Factors associated with low tuberculosis preventive therapy prescription rates among health care workers in rural South Africa

Acceptance and Completion Rates of 3-Month Isoniazid-Rifampicin (3HR) Tuberculosis Preventive Treatment (TPT) Among Contacts of Bacteriologically Confirmed TB Patients-Patients' and Healthcare Workers' Perspectives

Providing tuberculosis preventive treatment (TPT) to close contacts of persons with TB is a core strategy recommended by WHO for the prevention and control of TB. Nigeria rolled out the 3-month Isoniazid-Rifampicin (3HR) shorter regimen TPT as a pilot for use among eligible adult and child contacts. This study assesses acceptance and completion rates of 3HR TPT among contacts and determines the perspectives of healthcare workers (HCWs) and contacts on acceptance and completion of 3HR TPT in Nigeria. In this cross-sectional descriptive study using mixed methods, records of TPT-eligible clients were retrospectively reviewed, while 18 purposely selected HCWs and 18 contacts on 3HR were interviewed. Of the 30,012 eligible contacts, 12,040 (40.1%) were initiated on TPT. Among these, 8213 (68%) were enrolled on 3HR, and 6972 (84.7%) of them completed treatment. Perceived facilitators include belief in its effectiveness, training among HCWs, and a good understanding of TPT from HCW counseling sessions. Barriers reported were linked to stockouts, misconceptions about side effects, non-disclosures, and disincentive follow-up strategies. The acceptance and completion rate for 3HR TPT was good. Scaling up 3HR TPT will require redesigning policies towards addressing identified barriers and utilizing interventions linked to capabilities, opportunities, and motivations among contacts of TB patients and HCWs.

Challenges of Screening and Investigations of Contacts of Patients with Tuberculosis in Oyo and Osun States, Nigeria

Tuberculosis (TB) remains a significant public health challenge in Nigeria, with high rates of transmission and low case detection rates. This paper presents the challenges of screening and investigation of contacts of patients with TB in Oyo and Osun State, Nigeria. This descriptive-qualitative study was conducted in eight Local Government Areas with high TB burdens. Twenty-four focus group discussions and 30 key informant interviews were conducted among TB patients, household TB contacts, and government TB staff, among others. Respondents ages ranged from 17-85 years with a mean of 42.08 ± 14.9 years, and (4.0%) had a postgraduate degree. This study identified that the majority of TB contacts who tested negative for TB were unwilling to be placed on TB preventive therapy because of the belief that only a sick person should take drugs. Also, hostility from the TB contacts to the contact tracers during the house-to-house screening of presumptive TB cases due to community stigma associated with TB was another existing gap reported in TB contact investigations. The findings emphasise the importance of tailored approaches in TB prevention and control, addressing challenges in testing and contact investigations; this necessitates investments in community engagement strategies to enhance the cooperation of TB contacts.

Barriers and facilitators of implementing electronic monitors to improve adherence and health outcomes in tuberculosis patients: protocol for a systematic review based on the Consolidated Framework for Implementation Research

BACKGROUND

Tuberculosis (TB) has been regarded as 'a relentless scourge', increasing morbidity and mortality and burdening vulnerable populations. Poor adherence to TB treatment and ineffective traditional interventions hinders TB control. A novel TB approach called 'electronic monitors', equipping medication boxes with daily audio or visual reminders for electronically monitoring medication intake, seems promising in improving adherence and health outcomes and overcoming the weaknesses of traditional interventions. However, no review has systematically examined and synthesized the influencing factors of implementing electronic monitors. Implementation research offers the means to analyse the influencing factors of the implementation and its process, fitting well with the aim of this review. Therefore, the widely recognized Consolidated Framework for Implementation Research (CFIR), which offers a common taxonomy for evaluating intervention implementation, will be adopted to systematically identify barriers and facilitators of the electronic monitors for improving adherence and health outcomes in patients with TB.

