A systematic review of the effectiveness of hospital- and ambulatory-based management of multidrug-resistant tuberculosis

Survival status and risk factors for mortality among multidrug-resistant tuberculosis patients in Addis Ababa, Ethiopia: A retrospective follow-up study

Background

Tuberculosis continues to be a major health concern around the world. It kills an estimated 1.6 million people each year. The World Health Organization (WHO) removed Ethiopia from its list of thirty countries having a high prevalence of MDR/RR-TB in 2021. As a result, the aim of this study was to assess the current context of survival status and risk factors of multidrug-resistant tuberculosis patients in Addis Ababa, Ethiopia, in 2022.

Methods

An institutional-based retrospective cohort study with 245 patients was undertaken using multidrug-resistant tuberculosis patients who were recruited from January 1st, 2018 to December 30th, 2021, in St. Peter's specialized hospital. To find independent predictors of survival status, Cox regression analysis was used. An adjusted hazard ratio with a 95% confidence interval and a p-value of < 0.05 was used to establish association and statistical significance.

Results

The result of the study revealed that the incidence of mortality in this study was 13.1% (95% CI: 10.3-16.5). Moreover, being male (AOR = 3.7: 95% CI = 1.2, 11.4), old age (AOR = 14: 95% CI = 3.0, 60.4), site of TB (AOR = 0.2: 95% CI = 0.03, 0.6), and presence of comorbidity (AOR = 9.2: 95% CI = 2.4, 35.3), were independent predictors of time to death.

Conclusion

Generally, the death rate among research participants was high. Moreover, male gender, old age, site of tuberculosis, and presence of other comorbidity were predictors of mortality among MDR-TB patients.

Psychosocial support interventions to improve treatment outcomes for people living with tuberculosis: a mixed methods systematic review and meta-analysis

Background

People with tuberculosis (TB) face multi-dimensional barriers when accessing and engaging with care. There is evidence that providing psychosocial support within people-centered models of care can improve TB outcomes, however, there is limited consensus on what works. It remains important for such interventions to be rigorously assessed, and mixed methods systematic reviews are one way of synthesising data for policy makers to be able to access such evidence. Mixed methods reviews take a complexity perspective, with qualitative data being used to contextualise the quantitative findings and giving an insight into how interventions are contingent on variations in design and context.

Methods

Five electronic databases were searched from January 1 2015 to 14 January 2023 for randomised controlled trials, quasi-experimental trials, cohort studies and qualitative studies of interventions providing psychosocial support (material and/or psychological-based support) to adults with any clinical form of active TB. Studies with inpatient treatment as the standard of care were excluded. Quantitative studies reporting pre-specified standard TB outcomes were eligible. In line with established mixed methods review methodology, a convergent parallel-results synthesis design was followed: quantitative and qualitative syntheses were distinct and carried out using appropriate methods. A convergent coding matrix was then used to integrate the results. The protocol was registered on PROSPERO (CRD42021235211).

Findings

Twenty-three studies of interventions were included (12 quantitative, 10 qualitative, and 1 mixed methods study) were included. Most studies were conducted in low-and middle-income countries with a high-burden of TB. Three explanatory and contextual middle-range theories from the integration of qualitative and quantitative data were developed: effective interventions provide multi-dimensional support; psychological-based support is transformative but there is insufficient evidence that it improves treatment outcomes on its own; intervention delivery shapes a logic of care.

Interpretation

This review takes a complexity perspective to provide actionable and timely insight to inform the design and implementation of locally-appropriate and people-centered psychosocial support interventions within national TB programmes.

Funding

There was no funding source for this study.

Public health benefits of shifting from hospital-focused to ambulatory TB care in Eastern Europe: Optimising TB investments in Belarus, the Republic of Moldova, and Romania

High rates of drug-resistant tuberculosis (DR-TB) continue to threaten public health, especially in Eastern Europe. Costs for treating DR-TB are substantially higher than treating drug-susceptible TB, and higher yet if DR-TB services are delivered in hospital. The WHO recommends that multidrug-resistant (MDR) TB be treated using mainly ambulatory care, shown to have non-inferior health outcomes, however, there has been a delay to transition away from hospital-focused MDR-TB care in certain Eastern European countries. Allocative efficiency analyses were conducted for three countries in Eastern Europe, Belarus, the Republic of Moldova, and Romania, to minimise a combination of TB incidence, prevalence, and mortality by 2035. A primary focus of these studies was to determine the health benefits and financial savings that could be realised if DR-TB service delivery shifted from hospital-focused to ambulatory care. Here we provide a comprehensive assessment of findings from these studies to demonstrate the collective benefit of transitioning from hospital-focused to ambulatory TB care, and to address common regional considerations. We highlight that transitioning from hospital-focused to ambulatory TB care could reduce treatment costs by 20% in Romania, 24% in Moldova, and by as much as 40% in Belarus or almost 35 million US dollars across these three countries by 2035 without affecting quality of care. Improved TB outcomes could be achieved, however, without additional spending by reinvesting these savings in higher-impact TB diagnosis and more efficacious DR-TB treatment regimens. We found commonalities in the large portion of TB cases treated in hospital across these three regional countries, and similar obstacles to transitioning to ambulatory care. National governments in the Eastern European region should examine barriers delaying adoption of ambulatory DR-TB care and consider lost opportunities caused by delays in switching to more efficient treatment modes.

The dynamic impacts of environmental-health and MDR-TB diseases and their influence on environmental sustainability at Chinese hospitals

The purpose of this study is to identify at what extent multidrug-resistant tuberculosis (MDR-TB) diseases effect on environmental health issues in selected provinces of Chinese hospitals. In survival analysis approach, this study employs the Cox proportional hazard model (CPM) to incorporate the duration of event, probability of occurrence of an event, and the issue of right censoring. An advantage of using CPM is that one does not need to specify the distribution of baseline hazard H₀ (t) as it considers a common value for all units in population. The results indicate that male and travel expenditures have negative association with the duration of cure. Furthermore, the medical expenditures and the spatial characteristic of time expenditure have positive association with the duration of cure of MDR-TB patients. The inconsistent behavior of males in taking medicines as compared to females and males is also more prone to tuberculosis (TB).

Provision of Decentralized TB Care Services: A Detect-Treat-Prevent Strategy for Children and Adolescents Affected by TB

In this review, we discuss considerations and successful models for providing decentralized diagnosis, treatment, and prevention services for children and adolescents. Key approaches to building decentralized capacity for childhood TB diagnosis in primary care facilities include provider training and increased access to child-focused diagnostic tools and techniques. Treatment of TB disease should be managed close to where patients live; pediatric formulations of both first- and second-line drugs should be widely available; and any hospitalization should be for as brief a period as medically indicated. TB preventive treatment for child and adolescent contacts must be greatly expanded, which will require home visits to identify contacts, building capacity to rule out TB, and adoption of shorter preventive regimens. Decentralization of TB services should involve the private sector, with collaborations outside the TB program in order to reach children and adolescents where they first enter the health care system. The impact of decentralization will be maximized if programs are family-centered and designed around responding to the needs of children and adolescents affected by TB, as well as their families.

Adolescents in a tuberculosis hospital: Qualitative study of how relationships with doctors, caregivers, and peers mediate their mental wellbeing

Lengthy hospitalization can impact adolescents’ mental wellbeing in a number of negative ways. Scholarship has indicated that a young patient’s relationships play an important role in reducing the amount of stress felt and in improving emotional state. In this article we turn to the experiences of adolescents with tuberculosis [TB] in Russia to explore how exactly hospitalization together with the TB diagnosis itself impact their mental wellbeing and how relationships with others mediate these impacts. We conducted a qualitative, interview-based study in Tomsk pediatric TB clinic. Interviews were conducted with three groups relevant for reaching the aim of this research: adolescent patients, their adult caregivers, and their treating physicians [17 informants in total]. Interview data were complemented with prolonged observations in the same clinic. The results of our study highlight that threats to mental wellbeing of adolescents with TB are multiple. Adolescents who are about to enter the in-patient treatment feel apprehensive and anxious about their future. They tend to have a hard time accepting their diagnosis, which they often feel is something shameful, and, consequently, may develop a negative attitude towards themselves. Most importantly, many undergo painful loss of personal relationships and expect or actually experience rejection by peers because of having tuberculosis. However, relationships with physicians, caregivers, and other patients in the clinic mediate negative impacts of TB diagnosis and hospitalization on adolescents’ mental wellbeing and can open ways for providing support. Supportive practices include physicians leaving it up to adolescents to decide what they want to discuss and when, caregivers remaining available for contact and keeping regular communication, and other adolescents with TB proactively seeking contact with the newcomers and behaving in a non-judgmental way. These results can inform design of adolescent-friendly TB services.

