Latent Tuberculosis Infection Cascade Research Articles

Losses in the Care Cascade for Latent Tuberculosis Infection in the Tracing Contact Studies

Background: The control of latent tuberculosis infection (LTBI) encompasses multiple stages. The objective was to calculate the losses in the LTBI care cascade for pulmonary TB contacts in Catalonia (Spain). Methods: The LTBI care cascade was studied for pulmonary TB contacts reported from 1 January 2019 to 30 June 2021, considering three dependent variables: non-performance of testing; non-receipt of a treatment prescription; and non-adherence to treatment. Variables associated with the cascade were analysed using adjusted OR (aOR) and 95% confidence intervals (CI). Results: Identified from 847 cases of pulmonary TB were 7087 contacts, of whom 6537 (92.2%) could be screened for LTBI. LTBI prevalence was 25.5% (1670/6537); 69.4% of persons with LTBI (1159/1670) received a treatment prescription and 71.3% (827/1159) completed it. Treatment prescription was associated with age ≥65 years (aOR = 0.3; 95%CI: 0.2–0.6) and a daily exposure of ≥6 h to the TB index case (aOR = 3.6; 95%CI: 2.6–5.0). Treatment adherence was lower in men (aOR = 0.7; 95%CI: 0.5–1.0) and immigrants (aOR = 0.7; 95%CI: 0.5–0.9). Conclusions: Under 50% of contacts make it to the end of the LTBI cascade. Losses need to be reduced through education of both healthcare providers and patients and through treatment monitoring. The greater involvement of primary care physicians could help in monitoring and controling LTBI.

The latent tuberculosis infection cascade of care during the COVID-19 pandemic response in a Mid-Sized US city

BackgroundThe COVID-19 pandemic response may unintentionally disrupt multiple public health services, including tuberculosis control programs. We aimed to assess differences in the cascade of care for latent tuberculosis infection (LTBI) in a Midwest U.S. city during the COVID-19 pandemic response. MethodsWe conducted a retrospective cohort study of adult patients who presented for LTBI evaluation at the Hamilton County Public Health Tuberculosis Clinic in Ohio between 2019 and 2020. The pre-COVID-19 response period was defined as 01/2019 to 02/2020, and the COVID-19 pandemic response period (first wave) was defined as 04/2020 to 12/2020. We reviewed electronic medical records to extract sociodemographic information, medical history, follow-up and treatment data to define steps within the LTBI cascade of care. Logistic regressions were used to assess factors associated with LTBI treatment acceptance and completion, adjusted by potential confounders and COVID-19 period. ResultsData from 312 patients were included. There was a significant decrease in the number of monthly LTBI referrals (median, 18 vs. 8, p = 0.02) and LTBI evaluations (median, 17.5 vs. 7, p < 0.01) during the first wave of COVID-19. The proportion for whom immigration was listed as the indication for LTBI testing also declined (30% vs. 9%; p < 0.01) during COVID-19. More LTBI diagnoses were based on interferon-gamma release assay (IGRA; 30% vs. 49%; p < 0.01) during the COVID-19 response period. The proportion of people in the clinic for whom treatment for LTBI was recommended was similar before and during COVID-19 (76% vs. 81%, p = 0.41), as was LTBI treatment acceptance rates (56% vs. 64%, p = 0.28), and completion rates (65% vs. 63%, p = 0.85). In multivariate analysis, LTBI treatment acceptance was associated with Hispanic ethnicity, younger age, male sex, IGRA being used for diagnosis, and non-healthcare occupation, independent of COVID-19 period. LTBI treatment completion was associated with taking a rifamycin-containing regimen, independent of COVID-19 period. ConclusionWe observed a significant decline in the number of monthly LTBI referrals and evaluations during the first wave of COVID-19, revealing an unintended negative impact of the COVID-19 response in our region. However, LTBI treatment acceptance and completion rates were not affected during COVID-19.

Contextualizing and optimizing novel strategies to improve the latent TB continuum of care: Insights from people living with HIV and health care providers in Brazil.

