Research on implementation of interventions in tuberculosis control in low- and middle-income countries: a systematic review.
Research on implementation of interventions in tuberculosis control in low- and middle-income countries: a systematic review.
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DOI：
10.1371/journal.pmed.1001358
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发表时间：
2012
期刊：
影响因子：
15.8
通讯作者：
Lienhardt C
中科院分区：
文献类型：
--
作者：
Cobelens F;van Kampen S;Ochodo E;Atun R;Lienhardt C
Cobelens及其同事系统地审查了关于世卫组织推荐的结核病干预措施实施情况和成本效益的研究。在过去十年中，世界卫生组织（世卫组织）推荐了几种结核病控制干预措施。这些措施包括针对艾滋病毒感染者和传染性结核病患者家庭接触者的异烟肼预防性治疗（IPT），用于纳入或排除涂片阴性肺结核的诊断算法，以及针对耐多药结核病的规划治疗。目前还没有系统收集的关于可公开获得的证据类型的数据，以指导在低收入和中等收入国家扩大这些干预措施。我们调查了政策制定者在国家一级扩大这些干预措施所需的有效性、交付和成本效益方面已发表证据的可得性。在PubMed、Web of Science、EMBASE和几个区域数据库中检索了1990年1月1日至2012年3月31日期间发表的研究，这些研究评估了低收入或中等收入国家任何这些干预措施的健康结果、提供方面或成本效益。对所选研究的目的、设计、地理和机构设置以及普遍性进行评估。报告健康结果的研究被归类为主要解决干预的功效或有效性。这些标准被用于绘制已发表研究的景观。我们确定了59项关于HIV感染的IPT研究，14项关于家庭接触者的IPT研究，44项关于常规诊断，19项关于排除诊断，72项关于二线治疗。比较有效性的研究相对较少（n = 9），并且仅限于南美洲和撒哈拉以南非洲地区对hiv感染的IPT进行研究，没有对家庭接触者进行IPT的研究，很少对二线治疗进行研究（n = 3）。诊断和筛选算法的评估更频繁（n = 19），但地理上聚集，主要是非比较设计。54项研究评估了提供这些干预措施的方式，9项研究探讨了其成本效益。在国家一级扩大世卫组织推荐的五种结核病干预措施设置方面，已公布的证据存在很大差距，这可能使许多国家无法在规划范围内实施这些干预措施。迫切需要在规划环境中进行严格的业务研究，以了解如何最佳地利用现有和新的结核病控制干预措施。由结核分枝杆菌引起的结核病是可以治愈和预防的，但根据世界卫生组织（世卫组织）的数据，2011年，有870万人出现结核病症状（通常是咳嗽和发烧），140万人（95%来自低收入和中等收入国家）死于结核病。结核病也是全世界艾滋病毒感染者死亡的主要原因，2010年，约有1000万儿童因父母死于结核病而成为孤儿。为了帮助减轻结核病造成的巨大全球负担，世卫组织领导的一项名为控制结核病伙伴关系的全球倡议实施了一项战略，到2015年将结核病死亡人数减少50%，甚至超过千年发展目标6（到2015年扭转结核病发病率上升趋势）的具体目标。在过去几年中，世卫组织建议各国实施若干干预措施，通过改善预防、诊断和治疗的措施，帮助控制结核病的传播。世卫组织目前建议的五项此类干预措施是：用异烟肼治疗，以预防艾滋病毒阳性者以及结核病感染者的家庭接触者患结核病；使用临床途径（算法）对涂片检测呈阴性的获得卫生保健的人进行结核病诊断（涂片检测是最常用的诊断检测，依赖于痰样本）（“规则算法”）；在艾滋病毒感染者中排除结核病的筛查算法（“排除算法”）；最后，在规划条件下为耐多药结核病（一种对最常用药物无反应的结核病）提供二线治疗。这些干预措施的有效性、成本和实施的实用性都是寻求按照世卫组织指南控制结核病的国家的重要信息，但人们对这些信息的可得性知之甚少。因此，在本研究中，研究人员系统地回顾了已发表的研究，以找到在日常实践中实施这些干预措施的有效性的证据，并获得有关实施干预措施的设置和条件的额外信息，这可能对其他国家有用。使用特定的搜索策略，研究人员全面搜索了几个关键的出版物数据库，包括区域数据库，以确定1990年1月至2012年3月期间发表的208篇（最初发现的11,489篇）合适的研究论文。对于纳入的研究，研究人员还注意到地理位置和环境以及研究的类型和设计。在纳入的208项研究中，59项侧重于HIV感染的异烟肼预防治疗，只有14项侧重于家庭接触者的异烟肼预防治疗。“常规”临床诊断研究44项，“排除”临床诊断研究19项，二线治疗研究72项。对每种干预措施的研究都有一些弱点，总的来说，研究人员发现，很少有现实世界的研究报告在项目环境中干预措施的有效性（而不是在研究环境中的最佳条件下）。很少有研究评估用于实施干预措施的方法或解决交付和操作问题（如坚持治疗），并且对推荐干预措施的经济评估有限。此外，研究人员发现，总的来说，南亚地区的代表性很低。这些发现表明，尽管迫切需要实施世卫组织推荐的五项结核病控制干预措施，但在这些国家和环境中，指导扩大这些干预措施的有效性、实施和成本效益方面的证据有限。本审查中发现的证据基础不足，凸显了采纳建议的决定与适应当地情况的建议实施之间的紧张关系，这可能是许多国家没有实施这些干预措施的重要原因。这项研究还表明，需要创造性思维来解决世卫组织关于新干预措施的建议与全球卫生政策之间的差距及其在国家结核病控制规划中的实际实施情况。未来的研究应更多地侧重于操作研究，其结果应公开，研究人员、捐助者和医学期刊也许可以重新考虑他们的优先事项，以帮助弥合本研究中确定的知识差距。请通过本摘要的在线版本http://dx.doi.org/10.1371/journal.pmed.1001358访问这些网站。世卫组织有关于结核病和结核病研究的广泛信息，包括更多关于控制结核病战略和控制结核病伙伴关系的信息。联合国网站有关于千年发展目标6的更多信息。全球抗击艾滋病、结核病和疟疾基金有关于结核病控制进展的具体信息
Cobelens and colleagues systematically reviewed research on implementation and cost-effectiveness of the WHO-recommended interventions for tuberculosis. Several interventions for tuberculosis (TB) control have been recommended by the World Health Organization (WHO) over the past decade. These include isoniazid preventive therapy (IPT) for HIV-infected individuals and household contacts of infectious TB patients, diagnostic algorithms for rule-in or rule-out of smear-negative pulmonary TB, and programmatic treatment for multidrug-resistant TB. There is no systematically collected data on the type of evidence that is publicly available to guide the scale-up of these interventions in low- and middle-income countries. We investigated the availability of published evidence on their effectiveness, delivery, and cost-effectiveness that policy makers need for scaling-up these