1887
  1. Home
  2. Eurosurveillance
  3. Volume 23, Issue 14, 05/Apr/2018
  4. Article
Systematic Review Open Access
Like 0
Download

Abstract

Background

Migrants account for a large and growing proportion of tuberculosis (TB) cases in low-incidence countries in the European Union/European Economic Area (EU/EEA) which are primarily due to reactivation of latent TB infection (LTBI). Addressing LTBI among migrants will be critical to achieve TB elimination. We conducted a systematic review to determine effectiveness (performance of diagnostic tests, efficacy of treatment, uptake and completion of screening and treatment) and a second systematic review on cost-effectiveness of LTBI screening programmes for migrants living in the EU/EEA. We identified seven systematic reviews and 16 individual studies that addressed our aims. Tuberculin skin tests and interferon gamma release assays had high sensitivity (79%) but when positive, both tests poorly predicted the development of active TB (incidence rate ratio: 2.07 and 2.40, respectively). Different LTBI treatment regimens had low to moderate efficacy but were equivalent in preventing active TB. Rifampicin-based regimens may be preferred because of lower hepatotoxicity (risk ratio = 0.15) and higher completion rates (82% vs 69%) compared with isoniazid. Only 14.3% of migrants eligible for screening completed treatment because of losses along all steps of the LTBI care cascade. Limited economic analyses suggest that the most cost-effective approach may be targeting young migrants from high TB incidence countries. The effectiveness of LTBI programmes is limited by the large pool of migrants with LTBI, poorly predictive tests, long treatments and a weak care cascade. Targeted LTBI programmes that ensure high screening uptake and treatment completion will have greatest individual and public health benefit.

© Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.
Loading

Article metrics loading...

/content/10.2807/1560-7917.ES.2018.23.14.17-00543
2018-04-05
2024-11-21
http://instance.metastore.ingenta.com/content/10.2807/1560-7917.ES.2018.23.14.17-00543
Loading
Loading full text...

Full text loading...

/deliver/fulltext/eurosurveillance/23/14/eurosurv-23-14-3.html?itemId=/content/10.2807/1560-7917.ES.2018.23.14.17-00543&mimeType=html&fmt=ahah

