COVID-19 Pandemic Disruption on the Management of Tuberculosis Treatment in Indonesia

The global impact of COVID-19 on tuberculosis: A thematic scoping review, 2020-2023

BACKGROUND

This thematic scoping review of publications sought to understand the global impact of COVID-19 on tuberculosis (TB), interpret the scope of resonating themes, and offer policy recommendations to stimulate TB recovery and future pandemic preparedness.

DATA SOURCES

Publications were captured from three search engines, PubMed, EBSCO, and Google Scholar, and applicable websites written in English from January 1, 2020, to April 30, 2023.

STUDY SELECTION

Our scoping review was limited to publications detailing the impact of COVID-19 on TB. Original research, reviews, letters, and editorials describing the deleterious and harmful--yet sometimes positive--impact of COVID-19 (sole exposure) on TB (sole outcome) were included. The objective was to methodically categorize the impacts into themes through a comprehensive review of selected studies to provide significant health policy guidance.

DATA EXTRACTION

Two authors independently screened citations and full texts, while the third arbitrated when consensus was not met. All three performed data extraction.

DATA SYNTHESIS/RESULTS

Of 1,755 screened publications, 176 (10%) covering 39 countries over 41 months met the inclusion criteria. By independently using a data extraction instrument, the three authors identified ten principal themes from each publication. These themes were later finalized through a consensus decision. The themes encompassed TB's care cascade, patient-centered care, psychosocial issues, and health services: 1) case-finding and notification (n = 45; 26%); 2) diagnosis and laboratory systems (n = 19; 10.7%) 3) prevention, treatment, and care (n = 22; 12.2%); 4) telemedicine/telehealth (n = 12; 6.8%); 5) social determinants of health (n = 14; 8%); 6) airborne infection prevention and control (n = 8; 4.6%); 7) health system strengthening (n = 22; 13%); 8) mental health (n = 13; 7.4%); 9) stigma (n = 11; 6.3%); and 10) health education (n = 10; 5.7%).

LIMITATIONS

Heterogeneity of publications within themes.

CONCLUSIONS

We identified ten globally generalizable themes of COVID-19's impact on TB. The impact and lessons learned from the themed analysis propelled us to draft public health policy recommendations to direct evidence-informed guidance that strengthens comprehensive global responses, recovery for TB, and future airborne pandemic preparedness.

"I pity the TB patient": a mixed methods study assessing the impact of the COVID-19 pandemic on TB services in two major Indonesian cities and distilling lessons for the future

INTRODUCTION

In Indonesia, a country with around 280 million people and the second-highest tuberculosis (TB) incidence rate in the world, the impact of the COVID-19 pandemic on TB care needs careful assessment so that future response strategies can be strengthened. We conducted a study comparing TB testing and treatment rates before and during the first 2 years of the COVID-19 pandemic in Indonesia, and the reasons for any disruptions to care.

METHODS

We conducted retrospective secondary data analysis and qualitative interviews in Yogyakarta and Bandung, Indonesia. Routine data on TB testing and treatment were sourced from the national TB information system operated by the Indonesian Ministry of Health. TB testing and treatment outcomes were compared between two time periods: pre-COVID (2018-19); and during COVID-19 (2020-21). In-depth interviews were conducted with patients and health workers to explore their experiences in accessing and providing TB services during the pandemic.

RESULTS

There was a 45% (21 937/39 962) reduction in the number of patients tested for TB during the pandemic compared with pre-COVID-19, while the proportion of TB tests returning a positive result increased from 12% (4733/39 962) to 50% (10 945/21 937). The proportion of TB patients completing treatment increased by 2.6% during the pandemic, yet the proportion cured and the number of patients successfully treated both decreased (by 7% and 4.4%, respectively). Our qualitative interviews highlighted several factors influencing TB service access and delivery, including fear of being diagnosed with COVID-19 during TB-related clinic visits, fear of COVID-19 exposure among patients and health workers, healthcare facilities prioritising COVID-19 over other services, and mandatory mobility restrictions affecting both patients and health workers.

CONCLUSION

The COVID-19 pandemic impacted TB testing and treatment outcomes in Bandung and Yogyakarta. Policymakers should consider these findings in designing strategies to ensure TB services are maintained and supported during future health crises.

Evaluation of radiological capacity and usage in paediatric TB diagnosis: A mixed-method protocol of a comparative study in Mozambique, South Africa and Spain

INTRODUCTION

Tuberculosis remains one of the top ten causes of mortality globally. Children accounted for 12% of all TB cases and 18% of all TB deaths in 2022. Paediatric TB is difficult to diagnose with conventional laboratory tests, and chest radiographs remain crucial. However, in low-and middle-income countries with high TB burden, the capacity for radiological diagnosis of paediatric TB is rarely documented and data on the associated radiation exposure limited.

METHODS

A multicentre, mixed-methods study is proposed in three countries, Mozambique, South Africa and Spain. At the national level, official registry databases will be utilised to retrospectively compile an inventory of licensed imaging resources (mainly X-ray and Computed Tomography (CT) scan equipment) for the year 2021. At the selected health facility level, three descriptive cross-sectional standardised surveys will be conducted to assess radiology capacity, radiological imaging diagnostic use for paediatric TB diagnosis, and radiation protection optimization: a site survey, a clinician-targeted survey, and a radiology staff-targeted survey, respectively. At the patient level, potential dose optimisation will be assessed for children under 16 years of age who were diagnosed and treated for TB in selected sites in each country. For this component, a retrospective analysis of dosimetry will be performed on TB and radiology data routinely collected at the respective sites. National inventory data will be presented as the number of units per million people by modality, region and country. Descriptive analyses will be conducted on survey data, including the demographic, clinical and programmatic characteristics of children treated for TB who had imaging examinations (chest X-ray (CXR) and/or CT scan). Dose exposure analysis will be performed by children's age, gender and disease spectrum.

