus (HIV), tuberculosis (TB) and malaria in low- and middle-income countries with high burdens of those disease could lead to additional loss of life. Methods: We constructed plausible scenarios for the disruptions that could be incurred during the COVID-19 pandemic and used established transmission models for each disease to estimate the additional impact on health that could be caused in selected settings.Findings: In high burden settings, HIV-, TB- and malaria-related deaths over five years may increase by up to 10%, 20% and 36%, respectively, compared to if there were no COVID-19 pandemic. We estimate the greatest impact on HIV to be from interruption to antiretroviral therapy, which may occur during a period of high health system demand. For TB, we estimate the greatest impact is from reductions in timely diagnosis and treatment of new cases, which may result from any prolonged period of COVID-19 suppression interventions. We estimate that the greatest impact on malaria burden could come from interruption of planned net campaigns. These disruptions could lead to loss of life-years over five years that is of the same order of magnitude as the direct impact from COVID-19 in places with a high burden of malaria and large HIV/TB epidemics.Interpretation: Maintaining the most critical prevention activities and healthcare services for HIV, TB and malaria could significantly reduce the overall impact of the COVID-19 pandemic.Funding: Bill & Melinda Gates Foundation, The Wellcome Trust, DFID, MRC
Mandal S, Bhatia V, Sharma M, et al., 2020, The potential impact of preventive therapy against tuberculosis in the WHO South-East Asian Region: a modelling approach, BMC Medicine, Vol: 18, ISSN: 1741-7015
BackgroundThe prevention of tuberculosis (TB) is key for accelerating current, slow declines in TBburden. The 2018 World Health Organization (WHO) guidelines on eligibility forpreventive therapy to treat latent TB infection (LTBI) include: people living with humanimmunodeficiency virus (PLHIV), household contacts of TB patients including children,and those with clinical conditions including silicosis, dialysis, transplantation etc. andother country-specific groups. We aimed to estimate the potential impact of fullimplementation of these guidelines in the WHO South-East Asian (SEA) Region, whichbears the largest burden of TB and LTBI amongst the WHO Regions.MethodsWe developed mathematical models of TB transmission dynamics, calibratedindividually to each of the 11 countries in the Region. We modelled preventive therapyin the absence of other TB interventions. As an alternative comparator, reflectingongoing developments in TB control in the region, we also simulated improvements inthe treatment cascade for active TB, including private sector engagement andintensified case-finding. Relative to both scenarios, for each country in the region weprojected TB cases and deaths averted between 2020 and 2030, by full uptake ofpreventive therapy, defined as comprehensive coverage amongst eligible populationsas per WHO guidelines, and assuming outcomes consistent with clinical trials. We alsoperformed sensitivity analysis to illustrate impact under less-than-optimal conditions.ResultsAt the regional level, full uptake of preventive therapy amongst identified risk groupswould reduce annual incidence rates in 2030 by 8.30% (95% CrI 6.48 – 10.83) relativeto 2015, in the absence of any additional interventions. If implemented against abackdrop of improved TB treatment cascades, preventive therapy would achieve anincremental 6.93 percentage points (95% CrI 5.81 – 8.51) of reduction in annualincidence rates, compared to 2015. At the regional level, the numbers of individu
Cilloni L, Fu H, Vesga JF, et al., 2020, The potential impact of the COVID-19 pandemic on the tuberculosis epidemic: a modelling analysis, Publisher: SSRN
Background: Routine services for tuberculosis (TB) are being disrupted by stringent lockdowns against the novel SARS-CoV-2 virus. We sought to estimate the potential long-term epidemiological impact of such disruptions on TB burden in high-burden countries, and how this negative impact could be mitigated. Methods: We adapted mathematical models of TB transmission in three high-burden countries (India, Kenya and Ukraine) to incorporate lockdown-associated disruptions in the TB care cascade. The anticipated level of disruption reflected consensus from a rapid expert consultation. We modelled the impact of these disruptions on TB incidence and mortality over the next five years, and also considered potential interventions to curtail this impact. Results: Even temporary disruptions can cause long-term increases in TB incidence and mortality. We estimated that a 3-month lockdown, followed by 10 months to restore normal TB services, would cause, over the next 5 years, an additional 1.65 million TB cases (Crl 1.49– 1.85) and 438,000 TB deaths (CrI 403 – 483 thousand) in India, 41,400 (28,900–62,200) TB cases and 14,800 deaths (10.5 – 19.2 thousand) in Kenya, and 7,960 (6,250 – 9,880) cases and 2,050 deaths (1,610 - 2,360) in Ukraine. However, any such negative impacts could be averted through supplementary “catch-up” TB case detection and treatment, once restrictions are eased. Interpretation: Lockdown-related disruptions can cause long-lasting increases in TB burden, but these negative effects can be mitigated with targeted interventions implemented rapidly once lockdowns are lifted.Funding Statement: USAID and Stop TB Partnership.Declaration of Interests: The authors declare no conflict of interest.