METHODS AND ANALYSIS

The systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Literature research will be conducted in five electronic databases (Ovid MEDLINE, CINAHL, EMBASE, Cochrane Library and Web of Science) to identify the barriers and facilitators of implementing electronic monitors in patients with TB. The CFIR will be used as a guide for categorizing and synthesizing the barriers and facilitators. Study screening, data extraction, quality appraisal and data analysis will be conducted by two independent reviewers. The use of additional reviewers will solve any disagreements between the two reviewers.

DISCUSSION

Given the increased prominence of TB epidemiology and the adherence problem of electronic monitors, there is a solid rationale for synthesizing the existing studies via the CFIR. The findings and conclusion of this review will lay bare the achievements and effectiveness of implementing electronic monitors, as well as the attendant gaps and limitations. Further strategies for facilitating the implementation of electronic monitors will also be explored. This review will be of essential significance for research and practice, supporting future academic research initiatives centred on patients with TB and aiding electronic monitor design in lowering the morbidity and mortality associated with TB disease.

TRIAL REGISTRATION NUMBER

PROSPERO: CRD42023395747.

Roles and challenges of nurses in tuberculosis care in Africa: A narrative review

Nurses form the bulk of the health care workforce in Africa although their roles and challenges in tuberculosis (TB) care are not well documented. In this article we discuss roles and challenges of nurses in TB care in Africa. Nurses in Africa are key in TB prevention, diagnosis, treatment initiation, treatment monitoring, and evaluation and documentation of TB treatment outcomes. However, there is little involvement of nurses in TB-related research and policy. Challenges faced by nurses in TB care mostly relate to poor working conditions that compromise their occupational safety and mental health. There is need to expand nursing school curricula on TB to equip nurses with broad skills required for the wide repertoire of roles. Nurses should be equipped with research skills and funding opportunities for nurse-led TB research projects should be easily accessible. Occupational safety of nurses through infrastructural modification of TB units, provision of personal protective equipment and ensuring access to compensation in case a nurse develops active TB is important. Nurses also need psychosocial support given the complexity of caring for people with TB.

They do not have symptoms - why do they need to take medicines? Challenges in tuberculosis preventive treatment among children in Cambodia: a qualitative study

BACKGROUND

Latent tuberculosis (TB) infection has been known as a seedbed for TB disease later in life. The interruption from latent TB infection to TB disease can be done through TB preventive treatment (TPT). In Cambodia, only 40.0% of children under five years old who were the household contacts to bacteriologically confirmed TB cases were initiated with TPT in 2021. Scientific studies of context-specific operational challenges in TPT provision and uptake among children are scarce, particularly in high TB-burden countries. This study identified challenges in TPT provision and uptake among children in Cambodia from the perspective of healthcare providers and caregivers.

METHODS

Between October and December 2020, we conducted in-depth interviews with four operational district TB supervisors, four clinicians and four nurses in charge of TB in referral hospitals, four nurses in charge of TB in health centers, and 28 caregivers with children currently or previously on TB treatment or TPT, and those who refused TPT for their eligible children. Data were audio recorded along with field notetaking. After verbatim transcription, data analyses were performed using a thematic approach.

RESULTS

The mean age of healthcare providers and caregivers were 40.19 years (SD 12.0) and 47.9 years (SD 14.6), respectively. Most healthcare providers (93.8%) were male, and 75.0% of caregivers were female. More than one-fourth of caregivers were grandparents, and 25.0% had no formal education. Identified key barriers to TPT implementation among children included TPT side effects, poor adherence to TPT, poor understanding of TPT among caregivers, TPT risk perception among caregivers, TPT's child-unfriendly formula, TPT supply-chain issues, caregivers' concern about the effectiveness of TPT, being non-parental caregivers, and poor community engagement.

CONCLUSION

Findings from this study suggest that the national TB program should provide more TPT training to healthcare providers and strengthen supply chain mechanisms to ensure adequate TPT drug supplies. Improving community awareness of TPT among caregivers should also be intensified. These context-specific interventions will play a crucial role in expanding the TPT program to interrupt the development from latent TB infection to active and ultimately lead to ending TB in the country.