DISCUSSION

As far as we know, this is the first multicentre and multi-national study to compare radiological capacity, radiation protection optimization and practices between high and low TB burden settings in the context of childhood TB management. The planned comparative analyses will inform policy-makers of existing radiological capacity and deficiencies, allowing better resource prioritisation. It will inform clinicians and radiologists on best practices and means to optimise the use of radiological technology in paediatric TB management.

Trends in the Notification Rates and Treatment Outcome of Tuberculosis in Shandong Province, China, 2005-2021

Purpose

To analyze the time trends in the notification rates of registered tuberculosis (TB) and bacteriologically confirmed TB in Shandong Province. And analyze the changes in TB treatment outcomes during 2005-2021.

Patients and Methods

The information of TB patients registered in the Shandong Information Center for Disease Control and Prevention (CDC) was collected during 2005-2021. We calculated the notification rates of registered TB and bacteriologically confirmed TB. Moreover, we calculated the year-to-year change rate of TB in treatment outcomes before and after COVID-19. The time trends were analyzed using the joinpoint regression method and illustrated as the annual percentage change (APC) of notification rates.

Results

A total of 236,898 cases of TB were diagnosed during 2005-2021, of which 51.11% were bacteriologically confirmed cases. Since 2008, the notification rates of registered TB have declined. The notification rates of bacteriologically confirmed TB had been declining during 2005-2016, then remained stable after 2016. In subgroup, the notification rates of both registered TB and bacteriologically confirmed TB were higher among men, rural residents, and people aged ≥ 60 years. Compared with clinically confirmed TB, bacteriologically confirmed TB has shown higher rates of poor outcomes since 2008 and higher case fatality rate since 2005. The rate of poor outcomes remained stable during 2008-2019. However, after the COVID-19 outbreak, the rate of poor outcomes and case fatality rate of TB has risen significantly.

Conclusion

After unremitting efforts to fight against TB, the notification rates of registered TB and bacteriologically confirmed TB declined in Shandong Province. The rate of poor outcomes remained stable during 2008-2019, then rise significantly after the COVID-19 outbreak. In the context of the long-term existence of COVID-19, further efforts should be made in TB diagnosis and treatment among high-risk population, especially with regard to males, rural residents and older adults.

Rifampicin Resistant Tuberculosis Among Presumptive Pulmonary Tuberculosis in Province Referral Hospital, Indonesia: Dynamic Cases of a 7-Year Report

BACKGROUND

Indonesia has the second highest tuberculosis (TB) cases globally. This study aimed to determine the sociodemographic factors associated with TB and rifampicin-resistant tuberculosis (RR-TB) cases among presumptive pulmonary TB patients in Aceh Referral Hospital. Study Design: A retrospective cross-sectional study.

METHODS

A retrospective cross-sectional review of presumptive pulmonary TB patients having a sputum test at the clinical microbiology laboratory was conducted from January 2015 to December 2021. Patient characteristics and drug susceptibility data were abstracted from the hospital information system of TB (SITB) and analyzed by univariate and bivariate analysis.

RESULTS

The Mycobacterium tuberculosis (MTB) was detected in 32.8% sample (1,521/4,637). Of the TB-confirmed cases, 14.1% (215/1,521) were resistant to rifampicin (RR-TB). Most of them were male patients (71.63%), were in the age range of 35-54 years (48.7%), lived in rural areas of the country (56.3%), and were previously TB-treated cases (65.5%). Overall, 35-44-year-old patients (adjusted odds ratio [AOR]=2.11, 95% CI=1.25, 3.5, P<0.05) were more likely to have RR-TB compared to>65-year-old patients. Gender and residence were not associated with RR-TB (P>0.05). Case detection decreased in pandemic conditions (19.5% in 2019 to 13.9% and 7.91% in 2020 and 2021, respectively).

CONCLUSION

The findings revealed the dynamic cases and sociodemographic factors of TB and RR-TB in a province referral hospital in Indonesia for 7 years. The cases of TB and RR-TB among presumptive TB patients were 32.8% and 14.1%, respectively. The cases were found to be more noticeable in males, adults (45-54 years old), and patients residing in rural areas.

Perceptions of COVID-19 during and after the Omicron outbreak among healthcare personnel in Indonesia

Introduction

The COVID-19 pandemic occurred in several waves with different levels of seriousness. Healthcare personnel (HCP) constituted a high-risk population for COVID-19, necessitating monitoring of their knowledge, attitudes, and practices (KAP) status and level of psychological distress. This study investigated differences in the impacts of COVID-19 during and after the Omicron outbreak among HCP in Indonesia.

Methods

An online structured questionnaire survey was distributed twice in selected hospitals of Indonesia: the first survey was between December 2021 and February 2022 (Omicron era) and the second between August and October 2022 (post-Omicron era). A multiple logistic regression model was used to determine the differences in KAP and psychological distress among HCP toward COVID-19 with demographic characteristics adjusted for.

Results

This study included 402 (Omicron era) and 584 (post-Omicron era) HCP members. Positive attitudes were more common in the Omicron era than in the post-Omicron era (p = 0.001). The availability of face shields and protective eyewear significantly decreased from 62.7 to 55.6% (p = 0.028). However, psychological distress among HCP significantly increased after the Omicron outbreak (p = 0.024). Multiple logistic regression analyses revealed a decrease of positive attitudes (OR = 0.626; 95% CI = 0.476-0.823) in the post-Omicron era.

Conclusion

Our data indicated a significant increase in psychological distress among HCP in the post-Omicron era. These findings suggest a need for greater focus on psychological distress among HCP in Indonesia.

Impact of the COVID-19 pandemic on quality of tuberculosis care in private facilities in Bandung, Indonesia: a repeated cross-sectional standardized patients study

BACKGROUND

Indonesia has the second highest incidence of tuberculosis in the world. While 74% of people with tuberculosis in Indonesia first accessed the private health sector when seeking care for their symptoms, only 18% of tuberculosis notifications originate in the private sector. Little is known about the impact of the COVID-19 pandemic on the private sector. Using unannounced standardized patient visits to private providers, we aimed to measure quality of tuberculosis care during the COVID-19 pandemic.

