Directly-observed and self-administered tuberculosis treatment in a chronic, low-intensity conflict setting in India

TB treatment using family members, treatment supporters and self-administered therapies in rural Papua New Guinea

SETTING

Papua New Guinea (PNG) has one of the world's highest TB incidence rates. It is difficult for patients to access TB care in remote provinces due to insufficient infrastructure and challenging terrain, making varied, targeted delivery models for treating TB necessary.

OBJECTIVE

To assess treatment outcomes using self-administered treatment (SAT), family-supported treatment and community-based directly observed therapy (DOT) via treatment supporter (TS) in the PNG context.

DESIGN

A retrospective, descriptive analysis of routinely collected data from 360 patients at two sites in 2019-2020. All patients were assigned a treatment model based on risk factors (adherence or default) and offered patient education and counselling (PEC), family counselling and transportation fees. End-of-treatment outcomes were assessed for each model.

RESULTS

Treatment success rates among drug-susceptible TB (DS-TB) were good overall: 91.1% for SAT, 81.4% for family-supported treatment and 77% for DOT patients. SAT was strongly associated with favourable outcomes (OR 5.7, 95% CI 1.7-19.3), as were PEC sessions (OR 4.3, 95% CI 2.5-7.2).

CONCLUSION

By considering risk factors when determining their treatment delivery model, strong outcomes were seen in all three groups. Multiple modes of treatment administration, tailored to individuals' needs and risk factors, is a feasible, effective, patient-centred care model for hard-to-reach, resource-limited settings.

Treatment outcomes with daily self-administered treatment and thrice-weekly directly-observed treatment in two cohorts of newly-diagnosed, sputum-positive adults with pulmonary tuberculosis

BACKGROUND

The Revised National Tuberculosis Control Program (RNTCP) envisages shifting from thrice-weekly to a daily anti-tuberculosis treatment (ATT) regimen. The potential merits and demerits of both regimens continue to be debated.

METHODS

This retrospective study compared treatment outcomes in 191 HIV-negative, newly diagnosed, sputum-positive adults with pulmonary tuberculosis from Vellore district of Tamil Nadu who were treated at a private medical college during 2009 to 2012 with intermittent Directly Observed Treatment Short Course (intermittent DOTS cohort, n=132) or who opted for daily Self-Administered Treatment (daily SAT cohort, n=59). Treatment outcomes obtained from medical records were supplemented by interviews with consenting, traceable patients.

RESULTS

The rates for the RNTCP-recommended sputum smear examinations were suboptimal (42% for daily SAT and 72% for intermittent DOTS). However, treatment success with daily SAT and intermittent DOTS (76.2% vs. 70.4%); default (11.9% vs. 18.2%); death (6.8% vs. 5.3%); treatment failure (5.1% vs. 4.6%); and relapse (0% vs. 1.5%) did not significantly differ.

CONCLUSIONS

While evaluable treatment outcomes were not significantly different with daily SAT and intermittent DOTS, rates for timely smear examinations and for treatment success were lower, and for default higher, in both cohorts than comparable RNTCP data from Vellore district. Further strengthening of RNTCP facilities within private medical colleges and regular, real-time audits of performance and outcomes are needed if daily ATT regimen under the RNTCP is to succeed.

GeneXpert and Community Health Workers Supported Patient Tracing for Tuberculosis Diagnosis in Conflict-Affected Border Areas in India

Médecins Sans Frontières (MSF) has been providing diagnosis and treatment for patients with tuberculosis (TB) via mobile clinics in conflict-affected border areas of Chhattisgarh, India since 2009. The study objectives were to determine the proportion of patients diagnosed with TB and those who were lost-to-follow-up (LTFU) prior to treatment initiation among patients with presumptive TB between April 2015 and August 2018. The study also compared bacteriological confirmation and pretreatment LTFU during two time periods: a) April 2015–August 2016 and b) April 2017–August 2018 (before and after the introduction of GeneXpert as a first diagnostic test). Community health workers (CHW) supported patient tracing. This study was a retrospective analysis of routine program data. Among 1042 patients with presumptive TB, 376 (36%) were diagnosed with TB. Of presumptive TB patients, the pretreatment LTFU was 7%. Upon comparing the two time-periods, bacteriological confirmation increased from 20% to 33%, while pretreatment LTFU decreased from 11% to 4%. TB diagnosis with GeneXpert as the first diagnostic test and CHW-supported patient tracing in a mobile-clinic model of care shows feasibility for replication in similar conflict-affected, hard to reach areas.

Perspectives on TB patients' care and support: a qualitative study conducted in Accra Metropolis, Ghana

BACKGROUND

Tuberculosis (TB) was declared a global emergency in 1993 by the World Health Organization (WHO). Despite available interventions initiated by the WHO and some countries, the disease remains a key public health problem. The rates of TB infection and its associated burden is unevenly distributed across the globe with greater severity in low-to-middle income countries. This paper therefore explored the experiences of TB patients and health care providers pertaining to patients' care and support during treatment, in the Accra Metropolis of Ghana.