Management of Tuberculosis Infection: Current Situation, Recent Developments and Operational Challenges

Tuberculosis infection (TBI) is defined as a state of infection in which individuals host live Mycobacterium tuberculosis with or without clinical signs of active TB. It is now understood as a dynamic process covering a spectrum of responses to infection resulting from the interaction between the TB bacilli and the host immune system. The global burden of TBI is about one-quarter of the world’s population, representing a reservoir of approximately 2 billion people. On average, 5–10% of people who are infected will develop TB disease over the course of their lives, but this risk is enhanced in a series of conditions, such as co-infection with HIV. The End-TB strategy promotes the programmatic management of TBI as a crucial endeavor to achieving global targets to end the TB epidemic. The current development of new diagnostic tests capable of discriminating between simple TBI and active TB, combined with novel short-course preventive treatments, will help achieve this goal. In this paper, we present the current situation and recent developments of management of TBI and the operational challenges.

Perceptions of Teamwork and Knowledge Attitudes of Hemodialysis Unit Nurses on Infection Prevention

INTRODUCTION

The Nurses of Hemodialysis Units: it is necessary to face HAIs (hospital-acquired infections) as a "well-tuned" teamwork. The aim of this study was to investigate the perceptions of the teamwork as well as the knowledge attitudes of the nurses of hemodialysis units on infection prevention in Greece.

METHODOLOGY

A cross-sectional survey was conducted with a sample of 1018 HCWs (health care workers) of hemodialysis units in Greece. The questionnaires used were: Teamwork Perceptions Questionnaire (T-TPQ) TeamSTEPPS®-Instructor Manual, and questionnaire APPENDIX A.

RESULTS

The majority of them were nurses (69.45%) and nurse assistants (23.87%). About teamwork perceptions per factor, we observed uniformity in their responses with very high rates of agreement. The attitudes of nurses of hemodialysis units on the prevention of infections were distinguished in particularly high rates of compliance with a high perception of the risk of transmission of infections with better compliance being that of women. Also, women seem to be more knowledgeable about diseases that mostly affect the pediatric population. It seemed that level of knowledge between the two sexes did not differ regarding HBV (63.16% vs. 66.71%, p = 0.430), HCV (63.91% vs. 66.71%, p = 0.553), HIV infection (78.95% vs. 81.76%, p = 0.471), and influenza (55.64% vs. 59.61%, p = 0.394).

CONCLUSIONS

This study highlighted for the first time the high level of perceptions of teamwork of the HCWs of the hemodialysis units in Greece. It is recommended to investigate the correct application of prevention measures and to detect the causes of deviation from good practices with subsequent investigations on hemodialysis units of Greece.

Development of an infectious disease prevention behavior model for public health center workers in a rural area of Indonesia

The Infection Prevention Behavior (IPB) for health personnel at the Surade Public Health Center has not reached the target. The purpose of this study was to develop the IPB model for health personnel which is suitable to be applied in rural areas in Indonesia. The model was developed through a literature review from online journal database in the last 10 years. The model was tested using a cross-sectional design by the Structural Equation Model Partial Least Square (SEM-PLS). Six selected variables had direct and indirect influences on the IPB of health personnel. They were supervision (27.50%), facilities (9.87%), training (10.44%), compensation (16.97%), work climate (10.78%), and work motivation (8.15%). The model was valid and significant. The Q2 showed 95.7% which mean 95.7% of the components in the model could be applied to other Public Health Centers in the rural area. The development of IPB models for health personnel which wass measured from the direct and indirect effects of six variables proved valid and significant to help achievement Public Health Center reach the target of protecting health workers from infectious diseases.

The contribution of late HIV diagnosis on the occurrence of HIV-associated tuberculosis

OBJECTIVES

To describe the timing of tuberculosis (TB) presentation in relation to diagnosis of HIV infection and antiretroviral therapy (ART) initiation and to evaluate whether the established impact from late presentation to care and late initiation of ART on the risk of TB is retained beyond the observation period of clinical trials.

