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Geadas C, Millones AK, Acosta D, Campos H, Del Aguila-Rojas E, Farroñay S, Morales G, Ramirez-Sandoval J, Torres I, Jimenez J, Lecca L, Yuen CM. Barriers and facilitators to tuberculosis diagnosis in Lima, Peru: a mixed methods study. BMC Infect Dis 2024; 24:798. [PMID: 39118040 PMCID: PMC11308566 DOI: 10.1186/s12879-024-09707-0] [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: 12/01/2023] [Accepted: 08/02/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND Tuberculosis (TB) infectiousness decreases significantly with only a few days of treatment, but delayed diagnosis often leads to late treatment initiation. We conducted a sequential explanatory mixed methods study to understand the barriers and facilitators to prompt diagnosis among people with TB. METHODS We enrolled 100 adults who started TB treatment in the Carabayllo district of Lima, Peru, between November 2020 and February 2022 and administered a survey about their symptoms and healthcare encounters. We calculated total diagnostic delay as time from symptom onset to diagnosis. We conducted semi-structured interviews of 26 participants who had a range of delays investigating their experience navigating the health system. Interview transcripts were inductively coded for concepts related to diagnostic barriers and facilitators. RESULTS Overall, 38% of participants sought care first from public facilities and 42% from the private sector. Only 14% reported being diagnosed with TB on their first visit, and participants visited a median of 3 (interquartile range [IQR] health facilities before diagnosis. The median total diagnostic delay was 9 weeks (interquartile range [IQR] 4-22), with a median of 4 weeks (IQR 0-9) before contact with the health system and of 3 weeks (IQR 0-9) after. Barriers to prompt diagnosis included participants attributing their symptoms to an alternative cause or having misconceptions about TB, and leading them to postpone seeking care. Once connected to care, variations in clinical management, health facility resource limitations, and lack of formal referral processes contributed to the need for multiple healthcare visits before obtaining a diagnosis. Facilitators to prompt diagnosis included knowing someone with TB, supportive friends and family, referral documents, and seeing a pulmonologist. CONCLUSIONS Misinformation about TB among people with TB and providers, poor accessibility of health services, and the need for multiple encounters to obtain diagnostic tests were major factors leading to delays. Extending the hours of operation of public health facilities, improving community awareness and provider training, and creating a formal referral process between the public and private sectors should be priorities in the efforts to combat TB.
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Affiliation(s)
- Carolina Geadas
- Brigham and Women's Hospital, Division of Infectious Diseases, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | | | | | | | | | | | | | | | | | | | - Leonid Lecca
- Harvard Medical School, Boston, MA, USA
- Socios En Salud Sucursal Peru, Lima, Peru
| | - Courtney M Yuen
- Harvard Medical School, Boston, MA, USA
- Brigham and Women's Hospital, Division of Global Health Equity, Boston, MA, USA
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Al-Naser Y, Alshadeedi F. Bringing imaging to the people: Enhancing access and equity in healthcare through mobile imaging. J Med Imaging Radiat Sci 2024; 55:101715. [PMID: 39047372 DOI: 10.1016/j.jmir.2024.101715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 06/19/2024] [Accepted: 06/21/2024] [Indexed: 07/27/2024]
Affiliation(s)
- Yousif Al-Naser
- Medical Radiation Sciences, McMaster University, Hamilton, ON, Canada; Department of Diagnostic Imaging, Trillium Health Partners, Mississauga, ON, Canada.
