Tuberculosis Control in South African Gold Mines: Mathematical Modeling of a Trial of Community-Wide Isoniazid Preventive Therapy
Tuberculosis Control in South African Gold Mines: Mathematical Modeling of a Trial of Community-Wide Isoniazid Preventive Therapy
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DOI：
10.1093/aje/kwu320
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发表时间：
2015-04-15
影响因子：
5
通讯作者：
White, Richard G.
中科院分区：
文献类型：
--
作者：
Vynnycky, Emilia;Sumner, Tom;White, Richard G.
2006-2011年，在南非金矿工人中进行了一项为期9个月的筛查、积极疾病治疗和大规模异烟肼预防性治疗的大型集群随机试验，结果显示个人水平的结核病发病率降低，但没有可检测到的人群水平影响。我们对试验数据拟合了一个动态数学模型，并探讨了1）导致缺乏人群水平影响的因素，2）如果所有实施特征都增加到试验期间达到的最高水平，（“优化干预”）; 3）如何通过额外干预更好地控制结核病（改进诊断、减少治疗延误、持续向艾滋病毒抗体阳性者提供异烟肼预防性治疗或扩大抗逆转录病毒治疗的覆盖面）。我们发现以下内容：1）该模型表明，人类免疫缺陷病毒阳性人群中有一小部分潜伏感染被治愈，这可能是解释缺乏可检测的人群水平影响的关键因素。2)优化的实施仅将影响力提高了10%。3)单独和联合实施额外干预措施，10年后结核病发病率分别降低了30%和75%。控制结核病需要采取综合预防办法，包括加强卫生系统以尽量减少治疗延误，改进诊断，扩大抗逆转录病毒治疗的覆盖面，以及有效的预防性治疗方案。
A recent major cluster randomized trial of screening, active disease treatment, and mass isoniazid preventive therapy for 9 months during 2006-2011 among South African gold miners showed reduced individual-level tuberculosis incidence but no detectable population-level impact. We fitted a dynamic mathematical model to trial data and explored 1) factors contributing to the lack of population-level impact, 2) the best-achievable impact if all implementation characteristics were increased to the highest level achieved during the trial ("optimized intervention"), and 3) how tuberculosis might be better controlled with additional interventions (improving diagnostics, reducing treatment delay, providing isoniazid preventive therapy continuously to human immunodeficiency virus-positive people, or scaling up antiretroviral treatment coverage) individually and in combination. We found the following: 1) The model suggests that a small proportion of latent infections among human immunodeficiency virus-positive people were cured, which could have been a key factor explaining the lack of detectable population-level impact. 2) The optimized implementation increased impact by only 10%. 3) Implementing additional interventions individually and in combination led to up to 30% and 75% reductions, respectively, in tuberculosis incidence after 10 years. Tuberculosis control requires a combination prevention approach, including health systems strengthening to minimize treatment delay, improving diagnostics, increased antiretroviral treatment coverage, and effective preventive treatment regimens.