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Naidoo K, Perumal R, Cox H, Mathema B, Loveday M, Ismail N, Omar SV, Georghiou SB, Daftary A, O'Donnell M, Ndjeka N. The epidemiology, transmission, diagnosis, and management of drug-resistant tuberculosis-lessons from the South African experience. THE LANCET. INFECTIOUS DISEASES 2024; 24:e559-e575. [PMID: 38527475 DOI: 10.1016/s1473-3099(24)00144-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/29/2024] [Accepted: 02/20/2024] [Indexed: 03/27/2024]
Abstract
Drug-resistant tuberculosis (DR-TB) threatens to derail tuberculosis control efforts, particularly in Africa where the disease remains out of control. The dogma that DR-TB epidemics are fueled by unchecked rates of acquired resistance in inadequately treated or non-adherent individuals is no longer valid in most high DR-TB burden settings, where community transmission is now widespread. A large burden of DR-TB in Africa remains undiagnosed due to inadequate access to diagnostic tools that simultaneously detect tuberculosis and screen for resistance. Furthermore, acquisition of drug resistance to new and repurposed drugs, for which diagnostic solutions are not yet available, presents a major challenge for the implementation of novel, all-oral, shortened (6-9 months) treatment. Structural challenges including poverty, stigma, and social distress disrupt engagement in care, promote poor treatment outcomes, and reduce the quality of life for people with DR-TB. We reflect on the lessons learnt from the South African experience in implementing state-of-the-art advances in diagnostic solutions, deploying recent innovations in pharmacotherapeutic approaches for rapid cure, understanding local transmission dynamics and implementing interventions to curtail DR-TB transmission, and in mitigating the catastrophic socioeconomic costs of DR-TB. We also highlight globally relevant and locally responsive research priorities for achieving DR-TB control in South Africa.
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Affiliation(s)
- Kogieleum Naidoo
- SAMRC-CAPRISA HIV/TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
| | - Rubeshan Perumal
- SAMRC-CAPRISA HIV/TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Helen Cox
- Institute of Infectious Diseases and Molecular Medicine, Wellcome Centre for Infectious Disease Research and Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Barun Mathema
- Mailman School of Public Health, Columbia University, New York City, NY, USA
| | - Marian Loveday
- South African Medical Research Council, Durban, South Africa
| | - Nazir Ismail
- School of Pathology, University of Witwatersrand, Johannesburg, South Africa
| | - Shaheed Vally Omar
- Centre for Tuberculosis, National & WHO Supranational TB Reference Laboratory, National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa
| | | | - Amrita Daftary
- SAMRC-CAPRISA HIV/TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; School of Global Health and Dahdaleh Institute of Global Health Research, York University, Toronto, ON, Canada
| | - Max O'Donnell
- SAMRC-CAPRISA HIV/TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York City, NY, USA; Department of Epidemiology, Columbia University Irving Medical Center, New York City, NY, USA
| | - Norbert Ndjeka
- TB Control and Management, Republic of South Africa National Department of Health, Pretoria, South Africa
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Vibulchai N, Dana K, Sanchan M, Churari C, Jadboonnak B, Sawangsri W, Pothiporn WT, Sutthicharoen U. The effect of the peer support intervention on internalized stigma among Thai patients with tuberculosis: A repeated measures design. BELITUNG NURSING JOURNAL 2024; 10:408-415. [PMID: 39211457 PMCID: PMC11350345 DOI: 10.33546/bnj.3327] [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] [Received: 03/13/2024] [Revised: 04/14/2024] [Accepted: 07/09/2024] [Indexed: 09/04/2024] Open
Abstract
Background Internalized stigma among patients with tuberculosis (TB) significantly affects delayed diagnosis, increased disease transmission, and poor treatment outcomes. However, conclusive empirical evidence on psychosocial interventions to reduce internalized stigma among patients with TB in Thailand remains scarce. Objective This study aimed to examine the impact of a peer support intervention on reducing internalized stigma among patients with TB in Thailand. Methods A one-group within-subjects repeated-measure design was conducted in the Muang Maha Sarakham district, Thailand, from February 2023 to July 2023. The study included 26 participants who met specified criteria. Measurements were taken at baseline, three months, and six months following TB diagnosis and medication treatment. The peer support intervention comprised TB health education, psycho-educational sessions, self-management support, and home visits. The Internalized Stigma of Tuberculosis Scale Thai Version was used to measure internalized stigma. Statistical analyses included descriptive statistics and repeated measures ANOVA. Results Mean scores of total internalized stigma and its sub-dimensions (alienation, stereotype endorsement, discrimination experience, social withdrawal, and stigma resistance) differed significantly across the three-time points (p <0.001, p <0.001, p <0.001, p <0.001, p <0.001, p = 0.002, respectively). Furthermore, stigma resistance scores significantly increased from pre-intervention to three months (p = 0.005) and from pre-intervention to six months (p = 0.007). However, no significant increase was observed from three to six months (p = 0.079). Conclusions The study underlines the positive impact of peer support intervention in reducing internalized stigma among patients with TB in Thailand over time. The findings suggest that interventions focusing on peer support can potentially address internalized stigma, highlighting the importance of integrating these strategies into healthcare practices to enhance patient care and improve TB management outcomes.
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Affiliation(s)
- Nisakorn Vibulchai
- Boromarajonani College of Nursing, Nakhon Ratchasima, Faculty of Nursing, Praboromarajchanok Institute, Ministry of Public Health, Thailand
| | - Kamthorn Dana
- Srimahasarakham Nursing College, Faculty of Nursing, Praboromarajchanok Institute, Ministry of Public Health, Thailand
| | - Monruedee Sanchan
- Srimahasarakham Nursing College, Faculty of Nursing, Praboromarajchanok Institute, Ministry of Public Health, Thailand
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Mongia H, Mamnoon F, Silsarma A, Mahajan R, Dalal A, Galindo MA, Iyer A, Singh P, Mansoor H, Das M, Morales M, Spencer H, Isaakidis P. Concomitant bedaquiline and delamanid therapy in patients with drug-resistant extra-pulmonary tuberculosis in Mumbai, India. J Clin Tuberc Other Mycobact Dis 2024; 35:100433. [PMID: 38617837 PMCID: PMC11015490 DOI: 10.1016/j.jctube.2024.100433] [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: 04/16/2024] Open
Abstract
Background World Health Organization suggests concurrent bedaquiline-delamanid (BDQ-DLM) as part of individualised regimens for eligible patients with pulmonary drug-resistant tuberculosis (DR-TB); however, data for patients with drug-resistant extrapulmonary tuberculosis (EPTB) is extremely limited. This study documents the treatment outcomes and adverse events associated with concurrent BDQ-DLM-based regimens in patients with drug-resistant EPTB at a Médecins Sans Frontières clinic in Mumbai, India. Methods Retrospective cohort study based on routinely collected programmatic data. Individualised regimens were based on drug-susceptibility testing and previous drug exposure. Drug-resistant EPTB patients initiated on regimens containing concurrent BDQ and DLM from April 2016 to October 2019 were included. Patients who completed treatment were followed up at 12 months. Results Of 17 patients, median age was 23 years (IQR = 21-30 years) and 12/17 (71 %) were female. Pre-extensively drug-resistant tuberculosis and extensively drug-resistant TB was reported in 13/17 (76.4 %) and 2/17 (11.7 %) patients respectively. Microbiological reports were unavailable for two patients with central nervous system TB. Lymph node TB was the commonest form of EPTB in 9/17 (53 %) of patients. Median duration of treatment was 18.9 months. At least one grade three or four severe adverse event (SAE) was reported by 13/17 (76.4 %) patients. Thirteen (76.4 %) patients had favourable outcomes. None of the patients relapsed or died in the one-year period of post-treatment follow-up. Conclusion Concurrent BDQ-DLM-based regimens in drug-resistant EPTB were effective and associated with manageable adverse events.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Hannah Spencer
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | - Petros Isaakidis
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
- Clinical and Molecular Epidemiology Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
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Nagarajan K, Kumarswamy K, Begum R, Panibatla V, Singarajipura A, Adepu R, Munjattu JF, Sellapan S, Arangba S, Goswami A, Swamickan R, Basha J, Dsouza PM, Muniyandi M. Self-driven solutions and resilience adapted by people with drug-resistant tuberculosis and their caregivers in Bengaluru and Hyderabad, India: a qualitative study. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2024; 22:100372. [PMID: 38420270 PMCID: PMC10900834 DOI: 10.1016/j.lansea.2024.100372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/08/2024] [Accepted: 02/06/2024] [Indexed: 03/02/2024]
Abstract
Background One-fifth of people with drug-resistance tuberculosis (DR-TB) who were initiated on newer shorter treatment regimen (with injection) had unfavourable treatment outcomes in India as on 2020. Evidence on self-driven solutions and resilience adapted by people with DR-TB (PwDR-TB) towards their multi-dimensional disease and treatment challenges are scarce globally, which we aimed to understand. Methods In this qualitative study using positive deviance framework, we conducted semi-structured in-depth interviews among consenting adult PwDR-TB (7 women, 13 men) who completed shorter treatment regimen (including injections) with maximum treatment adherence. The study was conducted in the southern districts of Bengaluru and Hyderabad, India between June 2020 and December 2022. Caregivers (14 women, 6 men) and health providers (8 men, 2 women) of PwDR-TB were also interviewed. Interviews were conducted in local language (Kannada, Tamil, Telugu, Urdu and Hindi) and inquired about practices, behaviours, experiences, perceptions and attributes which enabled maximum adherence and resilience of PwDR-TB. Interviews were audio recorded, transcribed, and translated to English and coded for thematic analysis using inductive approach. Findings Distinctive themes explanatory of the self-driven solutions and resilience exhibited by PwDR-TB and their caregivers were identified: (i) Self-adaptation towards the biological consequences of drugs, by personalised nutritional and adjuvant practices, which helped to improve drug ingestion and therapeutic effects. Also home remedies and self-plans for ameliorating injection pain. (ii) Perceptual adaptation towards drugs aversion and fatigue, by their mind diversion practices, routinisation and normalisation of drug intake process. and constant reinforcement and re-interpretation of bodily signs of disease recovery (iii) Family caregivers intense and participatory care for PwDR-TB, by aiding their essential life activities and ensuring survival, learning and fulfilling special nutritional needs and goal oriented actions to aid drug intake (iv) Health care providers care, marked by swift and timely risk mitigation of side-effects and crisis response (v) Acquired self-efficacy of PwDR-TB, by their decisive family concerns resulting in attitudinal change. Also being sensitised on the detrimental consequences of disease and being motivated through positive examples. Interpretation Synthesised findings on self-driven solutions and resilience towards the multi-dimensional DR-TB challenges provides opportunity for developing and testing new interventions for its effectiveness in DR-TB care settings globally. Designing and testing personalised cognitive interventions for PwDR-TB: to inculcate attitudinal change and self-efficacy towards medication, developing cognitive reinforcements to address the perception burden of treatment, skill building and mainstreaming the role of family caregivers as therapeutic partners of PwDR-TB, curating self-adaptive behaviours and practices of PwDR-TB to normalise their drug consumptions experiences could be the way forward in building resilience towards DR-TB. Funding United States Agency for International Development (USAID) through Karnataka Health Promotion Trust (KHPT), Bengaluru, India.