METHODS

A qualitative approach using phenomenology was employed to explore participants' experiences. Maximum variation sampling, a type of purposive sampling was employed in selecting participants who exhibit a wide range of behaviours and experiences. Thirty (30) In-depth Interviews and three (3) Key Informant Interviews were conducted in selected facilities within a period of three months in 2018. The data was audio-recorded, transcribed, and transported into Nvivo version 11, for data management and coding. Content analysis of data was carried out for the generation of themes.

RESULTS

The findings revealed that good knowledge of TB treatment practices did not spontaneously shape perceptions towards treatment. Factors including prevailing cultural beliefs, physical and psychological stress, consequences of patient's interrupted labour and health system challenges were hindrances in caring for TB patients. Physical, mental and spiritual mechanisms were adopted to cope with challenges.

CONCLUSION

Personal patient-related challenges and health system bottlenecks were major influencing factors in providing care and support to TB clients. The National Tuberculosis control Program (NTP) of Ghana should adopt measures and provide the required financial, infrastructural and human resources for the augmentation of patients' treatment.

Treatment of drug-susceptible tuberculosis among people living with human immunodeficiency virus infection: an update

PURPOSE OF REVIEW

The present review describes recent advances in the treatment of drug-susceptible tuberculosis (DS-TB) among people living with human immunodeficiency virus (PLWH).

RECENT FINDINGS

Higher than standard rifampicin doses (>10 mg/kg/day) are well tolerated and have improved sterilizing activity. Standard pyrazinamide doses may result in low drug exposures; modeling reveals that higher doses (>25 mg/kg/day) may be required to reach target levels, although safety is unknown. Four-month fluoroquinolone-containing regimens are not recommended in the 2017 World Health Organization DS-TB treatment guidelines. These guidelines also recommend fixed-dose combination (FDC) therapy over single drug formulations based on patient preference, though FDC is not associated with improved outcomes. Treatment for 6 months is recommended, with an emphasis on expanded antiretroviral therapy (ART) coverage and monitoring for relapse among those not started on ART within 8 weeks of tuberculosis treatment. Directly observed therapy (DOT) is recommended over self-administered therapy, as is daily therapy over intermittent therapy - both are associated with better tuberculosis outcomes.

SUMMARY

Current WHO tuberculosis treatment guidelines recommend 6 months of daily tuberculosis treatment for PLWH who have DS-TB, and timely ART initiation. Higher rifampin and pyrazinamide doses may enhance treatment effectiveness, but safety data are needed. DOT and FDC therapy are recommended.

Treatment of tuberculosis in complex emergencies in developing countries: a scoping review

Almost 172 million people live in complex emergencies globally resulting from political and/or economic instability. The provision and continuity of health care in complex emergencies remain a significant challenge. Health agencies are often hesitant to implement tuberculosis programmes in particular because its treatment requires a longer commitment than most acute diseases. However, not treating tuberculosis promptly increases mortality and untreated tuberculosis further increases the incidence of tuberculosis. Given that complex emergencies are increasing globally, there is an urgent need to analyse the available evidence to improve our understanding of how best to deliver tuberculosis programmes in such settings. Using a scoping review method, we selected and analysed 15 studies on tuberculosis programmes in complex emergencies. We found that despite the challenges, tuberculosis programmes have been successful in complex emergencies. We identified seven cross-cutting factors that were found to be important: service providers and treatment regime, training and supervision, donor support, adherence, leadership and coordination, monitoring and government and community support. In general, programmes showed greater creativity and flexibility to adapt to the local conditions and at times, it also meant diverting from the WHO guidelines. We identify areas of further research including the need to study the effectiveness of programmes that divert from the WHO guidelines and their implication on drug resistance.

Predictors of tuberculosis treatment outcomes among a retrospective cohort in rural, Central India

Introduction

Programmatic design affects access to healthcare and can influence tuberculosis treatment outcomes. Potential predictors of tuberculosis treatment outcomes in one rural Indian setting were examined to improve outcomes with a focus on access to care.

Methods

Routinely collected tuberculosis treatment data from Jan Swasthya Sahyog, a community based healthcare system in rural Chhattisgarh, India were examined from 2003–2015. Predictors were analyzed for associations with death, loss to follow-up or failure in multivariable logistic regression models. The effect of distance from treatment on outcomes was graphed and Pearson's correlation coefficients (r²) calculated. Descriptive time to event analyses were performed for all deaths and loss to follow-up from January 2010 to September 2015.

Results

4979 patients with active TB were treated during the study period. Patients were mostly male, malnourished, diagnosed with pulmonary disease and many travelled lengthy distances. Positive treatment outcomes improved from 55% to 80% from 2003 to 2015 for all patients though positive treatment outcomes have been above 80% in the primary care setting since 2012. The annual case fatality rate was 4.4% with small yearly variation.Gender and site of treatment (primary versus secondary care facility) and also season of treatment initiation and travel time to care best predicted outcomes in both the complete model and model which included only patients with initial BMI data. No differences were found between primary and secondary care patients for initial BMI, percentage of sputum positivity among those with pulmonary disease and grade of sputum positivity among the sputum positive. Those who traveled the furthest to access care achieved the worst outcomes during the summer and, to a lesser degree, the monsoon. Distance from care was associated with treatment outcomes in a dose-response manner out to substantial distances. From 2010 to 2015, most patients who died or were lost to follow-up did so in the first week of treatment.

