Local staff making sense of their tuberculosis data: key to quality care and ending tuberculosis

<sec id="st1"> <title>BACKGROUND</title> The End TB Strategy's ambitious targets require universal health coverage, new tools and better data to monitor progress. </sec> <sec id="st2"> <title>OBJECTIVE</title> To assess the feasibility of a novel approach, whereby facility and district staff analyse and use their tuberculosis (TB) data to strengthen the quality of patient care and data. </sec> <sec id="st3"> <title>METHODS</title> This approach was piloted in Zimbabwe, and performance before and during the study were compared. Key indicators were defined for presumptive TB, TB disease, drug-resistant TB, TB and human immunodeficiency virus (HIV) co-infection, treatment outcomes, directly observed treatment and drug management. Staff validated, tabulated and analysed data quarterly to identify challenges and agree on action points at 'data-driven' supervision and performance review meetings. </sec> <sec id="st4"> <title>RESULTS</title> In the district that fully implemented the new approach, there was a significant increase in the identification of presumptive TB (63% vs. 30% in the rest of the province; P < 0.00001) and new smear-positive TB cases (87% vs. a decrease in the rest of the province; P < 0.0001), and a decline in the rate of pulmonary TB cases without diagnostic smear results (77% vs. 20% in the rest of the province; P = 0.037). </sec> <sec id="st5"> <title>CONCLUSION</title> The present study suggests that this approach led to an improvement in the quality of patient care and data, stimulated local staff to set priorities and increased 'ownership'. This approach can significantly help attain national TB goals and strengthen health systems. </sec>.

Challenges and opportunities to prevent tuberculosis in people living with HIV in low-income countries

People living with the human immunodeficiency virus (HIV) (PLHIV) are at high risk for tuberculosis (TB), and TB is a major cause of death in PLHIV. Preventing TB in PLHIV is therefore a key priority. Early initiation of antiretroviral therapy (ART) in asymptomatic PLHIV has a potent TB preventive effect, with even more benefits in those with advanced immunodeficiency. Applying the most recent World Health Organization recommendations that all PLHIV initiate ART regardless of clinical stage or CD4 cell count could provide a considerable TB preventive benefit at the population level in high HIV prevalence settings. Preventive therapy can treat tuberculous infection and prevent new infections during the course of treatment. It is now established that isoniazid preventive therapy (IPT) combined with ART among PLHIV significantly reduces the risk of TB and mortality compared with ART alone, and therefore has huge potential benefits for millions of sufferers. However, despite the evidence, this intervention is not implemented in most low-income countries with high burdens of HIV-associated TB. HIV and TB programme commitment, integration of services, appropriate screening procedures for excluding active TB, reliable drug supplies, patient-centred support to ensure adherence and well-organised follow-up and monitoring that includes drug safety are needed for successful implementation of IPT, and these features would also be needed for future shorter preventive regimens. A holistic approach to TB prevention in PLHIV should also include other important preventive measures, such as the detection and treatment of active TB, particularly among contacts of PLHIV, and control measures for tuberculous infection in health facilities, the homes of index patients and congregate settings.

Mobile targeted screening for tuberculosis in Zimbabwe: diagnosis, linkage to care and treatment outcomes

Setting

Targeted active screening for tuberculosis (Tas4TB) using mobile trucks in the community was implemented in 15 high TB burden districts in Zimbabwe. At-risk populations were screened for TB based on symptoms and chest radiography (CXR) results. Those with any positive symptom and/or an abnormal CXR had sputum collected for investigation and diagnosis and were linked to care and treatment if found to have TB.

Objective

To determine 1) the proportion and characteristics of those screened and diagnosed with TB; 2) the relationship between TB symptoms, CXR and diagnostic yields; and 3) the relationship between initiation of anti-TB treatment and treatment outcomes.

Design

Cohort study using routinely collected data.

Results

A total of 39 065 persons were screened, of whom 663 (1.7%) were diagnosed with TB; 126/663 (19.0%) were bacteriologically confirmed. The highest TB diagnostic yields were in symptomatic persons with CXRs suggestive of TB (19.4%), asymptomatic persons with CXRs suggestive of TB (8.4%) and persons at high-risk of TB (3.2%). For all diagnosed TB patients, pre-treatment loss to follow-up was 18.9% and treatment success was 59.9%.

Conclusion

Tas4TB resulted in high diagnostic yields; however, linkage of diagnosis to care was poor. Reasons for loss to follow-up need to be better understood and rectified.

