Rising challenge of multidrug-resistant tuberculosis in China: a predictive study using Markov modeling

Factors associated with tuberculosis drug resistance among presumptive multidrug resistance tuberculosis patients identified in a DRTB surveillance study in western Kenya

Multidrug-resistant tuberculosis (MDR-TB) is caused by M. tuberculosis (Mtb) with resistance to the first-line anti-TB medicines isoniazid (INH) and rifampicin (RIF). In Western Kenya, there is reported low prevalence of drug resistant strains among HIV tuberculosis patients, creating a need to determine factors associated with drug resistance patterns among presumptive MDR-TB patients. To determine factors associated with drug resistance patterns among presumptive MDR-TB patients in western Kenya. Three hundred and ninety (3 9 0) sputum sample isolates from among presumptive multidrug TB patients, were analyzed for TB drug resistance as per Ministry of Health (MoH) TB program diagnostic algorithm. Frequency and percentages were used to summarize categorical data while median and interquartile range (IQR) were used for continuous data. Multivariable logistic regression was carried out to identify factors associated with TB drug resistance. Out of 390 participants enrolled, 302/390 (77.4 %) were males, with a median age of 34 years. The HIV-infected were 118/390 (30.3 %). Samples included 322 (82.6 %) from presumptive patients, while 68/390 (17.4 %) were either lost to follow-up patients, failures to first-line treatment or newly diagnosed cases. A total of 64/390 (16.4 %) of the isolates had at least some form of drug resistance. Out of 390, 14/390 (3.6 %) had MDR, 12 (3.1 %) were RIF mono-resistance, 34 (8.7 %) had INH, while 4 (1 %) had ethambutol resistance. The category of previously treated patients (those who received or are currently on TB treatment) had a 70 % reduced likelihood of resistance (aOR: 0.30; 95 % CI: 0.13-0.70). In contrast, older age was associated with an increased likelihood of resistance to INH and RIF, with an adjusted odds ratio of 1.04 per year (95 % CI: 1.00-1.08). Prompt MDR-TB diagnosis is essential for appropriate patient care, management, and disease prevention and control. We recommend active surveillance on drug resistant TB in these regions to detect drug resistance patterns for rapid disease management.

Tracking multidrug resistant tuberculosis: a 30-year analysis of global, regional, and national trends

Objectives

To provide valuable insights for targeted interventions and resource allocation, our analysis delved into the multifaceted burden, trends, risks, and projections of multi drug resistant tuberculosis (MDR-TB).

Methods

This research employed data from the Global Burden of Disease (GBD) 2019 dataset, which used a comparative risk assessment to quantify the disease burden resulting from risk factors. Initially, this database was utilized to extract details concerning the disability-adjusted life years (DALYs), mortality, incidence, and the number of individuals afflicted by MDR-TB. Subsequently, regression analyses were conducted using the Joinpoint program to figure average annual percent change (AAPC) to ascertain the trend. Thirdly, the age-period-cohort model (APCM) was adopted to analyze evolutions in incidence and mortality. Finally, utilizing the Nordpred model within R software, we projected the incidence and mortality of MDR-TB from 2020 to 2030.

Results

MDR-TB remained a pressing global health concern in regions with lower socio-demographic indexes (SDI), where the AAPC in DALYs topped 7% from 1990 to 2019. In 2019, the cumulative DALYs attributed to MDR-TB tallied up to 4.2 million, with India, the Russian Federation, and China bearing the brunt. Notably, the incidence rates have shown a steadfast presence over the past decade, and a troubling forecast predicts an uptick in these areas from 2020 to 2030. Additionally, the risk of contracting MDR-TB grew with advancing age, manifesting most acutely among men aged 40+ in lower SDI regions. Strikingly, alcohol consumption had been identified as a significant contributor, surpassing the impacts of smoking and high fasting plasma glucose, leading to 0.7 million DALYs in 2019.

Conclusions

A robust strategy is needed to end tuberculosis (TB) by 2030, especially in lower SDI areas.

