Comparing early treatment outcomes of MDR-TB in decentralised and centralised settings in KwaZulu-Natal, South Africa

Care-seeking and treatment pathways of multidrug-resistant tuberculosis patients: an analysis of real-world data from regional health information system in Ningbo City in Eastern China

OBJECTIVES

The patient pathway of multidrug-resistant tuberculosis (MDR-TB) in China is an essential but not well-studied area. This study aimed to understand the alignment between patient-initiated care-seeking demands for MDR-TB and the availability of diagnostic and treatment services in Ningbo, a city in eastern China, using patient pathway analysis (PPA).

METHODS

We collected the diagnostic and treatment data of 240 patients with MDR-TB in Ningbo from 2015 to 2019. Using patient pathway analysis, we matched the medical data of patients from different medical institutions and mapped their care pathways to illustrate their access to medical services.

RESULT

Our study indicated that the proportion of patients with MDR-TB who chose non-TB-designated medical institutions (55%) was higher than those who chose TB-designated medical institutions (45%) at their initial visit. An estimated 69% of patients with MDR-TB patients received initial TB screening services during their first visit. In this study, 47% of patients needed to visit 4-7 medical institutions to be diagnosed with MDR-TB. Overall, 80% (n = 192) of patients were diagnosed with MDR-TB within four visits, while 13% (n = 30), 4% (n = 10), and 3% (n = 8) of patients were not diagnosed at the fourth visit and remained at level 2, 1, and 0 medical institutions, respectively.

CONCLUSION

The care-seeking pathway of patients with MDR-TB in Ningbo is complex. This indicates room for improvement in local diagnosis and referral services. There is a need to promote the deployment of MDR-TB screening, diagnosis, and treatment services at lower-level institutions.

Actor sensemaking and its role in implementation of the decentralized drug-resistant tuberculosis policy in South Africa

South Africa has a high burden of drug-resistant tuberculosis (DR-TB). A policy to decentralize DR-TB treatment from specialized central hospitals to more accessible district facilities was introduced in 2011, but to date implementation has been suboptimal, with variable pace, coverage, and models of care emerging. This study explored multilevel policy implementation of DR-TB decentralization in two provinces of South Africa, Western Cape and KwaZulu-Natal. Applying interpretive policy analysis, this paper describes how actors across health system levels and geographies made sense of the DR-TB policy and how this shaped implementation. In an embedded qualitative case study, districts of the two provinces were compared, through data collected in 94 in-depth interviews, and analysed using Vickers' framework of reality, value, and action judgements. Five district cases characterize variation in the pace of implementation and models of DR-TB care that emerged. Individual and collective attitudes for and against the policy were underpinned by different systems of meaning for interpreting policy problems and making decisions. These meaning systems were reflected in actor stances on whether DR-TB care needed to be specialized or generalized, nurse- or doctor-led, and institutionalized or ambulatory. Actors' stances influenced their actions and implementation strategies adopted. Resistance to decentralized DR-TB care related to perceived threats of budget cuts to and loss of authority of central facilities, and was often justified in fears of increased transmission, poor quality of care, and inadequate resources at lower levels. New advances in diagnosis and treatment to address the growing burden of DR-TB in South Africa will have little impact unless implementation dynamics are better understood, and attention paid to the mindsets, interests, and interpretations of policy by actors tasked with implementation. Deliberative policy implementation processes will enhance the quality of discourse, communication and cross-learning between policy actors, and critical for reaching synthesis of meaning systems.

The epidemiology, transmission, diagnosis, and management of drug-resistant tuberculosis-lessons from the South African experience

Drug-resistant tuberculosis (DR-TB) threatens to derail tuberculosis control efforts, particularly in Africa where the disease remains out of control. The dogma that DR-TB epidemics are fueled by unchecked rates of acquired resistance in inadequately treated or non-adherent individuals is no longer valid in most high DR-TB burden settings, where community transmission is now widespread. A large burden of DR-TB in Africa remains undiagnosed due to inadequate access to diagnostic tools that simultaneously detect tuberculosis and screen for resistance. Furthermore, acquisition of drug resistance to new and repurposed drugs, for which diagnostic solutions are not yet available, presents a major challenge for the implementation of novel, all-oral, shortened (6-9 months) treatment. Structural challenges including poverty, stigma, and social distress disrupt engagement in care, promote poor treatment outcomes, and reduce the quality of life for people with DR-TB. We reflect on the lessons learnt from the South African experience in implementing state-of-the-art advances in diagnostic solutions, deploying recent innovations in pharmacotherapeutic approaches for rapid cure, understanding local transmission dynamics and implementing interventions to curtail DR-TB transmission, and in mitigating the catastrophic socioeconomic costs of DR-TB. We also highlight globally relevant and locally responsive research priorities for achieving DR-TB control in South Africa.

Management of rifampicin-resistant tuberculosis in conflict-affected areas: The case of Iraq

Since December 2019, the World Health Organization (WHO) has encouraged National Tuberculosis Programs to deprioritize the use of injectable-containing regimens and roll-out all-oral bedaquiline-containing regimens for rifampicin-resistant tuberculosis (RR-TB) treatment. Consequently, Iraq gradually replaced the injectable-containing regimen with an all-oral regimen, including bedaquiline. To assess treatment enrolment and outcomes of both regimens during a transitioning phase in Iraq, where health system services are recovering from decades of war, we conducted a nationwide retrospective cohort study using routinely collected programmatic data for patients enrolled between 2019-2021. We describe treatment enrolment and use logistic regression to identify predictors of unfavorable treatment outcomes (failure, death, or lost to follow-up), including regimen type. Nationwide, a total of 301 RR-TB patients started treatment, of whom 167 concluded treatment. The proportion of patients enrolled on the all-oral regimen increased from 53.2% (50/94) in 2020, to 75.5% (80/106) in 2021. Successful treatment was achieved in 82.1% (32/39) and 63.3% (81/128), for all-oral and injectable-containing regimens respectively. Moreover, the proportion of lost to follow-up was lower among those treated with the all-oral versus the long injectable-containing regimen; respectively 2.6% (1/39) versus 17.9% (23/128: p = 0.02). Unfavorable treatment outcome was associated with male gender (aOR 2.12, 95%CI:1.02-4.43) and age <15 years (vs 30-49 years, aOR 5.80, 95%CI:1.30-25.86). Regimen type (aOR 2.37, 95%CI: 0.91-6.13) was not significantly associated with having an unfavorable treatment outcome. In Iraq, the use of bedaquiline-containing all-oral regimen resulted in a high treatment success and reduced lost to follow-up.

Organisation of care for people receiving drug-resistant tuberculosis treatment in South Africa: a mixed methods study

OBJECTIVES

Treatment for multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB) is increasingly transitioning from hospital-centred to community-based care. A national policy for decentralised programmatic MDR/RR-TB care was adopted in South Africa in 2011. We explored variations in the implementation of care models in response to this change in policy, and the implications of these variations for people affected by MDR/RR-TB.

DESIGN

A mixed methods study was done of patient movements between healthcare facilities, reconstructed from laboratory records. Facility visits and staff interviews were used to determine reasons for movements.

PARTICIPANTS AND SETTING

People identified with MDR/RR-TB from 13 high-burden districts within South Africa.

OUTCOME MEASURES

Geospatial movement patterns were used to identify organisational models. Reasons for patient movement and implications of different organisational models for people affected by MDR/RR-TB and the health system were determined.

RESULTS

Among 191 participants, six dominant geospatial movement patterns were identified, which varied in average hospital stay (0-281 days), average patient distance travelled (12-198 km) and number of health facilities involved in care (1-5 facilities). More centralised models were associated with longer delays to treatment initiation and lengthy hospitalisation. Decentralised models facilitated family-centred care and were associated with reduced time to treatment and hospitalisation duration. Responsiveness to the needs of people affected by MDR/RR-TB and health system constraints was achieved through implementation of flexible models, or the implementation of multiple models in a district.

CONCLUSIONS

Understanding how models for organising care have evolved may assist policy implementers to tailor implementation to promote particular patterns of care organisation or encourage flexibility, based on patient needs and local health system resources. Our approach can contribute towards the development of a health systems typology for understanding how policy-driven models of service delivery are implemented in the context of variable resources.

The Effect of HIV and Antiretroviral Therapy on Drug-Resistant Tuberculosis Treatment Outcomes in Eastern Cape, South Africa: A Cohort Study

South Africa has a dual high burden of HIV and drug-resistant TB (DR-TB). We sought to understand the association of HIV and antiretroviral therapy status with TB treatment outcomes. This was a retrospective chart review of 246 patients who began treatment at two DR-TB hospitals in Eastern Cape, South Africa between 2017 and 2020. A categorical outcome with three levels was considered: unfavorable, transferred out, and successful. Descriptive statistics and logistic regression were used to compare the individuals without HIV, with HIV and on antiretroviral therapy (ART), and with HIV but not on ART. Sixty-four percent of patients were co-infected with HIV, with eighty-seven percent of these individuals on ART at treatment initiation. The majority (59%) of patients had a successful treatment outcome. Twenty-one percent of patients transferred out, and an additional twenty-one percent did not have a successful outcome. Individuals without HIV had more than three and a half times the odds of success compared to individuals with HIV on ART and more than ten times the odds of a successful outcome compared to individuals with HIV not on ART (OR 3.64, 95% CI 1.11, 11.95; OR 10.24, 95% CI 2.79, 37.61). HIV co-infection, especially when untreated, significantly decreased the odds of treatment success compared to individuals without HIV co-infection.

