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      Geographic mobility and treatment outcomes among people in care for tuberculosis in the Lake Victoria region of East Africa: A multi-site prospective cohort study

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          Abstract

          Geographic mobility may disrupt continuity of care and contribute to poor clinical outcomes among people receiving treatment for tuberculosis (TB). This may occur especially where health services are not well coordinated across international borders, particularly in lower and middle income country settings. In this work, we describe mobility and the relationship between mobility and unfavorable TB treatment outcomes (i.e., death, loss to follow-up, or treatment failure) among a cohort of adults who initiated TB treatment at one of 12 health facilities near Lake Victoria. We abstracted data from health facility records for all 776 adults initiating TB treatment during a 6-month period at the selected facilities in Kenya, Tanzania, and Uganda. We interviewed 301 cohort members to assess overnight travel outside one’s residential district/sub-county. In our analyses, we estimated the proportion of cohort members traveling in 2 and 6 months following initiation of TB treatment, explored correlates of mobility, and examined the association between mobility and an unfavorable TB treatment outcome. We estimated that 40.7% (95% CI: 33.3%, 49.6%) of people on treatment for TB traveled overnight at least once in the 6 months following treatment initiation. Mobility was more common among people who worked in the fishing industry and among those with extra-pulmonary TB. Mobility was not strongly associated with other characteristics examined, however, suggesting that efforts to improve TB care for mobile populations should be broad ranging. We found that in this cohort, people who were mobile were not at increased risk of an unfavorable TB treatment outcome. Findings from this study can help inform development and implementation of mobility-competent health services for people with TB in East Africa.

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          Multiple imputation using chained equations: Issues and guidance for practice

          Multiple imputation by chained equations is a flexible and practical approach to handling missing data. We describe the principles of the method and show how to impute categorical and quantitative variables, including skewed variables. We give guidance on how to specify the imputation model and how many imputations are needed. We describe the practical analysis of multiply imputed data, including model building and model checking. We stress the limitations of the method and discuss the possible pitfalls. We illustrate the ideas using a data set in mental health, giving Stata code fragments. 2010 John Wiley & Sons, Ltd.
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            Multiple imputation of discrete and continuous data by fully conditional specification.

            The goal of multiple imputation is to provide valid inferences for statistical estimates from incomplete data. To achieve that goal, imputed values should preserve the structure in the data, as well as the uncertainty about this structure, and include any knowledge about the process that generated the missing data. Two approaches for imputing multivariate data exist: joint modeling (JM) and fully conditional specification (FCS). JM is based on parametric statistical theory, and leads to imputation procedures whose statistical properties are known. JM is theoretically sound, but the joint model may lack flexibility needed to represent typical data features, potentially leading to bias. FCS is a semi-parametric and flexible alternative that specifies the multivariate model by a series of conditional models, one for each incomplete variable. FCS provides tremendous flexibility and is easy to apply, but its statistical properties are difficult to establish. Simulation work shows that FCS behaves very well in the cases studied. The present paper reviews and compares the approaches. JM and FCS were applied to pubertal development data of 3801 Dutch girls that had missing data on menarche (two categories), breast development (five categories) and pubic hair development (six stages). Imputations for these data were created under two models: a multivariate normal model with rounding and a conditionally specified discrete model. The JM approach introduced biases in the reference curves, whereas FCS did not. The paper concludes that FCS is a useful and easily applied flexible alternative to JM when no convenient and realistic joint distribution can be specified.
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              Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis.

