Implementation of latent tuberculosis infection screening and treatment among newly arriving immigrants in the Netherlands: A mixed methods pilot evaluation

Interventions to improve latent and active tuberculosis treatment completion rates in underserved groups in low incidence countries: a scoping review

BACKGROUND

People in underserved groups have higher rates of tuberculosis (TB) and poorer treatment outcomes compared with people with no social risk factors.

OBJECTIVES

This scoping review aimed to identify interventions that improve TB treatment adherence or completion rates.

ELIGIBILITY CRITERIA

Studies of any design focusing on interventions to improve adherence or completion of TB treatment in underserved populations in low incidence countries.

SOURCES OF EVIDENCE

MEDLINE, Embase and Cochrane CENTRAL were searched (January 2015 to December 2023).

CHARTING METHODS

Piloted data extraction forms were used. Findings were tabulated and reported narratively. Formal risk of bias assessment or synthesis was not undertaken.

RESULTS

47 studies were identified. There was substantial heterogeneity in study design, population, intervention components, usual care and definition of completion rates. Most studies were in migrants or refugees, with fewer in populations with other risk factors (eg, homelessness, imprisonment or substance abuse). Based on controlled studies, there was limited evidence to suggest that shorter treatment regimens, video-observed therapy (compared with directly observed therapy), directly observed therapy (compared with self-administered treatment) and approaches that include tailored health or social support beyond TB treatment may lead to improved outcomes. This evidence is mostly observational and subject to confounding. There were no studies in Gypsy, Roma and Traveller populations, or individuals with mental health disorders and only one in sex workers. Barriers to treatment adherence included a lack of knowledge around TB, lack of general health or social support and side effects. Facilitators included health education, trusted relationships between patients and healthcare staff, social support and reduced treatment duration.

CONCLUSIONS

The evidence base is limited, and few controlled studies exist. Further high-quality research in well-defined underserved populations is needed to confirm the limited findings and inform policy and practice in TB management. Further qualitative research should include more people from underserved groups.

Pediatric Tuberculosis Infection Care Facilitators and Barriers: A Qualitative Study

BACKGROUND

A total of 700 000 US children and adolescents are estimated to have latent tuberculosis (TB) infection. Identifying facilitators and barriers to engaging in TB infection care is critical to preventing pediatric TB disease. We explored families' and clinicians' perspectives on pediatric TB infection diagnosis and care.

METHODS

We conducted individual interviews and small group discussions with primary care and subspecialty clinicians, and individual interviews with caregivers of children diagnosed with TB infection. We sought to elicit facilitators and barriers to TB infection care engagement. We used applied thematic analysis to elucidate themes relating to care engagement, and organized themes using a cascade-grounded pediatric TB infection care engagement framework.

RESULTS

We enrolled 19 caregivers and 24 clinicians. Key themes pertaining to facilitators and barriers to care emerged that variably affected engagement at different steps of care. Clinic and health system themes included the application of risk identification strategies and communication of risk; care ecosystem accessibility; programs to reduce cost-related barriers; and medication adherence support. Patient- and family-level themes included TB knowledge and beliefs; trust in clinicians, tests, and medical institutions; behavioral skills; child development and parenting; and family resources.

CONCLUSIONS

Risk identification, education techniques, trust, family resources, TB stigma, and care ecosystem accessibility enabled or impeded care cascade engagement. Our results delineate an integrated pediatric TB infection care engagement framework that can inform multilevel interventions to improve retention in the pediatric TB infection care cascade.

Mandatory, voluntary, repetitive, or one-off post-migration follow-up for tuberculosis prevention and control: A systematic review

BACKGROUND

Post-migration follow-up of migrants identified to be at-risk of developing tuberculosis during the initial screening is effective, but programmes vary across countries. We aimed to review main strategies applied to design follow-up programmes and analyse the effect of key programme characteristics on reported coverage (i.e., proportion of migrants screened among those eligible for screening) or yields (i.e., proportion of active tuberculosis among those identified as eligible for follow-up screening).

