Digital exposure notification tools: A global landscape analysis.

BACKGROUND: As the COVID-19 pandemic continues, digital exposure notification systems are increasingly used to support traditional contact tracing and other preventive strategies. Likewise, a plethora of COVID-19 mobile applications have emerged. Objective: To characterize the global landscape of pandemic related mobile applications, including digital exposure notification and contact tracing tools. DATA SOURCES AND METHODS: The following queries were entered into the Google search engine: "(*country name* COVID app) OR (COVID app *country name*) OR (COVID app *country name*+) OR (*country name*+ COVID app)". The App Store, Google Play, and official government websites were then accessed to collect descriptive data for each application. Descriptive data were qualified and quantified using standard methods. COVID-19 Exposure Notification Systems (ENS) and non-Exposure Notification products were categorized and summarized to provide a global landscape review. RESULTS: Our search resulted in a global count of 224 COVID-19 mobile applications, in 127 countries. Of these 224 apps, 128 supported exposure notification, with 75 employing the Google Apple Exposure Notification (GAEN) application programming interface (API). Of the 75 apps using the GAEN API, 15 apps were developed using Exposure Notification Express, a GAEN turnkey solution. COVID-19 applications that did not include exposure notifications (n = 96) focused on COVID-19 Self-Assessment (35·4%), COVID-19 Statistics and Information (32·3%), and COVID-19 Health Advice (29·2%). CONCLUSIONS: The digital response to COVID-19 generated diverse and novel solutions to support non-pharmacologic public health interventions. More research is needed to evaluate the extent to which these services and strategies were useful in reducing viral transmission.

Exposure notification system activity as a leading indicator for SARS-COV-2 caseload forecasting.

PURPOSE: Digital methods to augment traditional contact tracing approaches were developed and deployed globally during the COVID-19 pandemic. These "Exposure Notification (EN)" systems present new opportunities to support public health interventions. To date, there have been attempts to model the impact of such systems, yet no reports have explored the value of real-time system data for predictive epidemiological modeling. METHODS: We investigated the potential to short-term forecast COVID-19 caseloads using data from California's implementation of the Google Apple Exposure Notification (GAEN) platform, branded as CA Notify. CA Notify is a digital public health intervention leveraging resident's smartphones for anonymous EN. We extended a published statistical model that uses prior case counts to investigate the possibility of predicting short-term future case counts and then added EN activity to test for improved forecast performance. Additional predictive value was assessed by comparing the pandemic forecasting models with and without EN activity to the actual reported caseloads from 1-7 days in the future. RESULTS: Observation of time series presents noticeable evidence for temporal association of system activity and caseloads. Incorporating earlier ENs in our model improved prediction of the caseload counts. Using Bayesian inference, we found nonzero influence of EN terms with probability one. Furthermore, we found a reduction in both the mean absolute percentage error and the mean squared prediction error, the latter of at least 5% and up to 32% when using ENs over the model without. CONCLUSIONS: This preliminary investigation suggests smartphone based ENs can significantly improve the accuracy of short-term forecasting. These predictive models can be readily deployed as local early warning systems to triage resources and interventions.

Identification of the socio-cultural barriers of drug addiction treatment in Iran.

Introduction: Socio-cultural norms can either be encouraging or a barrier to addiction treatment. More, rigorous research is needed on nonindigenous models in addiction treatment, to better understand the role of socio-cultural differences. Methods: The present qualitative study is part of the project, "The Inclusive Assessment of the Barriers of Drug Addiction Treatment Services in Iran," which was conducted in Tehran from 2018 to 2021. The participants consisted of eight people who used drugs, seven individual family members of the people who used drugs participants, seven service providers, and four policymakers. A purposeful sampling method was used for the selection of the participants, and the process continued until reaching the theoretical saturation of data. Analysis used the Graneheim and Lundman methods, classifying primary codes, the sub-themes, and themes were classified according to the similarities and differences between primary codes. Finding: The most important socio-cultural barriers to addiction treatment in Iran are: unrealistic expectations of the family and society from the people who use drugs, addiction stigma, mistrust between various components of the treatment system, perceptions that professional substance use disorder treatment is inefficient and low uptake of that treatment, the disturbed relational boundaries between the people who use drugs and their relatives, the interweaving of treatment and ethical and religious principles, low acceptance of maintenance treatments, treatment focusing on short-term outcomes, and presence of facilitating backgrounds of using drugs. Conclusions: The Iranian socio-cultural characteristics play an important role in the addiction treatment of the people who use drugs, so it is necessary for treatment interventions to be sensitive to these characteristics.