References

  1. European Centre for Disease Prevention and Control (ECDC). Framework action plan to fight tuberculosis in the European Union. Stockholm: ECDC; 2008. Available from: https://ecdc.europa.eu/en/publications-data/framework-action-plan-fight-tuberculosis-european-union
  2. European Centre for Disease Prevention and Control (ECDC). Progressing towards TB elimination. Stockholm: ECDC; 2010. Available from: https://ecdc.europa.eu/en/publications-data/progressing-towards-tb-elimination
  3. Lönnroth K, Migliori GB, Abubakar I, D’Ambrosio L, de Vries G, Diel R, et al. Towards tuberculosis elimination: an action framework for low-incidence countries. Eur Respir J. 2015;45(4):928-52. PMID: 25792630 
  4. European Centre for Disease Prevention and Control (ECDC)/World Health Organization Regional Office for Europe. Tuberculosis surveillance and monitoring in Europe 2018 – 2016 data. Stockholm: ECDC; 2018. Available from: https://ecdc.europa.eu/sites/portal/files/documents/ecdc-tuberculosis-surveillance-monitoring-Europe-2018-19mar2018.pdf
  5. van der Werf MJ, Zellweger JP. Impact of migration on tuberculosis epidemiology and control in the EU/EEA. Euro Surveill. 2016;21(12):30174.  https://doi.org/10.2807/1560-7917.ES.2016.21.12.30174  PMID: 27035852 
  6. Getahun H, Matteelli A, Abubakar I, Aziz MA, Baddeley A, Barreira D, et al. Management of latent Mycobacterium tuberculosis infection: WHO guidelines for low tuberculosis burden countries. Eur Respir J. 2015;46(6):1563-76.  https://doi.org/10.1183/13993003.01245-2015  PMID: 26405286 
  7. European Centre for Disease Prevention and Control (ECDC). Tuberculosis surveillance and monitoring in Europe. Stockholm: ECDC; 2017. Available from: https://ecdc.europa.eu/en/publications-data/tuberculosis-surveillance-and-monitoring-europe-2017
  8. Eurostat. Migration and migrant population statistics. Luxembourg: European Commission. [Accessed: 30 Jan 2017]. Available from: http://ec.europa.eu/eurostat/statistics-explained/index.php/Migration_and_migrant_population_statistics
  9. International Organization for Migration (IOM). Migration flows - Europe. Geneva: IOM; [Accessed: 15 May 2017]. Available from: http://migration.iom.int/europe/
  10. Eurostat. European social statistics. Luxembourg; 2013.
  11. Pareek M, Baussano I, Abubakar I, Dye C, Lalvani A. Evaluation of immigrant tuberculosis screening in industrialized countries. Emerg Infect Dis. 2012;18(9):1422-9.  https://doi.org/10.3201/eid1809.120128  PMID: 22931959 
  12. Public Health England (PHE). Tuberculosis in England 2016 report (presenting data to end of 2015). London: PHE; 2016. Available from: https://www.tbalert.org/wp-content/uploads/2016/09/PHE_TB_Annual_Report_2016.pdf
  13. Campbell JR, Chen W, Johnston J, Cook V, Elwood K, Krot J, et al. Latent tuberculosis infection screening in immigrants to low-incidence countries: a meta-analysis. Mol Diagn Ther. 2015;19(2):107-17.  https://doi.org/10.1007/s40291-015-0135-6  PMID: 25851739 
  14. D’Ambrosio L, Centis R, Dara M, Solovic I, Sulis G, Zumla A, et al. European policies in the management of tuberculosis among migrants. In press Inter. J Infect Dis. 2017;56:85-9.
  15. Dara M, Solovic I, Sotgiu G, D’Ambrosio L, Centis R, Tran R, et al. Tuberculosis care among refugees arriving in Europe: a ERS/WHO Europe Region survey of current practices. Eur Respir J. 2016;48(3):808-17.  https://doi.org/10.1183/13993003.00840-2016  PMID: 27492827 
  16. Schünemann HJ, Wiercioch W, Brozek J, Etxeandia-Ikobaltzeta I, Mustafa RA, Manja V, et al. GRADE Evidence to Decision (EtD) frameworks for adoption, adaptation, and de novo development of trustworthy recommendations: GRADE-ADOLOPMENT. J Clin Epidemiol. 2017;81:101-10.  https://doi.org/10.1016/j.jclinepi.2016.09.009  PMID: 27713072 