Cost-Effectiveness of Community-Based Active Case Finding Strategy for Tuberculosis: Evidence From Shenzhen, China

BACKGROUND

Active case finding (ACF) is a potentially promising approach for the early identification and treatment of tuberculosis patients. However, evidence on its cost-effectiveness, particularly in low- and middle-income countries, remains limited. This study evaluates the cost-effectiveness of a community-based ACF practice in Shenzhen, China.

METHODS

We employed a Markov model-based decision analytic method to assess the costs and effectiveness of 3 tuberculosis detection strategies: passive case finding (PCF), basic ACF, and advanced ACF. The analysis was conducted from a societal perspective on a dynamic cohort over a 20-year horizon, focusing on active tuberculosis (ATB) prevalence and the incremental cost-effectiveness ratio (ICER).

RESULTS

Compared to the PCF strategy, the basic and advanced ACF strategies effectively reduced ATB cases by 6.8 and 10.2 per 100 000 population, respectively, by the final year of this 20-year period. The ICER for the basic and advanced ACF strategies were ¥14 757 and ¥8217 per quality-adjusted life-year, respectively. Both values fell below the cost-effectiveness threshold.

CONCLUSIONS

Our findings indicate that the community-based ACF screening strategy, which targets individuals exhibiting tuberculosis symptoms, is cost-effective. This underscores the potential benefits of adopting similar community-based ACF strategies for symptomatic populations in tuberculosis-endemic areas.

Development of a Conceptual Framework for Tuberculosis Management and Control; an Evidence Synthesis Using Text Mining Software: A Review

Background

The use of electronic systems supported by text-mining software applications that support the End TB strategy' needs to be explored. This study aimed to address this knowledge gap, and synthesis of evidence.

Methods

The PubMed database was searched for structured review articles published in English since 2012 on interventions to control and manage TB. Nine hundred twenty-five articles met the inclusion criteria. The included articles were synthesized using the text and content analysis software Leximancer. The themes were chosen based on the hit words that emerged in the frequency and heat maps. After the themes were chosen, the concept built the themes based on likelihood.

Results

The framework resulting in the study focuses on early detection and treatment to minimize the chance of TB transmission in the population, especially for highly susceptable populations. The main area highlighted is the appropriate screening and treatment domains. The framework generated in this study is somewhat in line with the WHO Final TB Strategy. This study highlights the importance of improving TB prevention through a patient-centered approach and protecting susceptible populations.

Conclusion

Our findings will be helpful in guiding TB practice, policy development and future research. Future research can elaborate the framework and elicit feedback from TB management stakeholdesr to assess its utility.

Development and Application of a Multidrug-Resistant Tuberculosis Case Management System - Yunnan Province, China, 2017-2020

INTRODUCTION

Treatment and case management of multidrug-resistant tuberculosis (MDR-TB) is a significant challenge in tuberculosis (TB) control and prevention. This pilot study aims to apply and test a new electronic information system in order to help bolster case management of MDR-TB.

METHODS

The MDR-TB Case Management System (CMS) was developed and piloted in the Yunnan Tuberculosis Clinical Center (TCC) in 2017. Next, 5 sites in Yunnan were randomly selected and sampled as pilots in 2018. The real-time regular follow-up rate (RFUR) was calculated for pilot sites. Loss to follow-up (LTFU) rates of MDR-TB treatment cohorts between pilot and non-pilot sites were compared by a chi-square test. LTFU for MDR-TB treatment cohorts was then assessed by univariate and multivariate binary logistic regression.

RESULTS

The average regular follow-up rate was 90.7% in TCC and 73.7% in five other pilot sites of Yunnan Province respectively. The average LTFU rate for pilot sites (9.0%) was lower than non-pilot sites (20.6%, P<0.01). The risk of LTFU during MDR-TB treatment reduced 61.7% in CMS pilot cases (adjusted odds ratio: 0.38, 95% confidence interval: 0.23-0.60) compared with non-pilot cases.

