Non-completion of latent tuberculous infection treatment among children in Rio de Janeiro State, Brazil

Factors associated with incomplete tuberculosis preventive treatment: a retrospective analysis of six-years programmatic data in Cambodia

Tuberculosis (TB) preventive treatment (TPT) effectively prevents the progression from TB infection to TB disease. This study explores factors associated with TPT non-completion in Cambodia using 6-years programmatic data (2018-2023) retrieved from the TB Management Information System (TB-MIS). Out of 14,262 individuals with latent TB infection (LTBI) initiated with TPT, 299 (2.1%) did not complete the treatment. Individuals aged between 15-24 and 25-34 years old were more likely to not complete the treatment compared to those aged < 5 years old, with aOR = 1.7, p = 0.034 and aOR = 2.1, p = 0.003, respectively. Individuals initiated with 3-month daily Rifampicin and Isoniazid (3RH) or with 6-month daily Isoniazid (6H) were more likely to not complete the treatment compared to those initiated with 3-month weekly Isoniazid and Rifapentine (3HP), with aOR = 2.6, p < 0.001 and aOR = 7, p < 0.001, respectively. Those who began TPT at referral hospitals were nearly twice as likely to not complete the treatment compared to those who started the treatment at health centers (aOR = 1.95, p = 0.003). To improve TPT completion, strengthen the treatment follow-up among those aged between 15 and 34 years old and initiated TPT at referral hospitals should be prioritized. The national TB program should consider 3HP the first choice of treatment.

Routine tuberculosis contact investigation yield and preventive treatment cascade in central Ethiopia

Introduction

There is a global gap between tuberculosis incident cases and the notified cases. Active household contact investigation is one of the strategies to narrow this gap. It has the advantage of giving early diagnosis and preventive treatment to vulnerable and eligible groups. This study assessed the practice of contact investigation and tuberculosis preventive treatment adherence in central Ethiopia.

Method

A cross-sectional study covering all registered bacteriologically confirmed pulmonary tuberculosis patients and their close contacts was conducted in central Ethiopia from January 1, 2022, to December 30, 2022.

Result

A total of 1372 household contacts were declared by the index cases. From these 79.44 % (1090) contacts received a one-time tuberculosis screening giving a total of four (0.36 %) active TB cases. Among 484 household contacts of drug-resistant tuberculosis index cases, 5.53 % (14) had presumptive tuberculosis and 0.79 % (2) had active tuberculosis. While among 837 household contacts of drug-susceptible tuberculosis index cases presumptive TB cases were 1.91 % (16) and active TB cases were 0.23 % (2). Of the 142 eligible under 15 children 81.69 % (116) had started tuberculosis preventive treatment and 84.48 % (98) completed the treatment. On multivariable logistic regression, the associated factor for tuberculosis preventive treatment non-adherence was age 2-5 years (aOR, 0.02, 95 % CI (0.002-0.20) and age 5-15 years (aOR, 0.04,95 % CI (0.002-0 0.95)) P=<0.05).

Conclusion

There was low contact screening practice in the DR-TB index cases as compared to national and global targets. The yield of routine contact investigation was low and it indicates the quality of screening. Tuberculosis preventive treatment initiation and completion rates were also low as compared to those of many other countries and global achievements which need further improvement, especially for completion. Alternative mechanisms should be planned to increase the yield of tuberculosis screening and tuberculosis preventive treatment adherence.

Testing and Scaling Interventions to Improve the Tuberculosis Infection Care Cascade

Tuberculosis (TB) preventive therapy (TPT) is increasingly recognized as the key to eliminating tuberculosis globally and is particularly critical for children with TB infection or who are in close contact with individuals with infectious TB. But many barriers currently impede successful scale-up to provide TPT to those at high risk of TB disease. The cascade of care in TB infection (and the related contact management cascade) is a conceptual framework to evaluate and improve the care of persons who are potential candidates for TPT. This review summarizes recent literature on barriers and solutions in the TB infection care cascade, focusing on children in both high- and low-burden settings, and drawing from studies on children and adults. Identifying and closing gaps in the care cascade will require the implementation of tools that are new (e.g. computer-assisted radiography) and old (e.g. efficient contact tracing), and will be aided by innovative implementation study designs, quality improvement methods, and shared clinical practice with primary care providers.

