MDR-TB treatment as prevention: The projected population-level impact of expanded treatment for multidrug-resistant tuberculosis.
MDR-TB treatment as prevention: The projected population-level impact of expanded treatment for multidrug-resistant tuberculosis.
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DOI：
10.1371/journal.pone.0172748
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发表时间：
2017
期刊：
影响因子：
3.7
通讯作者：
Dowdy DW
中科院分区：
文献类型：
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作者：
Kendall EA;Azman AS;Cobelens FG;Dowdy DW
2013年，约有48万人患上活动性耐多药结核病，而只有9.7万人开始接受耐多药结核病治疗。我们试图评估在多种诊断算法和治疗方案情景下，改善获得耐多药结核病诊断和治疗的机会对耐多药结核病发病率和死亡率十年预测的影响。我们以东亚/东南亚为例，构建了耐多药结核病流行的动态传播模型。使用近似贝叶斯计算，我们调查了一系列与当前通报数据和已知结核病流行病学相一致的潜在流行轨迹。尽管预计结核病发病率总体上会下降，但数据一致性模拟表明，在2013年继续治疗的情况下，2015年至2025年期间耐多药结核病发病率可能会上升，尽管存在相当大的不确定性(中位数增加17%，95%不确定范围[UR]-38%至+137%)。但是，如果到2017年，所有确诊的患有先前治疗过的结核病的活动性结核病患者都能进行药物敏感性测试，并且85%的耐多药结核病患者可以启动适当的耐多药治疗，那么2025年的耐多药结核病发病率可能比目前持续做法下的预测减少26%(95%-52%)。到2020年，将这种药物敏感性测试和适当的耐多药结核病治疗扩大到治疗初治和以前治疗的结核病病例，与继续目前的做法相比，可以将2025年的耐多药结核病发病率降低29%(95%-55%)。如果到2020年对所有已知的活动性肺结核病例进行耐多药结核病的诊断和治疗能够通过一种新的二线疗法实施，并且与目前的一线疗法具有类似的有效性和耐受性，那么到2025年，与目前的实践预测相比，耐多药结核病的发病率将减少54%(95%的URR为20-74%)。扩大耐多药结核病的诊断和治疗，即使使用目前次优的二线方案，也有望显著降低人口一级的耐多药结核病发病率。将MDR诊断努力集中在先前治疗的病例上是一种有效的第一步方法。
In 2013, approximately 480,000 people developed active multidrug-resistant tuberculosis (MDR-TB), while only 97,000 started MDR-TB treatment. We sought to estimate the impact of improving access to MDR-TB diagnosis and treatment, under multiple diagnostic algorithm and treatment regimen scenarios, on ten-year projections of MDR-TB incidence and mortality. We constructed a dynamic transmission model of an MDR-TB epidemic in an illustrative East/Southeast Asian setting. Using approximate Bayesian computation, we investigated a wide array of potential epidemic trajectories consistent with current notification data and known TB epidemiology. Despite an overall projected decline in TB incidence, data-consistent simulations suggested that MDR-TB incidence is likely to rise between 2015 and 2025 under continued 2013 treatment practices, although with considerable uncertainty (median 17% increase, 95% Uncertainty Range [UR] -38% to +137%). But if, by 2017, all identified active TB patients with previously-treated TB could be tested for drug susceptibility, and 85% of those with MDR-TB could initiate MDR-appropriate treatment, then MDR-TB incidence in 2025 could be reduced by 26% (95% UR 4–52%) relative to projections under continued current practice. Also expanding this drug-susceptibility testing and appropriate MDR-TB treatment to treatment-naïve as well as previously-treated TB cases, by 2020, could reduce MDR-TB incidence in 2025 by 29% (95% UR 6–55%) compared to continued current practice. If this diagnosis and treatment of all MDR-TB in known active TB cases by 2020 could be implemented via a novel second-line regimen with similar effectiveness and tolerability as current first-line therapy, a 54% (95% UR 20–74%) reduction in MDR-TB incidence compared to current-practice projections could be achieved by 2025. Expansion of diagnosis and treatment of MDR-TB, even using current sub-optimal second-line regimens, is expected to significantly decrease MDR-TB incidence at the population level. Focusing MDR diagnostic efforts on previously-treated cases is an efficient first-step approach.