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Affiliation(s)
- Karikalan Nagarajan
- ICMR-National Institute for Research in Tuberculosis (NIRT), Chennai, Tamil Nadu, 600031, India
| | - Karthikeyan Kumarswamy
- Karnataka Health Promotion Trust, IT Park, Rajajinagar Industrial Area, Bengaluru, Karnataka, 560044, India
| | - Rehana Begum
- Karnataka Health Promotion Trust, IT Park, Rajajinagar Industrial Area, Bengaluru, Karnataka, 560044, India
| | - Vikas Panibatla
- TB Alert India, Hyderabad, West Marredpally, Secunderabad, Telangana, 500026, India
| | - Anil Singarajipura
- State TB Office, 2nd Floor, Arogya Soudha, Magadi Road, Bengaluru, Karnataka, 560023, India
| | - Rajesham Adepu
- State TB Office, Directorate of Medical & Health Services, Hyderabad, Telangana, 500095, India
| | - Joseph Francis Munjattu
- Karnataka Health Promotion Trust, IT Park, Rajajinagar Industrial Area, Bengaluru, Karnataka, 560044, India
| | - Senthil Sellapan
- ICMR-National Institute for Research in Tuberculosis (NIRT), Chennai, Tamil Nadu, 600031, India
| | - Stephen Arangba
- ICMR-National Institute for Research in Tuberculosis (NIRT), Chennai, Tamil Nadu, 600031, India
| | | | | | - Javeed Basha
- ICMR-National Institute for Research in Tuberculosis (NIRT), Chennai, Tamil Nadu, 600031, India
| | - Pearl Maria Dsouza
- ICMR-National Institute for Research in Tuberculosis (NIRT), Chennai, Tamil Nadu, 600031, India
| | - Malaisamy Muniyandi
- ICMR-National Institute for Research in Tuberculosis (NIRT), Chennai, Tamil Nadu, 600031, India
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Karnan A, Jadhav U, Ghewade B, Ledwani A, Shivashankar P. A Comprehensive Review on Long vs. Short Regimens in Multidrug-Resistant Tuberculosis (MDR-TB) Under Programmatic Management of Drug-Resistant Tuberculosis (PMDT). Cureus 2024; 16:e52706. [PMID: 38384625 PMCID: PMC10879947 DOI: 10.7759/cureus.52706] [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: 01/04/2024] [Accepted: 01/22/2024] [Indexed: 02/23/2024] Open
Abstract
This comprehensive review delves into the intricate landscape of multidrug-resistant tuberculosis (MDR-TB) treatment within the programmatic management of drug-resistant tuberculosis (PMDT) framework. MDR-TB poses a substantial global health threat, necessitating targeted approaches for effective management. The analysis explores the historical evolution, efficacy, safety profiles, and implementation challenges associated with long and short regimens. The findings underscore the importance of individualized clinical practices, considering patient-specific factors, and the need for ongoing monitoring within PMDT programs. Recommendations advocate for integrating advanced diagnostics, continuous surveillance, and training for healthcare professionals. The review concludes with a nuanced outlook on long versus short regimens, emphasizing a balanced approach and the imperative role of collaborative efforts in shaping the future of MDR-TB treatment. This synthesis contributes to the ongoing discourse, providing valuable insights for healthcare practitioners, policymakers, and researchers working toward optimizing outcomes for individuals afflicted with MDR-TB.
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Affiliation(s)
- Ashwin Karnan
- Respiratory Medicine, Jawaharlal Nehru Medical College, Wardha, IND
| | - Ulhas Jadhav
- Respiratory Medicine, Jawaharlal Nehru Medical College, Wardha, IND
| | - Babaji Ghewade
- Respiratory Medicine, Jawaharlal Nehru Medical College, Wardha, IND
| | - Anjana Ledwani
- Respiratory Medicine, Jawaharlal Nehru Medical College, Wardha, IND
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Cheng Q, Dang T, Nguyen TA, Velen K, Nguyen VN, Nguyen BH, Vu DH, Long CH, Do TT, Vu TM, Marks GB, Yapa M, Fox GJ, Wiseman V. mHealth application for improving treatment outcomes for patients with multidrug-resistant tuberculosis in Vietnam: an economic evaluation protocol for the V-SMART trial. BMJ Open 2023; 13:e076778. [PMID: 38081668 PMCID: PMC10729151 DOI: 10.1136/bmjopen-2023-076778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 11/07/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION The Strengthen the Management of Multidrug-Resistant Tuberculosis in Vietnam (V-SMART) trial is a randomised controlled trial of using mobile health (mHealth) technologies to improve adherence to medications and management of adverse events (AEs) in people with multidrug-resistant tuberculosis (MDR-TB) undergoing treatment in Vietnam. This economic evaluation seeks to quantify the cost-effectiveness of this mHealth intervention from a healthcare provider and societal perspective. METHODS AND ANALYSIS The V-SMART trial will recruit 902 patients treated for MDR-TB across seven participating provinces in Vietnam. Participants in both intervention and control groups will receive standard community-based therapy for MDR-TB. Participants in the intervention group will also have a purpose-designed App installed on their smartphones to report AEs to health workers and to facilitate timely management of AEs. This economic evaluation will compare the costs and health outcomes between the intervention group (mHealth) and the control group (standard of care). Costs associated with delivering the intervention and health service utilisation will be recorded, as well as patient out-of-pocket costs. The health-related quality of life (HRQoL) of study participants will be captured using the 36-Item Short Form Survey (SF-36) questionnaire and used to calculate quality-adjusted life-years (QALYs). Incremental cost-effectiveness ratios (ICERs) will be based on the primary outcome (proportion of patients with treatment success after 24 months) and QALYs gained. Sensitivity analysis will be conducted to test the robustness of the ICERs. A budget impact analysis will be conducted from a payer perspective to provide an estimate of the total budget required to scale-up delivery of the intervention. ETHICS AND DISSEMINATION Ethical approval for the study was granted by the University of Sydney Human Research Ethics Committee (2019/676), the Scientific Committee of the Ministry of Science and Technology, Vietnam (08/QD-HDQL-NAFOSTED) and the Institutional Review Board of the National Lung Hospital, Vietnam (13/19/CT-HDDD). Study findings will be published in peer-reviewed journals and conference proceedings. TRIAL REGISTRATION NUMBER ACTRN12620000681954.
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Affiliation(s)
- Qinglu Cheng
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Tho Dang
- Woolcock Institute of Medical Research, Hanoi, Vietnam
| | - Thu-Anh Nguyen
- Woolcock Institute of Medical Research, Hanoi, Vietnam
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kavindhran Velen
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Binh Hoa Nguyen
- Vietnam National Tuberculosis Control Program, Hanoi, Vietnam
| | - Dinh Hoa Vu
- Hanoi University of Pharmacy, Hanoi, Vietnam
| | | | - Thu Thuong Do
- Vietnam National Tuberculosis Control Program, Hanoi, Vietnam
| | - Truong-Minh Vu
- Ho Chi Minh City Institute for Development Studies, Ho Chi Minh City, Vietnam
| | - Guy B Marks
- Woolcock Institute of Medical Research, Hanoi, Vietnam
- School of Clinical Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Manisha Yapa
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Gregory J Fox
- Woolcock Institute of Medical Research, Hanoi, Vietnam
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Virginia Wiseman
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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Dickson L, Le Roux SR, Mitrani L, Hill J, Jassat W, Cox H, Mlisana K, Black J, Loveday M, Grant A, Kielmann K, Ndjeka N, Moshabela M, Nicol M. Organisation of care for people receiving drug-resistant tuberculosis treatment in South Africa: a mixed methods study. BMJ Open 2023; 13:e067121. [PMID: 37977868 PMCID: PMC10660906 DOI: 10.1136/bmjopen-2022-067121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 10/09/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVES Treatment for multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB) is increasingly transitioning from hospital-centred to community-based care. A national policy for decentralised programmatic MDR/RR-TB care was adopted in South Africa in 2011. We explored variations in the implementation of care models in response to this change in policy, and the implications of these variations for people affected by MDR/RR-TB. DESIGN A mixed methods study was done of patient movements between healthcare facilities, reconstructed from laboratory records. Facility visits and staff interviews were used to determine reasons for movements. PARTICIPANTS AND SETTING People identified with MDR/RR-TB from 13 high-burden districts within South Africa. OUTCOME MEASURES Geospatial movement patterns were used to identify organisational models. Reasons for patient movement and implications of different organisational models for people affected by MDR/RR-TB and the health system were determined. RESULTS Among 191 participants, six dominant geospatial movement patterns were identified, which varied in average hospital stay (0-281 days), average patient distance travelled (12-198 km) and number of health facilities involved in care (1-5 facilities). More centralised models were associated with longer delays to treatment initiation and lengthy hospitalisation. Decentralised models facilitated family-centred care and were associated with reduced time to treatment and hospitalisation duration. Responsiveness to the needs of people affected by MDR/RR-TB and health system constraints was achieved through implementation of flexible models, or the implementation of multiple models in a district. CONCLUSIONS Understanding how models for organising care have evolved may assist policy implementers to tailor implementation to promote particular patterns of care organisation or encourage flexibility, based on patient needs and local health system resources. Our approach can contribute towards the development of a health systems typology for understanding how policy-driven models of service delivery are implemented in the context of variable resources.
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Affiliation(s)
- Lindy Dickson
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Sacha Roxanne Le Roux
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Leila Mitrani
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Jeremy Hill
- TB Centre, London School of Hygiene &Tropical Medicine, London, UK
| | - Waasila Jassat
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Helen Cox
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape Town, South Africa
- Institute for Infectious Disease and Molecular Medicine and Wellcome Centre for Infectious Disease Research, University of Cape Town, Cape Town, South Africa
| | - Koleka Mlisana
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal College of Health Sciences, Durban, KwaZulu-Natal, South Africa
| | - John Black
- Division of Infectious Diseases, University of Cape Town, Cape Town, South Africa
| | - Marian Loveday
- South African Medical Research Council, Durban, South Africa
| | - Alison Grant
- TB Centre, London School of Hygiene &Tropical Medicine, London, UK
- Africa Health Research Institute, Somkhele, South Africa
| | - Karina Kielmann
- Institute of Tropical Medicine, Antwerp, Belgium
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Norbert Ndjeka
- National Tuberculosis Control Programme, National Department of Health, Pretoria, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal College of Health Sciences, Durban, KwaZulu-Natal, South Africa
| | - Mosa Moshabela
- School of Nursing and Public Health, University of KwaZulu-Natal College of Health Sciences, Durban, KwaZulu-Natal, South Africa
| | - Mark Nicol
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape Town, South Africa
- Marshall Centre for Infectious DIsease Research and Training, School of Biomedical Sciences, University of Western Australia, Perth, Western Australia, Australia
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Vilbrun SC, Souroutzidis A, Walsh KF, Ellis J, Guiteau C, Delva S, Joissaint G, Joseph P, Pape JW, Koenig SP. Successful outcomes for patients with drug-resistant tuberculosis despite civil unrest and COVID-19 in Haiti. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002356. [PMID: 37698996 PMCID: PMC10497149 DOI: 10.1371/journal.pgph.0002356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 08/12/2023] [Indexed: 09/14/2023]
Abstract
Globally, treatment outcomes for people with multi-drug/rifampin-resistant tuberculosis (MDR/RR-TB) are sub-optimal, with MDR/RR-TB programs further weakened due to the COVID-19 pandemic, and in Haiti, by severe civil unrest. We assessed the impact of these disruptions on treatment outcomes at GHESKIO, in Port-au-Prince, Haiti. We conducted a retrospective analysis including all adults (age ≥18 years) who initiated MDR/RR-TB treatment at GHESKIO from 2010 to 2020. We assessed predictors of poor treatment outcome using multivariable logistic regression, adjusting for baseline characteristics and year of treatment. 453 patients initiated treatment for MDR/RR-TB at GHESKIO. Median age was 31 (IQR: 25, 40), 233 (51.4%) were male, and 100 (22.1%) were living with HIV. Three hundred sixty-nine patients (81.5%) achieved cure, 42 (9.3%) died, 40 (8.8%) were lost to follow-up and 2 (<1%) failed treatment. HIV status was associated with poor treatment outcome (aRR: 1.65 (95% CI: 1.09, 2.48)) but there was no difference by year of treatment initiation. Outcomes for patients with MDR/RR-TB remained outstanding, even during the COVID-19 pandemic and severe civil unrest in Haiti. We attribute this resilience in care to the adaptability of program staff and provision of economic and psychosocial support.