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Innes AL, Lebrun V, Hoang GL, Martinez A, Dinh N, Nguyen TTH, Huynh TP, Quach VL, Nguyen TB, Trieu VC, Tran NDB, Pham HM, Dinh VL, Nguyen BH, Truong TTH, Nguyen VC, Nguyen VN, Mai TH. An Effective Health System Approach to End TB: Implementing the Double X Strategy in Vietnam. GLOBAL HEALTH, SCIENCE AND PRACTICE 2024; 12:e2400024. [PMID: 38936961 PMCID: PMC11216706 DOI: 10.9745/ghsp-d-24-00024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 05/30/2024] [Indexed: 06/29/2024]
Abstract
Countries that are high burden for TB must reverse the COVID-19 pandemic's devastating effects to accelerate progress toward ending TB. Vietnam's Double X (2X) strategy uses chest radiography (CXR) and GeneXpert (Xpert) rapid diagnostic testing to improve early detection of TB disease. Household contacts and vulnerable populations (e.g., individuals aged 60 years and older, smokers, diabetics, those with alcohol use disorders, and those previously treated for TB) with and without TB symptoms were screened in community campaigns using CXRs, followed by Xpert for those with a positive screen. In public non-TB district facilities, diabetics, respiratory outpatients, inpatients with lung disease, and other vulnerable populations underwent 2X evaluation. During COVID-19 restrictions in Vietnam, the 2X strategy improved access to TB services by decentralization to commune health stations, the lowest level of the health system, and enabling self-screening using a quick response mobile application. The number needed to screen (NNS) with CXRs to diagnose 1 person with TB disease was calculated for all 2X models and showed the highest yield among self-screeners (11 NNS with CXR), high yield for vulnerable populations in communities (60 NNS) and facilities (19 NNS), and moderately high yield for household contacts in community campaigns (154 NNS). Computer-aided diagnosis for CXRs was incorporated into community and facility implementation and improved physicians' CXR interpretations and Xpert referral decisions. Integration of TB infection and TB disease evaluation increased eligibility for TB preventive treatment among household contacts, a major challenge during implementation. The 2X strategy increased the rational use of Xpert, employing a health system-wide approach that reached vulnerable populations with and without TB symptoms in communities and facilities for early detection of TB disease. This strategy was effectively adapted to different levels of the health system during COVID-19 restrictions and contributed to post-pandemic TB recovery in Vietnam.
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Affiliation(s)
- Anh L Innes
- FHI 360 Asia Pacific Regional Office, Bangkok, Thailand.
| | | | | | | | | | | | | | | | | | | | | | - Huy Minh Pham
- U.S. Agency for International Development/Vietnam, Hanoi, Vietnam
| | | | | | | | | | - Viet Nhung Nguyen
- Vietnam National Lung Hospital, Hanoi, Vietnam
- Pulmonology Department, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
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Sifumba Z, Claassen H, Olivier S, Khan P, Ngubane H, Bhengu T, Zulu T, Sithole M, Gareta D, Moosa MYS, Hanekom WA, Bassett IV, Wong EB. Subclinical tuberculosis linkage to care and completion of treatment following community-based screening in rural South Africa. BMC GLOBAL AND PUBLIC HEALTH 2024; 2:30. [PMID: 38832047 PMCID: PMC11144138 DOI: 10.1186/s44263-024-00059-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 04/18/2024] [Indexed: 06/05/2024]
Abstract
Background Tuberculosis (TB), a leading cause of infectious death, is curable when patients complete a course of multi-drug treatment. Because entry into the TB treatment cascade usually relies on symptomatic individuals seeking care, little is known about linkage to care and completion of treatment in people with subclinical TB identified through community-based screening. Methods Participants of the Vukuzazi study, a community-based survey that provided TB screening in the rural uMkhanyakude district of KwaZulu-Natal from May 2018 - March 2020, who had a positive sputum (GeneXpert or Mtb culture, microbiologically-confirmed TB) or a chest x-ray consistent with active TB (radiologically-suggested TB) were referred to the public health system. Telephonic follow-up surveys were conducted from May 2021 - January 2023 to assess linkage to care and treatment status. Linked electronic TB register data was accessed. We analyzed the effect of baseline HIV and symptom status (by WHO 4-symptom screen) on the TB treatment cascade. Results Seventy percent (122/174) of people with microbiologically-confirmed TB completed the telephonic survey. In this group, 84% (103/122) were asymptomatic and 46% (56/122) were people living with HIV (PLWH). By self-report, 98% (119/122) attended a healthcare facility after screening, 94% (115/122) started TB treatment and 93% (113/122) completed treatment. Analysis of electronic TB register data confirmed that 67% (116/174) of eligible individuals started TB treatment. Neither symptom status nor HIV status affected linkage to care. Among people with radiologically-suggested TB, 48% (153/318) completed the telephonic survey, of which 80% (122/153) were asymptomatic and 52% (79/153) were PLWH. By self-report, 75% (114/153) attended a healthcare facility after screening, 16% (24/153) started TB treatment and 14% (22/153) completed treatment. Nine percent (28/318) of eligible individuals had TB register data confirming that they started treatment. Conclusions Despite high rates of subclinical TB, most people diagnosed with microbiologically-confirmed TB after community-based screening were willing to link to care and complete TB treatment. Lower rates of linkage to care in people with radiologically-suggested TB highlight the importance of streamlined care pathways for this group. Clearer guidelines for the management of people who screen positive during community-based TB screening are needed. Supplementary Information The online version contains supplementary material available at 10.1186/s44263-024-00059-0.