Tuberculosis (TB) causes 1 in 3 deaths among people living with HIV (PLHIV). Diagnosing and treating latent tuberculosis infection (LTBI) is critical to reducing TB incidence and mortality. Blood-based screening tests (e.g., QuantiFERON-TB Gold Plus (QFT+)) and shorter-course TB preventive therapy (TPT) regimens such as 3HP (3 months weekly isoniazid-rifapentine) hold significant promise to improve TB outcomes. We qualitatively explored barriers and solutions to optimizing QFT+ and 3HP among PLHIV in three cities in Brazil. We conducted 110 in-depth interviews with PLHIV, health care providers (HCP) and key informants (KI). Content analysis was conducted including the use of case summaries and comparison of themes across populations and contexts. LTBI screening and treatment practices were dependent on HCP's perceptions of whether they were critical to improving TB outcomes. Many HCP lacked a strong understanding of LTBI and perceived the current TPT regimen as complicated. HCP reported that LTBI screening and treatment were constrained by clinic staffing challenges. While PLHIV generally expressed willingness to consider any test or treatment that doctors recommended, they indicated HCP rarely discussed LTBI and TPT. TB testing and treatment requests were constrained by structural factors including financial and food insecurity, difficulties leaving work for appointments, stigma and family responsibilities. QFT+ and 3HP were viewed by all participants as tools that could significantly improve the LTBI cascade by avoiding complexities of TB skin tests and longer LTBI treatment courses. QFT+ and 3HP were perceived to have challenges, including the potential to increase workload on over-burdened health systems if not implemented alongside improved supply chains, staffing, and training, and follow-up initiatives. Multi-level interventions that increase understanding of the importance of LTBI and TPT among HCP, improve patient-provider communication, and streamline clinic-level operations related to QFT+ and 3HP are needed to optimize their impact among PLHIV and reduce TB mortality.

1441. LTBI screening cascade for non-US-born persons in a large health system assessed using EMR data

Abstract Background The majority of tuberculosis (TB) diagnosed in the US is reactivation TB in non-US-born (nUSb) persons. Guidelines recommend screening persons born in high TB burden countries for latent TB infection (LTBI) and treating if positive. We evaluated the LTBI cascade in primary care among nUSb persons in a large academic medical system in Washington State. Methods We used electronic medical record (EMR) data to evaluate the LTBI screening cascade. nUSb individuals were identified using the primary language recorded in the EMR. Place of birth is not routinely collected in the EMR. All persons with a non-English primary language who entered care and attended one or more primary care visits in UW clinics between April 2016- April2021 were identified and considered eligible for LTBI screening. Persons with a documented IGRA or tuberculin skin test were considered screened for LTBI. Prescription records were reviewed to determine LTBI treatment. Results 5148 persons with non-English primary language attended primary care visits 2016-2021 and considered eligible for LTBI screening. Eligible persons were 58.5% female, median age 41 (IQR 30-58). Primary WHO regions of origin were Asia (37%), the Americas (36%), and Africa (19%), with a minority from North Africa, Middle East, and Europe. 1012 (20%) had a documented history of LTBI testing (Quantiferon-GOLD (N=949) or tuberculin skin testing (N=63)). Among 296 (29%) persons with a positive test for LTBI, 140 (47%) were treated for LTBI. The highest proportion of persons tested for LTBI were patients attending the HIV clinic (120, 66%) and the International/Refugee clinic (227, 81%). The majority of eligible patients were seen outside these clinics (N=4687) in whom the percent of persons tested ranged from 3-18% (14% overall). LTBI cascade among non-US-born primary care patients IGRA: interferon-gamma release assay; TST: tuberculin skin test. Conclusion Although this subset underestimates the number of non-US-born individuals (since many non-US-born individuals use English as their primary language) eligible for screening, it nonetheless highlights the significant gap between actual and guideline-recommended screening in primary care, as well as further drop-off on the cascade from positive LTBI test to LTBI treatment. EMR platforms could be leveraged to prompt LTBI screening and treatment initiations in primary care to help achieve TB elimination goals in the US. Disclosures Adrienne E. Shapiro, MD, PhD, Vir Biotechnology: Support as a trial site paid to my institution and non-financial support for medical writing GlaxoSmithKline third party funding to Vir support H. Nina Kim, MD, MSc, Gilead Sciences: Grant/Research Support.

