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Razak NA, Masood I, Baneen U, Ahmad Z, Shamsi H. Eliminate TB by 2025? A case report of MDR TB to reaffirm the need of follow UP! Indian J Tuberc 2023; 70:134-138. [PMID: 36740311 DOI: 10.1016/j.ijtb.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/30/2022] [Accepted: 05/16/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Nader Abdul Razak
- Department of Tuberculosis & Respiratory Diseases, Jawaharlal Nehru Medical College, Aligarh Muslim University, India.
| | - Imrana Masood
- Department of Tuberculosis & Respiratory Diseases, Jawaharlal Nehru Medical College, Aligarh Muslim University, India
| | - Ummul Baneen
- Department of Tuberculosis & Respiratory Diseases, Jawaharlal Nehru Medical College, Aligarh Muslim University, India
| | - Zuber Ahmad
- Department of Tuberculosis & Respiratory Diseases, Jawaharlal Nehru Medical College, Aligarh Muslim University, India
| | - Hassan Shamsi
- Department of Tuberculosis & Respiratory Diseases, Jawaharlal Nehru Medical College, Aligarh Muslim University, India
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Saranjav A, Parisi C, Zhou X, Dorjnamjil K, Samdan T, Erdenebaatar S, Chuluun A, Dalkh T, Ganbaatar G, Brooks MB, Spiegelman D, Ganmaa D, Davis JL. Assessing the quality of tuberculosis care using routine surveillance data: a process evaluation employing the Zero TB Indicator Framework in Mongolia. BMJ Open 2022; 12:e061229. [PMID: 35973702 PMCID: PMC9386240 DOI: 10.1136/bmjopen-2022-061229] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To evaluate the feasibility of the Zero TB Indicator Framework as a tool for assessing the quality of tuberculosis (TB) case-finding, treatment and prevention services in Mongolia. SETTING Primary health centres, TB dispensaries, and surrounding communities in four districts of Mongolia. DESIGN Three retrospective cross-sectional cohort studies, and two longitudinal studies each individually nested in one of the cohort studies. PARTICIPANTS 15 947 community members from high TB-risk populations; 8518 patients screened for TB in primary health centres and referred to dispensaries; 857 patients with index TB and 2352 household contacts. PRIMARY AND SECONDARY OUTCOME MEASURES 14 indicators of the quality of TB care defined by the Zero TB Indicator Framework and organised into three care cascades, evaluating community-based active case-finding, passive case-finding in health facilities and TB screening and prevention among close contacts; individual and health-system predictors of these indicators. RESULTS The cumulative proportions of participants receiving guideline-adherent care varied widely, from 96% for community-based active case-finding, to 79% for TB preventive therapy among household contacts, to only 67% for passive case-finding in primary health centres and TB dispensaries (range: 29%-80% across districts). The odds of patients completing active TB treatment decreased substantially with increasing age (aOR: 0.76 per decade, 95% CI: 0.71 to 0.83, p<0.001) and among men (aOR: 0.56, 95% CI: 0.36 to 0.88, p=0.013). Contacts of older index patients also had lower odds of initiating and completing of TB preventive therapy (aOR: 0.60 per decade, 95% CI: 0.38 to 0.93, p=0.022). CONCLUSIONS The Zero TB Framework provided a feasible and adaptable approach for using routine surveillance data to evaluate the quality of TB care and identify associated individual and health system factors. Future research should evaluate strategies for collecting process indicators more efficiently; gather qualitative data on explanations for low-quality care; and deploy quality improvement interventions.
