Improving access to multi-drug resistant tuberculosis diagnostic and health services for refugees and migrants

The unmet surgical needs of global refugee populations: A perspective review

The global refugee community, including those forced to flee due to persecution, conflict, or violence, faces significant challenges in accessing healthcare, resulting in a higher prevalence of surgical disease. These challenges have a profound impact on morbidity and mortality rates, particularly in low- and middle-income countries where many immigrants seek refuge. Limited availability of medical facilities, an inadequate surgical workforce, financial constraints and linguistic and cultural barriers all contribute to reduced access to healthcare. Limited access to competent healthcare leads to poor health outcomes, increased morbidity and mortality rates and suboptimal surgical results for refugees. To address these challenges, a multifaceted approach is necessary. This includes increased funding for healthcare initiatives, workforce recruitment and training and improved coordination between aid organisations and local healthcare systems. Strategies for managing surgical conditions in the global refugee community encompass the development of targeted public health programmes, removing legal barriers, establishing healthcare facilities to enhance surgical access and prioritising disease prevention among refugees.

Facilitators and barriers to tuberculosis active case findings in low- and middle-income countries: a systematic review of qualitative research

BACKGROUND

Tuberculosis (TB) is an ancient infection and a major public health problem in many low- and middle-income countries (LMICs). Active case finding (ACF) programs have been established to effectively reduce TB in endemic global communities. However, there is little information about the evidence-based benefits of active case finding at both the individual and community levels. Accurately identifying the facilitators and barriers to TB-ACF provides information that can be used in planning and design as the world aims to end the global TB epidemic by 2035. Therefore, this study aimed to identify the facilitators and barriers to tuberculosis ACF in LMICs.

METHODS

A systematic search was performed using recognized databases such as PubMed, Google Scholar, SCOPUS, HINARI, and other reference databases. Relevant studies that assessed or reported the ACF of TB conducted in LMICs were included in this study. The Joanna Briggs Institute's (JBI) Critical Appraisal Tool was used to assess the quality of the selected studies. The Statement of Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) was used to strengthen the protocol for this systematic review. The Confidence of Evidence Review Quality (CERQual) approach was also used to assess the reliability of the review findings.

RESULTS

From 228 search results, a total of 23 studies were included in the final review. Tuberculosis ACF results were generated under two main themes: barriers and facilitators in LMICs, and two sub-themes of the barriers (healthcare-related and non-healthcare-related barriers). Finally, barriers to active TB case finding were found to be related to (1) the healthcare workers' experience, knowledge, and skills in detecting TB-ACF, (2) distance and time; (3) availability and workload of ACF healthcare workers; (4) barriers related to a lack of resources such as diagnostic equipment, reagents, and consumables at TB-ACF; (5) the stigma associated with TB-ACF detection; (6) the lack of training of existing and new healthcare professionals to detect TB-ACF; (7) communication strategies and language limitations associated with TB ACF; and (8) poor or no community awareness of tuberculosis. Stigma was the most patient-related obstacle to detecting active TB cases in LMICs.

CONCLUSION

This review found that surveillance, monitoring, health worker training, integration into health systems, and long-term funding of health facilities were key to the sustainability of ACF in LMICs. Understanding the elimination of the identified barriers is critical to ensuring a maximum tuberculosis control strategy through ACF.

Catch-22: War, Refugees, COVID-19, and the Scourge of Antimicrobial Resistance

Wars have hidden repercussions beyond the immediate losses of life, well-being, and prosperity. Those that flee wars and seek refuge in safer locations are not immune to the tragic impacts. Of particular concern is the susceptibility of the refugee populations to infectious diseases and antimicrobial-resistant pathogens. This poses a detrimental risk to these disenfranchised populations, who often have limited access to medical care, sanitation, and nutritious and safe food. Furthermore, antimicrobial-resistant pathogens in refugees can be both transmitted to and acquired from their hosting communities. The latter is particularly problematic when the host countries suffer from serious challenges such as limited resources, pollution, and widespread antimicrobial resistance (AMR). Here, we discuss AMR in refugees of the ongoing Syrian war, a conflict that resulted in the largest population displacement in recent history. We argue that Syrian refugees and their hosting communities are at an elevated risk of complicated and life-threatening AMR infections. We also call on the international community to address this grievous problem that threatens the disenfranchised refugee populations and can spill over across geographic borders to affect multiple countries.