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Affiliation(s)
- Zolelwa Sifumba
- Africa Health Research Institute, Durban & Somkhele, KwaZulu-Natal South Africa
| | - Helgard Claassen
- Africa Health Research Institute, Durban & Somkhele, KwaZulu-Natal South Africa
| | - Stephen Olivier
- Africa Health Research Institute, Durban & Somkhele, KwaZulu-Natal South Africa
| | - Palwasha Khan
- Africa Health Research Institute, Durban & Somkhele, KwaZulu-Natal South Africa
- London School of Hygiene & Tropical Medicine, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London, Great Britain and Northern Ireland UK
| | - Hloniphile Ngubane
- Africa Health Research Institute, Durban & Somkhele, KwaZulu-Natal South Africa
| | - Thokozani Bhengu
- Africa Health Research Institute, Durban & Somkhele, KwaZulu-Natal South Africa
| | - Thando Zulu
- Africa Health Research Institute, Durban & Somkhele, KwaZulu-Natal South Africa
| | - Mareca Sithole
- Africa Health Research Institute, Durban & Somkhele, KwaZulu-Natal South Africa
| | - Dickman Gareta
- Africa Health Research Institute, Durban & Somkhele, KwaZulu-Natal South Africa
| | - Vukuzazi Team
- Africa Health Research Institute, Durban & Somkhele, KwaZulu-Natal South Africa
- Department of Infectious Disease, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- London School of Hygiene & Tropical Medicine, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London, Great Britain and Northern Ireland UK
- King Edward VIII Hospital, Durban, South Africa
- Division of Infection and Immunity, University College London, London, Great Britain and Northern Ireland UK
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA USA
- Division of Infectious Diseases, University of Alabama Birmingham, Birmingham, AL USA
| | - Mahomed-Yunus S. Moosa
- Department of Infectious Disease, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- King Edward VIII Hospital, Durban, South Africa
| | - Willem A. Hanekom
- Africa Health Research Institute, Durban & Somkhele, KwaZulu-Natal South Africa
- Division of Infection and Immunity, University College London, London, Great Britain and Northern Ireland UK
| | - Ingrid V. Bassett
- Africa Health Research Institute, Durban & Somkhele, KwaZulu-Natal South Africa
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA USA
| | - Emily B. Wong
- Africa Health Research Institute, Durban & Somkhele, KwaZulu-Natal South Africa
- Division of Infectious Diseases, University of Alabama Birmingham, Birmingham, AL USA
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Contreras C, Cruz JS, Galea JT, Chu AL, Puma D, Ramos L, Tovar M, Peinado J, Lecca L, Keshavjee S, Yuen CM, Raviola G. Programmatic implementation of depression screening and remote mental health support sessions for persons recently diagnosed with TB in Lima, Peru during the COVID-19 pandemic. Glob Ment Health (Camb) 2024; 11:e59. [PMID: 38751725 PMCID: PMC11094547 DOI: 10.1017/gmh.2024.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/31/2024] [Accepted: 02/15/2024] [Indexed: 05/18/2024] Open
Abstract
Background Few studies have explored a stepped care model for delivering mental health care to persons with tuberculosis (TB). Here, we evaluated depression screening and remote low-intensity mental health interventions for persons initiating TB treatment in Lima, Peru during the COVID-19 pandemic. Methods We used the Patient Health Questionnaire 9 (PHQ-9) to screen participants for depressive symptoms (PHQ-9 ≥ 5). Participants with PHQ-9, 5-14 received remote Psychological First Aid (PFA) or Problem Management Plus (PM+). Participants were reevaluated 6 months after intervention completion. We then compared the change in median PHQ-9 scores before and after intervention completion. Those with PHQ-9 ≥ 15 were referred to higher-level care. Findings We found that 62 (45.9%) of the 135 participants had PHQ-9 ≥ 5 at baseline. Then, 54 individuals with PHQ-9, 5-9 received PFA, of which 44 (81.5%) were reevaluated. We observed significant reductions in median PHQ-9 scores from 6 to 2 (r = 0.98; p < 0.001). Four participants with PHQ-9, 10-14 received PM+ but were unable to be reevaluated. Four participants with PHQ-9 ≥ 15 were referred to higher-level care. Conclusions Depressive symptoms were common among persons recently diagnosed with TB. We observed improvements in depressive symptoms 6 months later for most participants who received remote sessions of PFA.