A systematic review of risk factors for mortality among tuberculosis patients in South Africa

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.

Tuberculosis treatment outcomes among pulmonary TB patients attending public hospitals in Kebbi State, Northern Nigeria: a four-year retrospective study

BACKGROUND

In Nigeria, effective case management and evaluation of pulmonary tuberculosis treatment outcomes are an integral part of controlling the spread of infectious diseases. The study reviewed the treatment outcomes of pulmonary tuberculosis and the factors associated with rates of successful and unsuccessful treatment outcomes in the 21 referral hospitals in Kebbi State, Nigeria.

METHODS

Documented records of pulmonary tuberculosis patients from January 2018 to December 2021 in 21 Local Area Councils in Kebbi State, Northern Nigeria were reviewed. A structured questionnaire collated the socio-demographic and clinical data from the documented records. Descriptive statistics were used to compute and analyse the outcomes of successful and unsuccessful treatment. Logistic regression models were used to determine the association of socio-demographic and clinical data with the unsuccessful treatment outcomes.

RESULTS

The study reviewed data from 6114 records of TB patients. 1161 (18.9%) started treatment, 963 (82.9%) were males and 198 (17.1%) were females. Of the 1161 patients, 985 (18.2%) had documented treatment outcomes. 932 of 985 (95.1%) had a pulmonary infection. 64 (5.8%) patients with documented treatment outcomes were HIV seropositive. 903 (91.7%) were successfully treated, and 82 (8.3%) failed. Of the patients with failed treatment outcomes, 15 (1.5%) were lost to follow-up, 43 (4.4%) defaulted and 24 (2.4%) died. In the logistic analysis, the odds of unsuccessful treatment outcomes were higher among elderly patients (AOR = 2.00, 95% CI 1.37-2.92), patients with extrapulmonary infections (AOR = 2.40, 95% CI 1.12-5.39), and with old cases of pulmonary TB (AOR = 3.03, 95% CI 1.47-7.19) when compared to their groups.

CONCLUSIONS

The study reported a treatment success rate of 91.7% among TB patients attending public hospitals in Kebbi State. The outcome was higher than the projected success rate of 85% set by the WHO. However, one-fourth of the total patients reviewed were not documented for treatment. Therefore, the need to design an appropriate recruitment strategy to identify and enrol those patients for an effective and successful TB control program in Nigeria.

Association of HIV infection and antiretroviral therapy with the occurrence of an unfavorable TB treatment outcome in a rural district hospital in Eastern Cape, South Africa: A retrospective cohort study

Background

Our objective was to assess differences in TB treatment outcomes between individuals who were HIV negative, HIV positive on anti-retroviral treatment (ART) and HIV positive not on ART, at TB treatment initiation at a rural district hospital in Eastern Cape, South Africa.

Methods

This was a retrospective cohort study of individuals diagnosed with TB between January 2017 and April 2020 at a district hospital. Adults 15 years and over with reported HIV status and treatment outcome were included (N = 711). A categorical outcome with three levels was considered: unfavorable, down referral, and success. We report descriptive statistics for the association between HIV and ART status and treatment outcome using Chi-square and Fisher’s exact tests. A multinomial baseline logit model was used to estimate odds ratios for treatment outcomes.

Results

Overall, 59% of included patients were HIV positive with 75% on ART. Eighty-eight patients 12% had an unfavorable outcome. Half of all patients were down referred with an additional 37% having a successful outcome. Individuals without HIV were more likely to be down referred (versus unfavorable) compared to individuals with untreated HIV (2.90 OR, 1.36, 6.17 95% CI). There was a greater likelihood for individuals without HIV having a successful TB treatment outcome compared to individuals with untreated HIV (4.98 OR, 2.07, 11.25 95% CI).

Conclusion

The majority of individuals had positive TB treatment outcomes (down referred or success). However, people without HIV had nearly five times greater odds of having successful outcomes than those with untreated HIV.

High rates of culture conversion and low loss to follow-up in MDR-TB patients managed at Regional Referral Hospitals in Uganda

BACKGROUND

Multi-drug resistant-tuberculosis (MDR-TB) is an emerging public health concern in Uganda. Prior to 2013, MDR-TB treatment in Uganda was only provided at the national referral hospital and two private-not-for profit clinics. From 2013, it was scaled up to seven regional referral hospitals (RRH). The aim of this study was to measure interim (6 months) treatment outcomes among the first cohort of patients started on MDR-TB treatment at the RRH in Uganda.

METHODS

This was a cross-sectional study in which a descriptive analysis of data collected retrospectively on a cohort of 69 patients started on MDR-TB treatment at six of the seven RRH between 1st April 2013 and 30th June 2014 and had been on treatment for at least 9 months was conducted.

RESULTS

Of the 69 patients, 21 (30.4%) were female, 39 (56.5%) HIV-negative, 30 (43.5%) resistant to both isoniazid and rifampicin and 57 (82.6%) category 1 or 2 drug susceptible TB treatment failures. Median age at start of treatment was 35 years (Interquartile range (IQR): 27-45), median time-to-treatment initiation was 27.5 (IQR: 6-89) days and of the 30 HIV-positive patients, 27 (90.0%) were on anti-retroviral treatment with a median CD4 count of 206 cells/microliter of blood (IQR: 113-364.5). Within 6 months of treatment, 59 (85.5%) patients culture converted, of which 45 (65.2%) converted by the second month and the other 14 (20.3%) by the sixth month; one (1.5%) did not culture convert; three (4.4%) died; and six (8.8%) were lost-to-follow up. Fifty (76.8%) patients experienced at least one drug adverse event, while 40 (67.8%) gained weight. Mean weight gained was 4.7 (standard deviation: 3.2) kilograms.

CONCLUSIONS

Despite MDR-TB treatment initiation delays, most patients had favourable interim treatment outcomes with majority culture converting early and very few getting lost to follow-up. These encouraging interim outcomes indicate the potential for success of a scale-up of MDR-TB treatment to RRH.

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.

Impacts of a comprehensive tuberculosis control model on the quality of clinical services and the financial burden of treatment for patients with drug-resistant tuberculosis in China: a mixed-methods evaluation

Background

The China National Health Commission-Gates TB Project Phase III implemented a comprehensive TB control model including multiple interventions to address the burden of drug-resistant TB (DRTB). This study aims to evaluate the quality of DRTB clinical services and assess the financial burden of DRTB patients during the intervention period.

Methods

A mixed-methods approach was used to evaluate the effectiveness of interventions in the three project provinces: Zhejiang, Jilin and Ningxia Hui Autonomous Region. The quantitative data included de-identified DRTB registry data during 2015–2018 in project provinces from China CDC, medical records of DRTB patients registered in 2018 (n = 106) from designated hospitals, and a structured DRTB patient survey in six sample prefectures in 2019. The quality of clinical services was evaluated using seven indicators across patient screening, diagnosis and treatment. Logistic regression was conducted to explore factors associated with the extremely high financial burden. Semi-structured in-depth interviews with policymakers and focus group discussions with physicians and DRTB patients were conducted to understand the interventions implemented and their impacts.

Results

The percentage of bacterially confirmed patients taking a drug susceptibility test (DST) increased significantly between 2015 and 2018: from 57.4 to 93.6% in Zhejiang, 12.5 to 86.5% in Jilin, and 29.7 to 91.4% in Ningxia. The treatment enrollment rate among diagnosed DRTB patients also increased significantly and varied from 73 to 82% in the three provinces in 2018. Over 90% of patients in Zhejiang and Jilin and 75% in Ningxia remained in treatment by the end of the first six months’ treatment. Among all survey respondents 77.5% incurred extremely high financial burden of treatment. Qualitative results showed that interventions on promoting rapid DST technologies and patient referral were successfully implemented, but the new financing policies for reducing patients’ financial burden were not implemented as planned.

Conclusions

The quality of DRTB related clinical services has been significantly improved following the comprehensive interventions, while the financial burden of DRTB patients remains high due to the delay in implementing financing policies. Stronger political commitment and leadership are required for multi-channel financing to provide additional financial support to DRTB patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-021-00832-5.

Following Guidelines for Drug-Resistant Tuberculosis: “Yes, it’s a challenge”

Background

Drug-resistant tuberculosis (DR-TB) is a major contributor to antimicrobial resistance (AMR) globally and is projected to be responsible for up to a quarter of AMR-associated deaths in the future. Management of DR-TB is increasingly decentralised to primary healthcare settings, and simultaneously becoming more complex due to a growing range of treatment options (e.g. novel agents, shorter regimens). This is reflected in the numerous recent updates to international guidelines and as such understanding the barriers and enablers to how healthcare workers access and use guidelines is vital.