Optima TB: A tool to help optimally allocate tuberculosis spending

Approximately 85% of tuberculosis (TB) related deaths occur in low- and middle-income countries where health resources are scarce. Effective priority setting is required to maximise the impact of limited budgets. The Optima TB tool has been developed to support analytical capacity and inform evidence-based priority setting processes for TB health benefits package design. This paper outlines the Optima TB framework and how it was applied in Belarus, an upper-middle income country in Eastern Europe with a relatively high burden of TB. Optima TB is a population-based disease transmission model, with programmatic cost functions and an optimisation algorithm. Modelled populations include age-differentiated general populations and higher-risk populations such as people living with HIV. Populations and prospective interventions are defined in consultation with local stakeholders. In partnership with the latter, demographic, epidemiological, programmatic, as well as cost and spending data for these populations and interventions are then collated. An optimisation analysis of TB spending was conducted in Belarus, using program objectives and constraints defined in collaboration with local stakeholders, which included experts, decision makers, funders and organisations involved in service delivery, support and technical assistance. These analyses show that it is possible to improve health impact by redistributing current TB spending in Belarus. Specifically, shifting funding from inpatient- to outpatient-focused care models, and from mass screening to active case finding strategies, could reduce TB prevalence and mortality by up to 45% and 50%, respectively, by 2035. In addition, an optimised allocation of TB spending could lead to a reduction in drug-resistant TB infections by 40% over this period. This would support progress towards national TB targets without additional financial resources. The case study in Belarus demonstrates how reallocations of spending across existing and new interventions could have a substantial impact on TB outcomes. This highlights the potential for Optima TB and similar modelling tools to support evidence-based priority setting.

Tuberculosis (TB) remains a leading global cause of death and morbidity, and 85% of deaths occur in countries where resources for TB care and control are limited. Many countries cannot finance all TB interventions or technologies, which means difficult decisions on what to prioritise and publically finance. Modelling tools can help decision-makers set priorities based on evidence, in a systematic and transparent way. This study presents Optima TB, a tool that estimates which allocations of spending across interventions will most likely maximise specified objectives—such as minimising TB deaths, prevalence and incidence. In partnership with local decision-makers and stakeholders, Optima TB was applied in Belarus. Recommendations from the model findings include focussing investment on outpatient rather than inpatient care and actively finding people with TB (e.g. through contact tracing) rather than mass testing of the population. The recommended reallocations of spending could reduce TB prevalence and deaths by up to 45% and 50%, respectively, by 2035 for the same amount of spending. Key stakeholders were engaged throughout the analysis and findings and uncertainty around the results were clearly communicated with decision-makers. The timeliness of the results helped inform national dialogue on TB care reform, among other key policy discussions.

A cohort study analyzing the impact of socioeconomic and spatial characteristics alongside treatment regimens on the environmental-health outcomes of the MDR-TB treatment in Pakistan

This study identifies and analyzes a number of factors that correlate with the environmental-health outcome of multi-drug resistance tuberculosis (MDR-TB) treatment in Pakistan. Survival analysis is carried out by applying the multivariable Cox Proportional Hazard model on secondary data of 369 patients registered at three main MDR-TB sites in Pakistan during 2012-2017. Results show that there is no difference in survival of patients between the two treatment arms, hospital and ambulatory care. Male gender and travel expenditure are found to be negatively associated with the environmental-health outcome, whereas spatial characteristic of time expenditure is positively related to it supporting distance bias approach. Medical expenditure is also positively related to the environmental-health outcome. The study concludes that availability of affordable and accessible health services, better environmental conditions, and ambulatory care based on WHO recommendation as well as health education along with social protection schemes should be ensured by the government to improve environmental-health outcome in the resource-scarce setting in Pakistan.

TB management in the European Union/European Economic Area: a multi-centre survey

BACKGROUND:

Essential TB care in the European Union/European Economic Area (EU/EEA) comprises 21 standards for the diagnosis, treatment and prevention of TB that constitute the European Union Standards for Tuberculosis Care (ESTC).

METHODS:

In 2017, we conducted an audit on TB management and infection control measures against the ESTC standards. TB reference centres in five EU/EEA countries were purposely selected to represent the heterogeneous European TB burden and examine geographic variability.

RESULTS:

Data from 122 patients, diagnosed between 2012 and 2015 with multidrug-resistant TB (n = 49), extensively drug-resistant TB (XDR-TB) (n = 11), pre-XDR-TB (n = 29) and drug-susceptible TB (n = 33), showed that TB diagnosis and treatment practices were in general in agreement with the ESTC.

CONCLUSION:

Overall, TB management and infection control practices were in agreement with the ESTC in the selected EU/EEA reference centres. Areas for improvement include strengthening of integrated care services and further implementation of patient-centred approaches.

Hospitalizations and Treatment Outcomes in Patients with Urogenital Tuberculosis in Tashkent, Uzbekistan, 2016-2018

Despite the global shift to ambulatory tuberculosis (TB) care, hospitalizations remain common in Uzbekistan. This study examined the duration and determinants of hospitalizations among adult patients (≥18 years) with urogenital TB (UGTB) treated with first-line anti-TB drugs during 2016–2018 in Tashkent, Uzbekistan. This was a cohort study based on the analysis of health records. Of 142 included patients, 77 (54%) were males, the mean (±standard deviation) age was 40 ± 16 years, and 68 (48%) were laboratory-confirmed. A total of 136 (96%) patients were hospitalized during the intensive phase, and 12 (8%) had hospital admissions during the continuation phase of treatment. The median length of stay (LOS) during treatment was 56 days (Interquartile range: 56–58 days). LOS was associated with history of migration (adjusted incidence rate ratio (aIRR): 0.46, 95% confidence interval (CI): 0.32–0.69, p < 0.001); UGTB-related surgery (aIRR: 1.18, 95% CI: 1.01–1.38, p = 0.045); and hepatitis B comorbidity (aIRR: 3.18, 95% CI: 1.98–5.39, p < 0.001). The treatment success was 94% and it was not associated with the LOS. Hospitalization was almost universal among patients with UGTB in Uzbekistan. Future research should focus on finding out what proportion of hospitalizations were not clinically justified and could have been avoided.

Assessment of training and mentoring for DR-TB care decentralization in Tanzania

INTRODUCTION

Drug-resistant TB (DR-TB) care shifted from centralized to decentralized care in Tanzania in 2015. This study explored whether DR-TB training and mentoring supported healthcare workers' (HCWs) DR-TB care performance.

METHODS

This mixed study assessed HCWs' DR-TB care knowledge, the training quality, and the mentoring around 454 HCWs who were trained across 55 DR-TB sites between January 2016 and December 2017. Pre- and post-training tests, end-of-training evaluation, supervisor's interviews, DR-TB team self-assessment and team focus group discussion were conducted among trained HCWs. Interim and final treatment results of the national central site and the decentralized sites were compared.

RESULTS

HCW's knowledge increased for 15-20% between pre-training and post-training. HCWs and supervisors perceived mentoring as most appropriate to further develop their DR-TB competencies. Culture negativity after 6 months of treatment was similar for the decentralized sites compared to the national central site, 81% vs 79%, respectively, whereas decentralized sites had less loss to follow-up (0% versus 3%) and fewer deaths (3% versus 12%). Delays in laboratory results, stigma, and HCWs shortage were reported the main challenges of decentralized care.

CONCLUSIONS

Training and mentoring to provide DR-TB care at decentralized sites in Tanzania improved HCWs' knowledge and skills in DR-TB care and supported observed good interim and final patient treatment outcomes despite health system challenges.

Cost comparison of nine-month treatment regimens with 20-month standardized care for the treatment of rifampicin-resistant/multi-drug resistant tuberculosis in Nigeria

Background

Globally, drug resistant tuberculosis (DR-TB) continues to be a public health threat. Nigeria, which accounts for a significant proportion of the global burden of rifampicin/multi-drug resistant-TB (RR/MDR-TB) had a funding gap of $168 million dollars for TB treatment in 2018. Since 2010, Nigeria has utilized five different models of care for RR/MDR-TB (Models A-E); Models A, B and C based on a standardized WHO-approved treatment regimen of 20–24 months, were phased out between 2015 and 2019 and replaced by Models D and E. Model D is a fully ambulatory model of 9–12 months during which a shorter treatment regimen including a second-line injectable agent is utilized. Model E is identical to Model D but has patients hospitalized for the first four months of care while Model F which is to be introduced in 2020, is a fully ambulatory, oral bedaquiline-containing shorter treatment regimen of 9–12 months. Treatment models for RR/MDR-TB of 20–24 months duration have had treatment success rates of 52–66% while shorter treatment regimens have reported success rates of 85% and above. In addition, replacing the second-line injectable agent in a shorter treatment regimen with bedaquiline has been found to further improve treatment success in patients with fluoroquinolone-susceptible RR/MDR-TB.

Reliable cost data for RR/MDR-TB care are limited, specifically costs of models that utilize shorter treatment regimens and which are vital to guide Nigeria through the provision of RR/MDR-TB care at scale. We therefore conducted a cost analysis of shorter treatment regimens in use and to be used in Nigeria (Models D, E and F) and compared them to three models of longer duration utilized previously in Nigeria (Models A, B and C) to identify any changes in cost from transitioning from Models A-C to Models D-F and opportunities for cost savings.