Interventions to enhance psychological resilience in forcibly displaced children: a systematic review.

BACKGROUND: Children represent nearly 40% of forcibly displaced populations and are subject to stressors that affect well-being. Little is known about the effects of interventions to enhance psychological resilience in these children, outside clinical settings. METHODS: We conducted a systematic review, following Cochrane methods. Eligible studies tested resilience-enhancing interventions outside clinical settings in forcibly displaced children/adolescents. We included longitudinal quantitative studies with comparator conditions irrespective of geographical scope or language. We searched articles published between January 2010 and April 2020 in PubMed, Embase, Cochrane Library, Web of Science, PsycINFO and the WHO's Global Index Medicus. To standardise effect sizes across the different reported outcomes, we transformed reported mean differences to standardised mean differences using Hedge's g statistic with associated 95% CI. We pooled data for meta-analysis where appropriate. We used Cochrane tools to assess study risk of bias and used Grading of Recommendations Assessment, Development and Evaluation to determine evidence quality for meta-analysed outcomes. RESULTS: Searches yielded 4829 results. Twenty-three studies met inclusion criteria. Studies reported 18 outcomes measured by 48 different scales; only 1 study explicitly measured resilience. Eight studies were randomised controlled trials; the rest were non-randomised pre-post studies. Interventions were diverse and typically implemented in group settings. Studies reported significant improvement in outcomes pertinent to behavioural problems, coping mechanisms and general well-being but not to caregiver support or psychiatric symptoms. In meta-analysis, resilience was improved (gav=0.194, 95% CI 0.018 to 0.369), but anxiety symptoms and quality of life were not (gav=-0.326, 95% CI -0.782 to 0.131 and gav=0.325, 95% CI -0.027 to 0.678, respectively). Risk of bias varied. Quality of evidence for most graded outcomes was very low. CONCLUSIONS: The multiplicity of study designs, intervention types, outcomes and measures incumbered quantifying intervention effectiveness. Future resilience research in this population should use rigorous methods and follow reporting guidelines. PROSPERO REGISTRATION NUMBER: CRD42020177069.

Sexual Practice Changes Post-HIV Diagnosis Among Men Who Have Sex with Men in the United States: A Systematic Review and Meta-analysis.

Men who have sex with men (MSM) often change sexual behaviors following HIV diagnosis. This systematic review examined such changes, including sero-adaptive behaviors (i.e., deliberate safer-sex practices to reduce transmission risk) to better understand the magnitude of their association with HIV diagnosis. We searched four databases (1996-2017) and reviewed references from other systematic reviews. We included studies conducted in the United States that compared sexual behavior among HIV-infected "aware" versus "unaware" MSM. We meta-analytically pooled RRs and associated 95% confidence intervals (CI) using random-effects models, and assessed risk of bias and evidence quality. Twenty studies reported k = 131 effect sizes on sexual practices outcomes, most of which reported changes in unprotected sex (k = 85), and on sex with at-risk partners (k = 76); 11 reported sero-adaptive behaviors. Unprotected anal intercourse with an HIV-uninfected/unknown-status partner was less likely among aware MSM (insertive position: k = 2, RR 0.26, 95% CI 0.17, 0.41; receptive position: k = 2, RR 0.53, 95% CI 0.37, 0.77). Risk of not always serosorting among aware MSM (k = 3) was RR = 0.92 (0.83, 1.02). Existing evidence, although low-quality, suggests that HIV-infected MSM tend to adopt safer sexual practices once aware of their diagnosis. Variation in reporting of outcomes limits their comparability. Sero-adaptive behavior data are sparse.

