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      Constructing care cascades for active tuberculosis: A strategy for program monitoring and identifying gaps in quality of care

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          Abstract

          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.

          Abstract

          In a Guidelines and Guidance article, Ramnath Subbaraman and colleagues advise on using care cascade analyses to assess programs for active tuberculosis treatment.

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          Most cited references61

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          Tuberculosis prevalence in China, 1990-2010; a longitudinal analysis of national survey data.

          China scaled up a tuberculosis control programme (based on the directly observed treatment, short-course [DOTS] strategy) to cover half the population during the 1990s, and to the entire population after 2000. We assessed the effect of the programme. In this longitudinal analysis, we compared data from three national tuberculosis prevalence surveys done in 1990, 2000, and 2010. The 2010 survey screened 252,940 eligible individuals aged 15 years and older at 176 investigation points, chosen by stratified random sampling from all 31 mainland provinces. All individuals had chest radiographs taken. Those with abnormal radiographs, persistent cough, or both, were classified as having suspected tuberculosis. Tuberculosis was diagnosed by chest radiograph, sputum-smear microscopy, and culture. Trained staff interviewed each patient with tuberculosis. The 1990 and 2000 surveys were reanalysed and compared with the 2010 survey. From 1990 to 2010, the prevalence of smear-positive tuberculosis decreased from 170 cases (95% CI 166-174) to 59 cases (49-72) per 100,000 population. During the 1990s, smear-positive prevalence fell only in the provinces with the DOTS programme; after 2000, prevalence decreased in all provinces. The percentage reduction in smear-positive prevalence was greater for the decade after 2000 than the decade before (57% vs 19%; p<0.0001). 70% of the total reduction in smear-positive prevalence (78 of 111 cases per 100,000 population) occurred after 2000. Of these cases, 68 (87%) were in known cases-ie, cases diagnosed with tuberculosis before the survey. Of the known cases, the proportion treated by the public health system (using the DOTS strategy) increased from 59 (15%) of 370 cases in 2000 to 79 (66%) of 123 cases in 2010, contributing to reduced proportions of treatment default (from 163 [43%] of 370 cases to 35 [22%] of 123 cases) and retreatment cases (from 312 [84%] of 374 cases to 48 [31%] of 137 cases; both p<0.0001). In 20 years, China more than halved its tuberculosis prevalence. Marked improvement in tuberculosis treatment, driven by a major shift in treatment from hospitals to the public health centres (that implemented the DOTS strategy) was largely responsible for this epidemiological effect. Chinese Ministry of Health. Copyright © 2014 Elsevier Ltd. All rights reserved.
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            The cascade of care in diagnosis and treatment of latent tuberculosis infection: a systematic review and meta-analysis.

            WHO estimates that a third of the world's population has latent tuberculosis infection and that less than 5% of those infected are diagnosed and treated to prevent tuberculosis. We aimed to systematically review studies that report the steps from initial tuberculosis screening through to treatment for latent tuberculosis infection, which we call the latent tuberculosis cascade of care. We specifically aimed to assess the number of people lost at each stage of the cascade.
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              Incipient and Subclinical Tuberculosis: a Clinical Review of Early Stages and Progression of Infection.

              SUMMARYTuberculosis (TB) is the leading infectious cause of mortality worldwide, due in part to a limited understanding of its clinical pathogenic spectrum of infection and disease. Historically, scientific research, diagnostic testing, and drug treatment have focused on addressing one of two disease states: latent TB infection or active TB disease. Recent research has clearly demonstrated that human TB infection, from latent infection to active disease, exists within a continuous spectrum of metabolic bacterial activity and antagonistic immunological responses. This revised understanding leads us to propose two additional clinical states: incipient and subclinical TB. The recognition of incipient and subclinical TB, which helps divide latent and active TB along the clinical disease spectrum, provides opportunities for the development of diagnostic and therapeutic interventions to prevent progression to active TB disease and transmission of TB bacilli. In this report, we review the current understanding of the pathogenesis, immunology, clinical epidemiology, diagnosis, treatment, and prevention of both incipient and subclinical TB, two emerging clinical states of an ancient bacterium.
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                Author and article information

                Journal
                PLoS Med
                PLoS Med
                plos
                plosmed
                PLoS Medicine
                Public Library of Science (San Francisco, CA USA )
                1549-1277
                1549-1676
                27 February 2019
                February 2019
                : 16
                : 2
                : e1002754
                Affiliations
                [1 ] Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
                [2 ] Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, United States of America
                [3 ] Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
                [4 ] The Fenway Institute, Boston, Massachusetts, United States of America
                [5 ] Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, Paris, France
                [6 ] Central Leprosy Teaching and Research Institute, Chengalpattu, India
                [7 ] MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
                [8 ] Department of Epidemiology, Biostatistics and Occupational Health and McGill International TB Centre, McGill University, Montreal, Canada
                Author notes

                I have read the journal's policy and the authors of this manuscript have the following competing interests: MP is a member of the Editorial Board of PLOS Medicine. All other authors declare that no competing interests exist.

                Author information
                http://orcid.org/0000-0002-2063-943X
                http://orcid.org/0000-0002-3544-5021
                http://orcid.org/0000-0001-7460-733X
                http://orcid.org/0000-0002-5420-2551
                http://orcid.org/0000-0002-0412-150X
                http://orcid.org/0000-0003-3667-4536
                Article
                PMEDICINE-D-18-02926
                10.1371/journal.pmed.1002754
                6392267
                30811385
                3be922e2-7aee-4ddc-8de1-2cb2795ad904
                © 2019 Subbaraman et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Page count
                Figures: 3, Tables: 3, Pages: 18
                Funding
                RS is supported by a Doris Duke Clinical Scientist Development Award and a grant from the Bill & Melinda Gates Foundation via the Arcady group (OPP1154665), and acknowledges prior support from a Harvard Center for AIDS Research Developmental Award (5P30AI060354-13), and a Harvard Catalyst KL2/CMERIT Award (KL2 TR001100). RRN is supported by a National Institutes of Health Career Development Award (NIAID K23 AI13264801A1) and an American Society of Tropical Medicine and Hygiene Burroughs Wellcome Fellowship, and acknowledges prior support from a Harvard Center for AIDS Research Scholar Award (NIAID 2P30AI060354-11). NA acknowledges joint Centre funding from the UK Medical Research Council and Department for International Development (MR/R015600/1). MP holds a Canada Research Chair award from the Canadian Institutes of Health Research. No specific funding was received for this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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