Methods

We obtained costs for TB diagnostic and monitoring tests, in-patient and out-patient care from a previous study, inflated these costs to 2019 NGN and then converted to 2020 USD. We obtained other costs from the average of six health facilities and drug costs from the global drug facility. We modeled treatment on strict adherence to two Nigerian National guidelines for programmatic and clinical management of drug-resistant tuberculosis.

Results

We estimated that the total costs of care from the health sector perspective for Models D, E and F were $4,334, $7,705 and $3,420 respectively. This is significantly lower than the costs of Models A, B and C which were $14,781, $12, 113, $7,572 respectively.

Conclusion

Replacing Models A–C with Models D and E reduced the costs of RR/MDR-TB care in Nigeria by approximately $5,470 (48%) per patient treated and transitioning from Models D and E to Model F would result in further cost savings of $914 to $4,285 (21 to 56%) for every patient placed on Model F. If the improved outcomes of patients managed using bedaquiline-containing shorter treatment regimens in other countries can be attained in Nigeria, Model F would be the recommended model for the scale up of RR/MDR-TB care in Nigeria.

Preparedness of outpatient health facilities for ambulatory treatment with all-oral short DR-TB treatment regimens in Zhytomyr, Ukraine: a cross-sectional study

BACKGROUND

Ukraine has a high burden of drug-resistant tuberculosis (DR-TB). Mental health problems, including alcohol use disorder, are common co-morbidities. One in five DR-TB patients has human immunodeficiency virus (HIV). As part of health reform, the country is moving from inpatient care to ambulatory primary care for tuberculosis (TB). In Zhytomyr oblast, Médecins Sans Frontières (MSF) is supporting care for DR-TB patients on all-oral short DR-TB regimens. This study describes the preparedness of ambulatory care facilities in Zhytomyr oblast, Ukraine, to provide good quality ambulatory care.

METHODS

This is a retrospective analysis of routinely collected programme data. Before discharge of every patient from the hospital, MSF teams assess services available at outpatient facilities using a standardised questionnaire. The assessment evaluates access, human resources, availability of medicines, infection control measures, laboratory and diagnostic services, and psychosocial support.

RESULTS

We visited 68 outpatient facilities in 22 districts between June 2018 and September 2019. Twenty-seven health posts, 24 TB-units, 13 ambulatories, two family doctors and one polyclinic, serving 30% of DR-TB patients in the oblast by September 2019, were included. All facilities provided directly observed treatment, but only seven (10%) provided weekend-services. All facilities had at least one medical staff member, but TB-training was insufficient and mostly limited to TB-doctors. TB-treatment and adequate storage space were available in all facilities, but only five (8%) had ancillary medicines. HIV-positive patients had to visit a separate facility to access HIV-care. Personal protective equipment was unavailable in 32 (55%) facilities. Basic laboratory services were available in TB-units, but only four (17%) performed audiometry. Only ten (42%) TB-units had psychosocial support available, and nine (38%) offered psychiatric support.

CONCLUSION

Outpatient facilities in Zhytomyr oblast are not yet prepared to provide comprehensive care for DR-TB patients. Capacity of all facilities needs strengthening with trainings, infection control measures and infrastructure. Integration of psychosocial services, treatment of co-morbidities and adverse events at the same facility are essential for successful decentralisation. The health reform is an opportunity to establish quality, patient-centred care.

Strategic investment in tuberculosis control in the Republic of Bulgaria

As Bulgaria transitions away from Global Fund grant, robust estimates of the comparative impact of the various response strategies under consideration are needed to ensure sustained effectiveness of the tuberculosis (TB) programme. We tailored an established mathematical model for TB control to the epidemic in Bulgaria to project the likely outcomes of seven intervention scenarios. Under existing programmatic conditions projected forward, the country's targets for achieving TB elimination in the coming decades will not be achieved. No interventions under consideration were predicted to accelerate the baseline projected reduction in epidemiological indicators significantly. Discontinuation of the 'Open Doors' program and activities of non-governmental organisations would result in a marked exacerbation of the epidemic (increasing incidence in 2035 by 6-8% relative to baseline conditions projected forward). Changing to a short course regimen for multidrug-resistant TB (MDR-TB) would substantially decrease MDR-TB mortality (by 21.6% in 2035 relative to baseline conditions projected forward). Changing to ambulatory care for eligible patients would not affect TB burden but would be markedly cost-saving. In conclusion, Bulgaria faces important challenges in transitioning to a primarily domestically-financed TB programme. The country should consider maintaining currently effective programs and shifting towards ambulatory care to ensure program sustainability.

Challenges and controversies in childhood tuberculosis

Children bear a substantial burden of suffering when it comes to tuberculosis. Ironically, they are often left out of the scientific and public health advances that have led to important improvements in tuberculosis diagnosis, treatment, and prevention over the past decade. This Series paper describes some of the challenges and controversies in paediatric tuberculosis, including the epidemiology and treatment of tuberculosis in children. Two areas in which substantial challenges and controversies exist (ie, diagnosis and prevention) are explored in more detail. This Series paper also offers possible solutions for including children in all efforts to end tuberculosis, with a focus on ensuring that the proper financial and human resources are in place to best serve children exposed to, infected with, and sick from all forms of tuberculosis.

Effectiveness of interventions for reducing TB incidence in countries with low TB incidence: a systematic review of reviews

AIMS

What is the evidence base for the effectiveness of interventions to reduce tuberculosis (TB) incidence in countries which have low TB incidence?

METHODS

We conducted a systematic review of interventions for TB control and prevention relevant to low TB incidence settings (<10 cases per 100 000 population). Our analysis was stratified according to "direct" or "indirect" effects on TB incidence. Review quality was assessed using AMSTAR2 criteria. We summarised the strength of review level evidence for interventions as "sufficient", "tentative", "insufficient" or "no" using a framework based on the consistency of evidence within and between reviews.

RESULTS

We found sufficient review level evidence for direct effects on TB incidence/case prevention of vaccination and treatment of latent TB infection. We also found sufficient evidence of beneficial indirect effects attributable to drug susceptibility testing and adverse indirect effects (measured as sub-optimal treatment outcomes) in relation to use of standardised first-line drug regimens for isoniazid-resistant TB and intermittent dosing regimens. We found insufficient review level evidence for direct or indirect effects of interventions in other areas, including screening, adherence, multidrug-resistant TB, and healthcare-associated infection.

DISCUSSION

Our review has shown a need for stronger evidence to support expert opinion and country experience when formulating TB control policy.

Towards tailored regimens in the treatment of drug-resistant tuberculosis: a retrospective study in two Italian reference Centres

Background

The increased incidence of drug-resistant TB is a major challenge for effective TB control. Limited therapeutic options and poor treatment outcomes of DR-TB may increase drug-resistance rates. The objective of the study is to retrospectively compare MDR-TB and pre-XDR-TB treatment regimens and outcomes in two large TB reference centres in Italy from January 2000 to January 2015.

Methods

A retrospective, multicentre study was conducted at the Regional TB Reference Centre Villa Marelli Institute (Milan) and at the Reference Center for MDR-TB and HIV-TB, Eugenio Morelli Hospital (Sondalo). The supra-national Reference Laboratory in Milan performed DST. Inclusion criteria were: age ≥ 18 and culture-confirmed diagnosis of MDR- or pre-XDR TB. Chi-square or Fisher exact test was used to detect differences in the comparison between treatment outcomes, therapeutic regimens, and drug-resistances. Computations were performed with STATA 15.

Results

A total of 134 patients were selected. Median (IQR) age at admission was 33 (26–41) years and 90 patients (67.2%) were male. Pulmonary TB was diagnosed in 124 (92.5%) patients. MDR- and pre-XDR-TB cases were 91 (67.9%) and 43 (32.1%), respectively. The WHO shorter MDR-TB regimen could have been prescribed in 16/84 (19.1%) patients. Treatment success was not statistically different between MDR- and pre-XDR-TB (81.3% VS. 81.4%; P = 0.99). Mortality in MDR-TB and pre-XDR-TB groups was 4.4 and 9.3%, respectively (P = 0.2). Median duration of treatment was 18 months and a total of 110 different regimens were administered. Exposure to linezolid, meropenem, and amikacin was associated with a better outcome in both groups (P = 0.001, P < 0.001, and P = 0.004, respectively).

Conclusions

Tailored treatment regimens based on DST results can achieve successful outcomes in patients with pre-XDR-TB.

Reducing tuberculosis transmission: a consensus document from the World Health Organization Regional Office for Europe

Evidence-based guidance is needed on 1) how tuberculosis (TB) infectiousness evolves in response to effective treatment and 2) how the TB infection risk can be minimised to help countries to implement community-based, outpatient-based care.This document aims to 1) review the available evidence on how quickly TB infectiousness responds to effective treatment (and which factors can lower or boost infectiousness), 2) review policy options on the infectiousness of TB patients relevant to the World Health Organization European Region, 3) define limitations of the available evidence and 4) provide recommendations for further research.The consensus document aims to target all professionals dealing with TB (e.g TB specialists, pulmonologists, infectious disease specialists, primary healthcare professionals, and other clinical and public health professionals), as well as health staff working in settings where TB infection is prevalent.