Defining Key Performance Indicators for the California COVID-19 Exposure Notification System (CA Notify).

OBJECTIVES: Toward common methods for system monitoring and evaluation, we proposed a key performance indicator framework and discussed lessons learned while implementing a statewide exposure notification (EN) system in California during the COVID-19 epidemic. MATERIALS AND METHODS: California deployed the Google Apple Exposure Notification framework, branded CA Notify, on December 10, 2020, to supplement traditional COVID-19 contact tracing programs. For system evaluation, we defined 6 key performance indicators: adoption, retention, sharing of unique codes, identification of potential contacts, behavior change, and impact. We aggregated and analyzed data from December 10, 2020, to July 1, 2021, in compliance with the CA Notify privacy policy. RESULTS: We estimated CA Notify adoption at nearly 11 million smartphone activations during the study period. Among 1 654 201 CA Notify users who received a positive test result for SARS-CoV-2, 446 634 (27%) shared their unique code, leading to ENs for other CA Notify users who were in close proximity to the SARS-CoV-2-positive individual. We identified at least 122 970 CA Notify users as contacts through this process. Contact identification occurred a median of 4 days after symptom onset or specimen collection date of the user who received a positive test result for SARS-CoV-2. PRACTICE IMPLICATIONS: Smartphone-based EN systems are promising new tools to supplement traditional contact tracing and public health interventions, particularly when efficient scaling is not feasible for other approaches. Methods to collect and interpret appropriate measures of system performance must be refined while maintaining trust and privacy.

Barriers and Facilitators to Substance Use Disorder Treatment: An Overview of Systematic Reviews.

objective: This investigation explored the barriers and facilitators to substance use disorder (SUD) treatment in the integrated paradigm. methods: A search technique for barriers and facilitators of SUD treatment was applied to the PubMed and Web of Science databases to identify relevant systematic reviews. The eligibility criteria included systematic review (SR) or SR plus meta-analysis (MA) articles published before the end of 2021, human research, and the English language. Each of the 12 relevant review articles met the inclusion criteria. AMSTAR was utilised to evaluate the methodological quality of the systematic reviews. results: Two authors analysed 12 SR/SR-MA articles to identify barriers or facilitators of SUD treatment. The cumulative summary results of these 12 evaluations revealed that barriers and facilitators may be classified into 3 levels: individual, social and structural. By analysing these review papers, 37 structural barriers, 21 individual barriers and 19 social barriers were uncovered, along with 15 structural facilitators, 9 social facilitators and 3 individual facilitators. conclusions: The majority of barriers indicated in the review articles included in this analysis are structural, as are the majority of facilitators. Consequently, the design of macro models for the treatment of substance use disorders may yield various outcomes and potentially affect society and individual levels.

Viral blood-borne infections testing and linkage to care cascade among persons who experience homelessness in the United States: a systematic review and meta-analysis.

BACKGROUND: Persons who experience homelessness remain at increased risk for three viral blood-borne infections: human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). We assessed the yield of testing and linkage to care programs targeting this population for these infections in the United States (US). METHODS: We searched PubMed, Embase, Web of Science, and Cochrane Central for peer-reviewed articles through August 27, 2020. Additionally, we searched the grey literature. Two individuals independently reviewed all relevant studies to check for eligibility and extracted data for each step in the care cascade. We used random-effects model to generate weighted pooled proportions to assess yield at each step. Cumulative proportions were calculated as products of adjacent-step pooled proportions. We quantitatively synthesized data from the studies that focused on non-drug injecting individuals. RESULTS: We identified 24 studies published between 1996-2019 conducted in 19 US states. Seventeen studies screened for HIV, 12 for HCV, and two screened for HBV. For HIV, 72% of approached were recruited, 64% had valid results, 4% tested positive, 2% were given results, and 1% were referred and attended follow-up. Of positives, 25% were referred to treatment and started care. For HCV, 69% of approached were recruited, 63% had valid results, 16% tested positive, 14% were given results, and 3% attended follow-up. Of positives, 30% were referred for treatment and 19% started care. The yield at each care cascade step differs widely by recruitment strategy (for example, for HIV: 71.6% recruited of reached under service-based with zero yield under healthcare facility-based and outreach). CONCLUSIONS: A very large proportion of this population reached for HIV and HCV care were lost in the follow-up steps and never received treatment. Future programs should examine drop-out reasons and intervene to reduce health disparities in this population.

