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Basile FW, Sweeney S, Singh MP, Bijker EM, Cohen T, Menzies NA, Vassall A, Indravudh P. Uncertainty in tuberculosis clinical decision-making: An umbrella review with systematic methods and thematic analysis. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003429. [PMID: 39042611 PMCID: PMC11265660 DOI: 10.1371/journal.pgph.0003429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 06/12/2024] [Indexed: 07/25/2024]
Abstract
Tuberculosis is a major infectious disease worldwide, but currently available diagnostics have suboptimal accuracy, particularly in patients unable to expectorate, and are often unavailable at the point-of-care in resource-limited settings. Test/treatment decision are, therefore, often made on clinical grounds. We hypothesized that contextual factors beyond disease probability may influence clinical decisions about when to test and when to treat for tuberculosis. This umbrella review aimed to identify such factors, and to develop a framework for uncertainty in tuberculosis clinical decision-making. Systematic reviews were searched in seven databases (MEDLINE, CINAHL Complete, Embase, Scopus, Cochrane, PROSPERO, Epistemonikos) using predetermined search criteria. Findings were classified as barriers and facilitators for testing or treatment decisions, and thematically analysed based on a multi-level model of uncertainty in health care. We included 27 reviews. Study designs and primary aims were heterogeneous, with seven meta-analyses and three qualitative evidence syntheses. Facilitators for decisions to test included providers' advanced professional qualification and confidence in tests results, availability of automated diagnostics with quick turnaround times. Common barriers for requesting a diagnostic test included: poor provider tuberculosis knowledge, fear of acquiring tuberculosis through respiratory sampling, scarcity of healthcare resources, and complexity of specimen collection. Facilitators for empiric treatment included patients' young age, severe sickness, and test inaccessibility. Main barriers to treatment included communication obstacles, providers' high confidence in negative test results (irrespective of negative predictive value). Multiple sources of uncertainty were identified at the patient, provider, diagnostic test, and healthcare system levels. Complex determinants of uncertainty influenced decision-making. This could result in delayed or missed diagnosis and treatment opportunities. It is important to understand the variability associated with patient-provider clinical encounters and healthcare settings, clinicians' attitudes, and experiences, as well as diagnostic test characteristics, to improve clinical practices, and allow an impactful introduction of novel diagnostics.
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Affiliation(s)
- Francesca Wanda Basile
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sedona Sweeney
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Maninder Pal Singh
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Else Margreet Bijker
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- Department of Paediatrics, Maastricht University Medical Centre, MosaKids Children’s Hospital, Maastricht, the Netherlands
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Nicolas A. Menzies
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
- Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Pitchaya Indravudh
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
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2
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Turyahabwe S, Bamuloba M, Mugenyi L, Amanya G, Byaruhanga R, Imoko JF, Nakawooya M, Walusimbi S, Nidoi J, Burua A, Sekadde M, Muttamba W, Arinaitwe M, Henry L, Kengonzi R, Mudiope M, Kirenga BJ. Community tuberculosis screening, testing and care, Uganda. Bull World Health Organ 2024; 102:400-409. [PMID: 38812802 PMCID: PMC11132162 DOI: 10.2471/blt.23.290641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 01/14/2024] [Accepted: 02/29/2024] [Indexed: 05/31/2024] Open
Abstract
Objective To assess the effectiveness of a community-based tuberculosis and leprosy intervention in which village health teams and health workers conduct door-to-door tuberculosis screening, targeted screenings and contact tracing. Methods We conducted a before-and-after implementation study in Uganda to assess the effectiveness of the community tuberculosis intervention by looking at reach, outputs, adoption and effectiveness of the intervention. Campaign 1 was conducted in March 2022 and campaign 2 in September 2022. We calculated percentages of targets achieved and compared case notification rates during the intervention with corresponding quarters in the previous year. We also assessed the leprosy screening. Findings Over 5 days, campaign 1 screened 1 289 213 people (2.9% of the general population), of whom 179 144 (13.9%) fulfilled the presumptive tuberculosis criteria, and 4043 (2.3%) were diagnosed with bacteriologically-confirmed tuberculosis; 3710 (91.8%) individuals were linked to care. In campaign 2, 5 134 056 people (11.6% of the general population) were screened, detecting 428 444 (8.3%) presumptive tuberculosis patients and 8121 (1.9%) bacteriologically-confirmed tuberculosis patients; 5942 individuals (87.1%) were linked to care. The case notification rate increased from 48.1 to 59.5 per 100 000 population in campaign 1, with a case notification rate ratio of 1.24 (95% confidence interval, CI: 1.22-1.26). In campaign 2, the case notification rate increased from 45.0 to 71.6 per 100 000 population, with a case notification rate ratio of 1.59 (95% CI: 1.56-1.62). Of the 176 patients identified with leprosy, 137 (77.8%) initiated treatment. Conclusion This community tuberculosis screening initiative is effective. However, continuous monitoring and adaptations are needed to overcome context-specific implementation challenges.
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Affiliation(s)
- Stavia Turyahabwe
- National TB and Leprosy Program, Ministry of Health, Uganda, 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Muzamiru Bamuloba
- National TB and Leprosy Program, Ministry of Health, Uganda, 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Levicatus Mugenyi
- Department of Statistics, The Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Geoffrey Amanya
- National TB and Leprosy Program, Ministry of Health, Uganda, 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Raymond Byaruhanga
- National TB and Leprosy Program, Ministry of Health, Uganda, 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Joseph Fry Imoko
- Department of Research and Innovation, Makerere University Lung Institute, Kampala, Uganda
| | - Mabel Nakawooya
- National TB and Leprosy Program, Ministry of Health, Uganda, 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Simon Walusimbi
- Department of Research and Innovation, Makerere University Lung Institute, Kampala, Uganda
| | - Jasper Nidoi
- Department of Research and Innovation, Makerere University Lung Institute, Kampala, Uganda
| | - Aldomoro Burua
- National TB and Leprosy Program, Ministry of Health, Uganda, 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Moorine Sekadde
- National TB and Leprosy Program, Ministry of Health, Uganda, 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Winters Muttamba
- Department of Research and Innovation, Makerere University Lung Institute, Kampala, Uganda
| | - Moses Arinaitwe
- National TB and Leprosy Program, Ministry of Health, Uganda, 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Luzze Henry
- National TB and Leprosy Program, Ministry of Health, Uganda, 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Rose Kengonzi
- National TB and Leprosy Program, Ministry of Health, Uganda, 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Mary Mudiope
- Department of Health Systems Strengthening, Infectious Diseases Institute, Kampala, Uganda
| | - Bruce J Kirenga
- Department of Research and Innovation, Makerere University Lung Institute, Kampala, Uganda
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Steadman A, Andama A, Ball A, Mukwatamundu J, Khimani K, Mochizuki T, Asege L, Bukirwa A, Kato JB, Katumba D, Kisakye E, Mangeni W, Mwebe S, Nakaye M, Nassuna I, Nyawere J, Nakaweesa A, Cook C, Phillips P, Nalugwa T, Bachman CM, Semitala FC, Weigl BH, Connelly J, Worodria W, Cattamanchi A. New Manual Quantitative Polymerase Chain Reaction Assay Validated on Tongue Swabs Collected and Processed in Uganda Shows Sensitivity That Rivals Sputum-based Molecular Tuberculosis Diagnostics. Clin Infect Dis 2024; 78:1313-1320. [PMID: 38306491 DOI: 10.1093/cid/ciae041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 12/06/2023] [Accepted: 01/26/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Sputum-based testing is a barrier to increasing access to molecular diagnostics for tuberculosis (TB). Many people with TB are unable to produce sputum, and sputum processing increases assay complexity and cost. Tongue swabs are emerging as an alternative to sputum, but performance limits are uncertain. METHODS From June 2022 to July 2023, we enrolled 397 consecutive adults with cough >2 weeks at 2 health centers in Kampala, Uganda. We collected demographic and clinical information, sputum for TB testing (Xpert MTB/RIF Ultra and 2 liquid cultures), and tongue swabs for same-day quantitative polymerase chain reaction (qPCR) testing. We evaluated tongue swab qPCR diagnostic accuracy versus sputum TB test results, quantified TB targets per swab, assessed the impact of serial swabbing, and compared 2 swab types (Copan FLOQSWAB and Steripack spun polyester). RESULTS Among 397 participants, 43.1% were female, median age was 33 years, 23.5% were diagnosed with human immunodeficiency virus, and 32.0% had confirmed TB. Sputum Xpert Ultra and tongue swab qPCR results were concordant for 98.2% (95% confidence interval [CI]: 96.2-99.1) of participants. Tongue swab qPCR sensitivity was 92.6% (95% CI: 86.5 to 96.0) and specificity was 99.1% (95% CI: 96.9 to 99.8) versus microbiological reference standard. A single tongue swab recovered a 7-log range of TB copies, with a decreasing recovery trend among 4 serial swabs. Swab types performed equivalently. CONCLUSIONS Tongue swabs are a promising alternative to sputum for molecular diagnosis of TB, with sensitivity approaching sputum-based molecular tests. Our results provide valuable insights for developing successful tongue swab-based TB diagnostics.
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Affiliation(s)
- Amy Steadman
- Global Health Labs, Inc, Bellevue, Washington, USA
| | - Alfred Andama
- Department of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Walimu, Kampala, Uganda
| | - Alexey Ball
- Global Health Labs, Inc, Bellevue, Washington, USA
| | | | | | - Tessa Mochizuki
- Center for Tuberculosis, University of California-San Francisco, San Francisco, California, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Catherine Cook
- Center for Tuberculosis, University of California-San Francisco, San Francisco, California, USA
| | - Patrick Phillips
- Center for Tuberculosis, University of California-San Francisco, San Francisco, California, USA
| | | | | | - Fred Collins Semitala
- Department of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | | | | | - William Worodria
- Department of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Adithya Cattamanchi
- Division of Pulmonary Diseases and Critical Care Medicine, University of California-Irvine, Irvine, California, USA
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Mulaku MN, Ochodo E, Young T, Steingart KR. Pre-treatment loss to follow-up in adults with pulmonary TB in Kenya. Public Health Action 2024; 14:34-39. [PMID: 38798784 PMCID: PMC11122711 DOI: 10.5588/pha.23.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/25/2024] [Indexed: 05/29/2024] Open
Abstract
SETTING County referral hospital in western Kenya. OBJECTIVES To ascertain the proportion of pre-treatment loss to follow-up (PTLFU) and associated patient factors in adults with pulmonary TB (PTB) in western Kenya. DESIGN A retrospective data review of laboratory and treatment registers for adults with bacteriologically confirmed PTB between January 2018 to December 2021. We defined PTLFU as failure to initiate treatment within 14 days of diagnosis. We used multivariable logistic regression modelling to identify patient factors associated with PTLFU. RESULTS Of 476 patients with PTB, 67.2% were male; the mean age was 36.1 years; 37.0% were HIV-positive; 5.7% had a history of anti-TB treatment; 40.6% were not traceable in the treatment register; 202 (42.4%, 95% CI 38.1-46.9) experienced PTLFU. Age ≥55 years (aOR 2.6, 95% CI 1.0-6.7) and providing only an address (aOR 34.2, 95% CI 18.7-62.5) or only a telephone contact number (aOR 22.3, 95% CI 3.5-141.1) were associated with PTLFU. Sex, HIV status, history of anti-TB treatment and place of residence were not associated with PTLFU. CONCLUSION PTLFU contributes markedly to TB patient losses in western Kenya. Strengthening systems for documenting patient information and actively monitoring PTLFU are crucial for attrition reduction.
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Affiliation(s)
- M N Mulaku
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
- Department of Pharmacology, Clinical Pharmacy, and Pharmacy Practice, Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - E Ochodo
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - T Young
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - K R Steingart
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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Kerschberger B, Vambe D, Schomaker M, Mabhena E, Daka M, Dlamini T, Ngwenya S, Mamba B, Nxumalo B, Sibanda J, Dube S, Dlamini LM, Mukooza E, Ellman T, Ciglenecki I. Sustained high fatality during TB therapy amid rapid decline in TB mortality at population level: A retrospective cohort and ecological analysis from Shiselweni, Eswatini. Trop Med Int Health 2024; 29:192-205. [PMID: 38100203 DOI: 10.1111/tmi.13961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
OBJECTIVES Despite declining TB notifications in Southern Africa, TB-related deaths remain high. We describe patient- and population-level trends in TB-related deaths in Eswatini over a period of 11 years. METHODS Patient-level (retrospective cohort, from 2009 to 2019) and population-level (ecological analysis, 2009-2017) predictors and rates of TB-related deaths were analysed in HIV-negative and HIV-coinfected first-line TB treatment cases and the population of the Shiselweni region. Patient-level TB treatment data, and population and HIV prevalence estimates were combined to obtain stratified annual mortality rates. Multivariable Poisson regressions models were fitted to identify patient-level and population-level predictors of deaths. RESULTS Of 11,883 TB treatment cases, 1302 (11.0%) patients died during treatment: 210/2798 (7.5%) HIV-negative patients, 984/8443 (11.7%) people living with HIV (PLHIV), and 108/642 (16.8%) patients with unknown HIV-status. The treatment case fatality ratio remained above 10% in most years. At patient-level, fatality risk was higher in PLHIV (aRR 1.74, 1.51-2.02), and for older age and extra-pulmonary TB irrespective of HIV-status. For PLHIV, fatality risk was higher for TB retreatment cases (aRR 1.38, 1.18-1.61) and patients without antiretroviral therapy (aRR 1.70, 1.47-1.97). It decreases with increasing higher CD4 strata and the programmatic availability of TB-LAM testing (aRR 0.65, 0.35-0.90). At population-level, mortality rates decreased 6.4-fold (-147/100,000 population) between 2009 (174/100,000) and 2017 (27/100,000), coinciding with a decline in TB treatment cases (2785 in 2009 to 497 in 2017). Although the absolute decline in mortality rates was most pronounced in PLHIV (-826/100,000 vs. HIV-negative: -23/100,000), the relative population-level mortality risk remained higher in PLHIV (aRR 4.68, 3.25-6.72) compared to the HIV-negative population. CONCLUSIONS TB-related mortality rapidly decreased at population-level and most pronounced in PLHIV. However, case fatality among TB treatment cases remained high. Further strategies to reduce active TB disease and introduce improved TB therapies are warranted.
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Affiliation(s)
- Bernhard Kerschberger
- Médecins sans Frontières, Mbabane, Eswatini
- Médecins sans Frontières/Ärzte ohne Grenzen, Vienna Evaluation Unit, Vienna, Austria
| | - Debrah Vambe
- National TB Control Programme (NTCP), Manzini, Eswatini
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Statistics, Ludwig-Maximilians University Munich, Munich, Germany
| | | | | | | | | | - Bheki Mamba
- National TB Control Programme (NTCP), Manzini, Eswatini
| | | | - Joyce Sibanda
- National TB Control Programme (NTCP), Manzini, Eswatini
| | - Sisi Dube
- National TB Control Programme (NTCP), Manzini, Eswatini
| | | | | | - Tom Ellman
- Médecins sans Frontières, Cape Town, South Africa
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6
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Kasaie P, Pennington J, Gupta A, Dowdy DW, Kendall EA. The Impact of Preventive Treatment for Multidrug- and Rifampin-Resistant Tuberculosis Exceeds Trial-Based Estimates. Clin Infect Dis 2024; 78:133-143. [PMID: 37724763 PMCID: PMC10810707 DOI: 10.1093/cid/ciad557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/18/2023] [Accepted: 09/18/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Several clinical trials of tuberculosis preventive treatment (TPT) for household contacts of patients with multidrug- or rifampin-resistant tuberculosis (MDR/RR-TB) are nearing completion. The potential benefits of delivering TPT to MDR/RR-TB contacts extend beyond the outcomes that clinical trials can measure. METHODS We developed an agent-based, household-structured TB and MDR/RR-TB transmission model, calibrated to an illustrative setting in India. We simulated contact investigation in households of patients with MDR/RR-TB, comparing an MDR/RR-TPT regimen (assuming 6-month duration, 70% efficacy) and associated active case finding against alternatives of contact investigation without TPT or no household intervention. We simulated the TB and MDR/RR-TB incidence averted relative to placebo over 2 years, as measurable by a typical trial, as well as the incidence averted over a longer time horizon, in the broader population, and relative to no contact investigation. RESULTS Observing TPT and placebo recipients for 2 years as in a typical trial, MDR/RR-TPT was measured to prevent 72% (interquartile range, 45%-100%) of incident MDR/RR-TB among recipients; the median number needed to treat (NNT) to prevent 1 MDR/RR-TB case was 73, compared to placebo. This NNT decreased to 54 with 13-18 years of observation, to 27 when downstream transmission effects were also considered, and to 12 when the effects of active TB screening were included by comparing to a no-household-contact-intervention scenario. CONCLUSIONS If forthcoming trial results demonstrate efficacy, the long-term population impact of TPT for MDR/RR-TB-including the large effect of increased active TB detection among MDR/RR-TB contacts-could be much greater than suggested by trial outcomes alone.