A retrospective analysis of treatment outcomes of drug-susceptible TB in Kazakhstan, 2013-2016

Kazakhstan has a high burden of multidrug-resistant tuberculosis (TB). The patient-centered National Program for the treatment and prevention of TB has been implemented in Kazakhstan. The program is aimed at meeting the needs of patients and expansion of the outpatient treatment of TB in the country.The aim of the study was to compare the efficacy of the outpatient and inpatient treatment of drug-susceptible TB.This study was a retrospective cohort study.A total of 36.926 TB cases were included. The majority of patients were treated as inpatients. The socioeconomic factors, sex, age, HIV status, and other diagnostic factors (e.g., sputum smear results, extrapulmonary disease) may serve as risk factors to estimate the likely TB treatment outcome. The outpatient treatment of drug-susceptible TB seems to be a comparable option to the inpatient treatment in terms of efficacy.The socioeconomic factors are the main modifiable risk factors for treatment failure. The outpatient treatment of drug-susceptible TB is safe and effective.

Evaluation of Xpert MTB-RIF guided diagnosis and treatment of rifampicin-resistant tuberculosis in Indonesia: A retrospective cohort study

BACKGROUND

Rifampicin-resistant tuberculosis (RR-TB) is largely underdetected in Indonesia. Xpert MTB/RIF (Xpert) has recently been introduced, prioritizing patients at risk of RR-TB, followed by phenotypic drug-susceptibility (DST) if rifampicin resistance is detected.

OBJECTIVE

This study investigated Xpert-based management of presumptive RR-TB cases under routine practice in West Java, Indonesia.

METHODS

We examined all records of patients tested with Xpert in the referral hospital for West Java in 2015-2016. We measured loss across a limited cascade of care, time to Xpert diagnosis and the commencement of initial second-line treatment, and identified factors associated with diagnostic and treatment delay. Additionally, we analyzed the appropriateness of treatment according to DST results.

RESULTS

Of 3415 patients with presumptive RR-TB, 3215 (94%) were tested by Xpert, of whom 339 (10.5%) were diagnosed as RR-TB. 288 (85%) of 339 RR-TB patients started initial second-line TB treatment, with 48 (14%) patients being lost between diagnosis and pre-treatment assessment. Second-line treatment was commenced at a median of 41 days (IQR 29-70) after RR-TB diagnosis. Delays in both diagnosis and treatment initiation were observed in 104 (52%) of 201 RR-TB patients with identifiable referral date. Rural residence was associated with delay to diagnosis (adjusted OR 2.7; 95%CI 1.5-5.2) and treatment initiation (adjusted OR 2.0; 1.2-3.4). Of 162 patients with available DST result, 107 (66%) had multidrug-resistant tuberculosis (MDR-TB) and 32 (20%) had either pre-extensively drug resistant (pre-XDR) or extensively drug resistant tuberculosis (XDR-TB). We estimated that with the current algorithm 41% of pre-XDR or XDR-TB patients are diagnosed, and 33% of them started on an appropriate treatment regimen.

CONCLUSIONS

Many patients with Xpert-diagnosed RR-TB either do not start MDR-TB treatment or encountered diagnostic and treatment delays under programmatic conditions in Indonesia, and most pre-XDR and XDR-TB cases remain undiagnosed. Further expansion and ongoing quality improvement of RR-TB services are urgently needed.

Cost of three models of care for drug-resistant tuberculosis patients in Nigeria

Background

Nigeria accounts for a significant proportion of the global drug-resistant tuberculosis (DR-TB) burden, a large proportion of which goes untreated. Different models for managing DR-TB treatment with varying levels of hospitalization are in use across Nigeria, however costing evidence is required to guide the scale up of DR-TB care. We aimed to estimate and compare the costs of different DR-TB treatment and care models in Nigeria.

Methods

We estimated the costs associated with three models of DR-TB treatment and care: Model (A) patients are hospitalized throughout the 8-month intensive phase, Model (B) patients are partially hospitalized during the intensive phase and Model (C) is entirely ambulatory. Costs of treatment, in-patient and outpatient care and diagnostic and monitoring tests were collected using a standardized data collection sheet from six sites through an ingredient’s approach and cost models were based on the Nigerian National Tuberculosis, Leprosy and Buruli Ulcer Guideline - Sixth Edition (2014) and Guideline for programmatic and clinical management of drug-resistant tuberculosis in Nigeria (2015).

Results

Assuming adherence to the Nigerian DR-TB guidelines, the per patient cost of Model A was $18,528 USD, Model B $15,159 USD and Model C $9425 USD. Major drivers of cost included hospitalization (Models A and B) and costs of out-patient consultations and supervision (Model C).

Conclusion

Utilizing a decentralized ambulatory model, is a more economically viable approach for the expansion of DR-TB care in Nigeria, given that patient beds for DR-TB treatment and care are limited and costs of hospitalized treatment are considerably more expensive than ambulatory models. Scale-up of less expensive ambulatory care models should be carefully considered in particular, when treatment efficacy is demonstrated to be similar across the different models to allow for patients not requiring hospitalization to be cared for in the least expensive way.

Decentralized, Community-Based Treatment for Drug-Resistant Tuberculosis: Bangladesh Program Experience

Shifting from hospital- to community-based management of drug-resistant TB, increased treatment enrollment, reduced treatment initiation delays, improved follow-up and adherence, and lowered treatment failure, and was associated with higher cure rates and lower mortality.

Background:

Bangladesh is a highly populous country where the prevalence of drug-resistant tuberculosis (DR-TB) is growing. With the rapid increase in DR-TB notifications through GeneXpert technology, it was imperative to come up with a new treatment strategy that could keep up with the increase of patients diagnosed.

Intervention:

Intervention was designed to support national transition of DR-TB management of World Health Organization-approved long course (20-to-24-month regimen) treatment from a hospital-based approach to the decentralized model of community-based programmatic management of DR-TB (cPMDT). In close coordination with the Ministry of Health and Family Welfare and National TB Program, patients were initiated into treatment at hospitals and then transferred to community-based care. A cadre of directly observed therapy providers supported treatment at the household level, supervised by the outpatient DR-TB teams.

Methods:

We conducted a descriptive pre- and post-intervention study of all 1,946 DR-TB patients enrolled in treatment nationwide between May 2012 and June 2015. Data were collected from hospitals, patient cards, district records, and diagnostic laboratories through the National TB Program. Intervention results were assessed in comparison with the baseline (2011) indicators.

Results:

During the intervention period, treatment enrollment of 1,946 diagnosed DR-TB patients through the national program increased from 50% in 2011 to 100% in 2015. The delay between diagnosis and treatment initiation decreased from 69 days in 2011 to 6 days in 2014. Most (95%) of the patients completed all scheduled follow-up smear and culture tests. By the sixth month of treatment, 99% of patients had negative smear conversion and 98% had negative culture conversion. The treatment success rate increased from 70% in 2011 to 76% in 2015 at the end of the intervention period. The results also indicate a decline between baseline and end line from 34% to 9% for patients died, 34% to 10% for loss to follow-up, and 1.7% to 0% for treatment failure.

Conclusions:

Community-based management is an effective approach for increasing access to quality-assured DR-TB treatment. Using existing structures and resources, the intervention demonstrated that favorable treatment outcomes can be achieved and sustained by treating patients with DR-TB at their homes.

Cost effectiveness of decentralised care model for managing MDR-TB in India

BACKGROUND

In India, multidrug-resistant tuberculosis (MDR-TB) patients are usually treated in hospitals. Decentralised care model, however, has been suggested as a possible alternative by the World Health Organization (WHO). In the "End TB Strategy", the WHO highlights, as one of the key targets for 2035, that 'no TB-affected families should face catastrophic hardship due to the tuberculosis'. Removal of financial barriers to health-care access and mitigation of catastrophic expenditures are therefore considered vital to achieve the universal health coverage (UHC) goal. Since forgoing healthcare due to the financial constraints is a known fact in India, decentralised care as an intervention choice (as against hospital-based care) might enhance equity provided it is an affordable choice. Thus, an economic evaluation was conducted, from the perspective of the national health system in India, to assess the cost-effectiveness of decentralised care compared to centralised care for MDR-TB.

METHODS

This study uses a decision-analytic model with a follow-up of two years to assess the expected costs of the decentralised versus the centralised approaches for MDR-TB treatment. A published systematic review of observational studies yielded the MDR-TB treatment outcomes, which included treatment success, treatment default, treatment failure, and mortality parameters. It was observed that these parameters did not vary significantly between the two alternatives. Treatment costs included the following costs: hospital admission costs, clinic costs, visits to laboratory and MDR-TB centre, drug therapy, injections and food. Costs data of drugs, diagnosis, hospital stay and travel to public facilities, based on a simple market survey, were taken from a recently published study on MDR-TB expenditures in the Chhattisgarh state of India. Potential cost savings related to the implementation of decentralised MDR-TB care for all patients who initiated MDR-TB treatment in India were additionally estimated.