Indirect COVID-19 health effects and potential mitigating interventions: Cost-effectiveness framework.

BACKGROUND: The COVID-19 pandemic led to important indirect health and social harms in addition to deaths and morbidity due to SARS-CoV-2 infection. These indirect impacts, such as increased depression and substance abuse, can have persistent effects over the life course. Estimated health and cost outcomes of such conditions and mitigation strategies may guide public health responses. METHODS: We developed a cost-effectiveness framework to evaluate societal costs and quality-adjusted life years (QALYs) lost due to six health-related indirect effects of COVID-19 in California. Short- and long-term outcomes were evaluated for the adult population. We identified one evidence-based mitigation strategy for each condition and estimated QALYs gained, intervention costs, and savings from averted health-related harms. Model data were derived from literature review, public data, and expert opinion. RESULTS: Pandemic-associated increases in prevalence across these six conditions were estimated to lead to over 192,000 QALYs lost and to approach $7 billion in societal costs per million population over the life course of adults. The greatest costs and QALYs lost per million adults were due to adult depression. All mitigation strategies assessed saved both QALYs and costs, with five strategies achieving savings within one year. The greatest net savings over 10 years would be achieved by addressing depression ($242 million) and excessive alcohol use ($107 million). DISCUSSION: The COVID-19 pandemic is leading to significant human suffering and societal costs due to its indirect effects. Policymakers have an opportunity to reduce societal costs and health harms by implementing mitigation strategies.

Risk of Human Immunodeficiency Virus Acquisition Among High-Risk Heterosexuals With Nonviral Sexually Transmitted Infections: A Systematic Review and Meta-Analysis.

BACKGROUND: Nonviral sexually transmitted infections (STIs) increase risk of sexually acquired human immunodeficiency virus (HIV) infection. Updated risk estimates carefully scrutinizing temporality bias of studies are needed. METHODS: We conducted a systematic review (PROSPERO CRD42018084299) of peer-reviewed studies evaluating variation in risk of HIV infection among high-risk heterosexuals diagnosed with any of: Chlamydia trachomatis, Mycoplasma genitalium, Neisseria gonorrhoeae, Treponema pallidum, and/or Trichomonas vaginalis. We searched PubMed, Web of Science, and Embase databases through December 2017 and included studies where STIs and HIV were assessed using laboratory tests or medical examinations and where STI was diagnosed before HIV. After dual screening, data extraction, and risk of bias assessment, we meta-analytically pooled risk ratios (RRs). RESULTS: We found 32 eligible studies reporting k = 97 effect size estimates of HIV acquisition risk due to infection with one of the abovementioned STIs. Most data were based on women engaged in sex work or other high-risk occupations in developing countries. Many studies did not measure or adjust for known confounders, including drug injection and condom use, and most were at medium or high risk of bias because of the potential for undetected HIV infection to have occurred before STI infection. Human immunodeficiency virus acquisition risk increased among women infected with any pathogen; the effect was greatest for women infected with Mycoplasma genitalium (RR, 3.10; 95% confidence interval [CI], 1.63-5.92; k = 2) and gonorrhea (RR, 2.81; 95% CI, 2.25-3.50; k = 16) but also statistically significant for women infected with syphilis (RR, 1.67; 95% CI, 1.23-2.27; k = 17), trichomonas (RR, 1.54; 95% CI, 1.31-1.82; k = 17), and chlamydia (RR, 1.49; 95% CI, 1.08-2.04; k = 14). For men, data were space except for syphilis (RR, 1.77; 95% CI, 1.22-2.58; k = 5). CONCLUSION: Nonviral STI increases risk of heterosexual HIV acquisition, although uncertainty remains because of risk of bias in primary studies.

