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Socio-political prescriptions for latent tuberculosis infection are required to prevent reactivation of tuberculosis
Accepted Manuscript Title: Socio-political prescriptions for LTBI are required to prevent re-activation of TB Author: Anna K. Coussens PII: DOI: Reference:
S1201-9712(17)30036-X http://dx.doi.org/doi:10.1016/j.ijid.2017.01.033 IJID 2858
To appear in:
International Journal of Infectious Diseases
Author: Paul H. Mason PII: DOI: Reference:
S1201-9712(17)30036-X http://dx.doi.org/doi:10.1016/j.ijid.2017.01.033 IJID 2858
To appear in:
International Journal of Infectious Diseases
Author: Tolu Oni PII: DOI: Reference:
S1201-9712(17)30036-X http://dx.doi.org/doi:10.1016/j.ijid.2017.01.033 IJID 2858
To appear in:
International Journal of Infectious Diseases
Received date: Accepted date:
9-1-2017 25-1-2017
Please cite this article as: Oni Tolu.Socio-political prescriptions for LTBI are required to prevent re-activation of TB.International Journal of Infectious Diseases http://dx.doi.org/10.1016/j.ijid.2017.01.033 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Correspondence
Socio-political prescriptions for LTBI are required to prevent re-activation of TB
Anna K. Coussensa,b, Paul H. Masonb,c,d*, Tolu Onib,e
Affiliations: aDivision of Medical Microbiology, Department of Pathology, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, WC, South Africa; bGlobal Young Academy, Halle, Germany; cCentre for Values, Ethics and the Law in Medicine and Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia; dDepartment of Anthropology, Monash University, Clayton, Victoria, Australia; eDivision of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, WC, South Africa; * corresponding author.
In their review article, Fox et al.1 detail how screening and treatment of latent tuberculosis infection (LTBI), an asymptomatic condition, can be coupled with treating active tuberculosis to reduce the global burden of tuberculosis (TB). They differentially sort risk factors associated with disease progression from LTBI to TB based on exposures and comorbidities, outline rationales for different preventive therapy regimens to prevent drug-susceptible and drug-resistant TB, and reflect upon ethical considerations of the widespread scale-up of LTBI treatment. Their clinical and epidemiological considerations are robust, and they recognize that treatment of active TB alone will be in sufficient to achieve the steep annual reductions in incidence necessary to reach the End TB Strategy targets. However, they do not acknowledge the undeniable impact that improvement in living and social conditions has on reducing TB incidence.2 We believe that the politics and ethics of LTBI treatment need to be taken one step further. Given the contextual factors that foster the reactivation of TB in the absence of evident comorbidities, the blanket screening for LTBI using non-specific diagnostic technology with limited predictive value for risk of TB progression, with the goal of treating LTBI suspects with 3-9 months of multi-drug regimens, outsources social, economic and political issues and frames them as biomedical problems. Administering
population-wide LTBI treatment, it follows, is political. Should global health initiatives buttress the impoverished social conditions that foster TB reactivation in this manner?