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Affiliation(s)
- Carmen Contreras
- Socios En Salud Sucursal Peru, Lima, Peru
- Harvard Global Health Institute, Harvard University, Cambridge, MA, USA
| | | | - Jerome T. Galea
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- School of Social Work, University of South Florida, Tampa, FL, USA
| | - Alexander L. Chu
- Department of Medical Education, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | | | - Lourdes Ramos
- Socios En Salud Sucursal Peru, Lima, Peru
- Escuela Profesional de Tecnología Médica, Universidad Privada San Juan Bautista, Lima, Peru
| | - Marco Tovar
- Socios En Salud Sucursal Peru, Lima, Peru
- Escuela de Medicina, Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas, Lima, Peru
| | - Jesús Peinado
- Socios En Salud Sucursal Peru, Lima, Peru
- Escuela de Medicina, Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas, Lima, Peru
| | - Leonid Lecca
- Socios En Salud Sucursal Peru, Lima, Peru
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Partners In Health, Boston, MA, USA
| | - Salmaan Keshavjee
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Courtney M. Yuen
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Giuseppe Raviola
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Partners In Health, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
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Illemann NM, Illemann TM. Mobile imaging trailers: A scoping review of CT and MRI modalities. Radiography (Lond) 2024; 30:431-439. [PMID: 38199159 DOI: 10.1016/j.radi.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/21/2023] [Accepted: 12/13/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Mobile Imaging Trailers enable moving diagnostic imaging equipment between locations requiring very little setup and configuration, example given CT-scanners and MRI-scanners. However, despite the apparent benefits of utilising these imaging capabilities, very little research on the subject exists. This study aims at gaining an overview of the current state of the literature, using the scoping review methodology. METHODS The systematic literature search was conducted in three databases: Scopus, Embase and PubMed. Included sources were extracted based on the objectives of the scoping review, and inspired by the by PRISMA-ScR. RESULTS 29 papers were included. CONCLUSION The results of the review showed that three general categories of research on this subject exist - trailers used in research, trailers as the object of research and trailers as an element or tool of the research. Of these, the most prevalent one used is the latter - trailers used as an element or tool of the research. This; however, is an issue for the use of trailers in a clinical setting, as very little research has been conducted on how they might be used and how they compare to fixed installations. As seen during the recent COVID-19 pandemic, the potentials for the use of MITs are immense; however, with the current lack of knowledge and understanding, the full potential has not been realised, suggesting further research should be focused in this area. IMPLICATIONS FOR PRACTICE This study has shown that the limited research in the area does point towards a few benefits of MITs; however, there is a clear lack of sufficient research on the field to say this with confidence.
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Affiliation(s)
- N M Illemann
- University College of Northern Denmark, Selma Lagerløfts vej 2, 9220 Aalborg East, Denmark.