The yield of tuberculosis contact investigation in low- and middle-income settings: a systematic review and meta-analysis.

BACKGROUND: Contact investigation, the systematic evaluation of individuals in close contact with an infectious tuberculosis (TB) patient, is a key active case-finding strategy for global TB control. Better estimates of the yield of contact investigation can guide strategies to reduce the number of underreported and underdiagnosed TB cases, approximately three million cases per year globally. A systematic review (Prospero ID # CRD42019133380) and meta-analysis was conducted to update and enhance the estimates of the yield of TB contact investigation in low- and middle-income countries (LMIC). Pubmed, Web of Science, Embase and the WHO Global Index Medicus were searched for peer-reviewed studies (published between January 2006-April 2019); studies reporting the number of active TB or latent tuberculosis infection (LTBI) found through contact investigation were included. Pooled data were meta-analyzed using a random effects model and risk of bias was assessed. RESULTS: Of 1,644 unique citations obtained from database searches, 110 studies met eligibility criteria for descriptive data synthesis and 95 for meta-analysis. The pooled yields of contact investigation activities for different outcomes were: secondary cases of all active TB (defined as those bacteriologically confirmed or clinically diagnosed) 2.87% (2.61-3.14, I2 97.79%), bacteriologically confirmed active TB 2.04% (1.77-2.31, I2 98.06%), and LTBI 43.83% (38.11-49.55, I2 99.36%). Yields are interpreted as the percent of contacts screened who are diagnosed with active TB as a result of TB contact investigation activities. Pooled estimates were substantially heterogenous (I2 ≥ 75%). CONCLUSIONS: This study provides methodologically rigorous and up-to-date estimates for the yield of TB contact investigation activities in low- and middle-income countries (LMIC). While the data are heterogenous, these findings can inform strategic and programmatic planning for scale up of TB contact investigation activities.

Hepatitis B prevalence association with sexually transmitted infections: a systematic review and meta-analysis.

Background Hepatitis B vaccination is recommended for persons with current or past sexually transmitted infections (STI). Our aim is to systematically assess the association of hepatitis B virus (HBV) sero-markers for current or past infection with syphilis, chlamydia, gonorrhoea, or unspecified STIs. METHODS: We conducted a systematic review and meta-analysis. PubMed, Embase, and Web of Science from 1982 to 2018 were searched using medical subject headings (MeSH) terms for HBV, STIs and epidemiology. We included studies conducted in Organisation for Economic Cooperation and Development countries or Latin America that permit the calculation of prevalence ratios (PRs) for HBV and STIs and extracted PRs and counts by HBV and STI status. RESULTS: Of 3144 identified studies, 43 met inclusion requirements, yielding 72 PRs. We stratified outcomes by HBV sero-markers [surface antigen (HBsAg), hepatitis B core antibody (anti-HBc), combined], STI pathogen (syphilis, gonorrhoea/chlamydia, unspecified), and STI history (current, past) resulting in 18 potential outcome groups, for which results were available for 14. For the four outcome groups related to HBsAg, PR point estimates ranged from 1.65 to 6.76. For the five outcome groups related to anti-HBc, PRs ranged from 1.30 to 1.82; and for the five outcome groups related to combined HBV markers, PRs ranged from 1.15 to 1.89). The median HBsAg prevalence among people with a current or past STI was 4.17; not all studies reported HBsAg. Study settings and populations varied. CONCLUSION: This review found evidence of association between HBV infection and current or past STIs.