Social Determinants of Adherence to Treatment for Tuberculosis Infection and Disease Among Children, Adolescents, and Young Adults: A Narrative Review

Global efforts to eliminate tuberculosis (TB) must address the unique barriers that children (ages 0 through 9 years) and adolescents/young adults (AYA; ages 10 through 24 years) face in adhering to treatment for TB infection and disease. We conducted a narrative review to summarize current knowledge on the social determinants of treatment adherence among these age groups to guide efforts and policy to address their unique needs. Our findings revealed that research on TB treatment adherence among children and AYA is still in its nascent stage. The current literature revealed structural/community-, health system-, household-, and individual-level factors that influence treatment adherence and varied with developmental stage. There is a need to develop multilevel interventions to address the unique challenges that children and AYA face in adhering to TB treatment.

Strategies to detect and manage latent tuberculosis infection among household contacts of pulmonary TB patients in high TB burden countries - a systematic review and meta-analysis

OBJECTIVE

To summarise latent tuberculosis infection (LTBI) management strategies among household contacts of bacteriologically confirmed pulmonary tuberculosis (TB) patients in high-TB burden countries.

METHODS

PubMed/MEDLINE (NCBI) and Scopus were searched (January 2006 to December 2021) for studies reporting primary data on LTBI management. Study selection, data management and data synthesis were protocol-driven (PROSPERO-CRD42021208715). Primary outcomes were the proportions of LTBI, initiating and completing tuberculosis preventive treatment (TPT). Reported factors influencing the LTBI care cascade were qualitatively synthesised.

RESULTS

From 3694 unique records retrieved, 58 studies from 23 countries were included. Most identified contacts were screened (median 99%, interquartile range [IQR] 82%-100%; 46 studies). Random-effects meta-analysis yielded pooled proportions for: LTBI 41% (95% confidence interval [CI] 33%-49%; 21,566 tested contacts); TPT initiation 91% (95% CI 79%-97%; 129,573 eligible contacts, 34 studies); TPT completion 65% (95% CI 54%-74%; 108,679 TPT-initiated contacts, 28 studies). Heterogeneity was significant (I²  ≥ 95%-100%) and could not be explained in subgroup analyses. Median proportions (IQR) were: LTBI 44% (28%-59%); TPT initiation 86% (60%-100%); TPT completion 68% (44%-82%). Nine broad themes related to diagnostic testing, health system structure and functions, risk perception, documentation and adherence were considered likely to influence the LTBI care cascade.

CONCLUSION

The proportions of household contacts screened, detected with LTBI and initiated on TPT, though variable was high, but the proportions completing TPT were lower indicating current strategies used for LTBI management in high TB burden countries are not sufficient.

Barriers and facilitators for isoniazid preventive therapy (IPT) administration in children under 5 years of age in the Dominican Republic

INTRODUCTION

Throughout the world tuberculosis (TB) is the second leading cause of death due to an infectious agent. The World Health Organization promotes Isoniazid Preventive Therapy (IPT) in children under 5 years who are contacts of persons diagnosed with smear-positive pulmonary TB (SPPTB). In 2019, 33% of children identified as contacts received IPT globally, while in the Americas 11 countries reached coverages ≥ 75%, only 35% did so in the Dominican Republic (DR). The aim of this study was to identify barriers and facilitators for IPT administration in children under 5 in the Area IV Directorate of Health of the DR's National District.

METHODS

Descriptive study, using mixed methods and sequential explanatory approach. We characterized children under 5 years who were contacts of a person with SPPTB. Later, semi-structured interviews and content analysis allowed identification of barriers and facilitators for IPT administration in children who were contacts of a person diagnosed with SPPTB, as perceived by relatives and health system personnel.

RESULTS

A total of 238 children were identified as contacts of 174 persons with SPPTB: 36% of these received IPT while no data on IPT administration was found for 11% of them. The proportion of children who had a tuberculin skin test (TST) done was < 20%. However, those who had the test done had a greater opportunity to receive IPT (OR: 8.12, CI 95%: 1.60-41.35). Barriers identified include socioeconomic conditions of children and families, stigma, lack of information in clinical and follow-up records, lack of coordination between public and private providers and lack of coherence within national regulations. Facilitators include home based care of persons with TB and their contacts, transfer of treatment to a health centre near household, isoniazid availability, provision of information by health-workers and economic support for food and transportation.

