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Zhang Y, Wang S, Wang X, Liu N, Wang L, Wang X, Liang Z, Wang J, Aili A, Cao M. Effectiveness and Determinants of Implementing the "Xinjiang Model" for Tuberculosis Prevention and Control: A Quantitative Study. Infect Drug Resist 2024; 17:2609-2620. [PMID: 38947373 PMCID: PMC11213531 DOI: 10.2147/idr.s459228] [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: 01/14/2024] [Accepted: 06/14/2024] [Indexed: 07/02/2024] Open
Abstract
Objective To analyze the effectiveness of the "Xinjiang Model" for tuberculosis prevention and control in Kashgar Prefecture, Xinjiang, and to explore the determinants of the policy implementation effect. Methods The registration data of pulmonary tuberculosis (PTB) patients in Kashgar Prefecture from 2012 to 2021 were collected to describe the temporal trend of registered incidence. A questionnaire survey was conducted among PTB patients registered and treated in the tuberculosis management information system in Zepu and Shache Counties from January 2022 to July 2023 to collect and analyze "Xinjiang model" determinants of effectiveness. Results The PTB registered incidence in Kashgar Prefecture showed a significant increasing trend from 2012 to 2018 (APC=18.7%) and a significant decreasing trend from 2018-2021 (APC=-28.8%). Among the Kashgar Prefecture, compared with average registered incidence in 2012-2017, registered incidence in 2021 in Shufu, Maigaiti, and Zepu Counties had a greater decline rate of 58.68%, 57.16%, and 54.02%, respectively, while the registered incidence in 2021 in Shache County increased by 6.32%. According to the comprehensive analysis of the factors affecting the effect of policy implementation, the proportion of PTB patients in Zepu County whose health status has now significantly improved compared with that before treatment was significantly greater than that in Shache County (P<0.05); patients in Shache County were significantly less aware than those in Zepu County of how to take tuberculosis drugs, precautions, adverse reactions, and regular reviews during treatment; the factors that accounted for the greater proportion of heavy treatment burden in both Shache and Zepu Counties were discomfort caused by taking or injecting drugs, accounting for 12.8% and 8.7%, respectively. Conclusion The "Xinjiang model" can effectively control the epidemic situation of tuberculosis in Kashgar, and the knowledge of tuberculosis treatment, adverse reactions to tuberculosis drugs, and treatment costs were the determinants of the effectiveness of policy implementation.
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Affiliation(s)
- Yan Zhang
- Department of Epidemiology and Health Statistics, College of Public Health, Xinjiang Medical University, Urumqi, Xinjiang, 830011, People’s Republic of China
| | - Senlu Wang
- Department of Epidemiology and Health Statistics, College of Public Health, Xinjiang Medical University, Urumqi, Xinjiang, 830011, People’s Republic of China
| | - Xinqi Wang
- The Center for Disease Control and Prevention of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang, 830002, People’s Republic of China
| | - Nianqiang Liu
- The Center for Disease Control and Prevention of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang, 830002, People’s Republic of China
| | - Le Wang
- The Center for Disease Control and Prevention of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang, 830002, People’s Republic of China
| | - Xiaomin Wang
- Department of Epidemiology and Health Statistics, College of Public Health, Xinjiang Medical University, Urumqi, Xinjiang, 830011, People’s Republic of China
| | - Zhichao Liang
- Department of Epidemiology and Health Statistics, College of Public Health, Xinjiang Medical University, Urumqi, Xinjiang, 830011, People’s Republic of China
| | - Junan Wang
- Department of Epidemiology and Health Statistics, College of Public Health, Xinjiang Medical University, Urumqi, Xinjiang, 830011, People’s Republic of China
| | - Abulikemu Aili
- Department of Epidemiology and Health Statistics, College of Public Health, Xinjiang Medical University, Urumqi, Xinjiang, 830011, People’s Republic of China
| | - Mingqin Cao
- Department of Epidemiology and Health Statistics, College of Public Health, Xinjiang Medical University, Urumqi, Xinjiang, 830011, People’s Republic of China
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Mhazo AT, Miyango S, Palani L, Maponga CC. Tuberculosis commodities supply chain performance in the WHO African region: A scoping review. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003219. [PMID: 38753822 PMCID: PMC11098481 DOI: 10.1371/journal.pgph.0003219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 04/21/2024] [Indexed: 05/18/2024]
Abstract
Procurement and supply chain management [PSM] systems remain a critical pillar for the implementation of Directly Observed Therapy [DOTS] for tuberculosis [TB] and achievement of disease related aspirations such as 'ending TB by 2030'. We conducted a scoping review of literature using the Arksey and O'Malley [2005] framework to summarize and disseminate the results of available evidence in relation to TB commodities supply chain performance in the WHO African Region. We searched three electronic databases complemented by google search using relevant terms and identified 1,586 sources. Twenty-five studies published between 2009 and 2023 met the eligibility criteria, inclusive of 21 peer reviewed publications and four reports. The strengths we found included the existence of pooled procurement mechanisms [PPM], availability of funding through external sources, existence of logistics management information systems [LMIS] and integration of PSM systems into primary health care. The main challenge was frequent stock outs which mainly affected medicines for treating TB in children and those for preventing TB. Stock outs were found to follow a poverty gradient and pervasively inequitable since they disproportionately affected structurally disadvantaged populations and communities. Countries that rely on domestic mechanisms for procurement tend to be more vulnerable to stock outs due to inadequate and unpredictable financing, delayed disbursements of funds, longer procurement lead times and poor supplier management. We concluded that stock outs remain one of the foremost challenges to ending TB by 2030. We recommend leveraging existing performance-enhancing platforms such as PPMs, including utilization of such mechanisms by countries that utilize domestic resources to procure commodities. We recommend the design of people centric supply chains that are sensitive to the differentiated needs of the population to ensure that composite improvements in PSM performance do not mask underlying disparities. Context-relevant research is needed to inform future strategies for improving PSM performance.