CONCLUSIONS

As a significant supplement to the Tuberculosis Information Management System, the CMS strengthened the collection, analysis, and utilization of strategic information for MDR-TB cases. The system improved case management by embedding it as a tool of the Comprehensive Supportive Care service model.

Clinical characteristics of external bacterial ocular and periocular infections and their antimicrobial treatment patterns among a Ghanaian ophthalmic population

Empirical antimicrobial therapy is linked to a surge in antimicrobial resistant infections. However, an insight on the bacteria etiology of ocular infections is essential in the appropriation of choice of antimicrobial among clinicians, yet there remains a dearth of data from Ghana. We investigated the bacteria etiology of external ocular and periocular infections and antimicrobial treatment patterns among a Ghanaian ophthalmic population. A multicenter study design with purposive sampling approach was employed. Patients demographics and clinical data were collated using a pretested structure questionnaire. Cornea specimens and conjunctival swabs were obtained for bacterial isolation following standard protocols. About 95% (98/103) of ocular samples were positive for bacteria culture. The proportion of Gram-negative bacteria was 58.2%, and the predominant bacteria species were Pseudomonas aeruginosa 38.8% and Staphylococcus aureus 27.6%. Conjunctivitis 40.0% and keratitis 75.0% were mostly caused by Pseudomonas aeruginosa. The routinely administered antimicrobial therapy were polymyxin B 41.2%, neomycin 35.1% and ciprofloxacin 31.6%. Participants demographic and clinical characteristics were unrelated with positive bacteria culture (p > 0.05). Our results showed a markedly high burden of ocular bacterial infections and variations in etiology. Bacterial infection-control and antimicrobial agent management programs should be urgently institutionalized to prevent the emergence of resistant infections.

Spatial analysis and influencing factors of pulmonary tuberculosis among students in Nanning, during 2012-2018

BACKGROUND

Economically underdeveloped areas in western China are hotspots of tuberculosis, especially among students. However, the related spatial and temporal patterns and influencing factors are still unclear and there are few studies to analyze the causes of pulmonary tuberculosis in students from the perspective of space.

METHODS

We collected data regarding the reported incidence of pulmonary tuberculosis (PTB) among students at township level in Nanning, from 2012 to 2018. The reported incidence of pulmonary tuberculosis among students in Nanning was analyzed using spatial autocorrelation and spatial scan statistical analysis to depict hotspots of PTB incidence and spatial and temporal clustering. Spatial panel data of the reported incidence rates and influencing factors at district and county levels in Nanning were collected from 2015 to 2018. Then, we analyzed the spatial effects of incidence and influencing factors using the spatial Durbin model to explore the mechanism of each influencing factor in areas with high disease prevalence under spatial effects.

RESULTS

From 2012 to 2018, 1609 cases of PTB were reported among students in Nanning, with an average annual reported incidence rate of 14.84/100,000. Through the Joinpoint regression model, We observed a steady trend in the percentage of cases reported each year (P>0.05). There was spatial autocorrelation between the annual reported incidence and the seven-years average reported incidence from 2012 to 2018. The high-incidence area was distributed in the junction of six urban areas and spread to the periphery, with the junction at the center. The population of college students, per capita financial expenditure on health, per capita gross domestic product, and the number of health technicians per 1,000 population were all influencing factors in the reported incidence of PTB among students.

CONCLUSION

We identified spatial clustering of the reported incidence of PTB among students in Nanning, mainly located in the urban center and its surrounding areas. The clustering gradually decreased from the urban center to the surrounding areas. Spatial effects influenced the reported incidence of PTB. The population density of college students, per capita health financial expenditure, gross domestic product (GDP) per capita, and the number of health technicians per 1,000 were all influencing factors in the reported incidence of PTB among students.