Risk of HIV Acquisition Among Men Who Have Sex With Men Infected With Bacterial Sexually Transmitted Infections: A Systematic Review and Meta-Analysis.

BACKGROUND: Men who have sex with men (MSM) who have bacterial sexually transmitted infections (STIs) are at increased risk for HIV infection. We enhanced and updated past summary risk estimates. METHODS: We systematically reviewed (PROSPERO No. CRD42018084299) peer-reviewed studies assessing the risk of HIV infection among MSM attributable to Chlamydia trachomatis (CT), Mycoplasma genitalium (MG), Neisseria gonorrhoeae (NG), Treponema pallidum (TP), and/or Trichomonas vaginalis (TV). We searched 3 databases through December 2017. We excluded studies with self-reported data or simultaneous STI and HIV assessment. We conducted dual screening and data extraction, meta-analytically pooled risk ratios (RRs), and assessed potential risk of bias. RESULTS: We included 26 studies yielding 39 RR (k) for HIV acquisition due to one of TP, NG, or CT. We did not identify eligible data for MG or TV, or for HIV transmission. HIV acquisition risk increased among MSM infected with TP (k = 21; RR, 2.68, 95% confidence interval [CI], 2.00-3.58), NG (k = 11; RR, 2.38; 95% CI, 1.56-3.61), and CT (k = 7; RR, 1.99; 95% CI, 1.59-2.48). Subanalysis RRs for all 3 pathogens were ≥1.66 and remained statistically significant across geography and methodological characteristics. Pooled RR increased for data with the lowest risk of bias for NG (k = 3; RR, 5.49; 95% CI, 1.11-27.05) and TP (k = 4; RR, 4.32; 95% CI, 2.20-8.51). We observed mostly moderate to high heterogeneity and moderate to high risk of bias. CONCLUSIONS: Men who have sex with men infected with TP, NG, or CT have twice or greater risk of HIV acquisition, although uncertainties exist because of data heterogeneity and risk of bias.

Change in Condom Use in Populations Newly Aware of HIV Diagnosis in the United States and Canada: A Systematic Review and Meta-Analysis.

HIV-infected individuals "aware" of their infection are more likely to use condoms, compared to HIV-infected "unaware" persons. To quantify this likelihood, we undertook a systematic review and meta-analysis of U.S. and Canadian studies. Twenty-one eligible studies included men who have sex with men (MSM; k = 15), persons who inject drugs (PWID; k = 2), and mixed populations of high-risk heterosexuals (HRH; k = 4). Risk ratios (RR) of "not always using condoms" with partners of any serostatus were lower among aware MSM (RR 0.44 [not significant]), PWID (RR 0.70) and HRH (RR 0.27); and, in aware MSM, with partners of HIV-uninfected or unknown status (RR 0.46). Aware individuals had lower "condomless sex likelihood" with HIV-uninfected or unknown status partners (MSM: RR 0.58; male PWID: RR 0.44; female PWID: RR 0.65; HRH: RR 0.35) and with partners of any serostatus (MSM only, RR 0.72). The association diminished over time. High risk of bias compromised evidence quality.

Outdoor Transmission of SARS-CoV-2 and Other Respiratory Viruses: A Systematic Review.

BACKGROUND: While risk of outdoor transmission of respiratory viral infections is hypothesized to be low, there are limited data on SARS-CoV-2 transmission in outdoor compared to indoor settings. METHODS: We conducted a systematic review of peer-reviewed papers indexed in PubMed, EMBASE, and Web of Science and preprints in Europe PMC through 12 August 2020 that described cases of human transmission of SARS-CoV-2. Reports of other respiratory virus transmission were included for reference. RESULTS: Five identified studies found a low proportion of reported global SARS-CoV-2 infections occurred outdoors (<10%) and the odds of indoor transmission was very high compared to outdoors (18.7 times; 95% confidence interval, 6.0-57.9). Five studies described influenza transmission outdoors and 2 adenovirus transmission outdoors. There was high heterogeneity in study quality and individual definitions of outdoor settings, which limited our ability to draw conclusions about outdoor transmission risks. In general, factors such as duration and frequency of personal contact, lack of personal protective equipment, and occasional indoor gathering during a largely outdoor experience were associated with outdoor reports of infection. CONCLUSIONS: Existing evidence supports the wide-held belief that risk of SARS-CoV-2 transmission is lower outdoors but there are significant gaps in our understanding of specific pathways.

