Screening difficult-to-reach populations for tuberculosis using a mobile medical unit, Punjab India

Point-of-care test for tuberculosis: a boon in diagnosis

Rapid diagnosis of tuberculosis (TB) is an effective measure to eradicate this infectious disease worldwide. Traditional methods for screening TB patients do not provide an immediate diagnosis and thus delay treatment. There is an urgent need for the early detection of TB through point-of-care tests (POCTs). Several POCTs are widely available at primary healthcare facilities that assist in TB screening. In addition to the currently used POCTs, advancements in technology have led to the discovery of newer methods that provide accurate and fast information independent of access to laboratory facilities. In the present article, the authors tried to include and describe the potential POCTs for screening TB in patients. Several molecular diagnostic tests, such as nucleic acid amplification tests, including GeneXpert and TB-loop-mediated isothermal amplification, are currently being used as POCTs. Besides these methods, the pathogenic component of Mycobacterium tuberculosis can also be utilized as a biomarker for screening purposes through immunological assays. Similarly, the host immune response to infection has also been utilized as a marker for the diagnosis of TB. These novel biomarkers might include Mtb85, interferon-γ inducible protein-10, volatile organic compounds, acute-phase proteins, etc. Radiological tests have also been observed as POCTs in the TB screening POCT panel. Various POCTs are performed on samples other than sputum, which further eases the screening process. These POCTs should not require large-scale manpower and infrastructure. Hence, POCT should be able to identify patients with M. tuberculosis infection at the primary healthcare level only. There are several other advanced techniques that have been proposed as future POCTs and have been discussed in the present article.

Impact of COVID-19 on tuberculosis services: an experience from a tertiary care hospital

Introduction. India is home to the most significant number of tuberculosis (TB) cases around the globe. The COVID-19 crisis has massively affected TB healthcare services in the country.Hypothesis/Gap Statement. Are we sufficiently equipped to fight against TB during emergencies?Aim. Our study aims to provide a true insight into the disruption of TB care during the pandemic period at a tertiary care hospital in India.Methods. A retrospective observational cohort analysis was conducted on 6491 patients who accessed the TB diagnostics at the tertiary care hospital during the study period, i.e. the COVID-19 pandemic period (March 2020 to March 2021) compared with 14 665 in the control period (March 2019 to Feb 2020).Results. Out of the total tested, 3136 patients were notified as new TB cases in the study period than 4370 in the control period (P-value=0.0000001), i.e. 28.23 % decline in notifications. A drastic decline of 69 % in notifications was observed during the lock down months in the pandemic period, i.e. March to June 2020 (P-value=0.00001). A reduction of 44 % in treatment accession by 3690 TB patients in the control period compared with 2062 in the study period (P-value=0.0000001) was noted. Lost to follow-up patients increased by 65 % from 460 in the control period to 760 in the study period (P-value=0.0000001). Also, an increased death rate by 43 % from control to study period (P-value=0.0000001) was reported.Conclusion. There is an urgent need to maintain the continuity of essential TB services to reduce the rising burden in vulnerable populations. The need of the hour is to undertake novel strategies for tuberculosis control to combat such emergencies in the coming future.

Prevalence and predictors of gestational diabetes mellitus in rural Assam: a cross-sectional study using mobile medical units

OBJECTIVE

To determine the prevalence and predictors of gestational diabetes mellitus (GDM) in rural Assam, India using a network of Mobile Medical Units.

STUDY DESIGN

A field-based cross-sectional study.

SETTINGS

Rural areas of Assam state, India.

PARTICIPANTS

A total of 1410 pregnant women in gestational age of 24-28 weeks INTERVENTION: Identification of pregnant women in 24-28 weeks of pregnancy from villages and administering them Government of India recommended oral glucose tolerance test for GDM confirmation.

PRIMARY AND SECONDARY OUTCOME MEASURES

Presence of gestational diabetes among pregnant women, risk factors and predictors of GDM.

RESULTS

A total of 1212 pregnant women underwent the oral glucose tolerance test. One hundred and ninety-eight women were ineligible due to existing chronic diseases or very high blood glucose level before the test. The overall GDM prevalence in Assam was 16.67% (95% CI 14.61% to 18.89%). Women aged 26-30 years (adjusted odds ratio, aOR 1.70; CI 1.14 to 2.52), who passed 10th class (aOR 1.58; CI 1.05 to 2.37), belonging to Muslim religion (aOR 1.52; 95% CI 1.05 to 2.21) and above poverty line (aOR 1.38; 95% CI 1.00 to 1.91) had significantly increased likelihood of developing GDM compared with respective baseline groups (p<0.05). Body mass index, gravida and being non-anaemic were non-significant risk factors for GDM. Family history of diabetes (aOR 1.82; 95% CI 1.08 to 3.06) and smoking (aOR 1.61; 95% CI 1.10 to 2.35) were significant and independent predictors of GDM.