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Affiliation(s)
| | - Christina Parisi
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Xin Zhou
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut, USA
| | - Khulan Dorjnamjil
- Zero TB Mongolia, Mongolian Health Initiative, Ulaanbaatar, Mongolia
| | - Tumurkhuyag Samdan
- Zero TB Mongolia, Mongolian Health Initiative, Ulaanbaatar, Mongolia
- School of Public Health, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | | | - Altantogoskhon Chuluun
- Ulaanbaatar City Health Department, Governor's Office of Capital City Ulaanbaatar, Ulaanbaatar, Mongolia
| | - Tserendagva Dalkh
- Department of Hospital Development, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Gantungalag Ganbaatar
- Tuberculosis Surveillance and Research Department, National Center for Communicable Diseases, Ulaanbaatar, Mongolia
| | - Meredith B Brooks
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Donna Spiegelman
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut, USA
| | - Davaasambuu Ganmaa
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - J Lucian Davis
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
- Pulmonary, Critical Care, and Sleep Medicine Section, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Osewe PL, Peters MA. Prioritizing Global Public Health Investments for COVID-19 Response in Real Time: Results from a Delphi Exercise. Health Secur 2022; 20:137-146. [PMID: 35420445 PMCID: PMC9081018 DOI: 10.1089/hs.2021.0142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
In the first months of the COVID-19 pandemic, there was a lack of guidance on how to channel the unprecedented amount of health financing toward the pandemic response. We employed a multistep, interactive Delphi process to reach consensus on a “menu” of priority COVID-19 response interventions. In all, 27 health security experts—representing national governments, bilateral and multilateral organizations, academia, technical agencies, and nongovernmental organizations—participated in the exercise. The experts rated 11 technical investment areas and 37 interventions on a 5-point scale in terms of their importance to COVID-19 response. Initial findings were discussed at a virtual meeting where experts suggested modifications. A group of 19 experts then rated a revised list of 11 technical areas and 39 interventions. Consensus was defined as at least 80% of experts agreeing on the importance of a technical area or intervention; stability of scores across the rounds was identified using Wilcoxon matched-pairs and unpaired signed rank tests. Between the initial and final menu, 3 technical areas and 7 interventions were slightly modified, 3 interventions were added, and 1 intervention was removed. Consensus was reached on all 11 technical areas and 35 of the final 39 interventions, and between 34 and 37 interventions were stable across rounds depending on the test used. In this exercise, the health security experts agreed that COVID-19 response financing should prioritize interventions that enhance a country's capacity to test, trace, and treat high-risk populations. Simultaneously, supportive systems (eg, risk communication, community engagement, public health infrastructure, information systems, policy and coordination, workforce capacity, other social protections) should be developed to ensure that nonpharmaceutical and medical interventions can maximize the effectiveness of these systems.
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Affiliation(s)
- Patrick L Osewe
- Patrick L. Osewe, MD, MPH, is Chief of Health Sector Group, Asian Development Bank, Manila, Philippines
| | - Michael A Peters
- Michael A. Peters, MSPH, PhD, was a Consultant, Asian Development Bank, Manila, Philippines. He is now Associate Faculty, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Teo AKJ, Singh SR, Prem K, Hsu LY, Yi S. Duration and determinants of delayed tuberculosis diagnosis and treatment in high-burden countries: a mixed-methods systematic review and meta-analysis. Respir Res 2021; 22:251. [PMID: 34556113 PMCID: PMC8459488 DOI: 10.1186/s12931-021-01841-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 09/08/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Thirty countries with the highest tuberculosis (TB) burden bear 87% of the world's TB cases. Delayed diagnosis and treatment are detrimental to TB prognosis and sustain TB transmission in the community, making TB elimination a great challenge, especially in these countries. Our objective was to elucidate the duration and determinants of delayed diagnosis and treatment of pulmonary TB in high TB-burden countries. METHODS We conducted a systematic review and meta-analysis of quantitative and qualitative studies by searching four databases for literature published between 2008 