Missed opportunities for TB diagnostic testing among people living with HIV in Zimbabwe: Cross-sectional analysis of the Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) survey 2015-16

Background

Using data from the Zimbabwe Population-based HIV Impact Assessment survey 2015-2016, we examined the TB care cascade and factors associated with not receiving TB diagnostic testing among adult PLHIV with TB symptoms.

Methods

Statistical Analysis was limited to PLHIV aged 15 years and older in HIV care. Weighted logistic regression with not receiving TB testing as outcome was adjusted for covariates with crude odd ratios (ORs) with p < 0.25. All analyses accounted for multistage survey design.

Results

Among 3507 adult PLHIV in HIV care, 2288 (59.7 %, 95 % CI:58.1-61.3) were female and 2425 (63.6 %, 95 % CI:61.1-66.1) lived in rural areas. 1197(48.7 %, 95 % CI:46.5-51.0) reported being screened for TB symptoms at their last HIV care visit. In the previous 12 months, 639 (26.0 %, 95 % CI:23.9-28.1) reported having symptoms and of those, 239 (37.8 %, 95 % CI:33.3-42.2) received TB testing. Of PLHIV tested for TB, 36 (49.5 %, 95 % CI:35.0-63.1) were diagnosed with TB; 32 (90.3 %, 95 % CI:78.9-100) of those diagnosed with TB received treatment. Never having used IPT was associated with not receiving TB testing.

Conclusion

The results suggest suboptimal utilization of TB screening and diagnostic testing among PLHIV. New approaches are needed to reach opportunities missed in the HIV/TB integrated services.

Tuberculosis preventive treatment uptake among adults living with human immunodeficiency virus: Analysis of Zimbabwe population-based human immunodeficiency virus impact assessment 2020

BACKGROUND

Tuberculosis remains the leading cause of death by an infectious disease among people living with HIV (PLHIV). TB Preventive Treatment (TPT) is a cost-effective intervention known to reduce morbidity and mortality. We used data from ZIMPHIA 2020 to assess TPT uptake and factors associated with its use.

METHODOLOGY

ZIMPHIA a cross-sectional household survey, estimated HIV treatment outcomes among PLHIV aged ≥15 years. Randomly selected participants provided demographic and clinical information. We applied multivariable logistic regression models using survey weights. Variances were estimated via the Jackknife series to determine factors associated with TPT uptake.

RESULTS

The sample of 2419 PLHIV ≥15 years had 65% females, 44% had no primary education, and 29% lived in urban centers. Overall, 38% had ever taken TPT, including 15% currently taking TPT. Controlling for other variables, those screened for TB at last HIV-related visit, those who visited a TB clinic in the previous 12 months, and those who had HIV viral load suppression were more likely to take TPT.

CONCLUSION

The findings show suboptimal TPT coverage among PLHIV. There is a need for targeted interventions and policies to address the barriers to TPT uptake, to reduce TB morbidity and mortality among PLHIV.

Tuberculosis cohort analysis in Zimbabwe: The need to strengthen patient follow-up throughout the tuberculosis care cascade

INTRODUCTION

Globally people with tuberculosis (TB) continue to be missed each year. They are either not diagnosed or not reported which indicates possible leakages in the TB care cascade. Zimbabwe is not spared with over 12000 missed cases in 2020. A preliminary review of TB treatment outcomes indicated patient leakages throughout the presumptive cascade and undesirable treatment outcomes in selected cities. Chegutu District had pre-diagnosis and pretreatment losses to follow-up while Mutare City among others had 22.0% of outcomes not evaluated in the second quarter of 2021, and death rates as high as 14% were recorded in Gweru District. The problem persists despite training on data analysis and use. The TB cohorts were analysed to determine the performance of the care cascade and the spatial distribution of treatment outcomes in Zimbabwe.

METHODS

Using data from district health information software version 2.3 (DHIS2.3), a secondary data analysis of 2020 drug-sensitive (DS) TB treatment cohorts was conducted. We calculated the percentage of pre-diagnosis, and pre-treatment loss to follow-up (LTFU). For TB treatment outcomes, 'cured' and 'treatment completed' were categorized as treatment success, while 'death', 'loss to follow-up (LTFU), and 'not evaluated' were categorized as undesirable outcomes. Univariate analysis of the data was conducted where frequencies were calculated, and data was presented in graphs for the cascade, treatment success, and undesirable outcomes while tables were created for the description of study participants and data quality. QGIS was used to generate maps showing undesirable treatment outcomes.