| | - T M Illemann
- Department of the Built Environment, Aalborg University, Thomas Manns Vej 23, 9220 Aalborg East, Denmark
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Biewer AM, Tzelios C, Tintaya K, Roman B, Hurwitz S, Yuen CM, Mitnick CD, Nardell E, Lecca L, Tierney DB, Nathavitharana RR. Accuracy of digital chest x-ray analysis with artificial intelligence software as a triage and screening tool in hospitalized patients being evaluated for tuberculosis in Lima, Peru. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002031. [PMID: 38324610 PMCID: PMC10849246 DOI: 10.1371/journal.pgph.0002031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 01/08/2024] [Indexed: 02/09/2024]
Abstract
Tuberculosis (TB) transmission in healthcare facilities is common in high-incidence countries. Yet, the optimal approach for identifying inpatients who may have TB is unclear. We evaluated the diagnostic accuracy of qXR (Qure.ai, India) computer-aided detection (CAD) software versions 3.0 and 4.0 (v3 and v4) as a triage and screening tool within the FAST (Find cases Actively, Separate safely, and Treat effectively) transmission control strategy. We prospectively enrolled two cohorts of patients admitted to a tertiary hospital in Lima, Peru: one group had cough or TB risk factors (triage) and the other did not report cough or TB risk factors (screening). We evaluated the sensitivity and specificity of qXR for the diagnosis of pulmonary TB using culture and Xpert as primary and secondary reference standards, including stratified analyses based on risk factors. In the triage cohort (n = 387), qXR v4 sensitivity was 0.91 (59/65, 95% CI 0.81-0.97) and specificity was 0.32 (103/322, 95% CI 0.27-0.37) using culture as reference standard. There was no difference in the area under the receiver-operating-characteristic curve (AUC) between qXR v3 and qXR v4 with either a culture or Xpert reference standard. In the screening cohort (n = 191), only one patient had a positive Xpert result, but specificity in this cohort was high (>90%). A high prevalence of radiographic lung abnormalities, most notably opacities (81%), consolidation (62%), or nodules (58%), was detected by qXR on digital CXR images from the triage cohort. qXR had high sensitivity but low specificity as a triage in hospitalized patients with cough or TB risk factors. Screening patients without cough or risk factors in this setting had a low diagnostic yield. These findings further support the need for population and setting-specific thresholds for CAD programs.
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Affiliation(s)
- Amanda M. Biewer
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Christine Tzelios
- Harvard Medical School, Boston, Massachusetts, United States of America
| | | | | | - Shelley Hurwitz
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Courtney M. Yuen
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Carole D. Mitnick
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Edward Nardell
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | | | - Dylan B. Tierney
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- Massachusetts Department of Public Health, Boston, Massachusetts, United States of America
| | - Ruvandhi R. Nathavitharana
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
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Eneogu RA, Mitchell EMH, Ogbudebe C, Aboki D, Anyebe V, Dimkpa CB, Egbule D, Nsa B, van der Grinten E, Soyinka FO, Abdur-Razzaq H, Useni S, Lawanson A, Onyemaechi S, Ubochioma E, Scholten J, Verhoef J, Nwadike P, Chukwueme N, Nongo D, Gidado M. Iterative evaluation of mobile computer-assisted digital chest x-ray screening for TB improves efficiency, yield, and outcomes in Nigeria. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002018. [PMID: 38232129 DOI: 10.1371/journal.pgph.0002018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 11/29/2023] [Indexed: 01/19/2024]
Abstract
Wellness on Wheels (WoW) is a model of mobile systematic tuberculosis (TB) screening of high-risk populations combining digital chest radiography with computer-aided automated detection (CAD) and chronic cough screening to identify presumptive TB clients in communities, health facilities, and prisons in Nigeria. The model evolves to address technical, political, and sustainability challenges. Screening methods were iteratively refined to balance TB yield and feasibility across heterogeneous populations. Performance metrics were compared over time. Screening volumes, risk mix, number needed to screen (NNS), number needed to test (NNT), sample loss, TB treatment initiation and outcomes. Efforts to mitigate losses along the diagnostic cascade were tracked. Persons with high CAD4TB score (≥80), who tested negative on a single spot GeneXpert were followed-up to assess TB status at six months. An experimental calibration method achieved a viable CAD threshold for testing. High risk groups and key stakeholders were engaged. Operations evolved in real time to fix problems. Incremental improvements in mean client volumes (128 to 140/day), target group inclusion (92% to 93%), on-site testing (84% to 86%), TB treatment initiation (87% to 91%), and TB treatment success (71% to 85%) were recorded. Attention to those as highest risk boosted efficiency (the NNT declined from 8.2 ± SD8.2 to 7.6 ± SD7.7). Clinical diagnosis was added after follow-up among those with ≥ 80 CAD scores and initially spot -sputum negative found 11 additional TB cases (6.3%) after 121 person-years of follow-up. Iterative adaptation in response to performance metrics foster feasible, acceptable, and efficient TB case-finding in Nigeria. High CAD scores can identify subclinical TB and those at risk of progression to bacteriologically-confirmed TB disease in the near term.
