Pharmacists' Role in Global TB Elimination: Practices, Pitfalls, and Potential.

Tuberculosis (TB) is the top infectious killer in the world despite efforts to eliminate it. Pharmaceutical care roles are pillars of pharmacy practice, and pharmacists are well equipped to serve a unique role in the pathway to provide education about TB. Previous systematic reviews emphasize pharmacists' role in treating TB; however, pharmacists can and do play much broader roles in overall TB elimination efforts. Five researchers searched five electronic databases (PubMed, PsychInfo, CINAHL, Academic Search Premier, and Embase). Search terms included pharmacy, pharmacist, tuberculosis, antitubercular agents, supply, distribution, and drug therapy. Inclusion criteria were studies published from 2010 through March 2023, in English or Spanish, addressed a specific TB-related role for pharmacists/pharmacies, and were peer-reviewed. Exclusion criteria included pharmacology, pharmacokinetics, clinical trials on drug efficacy, and editorials. Two researchers conducted each level of review; for discordance, a third researcher reviewed, and a decision was reached by consensus. Roles were extracted and cross-referenced with traditional pharmaceutical care steps. Of the initial 682 hits, 133 were duplicates. After further review, we excluded 514 records, leaving 37 articles for full extraction. We found nine roles for pharmacists in TB prevention and classified them as implemented, not implemented, or recommended. These roles were: (1) TB symptom screening; (2) Referring to TB care systems; (3) TB testing; (4) Dispensing TB medication correctly and/or directly observed therapy; (5) Counseling; (6) Looking to reduce socioeconomic barriers; (7) Procurement of TB medications; (8) Quality assurance of TB medications; (9) Maintaining and using pharmacy data systems. Pharmacists are well situated to play a vital role in the global fight against TB. Findings suggested pharmacists in many settings have already expanded their roles related to TB elimination beyond traditional pharmaceutical care. Still others need to increase the understanding of TB procurement and treatment, their power to improve TB care, and their contributions to data systems that serve population health. Pharmacy curricula should increase TB-related training to better equip future pharmacists to contribute to TB elimination.

Mobile clinics for opioid use disorders: What they do and how they do it. A qualitative analysis.

INTRODUCTION: People with substance use disorders (SUD) face many barriers to receiving evidence-based treatments including access to and cost of treatment. People who use drugs face stigma that limits access to traditional office-based clinics. With the goal of reducing morbidity and mortality, mobile clinics reduce many of these barriers by providing harm reduction and on-demand low-threshold medical care. METHODS: In 2020 Massachusetts Department of Public Health (DPH) Mobile Addiction Services Program expanded a program called Community Care in Reach building on its success in reducing barriers to care and increasing patient encounters. In the current evaluation we conducted site visits to the four new mobile clinics and conducted one individual semi-structured provider interview at each of the four clinics. In addition, we supported a monthly learning collaborative of staff in four agencies involved with this initiative. The current evaluation used the RE-AIM framework to analyze the implementation of the mobile clinics. RESULTS: Clinicians described many challenges and opportunities. The typical patient is unhoused, having a substance use disorder, and disconnected from traditional pathways to care. Clinicians are able to initiate people on buprenorphine largely due to the trust they establish with patients. Referral networks are facilitated by established community linkages. The philosophy of care is patient-centered. Mobile clinics provide a wide range of healthcare services including harm reduction, although finding a location to park and relations with police can be challenging. The workflow is uneven due to the model that is built on unscheduled visits. CONCLUSION: This study provides insight into how mobile clinics address the gaps in care for persons with OUD and fatal opioid overdoses. Harm reduction services are a critical intervention and financial sustainability of mobile clinics has to be tested.

Economic Value of Initial Implementation Activities for Proposed Ban on Sales of Over-The-Counter Diet Pills and Muscle-Building Supplements to Minors.

Introduction: Over-the-counter diet pills, weight-loss supplements, and muscle-building supplements often contain harmful ingredients and are associated with eating disorder diagnoses and other negative health outcomes. This study estimated the value of state initial implementation activities, for example, regulation development, to implement a ban on the sale of dangerous over-the-counter diet pills and muscle-building supplements to minors. Methods: We enumerated minimum, best, and maximum values for 22 inputs among 11 activities state employees may undertake if the legislation were signed into law. For employment costs, we estimated staff hours on the basis of data from 10 key informants and obtained salary ranges from a state government website. Data were collected and analyzed between September 2021 and January 2022. We calculated 95% CIs using 10,000 Monte Carlo simulations that varied inputs simultaneously and probabilistically. We conducted two sensitivity analyses using all minimum and all maximum salaries. Results: The estimated value of state start-up activities was $47,536 (95% CI=$36,831-$57,381). Inputs with the largest impact on this estimate corresponded to combinations of the highest salary and greatest hours per task. Conclusions: The state's one-time opportunity cost to initiate this age-restriction policy would be minimal considering potential health gains. Sensitivity analyses did not change the conclusion, especially if the state produces subregulations linked to existing law rather than new regulations.