RESULTS

Estimated average expected total treatment cost was US$ 3390.56 for the hospital-based model and US$ 1724.1 for the decentralised model for a patient treated for MDR-TB in India, generating potential savings of US$1666.50 per case, with ICER US$ 2382.68 per QALY gained. One of the primary drivers of this difference was the significantly more intensive (thus expensive) stay charges in the hospital. If the costs and treatment probabilities are extrapolated to the whole country, with 48114 MDR-TB patients initiated on treatment in 2017, decentralised care would have additional 1058 patients cured, gain additional 3824 QALYs, and avert 2165 deaths, as compared to centralised care, in India. At various scenarios of coverage rates of decentralised and centralised care the cost difference would range between 23% and 94% for the country.

CONCLUSION

Our study provides evidence of cost savings for MDR-TB patients if patients choose decentralised treatment in comparison to suggested hospitalisation of these patients for centralised treatment with similar outcomes. The economic evaluation presented in this study expected significant efficiency gains in choice of two treatment options and the cost savings may improve equity. In India, treatment of MDR-TB using decentralised care is expected to result in similar patient outcomes at markedly reduced public health costs compared with centralised care.

Epidemiology of multidrug-resistant tuberculosis (MDR-TB) in Ethiopia: a systematic review and meta-analysis of the prevalence, determinants and treatment outcome

INTRODUCTION

The emergence of MDR-TB remained a major public health threat particularly in developing countries. With increased prevalence and complexity of treatment, the burden of MDR-TB challenged the country. It is of an important; the epidemiology of drug resistant TB is not well understood. There are few studies conducted to assess the prevalence, determinants and treatment outcome of MDR-TB with inconclusive finding. Therefore, we aimed to conduct a systematic review and meta-analysis on Epidemiology of MDR-TB in Ethiopia, So that policy makers and other stalk holders could have pooled evidence on the problem to make a decision.

METHODS

The review was conducted through a systematic literature search of articles published between 1997 and 2017. Five bibliographic databases and libraries: PubMed/Medline, Global Health Database, Embase, the Cochrane Library, and African Index Medicus were used. After cleaning and sorting, analysis was performed using STATA version 11. The pooled rate of MDR-TB prevalence, determinants and treatment outcome was estimated with a random-effects model. Heterogeneity was assessed by the I2 and publication bias through funnel plot.

RESULTS

The 34 studies that were retained for final analysis enrolled a total of 7461 TB or MDR-TB patients. We found that 2.18% (95% CI 1.44-2.92%) of newly diagnosed and 21.07% (95% CI 11.47-30.67%) of previously treated patients have MDR-TB with overall prevalence of 7.24% (95% CI 6.11-8.37). History of previous treatment is the major determinant (pooled OR = 4.78 (95% CI 3.16-6.39)), while contact history and adherence also contributed. In this review the pooled death computed among 5 articles showed that 12.25% (95% CI 9.39-15.11%) of MDR-TB patients were died in the course of treatment. Complication, drug side effects and HIV infection were the main determinants for the death.

CONCLUSION AND RECOMMENDATION

The prevalence is by far higher than the previous reports. It is mainly associated with history of previous treatment along with contact history. However, the treatment outcomes are comparable with previous studies, yet it is a concern. Comorbidities, drug side effects and HIV sero-positivity were the determinants. Thus, proper treatment of drug susceptible TB and early detection and treatment of MDR-TB before complication develops along with prevention of drug side effect and contacts with MDR-TB cases are very important.

Initiation, scale-up and outcomes of the Cambodian National MDR-TB programme 2006-2016: hospital and community-based treatment through an NGO-NTP partnership

Introduction

Prolonged inpatient multidrug-resistant tuberculosis (MDR-TB) treatment for all patients is not sustainable for high-burden settings, but there is limited information on community-based treatment programme outcomes for MDR-TB.

Methods

The Cambodian Health Committee, a non-governmental organisation (NGO), launched the Cambodian MDR-TB programme in 2006 in cooperation with the National Tuberculosis Program (NTP) including a community-based treatment option as a key programme component. The programme was transferred to NTP oversight in 2011 with NGO clinical management continuing. Patients electing to receive home-based treatment were followed by a dedicated adherence supporter and a multidisciplinary outpatient team of nurses, physicians and community health workers. Patients hospitalised for >1 month of treatment (hospital based) received similar management after discharge. All patients received a standardised second-line MDR-TB regimen and were provided nutritional and adherence support. Outcomes were reviewed for patients completing 24 months of treatment and predictors of treatment success were evaluated using logistic regression.

Results

Of 582 patients with MDR-TB who initiated treatment between September 2006 and June 2016, 20% were HIV coinfected, 288 (49%) initiated community-based treatment and 294 (51%) received hospital-based treatment. Of 486 patients with outcomes available, 364 (75%) were cured, 10 (2%) completed, 28 (6%) were lost to follow-up, 3 (0.6%) failed and 77 (16%) died. There was no difference between treatment success in community versus hospital-based groups (adjusted OR (aOR) 1.0, p=0.99). HIV infection, older age and body mass index <16 were strongly associated with decreased treatment success (aOR 0.33, p<0.001; aOR 0.40, p<0.001; aOR 0.40; p<0.001).

Conclusions

Cambodia’s NGO–NTP partnership successfully developed and scaled up a model MDR-TB treatment programme. The first large-scale MDR-TB programme in Asia with a significant community-based component, the programme achieved equally high treatment success in patients with community-based compared with hospital-based initiation of MDR treatment.

MDR-TB patients in KwaZulu-Natal, South Africa: Cost-effectiveness of 5 models of care

BACKGROUND

South Africa has a high burden of MDR-TB, and to provide accessible treatment the government has introduced different models of care. We report the most cost-effective model after comparing cost per patient successfully treated across 5 models of care: centralized hospital, district hospitals (2), and community-based care through clinics or mobile injection teams.

METHODS

In an observational study five cohorts were followed prospectively. The cost analysis adopted a provider perspective and economic cost per patient successfully treated was calculated based on country protocols and length of treatment per patient per model of care. Logistic regression was used to calculate propensity score weights, to compare pairs of treatment groups, whilst adjusting for baseline imbalances between groups. Propensity score weighted costs and treatment success rates were used in the ICER analysis. Sensitivity analysis focused on varying treatment success and length of hospitalization within each model.

RESULTS

In 1,038 MDR-TB patients 75% were HIV-infected and 56% were successfully treated. The cost per successfully treated patient was 3 to 4.5 times lower in the community-based models with no hospitalization. Overall, the Mobile model was the most cost-effective.

CONCLUSION

Reducing the length of hospitalization and following community-based models of care improves the affordability of MDR-TB treatment without compromising its effectiveness.

Sequelae of multidrug-resistant tuberculosis: protocol for a systematic review and meta-analysis

INTRODUCTION

The sequelae of multidrug-resistant tuberculosis (MDR-TB) are poorly understood and inconsistently reported. We will aim to assess the existing evidence for the clinical, psychological, social and economic sequelae of MDR-TB and to assess the health-related quality of life in patients with MDR-TB.

METHODS AND ANALYSIS

We will perform a systematic review and meta-analysis of published studies reporting sequelae of MDR-TB. We will search PubMed, SCOPUS, ProQuest, Web of Science and PsychINFO databases up to 5 September 2017. MDR-TB sequelae will include any clinical, psychological, social and economic effects as well as health-related quality of life that occur after MDR-TB treatment or illness. Two researchers will screen the titles and abstracts of all citations identified in our search, extract data, and assess the scientific quality using standardised formats. Providing there is appropriate comparability in the studies, we will use a random-effects meta-analysis model to produce pooled estimates of MDR-TB sequelae from the included studies. We will stratify the analyses based on treatment regimen, comorbidities (such as HIV status and diabetes mellitus), previous TB treatment history and study setting.

ETHICS AND DISSEMINATION

As this study will be based on published data, ethical approval is not required. The final report will be disseminated through publication in a peer-reviewed scientific journal and will also be presented at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42017073182.

Time to treatment for rifampicin-resistant tuberculosis: systematic review and meta-analysis

BACKGROUND

To reduce transmission and improve patient outcomes, rapid diagnosis and treatment of rifampicin-resistant tuberculosis (RR-TB) is required.

OBJECTIVE

To conduct a systematic review and meta-analysis assessing time to treatment for RR-TB and variability using diagnostic testing methods and treatment delivery approach.

DESIGN

Studies from 2000 to 2015 reporting time to second-line treatment initiation were selected from PubMed and published conference abstracts.