CONCLUSION

The prevalence of GDM in rural Assam is high. The mobile medical units may play a significant role in the implementation of GDM screening, diagnosis, treatment to ensure better maternal and foetal health outcomes in rural Assam.

Lessons learned from community-based tuberculosis case-finding in western Kenya

SETTING

Although Kenya has a high burden of tuberculosis (TB), only 46% of cases were diagnosed in 2016.

OBJECTIVE

To identify strategies for increasing attendance at community-based mobile screening units.

DESIGN

We analysed operational data from a cluster-randomised trial, which included community-based mobile screening implemented during February 2015-April 2016. Community health volunteers (CHVs) recruited individuals with symptoms from the community, who were offered testing for human immunodeficiency virus (HIV) and sputum collection for Xpert® MTB/RIF testing. We compared attendance across different mobile unit sites using Wilcoxon rank-sum test.

RESULTS

A total of 1424 adults with symptoms were screened at 25 mobile unit sites. The median total attendance among sites was 54 (range 6-134, interquartile range [IQR] 24-84). The median yields of TB diagnoses and new HIV diagnoses were respectively 2.4% (range 0.0-16.7, IQR 0.0-5.3) and 2.5% (range 0.0-33.3, IQR 1.2-4.2). Attendance at urban sites was variable; attendance at rural sites where CHVs were paid a daily minimum wage was significantly higher than at rural sites where CHVs were paid a nominal monthly stipend (P < 0.001).

CONCLUSION

Mobile units were most effective and efficient when implemented as a single event with community health workers who are paid a daily wage.

Operational research within a Global Fund supported tuberculosis project in India: why, how and its contribution towards change in policy and practice

BACKGROUND

The Global Fund encourages operational research (OR) in all its grants; however very few reports describe this aspect. In India, Project Axshya was supported by a Global Fund grant to improve the reach and visibility of the government Tuberculosis (TB) services among marginalised and vulnerable communities. OR was incorporated to build research capacity of professionals working with the national TB programme and to generate evidence to inform policies and practices.

OBJECTIVES

To describe how Project Axshya facilitated building OR capacity within the country, helped in addressing several TB control priority research questions, documented project activities and their outcomes, and influenced policy and practice.

METHODS

From September 2010 to September 2016, three key OR-related activities were implemented. First, practical output-oriented modular training courses were conducted (n = 3) to build research capacity of personnel involved in the TB programme, co-facilitated by The Union, in collaboration with the national TB programme, WHO country office and CDC, Atlanta. Second, two large-scale Knowledge, Attitude and Practice (KAP) surveys were conducted at baseline and mid-project to assess the changes pertaining to TB knowledge, attitudes and practices among the general population, TB patients and health care providers over the project period. Third, studies were conducted to describe the project's core activities and outcomes.

RESULTS

In the training courses, 44 participant teams were supported to develop research protocols on topics of national priority, resulting in 28 peer-reviewed scientific publications. The KAP surveys and description of project activities resulted in 14 peer-reviewed publications. Of the published papers at least 12 have influenced change in policy or practice.

CONCLUSIONS

OR within a Global Fund supported TB project has resulted in building OR capacity, facilitating research in areas of national priority and influencing policy and practice. We believe this experience will provide guidance for undertaking OR in Global Fund projects.

Public health impact of a novel smoking cessation outreach program in Ontario, Canada

Background

Provision of evidence-based smoking cessation treatment may contribute to health disparities if barriers to treatment are greater for more disadvantaged groups. We describe and evaluate the public health impact of a novel outreach program to improve access to smoking cessation treatment in Ontario, Canada.

Methods

We partnered with Public Health Units (PHUs) located across the province to deliver single-session workshops providing standardized evidence-based content and 10 weeks (2007–2008) or 5 weeks (2008–2016) of nicotine replacement therapy (NRT). Participants completed a baseline assessment and were followed up by phone or e-mail at 6 months. We used the RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework to evaluate the public health impact of the program from 2007 to 2016. Given the iterative design and changes in implementation over time, data is presented annually or bi-annually.

