Prevention and Public Health Interventions

SAIA-TB: Using the Systems Analysis and Improvement Approach (SAIA) to prevent TB in rural South Africa

  • Investigator: Meredith Brooks
  • Funding Source: National Institute of Nursing Research

South Africa estimates 80% of their population has TB infection, and 14% of the population lives with HIV, with an estimated 5-15% of South Africans at high risk of developing TB disease from recent infection or immunocompromised status. Therefore, utilization of routinely collected data to optimize the comprehensive TB care cascade – screening, evaluation, diagnosing, linkage to care, treatment, and TB-free survival – is important to assess at the clinic level to improve clinic flow and patient outcomes. The proposed study will leverage an evidence-based implementation science strategy, the Systems Analysis and Improvement Approach (SAIA), and recent TB cascade analyses piloted in the proposed site, to adapt and evaluate the effectiveness of SAIA-TB using a stepped wedge crossover cluster randomized trial across 12 clinics in rural Eastern Cape, South Africa.

Family-Centered Care to Improve Loss to Follow-Up in Children with TB who are Exposed at Home

  • Investigator: Meredith Brooks
  • Funding Source: National Institute of Allergy and Infectious Disease

When children live in a household with someone with tuberculosis (TB) disease, young children in particular are at high risk of TB infection and often progress rapidly to active TB disease if they are not promptly initiated on appropriate TB preventive treatment. Using data from a prospective household contact cohort study in Lima, Peru, we aim to explore individual-level characteristics for children and their adult household member with TB disease to identify risk factors for children initiated on drug-susceptible TB treatment being loss to follow-up. This information may identify family-related characteristics associated with loss to follow-up that can be mitigated through a family-centered care management approach.

Adaptive Design to Aid in the Planning of community-based Tuberculosis screening services (ADAPT-TB)

  • Investigator: Meredith Brooks
  • Funding Source: Carlin Foundation Award for Public Health Innovation

Community-based screening via mobile units can close gaps in missed diagnoses by bringing screening services into communities, making screening more convenient for individuals with limited access to appropriate services. Questions remain, however, about how to efficiently operate these mobile units. Leveraging longstanding relationships in Lima, Peru, including existing collaborations involving mobile screening units, I will collect data from health facilities and mobile screening units to [Aim 1] establish spatial and temporal trends of the local tuberculosis burden and [Aim 2] build neighborhood-level models reflecting local risk of tuberculosis. I will then [Aim 3] develop a baseline decision model via a restless multi-armed bandit framework to make data-driven decisions about where, when, and how long to place the mobile units in the community. The overall goal is to optimize the real-time movement of these units throughout a community to increase the detection of individuals with TB and allocate resources more efficiently.

Intensified Patient-Finding Intervention to Increase the Detection of Children with Tuberculosis

  • Investigator: Meredith Brooks
  • Funding Source: William F. Milton Fund at Harvard University; National Institute of Allergy and Infectious Disease

Children with tuberculosis are vastly under detected and underdiagnosed. An intensified patient-finding intervention using systematic verbal screening at health facilities was undertaken in two locations–Pakistan and Bangladesh–to increase the detection of children who may be at high risk for tuberculosis disease. These projects aim to identify gaps along the pediatric tuberculosis care cascade; understand age-specific clinical presentation and risk factors for tuberculosis disease, extrapulmonary presentations, and poor treatment outcomes; refine clinical algorithms to expedite decision-making for treatment initiation; and explore other topics related to pediatric tuberculosis epidemiology.

    New Approaches to Optimizing the Application and Measuring the Impact of Community-Based Tuberculosis Interventions

    • Investigator: Helen Jenkins
    • Funding Source: National Institute on Minority Health and Health Disparities

      Optimal Targeting for Individual and Population-Level TB Prevention

      • Investigator: C. Robert Horsburgh
      • Funding Source: National Institute of Allergy and Infectious Diseases

      Within the same community, TB risks can differ by several orders of magnitude due to differences in infectious exposure and immune competence, and TB control depends heavily on targeting services to those most at risk. Priority groups described by the CDC and other agencies capture major TB risk factors, but these broad categories include many individuals with low TB risk, and exclude others who would benefit from screening. Our long-term objective is to provide individually- and locally-tailored evidence on TB risks and intervention effects, to optimize TB prevention services. In Aim 1, we will create granular estimates of TB risk for the US population, via a Bayesian evidence synthesis combining time series data on TB cases and population size, prevalence of latent infection (LTBI), and the fraction of cases due to recent infection. This analysis will allow us to produce individually-tailored risk predictions to better target preventive services, and provide patients with quantitative information on the risks they face. Aim 2 will create highly-disaggregated estimates of the costs, harms, and benefits of LTBI testing and treatment, using a Markov microsimulation model of LTBI screening and treatment to estimate long-term patient-level outcomes, including changes in TB risk, survival, costs, and adverse events. Based on these analyses we will develop a user-friendly web tool to provide patients and clinicians prompt, validated, and individually-tailored information on possible treatment outcomes. We will also conduct analyses and develop a companion tool that will report the impact and cost-effectiveness of LTBI screening for user-defined target. To increase the reach and impact of these tools we will adapt them for other countries with TB incidence below 20 per 100,000. In Aim 3, we will develop a transmission-dynamic simulation model to predict long-term outcomes for a broad set of TB control options (including but not limited to LTBI treatment) and risk factor trends. The model will be calibrated for multiple jurisdictions, and a web-based interface will allow users to specify scenarios and visualize outcomes.

      Optimizing Tuberculosis Elimination Initiatives for High-Risk Populations

      • Investigator: Meredith Brooks
      • Funding Source: Zero TB Initiative

      Certain populations are at increased risk of tuberculosis infection and progression to tuberculosis disease. In Mexicali, Mexico, we are assessing the impact of novel diagnostics for tuberculosis infection testing in three high-risk populations–people who use drugs, household contacts of people with tuberculosis, and people confined to a penitentiary setting–to inform tailored algorithms for tuberculosis testing and initiation of tuberculosis preventive treatment. We also assess gaps identified along the tuberculosis comprehensive care cascade to guide local tuberculosis prevention and management guidelines.

        Prevention Policy Modeling Lab

        • Investigator: C. Robert Horsburgh
        • Funding Source: Centers for Disease Control and Prevention

        Important epidemiologic and policy changes that are reshaping national and local health landscapes necessitate a renewed focus on disease prevention and health promotion, and on strategic decision-making to prioritize programs for maximum impact and efficiency. The Prevention Policy Modeling Lab models the health impact, costs and cost-effectiveness of infectious disease treatment and prevention programs in the United States. We work closely with collaborators in the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) at the Centers for Disease Control and Prevention to inform U.S. health policy and guide public health decision-making at national, state and local levels. The models we build incorporate evidence-based prevention strategies, emphasize cross-cutting initiatives and produce results that can be operationalized within healthcare and other sectors.

        URBAN ARCH (3/5) Uganda Cohort – TB Prevention Therapy for HIV-Infected Alcohol Drinkers in Uganda

        • Investigator: Karen Jacobson
        • Funding Source: National Institute on Alcohol Abuse and Alcoholism