Fox et al. argue that the risk of drug toxicity and benefits of treatment must be carefully balanced for each individual. Risks and benefits are reconfigured from a public health perspective. Given that only in the instance of high transmission risk and the presence of known TB risk factors can a greater risk of TB development be predicted following a positive LTBI test, blanket TB preventative therapy, which only targets a current infection, is questionable. Is it not overtreatment to administer TB prophylaxis based on the results of an immunological test which only measures prior exposure, gives no induction of current infection status, is poorly predictive of the risk of TB development (those that revert to negative following recent positive conversion are at greater risk of TB than those who remain positive3), and is less sensitive in those at greatest risk of disease (ie. those HIV infected)? In the face of recurrent exposure, in high-burden settings, is treatment of LTBI the most economic choice for long-term disease prevention? TB risk factors are both biomedical and socio-economic and cannot be viewed in isolation: socio-economic status impacts immune competence4 and vice versa. Would correcting the immunological and socio-structural drivers of disease progression not be more cost effective for long term health benefits, with the further societal benefits beyond purely TB elimination? Treating LTBI in children under five years of age as well as patients with comorbidities is advisable due to their greater risk of progression to disease. A randomized control trial of isoniazid preventative therapy (IPT) in HIV infected individuals concurrently receiving antiretroviral therapy, showed those negative for LTBI had greatest benefit of IPT, than those positive by LTBI tests,5 demonstrating that tests for LTBI are not always reliable in predicting those who will benefit from preventative therapy. Fox et al. make sound epidemiological arguments about treating LTBI among the contacts of drug-resistant TB patients, which will arguably be an important measure to prevent strain replacement of drug-susceptible TB by drug-
resistant TB (once effective regimens are found through the V-QUIN, TB CHAMP, and PHOENIx trials). In high burden settings where TB transmission often occurs outside of the home, the effectiveness of household contact tracing would need to be compared to community-wide prophylaxis programs, but the question of socio-structural prevention still remains. The problem is that current politics of evidence in science favor the championing of antimicrobial treatments with a direct causal relationship to outcomes than the more distant relationships between social determinants and health.
If we contemplate the blanket treatment of LTBI patients in high-income countries, the situation becomes more ethically questionable. Will widespread treatment of LTBI in a high-income country have a significant effect on global disease burden? In efforts to lower TB disease burden, it can be costeffective for a low-burden high-income country to help bolster TB care and prevention for active cases in neighboring high-burden countries.6 Lowering the TB burden in one country has positive spillover effects in other countries.7 To emphasize the argument by Fox et al. to lower TB prevalence in high-burden countries, spending money to treat active cases in low-burden settings is a more equitable use of resources than treating LTBI cases in a high-burden setting.
In countries like Australia, a high-income country with a low-burden of TB, the bulk of TB occurs among immigrants and other recent arrivals from high incidence countries, who probably acquired Mycobacterium tuberculosis infection abroad.8 However, depicting TB as a migrant problem is an artefact of geopolitical history that brushes aside the fact that cross-border mobility is a given in a globalised world9 and overlooks the conditions of settlement that foster the disease.10 The exposure of recent migrants to different climatic conditions and poor living, working, and socio-economic conditions can be considered an effect modifying variable, detrimentally influencing the association between recent TB exposure and reactivation. Ironically, those who travel abroad are likely the wealthier who can afford to migrate, suggesting they would be less likely to develop TB if they had stayed in their home
country. In addition to the recommendations cited by Fox et al. for recently arrived migrants to be given preventative therapy, we would suggest a public health approach that considers and intervenes to mitigate adverse environmental and social exposures associated with re-activation in recent migrants, which would have positive run-on effects for other health conditions. Re-activation of TB is socio-political. Thus it follows that mass treatment of LTBI is not just clinical, but manifestly political. Treating LTBI in anticipation of future likelihood of developing the disease in the absence of co-morbidities such as type II diabetes or HIV infection offloads socio-structural issues as biomedical problems. If we were to address the social conditions that foster TB reactivation then there would be little need to mass-produce and distribute community-wide preventive therapy. The cascade of care described by Fox et al. addresses the individual level factors. In complement, more holistic, largely political interventions are required (Figure 1) to prevent TB re-activation of these population groups who are not inherently vulnerable but are chronically exposed to adverse conditions that place them in an at-risk category.
Conflict of Interest/Funding: None By focusing solely on pharmacological treatment of LTBI, healthcare workers who treat TB are inadvertently accepting as given the conditions that foster reactivation, conditions that no clinician with an interest in global health should accept. Clinicians have a strong role to play as advocates and in the writing of socio-political prescriptions that are required to dramatically reduce the incidence of TB globally.
References 1.
Fox GJ, Dobler CC, Marais BJ, and Denholm JT, Preventive therapy for latent tuberculosis infection—the promise and the challenges. Int J Infect Dis. 2016;http://dx.doi.org/10.1016/j.ijid.2016.11.006.