METHODS AND FINDINGS

We performed a systematic review and meta-analysis of studies reporting yields of follow-up screening programmes. Studies were included if they reported the rate of tuberculosis disease detected in international migrants through active case finding strategies and applied a post-migration follow-up (defined as one or more additional rounds of screening after finalising the initial round). For this, we retrieved all studies identified by Chan and colleagues for their systematic review (in their search until January 12, 2017) and included those reporting from active follow-up programmes. We then updated the search (from January 12, 2017 to September 30, 2022) using Medline and Embase via Ovid. Data were extracted on reported coverage, yields, and key programme characteristics, including eligible population, mode of screening, time intervals for screening, programme providers, and legal frameworks. Differences in follow-up programmes were tabulated and synthesised narratively. Meta-analyses in random effect models and exploratory analysis of subgroups showed high heterogeneity (I2 statistic > 95.0%). We hence refrained from pooling, and estimated yields and coverage with corresponding 95% confidence intervals (CIs), stratified by country, legal character (mandatory versus voluntary screening), and follow-up scheme (one-off versus repetitive screening) using forest plots for comparison and synthesis. Of 1,170 articles, 24 reports on screening programmes from 7 countries were included, with considerable variation in eligible populations, time intervals of screening, and diagnostic protocols. Coverage varied, but was higher than 60% in 15 studies, and tended to be lower in voluntary compared to compulsory programmes, and higher in studies from the United States of America, Israel, and Australia. Yield varied within and between countries and ranged between 53.05 (31.94 to 82.84) in a Dutch study and 5,927.05 (4,248.29 to 8,013.71) in a study from the United States. Of 15 estimates with narrow 95% CIs for yields, 12 were below 1,500 cases per 100,000 eligible migrants. Estimates of yields in one-off follow-up programmes tended to be higher and were surrounded by less uncertainty, compared to those in repetitive follow-up programmes. Yields in voluntary and mandatory programmes were comparable in magnitude and uncertainty. The study is limited by the heterogeneity in the design of the identified screening programmes as effectiveness, coverage and yields also depend on factors often underreported or not known, such as baseline incidence in the respective population, reactivation rate, educative and administrative processes, and consequences of not complying with obligatory measures.

CONCLUSION

Programme characteristics of post-migration follow-up screening for prevention and control of tuberculosis as well as coverage and yield vary considerably. Voluntary programmes appear to have similar yields compared with mandatory programmes and repetitive screening apparently did not lead to higher yields compared with one-off screening. Screening strategies should consider marginal costs for each additional round of screening.

"It's too hard" - the management of latent TB in under-served populations in the UK: a qualitative study

BACKGROUND

UK national guidance recommends systematic screening for latent tuberculosis infection (LTBI) in under-served populations, including people experiencing homelessness and people who use drugs. This is not routinely implemented in the UK, and the reasons for this policy-practice mismatch remain underexplored.

METHODS

Semi-structured qualitative interviews were conducted with 19 healthcare professionals from across the UK. Participants were recruited using purposive sampling and snowballing, identifying individuals with excellent knowledge of their regions practice and policy of LTBI management. The interviews were conducted online, and were audio recorded, with transcripts thematically analysed using a two-stage inductive coding process to explore perceived barriers and enablers to LTBI screening.

RESULTS

Most participants had previous experience managing LTBI in under-served populations, but none were conducting systematic screening as per national guidance. We identified service provision challenges and low prioritisation of LTBI as the key explanatory themes driving this policy-practice mismatch. Lack of resource, and the complexity of clinical decision making were two key service level barriers. System and service inertia, and lack of cost effectiveness evidence led to LTBI being deprioritised. Service integration and promotion of WHO targets for TB elimination were highlighted as potential solutions.