and 2018 following PRISMA guidelines. We performed a narrative synthesis of the covariates significantly associated with patient, health system, treatment, and total delays. The pooled median duration of delay and effect sizes of covariates were estimated using random-effects meta-analyses. We identified key qualitative themes using thematic analysis. RESULTS This review included 124 articles from 14 low- and lower-middle-income countries (LIC and LMIC) and five upper-middle-income countries (UMIC). The pooled median duration of delays (in days) were-patient delay (LIC/LMIC: 28 (95% CI 20-30); UMIC: 10 (95% CI 10-20), health system delay (LIC/LMIC: 14 (95% CI 2-28); UMIC: 4 (95% CI 2-4), and treatment delay (LIC/LMIC: 14 (95% CI 3-84); UMIC: 0 (95% CI 0-1). There was consistent evidence that being female and rural residence was associated with longer patient delay. Patient delay was also associated with other individual, interpersonal, and community risk factors such as poor TB knowledge, long chains of care-seeking through private/multiple providers, perceived stigma, financial insecurities, and poor access to healthcare. Organizational and policy factors mediated health system and treatment delays. These factors included the lack of resources and complex administrative procedures and systems at the health facilities. We identified data gaps in 11 high-burden countries. CONCLUSIONS This review presented the duration of delays and detailed the determinants of delayed TB diagnosis and treatment in high-burden countries. The gaps identified could be addressed through tailored approaches, education, and at a higher level, through health system strengthening and provision of universal health coverage to reduce delays and improve access to TB diagnosis and care. PROSPERO registration: CRD42018107237.
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Affiliation(s)
- Alvin Kuo Jing Teo
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore.
- Saw Swee Hock School of Public Health, National University of Singapore, #10-01, 12 Science Drive 2, Singapore, 117549, Singapore.
| | - Shweta R Singh
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
| | - Kiesha Prem
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Li Yang Hsu
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore, Singapore
| | - Siyan Yi
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
- KHANA Center for Population Health Research, Phnom Penh, Cambodia
- Center for Global Health Research, Touro University California, Vallejo, USA
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Ali SM, Naureen F, Noor A, Fatima I, Viney K, Ishaq M, Anjum N, Rashid A, Haider GR, Khan MA, Aamir J. Loss-to-follow-up and delay to treatment initiation in Pakistan's national tuberculosis control programme. BMC Public Health 2018. [PMID: 29523100 PMCID: PMC5845151 DOI: 10.1186/s12889-018-5222-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Researchers and policy-makers have identified loss to follow-up as a major programmatic problem. Therefore, the objective of this study is to quantify TB related pre-treatment loss to follow up and treatment delay in private sector health care facilities in Pakistan. METHODS This was a retrospective, descriptive cohort study using routinely collected programmatic data from TB referral, diagnosis and treatment registers. Data from 48 private healthcare facilities were collected using an online questionnaire prepared in ODK Collect, for the period October 2015 to March 2016. Data were analysed using SPSS. We calculated the: (1) number and proportion of patients who were lost to follow-up during the diagnostic period, (2) number and proportion of patients with pre-treatment loss to follow-up, and (3) the number of days between diagnosis and initiation of treatment. RESULTS One thousand five hundred ninety-six persons with presumptive TB were referred to the laboratory. Of these, 96% (n = 1538) submitted an on-the-spot sputum sample. Of the 1538 people, 1462 (95%) people subsequently visited the laboratory to submit the early morning (i.e. the second) sample. Hence, loss to follow-up during the diagnostic process was 8% overall (n = 134). Of the 1462 people who submitted both sputum samples, 243 (17%) were diagnosed with sputum smear-positive pulmonary TB and 231 were registered for anti-TB treatment, hence, loss in the pre-treatment phase was 4.9% (n = 12). 152 persons with TB (66%) initiated TB treatment either on the day of TB diagnosis or the next day. A further 79 persons with TB (34%) commenced TB treatment within a mean time of 7 days (range 2 to 64 days). CONCLUSION Concentrated efforts should be made by the National TB Control Programme to retain TB patients and innovative methods such as text reminders and behavior change communication may need to be used and tested.