2.
Hermans S, Horsburgh CR, and Wood R, A Century of Tuberculosis Epidemiology in the Northern and Southern Hemisphere: The Differential Impact of Control Interventions. PLoS One. 2015;10:e0135179.
3.
Andrews JR, Hatherill M, Mahomed H, Hanekom WA, Campo M, Hawn TR, et al., The dynamics of QuantiFERON-TB gold in-tube conversion and reversion in a cohort of South African adolescents. Am J Respir Crit Care Med. 2015;191:584-591.
4.
Snyder-Mackler N, Sanz J, Kohn JN, Brinkworth JF, Morrow S, Shaver AO, et al., Social status alters immune regulation and response to infection in macaques. Science. 2016;354:1041-1045.
5.
Rangaka MX, Wilkinson RJ, Boulle A, Glynn JR, Fielding K, van Cutsem G, et al., Isoniazid plus antiretroviral therapy to prevent tuberculosis: a randomised double-blind, placebo-controlled trial. Lancet. 2014.
6.
Schwartzman K, Oxlade O, Barr RG, Grimard F, Acosta I, Baez J, et al., Domestic returns from investment in the control of tuberculosis in other countries. N Engl J Med. 2005;353:1008-1020.
7.
Smith RD,MacKellar L, Global public goods and the global health agenda: problems, priorities and potential. Global Health. 2007;3:9.
8.
Lumb R, Bastion I, Carter R, Jelfs P, Keehner T, and Sievers A, Tuberculosis in Australia: bacteriologically confirmed cases and drug resistance, 2008 and 2009. A report of the Australian Mycobacterium Reference Laboratory Network. Commun Dis Intell Q Rep. 2011;35:154-161.
9.
Inda J,Rosaldo R, eds. The Anthropology of Globalisation. 2002, Blackwell: Oxford.
10.
Littleton J, Park J, Thornley C, Anderson A, and Lawrence J, Migrants and tuberculosis: analysing epidemiological data with ethnography. Aust N Z J Public Health. 2008;32:142-149.
Figure 1: Levels of biopyschosocial and political therapies required for LTBI management
S1201-9712(17)30036-X http://dx.doi.org/doi:10.1016/j.ijid.2017.01.033 IJID 2858
To appear in:
International Journal of Infectious Diseases
Author: Paul H. Mason PII: DOI: Reference:
S1201-9712(17)30036-X http://dx.doi.org/doi:10.1016/j.ijid.2017.01.033 IJID 2858
To appear in:
International Journal of Infectious Diseases
Author: Tolu Oni PII: DOI: Reference:
S1201-9712(17)30036-X http://dx.doi.org/doi:10.1016/j.ijid.2017.01.033 IJID 2858
To appear in:
International Journal of Infectious Diseases
Received date: Accepted date:
9-1-2017 25-1-2017
Please cite this article as: Oni Tolu.Socio-political prescriptions for LTBI are required to prevent re-activation of TB.International Journal of Infectious Diseases http://dx.doi.org/10.1016/j.ijid.2017.01.033 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Correspondence
Socio-political prescriptions for LTBI are required to prevent re-activation of TB
Anna K. Coussensa,b, Paul H. Masonb,c,d*, Tolu Onib,e
Affiliations: aDivision of Medical Microbiology, Department of Pathology, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, WC, South Africa; bGlobal Young Academy, Halle, Germany; cCentre for Values, Ethics and the Law in Medicine and Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia; dDepartment of Anthropology, Monash University, Clayton, Victoria, Australia; eDivision of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, WC, South Africa; * corresponding author.