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Affiliation(s)
- Parastu Kasaie
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jeff Pennington
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Amita Gupta
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Emily A Kendall
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Meehan SA, Hesseling AC, Boulle A, Chetty J, Connell L, Dlamini-Miti NJ, Dunbar R, Du Preez K, George G, Hoddinott G, Jennings K, Marx FM, Mudaly V, Naidoo P, Ndlovu N, Ngozo J, Smith M, Strauss M, Tanna G, Vanqa N, von Delft A, Osman M. Reducing Initial Loss to Follow-up Among People With Bacteriologically Confirmed Tuberculosis: LINKEDin, a Quasi-experimental Study in South Africa. Open Forum Infect Dis 2024; 11:ofad648. [PMID: 38221986 PMCID: PMC10787480 DOI: 10.1093/ofid/ofad648] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 12/16/2023] [Indexed: 01/16/2024] Open
Abstract
Every person diagnosed with tuberculosis (TB) needs to initiate treatment. The World Health Organization estimated that 61% of people who developed TB in 2021 were included in a TB treatment registration system. Initial loss to follow-up (ILTFU) is the loss of persons to care between diagnosis and treatment initiation/registration. LINKEDin, a quasi-experimental study, evaluated the effect of 2 interventions (hospital recording and an alert-and-response patient management intervention) in 6 subdistricts across 3 high-TB burden provinces of South Africa. Using integrated electronic reports, we identified all persons diagnosed with TB (Xpert MTB/RIF positive) in the hospital and at primary health care facilities. We prospectively determined linkage to care at 30 days after TB diagnosis. We calculated the risk of ILTFU during the baseline and intervention periods and the relative risk reduction in ILTFU between these periods. We found a relative reduction in ILTFU of 42.4% (95% CI, 28.5%-53.7%) in KwaZulu Natal (KZN) and 22.3% (95% CI, 13.3%-30.4%) in the Western Cape (WC), with no significant change in Gauteng. In KZN and the WC, the relative reduction in ILTFU appeared greater in subdistricts where the alert-and-response patient management intervention was implemented (KZN: 49.3%; 95% CI, 32.4%-62%; vs 32.2%; 95% CI, 5.4%-51.4%; and WC: 34.2%; 95% CI, 20.9%-45.3%; vs 13.4%; 95% CI, 0.7%-24.4%). We reported a notable reduction in ILTFU in 2 provinces using existing routine health service data and applying a simple intervention to trace and recall those not linked to care. TB programs need to consider ILTFU a priority and develop interventions specific to their context to ensure improved linkage to care.
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Affiliation(s)
- Sue-Ann Meehan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Health and Wellness, Health Intelligence Directorate, Western Cape Government, Cape Town, South Africa
| | - Jolene Chetty
- Interactive Research and Development South Africa (IRD SA), Sandton, Johannesburg
| | - Lucy Connell
- Right to Care South Africa, Helen Joseph Hospital, Johannesburg, South Africa
| | | | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Karen Du Preez
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gavin George
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
- Division of Social Medicine and Global Health, Lund University, Lund, Sweden
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Karen Jennings
- City of Cape Town Health Department, Cape Town, South Africa
| | - Florian M Marx
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
- DSI-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Vanessa Mudaly
- Department of Health and Wellness, Western Cape Government, Cape Town, South Africa
| | - Pren Naidoo
- Bill and Melinda gates Foundation, Johannesburg, South Africa
| | - Neo Ndlovu
- Right to Care South Africa, Helen Joseph Hospital, Johannesburg, South Africa
| | - Jacqueline Ngozo
- Kwa-Zulu Natal Department of Health and Wellness, Pietermaritzburg, South Africa
| | - Mariette Smith
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Health and Wellness, Health Intelligence Directorate, Western Cape Government, Cape Town, South Africa
| | - Michael Strauss
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Gaurang Tanna
- Bill and Melinda gates Foundation, Johannesburg, South Africa
| | - Nosivuyile Vanqa
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Arne von Delft
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Health and Wellness, Health Intelligence Directorate, Western Cape Government, Cape Town, South Africa
| | - Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- School of Human Sciences, University of Greenwich, London, UK
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8
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Mulaku MN, Nyagol B, Owino EJ, Ochodo E, Young T, Steingart KR. Factors contributing to pre-treatment loss to follow-up in adults with pulmonary tuberculosis: a qualitative evidence synthesis of patient and healthcare worker perspectives. Glob Health Action 2023; 16:2148355. [PMID: 36548521 PMCID: PMC9788701 DOI: 10.1080/16549716.2022.2148355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 11/12/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Since 2018, over 14 million people have been treated for tuberculosis (TB) globally. However, pre-treatment loss to follow-up (PTLFU) has been shown to contribute substantially to patient losses in the TB care cascade with subsequent high community transmission and mortality rates. OBJECTIVE To identify, appraise, and synthesise evidence on the perspectives of patients and healthcare workers on factors contributing to PTLFU in adults with pulmonary TB. METHODS We registered the title with PROSPERO (CRD42021253212). We searched nine relevant databases up to 24 May 2021 for qualitative studies. Two review authors independently reviewed records for eligibility and extracted data. We assessed methodological quality with the Evidence for Policy and Practice Information Centre tool and synthesised data using the Supporting the Use of Research Evidence framework. We assessed confidence in our findings using Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual). RESULTS We reviewed a total of 1239 records and included five studies, all from low- and middle-income countries. Key themes reported by patients and healthcare workers were communication challenges among healthcare workers and between healthcare workers and patients; knowledge, attitudes, and behaviours about TB and its management; accessibility and availability of facilities for TB care; and human resource and financial constraints, weakness in management and leadership in TB programmes. Patients' change of residence, long waiting times, and poor referral systems were additional factors that contributed to patients disengaging from care. We had moderate confidence in most of our findings. CONCLUSION Findings from our qualitative evidence synthesis highlight multiple factors that contribute to PTLFU. Central to addressing these factors will be the need to strengthen health systems and offer people-centred care.
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Affiliation(s)
- Mercy Namuma Mulaku
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Pharmacy, Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Bruce Nyagol
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Eddy Johnson Owino
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Eleanor Ochodo
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Taryn Young
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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9
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Mulaku MN, Corrie OM, Odero I, Young T, Steingart KR, Ochodo E. Health worker views on pre-treatment loss to follow-up in adults with pulmonary TB in Western Kenya. Public Health Action 2023; 13:77-82. [PMID: 37736575 PMCID: PMC10446661 DOI: 10.5588/pha.23.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/22/2023] [Indexed: 09/23/2023] Open
Abstract
SETTING County referral hospital in Western Kenya. OBJECTIVES To explore factors contributing to pre-treatment loss to follow-up (PTLFU) in adults with pulmonary TB and propose solutions to address PTLFU from healthcare worker (HCW) perspectives. DESIGN This was an exploratory qualitative study using thematic analysis. RESULTS We conducted 19 key informant interviews with HCWs representing laboratory, clinical care, management and the community. Participant age ranged from 26 to 62 years; 14 (74%) were females; and most (74%) had worked in TB care for ⩽5 years. They reported that patients experienced stigma and had misconceptions about TB that contributed to PTLFU. HCWs were hesitant to work in the TB clinic, which contributed to suboptimal patient care, leading to PTLFU. Unclear linkage between laboratory and clinician, and limited financial resources to track patients were among the healthcare system factors that led to PTLFU. HCWs suggested having proper patient preparation, assigning resources to track patients and holding regular interdisciplinary meetings as practical solutions to address PTLFU. CONCLUSION HCWs reported multiple factors that may influence PTLFU and recommended various solutions to address these. Knowledge of TB management, patient preparation, resources to track patients and multidisciplinary meetings will be central to addressing PTLFU.
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Affiliation(s)
- M N Mulaku
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
- Department of Pharmacology, Clinical Pharmacy, and Pharmacy Practice, Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - O M Corrie
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - I Odero
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - T Young
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - K R Steingart
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - E Ochodo
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
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Steadman A, Andama A, Ball A, Mukwatamundu J, Khimani K, Mochizuki T, Asege L, Bukirwa A, Kato JB, Katumba D, Kisakye E, Mangeni W, Mwebe S, Nakaye M, Nasuna I, Nyawere J, Visente D, Cook C, Nalugwa T, Bachman CM, Semitalia F, Weigl BH, Connelly J, Worodria W, Cattamanchi A. New manual qPCR assay validated on tongue swabs collected and processed in Uganda shows sensitivity that rivals sputum-based molecular TB diagnostics. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.10.23293680. [PMID: 37645869 PMCID: PMC10462213 DOI: 10.1101/2023.08.10.23293680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Background Reliance on sputum-based testing is a key barrier to increasing access to molecular diagnostics for tuberculosis (TB). Many people with TB are unable to produce and sputum processing increases the complexity and cost of molecular assays. Tongue swabs are emerging as an alternative to sputum, but performance limits are uncertain. Methods From June 2022 to July 2023, we enrolled 397 consecutive adults with cough >2 weeks at two health centers in Kampala, Uganda. We collected routine demographic and clinical information, sputum for routine TB testing (one Xpert MTB/RIF Ultra® and two liquid cultures), and up to four tongue swabs for same-day qPCR. We evaluated tongue swab qPCR diagnostic accuracy in reference to sputum TB test results, quantified TB targets per swab, assessed the impact of serial swabbing, and compared two swab types (Copan FLOQSWAB® and Steripack® spun polyester swabs). Results Among 397 participants, 43.1% were female, median age was 33 years, 23.5% were living with HIV (PLHIV) and 32.3% had confirmed TB. Sputum Xpert Ultra and tongue swab qPCR results were concordant for 98.2% [96.2-99.1] of participants. Tongue swab qPCR sensitivity was 91.0% [84.6-94.9] and specificity 98.9% [96.2-99.8] vs. microbiological reference standard (MRS). A single tongue swab recovered a seven-log range of TB copies, with a decreasing recovery trend among four serial swabs. We found no difference between swab types. Conclusions Tongue swabs show promise as an alternative to sputum for TB diagnosis, with sensitivity approaching sputum-based molecular tests. Our results provide valuable insights for developing successful tongue swab-based TB diagnostics.
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11
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Yotsu RR, Almamy D, Vagamon B, Ugai K, Itoh S, Koffi YD, Kaloga M, Dizoé LAS, Kouadio K, Aka N, Yeboue LKG, Yao KA, Blanton RE. An mHealth App (eSkinHealth) for Detecting and Managing Skin Diseases in Resource-Limited Settings: Mixed Methods Pilot Study. JMIR DERMATOLOGY 2023; 6:e46295. [PMID: 37632977 PMCID: PMC10335127 DOI: 10.2196/46295] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/17/2023] [Accepted: 05/08/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND In sub-Saharan Africa, the disease burden from skin diseases, including skin-related neglected tropical diseases (skin NTDs), is extremely high. These diseases often are overlooked due to limited access to health care stemming from, for example, remote geographical locations and a lack of experts. To address these gaps, we developed a mobile health app, eSkinHealth, which is a field-adapted platform to serve as a portable electronic patient chart and for teledermatology. OBJECTIVE The purpose of the study is to evaluate the usability and effectiveness of the app in rural Côte d'Ivoire for diagnosing and managing skin NTDs and other skin diseases. METHODS A 2-arm trial with local health care providers and patients with skin diseases was implemented over a 3-month period. The providers were assigned to an intervention receiving the eSkinHealth app or control with usual care. Four nurses and 8 community health care workers participated in each arm. The training was provided on the use of the app to the intervention arm only, while both arms were trained on skin diseases. For the usability study, we evaluated our approach with the System Usability Scale (SUS) and in-depth interviews. For the effectiveness study, our primary outcome was to evaluate the detection and management of 5 skin NTDs as our targeted diseases, namely, Buruli ulcer, leprosy, lymphatic filariasis, scabies, and yaws, using the eSkinHealth app. Procedures of our methods were reviewed and approved by the institutional review board of the Ministry of Health and by Tulane University. RESULTS The mean age of our participants (providers) was 40.5 and 42.5 years for the intervention and control arms, respectively, and all were male (n=24). The average SUS scores taken from the intervention arm at baseline, the midpoint (6 weeks), and the end of study (12 weeks) were 72.3 (SD 11.5), 72.3 (SD 12.4), and 86.3 (SD 10.8), respectively. All participants interviewed, including 4 dermatologists and program managers, were satisfied with the app. Especially community health care workers felt empowered by being equipped with the tool. A total of 79 cases of skin NTDs were reported in the intervention arm as compared to 17 cases in the control arm (P=.002). Besides the skin NTDs, more skin diseases and conditions were reported from the control than from the intervention arm (P<.001). However, 100 cases (66%) were not given any particular diagnosis in the control arm and were documented only as a "dermatosis." In the intervention arm, 151 cases (72.9%) were diagnosed within the eSkinHealth platform, and the remaining were diagnosed on-site by dermatologists. CONCLUSIONS The study provided evidence for the usability and effectiveness of the eSkinHealth app embedded into our surveillance approach to improve the detection and management of skin NTDs and other skin diseases in Côte d'Ivoire and, furthermore, is expected to contribute to knowledge on mobile health approaches in the control of skin diseases in resource-limited settings. TRIAL REGISTRATION ClinicalTrials.gov NCT05300399; https://clinicaltrials.gov/ct2/show/NCT05300399.
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Affiliation(s)
- Rie R Yotsu
- Department of Tropical Medicine, Tulane School of Public Health and Tropical Medicine, New Orleans, LA, United States
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Department of Dermatology, National Center for Global Health and Medicine, Shinjuku, Japan
| | - Diabate Almamy
- Department of Dermatology, Université Alassane Ouattara, Bouaké, Côte d'Ivoire
| | - Bamba Vagamon
- Department of Dermatology, Université Alassane Ouattara, Bouaké, Côte d'Ivoire
- Raoul Follereau Institute Côte d'Ivoire, Adzopé, Côte d'Ivoire
| | - Kazuko Ugai
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | - Sakiko Itoh
- Department of Genome Informatics, Graduate School of Medicine, Osaka University, Suita, Japan
- Department of Home Health and Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yao Didier Koffi
- Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, Abidjan, Côte d'Ivoire
- National Buruli Ulcer Control Program, Ministry of Health of Côte d'Ivoire, Abidjan, Côte d'Ivoire
| | - Mamadou Kaloga
- National Buruli Ulcer Control Program, Ministry of Health of Côte d'Ivoire, Abidjan, Côte d'Ivoire
| | - Ligué Agui Sylvestre Dizoé
- National Control Program for Elimination of Leprosy, Ministry of Health of Côte d'Ivoire, Abidjan, Côte d'Ivoire
| | | | | | | | | | - Ronald E Blanton
- Department of Tropical Medicine, Tulane School of Public Health and Tropical Medicine, New Orleans, LA, United States
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12
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Madybaeva D, Duishekeeva A, Meteliuk A, Kulzhabaeva A, Kadyrov A, Shumskaia N, Kumar AMV. "Together against Tuberculosis": Cascade of Care of Patients Referred by the Private Health Care Providers in the Kyrgyz Republic. Trop Med Infect Dis 2023; 8:316. [PMID: 37368734 PMCID: PMC10304244 DOI: 10.3390/tropicalmed8060316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/04/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
Until 2021, in the Kyrgyz Republic, tuberculosis (TB) was diagnosed and treated only in the public sector. With funding support of the STOP-TB partnership, the private providers in four regions of the country and Bishkek city were mapped, trained and incentivized to screen for and identify presumptive TB patients and refer them to the public facilities for diagnosis and treatment. In this study, we describe the cascade of care of such patients. This was a cohort study involving secondary analysis of routine data. Of 79,352 patients screened during February 2021-March 2022, 2511 (3%) had presumptive TB, of whom 903 (36%) were not tested for TB [pre-diagnostic loss to follow-up]. A total of 323 (13%) patients were diagnosed with TB, of whom, 42 (13%) were not started on treatment [pre-treatment loss to follow-up]. Among 257 patients eligible for outcome assessment, 197 (77%) had treatment success, 29 (11%) were lost-to-follow-up, 13 (5%) died, 4 (2%) had treatment failure and 14 (5%) were not evaluated. While this donor-funded, pioneering initiative was successful in engaging the private sector, we recommend that the national TB programme scales up the initiative nationally with dedicated budgets, activities and plans to monitor progress. Qualitative research is urgently needed to understand the reasons for the gaps in the care cascade.
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Affiliation(s)
- Dinara Madybaeva
- Public Foundation “AFEW KG”, 14 JalArtis, 103, Bishkek 720047, Kyrgyzstan;
| | - Aiymgul Duishekeeva
- Public Foundation “KNCV KG”, 121 Dzhantoshev St., Bishkek 720020, Kyrgyzstan; (A.D.); (A.K.)
