Knowledge about tuberculosis transmission and prevention and perceptions of health service utilization among index cases and contacts in Brazil: Understanding losses in the latent tuberculosis cascade of care

Optimizing the cascade of prevention to protect people from tuberculosis: A potential game changer for reducing global tuberculosis incidence

The provision of tuberculosis preventive treatment is one of the critical interventions to reduce tuberculosis incidence and ultimately eliminate the disease, yet we still miss appropriate tools for an impactful intervention and treatment coverage remains low. We used recent data, epidemiological estimates, and research findings to analyze the challenges of each step of the cascade of tuberculosis prevention that currently delay the strategy implementation. We addressed research gaps and implementation bottlenecks that withhold key actions in tuberculosis case finding, testing for tuberculosis infection, provision of preventive treatment with safer, shorter regimens and supporting people to complete their treatment. Empowering communities to generate demand for preventive therapy and other prevention services in a holistic manner and providing adequate financial support to sustain implementation are essential requirements. The adoption of an effective, universal monitoring and evaluation system is a prerequisite to provide general and granular insight, and to steer progress of the tuberculosis infection strategy at global and local level.

RATE OF INFECTION (TUBERCULOSIS) IN BRAZILIANS IBD PRIVATE PATIENTS: FOLLOW-UP 15 YEARS

BACKGROUND

Latent tuberculosis (LTB) is a condition where the patient is infected with Mycobacterium tuberculosis but does not develop active TB. There's a possibility of tuberculosis (TB) activation following the introduction of anti-TNFs.

OBJECTIVE

To assess the risk of biological therapy inducing LTB during inflammatory bowel diseases (IBD) treatment over 15 years in a high-risk area in Brazil.

METHODS

A retrospective study of an IBD patients' database was carried out in a private reference clinic in Brazil. All patients underwent TST testing and chest X-ray prior to treatment, and once a year after starting it. Patients were classified according to the Montreal stratification and risk factors were considered for developing TB.

RESULTS

Among the analyzed factors, age and gender were risk factors for LTB. DC (B2 and P) and UC (E2) patients showed a higher number of LTB cases with statistical significance, what was also observed for adalimumab and infliximab users, compared to other medications, and time of exposure to them favored it significantly. Other factors such as enclosed working environment have been reported as risk.

CONCLUSION

The risk of biological therapy causing LTB is real, so patients with IBD should be continually monitored. This study reveals that the longer the exposure to anti-TNFs, the greater the risk.

BACKGROUND

•Rate of infection (tuberculosis) in Brazilians IBD private patients: follow-up 15 years.

BACKGROUND

•Patients treated with immunosuppressants and/or anti-TNFs have a higher risk of developing opportunistic infections, among them the most common is latent tuberculosis or even active tuberculosis.

BACKGROUND

•Similar risks may be noted in patients with inflammatory bowel diseases (IBDs).

BACKGROUND

•This study reveals that the longer the exposure to anti-TNFs, the greater the risk for de IBD patients.

BACKGROUND

•The study demonstrated the importance of monitoring these patients permanently and continuously.

Healthcare workers' acceptance of and adherence to latent tuberculosis treatment

BACKGROUND

Healthcare workers (HCWs) with latent tuberculosis infection (LTBI) have a high risk of active tuberculosis and need systematic LTBI screening and treatment. However, acceptance and adherence rates of LTBI treatment are low.

AIMS

To examine the specific reasons for the loss at each LTBI treatment-cascade stage: acceptance, continuation and completion of LTBI treatment in HCWs.

METHODS

This retrospective descriptive study was conducted among 61 HCWs with an interferon-gamma release assay-confirmed LTBI diagnosis who were prescribed LTBI treatment at a tertiary hospital in the Republic of Korea. Data were analysed using Pearson's chi-square, Fisher's exact, independent t-test and Mann-Whitney U-test. A word cloud analysis was used to describe the perceived meaning of LTBI in HCWs.