METHODS

A cross-sectional study was conducted using standardized patients in Bandung City, West Java, Indonesia. Ten standardized patients completed 292 visits with private providers between 9 July 2021 and 21 January 2022, wherein standardized patients presented a presumptive tuberculosis case. Results were compared to standardized patients surveys conducted in the same geographical area before the onset of COVID-19.

RESULTS

Overall, 35% (95% confidence interval (CI): 29.2-40.4%) of visits were managed correctly according to national tuberculosis guidelines. There were no significant differences in the clinical management of presumptive tuberculosis patients before and during the COVID-19 pandemic, apart from an increase in temperature checks (adjusted odds ratio (aOR): 8.05, 95% CI: 2.96-21.9, p < 0.001) and a decrease in throat examinations (aOR 0.16, 95% CI: 0.06-0.41, p = 0.002) conducted during the pandemic.

CONCLUSIONS

Results indicate that providers successfully identify tuberculosis in their patients yet do not manage them according to national guidelines. There were no major changes found in quality of tuberculosis care due to the COVID-19 pandemic. As tuberculosis notifications have declined in Indonesia due to the COVID-19 pandemic, there remains an urgent need to increase private provider engagement in Indonesia and improve quality of care.

Care pathways of individuals with tuberculosis before and during the COVID-19 pandemic in Bandung, Indonesia

The COVID-19 pandemic is thought to have undone years' worth of progress in the fight against tuberculosis (TB). For instance, in Indonesia, a high TB burden country, TB case notifications decreased by 14% and treatment coverage decreased by 47% during COVID-19. We sought to better understand the impact of COVID-19 on TB case detection using two cross-sectional surveys conducted before (2018) and after the onset of the pandemic (2021). These surveys allowed us to quantify the delays that individuals with TB who eventually received treatment at private providers faced while trying to access care for their illness, their journey to obtain a diagnosis, the encounters individuals had with healthcare providers before a TB diagnosis, and the factors associated with patient delay and the total number of provider encounters. We found some worsening of care seeking pathways on multiple dimensions. Median patient delay increased from 28 days (IQR: 10, 31) to 32 days (IQR: 14, 90) and the median number of encounters increased from 5 (IQR: 4, 8) to 7 (IQR: 5, 10), but doctor and treatment delays remained relatively unchanged. Employed individuals experienced shorter delays compared to unemployed individuals (adjusted medians: -20.13, CI -39.14, -1.12) while individuals whose initial consult was in the private hospitals experienced less encounters compared to those visiting public providers, private primary care providers, and informal providers (-4.29 encounters, CI -6.76, -1.81). Patients who visited the healthcare providers >6 times experienced longer total delay compared to those with less than 6 visits (adjusted medians: 59.40, 95% CI: 35.04, 83.77). Our findings suggest the need to ramp up awareness programs to reduce patient delay and strengthen private provide engagement in the country, particularly in the primary care sector.

Insights from the molecular mechanism of pyrazinamide to mutated pyrazinamidase linked to the pncA gene in clinical isolates of Mycobacterium tuberculosis

This study aims to conduct a comprehensive molecular dynamics strategy to evaluate whether mutations found in pyrazinamide monoresistant (PZAMR) strains of Mycobacterium tuberculosis (MTB) can potentially reduce the effectiveness of pyrazinamide (PZA) for tuberculosis (TB) treatment. Five single point mutations of pyrazinamidase (PZAse), an enzyme which is responsible for the activation of prodrug PZA into pyrazinoic acid, found in MTB clinical isolates, namely His82Arg, Thr87Met, Ser66Pro, Ala171Val, and Pro62Leu, were analyzed by the dynamics simulations both in the apo state (unbound state) and in the PZA bound state. The results showed that the mutation of His82 to Arg, Thr87 to Met, and Ser66 to Pro in PZAse affects the coordination state of the Fe2+ ion, which is a cofactor required for enzyme activity. These mutations change the flexibility, stability, and fluctuation of His51, His57, and ASP49 amino acid residues around the Fe2+ ion, culminating in an unstable complex and dissociation of PZA from the PZAse binding site. However, mutations of Ala171 to Val and Pro62 to Leu were found to have no effect on the complex's stability. Based on the results, PZAse mutations of His82Arg, Thr87Met, and Ser66Pro culminated in weak binding affinity for PZA and caused significant structural deformations that led to PZA resistance. Future structural and functional studies, as well as investigations into other aspects of drug resistance in PZAse, will require experimental clarification.Communicated by Ramaswamy H. Sarma.

Drug-Resistant Tuberculosis and COVID-19: A Scoping Review on a New Threat to Antimicrobial Resistance

OBJECTIVE

To assess the impact of COVID-19 on the morbidity and mortality associated with drug-resistant tuberculosis (DR-TB).

METHODS

A comprehensive review of articles published in international databases since December 2019 was conducted. The findings are presented in a narrative format, supplemented with tables, diagrams, and a map created using ArcGIS software.

RESULTS

Thirty-five studies were selected, highlighting the significant consequences of COVID-19 on TB and DR-TB treatment progress. Four main thematic areas were identified: Clinical and epidemiological aspects of the interaction between COVID-19 and DR-TB; Management of physical resources and the team; Challenges and circumstances; Perspectives and possibilities.

CONCLUSIONS

This study revealed that the COVID-19 pandemic significantly negatively impacted the control of long-standing diseases like TB, particularly in the context of morbidity and mortality related to DR-TB.

Healthcare workers' acceptance of the integrated tuberculosis-COVID-19 screening in central Java Private Hospitals, Indonesia

Objective

COVID-19 pandemic has negatively impacted the diagnosis and management of tuberculosis (TB) cases, and TB-COVID-19 integrated screening was introduced as a strategy to overcome these problems. This study determined the acceptability of the TB-COVID-19 integrated screening by healthcare workers (HCWs) and its impact on achievement of the TB program.

