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Marley G, Zou X, Nie J, Cheng W, Xie Y, Liao H, Wang Y, Tao Y, Tucker JD, Sylvia S, Chou R, Wu D, Ong J, Tang W. Improving cascade outcomes for active TB: A global systematic review and meta-analysis of TB interventions. PLoS Med 2023; 20:e1004091. [PMID: 36595536 PMCID: PMC9847969 DOI: 10.1371/journal.pmed.1004091] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 01/18/2023] [Accepted: 12/13/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND To inform policy and implementation that can enhance prevention and improve tuberculosis (TB) care cascade outcomes, this review aimed to summarize the impact of various interventions on care cascade outcomes for active TB. METHODS AND FINDINGS In this systematic review and meta-analysis, we retrieved English articles with comparator arms (like randomized controlled trials (RCTs) and before and after intervention studies) that evaluated TB interventions published from January 1970 to September 30, 2022, from Embase, CINAHL, PubMed, and the Cochrane library. Commentaries, qualitative studies, conference abstracts, studies without standard of care comparator arms, and studies that did not report quantitative results for TB care cascade outcomes were excluded. Data from studies with similar comparator arms were pooled in a random effects model, and outcomes were reported as odds ratio (OR) with 95% confidence interval (CI) and number of studies (k). The quality of evidence was appraised using GRADE, and the study was registered on PROSPERO (CRD42018103331). Of 21,548 deduplicated studies, 144 eligible studies were included. Of 144 studies, 128 were from low/middle-income countries, 84 were RCTs, and 25 integrated TB and HIV care. Counselling and education was significantly associated with testing (OR = 8.82, 95% CI:1.71 to 45.43; I2 = 99.9%, k = 7), diagnosis (OR = 1.44, 95% CI:1.08 to 1.92; I2 = 97.6%, k = 9), linkage to care (OR = 3.10, 95% CI = 1.97 to 4.86; I2 = 0%, k = 1), cure (OR = 2.08, 95% CI:1.11 to 3.88; I2 = 76.7%, k = 4), treatment completion (OR = 1.48, 95% CI: 1.07 to 2.03; I2 = 73.1%, k = 8), and treatment success (OR = 3.24, 95% CI: 1.88 to 5.55; I2 = 75.9%, k = 5) outcomes compared to standard-of-care. Incentives, multisector collaborations, and community-based interventions were associated with at least three TB care cascade outcomes; digital interventions and mixed interventions were associated with an increased likelihood of two cascade outcomes each. These findings remained salient when studies were limited to RCTs only. Also, our study does not cover the entire care cascade as we did not measure gaps in pre-testing, pretreatment, and post-treatment outcomes (like loss to follow-up and TB recurrence). CONCLUSIONS Among TB interventions, education and counseling, incentives, community-based interventions, and mixed interventions were associated with multiple active TB care cascade outcomes. However, cost-effectiveness and local-setting contexts should be considered when choosing such strategies due to their high heterogeneity.
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Affiliation(s)
- Gifty Marley
- Dermatology Hospital of Southern Medical University, Guangzhou, China
- University of North Carolina Project-China, Guangzhou, China
| | - Xia Zou
- Global Health Research Center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Juan Nie
- Department of Research and Education, Guangzhou Concord Cancer Center, Guangzhou, China
| | - Weibin Cheng
- Institute for Healthcare Artificial Intelligence Application, Guangdong Second Provincial General Hospital, Guangzhou, China
- School of Data Science, City University of Hong Kong, Hong Kong, China
| | - Yewei Xie
- University of North Carolina Project-China, Guangzhou, China
| | - Huipeng Liao
- University of North Carolina Project-China, Guangzhou, China
| | - Yehua Wang
- University of North Carolina Project-China, Guangzhou, China
| | - Yusha Tao
- University of North Carolina Project-China, Guangzhou, China
| | - Joseph D. Tucker
- University of North Carolina Project-China, Guangzhou, China
- Faculty of Infectious and Tropical Diseases, London School of Health and Tropical Medicine, London, United Kingdom
| | - Sean Sylvia
- University of North Carolina Project-China, Guangzhou, China
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Roger Chou
- Oregon Health & Science University, Portland, Oregon, United States of America
| | - Dan Wu
- University of North Carolina Project-China, Guangzhou, China
- Faculty of Infectious and Tropical Diseases, London School of Health and Tropical Medicine, London, United Kingdom
| | - Jason Ong
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Weiming Tang
- Dermatology Hospital of Southern Medical University, Guangzhou, China
- University of North Carolina Project-China, Guangzhou, China