CONCLUSION

Integrating LTBI testing and treatment with existing health services for under-served populations could improve feasibility and efficacy. Promotion of UK TB elimination goals and generation of regional evidence to support commissioning for LTBI care is vital. Without such a multi-pronged approach inertia is likely to persist and the zeitgeist will remain: "it's too hard".

Fragmentation of Healthcare Services as a Possible Determinant of the Low Completion for the Tuberculosis Cascade of Prevention among Asylum Seekers: Results from a Prospective Study with Historical Comparison

Background: Effective screening for tuberculosis infection (TBI) among asylum seekers (AS) is crucial for tuberculosis (TB) elimination in low incidence countries. Methods: We assessed the proportion of completion of the screening for TBI among asylum seekers with a centralized delivery method compared to the decentralized model previously adopted in the study area (historical control). In the historical model (January 2017 to May 2018) screening of AS was performed at the arrival offering TBI testing (TST followed by IGRA among those positive), radiological investigation, treatment initiation and hospital referral, if needed, at three sites: migrant health clinic, pneumology clinic and infectious diseases department for active disease (decentralized model). In the study model (June 2018, centralized) all steps of screening were performed at a single site, at a minimum of 6 months after arrival. Multivariable Poisson regression analysis, with robust variance, was used to assess variables associated with the completion of screening for infection. Multivariable logistic regression was used to identify factors associated with the diagnosis of TB infection. Results: The intervention approach was offered to 144 AS with an overall 98.6% proportion of completion (98.7% for those with a positive TST). In the historical screening model, 1192 AS were candidates for screening, which was completed by 74.5% of those who started it (44.7% for those resulted TST positive). Major losses (55%) were detected in the TST/CXR-IGRA sequential step, followed by the execution of TST test (25%). The ratio of screening completion was significantly higher in the intervention period (aIRR 1.78, 95% CI 1.68–1.88) and for AS coming from high incidence TB countries (aIRR 1.14, 95% CI 1.04–1.25). Screening after 6 months from arrival and age were associated with TB infection (2.09, 95% CI 1.36–3.2 and 1.14, 95% CI 1.01–1.29). Conclusions: Screening for TBI can be improved by a centralized approach. Higher prevalence of TBI 6 months after arrival could reflect recent (either during travel or in Italy) acquisition of the infection.

Barriers and enablers to implementing tuberculosis control strategies in EU and European Economic Area countries: a systematic review

Meeting the 2035 WHO targets of reducing tuberculosis incidence by 90% from 2015 levels requires the implementation of country-specific tuberculosis control strategies. This systematic review aims to identify factors that facilitate or impede the implementation of such strategies in EU and European Economic Area (EEA) settings. Focusing on providers of care, health system constraints, and social and political factors, this Review complements available evidence on the accessibility of tuberculosis services to recipients of care. Databases were searched for EU and EEA articles published between Jan 1, 1997, and Nov 6, 2020, that presented empirical data on tuberculosis policies, strategies, guidelines, or interventions. 2061 articles were screened and 65 were included. The most common barrier to tuberculosis control strategies described the divergence of health-care practices from guidelines, often related to inadequate knowledge or perceived usefulness of the guidelines by clinicians. The most commonly identified enabler to tuberculosis control strategies was the documented positive attitudes of health-care workers towards tuberculosis programmes. Divergence between clinical practice and guidelines was described in most EU and EEA settings, indicating the need for a focused review of guideline adherence. Strengths of this study involve its broad inclusion criteria and wide range of tuberculosis control strategies analysed.

Initiation and completion of treatment for latent tuberculosis infection in migrants globally: a systematic review and meta-analysis

Background

Latent tuberculosis infection (LTBI) is one of the most prevalent infections globally and can lead to the development of active tuberculosis disease. In many low-burden countries, LTBI is concentrated within migrant populations often because of a higher disease burden in the migrant's country of origin. National programmes consequently focus on screening and treating LTBI in migrants to prevent future tuberculosis cases; however, how effective these programmes are is unclear. We aimed to assess LTBI treatment initiation and outcomes among migrants, and the factors that influence both.