Materials and Methods

We used an established psychological framework – the theoretical domains framework (TDF) – to construct and analyse an online survey and focus groups to explore healthcare workers current use of DR-TB guidelines in South Africa. We aimed to identify barriers and enablers with which to direct future attempts at improving guideline use.

Results

There were 19 responses to the online survey and 14 participants in two focus groups. 28% used the most up-to-date national guidelines, 79% accessed guidelines primarily on electronic devices. The TDF domains of ‘Social Influences’ (mean Likert score = 4.3) and ‘Beliefs about Consequences’ (4.2) were key enablers, with healthcare workers encouraged to use guidelines and also recognising the value in doing so. ‘Environmental Resources’ (3.7) and ‘Knowledge’ (3.3) were key barriers with limited, or variable access to guidelines and lack of confidence using them being notable issues. This was most noted for certain subgroups: children, HIV co-infected, pregnant women (2.7).

Discussion

Current use of DR-TB guidelines in South Africa is suboptimal. Planned interventions should focus on overcoming the identified key barriers and might include an increased use of digital tools.

Decentralized Care for Rifampin-Resistant Tuberculosis, Western Cape, South Africa

In 2011, South Africa implemented a policy to decentralize treatment for rifampin-resistant tuberculosis (TB) to reduce durations of hospitalization and enable local treatment. We assessed policy implementation in Western Cape Province, where services expanded from 6 specialized TB hospitals to 406 facilities, by analyzing National Health Laboratory Service data on TB during 2012-2015. We calculated the percentage of patients who visited a TB hospital <1 year after rifampin-resistant TB diagnosis, the median duration of their hospitalizations, and the total distance between facilities visited. We assessed temporal changes with linear regression and stratified results by location. Of 2,878 patients, 65% were from Cape Town. In Cape Town, 29% visited a TB hospital; elsewhere, 68% visited a TB hospital. We found that hospitalizations and travel distances were shorter in Cape Town than in the surrounding areas.

Provider perspectives of the introduction and implementation of care for drug-resistant tuberculosis patients in district-level facilities in South Africa: a qualitative study

OBJECTIVES

Drug-resistant tuberculosis (DR-TB) is a growing concern in many low-income and middle-income countries. Facing rising numbers of DR-TB patients, South Africa (SA) introduced a decentralised model of care for DR-TB in 2011. We aimed to document the introduction and implementation of the new models of care for patients with DR-TB in four provinces (Northern Cape, KwaZulu-Natal, Eastern Cape and Gauteng) in 2015 using mixed methods, including interviews, register reviews and clinical audits. This paper reports on the qualitative component of the study.

DESIGN

This is a qualitative interview study.

SETTING

Data were collected in 22 decentralised DR-TB sites, primary healthcare facilities and district hospitals and one provincial central DR-TB hospital.

PARTICIPANTS

58 healthcare workers (HCWs), facility staff and provincial and district TB coordinators were included in qualitative interviews.

RESULTS

HCWs felt that the introduction of DR-TB care in their facility came with little warning or engagement, creating fear and anxiety. They expressed a need for support from the district and province to guide them through the changes but this support was often lacking. In addition, many respondents expressed feeling isolated and not supported by other healthcare providers which they feel impacts on the quality of the care they provide.

CONCLUSION

Introduction of a new service such as DR-TB care can be difficult and does not always result in the intended outcomes. Improved engagement with front-line providers and addressing the fear and anxiety that may be raised by changes in daily practices should be addressed to ensure successful implementation and prevent negative consequences that can hamper quality of care for patients. Attention should be paid to how the decentralised DR-TB unit can be supported by district management and other healthcare providers.

Successful expansion of community-based drug-resistant TB care in rural Eswatini - a retrospective cohort study

Objectives

Provision of drug‐resistant tuberculosis (DR‐TB) treatment is scarce in resource‐limited settings. We assessed the feasibility of ambulatory DR‐TB care for treatment expansion in rural Eswatini.

Methods

Retrospective patient‐level data were used to evaluate ambulatory DR‐TB treatment provision in rural Shiselweni (Eswatini), from 2008 to 2016. DR‐TB care was either clinic‐based led by nurses or community‐based at the patient's home with involvement of community treatment supporters for provision of treatment to patients with difficulties in accessing facilities. We describe programmatic outcomes and used multivariate flexible parametric survival models to assess time to adverse outcomes. Both care models were costed in supplementary analyses.

Results

Of 698 patients initiated on DR‐TB treatment, 57% were women and 84% were HIV‐positive. Treatment initiations increased from 27 in 2008 to 127 in 2011 and decreased thereafter to 51 in 2016. Proportionally, community‐based care increased from 19% in 2009 to 77% in 2016. Treatment success was higher for community‐based care (79%) than clinic‐based care (68%, P = 0.002). After adjustment for covariate factors among adults (n = 552), the risk of adverse outcomes (death, loss to follow‐up, treatment failure) in community‐based care was reduced by 41% (adjusted hazard ratio 0.59, 95% CI: 0.39–0.91). Findings were supported by sensitivity analyses. The care provider's per‐patient costs for community‐based (USD13 345) and clinic‐based (USD12 990) care were similar.

Conclusions

Ambulatory treatment outcomes were good, and community‐based care achieved better treatment outcomes than clinic‐based care at comparable costs. Contextualised DR‐TB care programmes are feasible and can support treatment expansion in rural settings.

[Control and management strategies in multidrug-resistant tuberculosis: literature reviewEstrategias de control y atención de la tuberculosis multirresistente: una revisión de la literatura]

OBJECTIVE

To identify control and patient management strategies for multidrug-resistant tuberculosis (MDR-TB).

METHODS

An integrative review of the literature was performed through research in three health databases (LILACS, PubMed and CINAHL) and one multidisciplinary database (Scopus). Original articles published in English, Spanish or Portuguese, from 2006 to 2016, describing strategies to implement MDR-TB patient care, were included. The information collected was organized according to the strategies identified by the investigators, which were grouped into theme categories.

RESULTS

Based on a sample of 13 articles, four categories were identified: a) DOTS-plus: reorganization of health services, improvement of local structures, standardization of professional protocols and behaviors, provision of directly observed treatment; b) service decentralization: bringing health professionals closer to patients, especially in areas with high disease burden; c) use of communication tools: software and telephone calls that allowed consultations with specialists and/or optimization of care within multiprofessional teams; d) social protection of patients: establishment of mechanisms to provide emotional, social and/or economic support to patients under treatment, strengthening adherence to drug therapy.

CONCLUSIONS

Several strategies were identified beyond pharmacological measures, supporting the idea that the control of MDR-TB requires mechanisms that allow comprehensive care, consistent with the peculiarities and potentialities of the different scenarios where the disease occurs.

Impact of Xpert MTB/RIF and decentralized care on linkage to care and drug-resistant tuberculosis treatment outcomes in Johannesburg, South Africa

Background

In 2011, South Africa improved its ability to test for rifampicin-resistant TB (RR-TB) by introducing GeneXpert MTB/RIF. At the same time, the South African National TB program adopted a policy decentralized, outpatient treatment for drug resistant (DR-) TB. We aim to analyze the impact of these changes on linkage to care and DR-TB treatment outcomes.

Methods

We retrospectively matched adult patients diagnosed with laboratory-confirmed RR-TB in Johannesburg from 07/2011–06/2012 (early cohort) and 07/2013–06/2014 (late cohort) with records of patients initiating DR-TB treatment at one of the city’s four public sector treatment sites. We determine the proportion of persons diagnosed with RR-TB who initiated DR-TB treatment and report time to treatment initiation (TTI) before and after the implementation of Xpert MTB/RIF roll-out in Johannesburg, South Africa. We conducted a sub-analysis among those who initiated DR-TB treatment at the decentralized outpatient DR-TB centers to determine if delays in treatment initiation have a subsequent impact on treatment outcomes.

Results

Five hundred ninety four patients were enrolled in the early cohort versus 713 in the late cohort. 53.8 and 36.8% of patients were diagnosed with multi-drug resistant TB in the early and late cohorts, respectively. The proportion of RR-TB confirmed cases diagnosed by Xpert MTB/RIF increased from 43.4 to 60.5% between the early and late cohorts, respectively. The proportion who initiated treatment increased from 43.1% (n = 256) to 60.3% (n = 430) in the late cohort. Pre-treatment mortality during the early and the late cohort reduced significantly from 17.5 to 5.8% while lost to follow-up remained high.

Although TTI reduced by a median of 19 days, from 33 days (IQR 12–52) in the early cohort to 14 days (IQR 7–31) in the late cohort, this did not translate to improved treatment outcomes and we found no difference in terms of treatment success or on-treatment mortality for those that initiated without delay vs. those that deferred initiation.