CONCLUSIONS

Incomplete data, lack of use of TST to rule out active TB, socioeconomic and cultural conditions, were barriers for IPT administration. Implementation of a person centred approach to care was found to be the main facilitator for IPT uptake. Administration of IPT depends predominantly on modifiable health system factors. This allows rapid identification of strategies to improve IPT administration.

Gaps in the tuberculosis preventive therapy care cascade in children in contact with TB

BACKGROUND

Young children (<5 years) and children living with HIV in contact with an adult with tuberculosis (TB) should receive TB preventive therapy (TPT), but uptake is low.

AIMS

To determine gaps in the uptake of and adherence to TPT in child TB contacts under routine primary care clinic conditions.

METHODS

A cohort of child TB contacts (age <5 years or living with HIV <15 years) was followed at a primary care clinic in Johannesburg, South Africa.

RESULTS

Of 170 child contacts with 119 adult TB cases, only 45% (77/170) visited the clinic for TPT eligibility screening, two of whom had already initiated TPT at another clinic. Of the 75 other children, 18/75 (24%) commenced TB treatment and 56/75 (75%) started TPT. Health-care workers followed the guidelines, with 96% (64/67) of children screened for symptoms of TB and 97% (36/37) of those symptomatic assessed for TB, but microbiological testing was low (9/36, 25%) and none had microbiologically confirmed tuberculosis. Only half (24/46, 52%) of the children initiating TPT completed the 6-month course. Neither sociodemographic determinants (age, sex) nor clinical factors (HIV status, TB source, time to TPT initiation) was associated with non-adherence to TPT.

CONCLUSION

Most child contacts of an adult TB case do not visit the clinic, and half of those initiating TPT did not adhere to the full 6-month course. These programme failures result in missed opportunities for early diagnosis of active TB and prevention of progression to disease in young and vulnerable children.

Caregivers' knowledge and perceptions are associated with children's TB preventive treatment completion

SETTING

Forty-six health centers in south Lima, Peru.

OBJECTIVE

To assess the association between caregivers' knowledge and perceptions around isoniazid preventive therapy (IPT) and whether their children complete IPT.

DESIGN

We conducted a retrospective medical record review of children who initiated IPT during 2017-2018. We administered structured surveys to caregivers of the children about their knowledge about and perceptions of IPT. We used a modified Poisson regression to determine factors associated with IPT completion.

RESULTS

We included 550 children, of whom 31% did not complete IPT. Independent factors associated with not completing IPT were low caregiver knowledge about TB and IPT (adjusted risk ratio [aRR] 1.41, 95% CI 1.06-1.78), low caregiver perception of the importance of IPT (aRR 1.76, 95% CI 1.30-2.39), low caregiver satisfaction with the health services (aRR 1.57, 95% CI 1.14-2.16), experience of adverse events (aRR 2.08, 95% CI 1.51-2.87), and living in a household with moderate or severe family dysfunction (aRR 1.53, 95% CI 1.07-2.19).

CONCLUSION

IPT completion among children was associated with the knowledge and perceptions of their caregivers, as well as the experience of adverse events. To improve IPT completion among children, health care providers should prioritize education and counseling for caregivers, promote positive interpersonal relationships with them, and monitor adverse events.

A scoping review of paediatric latent tuberculosis infection care cascades: initial steps are lacking

BACKGROUND AND OBJECTIVES

Identifying and treating children with latent tuberculosis infection (TB infection) is critical to prevent progression to TB disease and to eliminate TB globally. Diagnosis and treatment of TB infection requires completion of a sequence of steps, collectively termed the TB infection care cascade. There has been no systematic attempt to comprehensively summarise literature on the paediatric TB infection care cascade.

METHODS

We performed a scoping review of the paediatric TB infection care cascade. We systematically searched PubMed, Cumulative Index to Nursing and Allied Health Literature, Cochrane and Embase databases. We reviewed articles and meeting abstracts that included children and adolescents ≤21 years old who were screened for or diagnosed with TB infection, and which described completion of at least one step of the cascade. We synthesised studies to identify facilitators and barriers to retention, interventions to mitigate attrition and knowledge gaps.