Feasibility and yield of screening for diabetes mellitus among tuberculosis patients in Harare, Zimbabwe

Setting

A resource-limited urban setting in Zimbabwe with a high burden of tuberculosis (TB) and human immunodeficiency virus (HIV).

Objectives

To determine the feasibility and yield of diabetes mellitus (DM) screening among TB patients in primary health care facilities.

Design

A descriptive study.

Results

Of the 1617 TB patients registered at 10 pilot facilities, close to two thirds (60%) were male and 798 (49%) were bacteriologically confirmed. The median age was 37 years; two thirds (67%) were co-infected with HIV. A total of 1305 (89%) were screened for DM, and 111 (8.5%, 95% CI 7.0-10.2) were newly diagnosed with DM. Low TB notifying sites were more likely than high TB notifying sites to screen patients using random blood glucose (RBG) (83% vs. 79%; P < 0.04). Screening increased gradually per quarter over the study period. There were, however, notable losses along the screening cascade, the reasons for which will need to be explored in future studies.

Conclusion

The study findings indicate the feasibility of DM screening among TB patients, with considerable yield of persons newly diagnosed with DM. Scaling up of this intervention will need to address the observed losses along the screening cascade.

A comparison of the yield and relative cost of active tuberculosis case-finding algorithms in Zimbabwe

Setting

Ten districts and three cities in Zimbabwe.

Objective

To compare the yield and relative cost of identifying a case of tuberculosis (TB) using the three WHO-recommended algorithms (WHO2b, symptom inquiry only; WHO2d, chest X-ray [CXR] after a positive symptom inquiry; WHO3b, CXR only) and the Zimbabwe active case finding (ZimACF) algorithm (symptom inquiry plus CXR) to everyone.

Design

Cross-sectional study using data from the ZimACF project.

Results

A total of 38 574 people were screened from April to December 2017; 488 (1.3%) were diagnosed with TB using the ZimACF algorithm. Fewer TB cases would have been diagnosed with the WHO-recommended algorithms. This ranged from 7% fewer (34 cases) with WHO3b, 18% fewer (88 cases) with WHO2b and 25% fewer (122 cases) with WHO2d. The need for CXR ranged from 36% (WHO2d) to 100% (WHO3b). The need for bacteriological confirmation ranged from 7% (WHO2d) to 40% (ZimACF). The relative cost per case of TB diagnosed ranged from US$180 with WHO3b to US$565 for the ZimACF algorithm.

Conclusion

The ZimACF algorithm had the highest case yield, but at a much higher cost per case than the WHO algorithms. It is possible to switch to algorithm WHO3b, but the trade-off between cost and yield needs to be reviewed by the Zimbabwean National TB Programme.

Has TB CARE I sputum transport improved access to culture services for retreatment tuberculosis patients in Zimbabwe?

Setting: Retreatment tuberculosis (TB) patients in Zimbabwe are investigated using microscopy, Xpert^® MTB/RIF and culture + drug susceptibility testing (CDST). TB CARE I, a sputum transport service using motorcycles, was introduced to transport specimens between peripheral health facilities and laboratories, including National Reference Laboratories (NRLs). Objectives: To compare access to CDST and treatment outcomes among retreatment TB patients in facilities with and those without TB CARE I support. Design: This was a retrospective cohort study. Results: There were 187 patients from TB CARE I-supported facilities and 116 from non-TB CARE I facilities, with no difference in demographic characteristics. Altogether, specimens from 22 (12%) retreatment TB patients had successful CDST from TB CARE I facilities, which was not statistically significantly different from non-supported facilities (n = 14, 12%; P = 0.94). The median number of days from sputum collection to receipt at the NRL was lower in TB CARE I facilities than in non-supported facilities (median 6, interquartile range [IQR] 4-8 vs. median 8, IQR 6-13.5; P = 0.000). Favourable treatment outcomes were documented in 65% of patients under TB CARE I, significantly more than among patients in non-supported facilities (47%, P < 0.01). Conclusion: The process of sputum specimen collection for CDST was not different between TB CARE I and non-TB CARE I-supported health facilities, apart from a slightly shorter time. Ways to improve the current system are discussed.

Age-stratified tuberculosis treatment outcomes in Zimbabwe: are we paying attention to the most vulnerable?