Methods

For this systematic review and meta-analysis, we searched Embase, MEDLINE, and Global Health, and manually searched grey literature from Jan 1, 2000, to April 21, 2020. We included primary research articles reporting on LTBI treatment initiation or completion, or both, in migrants and excluded articles in which data were not stratified by migrant status, or in which the data were related to outcomes before 2000. There were no geographical or language restrictions. All included studies were quality appraised using recognised tools depending on their design, and we assessed the heterogeneity of analyses using I². We extracted data on the numbers of migrants initiating and completing treatment. Our primary outcomes were LTBI treatment initiation and completion in migrants (defined as foreign-born). We used random-effects meta-regression to examine the influence of factors related to these outcomes. The study is registered with PROSPERO (CRD42019140338).

Findings

2199 publications were retrieved screened, after which 39 publications from 13 mostly high-income, low-burden countries were included in our analyses, with treatment initiation and completion data reported for 31 598 migrants positive for LTBI, with not all articles reporting the full pathway from initiation to completion. The pooled estimate for the true proportion of migrants testing positive who initiated treatment was 69% (95% CI 51–84; I²= 99·62%; 4409 of 8764). The pooled estimate for the true proportion of migrants on treatment in datasets, who subsequently completed it was 74% (95% CI = 66–81; I²= 99·19%; 15 516 of 25 629). Where data were provided for the entire treatment pathway, the pooled estimate for the true proportion of migrants who initiated and completed treatment after a positive test was only 52% (95% CI 40–64; I²= 98·90%; 3289 of 6652). Meta-regression showed that LTBI programmes are improving, with more recent reported data (2010–20) associated with better rates of treatment initiation and completion, with multiple complex factors affecting treatment outcomes in migrants.

Interpretation

Although our analysis highlights that LTBI treatment initiation and completion in migrants has improved considerably from 2010–20, there is still room for improvement, with drop out reported along the entire treatment pathway. The delivery of these screening and treatment programmes will require further strengthening if the targets to eradicate tuberculosis in low-incidence countries are to be met, with greater focus needed on engaging migrants more effectively in the clinic and understanding the diverse and unique barriers and facilitators to migrants initiating and completing treatment.

Funding

European Society of Clinical Microbiology and Infectious Diseases, the Rosetrees Trust, the National Institute for Health Research, and the Academy of Medical Sciences.

A scoping review of paediatric latent tuberculosis infection care cascades: initial steps are lacking

BACKGROUND AND OBJECTIVES

Identifying and treating children with latent tuberculosis infection (TB infection) is critical to prevent progression to TB disease and to eliminate TB globally. Diagnosis and treatment of TB infection requires completion of a sequence of steps, collectively termed the TB infection care cascade. There has been no systematic attempt to comprehensively summarise literature on the paediatric TB infection care cascade.

METHODS

We performed a scoping review of the paediatric TB infection care cascade. We systematically searched PubMed, Cumulative Index to Nursing and Allied Health Literature, Cochrane and Embase databases. We reviewed articles and meeting abstracts that included children and adolescents ≤21 years old who were screened for or diagnosed with TB infection, and which described completion of at least one step of the cascade. We synthesised studies to identify facilitators and barriers to retention, interventions to mitigate attrition and knowledge gaps.

RESULTS

We identified 146 studies examining steps in the paediatric TB infection care cascade; 31 included children living in low-income and middle-income countries. Most literature described the final cascade step (treatment initiation to completion). Studies identified an array of patient and caregiver-related factors associated with completion of cascade steps. Few health systems factors were evaluated as potential predictors of completion, and few interventions to improve retention were specifically tested.

