Tracking tuberculosis patients in Ukraine to understand pathways through care and the impact of geographic movements

项目摘要 2018年，结核病在全球造成145万人死亡。鉴于结核病发病率仅下降了 2%，实现世界卫生组织到2050年消除结核病的ENDTB目标将需要 我们结核病控制方法的创新。以前针对其他疾病的消除策略只取得了成功 一旦确定了疾病发病率的空间差异，并实施了与当地有关的干预措施。TB 消除策略需要纳入详细空间信息的纵向结核病队列。乌克兰是一个 由于其高利福平耐药（RR）结核病负担（全球第八高）， 欧洲艾滋病毒/结核病合并感染病例，集中收集人口、实验室、临床和空间 全国所有结核病诊断患者的数据（“eTB管理器”），以及结果对其他 前苏联（FSU）国家。我们将建立一个为期六年的国家结核病队列， 使用eTB Manager纵向和空间地包括结核病耐药性和艾滋病毒状况数据。我们 假设eTB Manager数据可用于确定地区结核病护理级联中的关键指标 水平，并评估人口流动与TB/RRTB护理级联缺口之间的关联， 负担在目标1a中，我们将编制2015-2020年乌克兰诊断的约180，000名结核病患者的六年队列。 在目标1b中，我们将评估结核病护理级联和按药物分层的治疗途径的关键指标 耐药性和艾滋病毒状况。在目标1c中，我们将按地区检查结核病护理级联， 护理级联指标的变化。在目标2中，我们将绘制患者运动图并了解 运动和关键护理级联指标与结核病结局之间的关系，按耐药性特征分层， 艾滋病毒感染状况。在目标2中，我们还将量化人口流动与TB/RRTB之间的关联 结核病的发病率和死亡率，从而制定有针对性的干预措施，降低结核病发病率和死亡率。这 这一贡献意义重大，因为它将建立一个全国性的结核病患者六年队列， 纵向和空间上，使当地的公共卫生专业人员能够在当地发展 采取适当的干预措施，以缩小结核病护理级联中的差距，并了解干预措施的影响， 新的结核病诊断方法。拟议的工作是创新的，因为它将提供第一批这种在一个 前苏联国家，这些数据的纵向和空间性质允许对结核病护理进行独特的评估 以及干预措施的影响。这将使决策者能够设计针对当地的干预措施， 结核病护理和流动人口中的具体差距，防止进一步传播并最终减少疾病 和结核病死亡率之间的关系。通过使用常规收集的数据，我们的模型增加了最小的财务成本， 适用于类似的环境，并具有严格收集的结核病数据。这项工作将导致一个R 01提案，以评估 可以缩小结核病护理级联差距、改善结果并减轻人口影响的干预措施 乌克兰结核病和RRTB传播的运动。

PROJECT SUMMARY Tuberculosis (TB) caused 1.45 million deaths globally in 2018. Given that TB incidence is decreasing by only 2% annually, achieving the World Health Organization’s ENDTB goal of TB elimination by 2050 will require innovations in our TB control approach. Previous elimination strategies for other diseases were only successful once spatial variation in disease incidence was identified and locally relevant interventions implemented. TB elimination strategies require longitudinal TB cohorts that incorporate detailed spatial information. Ukraine is an ideal setting for our proposal with its high rifampin resistant (RR) TB burden (eighth highest globally), one third of Europe’s HIV/TB co-infected cases, centralized collection of demographic, laboratory, clinical and spatial data on all patients diagnosed with TB nationally (“eTB Manager”), and generalizability of results to other Former Soviet Union (FSU) countries. We will develop a six-year national TB cohort to track patients longitudinally and spatially including TB drug resistance and HIV status data, using eTB Manager. We hypothesize that eTB Manager data can be used to identify key metrics in the TB care cascade, at the district level, and evaluate the association between population movement and TB/RRTB care cascade gaps and burden. In aim 1a, we will compile a six-year cohort of ~180,000 TB patients diagnosed in Ukraine 2015-2020. In aim 1b, we will estimate key metrics in the TB care cascade and treatment pathways stratified by drug resistance profiles and HIV status. In aim 1c, we will examine the TB care cascade by district to identify spatial variation in care cascade metrics. In aim 2, we will map patient movements and understand the relationship between movements and key care cascade metrics and TB outcomes, stratified by drug resistance profile and HIV status. In aim 2, we will also quantify the association between population movement and TB/RRTB burden, allowing for development of targeted interventions to reduce TB morbidity and mortality. This contribution is significant because it will develop a national six-year cohort of TB patients tracking them longitudinally and spatially during treatment, enabling local public health professionals to develop locally appropriate interventions to close gaps in the TB care cascade and understand the impact of interventions and new TB diagnostics. The proposed work is innovative because it will provide the first cohort of this kind in a FSU country, with the longitudinal and spatial nature of these data allowing for unique assessment of TB care and the impact of interventions. This will allow policy makers to design locally-relevant interventions targeting specific gaps in TB care and migrant populations, preventing further spread and ultimately reducing disease and mortality due to TB. By using routinely collected data, our model adds minimal financial costs and can be adapted for similar settings with routinely-collected TB data. This work will lead to an R01 proposal to evaluate interventions that can close TB care cascade gaps, improve outcomes and mitigate the impact of population movement on the spread of TB and RRTB in Ukraine.