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Wolde HF, Clements ACA, Alene KA. Development and validation of a risk prediction model for pulmonary tuberculosis among presumptive tuberculosis cases in Ethiopia. BMJ Open 2023; 13:e076587. [PMID: 38101842 PMCID: PMC10729072 DOI: 10.1136/bmjopen-2023-076587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/22/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Early diagnosis and treatment of tuberculosis (TB) is one of the key strategies to achieve the WHO End TB targets. This study aimed to develop and validate a simple, convenient risk score to diagnose pulmonary TB among presumptive TB cases. METHODS This prediction model used Ethiopian national TB prevalence survey data and included 5459 presumptive TB cases from all regions of Ethiopia. Logistic regression was used to determine which variables are predictive of pulmonary TB. A risk prediction model was developed, incorporating significant variables (p<0.05). The Youden Index method was used to choose the optimal cut-off point to separate the risk score of the patients as high and low. Model performance was assessed using discrimination power and calibration. Internal validation of the model was assessed using Efron's enhanced bootstrap method, and the clinical utility of the risk score was assessed using decision curve analysis. RESULTS Of total participants, 94 (1.7%) were confirmed to have TB. The final prediction model included three factors with different scores: (1) TB contact history, (2) chest X-ray (CXR) abnormality and (3) two or more symptoms of TB. The optimal cut-off point for the risk score was 6 and was found to have a good discrimination accuracy (c-statistic=0.70, 95% CI: 0.65 to 0.75). The risk score has sensitivity of 51.1%, specificity of 79.9%, positive predictive value of 4.3% and negative predictive value of 98.9%. After internal validation, the optimism coefficient was 0.003, which indicates the model is internally valid. CONCLUSION We developed a risk score that combines TB contact, number of TB symptoms and CXR abnormality to estimate individual risk of pulmonary TB among presumptive TB cases. Though the score is easy to calculate and internally validated, it needs external validation before widespread implementation in a new setting.
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Affiliation(s)
- Haileab Fekadu Wolde
- School of Population Health, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
- Geospatial and Tuberculosis Research Team, Telethon Kids Institute, Nedlands, Western Australia, Australia
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | | | - Kefyalew Addis Alene
- School of Population Health, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
- Geospatial and Tuberculosis Research Team, Telethon Kids Institute, Nedlands, Western Australia, Australia
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Garg T, Chaisson LH, Naufal F, Shapiro AE, Golub JE. A systematic review and meta-analysis of active case finding for tuberculosis in India. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2022; 7:100076. [PMID: 37383930 PMCID: PMC10305973 DOI: 10.1016/j.lansea.2022.100076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Background Active case finding (ACF) for tuberculosis (TB) is the cornerstone case-finding strategy in India's national TB policy. However, ACF strategies are highly diverse and pose implementation challenges in routine programming. We reviewed the literature to characterise ACF in India; assess the yield of ACF for different risk groups, screening locations, and screening criteria; and estimate losses to follow-up (LTFU) in screening and diagnosis. Methods We searched PubMed, EMBASE, Scopus, and the Cochrane library to identify studies with ACF for TB in India from November 2010 to December 2020. We calculated 1) weighted mean number needed to screen (NNS) stratified by risk group, screening location, and screening strategy; and 2) the proportion of screening and pre-diagnostic LTFU. We assessed risk of bias using the AXIS tool for cross-sectional studies. Findings Of 27,416 abstracts screened, we included 45 studies conducted in India. Most studies were from southern and western India and aimed to diagnose pulmonary TB at the primary health level in the public sector after screening. There was considerable heterogeneity in risk groups screened and ACF methodology across studies. Of the 17 risk groups identified, the lowest weighted mean NNS was seen in people with HIV (21, range 3-89, n=5), tribal populations (50, range 40-286, n=3), household contacts of people with TB (50, range 3-undefined, n=12), people with diabetes (65, range 21-undefined, n=3), and rural populations (131, range 23-737, n=5). ACF at facility-based screening (60, range 3-undefined, n=19) had lower weighted mean NNS than at other screening locations. Using the WHO symptom screen (135, 3-undefined, n=20) had lower weighted mean NNS than using criteria of abnormal chest x-ray or any symptom. Median screening and pre-diagnosis loss-to-follow-up was 6% (IQR 4.1%, 11.3%, range 0-32.5%, n=12) and 9.5% (IQR 2.4%, 34.4%, range 0-86.9%, n=27), respectively. Interpretation For ACF to be impactful in India, its design must be based on contextual understanding. The narrow evidence base available currently is insufficient for effectively targeting ACF programming in a large and diverse country. Achieving case-finding targets in India requires evidence-based ACF implementation. Funding WHO Global TB Programme.