Healthcare facility-based strategies to improve tuberculosis testing and linkage to care in non-U.S.-born population in the United States: A systematic review.

CONTEXT: An estimated 21% of non-U.S.-born persons in the United States have a reactive tuberculin skin test (TST) and are at risk of progressing to TB disease. The effectiveness of strategies by healthcare facilities to improve targeted TB infection testing and linkage to care among this population is unclear. EVIDENCE ACQUISITION: Following Cochrane guidelines, we searched several sources to identify studies that assessed strategies directed at healthcare providers and/or non-U.S.-born patients in U.S. healthcare facilities. EVIDENCE SYNTHESIS: Seven studies were eligible. In a randomized controlled trial (RCT), patients with reactive TST who received reminders for follow-up appointments were more likely to attend appointments (risk ratio, RR = 1.05, 95% confidence interval 1.00-1.10), but rates of return in a quasi-RCT study using patient reminders did not significantly differ between study arms (P = 0.520). Patient-provider language concordance in a retrospective cohort study did not increase provider referrals for testing (P = 0.121) or patient testing uptake (P = 0.159). Of three studies evaluating pre and post multifaceted interventions, two increased TB infection testing (from 0% to 77%, p < .001 and RR 2.28, 1.08-4.80) and one increased provider referrals for TST (RR 24.6, 3.5-174). In another pre-post study, electronic reminders to providers increased reading of TSTs (RR 2.84, 1.53-5.25), but only to 25%. All seven studies were at high risk of bias. CONCLUSIONS: Multifaceted strategies targeting providers may improve targeted TB infection testing in non-U.S.-born populations visiting U.S. healthcare facilities; uncertainties exist due to low-quality evidence. Additional high-quality studies on this topic are needed.

The discordance between evidence and health policy in the United States: the science of translational research and the critical role of diverse stakeholders.

BACKGROUND: There is often a discordance between health research evidence and public health policies implemented by the United States federal government. In the process of developing health policy, discordance can arise through subjective and objective factors that are unrelated to the value of the evidence itself, and can inhibit the use of research evidence. We explore two common types of discordance through four illustrative examples and then propose a potential means of addressing discordance. DISCUSSION: In Discordance 1, public health authorities make recommendations for policy action, yet these are not based on high quality, rigorously synthesised research evidence. In Discordance 2, evidence-based public health recommendations are ignored or discounted in developing United States federal government policy. Both types could lead to serious risks of public health and clinical patient harms. We suggest that, to mitigate risks associated with these discordances, public health practitioners, health policy-makers, health advocates and other key stakeholders should take the opportunity to learn or expand their knowledge regarding current research methods, as well as improve their skills for appropriately considering the strengths and limitations of research evidence. This could help stakeholders to adopt a more nuanced approach to developing health policy. Stakeholders should also have a more insightful contextual awareness of these discordances and understand their potential harms. In Discordance 1, public health organisations and authorities need to acknowledge their own historical roles in making public health recommendations with insufficient evidence for improving health outcomes. In Discordance 2, policy-makers should recognise the larger impact of their decision-making based on minimal or flawed evidence, including the potential for poor health outcomes at population level and the waste of huge sums. In both types of discordance, stakeholders need to consider the impact of their own unconscious biases in championing evidence that may not be valid or conclusive. CONCLUSION: Public health policy needs to provide evidence-based solutions to public health problems, but this is not always done. We discuss some of the factors inhibiting evidence-based decision-making in United States federal government public health policy and suggest ways these could be addressed.