RESULTS

An analysis of national data found 107583 people were presumed to have TB based on symptomatic screening and or x-ray and 21.4% were LTFU before the specimen was investigated. Of the 84534 that got tested, 10.0% did not receive their results. The treatment initiation rate was 99.1%. Analysis of treatment outcomes done at the provincial level showed that Matabeleland South Province had the lowest treatment success rate of 77.3% and high death rates were recorded in Matabeleland South (30.0%), Masvingo (27.3%), and Matabeleland North (26.1%) provinces. Overall, there were high percentages of not-evaluated treatment outcomes.

CONCLUSION

Pre-diagnosis LTFU was high, and high death and loss to follow-up rates were prevalent in provinces with artisanal and small-scale mining (ASM) activities. Unevaluated treatment outcomes were also prevalent and data quality remains a challenge within the national TB control program. We recommended strengthening patient follow-up at all levels within the TB care cascade, strengthening capacity-building for data analysis and use, further analysis to determine factors associated with undesirable outcomes and a study on why LTFU remains high.

Integrating 3HP-based tuberculosis preventive treatment into Zimbabwe's Fast Track HIV treatment model: experiences from a pilot study

INTRODUCTION

Tuberculosis (TB) causes one-third of HIV-related deaths worldwide, making TB preventive treatment (TPT) a critical element of HIV programmes. Approximately 16% of people living with HIV (PLHIV) on antiretrovirals in Zimbabwe are enrolled in the Fast Track (FT) differentiated service delivery model, which includes multi-month dispensing of antiretrovirals and quarterly health facility (HF) visits. We assessed the feasibility and acceptability of utilizing FT to deliver 3HP (3 months of once-weekly rifapentine and isoniazid) for TPT by aligning TPT and HIV visits, providing multi-month dispensing of 3HP, and using phone-based monitoring and adherence support.

METHODS

We recruited a purposive sample of 50 PLHIV enrolled in FT at a high-volume HF in urban Zimbabwe. At enrolment, participants provided written informed consent, completed a baseline survey, and received counselling, education and a 3-month supply of 3HP. A study nurse mentor called participants at weeks 2, 4 and 8 to monitor and support adherence and side effects. When participants returned for their routine 3-month FT visit, they completed another survey, and study staff conducted a structured medical record review. In-depth interviews were conducted with providers who participated in the pilot.

RESULTS

Participants were enrolled between April and June 2021 and followed through September 2021. Median age = 32 years (IQR 24,41), 50% female, median time in FT 1.8 years (IQR 0.8,2.7). Forty-eight participants (96%) completed 3HP in 13 weeks; one completed in 16 weeks, and one stopped due to jaundice. Most participants (94%) reported "always" or "almost always" taking 3HP correctly. All reported they were very satisfied with the counselling, education, support and quality of care they received from providers and FT service efficiency. Almost all (98%) said they would recommend it to other PLHIV. Challenges reported included pill burden (12%) and tolerability (24%), but none had difficulty with phone-based counselling or wished for additional HF-based visits.

DISCUSSION

Using FT to deliver 3HP was feasible and acceptable. Some reported tolerability challenges but 98% completed 3HP, and all appreciated the efficiency of aligning TPT and HIV HF visits, multi-month dispensing and phone-based counselling.

CONCLUSIONS

Scaling up this approach could expand TPT coverage in Zimbabwe.

Evidence to Action: Translating Innovations in Management of Child and Adolescent TB into Routine Practice in High-Burden Countries

Child and adolescent tuberculosis (TB) has been long neglected by TB programs but there have been substantive strides in prioritizing TB among these populations in the past two decades. Yet, gaps remain in translating evidence and policy to action at the primary care level, ensuring access to novel tools and approaches to diagnosis, treatment, and prevention for children and adolescents at risk of TB disease. This article describes the progress that has been made and the gaps that remain in addressing TB among children and adolescents while also highlighting pragmatic approaches and the role of multisectoral partnerships in facilitating integration of innovations into routine program practice.