RESULTS

From 53 studies, 83 cohorts (13 034 patients) were included. Overall weighted mean time to treatment from specimen collection was 81 days (95%CI 70-91), and was shorter with ambulatory (57 days, 95%CI 40-74) than hospital-based treatment (86 days, 95%CI 71-102). Time to treatment was shorter with genotypic susceptibility testing (38 days, 95%CI 27-49) than phenotypic testing (108 days, 95%CI 98-117). The mean percentage of diagnosed patients initiating treatment was 76% (95%CI 70-83, range 25-100).

CONCLUSION

Time to second-line anti-tuberculosis treatment initiation is extremely variable across studies, and often unnecessarily long. Reduced delays are associated with genotypic testing and ambulatory treatment settings. Routine monitoring of the proportion of diagnosed patients initiating treatment and time to treatment are necessary to identify areas for intervention.

Infection control, genetic assessment of drug resistance and drug susceptibility testing in the current management of multidrug/extensively-resistant tuberculosis (M/XDR-TB) in Europe: A tuberculosis network European Trialsgroup (TBNET) study

AIM

Europe has the highest documented caseload and greatest increase in multidrug and extensively drug-resistant tuberculosis (M/XDR-TB) of all World Health Organization (WHO) regions. This survey examines how recommendations for M/XDR-TB management are being implemented.

METHODS

TBNET is a pan-European clinical research collaboration for tuberculosis. An email survey of TBNET members collected data in relation to infection control, access to molecular tests and basic microbiology with drug sensitivity testing.

RESULTS

68/105 responses gave valid information and were from countries within the WHO European Region. Inpatient beds matched demand, but single rooms with negative pressure were only available in low incidence countries; ultraviolet decontamination was used in 5 sites, all with >10 patients with M/XDR-TB per year. Molecular tests for mutations associated with rifampicin resistance were widely available (88%), even in lower income and especially in high incidence countries. Molecular tests for other first line and second line drugs were less accessible (76 and 52% respectively). A third of physicians considered that drug susceptibility results were delayed by > 2 months.

CONCLUSION

Infection control for inpatients with M/XDR-TB remains a problem in high incidence countries. Rifampicin resistance is readily detected, but tests to plan regimens tailored to the drug susceptibilities of the strain of Mycobacterium tuberculosis are significantly delayed, allowing for further drug resistance to develop.

Decentralized care for multidrug-resistant tuberculosis: a systematic review and meta-analysis

OBJECTIVE

To assess the effectiveness of decentralized treatment and care for patients with multidrug-resistant (MDR) tuberculosis, in comparison with centralized approaches.

METHODS

We searched ClinicalTrials.gov, the Cochrane library, Embase®, Google Scholar, LILACS, PubMed®, Web of Science and the World Health Organization's portal of clinical trials for studies reporting treatment outcomes for decentralized and centralized care of MDR tuberculosis. The primary outcome was treatment success. When possible, we also evaluated, death, loss to follow-up, treatment adherence and health-system costs. To obtain pooled relative risk (RR) estimates, we performed random-effects meta-analyses.

FINDINGS

Eight studies met the eligibility criteria for review inclusion. Six cohort studies, with 4026 participants in total, reported on treatment outcomes. The pooled RR estimate for decentralized versus centralized care for treatment success was 1.13 (95% CI: 1.01-1.27). The corresponding estimate for loss to follow-up was RR: 0.66 (95% CI: 0.38-1.13), for death RR: 1.01 (95% CI: 0.67-1.52) and for treatment failure was RR: 1.07 (95% CI: 0.48-2.40). Two of three studies evaluating health-care costs reported lower costs for the decentralized models of care than for the centralized models.

CONCLUSION

Treatment success was more likely among patients with MDR tuberculosis treated using a decentralized approach. Further studies are required to explore the effectiveness of decentralized MDR tuberculosis care in a range of different settings.

Health system factors influencing management of multidrug-resistant tuberculosis in four European Union countries - learning from country experiences

BACKGROUND

In the European Union and European Economic Area only 38% of multidrug-resistant tuberculosis patients notified in 2011 completed treatment successfully at 24 months' evaluation. Socio-economic factors and patient factors such as demographic characteristics, behaviour and attitudes are associated with treatment outcomes. Characteristics of healthcare systems also affect health outcomes. This study was conducted to identify and better understand the contribution of health system components to successful treatment of multidrug-resistant tuberculosis.

METHODS

We selected four European Union countries to provide for a broad range of geographical locations and levels of treatment success rates of the multidrug-resistant tuberculosis cohort in 2009. We conducted semi-structured interviews following a conceptual framework with representatives from policy and planning authorities, healthcare providers and civil society organisations. Responses were organised according to the six building blocks of the World Health Organization health systems framework.

RESULTS

In the four included countries, Austria, Bulgaria, Spain, and the United Kingdom, the following healthcare system factors were perceived as key to achieving good treatment results for patients with multidrug-resistant tuberculosis: timely diagnosis of drug-resistant tuberculosis; financial systems that ensure access to a full course of treatment and support for multidrug-resistant tuberculosis patients; patient-centred approaches with strong intersectoral collaboration that address patients' emotional and social needs; motivated and dedicated healthcare workers with sufficient mandate and means to support patients; and cross-border management of multidrug-resistant tuberculosis to secure continuum of care between countries.

CONCLUSION

We suggest that the following actions may improve the success of treatment for multidrug-resistant tuberculosis patients: deployment of rapid molecular diagnostic tests; development of context-specific treatment guidance and criteria for hospital admission and discharge in the European context; strengthening patient-centred approaches; development of collaborative mechanisms to ensure cross-border care, and development of long-term sustainable financing strategies.

Hospitalized care for MDR-TB in Port Harcourt, Nigeria: a qualitative study

BACKGROUND

In Nigeria multidrug-resistant tuberculosis (MDR-TB) is prevalent in 2.9% of new TB cases and 14% of retreatment cases, and the country is one of 27 with high disease burden globally. Patients are admitted and confined to one of ten MDR-TB treatment facilities throughout the initial 8 months of treatment. The perspectives of MDR-TB patients shared on social media and in academic research and those of providers are limited to experiences of home-based care. In this study we explored the views of hospitalised MDR-TB patients and providers in one treatment facility in Nigeria, and describe how their experiences are linked to accessibility of care and support services, in line with international goals. We aimed to explore the physical, social and psychological needs of hospitalized MDR TB patients, examine providers' perceptions about the hospital based model and discuss the model's advantages and disadvantages from the patient and the provider perspective.

METHODS

We conducted two gender distinct focus group discussions and 11 in-depth interviews with recently discharged MDR-TB patients from one MDR-TB treatment facility in Nigeria. We triangulated this with the views of four providers who played key roles in the management of MDR-TB patients via key informant interviews. Transcribed data was thematically analysed, using an iterative process to constantly compare and contrast emerging themes across the data set for deeper understanding of the full range of participants' views.

RESULTS

The study findings demonstrate the psycho-social impacts of prolonged isolation and the coping mechanisms of patients in the facility. The dislocation of patients from their normal social networks and the detachment between providers and patients created the need for interdependence of patients for emotional and physical support. Providers' fears of infection contributed to stigma and hindered accessibility of care and support services.

CONCLUSION

The current trend towards discharging patients after culture conversion would reduce the psycho-social impacts of prolonged isolation and potentially reduce the risk of occupational TB from prolonged contact with MDR-TB patients. Building on shared experiences and interdependence of MDR-TB patients in our study, innovative patient-centred support systems would likely help to reduce stigma, promote access to care and support services, and potentially impact on the outcome of treatment.

Health system support and health system strengthening: two key facilitators to the implementation of ambulatory tuberculosis treatment in Uzbekistan

Uzbekistan inherited a hospital-based health system from the Soviet Union. We explore the health system-related challenges faced during the scale-up of ambulatory (outpatient) treatment for drug-susceptible and drug-resistant tuberculosis (TB) in Karakalpakstan in Uzbekistan. Semi-structured interviews were conducted with key informants of the TB services, the ministries of health and finance, and their TB control partners. Structural challenges and resource needs were both discussed as obstacles to the expansion of ambulatory TB treatment. Respondents stated need for revising the financing mechanisms of the TB services to incentivize referral to ambulatory TB treatment. An increased workload and need for transportation in ambulatory TB care were also pointed out by respondents, given the quickly rising outpatient numbers but per capita financing of outpatient care. Policy makers showed strong interest in good practice examples for financing ambulatory-based management of TB in comparable contexts and in guidance for revising the financing of the TB services in a way that strengthens ambulatory TB treatment. To facilitate changing the model of care, TB control strategies emphasizing ambulatory care in hospital-oriented health systems should anticipate health system support and strengthening needs, and provide a plan of action to resolve both. Addressing both types of needs may require not only involving TB control and health financing actors, but also increasing knowledge about viable and tested financing mechanisms that incentivize the adoption of new models of care for TB.