Influence of Public Health Services on the Goal of Ending Tuberculosis: Evidence From Panel Data in China

Background

The World Health Organization has proposed an initiative to “end tuberculosis (TB).” Unfortunately, TB continues to endanger the health of people worldwide. We investigated the impact of public health services (PHS) in China on TB incidence. In this way, we provided policy ideas for preventing the TB epidemic.

Methods

We used the “New Public Management Theory” to develop two indicators to quantify policy documents: multisector participation (MP) and the Assessable Public Health Service Coverage Rate (ASCR). The panel data from 31 provinces in Chinese mainland were collected from 2005 to 2019 based on 1,129 policy documents and the China Statistical Yearbook. A fixed-effect model was used to determine the impact of MP and the ASCR on TB incidence.

Results

From 2005 to 2019, the average MP increased from 89.25 to 97.70%, and the average ASCR increased from 53.97 to 78.40% in Chinese mainland. However, the development of ASCR between regions was not balanced, and the average level in the western region was lower than that in the eastern coastal provinces. With an increase in MP and the ASCR, the TB incidence had been decreasing gradually in recent years. The panel analysis results showed that MP (β = −0.76, p < 0.05). and ASCR (β = −0.40, p < 0.01) had a negative effect on TB incidence, respectively. Even if the control variables were added, the negative effects of MP (β = −0.86, p < 0.05) and ASCR (β = −0.35, p < 0.01) were still statistically significant.

Conclusions

Promoting the participation of multiple departments, as well as emphasizing the quality of PHS delivery, are important ways to alleviate the TB epidemic. The settings of evaluation indices for PHS provision should be strengthened in the future.

Patient-centered approach to the management of drug-resistant tuberculosis in France: How far off the mark are we?

Drug-resistant tuberculosis (DR-TB) is a major public health concern worldwide. The prolonged isolation required is a source of challenges for both healthcare workers and patients, especially in high-income countries where DR-TB patients are frequently migrants with vulnerabilities. However, data on the needs of these vulnerable patients are scarce. Our objective was to identify and quantify conflict or inappropriate care situations experienced by both DR-TB patients and healthcare workers. This 10-year retrospective observational study (01/2008 to 10/2018) was conducted in a referral center for resistant tuberculosis management in Paris, France. Sixty-five DR-TB patients were hospitalized during the study period. Their demographic, clinical and social characteristics and any conflict or inappropriate care situations they experienced with healthcare workers while hospitalized were analyzed. Conflict or inappropriate care situations with healthcare workers were reported for 24 patients during their stay (36.9%). Eleven patients (16.9%) had difficulty adhering to respiratory isolation rules, 15 (23.1%) were discharged against medical advice, 9 (13.8%) were excluded from hospital for disciplinary reasons, verbal or physical violence was reported for 7 patients (10.8%), and 4 arrests (6.2%) were made by the police. Conflict situations were reported more often when there was a language barrier (70.8%, p<0.0001). More than one-third of patients with DR-TB in this referral center experienced at least one inappropriate care situation with healthcare workers. This study illustrates the urgent need to promote a patient-centered approach and to respond to the challenges of its practical implementation.

Is deployement of diagnostic test alone enough? Comprehensive package of interventions to strengthen TB laboratory network: three years of experience in Burkina Faso

BACKGROUNDS

The laboratory plays a critical role in tuberculosis (TB) control by providing testing for diagnosis, treatment monitoring, and surveillance at each level of the health care system. Weak accessibility to TB diagnosric services still represents a big concern in many limited resources' countries. Here we report the experience of Burkina Faso in implementing a comprehensive intervention packages to strengthen TB laboratory capacity and diagnostic accessibility.