Protocol for the implementation of a statewide mobile addiction program.

With overdose deaths increasing, improving access to harm reduction and low barrier substance use disorder treatment is more important than ever. The Community Care in Reach® model uses a mobile unit to bring both harm reduction and clinical care for addiction to people experiencing barriers to office-based care. These mobile units provide many resources and services to people who use drugs, including safer consumption supplies, naloxone, medication for substance use disorder treatment, and a wide range of primary and preventative care. This protocol outlines the evaluation plan for the Community in Care® model in MA, USA. Using the RE-AIM framework, this evaluation will assess how mobile services engage new and underserved communities in addiction services and primary and preventative care.

Emergency department interventions for opioid use disorder: A synthesis of emerging models.

INTRODUCTION: Opioid overdose deaths are increasing, and improving access to evidence-based treatment is necessary. Emergency department (ED) initiation of treatment for opioid use disorder (OUD) via medications and referral to treatment is one approach that leverages a critical health care entry point for individuals with OUD. Efforts to engage patients in treatment through the ED are growing, but systematic analysis of program features as implemented and challenges across different models remains limited. Lessons from early adopter programs may benefit clinicians and others looking to offer ED-initiated treatment for OUD. METHODS: We conducted case studies of five ED-based efforts to address OUD across the United States, selected for diversity in structure, approach, and geography. We conducted telephone interviews with 37 individuals (ED physicians, ED nurses, navigators, hospital administrators, community providers, and state policymakers) affiliated with the five programs. Interviews were transcribed, coded, and analyzed using a framework analysis approach, identifying relevant lessons for replication. RESULTS: These five programs (an academic medical center, two large urban hospitals, a rural community hospital, and a community-based program) successfully implemented ED-initiated MOUD. Often a champion with knowledge of OUD treatment and a reliable connection with outpatient treatment began the program. The approach to patient identification varied from universal screening to relying on patient self-identification. Substance use treatment navigators provide crucial services but can be difficult to pay for within current reimbursement frameworks. Barriers to implementation include lack of knowledge about treatment options and effectiveness, stigma, community treatment capacity limits, and health insurance and reimbursement policies. Facilitators of success include taking a patient-centered, low-barrier approach, having a passionate champion, a strong structure with health system support, and a relationship with community partners. Metrics for success vary across programs. Some programs are expanding to include treating the use of other substances such as alcohol and stimulants. CONCLUSION: ED-initiated MOUD is feasible across different settings. Research and real world efforts need to promote programs that include OUD treatment as standard in ED treatment.

Adverse childhood experiences are associated with increased overdose risk in predominately Latinx adults seeking treatment for substance use disorders.

Introduction: Almost no previous studies explored the relationship between adverse childhood experiences (ACEs) and overdose risk for individuals with substance use disorders (SUDs), and these did not focus on a Latinx population. This study examined the relationship between ACEs, reporting PTSD symptoms, and lifetime experience of overdose in a sample (n = 149) of primarily Latinx adults seeking treatment for substance use disorder (SUD). Materials and methods: Administrative data from an integrated behavioral health and primary care treatment system in Massachusetts were analyzed through bivariate analyses and multiple logistic regression. The final model examined the association between self-reported ACEs, PTSD screen, and lifetime drug overdose. We controlled for demographic characteristics and heroin use and explored alternative measure specifications. Results: ACEs scores were high with 58% having experienced 4+ ACEs. Female gender was associated with a 24% higher ACE score than male gender (p < 0.01). In the multiple logistic model each additional ACE was associated with 1.3 times greater odds of overdose (p < 0.01). Those reporting heroin use had 8.8 times greater odds of reporting overdose compared to those reporting no heroin use (p < 0.001). Gender, age, Puerto Rican ethnicity, years of cocaine use, receiving public assistance income, and a positive initial PTSD screen were not significant. Findings were robust in sensitivity testing. Discussion and conclusion: We found the number of ACEs and reported heroin use significantly and positively associated with self-report of overdose in both bivariate and multiple logistic regression analyses. In contrast, a positive initial screen for PTSD was only significantly associated with overdose in the bivariate analysis. Increased screening for ACEs is warranted and ACE-specific treatment is suggested for SUD treatment programs offering trauma-informed services for adults.