CONCLUSIONS

We identified strengths and gaps in the literature describing the paediatric TB infection care cascade. Future research should examine cascade steps upstream of treatment initiation and focus on identification and testing of at-risk paediatric patients. Additionally, future studies should focus on modifiable health systems factors associated with attrition and may benefit from use of behavioural theory and implementation science methods to improve retention.

Towards elimination of childhood and adolescent tuberculosis in the Netherlands: an epidemiological time-series analysis of national surveillance data

BACKGROUND

Tuberculosis (TB) in children and adolescents is a sentinel event for ongoing transmission. In the Netherlands, epidemiological characteristics of childhood and adolescent TB have not been fully evaluated. Therefore, we aimed to assess TB epidemiology within this population to provide guidance for TB elimination.

METHODS

A retrospective time-series analysis using national surveillance data from 1993-2018 was performed in children (aged <15 years) and adolescents (aged 15-19 years) with TB. Poisson regression models offset with log-population size were used to estimate notification rates and rate ratios. Trends in notification rates were estimated using average annual percentage changes (AAPC) based on the segmented linear regression analysis.

RESULTS

Among 3899 children and adolescents with TB notified during 1993-2018, 2418 (62%) were foreign-born (725 (41.3%) out of 1755 children and 1693 (78.9%) out of 2144 adolescents). The overall notification rate in children was 2.3 per 100 000 person-years, declining steadily during the study period (AAPC -10.9%, 95% CI -12.6--9.1). In adolescents, the overall notification rate was 8.4 per 100 000 person-years, strongly increasing during 1993-2001 and 2012-2018. Compared to Dutch-born children and adolescents, substantially higher notification rates were observed among African-born children and adolescents (116.8 and 316.6 per 100 000 person-years, respectively). Additionally, an increasing trend was observed in African-born adolescents (AAPC 18.5%, 95% CI 11.9-25.5). Among the foreign-born population, those from countries in the horn of Africa contributed most to the TB caseload.

CONCLUSION

TB notification rate among children was low and constantly declining across different demographic groups. However, heterogeneities were shown in adolescents, with an increasing trend in the foreign-born, particularly those from Africa.

Knowledge, attitudes, beliefs, and stigma related to latent tuberculosis infection: a qualitative study among Eritreans in the Netherlands

Background

Tailored and culturally appropriate latent tuberculosis (TB) infection screening and treatment programs, including interventions against TB stigma, are needed to reduce TB incidence in low TB incidence countries. However, we lack insights in stigma related to latent TB infection (LTBI) among target groups, such as asylum seekers and refugees. We therefore studied knowledge, attitudes, beliefs, and stigma associated with LTBI among Eritrean asylum seekers and refugees in the Netherlands.

Methods

We used convenience sampling to interview adult Eritrean asylum seekers and refugees: 26 semi-structured group interviews following TB and LTBI related health education and LTBI screening, and 31 semi-structured individual interviews with Eritreans during or after completion of LTBI treatment (November 2016–May 2018). We used a thematic analysis to identify, analyse and report patterns in the data.

Results

Despite TB/LTBI education, misconceptions embedded in cultural beliefs about TB transmission and prevention persisted. Fear of getting infected with TB was the cause of reported enacted (isolation and gossip) and anticipated (concealment of treatment and self-isolation) stigma by participants on LTBI treatment.

Conclusion

The inability to differentiate LTBI from TB disease and consequent fear of getting infected by persons with LTBI led to enacted and anticipated stigma comparable to stigma related to TB disease among Eritreans. Additional to continuous culturally sensitive education activities, TB prevention programs should implement evidence-based interventions reducing stigma at all phases in the LTBI screening and treatment cascade.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12889-020-09697-z.