Quality of Life, Psychological Interventions and Treatment Outcome in Tuberculosis Patients: The Indian Scenario

Objective: Psychological distress is being recognized in individuals affected with many diseases since it affects quality of life (QOF) and has gained importance in the clinical settings. Psychological interventions and their effect on the treatment outcome have yielded encouraging results in many diseased conditions. Tuberculosis (TB) ranks as a deadly disease resulting in millions of deaths worldwide. However, the effect of TB on the psychological status of patients and interventions to improve treatment outcome is neglected, especially in underdeveloped and developing countries.

Methods: Systematic review of research papers that published on the QOF in TB and the effect of psychological interventions on treatment outcome were conducted.

Results: Tuberculosis patients experience high levels of stress and decreased QOF. In the Indian scenario, TB patients undergo immense psychological stress similar to what is reported in other locations. Psychological interventions renewed hope on life and adherence to medication and treatment outcomes. Such psychological interventions are not practiced in Indian clinical settings.

Conclusion: There is an urgent need for both governmental and non-governmental organizations to devise strategies to include psychological interventions mandatory during TB treatments. In the absence of such interventions, the fight against TB in India will remain incomplete.

Individualizing management of extensively drug-resistant tuberculosis: diagnostics, treatment, and biomarkers

INTRODUCTION

Success rates for treatment of extensively drug resistant tuberculosis (XDR-TB) are low due to limited treatment options, delayed diagnosis and inadequate health care infrastructure. Areas covered: This review analyses existing programmes of prevention, diagnosis and treatment of XDR-TB. Improved diagnostic procedures and rapid molecular tests help to select appropriate drugs and dosages. Drugs dosages can be further tailored to the specific conditions of the patient based on quantitative susceptibility testing of the M. tuberculosis isolate and use of therapeutic drug monitoring. Pharmacovigilance is important for preserving activity of the novel drugs bedaquiline and delamanid. Furthermore, biomarkers of treatment response must be developed and validated to guide therapeutic decisions. Expert commentary: Given the currently poor treatment outcomes and the association of XDR-TB with HIV in endemic regions, a more patient oriented approach regarding diagnostics, drug selection and tailoring and treatment evaluation will improve treatment outcome. The different areas of expertise should be covered by a multidisciplinary team and may involve the transition of patients from hospitalized to home or community-based treatment.

Psychosocial wellbeing of patients with multidrug resistant tuberculosis voluntarily confined to long-term hospitalisation in Nigeria

Background and objective

Patient isolation, which is a widely successful treatment strategy for tuberculosis (TB), has been suspected to have effects on patient psychosocial wellbeing. We assessed the psychosocial wellbeing of multidrug resistant TB (MDR-TB) patients in voluntary and isolated long-term hospitalisation in Nigeria.

Methods

98 accessible and consenting patients in four drug-resistant treatment centres (University College Hospital and Government Chest Hospital, Ibadan; Mainland Hospital, Lagos, and Lawrence Henshaw Memorial Hospital, Calabar) were enrolled in this study. Data were collected using an 18-item psychosocial wellbeing questionnaire including sociodemographic characteristics. We used descriptive statistics to present demographic characteristics; the χ² test was used to assess associations between psychosocial wellbeing and independent variables and the relationship was modelled using logistic regression.

Results

The mean age of respondents was 36.1±11.9 years and 63% were males. Respondents had been in hospital an average of 4.5±1.9 months. Females had more psychosocial concerns compared with males. The most common concerns recorded among respondents were concern that people will get to know that the respondent had a bad type of TB (70%), discontent with being separated from and longing for the company of their marital partner (72%), concerns that they may have taken too many drugs (73%), and displeasure with being unable to continue to engage in their usual social and economic activities (75%). Respondents who were employed had eight times the odds of having more psychosocial concerns than the median number among respondents. Respondents who were supported by their own families during hospitalisation experienced a lower burden of psychosocial concerns compared with those who were supported by third parties.

Conclusions

Prolonged hospitalisation resulted in significant psychosocial burden for the MDR-TB patients in our study centres. There is a need to consider alternative approaches that place less psychosocial burden on patients without compromising quality of care.

Scoping review: strategies of providing care for children with chronic health conditions in low- and middle-income countries

OBJECTIVES

To identify and review strategies of providing care for children living with chronic health conditions in low- and middle-income countries.

METHODS

We searched MEDLINE and Cochrane EPOC databases for papers evaluating strategies of providing care for children with chronic health conditions in low- or middle-income countries. Data were systematically extracted using a standardised data charting form, and analysed according to Arksey and O'Malley's 'descriptive analytical method' for scoping reviews.

RESULTS

Our search identified 71 papers addressing eight chronic conditions; two chronic communicable diseases (HIV and TB) accounted for the majority of papers (n = 37, 52%). Nine (13%) papers reported the use of a package of care provision strategies (mostly related to HIV and/or TB in sub-Saharan Africa). Most papers addressed a narrow aspect of clinical care provision, such as patient education (n = 23) or task-shifting (n = 15). Few papers addressed the strategies for providing care at the community (n = 10, 15%) or policy (n = 6, 9%) level. Low-income countries were under-represented (n = 24, 34%), almost exclusively involving HIV interventions in sub-Saharan Africa (n = 21). Strategies and summary findings are described and components of future models of care proposed.

CONCLUSIONS

Strategies that have been effective in reducing child mortality globally are unlikely to adequately address the needs of children with chronic health conditions in low- and middle-income settings. Current evidence mostly relates to disease-specific, narrow strategies, and more research is required to develop and evaluate the integrated models of care, which may be effective in improving the outcomes for these children.

The socioeconomic impact of multidrug resistant tuberculosis on patients: results from Ethiopia, Indonesia and Kazakhstan

BACKGROUND

One of the main goals of the post-2015 global tuberculosis (TB) strategy is that no families affected by TB face catastrophic costs. We revised an existing TB patient cost measurement tool to specifically also measure multi-drug resistant (MDR) TB patients' costs and applied it in Ethiopia, Indonesia and Kazakhstan.

METHODS

Through structured interviews with TB and MDR-TB patients in different stages of treatment, we collected data on the direct (out of pocket) and indirect (loss of income) costs of patients and their families related to the diagnosis and treatment of TB and MDR-TB. Direct costs included costs for hospitalization, follow-up tests, transport costs for health care visits, and food supplements. Calculation of indirect costs was based on time needed for diagnosis and treatment. Costs were extrapolated over the patient's total treatment phase.

RESULTS

In total 406 MDR-TB patients and 197 other TB patients were included in the survey: 169 MDR-TB patients and 25 other TB patients in Ethiopia; 143 MDR-TB patients and 118 TB patients in Indonesia; and 94 MDR-TB patients and 54 other TB patients in Kazakhstan. Total costs for diagnosis and current treatment episode for TB patients were estimated to be USD 260 in Ethiopia, USD 169 in Indonesia, and USD 929 in Kazakhstan, compared to USD 1838, USD 2342, and USD 3125 for MDR-TB patients, respectively. These costs represented 0.82-4.6 months of pre-treatment household income for TB patients and 9.3-24.9 months for MDR-TB patients. Importantly, 38-92 % reported income loss and 26-76 % of TB patients lost their jobs due to (MDR) TB illness, further aggravating the financial burden.

CONCLUSIONS

The financial burden of MDR-TB is alarming, although all TB patients experienced substantial socioeconomic impact of the disease. If the patient is the breadwinner of the family, the combination of lost income and extra costs is generally catastrophic. Therefore, it should be a priority of the government to relieve the financial burden based on the cost mitigation options identified.

New Antituberculosis Drugs: From Clinical Trial to Programmatic Use

Treatment of multidrug-resistant tuberculosis (MDR-TB) cases is challenging because it relies on second-line drugs that are less potent and more toxic than those used in the clinical management of drug-susceptible TB. Moreover, treatment outcomes for MDR-TB are generally poor compared to drug sensitive disease, highlighting the need for of new drugs. For the first time in more than 50 years, two new anti-TB drugs were approved and released. Bedaquiline is a first-in-class diarylquinoline compound that showed durable culture conversion at 24 weeks in phase IIb trials. Delamanid is the first drug of the nitroimidazole class to enter clinical practice. Similarly to bedaquiline results of phase IIb studies showed increased sputum-culture conversion at 2 months and better final treatment outcomes in patients with MDR-TB. Among repurposed drugs linezolid and carbapenems may represent a valuable drug to treat cases of MDR and extensively drug-resistant TB. The recommended regimen for MDR-TB is the combination of at least four drugs to which M. tuberculosis is likely to be susceptible for the duration of 20 months. Drugs are chosen with a stepwise selection process through five groups on the basis of efficacy, safety, and cost. Clinical phase III trials on new regimen are ongoing that could prove transformative against MDR-TB, by being shorter (six months), simpler (an all-oral regimen) and safer than current standard therapy. It is fundamental that the adoption of the new drugs is done responsibly to avoid inappropriate use. Concentration of in-patient MDR-TB treatment in specialized centers could be considered in countries with low numbers of cases in order to provide appropriate clinical case management and to prevent emergence of drug resistance.