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Affiliation(s)
- Rupert A Eneogu
- United States Agency for International Development (USAID), Abuja, Nigeria
| | - Ellen M H Mitchell
- Mycobacterial Diseases and Neglected Tropical Diseases Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Danjuma Aboki
- Nasarawa State TB and Leprosy Control Program, Nasarawa, Nigeria
| | | | | | - Daniel Egbule
- Nasarawa State TB and Leprosy Control Program, Nasarawa, Nigeria
| | | | | | | | | | | | - Adebola Lawanson
- National TB and Leprosy Program, Federal Ministry of Health Nigeria, Abuja, Nigeria
| | - Simeon Onyemaechi
- National TB and Leprosy Program, Federal Ministry of Health Nigeria, Abuja, Nigeria
| | - Emperor Ubochioma
- National TB and Leprosy Program, Federal Ministry of Health Nigeria, Abuja, Nigeria
| | | | | | | | | | - Debby Nongo
- United States Agency for International Development (USAID), Abuja, Nigeria
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9
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Biewer A, Tzelios C, Tintaya K, Roman B, Hurwitz S, Yuen CM, Mitnick CD, Nardell E, Lecca L, Tierney DB, Nathavitharana RR. Accuracy of digital chest x-ray analysis with artificial intelligence software as a triage and screening tool in hospitalized patients being evaluated for tuberculosis in Lima, Peru. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.17.23290110. [PMID: 37292955 PMCID: PMC10246158 DOI: 10.1101/2023.05.17.23290110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Introduction Tuberculosis (TB) transmission in healthcare facilities is common in high-incidence countries. Yet, the optimal approach for identifying inpatients who may have TB is unclear. We evaluated the diagnostic accuracy of qXR (Qure.ai, India) computer-aided detection (CAD) software versions 3.0 and 4.0 (v3 and v4) as a triage and screening tool within the FAST (Find cases Actively, Separate safely, and Treat effectively) transmission control strategy. Methods We prospectively enrolled two cohorts of patients admitted to a tertiary hospital in Lima, Peru: one group had cough or TB risk factors (triage) and the other did not report cough or TB risk factors (screening). We evaluated the sensitivity and specificity of qXR for the diagnosis of pulmonary TB using culture and Xpert as primary and secondary reference standards, including stratified analyses based on risk factors. Results In the triage cohort (n=387), qXR v4 sensitivity was 0.91 (59/65, 95% CI 0.81-0.97) and specificity was 0.32 (103/322, 95% CI 0.27-0.37) using culture as reference standard. There was no difference in the area under the receiver-operating-characteristic curve (AUC) between qXR v3 and qXR v4 with either a culture or Xpert reference standard. In the screening cohort (n=191), only one patient had a positive Xpert result, but specificity in this cohort was high (>90%). A high prevalence of radiographic lung abnormalities, most notably opacities (81%), consolidation (62%), or nodules (58%), was detected by qXR on digital CXR images from the triage cohort. Conclusions qXR had high sensitivity but low specificity as a triage in hospitalized patients with cough or TB risk factors. Screening patients without cough or risk factors in this setting had a low diagnostic yield. These findings further support the need for population and setting-specific thresholds for CAD programs.
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Affiliation(s)
- Amanda Biewer
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | | | | | | | | | - Courtney M Yuen
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Carole D Mitnick
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Edward Nardell
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | | | - Dylan B Tierney
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA
- Massachusetts Department of Public Health, Boston, MA
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10
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Puma D, Yuen CM, Millones AK, Brooks MB, Jimenez J, Calderon RI, Lecca L, Becerra MC, Keshavjee S. Sensitivity of Various Case Detection Algorithms for Community-based Tuberculosis Screening. Clin Infect Dis 2023; 76:e987-e989. [PMID: 35723266 DOI: 10.1093/cid/ciac492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/02/2022] [Accepted: 06/09/2022] [Indexed: 11/14/2022] Open
Abstract
Using data from 388 people diagnosed with tuberculosis through a community-based screening program in Lima, Peru, we estimated that cough screening followed by sputum smear microscopy would have detected only 23% of cases found using an algorithm of radiographic screening followed by rapid nucleic acid amplification testing and clinical evaluation.