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Affiliation(s)
- Alison T. Mhazo
- Ministry of Health Malawi, Community Health Sciences Unit, National TB & Leprosy Elimination Program [NTLEP], Lilongwe, Malawi
| | - Stanford Miyango
- Ministry of Health Malawi, Community Health Sciences Unit, National TB & Leprosy Elimination Program [NTLEP], Lilongwe, Malawi
| | - Lifton Palani
- Ministry of Health Malawi, Community Health Sciences Unit, National TB & Leprosy Elimination Program [NTLEP], Lilongwe, Malawi
| | - Charles C. Maponga
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
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Opito R, Kwenya K, Ssentongo SM, Kizito M, Alwedo S, Bakashaba B, Miya Y, Bukenya L, Okwir E, Onega LA, Kazibwe A, Othieno E, Kirya F, Olupot PO. Treatment success rate and associated factors among drug susceptible tuberculosis individuals in St. Kizito Hospital, Matany, Napak district, Karamoja region. A retrospective study. PLoS One 2024; 19:e0300916. [PMID: 38743721 PMCID: PMC11093355 DOI: 10.1371/journal.pone.0300916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 03/06/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Tuberculosis (TB) is the leading cause of death among infectious agents globally. An estimated 10 million people are newly diagnosed and 1.5 million die of the disease annually. Uganda is among the 30 high TB-burdenedd countries, with Karamoja having a significant contribution of the disease incidence in the country. Control of the disease in Karamoja is complex because a majority of the at-risk population remain mobile; partly because of the nomadic lifestyle. This study, therefore, aimed at describing the factors associated with drug-susceptible TB treatment success rate (TSR) in the Karamoja region. METHODS This was a retrospective study on case notes of all individuals diagnosed with and treated for drug-susceptible TB at St. Kizito Hospital Matany, Napak district, Karamoja from 1st Jan 2020 to 31st December 2021. Data were abstracted using a customised data abstraction tool. Data analyses were done using Stata statistical software, version 15.0. Chi-square test was conducted to compare treatment success rates between years 2020 and 2021, while Modified Poisson regression analysis was performed at multivariable level to determine the factors associated with treatment success. RESULTS We studied records of 1234 participants whose median age was 31 (IQR: 13-49) years. Children below 15 years of age accounted for 26.2% (n = 323). The overall treatment success rate for the study period was 79.3%(95%CI; 77.0%-81.5%), with a statistically significant variation in 2020 and 2021, 75.4% (422/560) vs 82.4% (557/674) respectively, (P = 0.002). The commonest reported treatment outcome was treatment completion at 52%(n = 647) and death was at 10.4% (n = 129). Older age, undernutrition (Red MUAC), and HIV-positive status were significantly associated with lower treatment success: aPR = 0.87(95%CI; 0.80-0.94), aPR = 0.91 (95%CI; 0.85-0.98) and aPR = 0.88 (95%CI; 0.78-0.98); respectively. Patients who were enrolled in 2021 had a high prevalence of treatment success compared to those enrolled in 2020, aPR = 1.09 (95%CI; 1.03-1.16). CONCLUSION TB TSR in Matany Hospital was suboptimal. Older age, poor nutrition, and being HIV-positive were negative predictors of treatment success. We propose integrating nutrition and HIV care into TB programming to improve treatment success.