  17. Pottie K, Mayhew AD, Morton RL, Greenaway C, Akl EA, Rahman P, et al. Prevention and assessment of infectious diseases among children and adult migrants arriving to the European Union/European Economic Association: a protocol for a suite of systematic reviews for public health and health systems. BMJ Open. 2017;7(9) e014608;e014608.  https://doi.org/10.1136/bmjopen-2016-014608  PMID: 28893741 
  18. Moher D, Liberati A, Tetzlaff J, Altman DGPRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264-9, W64.  https://doi.org/10.7326/0003-4819-151-4-200908180-00135  PMID: 19622511 
  19. Woolf S, Schünemann HJ, Eccles MP, Grimshaw JM, Shekelle P. Developing clinical practice guidelines: types of evidence and outcomes; values and economics, synthesis, grading, and presentation and deriving recommendations. Implement Sci. 2012;7(61).  https://doi.org/10.1186/1748-5908-7-61  PMID: 22762158 
  20. Kahwati LC, Feltner C, Halpern M, Woodell CL, Boland E, Amick HR, et al. Primary care screening and treatment for latent tuberculosis infection in adults: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2016;316(9):970-83.  https://doi.org/10.1001/jama.2016.10357  PMID: 27599332 
  21. Greenaway C, Sandoe A, Vissandjee B, Kitai I, Gruner D, Wobeser W, et al. Tuberculosis: evidence review for newly arriving immigrants and refugees. CMAJ. 2011;183(12):E939-51.  https://doi.org/10.1503/cmaj.090302  PMID: 20634392 
  22. Shea BJ, Hamel C, Wells GA, Bouter LM, Kristjansson E, Grimshaw J, et al. AMSTAR is a reliable and valid measurement tool to assess the methodological quality of systematic reviews. J Clin Epidemiol. 2009;62(10):1013-20.  https://doi.org/10.1016/j.jclinepi.2008.10.009  PMID: 19230606 
  23. Wells G, Shea B, O’Connell B, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. . Ottawa: Ottawa Hospital Research Institute; [Accessed: 15 Oct 2016]. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp
  24. Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64(4):383-94.  https://doi.org/10.1016/j.jclinepi.2010.04.026  PMID: 21195583 
  25. Alonso-Coello P, Schünemann HJ, Moberg J, Brignardello-Petersen R, Akl EA, Davoli M, et al. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 1: Introduction. BMJ. 2016;353:i2016.  https://doi.org/10.1136/bmj.i2016  PMID: 27353417 
  26. Drummond MFSM, Torrance GW, O’Brien BJ, Stoddart GL. Methods for the economic evaluation of health care programmes. 2nd edition. New York: Oxford University Press; 1997. 396 p.
  27. Pai M, Zwerling A, Menzies D. Systematic review: T-cell-based assays for the diagnosis of latent tuberculosis infection: an update. Ann Intern Med. 2008;149(3):177-84.  https://doi.org/10.7326/0003-4819-149-3-200808050-00241  PMID: 18593687 
  28. Kik SMRM. Predictive utility of the tuberculin skin test and interferon-gamma release assay among individuals who are not prescribed tuberculosis preventive therapy. Geneva: World Health Organization; 2014.
  29. Stagg HR, Zenner D, Harris RJ, Muñoz L, Lipman MC, Abubakar I. Treatment of latent tuberculosis infection: a network meta-analysis. Ann Intern Med. 2014;161(6):419-28.  https://doi.org/10.7326/M14-1019  PMID: 25111745 
  30. Sharma SK, Sharma A, Kadhiravan T, Tharyan P. Rifamycins (rifampicin, rifabutin and rifapentine) compared to isoniazid for preventing tuberculosis in HIV-negative people at risk of active TB. Evid Based Child Health. 2014;9(1):169-294.  https://doi.org/10.1002/ebch.1962  PMID: 25404581 
  31. Alsdurf H, Hill PC, Matteelli A, Getahun H, Menzies D. The cascade of care in diagnosis and treatment of latent tuberculosis infection: a systematic review and meta-analysis. Lancet Infect Dis. 2016;16(11):1269-78.  https://doi.org/10.1016/S1473-3099(16)30216-X  PMID: 27522233 
  32. Sandgren A, Vonk Noordegraaf-Schouten M, van Kessel F, Stuurman A, Oordt-Speets A, van der Werf MJ. Initiation and completion rates for latent tuberculosis infection treatment: a systematic review. BMC Infect Dis. 2016;16(1):204.  https://doi.org/10.1186/s12879-016-1550-y  PMID: 27184748 