Wagner CE, Hooshyar M, Baker RE, et al., 2020, Climatological, virological and sociological drivers of current and projected dengue fever outbreak dynamics in Sri Lanka, JOURNAL OF THE ROYAL SOCIETY INTERFACE, Vol: 17, ISSN: 1742-5689
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- Citations: 5
Saad-Roy CM, Arinaminpathy N, Wingreen NS, et al., 2020, Implications of localized charge for human influenza A H1N1 hemagglutinin evolution: Insights from deep mutational scans, PLOS COMPUTATIONAL BIOLOGY, Vol: 16, ISSN: 1553-734X
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- Citations: 2
Lewnard JA, Lo NC, Arinaminpathy N, et al., 2020, Childhood vaccines and antibiotic use in low- and middle-income countries, NATURE, Vol: 581, Pages: 94-+, ISSN: 0028-0836
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- Citations: 59
Arinaminpathy N, Chin DP, Sachdeva KS, et al., 2020, Modelling the potential impact of adherence technologies on tuberculosis in India, INTERNATIONAL JOURNAL OF TUBERCULOSIS AND LUNG DISEASE, Vol: 24, Pages: 526-533, ISSN: 1027-3719
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- Citations: 8
Deo S, Singh S, Jha N, et al., 2020, Predicting the impact of patient and private provider behavior on diagnostic delay for pulmonary tuberculosis patients in India: A simulation modeling study, PLOS MEDICINE, Vol: 17, ISSN: 1549-1277
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- Citations: 4
Arinaminpathy N, Gomez GB, Sachdeva KS, et al., 2020, The potential deployment of a pan-tuberculosis drug regimen in India: A modelling analysis, PLOS ONE, Vol: 15, ISSN: 1932-6203
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- Citations: 3
Mandal S, Bhatnagar T, Arinaminpathy N, et al., 2020, Prudent public health intervention strategies to control the coronavirus disease 2019 transmission in India: A mathematical model-based approach, INDIAN JOURNAL OF MEDICAL RESEARCH, Vol: 151, Pages: 190-199, ISSN: 0971-5916
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- Citations: 131
Arinaminpathy N, Riley S, Barclay W, et al., 2020, Population implications of the deployment of novel universal vaccines against epidemic and pandemic influenza, Journal of the Royal Society Interface, ISSN: 1742-5662
Fu H, Lin H-H, Hallett TB, et al., 2020, Explaining age disparities in tuberculosis burden in Taiwan: a modelling study, BMC Infectious Diseases, Vol: 20, ISSN: 1471-2334
BackgroundTuberculosis (TB) burden shows wide disparities across ages in Taiwan. In 2016, the age-specific notification rate in those older than 65 years old was about 100 times as much as in those younger than 15 years old (185.0 vs 1.6 per 100,000 population). Similar patterns are observed in other intermediate TB burden settings. However, driving mechanisms for such age disparities are not clear and may have importance for TB control efforts.MethodsWe hypothesised three mechanisms for the age disparity in TB burden: (i) older age groups bear a higher risk of TB progression due to immune senescence, (ii) elderly cases acquired TB infection during a past period of high transmission, which has since rapidly declined and thus contributes to little recent infections, and (iii) assortative mixing by age allows elders to maintain a higher risk of TB infection, while limiting spillover transmission to younger age groups. We developed a series of dynamic compartmental models to incorporate these mechanisms, individually and in combination. The models were calibrated to the TB notification rates in Taiwan over 1997–2016 and evaluated by goodness-of-fit to the age disparities and the temporal trend in the TB burden, as well as the deviance information criterion (DIC). According to the model performance, we compared contributions of the hypothesised mechanisms.ResultsThe ‘full’ model including all the three hypothesised mechanisms best captured the age disparities and temporal trend of the TB notification rates. However, dropping individual mechanisms from the full model in turn, we found that excluding the mechanism of assortative mixing yielded the least change in goodness-of-fit. In terms of their influence on the TB dynamics, the major contribution of the ‘immune senescence’ and ‘assortative mixing’ mechanisms was to create disparate burden among age groups, while the ‘declining transmission’ mechanism s
Bhatia V, Srivastava R, Reddy KS, et al., 2020, Ending TB in Southeast Asia: current resources are not enough, BMJ GLOBAL HEALTH, Vol: 5, ISSN: 2059-7908
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- Citations: 8
Arinaminpathy N, Batra D, Maheshwari N, et al., 2019, Tuberculosis treatment in the private healthcare sector in India: An analysis of recent trends and volumes using drug sales data, BMC Infectious Diseases, Vol: 19, ISSN: 1471-2334