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Affiliation(s)
- Ronald Opito
- Department of Public Health, School of Health Sciences, Soroti University, Soroti, Uganda
| | - Keneth Kwenya
- Directorate of Program Management and Capacity Development, The AIDS Support Organization, Kampala, Uganda
| | - Saadick Mugerwa Ssentongo
- Directorate of Program Management and Capacity Development, The AIDS Support Organization, Kampala, Uganda
| | - Mark Kizito
- Department of Internal Medicine, School of Health Sciences, Soroti University, Soroti, Uganda
| | - Susan Alwedo
- Directorate of Program Management and Capacity Development, The AIDS Support Organization, Kampala, Uganda
| | - Baker Bakashaba
- Directorate of Program Management and Capacity Development, The AIDS Support Organization, Kampala, Uganda
| | - Yunus Miya
- Directorate of Program Management and Capacity Development, The AIDS Support Organization, Kampala, Uganda
| | - Lameck Bukenya
- Directorate of Program Management and Capacity Development, The AIDS Support Organization, Kampala, Uganda
| | - Eddy Okwir
- Directorate of Programs and Community Services, Baylor College of Health Sciences, Kampala, Uganda
| | - Lilian Angwech Onega
- Directorate of Program Management and Capacity Development, The AIDS Support Organization, Kampala, Uganda
| | - Andrew Kazibwe
- Directorate of Program Management and Capacity Development, The AIDS Support Organization, Kampala, Uganda
| | - Emmanuel Othieno
- Department of Pathology, School of Health Sciences, Soroti University, Soroti, Uganda
| | - Fred Kirya
- Department of Anatomy, School of Health Sciences, Soroti University, Soroti, Uganda
| | - Peter Olupot Olupot
- Department of Public Health, Faculty of Health Sciences, Busitema University, Mbale, Uganda
- Mbale Clinical Research Institute, Mbale, Uganda
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Kim MK, Bhattacharya J, Bhattacharya J. Is income inequality linked to infectious disease prevalence? A hypothesis-generating study using tuberculosis. Soc Sci Med 2024; 345:116639. [PMID: 38364719 DOI: 10.1016/j.socscimed.2024.116639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 01/31/2024] [Accepted: 01/31/2024] [Indexed: 02/18/2024]
Abstract
We study the association between infectious disease incidence and income inequality. We hypothesize that random social mixing in an income-unequal society brings into contact a) susceptible and infected poor and b) the infected-poor and the susceptible-rich, raising infectious disease incidence. We analyzed publicly available, country-level panel data for a large cross-section of countries between 1995 and 2013 to examine whether countries with elevated levels of income inequality have higher rates of pulmonary Tuberculosis (TB) incidence per capita. A "negative control" using anemia and diabetes (both non-communicable diseases and hence impervious to the hypothesized mechanism) is also applied. We find that high levels of income inequality are positively associated with tuberculosis incidence. All else equal, countries with income-Gini coefficients 10% apart show a statistically significant 4% difference in tuberculosis incidence. Income inequality had a null effect on the negative controls. Our cross-country regression results suggest that income inequality may create conditions where TB spreads more easily, and policy action to reduce income inequities could directly contribute to a reduced TB burden.
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Puplampu P, Kyeremateng I, Asafu-Adjaye O, Asare AA, Agyabeng K, Sarkodee R, Oluwakemi O, Ganu V. Evaluation of treatment outcomes among adult patients diagnosed with tuberculosis in Ghana: A 10 year retrospective review. IJID REGIONS 2024; 10:9-14. [PMID: 38045863 PMCID: PMC10687693 DOI: 10.1016/j.ijregi.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 11/05/2023] [Accepted: 11/06/2023] [Indexed: 12/05/2023]
Abstract
Objectives The study determined tuberculosis (TB) treatment outcomes in Southern Ghana from 2012 to 2021. Methods A retrospective analysis of service data on TB cases was conducted. Treatment success was defined as TB cure or completion of treatment course, whereas unsuccessful outcomes was defined as death, failure of treatment and lost to follow up. Bivariate and multivariate logistic regression was used to determine factors associated with treatment outcomes. Results A total of 4106 adult TB cases were reported with a median age of 41 (interquartile range 32-52) years. Of these, 93.1% (n = 3823) were newly diagnosed. The treatment success rate declined from 71.0% in 2012 to 55.7% in 2021 (ktau-b = -0.56, P = 0.0318). Clinically diagnosed TB and extra-pulmonary TB had 7.0% (adjusted prevalence ratio [aPR]: 0.93, 95% confidence interval [CI]: 0.88-1.00) and 24.0% (aPR: 0.76, 95% CI: 0.69-0.84) respectively, less successful treatment outcome compared to pulmonary TB patients. HIV negative status was associated with 22% higher successful treatment outcome compared with being HIV positive (aPR: 1.22, 95% CI: 1.12-1.33). Conclusion Tuberculosis treatment success rate declined over the period. There is a need for the TB Control Programme to review the national and sub-national TB data to ascertain poor performing TB treatment sites to identify and address context specific challenges with treatment interventions and system inadequacies to improve treatment success rates.