Conclusion

Pre-treatment mortality reduced significantly during late Xpert MTB/RIF coverage but there was no significant difference after treatment was initiated. Despite improvements there is still a significant diagnosis and treatment gap for patients diagnosed with RR-TB and improving treatment outcomes remains critical.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3762-x) contains supplementary material, which is available to authorized users.

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.

Community-based management of multiple drug resistant tuberculosis in a tertiary hospital in Tanzania: a best practice implementation project

BACKGROUND

The World Health Organization (WHO) has prioritized collaboration with communities in its 2016 "End TB" implementation strategy. Acknowledging the difficulties that some communities face in gaining access to health facilities due to barriers such as stigma, discrimination, healthcare expenditure, transport and income loss, partnering with communities in the roll-out of community-based TB management activities is vital.

AIM

The aim of this project was to make a contribution to promoting evidence-based practice with regards to the community-based management of multidrug-resistant tuberculosis (MDR-TB) at Kibong'oto National Infectious Disease Hospital, Tanzania, and thereby supporting improvements in patient outcomes and resource utilization.

METHODS

The project utilized the Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI PACES) program to facilitate the collection of pre- and post-audit data. The Getting Research into Practice (GRiP) module was also used to analyze the potential barriers and for designing the final action plan. This project was conducted in three phases over a three-month period at the MDR-TB unit in a referral hospital in Northern Tanzania.

RESULTS

The project showed that there were significant improvements in compliance rates in staff education and documentation of patients' suitability and preferences in receiving community-based care for MDR-TB. The compliance rate of criterion 2, which was already 100% at baseline, was slightly lower at follow-up.

CONCLUSIONS

The project achieved significant improvements in the delivery of evidence-based practice with regards to community-based management of MDR-TB.

Spatial distribution of extensively drug-resistant tuberculosis (XDR TB) patients in KwaZulu-Natal, South Africa

Background

KwaZulu-Natal province, South Africa, has among the highest burden of XDR TB worldwide with the majority of cases occurring due to transmission. Poor access to health facilities can be a barrier to timely diagnosis and treatment of TB, which can contribute to ongoing transmission. We sought to determine the geographic distribution of XDR TB patients and proximity to health facilities in KwaZulu-Natal.

Methods

We recruited adults and children with XDR TB diagnosed in KwaZulu-Natal. We calculated distance and time from participants’ home to the closest hospital or clinic, as well as to the actual facility that diagnosed XDR TB, using tools within ArcGIS Network analyst. Speed of travel was assigned to road classes based on Department of Transport regulations. Results were compared to guidelines for the provision of social facilities in South Africa: 5km to a clinic and 30km to a hospital.

Results

During 2011–2014, 1027 new XDR TB cases were diagnosed throughout all 11 districts of KwaZulu-Natal, of whom 404 (39%) were enrolled and had geospatial data collected. Participants would have had to travel a mean distance of 2.9 km (CI 95%: 1.8–4.1) to the nearest clinic and 17.6 km (CI 95%: 11.4–23.8) to the nearest hospital. Actual distances that participants travelled to the health facility that diagnosed XDR TB ranged from <10 km (n = 143, 36%) to >50 km (n = 109, 27%), with a mean of 69 km. The majority (77%) of participants travelled farther than the recommended distance to a clinic (5 km) and 39% travelled farther than the recommended distance to a hospital (30 km). Nearly half (46%) of participants were diagnosed at a health facility in eThekwini district, of whom, 36% resided outside the Durban metropolitan area.

Conclusions

XDR TB cases are widely distributed throughout KwaZulu-Natal province with a denser focus in eThekwini district. Patients travelled long distances to the health facility where they were diagnosed with XDR TB, suggesting a potential role for migration or transportation in the XDR TB epidemic.

Evaluation of a nurse practitioner-physician task-sharing model for multidrug-resistant tuberculosis in South Africa

Background

Treatment success rates for multidrug-resistant tuberculosis (MDR-TB) in South Africa remain close to 50%. Lack of access to timely, decentralized care is a contributing factor. We evaluated MDR-TB treatment outcomes from a clinical cohort with task-sharing between a clinical nurse practitioner (CNP) and a medical officer (MO).

Methods

We completed a retrospective evaluation of outcomes from a prospective, programmatically-based MDR-TB cohort who were enrolled and received care between 2012 and 2015 at a peri-urban hospital in KwaZulu-Natal, South Africa. Treatment was provided by either by a CNP or MO.

Findings

The cohort included 197 participants with a median age of 33 years, 51% female, and 74% co-infected with HIV. The CNP initiated 123 participants on treatment. Overall MDR-TB treatment success rate in this cohort was 57.9%, significantly higher than the South African national average of 45% in 2012 (p<0·0001) and similar to the provincal average of 60% (p = NS). There were no significant differences by provider type: treatment success was 61% for patients initiated by the CNP and 52.7% for those initiated by the MO.

Interpretation

Clinics that adopted a task sharing approach for MDR-TB demonstrated greater treatment success rates than the national average. Task-sharing between the CNP and MO did not adversely impact treatment outcome with similar success rates noted. Task-sharing is a feasible option for South Africa to support decentralization without compromising patient outcomes. Models that allow sharing of responsibility for MDR-TB may optimize the use of human resources and improve access to care.

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.

Has universal screening with Xpert® MTB/RIF increased the proportion of multidrug-resistant tuberculosis cases diagnosed in a routine operational setting?

SETTING

Primary health services in Cape Town, South Africa where the introduction of Xpert® MTB/RIF (Xpert) enabled simultaneous screening for tuberculosis (TB) and drug susceptibility in all presumptive cases.

STUDY AIM

To compare the proportion of TB cases with drug susceptibility tests undertaken and multidrug-resistant tuberculosis (MDR-TB) diagnosed pre-treatment and during the course of 1st line treatment in the previous smear/culture and the newly introduced Xpert-based algorithms.

METHODS

TB cases identified in a previous stepped-wedge study of TB yield in five sub-districts over seven one-month time-points prior to, during and after the introduction of the Xpert-based algorithm were analysed. We used a combination of patient identifiers to identify all drug susceptibility tests undertaken from electronic laboratory records. Differences in the proportions of DST undertaken and MDR-TB cases diagnosed between algorithms were estimated using a binomial regression model.

RESULTS

Pre-treatment, the probability of having a DST undertaken (RR = 1.82)(p<0.001) and being diagnosed with MDR-TB (RR = 1.42)(p<0.001) was higher in the Xpert-based algorithm than in the smear/culture-based algorithm. For cases evaluated during the course of 1st-line TB treatment, there was no significant difference in the proportion with DST undertaken (RR = 1.02)(p = 0.848) or MDR-TB diagnosed (RR = 1.12)(p = 0.678) between algorithms.

CONCLUSION

Universal screening for drug susceptibility in all presumptive TB cases in the Xpert-based algorithm resulted in a higher overall proportion of MDR-TB cases being diagnosed and is an important strategy in reducing transmission. The previous strategy of only screening new TB cases when 1st line treatment failed did not compensate for cases missed pre-treatment.

Delays and loss to follow-up before treatment of drug-resistant tuberculosis following implementation of Xpert MTB/RIF in South Africa: A retrospective cohort study

BACKGROUND

South Africa has a large burden of rifampicin-resistant tuberculosis (RR-TB), with 18,734 patients diagnosed in 2014. The number of diagnosed patients has increased substantially with the introduction of the Xpert MTB/RIF test, used for tuberculosis (TB) diagnosis for all patients with presumptive TB. Routine aggregate data suggest a large treatment gap (pre-treatment loss to follow-up) between the numbers of patients with laboratory-confirmed RR-TB and those reported to have started second-line treatment. We aimed to assess the impact of Xpert MTB/RIF implementation on the delay to treatment initiation and loss to follow-up before second-line treatment for RR-TB across South Africa.

METHODS AND FINDINGS

A nationwide retrospective cohort study was conducted to assess second-line treatment initiation and treatment delay among laboratory-diagnosed RR-TB patients. Cohorts, including approximately 300 sequentially diagnosed RR-TB patients per South African province, were drawn from the years 2011 and 2013, i.e., before and after Xpert implementation. Patients with prior laboratory RR-TB diagnoses within 6 mo and currently treated patients were excluded. Treatment initiation was determined through data linkage with national and local treatment registers, medical record review, interviews with health care staff, and direct contact with patients or household members. Additional laboratory data were used to track cases. National estimates of the percentage of patients who initiated treatment and time to treatment were weighted to account for the sampling design. There were 2,508 and 2,528 eligible patients in the 2011 and 2013 cohorts, respectively; 92% were newly diagnosed with RR-TB (no prior RR-TB diagnoses). Nationally, among the 2,340 and 2,311 new RR-TB patients in the 2011 and 2013 cohorts, 55% (95% CI 53%-57%) and 63% (95% CI 61%-65%), respectively, started treatment within 6 mo of laboratory receipt of their diagnostic specimen (p < 0.001). However, in 2013, there was no difference in the percentage of patients who initiated treatment at 6 mo between the 1,368 new RR-TB patients diagnosed by Xpert (62%, 95% CI 59%-65%) and the 943 diagnosed by other methods (64%, 95% CI 61%-67%) (p = 0.39). The median time to treatment decreased from 44 d (interquartile range [IQR] 20-69) in 2011 to 22 d (IQR 2-43) in 2013 (p < 0.001). In 2013, across the nine provinces, there were substantial variations in both treatment initiation (range 51%-73% by 6 mo) and median time to treatment (range 15-36 d, n = 1,450), and only 53% of the 1,448 new RR-TB patients who received treatment were recorded in the national RR-TB register. This retrospective study is limited by the lack of information to assess reasons for non-initiation of treatment, particularly pre-treatment mortality data. Other limitations include the use of names and dates of birth to locate patient-level data, potentially resulting in missed treatment initiation among some patients.

