A literature review of the problems of delayed presentation for treatment and non-completion of treatment for tuberculosis in less developed countries and ways of addressing these problems using particular implementations of the DOTS strategy

The possible impact of socioeconomic, income, and educational status on adverse effects of drug and their therapeutic episodes in patients targeted with a combination of tuberculosis interventions

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Socio-economic status is very important in patient receiving DOT therapy.

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Income influences disease occurrence as well as adverse events.

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Occupation increases the risk of diseases and results increase risk of adverse events.

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Low income results mal nutrition and increased risk of drug intolerance or adverse events.

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DOTS is an effective treatment strategy for MTB patients.

First-line antituberculosis (anti-TB) compounds have been considered as proven components of the Directly Observed Treatment-Short course (DOTS). Drug therapy against tuberculosis has been categorized as I, II, or III following the Revised National Tuberculosis Control Program guidelines. Anti-TB are drugs are quite common and show limited adverse effects. However, first-line anti-TB compounds mediated DOTS therapy and were found with several complications. Thus, those drugs have been discontinued. Therefore, the present study was designed to find out the possible impact of socioeconomic, income, and educational status on the adverse effects of drugs and their therapeutic episodes in patients targeted with a combination of tuberculosis intervention. This study found that an increased incidence of tuberculosis was found in patients who have finished high school, contributing to a high percentage of adverse effects. Notably, adverse events were shown maximally in poor patients compared with rich- or high-income patients. On the contrary, a high prevalence of adverse events was shown to be increased in partially skilled workers compared with full-skilled workers. Consequently, adversely considerable events were implicated to be raised in patients associated with minimal socioeconomic class. Such interesting factors would help in monitoring such events in experimental patients.

Psychometric evaluation of a new drug-resistant tuberculosis stigma scale

OBJECTIVES

Stigma contributes to diagnostic delay, disease concealment, and reduced wellbeing for people with multidrug-resistant tuberculosis (MDR-TB) and their communities. Despite the negative effects of stigma, there are no scales to measure stigma in people with MDR-TB. This study aimed to develop and validate a scale to measure stigma in people affected by MDR-TB in Vietnam.

STUDY DESIGN AND SETTING

People with rifampicin-resistant (RR)-MDR-TB who had completed at least 3 months of treatment were invited to complete a survey containing 45 draft stigma items. Data analysis included exploratory factor analysis, internal consistency, content, criterion and construct validity, and test-retest reliability.

RESULTS

A total of 315 people with RR/MDR-TB completed the survey. Exploratory factor analysis revealed a 14 item RR/MDR-TB stigma scale with four subscales, including guilt, social exclusion, physical isolation, and blame. Internal consistency and test-retest reliability were good (Cronbach's Alpha = 0.76, ICC = 0.92). Construct validity was adequate with moderate correlations with related constructs.

CONCLUSION

Our RR/MDR-TB Scale demonstrated good psychometric properties in Vietnam. This scale will assist in the measurement of stigma in people with RR/MDR-TB. It will also aid in the evaluation of stigma reduction interventions in people with RR/MDR-TB.

Implementation fidelity of hospital based directly observed therapy for tuberculosis treatment in Bhutan: mixed-method study

Background

Direct observed treatment (DOT) has been implemented in Bhutan since 1997 and currently, it is offered in various model of delivery including a combination of hospital based, home based DOT and ambulatory DOT. Overall, treatment success rate for tuberculosis cases is higher than the global target; however, it is still need to be improved. Evaluation to the implementation fidelity of DOT is important to identify potential rooms for improvement. This study aimed to assess two major components of the program’s implementation fidelity: to assess patient’s adherence to DOT and explore factors for adherence; to assess provider’s compliance with DOT guideline and explore factors for compliance.

Methods

This research used a sequential explanatory mixed method. The conceptual framework of implementation fidelity was adopted to guide this study design. The cross-sectional study of TB patients was enrolled in two hospitals with highest TB load, between September to November 2017 in Bhutan. Interviewer assisted survey was conducted with 139 TB patients who visited the hospital in continuation phase. In-depth interview was then conducted with nine TB patients and four health staffs to explore the barriers and enablers of DOT.