Methods

This was a mixed-method study with an embedded design. Data on hospital TB program coverage from the national TB information system for all Muhammadiyah and Aisyiyah Hospitals (MAHs) in Central Java were compared before and after the implementation of TB-COVID-19 integrated screening. The informants consisted of HCWs from 21 MAHs in Central Java. Focus group discussions (FGDs) were carried out with 7 hospital TB, 19 emergency room, 10 outpatient, 6 inpatient, and 4 managerial staff. In-depth interview (IDIs) were also performed with the Technical Officer TB Recovery Head of the Muhammadiyah Center. All IDIs and FGDs were recorded, transcribed verbatim, and subjected to thematic analysis guided by the theoretical framework of acceptability (TFA).

Result

Implementation of the TB-COVID-19 integrated screening program led to an increase in the number of new TB case diagnoses at the Central Java Hospitals. Moreover, the program was acceptable based on seven indicators from TFA. Despite the obstacles faced by HCWs during the implementation process, the program still managed to meet the standards.

Conclusion

Acceptance by HCWs is a critical factor in the successful implementation of programs, including the TB-COVID-19 integrated screening. Furthermore, a multifaceted and cross-sectoral approach is required to address the constraints associated with the process.

Experiences of Patients with Tuberculosis Who Underwent Completed TB Treatment during the COVID-19 Pandemic in Indonesia: A Qualitative Study

Background

The scope of tuberculosis (TB) elimination programs, such as case detection, rapid diagnostics, and treatment success, has dramatically worsened because of the COVID-19 pandemic. Therefore, this study aimed to explore the experiences of patients with TB who had completed their treatment during the COVID-19 pandemic.

Methods

This qualitative study was performed using content analysis approach between May-July 2022. A total of 14 patients with TB who agreed to participate in this study were selected using purposive sampling. In-depth interviews were conducted using semi-structured interview guidelines, and the interviews ended after information saturation occurred. Data analysis was carried out concurrently to identify the main themes. The NVIVO software application version 12 was utilized to analyze the data.

Results

Several key themes emerged from the study, shedding light on various aspects of the experiences of TB patients during the COVID-19 pandemic. These themes encompass (1) Barriers to TB Diagnosis during the COVID-19 Pandemic; (2) Challenges in TB Treatment during the COVID-19 Pandemic; and (3) Support Resources during TB Treatment in pandemic era.

Conclusion

Patients have difficulty receiving healthcare because of changes in TB health services brought on by the pandemic. This research advances our knowledge of the effects of the COVID-19 pandemic on patients with TB and lays the groundwork for improved patient support and interventions.

Development and validation of assessment instrument for the perception and attitude toward tuberculosis among the general population in Indonesia: a Rasch analysis of psychometric properties

Introduction

Tuberculosis (TB)-related knowledge is an important evaluation metric for health education interventions. Factor analysis is limited when used on ordinal scales and does not provide in-depth item function examinations, whereas Rasch analysis addresses these limitations and offers potential advantages such as generalizability, testing of unidimensionality, producing an ordered set of items, and identifying poorly functioning items. Therefore, this research aims to develop a reliable and valid measure of perception and attitude toward TB (PATT) for public application use Rasch Analysis.

Methods

A questionnaire-based survey was conducted on the Indonesian general population using the Google Form platform. Rasch analysis was then employed to examine the psychometric properties and develop the final items of PATT.

Results

Experts from across the TB community participated in the PATT development, producing an initial scale of 16 items. Up to 1,616 participants completed the PATT questionnaire, where 74.8% were female, and 5% had a TB history. The final unidimensional 16-item scale has an item reliability of 1.00 for the two components (perception and attitude), a person reliability index of 0.87 and 0.60, as well as a Cronbach's test reliability of 0.88 and 0.88 for perception and attitude, respectively.

Conclusion

The PATT is a unidimensional scale with good construct validity and internal consistency. It has the potential to be useful for the assessment of TB perception and attitude in research and clinical practice.

Impact of the COVID-19 pandemic on tuberculosis control in Indonesia: a nationwide longitudinal analysis of programme data

BACKGROUND

The impact of the COVID-19 pandemic on tuberculosis control in high-burden countries has not been adequately assessed. We aimed to estimate the impact of the COVID-19 pandemic on the national tuberculosis programme in Indonesia, in association with indicators of human development and health-system capacity across all 514 districts in 34 provinces.

METHODS

We did a nationwide longitudinal analysis to compare tuberculosis case notification, treatment coverage, and mortality rates in Indonesia before (2016-19) and during (2020-21) the COVID-19 pandemic. The following outcomes were assessed: the district-level quarterly reported tuberculosis case notification rate (number of all reported tuberculosis cases per 100 000 population), treatment coverage (proportion of tuberculosis patients who started treatment), and all-cause mortality rate in patients with tuberculosis (number of reported deaths per 100 000 population). District-level data on COVID-19 incidence and deaths, health-system capacity, and human development and sociodemographics were also analysed. Multilevel linear spline regression was done to assess quarterly time trends for the three outcomes.

FINDINGS

During the COVID-19 pandemic, the tuberculosis case notification rate declined by 26% (case notification rate ratio 0·74, 95% CI 0·72-0·77) and treatment coverage declined by 11% (treatment coverage ratio 0·89, 95% CI 0·88-0·90), but there was no significant increase in all-cause mortality (all-cause mortality rate ratio 0·97, 95% CI 0·91-1·04) compared with the pre-pandemic period. In the second year of the pandemic, we observed a partial recovery of the case notification rate from Q1 to Q4 of 2021, a persistent decrease in treatment coverage, and a decrease in the all-cause mortality rate from Q2 of 2020 to Q4 of 2021. The multivariable analysis showed that the reduction in the tuberculosis case notification rate was associated with a higher COVID-19 incidence rate (adjusted odds ratio 3·1, 95% CI 1·1-8·6, for the highest compared with the lowest group) and fewer GeneXpert machines for tuberculosis diagnosis (3·1, 1·0-9·4, for the lowest compared with the highest group) per 100 000 population. The reduction in tuberculosis treatment coverage was associated with higher COVID-19 incidence (adjusted odds ratio 11·7, 95% CI 1·5-93·4, for the highest compared with the lowest group), fewer primary health centres (10·6, 4·1-28·0, for the lowest compared with the middle-high group), and a very low number of doctors (0·3, 0·1-0·9, for the low-middle compared with the lowest group) per 100 000 population. No factors were shown to be significantly associated with all-cause mortality.