CONCLUSIONS

In 2013, there was a large treatment gap for RR-TB in South Africa that varied significantly across provinces. Xpert implementation, while reducing treatment delay, had not contributed substantially to reducing the treatment gap in 2013. However, given improved case detection with Xpert, a larger proportion of RR-TB patients overall have received treatment, with reduced delays. Nonetheless, strategies to further improve linkage to treatment for all diagnosed RR-TB patients are urgently required.

The effect of the Xpert MTB/RIF test on the time to MDR-TB treatment initiation in a rural setting: a cohort study in South Africa's Eastern Cape Province

Background

There are significant delays in initiation of multidrug-resistant tuberculosis (MDR –TB) treatment. The Xpert MTB/RIF test has been shown to reduce the time to diagnosis and treatment of MDR-TB predominantly in urban centres. This study describes the time to treatment of MDR-TB and the effect of Xpert MTB/RIF on time to treatment in a deprived rural area in South Africa.

Methods

This was a retrospective cohort study analysing the medical records of patients diagnosed with MDR-TB in King Sabata Dalindyebo Sub-District between 2009 and 2014. Numerical data were reported using the Kruskal-Wallis and Wilcoxon sum rank tests and categorical data compared using the two-sample test of proportions.

Results

Of the 342 patients with MDR-TB identified, 285 were eligible for analysis, of whom 145 (61.4%) were HIV positive. The median time from sputum collection to MDR-TB diagnosis was 27 days (IQR: 2–45) and differed significantly between diagnostic modalities: Xpert MTB/RIF, 1 day (IQR: 1–4; n = 114: p < 0.0001); Line Probe Assay 12 days (IQR: 8–21; n = 28; p < 0.0001); and culture/phenotypic drug sensitivity testing 45 days (IQR: 39–59; n = 143: p < 0.0001). The time from diagnosis to treatment initiation was 14 days (IQR: 8–27) and did not differ significantly between diagnostic modality. The median time from sputum collection to treatment initiation was 49 days (IQR: 20–69) but differed significantly between diagnostic modalities: Xpert MTB/RIF, 18 days (IQR: 11–27; n = 114; p < 0.0001); Line Probe Assay 29 days (IQR: 14.5–53; n = 28; p < 0.0001); and culture/phenotypic drug sensitivity, 64 days (IQR: 50–103; n = 143: P < 0.0001). Age, sex and HIV status did not influence the time intervals.

Conclusions

Xpert MTB/RIF significantly reduced the time to MDR-TB treatment in a deprived rural setting as a result of a reduced time to diagnosis. However, the national target of five days was not achieved. Further research is needed to explore and address programmatic and patient-related challenges contributing to delayed treatment initiation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2200-8) contains supplementary material, which is available to authorized users.

Cost-Effectiveness of Community-Based TB/HIV Screening and Linkage to Care in Rural South Africa

South Africa has one of the highest burdens of TB worldwide, driven by the country's widespread prevalence of HIV, and further complicated by drug resistance. Active case finding within the community, particularly in rural areas where healthcare access is limited, can significantly improve diagnosis and treatment coverage in high-incidence settings. We evaluated the potential health and economic consequences of implementing community-based TB/HIV screening and linkage to care. Using a dynamic model of TB and HIV transmission over a time horizon of 10 years, we compared status quo TB/HIV control to community-based TB/HIV screening at frequencies of once every two years, one year, and six months. We also considered the impact of extending IPT from 36 months for TST positive and 12 months for TST negative or unknown patients (36/12) to lifetime use for all HIV-infected patients. We conducted a probabilistic sensitivity analysis to assess the effect of parameter uncertainty on the cost-effectiveness results. We identified four strategies that saved the most life years for a given outlay: status quo TB/HIV control with 36/12 months of IPT and TB/HIV screening strategies at frequencies of once every two years, one year, and six months with lifetime IPT. All of these strategies were very cost-effective at a threshold of $6,618 per life year saved (the per capita GDP of South Africa). Community-based TB/HIV screening with linkage to care is therefore very cost-effective in rural South Africa.

Early Outcomes Of Decentralized Care for Rifampicin-Resistant Tuberculosis in Johannesburg, South Africa: An Observational Cohort Study

OBJECTIVE

We describe baseline characteristics, time to treatment initiation and interim patient outcomes at a decentralized, outpatient treatment site for rifampicin-resistant TB (RR-TB).

METHODS

Prospective observational cohort study of RR-TB patients from March 2013 until December 2014. Study subjects were followed until completion of the intensive phase of treatment (6 months), transfer out, or a final outcome (loss from treatment (LFT) or death).

RESULTS

214 patients with RR-TB were enrolled in the study. Xpert MTB/RIF was the diagnostic test of rifampicin resistance for 87% (n = 186), followed by direct PCR on AFB positive specimen in 14 (7%) and indirect PCR on cultured isolate in 5 (2%). Median time between sputum testing and treatment initiation was 10 days (IQR 6-21). Interim outcomes were available in 148 patients of whom 78% (n = 115) were still on treatment, 9% (n = 13) had died, and 14% (n = 20) were LFT. Amongst 131 patients with culture positive pulmonary TB, 85 (64.9%) were culture negative at 6 months, 12 were still sputum culture positive (9.2%) and 34 had no culture documented or contaminated culture (26%). Patients who initiated as outpatients within 1 week of sputum collection for diagnosis of RR-TB had a significantly lower incidence of LFT (IRR 0.30, 95% CI: 0.09-0.98). HIV co-infection occurred in 178 patients (83%) with a median CD4 count 88 cells/ml3 (IQR 27-218).

CONCLUSIONS

Access to decentralized treatment coupled with the rapid diagnosis of RR-TB has resulted in short time to treatment initiation. Despite the lack of treatment delays, early treatment outcomes remain poor with high rates of death and loss from care.

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.

Community-based management versus traditional hospitalization in treatment of drug-resistant tuberculosis: a systematic review and meta-analysis

Background

Multidrug drug resistant Tuberculosis (MDR-TB) and extensively drug resistant Tuberculosis (XDR-TB) have emerged as significant public health threats worldwide. This systematic review and meta-analysis aimed to investigate the effects of community-based treatment to traditional hospitalization in improving treatment success rates among MDR-TB and XDR-TB patients in the 27 MDR-TB High burden countries (HBC).

Methods

We searched PubMed, Cochrane, Lancet, Web of Science, International Journal of Tuberculosis and Lung Disease, and Centre for Reviews and Dissemination (CRD) for studies on community-based treatment and traditional hospitalization and MDR-TB and XDR-TB from the 27 MDR-TB HBC. Data on treatment success and failure rates were extracted from retrospective and prospective cohort studies, and a case control study. Sensitivity analysis, subgroup analyses, and meta-regression analysis were used to explore bias and potential sources of heterogeneity.

Results

The final sample included 16 studies involving 3344 patients from nine countries; Bangladesh, China, Ethiopia, Kenya, India, South Africa, Philippines, Russia, and Uzbekistan. Based on a random-effects model, we observed a higher treatment success rate in community-based treatment (Point estimate = 0.68, 95 % CI: 0.59 to 0.76, p < 0.01) compared to traditional hospitalization (Point estimate = 0.57, 95 % CI: 0.44 to 0.69, p < 0.01). A lower treatment failure rate was observed in community-based treatment 7 % (Point estimate = 0.07, 95 % CI: 0.03 to 0.10; p < 0.01) compared to traditional hospitalization (Point estimate = 0.188, 95 % CI: 0.10 to 0.28; p < 0.01). In the subgroup analysis, studies without HIV co-infected patients, directly observed therapy short course-plus (DOTS-Plus) implemented throughout therapy, treatment duration > 18 months, and regimen with drugs >5 reported higher treatment success rate. In the meta-regression model, age of patients, adverse events, treatment duration, and lost to follow up explains some of the heterogeneity of treatment effects between studies.

Conclusion

Community-based management improved treatment outcomes. A mix of interventions with DOTS-Plus throughout therapy and treatment duration > 18 months as well as strategies in place for lost to follow up and adverse events should be considered in MDR-TB and XDR-TB interventions, as they influenced positively, treatment success.