- Department of Phthisiology, Kyrgyz State Medical Academy, 92 Akhunbaev St., Bishkek 720020, Kyrgyzstan
| | - Anna Meteliuk
- International Charitable Foundation Alliance for Public Health, 03150 Kyiv, Ukraine;
| | - Aizat Kulzhabaeva
- Public Foundation “KNCV KG”, 121 Dzhantoshev St., Bishkek 720020, Kyrgyzstan; (A.D.); (A.K.)
- Department of Public Health, Kyrgyz State Medical Academy, 92 Akhunbaev St., Bishkek 720020, Kyrgyzstan
| | - Abdullaat Kadyrov
- National Center for Phthisiology of MoH Kyrgyzstan, Ahunbaev St., 90a, Bishkek 720064, Kyrgyzstan;
| | - Natalia Shumskaia
- Public Foundation “AFEW KG”, 14 JalArtis, 103, Bishkek 720047, Kyrgyzstan;
| | - Ajay M. V. Kumar
- International Union Against Tuberculosis and Lung Disease, 2 Rue Jean Lantier, 75001 Paris, France;
- International Union Against Tuberculosis and Lung Disease, South-East Asia Office, C-6 Qutub Institutional Area, New Delhi 110016, India
- Department of Community Medicine, Yenepoya Medical College, Yenepoya (Deemed to be University), University Road, Deralakatte, Karnataka, Mangalore 575018, India
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13
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Linn AR, Dubois MM, Steenhoff AP. Under-Reporting of Tuberculosis Disease among Children and Adolescents in Low and Middle-Income Countries: A Systematic Review. Trop Med Infect Dis 2023; 8:300. [PMID: 37368718 DOI: 10.3390/tropicalmed8060300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/23/2023] [Accepted: 05/26/2023] [Indexed: 06/29/2023] Open
Abstract
Under-reporting of tuberculosis (TB) disease in children and adolescents is a significant global concern, as many children are missing from TB notification data. A systematic literature review was conducted to understand the global reporting gap of child and adolescent TB as well as current interventions to close this gap in Low- and Middle- Income Countries (LMIC). Our study found large and variable gaps in child and adolescent TB reporting, due to various factors. Interventions to close this gap exist but are limited. Future studies are necessary to improve global surveillance systems to improve TB care delivery for children and adolescents.
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Affiliation(s)
- Alexandra R Linn
- Global Health Center, Children's Hospital of Philadelphia & Department of Pediatrics, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Melanie M Dubois
- Division of Pediatric Infectious Diseases, Weill Cornell Medicine, New York, NY 10065, USA
| | - Andrew P Steenhoff
- Global Health Center, Children's Hospital of Philadelphia & Department of Pediatrics, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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14
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Quang Vo LN, Forse RJ, Tran J, Dam T, Driscoll J, Codlin AJ, Creswell J, Sidney-Annerstedt K, Van Truong V, Thi Minh HD, Huu LN, Nguyen HB, Nguyen NV. Economic evaluation of a community health worker model for tuberculosis care in Ho Chi Minh City, Viet Nam: a mixed-methods Social Return on Investment Analysis. BMC Public Health 2023; 23:945. [PMID: 37231468 DOI: 10.1186/s12889-023-15841-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 05/08/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND There is extensive evidence for the cost-effectiveness of programmatic and additional tuberculosis (TB) interventions, but no studies have employed the social return on investment (SROI) methodology. We conducted a SROI analysis to measure the benefits of a community health worker (CHW) model for active TB case finding and patient-centered care. METHODS This mixed-method study took place alongside a TB intervention implemented in Ho Chi Minh City, Viet Nam, between October-2017 - September-2019. The valuation encompassed beneficiary, health system and societal perspectives over a 5-year time-horizon. We conducted a rapid literature review, two focus group discussions and 14 in-depth interviews to identify and validate pertinent stakeholders and material value drivers. We compiled quantitative data from the TB program's and the intervention's surveillance systems, ecological databases, scientific publications, project accounts and 11 beneficiary surveys. We mapped, quantified and monetized value drivers to derive a crude financial benefit, which was adjusted for four counterfactuals. We calculated a SROI based on the net present value (NPV) of benefits and investments using a discounted cash flow model with a discount rate of 3.5%. A scenario analysis assessed SROI at varying discount rates of 0-10%. RESULTS The mathematical model yielded NPVs of US$235,511 in investments and US$8,497,183 in benefits. This suggested a return of US$36.08 for each dollar invested, ranging from US$31.66-US39.00 for varying discount rate scenarios. CONCLUSIONS The evaluated CHW-based TB intervention generated substantial individual and societal benefits. The SROI methodology may be an alternative for the economic evaluation of healthcare interventions.
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Affiliation(s)
- Luan Nguyen Quang Vo
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam.
| | - Rachel Jeanette Forse
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | - Jacqueline Tran
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | - Thu Dam
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | - Jenny Driscoll
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | - Andrew James Codlin
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | | | - Kristi Sidney-Annerstedt
- Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Solna, Sweden
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15
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Jiang Y, Chen J, Ying M, Liu L, Li M, Lu S, Li Z, Zhang P, Xie Q, Liu X, Lu H. Factors associated with loss to follow-up before and after treatment initiation among patients with tuberculosis: A 5-year observation in China. Front Med (Lausanne) 2023; 10:1136094. [PMID: 37181365 PMCID: PMC10167013 DOI: 10.3389/fmed.2023.1136094] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/28/2023] [Indexed: 05/16/2023] Open
Abstract
Background Loss to follow-up (LTFU) is a significant barrier to the completion of anti-tuberculosis (TB) treatment and a major predictor of TB-associated deaths. Currently, research on LTFU-related factors in China is both scarce and inconsistent. Methods We collected information from the TB observation database of the National Clinical Research Center for Infectious Diseases. The data of all patients who were documented as LTFU were assessed retrospectively and compared with those of patients who were not LTFU. Descriptive epidemiology and multivariable logistic regression analyses were conducted to identify the factors associated with LTFU. Results A total of 24,265 TB patients were included in the analysis. Of them, 3,046 were categorized as LTFU, including 678 who were lost before treatment initiation and 2,368 who were lost afterwards. The previous history of TB was independently associated with LTFU before treatment initiation. Having medical insurance, chronic hepatitis or cirrhosis, and providing an alternative contact were independent predictive factors for LTFU after treatment initiation. Conclusion Loss to follow-up is frequent in the management of patients with TB and can be predicted using patients' treatment history, clinical characteristics, and socioeconomic factors. Our research illustrates the importance of early assessment and intervention after diagnosis. Targeted measures can improve patient engagement and ultimately treatment adherence, leading to better health outcomes and disease control.
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Affiliation(s)
- Youli Jiang
- Hengyang Medical School, School of Nursing, University of South China, Hengyang, China
| | | | - Meng Ying
- Shenzhen Third People’s Hospital, Shenzhen, China
| | - Linlin Liu
- Shenzhen Third People’s Hospital, Shenzhen, China
| | - Min Li
- Hengyang Medical School, School of Nursing, University of South China, Hengyang, China
| | - Shuihua Lu
- Hengyang Medical School, School of Nursing, University of South China, Hengyang, China
| | - Zhihuan Li
- Department of Intelligent Security Laboratory, Shenzhen Tsinghua University Research Institute, Shenzhen, China
| | - Peize Zhang
- Hengyang Medical School, School of Nursing, University of South China, Hengyang, China
| | - Qingyao Xie
- Hengyang Medical School, School of Nursing, University of South China, Hengyang, China
| | - Xuhui Liu
- Shenzhen Third People’s Hospital, Shenzhen, China
| | - Hongzhou Lu
- Shenzhen Third People’s Hospital, Shenzhen, China
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16
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Coulibaly G, Georges Togo AC, Somboro AM, Kone M, Traore FG, Diallo F, Degoga B, Somboro A, Dramé HM, Sanogo M, Kodio O, Baya B, Tolofoudie M, Maiga A, Maiga M, Saliba-Shaw K, Diallo S, Doumbia S, Maiga II, Samaké F, Diarra B. Use of light-emitting diode fluorescence microscopy to detect acid-fast bacilli in sputum as proficient alternative tool in the diagnosis of pulmonary tuberculosis in countries with limited resource settings. Int J Mycobacteriol 2023; 12:144-150. [PMID: 37338475 DOI: 10.4103/ijmy.ijmy_13_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023] Open
Abstract
Background Despite recent advances in the development of more sensitive technologies for the diagnosis of tuberculosis (TB), in resource-limited settings, the diagnosis continues to rely on sputum smear microscopy. This is because smear microscopy is simple, cost-efficient and the most accessible tool for the diagnosis of TB. Our study evaluated the performance of light-emitting diode fluorescence microscopy (LED-FM) using auramine/rhodamine (auramine) and the fluorescein di-acetate (FDA) vital stain in the diagnostic of pulmonary TB in Bamako, Mali. Methods Sputum smear microscopy was conducted using the FDA and auramine/rhodamine staining procedures on fresh samples using LED-FM to evaluate the Mycobacterium TB (MTB) metabolic activity and to predict contagiousness. Mycobacterial culture assay was utilized as a gold standard method. Results Out of 1401 TB suspected patients, 1354 (96.65%) were retrieved from database, which were MTB complex culture positive, and 47 (3.40%) were culture negative (no mycobacterial growth observed). Out of the 1354 included patients, 1343 (95.86%), were acid-fast bacillus (AFB) positive after direct FDA staining, 1352 (96.50%) AFB positive after direct Auramine, and 1354 (96.65%) AFB positive with indirect auramine after digestion and centrifugation. Overall, the FDA staining method has a sensitivity of 98.82%, while the sensitivity of Auramine with direct observation was 99.48%, and 99.56% with the indirect examination. Conclusion This study showed that, using fresh sputum both auramine/rhodamine and FDA are highly sensitive methods in diagnosing pulmonary TB and could be easily used in countries with limited resource settings.
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Affiliation(s)
- Gagni Coulibaly
- University Clinical Research Center-SEREFO Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Antièmé Combo Georges Togo
- University Clinical Research Center-SEREFO Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Anou Moise Somboro
- University Clinical Research Center-SEREFO Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali; Medical Biochemistry, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Mahamadou Kone
- University Clinical Research Center-SEREFO Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Fah Gaoussou Traore
- University Clinical Research Center-SEREFO Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Fatimata Diallo
- University Clinical Research Center-SEREFO Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Boureima Degoga
- University Clinical Research Center-SEREFO Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Amadou Somboro
- University Clinical Research Center-SEREFO Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Hawa M'baye Dramé
- University Clinical Research Center-SEREFO Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Moumine Sanogo
- University Clinical Research Center-SEREFO Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Ousmane Kodio
- University Clinical Research Center-SEREFO Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Bocar Baya
- University Clinical Research Center-SEREFO Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Mohamed Tolofoudie
- University Clinical Research Center-SEREFO Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Aminata Maiga
- Laboratory and Hospital Hygiene Services, University Teaching Hospital of Point G, Bamako, Mali
| | - Mamoudou Maiga
- University Clinical Research Center-SEREFO Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali; Center for Innovation in Global Health Technology, Northwestern University, Chicago, Illinois, USA
| | - Katy Saliba-Shaw
- Collaborative Clinical Research Branch, Division of Clinical Research, NIAID/NIH, Bethesda, Maryland, USA
| | - Souleymane Diallo
- University Clinical Research Center-SEREFO Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Seydou Doumbia
- University Clinical Research Center-SEREFO Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | | | - Fassé Samaké
- Microbial Biotechnology Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | - Bassirou Diarra
- University Clinical Research Center-SEREFO Laboratory, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
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17
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Nicholson TJ, Hoddinott G, Seddon JA, Claassens MM, van der Zalm MM, Lopez E, Bock P, Caldwell J, Da Costa D, de Vaal C, Dunbar R, Du Preez K, Hesseling AC, Joseph K, Kriel E, Loveday M, Marx FM, Meehan SA, Purchase S, Naidoo K, Naidoo L, Solomon-Da Costa F, Sloot R, Osman M. A systematic review of risk factors for mortality among tuberculosis patients in South Africa. Syst Rev 2023; 12:23. [PMID: 36814335 PMCID: PMC9946877 DOI: 10.1186/s13643-023-02175-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 01/17/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Tuberculosis (TB)-associated mortality in South Africa remains high. This review aimed to systematically assess risk factors associated with death during TB treatment in South African patients. METHODS We conducted a systematic review of TB research articles published between 2010 and 2018. We searched BioMed Central (BMC), PubMed®, EBSCOhost, Cochrane, and SCOPUS for publications between January 2010 and December 2018. Searches were conducted between August 2019 and October 2019. We included randomised control trials (RCTs), case control, cross sectional, retrospective, and prospective cohort studies where TB mortality was a primary endpoint and effect measure estimates were provided for risk factors for TB mortality during TB treatment. Due to heterogeneity in effect measures and risk factors evaluated, a formal meta-analysis of risk factors for TB mortality was not appropriate. A random effects meta-analysis was used to estimate case fatality ratios (CFRs) for all studies and for specific subgroups so that these could be compared. Quality assessments were performed using the Newcastle-Ottawa scale or the Cochrane Risk of Bias Tool. RESULTS We identified 1995 titles for screening, 24 publications met our inclusion criteria (one cross-sectional study, 2 RCTs, and 21 cohort studies). Twenty-two studies reported on adults (n = 12561) and two were restricted to children < 15 years of age (n = 696). The CFR estimated for all studies was 26.4% (CI 18.1-34.7, n = 13257 ); 37.5% (CI 24.8-50.3, n = 5149) for drug-resistant (DR) TB; 12.5% (CI 1.1-23.9, n = 1935) for drug-susceptible (DS) TB; 15.6% (CI 8.1-23.2, n = 6173) for studies in which drug susceptibility was mixed or not specified; 21.3% (CI 15.3-27.3, n = 7375) for people living with HIV/AIDS (PLHIV); 19.2% (CI 7.7-30.7, n = 1691) in HIV-negative TB patients; and 6.8% (CI 4.9-8.7, n = 696) in paediatric studies. The main risk factors associated with TB mortality were HIV infection, prior TB treatment, DR-TB, and lower body weight at TB diagnosis. CONCLUSIONS In South Africa, overall mortality during TB treatment remains high, people with DR-TB have an elevated risk of mortality during TB treatment and interventions to mitigate high mortality are needed. In addition, better prospective data on TB mortality are needed, especially amongst vulnerable sub-populations including young children, adolescents, pregnant women, and people with co-morbidities other than HIV. Limitations included a lack of prospective studies and RCTs and a high degree of heterogeneity in risk factors and comparator variables. SYSTEMATIC REVIEW REGISTRATION The systematic review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42018108622. This study was funded by the Bill and Melinda Gates Foundation (Investment ID OPP1173131) via the South African TB Think Tank.
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Affiliation(s)
- Tamaryn J Nicholson
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
| | - Mareli M Claassens
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Human, Biological and Translational Medical Sciences, School of Medicine, University of Namibia, Windhoek, Namibia
| | - Marieke M van der Zalm
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elisa Lopez
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- IS Global, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-Universidad de Barcelona, Barcelona, Spain
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Judy Caldwell
- Community Services and Health Directorate, City of Cape Town, Cape Town, South Africa
| | - Dawood Da Costa
- Division of Medical Microbiology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Celeste de Vaal
- Division of Forensic Medicine and Toxicology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Karen Du Preez
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kay Joseph
- Community Services and Health Directorate, City of Cape Town, Cape Town, South Africa
| | - Ebrahim Kriel
- Metro Health Services, Southern and Western Substructure, Western Cape Government: Health, Cape Town, South Africa
| | - Marian Loveday
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa, CAPRISA-SA-MRC HIV-TB Pathogenesis and Treatment Research Unit, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Florian M Marx
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Sue-Ann Meehan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Susan Purchase
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa, CAPRISA-SA-MRC HIV-TB Pathogenesis and Treatment Research Unit, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Lenny Naidoo
- Community Services and Health Directorate, City of Cape Town, Cape Town, South Africa
| | | | - Rosa Sloot
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
- School of Human Sciences, Faculty of Education, Health and Human Sciences, University of Greenwich, London, United Kingdom.