RESULTS

HCWs who refused or discontinued LTBI treatment perceived LTBI as 'not a big deal', whereas HCWs who completed LTBI treatment had a high-risk perception of the LTBI prognosis, such as 'frightened about adverse prognosis'. Determinants of non-adherence to the recommended LTBI treatment included a busy work schedule, side effects of anti-tuberculosis agents and the inconvenience of regularly taking anti-tuberculosis agents.

CONCLUSIONS

To ensure LTBI treatment adherence in HCWs, effective interventions that are customized to each stage of the LTBI treatment should be developed, with due consideration of the stage-specific perceived facilitators and barriers in the LTBI treatment cascade.

Scaling up investigation and treatment of household contacts of tuberculosis patients in Brazil: a cost-effectiveness and budget impact analysis

Background

In Brazil, investigation and treatment of tuberculosis infection (TBI) in households contacts (HHC) of TB patients is not a priority. We estimated the cost-effectiveness and budget-impact of scaling-up an enhanced HHC management in Brazil.

Methods

We conceptualized a cascade-of-care that captures how HHC of tuberculosis patients are investigated in Brazil (status quo) and two enhanced strategies for management of HHC focusing on: (1) only tuberculosis disease (TBD) detection and, (2) TBD and TBI detection and treatment. Effectiveness was the number of HHC diagnosed with TBD and completing TBI treatment. Proportions in the cascades-of-care were derived from a meta-analysis. Health-system costs (2019 US$) were based on literature and official data from Brazil. The impact of enhanced strategies was extrapolated using reported data from 2019.

Findings

With the status quo, 0 (95% uncertainty interval: 0-1) HHC are diagnosed with TBD and 2 (0-16) complete TBI treatment. With strategy(1), an additional 15 (3-45) HHC would be diagnosed with TBD at a cost of US$346 each. With strategy(2), 81 (19-226) additional HHC would complete TBI treatment at a cost of US$84 each. A combined strategy, implemented nationally to enhance TBD detection and TBI treatment would result in an additional 9,711 (845-28,693) TBD being detected, and 51,277 (12,028-143,495) more HHC completing TBI treatment each year, utilizing 10.9% and 11.6% of the annual national tuberculosis program budget, respectively.

Interpretation

Enhanced detection and treatment of TBD and TBI among HHC in Brazil can be achieved at a national level using current tools at reasonable cost.

Funding

None.

Framing the Detection of Incipient Tuberculosis Infection: a qualitative study of political prioritization

Objective

Incipient Tuberculosis (ITB) refers to Mycobacterium tuberculosis infection that is likely to progress to active disease in the absence of treatment, but without clinical signs, symptoms, radiographic or microbiological evidence of disease. Biomarker‐based tests to diagnose incipient TB hold promise for better prediction and, through TB preventive therapy, prevention of disease. This study explored current and future framing and prioritisation of ITB.

Methods

Twenty‐two interviews across eight countries were conducted. A modified Shiffman & Smith Framework, containing four categories—Ideas, Issue Characteristics, Actor Power, and Political Contexts—was used to analyse the current landscape and potential for prioritisation of diagnosis and treatment of ITB.

Results

Latent TB policy implementation has been slow due to technical, logistical and financial challenges, and because it has been framed in a manner non‐conducive to gaining political priority. Framing ITB testing as ‘early detection’ rather than ‘prediction’, and its management as ‘treatment’ rather than ‘preventive therapy’, may help raise its importance in policies, and its acceptance among actors.

Conclusion

Consensus surrounding the framing of ITB will be crucial for the successful adoption of ITB diagnostics and treatment. When designing ITB tools and policies, it will be important to address challenges that pertain to latent TB policies.