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Affiliation(s)
- Peter Puplampu
- Department of Medicine & Therapeutics, University of Ghana Medical School, Accra, Ghana
- Infectious disease unit, Department of Medicine, Korle Bu Teaching Hospital, Accra, Ghana
| | | | | | - Anita Ago Asare
- Infectious disease unit, Department of Medicine, Korle Bu Teaching Hospital, Accra, Ghana
- Department of Community Health, University of Ghana Medical School, Accra, Ghana
| | - Kofi Agyabeng
- Department of Biostatistics, School of Public Health, University of Ghana, Accra, Ghana
| | - Roderick Sarkodee
- Infectious disease unit, Department of Medicine, Korle Bu Teaching Hospital, Accra, Ghana
| | - Oladele Oluwakemi
- Infectious disease unit, Department of Medicine, Korle Bu Teaching Hospital, Accra, Ghana
| | - Vincent Ganu
- Infectious disease unit, Department of Medicine, Korle Bu Teaching Hospital, Accra, Ghana
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Izudi J, Okello G, Bajunirwe F. Low treatment success rate among previously treated persons with drug-susceptible pulmonary tuberculosis in Kampala, Uganda. J Clin Tuberc Other Mycobact Dis 2023; 32:100375. [PMID: 37214160 PMCID: PMC10199253 DOI: 10.1016/j.jctube.2023.100375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
Rationale In 2017, the treatment regimen for previously treated persons with tuberculosis (TB) changed to a shorter regimen that lasts six months and consists of Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol. Few studies have examined treatment success rate (TSR) among previously treated persons with TB including the associated factors. Objective To determine TSR and the associated factors among previously treated persons with bacteriologically confirmed pulmonary TB on a six-month treatment regimen in Kampala, Uganda. Methods We retrieved data (January 2012 and December 2021) across six TB clinics in the Kampala Metropolitan area for all previously treated persons with bacteriologically confirmed pulmonary TB. TSR was defined as cure or treatment completion. Frequencies and percentages for categorical data, and the mean and standard deviation for numerical data were computed. Multivariable modified Poisson regression analysis was performed to identify factors associated with TSR, reported as adjusted risk ratio (aRR) with a 95% confidence interval (CI). Measurements and main results We enrolled 230 participants with a mean age of 34.8±10.6 years. TSR was 52.2% and was associated with Mycobacterium tuberculosis (MTB) sputum smear load of ≥2+ (1-10 or >10 Acid Fast Bacilli (AFB)/Field) (aRR = 0.51; 95% CI, 0.38-0.68), TB/human immunodeficiency virus (HIV) (aRR = 0.67; 95% CI, 0.51-0.88) or unknown HIV serostatus (aRR = 0.42; 95% CI, 0.26-0.68), and digital community-based directly observed therapy short-course (DOTS) (aRR = 0.42; 95% CI, 0.20-0.88). Conclusions The TSR among previously treated persons with bacteriologically confirmed pulmonary TB on a six-month treatment regimen is suboptimal. TSR is less likely for people with TB/HIV co-infection or unknown HIV serostatus, high MTB sputum smear load, and on digital community-based DOTs. We recommend strengthening of TB/HIV collaborative activities and people with TB with high MTB sputum smear load should receive targeted treatment support, and the contextual barriers to digital community DOTS should be addressed.
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Affiliation(s)
- Jonathan Izudi
- Department of Community Health, Mbarara University of Science and Technology, Box 1410, Mbarara, Uganda
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Uganda
| | - Gerald Okello
- Makerere University College of Health Sciences, School of Public Health
| | - Francis Bajunirwe
- Department of Community Health, Mbarara University of Science and Technology, Box 1410, Mbarara, Uganda
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Rosu L, Morgan L, Tomeny EM, Worthington C, Jin M, Nidoi J, Worthington D. Cost of treatment support for multidrug-resistant tuberculosis using patient-centred approaches in Ethiopia: a model-based method. Infect Dis Poverty 2023; 12:65. [PMID: 37420269 DOI: 10.1186/s40249-023-01116-w] [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: 03/06/2023] [Accepted: 06/20/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND Patient and health system costs for treating multidrug-resistant tuberculosis (MDR-TB) remain high even after treatment duration was shortened. Many patients do not finish treatment, contributing to increased transmission and antimicrobial resistance. A restructure of health services, that is more patient-centred has the potential to reduce costs and increase trust and patient satisfaction. The aim of the study is to investigate how costs would change in the delivery of MDR-TB care in Ethiopia under patient-centred and hybrid approaches compared to the current standard-of-care. METHODS We used published data, collected from 2017 to 2020 as part of the Standard Treatment Regimen of Anti-Tuberculosis Drugs for Patients with MDR-TB (STREAM) trial, to populate a discrete event simulation (DES) model. The model was developed to represent the key characteristics of patients' clinical pathways following each of the three treatment delivery strategies. To the pathways of 1000 patients generated by the DES model we applied relevant patient cost data derived from the STREAM trial. Costs are calculated for treating patients using a 9-month MDR-TB treatment and are presented in 2021 United States dollars (USD). RESULTS The patient-centred and hybrid strategies are less costly than the standard-of-care, from both a health system (by USD 219 for patient-centred and USD 276 for the hybrid strategy) and patient perspective when patients do not have a guardian (by USD 389 for patient-centred and USD 152 for the hybrid strategy). Changes in indirect costs, staff costs, transport costs, inpatient stay costs or changes in directly-observed-treatment frequency or hospitalisation duration for standard-of-care did not change our results. CONCLUSION Our findings show that patient-centred and hybrid strategies for delivering MDR-TB treatment cost less than standard-of-care and provide critical evidence that there is scope for such strategies to be implemented in routine care. These results should be used inform country-level decisions on how MDR-TB is delivered and also the design of future implementation trials.
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Affiliation(s)
- Laura Rosu
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L35QA, UK.