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Affiliation(s)
- Stalz Charles Vilbrun
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Kathleen F. Walsh
- Center for Global Health, Weill Cornell Medicine, New York, NY, United States of America
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, United States of America
| | - Joshua Ellis
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Colette Guiteau
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Sobieskye Delva
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Guy Joissaint
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Patrice Joseph
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jean William Pape
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Center for Global Health, Weill Cornell Medicine, New York, NY, United States of America
| | - Serena P. Koenig
- Division of Infectious Diseases and Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
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Choi H, Mok J, Ae Kang Y, Jeong D, Kang HY, Kim HJ, Kim HS, Jeon D. Retreatment after loss to follow-up reduces mortality in patients with multidrug/rifampicin-resistant tuberculosis. ERJ Open Res 2023; 9:00135-2023. [PMID: 37583964 PMCID: PMC10423986 DOI: 10.1183/23120541.00135-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/22/2023] [Indexed: 08/17/2023] Open
Abstract
Background This study evaluated the risk factors of long-term mortality in patients with multidrug/rifampicin-resistant tuberculosis (MDR/RR-TB) in South Korea who were lost to follow-up (LTFU). Methods This was a retrospective longitudinal follow-up study using an integrated database constructed by data linkage of the three national databases, which included 7226 cases of MDR/RR-TB notified between 2011 and 2017 in South Korea. Post-treatment outcomes of patients who were LTFU were compared with those of patients who achieved treatment success. Results Of the 7226 MDR/RR-TB cases, 730 (10.1%) were LTFU. During a median follow-up period of 4.2 years, 101 (13.8%) of the LTFU patients died: 25 deaths (3.4%) were TB related and 76 (10.4%) were non-TB related. In the LTFU group, the adjusted hazard ratio (aHR) of all-cause mortality (aHR 2.50, 95% CI 1.99-3.15, p<0.001), TB-related mortality (aHR 5.38, 95% CI 3.19-9.09, p<0.001) and non-TB-related mortality (HR 2.21, 95% CI 1.70-2.87, p<0.001) was significantly higher than that in the treatment success group. Independent risk factors for all-cause mortality in the LTFU group were age >55 years, fluoroquinolone resistance, cancer and no retreatment. In the LTFU patients who did not receive retreatment, the risk of non-TB-related mortality (aHR 5.00, 95% CI 1.53-16.37, p=0.008) and consequent all-cause mortality (aHR 2.18, 95% CI 1.08-4.40, p=0.030) was significantly higher than that of patients who received retreatment. Conclusion Non-TB-related mortality was the main cause of death and might be reduced by retreatment in LTFU patients with MDR/RR-TB.
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Affiliation(s)
- Hongjo Choi
- Department of Preventive Medicine, Konyang University College of Medicine, Daejeon, South Korea
| | - Jeongha Mok
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, South Korea
| | - Young Ae Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Dawoon Jeong
- Department of Preventive Medicine, Seoul National University, College of Medicine, Seoul, South Korea
| | - Hee-Yeon Kang
- Department of Cancer Control and Population Health, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, South Korea
| | - Hee Jin Kim
- Central Training Institute, Korean National Tuberculosis Association, Seoul, South Korea
| | - Hee-Sun Kim
- Department of Health Policy Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, South Korea
| | - Doosoo Jeon
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, South Korea
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10
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Maynard C, Tariq S, Sotgiu G, Migliori GB, van den Boom M, Field N. Psychosocial support interventions to improve treatment outcomes for people living with tuberculosis: a mixed methods systematic review and meta-analysis. EClinicalMedicine 2023; 61:102057. [PMID: 37457116 PMCID: PMC10338299 DOI: 10.1016/j.eclinm.2023.102057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 06/06/2023] [Accepted: 06/06/2023] [Indexed: 07/18/2023] Open
Abstract
Background People with tuberculosis (TB) face multi-dimensional barriers when accessing and engaging with care. There is evidence that providing psychosocial support within people-centered models of care can improve TB outcomes, however, there is limited consensus on what works. It remains important for such interventions to be rigorously assessed, and mixed methods systematic reviews are one way of synthesising data for policy makers to be able to access such evidence. Mixed methods reviews take a complexity perspective, with qualitative data being used to contextualise the quantitative findings and giving an insight into how interventions are contingent on variations in design and context. Methods Five electronic databases were searched from January 1 2015 to 14 January 2023 for randomised controlled trials, quasi-experimental trials, cohort studies and qualitative studies of interventions providing psychosocial support (material and/or psychological-based support) to adults with any clinical form of active TB. Studies with inpatient treatment as the standard of care were excluded. Quantitative studies reporting pre-specified standard TB outcomes were eligible. In line with established mixed methods review methodology, a convergent parallel-results synthesis design was followed: quantitative and qualitative syntheses were distinct and carried out using appropriate methods. A convergent coding matrix was then used to integrate the results. The protocol was registered on PROSPERO (CRD42021235211). Findings Twenty-three studies of interventions were included (12 quantitative, 10 qualitative, and 1 mixed methods study) were included. Most studies were conducted in low-and middle-income countries with a high-burden of TB. Three explanatory and contextual middle-range theories from the integration of qualitative and quantitative data were developed: effective interventions provide multi-dimensional support; psychological-based support is transformative but there is insufficient evidence that it improves treatment outcomes on its own; intervention delivery shapes a logic of care. Interpretation This review takes a complexity perspective to provide actionable and timely insight to inform the design and implementation of locally-appropriate and people-centered psychosocial support interventions within national TB programmes. Funding There was no funding source for this study.
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Affiliation(s)
| | | | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, University of Sassari, Italy
| | | | | | - Nigel Field
- UCL Institute for Global Health, UK
- Centre for Molecular Epidemiology and Translational Research, UCL Institute for Global Health, UK
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11
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A Dual Perspective of Psycho-Social Barriers and Challenges Experienced by Drug-Resistant TB Patients and Their Caregivers through the Course of Diagnosis and Treatment: Findings from a Qualitative Study in Bengaluru and Hyderabad Districts of South India. Antibiotics (Basel) 2022; 11:antibiotics11111586. [DOI: 10.3390/antibiotics11111586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/31/2022] [Accepted: 11/05/2022] [Indexed: 11/11/2022] Open
Abstract
Qualitative insights regarding psycho-social barriers and challenges experienced by drug-resistant tuberculosis (DR-TB) patients and their caregivers are understudied in India. We conducted a qualitative study using semi-structured qualitative interviews among treatment-completed DR-TB patients (n = 20) and caregivers (n = 20) in Bengaluru and Hyderabad districts, which represented two different socio-cultural settings in South India. Criterion sampling was used for recruiting the eligible participants who completed treatment with adherence. “Emotional issues and social barriers” were identified to represent a major challenge for patients and caregivers, which occurred acutely after disease diagnosis, characterized by fear and emotional distress due to their perceived loss of life prospects, severity of symptoms, discomfort, and disease denial. Medication intolerance, chronic symptoms, lack of visible signs of treatment progress, loss of weight, and physical concerns caused subsequent fear and distress during the treatment phases for patients along with experiences of stigma. External triggers generated “decisive moments” of hopelessness and life-ending thoughts for patients at the diagnosis and early treatment phase. Medication related challenges included the perceived burden and power of pills which caused emotional distress for patients and intolerance towards caregivers. Pill burden was found as consequential as the side effects of injections. Challenges related to lack of support were another major theme, in which caregivers lacked resources for treatment support and nutrition. Throughout treatment, caregivers and patients expressed concern about a lack of supportive care from family members, sympathy, and intangible social support. Challenges during hospital admission in terms of lack of privacy, quality of services, individual attention, and empathy from health care workers were reported by patients and caregivers. Despite better adherence, DR-TB patients and caregivers experienced considerable emotional and social consequences. Differentiating DR-TB patients and caregivers’ issues at different stages of diagnosis and treatment could help improve patient-centered outcomes in India and other high-burden nations.
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12
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Harrison RE, Shyleika V, Falkenstein C, Garsevanidze E, Vishnevskaya O, Lonnroth K, Sayakci Ö, Sinha A, Sitali N, Skrahina A, Stringer B, Tan C, Mar HT, Venis S, Vetushko D, Viney K, Vishneuski R, Carrion Martin AI. Patient and health-care provider experience of a person-centred, multidisciplinary, psychosocial support and harm reduction programme for patients with harmful use of alcohol and drug-resistant tuberculosis in Minsk, Belarus. BMC Health Serv Res 2022; 22:1217. [PMID: 36180873 PMCID: PMC9523183 DOI: 10.1186/s12913-022-08525-x] [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] [Received: 11/04/2021] [Accepted: 08/31/2022] [Indexed: 11/10/2022] Open
Abstract
Background Tuberculosis (TB) often concentrates in groups of people with complex health and social issues, including alcohol use disorders (AUD). Risk of TB, and poor TB treatment outcomes, are substantially elevated in people who have AUD. Médecins sans Frontières and the Belarus Ministry of Health have worked to improve treatment adherence in patients with multi-drug or rifampicin resistant (MDR/RR)-TB and harmful use of alcohol. In 2016, a person-centred, multidisciplinary, psychosocial support and harm reduction programme delivered by TB doctors, counsellors, psychiatrists, health-educators, and social workers was initiated. In 2020, we described patient and provider experiences within the programme as part of a wider evaluation. Methods We recruited 12 patients and 20 health-care workers, using purposive sampling, for in-depth individual interviews and focus group discussions. We used a participant-led, flexible, exploratory approach, enabling participants and the interviewer to shape topics of conversation. Qualitative data were coded manually and analysed thematically. As part of the analysis process, identified themes were shared with health-care worker participants to enable their reflections to be incorporated into the findings. Results Key themes related to the patients’ and practitioners experience of having and treating MDRTB with associated complex health and social issues were: fragility and despair and guidance, trust and health. Prejudice and marginalisation were global to both themes. Counsellors and other health workers built a trusting relationship with patients, enabling guidance through a multi-disciplinary approach, which supported patients to achieve their vision of health. This guidance was achieved by a team of social workers, counsellors, doctors and health-educators who provided professional and individualised help for patients’ illnesses, personal or interpersonal problems, administrative tasks, and job searches. Conclusions Patients with MDR/RR-TB and harmful use of alcohol faced complex issues during treatment. Our findings describe how person-centred, multi-disciplinary, psychosocial support helped patients in this setting to cope with these challenges and complete the treatment programme. We recommend that these findings are used to: i) inform programmatic changes to further boost the person-centred care nature of this program; and ii) advocate for this type of person-centred care approach to be rolled out across Belarus, and in contexts that face similar challenges. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08525-x.