Impact and benefit-cost ratio of a program for the management of latent tuberculosis infection among refugees in a region of Canada.

The identification and treatment of latent tuberculosis infection (LTBI) among immigrants from high-incidence regions who move to low-incidence countries is generally considered an ineffective strategy because only ≈14% of them comply with the multiple steps of the 'cascade of care' and complete treatment. In the Estrie region of Canada, a refugee clinic was opened in 2009. One of its goals is LTBI management. Key components of this intervention included: close collaboration with community organizations, integration within a comprehensive package of medical care for the whole family, timely delivery following arrival, shorter treatment through preferential use of rifampin, and risk-based selection of patients to be treated. Between 2009-2020, 5131 refugees were evaluated. To determine the efficacy and benefit-cost ratio of this intervention, records of refugees seen in 2010-14 (n = 1906) and 2018-19 (n = 1638) were reviewed. Cases of tuberculosis (TB) among our foreign-born population occurring before (1997-2008) and after (2009-2020) setting up the clinic were identified. All costs associated with TB or LTBI were measured. Out of 441 patients offered LTBI treatment, 374 (85%) were compliant. Adding other losses, overall compliance was 69%. To prevent one case of TB, 95.1 individuals had to be screened and 11.9 treated, at a cost of $16,056. After discounting, each case of TB averted represented $32,631, for a benefit-cost ratio of 2.03. Among nationals of the 20 countries where refugees came from, incidence of TB decreased from 68.2 (1997-2008) to 26.3 per 100,000 person-years (2009-2020). Incidence among foreign-born persons from all other countries not targeted by the intervention did not change. Among refugees settling in our region, 69% completed the LTBI cascade of care, leading to a 61% reduction in TB incidence. This intervention was cost-beneficial. Current defeatism towards LTBI management among immigrants and refugees is misguided. Compliance can be enhanced through simple measures.

Latent Tuberculosis Infection Cascade of Care among Asylum Seekers in Verona, Italy.

Our study aimed to assess latent tuberculosis infection (LTBI) prevalence, screening uptake, adherence to preventive treatment, and their predictors in a large cohort of asylum seekers. We retrospectively analysed data of migrants screened in 2015-2017 at the Migrant's Service in Verona, Italy. Sequential interferon-gamma-release-assay (IGRA) was performed to confirm only tuberculin-skin-test (TST) results ranking from 5 to 14 mm. Among 2,486 asylum seekers, screening adherence was 89.74% and LTBI prevalence was 28.8% (CI95% 27.0;30.5). Predictors of LTBI diagnosis were: male gender (OR 1.62), age 24 years or older (OR 1.47) and African origin (OR 1.78). Therapy completion rate was 69.6% and resulted associated with African origin (OR 1.75) and being older than 24 years (OR 2.89). Sequential IGRA testing, given its expensiveness, could be used to confirm only intermediate TST results, thus enabling further LTBI cases to be detected and avoiding unnecessary preventive treatments.