interventions at country level. PubMed, Web of Science, EMBASE, and several regional databases were searched for studies published from 1 January 1990 through 31 March 2012 that assessed health outcomes, delivery aspects, or cost-effectiveness for any of these interventions in low- or middle-income countries. Selected studies were evaluated for their objective(s), design, geographical and institutional setting, and generalizability. Studies reporting health outcomes were categorized as primarily addressing efficacy or effectiveness of the intervention. These criteria were used to draw landscapes of published research. We identified 59 studies on IPT in HIV infection, 14 on IPT in household contacts, 44 on rule-in diagnosis, 19 on rule-out diagnosis, and 72 on second-line treatment. Comparative effectiveness studies were relatively few (n = 9) and limited to South America and sub-Saharan Africa for IPT in HIV-infection, absent for IPT in household contacts, and rare for second-line treatment (n = 3). Evaluations of diagnostic and screening algorithms were more frequent (n = 19) but geographically clustered and mainly of non-comparative design. Fifty-four studies evaluated ways of delivering these interventions, and nine addressed their cost-effectiveness. There are substantial gaps in published evidence for scale-up for five WHO-recommended TB interventions settings at country level, which for many countries possibly precludes program-wide implementation of these interventions. There is a strong need for rigorous operational research studies to be carried out in programmatic settings to inform on best use of existing and new interventions in TB control. Please see later in the article for the Editors' Summary Tuberculosis (TB), caused by Mycobacterium tuberculosis, is curable and preventable, but according to the World Health Organization (WHO), in 2011, 8.7 million people had symptoms of TB (usually a productive cough and fever) and 1.4 million people—95% from low- and middle-income countries—died from TB. TB is also the leading cause of death in people with HIV worldwide, and in 2010 about 10 million children were orphaned as a result of their parents dying from TB. To help reduce the considerable global burden of TB, a global initiative called the Stop TB Partnership, led by WHO, has implemented a strategy to reduce deaths from TB by 50% by 2015—even greater than the target of Millennium Development Goal 6 (to reverse the increase in TB incidence by 2015). Over the past few years, WHO has recommended that countries implement several interventions to help control the spread of tuberculosis through measures to improve prevention, diagnosis, and treatment. Five such interventions currently recommended by WHO are: treatment with isoniazid to prevent TB among people who are HIV positive, and also among household contacts of people infected with TB; the use of clinical pathways (algorithms) for diagnosing TB in people accessing health care who have a negative smear test—the most commonly used diagnostic test, which relies on sputum samples—(“rule-in algorithms”); screening algorithms for excluding TB in people who have HIV (“rule-out algorithms”); and finally, provision of second-line treatment for multidrug-resistant tuberculosis (a form of TB that does not respond to the most commonly used drugs) under programmatic conditions. The effectiveness of these interventions, their costs, and the practicalities of implementation are all important information for countries seeking to control TB following the WHO guidelines, but little is known about the availability of this