METHODS

The intervention lasted from October 2016 to December 2018 and focused on two main areas: i) development of strategic documents and policies; ii) implementation of TB diagnostic technology. National TB laboratory data were collected between 2016 and 2018 and evaluated according to five programmatic TB laboratory indicators: i) Percentage of notified new and relapse TB cases with bacteriological confirmation; ii) Percentage of notified new and relapse TB cases tested by Xpert MTB/RIF; iii) Percentage of notified, bacteriologically confirmed TB cases with a drug susceptibility testing (DST) result for rifampin; iv) Percentage of notified MDR-TB cases on the estimated number of MDR-TB cases; v) The ration between the number of smear microscopy and Xpert MTB/RIF tests. We compared these indicators between a 1 year (2016-2017) and 2 years (2016-2018) timeframe.

RESULTS

From 2016 to 2018, the percentage of bacteriologically confirmed cases increased from 67 to 71%. The percentage of new and relapse TB cases notified tested by Xpert MTB/RIF increased from 18% in 2016 to 46% in 2018 and the percentage of bacteriologically confirmed cases with an available DST result for rifampicin increased from 27% in 2016 to 66% in 2018.. The percentage of notified MDR-TB cases on the estimated number of MDR-TB cases in 2018 increased from 43% in 2016 to 78% in 2018. In 2018, the ratio between the number of smear microscopy and Xpert MTB/RIF tests decreased from 53% in 2016 to 21% in 2018.

CONCLUSION

We demonstrated that the implementation of a comprehensive package of laboratory strengthening interventions led to a significant improvement of all indicators. External technical assistance played a key role in speeding up the TB laboratory system improvement process.

Policy changes and the screening, diagnosis and treatment of drug-resistant tuberculosis patients from 2015 to 2018 in Zhejiang Province, China: a retrospective cohort study

OBJECTIVES

To examine changes in the screening, diagnosis, treatment and management of drug-resistant tuberculosis (DRTB) patients, and investigate the impacts of DRTB-related policies on patients of different demographic and socioeconomic characteristics.

DESIGN

A retrospective cohort study using registry data, plus a survey on DRTB-related policies.

SETTING

All prefecture-level Centres for Disease Control in Zhejiang Province, China.

MAIN OUTCOME MEASURES

Alongside the care cascade, we examined: (1) reported number of presumptive DRTB patients; (2) percentage of presumptive patients with drug susceptibility testing (DST) records; (3) percentage of DRTB/rifampicin-resistant (RR) patients registered; (4) percentage of RR/multidrug-resistant TB (MDRTB) patients that received anti-DRTB treatment; and (5) percentage of RR/MDRTB patients cured/completed treatment among those treated. Multivariate logistic regressions were conducted to explore the impacts of DRTB policies after adjusting for other factors.

RESULTS

The number of reported presumptive DRTB patients and the percentage with DST records largely increased during 2015-2018, and the percentage of registered patients who received anti-DRTB treatment also increased from 59.0% to 86.5%. Patients under the policies of equipping GeneXpert plus expanded criteria for DST had a higher likelihood of being registered compared with no GeneXpert (adjusted OR (aOR)=2.57, 95% CI: 1.20 to 5.51), while for treatment initiation the association was only significant when further expanding the registration criteria (aOR=2.38, 95% CI: 1.19 to 4.79). Patients with registered residence inside Zhejiang were more likely to be registered (aOR=1.96, 95% CI: 1.52 to 2.52), treated (aOR=3.83, 95% CI: 2.78 to 5.28) and complete treatment (aOR=1.92, 95% CI: 1.03 to 3.59) compared with those outside.

CONCLUSION

The policy changes on DST and registration have effectively improved DRTB case finding and care. Nevertheless, challenges remain in servicing vulnerable groups such as migrants and improving equity in the access to TB care. Future policies should provide comprehensive support for migrants to complete treatment at their current place of residence.