BackgroundThere is a pressing need for systematic approaches for monitoring how much TB treatment is ongoing in the private sector in India: both to cast light on the true scale of the problem, and to help monitor the progress of interventions currently being planned to address this problem.MethodsWe used commercially available data on the sales of rifampicin-containing drugs in the private sector, adjusted for data coverage and indication of use. We examined temporal, statewise trends in volumes (patient-months) of TB treatment from 2013 to 2016. We additionally analysed the proportion of drugs that were sold in combination packaging (designed to simplify TB treatment), or as loose pills.ResultsDrug sales suggest a steady trend of TB treatment dispensed by the private sector, from 18.4 million patient-months (95% CI 17.3–20.5) in 2013 to 16.8 patient-months (95% CI 15.5–19.0) in 2016. Overall, seven of 29 states in India accounted for more than 70% of national-level TB treatment volumes, including Uttar Pradesh, Maharashtra and Bihar. The overwhelming majority of TB treatment was dispensed not as loose pills, but in combination packaging with other TB drugs, accounting for over 96% of private sector TB treatment in 2017.ConclusionsOur findings suggest consistent levels of TB treatment in the private sector over the past 4 years, while highlighting specific states that should be prioritized for intervention. Drug sales data can be helpful for monitoring a system as large, disorganised and opaque as India’s private sector.
Nathavitharana RR, Yoon C, MacPherson P, et al., 2019, Guidance for Studies Evaluating the Accuracy of Tuberculosis Triage Tests, JOURNAL OF INFECTIOUS DISEASES, Vol: 220, Pages: S116-S125, ISSN: 0022-1899
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- Citations: 24
Vesga JF, Arinaminpathy N, 2019, Modelling tuberculosis control priorities: more of the same will not do, LANCET GLOBAL HEALTH, Vol: 7, Pages: E1320-E1320, ISSN: 2214-109X
Arinaminpathy N, Riley S, Barclay WS, et al., 2019, Considerations in the deployment of novel universal vaccines against epidemic and pandemic influenza
<jats:title>Abstract</jats:title><jats:p>There is increasing interest in the development of new, ‘universal’ influenza vaccines (UIV) that - unlike current vaccines - are effective against a broad range of seasonal influenza strains, as well as against novel pandemic viruses. Even where these vaccines do not block infection, they can moderate clinical severity, reducing morbidity and mortality while potentially also reducing opportunities for transmission. Previous modelling studies have illustrated the potential epidemiological benefits of UIVs, including their potential to mitigate pandemic burden. However, these new vaccines could shape population immunity in complex ways. Here, using mathematical models of influenza transmission, we illustrate two types of unintended consequences that could arise from their future deployment. First, by reducing the amount of infection-induced immunity in a population without fully replacing it, a seasonal UIV programme may permit larger pandemics than in the absence of vaccination. Second, the more successful a future UIV programme is in reducing transmission of seasonal influenza, the more vulnerable the population could become to the emergence of a vaccine-escape variant. These risks could be mitigated by optimal deployment of any future UIV vaccine: namely, the use of a combined vaccine formulation (incorporating conventional as well as multiple universal antigenic targets), and by achieving sufficient population coverage to compensate for reductions in infection-induced immunity. As early candidates of UIVs approach advanced clinical trials, there is a need to monitor their characteristics in such a way that is focused on their potential impact. This work offers a first step in this direction.</jats:p>
Vesga JF, Hallett TB, Reid MJA, et al., 2019, Assessing tuberculosis control priorities in high-burden settings: a modelling approach, The Lancet Global Health, Vol: 7, Pages: e585-e595, ISSN: 2214-109X
Background:In the context of WHO's End TB strategy, there is a need to focus future control efforts on those interventions and innovations that would be most effective in accelerating declines in tuberculosis burden. Using a modelling approach to link the tuberculosis care cascade to transmission, we aimed to identify which improvements in the cascade would yield the greatest effect on incidence and mortality.Methods:We engaged with national tuberculosis programmes in three country settings (India, Kenya, and Moldova) as illustrative examples of settings with a large private sector (India), a high HIV burden (Kenya), and a high burden of multidrug resistance (Moldova). We collated WHO country burden estimates, routine surveillance data, and tuberculosis prevalence surveys from 2011 (for India) and 2016 (for Kenya). Linking the tuberculosis care cascade to tuberculosis transmission using a mathematical model with Bayesian melding in each setting, we examined which cascade shortfalls would have the greatest effect on incidence and mortality, and how the cascade could be used to monitor future control