Association between Directly Observed Therapy and Treatment Outcomes in Multidrug-Resistant Tuberculosis: A Systematic Review and Meta-Analysis

Background

Multidrug-resistant tuberculosis (MDR-TB) represents a major obstacle towards successful TB control. Directly observed therapy (DOT) was recommended by WHO to improve adherence and treatment outcomes of MDR-TB patients, however, the effectiveness of DOT on treatment outcomes of MDR-TB patients was mixed in previous studies. We conducted this systematic review and meta-analysis to assess the association between DOT and treatment outcomes and to examine the impact of different DOT providers and DOT locations on successful treatment outcomes in MDR-TB patients.

Methods

We searched studies published in English between January 1970 and December 2015 in major electronic databases. Two reviewers independently screened articles and extracted information of DOT, treatment success rate and other characteristics of studies. Random effects model was used to calculate the pooled treatment success rate and 95% confidence interval (CI). Sub-group analyses were conducted to access factors associated with successful treatment outcomes.

Results

A total of 31 articles 7,466 participants were included. Studies reporting full DOT (67.4%, 95% CI: 61.4–72.8%) had significantly higher pooled treatment success rates than those reporting self-administration therapy (46.9%, 95% CI: 41.4–52.4%). No statistically difference was found among DOT provided by healthcare providers (65.8%, 95% CI: 55.7–74.7%), family members (72.0%, 95% CI: 31.5–93.5%) and private DOT providers (69.5%, 95% CI: 57.0–79.7%); and neither did we find significantly difference on pooled treatment success rates between patients having health facility based DOT (70.5%, 95% CI: 61.5–78.1%) and home-based DOT (68.4%, 95% CI: 51.5–81.5%).

Conclusion

Providing DOT for a full course of treatment associated with a higher treatment success rate in MDR-TB patients.

Health status and quality of life in tuberculosis

Tuberculosis (TB) is a leading cause of global morbidity, yet there is limited information regarding its impact on quality of life and health status. This is surprising given the implications for patient care, the evaluation of novel treatments or preventative strategies, and also health policy. Furthermore, there is no validated TB-specific instrument that measures health status, and thus a wide and non-standardized range of assessment tools have been employed. The studies to date have chosen a number of different comparator populations, and in many TB endemic areas there is a lack of normative data regarding the health status of the general population. Systematic evaluations of quality of life are urgently needed in specific groups, including those with extrapulmonary TB, drug-resistant disease, HIV co-infection, and latent TB infection, and in children with TB; the assessment of post-treatment disability is also required.

Cost-optimization in the treatment of multidrug resistant tuberculosis in Nigeria

OBJECTIVE

To compare the cost of facility-based MDR TB care (F) to home-based care (H) from the perspective of the Nigerian national health system.

METHODS

We assessed the expected costs of the two MDR TB treatment approaches using a decision-analytic model with a follow-up of 6 months. MDR TB treatment outcomes were obtained from a systematic review of randomised clinical trials. The outcomes of interest included treatment success, treatment failure, treatment default and mortality and did not vary significantly between the two alternatives. Treatment costs included the cost of the following: drug therapy (F, H), hospital stay (F), nurse care (F, H), physician care (F), nursing facility (F) and transport to the healthcare provider (H). Finally, we estimated the potential cost savings associated with home-based treatment for all patients starting MDR TB treatment in Nigeria.

RESULTS

The average expected total treatment cost for a Nigerian patient treated for MDR TB was estimated at US2095 for facility - based care and 1535 for home-based care, a potential saving of 25%. One of the major drivers of this difference is significantly more intensive, and therefore more costly, nursing care in hospitals. In 2013, a total of 426 patients were initiated on facility-based MDR TB treatment in Nigeria. Thus, the potential savings through home-based care are US$ 223 204 per year.

CONCLUSION

In Nigeria, treatment of MDR TB using home-based care is expected to result in similar patient outcomes at markedly reduced public health costs as facility-based care.

Evaluation of community-based treatment for drug-resistant tuberculosis in Bangladesh

OBJECTIVE

Drug-resistant tuberculosis (TB) threatens global TB control because it is difficult to diagnose and treat. Community-based programmatic management of drug-resistant TB (cPMDT) has made therapy easier for patients, but data on these models are scarce. Bangladesh initiated cPMDT in 2012, and in 2013, we sought to evaluate programme performance.

METHODS

In this retrospective review, we abstracted demographic, clinical, microbiologic and treatment outcome data for all patients enrolled in the cPMDT programme over 6 months in three districts of Bangladesh. We interviewed a convenience sample of patients about their experience in the programme.

RESULTS

Chart review was performed on 77 patients. Sputum smears and cultures were performed, on average, once every 1.35 and 1.36 months, respectively. Among 74 initially culture-positive patients, 70 (95%) converted their cultures and 69 (93%) patients converted the cultures before the sixth month. Fifty-two (68%) patients had evidence of screening for adverse events. We found written documentation of musculoskeletal complaints for 16 (21%) patients, gastrointestinal adverse events for 16 (21%), hearing loss for eight (10%) and psychiatric events for four (5%) patients; conversely, on interview of 60 patients, 55 (92%) reported musculoskeletal complaints, 54 (90%) reported nausea, 36 (60%) reported hearing loss, and 36 (60%) reported psychiatric disorders.

CONCLUSIONS

The cPMDT programme in Bangladesh appears to be programmatically feasible and clinically effective; however, inadequate monitoring of adverse events raises some concern. As the programme is brought to scale nationwide, renewed efforts at monitoring adverse events should be prioritised.

Drug-resistant tuberculosis in Eastern Europe: challenges and ways forward

Encouragingly, global rates of new tuberculosis (TB) cases have been falling since 2005, in line with the Millennium Development Goal targets; however, cases of multidrug-resistant (MDR-) and extensively drug-resistant TB (XDR-TB) have been increasing. Fifteen of the world's 27 high MDR- and XDR-TB burden countries are in the World Health Organization (WHO) European Region, of which 10 are in Eastern Europe (including Baltic and Caucasus countries). To address the MDR- and XDR-TB situation in the WHO European Region, a Consolidated Action Plan to Prevent and Combat M/XDR-TB (2011-2015) was developed for all 53 Member States and implemented in 2011. Since the implementation of the Action Plan, the proportion of MDR-TB appears largely to have levelled off among bacteriologically confirmed TB cases in high-burden countries with universal or near universal (>95%) first-line drug susceptibility testing (DST). The treatment success rate, however, continues to decrease. A contributing factor is the substantial proportion of MDR-TB cases that are additionally resistant to either a fluoroquinolone, a second-line injectable agent or both (XDR-TB); high-burden country proportions range from 12.6% to 80.4%. Proportions of XDR-TB range from 5% to 24.8%. Despite much progress in Eastern Europe, critical challenges remain as regards access to appropriate treatment regimens; patient hospitalisation; scale-up of laboratory capacity, including the use of rapid diagnostics and second-line DST; vulnerable populations; human resources; and financing. Solutions to these challenges are aligned with the Post-2015 Global TB strategy. As a first step, the global strategy should be adapted at regional and country levels to serve as a framework for immediate actions as well as longer-term ways forward.

Comparison of Results from Inpatient and Outpatient Treatment of Tuberculosis in Republic of Macedonia

BACKGROUND

The successful treatment of patients with active tuberculosis is one of the priorities in the Tuberculosis Control Programs.

AIM

The aim was to establish whether there was a statistically significant difference in the treatment outcome in patients with tuberculosis who began their initial treatment phase and/or pursued it as inpatient, as opposed to patients with tuberculosis who underwent their entire treatment regime as outpatient. Moreover, our goal was to determine whether there is a statistically significant difference in the outcome from the treatment between patients with tuberculosis who were hospitalized up to one month, two months, or more than two months.

MATERIALS AND METHOD

The study includes 355 patients, divided into two groups. The first group, which consists of 219 patients, began their initial treatment phase as inpatient, and then they continued the treatment as outpatient. The second group, 136 patients, underwent their entire treatment as outpatient. The treatment outcome is determined with every patient (cured, treatment completed, treatment default, treatment failed, died, treatment in progress). For the statistical data analysis and for establishing the significance of the findings regarding the differences between the two groups we used the Pearson Chi-Square Test and the Yates Corrected Test.

RESULTS

The statistical analysis with the Pearson Chi-Square Test showed that the treatment outcome does not significantly depend on the model of treatment (p = 0.31). The statistical data analysis showed that there is no statistically significant difference in the achievement of conversion of the bacterial result of the sputum at the end of the initial phase of treatment regarding the studied groups (p = 0.89). The statistical data analysis showed that the length of inpatient treatment affects the outcome of the treatment and that the difference is statistically highly significant (p < 0.00005).

CONCLUSION

There are no statistically significant differences in the sputum conversion and the treatment outcome among inpatient/outpatient with tuberculosis or outpatient only; however, the length of inpatient treatment is statistically significant regarding its effect on the treatment outcome.