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Affiliation(s)
| | | | | | | | | | - Knut Lonnroth
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | | | | | - Alena Skrahina
- Republican Scientific and Practical Centre of Pulmonology and Tuberculosis (RSPCPT), Minsk, Republic of Belarus
| | | | | | | | | | - Dmitri Vetushko
- Republican Scientific and Practical Centre of Pulmonology and Tuberculosis (RSPCPT), Minsk, Republic of Belarus
| | - Kerri Viney
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,School of Public Health, The University of Sydney, Sydney, Australia
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13
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Community pharmacists-led interventions in tuberculosis care: A systematic review. Res Social Adm Pharm 2022; 19:5-15. [PMID: 36096865 DOI: 10.1016/j.sapharm.2022.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 08/10/2022] [Accepted: 09/01/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND A multidisciplinary approach is required to tackle the tuberculosis (TB) epidemic, which is one of the most pressing public health concerns worldwide. However, community pharmacists are underutilized in TB programs. OBJECTIVE To identify community pharmacists-led interventions in TB management with their corresponding impacts in TB case detection and treatment outcomes. METHODS A systematic search was performed in six electronic databases and health organization websites, from database inception to August 2, 2022. Studies which described TB screening, referral and/or treatment monitoring by community pharmacists with their corresponding outcomes were screened and reviewed independently by two reviewers. The studies were checked for the risk of bias using Cochrane risk of bias tools. All data of included studies were analysed qualitatively and presented narratively. RESULTS The search yielded 8,121 studies and five reports for initial screening. Sixteen studies and two case study reports were included in this review. Community pharmacists were involved throughout the TB care cascade, contributing their services in TB screening, referrals and in directly observed treatment-short course (DOTS) program. These interventions showed improvements in the effective control and prevention of further spread of TB, which improves individual, community and population level outcomes. CONCLUSIONS The inclusion of community pharmacists into TB program can improve the continuity of care, bridging the gaps in TB case detection and treatment monitoring. Adequate training and support are essential, to further empower the role of community pharmacists in TB control and prevention, in building a TB-free world.
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14
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O’Donnell MR, Padayatchi N, Wolf A, Zelnick J, Daftary A, Orrell C, Nimmo C, Baldwin M, Boodhram R, Maharaj B, Amico KR, Friedland G. Bedaquiline Adherence Measured by Electronic Dose Monitoring Predicts Clinical Outcomes in the Treatment of Patients With Multidrug-Resistant Tuberculosis and HIV/AIDS. J Acquir Immune Defic Syndr 2022; 90:325-332. [PMID: 35195572 PMCID: PMC11077859 DOI: 10.1097/qai.0000000000002940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 02/02/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Novel regimens have revolutionized multidrug-resistant tuberculosis (MDR-TB) treatment; however, medication adherence remains challenging and poorly characterized. We hypothesized that bedaquiline adherence, measured using electronic dose monitoring, would predict MDR-TB treatment outcomes. SETTING This is a prospective cohort study conducted in KwaZulu-Natal, South Africa. METHODS Adults with MDR-TB and HIV initiating bedaquiline and on antiretroviral therapy (ART) were eligible. Separate electronic dose monitoring devices measured bedaquiline and ART adherence through 6 months, calculated as observed versus expected doses. Whole-genome sequencing was performed to identify bedaquiline resistance-associated variants. RESULTS From November 2016 through February 2018, 199 participants with MDR-TB and HIV were enrolled and followed up through treatment completion (median 17.2 months interquartile range 12.2-19.6). The median bedaquiline adherence was higher than ART adherence (97 vs. 89%, P < 0.001) but correlated (r2 = 0.68, P < 0.001). High bedaquiline adherence (≥90%) compared with lower adherence was associated with improved end of treatment successful outcome (83.4% vs. 46.3%, P < 0.001), decreased mortality (11.0% vs. 29.6% P = 0.004), and improved retention in care through end of treatment (94.5% vs. 79.6% P = 0.002). Modeling identified a highly significant but linear association between bedaquiline adherence and outcome. On multivariable analysis, bedaquiline adherence was independently associated with mortality and outcome. Bedaquiline resistance-associated variants were seen in 12% (7/57) of sequenced isolates (7% baseline, 5% emergent) with only 28.6% experiencing successful treatment outcome. CONCLUSIONS Bedaquiline adherence through 6 months independently predicted end of MDR-TB treatment outcome, but a specific bedaquiline adherence threshold was not identified. Interventions to optimize bedaquiline adherence are urgently needed to improve MDR-TB HIV treatment outcomes.
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Affiliation(s)
- Max R O’Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine
- Department of Epidemiology, Columbia University Medical Center, New York City, USA
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Nesri Padayatchi
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Allison Wolf
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York City, USA
| | - Jennifer Zelnick
- Graduate School of Social Work, Touro College and University System, New York City, USA
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, School of Global Health, York University Toronto, Canada
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | | | - Camus Nimmo
- Division of Infection and Immunity, University College London, London, UK
- UCL Genetics Institute, University College London, London, UK
- Africa Health Research Institute, Durban, South Africa
| | - Matt Baldwin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York City, USA
| | - Resha Boodhram
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Bhavna Maharaj
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - K. Rivet Amico
- University of Michigan School of Public Health, Ann Arbor, MI, USA
- Kogieleum Naidoo CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
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15
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Gill CM, Dolan L, Piggott LM, McLaughlin AM. New developments in tuberculosis diagnosis and treatment. Breathe (Sheff) 2022; 18:210149. [PMID: 35284018 PMCID: PMC8908854 DOI: 10.1183/20734735.0149-2021] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/16/2021] [Indexed: 01/12/2023] Open
Abstract
Tuberculosis (TB) is a major cause of morbidity and mortality worldwide. It is estimated that 25% of the world's population are infected with Mycobacterium tuberculosis, with a 5–10% lifetime risk of progression into TB disease. Early recognition of TB disease and prompt detection of drug resistance are essential to halting its global burden. Culture, direct microscopy, biomolecular tests and whole genome sequencing are approved methods of diagnosis; however, their widespread use is often curtailed owing to costs, local resources, time constraints and operator efficiency. Methods of optimising these diagnostics, in addition to developing novel techniques, are under review. The selection of an appropriate drug regimen is dependent on the susceptibility pattern of the isolate detected. At present, there are 16 new drugs under evaluation for TB treatment in phase I or II clinical trials, with an additional 22 drugs in preclinical stages. Alongside the development of these new drugs, most of which are oral medications, new shorter regimes are under evaluation. The aim of these shorter regimens is to encourage patient adherence, and prevent relapse or the evolution of further drug resistance. Screening for TB infection, especially in vulnerable populations, provides an opportunity for intervention prior to progression towards infectious TB disease. New regimens are currently under evaluation to assess the efficacy of shorter durations of treatment in this population. In addition, there is extensive research into the use of post-exposure vaccinations in this cohort. Worldwide collaboration and sharing of expertise are essential to our ultimate aim of global eradication of TB disease. Early detection of drug resistance is essential to our goal of global eradication of TB. Tolerable drugs and shorter regimens promote patient adherence. Treating TB infection in vulnerable groups will prevent further global spread of TB disease.https://bit.ly/3oUW0SN
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16
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Reuter A, Beko B, Memani B, Furin J, Daniels J, Rodriguez E, Reuter H, Weich L, Isaakidis P, von der Heyden E, Kock Y, Mohr-Holland E. Implementing a Substance-Use Screening and Intervention Program for People Living with Rifampicin-Resistant Tuberculosis: Pragmatic Experience from Khayelitsha, South Africa. Trop Med Infect Dis 2022; 7:tropicalmed7020021. [PMID: 35202216 PMCID: PMC8879094 DOI: 10.3390/tropicalmed7020021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 02/01/2023] Open
Abstract
Substance use (SU) is associated with poor rifampicin-resistant tuberculosis (RR-TB) treatment outcomes. In 2017, a SBIRT (SU screening-brief intervention-referral to treatment) was integrated into routine RR-TB care in Khayelitsha, South Africa. This was a retrospective study of persons with RR-TB who were screened for SU between 1 July 2018 and 30 September 2020 using the ASSIST (Alcohol, Smoking and Substance Involvement Screening Test). Here we describe outcomes from this program. Persons scoring moderate/high risk received a brief intervention and referral to treatment. Overall, 333 persons were initiated on RR-TB treatment; 38% (n = 128) were screened for SU. Of those, 88% (n = 113/128) reported SU; 65% (n = 83/128) had moderate/high risk SU. Eighty percent (n = 103/128) reported alcohol use, of whom 52% (n = 54/103) reported moderate/high risk alcohol use. Seventy-seven persons were screened for SU within ≤2 months of RR-TB treatment initiation, of whom 69%, 12%, and 12% had outcomes of treatment success, loss to follow-up and death, respectively. Outcomes did not differ between persons with no/low risk and moderate/high risk SU or based on the receipt of naltrexone (p > 0.05). SU was common among persons with RR-TB; there is a need for interventions to address this co-morbidity as part of “person-centered care”. Integrated, holistic care is needed at the community level to address unique challenges of persons with RR-TB and SU.
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Affiliation(s)
- Anja Reuter
- Médecins Sans Frontières, Khayelitsha 7784, South Africa; (B.B.); (B.M.); (J.D.); (E.R.); or (E.M.-H.)
- Correspondence:
| | - Buci Beko
- Médecins Sans Frontières, Khayelitsha 7784, South Africa; (B.B.); (B.M.); (J.D.); (E.R.); or (E.M.-H.)
| | - Boniwe Memani
- Médecins Sans Frontières, Khayelitsha 7784, South Africa; (B.B.); (B.M.); (J.D.); (E.R.); or (E.M.-H.)
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA;
| | - Johnny Daniels
- Médecins Sans Frontières, Khayelitsha 7784, South Africa; (B.B.); (B.M.); (J.D.); (E.R.); or (E.M.-H.)
| | - Erickmar Rodriguez
- Médecins Sans Frontières, Khayelitsha 7784, South Africa; (B.B.); (B.M.); (J.D.); (E.R.); or (E.M.-H.)
| | - Hermann Reuter
- Faculty of Health Sciences, University of Cape Town, Cape Town 7701, South Africa;
| | - Lize Weich
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7701, South Africa;
| | - Petros Isaakidis
- Médecins Sans Frontières Southern Africa Medical Unit, Cape Town 7925, South Africa;
| | | | - Yulene Kock
- National Department of Health Tuberculosis Program, Pretoria 0187, South Africa;
| | - Erika Mohr-Holland
- Médecins Sans Frontières, Khayelitsha 7784, South Africa; (B.B.); (B.M.); (J.D.); (E.R.); or (E.M.-H.)
- Médecins Sans Frontières Southern Africa Medical Unit, Cape Town 7925, South Africa;
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17
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Pietersen E, Anderson K, van der Heijden YF. Public health and hospital-based nursing intersection: Case study of drug-resistant tuberculosis patients. Public Health Nurs 2022; 39:170-179. [PMID: 34990027 DOI: 10.1111/phn.13042] [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: 07/05/2021] [Revised: 12/06/2021] [Accepted: 12/09/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Public health nurses (PHN) are key partners in continuity of care for drug-resistant tuberculosis (DR-TB) patients. We examined complexities in DR-TB care transition between community- and hospital-based care. DESIGN We conducted a case study using medical record data. Four patients were purposively selected to illustrate intersectional complexities in DR-TB care transition involving PHN. RESULTS Case A (HIV negative male) received PHN care at a community-based facility 124 km from Cape Town. Cases B, C, and D (males living with HIV) received PHN community-based care, averaging 25 km from the hospital. Treatment failed in cases A, B, and C; they subsequently died. Case D was cured. All cases were granted leave of absence at least once while hospitalized. None returned when expected mainly due to lack of transport funds. PHN played critical roles regarding patients' return by conducting home visits, interacting with relatives, and assisting emergency officers to transport patients back to the hospital. PHN supported relatives to endure protracted patient hospitalizations. CONCLUSION The role of PHN in continuity of DR-TB care in low-middle income countries is unambiguous. PHN are key partners in the DR-TB care cascade, namely facilitating retention in care between hospital and community-based care. Effective DR-TB control relies on effective partnerships among healthcare personnel, patients, and their families.