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Mhimbira FA, Cuevas LE, Dacombe R, Mkopi A, Sinclair D. Interventions to increase tuberculosis case detection at primary healthcare or community-level services. Cochrane Database Syst Rev 2017; 11:CD011432. [PMID: 29182800 PMCID: PMC5721626 DOI: 10.1002/14651858.cd011432.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pulmonary tuberculosis is usually diagnosed when symptomatic individuals seek care at healthcare facilities, and healthcare workers have a minimal role in promoting the health-seeking behaviour. However, some policy specialists believe the healthcare system could be more active in tuberculosis diagnosis to increase tuberculosis case detection. OBJECTIVES To evaluate the effectiveness of different strategies to increase tuberculosis case detection through improving access (geographical, financial, educational) to tuberculosis diagnosis at primary healthcare or community-level services. SEARCH METHODS We searched the following databases for relevant studies up to 19 December 2016: the Cochrane Infectious Disease Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library, Issue 12, 2016; MEDLINE; Embase; Science Citation Index Expanded, Social Sciences Citation Index; BIOSIS Previews; and Scopus. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), ClinicalTrials.gov, and the metaRegister of Controlled Trials (mRCT) for ongoing trials. SELECTION CRITERIA Randomized and non-randomized controlled studies comparing any intervention that aims to improve access to a tuberculosis diagnosis, with no intervention or an alternative intervention. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for eligibility and risk of bias, and extracted data. We compared interventions using risk ratios (RR) and 95% confidence intervals (CI). We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included nine cluster-randomized trials, one individual randomized trial, and seven non-randomized controlled studies. Nine studies were conducted in sub-Saharan Africa (Ethiopia, Nigeria, South Africa, Zambia, and Zimbabwe), six in Asia (Bangladesh, Cambodia, India, Nepal, and Pakistan), and two in South America (Brazil and Colombia); which are all high tuberculosis prevalence areas.Tuberculosis outreach screening, using house-to-house visits, sometimes combined with printed information about going to clinic, may increase tuberculosis case detection (RR 1.24, 95% CI 0.86 to 1.79; 4 trials, 6,458,591 participants in 297 clusters, low-certainty evidence); and probably increases case detection in areas with tuberculosis prevalence of 5% or more (RR 1.52, 95% CI 1.10 to 2.09; 3 trials, 155,918 participants, moderate-certainty evidence; prespecified stratified analysis). These interventions may lower the early default (prior to starting treatment) or default during treatment (RR 0.67, 95% CI 0.47 to 0.96; 3 trials, 849 participants, low-certainty evidence). However, this intervention may have may have little or no effect on treatment success (RR 1.07, 95% CI 1.00 to 1.15; 3 trials, 849 participants, low-certainty evidence), and we do not know if there is an effect on treatment failure or mortality. One study investigated long-term prevalence in the community, but with no clear effect due to imprecision and differences in care between the two groups (RR 1.14, 95% CI 0.65 to 2.00; 1 trial, 556,836 participants, very low-certainty evidence).Four studies examined health promotion activities to encourage people to attend for screening, including mass media strategies and more locally organized activities. There was some increase, but this could have been related to temporal trends, with no corresponding increase in case notifications, and no evidence of an effect on long-term tuberculosis prevalence. Two studies examined the effects of two to six nurse practitioner educational sessions in tuberculosis diagnosis, with no clear effect on tuberculosis cases detected. One trial compared mobile clinics every five days with house-to-house screening every six months, and showed an increase in tuberculosis cases.There was also insufficient evidence to determine if sustained improvements in case detection impact on long-term tuberculosis prevalence; this was evaluated in one study, which indicated little or no effect after four years of either contact tracing, extensive health promotion activities, or both (RR 1.31, 95% CI 0.75 to 2.30; 1 study, 405,788 participants in 12 clusters, very low-certainty evidence). AUTHORS' CONCLUSIONS The available evidence demonstrates that when used in appropriate settings, active case-finding approaches may result in increase in tuberculosis case detection in the short term. The effect of active case finding on treatment outcome needs to be further evaluated in sufficiently powered studies.