| | - Lucy Morgan
- Management Science, Lancaster University, Lancaster, UK
| | - Ewan M Tomeny
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L35QA, UK
| | | | - Mengdi Jin
- Management Science, Lancaster University, Lancaster, UK
| | - Jasper Nidoi
- Makerere University Lung Institute, Kampala, Uganda
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Gichuhi HW, Magumba M, Kumar M, Mayega RW. A machine learning approach to explore individual risk factors for tuberculosis treatment non-adherence in Mukono district. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001466. [PMID: 37399173 DOI: 10.1371/journal.pgph.0001466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 06/05/2023] [Indexed: 07/05/2023]
Abstract
Despite the availability and implementation of well-known efficacious interventions for tuberculosis treatment by the Ministry of Health, Uganda (MoH), treatment non-adherence persists. Moreover, identifying a specific tuberculosis patient at risk of treatment non-adherence is still a challenge. Thus, this retrospective study, based on a record review of 838 tuberculosis patients enrolled in six health facilities, presents, and discusses a machine learning approach to explore the individual risk factors predictive of tuberculosis treatment non-adherence in the Mukono district, Uganda. Five classification machine learning algorithms, logistic regression (LR), artificial neural networks (ANN), support vector machines (SVM), random forest (RF), and AdaBoost were trained, and evaluated by computing their accuracy, F1 score, precision, recall, and the area under the receiver operating curve (AUC) through the aid of a confusion matrix. Of the five developed and evaluated algorithms, SVM (91.28%) had the highest accuracy (AdaBoost, 91.05% performed better than SVM when AUC is considered as evaluation parameter). Looking at all five evaluation parameters globally, AdaBoost is quite on par with SVM. Individual risk factors predictive of non-adherence included tuberculosis type, GeneXpert results, sub-country, antiretroviral status, contacts below 5 years, health facility ownership, sputum test results at 2 months, treatment supporter, cotrimoxazole preventive therapy (CPT) dapsone status, risk group, patient age, gender, middle and upper arm circumference, referral, positive sputum test at 5 and 6 months. Therefore, machine learning techniques, specifically classification types, can identify patient factors predictive of treatment non-adherence and accurately differentiate between adherent and non-adherent patients. Thus, tuberculosis program management should consider adopting the classification machine learning techniques evaluated in this study as a screening tool for identifying and targeting suited interventions to these patients.
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Affiliation(s)
- Haron W Gichuhi
- Department of Biostatistics and Epidemiology, Makerere University School of Public Health, Kampala, Uganda
| | - Mark Magumba
- Department of Information Systems, Makerere University College of Computing, and Information Science, Kampala, Uganda
| | - Manish Kumar
- Public Health Leadership Program, Gilling's School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Roy William Mayega
- Department of Biostatistics and Epidemiology, Makerere University School of Public Health, Kampala, Uganda
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Mulholland GE, Herce ME, Bahemuka UM, Kwena ZA, Jeremiah K, Okech BA, Bukusi E, Okello ES, Nanyonjo G, Ssetaala A, Seeley J, Emch M, Pettifor A, Weir SS, Edwards JK. Geographic mobility and treatment outcomes among people in care for tuberculosis in the Lake Victoria region of East Africa: A multi-site prospective cohort study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001992. [PMID: 37276192 PMCID: PMC10241360 DOI: 10.1371/journal.pgph.0001992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 05/04/2023] [Indexed: 06/07/2023]
Abstract
Geographic mobility may disrupt continuity of care and contribute to poor clinical outcomes among people receiving treatment for tuberculosis (TB). This may occur especially where health services are not well coordinated across international borders, particularly in lower and middle income country settings. In this work, we describe mobility and the relationship between mobility and unfavorable TB treatment outcomes (i.e., death, loss to follow-up, or treatment failure) among a cohort of adults who initiated TB treatment at one of 12 health facilities near Lake Victoria. We abstracted data from health facility records for all 776 adults initiating TB treatment during a 6-month period at the selected facilities in Kenya, Tanzania, and Uganda. We interviewed 301 cohort members to assess overnight travel outside one's residential district/sub-county. In our analyses, we estimated the proportion of cohort members traveling in 2 and 6 months following initiation of TB treatment, explored correlates of mobility, and examined the association between mobility and an unfavorable TB treatment outcome. We estimated that 40.7% (95% CI: 33.3%, 49.6%) of people on treatment for TB traveled overnight at least once in the 6 months following treatment initiation. Mobility was more common among people who worked in the fishing industry and among those with extra-pulmonary TB. Mobility was not strongly associated with other characteristics examined, however, suggesting that efforts to improve TB care for mobile populations should be broad ranging. We found that in this cohort, people who were mobile were not at increased risk of an unfavorable TB treatment outcome. Findings from this study can help inform development and implementation of mobility-competent health services for people with TB in East Africa.