1407. The Latent Tuberculosis Infection Cascade of Care during the COVID-19 Pandemic Response in a Mid-Sized US City

BackgroundThe COVID-19 pandemic response may unintendedly disrupt multiple public health services, including tuberculosis control programs. We aimed to assess the cascade of care of latent tuberculosis infection (LTBI) in an urban US city during the COVID-19 pandemic response.MethodsWe conducted a retrospective cohort study of adult patients who presented for LTBI evaluation at the Hamilton County Public Health Tuberculosis Clinic in Ohio between 2019 and 2020. We defined 01/2019 to 02/2020 as the pre-COVID-19 response period, and 04/2020 to 12/2020 as the COVID-19 pandemic response period. We reviewed electronic medical records and extracted sociodemographic information, medical history, and follow-up and treatment data to define steps within the LTBI cascade of care. Logistic regressions were used to assess factors associated with LTBI treatment acceptance and completion, adjusted by potential confounders and COVID-19 period.ResultsData from 312 patients were included. There was a significant decrease in the number of monthly LTBI referrals (median, 18 vs. 8, p=0.02) and LTBI evaluations (median, 17.5 vs. 7, p< 0.01) during COVID-19. There was a decrease in the proportion of immigrants as indication for LTBI testing (30% vs. 9%; p< 0.01), and an increase in LTBI diagnoses based on interferon-gamma release assay (IGRA; 30% vs. 49%; p< 0.01) during COVID-19. The proportion of people who were recommended LTBI treatment was similar before and during COVID-19 (76% vs. 81%, p=0.41), as well as the LTBI treatment acceptance rates (56% vs. 64%, p=0.28), and LTBI treatment completion rates (65% vs. 63%, p=0.85). In multivariate analysis, LTBI treatment acceptance was associated with Hispanic ethnicity, younger age, male sex, IGRA use, no comorbidities, and non-healthcare occupation, independent of COVID-19 period. LTBI treatment completion was associated with taking a rifamycin-containing regimen, independent of COVID-19 period.ConclusionWe observed a significant decline in the number of monthly LTBI referrals and evaluations during COVID-19. Our findings indicate an unintended negative impact of the COVID-19 response in LTBI screening efforts in our region. LTBI treatment acceptance and completion rates were not affected during COVID-19.Disclosures All Authors: No reported disclosures

Fewer losses in the cascade of care for latent tuberculosis with solo interferon-gamma release assay screening compared to sequential screening

BackgroundRefugees are at increased risk of developing tuberculosis (TB) soon after resettlement. Targeting high-risk populations for latent tuberculosis infection (LTBI) screening and treatment is an important measure towards eliminating TB in low incidence countries, however, there are low rates of screening and treatment completion in the LTBI cascade of care. The authors hypothesized that an interferon-gamma release assay (IGRA) screening strategy would lead to a higher proportion of refugees completing LTBI screening and treatment, compared to sequential screening with tuberculin skin test (TST) and confirmatory IGRA.MethodsThis retrospective cohort study included eligible refugees screened with a sequential strategy versus a solo-IGRA strategy at different time periods from a centralized refugee clinic. The primary outcome was the proportion completing LTBI screening in each cohort.ResultsA total of 471 subjects were included (240 in sequential screening, 231 in solo-IGRA screening). 54% of refugees completed LTBI screening with sequential testing, compared to 85% of those screened with a solo-IGRA. Time to completing screening was also shorter in the solo-QFT group (difference 16.5 days, p < 0.01, 95% confidence interval 9.3, 23.7). There was a higher incidence of LTBI diagnosis in the solo-IGRA group (41 versus 20, p = 0.002). Screening completion was predicted by solo-IGRA screening (aOR 3.74, 95% confidence interval 2.30, 6.09; p < 0.001) and if refugees were privately-sponsored (aOR 2.81, 95% confidence interval 1.53, 5.15; p = 0.001). Treatment completion rates did not differ between groups.ConclusionThis study has identified fewer dropouts in the LTBI cascade of care if a solo-IGRA strategy is used for screening. An IGRA should be strongly considered as the screening method for refugees arriving in low-incidence settings if resources are available.

Determinants of losses in the latent tuberculosis infection cascade of care in Brazil

IntroductionFactors associated with losses in the latent tuberculosis infection (LTBI) cascade of care in contacts of patients with tuberculosis (TB) were investigated in a multicentre prospective cohort from highly endemic...