efforts.Findings:Modelling suggests that combined measures to strengthen the care cascade could reduce cumulative tuberculosis incidence by 38% (95% Bayesian credible intervals 27–43) in India, 31% (25–41) in Kenya, and 27% (17–41) in Moldova between 2018 and 2035. For both incidence and mortality, modelling suggests that the most important cascade losses are the proportion of patients visiting the private health-care sector in India, missed diagnosis in health-care settings in Kenya, and drug sensitivity testing in Moldova. In all settings, the most influential delay is the interval before a patient's first presentation for care. In future interventions, the proportion of individuals with tuberculosis who are on high-quality treatment could offer a more robust monitoring tool than routine notifications of tuberculosis.Interpretation:Linked to transmissi
Steuten L, Garau M, Gomez G, et al., 2019, HEALTH-ECONOMIC MODELLING TO INFORM PRIVATE SECTOR INVESTMENT IN INFECTIOUS DISEASE TREATMENTS IN MIDDLE-INCOME COUNTRIES: THE CASE OF TUBERCULOSIS, Publisher: ELSEVIER SCIENCE INC, Pages: S209-S209, ISSN: 1098-3015
Arinaminpathy N, Mandal S, Bhatia V, et al., 2019, Strategies for ending tuberculosis in the South-East Asian Region: A modelling approach, INDIAN JOURNAL OF MEDICAL RESEARCH, Vol: 149, Pages: 517-527, ISSN: 0971-5916
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- Citations: 6
Reid MJA, Arinaminpathy N, Bloom A, et al., 2019, Building a tuberculosis-free world: The Lancet Commission on tuberculosis, The Lancet, Vol: 393, Pages: 1331-1384, ISSN: 0140-6736
Arinaminpathy N, Deo S, Singh S, et al., 2019, Modelling the impact of effective private provider engagement on tuberculosis control in urban India, SCIENTIFIC REPORTS, Vol: 9, ISSN: 2045-2322
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- Citations: 11
Subbaraman R, Nathavitharana RR, Mayer KH, et al., 2019, Constructing care cascades for active tuberculosis: A strategy for program monitoring and identifying gaps in quality of care, PLoS Medicine, Vol: 16, ISSN: 1549-1277
The cascade of care is a model for evaluating patient retention across sequential stages of care required to achieve a successful treatment outcome. This approach was first used to evaluate HIV care and has since been applied to other diseases. The tuberculosis (TB) community has only recently started using care cascade analyses to quantify gaps in quality of care. In this article, we describe methods for estimating gaps (patient losses) and steps (patients retained) in the care cascade for active TB disease. We highlight approaches for overcoming challenges in constructing the TB care cascade, which include difficulties in estimating the population-level burden of disease and the diagnostic gap due to the limited sensitivity of TB diagnostic tests. We also describe potential uses of this model for evaluating the impact of interventions to improve case finding, diagnosis, linkage to care, retention in care, and post-treatment monitoring of TB patients.
Davidovic S, Kothiyal A, Galesic M, et al., 2019, Liquidity Hoarding in Financial Networks: The Role of Structural Uncertainty, COMPLEXITY, ISSN: 1076-2787
Arinaminpathy N, Deo S, Singh S, et al., 2018, Delays, behaviour and transmission: modelling the impact of effective private provider engagement on tuberculosis control in urban India
<jats:title>Abstract</jats:title><jats:p>In India, the country with the world’s largest burden of tuberculosis (TB), most patients first seek care in the private healthcare sector, which is fragmented and unregulated. Ongoing initiatives are demonstrating effective approaches for engaging with this sector, and form a central part of India’s recent National Strategic Plan: here we aimed to address their potential impact on TB transmission in urban settings, when taken to scale. We developed a mathematical model of TB transmission dynamics, calibrated to urban populations in Mumbai and Patna, two major cities in India where pilot interventions are currently ongoing.</jats:p><jats:p>We found that, when taken to sufficient scale to capture 75% of patient-provider interactions, the intervention could reduce incidence by upto 21.3% (95% Bayesian credible interval (CrI) 13.0 – 32.5%) and 15.8% (95% CrI 7.8 – 28.2%) in Mumbai and Patna respectively, between 2018 and 2025. There is a stronger impact on TB mortality, with a reduction of up to 38.1% (95% CrI 20.0 – 55.1%) in the example of Mumbai. The incidence impact of this intervention alone may be limited by the amount of transmission that has already occurred by the time a patient first presents for care: model estimates suggest an initial patient delay of 4-5 months before first seeking care, followed by a diagnostic delay of 1-2 months before ultimately initiating TB treatment. Our results suggest that the transmission impact of such interventions could be maximised by additional measures to encourage early uptake of TB services.</jats:p>
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