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Affiliation(s)
- Francis A Mhimbira
- Ifakara Health Institute (IHI)Bagamoyo Research and Training Center (BRTC)PO Box 74BagamoyoTanzania
- Swiss Tropical and Public Health InstituteBaselSwitzerland
- University of BaselBaselSwitzerland
| | - Luis E. Cuevas
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolUKL3 5QA
| | - Russell Dacombe
- Liverpool School of Tropical MedicineDepartment of International Public HealthPembroke PlaceLiverpoolUKL3 5QA
| | - Abdallah Mkopi
- Ifakara Health Institute (IHI)Impact Evaluation, Health Systems Interventions & Policy TranslationPO Box 78373Dar es SalaamTanzania
| | - David Sinclair
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolUKL3 5QA
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Heuvelings CC, de Vries SG, Greve PF, Visser BJ, Bélard S, Janssen S, Cremers AL, Spijker R, Shaw B, Hill RA, Zumla A, Sandgren A, van der Werf MJ, Grobusch MP. Effectiveness of interventions for diagnosis and treatment of tuberculosis in hard-to-reach populations in countries of low and medium tuberculosis incidence: a systematic review. THE LANCET. INFECTIOUS DISEASES 2017; 17:e144-e158. [PMID: 28291722 DOI: 10.1016/s1473-3099(16)30532-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 10/11/2016] [Accepted: 11/03/2016] [Indexed: 10/20/2022]
Abstract
Tuberculosis is over-represented in hard-to-reach (underserved) populations in high-income countries of low tuberculosis incidence. The mainstay of tuberculosis care is early detection of active tuberculosis (case finding), contact tracing, and treatment completion. We did a systematic review with a scoping component of relevant studies published between 1990 and 2015 to update and extend previous National Institute for Health and Care Excellence (NICE) reviews on the effectiveness of interventions for identifying and managing tuberculosis in hard-to-reach populations. The analyses showed that tuberculosis screening by (mobile) chest radiography improved screening coverage and tuberculosis identification, reduced diagnostic delay, and was cost-effective among several hard-to-reach populations. Sputum culture for pre-migration screening and active referral to a tuberculosis clinic improved identification. Furthermore, monetary incentives improved tuberculosis identification and management among drug users and homeless people. Enhanced case management, good cooperation between services, and directly observed therapy improved treatment outcome and compliance. Strong conclusions cannot be drawn because of the heterogeneity of evidence with regard to study population, methodology, and quality.
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Affiliation(s)
- Charlotte C Heuvelings
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Sophia G de Vries
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Patrick F Greve
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Benjamin J Visser
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Sabine Bélard
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Saskia Janssen
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Anne L Cremers
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - René Spijker
- Medical Library, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands; Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Beth Shaw
- National Institute for Health and Care Excellence, Piccadilly Plaza, Manchester, UK
| | - Ruaraidh A Hill
- National Institute for Health and Care Excellence, Piccadilly Plaza, Manchester, UK; Health Services Research, University of Liverpool, Liverpool, UK
| | - Alimuddin Zumla
- Division of Infection and Immunity, University College London, London, UK; National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, UK
| | - Andreas Sandgren
- European Centre for Disease Prevention and Control, Solna, Sweden
| | | | - Martin P Grobusch
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
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Heuvelings CC, de Vries SG, Grobusch MP. Tackling TB in low-incidence countries: improving diagnosis and management in vulnerable populations. Int J Infect Dis 2017; 56:77-80. [PMID: 28062228 DOI: 10.1016/j.ijid.2016.12.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 12/22/2016] [Accepted: 12/22/2016] [Indexed: 11/30/2022] Open
Abstract
In low tuberculosis incidence regions, tuberculosis is mainly concentrated among hard-to-reach populations like migrants, homeless people, drug or alcohol abusers, prisoners and people living with HIV. To be able to eliminate tuberculosis from these low incidence regions tuberculosis screening and treatment programs should focus on these hard-to-reach populations. Here we discuss the barriers and facilitators of health care-seeking, interventions improving tuberculosis screening uptake and interventions improving treatment adherence in these hard-to-reach populations.
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Affiliation(s)
- C C Heuvelings
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - S G de Vries
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - M P Grobusch
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
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Gupta A, Mbwambo J, Mteza I, Shenoi S, Lambdin B, Nyandindi C, Doula BI, Mfaume S, Bruce RD. Active case finding for tuberculosis among people who inject drugs on methadone treatment in Dar es Salaam, Tanzania. Int J Tuberc Lung Dis 2015; 18:793-8. [PMID: 24902554 DOI: 10.5588/ijtld.13.0208] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
SETTING Active case finding is a World Health Organization (WHO) endorsed strategy for improving tuberculosis (TB) case detection. Despite WHO recommendations for active case finding among people who inject drugs (PWID), few studies have been published. The historical focus of case finding has been in populations that are human immunodeficiency virus-positive, incarcerated or at higher occupational risk. OBJECTIVE We sought to examine the yield of active case finding among PWID newly started on methadone in Tanzania. DESIGN Of 222 methadone clients, 156 (70%) met with study administrators; 150 consented to participate, 139 (93%) of whom were male. The median age was 34 years. A symptom-based questionnaire was developed by the investigators and administered to every consenting patient by a native Swahili speaker. RESULTS Of the 150 patients surveyed, 16 (11%) had one or more TB symptoms and were referred for laboratory testing. Six new TB cases were identified in this active case finding program, with a prevalence of 4%. CONCLUSION This study presents the first data on TB prevalence in a population of PWID in Tanzania. This prevalence is 23 times that of the general Tanzanian TB prevalence of 0.2%. These results have significant implications for TB control.