Effects of programmatic interventions to improve the management of latent tuberculosis: a follow up study up to five months after implementation

BackgroundLess than 19% of those needing tuberculosis (TB) preventive treatment complete it, due to losses in several steps of the cascade of care for latent TB infection. A cluster randomized trial of a programmatic public health intervention to improve management of latent TB infection in household contacts was conducted in Rio de Janeiro. Interventions included contact registry, initial and in-service training, and a TB booklet. We conducted a follow-up study starting one month after the conclusion of this trial, to measure the effect of interventions implemented, and to identify remaining barriers and facilitators to latent TB infection treatment, from different perspectives.MethodsIn two health clinics in Rio de Janeiro that received the interventions in the trial, data for the latent TB infection cascade of care for household contacts was collected over a five-month period. The number of household contacts initiating treatment per 100 index-TB patients was compared with the cascade of care data obtained before and during the intervention trial. Semi-structured open-ended questionnaires were administered to healthcare workers, household contacts and index-TB patients regarding knowledge and perceptions about TB and study interventions.ResultsIn this follow-up study, 184 household contacts per 100 index-TB patients were identified. When compared to the intervention period, there were 65 fewer household contacts per 100 index-TB patients, (95% CI -115, − 15) but the number starting latent TB infection treatment was sustained (difference -2, 95% CI -8,5). A total of 31 index-TB patients, 22 household contacts and 19 health care workers were interviewed. Among index-TB patients, 61% said all their household contacts had been tested for latent TB infection. All health care workers said it was very important to test household contacts, and 95% mentioned that possessing correct knowledge on the benefits of latent TB infection treatment was the main facilitator to enable them to recommend this treatment.ConclusionIn this follow-up study, we observed a sustained effect of interventions to strengthen the latent TB infection cascade of care on increasing the number of household contacts starting latent TB infection treatment.

1651. Describing the Tuberculosis Infection Cascade of Care Based on Electronic Health Record Data

BackgroundAppropriate screening of individuals to detect latent tuberculosis infection (LTBI) is a critical step for achieving tuberculosis (TB) elimination in the US; >80% of TB cases are attributed to LTBI reactivation. TB infection testing and treatment must engage community health clinics where populations at risk seek care. However, there are significant data knowledge gaps in the current LTBI cascade of care (CoC) in this setting. We used an electronic health record (EHR) database from OCHIN, Inc., to characterize the LTBI CoC and identify potential future interventions.MethodsWe extracted a cohort of patients from 2012–2016 EHR data; we stratified by whether patients were at risk for TB based on meeting at least one of the following criteria: non-US born or non-English language preference, homelessness, encounter at correctional facility, history of close contact with a TB case, or being immunocompromised. Along each step of the LTBI CoC, we determined the proportions with a test for TB infection, with available test results, with a positive test, with an LTBI diagnosis, and with LTBI treatment prescribed. We used Χ 2 tests to compare the LTBI CoCs among patients at risk with those classified as not at risk.ResultsOf nearly 2.2 million patient records, 701,467 (32.0%) met criteria for being at risk for TB; 84,422 at risk (12.0%) were tested; 65,562 (77.7%) had available results, of whom 9,624 (14.7%) were positive. Among those with positive results, 6,958 (72.3%) had an LTBI diagnosis, of whom 1,732 (24.9%) were prescribed treatment. Among those classified as not at risk, fewer were tested (66,773 [4.5%], p< 0.001) and had positive results (2,500 [3.7%], p< 0.0001). Among those with positive results, 1,998 (80.0%) had an LTBI diagnosis, of whom 395 (19.8%) initiated treatment.ConclusionThis study highlights gaps in the LTBI CoC, and where interventions are most needed. The largest gaps were in testing patients at risk, as 88% were not tested, and treatment, as 75% diagnosed with LTBI were not treated. Just under half (44%) of all TB tests appeared to be performed in persons with little risk for TB; this is a substantial amount of testing given very few begin treatment. Resources could be redirected to increase screening and treatment among populations at risk.Disclosures All Authors: No reported disclosures

Solutions to improve the latent tuberculosis Cascade of Care in Ghana: a longitudinal impact assessment