DISCOURSES OF HEALTH PROFESSIONALS ON LATENT TUBERCULOSIS INFECTION AND THE USE OF ISONIAZID

ABSTRACT Objective to understand the collective thinking and action of health workers in relation to Latent Tuberculosis Infection and its treatment with Isoniazid. Method qualitative study with 22 health professionals from four cities in Brazil and the Federal District. Data collection occurred through a semi-structured group interview in March 2019, with an average duration of one hour and thirty minutes. Content analysis was performed using the Collective Subject Discourse technique. Results the professionals' discourses revealed uncertainties related to the prevention and treatment of Latent Tuberculosis Infection, the "fear of error" and inadequate forms of use of Isoniazid 300 mg, the power of the decision on the treatment of Latent Tuberculosis Infection, the difficulties of integration between services and the organization of care flows. Conclusion although the emphasis in the professionals' discourse considers objective aspects in the management of Latent Tuberculosis Infection, subjective manifestations related to the need to address the fears that affect the decision about treatment and possible medication errors were identified, among others, and to think about this process in a collaborative way, which considers autonomy in acting, both of professionals and of the person with Latent Tuberculosis Infection.

DISCURSOS DE PROFISSIONAIS DE SAÚDE SOBRE INFECÇÃO LATENTE POR TUBERCULOSE E USO DE ISONIAZIDA

RESUMO Objetivo compreender o pensar e o agir coletivo de trabalhadores da saúde em relação à Infecção Latente por Tuberculose e ao uso da Isoniazida no enfrentamento da doença. Método estudo qualitativo com 22 profissionais de saúde de quatro cidades do Brasil e do Distrito Federal. A coleta de dados ocorreu mediante realização de entrevista coletiva semiestruturada, em março de 2019, com duração média de uma hora e trinta minutos. Realizou-se análise de conteúdo pela técnica do Discurso do Sujeito Coletivo. Resultados os discursos dos profissionais revelaram incertezas relacionadas à prevenção e ao tratamento da Infecção Latente por Tuberculose, ao “medo de errar” e formas inadequadas de uso da Isoniazida 300 mg, ao poder da decisão sobre o tratamento da Infecção Latente por Tuberculose, às dificuldades da integração entre os serviços e à organização de fluxos assistenciais. Conclusão embora a ênfase no discurso dos profissionais considere aspectos objetivos no manejo da Infecção Latente por Tuberculose, foram identificadas, dentre outras, manifestações subjetivas relacionadas à necessidade de trabalhar os receios que afetam a decisão sobre o tratamento e os possíveis erros de medicação, e de pensar esse processo de forma colaborativa, que considere autonomia no agir, tanto dos profissionais quanto da pessoa com Infecção Latente por Tuberculose.

Determinants of losses in the latent tuberculosis infection cascade of care in Brazil

INTRODUCTION

Factors associated with losses in the latent tuberculosis infection (LTBI) cascade of care in contacts of patients with tuberculosis (TB) were investigated in a multicentre prospective cohort from highly endemic regions in Brazil.

METHODS

Close contacts of 1187 patients with culture-confirmed pulmonary TB were prospectively studied between 2015 and 2019, with follow-up of 6-24 months. Data on TB screening by clinical investigation, radiographic examination and interferon-gamma release assay (IGRA) were collected. Multivariable regressions were used to identify determinants of losses in the LTBI cascade.

RESULTS

Among 4145 TB contacts initially identified, 1901 were examined (54% loss). Among those examined, 933 were people living with HIV, ≤5 years old and/or had positive IGRA results, and therefore had a recommendation to start TB preventive treatment (TPT). Of those, 454 (23%) initiated treatment, and 247 (54% of those initiating; 26% of those in whom treatment was recommended) completed TPT. Multivariable regression analysis revealed that living with HIV, illiteracy and black/pardo (brown) race were independently associated with losses in the cascade.

CONCLUSION

There were losses at all LTBI cascade stages, but particularly at the initial screening and examination steps. Close contacts of low socioeconomic status and living with HIV were at heightened risk of not completing the LTBI cascade of care in Brazil.