  33. Iqbal AZ, Leighton J, Anthony J, Knaup RC, Peters EB, Bailey TC. Cost-effectiveness of using Quantiferon Gold (QFT-G)® versus tuberculin skin test (TST) among U.S. and foreign born populations at a public health department clinic with a low prevalence of tuberculosis. Public Health Nurs. 2014;31(2):144-52.  https://doi.org/10.1111/phn.12083  PMID: 24117837 
  34. Shah M, Miele K, Choi H, DiPietro D, Martins-Evora M, Marsiglia V, et al. QuantiFERON-TB gold in-tube implementation for latent tuberculosis diagnosis in a public health clinic: a cost-effectiveness analysis. BMC Infect Dis. 2012;12(1):360.  https://doi.org/10.1186/1471-2334-12-360  PMID: 23253780 
  35. Pareek M, Watson JP, Ormerod LP, Kon OM, Woltmann G, White PJ, et al. Screening of immigrants in the UK for imported latent tuberculosis: a multicentre cohort study and cost-effectiveness analysis. Lancet Infect Dis. 2011;11(6):435-44.  https://doi.org/10.1016/S1473-3099(11)70069-X  PMID: 21514236 
  36. Linas BP, Wong AY, Freedberg KA, Horsburgh CR Jr. Priorities for screening and treatment of latent tuberculosis infection in the United States. Am J Respir Crit Care Med. 2011;184(5):590-601.  https://doi.org/10.1164/rccm.201101-0181OC  PMID: 21562129 
  37. Mancuso JD, Niebuhr DW, Frick KD, Keep LW, Anderson KM. Cost-effectiveness analysis of targeted and sequential screening strategies for latent tuberculosis. Int J Tuberc Lung Dis. 2011;15(9):1223-30, i.  https://doi.org/10.5588/ijtld.10.0542  PMID: 21943850 
  38. Pooran A, Booth H, Miller RF, Scott G, Badri M, Huggett JF, et al. Different screening strategies (single or dual) for the diagnosis of suspected latent tuberculosis: a cost effectiveness analysis. BMC Pulm Med. 2010;10(1):7.  https://doi.org/10.1186/1471-2466-10-7  PMID: 20170555 
  39. Deuffic-Burban S, Atsou K, Viget N, Melliez H, Bouvet E, Yazdanpanah Y. Cost-effectiveness of QuantiFERON-TB test vs. tuberculin skin test in the diagnosis of latent tuberculosis infection. Int J Tuberc Lung Dis. 2010;14(4):471-81. PMID: 20202306 
  40. Hardy AB, Varma R, Collyns T, Moffitt SJ, Mullarkey C, Watson JP. Cost-effectiveness of the NICE guidelines for screening for latent tuberculosis infection: the QuantiFERON-TB Gold IGRA alone is more cost-effective for immigrants from high burden countries. Thorax. 2010;65(2):178-80.  https://doi.org/10.1136/thx.2009.119677  PMID: 19996345 
  41. Oxlade O, Schwartzman K, Menzies D. Interferon-gamma release assays and TB screening in high-income countries: a cost-effectiveness analysis. Int J Tuberc Lung Dis. 2007;11(1):16-26. PMID: 17217125 
  42. Brassard P, Steensma C, Cadieux L, Lands LC. Evaluation of a school-based tuberculosis-screening program and associate investigation targeting recently immigrated children in a low-burden country. Pediatrics. 2006;117(2):e148-56.  https://doi.org/10.1542/peds.2005-1534  PMID: 16452324 
  43. Porco TC, Lewis B, Marseille E, Grinsdale J, Flood JM, Royce SE. Cost-effectiveness of tuberculosis evaluation and treatment of newly-arrived immigrants. BMC Public Health. 2006;6(1):157.  https://doi.org/10.1186/1471-2458-6-157  PMID: 16784541 
  44. Khan K, Muennig P, Behta M, Zivin JG. Global drug-resistance patterns and the management of latent tuberculosis infection in immigrants to the United States. N Engl J Med. 2002;347(23):1850-9.  https://doi.org/10.1056/NEJMsa021099  PMID: 12466510 
  45. Chang S, Wheeler LS, Farrell KP. Public health impact of targeted tuberculosis screening in public schools. Am J Public Health. 2002;92(12):1942-5.  https://doi.org/10.2105/AJPH.92.12.1942  PMID: 12453813 
  46. Dasgupta K, Schwartzman K, Marchand R, Tennenbaum TN, Brassard P, Menzies D. Comparison of cost-effectiveness of tuberculosis screening of close contacts and foreign-born populations. Am J Respir Crit Care Med. 2000;162(6):2079-86.  https://doi.org/10.1164/ajrccm.162.6.2001111  PMID: 11112118 