TB prevalence in Zimbabwe: a national cross-sectional survey, 2014

BACKGROUND: We conducted the first national TB prevalence survey to provide accurate estimates of bacteriologically confirmed pulmonary TB disease among adults aged ≥15 years in 2014.METHODS: A TB symptoms screen and chest X-ray (CXR) were used to identify presumptive TB cases who submitted two sputum samples for smear microscopy, liquid and solid culture. Bacteriological confirmation included acid-fast bacilli smear positivity confirmed using Xpert^® MTB/RIF and/or culture. Prevalence estimates were calculated using random effects logistic regression with multiple imputations and inverse probability weighting.RESULTS: Of 43,478 eligible participants, 33,736 (78%) were screened; of these 5,820 (17%) presumptive cases were identified. There were 107 (1.9%) bacteriologically confirmed TB cases, of which 23 (21%) were smear-positive. The adjusted prevalences of smear-positive and bacteriologically confirmed TB disease were respectively 82/100,000 population (95% CI 47-118/100,000) and 344/100,000 (95% CI 268-420/100,000), with an overall all-ages, all-forms TB prevalence of 275/100,000 population (95% CI 217-334/100,000). TB prevalence was higher in males, and age groups 35-44 and ≥65 years. CXR identified 93/107 (87%) cases vs. 39/107 (36%) using the symptom screen.CONCLUSION: Zimbabwe TB disease prevalence has decreased relative to prior estimates, possibly due to increased antiretroviral therapy coverage and successful national TB control strategies. Continued investments in TB diagnostics for improved case detection are required.

Coverage and effectiveness of conditional cash transfer for people with drug resistant tuberculosis in Zimbabwe: A mixed methods study

The End TB strategy recommends social protection to mitigate socio-economic impacts of tuberculosis. Zimbabwe started implementing a conditional cash transfer (CCT) programme for people on drug resistant tuberculosis (DR-TB) treatment in 2013. We aimed to determine the proportion of people receiving CCT and effectiveness of CCT in improving treatment outcomes, explore their experiences with registering for CCT and understand the impact of CCT from the perspective of beneficiaries. Data from 2014-2021 were extracted from TB registers and CCT payment records within the National TB Programme. Sixteen in-depth interviews were conducted with people who were completing treatment or had completed treatment within two months. Poisson regression, adjusted for province, year of treatment, age and sex was used to investigate associations between receiving CCT and successful treatment outcomes among people who were in DR-TB care for ≥3 months after treatment initiation. Qualitative data were analyzed using thematic analysis. A total of 481 people were included in the quantitative study. Of these, 53% (254/481) received CCT at some point during treatment. People who exited DR-TB care within three months were 73% less likely to receive CCT than those who did not (prevalence ratio (PR) = 0.27 [95%CI: 0.18-0.41]). Among those who were alive and in care three months after treatment initiation, CCT recipients were 32% more likely to have successful outcomes than those who did not (adjusted PR = 1.32, [95%CI: 1.00-1.75]). Qualitative results revealed lack of knowledge about availability of CCT among people with DR-TB and missed opportunities by healthcare providers to provide information about availability of CCT. Delays and inconsistencies in disbursements of CCT were frequent themes. CCT were associated with successful treatment outcomes. Improvements in coverage, timeliness and predictability of disbursements are recommended.

Tuberculosis and Silicosis Burden in Artisanal and Small-Scale Gold Miners in a Large Occupational Health Outreach Programme in Zimbabwe

Artisanal and small-scale miners (ASMs) labour under archaic working conditions and are exposed to high levels of silica dust. Exposure to silica dust has been associated with an increased risk of tuberculosis and silicosis. ASMs are highly mobile and operate in remote areas with near absent access to health services. The main purpose of this study was to evaluate the prevalence of tuberculosis, silicosis and silico-tuberculosis among ASMs in Zimbabwe. A cross-sectional study was conducted from 1 October to 31 January 2021 on a convenient sample of 514 self-selected ASMs. We report the results from among those ASMs who attended an outreach medical facility and an occupational health clinic. Data were collected from clinical records using a precoded data proforma. Data variables included demographic (age, sex), clinical details (HIV status, GeneXpert results, outcomes of chest radiographs, history of tuberculosis) and perceived exposure to mine dust. Of the 464 miners screened for silicosis, 52 (11.2%) were diagnosed with silicosis, while 17 (4.0%) of 422 ASMs were diagnosed with tuberculosis (TB). Of the 373 ASMs tested for HIV, 90 (23.5%) were sero-positive. An HIV infection was associated with a diagnosis of silicosis. There is need for a comprehensive occupational health service package, including TB and silicosis surveillance, for ASMs in Zimbabwe. These are preliminary and limited findings, needing confirmation by more comprehensive studies.