Setting: A high tuberculosis (TB) incidence, resource-limited urban setting in Zimbabwe. Objectives: To compare treatment outcomes among people initiated on first-line anti-tuberculosis treatment in relation to age and other explanatory factors. Design: This was a retrospective record review of routine programme data. Results: Of 2209 patients included in the study, 133 (6%) were children (aged <10 years), 132 (6%) adolescents (10-19 years), 1782 (81%) adults (20-59 years) and 162 (7%) were aged ⩾60 years, defined as elderly. The highest proportion of smear-negative pulmonary TB cases was among the elderly (40%). Unfavourable outcomes, mainly deaths, increased proportionately with age, and were highest among the elderly (adjusted relative risk 3.8, 95%CI 1.3-10.7). Having previous TB, being human immunodeficiency virus positive and not on antiretroviral treatment or cotrimoxazole preventive therapy were associated with an increased risk of unfavourable outcomes. Conclusion: The elderly had the worst outcomes among all the age groups. This may be related to immunosuppressant comorbidities or other age-related diseases mis-classified as TB, as a significant proportion were smear-negative. Older persons need better adapted TB management and more sensitive diagnostic tools, such as Xpert^® MTB/RIF.

Declining tuberculosis case notification rates with the scale-up of antiretroviral therapy in Zimbabwe

Setting: Zimbabwe has a human immunodeficiency virus (HIV) driven tuberculosis (TB) epidemic, with antiretroviral therapy (ART) scaled up in the public sector since 2004. Objective: To determine whether national ART scale-up was associated with annual national TB case notification rates (CNR), stratified by disease type and category, between 2000 and 2013. Design: This was a retrospective study using aggregate data from global reports. Results: The number of people living with HIV and retained on ART from 2004 to 2013 increased from 8400 to 665 299, with ART coverage increasing from <0.5% to 48%. TB CNRs, all types and categories, increased from 2000 to 2003, and declined thereafter from 2004 to 2013. The decreases in annual TB notifications between the highest rates (before 2004) and lowest rates (2013) were all forms of TB (56%), new TB (60%), previously treated TB (53%), new smear-positive pulmonary TB (PTB) (40%), new smear-negative/smear-unknown PTB (58%) and extra-pulmonary TB (58%). Conclusion: Significant declines in TB CNRs were observed during ART scale-up, especially for smear-negative PTB and extra-pulmonary TB. These encouraging national trends support the continued scale-up of ART for people living with HIV as a way of tackling the twin epidemics of HIV/acquired immune-deficiency syndrome and TB in Zimbabwe.

Diagnosis and treatment of TB patients with rifampicin resistance detected using Xpert(®) MTB/RIF in Zimbabwe

SETTING

In Zimbabwe, there are concerns about the management of tuberculosis (TB) patients with rifampicin (RMP) resistance diagnosed using Xpert(®) MTB/RIF.

OBJECTIVE

To assess linkages between diagnosis and treatment for these patients in Harare and Manicaland provinces in 2014.

DESIGN

A retrospective cohort study.

RESULTS

Of 20 329 Xpert assays conducted, 90% were successful, 11% detected Mycobacterium tuberculosis and 4.5% showed RMP resistance. Of 77 patients with RMP-resistant TB diagnosed by Xpert, 70% had samples sent to the reference laboratory for culture and drug susceptibility testing (CDST); 53% of the samples arrived. In 21% the samples showed M. tuberculosis growth, and in 17% the DST results were recorded, all of which confirmed RMP resistance. Of the 77 patients, 34 (44%) never started treatment for multidrug-resistant (MDR) TB, with documented reasons being death, loss to follow-up and incorrect treatment. Of the 43 patients who started MDR-TB treatment, 12 (71%) in Harare and 17 (65%) in Manicaland started within 2 weeks of diagnosis.

CONCLUSION

Xpert has been rolled out successfully in two Zimbabwe provinces. However, the process of confirming CDST for Xpert-diagnosed RMP-resistant TB works poorly, and many patients are either delayed or never initiate MDR-TB treatment. These shortfalls must be addressed at the programmatic level.

Caesarean section rate as a process indicator of safe motherhood programmes: the case of Midlands Province

OBJECTIVE

To evaluate the Safe Motherhood Programme of Midlands Province by means of process indicators, in particular Caesarean Section Rates (CSR), in comparison with the commonly used outcome indicator Maternal Mortality Ratio (MMR).

DESIGN

A cross sectional descriptive study.

SETTING

Midlands Province, Zimbabwe.

MAIN OUTCOME MEASURES

Process indicators of the Safe Motherhood Programme of Midlands Province, and Maternal Mortality Ratio as an outcome indicator for the nation and the province.