Results

There were 26,122 enrollments from 2007 to 2016. Between 31 and 442 workshops were held annually. The annual reach was estimated to be 0.1–0.3% of eligible smokers in Ontario. Participants were older, smoked more heavily, had a lower household income, were more likely to be female and be diagnosed with a mood or anxiety disorder, and less likely to have a postsecondary degree compared to average Ontario smokers eligible for participation. The intervention was effective; at 6-month follow-up 22–33% of respondents reported abstinence from smoking. Adoption by PHUs was 81% by the second year of operation and remained high (72–97%) thereafter, with the exception of 2009–2010 (33–56%) when the program was temporarily unavailable to PHUs due to lack of funding. Implementation at the organizational level was not tracked; however, at the individual level, approximately half of participants used most or all of the NRT received. On average, maintenance of the program was high, with PHUs conducting workshops for 7 of the 10 years (2007–2016) and 4 of the 5 most recent years (2012–2016).

Conclusions

The smoking cessation program had a high rate of adoption and maintenance, reached smokers over a large geographic area, including individuals more likely to experience disparities, and helped them make successful quit attempts. This novel model can be adopted in other jurisdictions with limited resources.

A Sustainable Model for Patient follow-up following an International Cleft Mission

Purpose:

Patient follow-up after cleft missions is imperative if we are to critically assess the quality of care provided in these settings. The adoption of mobile telephones among disadvantaged families abroad may enable such an undertaking in a cost-effective manner. This project aimed to assess the efficacy of cellular phone-based follow-up in a developing country following a cleft mission to Thailand.

Methods:

Changing Children's Lives Inc. performed a cleft surgical mission to Udon Thani, Thailand, in January 2013. Telephone numbers collected at that time were used to survey the patients or their parents 1.5 years postoperatively.

Results:

Of the 56 patients who underwent cleft lip and/or palate surgery during the mission, more than 50% ( n = 30, 54%) were reachable by telephone; all chose to participate in the study. The cost for families was U.S. $124.92 (56.15); 26 families (87%) believed their money was well spent. Follow-up care was received by 22 (73%) patients, and all but one family ( n = 29, 97%) felt that their child received all of the medical care and support required. All families ( N = 30) would recommend similar cleft care to a friend. Of the patients younger than 18 years of age ( n = 24, 80%), 20 (80%) families found their child more comfortable interacting with peers, more comfortable interacting with adults, and more confident postoperatively.

Conclusion:

In one month, a survey response rate of more than 50% was obtained by leveraging the increased adoption of mobile phones in rural settings. Nearly all patients/families treated during the cleft mission were satisfied with the care that they received.

Active case-finding for tuberculosis by mobile teams in Myanmar: yield and treatment outcomes

Background

Since 2005, the Myanmar National Tuberculosis Programme (NTP) has been implementing active case finding (ACF) activities involving mobile teams in hard-to-reach areas. This study revealed the contribution of mobile team activities to total tuberculosis (TB) case detection, characteristics of TB patients detected by mobile teams and their treatment outcomes.

Methods

This was a descriptive study using routine programme data between October 2014 and December 2014. Mobile team activities were a one-stop service and included portable digital chest radiography (CXR) and microscopy of two sputum samples. The algorithm of the case detection included screening patients by symptoms, then by CXR followed by sputum microscopy for confirmation. Diagnosed patients were started on treatment and followed until a final outcome was ascertained.

Results

A total of 9 349 people with symptoms suggestive of TB were screened by CXR, with an uptake of 96.6%. Of those who were meant to undergo sputum smear microscopy, 51.4% had sputum examinations. Finally, 504 TB patients were identified by the mobile teams and the overall contribution to total TB case detection in the respective townships was 25.3%. Among total cases examined by microscopy, 6.4% were sputum smear positive TB. Treatment success rate was high as 91.8% in study townships compared to national rate 85% (2014 cohort).

Conclusions

This study confirmed the feasibility and acceptability of ACF by mobile teams in hard-to-reach contexts, especially when equipped with portable, digital CXR machines that provided immediate results. However, the follow-up process of sputum examination created a significant barrier to confirmation of the diagnosis. In order to optimize the ACF through mobile team activity, future ACF activities were needed to be strengthened one stop service including molecular diagnostics or provision of sputum cups to all presumptive TB cases prior to CXR and testing if CXR suggestive of TB.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-017-0291-5) contains supplementary material, which is available to authorized users.