Effect of different interventions for latent tuberculosis infections in China: a model-based study

BACKGROUND

Tuberculosis (TB) has a serious impact on people's health. China is one of 30 countries that has a high TB burden. As the currently decreasing speed of the incidence of TB, the WHO's goal of "End TB Strategy" is hard to achieve by 2035. As a result, a SEIR model that determines the impact of different tuberculosis preventive treatments (TPTs) in different age groups, and the effect of different interventions on latent TB infections (LTBIs) in China is developed.

METHODS

A Susceptible-Exposed-Infectious-Recovered (SEIR) model was established. Goodness-of-fit tests were used to assess model performance. Predictive analysis was used to assess the effect of different interventions on LTBIs and achieving the goals of the "End TB Strategy".

RESULTS

The Chi-square test indicated the model provided a good statistical fit to previous data on the incidence of TB (χ² = 0.3085, p > 0.999). The 1HP treatment regimen (daily rifapentine + isoniazid for 4 weeks) was most effective in reducing the number of TB cases by 2035. The model indicated that several strategies could achieve the 2035 target of the "End TB Strategy": completion of active case finding (ACF) for LTBI and TPT nation-wide within 5 years; completion of ACF for LTBIs and TPT within 2 years in high-incidence areas; completion of TPT in the elderly within 2 years; or introduction of a new vaccine in which the product of annual doses and vaccine efficiency in the three age groups above 14 years old reached 10.5 million.

CONCLUSION

The incidence of TB in China declined gradually from 2005 to 2019. Implementation of ACF for LTBIs and TPT nation-wide or in areas with high incidence, in the elderly, or administration of a new and effective vaccine could greatly reduce the number of TB cases and achieve the 2035 target of the "End TB Strategy" in China.

Establishment and evaluation of an overlap extension polymerase chain reaction technique for rapid and efficient detection of drug-resistance in Mycobacterium tuberculosis

BACKGROUND

Rapid and accurate detection of drug resistance in Mycobacterium tuberculosis is critical for effective control of tuberculosis (TB). Herein, we established a novel, low cost strategy having high accuracy and speed for the detection of M. tuberculosis drug resistance, using gene splicing by overlap extension PCR (SOE PCR).

METHODS

The SOE PCR assay and Sanger sequencing are designed and constructed to detect mutations of rpoB, embB, katG, and inhA promoter, which have been considered as the major contributors to rifampicin (RFP), isoniazid (INH), and ethambutol (EMB) resistance in M. tuberculosis. One hundred and eight M. tuberculosis isolates came from mycobacterial cultures of TB cases at Chongqing Public Health Medical Center in China from December 2018 to April 2019, of which 56 isolates were tested with the GeneXpert MTB/RIF assay. Performance evaluation of the SOE PCR technique was compared with traditional mycobacterial culture and drug susceptibility testing (DST) or GeneXpert MTB/RIF among these isolates. Kappa identity test was used to analyze the consistency of the different diagnostic methods.

RESULTS

We found that the mutations of S531L, S315T and M306V were most prevalent for RFP, INH and EMB resistance, respectively, in the 108 M. tuberculosis isolates. Compared with phenotypic DST, the sensitivity and specificity of the SOE PCR assay for resistance detection were 100.00% and 88.00% for RFP, 94.64% and 94.23% for INH, and 68.97% and 79.75% for EMB, respectively. Compared with the GeneXpert MTB/RIF, the SOE PCR method was completely consistent with results of the GeneXpert MTB/RIF, with a concordance of 100% for resistance to RFP.

CONCLUSIONS

In present study, a novel SOE PCR diagnostic method was successfully developed for the accurate detection of M. tuberculosis drug resistance. Our results using this method have a high consistency with that of traditional phenotypic DST or GeneXpert MTB/RIF, and SOE PCR testing in clinical isolates can also be conducted rapidly and simultaneously for detection of drug resistance to RFP, EMB, and INH.

Risk factors associated with unsuccessful tuberculosis treatment outcomes in Hunan Province, China

OBJECTIVES

Globally, China has the third highest number of tuberculosis (TB) cases despite high rates (85.6%) of effective treatment coverage. Identifying risk factors associated with unsuccessful treatment outcomes is an important component of maximizing the efficacy of TB control programs.