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Affiliation(s)
- Tushar Garg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Lelia H. Chaisson
- Division of Infectious Diseases, Department of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Fahd Naufal
- Wilmer Eye Institute, Johns Hopkins Medicine, Baltimore, MD, United States
| | - Adrienne E. Shapiro
- Department of Global Health and Department of Medicine, University of Washington, Seattle, WA, United States
| | - Jonathan E. Golub
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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Abeid R, Mergenthaler C, Muzuka V, Goodluck A, Nkwabi T, Bigio J, Vasquez N A, Pande T, Haraka F, Creswell J, Rahman T, Straetemans M. Increasing TB/HIV Case Notification through an Active Case-Finding Approach among Rural and Mining Communities in Northwest Tanzania. J Trop Med 2022; 2022:4716151. [PMID: 35432549 PMCID: PMC9007682 DOI: 10.1155/2022/4716151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/03/2022] [Indexed: 11/18/2022] Open
Abstract
While Tanzania is among the high TB burden countries to reach the WHO's End TB 2030 milestones, 41% of the people estimated to have had TB in 2020 were not diagnosed and notified. As part of the response to close the TB treatment coverage gap, SHDEPHA+ Kahama conducted a TB REACH active case-finding (ACF) intervention among rural and mining communities in Northwest Tanzania to increase TB/HIV case notification from July 2017 to June 2020. The intervention successfully linked marginalized mining communities with integrated TB/HIV screening, diagnostic, and referral services, screening 144,707 people for TB of whom 24,200 were tested for TB and 4,478 were tested for HIV, diagnosing 1,499 people with TB and 1,273 people with HIV (including at least 154 people with TB/HIV coinfection). The intervention revealed that community-based ACF can ensure high rates of linkage to care among hard-to-reach populations for TB. Providing integrated TB and HIV screening and diagnostic services during evening hours (Moonlight Events) in and around mining settlements can yield a large number of people with undiagnosed TB and HIV. For TB, this is true not only amongst miners but also FSW living in the same communities, who appear to be at similar or equally high risk of infection. Local NGOs can help to bridge the TB treatment coverage gap and to improve TB and HIV health outcomes by linking these marginalized groups with public sector services. Capturing the number of referrals arriving at CTCs is an important next step to identify how well the integrated TB/HIV outreach services operate and how they can be strengthened.