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Affiliation(s)
- Elize Pietersen
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Kim Anderson
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Yuri F van der Heijden
- Vanderbilt Tuberculosis Center, Vanderbilt University School of Medicine, Nashville, USA.,Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, USA.,The Aurum Institute, Johannesburg, South Africa
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18
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Mesic A, Ishaq S, Khan WH, Mureed A, Mar HT, Khaing EE, Bermudez-Aza E, Rose L, Lynen L, Seddiq MK, Amirzada HK, Keus K, Decroo T. Person-centred care and short oral treatment for rifampicin-resistant tuberculosis improve retention in care in Kandahar, Afghanistan. Trop Med Int Health 2022; 27:207-215. [PMID: 34978748 PMCID: PMC9306566 DOI: 10.1111/tmi.13716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Objectives To describe the effect of adaptations to a person‐centred care with short oral regimens on retention in care for rifampicin‐resistant TB (RR‐TB) in Kandahar province, Afghanistan. Methods The study included people with RR‐TB registered in the programme between 01 October 2016 and 18 April 2021. From 19 November 2019, the programme implemented a trial investigating the safety and effectiveness of short oral RR‐TB regimens. During the trial, person‐centred care was adapted. We included the data from people living with RR‐TB treated in the period before and after the care model was adapted and applied Kaplan‐Meier statistics to compare rates of retention in care. Results Of 236 patients registered in the RR‐TB programme, 146 (61.9%) were registered before and 90 (38.1%) after the model of care was adapted. Before adaptations enhancing person‐centred care, pre‐treatment attrition was 23.3% (n = 34/146), whilst under the adapted care model it was 5.6% (n = 5/90). Attrition on treatment was 22.3% (n = 25/112) before adaptations, whilst during the study period none of the participants were lost‐to‐follow‐up on treatment and 3.3% died (n = 3/90). Conclusions As person‐centred care delivery and treatment regimens were adapted to better fit‐specific contextual challenges and the needs of the target population, retention in care improved amongst people with RR‐TB in Kandahar, Afghanistan.
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Affiliation(s)
- Anita Mesic
- Médecins Sans Frontières, Amsterdam, The Netherlands.,Institute of Tropical Medicine Antwerp, Antwerp, Belgium
| | | | | | | | | | | | | | | | - Lutgarde Lynen
- Institute of Tropical Medicine Antwerp, Antwerp, Belgium
| | | | - Hashim Khan Amirzada
- National Tuberculosis Control Programme, Ministry of Public Health, Kabul, Afghanistan
| | - Kees Keus
- Médecins Sans Frontières, Amsterdam, The Netherlands
| | - Tom Decroo
- Institute of Tropical Medicine Antwerp, Antwerp, Belgium.,Research Foundation Flanders, Brussels, Belgium
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Liu X, Lin KH, Li YH, Jiang JN, Zhong ZD, Xiong YB, Zhou J, Xiang L. Impacts of Medical Security Level on Treatment Outcomes of Drug-Resistant Tuberculosis: Evidence from Wuhan City, China. Patient Prefer Adherence 2022; 16:3341-3355. [PMID: 36573226 PMCID: PMC9789709 DOI: 10.2147/ppa.s389231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Drug-resistant tuberculosis (DR-TB) is an increasingly serious global issue. DR-TB has a lower success rate and more severe interruption of treatment than ordinary tuberculosis. Incomplete treatment not only reduces recovery rate in DR-TB patients but also increases the spread of DR-TB. Optimizing medical security policies for DR-TB can reduce the economic burden of patients and can thereby improve treatment success rate. METHODS Patients with DR-TB who were registered in Wuhan Center for Tuberculosis Control and Prevention from January 2016 to December 2019 were selected as research subjects. General descriptive statistical analysis methods were used in analyzing patients' treatment outcomes and medical security compensation rate. The binary logistic regression was used in analyzing the impacts of medical security level on treatment outcomes of DR-TB. RESULTS A total of 409 DR-TB patients were included in the study, and the refusal rate was 12.47%. The treatment success rate was only 37.09% for patients who started treatment and had treatment outcomes. The total out-of-pocket expenses (OOPs) per capita for DR-TB patients were 13,005.61 Chinese yuan. The outpatient effective compensation ratio (ECR) of DR-TB patients was only 51.04%. The outpatient ECR of DR-TB with subsidies of public health projects (SPHPs) were nearly 80% higher than those without SPHP. high outpatient ECR helped optimize treatment outcomes (P < 0.001, OR = 1.038). The inpatient ECR had no effect on patients' treatment outcomes (P = 0.158, OR = 0.986). CONCLUSION Many DR-TB patients did not receive complete treatment. The key breakthrough point in improving DR-TB treatment outcomes is to optimize the outpatient medical insurance compensation policy. Including the costs of DR-TB in expenses for severe diseases in outpatient care is recommended, and financial investment should be appropriately increased to ensure the high coverage ratio of subsidies for public health projects.
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Affiliation(s)
- Xiao Liu
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Kun-He Lin
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Yue-Hua Li
- Wuhan Center for Tuberculosis Control and Prevention, Wuhan Pulmonary Hospital, Wuhan, People’s Republic of China
| | - Jun-Nan Jiang
- School of Public Administration, Zhongnan University of Economics and Law, Wuhan, People’s Republic of China
| | - Zheng-Dong Zhong
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Ying-Bei Xiong
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Jin Zhou
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Li Xiang
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
- HUST Base of National Institute of Healthcare Security, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
- Correspondence: Li Xiang, Huazhong University of Science and Technology, Wuhan, People’s Republic of China, Email
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20
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McNabb KC, Bergman A, Farley JE. Risk factors for poor engagement in drug-resistant TB care in South Africa: a systematic review. Public Health Action 2021; 11:139-145. [PMID: 34567990 PMCID: PMC8455023 DOI: 10.5588/pha.21.0007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Metrics of poor patient engagement, including missed appointments, treatment interruption, sub-optimal medication adherence, and loss to follow-up, have been linked to poor clinical multidrug-resistant TB (MDR-TB) outcomes. Understanding the risk factors for poor patient engagement is necessary to improve outcomes and control TB. This review synthesizes the risk factors for poor patient engagement in MDR-TB treatment across South Africa. DESIGN A systematic review of five databases (PubMed, Embase, CINAHL, Cochrane, and Web of Science) was conducted, covering articles published between 2010 and 2020. Articles were included if they provided information about risk factors associated with poor engagement among adults (⩾15 years) in treatment for MDR-TB in South Africa. Reviews, editorials, abstracts, and case studies were excluded. RESULTS Six studies met the inclusion criteria. Male sex and younger age were the most consistently identified risk factors for poor engagement; however, there was a lack of consistency in the choice of covariates, measurement of the variables, analytic methods, and significant factors associated with poor engagement between studies. Alcohol use, substance use, living with HIV, pulmonary TB site, and ethnicity were all identified as risk factors in at least one included study, while formal housing and steady employment were found to be protective. CONCLUSION The available literature offers little cohesive data to address poor patient engagement in this population. Further research needs to focus on identifying and addressing risk factors for poor patient engagement. This is particularly salient within the context of newer all-oral and short-course MDR-TB treatment regimens.
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Affiliation(s)
- K C McNabb
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | - A Bergman
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | - J E Farley
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
- REACH Initiative, Johns Hopkins University School of Nursing, Baltimore, MD, USA
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21
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Kuchukhidze G, Baliashvili D, Adamashvili N, Kasradze A, Kempker RR, Magee MJ. Long-Term Mortality and Active Tuberculosis Disease Among Patients Who Were Lost to Follow-Up During Second-Line Tuberculosis Treatment in 2011-2014: Population-Based Study in the Country of Georgia. Open Forum Infect Dis 2021; 8:ofab127. [PMID: 34189157 PMCID: PMC8231391 DOI: 10.1093/ofid/ofab127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 03/12/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND High rates of loss to follow-up (LFU) exist among patients with multidrug and extensively drug-resistant tuberculosis (M/XDR TB). We aimed to identify long-term clinical outcomes of patients who were LFU during second-line TB treatment. METHODS We conducted a follow-up study among adults who received second-line TB treatment in the country of Georgia during 2011-2014 with a final outcome of LFU. We attempted to interview all LFU patients, administered a structured questionnaire, and obtained sputum samples. Active TB at follow-up was defined by positive sputum Xpert-TB/RIF or culture. RESULTS Follow-up information was obtained for 461 patients. Among these patients, 107 (23%) died and 177 (38%) were contacted. Of those contacted, 123 (69%) consented to participate and 92 provided sputum samples. Thirteen (14%) had active TB with an estimated infectious time period for transmitting drug-resistant TB in the community of 480 days (interquartile range = 803). In multivariable analysis, positive culture at the time of LFU was associated with active TB at the time of our study (adjusted risk ratio = 13.3; 95% confidence interval, 4.2-42.2). CONCLUSIONS Approximately one quarter of patients on second-line TB treatment who were LFU died. Among those LFU evaluated in our study, 1 in 7 remained in the community with positive sputum cultures. To reduce death and transmission of disease, additional strategies are needed to encourage patients to complete treatment.
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Affiliation(s)
| | - Davit Baliashvili
- National Centre for Disease Control and Public Health, Tbilisi, Georgia
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, Georgia, USA
| | | | - Ana Kasradze
- National Centre for Disease Control and Public Health, Tbilisi, Georgia
| | | | - Matthew J Magee
- Hubert Department of Global Health, Emory Rollins School of Public Health, Atlanta, Georgia, USA
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22
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Sotgiu G, Rosales-Klintz S, Centis R, D'Ambrosio L, Verduin R, Correia AM, Cirule A, Duarte R, Gadzheva B, Gualano G, Kunst H, Palmieri F, Riekstina V, Stefanova D, Tiberi S, van der Werf MJ, Migliori GB. TB management in the European Union/European Economic Area: a multi-centre survey. Int J Tuberc Lung Dis 2021; 25:126-133. [PMID: 33656424 PMCID: PMC7849393 DOI: 10.5588/ijtld.20.0849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND: Essential TB care in the European Union/European Economic Area (EU/EEA) comprises 21 standards for the diagnosis, treatment and prevention of TB that constitute the European Union Standards for Tuberculosis Care (ESTC). METHODS: In 2017, we conducted an audit on TB management and infection control measures against the ESTC standards. TB reference centres in five EU/EEA countries were purposely selected to represent the heterogeneous European TB burden and examine geographic variability. RESULTS: Data from 122 patients, diagnosed between 2012 and 2015 with multidrug-resistant TB (n = 49), extensively drug-resistant TB (XDR-TB) (n = 11), pre-XDR-TB (n = 29) and drug-susceptible TB (n = 33), showed that TB diagnosis and treatment practices were in general in agreement with the ESTC. CONCLUSION: Overall, TB management and infection control practices were in agreement with the ESTC in the selected EU/EEA reference centres. Areas for improvement include strengthening of integrated care services and further implementation of patient-centred approaches.