A simple protocol for tuberculin skin test reading certification

Although tuberculosis preventive therapy is one of the cornerstones for eliminating the disease, many barriers exist in the cascade of care for latent tuberculosis infection, including the need to certify healthcare professionals for reading tuberculin skin tests (TST). This paper proposes and evaluates a simple protocol for TST reading training. Primary care workers from different backgrounds received a 2-hour theoretical course, followed by a practical course on bleb reading. Blebs were obtained by injecting saline into sausages and then in volunteers. A certified trainer then evaluated the effectiveness of this protocol by analyzing the trainees' ability to read TST induration in clinical routine, blinded to each other's readings. Interobserver agreement was analyzed using the Bland-Altman test. The trainees' reading accuracy was calculated using two cut-off points - 5 and 10mm - and the effect of the number of readings was analyzed using a linear mixed model. Eleven healthcare workers read 53 saline blebs and 88 TST indurations, with high agreement for TST reading (0.07mm average bias). Sensitivity was 100% (94.6; 100.0) at 5mm cut-off and 87.3% (75.5; 94.7) at 10mm cut-off. The regression model found no effect of the number of readings [coefficient: -0.007 (-0.055; 0.040)]. A simple training protocol for reading TST with saline blebs simulations in sausages and volunteers was sufficient to achieve accurate TST induration readings, with no effect observed for the number of readings. Training with saline blebs injected into voluntary individuals is safer and easier than the traditional method.

Effects of programmatic interventions to improve the management of latent tuberculosis: a follow up study up to five months after implementation

Background

Less than 19% of those needing tuberculosis (TB) preventive treatment complete it, due to losses in several steps of the cascade of care for latent TB infection. A cluster randomized trial of a programmatic public health intervention to improve management of latent TB infection in household contacts was conducted in Rio de Janeiro. Interventions included contact registry, initial and in-service training, and a TB booklet. We conducted a follow-up study starting one month after the conclusion of this trial, to measure the effect of interventions implemented, and to identify remaining barriers and facilitators to latent TB infection treatment, from different perspectives.

Methods

In two health clinics in Rio de Janeiro that received the interventions in the trial, data for the latent TB infection cascade of care for household contacts was collected over a five-month period. The number of household contacts initiating treatment per 100 index-TB patients was compared with the cascade of care data obtained before and during the intervention trial. Semi-structured open-ended questionnaires were administered to healthcare workers, household contacts and index-TB patients regarding knowledge and perceptions about TB and study interventions.

Results

In this follow-up study, 184 household contacts per 100 index-TB patients were identified. When compared to the intervention period, there were 65 fewer household contacts per 100 index-TB patients, (95% CI -115, − 15) but the number starting latent TB infection treatment was sustained (difference -2, 95% CI -8,5). A total of 31 index-TB patients, 22 household contacts and 19 health care workers were interviewed. Among index-TB patients, 61% said all their household contacts had been tested for latent TB infection. All health care workers said it was very important to test household contacts, and 95% mentioned that possessing correct knowledge on the benefits of latent TB infection treatment was the main facilitator to enable them to recommend this treatment.

Conclusion

In this follow-up study, we observed a sustained effect of interventions to strengthen the latent TB infection cascade of care on increasing the number of household contacts starting latent TB infection treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10195-z.

Exploration of barriers and facilitators to household contact tracing of index tuberculosis cases in Anlemo district, Hadiya zone, Southern Ethiopia: Qualitative study

BACKGROUND

Tuberculosis [TB] is the second leading cause of death from an infectious disease in the world. Intensifying tuberculosis screening and contact investigation strategy is recommended to ensure early diagnosis among household contacts of TB patients. Studies showed that there is low TB contact tracing. There was limited evidence on barriers and facilitators of household contact tracing. Therefore, this study was aimed at exploring barriers and facilitators for household contact tracing of index TB cases.