Results

Total of 61.9% (86/139) of patients has received DOT at intensive phase. Proportion was higher among MDR-TB cases (100%), and smear sputum positive TB cases (84.7%). In the continuation phase, 5.8% of patients took medicine at hospital, 48.9% at home and the rest 45.3% no longer practiced DOT. More than 90% of patient received correct dosage and standard regimen of anti-TB drugs according to the guideline. The key factors affecting poor adherence to DOT as perceived by patients were; lack of willingness to visit the clinic on daily basis due to long distance, financial implications and family support. However, patient’s satisfaction to the quality of TB treatment service delivery was high (98.6%). Providing incentives to the patient was most agreed enabler felt by both health workers and patients.

Conclusion

In the selected hospital sites, the patient’s adherence to DOT and provider’s compliance with DOT guideline is partially implemented; the coverage and the duration of DOT is very low, therefore, need to revise and improve DOT model and structure.

Detection and management of drug-resistant tuberculosis in HIV-infected patients in lower-income countries

SETTING

Drug resistance threatens tuberculosis (TB) control, particularly among human immunodeficiency virus (HIV) infected persons.

OBJECTIVE

To describe practices in the prevention and management of drug-resistant TB under antiretroviral therapy (ART) programs in lower-income countries.

DESIGN

We used online questionnaires to collect program-level data on 47 ART programs in Southern Africa (n = 14), East Africa (n = 8), West Africa (n = 7), Central Africa (n = 5), Latin America (n = 7) and the Asia-Pacific (n = 6 programs) in 2012. Patient-level data were collected on 1002 adult TB patients seen at 40 of the participating ART programs.

RESULTS

Phenotypic drug susceptibility testing (DST) was available in 36 (77%) ART programs, but was only used for 22% of all TB patients. Molecular DST was available in 33 (70%) programs and was used in 23% of all TB patients. Twenty ART programs (43%) provided directly observed therapy (DOT) during the entire course of treatment, 16 (34%) during the intensive phase only, and 11 (23%) did not follow DOT. Fourteen (30%) ART programs reported no access to second-line anti-tuberculosis regimens; 18 (38%) reported TB drug shortages.

CONCLUSIONS

Capacity to diagnose and treat drug-resistant TB was limited across ART programs in lower-income countries. DOT was not always implemented and drug supplies were regularly interrupted, which may contribute to the global emergence of drug resistance.

The views of the elderly on the impact that HIV and AIDS has on their lives in the Thulamela Municipality, Vhembe District, Limpopo province

BACKGROUND

HIV and AIDS have a devastating impact on the lives of elderly people, particularly so because they are often expected to take care of their terminally ill children and assume the responsibility of looking after children orphaned by AIDS - in most cases with very little resources.

OBJECTIVES

The study sought to achieve to describe the views of elderly people regarding the impact of HIV and AIDS on their lives, to determine the challenges that elderly people living with HIV or AIDS (EPLWHA) face in their daily lives, and to gain a sense of the coping strategies they use to overcome the obstacles they face in relation to HIV and AIDS. Ethical issues, such as permission to conduct the study, informed consent, confidentiality and anonymity, withdrawal of participation and measure to ensure trustworthiness, were ensured.

DESIGN

This was a qualitative, explorative, descriptive study. Participants were interviewed using an interview guide. Information provided by the participants was captured on a tape recorder and analysed using open coding, and thereafter collated into themes, categories and sub-themes.

RESULTS

The study findings revealed that HIV and AIDS have serious negative impacts on the lives of elderly people, particularly those living in poverty. The following key areas in relation to EPLWHA were established: psychological or emotional health, as well as household and socio-economic burdens. Considering the role that elderly people play in the community in so far as HIV and AIDS are concerned, primary health promotion and social welfare programmes should be directed at educating all elderly people and their service providers on how to cope with the health and social problems related to HIV and AIDS.