  47. Schwartzman K, Menzies D. Tuberculosis screening of immigrants to low-prevalence countries. A cost-effectiveness analysis. Am J Respir Crit Care Med. 2000;161(3 Pt 1):780-9.  https://doi.org/10.1164/ajrccm.161.3.9902005  PMID: 10712322 
  48. Pareek M, Bond M, Shorey J, Seneviratne S, Guy M, White P, et al. Community-based evaluation of immigrant tuberculosis screening using interferon γ release assays and tuberculin skin testing: observational study and economic analysis. Thorax. 2013;68(3):230-9.  https://doi.org/10.1136/thoraxjnl-2011-201542  PMID: 22693179 
  49. World Health Organisation WHO). The End TB Strategy. Geneva: WHO; 2015. Available from: http://www.who.int/tb/End_TB_brochure.pdf?ua=1
  50. World Health Organisation (WHO). Towards TB Elimination. An action framework for low-incidence countries. Geneva: WHO; 2014. Available from: http://apps.who.int/iris/bitstream/10665/132231/1/9789241507707_eng.pdf?ua=1
  51. Marks GB, Bai J, Simpson SE, Sullivan EA, Stewart GJ. Incidence of tuberculosis among a cohort of tuberculin-positive refugees in Australia: reappraising the estimates of risk. Am J Respir Crit Care Med. 2000;162(5):1851-4.  https://doi.org/10.1164/ajrccm.162.5.2004154  PMID: 11069825 
  52. Trauer JM, Moyo N, Tay EL, Dale K, Ragonnet R, McBryde ES, et al. Risk of active tuberculosis in the five years following infection. . .15%? Chest. 2016;149(2):516-25.  https://doi.org/10.1016/j.chest.2015.11.017  PMID: 26867835 
  53. Fox GJ, Barry SE, Britton WJ, Marks GB. Contact investigation for tuberculosis: a systematic review and meta-analysis. Eur Respir J. 2013;41(1):140-56.  https://doi.org/10.1183/09031936.00070812  PMID: 22936710 
  54. Farah MG, Meyer HE, Selmer R, Heldal E, Bjune G. Long-term risk of tuberculosis among immigrants in Norway. Int J Epidemiol. 2005;34(5):1005-11.  https://doi.org/10.1093/ije/dyi058  PMID: 15802379 
  55. Aldridge RW, Zenner D, White PJ, Williamson EJ, Muzyamba MC, Dhavan P, et al. Tuberculosis in migrants moving from high-incidence to low-incidence countries: a population-based cohort study of 519 955 migrants screened before entry to England, Wales, and Northern Ireland. Lancet. 2016;388(10059):2510-8.  https://doi.org/10.1016/S0140-6736(16)31008-X  PMID: 27742165 
  56. Creatore MI, Lam M, Wobeser WL. Patterns of tuberculosis risk over time among recent immigrants to Ontario, Canada. Int J Tuberc Lung Dis. 2005;9(6):667-72. PMID: 15971395 
  57. Cain KP, Haley CA, Armstrong LR, Garman KN, Wells CD, Iademarco MF, et al. Tuberculosis among foreign-born persons in the United States: achieving tuberculosis elimination. Am J Respir Crit Care Med. 2007;175(1):75-9.  https://doi.org/10.1164/rccm.200608-1178OC  PMID: 17038659 
  58. Lönnroth K, Mor Z, Erkens C, Bruchfeld J, Nathavitharana RR, van der Werf MJ, et al. Tuberculosis in migrants in low-incidence countries: epidemiology and intervention entry points. Int J Tuberc Lung Dis. 2017;21(6):624-37.  https://doi.org/10.5588/ijtld.16.0845  PMID: 28482956 
  59. Kik SV, Mensen M, Beltman M, Gijsberts M, van Ameijden EJ, Cobelens FG, et al. Risk of travelling to the country of origin for tuberculosis among immigrants living in a low-incidence country. Int J Tuberc Lung Dis. 2011;15(1):38-43. PMID: 21276294 
  60. McCarthy OR. Asian immigrant tuberculosis--the effect of visiting Asia. Br J Dis Chest. 1984;78(3):248-53.  https://doi.org/10.1016/0007-0971(84)90136-0  PMID: 6743520 
  61. Pai M, Behr M. Latent Mycobacterium tuberculosis infection and interferon-gamma release assays. Microbiol Spectr. 2016;4(5). PMID: 27763261 
  62. Munro SA, Lewin SA, Smith HJ, Engel ME, Fretheim A, Volmink J. Patient adherence to tuberculosis treatment: a systematic review of qualitative research. PLoS Med. 2007;4(7):e238.  https://doi.org/10.1371/journal.pmed.0040238  PMID: 17676945 