INTERPRETATION

The COVID-19 pandemic adversely and unevenly affected the national tuberculosis programme across Indonesia, with the greatest impacts observed in districts with the lowest health-system capacity. These disruptions could lead to an escalation in tuberculosis transmission in the coming years, warranting the need for intensified efforts to control tuberculosis and strengthen local health systems.

FUNDING

Wellcome Africa Asia Programme Vietnam.

TRANSLATION

For the Bahasa translation of the abstract see Supplementary Materials section.

COVID-19 impact on health service- and TB-related practices among private providers in Indonesia

SETTING

The COVID-19 pandemic has caused disruptions to healthcare services worldwide, including in private healthcare facilities (HCFs), where TB patients mostly initiate their care-seeking journey.

OBJECTIVE

To identify adjustments to TB-related practices made by HCFs during the pandemic.

DESIGN

We identified, contacted and invited private HCFs across West Java, Indonesia, to fill an online questionnaire. The questionnaire explored participants' sociodemographic characteristics, adaptations and TB management practices implemented in their facilities during the pandemic. Data were analysed using descriptive statistics.

RESULTS

Of the 240 HCFs surveyed, 40.0% shortened their operational hours and 21.3% have ever closed their practices during the pandemic; 217 (90.4%) made adjustments to keep delivering services, 77.9% by requiring the use of personal protective equipment (PPE); 137 (57.1%) observed fewer patient visits; 140 (58.3%) used telemedicine, a few of which (7.9%) ever handled TB patients on that platform. Respectively 89.5%, 87.5% and 73.3% of HCFs referred patients for chest radiography, smear microscopy and Xpert testing. Only a median of 1 (IQR 1-3) TB patient per month was diagnosed by the HCFs.

CONCLUSION

Two major adaptations rolled out during COVID-19 were the use of telemedicine and PPE. Optimisation of the diagnostic referral system to increase TB case detection in private HCFs is warranted.

Gated Calcium Ion Channel and Mutation Mechanisms in Multidrug-Resistant Tuberculosis

A wide spectrum of Gram-positive/Gram-negative bacteria has been found resistant to a wide spectrum of antibiotics in the United States of America during the past decade. Drug-resistant tuberculosis is not yet a major threat in North/South America, Europe, and the Middle East. However, the migration of populations in times of drought, famine, and hostilities may increase the global reach of this ancient pathogen. Given an increased spread from China and India to African countries, drug-resistant Mycobacterium tuberculosis has become an emerging topic of concern for Europe and North America. Due to the dangers associated with the spread of pathogens among different populations, the World Health Organization continues to expand healthcare advisories for therapeutic approaches for both stationary and migrating populations. As much of the literature focuses on endemic to pandemic viruses, we remain concerned that other treatable communicable diseases may be ignored. One such disease is multidrug-resistant tuberculosis. We focus on molecular mechanisms that this pathogen relies upon for the development of multidrug resistance via gene mutation and the evolutionary development of new enzyme and calcium channels.

Mycobacterium tuberculosis - atpE gene profile of bedaquiline-treated pulmonary tuberculosis patients at the referral hospital Dr. Soetomo, Indonesia

Background

The atpE gene is a target for bedaquiline (Bdq)-activating drug action and mutations in the gene are fixed to cause resistance. However, changes in the amino acid of ATPase have been little reported from a clinical setting since it was first used in 2015 in Indonesia. This study aims to observe the sequence of nucleotide and amino acid from rifampicin-resistant (RR) pulmonary tuberculosis (TB) patients, both new and relapse cases treated with Bdq.

Methods

This is an observational descriptive study performed in the referral hospital Dr Soetomo, Indonesia, at August 2022-November 2022. We performed Sanger sequencing and comparison of the atpE gene from the patient's sputum from August to November 2022 to wild-type Mycobacterium tuberculosis H37Rv and species of mycobacteria using BioEdit version 7.2 and BLAST NCBI software. We also conducted an epidemiological study on patients' characteristics. This study uses a descriptive statistic to show the percentage of data.

Results

The total of 12 M. tuberculosis isolates showed that the atpE gene sequence was 100% similar to the wild-type M. tuberculosis H37Rv. No single-nucleotide polymorphisms or mutations were found, and no change in the amino acid structure at position 28 (Asp), 61 (Glu), 63 (Ala), and 66 (Ile). The percentage identity of atpE to M. tuberculosis H37Rv and M. tuberculosis complex was 99%-100%, while the similarity with the other mycobacteria species other than TB (Mycobacterium avium complex, Mycobacterium abscessus, and Mycobacterium lepraemurium) was 88%-91%.

Conclusions

This study revealed M. tuberculosis -atpE gene sequence profile of RR-TB patients had no mutations, as the specific gene region, and no change in the amino acid structure. Therefore, Bdq can be continually trusted as an effective anti-tubercular drug in RR-TB patients.

Patterns of cutaneous leishmaniasis during the COVID-19 pandemic in four endemic regions of Iran

BACKGROUND

Both zoonotic cutaneous leishmaniasis (ZCL) and anthroponotic cutaneous leishmaniasis are endemic in different regions of Iran. It is important to know the type of cutaneous leishmaniasis (CL) for prevention strategies. On the other hand, Iran is one of the countries that was severely affected by the coronavirus 2019 (COVID-19) pandemic. However, little is known about the causative agents of CL during the COVID-19 pandemic in Iran.