METHODS

Retrospective cohort study to evaluate the outcomes of 306,860 drug-susceptible TB patients who underwent treatment in Hunan Province, China between 2013 and 2018. Univariable and multivariable logistic regression models were used to identify factors associated with unsuccessful TB treatment outcomes.

RESULTS

A successful treatment outcome was recorded for 98.6% of patients, defined as the sum of patients who were cured (36.2%) and completed treatment (62.4%). An unsuccessful treatment outcome was recorded for 1.8% of patients, defined as the sum of treatment failure (1.1%), deaths (0.5%) and lost to follow up (0.2%). The odds of an unsuccessful treatment outcome showed an increasing trend in more recent years of registration (2018 Adjusted Odds Ratio (AOR): 1.43; 95% Confidence Interval (CI) 1.31, 1.57 relative to 2013). Other significant risk factors were male sex (AOR: 1.17; 95% CI 1.10, 1.25); increasing age (AOR:1.02 per year increase; 95% CI 1.02,1.02); being severely ill (AOR: 1.50; 95% CI 1.33, 1.70); having a history of TB treatment (AOR: 2.93; 95% CI 2.69, 3.20); not being under systematic management (AOR: 16.10 (14.49, 17.88) and treatment regimens that differed from full course management.

CONCLUSIONS

The increasing likelihood of an unsuccessful treatment outcome over time necessitates the need for further research.

Impacts of Medical Security Level on Treatment Outcomes of Drug-Resistant Tuberculosis: Evidence from Wuhan City, China

BACKGROUND

Drug-resistant tuberculosis (DR-TB) is an increasingly serious global issue. DR-TB has a lower success rate and more severe interruption of treatment than ordinary tuberculosis. Incomplete treatment not only reduces recovery rate in DR-TB patients but also increases the spread of DR-TB. Optimizing medical security policies for DR-TB can reduce the economic burden of patients and can thereby improve treatment success rate.

METHODS

Patients with DR-TB who were registered in Wuhan Center for Tuberculosis Control and Prevention from January 2016 to December 2019 were selected as research subjects. General descriptive statistical analysis methods were used in analyzing patients' treatment outcomes and medical security compensation rate. The binary logistic regression was used in analyzing the impacts of medical security level on treatment outcomes of DR-TB.

RESULTS

A total of 409 DR-TB patients were included in the study, and the refusal rate was 12.47%. The treatment success rate was only 37.09% for patients who started treatment and had treatment outcomes. The total out-of-pocket expenses (OOPs) per capita for DR-TB patients were 13,005.61 Chinese yuan. The outpatient effective compensation ratio (ECR) of DR-TB patients was only 51.04%. The outpatient ECR of DR-TB with subsidies of public health projects (SPHPs) were nearly 80% higher than those without SPHP. high outpatient ECR helped optimize treatment outcomes (P < 0.001, OR = 1.038). The inpatient ECR had no effect on patients' treatment outcomes (P = 0.158, OR = 0.986).

CONCLUSION

Many DR-TB patients did not receive complete treatment. The key breakthrough point in improving DR-TB treatment outcomes is to optimize the outpatient medical insurance compensation policy. Including the costs of DR-TB in expenses for severe diseases in outpatient care is recommended, and financial investment should be appropriately increased to ensure the high coverage ratio of subsidies for public health projects.

Efficacy of integrating short-course chemotherapy with Chinese herbs to treat multi-drug resistant pulmonary tuberculosis in China: a study protocol

Background

Tuberculosis (TB) caused Mycobacterium tuberculosis (M.tb) is one of infectious disease that lead a large number of morbidity and mortality all over the world. Although no reliable evidence has been found, it is considered that combining chemotherapeutic drugs with Chinese herbs can significantly improves the cure rate and the clinical therapeutic effect.