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Affiliation(s)
- R. Abeid
- SHDEPHA+ Kahama, Shinyanga, Tanzania
| | | | - V. Muzuka
- SHDEPHA+ Kahama, Shinyanga, Tanzania
| | | | - T. Nkwabi
- SHDEPHA+ Kahama, Shinyanga, Tanzania
| | - J. Bigio
- Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Aguilera Vasquez N
- Research Institute of the McGill University Health Centre, Montreal, Canada
| | - T. Pande
- Research Institute of the McGill University Health Centre, Montreal, Canada
| | - F. Haraka
- Ifakara Health Institute, TB Interventions and Clinical Trials Department, Ifakara, Tanzania
- Elizabeth Glaser Pedatric AIDS Foundation, Dar esa Salaam, Tanzania
| | - J. Creswell
- Innovations & Grants Team, Stop TB Partnership, Geneva, Switzerland
| | - T. Rahman
- Innovations & Grants Team, Stop TB Partnership, Geneva, Switzerland
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Accuracy and Incremental Yield of the Chest X-Ray in Screening for Tuberculosis in Uganda: A Cross-Sectional Study. Tuberc Res Treat 2021; 2021:6622809. [PMID: 33828862 PMCID: PMC8004368 DOI: 10.1155/2021/6622809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 03/02/2021] [Accepted: 03/08/2021] [Indexed: 11/17/2022] Open
Abstract
The WHO END TB strategy requires ≥90% case detection to combat tuberculosis (TB). Increased TB case detection requires a more sensitive and specific screening tool. Currently, the symptoms recommended for screening TB have been found to be suboptimal since up to 44% of individuals with TB are asymptomatic. The chest X-ray (CXR) as a screening tool for pulmonary TB was evaluated in this study, as well as its incremental yield in TB diagnosis using a cross-sectional study involving secondary analysis of data of 4512 consented/assented participants ≥15 years who participated in the Uganda National TB prevalence survey between 2014 and 2015. Participants with a cough ≥2 weeks, fever, weight loss, and night sweats screened positive for TB using the symptoms screening method, while participants with a TB defining abnormality on CXR screened positive for TB by the CXR screening method. The Löwenstein-Jensen (LJ) culture was used as a gold standard for TB diagnosis. The CXR had 93% sensitivity and 65% specificity compared to LJ culture results, while symptoms had 76% sensitivity and 31% specificity. The screening algorithm involving the CXR in addition to symptoms led to a 38% increment in the yield of diagnosed tuberculosis. The number needed to screen using the CXR and symptoms screening algorithm was 32 compared to 45 when the symptoms are used alone. Therefore, the CXR in combination with symptoms is a good TB screening tool and increases the yield of diagnosed TB.
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Singh AA, Creswell J, Bhatia V. Framework for planning and monitoring active TB case finding interventions to meet the global targets in the COVID-19 era and beyond: South-East Asia perspective. PLOS GLOBAL PUBLIC HEALTH 2021; 1:e0000073. [PMID: 36962114 PMCID: PMC10021227 DOI: 10.1371/journal.pgph.0000073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There was an estimated 20-40% decline in tuberculosis (TB) case detection in the South-East Asia Region (SEA Region) during 2020 due to COVID-19 outbreak. This is over and above a million people with TB who were missed each year, prior to the pandemic. Active case finding (ACF) for TB has been gaining considerable interest and investment in the SEA Region and will be even more essential for finding people with TB missed due to the COVID-19 pandemic. Many countries in the Region have incorporated ACF activities into national strategic plans and are conducting large scale activities with varying results. ACF can reach people with TB earlier than routine approaches, can lead to increases in the numbers of people diagnosed, and is often needed for certain key populations who face stigma, social, and economic barriers. However, ACF is not a one size fits all approach, and has higher costs than routine care. So, planning interventions in consultation with relevant stakeholders including the affected communities is critical. Furthermore, continuous monitoring during the intervention and after completion is crucial as national TB programmes review progress and decide on the effective utilization of limited resources. Planning and monitoring become more relevant in the COVID-19 era because of constraints posed by resource diversion towards pandemic control. Here, we summarize different aspects of planning and monitoring of ACF approaches to inform national TB programmes and partners based on experiences in the SEA Region, as programmes look to reach those who are missed and catch-up on progress towards ending TB.