In their review article, Fox et al.1 detail how screening and treatment of latent tuberculosis infection (LTBI), an asymptomatic condition, can be coupled with treating active tuberculosis to reduce the global burden of tuberculosis (TB). They differentially sort risk factors associated with disease progression from LTBI to TB based on exposures and comorbidities, outline rationales for different preventive therapy regimens to prevent drug-susceptible and drug-resistant TB, and reflect upon ethical considerations of the widespread scale-up of LTBI treatment. Their clinical and epidemiological considerations are robust, and they recognize that treatment of active TB alone will be in sufficient to achieve the steep annual reductions in incidence necessary to reach the End TB Strategy targets. However, they do not acknowledge the undeniable impact that improvement in living and social conditions has on reducing TB incidence.2 We believe that the politics and ethics of LTBI treatment need to be taken one step further. Given the contextual factors that foster the reactivation of TB in the absence of evident comorbidities, the blanket screening for LTBI using non-specific diagnostic technology with limited predictive value for risk of TB progression, with the goal of treating LTBI suspects with 3-9 months of multi-drug regimens, outsources social, economic and political issues and frames them as biomedical problems. Administering
population-wide LTBI treatment, it follows, is political. Should global health initiatives buttress the impoverished social conditions that foster TB reactivation in this manner?
Fox et al. argue that the risk of drug toxicity and benefits of treatment must be carefully balanced for each individual. Risks and benefits are reconfigured from a public health perspective. Given that only in the instance of high transmission risk and the presence of known TB risk factors can a greater risk of TB development be predicted following a positive LTBI test, blanket TB preventative therapy, which only targets a current infection, is questionable. Is it not overtreatment to administer TB prophylaxis based on the results of an immunological test which only measures prior exposure, gives no induction of current infection status, is poorly predictive of the risk of TB development (those that revert to negative following recent positive conversion are at greater risk of TB than those who remain positive3), and is less sensitive in those at greatest risk of disease (ie. those HIV infected)? In the face of recurrent exposure, in high-burden settings, is treatment of LTBI the most economic choice for long-term disease prevention? TB risk factors are both biomedical and socio-economic and cannot be viewed in isolation: socio-economic status impacts immune competence4 and vice versa. Would correcting the immunological and socio-structural drivers of disease progression not be more cost effective for long term health benefits, with the further societal benefits beyond purely TB elimination? Treating LTBI in children under five years of age as well as patients with comorbidities is advisable due to their greater risk of progression to disease. A randomized control trial of isoniazid preventative therapy (IPT) in HIV infected individuals concurrently receiving antiretroviral therapy, showed those negative for LTBI had greatest benefit of IPT, than those positive by LTBI tests,5 demonstrating that tests for LTBI are not always reliable in predicting those who will benefit from preventative therapy. Fox et al. make sound epidemiological arguments about treating LTBI among the contacts of drug-resistant TB patients, which will arguably be an important measure to prevent strain replacement of drug-susceptible TB by drug-
resistant TB (once effective regimens are found through the V-QUIN, TB CHAMP, and PHOENIx trials). In high burden settings where TB transmission often occurs outside of the home, the effectiveness of household contact tracing would need to be compared to community-wide prophylaxis programs, but the question of socio-structural prevention still remains. The problem is that current politics of evidence in science favor the championing of antimicrobial treatments with a direct causal relationship to outcomes than the more distant relationships between social determinants and health.
If we contemplate the blanket treatment of LTBI patients in high-income countries, the situation becomes more ethically questionable. Will widespread treatment of LTBI in a high-income country have a significant effect on global disease burden? In efforts to lower TB disease burden, it can be costeffective for a low-burden high-income country to help bolster TB care and prevention for active cases in neighboring high-burden countries.6 Lowering the TB burden in one country has positive spillover effects in other countries.7 To emphasize the argument by Fox et al. to lower TB prevalence in high-burden countries, spending money to treat active cases in low-burden settings is a more equitable use of resources than treating LTBI cases in a high-burden setting.
