After steady decline since the 1990s, tuberculosis incidence in New York City and throughout the USA has plateaued. We aimed to explore the major drivers of the flattening of tuberculosis incidence ...in New York City and to project the future trajectory of the tuberculosis epidemic in the absence of any additional intervention.
We developed a compartmental transmission model of tuberculosis in New York City. The model was parameterised with detailed epidemiological data and stratified by age and nativity (US-born vs foreign-born). We ran the model under five alternative scenarios representing different explanations for recent declines in tuberculosis incidence. We evaluated the relative likelihood of each scenario by comparing its output with available data. We used the most likely scenarios to explore potential mechanisms underlying the recent declines in tuberculosis in New York City and to describe the reasonable range of future epidemic trajectories. Our primary outcome was the projected rate of decline in tuberculosis incidence from 2015 to 2025. Model calibration yielded estimates of future disease incidence and reductions in incidence with 95% credible intervals (CrIs).
Demographic changes and declining tuberculosis transmission alone were insufficient to explain recent trends in tuberculosis incidence in New York City. Only scenarios that assumed contemporary changes in tuberculosis dynamics among foreign-born individuals—a declining rate of reactivation or a decrease in imported subclinical tuberculosis—could accurately describe the trajectory of disease incidence since 2007. In those scenarios, the projected decline in incidence from 2015 to 2025 varied from minimal (2·0% per year 95% CrI 0·4–3·5) to similar to 2005 to 2009 trends (4·4% per year 2·5–6·4). The primary factor differentiating optimistic from pessimistic projections was the degree to which improvements in tuberculosis dynamics among the foreign-born population continued into the coming decade.
Further progress towards elimination of tuberculosis in New York City requires additional focus on the foreign-born population. Without additional intervention in this group, tuberculosis incidence might not decline further.
None.
Duty hour limits have shortened intern shifts without concurrent reductions in workload, creating work compression. Multiple admissions during shortened shifts can result in poor training experience ...and patient care.
To relieve work compression, improve resident satisfaction, and improve duty hour compliance in an academic internal medicine program.
In 2014, interns on general ward services were allotted 90 minutes per admission from 3 pm to 7 pm, when the rate of admissions was high. Additional admissions arriving during the protected period were directed to hospitalists. Resident teams received 2 patients admitted by the night float team to start the call day (
).
Of the 51 residents surveyed before and after the implementation of the intervention, 39 (77%) completed both surveys. Respondents reporting an unmanageable workload fell from 14 to 1 (
< .001), and the number of residents reporting that they felt unable to admit patients in a timely manner decreased from 14 to 2 (
< .001). Reports of adequate time with patients increased from 16 to 36 (
< .001), and residents indicating that they had time to learn from patients increased from 19 to 35 (
< .001). Reports of leaving on time after call days rose from 12 to 33 (
< .01), and overall satisfaction increased from 26 to 35 (
= .002). Results were similar when residents were resurveyed 6 months after the intervention.
Call day modifications improved resident perceptions of their workload and time for resident learning and patient care.
We have designed and developed a Gene Ontology based navigation tool, GoMiner, which organizes lists of interesting genes from a microarray or a protein array experiment for biological ...interpretation. It provides quantitative and statistical output files and useful visualization (e.g., a tree-like structure) to map the list of genes to its biological functional categories. It also provides links to other resources such as pubmed, locuslink, and biological molecular interaction map and signaling pathway packages.
Pre-exposure prophylaxis (PrEP) is a key component in helping to reduce HIV incidence in the United States. Long-acting injectable (LAI) PrEP is a new alternative to oral PrEP; its potential to ...affect local HIV epidemics remains unclear.
The Johns Hopkins HIV Economic Epidemiological model (JHEEM) is a dynamic model of HIV transmission in 32 US urban areas. We used JHEEM to project the HIV incidence among men who have sex with men (MSM) from 2020 to 2030 under a range of interventions aimed at increasing PrEP use.
In the absence of any intervention (ie, current levels of oral PrEP and HIV care engagement), we projected a 19% reduction (95% credible interval, CrI 1% to 36%) in HIV incidence among MSM from 2020 to 2030 across all 32 cities. Adding 10% LAI PrEP uptake (above a base case of all oral PrEP) reduced the incidence by 36% (95% CrI 23% to 50%) by year 2030. This effect varied between cities, ranging from 22% in Atlanta to 51% in San Francisco. At 25% additional LAI PrEP uptake, this incidence reduction increased to 54% (95% CrI 45% to 64%). Reductions in incidence after introducing LAI PrEP were driven primarily by increased uptake and sustained usage rather than increased efficacy.
LAI PrEP has the potential to substantially reduce HIV incidence among MSM, particularly if it increases PrEP uptake and continued use beyond existing levels. Because potential effects vary by city, the effectiveness of expanding PrEP use is dependent on local dynamics.
The Ending the HIV Epidemic (EHE) initiative aims to reduce incident HIV infections by 90% over a span of 10 years. The intensity of interventions needed to achieve this for local epidemics is ...unclear.
To estimate the effect of HIV interventions at the city level.
A compartmental model of city-level HIV transmission stratified by age, race, sex, and HIV risk factor was developed and calibrated.
32 priority metropolitan statistical areas (MSAs).
Simulated populations in each MSA.
Combinations of HIV testing and preexposure prophylaxis (PrEP) coverage among those at risk for HIV, plus viral suppression in persons with diagnosed HIV infection.