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Affiliation(s)
- G Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - S Rosales-Klintz
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - R Centis
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Tradate, Italy
| | - L D'Ambrosio
- Public Health Consulting Group, Lugano, Switzerland
| | - R Verduin
- Verduin Public Health Consult, Oegstgeest, the Netherlands
| | - A M Correia
- Regional Health Administration of the North, Department of Public Health, Porto, Portugal
| | - A Cirule
- Centre of TB and Lung Diseases, Riga East University Hospital, Riga, Latvia
| | - R Duarte
- National Reference Centre for MDR-TB, Hospital Centre Vila Nova de Gaia, Department of Pneumology; Public Health Science and Medical Education Department, Faculty of Medicine, University of Porto, Porto, Portugal
| | - B Gadzheva
- The Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) Programme, Department of Management of Specialized Donor-Funded Programmes, Ministry of Health, Sofia, Bulgaria
| | - G Gualano
- Respiratory Infectious Diseases Unit, L Spallanzani National Institute for Infectious Diseases, IRCCS, Rome, Italy
| | - H Kunst
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University, London, UK
| | - F Palmieri
- Respiratory Infectious Diseases Unit, L Spallanzani National Institute for Infectious Diseases, IRCCS, Rome, Italy
| | - V Riekstina
- Centre of TB and Lung Diseases, Riga East University Hospital, Riga, Latvia
| | - D Stefanova
- St Sofia University Hospital for Active Treatment of Respiratory Diseases, Sofia, Bulgaria
| | - S Tiberi
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University, London, UK, Division of Infection, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - M J van der Werf
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - G B Migliori
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Tradate, Italy
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23
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Law S, Seepamore B, Oxlade O, Sikhakhane N, Dawood H, Chetty S, Padayatchi N, Menzies D, Daftary A. Acceptability, feasibility, and impact of a pilot tuberculosis literacy and treatment counselling intervention: a mixed methods study. BMC Infect Dis 2021; 21:449. [PMID: 34006254 PMCID: PMC8132373 DOI: 10.1186/s12879-021-06136-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 05/04/2021] [Indexed: 11/10/2022] Open
Abstract
Background There is a need for innovative strategies to improve TB testing uptake and patient retention along the continuum of TB care early-on in treatment without burdening under-resourced health systems. We used a mixed methods approach to develop and pilot test a tuberculosis literacy and counselling intervention at an urban clinic in KwaZulu Natal, South Africa, to improve TB testing uptake and retention in tuberculosis care. Methods We engaged in discussions with clinic staff to plan and develop the intervention, which was delivered by senior social work students who received one-week training. The intervention included: 1) group health talks with all patients attending the primary clinic; and 2) individual counselling sessions, using motivational interviewing techniques, with newly diagnosed tuberculosis patients. We compared social work students’ tuberculosis knowledge, attitudes, and practices before and after their training. We assessed the change in number of tuberculosis diagnostic tests performed after implementation via an interrupted time series analysis with a quasi-Poisson regression model. We compared pre- and post-intervention probabilities of treatment initiation and completion using regression analyses, adjusting for potential baseline confounders. We conducted focus groups with the students, as well as brief surveys and one-on-one interviews with patients, to assess acceptability, feasibility, and implementation. Results During the study period, 1226 individuals received tuberculosis diagnostic testing and 163 patients started tuberculosis treatment, of whom 84 (51.5%) received individual counselling. The number of diagnostic tuberculosis tests performed increased by 1.36 (95%CI 1.23–1.58) times post-intervention, adjusting for background calendar trend. Probabilities of TB treatment initiation and treatment completion increased by 10.1% (95%CI 1.5–21.3%) and 4.4% (95%CI -7.3-16.0%), respectively. Patients found the counselling sessions alleviated anxiety and increased treatment self-efficacy. Social work students felt the clinic staff were collaborative and highly supportive of the intervention, and that it improved patient engagement and adherence. Conclusions Engaging clinic staff in the development of an intervention ensures buy-in and collaboration. Education and counselling before and early-on in tuberculosis treatment can increase tuberculosis testing and treatment uptake. Training junior social workers can enable task-shifting in under-resourced settings, while addressing important service gaps in tuberculosis care. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06136-1.
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Affiliation(s)
- Stephanie Law
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA. .,McGill International TB Centre, Research Institute of the McGill University Health Centre, 1001 rue Decarie, Montreal, Quebec, H4A 3J1, Canada.
| | - Boitumelo Seepamore
- School of Applied Human Sciences, University of KwaZulu-Natal, Howard College Campus, 238 Mazisi Kunene Rd, Glenwood, Durban, 4041, South Africa
| | - Olivia Oxlade
- McGill International TB Centre, Research Institute of the McGill University Health Centre, 1001 rue Decarie, Montreal, Quebec, H4A 3J1, Canada
| | - Nondumiso Sikhakhane
- CAPRISA- MRC HIV-TB Treatment and Pathogenesis Unit, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Private Bag X7, Congella, 4013, South Africa
| | - Halima Dawood
- CAPRISA- MRC HIV-TB Treatment and Pathogenesis Unit, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Private Bag X7, Congella, 4013, South Africa.,Department Medicine, Infectious Disease Unit, Greys Hospital, The Msunduzi, Town Hill, Pietermaritzburg, 3201, South Africa
| | - Sheldon Chetty
- East Boom Community Healthcare Centre, 541 Boom Street, Pietermaritzburg, 3201, South Africa
| | - Nesri Padayatchi
- CAPRISA- MRC HIV-TB Treatment and Pathogenesis Unit, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Private Bag X7, Congella, 4013, South Africa
| | - Dick Menzies
- McGill International TB Centre, Research Institute of the McGill University Health Centre, 1001 rue Decarie, Montreal, Quebec, H4A 3J1, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1020 Pine Ave W, Montreal, Quebec, H3A 1A2, Canada
| | - Amrita Daftary
- CAPRISA- MRC HIV-TB Treatment and Pathogenesis Unit, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Private Bag X7, Congella, 4013, South Africa.,School of Global Health and Dahdaleh Institute of Global Health Research, York University, 88 The Pond Rd, North York, ON, M3J 2S5, Canada
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24
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Daftary A, Mondal S, Zelnick J, Friedland G, Seepamore B, Boodhram R, Amico KR, Padayatchi N, O'Donnell MR. Dynamic needs and challenges of people with drug-resistant tuberculosis and HIV in South Africa: a qualitative study. Lancet Glob Health 2021; 9:e479-e488. [PMID: 33740409 PMCID: PMC8009302 DOI: 10.1016/s2214-109x(20)30548-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/18/2020] [Accepted: 12/15/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is little evidence of patient acceptability for drug-resistant tuberculosis (DRTB) care in the context of new treatment regimens and HIV co-infection. We aim to describe experiences of DRTB-HIV care among patients in KwaZulu-Natal province, South Africa. METHODS In this qualitative study using Bury's framework for chronic illness, we conducted 13 focus groups at a tertiary hospital with 55 patients co-infected with DRTB and HIV (28 women, 27 men) who were receiving new bedaquiline-based treatment for DRTB, concurrent with antiretroviral therapy. Eligible patients were consenting adults (aged >18 years) with confirmed DRTB and HIV who were enrolled into the PRAXIS study within 2 weeks of initiating bedaquiline-based treatment for DRTB. Participants were recruited from the PRAXIS cohort to participate in a focus group based on their time in DRTB treatment: early (2-6 weeks after treatment initiation), middle (2-6 months after discharge or treatment initiation if never hospitalised), and late (>6 months after treatment initiation). Focus groups were carried out in isiZulu language, audio recorded, and translated to English within 4 weeks. Participants were asked about their experiences of DRTB and HIV care and treatment, and qualitative data were coded and thematically analysed. FINDINGS From March, 2017, to June, 2018, distinctive patient challenges were identified at four critical stages of DRTB care: diagnosis, marked by centralised hospitalisation, renunciation from routine life, systemic stigmatisation and, for patients with longstanding HIV, renewed destabilisation; treatment initiation, marked by side-effects, isolation, and social disconnectedness; discharge, marked by brief respite and resurgent therapeutic and social disruption; and continuity, marked by deepening socioeconomic challenges despite clinical recovery. The periods of diagnosis and discharge into the community were particularly difficult. Treatment information and agency in decision making was a persistent gap. Sources of stigmatisation shifted with movement between the hospital and community. Resilience was built by connecting to peers, self-isolating, financial and material security, and a focus on recovery. INTERPRETATION People with DRTB and HIV undergo disruptive, life-altering experiences. The lack of information, agency, and social protections in DRTB care and treatment causes wider-reaching challenges for patients compared with HIV. Decentralised, community, peer-support, and differentiated care models for DRTB might be ameliorative and help to maximise the promise of new regimens. FUNDING US National Institutes of Health. TRANSLATION For the isiZulu translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Amrita Daftary
- Dahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, ON, Canada; Centre for the Aids Programme of Research in South Africa MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa.
| | - Shinjini Mondal
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Jennifer Zelnick
- Graduate School of Social Work, Touro College and University System, New York, NY, USA
| | | | - Boitumelo Seepamore
- Department of Social Work, University of KwaZulu-Natal, Durban, South Africa
| | - Resha Boodhram
- Centre for the Aids Programme of Research in South Africa MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - K Rivet Amico
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Nesri Padayatchi
- Centre for the Aids Programme of Research in South Africa MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Max R O'Donnell
- Centre for the Aids Programme of Research in South Africa MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa; Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, NY, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY, USA
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25
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Roberts T, Sahu S, Malar J, Abdullaev T, Vandevelde W, Pillay YG, Fujiwara PI, Reid A, Hader S, Singh S, Kamarulzaman A, Ahmedov S. Turning threats into opportunities: how to implement and advance quality TB services for people with HIV during the COVID-19 pandemic and beyond. J Int AIDS Soc 2021; 24:e25696. [PMID: 33787058 PMCID: PMC8010364 DOI: 10.1002/jia2.25696] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/22/2021] [Accepted: 03/02/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Until COVID-19, tuberculosis (TB) was the leading infectious disease killer globally, disproportionally affecting people with HIV. The COVID-19 pandemic is threatening the gains made in the fight against both diseases. DISCUSSION Although crucial guidance has been released on how to maintain TB and HIV services during the pandemic, it is acknowledged that what was considered normal service pre-pandemic needs to improve to ensure that we rebuild person-centred, inclusive and quality healthcare services. The threat that the pandemic may reverse gains in the response to TB and HIV may be turned into an opportunity by pivoting to using proven differentiated service delivery approaches and innovative technologies that can be used to maintain care during the pandemic and accelerate improved service delivery in the long term. Models of care should be convenient, supportive and sufficiently differentiated to avoid burdensome clinic visits for medication pick-ups or directly observed treatments. Additionally, the pandemic has highlighted the chronic and short-sighted lack of investment in health systems and the need to prioritize research and development to close the gaps in TB diagnosis, treatment and prevention, especially for children and people with HIV. Most importantly, TB-affected communities and civil society must be supported to lead the planning, implementation and monitoring of TB and HIV services, especially in the time of COVID-19 where services have been disrupted, and to report on legal, policy and gender-related barriers to access experienced by affected people. This will help to ensure that TB services are held accountable by affected communities for delivering equitable access to quality, affordable and non-discriminatory services during and beyond the pandemic. CONCLUSIONS Successfully reaching the related targets of ending TB and AIDS as public health threats by 2030 requires rebuilding of stronger, more inclusive health systems by advancing equitable access to quality TB services, including for people with HIV, both during and after the COVID-19 pandemic. Moreover, services must be rights-based, community-led and community-based, to ensure that no one is left behind.
