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Addressing Institutional Amplifiers in the Dynamics and Control of Tuberculosis Epidemics

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  • Department of Medicine, University of California, Division of General Internal Medicine, San Francisco General Hospital, San Francisco, California; Department of Sociology, Oxford University, Oxford, United Kingdom; Department of Public Health and Policy, European Observatory on Health Systems and Policies, London School of Hygiene and Tropical Medicine, London, United Kingdom

Tuberculosis outbreaks originating in prisons, mines, or hospital wards can spread to the larger community. Recent proposals have targeted these high-transmission institutional amplifiers by improving case detection, treatment, or reducing the size of the exposed population. However, what effects these alternative proposals may have is unclear. We mathematically modeled these control strategies and found case detection and treatment methods insufficient in addressing epidemics involving common types of institutional amplifiers. Movement of persons in and out of amplifiers fundamentally altered the transmission dynamics of tuberculosis in a manner not effectively mitigated by detection or treatment alone. Policies increasing the population size exposed to amplifiers or the per-person duration of exposure within amplifiers potentially worsened incidence, even in settings with high rates of detection and treatment success. However, reducing the total population size entering institutional amplifiers significantly lowered tuberculosis incidence and the risk of propagating new drug-resistant tuberculosis strains.

Author Notes

*Address correspondence to: Sanjay Basu, Department of Medicine, University of California, San Francisco, 505 Parnassus, Room M-987, San Francisco, CA 94143. E-mail: sanjay.basu@ucsf.edu

Financial support: Sanjay Basu is supported by the U.S. Centers for Disease Control and Prevention (R36) and the National Institutes of Health (T32). Martin McKee is supported by the European Observatory on Health Systems and Policies.

Authors' addresses: Sanjay Basu, Department of Medicine, University of California, San Francisco, Division of General Internal Medicine, San Francisco General Hospital, San Francisco, CA, E-mail: sanjay.basu@ucsf.edu. David Stuckler, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom, and Department of Sociology, Oxford University, Meadow Flat, Christ Church, Oxford, United Kingdom, E-mail: david.stuckler@chch.ox.ac.uk. Martin McKee, European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, London, United Kingdom, E-mail: martin.mckee@lshtm.ac.uk.

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