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Affiliation(s)
- Grace E. Mulholland
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Michael E. Herce
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Ubaldo M. Bahemuka
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
| | | | - Kidola Jeremiah
- Mwanza Intervention Trials Unit, Mwanza Research Centre, National Institute for Medical Research, Mwanza, Tanzania
| | | | | | - Elialilia S. Okello
- Mwanza Intervention Trials Unit, Mwanza Research Centre, National Institute for Medical Research, Mwanza, Tanzania
| | | | - Ali Ssetaala
- UVRI-IAVI HIV Vaccine Program Limited, Entebbe, Uganda
| | - Janet Seeley
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
- Global Health and Development Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Michael Emch
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Geography, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Audrey Pettifor
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Sharon S. Weir
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Jessie K. Edwards
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Foster N, Tadesse AW, McQuaid CF, Gosce L, Abdurhman T, Assefa D, Bedru A, Houben RMGJ, van Kalmthout K, Letta T, Mohammed Z, van Rest J, Umeta DG, Weldemichael GT, Yazew H, Jerene D, Quaife M, Fielding KL. Evaluating the equity impact and cost-effectiveness of digital adherence technologies with differentiated care to support tuberculosis treatment adherence in Ethiopia: protocol and analysis plan for the health economics component of a cluster randomised trial. Trials 2023; 24:292. [PMID: 37095533 PMCID: PMC10123464 DOI: 10.1186/s13063-023-07289-x] [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: 01/25/2023] [Accepted: 04/03/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Tuberculosis remains a leading infectious cause of death in resource-limited settings. Effective treatment is the cornerstone of tuberculosis control, reducing mortality, recurrence and transmission. Supporting treatment adherence through facility-based observations of medication taking can be costly to providers and patients. Digital adherence technologies (DATs) may facilitate treatment monitoring and differentiated care. The ASCENT-Ethiopia study is a three-arm cluster randomised trial assessing two DATs with differentiated care for supporting tuberculosis treatment adherence in Ethiopia. This study is part of the ASCENT consortium, assessing DATs in South Africa, the Philippines, Ukraine, Tanzania and Ethiopia. The aim of this study is to determine the costs, cost-effectiveness and equity impact of implementing DATs in Ethiopia. METHODS AND DESIGN A total of 78 health facilities have been randomised (1:1:1) into one of two intervention arms or a standard-of-care arm. Approximately 50 participants from each health facility will be enrolled on the trial. Participants in facilities randomised to the intervention arms are offered a DAT linked to the ASCENT adherence platform for daily adherence monitoring and differentiated response for those who have missed doses. Participants at standard-of-care facilities receive routine care. Treatment outcomes and resource utilisation will be measured for each participant. The primary effectiveness outcome is a composite index of unfavourable end-of-treatment outcomes (lost to follow-up, death or treatment failure) or treatment recurrence within 6 months of end-of-treatment. For the cost-effectiveness analysis, end-of-treatment outcomes will be used to estimate disability-adjusted life years (DALYs) averted. Provider and patient cost data will be collected from a subsample of 5 health facilities per study arm, 10 participants per facility (n = 150). We will conduct a societal cost-effectiveness analysis using Bayesian hierarchical models that account for the individual-level correlation between costs and outcomes as well as intra-cluster correlation. An equity impact analysis will be conducted to summarise equity efficiency trade-offs. DISCUSSION Trial enrolment is ongoing. This paper follows the published trial protocol and describes the protocol and analysis plan for the health economics work package of the ASCENT-Ethiopia trial. This analysis will generate economic evidence to inform the implementation of DATs in Ethiopia and globally. TRIAL REGISTRATION Pan African Clinical Trial Registry (PACTR) PACTR202008776694999. Registered on 11 August 2020, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=12241 .
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Affiliation(s)
- Nicola Foster
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
| | - Amare W Tadesse
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Christopher Finn McQuaid
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Lara Gosce
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Ahmed Bedru
- KNCV Tuberculosis Foundation, Addis Ababa, Ethiopia
| | - Rein M G J Houben
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Taye Letta
- National Tuberculosis Control Program, Ethiopian Ministry of Health, Addis Ababa, Ethiopia
| | | | - Job van Rest
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | | | | | - Hiwot Yazew
- KNCV Tuberculosis Foundation, Addis Ababa, Ethiopia
| | - Degu Jerene
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | - Matthew Quaife
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Katherine L Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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11
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Ngah VD, Rangoanana M, Fwemba I, Maama L, Maphalale S, Molete M, Ratikoane R, Ogunrombi M, Daramola J, Nyasulu PS. Evaluating determinants of treatment outcomes among tuberculosis patients in the mining district of Butha Buthe, Lesotho. IJID REGIONS 2022; 6:62-67. [PMID: 36593894 PMCID: PMC9797408 DOI: 10.1016/j.ijregi.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/21/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022]
Abstract
Background Before the COVID-19 pandemic, tuberculosis (TB) was the leading infectious cause of death globally. In low- and middle-income countries (LMIC) including Lesotho, treatment outcome is lower than the recommended rate and poor TB treatment outcomes remain a programmatic challenge. The aim of this study was to determine unfavourable treatment outcomes and associated risk factors among TB patients in Butha Buthe district. Methods This was a retrospective record review of TB patients registered between January 2015 and December 2020. Data were collected from TB registers and patients' files and entered Microsoft Excel 2012. Analysis was conducted using R and INLA statistical software. Descriptive statistics were presented as frequencies and percentages. The differences between groups were compared using Pearson's X 2 test in bivariate analysis. Frailty Cox proportional hazards model was used to determine the risk of unfavourable outcomes among the variables. Results A total of 1792 TB patients were enrolled in the study with about 70% males (1,257). Majority (71.7%) of the patients were between 20 and 59 years old, with 48% of the patients being unemployed. Almost a quarter of the patients (23.1%) had unfavourable outcomes with death (342 patients) being the most common unfavourable outcome. Our study has shown that patients older than 59 years, and unemployment increased the risk of having unfavourable treatment outcomes. Death was the most common unfavourable outcome followed by lost-to-follow up. We also observed that the patients in the initiation phase of treatment died at a faster rate compared to those in the continuation phase (p=0.02). Conclusion TB treatment programs should have efficient follow-up methods geared more toward elderly patients. Active case finding to identify population at risk should be part of a TB program which would improve early diagnosis and treatment initiation. Patients in the intensive phase of the treatment program should be monitored more closely to determine adverse drug effects and nutritional requirement to prevent death during this phase of treatment.