Rapid impact of effective treatment on transmission of multidrug-resistant tuberculosis

BACKGROUND

Effective treatment for drug-susceptible tuberculosis (TB) rapidly renders patients non-infectious, long before conversion of sputum acid-fast smear or culture to negative. Multidrug-resistant TB (MDR-TB) patients on treatment are currently assumed to remain infectious for months. While the resources required for prolonged hospitalization are a barrier to the scale-up of MDR-TB treatment, the safety of community treatment is clear.

OBJECTIVES

To estimate the impact of treatment on infectiousness among MDR-TB patients.

METHODS

A series of five human-to-guinea pig TB transmission studies was conducted to test various interventions for infection control. Guinea pigs in adjacent chambers were exposed to exhaust air from a hospital ward occupied by mostly sputum smear- and culture-positive MDR-TB patients. The guinea pigs then underwent tuberculin skin testing for infection. Only the control groups of guinea pigs from each study (no interventions used) provide the data for this analysis. The number of guinea pigs infected in each study is reported and correlated with Mycobacterium tuberculosis drug susceptibility relative to treatment.

RESULTS

Despite exposure to presumably infectious MDR-TB patients, infection percentages among guinea pigs ranged from 1% to 77% in the five experiments conducted. In one experiment in which guinea pigs were exposed to 27 MDR-TB patients newly started on effective treatment for 3 months, there was minimal transmission. In four other experiments with greater transmission, guinea pigs had been exposed to patients with unsuspected extensively drug-resistant tuberculosis who were not on effective treatment.

CONCLUSIONS

In this model, effective treatment appears to render MDR-TB patients rapidly non-infectious. Further prospective studies on this subject are needed.

The effect of early versus late treatment initiation after diagnosis on the outcomes of patients treated for multidrug-resistant tuberculosis: a systematic review

BACKGROUND

Globally it is estimated that 480 000 people developed multidrug-resistant tuberculosis (MDR-TB) in 2014 and 190 000 people died from the disease. Successful treatment outcomes are achieved in only 50 % of patients with MDR-TB, compared to 86 % for drug susceptible disease. It is widely held that delay in time to initiation of treatment for MDR-TB is an important predictor of treatment outcome. The objective of this review was to assess the existing evidence on the outcomes of multidrug- and extensively drug-resistant tuberculosis patients treated early (≤4 weeks) versus late (>4 weeks) after diagnosis of drug resistance.

METHODS

Eight sources providing access to 17 globally representative electronic health care databases, indexes, sources of evidence-based reviews and grey literature were searched using terms incorporating time to treatment and MDR-TB. Two-stage sifting in duplicate was employed to assess studies against pre-specified inclusion and exclusion criteria. Only those articles reporting WHO-defined treatment outcomes were considered for inclusion. Articles reporting on fewer than 10 patients, published before 1990, or without a comparison of outcomes in patient groups experiencing different delays to treatment initiation were excluded.

RESULTS

The initial search yielded 1978 references, of which 1475 unique references remained after removal of duplicates and 28 articles published pre-1990. After title and abstract sifting, 64 papers underwent full text review. None of these articles fulfilled the criteria for inclusion in the review.

CONCLUSIONS

Whilst there is an inherent logic in the theory that treatment delay will lead to poorer treatment outcomes, no published evidence was identified in this systematic review to support this hypothesis. Reports of programmatic changes leading to reductions in treatment delay exist in the literature, but attribution of differences in outcomes specifically to treatment delay is confounded by other contemporaneous changes. Further primary research on this question is not considered a high priority use of limited resources, though where data are available, improved reporting of outcomes by time to treatment should be encouraged.

KS-Detect - Validation of Solar Thermal PCR for the Diagnosis of Kaposi's Sarcoma Using Pseudo-Biopsy Samples

Resource-limited settings present unique engineering challenges for medical diagnostics. Diagnosis is often needed for those unable to reach central healthcare systems, making portability and independence from traditional energy infrastructure essential device parameters. In 2014, our group presented a microfluidic device that performed a solar-powered variant of the polymerase chain reaction, which we called solar thermal PCR. In this work, we expand on our previous effort by presenting an integrated, portable, solar thermal PCR system targeted towards the diagnosis of Kaposi’s sarcoma. We call this system KS-Detect, and we now report the system’s performance as a diagnostic tool using pseudo-biopsy samples made from varying concentrations of human lymphoma cell lines positive for the KS herpesvirus (KSHV). KS-Detect achieved 83% sensitivity and 70% specificity at high (≥10%) KSHV+ cell concentrations when diagnosing pseudo-biopsy samples by smartphone image. Using histology, we confirm that our prepared pseudo-biopsies contain similar KSHV+ cell concentrations as human biopsies positive for KS. Through our testing of samples derived from human cell lines, we validate KS-Detect as a viable, portable KS diagnostic tool, and we identify critical engineering considerations for future solar-thermal PCR devices.

A hospital-based tuberculosis focal point to improve tuberculosis care provision in a very high burden setting

SETTING

A hospital-based tuberculosis focal point (TBFP) at a tertiary hospital in Johannesburg, South Africa.

OBJECTIVE

To describe the possible tasks and impact of a hospital-based TBFP as well as staffing and infrastructure requirements for setting up a hospital-based TBFP.

ACTIVITIES

A TBFP can centralize the notification and referral of new TB cases, perform human immunodeficiency virus counseling and testing, assessment of difficult to diagnose TB suspects and management of complicated TB cases, and it can provide an ideal setting for research and health care worker training.

RESULTS

The number of TB suspects assessed by sputum initially increased, followed by a decrease starting in 2010, which correlates with the globally decreasing TB incidence. The proportion of TB cases who failed to link to TB care decreased from 23% to 14% between 2009 and 2012. Almost 40% of cases with hepatotoxicity required an adjusted treatment regimen. Roll-out of Xpert(®) MTB/RIF testing and decentralized drug-resistant TB treatment increased the number of rifampicin monoresistant and sputum smear-negative multidrug-resistant TB cases treated on an out-patient basis.

CONCLUSION

A hospital-based TBFP complements care at primary care level by coordinating TB care for a vulnerable population of patients diagnosed in a hospital setting, and by coordinating the diagnosis and treatment of complex TB cases.

Community-based care vs. centralised hospitalisation for MDR-TB patients, KwaZulu-Natal, South Africa

SETTING

KwaZulu-Natal, South Africa, a predominantly rural province with a high burden of tuberculosis (TB), multidrug-resistant TB (MDR-TB) and human immunodeficiency virus (HIV) infection.

OBJECTIVE

To determine the most effective care model by comparing MDR-TB treatment outcomes at community-based sites with traditional care at a central, specialised hospital.

DESIGN

A non-randomised observational prospective cohort study comparing community-based and centralised care. Patients at community-based sites were closer to home and had easier access to care, and home-based care was available from treatment initiation.

RESULTS

Four community-based sites treated 736 patients, while 813 were treated at the centralised hospital (total = 1549 patients). Overall, 75% were HIV co-infected (community: 76% vs. hospitalised: 73%, P = 0.45) and 86% received antiretroviral therapy (community: 91% vs. hospitalised: 82%, P = 0.22). On multivariate analysis, MDR-TB patients were more likely to have a successful treatment outcome if they were treated at a community-based site (adjusted OR 1.43, P = 0.01). However, outcomes at the four community-based sites were heterogeneous, with Site 1 demonstrating that home-based care was associated with an increased treatment success of 72% compared with success rates of 52-60% at the other three sites.

CONCLUSION

Community-based care for MDR-TB patients was more effective than care in a central, specialised hospital. Home-based care further increased treatment success.

Predictors of mortality and treatment success during treatment for rifampicin-resistant tuberculosis within the South African National TB Programme, 2009 to 2011: a cohort analysis of the national case register

BACKGROUND

The South African Electronic Drug-Resistant Tuberculosis Register (EDRweb) is the national database of registered drug-resistant tuberculosis (DR-TB) cases.

METHODS

This study was a retrospective, de-identified secondary analysis of EDRweb patients initiating treatment for rifampicin-resistant TB (January 2009 to September 2011). The relative risks of death and treatment success were estimated using modified Poisson regression with robust error estimation.

RESULTS

Seventeen thousand six hundred and ninety-seven cases of DR-TB were registered and met the inclusion criteria; 52.0% (n=9207) were male and the median age was 35 years (interquartile range 27-43 years). Of the 9419 cases with HIV infection (53.2%), 7157 (76.0%) were on antiretroviral therapy. Most had undergone previous TB treatment (76.5%, n=13531). Multidrug-resistant TB was the most common diagnosis, at 80.6% (n=14272). No treatment outcome was available for 6934 patients (39.2%). For patients with outcomes, 4227 (39.4%) were successfully treated, 2987 (27.8%) died, 2533 (23.7%) were lost to follow-up, and 996 (9.3%) failed. Second-line drug resistance was the strongest predictor of death during DR-TB treatment; extensively drug-resistant TB patients were more likely to have died during treatment (adjusted relative risk 2.63, 95% confidence interval 2.45-2.84).

CONCLUSIONS

Testing for second-line drug resistance at initiation of DR-TB treatment can identify patients most at risk of treatment failure and death and most in need of individualized treatment.