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Affiliation(s)
| | - Farah Naureen
- Mercy Corps, Rawal Chowk, Murree Road, Islamabad, Pakistan
| | - Arif Noor
- Mercy Corps, Rawal Chowk, Murree Road, Islamabad, Pakistan
| | - Irum Fatima
- Mercy Corps, Rawal Chowk, Murree Road, Islamabad, Pakistan
| | - Kerri Viney
- Australian National University, Canberra, Australia
| | - Muhammad Ishaq
- Mercy Corps, Rawal Chowk, Murree Road, Islamabad, Pakistan
| | - Naveed Anjum
- Mercy Corps, Rawal Chowk, Murree Road, Islamabad, Pakistan
| | - Aamna Rashid
- Mercy Corps, Rawal Chowk, Murree Road, Islamabad, Pakistan
| | | | | | - Javariya Aamir
- Mercy Corps, Rawal Chowk, Murree Road, Islamabad, Pakistan
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Davis JL. Bringing patient-centered tuberculosis diagnosis into the light of day. BMC Med 2017; 15:219. [PMID: 29258526 PMCID: PMC5738029 DOI: 10.1186/s12916-017-0992-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 12/12/2017] [Indexed: 11/10/2022] Open
Abstract
In 2015, the WHO End TB Strategy laid out ambitious goals to dramatically reduce tuberculosis (TB) deaths, incidence, and catastrophic costs through research, bold new strategies, and patient-centered care. In this commentary, recent evidence on sputum collection strategies for smear microscopy is reviewed, and the argument is made that redesigning smear microscopy as a patient-centered service offers the only realistic and widely available strategy to advance TB diagnostic care towards the initial End TB Strategy goals laid out for 2025. Finally, the successful adoption of same-day sputum smear microscopy as a model for patient-centered TB care is suggested to be synergistic with and to form part of the scale-up of new TB diagnostic tools.Please see related article: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0947-9.
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Affiliation(s)
- J Lucian Davis
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, 60 College Street, Room 620, New Haven, Connecticut, 06520-8034, USA. .,Pulmonary, Critical Care, and Sleep Medicine Section, Yale School of Medicine, New Haven, Connecticut, USA.
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Ayakaka I, Ackerman S, Ggita JM, Kajubi P, Dowdy D, Haberer JE, Fair E, Hopewell P, Handley MA, Cattamanchi A, Katamba A, Davis JL. Identifying barriers to and facilitators of tuberculosis contact investigation in Kampala, Uganda: a behavioral approach. Implement Sci 2017; 12:33. [PMID: 28274245 PMCID: PMC5343292 DOI: 10.1186/s13012-017-0561-4] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 02/21/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The World Health Organization recommends routine household tuberculosis contact investigation in high-burden countries but adoption has been limited. We sought to identify barriers to and facilitators of TB contact investigation during its introduction in Kampala, Uganda. METHODS We collected cross-sectional qualitative data through focus group discussions and interviews with stakeholders, addressing three core activities of contact investigation: arranging household screening visits through index TB patients, visiting households to screen contacts and refer them to clinics, and evaluating at-risk contacts coming to clinics. We analyzed the data using a validated theory of behavior change, the Capability, Opportunity, and Motivation determine Behavior (COM-B) model, and sought to identify targeted interventions using the related Behavior Change Wheel implementation framework. RESULTS We led seven focus-group discussions with 61 health-care workers, two with 21 lay health workers (LHWs), and one with four household contacts of newly diagnosed TB patients. We, in addition, performed 32 interviews with household contacts from 14 households of newly diagnosed TB patients. Commonly noted barriers included stigma, limited knowledge about TB among contacts, insufficient time and space in clinics for counselling, mistrust of health-center staff among index patients and contacts, and high travel costs for LHWs and contacts. The most important facilitators identified were the personalized and enabling services provided by LHWs. We identified education, persuasion, enablement, modeling of health-positive behaviors, incentivization, and restructuring of the service environment as relevant intervention functions with potential to alleviate barriers to and enhance facilitators of TB contact investigation. CONCLUSIONS The use of a behavioral theory and a validated implementation framework provided a comprehensive approach for systematically identifying barriers to and facilitators of TB contact investigation. The behavioral determinants identified here may be useful in tailoring interventions to improve implementation of contact investigation in Kampala and other similar urban settings.