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18
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Thompson RR, Nalugwa T, Oyuku D, Tucker A, Nantale M, Nakaweesa A, Musinguzi J, Reza TF, Zimmer AJ, Ferguson O, Turyahabwe S, Joloba M, Cattamanchi A, Katamba A, Dowdy DW, Sohn H. Multicomponent strategy with decentralised molecular testing for tuberculosis in Uganda: a cost and cost-effectiveness analysis. Lancet Glob Health 2023; 11:e278-e286. [PMID: 36669808 PMCID: PMC9848406 DOI: 10.1016/s2214-109x(22)00509-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Decentralised molecular testing for tuberculosis could reduce missed diagnoses and losses to follow-up in high-burden settings. The aim of this study was to evaluate the cost and cost-effectiveness of the Xpert Performance Evaluation for Linkage to Tuberculosis Care (XPEL-TB) study strategy, a multicomponent strategy including decentralised molecular testing for tuberculosis, in Uganda. METHODS We conducted a costing and cost-effectiveness analysis nested in a pragmatic cluster-randomised trial of onsite (decentralised) versus hub-and-spoke (centralised) testing for tuberculosis with Xpert MTB/RIF Ultra (Xpert) in 20 community health centres in Uganda. We collected empirical data on the cost of the XPEL-TB strategy (decentralised Xpert testing, workflow redesign, and performance feedback) and routine tuberculosis testing (onsite smear microscopy with specimen transport for centralised Xpert testing) from the health system perspective. Time-and-motion studies were performed to estimate activity-based service costs. Cost-effectiveness was assessed as the incremental cost (2019 US$) per tuberculosis diagnosis and per 14-day treatment initiation. FINDINGS The XPEL-TB study ran from Oct 22, 2018, to March 1, 2020. Effectiveness and cost-effectiveness outcomes were assessed from Dec 1, 2018, to Nov 30, 2019 and included 4867 women and 3139 men. On a per-test basis, the cost of decentralised ($20·46, range $17·85-25·72) and centralised ($18·20, range $16·58-24·25) Xpert testing was similar. However, decentralised testing resulted in more patients receiving appropriate Xpert testing, so the per-patient cost of decentralised testing was higher: $20·28 (range $17·68-25·48) versus $9·59 (range $7·62-14·34). The XPEL-TB strategy was estimated to cost $1332 (95% uncertainty range $763-5558) per incremental tuberculosis diagnosis and $687 ($501-1207) per incremental patient initiating tuberculosis treatment within 14 days. Cost-effectiveness was reduced in sites performing fewer than 150-250 tests annually. INTERPRETATION The XPEL-TB strategy facilitated higher rates of Xpert testing for tuberculosis at a similar per-test cost and modest incremental cost per tuberculosis diagnosis and treatment initiation. Decentralised Xpert testing, with appropriate implementation supports, should be scaled up to clinics with sufficient testing volume to support a single-module device. FUNDING The National Heart, Lung, and Blood Institute.
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Affiliation(s)
- Ryan R Thompson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Talemwa Nalugwa
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Denis Oyuku
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Austin Tucker
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Mariam Nantale
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Annet Nakaweesa
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Johnson Musinguzi
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Tania F Reza
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Alexandra J Zimmer
- McGill International Tuberculosis Centre, McGill University, Montreal, QC, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Olivia Ferguson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stavia Turyahabwe
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda; National Tuberculosis and Leprosy Program, Uganda Ministry of Health, Kampala, Uganda
| | - Moses Joloba
- National Tuberculosis and Leprosy Program, Uganda Ministry of Health, Kampala, Uganda; School of Biomedical Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Adithya Cattamanchi
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda; Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA; Partnerships for Research in Implementation Science for Equity Center, University of California San Francisco, San Francisco, CA, USA
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda; Clinical Epidemiology & Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Hojoon Sohn
- Department of Preventive Medicine, College of Medicine, Seoul National University, Seoul, South Korea.
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19
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Widoyo R, Djafri D, Putri ASE, Yani FF, Kusumawati RL, Wongsirichot T, Chongsuvivatwong V. Missing Cases of Bacteriologically Confirmed TB/DR-TB from the National Treatment Registers in West and North Sumatra Provinces, Indonesia. Trop Med Infect Dis 2023; 8:31. [PMID: 36668938 PMCID: PMC9861403 DOI: 10.3390/tropicalmed8010031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/15/2022] [Accepted: 12/30/2022] [Indexed: 01/04/2023] Open
Abstract
This study aimed to assess the percentage of confirmed drug-sensitive (DS) TB and drug-resistant (DR) TB patients who were missing in the national treatment registration in North Sumatra and West Sumatra, where treatment services for DR-TB in North Sumatra are relatively well established compared with West Sumatra, where the system recently started. Confirmed DS/DR-TB records in the laboratory register at 40 government health facilities in 2017 and 2018 were traced to determine whether they were in the treatment register databases. A Jaro-Winkler soundexed string distance analysis enhanced by socio-demographic information matching had sensitivity and specificity over 98% in identifying the same person in the same or different databases. The laboratory data contained 5885 newly diagnosed records of bacteriologically confirmed TB cases. Of the 5885 cases, 1424 of 5353 (26.6%) DS-TB cases and 133 of 532 (25.0%) DR-TB cases were missing in the treatment notification database. The odds of missing treatment for DS-TB was similar for both provinces (AOR = 1.0 (0.9, 1.2), but for DR-TB, North Sumatra had a significantly lower missing odds ratio (AOR = 0.4 (0.2, 0.7). The system must be improved to reduce this missing rate, especially for DR-TB in West Sumatra.
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Affiliation(s)
- Ratno Widoyo
- Epidemiology Unit, Faculty of Medicine, Prince Songkla University, Hat Yai 90110, Thailand
- Department of Epidemiology and Biostatistics, Faculty of Public Health, Universitas Andalas, Padang 25128, Indonesia
| | - Defriman Djafri
- Department of Epidemiology and Biostatistics, Faculty of Public Health, Universitas Andalas, Padang 25128, Indonesia
| | - Ade Suzana Eka Putri
- Department of Epidemiology and Biostatistics, Faculty of Public Health, Universitas Andalas, Padang 25128, Indonesia
| | - Finny Fitry Yani
- Department of Child Health, Faculty of Medicine, Universitas Andalas, Dr. M. Djamil General Hospital, Padang 25128, Indonesia
| | - R Lia Kusumawati
- Department of Microbiology, Faculty of Medicine, Universitas Sumatra Utara, H. Adam Malik Hospital, Medan 20136, Indonesia
| | - Thakerng Wongsirichot
- Division of Computational Science, Faculty of Science, Prince of Songkla University, Hat Yai 90110, Thailand
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20
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Masina HV, Lin IF, Chien LY. The Impact of the COVID-19 Pandemic on Tuberculosis Case Notification and Treatment Outcomes in Eswatini. Int J Public Health 2022; 67:1605225. [PMID: 36387290 PMCID: PMC9643149 DOI: 10.3389/ijph.2022.1605225] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 10/17/2022] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
| | - I-Feng Lin
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Li-Yin Chien
- Institute of Community Health Care, College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
- *Correspondence: Li-Yin Chien,
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21
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Rahmati S, Bahrampour A, Nasehi M, Mirzazadeh A, Ghaderi H, Shahesmaeili A. An Evaluation of The Diagnostic Value of Sputum Smears Microscopy and Pcr Relative to Sputum Culture in The Diagnosis of Pulmonary Tuberculosis: A Systematic Review and Meta-Analysis in Iran. Med J Islam Repub Iran 2022; 36:112. [PMID: 36447544 PMCID: PMC9700423 DOI: 10.47176/mjiri.36.112] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Indexed: 11/15/2023] Open
Abstract
Background: Tuberculosis is one of the oldest known diseases in humans, and early detection of tuberculosis is one of the main measures to decrease the spread of tuberculosis. In many parts of the world, including Iran, the diagnosis of tuberculosis is based on the detection of acid-fast bacillus in sputum smear microscopy and PCR. this study aimed to synthesize evidence on the diagnostic accuracy of sputum smear and PCR compared to sputum culture for the diagnosis of PT in Iranian patients. Methods: This systematic review and meta-analysis was conducted based on PRISMA guideline for systematic review and meta-analysis. Eligible studies were cross-sectional original diagnostic studies published in English and Persian in Iran which examined the sensitivity or specificity(study outcome) of sputum smear microscopy or PCR( as the test) relative to sputum culture (as the gold standard/comparator) among Iranian patients suspected of having tuberculosis( study population). Studies whose data were not complete or extractable were excluded. Results: A total of 3518 subjects were evaluated from 15 eligible studies. The pooled sensitivity of sputum smear and PCR was 75.12 (95% CI: 66.68-83.56) and 88.02 (95% CI: 82.87-93.27), respectively. The specificity for sputum smear and PCR was 93.94 (95% CI: 91.26-96.63) and 91.82 (95% CI: 87.29-96.35) respectively. The sensitivity of both sputum smears was higher in studies published after 2010, and had higher quality. The specificity of sputum smear was a bit lower in studies published after2010 but higher in studies with higher quality. The specificity of PCR was higher in studies published after 2010 but higher in studies with higher quality. Conclusion:The increased sensitivity of sputum smear and PCR during recent years suggests the improvement of preparation and laboratory methods in recent years. However, the imperfect sensitivity of these tests highlights the need for a more accurate diagnostic method for the detection of pulmonary tuberculosis in Iran.
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Affiliation(s)
- Shoboo Rahmati
- Student Research Committee, Kerman University of Medical Sciences, Kerman, Iran
| | - Abbas Bahrampour
- Modeling in Health Research Center, Institute for Futures Studies in Health, Department of Biostatistics and Epidemiology, Faculty of Health Kerman University of Medical Sciences, Kerman, IRAN. Adjunct Professor of Griffith University, Brisbane, QLD, Australia
| | - Mahshid Nasehi
- Department of Epidemiology, School of Health, Iran University of Medical Sciences, Iran
| | - Ali Mirzazadeh
- Department of Epidemiology, University of San Francisco, California, USA
| | - Hosna Ghaderi
- Department of Laboratory Sciences, Faculty of Paramedical, Kurdistan University of Medical Sciences, Kurdistan, Iran
| | - Armita Shahesmaeili
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
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22
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Lungu PS, Kabaso ME, Mihova R, Silumesii A, Chisenga T, Kasapo C, Mwaba I, Kerkhoff AD, Muyoyeta M, Chimzizi R, Malama K. Undernotification and underreporting of tuberculosis in Zambia: a national data quality assessment. BMC Health Serv Res 2022; 22:1074. [PMID: 35996175 PMCID: PMC9396838 DOI: 10.1186/s12913-022-08431-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 07/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite national implementation of several high impact interventions and innovations to bolster tuberculosis (TB) detection and improve quality of TB services in Zambia, notifications have been declining since 2004. A countrywide data quality assessment (DQA) of Zambia's National TB and Leprosy Programme (NTLP) was undertaken to quantify the degree to which undernotification and underreporting of TB notifications may be occurring. METHODS The NTLP conducted a retrospective DQA of health facilities in high burden districts in all ten Zambian provinces. Multiple routine programmatic data sources were triangulated through a multi-step verification process to enumerate the total number of unique TB patients diagnosed between 1st January and 31st August 2019; both bacteriologically confirmed and clinically diagnosed TB patients were included. Undernotification was defined as the number of TB patients identified through the DQA that were not documented in facility treatment registers, while underreporting was defined as the number of notified TB cases not reported to the NTLP. RESULTS Overall, 265 health facilities across 55 districts were assessed from which 28,402 TB patients were identified; 94.5% of TB patients were ≥ 15 years old, 65.1% were male, 52.0% were HIV-positive, and 89.6% were a new/relapse case. Among all TB cases, 32.8% (95%CI: 32.2-33.3) were unnotified. Undernotification was associated with age ≥ 15 years old (adjusted prevalence odds ratio [aPOR] = 2.4 [95%CI: 2.0-2.9]), HIV-positive status (aPOR = 1.6 [95%CI: 1.5-1.8]), being a new/relapse TB case (aPOR = 17.5 [95%CI: 13.4-22.8]), being a clinically diagnosed TB case (aPOR = 4.2 [95%CI:3.8-4.6]), and being diagnosed at a hospital (range, aPOR = 1.5 [95%CI: 1.3-1.6] to 2.6 [95%CI: 2.3-2.9]). There was substantial heterogeneity in the proportion of unnotified TB cases by province (range, 18.2% to 43.6%). In a sub-analysis among 22,199 TB patients with further data available, 55.9% (95%CI: 55.2-56.6) were notified and reported to the NTLP, 32.8% (95%CI: 32.2-33.4) were unnotified, and 11.3% (95%CI: 10.9-11.7) went unreported to the NTLP. CONCLUSIONS The findings from Zambia's first countrywide TB programme DQA demonstrate substantial undernotification and underreporting of TB cases across all provinces. This underscores the urgent need to implement a robust and integrated data management system to facilitate timely registration and reporting of all TB patients who are diagnosed and treated.
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Affiliation(s)
| | - M E Kabaso
- Ministry of Health, Lusaka, Zambia.,USAID Sustaining Technical and Analytic Resources (STAR) Project, Lusaka, Zambia
| | - R Mihova
- USAID Eradicate TB Program, Lusaka, Zambia
| | | | | | - C Kasapo
- Ministry of Health, Lusaka, Zambia
| | - I Mwaba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - A D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center University of California, San Francisco, San Francisco, CA, USA
| | - M Muyoyeta
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - K Malama
- Ministry of Health, Lusaka, Zambia
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23
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Barrios-Rivera E, Bastidas-Santacruz HE, Ramirez-Bernate CA, Vasilieva O. A synthesized model of tuberculosis transmission featuring treatment abandonment. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2022; 19:10882-10914. [PMID: 36124574 DOI: 10.3934/mbe.2022509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
In this paper, we propose and justify a synthesized version of the tuberculosis transmission model featuring treatment abandonment. In contrast to other models that account for the treatment abandonment, our model has only four state variables or classes (susceptible, latent, infectious, and treated), while people abandoning treatment are not gathered into an additional class. The proposed model retains the core properties that are highly desirable in epidemiological modeling. Namely, the disease transmission dynamics is characterized by the basic reproduction number $ \mathscr{R}_0 $, a threshold value that determines the number of possible steady states and their stability properties. It is shown that the disease-free equilibrium is globally asymptotically stable (GAS) only if $ \mathscr{R}_0 < 1 $, while a strictly positive endemic equilibrium exists and is GAS only if $ \mathscr{R}_0 > 1. $ Analysis of the dependence of $ \mathscr{R}_0 $ on the treatment abandonment rate shows that a reduction of the treatment abandonment rate has a positive effect on the disease incidence and results in avoiding disease-related fatalities.
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Affiliation(s)
- Edwin Barrios-Rivera
- Department of Mathematics, Universidad del Valle, Calle 13 No. 100-00, Cali 760032, Colombia
| | | | | | - Olga Vasilieva
- Department of Mathematics, Universidad del Valle, Calle 13 No. 100-00, Cali 760032, Colombia
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24
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Veisi N, Sharifi H, Shahesmaeili A, Ghaderi E, Rahmati S. An explanation of the 15-year trend and investigation of the tuberculosis cascade in Kurdistan province. J Clin Tuberc Other Mycobact Dis 2022; 28:100323. [PMID: 35813284 PMCID: PMC9263965 DOI: 10.1016/j.jctube.2022.100323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Objective This study's objectives were to describe the 15-year trend from 2005 to 2019 and examine the tuberculosis cascade in the Kurdistan province from 21 march 2018–20 march 2019. Methods This retrospective study was in 2744 patients with tuberculosis from 2005 to 2019 who were registered in Kurdistan disease registration centers. For the initial evaluation of demographic data, we utilized SPSS software version 20 and excel. Additionally, to design a care cascade, we utilized draw.io software for registered patients between March 21, 2018, and March 20, 2019. As a result, 2489 new cases of tuberculosis remained in our study. Results The results showed that the mean of age of people with tuberculosis was 58 years and sex distribution were 1441 (57.9) female and 1048 (42.1) male. Additionally, a cascade model showed that in Kurdistan Province, an estimated 112 new cases of smear-positive pulmonary tuberculosis in 2018, of which 90% (101 people) were sent to medical facilities and underwent diagnostic testing, with 80% of these patients (81 people). Infection was identified in 81 individuals, all of whom had their diagnoses recorded in the medical database. 82% (67 patients) of the patients who were enrolled in the treatment system received access to treatment, and 65 patients, or 97 percent, experienced no recurrence for at least a year after treatment. Correct diagnosis and therapy represented the biggest gap. Conclusion Cascade can enhance surveillance program and focus activities to better cases, diagnose, connect to care, and help TB patients survive without recurrence.