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Affiliation(s)
| | | | - Vineet Bhatia
- South-East Asia Regional Office, World Health Organization, New Delhi, India
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Nguyen LH, Codlin AJ, Vo LNQ, Dao T, Tran D, Forse RJ, Vu TN, Le GT, Luu T, Do GC, Truong VV, Minh HDT, Nguyen HH, Creswell J, Caws M, Nguyen HB, Nguyen NV. An Evaluation of Programmatic Community-Based Chest X-ray Screening for Tuberculosis in Ho Chi Minh City, Vietnam. Trop Med Infect Dis 2020; 5:tropicalmed5040185. [PMID: 33321696 PMCID: PMC7768495 DOI: 10.3390/tropicalmed5040185] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/28/2020] [Accepted: 11/12/2020] [Indexed: 02/08/2023] Open
Abstract
Across Asia, a large proportion of people with tuberculosis (TB) do not report symptoms, have mild symptoms or only experience symptoms for a short duration. These individuals may not seek care at health facilities or may be missed by symptom screening, resulting in sustained TB transmission in the community. We evaluated the yields of TB from 114 days of community-based, mobile chest X-ray (CXR) screening. The yields at each step of the TB screening cascade were tabulated and we compared cohorts of participants who reported having a prolonged cough and those reporting no cough or one of short duration. We estimated the marginal yields of TB using different diagnostic algorithms and calculated the relative diagnostic costs and cost per case for each algorithm. A total of 34,529 participants were screened by CXR, detecting 256 people with Xpert-positive TB. Only 50% of those diagnosed with TB were detected among participants reporting a prolonged cough. The study’s screening algorithm detected almost 4 times as much TB as the National TB Program’s standard diagnostic algorithm. Community-based, mobile chest X-ray screening can be a high yielding strategy which is able to identify people with TB who would likely otherwise have been missed by existing health services.
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Affiliation(s)
- Lan Huu Nguyen
- Pham Ngoc Thach Hospital, Ho Chi Minh City 700 000, Vietnam; (L.H.N.); (G.C.D.); (V.V.T.); (H.D.T.M.)
| | - Andrew J. Codlin
- Friends for International TB Relief, Ho Chi Minh City 700 000, Vietnam; (L.N.Q.V.); (D.T.); (R.J.F.)
- Correspondence: ; Tel.: +84-352512847
| | - Luan Nguyen Quang Vo
- Friends for International TB Relief, Ho Chi Minh City 700 000, Vietnam; (L.N.Q.V.); (D.T.); (R.J.F.)
- Interactive Research and Development, Singapore 238884, Singapore
| | - Thang Dao
- IRD VN, Ho Chi Minh City 700 000, Vietnam;
| | - Duc Tran
- Friends for International TB Relief, Ho Chi Minh City 700 000, Vietnam; (L.N.Q.V.); (D.T.); (R.J.F.)
| | - Rachel J. Forse
- Friends for International TB Relief, Ho Chi Minh City 700 000, Vietnam; (L.N.Q.V.); (D.T.); (R.J.F.)
| | - Thanh Nguyen Vu
- Ho Chi Minh City Public Health Association, Ho Chi Minh City 700 000, Vietnam; (T.N.V.); (G.T.L.)
| | - Giang Truong Le
- Ho Chi Minh City Public Health Association, Ho Chi Minh City 700 000, Vietnam; (T.N.V.); (G.T.L.)
| | - Tuan Luu
- Clinton Health Access Initiative Vietnam, Ha Noi 100 000, Vietnam;
| | - Giang Chau Do
- Pham Ngoc Thach Hospital, Ho Chi Minh City 700 000, Vietnam; (L.H.N.); (G.C.D.); (V.V.T.); (H.D.T.M.)
| | - Vinh Van Truong
- Pham Ngoc Thach Hospital, Ho Chi Minh City 700 000, Vietnam; (L.H.N.); (G.C.D.); (V.V.T.); (H.D.T.M.)
| | - Ha Dang Thi Minh
- Pham Ngoc Thach Hospital, Ho Chi Minh City 700 000, Vietnam; (L.H.N.); (G.C.D.); (V.V.T.); (H.D.T.M.)
| | - Hung Huu Nguyen
- Ho Chi Minh City Department of Health, Ho Chi Minh City 700 000, Vietnam;
| | | | - Maxine Caws
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK;
- Birat Nepal Medical Trust Nepal, Kathmandu 44600, Nepal
| | - Hoa Binh Nguyen
- Viet Nam National Lung Hospital, Ha Noi 100 000, Vietnam; (H.B.N.); (N.V.N.)
| | - Nhung Viet Nguyen
- Viet Nam National Lung Hospital, Ha Noi 100 000, Vietnam; (H.B.N.); (N.V.N.)
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