DESIGN

We used marginal structural models to emulate a clinical trial with up to 5 years of follow-up to evaluate the impact of late initiation on TB risk.

METHODS

People with HIV (PWH) were enrolled from 2007 to 2016 in observational cohorts from Uganda, Peru, Mexico and Italy. The risk of TB was compared in LP (accessing care with CD4 + cell count ≤350 cells/μl) vs. nonlate presentation using survival curves and a weighted Cox regression. We emulated two strategies: initiating ART with CD4 + cell count less than 350 cells/μl vs. CD4 + cell count at least 350 cells/μl (late initiation). We estimated TB attributable risk and population attributable fraction up to 5 years from the emulated date of randomization.

RESULTS

Twenty thousand one hundred and twelve patients and 1936 TB cases were recorded. Over 50% of TB cases were diagnosed at presentation for HIV care. More than 50% of the incident cases of TB after ART initiation were attributable to late presentation; nearly 70% of TB cases during the first year of follow-up could be attributed to late presentation and more than 50%, 5 years after first attending HIV care.

CONCLUSION

Late presentation accounted for a large share of TB cases. Delaying ART initiation was detrimental for incident TB rates, and the impact of late presentation persisted up to 5 years from HIV care entry.

Incidence of active tuberculosis among people living with HIV receiving long-term antiretroviral therapy in high TB/HIV burden settings in Thailand: implication for tuberculosis preventive therapy

Introduction

Among high tuberculosis (TB) and HIV burden countries in Asia, tuberculosis preventive therapy (TPT) in people living with HIV (PLWH) has been underutilized despite its proven benefits independent of antiretroviral therapy (ART). Therefore, we determined the incidence of active TB and mortality among 9179 adult PLWH who attended and received ART from 15 tertiary care hospitals across Thailand.

Methods

A retrospective study was conducted in 2018 using follow‐up data from 1999 to 2018. The primary endpoint was incident TB disease after ART initiation. Factors associated with TB incidence were analysed using competing risk regression. The Kaplan–Meier method was used to estimate mortality after ART initiation.

Results

During a median of 5.1 years of ART (IQR 2.2–9.5 years), 442 (4.8%) PLWH developed TB (TB/HIV), giving an overall incidence of 750 (95% CI 683–823) per 100,000 persons‐year of follow up (PYFU). In multivariate analysis, lower CD4 at ART initiation (≤100 cells/mm³, adjusted sub‐distribution hazard ratio [aSHR]: 2.08, 95% CI, 1.47–2.92; 101–200 cells/mm³, aSHR: 2.21, 95% CI, 1.54–3.16; 201–350 cells/mm³, aSHR: 1.59, 95% CI, 1.11–2.28 vs. >350 cells/mm³), male sex (aSHR: 1.40, 95% CI, 1.11–1.78), lower body weight (<50 kg, aSHR: 1.52, 95% CI, 1.17–1.95) and prior TB event (aSHR: 3.50, 95% CI, 2.72–4.52) were associated with TB incidence. PLWH with HIV RNA ≥50 copies/ml had 5–9 times higher risk of active TB disease higher than those with HIV RNA <50 copies/ml at the same CD4 level. The risk for developing TB was remarkably high during the initial period of ART (175,511 per 100,000 PYFU at<3 months) and was comparable to the general population after 10 years of ART (151 per 100,000 PYFU). TB/HIV had higher mortality (10% vs. 5%) and poorer HIV treatment outcomes: HIV RNA <50 copies/ml (63.8% vs. 82.8%), CD4 cells count (317 vs. 508 cells/mm³) at the most recent visit.

Conclusions

In this high TB burden country, TB incidence was remarkably high during the first few years after ART initiation and thereafter decreased significantly. Rapid ART initiation and appropriate TPT can be potential key interventions to tackle the TB epidemic and reduce mortality among PLWH in TB/HIV high burden settings.