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Affiliation(s)
- Nasrollah Veisi
- Zoonoses Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Hamid Sharifi
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Armita Shahesmaeili
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Ebrahim Ghaderi
- Zoonoses Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Shoboo Rahmati
- PhD of Epidemiology, Student Research Committee, Kerman University of Medical Sciences, Kerman, Iran
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Zawedde-Muyanja S, Manabe YC, Cattamanchi A, Castelnuovo B, Katamba A. Patient and health system level barriers to and facilitators for tuberculosis treatment initiation in Uganda: a qualitative study. BMC Health Serv Res 2022; 22:831. [PMID: 35764982 PMCID: PMC9513807 DOI: 10.1186/s12913-022-08213-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The WHO END TB strategy targets to place at least 90% of all patients diagnosed with Tuberculosis (TB) on appropriate treatment. In Uganda, approximately 20% of patients diagnosed with TB are not initiated on TB treatment. We sought to identify the patient and health system level barriers to and facilitators for TB treatment initiation in Uganda. METHODS We conducted the study at ten public health facilities (three primary care, four district and three tertiary referral hospitals). We carried out in-depth interviews with patients diagnosed with TB and key informant interviews with health managers. In addition, we held focus group discussions with healthcare workers involved in TB care. Data collection and thematic analysis of transcripts was informed by the Capability, Opportunity, Motivation and Behavior (COM-B) model. We identified relevant intervention functions using the Behavior Change Wheel. RESULTS We interviewed 79 respondents (31 patients, 10 health managers and 38 healthcare workers). Common barriers at the health facility level included; lack of knowledge about the proportion of patients not initiated on TB treatment (psychological capability); difficulty accessing sputum results from the laboratory as well as difficulty tracing patients due to inadequate recording of patient addresses (physical opportunity). At the patient level, notable barriers included long turnaround time for sputum results and lack of transport funds to return to health facilities (physical opportunity); limited TB knowledge (psychological capability) and stigma (social opportunity). The most important facilitators identified were quick access to sputum test results either on the date of first visit (same-day diagnosis) or on the date of first return and availability of TB treatment (physical opportunity). We identified education, restructuring of the service environment to improve sputum results turnaround time and enablement to improve communication of test results as relevant intervention functions to alleviate these barriers to and enhance facilitators for TB treatment initiation. CONCLUSION We found that barriers to treatment initiation existed at both the patient and health facility-level across all levels of the (Capability, Opportunity and Motivation) model. The intervention functions identified here should be tested for feasibility.
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Affiliation(s)
- Stella Zawedde-Muyanja
- The Infectious Diseases Institute, College of Health Sciences, Makerere University Kampala, Mulago Hospital Complex, P.O. Box 22418, Kampala, Uganda.
| | - Yukari C Manabe
- The Infectious Diseases Institute, College of Health Sciences, Makerere University Kampala, Mulago Hospital Complex, P.O. Box 22418, Kampala, Uganda.,Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco California, USA.,Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Barbara Castelnuovo
- The Infectious Diseases Institute, College of Health Sciences, Makerere University Kampala, Mulago Hospital Complex, P.O. Box 22418, Kampala, Uganda
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda. .,Clinical Epidemiology and Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Mulago Hospital Complex, P.O. Box 7072, Kampala, Uganda.
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26
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Dheda K, Perumal T, Moultrie H, Perumal R, Esmail A, Scott AJ, Udwadia Z, Chang KC, Peter J, Pooran A, von Delft A, von Delft D, Martinson N, Loveday M, Charalambous S, Kachingwe E, Jassat W, Cohen C, Tempia S, Fennelly K, Pai M. The intersecting pandemics of tuberculosis and COVID-19: population-level and patient-level impact, clinical presentation, and corrective interventions. THE LANCET. RESPIRATORY MEDICINE 2022; 10:603-622. [PMID: 35338841 PMCID: PMC8942481 DOI: 10.1016/s2213-2600(22)00092-3] [Citation(s) in RCA: 83] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 02/17/2022] [Accepted: 03/03/2022] [Indexed: 01/19/2023]
Abstract
The global tuberculosis burden remains substantial, with more than 10 million people newly ill per year. Nevertheless, tuberculosis incidence has slowly declined over the past decade, and mortality has decreased by almost a third in tandem. This positive trend was abruptly reversed by the COVID-19 pandemic, which in many parts of the world has resulted in a substantial reduction in tuberculosis testing and case notifications, with an associated increase in mortality, taking global tuberculosis control back by roughly 10 years. Here, we consider points of intersection between the tuberculosis and COVID-19 pandemics, identifying wide-ranging approaches that could be taken to reverse the devastating effects of COVID-19 on tuberculosis control. We review the impact of COVID-19 at the population level on tuberculosis case detection, morbidity and mortality, and the patient-level impact, including susceptibility to disease, clinical presentation, diagnosis, management, and prognosis. We propose strategies to reverse or mitigate the deleterious effects of COVID-19 and restore tuberculosis services. Finally, we highlight research priorities and major challenges and controversies that need to be addressed to restore and advance the global response to tuberculosis.
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Affiliation(s)
- Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa; South African Medical Research Council (SAMRC) Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa; Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
| | - Tahlia Perumal
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa; South African Medical Research Council (SAMRC) Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Harry Moultrie
- Centre for TB, National Institute for Communicable Diseases, Division of the National Health Laboratory Services, Johannesburg, South Africa; School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rubeshan Perumal
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa; SAMRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Aliasgar Esmail
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa; South African Medical Research Council (SAMRC) Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Alex J Scott
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa; South African Medical Research Council (SAMRC) Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Zarir Udwadia
- Department of Pulmonology, P D Hinduja Hospital and Medical Research Centre, Mumbai, India
| | - Kwok Chiu Chang
- Tuberculosis and Chest Service, Department of Health, Hong Kong Special Administrative Region, China
| | - Jonathan Peter
- Allergy and Immunology unit, Division of Allergy and Clinical Immunology, University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Anil Pooran
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa; South African Medical Research Council (SAMRC) Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Arne von Delft
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; TB Proof, Cape Town, South Africa
| | | | - Neil Martinson
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Johns Hopkins University Center for TB Research, Baltimore, MD, USA
| | - Marian Loveday
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
| | - Salome Charalambous
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; The Aurum Institute, Johannesburg, South Africa
| | - Elizabeth Kachingwe
- Centre for TB, National Institute for Communicable Diseases, Division of the National Health Laboratory Services, Johannesburg, South Africa
| | - Waasila Jassat
- Division of Public Health Surveillance and Response, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | - Cheryl Cohen
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | - Stefano Tempia
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | - Kevin Fennelly
- Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal, QC, Canada
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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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Mwansa-Kambafwile JRM, Chasela C, Levin J, Ismail N, Menezes C. Treatment initiation among tuberculosis patients: the role of short message service (SMS) technology and Ward-based outreach teams (WBOTs). BMC Public Health 2022; 22:318. [PMID: 35168581 PMCID: PMC8848795 DOI: 10.1186/s12889-022-12736-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/07/2022] [Indexed: 11/10/2022] Open
Abstract
Background In South Africa, tuberculosis (TB) is a public health problem with treatment initiation failure rates varying between 14.9 and 25%. Lack of proper provider/patient communication on next steps after testing, not being aware that results are ready; and other competing priorities are some of the reasons for this failure. We aimed to assess the effectiveness of Short Message Service (SMS) technology and ward-based outreach teams (WBOTs) in improving TB treatment initiation. A 3-arm randomized controlled trial (Standard of care-SOC, SMS technology or WBOTs) was conducted between September 2018 and April 2020. Newly diagnosed TB patients randomly allocated to SMS and WBOTs groups were sent reminder messages (text message or paper slip respectively) that results were ready. Due to unforeseen challenges (financial and impact of the COVID 19 pandemic), implementation was only in two of the eight clinics planned. Results 314 TB patients were assigned to one of three groups (SOC = 104, WBOTs = 105, and SMS = 105). Chi-square tests were used to compare proportions starting treatment (primary outcome). More patients in the SMS group (92/105; 88%) initiated treatment than in the SOC group (81/104; 78%), although this difference did not reach statistical significance (P = 0.062). The time to treatment initiation was significantly shorter in the SMS group than in the SOC group (P < 0.001). The proportions of patients initiated on treatment in the WBOTs group (45/62; 73%) and in the SOC group (44/61; 72%) were similar (P = 0.956). The times to treatment initiation for these two groups were also similar. The 3 group analysis yielded similar proportions initiated on treatment (P = 0.048 for SMS/SOC comparison and P = 0.956 for WBOTs/SOC comparison) but analysis of times to treatment initiation yielded some variations. Conclusion Reminder SMS messages sent to newly diagnosed TB patients improved the time to treatment initiation. Further research is required to show effect of the WBOTs intervention. Trial registration Retrospectively registered with the Pan African Clinical Trial Registry (PACTR202101914895981). The trial was registered with the Pan African Clinical Trial Registry on 25 January, 2021 (ref: PACTR202101914895981; https://pactr.samrc.ac.za). The registration was retrospective due to an oversight. Nevertheless, the protocol details outlined in our ethics application were strictly adhered to. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-12736-6.
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Affiliation(s)
- Judith R M Mwansa-Kambafwile
- Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa. .,Centre for Tuberculosis, National Institute of Communicable Diseases, Johannesburg, South Africa. .,Fellow of the Consortium for Advanced Research Training in Africa (CARTA), Johannesburg, South Africa.
| | - Charles Chasela
- Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Jonathan Levin
- Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Nazir Ismail
- Division of Infectious Diseases, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Colin Menezes
- Division of Infectious Diseases, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Zawedde-Muyanja S, Musaazi J, Castelnuovo B, Cattamanchi A, Katamba A, Manabe YC. Feasibility of a multifaceted intervention to improve treatment initiation among patients diagnosed with TB using Xpert MTB/RIF testing in Uganda. PLoS One 2022; 17:e0265035. [PMID: 35714072 PMCID: PMC9491700 DOI: 10.1371/journal.pone.0265035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 02/22/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND One in five patients diagnosed with TB in Uganda are not initiated on TB treatment within two weeks of diagnosis. We evaluated a multifaceted intervention for improving TB treatment initiation among patients diagnosed with TB using Xpert® MTB/RIF testing in Uganda. METHODS This was a pre-post interventional study at one tertiary referral hospital. The intervention was informed by the COM-B model and included; i) medical education sessions to improve healthcare worker knowledge about the magnitude and consequences of pretreatment loss to follow-up; ii) modified laboratory request forms to improve recording of patient contact information; and iii) re-designed workflow processes to improve timeliness of sputum testing and results dissemination. TB diagnostic process and outcome data were collected and compared from the period before (June to August 2019) and after (October to December 2019) intervention initiation. RESULTS In September 2019, four CME sessions were held at the hospital and were attended by 58 healthcare workers. During the study period, 1242 patients were evaluated by Xpert® MTB/RIF testing at the hospital (679 pre and 557 post intervention). Median turnaround time for sputum test results improved from 12 hours (IQR 4-46) in the pre-intervention period to 4 hours (IQR 3-6) in the post-intervention period. The proportion of patients started on treatment within two weeks of diagnosis improved from 59% (40/68) to 89% (49/55) (difference 30%, 95% CI 14%-43%, p<0.01) while the proportion of patients receiving a same-day diagnosis increased from 7.4% (5/68) to 25% (14/55) (difference 17.6%, 95% CI 3.9%-32.7%, p<0.01). CONCLUSION The multifaceted intervention was feasible and resulted in a higher proportion of patients initiating TB treatment within two weeks of diagnosis.
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Affiliation(s)
- Stella Zawedde-Muyanja
- The Infectious Diseases Institute, College of Health Sciences, Makerere
University, Kampala, Uganda
- * E-mail:
| | - Joseph Musaazi
- The Infectious Diseases Institute, College of Health Sciences, Makerere
University, Kampala, Uganda
| | - Barbara Castelnuovo
- The Infectious Diseases Institute, College of Health Sciences, Makerere
University, Kampala, Uganda
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine and Center for
Tuberculosis, University of California San Francisco, San Francisco, California,
United States of America
| | - Achilles Katamba
- Department of Medicine, School of Medicine, Makerere University College
of Health Sciences, Kampala, Uganda
| | - Yukari C. Manabe
- The Infectious Diseases Institute, College of Health Sciences, Makerere
University, Kampala, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins
University School of Medicine, Baltimore, Maryland, United States of
America
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30
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Cattamanchi A, Reza TF, Nalugwa T, Adams K, Nantale M, Oyuku D, Nabwire S, Babirye D, Turyahabwe S, Tucker A, Sohn H, Ferguson O, Thompson R, Shete PB, Handley MA, Ackerman S, Joloba M, Moore DAJ, Davis JL, Dowdy DW, Fielding K, Katamba A. Multicomponent Strategy with Decentralized Molecular Testing for Tuberculosis. N Engl J Med 2021; 385:2441-2450. [PMID: 34936740 PMCID: PMC9212879 DOI: 10.1056/nejmoa2105470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Effective strategies are needed to facilitate the prompt diagnosis and treatment of tuberculosis in countries with a high burden of the disease. METHODS We conducted a cluster-randomized trial in which Ugandan community health centers were assigned to a multicomponent diagnostic strategy (on-site molecular testing for tuberculosis, guided restructuring of clinic workflows, and monthly feedback of quality metrics) or routine care (on-site sputum-smear microscopy and referral-based molecular testing). The primary outcome was the number of adults treated for confirmed tuberculosis within 14 days after presenting to the health center for evaluation during the 16-month intervention period. Secondary outcomes included completion of tuberculosis testing, same-day diagnosis, and same-day treatment. Outcomes were also assessed on the basis of proportions. RESULTS A total of 20 health centers underwent randomization, with 10 assigned to each group. Of 10,644 eligible adults (median age, 40 years) whose data were evaluated, 60.1% were women and 43.8% had human immunodeficiency virus infection. The intervention strategy led to a greater number of patients being treated for confirmed tuberculosis within 14 days after presentation (342 patients across 10 intervention health centers vs. 220 across 10 control health centers; adjusted rate ratio, 1.56; 95% confidence interval [CI], 1.21 to 2.01). More patients at intervention centers than at control centers completed tuberculosis testing (adjusted rate ratio, 1.85; 95% CI, 1.21 to 2.82), received a same-day diagnosis (adjusted rate ratio, 1.89; 95% CI, 1.39 to 2.56), and received same-day treatment for confirmed tuberculosis (adjusted rate ratio, 2.38; 95% CI, 1.57 to 3.61). Among 706 patients with confirmed tuberculosis, a higher proportion in the intervention group than in the control group were treated on the same day (adjusted rate ratio, 2.29; 95% CI, 1.23 to 4.25) or within 14 days after presentation (adjusted rate ratio, 1.22; 95% CI, 1.06 to 1.40). CONCLUSIONS A multicomponent diagnostic strategy that included on-site molecular testing plus implementation supports to address barriers to delivery of high-quality tuberculosis evaluation services led to greater numbers of patients being tested, receiving a diagnosis, and being treated for confirmed tuberculosis. (Funded by the National Heart, Lung, and Blood Institute; XPEL-TB ClinicalTrials.gov number, NCT03044158.).
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Affiliation(s)
- Adithya Cattamanchi
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Tania F Reza
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Talemwa Nalugwa
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Katherine Adams
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Mariam Nantale
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Denis Oyuku
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Sarah Nabwire
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Diana Babirye
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Stavia Turyahabwe
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Austin Tucker
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Hojoon Sohn
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Olivia Ferguson
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Ryan Thompson
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Priya B Shete
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Margaret A Handley
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Sara Ackerman
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Moses Joloba
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - David A J Moore
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - J Lucian Davis
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - David W Dowdy
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Katherine Fielding
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Achilles Katamba
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
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Umo I, Kulai M, Commons RJ. Factors associated with loss to follow-up among TB patients in rural Papua New Guinea. Public Health Action 2021; 11:186-190. [PMID: 34956846 DOI: 10.5588/pha.21.0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Papua New Guinea (PNG) is a lower middle-income country that has struggled to contain TB. The loss of patients to follow-up is a major contributing factor towards the high disease burden. OBJECTIVE To describe persons with drug-susceptible TB (DS-TB) registered for treatment at the Gaubin Rural Hospital (GRH) on Karkar Island, Madang Province, PNG, and to investigate factors associated with patient loss to follow-up (LTFU). DESIGN A retrospective cohort study was conducted using data from GRH DS-TB registers. Factors associated with LTFU were investigated using univariable and multivariable logistic regression. RESULTS A total of 722 patients were registered for DS-TB treatment and eligible for inclusion between 1 January 2014 and 30 June 2018, of whom 97 (13.4%) were lost to follow-up. Male sex was associated with an increased odds of LTFU (adjusted OR [aOR] 1.9, 95% CI 1.2-3.0; P = 0.005), as was travel time to GRH >3 h (aOR 3.7, 95%, CI 2.2-6.3; P < 0.001). CONCLUSION A high LTFU rate has been identified in patients with TB in PNG. This study found male sex and increased travel time from treatment location to be associated with unsuccessful treatment adherence, highlighting the need for further interventions to improve adherence.