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Affiliation(s)
- A Gupta
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - J Mbwambo
- Muhimbili University of Health and Allied Sciences, Dar es Salaam
| | - I Mteza
- Muhimbili National Hospital, Dar es Salaam
| | - S Shenoi
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - B Lambdin
- Pangaea Global AIDS Foundation, Oakland, California, USA
| | - C Nyandindi
- Muhimbili University of Health and Allied Sciences, Dar es Salaam
| | - B I Doula
- Central TB Reference Laboratory, Dar es Salaam, Tanzania
| | - S Mfaume
- Central TB Reference Laboratory, Dar es Salaam, Tanzania
| | - R D Bruce
- Yale University School of Medicine, New Haven, Connecticut, USA
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Al-Darraji HAA, Wong KC, Yeow DGE, Fu JJ, Loeliger K, Paiji C, Kamarulzaman A, Altice FL. Tuberculosis screening in a novel substance abuse treatment center in Malaysia: implications for a comprehensive approach for integrated care. J Subst Abuse Treat 2014; 46:144-9. [PMID: 24074846 PMCID: PMC5189907 DOI: 10.1016/j.jsat.2013.08.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 07/26/2013] [Accepted: 08/05/2013] [Indexed: 01/13/2023]
Abstract
People who use drugs (PWUD) represent a key high risk group for tuberculosis (TB). The prevalence of both latent TB infection (LTBI) and active disease in drug treatment centers in Malaysia is unknown. A cross-sectional convenience survey was conducted to assess the prevalence and correlates of LTBI among attendees at a recently created voluntary drug treatment center using a standardized questionnaire and tuberculin skin testing (TST). Participants (N=196) were mostly men (95%), under 40 (median age=36 years) and reported heroin use immediately before treatment entry (75%). Positive TST prevalence was 86.7%. Nine (4.6%) participants were HIV-infected. Previous arrest/incarcerations (AOR=1.1 for every entry, p<0.05) and not being HIV-infected (AOR=6.04, p=0.03) were significantly associated with TST positivity. There is an urgent need to establish TB screening and treatment programs in substance abuse treatment centers and to tailor service delivery to the complex treatment needs of patients with multiple medical and psychiatric co-morbidities.
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Grenfell P, Baptista Leite R, Garfein R, de Lussigny S, Platt L, Rhodes T. Tuberculosis, injecting drug use and integrated HIV-TB care: a review of the literature. Drug Alcohol Depend 2013; 129:180-209. [PMID: 23306095 DOI: 10.1016/j.drugalcdep.2012.11.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 11/13/2012] [Accepted: 11/17/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND People who inject drugs (PWID) are at increased risk of tuberculosis (TB) and reduced retention in treatment. There is a need to document strategies for integrated delivery of HIV, TB and drug dependency care. METHODS This article reviews the literature on rates of TB mono- and co-infection, and published and grey literature descriptions of TB and HIV-TB care, among PWID. RESULTS Latent TB infection prevalence was high and active disease more common among HIV-positive PWID. Data on multidrug-resistant TB and co-infections among PWID were scarce. Models of TB care fell into six categories: screening and prevention within HIV-risk studies; prevention at TB clinics; screening and prevention within needle-and-syringe-exchange (NSP) and drug treatment programmes; pharmacy-based TB treatment; TB service-led care with harm reduction/drug treatment programmes; and TB treatment within drug treatment programmes. Co-location with NSP and opioid substitution therapy (OST), combined with incentives, consistently improved screening and prevention uptake. Small-scale combined TB treatment and OST achieved good adherence in diverse settings. Successful interventions involved collaboration across services; a client-centred approach; and provision of social care. No peer-reviewed studies described models of integrated HIV-TB care for PWID but grey literature highlighted key components: co-located services, provision of drug treatment, multidisciplinary staff training; and remaining barriers: staffing inefficiencies, inadequate funding, police interference, and limited OST availability. CONCLUSIONS Integration with drug treatment improves PWID engagement in TB services but there is a need to document approaches to HIV-TB care, improve surveillance of TB and co-infections among PWID, and advocate for improved OST availability.
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Affiliation(s)
- Pippa Grenfell
- Centre for Research on Drugs and Health Behaviour, London School of Hygiene & Tropical Medicine, London, UK.
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