Will more sensitive diagnostics identify tuberculosis missed by clinicians? Evaluating Xpert MTB/RIF testing in Guatemala

Improving measurement of tuberculosis care cascades to enhance people-centred care

Care cascades represent the proportion of people reaching milestones in care for a disease and are widely used to track progress towards global targets for HIV and other diseases. Despite recent progress in estimating care cascades for tuberculosis (TB) disease, they have not been routinely applied at national and subnational levels, representing a lost opportunity for public health impact. As researchers who have estimated TB care cascades in high-incidence countries (India, Madagascar, Nigeria, Peru, South Africa, and Zambia), we describe the utility of care cascades and identify measurement challenges, including the lack of population-based disease burden data and electronic data capture, the under-reporting of people with TB navigating fragmented and privatised health systems, the heterogeneity of TB tests, and the lack of post-treatment follow-up. We outline an agenda for rectifying these gaps and argue that improving care cascade measurement is crucial to enhancing people-centred care and achieving the End TB goals.

Integrating Xpert MTB/RIF for TB diagnosis in the private sector: evidence from large-scale pilots in Patna and Mumbai, India

Background

Xpert MTB/RIF (Xpert) has been recommended by WHO as the initial diagnostic test for TB and rifampicin-resistance detection. Existing evidence regarding its uptake is limited to public health systems and corresponding resource and infrastructure challenges. It cannot be readily extended to private providers, who treat more than half of India’s TB cases and demonstrate complex diagnostic behavior.

Methods

We used routine program data collected from November 2014 to April 2017 from large-scale private sector engagement pilots in Mumbai and Patna. It included diagnostic vouchers issued to approximately 150,000 patients by about 1400 providers, aggregated to 18,890 provider-month observations. We constructed three metrics to capture provider behavior with regards to adoption of Xpert and studied their longitudinal variation: (i) Uptake (ordering of test), (ii) Utilization for TB diagnosis, and (iii) Non-adherence to negative results. We estimated multivariate linear regression models to assess heterogeneity in provider behavior based on providers’ prior experience and Xpert testing volumes.

Results

Uptake of Xpert increased considerably in both Mumbai (from 36 to 60.4%) and Patna (from 12.2 to 45.1%). However, utilization of Xpert for TB diagnosis and non-adherence to negative Xpert results did not show systematic trends over time. In regression models, cumulative number of Xpert tests ordered was significantly associated with Xpert uptake in Patna and utilization for diagnosis in Mumbai (p-value< 0.01). Uptake of Xpert and its utilization for diagnosis was predicted to be higher in high-volume providers compared to low-volume providers and this gap was predicted to widen over time.

Conclusions

Private sector engagement led to substantial increase in uptake of Xpert, especially among high-volume providers, but did not show strong evidence of Xpert results being integrated with TB diagnosis. Increasing availability and affordability of a technically superior diagnostic tool may not be sufficient to fundamentally change diagnosis and treatment of TB in the private sector. Behavioral interventions, specifically aimed at, integrating Xpert results into clinical decision making of private providers may be required to impact patient-level outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-05817-1.

Islands of Tuberculosis Elimination: An Evaluation of Community-Based Active Case Finding in North Sumatra, Indonesia

Community-based active case finding (ACF) is needed to reach key/vulnerable populations with limited access to tuberculosis (TB) care. Published reports of ACF interventions in Indonesia are scarce. We conducted an evaluation of a multicomponent community-based ACF intervention as it scaled from one district to nine in Nias and mainland North Sumatra. Community and health system support measures including laboratory strengthening, political advocacy, sputum transport, and community awareness were instituted. ACF was conducted in three phases: pilot (18 months, 1 district), intervention (12 months, 4 districts) and scale-up (9 months, 9 districts). The pilot phase identified 215 individuals with bacteriologically positive (B+) TB, representing 42% of B+ TB notifications. The intervention phase yielded 509, representing 54% of B+ notifications and the scale-up phase identified 1345 individuals with B+ TB (56% of notifications). We observed large increases in B+ notifications on Nias, but no overall change on the mainland despite district variation. Overall, community health workers screened 377,304 individuals of whom 1547 tested positive, and 95% were initiated on treatment. Our evaluation shows that multicomponent community-based ACF can reduce the number of people missed by TB programs. Community-based organizations are best placed for accessing and engaging hard to reach populations and providing integrated support which can have a large positive effect on TB notifications.