RESULTS

For Midlands province, a population based CSR of 3.1% was calculated for 1999, which is well below the internationally recommended 5%. The figures for the eight districts ranged considerably from 0.18 to 7.1%. The provincial institutional CSR for the same year was 8.7% (range: 0.53 to 34.5) with a significantly higher rate in private institutions (24%) as compared to government run hospitals (8%), (Chi-square 398.26, p << 0.05). The Ante Natal Care (ANC) coverage ranged from 43.9 to 75.4% with a provincial average of 62.8%. The provincial institutional delivery coverage figure was 55% (range: 49.9 to 63.6%). These findings differed from the figures obtained in the Demographic and Health Survey for the same year: ANC and institutional delivery coverages for the Midlands province were 95.2% and 73% respectively. The availability of obstetric services was well above the minimum acceptable level as defined by the World Health Organisation (WHO) guidelines.

CONCLUSION

MMR is not a very useful indicator to monitor progress in Safe Motherhood Programmes. The figures are unreliable, difficult to obtain if population based, and they show a wide range, even within one given year. Process indicators, especially CSR are easily accessible and give insight in the degree of unmet obstetric need and in referral patterns within one district and the province.

Post natal maternal morbidity patterns in mothers delivering in Gweru City (Midlands province)

OBJECTIVES

To determine morbid conditions suffered by mothers during the first six weeks post delivery and risk factors associated with them in Gweru district.

DESIGN

A cross sectional survey.

SETTING

Gweru district hospital, Monomotapa, Mkoba 1 and Mkoba polyclinic.

SUBJECTS

A consecutive sample of 201 mothers residing in Gweru district who delivered in these facilities during the month of June 1997.

MAIN OUTCOME MEASURES

Morbid conditions, magnitude and the risk factors.

RESULTS

During follow up checks on recruited mothers, turn up rates were 82% and 63% at two and six weeks respectively. Fifty eight percent (58%) of the mothers reported at least one morbid condition within the first 24 hours post delivery and pain was a dominant feature. At two weeks, 56% of those who turned up predominantly presented with sepsis in areas of the reproductive tract. The figure fell to 35% among mothers who turned up at six weeks and a mixture of pain and sepsis were the predominant complaints. Episiotomies caused a lot of pain post operatively and the risk of subsequent sepsis was high, (OR: 9; 95% CI: 1.16 < OR < 69.7; p = 0.020). Statistically significant associations were found between backache and multiparity (OR: 1.89; 95% CI: 1 < OR < 3.4; p = 0.040) and also between Caesarian section and some morbid conditions (OR: 4.14; p = 0.002; 95% CI 2.05 < OR < 10.91). The prevalence rate of HIV was 29.4%. HIV positivity was associated with marriage below the age of 19 years (OR: 2.4; 95% CI 1.21 < OR < 3.8; p = 0.024). There was no association between HIV serostatus and maternal morbidity. Use of traditional medication during pregnancy was reported by 42% of mothers, but it did not have any immediately observable intrapartum of post partum effects. Similarly the place of delivery was not associated with post natal maternal morbidity.

CONCLUSION

The first two weeks post delivery were the most critical for the mother in terms of post natal maternal morbidity. Sepsis associated pain was the predominant condition. To improve the effectiveness of post natal care, a review within the first two weeks post delivery is an essential intervention, in addition to the routine six weeks check.

Stab wounds in Bulawayo, Zimbabwe: a four year audit

Between January 1989 and December 1992 a total of 102 patients (88 pc male and 12 pc female) were treated for stab wounds at Mpilo Central Hospital, Bulawayo, Zimbabwe. The case records of these patients have been studied retrospectively. The mean age of the patients was 30 years (Standard Deviation 9). Most of the patients, 82 pc (82/102) were residents of the city of Bulawayo with only 18 pc (18/102) coming from rural areas. The mean delay in presentation was 12 hours (SD 11). A knife was the stabbing instrument in most cases (82 pc). Fights, 38 pc (26/68), domestic disputes, 26 pc (18/68) and robbery 21 pc (14/68) were the commonest motives for stabbing. In most cases stabbing occurred in a beer hall, 47 pc (26/55) and at home, 31 pc (17/55). The majority of stab wounds occurred in the chest, 51 pc followed by the abdomen, 31 pc. Of the patients with stab wounds of the chest 22 pc (14/65) required intercostal chest drains. Of the 39 patients with stab wounds of the abdomen 20 patients were subjected to laparotomy. No abnormality was found at operation in 50 pc (10/20) of cases. No major complications or mortality were recorded in this series. Based on the findings in this study, there is need for us to adopt a more conservative approach to the management of stab wounds, especially those involving the abdomen. This policy of "selective conservatism" should be based on a thorough physical examination and appropriate special investigations. Active surgical intervention should be reserved for specific indications.