  63. Abarca Tomás B, Pell C, Bueno Cavanillas A, Guillén Solvas J, Pool R, Roura M. Tuberculosis in migrant populations. A systematic review of the qualitative literature. PLoS One. 2013;8(12):e82440.  https://doi.org/10.1371/journal.pone.0082440  PMID: 24349284 
  64. Griffiths C, Sturdy P, Brewin P, Bothamley G, Eldridge S, Martineau A, et al. Educational outreach to promote screening for tuberculosis in primary care: a cluster randomised controlled trial. Lancet. 2007;369(9572):1528-34.  https://doi.org/10.1016/S0140-6736(07)60707-7  PMID: 17482983 
  65. Zenner D, Hafezi H, Potter J, Capone S, Matteelli A. Effectiveness and cost-effectiveness of screening migrants for active tuberculosis and latent tuberculous infection. Int J Tuberc Lung Dis. 2017;21(9):965-76.  https://doi.org/10.5588/ijtld.16.0935  PMID: 28826445 
The effectiveness and cost-effectiveness of screening for latent tuberculosis among migrants in the EU/EEA: a systematic review
<p class="citation"> <span>Citation style for this article:</span> <span class="meta-value authors"> <a href="/search?value1=Christina+Greenaway&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Greenaway Christina</a>, <a href="/search?value1=Manish+Pareek&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Pareek Manish</a>, <a href="/search?value1=Claire-Nour+Abou+Chakra&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Abou Chakra Claire-Nour</a>, <a href="/search?value1=Moneeza+Walji&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Walji Moneeza</a>, <a href="/search?value1=Iuliia+Makarenko&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Makarenko Iuliia</a>, <a href="/search?value1=Balqis+Alabdulkarim&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Alabdulkarim Balqis</a>, <a href="/search?value1=Catherine+Hogan&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Hogan Catherine</a>, <a href="/search?value1=Ted+McConnell&option1=author&noRedirect=true" class="nonDisambigAuthorLink">McConnell Ted</a>, <a href="/search?value1=Brittany+Scarfo&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Scarfo Brittany</a>, <a href="/search?value1=Robin+Christensen&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Christensen Robin</a>, <a href="/search?value1=Anh+Tran&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Tran Anh</a>, <a href="/search?value1=Nick+Rowbotham&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Rowbotham Nick</a>, <a href="/search?value1=Marieke+J+van+der+Werf&option1=author&noRedirect=true" class="nonDisambigAuthorLink">van der Werf Marieke J</a>, <a href="/search?value1=Teymur+Noori&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Noori Teymur</a>, <a href="/search?value1=Kevin+Pottie&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Pottie Kevin</a>, <a href="/search?value1=Alberto+Matteelli&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Matteelli Alberto</a>, <a href="/search?value1=Dominik+Zenner&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Zenner Dominik</a>, <a href="/search?value1=Rachael+L.+Morton&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Morton Rachael L.</a></span>. The effectiveness and cost-effectiveness of screening for latent tuberculosis among migrants in the EU/EEA: a systematic review. <a href="/content/ecdc">Euro Surveill.</a> 2018;23(14):pii=17-00543. <a href="https://doi.org/10.2807/1560-7917.ES.2018.23.14.17-00543" title="doi link" target="_blank">https://doi.org/10.2807/1560-7917.ES.2018.23.14.17-00543</a> <span class="ES_Article_citation"> <span class="generated">Received</span>: 31 Jul 2017;&nbsp;&nbsp; <span class="generated">Accepted</span>: 16 Mar 2018 </span> </p>
/content/10.2807/1560-7917.ES.2018.23.14.17-00543
/content/10.2807/1560-7917.ES.2018.23.14.17-00543
Loading

Data & Media loading...

Supplementary data

  • Download

    • Search Strategy #1: Effectiveness and cost-effectiveness search

Submit comment
Close
Comment moderation successfully completed
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error