Factors associated with patient and health care system delay in diagnosis for tuberculosis in the province of Luanda, Angola

Background

Tuberculosis (TB) is still a great challenge to public health in sub-Saharan Africa. Most transmissions occur between the onset of coughing and initiation of treatment. Delay in diagnosis is significant to disease prognosis, thus early diagnosis and prompt effective therapy represent the key elements in controlling the disease. The objective of this study was to investigate the factors influencing the patient delay and the health system delay in TB diagnosis in Angola.

Methods

On a cross-sectional study, 385 TB patients who visited 21 DOTS clinics in Luanda were included consecutively. The time from the onset of symptoms to the first consultation of health providers (patients’ delay) and the time from the first consultation to the date of diagnosis (health system’s delay) were analysed. Bivariate and logistics regression were applied to analyse the risk factors of delays.

Results

The median total time elapsed from the onset of symptoms to diagnosis was 45 days (interquartile range [IQR]: 21–97 days). The median patient delay was 30 days (IQR: 14–60 days), and the median health care system delay was 7 days (IQR: 5–15 days). Primary education (AOR = 1.75; CI [95%] 1.06–2.88; p <0.029) and the health centre of the first contact differing from the DOTS centre (AOR = 1.66; CI [95%] 1.01–2.75; p <0.046) were independent risk factors for patient delay >4 weeks. Living in a suburban area (AOR = 2,32; CI [95%] 1.21–4.46; p = 0.011), having a waiting time in the centre >1 hour (AOR = 4.37; CI [95%] 1.72–11.14; p = 0.002) and the health centre of the first contact differening from the DOTS centre (AOR = 5.68; CI [95%] 2.72–11,83; p < 0,00001) were factors influencing the system delay.

Conclusions

The results indicate that the delay is principally due to the time elapsed between the onset of symptoms and the first consultation. More efforts should be placed in ensuring the availability of essential resources and skills in all healthcare facilities other than the DOTS centres, especially those located in suburban areas.

Determinants of tuberculosis treatment default in Morocco: results from a national cohort study

Introduction

Studies have shown an association between smoking and tuberculosis (TB) infection, disease and TB-related mortality. We thus documented the impact of smoking and others factors on TB treatment default.

Methods

A cohort of 1039 new TB cases matched on smoking status was followed between 2004 and 2009 in eight Moroccan regions. Treatment default was defined according to international criteria. Univariate analyses were used to assess associations of treatment default with smoking status and demographic characteristics. Multivariate logistic regression was used to adjust for potential confounding.

Results

Patients’ mean age was 35.0 ±13.2 years. The rate of treatment default was 30.2%. Default was significantly higher among men, smokers, persons living in urban areas and non-religious Muslims. After adjusting for confounding variables, factors that remained significantly associated with treatment default were: being male (OR = 3.2; 95% CI: 1.2-8.7), being a non-religious Muslim (OR = 2.0; 95% CI: 1.4-2.9) and living in an urban area OR = 3.0; 95% CI: 1.8-4.9).

Conclusion

The high rate found for default suggests important program's inadequacies and an urgent need for change. Therefore continued research of predictors of default and strategies to reinforce adherence is recommended.