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Affiliation(s)
| | - Courtney M Yuen
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Center for Global Health Delivery, Harvard Medical School, Boston, Massachusetts, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Meredith B Brooks
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Center for Global Health Delivery, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Roger I Calderon
- Socios En Salud Sucursal Perú, Lima, Peru.,Programa Acadêmico de Tuberculose, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leonid Lecca
- Socios En Salud Sucursal Perú, Lima, Peru.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Mercedes C Becerra
- Socios En Salud Sucursal Perú, Lima, Peru.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Center for Global Health Delivery, Harvard Medical School, Boston, Massachusetts, USA
| | - Salmaan Keshavjee
- Socios En Salud Sucursal Perú, Lima, Peru.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Center for Global Health Delivery, Harvard Medical School, Boston, Massachusetts, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
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11
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Ramírez-Koctong O, Colorado A, Cruzado-Castro L, Marin-Samanez H, Lecca L. Observatorios sociales nacionales y regional de tuberculosis en ocho países de Latinoamérica y el Caribe. Rev Panam Salud Publica 2022; 46:e163. [DOI: 10.26633/rpsp.2022.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 07/11/2022] [Indexed: 11/24/2022] Open
Abstract
Poner fin a la tuberculosis (TB) requiere de un enfoque y participación multisectorial, incluyendo a la sociedad civil organizada. Entonces con el apoyo de un proyecto regional financiado por el Fondo Mundial (OBSERVA TB), desde el año 2019 se conformaron observatorios sociales de tuberculosis en 8 países de Latinoamérica y el Caribe (LAC) (Bolivia, Colombia, El Salvador, Guatemala, Haití, México, Perú y República Dominicana) y un Observatorio Social Regional de TB, como expresión de la implementación del enfoque ENGAGE-TB impulsado por la Organización Mundial de la Salud. Este artículo presenta el modelo de implementación, los avances y los desafíos de los observatorios sociales de tuberculosis. A diciembre de 2021, se incluyeron 135 organizaciones de la sociedad civil de LAC en los 8 observatorios implementados, espacios que sirven como plataformas para la vigilancia social, la incidencia política y el monitoreo social de las respuestas nacionales contra la TB, además de contribuir a los indicadores del ENGAGE-TB relacionados a la detección de casos TB y a los apoyos durante el tratamiento. Por ello, recomendamos la consolidación y expansión de los observatorios existentes, así como la participación de otros países de la región LAC.
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12
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Yuen CM, Brooks MB, Millones AK, Acosta D, Del Águila-Rojas E, Campos H, Farroñay S, Morales G, Ramirez-Sandoval J, Nichols TC, Jimenez J, Jenkins HE, Lecca L. Geospatial analysis of reported activity locations to identify sites for tuberculosis screening. Sci Rep 2022; 12:14094. [PMID: 35982104 PMCID: PMC9387880 DOI: 10.1038/s41598-022-18456-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
Mobile screening units can help close tuberculosis case detection gaps. Placing screening units where people at high risk for undiagnosed tuberculosis preferentially spend time could make screening more resource-effective. We conducted a case–control study in Lima, Peru to identify locations where people with tuberculosis were more likely to spend time than community controls. We surveyed participants about activity locations over the past 6 months. We used density-based clustering to assess how patient and control activity locations differed, and logistic regression to compare location-based exposures. We included 109 tuberculosis patients and 79 controls. In density-based clustering analysis, the two groups had similar patterns of living locations, but their work locations clustered in distinct areas. Both groups were similarly likely to use public transit, but patients predominantly used buses and were less likely to use rapid transit (adjusted odds ratio [aOR] 0.31, 95% confidence interval [CI] 0.10–0.96) or taxis (aOR 0.42, 95% CI 0.21–0.85). Patients were more likely to have spent time in prison (aOR 11.55, 95% CI 1.48–90.13). Placing mobile screening units at bus terminals serving locations where tuberculosis patients have worked and within and around prisons could help reach people with undiagnosed tuberculosis.