METHODS

In this study, a total of 181 samples were isolated from patients with CL lesions in four different endemic cities of Iran (Jahrom, Juyom, Kashan and Shoushtar) during the COVID-19 pandemic (the summer and autumn of 2021). The nested-PCR targeting kinetoplast DNA (kDNA) minicircles was applied for species identification of the parasite and the internal transcribed spacer-1 (ITS-1) gene was applied for sequencing and phylogenetic analysis.

RESULTS

Molecular detection of kDNA minicircles revealed that all isolates from the four cities were Leishmania major, indicating the ZCL pattern. Ten isolates were sequenced by the ITS-1 gene and deposited in GenBank [accession numbers: OL627363-72]. Sequencing and phylogenetic analysis displayed a high similarity rate of the isolates with sequences from other parts of Iran and Iraq. Over half of the patients (53.59%) had a single lesion, while 17.12, 14.92, 2.21 and 12.16% of cases had two, three, four and more than four lesions, respectively. About half of the patients (50.27%) had lesions on their hands, while the rest had lesions on multiple locations (19.34%), legs (16.58%), face (9.94%), ears (1.66%) and waist (2.21%).

CONCLUSIONS

This study revealed the occurrence of ZCL during the COVID-19 pandemic in four endemic regions of Iran. Strategies for prevention and control of the disease should be considered to mitigate the occurrence of ZCL.

Clinical and economic burden of drug-susceptible tuberculosis in Indonesia: national trends 2017-19

BACKGROUND

The global incidence of tuberculosis is decreasing, yet it remains high in Indonesia. The Indonesian National Tuberculosis Program facilitates mandatory notification, which enables early detection and treatment, minimises complications, prevents transmission, and decreases deaths. This study aimed to assess the characteristics, trends, and economic burden of notified drug-susceptible tuberculosis cases registered in this system from 2017 to 2019.

METHODS

We performed a multiyear cross-sectional study focusing on drug-susceptible tuberculosis notified cases, incidence, geographical tuberculosis case distribution, treatment outcomes, and costs in Indonesia using data from Sistem Informasi Tuberkulosis (2017-19). The settings were Indonesian health-care facilities that provide tuberculosis control programmes and services. Eligible patients were those who were diagnosed with drug-susceptible tuberculosis and notified to Sistem Informasi Tuberkulosis.

FINDINGS

Between 2017 and 2019, notified cases increased from 429 219 to 523 614 individuals, corresponding to an increase in incidence from 167 cases per 100 000 to 196 cases per 100 000. In 2019, more than 250 cases per 100 000 inhabitants were notified in Jakarta, North Sulawesi, Gorontalo, and Papua. Treatment success rate increased from 363 098 (84·60%) of 429 219 in 2017 to 452 966 (86·51%) of 523 614 in 2019, with a relatively stable mortality, changing from 3·15% to 3·05%. HIV status was increasingly confirmed, with unknown status decreasing from 66·21% to 43·68%. The costs of visits and monitoring and drug regimens were relatively stable, with total direct medical costs slightly increasing from US$39·40 to $40·40 per case.

INTERPRETATION

Progress was made on drug-susceptible tuberculosis management in Indonesia. However, further intensified efforts, including case-finding, optimising diagnosis, and cost-effective tuberculosis management are required if Indonesia is to achieve the 2025 WHO End Tuberculosis Strategy target incidence of fewer than 55 cases per 100 000 people. These data are an important starting point for understanding drug-susceptible tuberculosis dynamics in Indonesia and optimising its management.

FUNDING

Directorate General of Higher Education; Ministry of Education, Culture, Research, and Technology of the Republic of Indonesia.

Service delivery challenges in HIV care during the first year of the COVID-19 pandemic: results from a site assessment survey across the global IeDEA consortium

INTRODUCTION

Interruptions in treatment pose risks for people with HIV (PWH) and threaten progress in ending the HIV epidemic; however, the COVID-19 pandemic's impact on HIV service delivery across diverse settings is not broadly documented.

METHODS

From September 2020 to March 2021, the International epidemiology Databases to Evaluate AIDS (IeDEA) research consortium surveyed 238 HIV care sites across seven geographic regions to document constraints in HIV service delivery during the first year of the pandemic and strategies for ensuring care continuity for PWH. Descriptive statistics were stratified by national HIV prevalence (<1%, 1-4.9% and ≥5%) and country income levels.

RESULTS

Questions about pandemic-related consequences for HIV care were completed by 225 (95%) sites in 42 countries with low (n = 82), medium (n = 86) and high (n = 57) HIV prevalence, including low- (n = 57), lower-middle (n = 79), upper-middle (n = 39) and high- (n = 50) income countries. Most sites reported being subject to pandemic-related restrictions on travel, service provision or other operations (75%), and experiencing negative impacts (76%) on clinic operations, including decreased hours/days, reduced provider availability, clinic reconfiguration for COVID-19 services, record-keeping interruptions and suspension of partner support. Almost all sites in low-prevalence and high-income countries reported increased use of telemedicine (85% and 100%, respectively), compared with less than half of sites in high-prevalence and lower-income settings. Few sites in high-prevalence settings (2%) reported suspending antiretroviral therapy (ART) clinic services, and many reported adopting mitigation strategies to support adherence, including multi-month dispensing of ART (95%) and designating community ART pick-up points (44%). While few sites (5%) reported stockouts of first-line ART regimens, 10-11% reported stockouts of second- and third-line regimens, respectively, primarily in high-prevalence and lower-income settings. Interruptions in HIV viral load (VL) testing included suspension of testing (22%), longer turnaround times (41%) and supply/reagent stockouts (22%), but did not differ across settings.

