Abstract
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. 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. 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. Linked to transmission, the care cascade can be valuable, not only for improving patient outcomes but also in identifying and monitoring programmatic priorities to reduce tuberculosis incidence and mortality. US Agency for International Development, Stop TB Partnership, UK Medical Research Council, and Department for International Development.
Highlights
Despite being a disease of antiquity that is largely curable with affordable treatment, tuberculosis is currently the leading cause of death due to infectious disease.[1]
Recent years have seen renewed global ambitions for accelerating these declines in tuberculosis burden—eg, with the End TB strategy launched in 2015, calling for reductions of 90% in tuber culosis incidence and 95% in tuberculosis mortality by 2035.7
A 2016 modelling study showed that avail able interventions for tuberculosis control would not be sufficient to reach the 2025 milestones of the End TB strategy in either China or India, two of the countries with the highest burden.[8]
Summary
Despite being a disease of antiquity that is largely curable with affordable treatment, tuberculosis is currently the leading cause of death due to infectious disease.[1]. A 2016 modelling study showed that avail able interventions for tuberculosis control (enhancing access to high-quality tuberculosis services, active casefinding, and other approaches) would not be sufficient to reach the 2025 milestones of the End TB strategy in either China or India, two of the countries with the highest burden.[8] the question remains as to where control and research efforts should be focused in the future to meet the End TB goals by 2035. Strategic planning in the End TB era should address where deployment of current tools should be improved (eg, optimising treatment outcomes), as well as high lighting priority areas for future research, to identify
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