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Affiliation(s)
- I Umo
- Surgical Department, Milne Bay Provincial Health Authority, Alotau, Papua New Guinea (PNG)
| | - M Kulai
- School of Medicine and Health Science, Divine Word University, Madang, PNG
| | - R J Commons
- Global and Tropical Health Division, Charles Darwin University and Menzies School of Health Research, Darwin, NT, Australia.,Internal Medicine Services, Ballarat Health Services, Ballarat, VIC, Australia
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Controlling Droplet Marangoni Flows to Improve Microscopy-Based TB Diagnosis. Diagnostics (Basel) 2021; 11:diagnostics11112155. [PMID: 34829502 PMCID: PMC8618690 DOI: 10.3390/diagnostics11112155] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 11/15/2021] [Accepted: 11/19/2021] [Indexed: 11/17/2022] Open
Abstract
In developing countries, the most common diagnostic method for tuberculosis (TB) is microscopic examination sputum smears. Current assessment requires time-intensive inspection across the microscope slide area, and this contributes to its poor diagnostic sensitivity of ≈50%. Spatially concentrating TB bacteria in a smaller area is one potential approach to improve visual detection and potentially increase sensitivity. We hypothesized that a combination of magnetic concentration and induced droplet Marangoni flow would spatially concentrate Mycobacterium tuberculosis on the slide surface by preferential deposition of beads and TB–bead complexes in the center of an evaporating droplet. To this end, slide substrate and droplet solvent thermal conductivities and solvent surface tension, variables known to impact microfluidic flow patterns in evaporating droplets, were varied to select the most appropriate slide surface coating. Optimization in a model system used goniometry, optical coherence tomography, and microscope images of the final deposition pattern to observe the droplet flows and maximize central deposition of 1 μm fluorescent polystyrene particles and 200 nm nanoparticles (NPs) in 2 μL droplets. Rain-X® polysiloxane glass coating was identified as the best substrate material, with a PBS-Tween droplet solvent. The use of smaller, 200 nm magnetic NPs instead of larger 1 μm beads allowed for bright field imaging of bacteria. Using these optimized components, we compared standard smear methods to the Marangoni-based spatial concentration system, which was paired with magnetic enrichment using iron oxide NPs, isolating M. bovis BCG (BCG) from samples containing 0 and 103 to 106 bacilli/mL. Compared to standard smear preparation, paired analysis demonstrated a combined volumetric and spatial sample enrichment of 100-fold. With further refinement, this magnetic/Marangoni flow concentration approach is expected to improve whole-pathogen microscopy-based diagnosis of TB and other infectious diseases.
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Vanqa N, Hoddinott G, Mbenyana B, Osman M, Meehan SA. Linkage to TB care: A qualitative study to understand linkage from the patients' perspective in the Western Cape Province, South Africa. PLoS One 2021; 16:e0260200. [PMID: 34797855 PMCID: PMC8604355 DOI: 10.1371/journal.pone.0260200] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 11/05/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Delayed linkage to tuberculosis (TB) treatment leads to poor patient outcomes and increased onward transmission. Between 12% and 25% of people diagnosed with TB are never linked to a primary health care facility for continued care. The TB health program is for creating processes that promote and facilitates easy access to care. We explored how TB patients experience TB services and how this influenced their choices around linkage to TB care and treatment. METHODS We enrolled 20 participants routinely diagnosed with TB in hospital or at primary health care facilities (PHC) in a high TB/HIV burdened peri-urban community in South Africa. Using the Western Cape Provincial Health Data centre (PHDC) which consolidates person-level clinical data, we used dates of diagnosis and treatment initiation to select participants who had been linked (immediately, after a delay, or never). Between June 2019 and January 2020, we facilitated in-depth discussions to explore both the participants' experience of their TB diagnosis and their journey around linking to TB care at a primary health care facility. We analysed the data using case descriptions. RESULTS Twelve of twenty (12/20) participants interviewed who experienced a delay linking were diagnosed at the hospital. Participants who experienced delays in linking or never linked explained this as a result of lack of information and support from health care providers. Unpleasant previous TB treatment episodes made it difficult to 'face' TB again and being uncertain of their TB diagnosis. In contrast, participants said the main motivator for linking was a personal will to get better. CONCLUSION The health care system, especially in hospitals, should focus on strengthening patient-centred care. Communication and clear messaging on TB processes is key, to prepare patients in transitioning from a hospital setting to PHC facilities for continuation of care. This should not just include a thorough explanation of their TB diagnosis but ensure that patients understand treatment processes. Former TB patients may require additional counselling and support to re-engage in care.
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Affiliation(s)
- Nosivuyile Vanqa
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Tygerberg, South Africa
- * E-mail: ,
| | - Graeme Hoddinott
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Tygerberg, South Africa
| | - Baxolele Mbenyana
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Tygerberg, South Africa
| | - Muhammad Osman
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Tygerberg, South Africa
| | - Sue-Ann Meehan
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Tygerberg, South Africa
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Durations of asymptomatic, symptomatic, and care-seeking phases of tuberculosis disease with a Bayesian analysis of prevalence survey and notification data. BMC Med 2021; 19:298. [PMID: 34753468 PMCID: PMC8579670 DOI: 10.1186/s12916-021-02128-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 09/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ratios of bacteriologically positive tuberculosis (TB) prevalence to notification rates are used to characterise typical durations of TB disease. However, this ignores the clinical spectrum of tuberculosis disease and potentially long infectious periods with minimal or no symptoms prior to care-seeking. METHODS We developed novel statistical models to estimate progression from initial bacteriological positivity including smear conversion, symptom onset and initial care-seeking. Case-detection ratios, TB incidence, durations, and other parameters were estimated by fitting the model to tuberculosis prevalence survey and notification data (one subnational and 11 national datasets) within a Bayesian framework using Markov chain Monte Carlo methods. RESULTS Analysis across 11 national datasets found asymptomatic tuberculosis durations in the range 4-8 months for African countries; three countries in Asia (Cambodia, Lao PDR, and Philippines) showed longer durations of > 1 year. For the six countries with relevant data, care-seeking typically began half-way between symptom onset and notification. For Kenya and Blantyre, Malawi, individual-level data were available. The sex-specific durations of asymptomatic bacteriologically-positive tuberculosis were 9.0 months (95% credible interval [CrI]: 7.2-11.2) for men and 8.1 months (95% CrI: 6.2-10.3) for women in Kenya, and 4.9 months (95% CrI: 2.6-7.9) for men and 3.5 months (95% CrI: 1.3-6.2) for women in Blantyre. Age-stratified analysis of data for Kenya showed no strong age-dependence in durations. For Blantyre, HIV-stratified analysis estimated an asymptomatic duration of 1.3 months (95% CrI: 0.3-3.0) for HIV-positive people, shorter than the 8.5 months (95% CrI: 5.0-12.7) for HIV-negative people. Additionally, case-detection ratios were higher for people living with HIV than HIV-negative people (93% vs 71%). CONCLUSION Asymptomatic TB disease typically lasts around 6 months. We found no evidence of age-dependence, but much shorter durations among people living with HIV, and longer durations in some Asian settings. To eradicate TB transmission, greater gains may be achieved by proactively screening people without symptoms through active case finding interventions.
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Hussain H, Malik A, Ahmed JF, Siddiqui S, Amanullah F, Creswell J, Tylleskär T, Robberstad B. Cost-effectiveness of household contact investigation for detection of tuberculosis in Pakistan. BMJ Open 2021; 11:e049658. [PMID: 34686551 PMCID: PMC8543626 DOI: 10.1136/bmjopen-2021-049658] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Despite WHO guidelines recommending household contact investigation, and studies showing the impact of active screening, most tuberculosis (TB) programmes in resource-limited settings only carry out passive contact investigation. The cost of such strategies is often cited as barriers to their implementation. However, little data are available for the additional costs required to implement this strategy. We aimed to estimate the cost and cost-effectiveness of active contact investigation as compared with passive contact investigation in urban Pakistan. METHODS We estimated the cost-effectiveness of 'enhanced' (passive with follow-up) and 'active' (household visit) contact investigations compared with standard 'passive' contact investigation from providers and the programme's perspective using a simple decision tree. Costs were collected in Pakistan from a TB clinic performing passive contact investigation and from studies of active contact tracing interventions conducted. The effectiveness was based on the number of patients with TB identified among household contacts screened. RESULTS The addition of enhanced contact investigation to the existing passive mode detected 3.8 times more cases of TB per index patient compared with passive contact investigation alone. The incremental cost was US$30 per index patient, which yielded an incremental cost of US$120 per incremental patient identified with TB. The active contact investigation was 1.5 times more effective than enhanced contact investigation with an incremental cost of US$238 per incremental patient with TB identified. CONCLUSION Our results show that enhanced and active approaches to contact investigation effectively identify additional patients with TB among household contacts at a relatively modest cost. These strategies can be added to the passive contact investigation in a high burden setting to find the people with TB who are missed and meet the End TB strategy goals.
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Affiliation(s)
- Hamidah Hussain
- Centre for International Health, Department of Global Public Health and Primary Care, Universitetet i Bergen, Bergen, Norway
- Interactive Research and Development (IRD) Global, Singapore
| | - Amyn Malik
- Interactive Research and Development (IRD) Global, Singapore
| | - Junaid F Ahmed
- Global Health Directorate, Indus Health Network, Karachi, Pakistan
| | - Sara Siddiqui
- Global Health Directorate, Indus Health Network, Karachi, Pakistan
| | | | | | - Thorkild Tylleskär
- Centre for International Health, Department of Global Public Health and Primary Care, Universitetet i Bergen, Bergen, Norway
| | - Bjarne Robberstad
- Centre for International Health, Department of Global Public Health and Primary Care, Universitetet i Bergen, Bergen, Norway
- Section for Ethics and Health Economics, Department of Global Public Health and Primary Care, Universitetet i Bergen, Bergen, Norway
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Burger R, Caldwell J, Claassens M, Mama K, Naidoo P, Rieger M, Rossouw L, van Doorslaer E, Wagstaff A. Who is more likely to return for TB test results? A survey at three high-burden primary healthcare facilities in Cape Town, South Africa. Int J Infect Dis 2021; 113:259-267. [PMID: 34653655 DOI: 10.1016/j.ijid.2021.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 10/06/2021] [Accepted: 10/06/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND In low- and middle-income countries with a high burden of tuberculosis (TB), a large proportion of people who are tested for TB do not return to the health facility to collect their test results and initiate treatment, thus putting themselves at increased risk of adverse outcomes. METHODS This prospective study aimed to identify predictors of returning to the primary health care (PHC) facility to collect TB test results. From 15 August to 15 December 2017, 1105 people who tested for pulmonary TB at three Cape Town PHC facilities were surveyed. Using multi-variate logistic regressions on an analysis sample of 1097 people, three groups of predictors were considered: (i) demographics, health and socio-economic status; (ii) costs and benefits; and (iii) behavioural factors. RESULTS Forty-four percent of people tested returned to the PHC facility to collect their test results within the stipulated 2 days, and 68% returned before the end of the study period. Return was strongly and positively correlated with expecting a TB-positive result, cognitive avoidance and postponement behaviour. CONCLUSION Interventions to improve pre-treatment loss to follow-up should target patients who think they do not have TB, and those with a history of postponement behaviour and cognitive avoidance.
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Affiliation(s)
- Ronelle Burger
- Economics Department, University of Stellenbosch, Stellenbosch, South Africa
| | | | - Mareli Claassens
- Department of Biochemistry and Microbiology, University of Namibia, Windhoek, Namibia; Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Khanya Mama
- Economics Department, University of Stellenbosch, Stellenbosch, South Africa
| | - Pren Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Matthias Rieger
- International Institute of Social Studies, Erasmus University Rotterdam, Den Haag, The Netherlands.
| | - Laura Rossouw
- Economics Department, University of Stellenbosch, Stellenbosch, South Africa
| | - Eddy van Doorslaer
- Economics Department, University of Stellenbosch, Stellenbosch, South Africa; Erasmus School of Economics, Erasmus University Rotterdam, Den Haag, The Netherlands; Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Den Haag, The Netherlands; Stellenbosch Institute of Advanced Study, Stellenbosch, South Africa
| | - Adam Wagstaff
- Development Research Group, World Bank, Washington, DC, USA
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Telisinghe L, Ruperez M, Amofa-Sekyi M, Mwenge L, Mainga T, Kumar R, Hassan M, Chaisson L, Naufal F, Shapiro A, Golub J, Miller C, Corbett E, Burke R, MacPherson P, Hayes R, Bond V, Daneshvar C, Klinkenberg E, Ayles H. Does tuberculosis screening improve individual outcomes? A systematic review. EClinicalMedicine 2021; 40:101127. [PMID: 34604724 PMCID: PMC8473670 DOI: 10.1016/j.eclinm.2021.101127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 08/19/2021] [Accepted: 08/20/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND To determine if tuberculosis (TB) screening improves patient outcomes, we conducted two systematic reviews to investigate the effect of TB screening on diagnosis, treatment outcomes, deaths (clinical review assessing 23 outcome indicators); and patient costs (economic review). METHODS Pubmed, EMBASE, Scopus and the Cochrane Library were searched between 1/1/1980-13/4/2020 (clinical review) and 1/1/2010-14/8/2020 (economic review). As studies were heterogeneous, data synthesis was narrative. FINDINGS Clinical review: of 27,270 articles, 18 (n=3 trials) were eligible. Nine involved general populations. Compared to passive case finding (PCF), studies showed lower smear grade (n=2/3) and time to diagnosis (n=2/3); higher pre-treatment losses to follow-up (screened 23% and 29% vs PCF 15% and 14%; n=2/2); and similar treatment success (range 68-81%; n=4) and case fatality (range 3-11%; n=5) in the screened group. Nine reported on risk groups. Compared to PCF, studies showed lower smear positivity among those culture-confirmed (n=3/4) and time to diagnosis (n=2/2); and similar (range 80-90%; n=2/2) treatment success in the screened group. Case fatality was lower in n=2/3 observational studies; both reported on established screening programmes. A neonatal trial and post-hoc analysis of a household contacts trial found screening was associated with lower all-cause mortality. Economic review: From 2841 articles, six observational studies were eligible. Total costs (n=6) and catastrophic cost prevalence (n=4; range screened 9-45% vs PCF 12-61%) was lower among those screened. INTERPRETATION We found very limited patient outcome data. Collecting and reporting this data must be prioritised to inform policy and practice. FUNDING WHO and EDCTP.
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Affiliation(s)
- L Telisinghe
- London School of Hygiene and Tropical Medicine, London, UK
- Zambart, University of Zambia School of Public Health, Ridgeway, Zambia
| | - M Ruperez
- London School of Hygiene and Tropical Medicine, London, UK
| | - M Amofa-Sekyi
- Zambart, University of Zambia School of Public Health, Ridgeway, Zambia
| | - L Mwenge
- Zambart, University of Zambia School of Public Health, Ridgeway, Zambia
| | - T Mainga
- Zambart, University of Zambia School of Public Health, Ridgeway, Zambia
| | - R Kumar
- Zambart, University of Zambia School of Public Health, Ridgeway, Zambia
| | - M Hassan
- University Hospitals Plymouth NHS Trust, UK
- Chest Diseases Department, Faculty of Medicine, Alexandria University, Egypt
| | - L.H Chaisson
- Division of Infectious Diseases, Department of Medicine, University of Illinois at Chicago, Chicago, USA
| | - F Naufal
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, USA
| | - A.E Shapiro
- Departments of Global Health and Medicine, University of Washington, Seattle, USA
| | - J.E Golub
- Johns Hopkins University School of Medicine, Center for Tuberculosis Research, Baltimore, USA
| | - C Miller
- Global TB programme, World Health Organization, Geneva, Switzerland
| | - E.L Corbett
- London School of Hygiene and Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - R.M Burke
- London School of Hygiene and Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - P MacPherson
- London School of Hygiene and Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - R.J Hayes
- London School of Hygiene and Tropical Medicine, London, UK
| | - V Bond
- London School of Hygiene and Tropical Medicine, London, UK
- Zambart, University of Zambia School of Public Health, Ridgeway, Zambia
| | | | - E Klinkenberg
- London School of Hygiene and Tropical Medicine, London, UK
- Department of Global Health and Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - H.M Ayles
- London School of Hygiene and Tropical Medicine, London, UK
- Zambart, University of Zambia School of Public Health, Ridgeway, Zambia
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Haldane V, Zhang Z, Ma Q, Yin T, Zhang B, Li Y, Pan Q, Dainty KN, Rea E, Pasang P, Wei X, Hu J. A qualitative study of perspectives on access to tuberculosis health services in Xigaze, China. Infect Dis Poverty 2021; 10:120. [PMID: 34544492 PMCID: PMC8451167 DOI: 10.1186/s40249-021-00906-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/08/2021] [Indexed: 11/18/2022] Open
Abstract
Background Tuberculosis (TB) is a major global health threat and the leading infectious disease cause of death worldwide. Access to and retention in TB care remains a challenge for patients, particularly those living in rural and remote settings. This qualitative study explored barriers and facilitators to accessing and maintaining contact with TB care services in communities in Xigaze (Shigatse) prefecture, Xizang Autonomous Region (Tibet Autonomous Region), China from the perspective of persons impacted by TB. Methods We conduced in-depth interviews with 23 participants impacted by TB in four rural districts in Xigaze prefecture, Xizang Autonomous Region, China between April 2019 and November 2020. Interviews were conducted in Tibetan and Mandarin, transcribed in Mandarin and translated into English. Transcripts were checked against recordings by native Tibetan and Mandarin speakers. QSR NVivo12 software was used for framework analysis guided by an access to care conceptual framework by Levesque et al. Results Overall patients reported low awareness of and an indifferent attitude towards TB, although all reported understanding the need to adhere to treatment. Participants reported complex pathways to care, often requiring visits to multiple healthcare facilities. Some participants reported visiting traditional Tibetan medicine (TTM) providers. Participants reported various barriers to accessing care including challenges physically reaching care, out-of-pocket payments for tests, diagnostics and transport. Barriers to maintaining care included medication side effects and worry about treatment effectiveness. Enablers to accessing care identified included knowledge or past experience with TB, integrated models of TTM and western care, supportive village doctors who conducted home visits, free TB treatment and other subsidies, as well as having family support with care and social support as barriers and facilitators to maintaining treatment. Conclusions We identified barriers and facilitators to accessing services in rural communities in Xigaze from the perspective of persons impacted by TB. Challenges include complex pathways to care, travel distances, wait times and low awareness. Tuberculosis care in the region could be strengthened by ongoing culturally tailored educational campaigns to increase awareness, partnerships with TTM providers, providing comprehensive treatment subsidies and strengthening the role of family members in comprehensive TB care. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s40249-021-00906-4.