CONCLUSIONS

While many sites in high HIV prevalence settings and lower-income countries reported introducing or expanding measures to support treatment adherence and continuity of care, the COVID-19 pandemic resulted in disruptions to VL testing and ART supply chains that may negatively affect the quality of HIV care in these settings.

Spatio-temporal analysis of tuberculosis incidence in North Aceh District, Indonesia 2019-2021

Tuberculosis (TB) infection continues to present as a leading cause of morbidity and mortality in North Aceh District, Aceh Province, Indonesia. Local TB spatial risk factors have been investigated but space-time clusters of TB in the district have not yet been the subject of study. To that end, research was undertaken to detect clusters of TB incidence during 2019-2021 in this district. First, the office of each of the 27 sub-districts wasgeocoded by collecting data of their geographical coordinates. Then, a retrospective space-time scan statistics analysis based on population data and annual TB incidence was performed using SaTScan TM v9.4.4. The Poisson model was used to identify the areas at high risk of TB and the clusters found were ranked by their likelihood ratio (LLR), with the significance level set at 0.05.There were 2,266 TB cases reported in North Aceh District and the annualized average incidence was 122.91 per 100,000 population. The SaTScan analysis identified that there were three most like clusters and ten secondary clusters, while Morans'Ishowed that there was spatial autocorrelation of TB in the district. The sub-district of GeureudongPase was consistently the location of most likely clusters. The indicators showed that there were significant differences between TB data before the COVID-19 pandemic and those found during the study period. These findings may assist health authorities to improve the TB preventive strategies and develop public health interventions, with special reference to the areas where the clusters were found.

Role of Pharmacists in Antimicrobial Stewardship During COVID-19 Outbreak: A Scoping Review

Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, pharmacists have been on the front lines of health care, offering vital services. Consequently, the need for pharmacists to support an effective antibiotic stewardship (AMS) program during the COVID-19 outbreak has become increasingly evident. This scoping review was performed to examine related articles in 2020-2022 published in the Scopus, SAGE, and Cochrane databases with the keywords "Pharmacist" and "Antibiotic Stewardship" and "COVID-19". The inclusion criteria were full-text articles written in English. A total of 15 articles were included in this review to describe the role of pharmacists in AMS during the COVID-19 outbreak. In general, pharmacists are responsible for identifying and treating patients during pandemics, ensuring the continued supply and accessibility of medications, promoting health policies, and monitoring antibiotic use for COVID-19 cases and co-infections. At the hospital, as the most significant element for pharmacists on the AMS team, the apparent change is demonstrated in educating patients on telehealth services, clarifying misconceptions about treatments and antibiotic consumption, as well as taking a leadership position to establish local guidelines for the COVID-19 treatment protocol. Pharmacists have an important role in the AMS program, and the COVID-19 pandemic was perceived as a highlight their importance. Therefore, their work with the AMS program needs to be improved as they learn to extend their role in telehealth services, educate and clarify the misconceptions about COVID-19 treatments and other antibiotic consumption in the community, inventory control the COVID-19 drug, antibiotics, and vaccine, as well as take the lead in establishing local guidelines on antibiotic consumption during the pandemic outbreak.

The Impact of the COVID-19 Pandemic on Tuberculosis Case Notification and Treatment Outcomes in Eswatini

Objectives: We investigated the impact of COVID-19 on tuberculosis (TB) case notification and treatment outcomes in Eswatini.

Methods: A comparative retrospective cohort study was conducted using TB data from eight facilities. An interrupted time series analysis, using segmented Poisson regression was done to assess the impact of COVID-19 on TB case notification comparing period before (December 2018-February 2020, n = 1,560) and during the pandemic (March 2020–May 2021, n = 840). Case notification was defined as number of TB cases registered in the TB treatment register. Treatment outcomes was result assigned to patients at the end of treatment according to WHO rules.

Results: There was a significant decrease in TB case notification (IRR 0.71, 95% CI: 0.60–0.83) and a significant increase in death rate among registrants during the pandemic (21.3%) compared to pre-pandemic (10.8%, p < 0.01). Logistic regression indicated higher odds of unfavorable outcomes (death, lost-to-follow-up, and not evaluated) during the pandemic than pre-pandemic (aOR 2.91, 95% CI: 2.17–3.89).

Conclusion: COVID-19 negatively impacted TB services in Eswatini. Eswatini should invest in strategies to safe-guard the health system against similar pandemics.

Tuberculosis Treatment Compliance under Smartphone-based Video-Observed Therapy versus Community-based Directly Observed Therapy: A Protocol of a Cluster Randomized Controlled Trial (Preprint)

Background

The health care system in Thailand has struggled to cope with the COVID-19 pandemic, resulting in decreased administration of community-based directly observed therapy (DOT) for tuberculosis (TB). As an alternative to failed DOT, video-observed therapy (VOT) or the Thai asynchronous VOT system, “TH VOT,” was devised. We developed a protocol for a study to test the superiority of VOT over DOT in ensuring treatment compliance.

Objective

We aim to compare the mean cumulative compliance days of TB patients and their observers under the VOT program with that of individuals under the DOT program during the intensive phase of TB treatment.

Methods

A cluster randomized controlled trial of pulmonary TB patients and their observers will be conducted over a 2-month period. This study will be conducted in the Hat Yai and Meuang Songkhla districts of Songkhla Province, Southern Thailand. A total of 38 observers working at 38 primary care units (PCUs) will be randomized equally into VOT and DOT groups. The TH VOT system will be implemented in 19 PCUs in the VOT group while the other 19 PCUs will continue with the traditional DOT program. Approximately 1-5 TB patients will be under observation, depending on the PCU jurisdiction in which the patients reside. The inclusion criteria for TB patients will be as follows: patients diagnosed with newly active pulmonary TB with a positive acid-fast bacilli sputum smear, aged >18 years, own a smartphone, and are able to use the LINE (Line Corporation) app. The exclusion criteria will be patients with a condition that requires the intervention of a specialist, rifampicin resistance according to a cartridge-based nucleic acid amplification test (GeneXpert MTB/RIF), unable to continue the treatment, and/or alcohol dependence. After the 2-month observation period, all sessions and follow-up clinical outcomes recorded will be retrieved. An intention-to-treat analysis will be performed to assess the compliance of both patients undergoing drug administration and their observers.