information. Therefore, in this study the researchers systematically reviewed published studies to find evidence of the effectiveness of each of these interventions when implemented in routine practice, and also for additional information on the setting and conditions of implemented interventions, which might be useful to other countries. Using a specific search strategy, the researchers comprehensively searched through several key databases of publications, including regional databases, to identify 208 (out of 11,489 found initially) suitable research papers published between January 1990 and March 2012. For included studies, the researchers also noted the geographical location and setting and the type and design of study. Of the 208 included studies, 59 focused on isoniazid prevention therapy in HIV infection, and only 14 on isoniazid prevention therapy for household contacts. There were 44 studies on “rule-in” clinical diagnosis, 19 on “rule-out” clinical diagnosis, and 72 studies on second-line treatment for TB. Studies on each intervention had some weaknesses, and overall, researchers found that there were very few real-world studies reporting on the effectiveness of interventions in program settings (rather than under optimal conditions in research settings). Few studies evaluated the methods used to implement the intervention or addressed delivery and operational issues (such as adherence to treatment), and there were limited economic evaluations of the recommended interventions. Furthermore, the researchers found that in general, the South Asian region was poorly represented. These findings suggest that there is limited evidence on effectiveness, delivery, and cost-effectiveness to guide the scale-up of five WHO recommended interventions to control tuberculosis in the countries and settings, despite the urgent need for such interventions to be implemented. The poor evidence base identified in this review highlights the tension between the decision to adopt the recommendation and its implementation adapted to local circumstances, and may be an important reason as to why these interventions are not implemented in many countries. This study also suggests creative thinking is necessary to address the gaps between WHO recommendations and global health policy on new interventions and their real-world implementation in country-wide TB control programs. Future research should focus more on operational studies, the results of which should be made publicly available, and researchers, donors, and medical journals could perhaps re-consider their priorities to help bridge the knowledge gap identified in this study. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001358. WHO has a wide range of information about TB and research on TB, including more about the STOP TB strategy and the STOP TB Partnership The UN website has more information about MDG 6 The Global Fund to Fight AIDS, Tuberculosis and Malaria has specific information about progress on TB control
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影响因子：
56.3
作者：
Holtz, Timothy H.;Kabera, Gaetan;Rustomjee, Roxana
通讯作者：
Rustomjee, Roxana
影响因子：
2.7
作者：
Clark, Philip M.;Karagoz, Turan;Izzettin, Fikret Vehbi
通讯作者：
Izzettin, Fikret Vehbi
影响因子：
2.2
作者：
Hussey, Michael A.;Hughes, James P.
通讯作者：
Hughes, James P.
影响因子：
3.7
作者：
Dwan, Kerry;Altman, Douglas G.;Williamson, Paula R.
通讯作者：
Williamson, Paula R.
DOI：
10.1097/01.aids.0000391022.95412.a6
发表时间：
2010-11
期刊：
AIDS (London, England)
影响因子：
--
作者：
Durovni B;Cavalcante SC;Saraceni V;Vellozo V;Israel G;King BS;Cohn S;Efron A;Pacheco AG;Moulton LH;Chaisson RE;Golub JE
通讯作者：
Golub JE