BackgroundLoss of patients in the latent tuberculosis infection (LTBI) cascade of care is a major barrier to LTBI management. We evaluated the impact and acceptability of local solutions implemented to strengthen LTBI management of household contacts (HHCs) at an outpatient clinic in Ghana.MethodsLocal solutions to improve LTBI management were informed by a baseline evaluation of the LTBI cascade and questionnaires administered to index patients, HHCs, and health care workers at the study site in Offinso, Ghana. Solutions aimed to reduce patient costs and improve knowledge. We evaluated the impact and acceptability of the solutions. Specific objectives were to: 1) Compare the proportion of eligible HHCs completing each step in the LTBI cascade of care before and after solution implementation; 2) Compare knowledge, attitude, and practices (KAP) before and after solution implementation, based on responses of patients and health care workers (HCW) to structured questionnaires; 3) Evaluate patient and HCW acceptability of solutions using information obtained from these questionnaires.ResultsPre and Post-Solution LTBI Cascades included 58 and 125 HHCs, respectively. Before implementation, 39% of expected < 5-year-old HHCs and 66% of ≥5-year-old HHCs were identified. None completed any further cascade steps. Post implementation, the proportion of eligible HHCs who completed identification, assessment, evaluation, and treatment initiation increased for HHCs < 5 to 94, 100, 82, 100%, respectively, and for HHCs ≥5 to 96, 69, 67, 100%, respectively. Pre and Post-Solutions questionnaires were completed by 80 and 95 respondents, respectively. Study participants most frequently mentioned financial support and education as the solutions that supported LTBI management.ConclusionImplementation of locally selected solutions was associated with an increase in the proportion of HHCs completing all steps in the LTBI cascade. Tuberculosis programs should consider prioritizing financial support, such as payment for chest x-rays, to support LTBI cascade completion.

Resource implications of the latent tuberculosis cascade of care: a time and motion study in five countries

BackgroundThe End TB Strategy calls for global scale-up of preventive treatment for latent tuberculosis infection (LTBI), but little information is available about the associated human resource requirements. Our study aimed to quantify the healthcare worker (HCW) time needed to perform the tasks associated with each step along the LTBI cascade of care for household contacts of TB patients.MethodsWe conducted a time and motion (TAM) study between January 2018 and March 2019, in which consenting HCWs were observed throughout a typical workday. The precise time spent was recorded in pre-specified categories of work activities for each step along the cascade. A linear mixed model was fit to estimate the time at each step.ResultsA total of 173 HCWs in Benin, Canada, Ghana, Indonesia, and Vietnam participated. The greatest amount of time was spent for the medical evaluation (median: 11 min; IQR: 6–16), while the least time was spent on reading a tuberculin skin test (TST) (median: 4 min; IQR: 2–9). The greatest variability was seen in the time spent for each medical evaluation, while TST placement and reading showed the least variability. The total time required to complete all steps along the LTBI cascade, from identification of household contacts (HHC) through to treatment initiation ranged from 1.8 h per index TB patient in Vietnam to 5.2 h in Ghana.ConclusionsOur findings suggest that the time requirements are very modest to perform each step in the latent TB cascade of care, but to achieve full identification and management of all household contacts will require additional human resources in many settings.

Determinants of losses in the latent tuberculosis cascade of care in Brazil: A retrospective cohort study

BackgroundThe present study evaluated factors associated with losses in the latent tuberculosis infection (LTBI) cascade of care in contacts of tuberculosis (TB) patients, in a referral center from a highly endemic region in Brazil. MethodsContacts of 1672 TB patients were retrospectively studied between 2009 and 2014. Data on TB screening by clinical investigation, radiographic examination and tuberculin skin test (TST) were extracted from medical records. Losses in the cascade of care and TB incidence within 2-year follow-up were calculated. ResultsFrom a total of 1180 TB contacts initially identified, only 495 were examined (58% loss), and 20 were diagnosed with active TB at this stage. Furthermore, 435 persons returned for TST result interpretation and 351 (∼81%) were TST positive. Among those with positive TST, 249 (73%) were treated with isoniazid for 6 months whereas 51 abandoned therapy early. Three individuals who did not receive LTBI treatment, one with incomplete treatment and another who completed treatment developed active TB. A logistic regression analysis revealed that increases in age were associated with losses in the LTBI cascade independent of other clinical and epidemiological characteristics. ConclusionsMajor losses occur at initial stages and older patients are at higher risk of not completing the LTBI cascade of care.