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Affiliation(s)
- Victoria Haldane
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON, M5T 3M6, Canada
| | - Zhitong Zhang
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, M5T 3M7, Canada
| | - Qi Ma
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON, M5T 3M6, Canada
| | - Tingting Yin
- Weifang Medical College, Weifang, Shandong, China
| | - Bei Zhang
- Weifang Medical College, Weifang, Shandong, China
| | - Yinlong Li
- Jining Medical University, Jining, Shandong, China
| | - Qiuyu Pan
- North Sichuan Medical College, Nanchong, Sichuan, China
| | - Katie N Dainty
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON, M5T 3M6, Canada
| | - Elizabeth Rea
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, M5T 3M7, Canada
| | - Pande Pasang
- Xigaze Centre for Disease Control and Prevention, 7 Keji Road, Sangzhuzi District, Xigaze, Xizang, China
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, M5T 3M7, Canada.
| | - Jun Hu
- Shandong University of Traditional Chinese Medicine, Jinan, 250355, China.
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Vo LNQ, Codlin A, Ngo TD, Dao TP, Dong TTT, Mo HTL, Forse R, Nguyen TT, Cung CV, Nguyen HB, Nguyen NV, Nguyen VV, Tran NT, Nguyen GH, Qin ZZ, Creswell J. Early Evaluation of an Ultra-Portable X-ray System for Tuberculosis Active Case Finding. Trop Med Infect Dis 2021; 6:163. [PMID: 34564547 PMCID: PMC8482270 DOI: 10.3390/tropicalmed6030163] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/31/2021] [Accepted: 09/02/2021] [Indexed: 12/20/2022] Open
Abstract
X-ray screening is an important tool in tuberculosis (TB) prevention and care, but access has historically been restricted by its immobile nature. As recent advancements have improved the portability of modern X-ray systems, this study represents an early evaluation of the safety, image quality and yield of using an ultra-portable X-ray system for active case finding (ACF). We reported operational and radiological performance characteristics and compared image quality between the ultra-portable and two reference systems. Image quality was rated by three human readers and by an artificial intelligence (AI) software. We deployed the ultra-portable X-ray alongside the reference system for community-based ACF and described TB care cascades for each system. The ultra-portable system operated within advertised specifications and radiologic tolerances, except on X-ray capture capacity, which was 58% lower than the reported maximum of 100 exposures per charge. The mean image quality rating from radiologists for the ultra-portable system was significantly lower than the reference (3.71 vs. 3.99, p < 0.001). However, we detected no significant differences in TB abnormality scores using the AI software (p = 0.571), nor in any of the steps along the TB care cascade during our ACF campaign. Despite some shortcomings, ultra-portable X-ray systems have significant potential to improve case detection and equitable access to high-quality TB care.
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Affiliation(s)
- Luan Nguyen Quang Vo
- Friends for International TB Relief, Ha Noi 100000, Vietnam; (A.C.); (T.T.T.D.); (R.F.)
| | - Andrew Codlin
- Friends for International TB Relief, Ha Noi 100000, Vietnam; (A.C.); (T.T.T.D.); (R.F.)
| | - Thuc Doan Ngo
- IRD VN, Ho Chi Minh City 700000, Vietnam; (T.D.N.); (T.P.D.); (H.T.L.M.); (N.T.T.); (G.H.N.)
| | - Thang Phuoc Dao
- IRD VN, Ho Chi Minh City 700000, Vietnam; (T.D.N.); (T.P.D.); (H.T.L.M.); (N.T.T.); (G.H.N.)
| | - Thuy Thi Thu Dong
- Friends for International TB Relief, Ha Noi 100000, Vietnam; (A.C.); (T.T.T.D.); (R.F.)
| | - Huong Thi Lan Mo
- IRD VN, Ho Chi Minh City 700000, Vietnam; (T.D.N.); (T.P.D.); (H.T.L.M.); (N.T.T.); (G.H.N.)
| | - Rachel Forse
- Friends for International TB Relief, Ha Noi 100000, Vietnam; (A.C.); (T.T.T.D.); (R.F.)
| | | | - Cong Van Cung
- National Lung Hospital, Ha Noi 100000, Vietnam; (C.V.C.); (H.B.N.); (N.V.N.)
| | - Hoa Binh Nguyen
- National Lung Hospital, Ha Noi 100000, Vietnam; (C.V.C.); (H.B.N.); (N.V.N.)
| | - Nhung Viet Nguyen
- National Lung Hospital, Ha Noi 100000, Vietnam; (C.V.C.); (H.B.N.); (N.V.N.)
| | | | - Ngan Thi Tran
- IRD VN, Ho Chi Minh City 700000, Vietnam; (T.D.N.); (T.P.D.); (H.T.L.M.); (N.T.T.); (G.H.N.)
| | - Giang Hoai Nguyen
- IRD VN, Ho Chi Minh City 700000, Vietnam; (T.D.N.); (T.P.D.); (H.T.L.M.); (N.T.T.); (G.H.N.)
| | - Zhi Zhen Qin
- Stop TB Partnership, 1218 Geneva, Switzerland; (Z.Z.Q.); (J.C.)
| | - Jacob Creswell
- Stop TB Partnership, 1218 Geneva, Switzerland; (Z.Z.Q.); (J.C.)
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Lungu P, Kerkhoff AD, Kasapo CC, Mzyece J, Nyimbili S, Chimzizi R, Silumesii A, Kagujje M, Subbaraman R, Muyoyeta M, Malama K. Tuberculosis care cascade in Zambia - identifying the gaps in order to improve outcomes: a population-based analysis. BMJ Open 2021; 11:e044867. [PMID: 34376439 PMCID: PMC8356169 DOI: 10.1136/bmjopen-2020-044867] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Tuberculosis (TB) remains a leading cause of morbidity and mortality in Zambia, especially for people living with HIV (PLHIV). We undertook a care cascade analysis to quantify gaps in care and align programme improvement measures with areas of need. DESIGN Retrospective, population-based analysis. SETTING We derived national-level estimates for each step of the TB care cascade in Zambia. Estimates were informed by WHO incidence estimates, nationally aggregated laboratory and notification registers, and individual-level programme data from four provinces. PARTICIPANTS Participants included all individuals with active TB disease in Zambia in 2018. We characterised the overall TB cascade and disaggregated by drug susceptibility results and HIV status. RESULTS In 2018, the total burden of TB in Zambia was estimated to be 72 495 (range, 40 495-111 495) cases. Of these, 43 387 (59.8%) accessed TB testing, 40 176 (55.4%) were diagnosed with TB, 36 431 (50.3%) were started on treatment and 32 700 (45.1%) completed treatment. Among all persons with TB lost at any step along the care cascade (n=39 795), 29 108 (73.1%) were lost prior to accessing diagnostic services, 3211 (8.1%) prior to diagnosis, 3745 (9.4%) prior to initiating treatment and 3731 (9.4%) prior to treatment completion. PLHIV were less likely than HIV-negative individuals to successfully complete the care cascade (42.8% vs 50.2%, p<0.001). Among those with rifampicin-resistant TB, there was substantial attrition at each step of the cascade and only 22.8% were estimated to have successfully completed treatment. CONCLUSIONS Losses throughout the care cascade resulted in a large proportion of individuals with TB not completing treatment. Ongoing health systems strengthening and patient-centred engagement strategies are needed at every step of the care cascade; however, scale-up of active case finding strategies is particularly critical to ensure individuals with TB in the population reach initial stages of care. Additionally, a renewed focus on PLHIV and individuals with drug-resistant TB is urgently needed to improve TB-related outcomes in Zambia.
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Affiliation(s)
- Patrick Lungu
- National Tuberculosis and Leprosy Control Programme, Lusaka, Zambia
- Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, California, USA
| | - Clara C Kasapo
- National Tuberculosis and Leprosy Control Programme, Lusaka, Zambia
| | - Judith Mzyece
- National Tuberculosis and Leprosy Control Programme, Lusaka, Zambia
| | - Sulani Nyimbili
- National Tuberculosis and Leprosy Control Programme, Lusaka, Zambia
| | - Rhehab Chimzizi
- National Tuberculosis and Leprosy Control Programme, Lusaka, Zambia
| | - Andrew Silumesii
- Department of Public Health and Research, Ministry of Health, Lusaka, Zambia
| | - Mary Kagujje
- Tuberculosis Department, Center for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Ramnath Subbaraman
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Monde Muyoyeta
- Tuberculosis Department, Center for Infectious Disease Research in Zambia, Lusaka, Zambia
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Osman M, Meehan SA, von Delft A, Du Preez K, Dunbar R, Marx FM, Boulle A, Welte A, Naidoo P, Hesseling AC. Early mortality in tuberculosis patients initially lost to follow up following diagnosis in provincial hospitals and primary health care facilities in Western Cape, South Africa. PLoS One 2021; 16:e0252084. [PMID: 34125843 PMCID: PMC8202951 DOI: 10.1371/journal.pone.0252084] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 05/06/2021] [Indexed: 11/18/2022] Open
Abstract
In South Africa, low tuberculosis (TB) treatment coverage and high TB case fatality remain important challenges. Following TB diagnosis, patients must link with a primary health care (PHC) facility for initiation or continuation of antituberculosis treatment and TB registration. We aimed to evaluate mortality among TB patients who did not link to a TB treatment facility for TB treatment within 30 days of their TB diagnosis, i.e. who were “initial loss to follow-up (ILTFU)” in Cape Town, South Africa. We prospectively included all patients with a routine laboratory or clinical diagnosis of TB made at PHC or hospital level in Khayelitsha and Tygerberg sub-districts in Cape Town, using routine TB data from an integrated provincial health data centre between October 2018 and March 2020. Overall, 74% (10,208/13,736) of TB patients were diagnosed at PHC facilities and ILTFU was 20.0% (2,742/13,736). Of ILTFU patients, 17.1% (468/2,742) died, with 69.7% (326/468) of deaths occurring within 30 days of diagnosis. Most ILTFU deaths (85.5%; 400/468) occurred in patients diagnosed in hospital. Multivariable logistic regression identified increasing age, HIV positive status, and hospital-based TB diagnosis (higher in the absence of TB treatment initiation and being ILTFU) as predictors of mortality. Although hospitals account for a modest proportion of diagnosed TB patients they have high TB-associated mortality. A hospital-based TB diagnosis is a critical opportunity to identify those at high risk of early and overall mortality. Interventions to diagnose TB before hospital admission, improve linkage to TB treatment following diagnosis, and reduce mortality in hospital-diagnosed TB patients should be prioritised.
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Affiliation(s)
- Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- * E-mail:
| | - Sue-Ann Meehan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Arne von Delft
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Health, Health Impact Assessment Directorate, Western Cape Government, Cape Town, South Africa
| | - Karen Du Preez
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Florian M. Marx
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- DSI-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Health, Health Impact Assessment Directorate, Western Cape Government, Cape Town, South Africa
| | - Alex Welte
- DSI-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Pren Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anneke C. Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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A prospective multicentre diagnostic accuracy study for the Truenat tuberculosis assays. Eur Respir J 2021; 58:13993003.00526-2021. [PMID: 34049948 PMCID: PMC8607906 DOI: 10.1183/13993003.00526-2021] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 03/29/2021] [Indexed: 11/26/2022]
Abstract
Background Bringing reliable and accurate tuberculosis (TB) diagnosis closer to patients is a key priority for global TB control. Molbio Diagnostics have developed the Truenat point-of-care molecular assays for detection of TB and rifampicin (RIF) resistance. Methods We conducted a prospective multicentre diagnostic accuracy study at 19 primary healthcare centres and seven reference laboratories in Peru, India, Ethiopia and Papua New Guinea to estimate the diagnostic accuracy of the point-of-care Truenat MTB, MTB Plus and MTB-RIF Dx assays for pulmonary TB using culture and phenotypic drug susceptibility testing as the reference standard, compared with Xpert MTB/RIF or Ultra. Results Of 1807 enrolled participants with TB signs/symptoms, 24% were culture-positive for Mycobacterium tuberculosis, of which 15% were RIF-resistant. In microscopy centres, the pooled sensitivity of Truenat MTB and Truenat MTB Plus was 73% (95% CI 67–78%) and 80% (95% CI 75–84%), respectively. Among smear-negative specimens, sensitivities were 36% (95% CI 27–47%) and 47% (95% CI 37–58%), respectively. Sensitivity of Truenat MTB-RIF was 84% (95% CI 62–95%). Truenat assays showed high specificity. Head-to-head comparison in the central reference laboratories suggested that the Truenat assays have similar performance to Xpert MTB/RIF. Conclusion We found the performance of Molbio's Truenat MTB, MTB Plus and MTB-RIF Dx assays to be comparable to that of the Xpert MTB/RIF assay. Performing the Truenat tests in primary healthcare centres with very limited infrastructure was feasible. These data supported the development of a World Health Organization policy recommendation of the Molbio assays. Diagnostic performance of point-of-care Truenat assays in primary healthcare centres is comparable to that of Xpert MTB/RIF placed in reference laboratories. The WHO now recommends Truenat as an initial test for detection of TB and RIF resistance.https://bit.ly/31Wj3S6
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Haraka F, Kakolwa M, Schumacher SG, Nathavitharana RR, Denkinger CM, Gagneux S, Reither K, Ross A. Impact of the diagnostic test Xpert MTB/RIF on patient outcomes for tuberculosis. Cochrane Database Syst Rev 2021; 5:CD012972. [PMID: 34097769 PMCID: PMC8208889 DOI: 10.1002/14651858.cd012972.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The World Health Organization (WHO) recommends Xpert MTB/RIF in place of smear microscopy to diagnose tuberculosis (TB), and many countries have adopted it into their diagnostic algorithms. However, it is not clear whether the greater accuracy of the test translates into improved health outcomes. OBJECTIVES To assess the impact of Xpert MTB/RIF on patient outcomes in people being investigated for tuberculosis. SEARCH METHODS We searched the following databases, without language restriction, from 2007 to 24 July 2020: Cochrane Infectious Disease Group (CIDG) Specialized Register; CENTRAL; MEDLINE OVID; Embase OVID; CINAHL EBSCO; LILACS BIREME; Science Citation Index Expanded (Web of Science), Social Sciences citation index (Web of Science), and Conference Proceedings Citation Index - Social Science & Humanities (Web of Science). We also searched the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and the Pan African Clinical Trials Registry for ongoing trials. SELECTION CRITERIA We included individual- and cluster-randomized trials, and before-after studies, in participants being investigated for tuberculosis. We analysed the randomized and non-randomized studies separately. DATA COLLECTION AND ANALYSIS: For each study, two review authors independently extracted data, using a piloted data extraction tool. We assessed the risk of bias using Cochrane and Effective Practice and Organisation of Care (EPOC) tools. We used random effects meta-analysis to allow for heterogeneity between studies in setting and design. The certainty of the evidence in the randomized trials was assessed by GRADE. MAIN RESULTS We included 12 studies: eight were randomized controlled trials (RCTs), and four were before-and-after studies. Most included RCTs had a low risk of bias in most domains of the Cochrane 'Risk of bias' tool. There was inconclusive evidence of an effect of Xpert MTB/RIF on all-cause mortality, both overall (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.75 to 1.05; 5 RCTs, 9932 participants, moderate-certainty evidence), and restricted to studies with six-month follow-up (RR 0.98, 95% CI 0.78 to 1.22; 3 RCTs, 8143 participants; moderate-certainty evidence). There was probably a reduction in mortality in participants known to be infected with HIV (odds ratio (OR) 0.80, 95% CI 0.67 to 0.96; 5 RCTs, 5855 participants; moderate-certainty evidence). It is uncertain whether Xpert MTB/RIF has no or a modest effect on the proportion of participants starting tuberculosis treatment who had a successful treatment outcome (OR) 1.10, 95% CI 0.96 to 1.26; 3RCTs, 4802 participants; moderate-certainty evidence). There was also inconclusive evidence of an effect on the proportion of participants who were treated for tuberculosis (RR 1.10, 95% CI 0.98 to 1.23; 5 RCTs, 8793 participants; moderate-certainty evidence). The proportion of participants treated for tuberculosis who had bacteriological confirmation was probably higher in the Xpert MTB/RIF group (RR 1.44, 95% CI 1.29 to 1.61; 6 RCTs, 2068 participants; moderate-certainty evidence). The proportion of participants with bacteriological confirmation who were lost to follow-up pre-treatment was probably reduced (RR 0.59, 95% CI 0.41 to 0.85; 3 RCTs, 1217 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS We were unable to confidently rule in or rule out the effect on all-cause mortality of using Xpert MTB/RIF rather than smear microscopy. Xpert MTB/RIF probably reduces mortality among participants known to be infected with HIV. We are uncertain whether Xpert MTB/RIF has a modest effect or not on the proportion treated or, among those treated, on the proportion with a successful outcome. It probably does not have a substantial effect on these outcomes. Xpert MTB/RIF probably increases both the proportion of treated participants who had bacteriological confirmation, and the proportion with a laboratory-confirmed diagnosis who were treated. These findings may inform decisions about uptake alongside evidence on cost-effectiveness and implementation.
