Abstract
BackgroundHong Kong is an affluent subtropical city with a well-developed healthcare infrastructure but an intermediate TB burden. Declines in notification rates through the 1960s and 1970s have slowed since the 1980s to the current level of around 82 cases per 100 000 population. We studied the transmission dynamics of TB in Hong Kong to explore the factors underlying recent trends in incidence.Methodology/Principal FindingsWe fitted an age-structured compartmental model to TB notifications in Hong Kong between 1968 and 2008. We used the model to quantify the proportion of annual cases due to recent transmission versus endogenous reactivation of latent infection, and to project trends in incidence rates to 2018. The proportion of annual TB notifications attributed to endogenous reactivation increased from 46% to 70% between 1968 and 2008. Age-standardized notification rates were projected to decline to approximately 56 per 100 000 in 2018.Conclusions/SignificanceContinued intermediate incidence of TB in Hong Kong is driven primarily by endogenous reactivation of latent infections. Public health interventions which focus on reducing transmission may not lead to substantial reductions in disease burden associated with endogenous reactivation of latent infections in the short- to medium-term. While reductions in transmission with socio-economic development and public health interventions will lead to declines in TB incidence in these regions, a high prevalence of latent infections may hinder substantial declines in burden in the longer term. These findings may therefore have important implications for the burden of TB in developing regions with higher levels of transmission currently.
Highlights
While tuberculosis (TB) remains a leading cause of death in many developing countries [1], some developed countries with low incidence and prevalence have begun to investigate measures to eliminate TB [2,3,4]
While at diagnosis it may be difficult to determine whether an individual case has resulted from recent exogenous infection/reinfection or endogenous reactivation of a long-term latent infection, the distinction is important for TB control
We found that the dominant force responsible for the attenuating declines in local TB incidence is a substantial proportion of notifications arising from endogenous reactivation of latent infections, even with a low estimated progression rate to active TB disease [24,25]
Summary
While tuberculosis (TB) remains a leading cause of death in many developing countries [1], some developed countries with low incidence and prevalence have begun to investigate measures to eliminate TB [2,3,4]. Hong Kong is an affluent subtropical city with a well-developed healthcare infrastructure but a relatively high TB burden with around 82 cases per 100 000 population in 2008 [5]. We constructed a mathematical model to study the transmission dynamics of TB in Hong Kong between 1968 and 2008 and to explore the potential factors underlying the attenuating declines in incidence. By accounting in our model for the routes by which active TB disease developed, we differentiate notifications due to recent exogenous transmission versus endogenous reactivation, with implications for control measures and trends in disease burden in the short- to mediumterm future. Hong Kong is an affluent subtropical city with a well-developed healthcare infrastructure but an intermediate TB burden. We studied the transmission dynamics of TB in Hong Kong to explore the factors underlying recent trends in incidence
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