[Contact tracing in patients infected with SARS-CoV-2. The fundamental role of Primary Health Care and Public Health]

Con el objetivo de favorecer la rápida identificación de los contactos de pacientes infectados por SARS-CoV-2 y por tanto el control de la pandemia, se revisaron diferentes metodologías y recomendaciones sobre estudio de contactos (EECC) aplicables a la Atención Primaria (AP) y a la Salud Pública (SP): artículos en Pubmed sobre COVID-19 y EECC, definiciones de contacto en documentos oficiales, el sistema clásico de EECC en tuberculosis (TB), informaciones sobre apps para EECC y el papel de las pruebas diagnósticas.

Para establecer medidas de prevención y control eficientes, se precisa actuar siempre bajo sospecha clínica, diagnóstico y aislamiento precoz de los casos y de los contactos y su seguimiento. El modelo clásico de EECC en TB es aplicable a esta nueva infección pero acelerando el proceso dado su carácter agudo y su potencial gravedad. Es imprescindible una buena coordinación entre AP y SP y disponer de recursos suficientes.

Strategies to reach and motivate migrant communities at high risk for TB to participate in a latent tuberculosis infection screening program: a community-engaged, mixed methods study among Eritreans

Background

In the Netherlands, migrant populations with a high tuberculosis (TB) incidence are an important target group for TB prevention. However, there is a lack of insight in effective community-engaged strategies to reach and motivate these migrants to participate in latent TB infection (LTBI) screening and treatment programs.

Methods

In cocreation with Eritrean key figures and TB staff, we designed and executed six strategies to reach and motivate Eritrean communities to participate in LTBI programs, in five regions in the Netherlands. We registered participation in LTBI education and screening, and LTBI treatment uptake and completion. We used semi-structured group and individual interviews with Eritrean participants, key figures, and TB staff to identify facilitators and barriers.

Results

Uptake of LTBI education (13–75%) and consequent screening (10–124%) varied between strategies. LTBI screening uptake > 100% resulted from educated participants motivating others to participate in screening. Two strategies, using face-to-face promotion and targeting smaller groups, were the most successful. The program resulted in high LTBI treatment initiation and completion (both 97%). Reported program barriers included: competing priorities in the target group, perceived good health, poor risk perception, and scepticism towards the program purpose. TB staff perceived the program as useful but demanding in terms of human resources.

Conclusions

Eritrean migrant communities can be successfully reached and motivated for LTBI screening and treatment programs, when sufficient (human) resources are in place and community members, well-connected to and trusted by the community, are engaged in the design and execution of the program.

Latent tuberculosis screening and treatment among asylum seekers: a mixed-methods study

Introduction

Evidence on conditions for implementation of latent tuberculosis infection (LTBI) screening and treatment among asylum seekers is needed to inform tuberculosis (TB) control policies. We used mixed-methods to evaluate the implementation of an LTBI screening and treatment programme among asylum seekers in the Netherlands.

Methods

We offered voluntary LTBI screening to asylum seekers aged ≥12 years living in asylum seeker centres from countries with a TB incidence >200 per 10 000 population. We calculated LTBI screening and treatment cascade coverage, and assessed associated factors with Poisson regression using robust variance estimators. We interviewed TB care staff (seven group interviews) and Eritrean clients (21 group and 21 individual interviews) to identify programme enhancers and barriers.

Results

We screened 719 (63% of 1136) clients for LTBI. LTBI was diagnosed among 178 (25%) clients; 149 (84%) initiated LTBI treatment, of whom 129 (87%) completed treatment. In-person TB and LTBI education, the use of professional interpreters, and collaboration with partner organisations were enhancers for LTBI screening uptake. Demand-driven LTBI treatment support by TB nurses enhanced treatment completion. Factors complicating LTBI screening and treatment were having to travel to public health services, language barriers and moving from asylum seeker centres to the community during treatment.

Conclusion

LTBI screening and treatment of asylum seekers is feasible and effective when high quality of care is provided, including culture-sensitive TB education throughout the care cascade. Additionally, collaboration with partner organisations, such as agencies responsible for reception and support of asylum seekers, should be in place.