Pharmaceutical aerosols for the treatment and prevention of tuberculosis

Historically, pharmaceutical aerosols have been employed for the treatment of obstructive airway diseases, such as asthma and chronic obstructive pulmonary disease, but in the past decades their use has been expanded to treat lung infections associated with cystic fibrosis and other respiratory diseases. Tuberculosis (TB) is acquired after inhalation of aerosol droplets containing the bacilli from the cough of infected individuals. Even though TB affects other organs, the lungs are the primary site of infection, which makes the pulmonary route an ideal alternative route to administer vaccines or drug treatments. Optimization of formulations and delivery systems for anti-TB vaccines and drugs, as well as the proper selection of the animal model to evaluate those is of paramount importance if novel vaccines or drug treatments are to be successful. Pharmaceutical aerosols for patient use are generated from metered dose inhalers, nebulizers, and dry powder inhalers (DPIs). In addition to the advantages of providing more efficient delivery of the drug, low cost, and portability, pharmaceutical dry powder aerosols are more stable than inhalable liquid dosage forms and do not require refrigeration. Methods to manufacture dry powders in respirable sizes include micronization, spray drying, and other proprietary technologies. Inhalable dry powders are characterized in terms of their drug content, particle size, and dispersibility to ensure deposition in the appropriate lung region and effective aerosolization from the device. These methods will be illustrated as they were applied for the manufacture and characterization of powders containing anti-tubercular agents and vaccines for pulmonary administration. The influence of formulation, selection of animal model, method of aerosol generation, and administration on the efficacy demonstrated in a given study will be illustrated by the evaluation of pharmaceutical aerosols of anti-TB drugs and vaccines in guinea pigs by our group.

Delay and completion of tuberculosis treatment: a cross-sectional study in the West Midlands, UK

BACKGROUND

TB remains a significant problem in the UK with the West Midlands having the highest incidence after London. Treatment is usually for a minimum of 6 months and requires a high level of compliance. We investigated potential determinants of delays and completion of treatment for tuberculosis (TB) in the West Midlands, UK.

METHODS

We used data on 4840 patients with TB in the West Midlands from the Enhanced Tuberculosis Surveillance database from 1 January 2005 to 1 October 2010. We used regression models to investigate the cross-sectional association between sociodemographic and clinical risk factors and the timeliness and completion of TB treatment.

RESULTS

Patients with TB waited 82 days on average from symptom onset to treatment initiation. Female patients spent 6% longer time than males before receiving treatment [95% confidence interval (CI): 1.2-11.6%, P = 0.015]. Asian/Asian British patients were 11 times more likely to complete treatment than White patients (adjusted odds ratio: 11.4, 95% CI: 1.31-100.3, P = 0.028).

CONCLUSIONS

Females in the West Midlands took longer time to receive TB treatment than males, representing a health inequality that could be addressed through gender-sensitive awareness raising programmes. White patients were less likely to complete treatment than Asian/Asian British patients; additional support is needed in this group.

Factors associated with patient and health care system delay in diagnosis and treatment for TB in sub-Saharan African countries with high burdens of TB and HIV

OBJECTIVE

To identify factors causing delayed diagnosis and treatment for tuberculosis in high tuberculosis (TB)/HIV burden African countries.

METHODS

We searched Ovid Medline, CINAHL, PsychInfo, Scopus and Sabinet-South African journals and reference lists, Google, Google Scholar and Google SA for reports in English, ≥1992, of original data from sub-Saharan countries on patient or system delay in TB diagnosis or treatment with populations ≥15 years old. Two reviewers extracted data independently for each study. We categorized independent variables as predisposing, enabling or reinforcing (PRECEDE model). Meta-analysis was conducted for factors associated with delay in ≥2 studies.

RESULTS

Of 20 eligible studies, 12 assessed both sources of delay; 1, system delay; and 7, patient delay only. Most were cross-sectional surveys (k = 13) with samples of consecutive patients (k = 13) and bivariate analyses (k = 11). Starting and endpoints for patient delay were consistent, but not system delay. Patient characteristics were studied frequently; HIV stigma and enabling factors were studied infrequently, although the last were most often associated with delay. Consulting traditional healers first--usually by rural residents--consistently led to patient delay; OR = 3.45 (1.91-6.21). Travel time for the return visit was consistently associated with system delay OR = 1.87 (1.378-2.531).

CONCLUSIONS

We recommend partnerships with traditional healers and research emphasizing HIV and system factors, standard definitions of delay and qualitative and cohort studies to identify enabling and reinforcing factors related to delay.