Results

The Human Research Ethics Committee, Faculty of Medicine, Prince of Songkla University approved the trial on February 19, 2021 (approval number 64-03618-9). The trial was funded in May 2021. The recruitment period will be from January 2022 to July 2022. The observation is scheduled to end by September 2022.

Conclusions

If the VOT shows superiority in observational compliance among patients and observers, the existing DOT policy will be replaced with VOT.

Trial Registration

Thai Clinical Trials Registry TCTR20210624002; https://www.thaiclinicaltrials.org/show/TCTR20210624002

International Registered Report Identifier (IRRID)

DERR1-10.2196/38796

Changing Epidemiology of Respiratory Tract Infection during COVID-19 Pandemic

The outbreak of COVID-19 has significantly changed the epidemiology of respiratory tract infection in several ways. The implementation of non-pharmaceutical interventions (NPIs) including universal masking, hand hygiene, and social distancing not only resulted in a decline in reported SARS-CoV-2 cases but also contributed to the decline in the non-COVID-19 respiratory tract infection-related hospital utilization. Moreover, it also led to the decreased incidence of previous commonly encountered respiratory pathogens, such as influenza and Streptococcus pneumoniae. Although antimicrobial agents are essential for treating patients with COVID-19 co-infection, the prescribing of antibiotics was significantly higher than the estimated prevalence of bacterial co-infection, which indicated the overuse of antibiotics or unnecessary antibiotic use during the COVID-19 pandemic. Furthermore, inappropriate antimicrobial exposure may drive the selection of drug-resistant microorganisms, and the disruption of infection control in COVID-19 setting measures may result in the spread of multidrug-resistant organisms (MDROs). In conclusion, NPIs could be effective in preventing respiratory tract infection and changing the microbiologic distribution of respiratory pathogens; however, we should continue with epidemiological surveillance to establish updated information, antimicrobial stewardship programs for appropriate use of antibiotic, and infection control prevention interventions to prevent the spread of MDROs during the COVID-19 pandemic.

Impacts of tuberculosis services strengthening and the COVID-19 pandemic on case detection and treatment outcomes in Mimika District, Papua, Indonesia: 2014-2021

Indonesia is a high-burden tuberculosis (TB) country with a wide case detection gap, exacerbated by the COVID-19 pandemic. We aimed to review the epidemiology of TB in a high-endemic setting of Indonesia before and during the implementation of health system strengthening activities for TB, including during the first two years of the COVID-19 pandemic. We analysed TB program data from Mimika District, Papua, Indonesia from 2014 to 2021. Health system strengthening activities to improve the programmatic management of TB were implemented from 2017 onwards. Activities included decentralization of TB services, training and mentoring of healthcare workers, improved screening for co-morbidities, and introduction and optimisation of Xpert testing in 2018. A total of 11,803 TB cases were notified to the Mimika District Health Office over eight years (2014-21). Between 2015 and 2019, there was a 67% increase in annual case notifications, an 89% increase in bacteriologically confirmed cases and the proportion of TB cases detected in primary care increased from 26% to 46%. In 2020, coinciding with the COVID-19 pandemic, investigation of people with presumptive TB fell by 38%, but the proportion of those tested with Xpert increased. TB case notifications decreased by 19% from 1,796 in 2019 to 1,461 in 2020, but then increased by 17% to 1,716 in 2021. Routine screening for co-morbidities (HIV, diabetes) among TB patients improved over time and was not affected by the pandemic. Treatment success overall was 71% and remained relatively unchanged. Loss to follow-up and death were 18% and 3.7% respectively. Improvements in TB case finding were observed over a period in which a range of health system strengthening activities were implemented. While COVID-19 had a negative impact on the TB program in Mimika District, there are encouraging signs of recovery. Further work is needed to improve TB treatment outcomes.

Usability of Video Observed Therapy with a Notification System to Improve Monitoring of Tuberculosis Treatment in Thailand (Preprint)

Background

In Thailand, the health care system has struggled to cope with COVID-19, resulting in directly observed therapy for tuberculosis being de-emphasized. A video-observed therapy (VOT) system, or more specifically, the Thai VOT (TH VOT) system, was developed to replace directly observed therapy. According to the pilot study, the system needed notifications to improve usability and user compliance. The updated version of the TH VOT system thus enabled LINE (Line Corporation) notifications.

Objective

This study aimed to reassess users’ compliance with and the usability of the updated TH VOT system.

Methods

This study was conducted in the Hat Yai and Mueang Songkhla districts in Songkhla Province, Southern Thailand, from September 18 to December 1, 2021. The system was used by not only patients with tuberculosis but also tuberculosis staff, who acted as observers in primary health care settings. Some of the observers used the simulated VOT system instead of the actual system due to the lack of participating patients in their jurisdiction. After 30 days of using the system, VOT session records were analyzed to determine the compliance of the patients and observers. The User Experience Questionnaire was administered to reassess the usability of the system and compare the ratings of the participants with the general benchmark scores of the User Experience Questionnaire. The results were summarized to reveal the degree of user compliance and usability in the following three groups: the patients, actual VOT observers, and simulated VOT observers.

Results

Of the 19 observers, 10 used the actual VOT system, and the remaining 9 used the simulated VOT system; there were also 10 patients with tuberculosis. The patients, actual VOT observers, and simulated VOT observers exhibited about 70%, 65%, and 50% compliance, respectively, in terms of following the standard operating procedures every day. The scores of all groups on all dimensions were well above the average scores. There was no significant difference in any of the dimensional scores among the three groups.

Conclusions

The updated version of the TH VOT system was deemed usable by both the patients and the health care staff. Compliance with the use of the system was high among the patients but moderate among the observers.