METHODS

A descriptive qualitative study was conducted at Anlemo district, Hadiya zone, Ethiopia from March 12-April 9, 2019. Purposive sampling technique was used to recruit study participants. A total of 16 participants were involved in the study which included health extension workers [HEWs], index TB patients, household contacts of TB patients, health center TB focal and district TB coordinator. Data were collected through in-depth interviews using a semi-structured guide, transcribed verbatim and translated into English. Inductive thematic analysis was employed using ATLAS.ti7.1 software and the findings were presented on major themes, categories, and quotations.

RESULTS

This study found low TB contact tracing and investigation, and explored barriers and facilitators such as monitoring and supervision, training of health workers, logistics and infrastructure, waiting time and institutional readiness, referral, feedback and linkage, human resource, charge for some laboratory, transportation, budget, knowledge, commitment and motivation, workload, distance, social support, economic constrain, and stigma and discrimination for household contact tracing of index TB cases under four themes.

CONCLUSIONS

From this study, it was understood that there was a gap in addressing all household contacts. Also, the study explored a wide range of possible barriers and facilitators for it. Explored barriers outweigh the facilitators which might have an implication facilitating the dissemination of TB silently within the community. This underscores the importance of taking action to avert those barriers by developing different strategies to increase TB contact tracing. Therefore, health care providers should have to improve the implementation of contact tracing by designing and developing appropriate strategies that should fit the local context.

Determinants of losses in the latent tuberculosis cascade of care in Brazil: A retrospective cohort study

Background:

The present study evaluated factors associated with losses in the latent tuberculosis infection (LTBI) cascade of care in contacts of tuberculosis (TB) patients, in a referral center from a highly endemic region in Brazil.

Methods:

Contacts of 1672 TB patients were retrospectively studied between 2009 and 2014. Data on TB screening by clinical investigation, radiographic examination and tuberculin skin test (TST) were extracted from medical records. Losses in the cascade of care and TB incidence within 2-year follow-up were calculated.

Results:

From a total of 1180 TB contacts initially identified, only 495 were examined (58% loss), and 20 were diagnosed with active TB at this stage. Furthermore, 435 persons returned for TST result interpretation and 351 (~81%) were TST positive. Among those with positive TST, 249 (73%) were treated with isoniazid for 6 months whereas 51 abandoned therapy early. Three individuals who did not receive LTBI treatment, one with incomplete treatment and another who completed treatment developed active TB. A logistic regression analysis revealed that increases in age were associated with losses in the LTBI cascade independent of other clinical and epidemiological characteristics.

Conclusions:

Major losses occur at initial stages and older patients are at higher risk of not completing the LTBI cascade of care.

User experience and patient satisfaction with tuberculosis care in low- and middle-income countries: A systematic review

Background

Patient-centered care is at the forefront of the End TB strategy, yet little is known about user (patient's) experience and patient satisfaction with TB services. Our study aims to systematically review quantitative studies evaluating user experience and TB patient satisfaction within the health care system.

Methods

Five medical databases were systematically searched between January 1st, 2009 and December 31st, 2018. English studies assessing user experience and patient satisfaction within the healthcare system from a TB patient's perspective in low and middle-income countries, were included.

Results

Thirty-five studies from 16 low and middle-income countries evaluated three major themes; facilities and patient centeredness (n = 23), patient-provider relationship (n = 22) and overall satisfaction (n = 19). Overall study quality was low as they used varying tools to measure user experience and patient satisfaction.

Conclusion

Our study shows large variability in measurement of user experiences and patient satisfaction. Studies reported that patients were mostly satisfied with TB care services, and those that were dissatisfied were substantially more likely to be lost to follow-up. The high satisfaction rates could have been due to lack of education on good quality patient care or fear of losing access to health care. A standardized patient centered tool could be designed to help assess user experience and patient satisfaction to allow comparisons among health systems and countries.