              The American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America jointly sponsored the development of this guideline for the treatment of drug-susceptible tuberculosis, which is also endorsed by the European Respiratory Society and the US National Tuberculosis Controllers Association. Representatives from the American Academy of Pediatrics, the Canadian Thoracic Society, the International Union Against Tuberculosis and Lung Disease, and the World Health Organization also participated in the development of the guideline. This guideline provides recommendations on the clinical and public health management of tuberculosis in children and adults in settings in which mycobacterial cultures, molecular and phenotypic drug susceptibility tests, and radiographic studies, among other diagnostic tools, are available on a routine basis. For all recommendations, literature reviews were performed, followed by discussion by an expert committee according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. Given the public health implications of prompt diagnosis and effective management of tuberculosis, empiric multidrug treatment is initiated in almost all situations in which active tuberculosis is suspected. Additional characteristics such as presence of comorbidities, severity of disease, and response to treatment influence management decisions. Specific recommendations on the use of case management strategies (including directly observed therapy), regimen and dosing selection in adults and children (daily vs intermittent), treatment of tuberculosis in the presence of HIV infection (duration of tuberculosis treatment and timing of initiation of antiretroviral therapy), as well as treatment of extrapulmonary disease (central nervous system, pericardial among other sites) are provided. The development of more potent and better-tolerated drug regimens, optimization of drug exposure for the component drugs, optimal management of tuberculosis in special populations, identification of accurate biomarkers of treatment effect, and the assessment of new strategies for implementing regimens in the field remain key priority areas for research. See the full-text online version of the document for detailed discussion of the management of tuberculosis and recommendations for practice.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – review & editing
                Role: Data curationRole: InvestigationRole: SupervisionRole: Writing – review & editing
                Role: Data curationRole: InvestigationRole: SupervisionRole: Writing – review & editing
                Role: Data curationRole: InvestigationRole: SupervisionRole: Writing – review & editing
                Role: InvestigationRole: SupervisionRole: Writing – review & editing
                Role: InvestigationRole: Writing – review & editing
                Role: Data curationRole: InvestigationRole: SupervisionRole: Writing – review & editing
                Role: Project administrationRole: SupervisionRole: Writing – review & editing
                Role: InvestigationRole: Project administrationRole: SupervisionRole: Writing – review & editing
                Role: Writing – review & editing
                Role: ConceptualizationRole: Writing – review & editing
                Role: ConceptualizationRole: Writing – review & editing
                Role: ConceptualizationRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: MethodologyRole: Writing – review & editing
                Role: Editor
                Journal
                PLOS Glob Public Health
                PLOS Glob Public Health
                plos
                PLOS Global Public Health
                Public Library of Science (San Francisco, CA USA )
                2767-3375
                5 June 2023
                2023
                : 3
                : 6
                : e0001992
                Affiliations
                [1 ] Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
                [2 ] Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
                [3 ] Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
                [4 ] Kenya Medical Research Institute, Nairobi, Kenya
                [5 ] Mwanza Intervention Trials Unit, Mwanza Research Centre, National Institute for Medical Research, Mwanza, Tanzania
                [6 ] UVRI-IAVI HIV Vaccine Program Limited, Entebbe, Uganda
                [7 ] Global Health and Development Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
                [8 ] Department of Geography, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
                Africa Health Research Institute, SOUTH AFRICA
                Author notes

                The authors have declared that no competing interests exist.

                Author information
                https://orcid.org/0000-0003-0046-2144
                https://orcid.org/0000-0002-3629-3867
                https://orcid.org/0000-0003-1092-4832
                https://orcid.org/0000-0001-7900-9689
                https://orcid.org/0000-0003-2156-3024
                https://orcid.org/0000-0002-0583-5272
                https://orcid.org/0000-0002-3387-0817
                https://orcid.org/0000-0002-1741-335X
                Article
                PGPH-D-22-01578
                10.1371/journal.pgph.0001992
                10241360
                b5708d23-4810-4b63-bc13-fad5443d3e17
                © 2023 Mulholland et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 29 September 2022
                : 4 May 2023
                Page count
                Figures: 3, Tables: 4, Pages: 20
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100000200, United States Agency for International Development;
                Award ID: AID-OAA-L-14-00004
                Funded by: funder-id http://dx.doi.org/10.13039/100000060, National Institute of Allergy and Infectious Diseases;
                Award ID: R01AI157758
                Award Recipient :
                The parent study was supported by the United States Agency for International Development (USAID) under the terms of MEASURE Evaluation cooperative agreement AID‐OAA‐L‐14‐00004. MEASURE Evaluation was implemented by the Carolina Population Center, University of North Carolina at Chapel Hill in partnership with ICF International; John Snow, Inc.; Management Sciences for Health; Palladium; and Tulane University. Views expressed are not necessarily those of USAID or the United States Government. GEM and JKE were also supported by R01AI157758. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
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                Data are available from the UNC Dataverse ( https://doi.org/10.15139/S3/IURHL6).

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