Conclusions

The provision of care through local facilities improves the treatment of tuberculosis in rural India. Interventions addressing death or loss to follow-up should focus on the newly diagnosed. Rural Indian physicians should be aware of how access issues affect TB treatment outcomes.

Adherence interventions and outcomes of tuberculosis treatment: A systematic review and meta-analysis of trials and observational studies

BACKGROUND

Incomplete adherence to tuberculosis (TB) treatment increases the risk of delayed culture conversion with continued transmission in the community, as well as treatment failure, relapse, and development or amplification of drug resistance. We conducted a systematic review and meta-analysis of adherence interventions, including directly observed therapy (DOT), to determine which approaches lead to improved TB treatment outcomes.

METHODS AND FINDINGS

We systematically reviewed Medline as well as the references of published review articles for relevant studies of adherence to multidrug treatment of both drug-susceptible and drug-resistant TB through February 3, 2018. We included randomized controlled trials (RCTs) as well as prospective and retrospective cohort studies (CSs) with an internal or external control group that evaluated any adherence intervention and conducted a meta-analysis of their impact on TB treatment outcomes. Our search identified 7,729 articles, of which 129 met the inclusion criteria for quantitative analysis. Seven adherence categories were identified, including DOT offered by different providers and at various locations, reminders and tracers, incentives and enablers, patient education, digital technologies (short message services [SMSs] via mobile phones and video-observed therapy [VOT]), staff education, and combinations of these interventions. When compared with DOT alone, self-administered therapy (SAT) was associated with lower rates of treatment success (CS: risk ratio [RR] 0.81, 95% CI 0.73-0.89; RCT: RR 0.94, 95% CI 0.89-0.98), adherence (CS: RR 0.83, 95% CI 0.75-0.93), and sputum smear conversion (RCT: RR 0.92, 95% CI 0.87-0.98) as well as higher rates of development of drug resistance (CS: RR 4.19, 95% CI 2.34-7.49). When compared to DOT provided by healthcare providers, DOT provided by family members was associated with a lower rate of adherence (CS: RR 0.86, 95% CI 0.79-0.94). DOT delivery in the community versus at the clinic was associated with a higher rate of treatment success (CS: RR 1.08, 95% CI 1.01-1.15) and sputum conversion at the end of two months (CS: RR 1.05, 95% CI 1.02-1.08) as well as lower rates of treatment failure (CS: RR 0.56, 95% CI 0.33-0.95) and loss to follow-up (CS: RR 0.63, 95% CI 0.40-0.98). Medication monitors improved adherence and treatment success and VOT was comparable with DOT. SMS reminders led to a higher treatment completion rate in one RCT and were associated with higher rates of cure and sputum conversion when used in combination with medication monitors. TB treatment outcomes improved when patient education, healthcare provider education, incentives and enablers, psychological interventions, reminders and tracers, or mobile digital technologies were employed. Our findings are limited by the heterogeneity of the included studies and lack of standardized research methodology on adherence interventions.

CONCLUSION

TB treatment outcomes are improved with the use of adherence interventions, such as patient education and counseling, incentives and enablers, psychological interventions, reminders and tracers, and digital health technologies. Trained healthcare providers as well as community delivery provides patient-centered DOT options that both enhance adherence and improve treatment outcomes as compared to unsupervised, SAT alone.

Tuberculosis-associated mortality in Shanghai, China: a longitudinal study

Objective

To determine excess mortality in a cohort of people with tuberculosis in Shanghai.

Methods

Participants were local residents in 4 (of 19) districts in Shanghai, registered in one of four tuberculosis clinics between January 1, 2004 and December 31, 2008. Baseline data were collected at the most recent diagnosis of tuberculosis and mortality was assessed between March and May of 2014. We calculated standardized mortality ratios (SMR) and case-fatality rates for all participants and for subgroups. Univariate and multivariate Cox regression models were used to quantify associations between co-morbidities and mortality from all causes and from tuberculosis.

Findings

We registered 4569 subjects in the cohort. Overall, the cohort had an SMR for deaths from all causes of 5.2 (95% confidence interval, CI: 4.8–5.6). Males had a higher SMR than females (6.1 versus 3.0). After adjustment for age and sex, hazard ratios (HR) for deaths from all causes were significantly greater in previously treated people (HR: 1.26; 95% CI: 1.08–1.49) and sputum smear-test positive people (HR: 1.55; 95% CI: 1.35–1.78). The risk of death from tuberculosis was also significantly greater for previously treated people (HR: 1.88; 95% CI: 1.24–2.86) and smear positive people (HR: 3.16; 95% CI: 2.06–4.87).

Conclusion

People with tuberculosis in Shanghai have an increased risk of mortality. Earlier diagnosis and more vigilant follow-up may help to reduce mortality in this group.