Persistence of symptoms in dengue patients: a clinical cohort study.

BACKGROUND: Dengue is commonly considered an acute illness and follows three phases: febrile, critical in some cases and recovery. However, a number of studies have described a continuation of dengue symptoms for weeks or months, extending the recovery phase. Here we evaluate this persistence of dengue symptoms during convalescence. METHODS: Our clinical cohort study included patients who sought medical services 48 to 144 h from the onset of fever at seven hospitals or ambulatory centers in Morelos, Mexico. Seventy-nine laboratory-confirmed dengue patients were followed up regularly using clinic and/or home visits and telephone calls for as long as symptoms persisted or up to 6 mo. RESULTS: In total, 55.7% of patients had dengue-related symptoms 1 mo after the onset of fever; pain and dermatological manifestations were the most common persistent symptoms. Prognostic factors for symptom persistence were: ≥4 d of fever (RR 1.72; 95% CI 1.35 to 2.19), platelet count ≤100 000/mm3 (RR 1.20; 95% CI 1.20 to 2.20), petechiae/bruises (RR 1.97; 95% CI 1.56 to 2.48) and abdominal pain/hepatomegaly (RR 1.79; 95% CI 1.41 to 2.28). CONCLUSIONS: Persistence of dengue symptoms were common in laboratory-confirmed dengue patients. Manifestations related to tissue damage were associated with persistence after 30 d; host characteristics, such as age and health status before infection, were associated with prolonged persistence (>60 d). The burden of dengue may be higher than previously estimated.

Cost-effectiveness of community mobilization (Camino Verde) for dengue prevention in Nicaragua and Mexico: A cluster randomized controlled trial.

BACKGROUND: We assessed the cost-effectiveness of Camino Verde, a community-based mobilization strategy to prevent and control dengue and other mosquito-borne diseases. A cluster-randomized controlled trial in Managua, Nicaragua, and in three coastal regions in Guerrero, Mexico (75 intervention and 75 control clusters), Camino Verde used non-governmental community health workers, called brigadistas, to support community mobilization. This donor-funded trial demonstrated reductions of 29.5% (95% confidence interval, CI: 3.8%-55.3%) on dengue infections and 24.7% (CI: 1.8%-51.2%) on self-reported cases. METHODS: We estimated program costs through a micro-costing approach and semi-structured questionnaires. We show results as incremental cost-effectiveness ratios (ICERs) for costs per disability-adjusted life-year (DALYs) averted and conducted probabilistic sensitivity analyses. FINDINGS: The Camino Verde trial spent US$16.72 in Mexico and $7.47 in Nicaragua per person annually. We found an average of 910 (CI: 487-1 353) and 500 (CI: 250-760) dengue cases averted annually per million population in Mexico and Nicaragua, respectively, compared to control communities. The ICER in Mexico was US$29 618 (CI: 13 869-66 898) per DALY averted, or 3.0 times per capita GDP. For Nicaragua, the ICER was US$29 196 (CI: 14294-72181) per DALY averted, or 16.9 times per capita GDP. INTERPRETATION: Camino Verde, as implemented in the research context, was marginally cost-effective in Mexico, and not cost-effective in Nicaragua, from a healthcare sector perspective. Nicaragua's low per capita GDP and the use of grant-funded management personnel weakened the cost-effectiveness results. Achieving efficiencies by incorporating Camino Verde activities into existing public health programs would make Camino Verde cost-effective.

Health-Related Quality of Life after Dengue Fever, Morelos, Mexico, 2016-2017.

We adapted the EQ-5D-3L questionnaire and visual analog scale to assess health-related quality of life (HRQOL) and persistent symptoms in 79 patients with laboratory-confirmed dengue in Morelos, Mexico. The lowest HRQOLs were 0.53 and 38.1 (febrile phase). Patients recovered baseline HRQOL in ≈2 months.

Broken smiles: The impact of untreated dental caries and missing anterior teeth on employment.