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Affiliation(s)
- Courtney M Yuen
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA. .,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
| | - Meredith B Brooks
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | | | | | | - Tim C Nichols
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Helen E Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Leonid Lecca
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Socios En Salud Sucursal Peru, Lima, Peru
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13
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Brooks MB, Jenkins HE, Puma D, Tzelios C, Millones AK, Jimenez J, Galea JT, Lecca L, Becerra MC, Keshavjee S, Yuen CM. A role for community-level socioeconomic indicators in targeting tuberculosis screening interventions. Sci Rep 2022; 12:781. [PMID: 35039612 PMCID: PMC8764089 DOI: 10.1038/s41598-022-04834-7] [Citation(s) in RCA: 2] [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] [Received: 06/03/2021] [Accepted: 12/30/2021] [Indexed: 11/29/2022] Open
Abstract
Tuberculosis screening programs commonly target areas with high case notification rates. However, this may exacerbate disparities by excluding areas that already face barriers to accessing diagnostic services. We compared historic case notification rates, demographic, and socioeconomic indicators as predictors of neighborhood-level tuberculosis screening yield during a mobile screening program in 74 neighborhoods in Lima, Peru. We used logistic regression and Classification and Regression Tree (CART) analysis to identify predictors of screening yield. During February 7, 2019-February 6, 2020, the program screened 29,619 people and diagnosed 147 tuberculosis cases. Historic case notification rate was not associated with screening yield in any analysis. In regression analysis, screening yield decreased as the percent of vehicle ownership increased (odds ratio [OR]: 0.76 per 10% increase in vehicle ownership; 95% confidence interval [CI]: 0.58-0.99). CART analysis identified the percent of blender ownership (≤ 83.1% vs > 83.1%; OR: 1.7; 95% CI: 1.2-2.6) and the percent of TB patients with a prior tuberculosis episode (> 10.6% vs ≤ 10.6%; OR: 3.6; 95% CI: 1.0-12.7) as optimal predictors of screening yield. Overall, socioeconomic indicators were better predictors of tuberculosis screening yield than historic case notification rates. Considering community-level socioeconomic characteristics could help identify high-yield locations for screening interventions.
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Affiliation(s)
- Meredith B Brooks
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA.
- Harvard Medical School Center for Global Health Delivery, Boston, MA, USA.
| | - Helen E Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | | | - Christine Tzelios
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
- Socios En Salud Sucursal Peru, Lima, Peru
| | | | | | - Jerome T Galea
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
- School of Social Work, University of South Florida, Tampa, FL, USA
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Leonid Lecca
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
- Socios En Salud Sucursal Peru, Lima, Peru
| | - Mercedes C Becerra
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
- Harvard Medical School Center for Global Health Delivery, Boston, MA, USA
| | - Salmaan Keshavjee
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
- Harvard Medical School Center for Global Health Delivery, Boston, MA, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Courtney M Yuen
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
- Harvard Medical School Center for Global Health Delivery, Boston, MA, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
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14
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Andom AT, Gilbert HN, Ndayizigiye M, Mukherjee JS, Nthunya J, Marole TA, Smith Fawzi MC, Yuen CM. Understanding reasons for suboptimal tuberculosis screening in a low-resource setting: A mixed-methods study in the Kingdom of Lesotho. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000249. [PMID: 36962295 PMCID: PMC10021370 DOI: 10.1371/journal.pgph.0000249] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/13/2022] [Indexed: 11/19/2022]
Abstract
Lesotho has one of the highest tuberculosis (TB) incidence rates in the world, estimated at 654/100,000 population. However, TB detection remains low, with only 51% of people with TB being diagnosed and treated. The aim of this study was to evaluate implementation of TB screening and identify drivers of suboptimal TB screening in Lesotho. We used a convergent mixed methods study design. We collected data on the number of health facility visits and the number of clients screened for TB during March-August, 2019 from one district hospital and one health center. We conducted interviews and focus group discussions with patients and health workers to elucidate the mechanisms associated with suboptimal screening. Out of an estimated 70,393 visitors to the two health facilities, only 22% of hospital visitors and 48% of health center visitors were asked about TB symptoms. Only 2% of those screened at each facility said that they had TB symptoms, comprising a total of 510 people. Lack of training on tuberculosis screening, overall staff shortages, barriers faced by patients in accessing care, and health care worker mistrust of tuberculosis screening procedures were identified as drivers of suboptimal TB screening. TB screening could be improved by ensuring the availability of well-trained, incentivized, and dedicated screeners at health facilities, and by providing TB screening services in community settings.
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Affiliation(s)
- Afom T Andom
- Partners In Health-Lesotho, Maseru, Lesotho
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Hannah N Gilbert
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
| | | | - Joia S Mukherjee
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, United States of America
- Partners in Health, Boston, MA, United States of America
| | | | | | - Mary C Smith Fawzi
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Courtney M Yuen
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, United States of America
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