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Govender T, Furin JJ, Edwards A, Pillay S, Murphy RA. What clinic closure reveals about care for drug-resistant TB: a qualitative study. BMC Infect Dis 2023; 23:474. [PMID: 37460960 DOI: 10.1186/s12879-023-08405-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 06/19/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND There have been calls for "person-centered" approaches to drug-resistant tuberculosis (DR-TB) care. In 2020, Charles James Hospital in South Africa, which incorporated person-centered care, was closed. Patients were referred mid-course to a centralized, tertiary hospital, providing an opportunity to examine person-centered DR-TB and HIV care from the perspective of patients who lost access to it. METHODS The impact of transfer was explored through qualitative interviews performed using standard methods. Analysis involved grounded theory; interviews were assessed for theme and content. RESULTS After switching to the centralized site, patients reported being unsatisfied with losing access to a single clinic and pharmacy where DR-TB, HIV and chronic disease care were integrated. Patients also reported a loss of care continuity; at the decentralized site there was a single, familiar clinician whereas the centralized site had multiple, changing clinicians and less satisfactory communication. Additionally, patients reported more disease-related stigma and less respectful treatment, noting the loss of a "special place" for DR-TB treatment. CONCLUSION By focusing on a DR-TB clinic closure, we uncovered aspects of person-centered care that were critical to people living with DR-TB and HIV. These perspectives can inform how care for DR-TB is operationalized to optimize treatment retention and effectiveness.
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Affiliation(s)
| | | | - Alex Edwards
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, GA, USA
- University of Lincoln, Brayford Pool, Lincoln, UK
| | - Selvan Pillay
- Adrenergy Research Innovations, Durban, South Africa
| | - Richard A Murphy
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
- White River Junction Veterans Affairs Medical Center, Medicine Service 163 Veterans Drive, 05009, White River Junction, VT, USA.
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Govender T, Jham MA, Zhang JC, Pillay S, Pak Y, Pillay P, Furin J, Malenfant J, Murphy RA. Decentralized, Integrated Treatment of RR/MDR-TB and HIV Using a Bedaquiline-Based, Short-Course Regimen Is Effective and Associated With Improved HIV Disease Control. J Acquir Immune Defic Syndr 2023; 92:385-392. [PMID: 36729541 PMCID: PMC10006315 DOI: 10.1097/qai.0000000000003150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/01/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND In decentralized sites, with fewer resources and a high prevalence of advanced HIV, the effectiveness of the new short-course, bedaquiline-based regimen for rifampicin-resistant and multidrug-resistant tuberculosis (RR/MDR-TB) is not well-described. SETTING Adults with pulmonary RR/MDR-TB initiating the short-course regimen in KwaZulu-Natal, South Africa were prospectively enrolled at a decentralized program that integrated person-centered TB care. METHODS In addition to standard of care monitoring, study visits occurred at enrollment and months 1, 2, 4, 6, and 9. Favorable RR/MDR-TB outcome was defined as cure or treatment completion without loss to follow-up, death, or failure by treatment. In patients with HIV, we assessed antiretroviral therapy (ART) uptake, virologic and immunologic outcomes. RESULTS Among 57 patients, HIV was present in 73.7% (95% CI: 60.3-84.5), with a median CD4 count of 170 cells/mm 3 (intraquartile range 49-314). A favorable RR/MDR-TB outcome was achieved in 78.9% (CI: 67.1-87.9). Three deaths occurred, all in the setting of baseline advanced HIV and elevated viral load. Overall, 21.1% (95% CI: 12.1-32.9) experienced a severe or life-threatening adverse event, the most common of which was anemia. Among patients with HIV, enrollment resulted in increased ART uptake by 24% (95% CI: 12.1%-39.4%), a significant improvement from baseline ( P = 0.004); virologic suppression during concomitant treatment was observed in 71.4% (n = 30, 95% CI: 55.4-84.3). CONCLUSION Decentralized, person-centered care for RR/MDR-TB in patients with HIV using the short-course, bedaquiline-based regimen is effective and safe. In patients with HIV, enrollment led to improved ART use and reassuring virologic outcomes.