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Affiliation(s)
| | | | | | | | | | | | - Paula I Fujiwara
- International Union Against Tuberculosis and Lung DiseaseParisFrance
| | | | | | | | - Adeeba Kamarulzaman
- International AIDS SocietyGenevaSwitzerland
- University of MalayaKuala LumpurMalaysia
| | - Sevim Ahmedov
- United States Agency for International DevelopmentWashingtonDCUSA
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26
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O'Donnell M, Mathema B. Operational Research on the Treatment of Drug-Resistant Tuberculosis: Exciting Results That Need to Be Protected. Am J Respir Crit Care Med 2021; 203:11-13. [PMID: 32822207 PMCID: PMC7781148 DOI: 10.1164/rccm.202007-2974ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Max O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine Columbia University Irving Medical Center New York, New York.,Mailman School of Public Health Columbia University Irving Medical Center New York, New York and.,Centre for AIDS Programme of Research in South Africa Durban, South Africa
| | - Barun Mathema
- Mailman School of Public Health Columbia University Irving Medical Center New York, New York and
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27
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Drake WP, Culver DA, Baughman RP, Judson MA, Crouser ED, James WE, Ayers GD, Ding T, Abel K, Green A, Kerrigan A, Sesay A, Bernard GR. Phase II Investigation of the Efficacy of Antimycobacterial Therapy in Chronic Pulmonary Sarcoidosis. Chest 2020; 159:1902-1912. [PMID: 33387486 PMCID: PMC8129732 DOI: 10.1016/j.chest.2020.12.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 11/30/2020] [Accepted: 12/04/2020] [Indexed: 11/27/2022] Open
Abstract
Background A Phase I, single-center investigation found that 8 weeks of antimycobacterial therapy improved sarcoidosis FVC. Safety and efficacy assessments have not been performed in a multicenter cohort. Research Question The objective of this study was to determine the safety and efficacy of antimycobacterial therapy on the physiological and immunologic end points of sarcoidosis. Study Design and Methods In a double-blind, placebo-controlled, multicenter investigation, patients with pulmonary sarcoidosis were randomly assigned to receive 16 weeks of concomitant levofloxacin, ethambutol, azithromycin, and rifabutin (CLEAR) or matching placebo to investigate the effect on FVC. The primary outcome was a comparison of change in percentage of predicted FVC among patients randomized to receive CLEAR or placebo in addition to their baseline immunosuppressive regimen. Secondary outcomes included 6-min walk distance (6MWD), St. George’s Respiratory Questionnaire (SGRQ) score, adverse events, and decrease in mycobacterial early secreted antigenic target of 6 kDa (ESAT-6) immune responses. Results The intention-to-treat analysis revealed no significant differences in change in FVC among the 49 patients randomized to receive CLEAR (1.1% decrease) compared with the 48 randomized to receive placebo (0.02% increase) (P = .64). Physiological parameters such as the change in 6MWD were likewise similar (P = .91); change in SGRQ favored placebo (–8.0 for placebo vs –1.5 for CLEAR; P = .028). The per-protocol analysis revealed no significant change in FVC at 16 weeks between CLEAR and placebo. There was no significant change in 6MWD (36.4 m vs 6.3 m; P = .24) or SGRQ (–2.3 vs –7.0; P = .14). A decline in ESAT-6 immune responses at 16 weeks was noted among CLEAR-treated patients (P = .0003) but not patients receiving placebo (P = .24). Interpretation Despite a significant decline in ESAT-6 immune responses, a 16-week CLEAR regimen provided no physiological benefit in FVC or 6MWD among patients with sarcoidosis.
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Affiliation(s)
- Wonder P Drake
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN; Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, TN.
| | - Daniel A Culver
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Robert P Baughman
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati Medical Center, Cincinnati, OH
| | - Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY
| | - Elliott D Crouser
- Division of Pulmonary, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - W Ennis James
- Division of Pulmonary and Critical Care, Medical University of South Carolina, Charleston, SC
| | - Gregory D Ayers
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Tan Ding
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Kenny Abel
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Abena Green
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Amy Kerrigan
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Ahmed Sesay
- Division of Pulmonary and Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Gordon R Bernard
- Division of Pulmonary and Critical Care, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
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Understanding the gaps in DR-TB care cascade in Nigeria: A sequential mixed-method study. J Clin Tuberc Other Mycobact Dis 2020; 21:100193. [PMID: 33102811 PMCID: PMC7578750 DOI: 10.1016/j.jctube.2020.100193] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Despite the availability of free drug-resistant tuberculosis (DR-TB) care in Nigeria since 2011, the country continues to tackle low case notification and treatment rates. In 2018, 11% of an estimated 21,000 cases were diagnosed and 9% placed on treatment. These low rates are nevertheless a marked improvement from 2015 when only 3.4% were diagnosed and 2.3% placed on treatment of an estimated 29,000 cases. This study describes the Nigerian DR-TB care cascade from 2013 to 2017 and considers factors influencing gaps in care. Methods Our study utilized a mixed-method design. For the quantitative component, we utilized the national diagnosis and treatment databases, as well as the World Health Organization’s estimates for prevalence to construct a 5-year care cascade: numbers of patients at each level of DR-TB care, including incident cases, individuals who accessed testing, were diagnosed, initiated treated and completed treatment in Nigeria between 2013 and 2017. Using retrospective data for patients diagnosed in 2015, we performed the Fisher’s exact test to determine the association between patient (age and gender) and provider/patient (region- north or south) variables, permitting a closer look at the gaps in care revealed across the 5 years. Barriers to care were explored using framework thematic analysis of 57 qualitative interviews and focus group discussions with patients, including 5 cases not initiated on treatment from the 2015 cohort, treatment supporters, community members, healthcare workers and program managers in 2017. Results A 5-year analysis of cascade of care data shows significant, but inadequate, increases in overall numbers of cases accessing care. On average, between 2013 and 2017, 80% of estimated cases did not access testing; 75% of those who tested were not diagnosed; 36% of those diagnosed were not initiated on treatment and 23% of these did not finish treatment. In 2015, children and patients in Northern Nigeria had odds of 0.3 [95% CI 0.1–0.7] and 0.4 [0.3–0.5] of completing treatment once diagnosed; while males were shown to have a 1.34 [95% CI 1.0–1.7] times greater chance of completing treatment after diagnosis. The main themes from qualitative data identified barriers to care along the care cascade at individual, family and community, as well as health systems levels. At the individual level, a lack of awareness of the true cause of disease and the availability of ‘free’ care was a recurring theme. Family interference was found to be a particular challenge for children and women. At the health system level, low index of suspicion, lack of rapid diagnostic tools and human resource shortages appeared to limit patients’ access. Conclusions Any gains in diagnostic technology and shorter regimens are lost with inadequate access to DR-TB services. The biggest losses in the Nigerian cascade happen before treatment initiation. There is a need for urgent action on identified gaps in the DR-TB cascade in order to improve care continuity at multiple stages, improve health service delivery and facilitate TB control in Nigeria.
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Zelnick JR, Daftary A, Hwang C, Labar AS, Boodhram R, Maharaj B, Wolf AK, Mondal S, Amico KR, Orrell C, Seepamore B, Friedland G, Padayatchi N, O'Donnell MR. Electronic dose monitoring identifies a high-risk subpopulation in the treatment of drug-resistant tuberculosis and HIV. Clin Infect Dis 2020; 73:e1901-e1910. [PMID: 33053186 DOI: 10.1093/cid/ciaa1557] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND In generalized drug-resistant tuberculosis (DR-TB) HIV epidemics, identifying subpopulations at high risk for treatment failure and loss to care is critically important to improve treatment outcomes and prevent amplification of drug resistance. We hypothesized that an electronic dose-monitoring (EDM) device could empirically identify adherence-challenged patients and that a mixed-methods approach would characterize treatment challenges. METHODS A prospective study of DR-TB HIV patients on antiretroviral therapy (ART) initiating bedaquiline-containing regimens in KwaZulu-Natal, South Africa. Separate EDM devices measured adherence for bedaquiline and ART. Patients with low adherence (<85%) to both bedaquiline and ART were identified as high-risk for poor outcomes. Baseline survey, study visit notes and focus group discussions characterized treatment challenges. RESULTS From December 2016-February 2018, 32 of 198 (16%) enrolled DR-TB HIV patients were identified as dual adherence-challenged. In a multivariate model including baseline characteristics, only receiving a disability grant was significantly associated with dual non-adherence at 6-months. Mixed-methods identified treatment barriers including, alcohol abuse, family conflicts, and mental health issues. Compared to adherent patients, dual-adherence challenged patients struggled to prioritize treatment and lacked support, and dual adherence-challenged patients experienced higher rates of detectable HIV viral load and mortality compared to more adherent patients. CONCLUSION EDM empirically identified a subpopulation of DR-TB HIV patients with dual adherence challenges early in treatment. Mixed-methods revealed intense psychosocial, behavioral, and structural barriers to care in this subpopulation. Our data supports developing differential, patient-centered, adherence support interventions focused on psychosocial and structural challenges for subpopulations of at-risk DR-TB HIV patients.
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Affiliation(s)
- Jennifer R Zelnick
- Graduate School of Social Work, Touro College and University System, NY, NY USA
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, Ontario Canada.,CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Christina Hwang
- Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, NY, NY, USA
| | - Amy S Labar
- Vagelos College of Physician & Surgeons, Columbia University, NY, NY USA
| | - Resha Boodhram
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Bhavna Maharaj
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Allison K Wolf
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, NY, NY, USA
| | - Shinjini Mondal
- Department of Family Medicine, McGill University, Montreal, Canada
| | - K Rivet Amico
- University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, South Africa
| | | | | | - Nesri Padayatchi
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Max R O'Donnell
- Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, NY, NY, USA.,CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa.,Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, NY, NY, USA
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Wen S, Yin J, Sun Q. Impacts of social support on the treatment outcomes of drug-resistant tuberculosis: a systematic review and meta-analysis. BMJ Open 2020; 10:e036985. [PMID: 33033087 PMCID: PMC7545632 DOI: 10.1136/bmjopen-2020-036985] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To assess the effectiveness of social support on treatment success promotion or lost to follow-up (LTFU) reduction for patients with drug-resistant tuberculosis (DR-TB). DESIGN We searched Pubmed, Web of Science, Embase, Scopus and Medline databases until 18 June 2020 for interventional or mixed-method studies which reported social support and treatment outcomes of DR-TB patients. Two independent reviewers extracted data and disagreements were resolved by consensus with a third reviewer. Random-effects meta-analysis was performed to calculate the OR and 95% CI for the effects of social support on the improvement of treatment outcomes and the heterogeneity and risk of bias were assessed. SETTING Low-income and middle-income countries. PARTICIPANTS DR-TB patients. OUTCOMES Treatment success is defined as the combination of the cured and treatment completion, and LTFU is measured as treatment being interrupted for two consecutive months or more. RESULTS Among 173 articles selected for full-text review, 162 were excluded through independent review (kappa=0.87) and 10 studies enrolling 1621 DR-TB patients in eight countries were included for qualitative analysis. In these studies, the most frequently introduced social support was material support (10 studies), followed by informational (eight studies), emotional (seven studies) and companionship support (four studies). Seven studies that reported treatment outcomes in both intervention arm and control arm are qualified for meta-analysis. An encouraging improvement on treatment success rate (OR: 2.58; 95% CI: 1.80 to 3.69) was found when material support was integrated into social support packages and no heterogeneity was observed (I1 of 0%, Q test p=0.72). Reduction on LTFU rate (OR: 0.17; 95% CI: 0.05 to 0.55) was also noted when material support was available but substantial heterogeneity was found (I2 of 80%, Q test p=0.002). CONCLUSION Material support appeared feasible and effective to improve treatment success for DR-TB patients combined with other social support interventions. PROSPERO REGISTRATION NUMBER CRD42019140824.