OBJECTIVES: We aimed to quantify the impact of dental caries and missing anterior teeth on employment, estimate the impact of a routine dental visit on the health of anterior teeth, and the benefits of expanding dental coverage for nonelderly adults. METHODS: We used the 2013-2014 Continuous National Health and Nutritional Examination Survey to develop a dental problem index (DPI) using tooth counts and tooth surface conditions. We estimated the impact of DPI on employment with logistic regression, controlling for seven demographic and socioeconomic covariates. We used a routine dental visit within 6 months as a proxy for access to dental services, and a linear regression to predict the DPI score for an average individual with and without a recent routine dental visit. We then computed the incremental probability of employment associated with a recent routine dental visit. Finally, we estimated the additional number of working age adults who might become employed due to improved access to dental services. RESULTS: The probability of being employed was negatively associated with poor oral health: a one-point increase in DPI decreased the odds of being employed by 7.70 percent (CI: 5.15-10.19%). Having a routine dental visit had a negative and statistically significant impact on DPI [-0.41 (CI: -0.68 to -0.14)]. The incremental probability of employment associated with a routine dental visit was 0.62 percent (CI: 0.21-1.03%). CONCLUSIONS: Oral health in the United States is worse among minorities and poor than among other residents. The benefits associated with access to dental care should justify expanding dental services.

Persistent Symptoms of Dengue: Estimates of the Incremental Disease and Economic Burden in Mexico.

Dengue is mostly considered an acute illness with three phases: febrile, critical with possible hemorrhagic manifestations, and recovery. But some patients present persistent symptoms, including fatigue and depression, as acknowledged by the World Health Organization. If persistent symptoms affect a non-negligible share of patients, the burden of dengue will be underestimated. On the basis of a systematic literature review and econometric modeling, we found a significant relationship between the share of patients reporting persisting symptoms and time. We updated estimates of the economic burden of dengue in Mexico, addressing uncertainty in productivity loss and incremental expenses using Monte Carlo simulations. Persistent symptoms represent annually about US$22.6 (95% certainty level [CL]: US$13-US$29) million in incremental costs and 28.2 (95% CL: 21.6-36.2) additional disability-adjusted life years per million population, or 13% and 43% increases over previous estimates, respectively. Although our estimates have uncertainty from limited data, they show a substantial, unmeasured burden. Similar patterns likely extend to other dengue-endemic countries.

Use of Transnational Services to Prevent Treatment Interruption in Tuberculosis-Infected Persons Who Leave the United States.

A major problem resulting from interrupted tuberculosis (TB) treatment is the development of drug-resistant TB, including multidrug-resistant TB (MDR TB), a more deadly and costly-to-treat form of the disease. Global health systems are not equipped to diagnose and treat the current burden of MDR TB. TB-infected foreign visitors and temporary US residents who leave the country during treatment can experience treatment interruption and, thus, are at greater risk for drug-resistant TB. Using epidemiologic and demographic data, we estimated TB incidence among this group, as well as the proportion of patients referred to transnational care-continuity and management services during relocation; each year, ≈2,827 visitors and temporary residents are at risk for TB treatment interruption, 222 (8%) of whom are referred for transnational services. Scale up of transnational services for persons at high risk for treatment interruption is possible and encouraged because of potential health gains and reductions in healthcare costs for the United States and receiving countries.

The need for performance measures on testing for latent tuberculosis infection in primary care.

BACKGROUND: The millions of people living in the United States with latent tuberculosis infection (LTBI) represent a reservoir of potentially active tuberculosis (TB) disease. When LTBI is left to activate, the consequences may include intense suffering, permanent disability, and high economic costs for patients, their caretakers, and society at large as TB spreads. The introduction of performance measures would improve accountability for quality of care and to reduce disparities, especially if the measures are group-targeted. PERFORMANCE MEASURES PROPOSAL: One National Quality Forum-endorsed measure (#0408) calculates the rate of TB screening in persons with HIV. Using the measure as a model, a set of performance measures is proposed. Denominators will include all persons in a given high-risk category, and numerators will include those persons from the denominators with LTBI test results. National guidelines informed appropriate exclusions. IMPLEMENTATION CHALLENGES AND SOLUTIONS: Challenges to implementation include lack of TB knowledge among primary care providers, potential for overwhelming already burdened schedules, and stigma associated with TB. However, the new measures, along with publication of educational resources, would raise clinicians' awareness. Short checklists and electronic supports would minimize time pressures. The routinization of screening would help reduce stigma. Finally, new federal funding and political will for electronic health records would facilitate data collection and impact assessment. CONCLUSIONS: TB sits at the crossroads of health and economic inequity and is a huge public health problem. The proposed performance measures will address a neglected secondary prevention opportunity and will be consistent with national priorities and health reform.