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Affiliation(s)
| | - Menal A. Jham
- UMMA Community Clinic, Community Clinic Association of Los Angeles County, CA, USA
| | | | - Selvan Pillay
- Adrenergy Research Innovations, Durban, South Africa
| | - Youngju Pak
- Lundquist Institute for Biomedical Innovation, CA, USA
| | | | | | | | - Richard A. Murphy
- Geisel School of Medicine at Dartmouth, NH, USA
- White River Junction Veterans Affairs Medical Center, VT, USA
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South A, Dhesi P, Tweed CD, Tsogt B, Staples S, Tukvadze N, Dorj G, Zaca S, Sanikidze E, Purev N, Esmail H, Burgess R. Patients' priorities around drug-resistant tuberculosis treatment: A multi-national qualitative study from Mongolia, South Africa and Georgia. Glob Public Health 2023; 18:2234450. [PMID: 37431789 PMCID: PMC7616316 DOI: 10.1080/17441692.2023.2234450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 07/04/2023] [Indexed: 07/12/2023]
Abstract
We conducted qualitative research exploring the treatment experience of people with DR-TB. We held nine focus group discussions with 57 adults undergoing/recently completed treatment for DR-TB in Georgia, Mongolia and South Africa. Translated transcripts were analysed using thematic analysis. We identified three higher order themes: (1) Treatment experience and the role of good relationships with healthcare providers: Treatment duration, pill burden and side-effects were challenging aspects of treatment. Side-effects/symptoms that were visible signs of illness were particularly troubling. Good relations with clinical staff helped combat fear and uncertainty regarding treatment. (2) Mental distress and opportunities for wellbeing: The shame, stigma and isolation people experienced as a result of their DR-TB diagnosis was an important cause of mental distress. No longer being infectious enabled people to resume work and socialising. Positive emotions emerged with good treatment outcomes. (3) Fear and worry along the treatment journey: Participants expressed fears about TB: infecting others; whether they would be able to endure treatment; side-effects; health consequences of treatment. Worries mostly disappeared with successful treatment. Alongside measuring side-effects, time to culture conversion and cure rates, future trials of DR-TB treatments should capture how quickly visible symptoms resolve, quality of life measures, and mental health outcomes.
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Affiliation(s)
| | | | | | | | - Suzanne Staples
- THINK: TB and HIV Investigative Network, Durban, South Africa
| | - Nestani Tukvadze
- TB Clinical Research Unit, National Centre for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Gantsetseg Dorj
- TB Research and Surveillance Department, National Center for Communicable Diseases, Ulaanbaatar, Mongolia
| | - Sindisiwe Zaca
- THINK: TB and HIV Investigative Network, Durban, South Africa
| | | | - Nasanjargal Purev
- TB Research and Surveillance Department, National Center for Communicable Diseases, Ulaanbaatar, Mongolia
| | - Hanif Esmail
- MRC Clinical Trials Unit at UCL, UCL, London, UK
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Hajissa K, Marzan M, Idriss MI, Islam MA. Prevalence of Drug-Resistant Tuberculosis in Sudan: A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2021; 10:antibiotics10080932. [PMID: 34438982 PMCID: PMC8388945 DOI: 10.3390/antibiotics10080932] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 11/16/2022] Open
Abstract
Drug-resistant tuberculosis (DR-TB) is still one of the most critical issues impeding worldwide TB control efforts. The aim of this systematic review and meta-analysis was to give an updated picture of the prevalence of DR-TB in Sudan. A comprehensive systematic search was performed on four electronic databases (PubMed, Scopus, Web of Science and Google Scholar) to identify all published studies reporting prevalence data of DR-TB in Sudan. Sixteen eligible studies published during 2002-2020 were included. Using meta-analysis of proportions, the pooled prevalence of TB cases with resistance to any anti-TB drugs was 47.0% (95% CI: 35.5-58.6%). The overall prevalence of mono, multi, poly and extensive drug resistance were estimated to be 16.2% (95% CI: 9.0-23.4%), 22.8% (95% CI: 16.0-29.7%), 6.8% (95% CI: 0.5-13.0%) and 0.7% (95% CI: 0-2.1%), respectively. Considering any first-line anti-TB drugs, the resistance prevalence was highest for isoniazid (32.3%) and streptomycin (31.7%), followed by rifampicin (29.2%). In contrast, resistance against second-line drugs was reported for only two antibiotics, namely, ofloxacin (2.1%) and kanamycin (0.7%). Of note, the resistance profile of the previously treated patients was found to be remarkably high compared with the newly diagnosed TB patients. The relatively high prevalence estimation of anti-TB drug resistance warrants strengthening TB control and treatment strategies in Sudan.