In countries like Australia, a high-income country with a low-burden of TB, the bulk of TB occurs among immigrants and other recent arrivals from high incidence countries, who probably acquired Mycobacterium tuberculosis infection abroad.8 However, depicting TB as a migrant problem is an artefact of geopolitical history that brushes aside the fact that cross-border mobility is a given in a globalised world9 and overlooks the conditions of settlement that foster the disease.10 The exposure of recent migrants to different climatic conditions and poor living, working, and socio-economic conditions can be considered an effect modifying variable, detrimentally influencing the association between recent TB exposure and reactivation. Ironically, those who travel abroad are likely the wealthier who can afford to migrate, suggesting they would be less likely to develop TB if they had stayed in their home
country. In addition to the recommendations cited by Fox et al. for recently arrived migrants to be given preventative therapy, we would suggest a public health approach that considers and intervenes to mitigate adverse environmental and social exposures associated with re-activation in recent migrants, which would have positive run-on effects for other health conditions. Re-activation of TB is socio-political. Thus it follows that mass treatment of LTBI is not just clinical, but manifestly political. Treating LTBI in anticipation of future likelihood of developing the disease in the absence of co-morbidities such as type II diabetes or HIV infection offloads socio-structural issues as biomedical problems. If we were to address the social conditions that foster TB reactivation then there would be little need to mass-produce and distribute community-wide preventive therapy. The cascade of care described by Fox et al. addresses the individual level factors. In complement, more holistic, largely political interventions are required (Figure 1) to prevent TB re-activation of these population groups who are not inherently vulnerable but are chronically exposed to adverse conditions that place them in an at-risk category.
Conflict of Interest/Funding: None By focusing solely on pharmacological treatment of LTBI, healthcare workers who treat TB are inadvertently accepting as given the conditions that foster reactivation, conditions that no clinician with an interest in global health should accept. Clinicians have a strong role to play as advocates and in the writing of socio-political prescriptions that are required to dramatically reduce the incidence of TB globally.
References 1.
Fox GJ, Dobler CC, Marais BJ, and Denholm JT, Preventive therapy for latent tuberculosis infection—the promise and the challenges. Int J Infect Dis. 2016;http://dx.doi.org/10.1016/j.ijid.2016.11.006.
2.
Hermans S, Horsburgh CR, and Wood R, A Century of Tuberculosis Epidemiology in the Northern and Southern Hemisphere: The Differential Impact of Control Interventions. PLoS One. 2015;10:e0135179.
3.
Andrews JR, Hatherill M, Mahomed H, Hanekom WA, Campo M, Hawn TR, et al., The dynamics of QuantiFERON-TB gold in-tube conversion and reversion in a cohort of South African adolescents. Am J Respir Crit Care Med. 2015;191:584-591.
4.
Snyder-Mackler N, Sanz J, Kohn JN, Brinkworth JF, Morrow S, Shaver AO, et al., Social status alters immune regulation and response to infection in macaques. Science. 2016;354:1041-1045.
5.
Rangaka MX, Wilkinson RJ, Boulle A, Glynn JR, Fielding K, van Cutsem G, et al., Isoniazid plus antiretroviral therapy to prevent tuberculosis: a randomised double-blind, placebo-controlled trial. Lancet. 2014.
6.
Schwartzman K, Oxlade O, Barr RG, Grimard F, Acosta I, Baez J, et al., Domestic returns from investment in the control of tuberculosis in other countries. N Engl J Med. 2005;353:1008-1020.
7.
Smith RD,MacKellar L, Global public goods and the global health agenda: problems, priorities and potential. Global Health. 2007;3:9.
8.
Lumb R, Bastion I, Carter R, Jelfs P, Keehner T, and Sievers A, Tuberculosis in Australia: bacteriologically confirmed cases and drug resistance, 2008 and 2009. A report of the Australian Mycobacterium Reference Laboratory Network. Commun Dis Intell Q Rep. 2011;35:154-161.
9.
Inda J,Rosaldo R, eds. The Anthropology of Globalisation. 2002, Blackwell: Oxford.
10.
Littleton J, Park J, Thornley C, Anderson A, and Lawrence J, Migrants and tuberculosis: analysing epidemiological data with ethnography. Aust N Z J Public Health. 2008;32:142-149.
Figure 1: Levels of biopyschosocial and political therapies required for LTBI management