Difficulties in tuberculosis infection control in a general hospital of Vietnam: a knowledge, attitude, and practice survey and screening for latent tuberculosis infection among health professionals

BACKGROUND

In Vietnam, a country with a high tuberculosis (TB) burden, health professionals in both TB-specialized and non-TB-specialized general hospitals have a high risk of acquiring TB. The aims of the present study were to clarify the difficulties in TB infection control at non-TB specialized hospitals and whether any associated risks of latent TB infection exist among health professionals in Vietnam.

METHODS

We conducted a cross-sectional study in a national tertiary and general hospital of Hanoi, Vietnam. Participants were health professionals, including physicians, nurses, and other health professionals. We assessed difficulties in TB infection control by conducting a knowledge, attitude, and practice (KAP) survey. We also collected data on the results of tuberculin skin tests (TSTs) conducted during health check-ups for hospital staff to determine whether health professionals had latent TB infection or TB disease. KAP scores were compared among health professional groups (physicians vs. nurses vs. other health professionals). Factors influencing knowledge scores were evaluated using multiple regression analysis.

RESULTS

A total 440 health professionals at the study site participated in the KAP survey, and we collected the results of TSTs from a total of 299 health professionals. We observed a high prevalence of latent TB infection (74.2%), especially among participants in the emergency department. Although participants had high KAP scores, some topics were less understood, such as symptoms and risks of TB, proper use of protective equipment such as N95 respirators, and preventing transmission by patients with confirmed or suspected TB. Factors influencing knowledge scores associated with TB were age, a belief that TB is the most important infectious disease, being a medical professional, having previously attended workshops or seminars, and knowing that Vietnam has a high burden of TB.

CONCLUSION

In a non-TB specialized hospital of Vietnam, we observed a risk of TB infection among health professionals and difficulties in properly controlling TB infection. Early awareness regarding patients with suspected TB, to apply proper measures and prevent transmission, and education regarding obtaining updated knowledge through scientific information are crucial to enhancing TB infection control in general hospitals of Vietnam.

Knowledge, attitudes and practices on tuberculosis transmission and prevention among auxiliary healthcare professionals in three Brazilian high-burden cities: a cross-sectional survey

Background

Tuberculosis elimination requires treatment of latently infected high-risk persons, such as contacts of index cases. Identification and referral of tuberculosis contacts for investigation are major barriers in the contact cascade-of-care. These tasks rely heavily on auxiliary primary healthcare workers in many low- and middle-income countries. We aimed to understand their knowledge, attitudes and practices (KAP) regarding contact investigation in Brazil.

Methods

We conducted a cross-sectional KAP survey on tuberculosis transmission and prevention among 135 auxiliary healthcare workers in three tuberculosis high-burden Brazilian cities. Trained interviewers applied a translated version of a previously applied questionnaire. Open answers were classified in pre-defined objective categories and analysed quantitatively. Answers were further classified as satisfactory or not according to criteria set by a panel of three specialists.

Results

Although 66% had received tuberculosis training in the past 10 years, only 19% were trained for tuberculosis prevention. 64% could not clearly distinguish latent tuberculosis infection (LTBI) from active tuberculosis; 63% did not know how to diagnose LTBI and 52% did not know how to prevent progression to active tuberculosis. Most believed that it is important to investigate adult (99%) and child (96%) contacts for LTBI. However, not all invite contacts - children (81%) or adults (71%) - to the clinic, despite only 24% perceiving difficulties for investigation.

Conclusions

Gaps in KAP among auxiliary health workers have been reported in other areas, such as obstetrics and other infectious diseases. To the best of our knowledge, this is the first KAP survey on tuberculosis transmission and prevention among auxiliary health care workers, and relevant gaps were also found. Knowledge gaps were notably related to LTBI management, including how to recognize it and prevent progression to active tuberculosis through treatment, despite most recognizing the importance of investigating contacts. Auxiliary healthcare workers in three Brazilian high-burden cities have important knowledge gaps despite their perception of the importance of tuberculosis prevention among contacts. They need to incorporate contact referral as one of their tasks to enable progress toward the target of tuberculosis elimination.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4231-x) contains supplementary material, which is available to authorized users.