The primary outcome was the projected reduction in incident cases from 2020 to 2030.
Absent intervention, HIV incidence was projected to decrease by 19% across all 32 MSAs. Modest increases in testing (1.25-fold per year), PrEP coverage (5 percentage points), and viral suppression (10 percentage points) across the population could achieve reductions of 34% to 67% by 2030. Twenty-five percent PrEP coverage, testing twice a year on average, and 90% viral suppression among young Black and Hispanic men who have sex with men (MSM) achieved similar reductions (13% to 68%). Including all MSM and persons who inject drugs could reduce incidence by 48% to 90%. Thirteen of 32 MSAs could achieve greater than 90% reductions in HIV incidence with large-scale interventions that include heterosexuals. A web application with location-specific results is publicly available (www.jheem.org).
The COVID-19 pandemic was not represented.
Large reductions in HIV incidence are achievable with substantial investment, but the EHE goals will be difficult to achieve in most locations. An interactive model that can help policymakers maximize the effect in their local environments is presented.
National Institutes of Health.
Abstract
Background
The degree to which the 2019 novel coronavirus disease (COVID-19) pandemic will affect the US human immunodeficiency virus (HIV) epidemic is unclear.
Methods
We used the Johns ...Hopkins Epidemiologic and Economic Model to project HIV infections from 2020 to 2025 in 32 US metropolitan statistical areas (MSAs). We sampled a range of effects of the pandemic on sexual transmission (0–50% reduction), viral suppression among people with HIV (0–40% reduction), HIV testing (0–50% reduction), and pre-exposure prophylaxis use (0–30% reduction), and indexed reductions over time to Google Community Mobility Reports.
Results
Simulations projected reported diagnoses would drop in 2020 and rebound in 2021 or 2022, regardless of underlying incidence. If sexual transmission normalized by July 2021 and HIV care normalized by January 2022, we projected 1161 (1%) more infections from 2020 to 2025 across all 32 cities than if COVID-19 had not occurred. Among “optimistic” simulations in which sexual transmission was sharply reduced and viral suppression was maintained we projected 8% lower incidence (95% credible interval: 14% lower to no change). Among “pessimistic” simulations where sexual transmission was largely unchanged but viral suppression fell, we projected 11% higher incidence (1–21% higher). MSA-specific projections are available at www.jheem.org?covid.
Conclusions
The effects of COVID-19 on HIV transmission remain uncertain and differ between cities. Reported diagnoses of HIV in 2020–2021 are likely to correlate poorly with underlying incidence. Minimizing disruptions to HIV care is critical to mitigating negative effects of the COVID-19 pandemic on HIV transmission.
The impact of the COVID-19 pandemic on HIV is uncertain and depends on its local effects on sexual transmission and viral suppression. Reported cases of HIV during and following the pandemic will likely not correlate well with underlying incidence.
Global progress towards reducing tuberculosis (TB) incidence and mortality has consistently lagged behind the World Health Organization targets leading to a perception that large reductions in TB ...burden cannot be achieved. However, several recent and historical trials suggest that intervention efforts that are comprehensive and intensive can have a substantial epidemiological impact. We aimed to quantify the potential epidemiological impact of an intensive but realistic, community-wide campaign utilizing existing tools and designed to achieve a "step change" in the TB burden.
We developed a compartmental model that resembled TB transmission and epidemiology of a mid-sized city in India, the country with the greatest absolute TB burden worldwide. We modeled the impact of a one-time, community-wide screening campaign, with treatment for TB disease and preventive therapy for latent TB infection (LTBI). This one-time intervention was followed by the strengthening of the tuberculosis-related health system, potentially facilitated by leveraging the one-time campaign. We estimated the tuberculosis cases and deaths that could be averted over 10 years using this comprehensive approach and assessed the contributions of individual components of the intervention.
A campaign that successfully screened 70% of the adult population for active and latent tuberculosis and subsequently reduced diagnostic and treatment delays and unsuccessful treatment outcomes by 50% was projected to avert 7800 (95% range 5450-10,200) cases and 1710 (1290-2180) tuberculosis-related deaths per 1 million population over 10 years. Of the total averted deaths, 33.5% (28.2-38.3) were attributable to the inclusion of preventive therapy and 52.9% (48.4-56.9) to health system strengthening.
A one-time, community-wide mass campaign, comprehensively designed to detect, treat, and prevent tuberculosis with currently existing tools can have a meaningful and long-lasting epidemiological impact. Successful treatment of LTBI is critical to achieving this result. Health system strengthening is essential to any effort to transform the TB response.
Abstract
Data from several modeling studies demonstrate that large-scale increases in human immunodeficiency virus (HIV) testing across settings with a high burden of HIV may produce the largest ...incidence reductions to support the US Ending the HIV Epidemic (EHE) initiative's goal of reducing new HIV infections 90% by 2030. Despite US Centers for Disease Control and Prevention's recommendations for routine HIV screening within clinical settings and at least yearly screening for individuals most at risk of acquiring HIV, fewer than half of US adults report ever receiving an HIV test. Furthermore, total domestic funding for HIV prevention has remained unchanged between 2013 and 2019. The authors describe the evidence supporting the value of expanded HIV testing, identify challenges in implementation, and present recommendations to address these barriers through approaches at local and federal levels to reach EHE targets.
Large-scale increases in HIV testing across high-burden settings is a recommended strategy to support the goals of the US Ending the HIV Epidemic initiative. Recommendations are presented to address barriers in the implementation of increased HIV testing.
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