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Affiliation(s)
- Irene Ayakaka
- Uganda Tuberculosis Implementation Research Consortium, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sara Ackerman
- Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, CA USA
| | - Joseph M. Ggita
- Uganda Tuberculosis Implementation Research Consortium, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Phoebe Kajubi
- Child Health and Development Centre, School of Medicine; College of Health Sciences, Makerere University, Kampala, Uganda
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland USA
| | - Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital, and Harvard University Medical School, Boston, MA USA
| | - Elizabeth Fair
- Division of Pulmonary and Critical Care Medicine, and Curry International Tuberculosis Center, San Francisco General Hospital, University of California, San Francisco, CA USA
| | - Philip Hopewell
- Division of Pulmonary and Critical Care Medicine, and Curry International Tuberculosis Center, San Francisco General Hospital, University of California, San Francisco, CA USA
| | - Margaret A. Handley
- Department of Biostatistics and Epidemiology, School of Medicine, University of California, San Francisco, CA USA
- Division of General Internal Medicine, San Francisco General Hospital, University of California, San Francisco, CA USA
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, and Curry International Tuberculosis Center, San Francisco General Hospital, University of California, San Francisco, CA USA
| | - Achilles Katamba
- Clinical Epidemiology Unit, Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - J. Lucian Davis
- Department of Epidemiology of Microbial Diseases, School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, CT USA
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Roy M, Muyindike W, Vijayan T, Kanyesigye M, Bwana M, Wenger M, Martin J, Geng E. Implementation and Operational Research: Use of Symptom Screening and Sputum Microscopy Testing for Active Tuberculosis Case Detection Among HIV-Infected Patients in Real-World Clinical Practice in Uganda. J Acquir Immune Defic Syndr 2016; 72:e86-91. [PMID: 27159224 PMCID: PMC5621516 DOI: 10.1097/qai.0000000000001067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The uptake of intensified active TB case-finding among HIV-infected patients using symptom screening is not well understood. We evaluated the rate and completeness of each interim step in the TB pulmonary "diagnostic cascade" to understand real-world barriers to active TB case detection. METHODS We conducted a cohort analysis of new, antiretroviral therapy-naive, HIV-infected patients who attended a large HIV clinic in Mbarara, Uganda (March 1, 2012-September 30, 2013). We used medical records to extract date of completion of each step in the diagnostic cascade: symptom screen, order, collection, processing, and result. Factors associated with lack of sputum order were evaluated using multivariate Poisson regression and chart review of 50 screen-positive patients. RESULTS Of 2613 patients, 2439 (93%) were screened for TB and 682 (28%) screened positive. Only 90 (13.2%) had a sputum order. Of this group, 83% completed the diagnostic cascade, 13% were diagnosed with TB, and 50% had a sputum result within 1 day of their visit. Sputum ordering was associated with WHO stage 3 or 4 HIV disease and greater number of symptoms. The main identifiable reasons for lack of sputum order in chart review were treatment of presumed malaria (51%) or bacterial infection (43%). CONCLUSIONS The majority of newly enrolled HIV-infected patients who screened positive for suspected TB did not have a sputum order, and those who did were more likely to have more symptoms and advanced HIV disease. Further evaluation of provider behavior in the management of screen-positive patients could improve active TB case detection rates.