Methods

Multi-drug resistant pulmonary tuberculosis (MDR-PTB, n = 258) patients with Qi-yin deficiency syndrome will be randomly assigned into a treatment group (n = 172) or control/placebo group (n = 86). The treatment group will receive the chemotherapeutic drugs combined with Chinese herbs granules (1 + 3 granules), while the control group will receive the chemotherapeutic drugs combined with Chinese herbs placebo (1 + 3 placebo granules). In addition, MDR-PTB (n = 312) patients with Yin deficiency lung heat syndrome will be randomly assigned to a treatment (n = 208) or control/placebo (n = 104) group. The treatment group will receive the chemotherapeutic regimen combined with Chinese herbs granules (2 + 4 granules), while the control group will receive the chemotherapeutic drugs and Chinese herbs placebo (2 + 4 placebo granules). The primary outcome is cure rate, the secondary outcomes included time to sputum culture conversion, lesion absorption rate and cavity closure rate. BACTEC™ MGIT™ automated mycobacterial detection system will be used to evaluate the M.tb infection and drug resistance. Chi-square test and Cox regression will be conducted with SAS 9.4 Statistical software to analyze the data.

Discussion

The treatment cycle for MDR-PTB using standardized modern medicine could cause lengthy substantial side effects. Chinese herbs have been used for many years to treat MDR-PTB, but are without high-quality evidence. Hence, it is unknown whether Chinese herbs enhances the clinical therapeutic effect of synthetic drugs for treating MDR-PTB. Therefore, this study will be conducted to evaluate the clinical therapeutic effect of combining Chinese herbs and chemotherapeutic drugs to treat MDR-PTB cases. It will assist in screening new therapeutic drugs and establishing treatment plan that aims to improve the clinical therapeutic effect for MDR-PTB patients.

Trial registration

This trial was registered at ClinicalTrials.gov (ChiCTR1900027720) on 24 November 2019 (prospective registered).

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-021-00913-5.

A metagenomic study of the gut microbiome in PTB'S disease

BACKGROUND

There is an abundant link between the gut microbiota and human health and it plays a critical role in the clinic. It is recognized that microbial dysregulation contributes to the pathogenesis of tuberculosis (TB), but the underlying mechanisms remain unclear. In this study, we investigated the association of gut microbiome composition with TB as well as its possible roles in the development of this disease.

METHODS

Fecal samples were collected from 10 TB patients and 20 healthy control samples. DNA extracted from fecal samples was subjected to 16S rDNA gene sequencing analysis on the Illumina MiSeq platform.

RESULTS

Compared with healthy control samples, the gut microbiome of patients with TB was characterized by the decreased Alpha diversity. Perhaps, the decrease of microbial diversity which results in microbial dysregulation is the reason for clinical patients with more symptoms. The PTB group showed the most unique microbiota by higher abundance of Bifidobacteriaceae, Bifidobacteriales, Coriobacteriaceae, Coriobacteriales, Actinobacteria, Caulobacteraceae, Phyllobacteriaceae, Rhizobiales, Burkholderiaceae, Burkholderiaceae. Inflammatory status in PTB patients may be associated with the increased abundance of Clostridia and decreased abundance of Prevotella. We found that the abundance of Solobacterium and Actinobacteria was higher in the patients. There were 4 significant differences (p<0.05) in the two groups which belonged to four metabolic categories, including endocytosis, phosphotransferase system (PTS), toluene degradation, and amoebiasis.

CONCLUSION

We applied the approach of metagenomic sequencing to characterize the features of gut microbiota in PTB patients. The present study provided a detailed analysis of the characterization of the gut microbiota in patients based on the clinic. According to the metagenome analysis, our results indicated that the gut microbiota in PTB patients was significantly different from healthy control samples as characterized by the bacteria and metabolic pathway. The richness of the gut microbiota in patients was revealed. It was hypothesized that the above-mentioned changes of the gut microbiota could exert an impact on the development of PTB through the downstream regulation of the immune status of the host by way of the gut-lung axis.

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.