Isoniazid preventive therapy use among adult people living with HIV in Zimbabwe

We assessed the prevalence of isoniazid preventive therapy (IPT) uptake and explored factors associated with IPT non-uptake among people living with HIV (PLHIV) using nationally representative data from the Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) 2015-2016. This was a cross-sectional study of 3418 PLHIV ZIMPHIA participants eligible for IPT, aged ≥15 years and in HIV care. Logistic regression modeling was performed to assess factors associated with self-reported IPT uptake. All analyses accounted for multistage survey design. IPT uptake among PLHIV was 12.7% (95% confidence interval (CI): 11.4-14.1). After adjusting for sex, age, rural/urban residence, TB screening at the last clinic visit, and hazardous alcohol use, rural residence was the strongest factor associated with IPT non-uptake (adjusted OR (aOR): 2.39, 95% CI: 1.82-3.12). Isoniazid preventive therapy non-uptake having significant associations with no TB screening at the last HIV care (aOR: 2.07, 95% CI: 1.54-2.78) and with hazardous alcohol use only in urban areas (aOR: 10.74, 95% CI: 3.60-32.0) might suggest suboptimal IPT eligibility screening regardless of residence, but more so in rural areas. Self-reported IPT use among PLHIV in Zimbabwe was low, 2 years after beginning national scale-up. This shows the importance of good TB screening procedures for successful IPT implementation.

Predictors of mortality and treatment success of multi-drug resistant and Rifampicin resistant tuberculosis in Zimbabwe: a retrospective cohort analysis of patients initiated on treatment during 2010 to 2015

Introduction

Zimbabwe is one of the 30 countries globally with a high burden of multidrug-resistant TB or rifampicin-resistant TB. The World Health Organization recommended that patients diagnosed with multidrug-resistant TB be treated with 20-24 month standardized second-line drugs since 2010. However, factors associated with mortality and treatment success have not been systematically evaluated in Zimbabwe. The Objective of the study was to assess factors associated with Mortality and treatment success among multidrug-resistant-TB patients registered and treated under the National Tuberculosis programme in Zimbabwe.

Methods

the study was conducted using secondary data routinely collected from the National tuberculosis (TB) programme. Categorical variables were summarised using frequencies and a generalized linear model with a log-link function and a Poisson distribution was used to assess factors associated with mortality and treatment success. The level of significance was set at P-Value < 0.05.

Results

patient antiretroviral therapy (ART) status was a significant associated factor of treatment success or failure (RRR = 3.92, p < 0.001). Patients who were not on ART had a high risk of death by 3.92 times compared to patients who were on ART. In the age groups 45 - 54 years (relative risk ratios (RRR) = 1.41, p = 0.048), the risk of death was increased by 1.41 times compared to other age groups. Patients aged 55 years and above (RRR = 1.55, p = 0.017), had a risk of dying increased by 1.55 times compared to other age groups. Diagnosis time duration of 8 - 30 days (RRR = 0.62, p = 0.022) was found to be protective, a shorter diagnosis time duration between 8 to 30 days reduced the risk of TB deaths by 0.62 times compared to longer periods. Missed TB doses of > 10% (RRR = 2.03, p < 0.001) increased the risk of MDR/RR-TB deaths by 2.03 times compared to missing TB doses of ≤ 10%.

Conclusion

not being on ART when HIV positive was a major significant predictor of mortality. Improving ART uptake among those ART-naïve and strategies aimed at improving treatment adherence are important in improving treatment success rates.