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Semitala FC, Chaisson LH, den Boon S, Walter N, Cattamanchi A, Awor M, Katende J, Huang L, Joloba M, Albert H, Kamya MR, Davis JL. Impact of mycobacterial culture among HIV-infected adults with presumed TB in Uganda: a prospective cohort study. Public Health Action 2015; 5:106-11. [PMID: 26400379 PMCID: PMC4487479 DOI: 10.5588/pha.14.0096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 02/25/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementation of new tuberculosis (TB) diagnostic strategies in resource-constrained settings is challenging. We measured the impact of solid and liquid mycobacterial cultures on treatment practices for patients undergoing TB evaluation in Kampala, Uganda. METHODS We enrolled consecutive smear-negative, human immunodeficiency virus positive adults with cough of ⩾2 weeks from September 2009 to April 2010. Laboratory technicians performed mycobacterial cultures on solid and liquid media. We compared empiric treatment decisions with solid and liquid culture in terms of diagnostic yield and time to results, and assessed impact on patient management. RESULTS Of 200 patients enrolled, 26 (13%) had culture-confirmed TB: 22 (85%) on solid culture alone, 2 (8%) on liquid culture alone, and 2 (8%) on both solid and liquid culture. Thirty-four patients received empiric anti-tuberculosis treatment, but only 10 (29%) were culture-positive. Median time to a positive result on solid culture was 92 days (interquartile range [IQR] 69-148) compared to 106 days (IQR 66-157) for liquid culture. No patients initiated treatment following a positive result on liquid culture. CONCLUSION The introduction of mycobacterial culture did not influence care for patients undergoing evaluation for TB in Kampala, Uganda. Attention to contextual factors surrounding implementation is needed to ensure the effective introduction of new testing strategies in low-income countries.
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Affiliation(s)
- F. C. Semitala
- Department of Medicine, Mulago Hospital, Makerere University College of Health Sciences, Kampala, Uganda
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - L. H. Chaisson
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
| | - S. den Boon
- Makerere University-University of California San Francisco Research Collaboration, Kampala, Uganda
| | - N. Walter
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver, Colorado, USA
| | - A. Cattamanchi
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
- Makerere University-University of California San Francisco Research Collaboration, Kampala, Uganda
- Curry International Tuberculosis Center, San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
| | - M. Awor
- Makerere University-University of California San Francisco Research Collaboration, Kampala, Uganda
| | - J. Katende
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - L. Huang
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
| | - M. Joloba
- Department of Microbiology, Makerere University School of Biomedical Sciences, Kampala, Uganda
| | - H. Albert
- Foundation for Innovative New Diagnostics, Kampala, Uganda
| | - M. R. Kamya
- Department of Medicine, Mulago Hospital, Makerere University College of Health Sciences, Kampala, Uganda
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - J. L. Davis
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
- Makerere University-University of California San Francisco Research Collaboration, Kampala, Uganda
- Curry International Tuberculosis Center, San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
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Cattamanchi A, Miller CR, Tapley A, Haguma P, Ochom E, Ackerman S, Davis JL, Katamba A, Handley MA. Health worker perspectives on barriers to delivery of routine tuberculosis diagnostic evaluation services in Uganda: a qualitative study to guide clinic-based interventions. BMC Health Serv Res 2015; 15:10. [PMID: 25609495 PMCID: PMC4307676 DOI: 10.1186/s12913-014-0668-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 12/16/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Studies of the quality of tuberculosis (TB) diagnostic evaluation of patients in high burden countries have generally shown poor adherence to international or national guidelines. Health worker perspectives on barriers to improving TB diagnostic evaluation are critical for developing clinic-level interventions to improve guideline implementation. METHODS We conducted structured, in-depth interviews with staff at six district-level health centers in Uganda to elicit their perceptions regarding barriers to TB evaluation. Interviews were transcribed, coded with a standardized framework, and analyzed to identify emergent themes. We used thematic analysis to develop a logic model depicting health system and contextual barriers to recommended TB evaluation practices. To identify possible clinic-level interventions to improve TB evaluation, we categorized findings into predisposing, enabling, and reinforcing factors as described by the PRECEDE model, focusing on potentially modifiable behaviors at the clinic-level. RESULTS We interviewed 22 health center staff between February 2010 and November 2011. Participants identified key health system barriers hindering TB evaluation, including: stock-outs of drugs/supplies, inadequate space and infrastructure, lack of training, high workload, low staff motivation, and poor coordination of health center services. Contextual barrier challenges to TB evaluation were also reported, including the time and costs borne by patients to seek and complete TB evaluation, poor health literacy, and stigma against patients with TB. These contextual barriers interacted with health system barriers to contribute to sub-standard TB evaluation. Examples of intervention strategies that could address these barriers and are related to PRECEDE model components include: assigned mentors/peer coaching for new staff (targets predisposing factor of low motivation and need for support to conduct job duties); facilitated workshops to implement same day microscopy (targets enabling factor of patient barriers to completing TB evaluation), and recognition/incentives for good TB screening practices (targets low motivation and self-efficacy). CONCLUSIONS Our findings suggest that health system and contextual barriers work together to impede TB diagnosis at health centers and, if not addressed, could hinder TB case detection efforts. Qualitative research that improves understanding of the barriers facing TB providers is critical to developing targeted interventions to improve TB care.