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Affiliation(s)
- Veranyuy D. Ngah
- Division of Epidemiology and Biostatistics, Faculty of Medicine, and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Motlatsi Rangoanana
- Division of Epidemiology and Biostatistics, Faculty of Medicine, and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Isaac Fwemba
- Division of Epidemiology and Biostatistics, Faculty of Medicine, and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Llang Maama
- Disease Control Directorate, National Tuberculosis Program, Ministry of Health Lesotho
| | - Sele Maphalale
- District Health Management team Butha Buthe, Ministry of Health Lesotho National Tuberculosis Program, Ministry of Health Lesotho
| | - Mabatho Molete
- District Health Management team Butha Buthe, Ministry of Health Lesotho National Tuberculosis Program, Ministry of Health Lesotho
| | - Retselisitsoe Ratikoane
- District Health Management team Butha Buthe, Ministry of Health Lesotho National Tuberculosis Program, Ministry of Health Lesotho
| | - Modupe Ogunrombi
- Department of Clinical Pharmacology, Sefako Makgatho Health Sciences University, Pretoria South Africa
| | - Justine Daramola
- Department of Information Technology, Faculty of Informatics and Design, Cape Peninsula University of Technology
| | - Peter S. Nyasulu
- Division of Epidemiology and Biostatistics, Faculty of Medicine, and Health Sciences, Stellenbosch University, Cape Town, South Africa,Division of Epidemiology & Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,Corresponding Author:
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12
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Kallon II, Colvin CJ. A qualitative exploration of continuity of TB care in clinics after discharge from hospitals in Cape Town, South Africa. BMC Health Serv Res 2022; 22:1489. [PMID: 36474237 PMCID: PMC9727991 DOI: 10.1186/s12913-022-08880-9] [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: 08/11/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Continuity of care remains a challenge for TB patients who are discharged from hospital and referred to primary health care clinics in South Africa. The aim of this study was to explore the experiences and perceptions of patients, health care workers and family members regarding continuity of TB care in a Cape Town health district. METHODS We conducted one-on-one interviews, using semi-structured interview guides, with TB patients and their families and health care workers. We also conducted focus group interviews with other health care workers who performed similar duties. Field notes were kept and patients' home circumstances were also physically observed. Data saturation was achieved after 31 interviews. We used Miles and Huberman's qualitative data analysis framework to interpret the data. RESULTS Themes identified in the interviews were grouped into two categories: (1) patients' socio-economic circumstances including complex family relationships, good or lack of family support, inadequate income, and agency; and (2) health system challenges, including inadequate referral links between the clinic and the hospital and negative emotions as a result of poor service delivery experienced by patients. CONCLUSION Some TB Patients experienced poor continuity of care on discharge from hospitals to primary health clinics and perceived that this resulted from socio-economic conditions and health system-related problems that triggered negative emotions. Proper communication between the hospital and clinic regarding patients' care, adequate counselling, and patient-centred treatment are required to address poor continuity of care among patients with TB down-referred to clinics.
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Affiliation(s)
- Idriss Ibrahim Kallon
- grid.7836.a0000 0004 1937 1151Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa ,grid.11956.3a0000 0001 2214 904XCentre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Christopher J Colvin
- grid.7836.a0000 0004 1937 1151Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa ,grid.27755.320000 0000 9136 933XDepartment of Public Health Sciences, University of Virginia, Virginia, USA ,grid.40263.330000 0004 1936 9094Department of Epidemiology, Brown University, Providence, USA
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13
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Korri R, Bakuli A, Owolabi OA, Lalashowi J, Azize C, Rassool M, Sathar F, Rachow A, Ivanova O. Tuberculosis and Sexual and Reproductive Health of Women in Four African Countries. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15103. [PMID: 36429820 PMCID: PMC9690042 DOI: 10.3390/ijerph192215103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 06/16/2023]
Abstract
Tuberculosis (TB) is a major reason of maternal mortality in low-income countries, and it increases the probability of adverse sexual and reproductive health (SRH) outcomes, including ectopic pregnancy and perinatal mortality. The data presented here is from the TB Sequel observational cohort conducted in four African countries. For this sub-study, we selected only female participants, who were diagnosed with drug susceptible TB and followed-up until the end of anti-TB treatment. The data collection included questionnaires, clinical examination and laboratory tests at TB diagnosis, day 14, month 2, 4 and 6. A total of 486 women, with 88.3% being 18-49 years old, were included in the analysis. Around 54.7% were HIV positive. Most of the participants (416/486; 85.6%) in our cohort were considered cured at month 6. Only 40.4% of non-pregnant women of reproductive age used contraception at TB diagnosis. A total of 31 out of 486 women experienced pregnancy during TB treatment. Pregnancy outcomes varied between live birth (16/31; 51.6%), induced abortion (6/31; 19.4%), miscarriage (4/31; 12.9%) and stillbirth (3/31; 9.6%). Integration and linking of SRH services with TB programmes are vital to increase contraception use and protect women from obstetric risks associated with pregnancy during TB treatment.