RESULTS

We identified 146 studies examining steps in the paediatric TB infection care cascade; 31 included children living in low-income and middle-income countries. Most literature described the final cascade step (treatment initiation to completion). Studies identified an array of patient and caregiver-related factors associated with completion of cascade steps. Few health systems factors were evaluated as potential predictors of completion, and few interventions to improve retention were specifically tested.

CONCLUSIONS

We identified strengths and gaps in the literature describing the paediatric TB infection care cascade. Future research should examine cascade steps upstream of treatment initiation and focus on identification and testing of at-risk paediatric patients. Additionally, future studies should focus on modifiable health systems factors associated with attrition and may benefit from use of behavioural theory and implementation science methods to improve retention.

An evaluation of non-adherence to pharmacotherapy for chronic diseases and socioeconomic inequalities in Brazil

OBJECTIVE

To evaluate non-adherence to pharmacotherapy for chronic diseases and to investigate the existence of socioeconomic inequalities related to this outcome in Brazil.

METHODS

This was a cross-sectional study based on data from the National Survey on Access, Use and Promotion of the Rational Use of Medicines (PNAUM). The study population corresponded to individuals aged 18 years or older with a medical diagnosis of at least one chronic disease and an indication for pharmacological treatment. The dependent variable was non-adherence to chronic disease pharmacotherapy measured by less than 80% adherence to drug therapy. Socioeconomic inequality related to non-adherence was assessed by absolute (SII) and relative (RII) inequality indices, calculated by logistic regression analyses.

RESULTS

The prevalence of non-adherence to pharmacotherapy in Brazil was 20.2%, ranging from 17.0 to 27.8% between regions. Furthermore, this study revealed absolute and relative socioeconomic inequalities in non-adherence to pharmacotherapy of chronic diseases in Brazil (SII = -7.4; RII = 0.69) and the Northeast (SII = -14.0; RII = 0.59) and Center West (SII = -20.8; RII = 0.38) regions. The probability of non-adherence to pharmacotherapy in Brazil was higher among individuals with worse socioeconomic status.

CONCLUSION

The findings of the present study indicate the need for the restructuring and strengthening of public policies aimed at reducing socioeconomic inequalities, in order to promote equity in adherence to the pharmacotherapy associated with chronic diseases.

Barriers to the implementation of isoniazid preventive therapy for tuberculosis in children in endemic settings: A review

Isoniazid preventive therapy is one of the key interventions in reducing the risk of active disease among children exposed to tuberculosis. However, initiation and maintenance of this treatment is poor in many areas. This review summarises the existing literature on barriers to implementation of isoniazid preventive therapy for tuberculosis in children in endemic settings. MEDLINE, EMBASE and CINAHL databases were used to search for primary research studies published between 1998 and 2018, specifically mentioning isoniazid preventive therapy, tuberculosis and children. Barriers identified in most study settings included absence of parental risk perception, health-care worker knowledge gaps and treatment access. Focusing on patient-centred care, enhancing community and health-care worker education and securing stable medication supply to effectively deliver this therapy is crucial in order to reduce childhood morbidity and mortality from tuberculosis.

Using a quality improvement approach to improve care for latent tuberculosis infection

INTRODUCTION

Latent tuberculosis infection (LTBI) management is recognized as a key component of the World Health Organization End Tuberculosis Strategy. The term 'cascade of care in LTBI' has recently been used to refer to the process of LTBI management from identification of persons who may have LTBI to completion of treatment. Large gaps throughout the LTBI cascade of care have been identified. Areas covered: We have reviewed quality improvement (QI) as a potential approach for systematically improving gaps within the LTBI cascade of care. QI principles and approaches were reviewed, as well as the determinants of losses and evidence for solutions (interventions) within the LTBI cascade of care. An example of QI application in LTBI management is described. Expert commentary: Improving LTBI care at the magnitude required to reach the End TB Strategy goals will require systematic and context specific improvements at all steps in the cascade of care in LTBI. A continuous QI approach based on systems thinking, use of locally gathered data, and an iterative learning process can facilitate the process required to make the necessary improvements.