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Affiliation(s)
- Frederick Haraka
- Elizabeth Glaser Pediatric AIDS Foundation, Dar es Salaam, Tanzania
- Ifakara Health Institute, Bagamoyo, Tanzania
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | | | | | - Ruvandhi R Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Claudia M Denkinger
- FIND, Geneva, Switzerland
- Division of Tropical Medicine, Centre for Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Sebastien Gagneux
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Klaus Reither
- Ifakara Health Institute, Bagamoyo, Tanzania
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Amanda Ross
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
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Arora R, Khanna A, Sharma N, Khanna V, Shringarpure K, Kathirvel S. Early implementation challenges in electronic referral and feedback mechanism for patients with tuberculosis using Nikshay - A mixed-methods study from a medical college TB referral unit of Delhi, India. J Family Med Prim Care 2021; 10:1678-1686. [PMID: 34123912 PMCID: PMC8144801 DOI: 10.4103/jfmpc.jfmpc_1360_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/12/2020] [Accepted: 02/12/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Diagnosis, notification and timely initiation of treatment is an important cornerstone for the elimination of tuberculosis (TB). The referral and feedback mechanism under National Tuberculosis Programme of India has been changed from paper-based to web-based electronic system (Nikshay) since 2018. The current study was carried out to assess the effect of Nikshay in referral and receipt of feedback on treatment initiation and to understand the early implementation challenges. Methods: A mixed-methods study was conducted in a medical college referral unit (MCRU) of Delhi, India. The electronic TB notification data for July 2018–March 2019 were abstracted from Nikshay portal and analysed. Unadjusted and adjusted relative risk (aRR) was calculated to assess the factors associated with the receipt of feedback. Themes and subthemes were generated from qualitative data obtained through key-informant interviews of healthcare providers. Results: Of the total 4395 patients handled by MCRU during the study period, 3315 (75.4%) were referred out within and outside Delhi for treatment. Feedback was received among 797 (24.0%) of the patients who were referred out. Patients with extrapulmonary TB (aRR: 1.3, confidence interval (CI): 1.1–1.8), previously treated (aRR: 1.2, CI: 1.2–1.3) and registered for drug-resistant TB care (aRR: 1.4, CI: 1.1–1.8), had high chance of receiving feedback. Four broad themes emerged, namely, (a) awareness of programme and Nikshay; (b) tracking of patients; (c) user-friendly portal and (d) workload. Conclusion: The low feedback on treatment initiation of patients with TB needs further research after health system-level quality improvement interventions. Real-time tracking of patients is the need of the hour towards the path for TB elimination.
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Affiliation(s)
- Reema Arora
- RNTCP, Referral Unit, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
| | | | - Nandini Sharma
- Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
| | | | - Kalpita Shringarpure
- Department of Preventive and Social Medicine, Medical College, Baroda, Gujarat, India
| | - Soundappan Kathirvel
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Yuldashev S, Parpieva N, Alimov S, Turaev L, Safaev K, Dumchev K, Gadoev J, Korotych O, Harries AD. Scaling Up Molecular Diagnostic Tests for Drug-Resistant Tuberculosis in Uzbekistan from 2012-2019: Are We on the Right Track? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094685. [PMID: 33924862 PMCID: PMC8124440 DOI: 10.3390/ijerph18094685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/12/2021] [Accepted: 03/19/2021] [Indexed: 11/16/2022]
Abstract
Uzbekistan has a large burden of drug-resistant tuberculosis (TB). To deal with this public health threat, the National TB Program introduced rapid molecular diagnostic tests such as Xpert MTB/RIF (Xpert) and line probe assays (LPAs) for first-line and second-line drugs. We documented the scale-up of Xpert and LPAs from 2012–2019 and assessed whether this led to an increase in patients with laboratory-confirmed multidrug-resistant/rifampicin-resistant TB (MDR/RR-TB) and extensively drug-resistant TB (XDR-TB). This was a descriptive study using secondary program data. The numbers of GeneXpert instruments cumulatively increased from six to sixty-seven, resulting in annual assays increasing from 5574 to 107,330. A broader use of the technology resulted in a lower proportion of tests detecting Mycobacterium tuberculosis with half of the positive results showing rifampicin resistance. LPA instruments cumulatively increased from two to thirteen; the annual first-line assays for MDR-TB increased from 2582 to 6607 while second-line assays increased from 1435 in 2016 to 6815 in 2019 with about one quarter to one third of diagnosed patients showing second-line drug resistance. Patient numbers with laboratory-confirmed MDR-TB remained stable (from 1728 to 2060) but there was a large increase in patients with laboratory-confirmed XDR-TB (from 31 to 696). Programmatic implications and ways forward are discussed.
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Affiliation(s)
- Sharofiddin Yuldashev
- Republican Specialized Scientific Practical Medical Centre of Phthisiology and Pulmonology under Ministry of Health of the Republic of Uzbekistan, 1 Majlisiy str, Tashkent 100086, Uzbekistan; (N.P.); (S.A.); (L.T.); (K.S.)
- Correspondence: ; Tel.: +998-90-175-18-48
| | - Nargiza Parpieva
- Republican Specialized Scientific Practical Medical Centre of Phthisiology and Pulmonology under Ministry of Health of the Republic of Uzbekistan, 1 Majlisiy str, Tashkent 100086, Uzbekistan; (N.P.); (S.A.); (L.T.); (K.S.)
| | - Salikhdjan Alimov
- Republican Specialized Scientific Practical Medical Centre of Phthisiology and Pulmonology under Ministry of Health of the Republic of Uzbekistan, 1 Majlisiy str, Tashkent 100086, Uzbekistan; (N.P.); (S.A.); (L.T.); (K.S.)
| | - Laziz Turaev
- Republican Specialized Scientific Practical Medical Centre of Phthisiology and Pulmonology under Ministry of Health of the Republic of Uzbekistan, 1 Majlisiy str, Tashkent 100086, Uzbekistan; (N.P.); (S.A.); (L.T.); (K.S.)
| | - Khasan Safaev
- Republican Specialized Scientific Practical Medical Centre of Phthisiology and Pulmonology under Ministry of Health of the Republic of Uzbekistan, 1 Majlisiy str, Tashkent 100086, Uzbekistan; (N.P.); (S.A.); (L.T.); (K.S.)
| | - Kostyantyn Dumchev
- The Charitable Organization “Ukrainian Institute of Public Health Policy”, Biloruska St, 5, 02000 Kyiv, Ukraine;
| | - Jamshid Gadoev
- World Health Organization Country Office to Uzbekistan, M. Tarobiy St, 16, Tashkent 100100, Uzbekistan;
| | - Oleksandr Korotych
- World Health Organization Regional Office for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen, Denmark;
| | - Anthony D. Harries
- International Union against Tuberculosis and Lung Disease, 68 Boulevard Saint Michel, 75006 Paris, France;
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
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Rudolf F, Abate E, Moges B, Mendes AM, Mengistu MY, Sifna A, Fekadu H, Bizuneh S, Schön T, Wejse C. Increasing smear positive tuberculosis detection using a clinical score - A stepped wedge multicenter trial from Africa. Int J Infect Dis 2021; 113 Suppl 1:S55-S62. [PMID: 33757875 DOI: 10.1016/j.ijid.2021.03.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The Bandim TBscore is a clinical score that predicts treatment outcome in Tuberculosis (TB) patients and proved useful as an indicator of which healthcare-seeking adults to refer for sputum smear microcopy. We aimed to test in a randomized trial if the TBscore could be used to enhance the detection of smear positive (SP) TB. METHODS We carried out a stepped wedge cluster-randomized trial at six health centers in Bissau, Guinea-Bissau, and Gondar, Ethiopia. The primary outcome was diagnostic yield for SP TB. Secondary outcomes were successful treatment and effect on overall 12 months mortality. The study was registered at the Pan African Clinical Trials Registry (PACTR201611001838365). RESULTS We included 3571 adults. Overall, there was no effect of the intervention on SP PTB detected (OR 1.39 (95%CI 0.75 - 2.56). Analysis stratified by country, showed that the TBscore increased case detection in Gondar (OR 4.05 (95%CI 1.67 - 9.85)) but no effect was found in Bissau (OR 0.47 (95%CI 0.22 - 1.05)) where take-up was much lower. Overall mortality decreased during the intervention (HR 0.31 (95%CI 0.13-0.72)). CONCLUSION Using the TBscore for triage before smear microscopy may improve case detection and decrease mortality if there is sufficient laboratory capacity to increase sputum smears.
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Affiliation(s)
- Frauke Rudolf
- Bandim Health Project, INDEPTH Network, Apartado 861, Bissau, Guinea-Bissau; Department of Infectious Diseases, Aarhus University Hospital, Denmark.
| | - Ebba Abate
- Ethiopian Public Health Institute (EPHI), Addis Ababa, Ethiopia; Tropical & Infectious Diseases Research Centre, University of Gondar, Ethiopia
| | - Binyam Moges
- Tropical & Infectious Diseases Research Centre, University of Gondar, Ethiopia
| | | | - Mezgebu Yitayal Mengistu
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Ethiopia
| | - Armando Sifna
- Bandim Health Project, INDEPTH Network, Apartado 861, Bissau, Guinea-Bissau
| | - Hikma Fekadu
- Department of Internal Medicine, College of Medicine and Health Science, University of Gondar, Ethiopia
| | - Segenet Bizuneh
- Department of Internal Medicine, College of Medicine and Health Science, University of Gondar, Ethiopia
| | - Thomas Schön
- Department of Microbiology and Infectious Medicine, Kalmar County Hospital, Sweden; Department of Biomedical and Clinical Sciences, Division of Infectious Diseases, Linköping University, Sweden
| | - Christian Wejse
- Bandim Health Project, INDEPTH Network, Apartado 861, Bissau, Guinea-Bissau; Department of Infectious Diseases, Aarhus University Hospital, Denmark; GloHAU, Center for Global Health, School of Public Health, Aarhus University, Denmark
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Mitchell EMH, Adejumo OA, Abdur-Razzaq H, Ogbudebe C, Chukwueme N, Olorunju SB, Gidado M. Hybrid Approach to Estimation of Underreporting of Tuberculosis Case Notification in High-Burden Settings With Weak Surveillance Infrastructure: Design and Implementation of an Inventory Study. JMIR Public Health Surveill 2021; 7:e22352. [PMID: 33720030 PMCID: PMC8088841 DOI: 10.2196/22352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 12/03/2020] [Accepted: 12/08/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The greatest risk of infectious disease undernotification occurs in settings with limited capacity to detect it reliably. World Health Organization guidance on the measurement of misreporting is paradoxical, requiring robust, independent systems to assess surveillance rigor. Methods are needed to estimate undernotification in settings with incomplete, flawed, or weak surveillance systems. This study attempted to design a tuberculosis (TB) inventory study that balanced rigor with feasibility for high-need settings. OBJECTIVE This study aims to design a hybrid TB inventory study for contexts without World Health Organization preconditions. We estimated the proportion of TB cases that were not reported to the Ministry of Health in 2015. The study sought to describe TB surveillance coverage and quality at different levels of TB care provision. Finally, we aimed to identify structural-, facility-, and provider-level barriers to notification and reasons for underreporting, nonreporting, and overreporting. METHODS Retrospective partial digitalization of paper-based surveillance and facility records preceded deterministic and probabilistic record linkage; a hybrid of health facilities and laboratory census with a stratified sampling of HFs with no capacity to notify leveraged a priori knowledge. Distinct extrapolation methods were applied to the sampled health facilities to estimate bacteriologically confirmed versus clinical TB. In-depth interviews and focus groups were used to identify causal factors responsible for undernotification and test the acceptability of remedies. RESULTS The hybrid approach proved viable and instructive. High-specificity verification of paper-based records in the field was efficient and had minimal errors. Limiting extrapolation to clinical cases improved precision. Probabilistic record linkage is computationally intensive, and the choice of software influences estimates. Record absence, decay, and overestimation of the private sector TB treatment behavior threaten validity, meriting mitigation. Data management demands were underestimated. Treatment success was modest in all sectors (R=37.9%-72.0%) and did not align with treatment success reported by the state (6665/8770, 75.99%). One-fifth of TB providers (36/178, 20%) were doubtful that the low volume of patients with TB treated in their facility merited mastery of the extensive TB notification forms and procedures. CONCLUSIONS Subnational inventory studies can be rigorous, relevant, and efficient in countries that need them even in the absence of World Health Organization preconditions, if precautions are taken. The use of triangulation techniques, with minimal recourse to sampling and extrapolation, and the privileging of practical information needs of local decision makers yield reasonable misreporting estimates and viable policy recommendations.
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Affiliation(s)
- Ellen M H Mitchell
- Tropical Infectious Diseases, Department of Public Health, Institute for Tropical Medicine, Antwerp, Belgium
| | | | | | | | | | - Samson Bamidele Olorunju
- Department of Epidemiology and Medical Statistics, Faculty of Public Health, University of Ibadan, Ibadan, Nigeria
| | - Mustapha Gidado
- KNCV TB Foundation, Koninklijke Centrale Vereniging tot bestrijding der Tuberculose (KNCV), The Hague, Netherlands
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Feasey HRA, Corbett EL, Nliwasa M, Mair L, Divala TH, Kamchedzera W, Khundi ME, Burchett HED, Webb EL, Maheswaran H, Squire SB, MacPherson P. Tuberculosis diagnosis cascade in Blantyre, Malawi: a prospective cohort study. BMC Infect Dis 2021; 21:178. [PMID: 33588804 PMCID: PMC7883960 DOI: 10.1186/s12879-021-05860-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/31/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) control relies on early diagnosis and treatment. International guidelines recommend systematic TB screening at health facilities, but implementation is challenging. We investigated completion of recommended TB screening steps in Blantyre, Malawi. METHODS A prospective cohort recruited adult outpatients attending Bangwe primary clinic. Entry interviews were linked to exit interviews. The proportion of participants progressing through each step of the diagnostic pathway were estimated. Factors associated with request for sputum were investigated using multivariable logistic regression. RESULTS Of 5442 clinic attendances 2397 (44%) had exit interviews. In clinically indicated participants (n = 445) 256 (57.5%) were asked about cough, 36 (8.1%) were asked for sputum, 21 (4.7%) gave sputum and 1 (0.2%) received same-day results. Significant associations with request for sputum were: any TB symptom (aOR:3.20, 95%CI:2.02-5.06), increasing age (aOR:1.02, 95%CI:1.01-1.04 per year) and for HIV-negative participants only, a history of previous TB (aOR:3.37, 95%CI:1.45-7.81). Numbers requiring sputum tests (26/day) outnumbered diagnostic capacity (8-12/day). CONCLUSIONS Patients were lost at every stage of the TB care cascade, with same day sputum submission following all steps of the diagnosis cascade achieved in only 4.7% if clinically indicated. Infection control strategies should be implemented, with reporting on early steps of the TB care cascade formalised. High-throughput screening interventions, such as digital CXR, that can achieve same-day TB diagnosis are urgently needed to meet WHO End TB goals.
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Affiliation(s)
- Helena R. A. Feasey
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
| | - Elizabeth L. Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
| | - Marriott Nliwasa
- Helse Nord Tuberculosis Initiative, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Luke Mair
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Titus H. Divala
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
- Helse Nord Tuberculosis Initiative, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Wala Kamchedzera
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Mc Ewen Khundi
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
| | - Helen E. D. Burchett
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
| | - Emily L. Webb
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
| | | | | | - Peter MacPherson
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
- Liverpool School of Tropical Medicine, Liverpool, UK
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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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50
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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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