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Affiliation(s)
- Rayan Korri
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), 80802 Munich, Germany
| | - Abhishek Bakuli
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), 80802 Munich, Germany
| | - Olumuyiwa A. Owolabi
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul P.O. Box 273, The Gambia
| | - Julieth Lalashowi
- National Institute for Medical Research (NIMR), Mbeya Medical Research Centre, Mbeya P.O. Box 2410, Tanzania
| | - Cândido Azize
- Instituto Nacional de Saúde (INS), Marracuene 3943, Mozambique
| | - Mohammed Rassool
- Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg 2092, South Africa
| | | | - Andrea Rachow
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), 80802 Munich, Germany
- German Center for Infection Research (DZIF), Partner Site Munich, 80802 Munich, Germany
| | - Olena Ivanova
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), 80802 Munich, Germany
- German Center for Infection Research (DZIF), Partner Site Munich, 80802 Munich, Germany
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14
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Makgopa S, Cele LP, Mokgatle MM. Pre-Diagnosis Health Seeking Behaviors and Experiences Post-Diagnosis, among Men Diagnosed with Tuberculosis in a District of Gauteng Metropolitan City, South Africa: In-Depth Interviews. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13635. [PMID: 36294215 PMCID: PMC9603212 DOI: 10.3390/ijerph192013635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/14/2022] [Accepted: 10/17/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Tuberculosis remains the number one killer among infectious diseases in South Africa. The TB disease burden is said to be higher among males, 1.6 times more than females in 2018. Moreover, men are reported to have poor healthcare-seeking behaviors. Loss in social and physical functioning, including reduced sexual desires and changes in family life, have been reported following a TB diagnosis. This study explored the meaning that male TB patients attach to their TB diagnosis and impact of TB infection in their lives and those of the people living with them. METHODS This exploratory qualitative study was conducted among 25 participants recruited among male patients seeking TB care from two clinics in informal settlements of the city of Johannesburg. In-depth interviews with open-ended questions were conducted using an audio recorder for the collection of data. Data analysis was conducted on the NVivo version 12 software following an inductive thematic approach. RESULTS The ages of the participants ranged between 18 and 61 years. Most were unemployed, and only a few were married or in steady relationships. From the two emerging themes, pre-TB diagnosis health-seeking behaviors and post TB-diagnosis experiences, several subthemes were identified. For the former theme, the subthemes include, seeking help from community-based healers and self-medicating, waiting for some period to see if the alternative medicine or treatment worked, taking time to visit a healthcare facility, triggers to seek healthcare, and symptoms reported on presentation to the healthcare facility. The post-TB diagnosis subthemes include making sense of the TB diagnosis, context of disclosing the TB status, fear of social exclusion and experiences of stigma, support received during illness, life changes after TB infection and diagnosis, and lessons learned from the TB experience and future healthcare-seeking behavior. CONCLUSION Secrecy about the TB diagnosis indicates fear of social exclusion, and this could be due to the highly stigmatized nature of TB. Waiting to see if alternative medication worked, delayed the TB diagnosis, with consequent late initiation of the anti-TB treatment. The life changes experienced post-TB diagnosis affect the quality of life of the participants and their families. The study recommends that these issues be addressed as a priority.
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15
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Kim HW, Park S, Min J, Sun J, Shin AY, Ha JH, Park JS, Lee SS, Lipman M, Abubakar I, Stagg HR, Kim JS. Hidden loss to follow-up among tuberculosis patients managed by public-private mix institutions in South Korea. Sci Rep 2022; 12:12362. [PMID: 35859107 PMCID: PMC9300674 DOI: 10.1038/s41598-022-16441-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 07/11/2022] [Indexed: 11/18/2022] Open
Abstract
In South Korea, public-private mix (PPM) was launched in 2011. This retrospective cohort study sought to determine the rate of loss to follow-up (LTFU) among drug-susceptible tuberculosis (DS-TB) patients in all nationwide PPM institutions, and the risk factors for LTFU. National notification data for DS-TB patients diagnosed between August 2011 and July 2014 in PPM institutions were analysed. Determination of LTFU included detection of instances where patients were transferred out, but when they did not attend at other TB centres in the following two months. Univariable and multivariable competing risk models were used to determine risk factors for LTFU. 73,046 patients with 78,485 records were enrolled. Nominally, 3426 (4.4%) of records were LTFU. However, after linking the multiple records in each patient, the percentage of LTFU was 12.3% (9004/73,046). Risk factors for LTFU were: being foreign-born (3.13 (95% CI 2.77-3.53)), prior LTFU (2.31 (2.06-2.59)) and greater distance between the patient's home and the TB centre (4.27 (4.03-4.53)). 'Transfer-out' was a risk factor in patients managed by treatment centres close to home (1.65 (1.49-1.83)), but protective for those attending centres further (0.77 (0.66-0.89)) or far-away (0.52 (0.46-0.59)) from home. By considering the complete picture of a patient's interactions with healthcare, we identified a much higher level of LTFU than previously documented. This has implications for how outcomes of treatment are reported and argues for a joined-up national approach for the management and surveillance of TB patients, in nations with similar healthcare systems.
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Affiliation(s)
- Hyung Woo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sohee Park
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
- Department of Biostatistics, Graduate School of Public Health, Yonsei University, Seoul, Republic of Korea
| | - Jinsoo Min
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jiyu Sun
- Division of Biostatistics, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ah Young Shin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jick Hwan Ha
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jae Seuk Park
- Division of Pulmonary Medicine, Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Sung-Soon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea
| | - Marc Lipman
- UCL-TB, University College London, London, UK
- Division of Medicine, UCL Respiratory, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK
| | - Helen R Stagg
- Usher Institute, The University of Edinburgh, Edinburgh, UK.
| | - Ju Sang Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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