Integrating Community-Based Interventions to Reverse the Convergent TB/HIV Epidemics in Rural South Africa

The WHO recommends integrating interventions to address the devastating TB/HIV co-epidemics in South Africa, yet integration has been poorly implemented and TB/HIV control efforts need strengthening. Identifying infected individuals is particularly difficult in rural settings. We used mathematical modeling to predict the impact of community-based, integrated TB/HIV case finding and additional control strategies on South Africa’s TB/HIV epidemics. We developed a model incorporating TB and HIV transmission to evaluate the effectiveness of integrating TB and HIV interventions in rural South Africa over 10 years. We modeled the impact of a novel screening program that integrates case finding for TB and HIV in the community, comparing it to status quo and recommended TB/HIV control strategies, including GeneXpert, MDR-TB treatment decentralization, improved first-line TB treatment cure rate, isoniazid preventive therapy, and expanded ART. Combining recommended interventions averted 27% of expected TB cases (95% CI 18–40%) 18% HIV (95% CI 13–24%), 60% MDR-TB (95% CI 34–83%), 69% XDR-TB (95% CI 34–90%), and 16% TB/HIV deaths (95% CI 12–29). Supplementing these interventions with annual community-based TB/HIV case finding averted a further 17% of TB cases (44% total; 95% CI 31–56%), 5% HIV (23% total; 95% CI 17–29%), 8% MDR-TB (68% total; 95% CI 40–88%), 4% XDR-TB (73% total; 95% CI 38–91%), and 8% TB/HIV deaths (24% total; 95% CI 16–39%). In addition to increasing screening frequency, we found that improving TB symptom questionnaire sensitivity, second-line TB treatment delays, default before initiating TB treatment or ART, and second-line TB drug efficacy were significantly associated with even greater reductions in TB and HIV cases. TB/HIV epidemics in South Africa were most effectively curtailed by simultaneously implementing interventions that integrated community-based TB/HIV control strategies and targeted drug-resistant TB. Strengthening existing TB and HIV treatment programs is needed to further reduce disease incidence.

Predictors of cure among HIV co-infected multidrug-resistant TB patients at Sizwe Tropical Disease Hospital Johannesburg, South Africa

BACKGROUND

The global incidence of multidrug-resistant tuberculosis (MDR-TB) is rising, especially among HIV infected patients, despite intervention programs. Limited data are available on outcomes of MDR-TB treatment, specifically in a cohort of HIV co-infected patients in sub-Saharan Africa. The objective of this study was to determine the predictors of cure among MDR-TB HIV co-infected patients.

METHODS

A retrospective review of 1200 medical records of HIV co-infected MDR-TB patients was performed at Sizwe Tropical Disease Hospital, Johannesburg covering the period 2007 to 2010. Logistic regression analysis was done to identify predictors of cure.

RESULTS

Of 1137 patients included in the analysis, 29.8% (339/1137) were cured, 16.5% (188/1137) completed treatment, 22.3% (254/1137) defaulted treatment, 2.9% (33/1137) failed treatment and 22.7% (258/1137) died while on treatment. The remaining 5.7% (65/1137) were transferred-out or still-on-treatment. There was a significant interaction between sex and timing of antiretroviral treatment (ART) initiation (p=0.008). Factors predicting cure were male patients on ART prior to commencing MDR-TB treatment (OR 1.87, [1.11-3.13]), CD4(+) cell counts between 201-349 (OR 2.06, [1.10-3.84]) and ≥ 350 cells/mm³ (OR 1.98, [0.98-3.97]). Negative predictors of cure included the presence of cavitary lesions on chest x-rays (OR 0.55, [0.38-0.78]) and modified individualised regimen at baseline (OR 0.62, [0.42-0.92]).

CONCLUSIONS

Cure was higher in males on ART prior to initiating MDR-TB treatment compared with males on ART after initiating MDR-TB treatment. The inverse was the case among females. Therefore, future research should explore the biological and behavioural mechanisms that may possibly be responsible for this observed trend. This will help improve MDR-TB treatment outcomes in HIV co-infected patients on ART.

Impact of Decentralized Care and the Xpert MTB/RIF Test on Rifampicin-Resistant Tuberculosis Treatment Initiation in Khayelitsha, South Africa

Decentralization of treatment for rifampicin-resistant tuberculosis was associated with high treatment initiation and resulted in reduced time to treatment initiation. Xpert for TB diagnosis resulted in a significant further reduction in time to treatment.

Background. Globally, case detection and treatment access are poor for rifampicin-resistant tuberculosis (RR-TB). The Xpert MTB/RIF test has the potential to increase detection and reduce time to treatment (TTT). However, these benefits are dependent on health system capacity to provide treatment.

Methods. We retrospectively assessed the impact of Xpert on treatment initiation and TTT in the context of decentralized RR-TB care in Khayelitsha, Cape Town, using routine programmatic data. Community-based treatment was introduced progressively from 2008. Before 2007, diagnosis relied on phenotypic resistance (culture). During 2007–2008, the line probe assay (LPA) was introduced, followed by Xpert in 2012.

Results. Before decentralization (2003–2006), median TTT was 71 days (interquartile range [IQR], 49–134; n = 158). The LPA introduction during 2007–2008 was associated with reduced median TTT from 76 to 50 days (P < .0001, n = 257). Between January 2009 and June 2013, 938 RR-TB cases were diagnosed (74% human immunodeficiency virus [HIV]-infected). Decentralization during 2008–2011 was associated with declining TTT (P < .0001, test for trend), a decline to 28 days in 2011 (IQR, 16–40; n = 173). Xpert was associated with a further reduction to 8 days in 2013 (IQR, 5–25; n = 89; P < .0001). Treatment initiation remained unchanged with Xpert and was lower among HIV-infected (2010–2013); 87.9% (445 of 506) compared with 96.9% (188 of 194) for HIV-uninfected (P < .0001) patients.

Conclusions. Improved case detection and rapid treatment initiation are required to interrupt transmission and reduce mortality. In this setting, decentralization was associated with high treatment initiation and reduced TTT. Xpert implementation significantly enhanced the reduction in TTT and has the potential to reduce transmission.

Integration of HIV and tuberculosis in the community

Current strategies are insufficient to contain the growing tuberculosis (TB) epidemic in areas of high HIV prevalence such as sub-Saharan Africa. Due to the increased risk of morbidity and mortality among those coinfected, early detection is critical. However,strategies dependent on passive, facility-based case finding have failed due to severe limitations in the HIV-positive population.There is growing evidence from multiple clinical trials that early initiation of antiretroviral therapy (ART) in patients coinfected with HIV and TB reduces mortality. Integration of community-based distribution of ART and TB medicines should be considered for coinfected patients to help improve retention in care and to off-load busy health systems. Several models of integration of HIV and TB care in sub-Saharan Africa have been successful. This review article examines the concepts of HIV and TB integration of testing and treatment at the community level.

Diagnostic delays and clinical decision making with centralized Xpert MTB/RIF testing in Durban, South Africa

SETTING

We conducted a retrospective study among HIV-infected adult suspects (≥18 years) with pulmonary tuberculosis (TB), who underwent Xpert MTB/RIF (Xpert) testing at McCord Hospital and its adjoining HIV clinic in Durban, South Africa.

OBJECTIVE

To determine if Xpert testing performed at a centralized laboratory accelerated time to TB diagnosis.

DESIGN

We obtained data on sputum smear microscopy [acid-fast bacilli (AFB)], Xpert, and the rationale for treatment initiation from medical records. The primary outcome was "total diagnostic time," defined as time from sputum collection to clinicians' receipt of results. A linear mixed-effect model compared the duration of steps in the diagnostic pathway across testing modalities.

RESULTS

Among 403 participants, the median "total diagnostic time" for AFB and Xpert was 3.3 and 6.4 days, respectively (P < 0.001). When compared with AFB, the median delay for Xpert "laboratory processing" was 1.4 days (P < 0.001) and "result transfer to clinic" was 1.7 days (P < 0.001). Among 86 Xpert-positive participants who initiated treatment, 49 (57%) started treatment based on clinical suspicion or AFB-positive results, whereas only 32 (37%) started treatment based on Xpert-positive results.

CONCLUSIONS

In our setting, Xpert results took twice as long as AFB results to reach clinicians. Replacing AFB with centralized Xpert may delay TB diagnoses in some settings.

Effects of introducing Xpert MTB/RIF test on multi-drug resistant tuberculosis diagnosis in KwaZulu-Natal South Africa

Background

An algorithm instituted following Xpert MTB/RIF (Xpert) introduction in South Africa advocates for treating all Xpert rifampicin resistant patients as MDR-TB cases while awaiting confirmation by phenotypic or genotypic drug susceptibility testing. This study evaluates how the Xpert has influenced the diagnosis and management of drug resistant TB in the highest burdened district of KwaZulu-Natal Province.