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Affiliation(s)
- Adithya Cattamanchi
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, Room 5K1, 1001 Potrero Avenue, San Francisco, California, 94110, USA.
- Curry International Tuberculosis Center, University of California San Francisco, San Francisco, California, USA.
- School of Medicine, University of California San Francisco, San Francisco, California, USA.
- Infectious Diseases Research Collaboration, Kampala, Uganda.
| | - Cecily R Miller
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, Room 5K1, 1001 Potrero Avenue, San Francisco, California, 94110, USA.
- Curry International Tuberculosis Center, University of California San Francisco, San Francisco, California, USA.
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA.
| | - Asa Tapley
- School of Medicine, University of California San Francisco, San Francisco, California, USA.
| | | | - Emmanuel Ochom
- Infectious Diseases Research Collaboration, Kampala, Uganda.
| | - Sara Ackerman
- Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, California, USA.
| | - J Lucian Davis
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, Room 5K1, 1001 Potrero Avenue, San Francisco, California, 94110, USA.
- Curry International Tuberculosis Center, University of California San Francisco, San Francisco, California, USA.
- School of Medicine, University of California San Francisco, San Francisco, California, USA.
- Infectious Diseases Research Collaboration, Kampala, Uganda.
| | - Achilles Katamba
- School of MedicineMakerere University College of Health Sciences, Kampala, Uganda.
- Infectious Diseases Research Collaboration, Kampala, Uganda.
| | - Margaret A Handley
- School of Medicine, University of California San Francisco, San Francisco, California, USA.
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA.
- Center for Vulnerable Populations, University of California San Francisco, San Francisco, California, USA.
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11
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Otero L, De Orbegoso A, Navarro AF, Ríos J, Párraga T, Gotuzzo E, Seas C, Van der Stuyft P. Time to initiation of multidrug-resistant tuberculosis treatment and its relation with outcome in a high incidence district in Lima, Peru. Trop Med Int Health 2014; 20:322-5. [PMID: 25429916 DOI: 10.1111/tmi.12430] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the time from diagnosis to start of multidrug resistant tuberculosis (MDR TB) treatment in Lima, Peru. METHODS We studied new smear-positive TB adults that were started on MDR TB treatment or that were switched to it between June 2008 and December 2011. RESULTS Time from the first positive smear to MDR-TB treatment was >30 days in 35% (13/37) of patients. Among the 27% (24/88) of patients that switched to MDR-TB treatment, time from the last dose of a drug-susceptible regimen was >30 days. CONCLUSION Start of and switching to MDR TB treatment is still delayed.