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Affiliation(s)
- Khalid Hajissa
- Department of Medical Microbiology & Parasitology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia;
- Department of Zoology, Faculty of Science and Technology, Omdurman Islamic University, P.O. Box 382, Omdurman 14415, Sudan
| | - Mahfuza Marzan
- Department of Microbiology, Jahangirnagar University, Savar, Dhaka 1342, Bangladesh;
| | | | - Md Asiful Islam
- Department of Haematology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
- Correspondence: or
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Bigio J, Sassi A, Temesgen Z, Pai M. Improving the quality of tuberculosis care in the post-pandemic world. J Clin Tuberc Other Mycobact Dis 2021; 23:100212. [PMID: 34095545 PMCID: PMC8167427 DOI: 10.1016/j.jctube.2021.100212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- Jacob Bigio
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada.,Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Angelina Sassi
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada.,Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada
| | - Zelalem Temesgen
- Mayo Clinic Center for Tuberculosis & Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA
| | - Madhukar Pai
- McGill International TB Centre, McGill University, Dept of Epidemiology & Biostatistics, 1020 Pine Ave West, Montreal, Quebec H3A 1A2, Canada.,Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada
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Leavitt SV, Jacobson KR, Ragan EJ, Bor J, Hughes J, Bouton TC, Dolby T, Warren RM, Jenkins HE. Decentralized Care for Rifampin-Resistant Tuberculosis, Western Cape, South Africa. Emerg Infect Dis 2021; 27:728-739. [PMID: 33622466 PMCID: PMC7920662 DOI: 10.3201/eid2703.203204] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
In 2011, South Africa implemented a policy to decentralize treatment for rifampin-resistant tuberculosis (TB) to reduce durations of hospitalization and enable local treatment. We assessed policy implementation in Western Cape Province, where services expanded from 6 specialized TB hospitals to 406 facilities, by analyzing National Health Laboratory Service data on TB during 2012-2015. We calculated the percentage of patients who visited a TB hospital <1 year after rifampin-resistant TB diagnosis, the median duration of their hospitalizations, and the total distance between facilities visited. We assessed temporal changes with linear regression and stratified results by location. Of 2,878 patients, 65% were from Cape Town. In Cape Town, 29% visited a TB hospital; elsewhere, 68% visited a TB hospital. We found that hospitalizations and travel distances were shorter in Cape Town than in the surrounding areas.
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Gils T, Laxmeshwar C, Duka M, Malakyan K, Siomak OV, Didik VS, Lytvynenko N, Terleeva Y, Donchuk D, Isaakidis P. Preparedness of outpatient health facilities for ambulatory treatment with all-oral short DR-TB treatment regimens in Zhytomyr, Ukraine: a cross-sectional study. BMC Health Serv Res 2020; 20:890. [PMID: 32957966 PMCID: PMC7507621 DOI: 10.1186/s12913-020-05735-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 09/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ukraine has a high burden of drug-resistant tuberculosis (DR-TB). Mental health problems, including alcohol use disorder, are common co-morbidities. One in five DR-TB patients has human immunodeficiency virus (HIV). As part of health reform, the country is moving from inpatient care to ambulatory primary care for tuberculosis (TB). In Zhytomyr oblast, Médecins Sans Frontières (MSF) is supporting care for DR-TB patients on all-oral short DR-TB regimens. This study describes the preparedness of ambulatory care facilities in Zhytomyr oblast, Ukraine, to provide good quality ambulatory care. METHODS This is a retrospective analysis of routinely collected programme data. Before discharge of every patient from the hospital, MSF teams assess services available at outpatient facilities using a standardised questionnaire. The assessment evaluates access, human resources, availability of medicines, infection control measures, laboratory and diagnostic services, and psychosocial support. RESULTS We visited 68 outpatient facilities in 22 districts between June 2018 and September 2019. Twenty-seven health posts, 24 TB-units, 13 ambulatories, two family doctors and one polyclinic, serving 30% of DR-TB patients in the oblast by September 2019, were included. All facilities provided directly observed treatment, but only seven (10%) provided weekend-services. All facilities had at least one medical staff member, but TB-training was insufficient and mostly limited to TB-doctors. TB-treatment and adequate storage space were available in all facilities, but only five (8%) had ancillary medicines. HIV-positive patients had to visit a separate facility to access HIV-care. Personal protective equipment was unavailable in 32 (55%) facilities. Basic laboratory services were available in TB-units, but only four (17%) performed audiometry. Only ten (42%) TB-units had psychosocial support available, and nine (38%) offered psychiatric support. CONCLUSION Outpatient facilities in Zhytomyr oblast are not yet prepared to provide comprehensive care for DR-TB patients. Capacity of all facilities needs strengthening with trainings, infection control measures and infrastructure. Integration of psychosocial services, treatment of co-morbidities and adverse events at the same facility are essential for successful decentralisation. The health reform is an opportunity to establish quality, patient-centred care.