Methods

Data was retrospectively collected from all patients with rifampicin resistance on Xpert performed between March 2011 and April 2012. Xpert results were compared with those of phenotypic and/genotypic drug susceptibility testing. Patients’ records were used to determine the time to treatment initiation.

Results

Out of 637 patients tested by Xpert, 50% had confirmatory results, of which a third were sent on the same day as Xpert test. The rate of rifampicin discordance and monoresistance was 8.8% and 13.4% respectively and there was no difference between phenotypic and genotypic confirmation. Among those who had been initiated on treatment, 28%, 40%, 21% and 8% of patients commenced within 2 weeks, 1 month, 2 months and 3 months of Xpert testing respectively, while the remaining 3% were observed without treatment.

Conclusion

This study emphasizes the importance of complying with the algorithm in confirming all Xpert rif resistant cases so as to ensure proper management of these patients. Despite the rapidity of the Xpert results, only about 70% of patients had been initiated treatment at one month. Therefore there is a definite need to improve the health systems in order to improve on these delays.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2334-14-442) contains supplementary material, which is available to authorized users.

The treatment journey of a patient with multidrug-resistant tuberculosis in South Africa: is it patient-centred?

To improve the treatment of patients co-infected with multidrug-resistant tuberculosis (MDR-TB) and the human immunodeficiency virus, we measured the relationship between treatment outcomes and hospital performance at four decentralised MDR-TB sites in South Africa. We describe hospital performance from the patient's perspective by the use of a graphic that visually represents a patient's treatment journey. The graphic was used to report study findings to study sites and as a catalyst for a quality improvement process.

Association between health systems performance and treatment outcomes in patients co-infected with MDR-TB and HIV in KwaZulu-Natal, South Africa: implications for TB programmes

OBJECTIVE

To improve the treatment of MDR-TB and HIV co-infected patients, we investigated the relationship between health system performance and patient treatment outcomes at 4 decentralised MDR-TB sites.

METHODS

In this mixed methods case study which included prospective comparative data, we measured health system performance using a framework of domains comprising key health service components. Using Pearson Product Moment Correlation coefficients we quantified the direction and magnitude of the association between health system performance and MDR-TB treatment outcomes. Qualitative data from participant observation and interviews analysed using systematic text condensation (STC) complemented our quantitative findings.

FINDINGS

We found significant differences in treatment outcomes across the sites with successful outcomes varying from 72% at Site 1 to 52% at Site 4 (p<0.01). Health systems performance scores also varied considerably across the sites. Our findings suggest there is a correlation between treatment outcomes and overall health system performance which is significant (r = 0.99, p<0.01), with Site 1 having the highest number of successful treatment outcomes and the highest health system performance. Although the 'integration' domain, which measured integration of MDR-TB services into existing services appeared to have the strongest association with successful treatment outcomes (r = 0.99, p<0.01), qualitative data indicated that the 'context' domain influenced the other domains.

CONCLUSION

We suggest that there is an association between treatment outcomes and health system performance. The chance of treatment success is greater if decentralised MDR-TB services are integrated into existing services. To optimise successful treatment outcomes, regular monitoring and support are needed at a district, facility and individual level to ensure the local context is supportive of new programmes and implementation is according to guidelines.

A pilot study of an mHealth application for healthcare workers: poor uptake despite high reported acceptability at a rural South African community-based MDR-TB treatment program

Introduction

As the South African province of KwaZulu-Natal addresses a growing multidrug-resistant tuberculosis (MDR-TB) epidemic by shifting care and treatment from trained specialty centers to community hospitals, delivering and monitoring MDR-TB therapy has presented new challenges. In particular, tracking and reporting adverse clinical events have been difficult for mobile healthcare workers (HCWs), trained health professionals who travel daily to patient homes to administer and monitor therapy. We designed and piloted a mobile phone application (Mobilize) for mobile HCWs that electronically standardized the recording and tracking of MDR-TB patients on low-cost, functional phones.

Objective

We assess the acceptability and feasibility of using Mobilize to record and submit adverse events forms weekly during the intensive phase of MDR-TB therapy and evaluate mobile HCW perceptions throughout the pilot period.

Methods

All five mobile HCWs at one site were trained and provided with phones. Utilizing a mixed-methods evaluation, mobile HCWs’ usage patterns were tracked electronically for seven months and analyzed. Qualitative focus groups and questionnaires were designed to understand the impact of mobile phone technology on the work environment.

Results

Mobile HCWs submitted nine of 33 (27%) expected adverse events forms, conflicting with qualitative results in which mobile HCWs stated that Mobilize improved adverse events communication, helped their daily workflow, and could be successfully expanded to other health interventions. When presented with the conflict between their expressed views and actual practice, mobile HCWs cited forgetfulness and believed patients should take more responsibility for their own care.

Discussion

This pilot experience demonstrated poor uptake by HCWs despite positive responses to using mHealth. Though our results should be interpreted cautiously because of the small number of mobile HCWs and MDR-TB patients in this study, we recommend carefully exploring the motivations of HCWs and technologic enhancements prior to scaling new mHealth initiatives in resource poor settings.

Diagnosis and interim treatment outcomes from the first cohort of multidrug-resistant tuberculosis patients in Tanzania

Setting

Kibong’oto National Tuberculosis Hospital (KNTH), Kilimanjaro, Tanzania.

Objective

Characterize the diagnostic process and interim treatment outcomes from patients treated for multidrug-resistant tuberculosis (MDR-TB) in Tanzania.

Design

A retrospective cohort study was performed among all patients treated at KNTH for pulmonary MDR-TB between November 2009 and September 2011.

Results

Sixty-one culture-positive MDR-TB patients initiated therapy, 60 (98%) with a prior history of TB treatment. Forty-one (67%) were male and 9 (14%) were HIV infected with a mean CD4 count of 424 (±106) cells/µl. The median time from specimen collection to MDR-TB diagnosis and from diagnosis to initiation of MDR-TB treatment was 138 days (IQR 101–159) and 131 days (IQR 32–233), respectively. Following treatment initiation four (7%) patients died (all HIV negative), 3 (5%) defaulted, and the remaining 54 (89%) completed the intensive phase. Most adverse drug reactions were mild to moderate and did not require discontinuation of treatment. Median time to culture conversion was 2 months (IQR 1–3) and did not vary by HIV status. In 28 isolates available for additional second-line drug susceptibility testing, fluoroquinolone, aminoglycoside and para-aminosalicylic acid resistance was rare yet ethionamide resistance was present in 9 (32%).

Conclusion

The majority of MDR-TB patients from this cohort had survived a prolonged referral process, had multiple episodes of prior TB treatment, but did not have advanced AIDS and converted to culture negative early while completing an intensive inpatient regimen without serious adverse event. Further study is required to determine the clinical impact of second-line drug susceptibility testing and the feasibility of alternatives to prolonged hospitalization.

Basic research at the epicenter of an epidemic

William R Bishai, director of the KwaZulu-Natal Research Institute for Tuberculosis and HIV (K-RITH), argues that the best place to carry out research into a disease is in its midst.

Research on implementation of interventions in tuberculosis control in low- and middle-income countries: a systematic review

BACKGROUND

Several interventions for tuberculosis (TB) control have been recommended by the World Health Organization (WHO) over the past decade. These include isoniazid preventive therapy (IPT) for HIV-infected individuals and household contacts of infectious TB patients, diagnostic algorithms for rule-in or rule-out of smear-negative pulmonary TB, and programmatic treatment for multidrug-resistant TB. There is no systematically collected data on the type of evidence that is publicly available to guide the scale-up of these interventions in low- and middle-income countries. We investigated the availability of published evidence on their effectiveness, delivery, and cost-effectiveness that policy makers need for scaling-up these interventions at country level.

METHODS AND FINDINGS

PubMed, Web of Science, EMBASE, and several regional databases were searched for studies published from 1 January 1990 through 31 March 2012 that assessed health outcomes, delivery aspects, or cost-effectiveness for any of these interventions in low- or middle-income countries. Selected studies were evaluated for their objective(s), design, geographical and institutional setting, and generalizability. Studies reporting health outcomes were categorized as primarily addressing efficacy or effectiveness of the intervention. These criteria were used to draw landscapes of published research. We identified 59 studies on IPT in HIV infection, 14 on IPT in household contacts, 44 on rule-in diagnosis, 19 on rule-out diagnosis, and 72 on second-line treatment. Comparative effectiveness studies were relatively few (n = 9) and limited to South America and sub-Saharan Africa for IPT in HIV-infection, absent for IPT in household contacts, and rare for second-line treatment (n = 3). Evaluations of diagnostic and screening algorithms were more frequent (n = 19) but geographically clustered and mainly of non-comparative design. Fifty-four studies evaluated ways of delivering these interventions, and nine addressed their cost-effectiveness.

CONCLUSIONS

There are substantial gaps in published evidence for scale-up for five WHO-recommended TB interventions settings at country level, which for many countries possibly precludes program-wide implementation of these interventions. There is a strong need for rigorous operational research studies to be carried out in programmatic settings to inform on best use of existing and new interventions in TB control.