Identifying gaps in the quality of latent tuberculosis infection care

Latent tuberculosis infection (LTBI) occurs after transmission and acquisition of infection, when the tuberculosis (TB) bacteria lie dormant in a person. Nearly one-quarter of the world's population is estimated to have LTBI, yet few studies have been published assessing the quality of LTBI services globally. This paper reviews issues to providing patient-centered LTBI services and offers an example framework to formally assess the quality of LTBI patient care. By applying the LTBI cascade of care model, TB programmes can evaluate the gaps and barriers to high-quality care and develop locally-driven solutions to improve LTBI services. Quality care for LTBI must address some of the key challenges to services including: (1) low prioritization of LTBI; (2) gaps in healthcare provider knowledge about testing and treatment; and (3) patient concerns about side effects of preventive treatment regimens. TB programmes need to ensure that these issues are addressed in a patient-centered manner, with clear communication and ongoing evaluation of the quality of LTBI services. Quality LTBI care must be a central focus, particularly identifying and engaging more household contacts in preventive treatment, in order to halt the progression to active disease thereby stopping TB transmission globally.

Interventions to reduce losses in the cascade of care for latent tuberculosis: a systematic review and meta-analysis.

BACKGROUND: Losses can occur throughout the latent tuberculosis infection (LTBI) cascade of care. This can result in suboptimal rates of effective treatment for LTBI. We conducted a systematic review and meta-analysis to estimate the effect of different interventions to reduce losses in the LTBI cascade before treatment completion.METHODS: We searched several databases for articles reporting outcomes for interventions designed to strengthen the LTBI cascade. We included papers published in English from January 1990 until February 2018. Where possible, estimates were pooled using random-effects meta-analysis.RESULTS: We identified 30 studies that evaluated 32 different interventions aimed at reducing losses in the LTBI cascade. In pooled analysis, interventions that improved completion of cascade steps included patient incentives (respectively 42 [95% CI 34-51] and 48 [95% CI 15-81] additional patients completing initial assessment and medical evaluation per 100 starting); health care worker education (28 [95% CI 4-52] additional patients initiating initial assessment per 100 identified; home visits (additional 13 [95% CI 4-21] patients completing initial assessment per 100 starting); digital solutions (additional 11 [95% CI 4-21] patients initiating initial assessment per 100 identified); and patient reminders (additional 7 [95% CI 0.3-13] patients completing initial assessment per 100 starting). Several other interventions reduced losses at specific cascade steps, but evidence for these interventions came from single studies and could not be pooled.CONCLUSIONS: Although there is limited evidence that any single intervention significantly improves the LTBI cascade, many studies provide information about effective ways to strengthen it.

Screening for active and latent tuberculosis among asylum seekers in Italy: A retrospective cohort analysis.

The World Health Organization conditionally recommends systematic screening of tuberculosis (TB) and Latent Tuberculosis Infection (LTBI) among asylum seekers (AS) from high-burden countries, but the effectiveness of different screening approaches is controversial. We report the results of a retrospective cohort analysis of TB and LTBI screening among consecutive AS in Brescia, Italy during 2015-2016. TB screening was based on symptoms, LTBI screening on the tuberculin skin test (TST). Logistic regression analysis was performed to identify factors associated with screening uptake. Of 2904 registered AS 2567 (88.4%) were evaluated for TB, 62 (2.4%) had symptoms and active TB yield was 155/100,000. Prevalence and incidence TB rates were 545/100,000 persons and 220/100,000 person-years. Questionnaire screening identified 28.6% (4/14) prevalent cases. Of 2303 (89.7%) AS with TST result, the positivity rate was 36.6% (843/2303). Of the 843 candidates for LTBI treatment 413 (49.0%) completed the screening. LTBI treatment was prescribed to 190 (47.9%) of 397 eligible individuals, 10.8% (91) completed treatment. TB prevalence and incidence rates were high in this AS population, but symptom-based screening performed poorly. LTBI cascade losses were significant and mainly attributable to the defragmentation of the health care system.