The influence of socio-economic deprivation on tuberculosis treatment delays in England, 2000–2005

This study investigates the association between socio-economic deprivation and tuberculosis (TB) treatment delays in England, 2000–2005. Patients reported to the Enhanced TB Surveillance system were assigned a deprivation score based on residential postcode, and categorized into deprivation quartiles. Data were analysed using Cox regression. The median interval from symptom onset to treatment initiation was 67 days (inter-quartile range 30–131). The effect of deprivation on this interval was modified by ethnic group and place of birth/time since entry into the United Kingdom. Longer intervals were experienced by the most deprived black Africans, Indians/Pakistanis/Bangladeshis and recent entrants to the United Kingdom, compared to the least deprived. In contrast, among white and UK-born patients, longer intervals were experienced by the least deprived. In conclusion, the effect of deprivation on TB treatment delays varies in different population groups. Efforts are needed to reduce delays including improving awareness of TB and increasing the index of clinical suspicion.

Novel strategies to identify biomarkers in tuberculosis

The more we learn about the immune response against tuberculosis (TB) and particularly about the features which distinguish protective immunity, disease susceptibility and pathology, the better we can define biomarkers which correlate with these different stages of infection. The most widely used biomarker in TB, which without a doubt is an important component of protective immunity, is IFNγ secreted by antigen-specific CD4 T-cells. However, the complexity of the immune response against TB makes it more than likely that additional biomarkers are required for a reliable correlate of protection. As a corollary, we assume that a set of biomarkers will be required, termed a biosignature.

Determinants of treatment adherence among smear-positive pulmonary tuberculosis patients in Southern Ethiopia

BACKGROUND

Defaulting from treatment remains a challenge for most tuberculosis control programmes. It may increase the risk of drug resistance, relapse, death, and prolonged infectiousness. The aim of this study was to determine factors predicting treatment adherence among smear-positive pulmonary tuberculosis patients.

METHODS AND FINDINGS

A cohort of smear-positive tuberculosis patients diagnosed and registered in Hossana Hospital in southern Ethiopia from 1 September 2002 to 30 April 2004 were prospectively included. Using a structured questionnaire, potential predictor factors for defaulting from treatment were recorded at the beginning of treatment, and patients were followed up until the end of treatment. Default incidence rate was calculated and compared among preregistered risk factors. Of the 404 patients registered for treatment, 81 (20%) defaulted from treatment. A total of 91% (74 of 81) of treatment interruptions occurred during the continuation phase of treatment. On a Cox regression model, distance from home to treatment centre (hazard ratio [HR] = 2.97; p < 0.001), age > 25 y (HR = 1.71; p = 0.02), and necessity to use public transport to get to a treatment centre (HR = 1.59; p = 0.06) were found to be independently associated with defaulting from treatment.

CONCLUSIONS

Defaulting due to treatment noncompletion in this study setting is high, and the main determinants appear to be factors related to physical access to a treatment centre. The continuation phase of treatment is the most crucial time for treatment interruption, and future interventions should take this factor into consideration.

Role of chemokine ligand 2 in the protective response to early murine pulmonary tuberculosis

Chemokines play an important role in the development of immunity to tuberculosis. Chemokine ligand 2 (CCL2, JE, monocyte chemoattractant protein-1) is thought to be primarily responsible for recruiting monocytes, dendritic cells, natural killer cells and activated T cells, all of which play critical roles in the effective control of tuberculosis infection in mice. We show here that in mice in which the CCL2 gene was disrupted, low-dose aerosol infection with Mycobacterium tuberculosis resulted in fewer macrophages entering the lungs, but only a minor and transient increase in bacterial load in the lungs; these mice were still able to establish a state of chronic disease. Such animals showed similar numbers of activated T cells as wild-type mice, as determined by their expression of the CD44hi CD62lo phenotype, but a transient reduction in cells secreting interferon-gamma. These data indicate that the primary deficiency in mice unable to produce CCL2 is a transient failure to focus antigen-specific T lymphocytes into the infected lung, whereas other elements of the acquired host response are compensated for by different ligands interacting with the chemokine receptor CCR2.