Yield of testing and treatment for tuberculosis among foreign-born persons during contact investigations in the United States: A semi-systematic review.

BACKGROUND: Contact investigation is an important strategy for maintaining control of tuberculosis (TB) in the United States. However, testing and treatment outcomes specifically to foreign-born populations are poorly understood. We reviewed literature on testing and LTBI identified during contact investigations in foreign-born populations living in the US. METHODS: We conducted a comprehensive search of peer-reviewed and grey literature using Cochrane systematic review methods. We included studies with adult and adolescent populations that were at least 50% foreign-born. Pooled proportions and 95% confidence intervals (CIs) were calculated via inverse-variance weighted meta-analysis, and cumulative proportions were calculated as products of adjacent step proportions. RESULTS: We identified 22 studies published between 1997 and 2014 that included at least 50% foreign-born participants. From studies of predominantly (>90%) foreign-born populations, almost all identified contacts were recruited and had valid test results, and 54.8% (95% CI 45.1-62.5%) of contacts with valid test results tested positive. From studies of majority (50% to 90%) foreign-born populations, 78.4% (95% CI 78.0-78.9%) of identified contacts were recruited, 92.0% (95% CI 91.6-92.3%) of recruited contacts had valid test results, and 38.5% (95% CI 31.9%-44.2%) of persons with valid results tested positive. These proportions varied by test type in studies of predominantly foreign-born populations. For every 1000 contacts identified in predominantly foreign-born populations, we estimate that 535 (95% CI 438 to 625) will test positive, and 354 (95% CI 244 to 453) will complete LTBI treatment. For every 1000 contacts identified in majority foreign-born populations, these estimates are 276 (95% CI 230 to 318), and 134 (95% CI 44 to 264), respectively. CONCLUSIONS: Contact investigation is a high yield activity for identifying and treating foreign-born persons with LTBI, but must be complemented by other tuberculosis control activities in order to achieve continued progress toward TB elimination.

Care Cascade for targeted tuberculosis testing and linkage to Care in Homeless Populations in the United States: a meta-analysis.

BACKGROUND: Homelessness increases the risk of tuberculosis (TB) disease and latent TB infection (LTBI), but persons experiencing homelessness often lack access to testing and treatment. We assessed the yield of TB testing and linkage to care for programs targeting homeless populations in the United States. METHODS: We conducted a comprehensive search of peer-reviewed and grey literature, adapting Cochrane systematic review methods. Two reviewers independently assessed study eligibility and abstracted key data on the testing to care cascade: number of persons reached, recruited for testing, tested for LTBI, with valid test results, referred to follow-up care, and initiating care. We used random effects to calculate pooled proportions and 95% confidence intervals (CI) of persons retained in each step via inverse-variance weighted meta-analysis, and cumulative proportions as products of adjacent step proportions. RESULTS: We identified 23 studies published between 1986 and 2014, conducted in 12 states and 15 cities. Among studies using tuberculin skin tests (TST) we found that 93.7% (CI 72.4-100%) of persons reached were recruited, 97.9% (89.3-100%) of those recruited had tests placed, 85.5% (78.6-91.3%) of those with tests placed returned for reading, 99.9% (99.6-100%) of those with tests read had valid results, and 24.7% (21.0-28.5%) with valid results tested positive. All persons testing positive were referred to follow-up care, and 99.8% attended at least one session of follow-up care. Heterogeneity was high for most pooled proportions. For a hypothetical cohort of 1000 persons experiencing homelessness reached by a targeted testing program using TST, an estimated 917 were tested, 194 were positive, and all of these initiated follow-up care. CONCLUSIONS: Targeted TB testing of persons experiencing homelessness appears effective in detecting LTBI and connecting persons to care and potential treatment. Future evaluations should assess diagnostic use of interferon gamma release assays and completion of treatment, and costs of testing and treatment.