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Affiliation(s)
- L Otero
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru; Unit of General Epidemiology and Disease Control, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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12
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MacPherson P, Houben RMGJ, Glynn JR, Corbett EL, Kranzer K. Pre-treatment loss to follow-up in tuberculosis patients in low- and lower-middle-income countries and high-burden countries: a systematic review and meta-analysis. Bull World Health Organ 2013; 92:126-38. [PMID: 24623906 DOI: 10.2471/blt.13.124800] [Citation(s) in RCA: 156] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 10/02/2013] [Accepted: 10/03/2013] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To assess the magnitude of loss to follow-up in smear- or culture-positive tuberculosis patients before treatment initiation and outcomes among patients who were traced. METHODS Ovid Medline and Global Health databases were searched for studies published between 1994 and January 2013 that described pre-treatment loss to follow-up in patients with smear- or culture-positive tuberculosis in routine national tuberculosis programmes (NTPs) in low- and lower-middle-income countries and in countries with a high burden of tuberculosis. Data on the proportion of patients who did not initiate treatment after their tuberculosis diagnosis were extracted from studies meeting inclusion criteria. Where available, data on causes and outcomes, including initiation of tuberculosis treatment at another facility, were investigated. Heterogeneity and publication bias were assessed and random-effects meta-analyses by subgroup (region) were performed. FINDINGS Twenty-three eligible studies were identified, with a total of 34 706 smear- or culture-positive tuberculosis patients from 14 countries (8 in Africa, 5 in Asia and 1 in the western Pacific). Most studies were retrospective and linked laboratory and treatment registers to identify pre-treatment loss to follow-up. Pre-treatment loss to follow-up varied from 4 to 38% and was common in studies from Africa (random-effects weighted proportion, WP: 18%; 95% confidence interval, CI: 13-22) and Asia (WP: 13%; 95% CI: 10-15). CONCLUSION Pre-treatment loss to follow-up, common in most settings, can hinder tuberculosis control efforts. By not counting individuals who are lost to follow-up before treatment when reporting standard programme indicators, NTPs underestimate case detection rates and mortality and overestimate cure rates.
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Affiliation(s)
- Peter MacPherson
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, England
| | - Rein M G J Houben
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, England
| | - Judith R Glynn
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, England
| | - Elizabeth L Corbett
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, England
| | - Katharina Kranzer
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, England
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13
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Population-level impact of same-day microscopy and Xpert MTB/RIF for tuberculosis diagnosis in Africa. PLoS One 2013; 8:e70485. [PMID: 23950942 PMCID: PMC3741313 DOI: 10.1371/journal.pone.0070485] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 06/19/2013] [Indexed: 11/23/2022] Open
Abstract
Objective To compare the population-level impact of two World Health Organization-endorsed strategies for improving the diagnosis of tuberculosis (TB): same-day microscopy and Xpert MTB/RIF (Cepheid, USA). Methods We created a compartmental transmission model of TB in a representative African community, fit to the regional incidence and mortality of TB and HIV. We compared the population-level reduction in TB burden over ten years achievable with implementation over two years of same-day microscopy, Xpert MTB/RIF testing, and the combination of both approaches. Findings Same-day microscopy averted an estimated 11.0% of TB incidence over ten years (95% uncertainty range, UR: 3.3%–22.5%), and prevented 11.8% of all TB deaths (95% UR: 7.7%–27.1%). Scaling up Xpert MTB/RIF to all centralized laboratories to achieve 75% population coverage had similar impact on incidence (9.3% reduction, 95% UR: 1.9%–21.5%) and greater effect on mortality (23.8% reduction, 95% UR: 8.6%–33.4%). Combining the two strategies (i.e., same-day microscopy plus Xpert MTB/RIF) generated synergistic effects: an 18.7% reduction in incidence (95% UR: 5.6%–39.2%) and 33.1% reduction in TB mortality (95% UR: 18.1%–50.2%). By the end of year ten, combining same-day microscopy and Xpert MTB/RIF could reduce annual TB mortality by 44% relative to the current standard of care. Conclusion Scaling up novel diagnostic tests for TB and optimizing existing ones are complementary strategies that, when combined, may have substantial impact on TB epidemics in Africa.
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