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Affiliation(s)
- Shuqin Wen
- Centre for Health Management and Policy Research, School of Public Health, Shandong University Cheeloo College of Medicine, Jinan, Shandong, China
- NHC Key Lab of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China
| | - Jia Yin
- Centre for Health Management and Policy Research, School of Public Health, Shandong University Cheeloo College of Medicine, Jinan, Shandong, China
- NHC Key Lab of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China
| | - Qiang Sun
- Centre for Health Management and Policy Research, School of Public Health, Shandong University Cheeloo College of Medicine, Jinan, Shandong, China
- NHC Key Lab of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China
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Ciza F, Gils T, Sawadogo M, Decroo T, Roggi A, Piubello A, Ortuño-Gutiérrez N. Course of Adverse Events during Short Treatment Regimen in Patients with Rifampicin-Resistant Tuberculosis in Burundi. J Clin Med 2020; 9:jcm9061873. [PMID: 32560052 PMCID: PMC7356788 DOI: 10.3390/jcm9061873] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/05/2020] [Accepted: 06/12/2020] [Indexed: 11/16/2022] Open
Abstract
The introduction of the nine-month short-treatment regimen (STR) has drastically improved outcomes of rifampicin-resistant tuberculosis (RR-TB) treatment. Adverse events (AE) commonly occur, including injectable-induced hearing loss. In Burundi we retrospectively assessed the frequency of adverse events and treatment modifications in all patients who initiated the STR between 2013–2017. Among 225 included patients, 93% were successfully treated without relapse, 5% died, 1% was lost-to-follow-up, 0.4% had treatment failure and 0.4% relapsed after completion. AE were reported in 53%, with grade 3 or 4 AE in 4% of patients. AE occurred after a median of two months. Hepatotoxicity (31%), gastro-intestinal toxicity (22%) and ototoxicity (10%) were most commonly reported. One patient suffered severe hearing loss. Following AE, 7% of patients had a dose reduction and 1% a drug interruption. Kanamycin-induced ototoxicity led to 94% of modifications. All 18 patients with a modified regimen were cured relapse-free. In this exhaustive national RR-TB cohort, RR-TB was treated successfully with the STR. Adverse events were infrequent. To replace the present STR, all-oral regimens should be at least as effective and also less toxic. During and after transition, monitoring, management, and documentation of AE will remain essential.
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Affiliation(s)
- François Ciza
- Damien Foundation, Burundi 15, Avenue du Poisson 15, Ntahangwa, Bujumbura 2426, Burundi; (F.C.); (M.S.)
| | - Tinne Gils
- Department of Clinical Sciences, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium;
- Correspondence: ; Tel.: +32-32-476666
| | - Michel Sawadogo
- Damien Foundation, Burundi 15, Avenue du Poisson 15, Ntahangwa, Bujumbura 2426, Burundi; (F.C.); (M.S.)
| | - Tom Decroo
- Department of Clinical Sciences, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium;
- Research Foundation Flanders, Egmonstraat 5, 1000 Brussels, Belgium
| | - Alberto Roggi
- Damien Foundation, Boulevard Léopold-II 263, 1081 Brussels, Belgium; (A.R.); (N.O.-G.)
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Daines L, Lewis S, Schneider A, Sheikh A, Pinnock H. Defining high probability when making a diagnosis of asthma in primary care: mixed-methods consensus workshop. BMJ Open 2020; 10:e034559. [PMID: 32317260 PMCID: PMC7204930 DOI: 10.1136/bmjopen-2019-034559] [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: 11/15/2022] Open
Abstract
OBJECTIVE Making the diagnosis of asthma is challenging. Guidelines recommend that clinicians identify a group at 'high probability' of asthma. High probability, however, is not numerically defined giving rise to uncertainty. The aim of this work was to build consensus on what constitutes a high probability of asthma in primary care. High probability was defined as the probability threshold at which there is enough information to make a firm diagnosis of asthma, and a subsequent negative test would not alter that opinion (assumed to be a false negative). DESIGN Mixed-methods study. SETTING A consensus workshop using modified nominal group technique was held during an international respiratory conference. PARTICIPANTS International conference attendees eligible if they had knowledge/experience of working in primary care, respiratory medicine and spoke English. METHODS Participants took part in facilitated discussions and voted over three rounds on what constituted a high probability of asthma diagnosis. The workshop was audio-recorded, transcribed and qualitatively analysed. RESULTS Based on final votes, the mean value for a high probability of asthma in primary care was 75% (SD 7.6), representing a perceived trade-off between limiting the number of false positives (more likely if a lower threshold was used) and pragmatism on the basis that first-line preventive therapies (ie, low-dose inhaled corticosteroids) are relatively low risk. The need to review response to treatment was strongly emphasised for detecting non-responders and reviewing the diagnosis. CONCLUSION A consensus probability of 75% was the threshold at which the primary care participants in this workshop felt confident to establish the diagnosis of asthma, albeit with the caveat that a review of treatment response was essential. Contextual factors, including availability and timing of tests and the ease with which patients could be reviewed, influenced participants' decision making.
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Affiliation(s)
- Luke Daines
- Asthma UK Centre for Applied Research, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Steff Lewis
- Asthma UK Centre for Applied Research, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Antonius Schneider
- TUM School of Medicine, Institute of General Practice and Health Services Research, Technical University of Munich, Munich, Germany
| | - Aziz Sheikh
- Asthma UK Centre for Applied Research, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Hilary Pinnock
- Asthma UK Centre for Applied Research, Usher Institute, The University of Edinburgh, Edinburgh, UK
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Campbell JR, Falzon D, Mirzayev F, Jaramillo E, Migliori GB, Mitnick CD, Ndjeka N, Menzies D. Improving Quality of Patient Data for Treatment of Multidrug- or Rifampin-Resistant Tuberculosis. Emerg Infect Dis 2020; 26. [PMID: 31922953 PMCID: PMC7045826 DOI: 10.3201/eid2603.190997] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
International policy for treatment of multidrug- and rifampin-resistant tuberculosis (MDR/RR TB) relies largely on individual patient data (IPD) from observational studies of patients treated under routine conditions. We prepared guidance on which data to collect and what measures could improve consistency and utility for future evidence-based recommendations. We highlight critical stages in data collection at which improvements to uniformity, accuracy, and completeness could add value to IPD quality. Through a repetitive development process, we suggest essential patient- and treatment-related characteristics that should be collected by prospective contributors of observational IPD in MDR/RR TB.
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Furin J, Loveday M, Hlangu S, Dickson-Hall L, le Roux S, Nicol M, Cox H. "A very humiliating illness": a qualitative study of patient-centered Care for Rifampicin-Resistant Tuberculosis in South Africa. BMC Public Health 2020; 20:76. [PMID: 31952494 PMCID: PMC6969445 DOI: 10.1186/s12889-019-8035-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 12/04/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Patient-centered care is pillar 1 of the "End TB" strategy, but little has been documented in the literature about what this means for people living with rifampicin-resistant (RR-TB). Optimizing care for such individuals requires a better understanding of the challenges they face and the support they need. METHODS A qualitative study was done among persons living with RR-TB and members of their support network. A purposive sample was selected from a larger study population and open-ended interviews were conducted using a semi-standard interview guide. Interviews were recorded and transcribed and the content analyzed using an iterative thematic analysis based in grounded theory. RESULTS 16 participants were interviewed from three different provinces. Four distinct periods in which support was needed were identified: 1) pre-diagnosis; 2) pre-treatment; 3) treatment; and 4) post-treatment. Challenges common in all four periods included: socioeconomic issues, centralized care, and the need for better counseling at multiple levels. CONCLUSIONS Beyond being a "very humiliating illness", RR-TB robs people of their physical, social, economic, psychological, and emotional well-being far beyond the period when treatment is being administered. Efforts to tackle these issues are as important as new drugs and diagnostics in the fight against TB.
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Affiliation(s)
- Jennifer Furin
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA, 02115, USA.
| | - Marian Loveday
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Sindisiwe Hlangu
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Lindy Dickson-Hall
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape town, South Africa
| | - Sacha le Roux
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape town, South Africa
| | - Mark Nicol
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape town, South Africa
- Institute of Infectious Disease and Molecular Medicine and Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Cape Town, South Africa
- Division of Infection and Immunity, School of Biomedical Sciences, University of Western Australia, Perth, Australia
| | - Helen Cox
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape town, South Africa
- Institute of Infectious Disease and Molecular Medicine and Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Cape Town, South Africa
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What works best for ensuring treatment adherence. Lessons from a social support program for people treated for tuberculosis in Ukraine. PLoS One 2019; 14:e0221688. [PMID: 31449542 PMCID: PMC6709888 DOI: 10.1371/journal.pone.0221688] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/13/2019] [Indexed: 11/19/2022] Open
Abstract
Background Worldwide, TB is one of the top 10 causes of death and the leading cause from a single infectious agent. Ukraine is one of 30 countries with the highest burden of multidrug-resistant tuberculosis. Global literature shows that social support (SS) is important in improving TB treatment adherence, reducing lost to follow up rates and improving treatment outcomes. There are several models of SS available, and the literature provides little information on what aspects of SS are most important to TB patients in improving their adherence. Methods We used qualitative data collected through in-depth interviews (IDI) with 21 TB patients and 15 SS providers and coordinators in Ukraine in August-September 2016 to understand how the SS program promoted treatment adherence among patients. We examined the aspects of outpatient TB treatment that made adherence particularly difficult for patients in at-risk groups and aspects of the SS programs that worked best for addressing those barriers. Interviews were transcribed and analysis was performed to derive emergent themes. Results Main barriers included side effects from medicine, the amount of time required daily for transportation and waiting in lines at the health facility, transportation expenses, risks of being identified when visiting a TB facility and lack of motivation to seek treatment. Features of the SS program most valued by patients were convenience of not having to visit facility and support provided by nurses. These two features directly addressed most of the barriers identified. The commitment and qualities of the nurses that provided the SS was an important element of the program. Conclusions This qualitative study suggests that the SS program in Ukraine was successful in reducing treatment default among patients at high risk of default because it directly addressed most of the major barriers they faced to treatment adherence.
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Designing noninferiority tuberculosis treatment trials: Identifying practical advantages for drug regimens with acceptable effectiveness. PLoS Med 2019; 16:e1002850. [PMID: 31299047 PMCID: PMC6625704 DOI: 10.1371/journal.pmed.1002850] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
In this Collection Review for the Novel Treatments for Tuberculosis Collection, Piero Olliaro and Michael Vaillant discuss the considerations when choosing a non-inferiority margin that is meaningful from statistical, ethical, clinical, and health standpoint.
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37
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Schwarz D, Hirschhorn LR, Kim JH, Ratcliffe HL, Bitton A. Continuity in primary care: a critical but neglected component for achieving high-quality universal health coverage. BMJ Glob Health 2019; 4:e001435. [PMID: 31263586 PMCID: PMC6570977 DOI: 10.1136/bmjgh-2019-001435] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/07/2019] [Accepted: 04/27/2019] [Indexed: 11/03/2022] Open
Affiliation(s)
- Dan Schwarz
- Primary Health Care, Ariadne Labs, Boston, Massachusetts, USA.,Division of Global Health Equity, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Lisa R Hirschhorn
- Primary Health Care, Ariadne Labs, Boston, Massachusetts, USA.,Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - June-Ho Kim
- Primary Health Care, Ariadne Labs, Boston, Massachusetts, USA.,Division of General Internal Medicine, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | | | - Asaf Bitton
- Primary Health Care, Ariadne Labs, Boston, Massachusetts, USA.,Division of General Internal Medicine, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
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38
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Abubakar I, Lipman M. Reducing loss to follow-up during treatment for drug-resistant tuberculosis. Eur Respir J 2019; 53:53/1/1802268. [PMID: 30630854 DOI: 10.1183/13993003.02268-2018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 12/14/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK.,UCL-TB, University College London, London, UK
| | - Marc Lipman
- UCL-TB, University College London, London, UK.,UCL Respiratory, Division of Medicine, University College London, London, UK.,Royal Free London NHS Foundation Trust, London, UK
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