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Affiliation(s)
- Tinne Gils
- Médecins Sans Frontières, 64 Berdychivska St., Huiva, Zhytomyr, Oblast, Ukraine.
| | - Chinmay Laxmeshwar
- Médecins Sans Frontières, 64 Berdychivska St., Huiva, Zhytomyr, Oblast, Ukraine
| | - Marve Duka
- Médecins Sans Frontières, 64 Berdychivska St., Huiva, Zhytomyr, Oblast, Ukraine
| | - Khachatur Malakyan
- Médecins Sans Frontières, 64 Berdychivska St., Huiva, Zhytomyr, Oblast, Ukraine
| | | | | | - Natalia Lytvynenko
- National Institute of Phthisiology and Pulmonology named after F.G. Yanovsky of National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine
| | - Yana Terleeva
- Department of Tuberculosis Programme Coordination, Public Health Centre of the Ministry of Health of Ukraine, Kyiv, Ukraine
| | - Dmytri Donchuk
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | - Petros Isaakidis
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
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Burtscher D, Juul Bjertrup P, Vambe D, Dlamini V, Mmema N, Ngwenya S, Rusch B, Kerschberger B. 'She is like my mother': Community-based care of drug-resistant tuberculosis in rural Eswatini. Glob Public Health 2020; 16:911-923. [PMID: 32816634 DOI: 10.1080/17441692.2020.1808039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Patients with drug-resistant tuberculosis (DR-TB) have received community-based care in Eswatini since 2009. Trained and compensated community treatment supporters (CTSs) provide directly observed therapy (DOT), injectables and psychological support. We examined the acceptability of this model of care among DR-TB patients, including the perspective of family members of DR-TB patients and their CTSs in relation to the patient's experience of care and quality of life. This qualitative research was conducted in rural Eswatini in February 2018. DR-TB patients, CTSs and family members participated in in-depth interviews, paired interviews, focus group discussions and PhotoVoice. Data were thematically analysed and coded, and themes were extracted. Methodological triangulation enhanced the interpretation. All patients and CTSs and most family members considered community-based DR-TB care to be supportive. Positive aspects were emotional support, trust and dedicated individual care, including enabling practical, financial and social factors. Concerns were related to social and economic problems within the family and fears about infection risks for the family and the CTSs. Community-based DR-TB care was acceptable to patients, family members and CTSs. To reduce family members' fears of TB infection, information and sensitisation within the family and constant follow-up appear crucial.
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Affiliation(s)
- Doris Burtscher
- Médecins Sans Frontières/Ärzte ohne Grenzen, Vienna Evaluation Unit/Anthropology, Wien, Austria
| | | | - Debrah Vambe
- National Tuberculosis Control Program (NTCP), Manzini, Swaziland
| | | | | | | | - Barbara Rusch
- Médecins Sans Frontières, Operational Centre Geneva, Geneva, Switzerland
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Arya A, Singh S, Dwivedi VD, Shakila H. Integration of biometric ID for the effective collection and epidemiological evaluation of antibiotic prescription in tuberculosis and other diseases: A medical hypothesis. J Glob Antimicrob Resist 2019; 21:439-444. [PMID: 31841713 DOI: 10.1016/j.jgar.2019.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 10/22/2019] [Accepted: 12/03/2019] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Tuberculosis (TB) poses a huge socioeconomic burden and remains listed among the top ten causes of deaths across the globe, despite enormous efforts of health agencies and researchers. The primary concern in a relatively slower pace of curbing TB is the emergence of multi-drug resistance and difficulty in tracking antibiotic consumption. METHODS We propose here a biometric-linked digital means of antibiotic prescription data collection and its utility for various epidemiological assessments. RESULTS In this short communication, we propose here, a visionary workflow to explore the use of biometric identification system to gather the antibiotic prescription information for tuberculosis cases and real-time monitoring over a global scale. Our proposal is mainly aimed at collection of antibiotic prescription data at clinician level and point of sales level using a simple fingerprint-based biometric approach and its linkage to unique biometric IDs such as Aadhar in India and related systems in other countries. CONCLUSION The online server and web-interface are aimed at facilitating the health organizations and medical councils to monitor the antibiotic prescription and their consumption in real time. This will not only augment the existing policy-making regarding drug-resistance programs but also promote the collection and downstream exploratory analysis of huge amount of data to get a deeper insight into the epidemiology of tuberculosis and related diseases.
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Affiliation(s)
- Aditya Arya
- Centre for Bioinformatics, Computational and Systems Biology, Pathfinder Research and Training Foundation, Knowledge Park III, Greater Noida, Uttar Pradesh, India.
| | - Sneha Singh
- Department of Toxicology, Jamia Hamdard University, New Delhi, India
| | - Vivek Dhar Dwivedi
- Centre for Bioinformatics, Computational and Systems Biology, Pathfinder Research and Training Foundation, Knowledge Park III, Greater Noida, Uttar Pradesh, India
| | - H Shakila
- School of Biotechnology, Madurai Kamaraj University, Madurai, Tamil Nadu, India
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