Social determinants of pulmonary tuberculosis treatment non-adherence in Rio de Janeiro, Brazil

Success in tuberculosis control depends on the implementation of steps that reduce social inequities, allowing the diagnosis and effective treatment of the disease. Little is known about the conditions affecting antituberculosis treatment non-adherence in areas of great social and economic heterogeneity, such as the municipality of Rio de Janeiro. This study aimed to describe and identify the social determinants of antituberculosis treatment non-adherence in the municipality of Rio de Janeiro between 2008 and 2012. An ecological study was conducted with the districts of Rio de Janeiro as the units of analysis. Analyzes using Poisson regression models allowed us to identify the association between dropout from antituberculosis treatment and the human development index and social development index. The final model showed that economic conditions, infrastructure, and the tuberculosis control quality of surveillance were associated with treatment non-adherence. This study demonstrated that the scenarios of socio-environmental precariousness found in the districts of Rio de Janeiro were able to identify populations with an increased risk of default treatment from antituberculosis.

Knowledge about tuberculosis transmission and prevention and perceptions of health service utilization among index cases and contacts in Brazil: Understanding losses in the latent tuberculosis cascade of care

Introduction

Tuberculosis contacts are candidates for active and latent tuberculosis infection screening and eventual treatment. However, many losses occur in the different steps of the contacts’ cascade of care. Reasons for this are poorly understood.

Objective

To describe the different steps where losses in the contact cascade occur and to explore knowledge and attitudes regarding tuberculosis transmission/prevention and perceptions about tuberculosis services in order to understand the reasons for losses from the tuberculosis service users’ perspective.

Design

We collected routine data from the index case and contact registry books and from patients’ records to build the cascade of care of contacts in 12 health facilities in three Brazilian cities with high tuberculosis incidence rates. During a knowledge, attitudes and practices (KAP) survey, trained interviewers administered a semi-structured questionnaire to 138 index cases and 98 contacts.

Results

Most of the losses in the cascade occurred in the first two steps (contact identification, 43% and tuberculin skin testing placement, 91% of the identified contacts). Among KAP-interviewed contacts, 67% knew how tuberculosis is transmitted, 87% knew its key symptoms and 81% declared they would take preventive therapy if prescribed. Among KAP-interviewed index cases, 67% knew they could spread tuberculosis, 70% feared for the health of their families and 88% would like their family to be evaluated in the same services.

Conclusion

Only a small proportion of contacts are evaluated for active and latent tuberculosis, despite their—and their index cases’—reasonable knowledge, positive attitudes towards prevention and satisfaction with tuberculosis services. In these services, education of service users would not be a sufficient solution. Healthcare workers’ and managers’ perspective, not explored in this study, may bring more light to this subject.

Treatment of latent tuberculosis in patients with juvenile rheumatic diseases: a systematic review

INTRODUCTION

Children and adolescents with rheumatic diseases receiving TNF blockers are at risk for the activation of latent Mycobacterium tuberculosis infection (LTBI). Although LTBI treatment is indicated in this group, there are different therapeutic regimens in the literature, without a definite consensus.

OBJECTIVES

To review in the literature therapeutic schemes used and indicated for the treatment of LTBI in these patients.

METHODS

Systematic review of the literature, using health databases, selecting studies that addressed the treatment of LTBI in patients with juvenile rheumatic diseases using TNF blockers, from 1990 to 2015. All study designs were considered.

RESULTS

A total of 162 studies were identified through the electronic databases and one was found through a manual search by the author, totaling 163 articles. We excluded studies that did not meet the mentioned inclusion criteria, and included a retrospective cohort study and two prospective cohort studies. The three studies addressed treatment with isoniazid (INH) for 9 months and one of them also addressed INH treatment associated with rifampicin for 3 months.

CONCLUSIONS

Only one case of LTBI activation was observed; there was good treatment adherence and absence of complications during follow-up. More studies are necessary to evaluate the response to the other available therapeutic regimens, with better tolerability assessment and a larger sample. However, the results showed that INH therapy for 9 months and INH therapy plus rifampicin for 3 months had a low rate of LTBI activation and complications.