The role of bacteriological monitoring using culture and drug susceptibility tests (CDST) on treatment outcomes among MDR/RR-TB patients on treatment: a cohort analysis of patients enrolled on treatment 2010-2015 in Zimbabwe

Introduction

an estimated 25% of the world population is infected with Mycobacterium tuberculosis. In 2017, new tuberculosis cases were estimated at 10 million, while 1.6 million tuberculosis related deaths were recorded, 25% residing in Africa. Treatment outcomes of multi drug resistant Tuberculosis patients in Zimbabwe has been well documented but the role of bacteriological monitoring on treatment outcomes has not been systematically evaluated. The objective of the study was to determine the role of bacteriological monitoring using culture and drug susceptibility tests on treatment outcomes among patients with multi drug resistant tuberculosis.

Methods

a retrospective, secondary data analysis was conducted using routinely collected data of patients with multi drug resistant TB in Zimbabwe. Frequencies were used to summarize categorical variables and a generalized linear model with a log-link function and a Poisson distribution was used to assess factors associated with unfavourable outcomes. The level of significance was set at P-Value<0.05.

Results

about the study collected data from 473 records of patients with an average age of 36.35 years. Forty-nine percent (49%) were male and 51% were female. Results showed that when a patient has baseline culture result missing, has no culture conversion result, regardless of having a follow up culture and drug susceptibility test result, the risk of developing unfavourable outcomes increase by 3.9 times compared to a patient who has received all the three (3) bacteriological monitoring tests.

Conclusion

results highlights the need for consistent bacteriological monitoring of patients to avert unfavourable treatment outcomes.

Catastrophic costs among tuberculosis-affected households in Zimbabwe: a national health facility-based survey

OBJECTIVES

To determine the incidence and major drivers of catastrophic costs among TB-affected households in Zimbabwe.

METHODS

We conducted a nationally representative health facility-based survey with random cluster sampling among consecutively enrolled drug-susceptible (DS-TB) and drug-resistant TB (DR-TB) patients. Costs incurred and income lost due to TB illness were captured using an interviewer-administered standardised questionnaire. We used multivariable logistic regression to determine the risk factors for experiencing catastrophic costs.

RESULTS

A total of 841 patients were enrolled and were weighted to 900 during data analysis. There were 500 (56%) males and 46 (6%) DR-TB patients. Thirty-five (72%) DR-TB patients were HIV co-infected. Overall, 80% (95% CI: 77-82) of TB patients and their households experienced catastrophic costs. The major cost driver pre-TB diagnosis was direct medical costs. Nutritional supplements were the major cost driver post-TB diagnosis, with a median cost of US$360 (IQR: 240-600). Post-TB median diagnosis costs were three times higher among DR-TB (US$1,659 [653-2,787]) than drug DS-TB-affected households (US$537 [204-1,134]). Income loss was five times higher among DR-TB than DS-TB patients. In multivariable analysis, household wealth was the only covariate that remained significantly associated with catastrophic costs: The poorest households had 16 times the odds of incurring catastrophic costs versus the wealthiest households (adjusted odds ratio [aOR: 15.7 95% CI: 7.5-33.1]).

CONCLUSION

The majority of TB-affected households, especially those affected by DR-TB, experienced catastrophic costs. Since the major cost drivers fall outside the healthcare system, multi-sectoral approaches to TB control and linking TB patients to social protection may reduce catastrophic costs.

Spatial patterns of pulmonary tuberculosis (TB) cases in Zimbabwe from 2015 to 2018

INTRODUCTION

Accurate mapping of spatial heterogeneity in tuberculosis (TB) cases is critical for achieving high impact control as well as guide resource allocation in most developing countries. The main aim of this study was to explore the spatial patterns of TB occurrence at district level in Zimbabwe from 2015 to 2018 using GIS and spatial statistics as a preamble to identifying areas with elevated risk for prioritisation of control and intervention measures.

METHODS

In this study Getis-Ord Gi* statistics together with SaTscan were used to characterise TB hotspots and clusters in Zimbabwe at district level from 2015 to 2018. GIS software was used to map and visualise the results of cluster analysis.

RESULTS

Results show that TB occurrence exhibits spatial heterogeneity across the country. The TB hotspots were detected in the central, western and southern part of the country. These areas are characterised by artisanal mining activities as well as high poverty levels.

CONCLUSIONS AND RECOMMENDATIONS

Results of this study are useful to guide TB control programs and design effective strategies which are important in achieving the United Nations Sustainable Development goals (UNSDGs).

A feasibility study using time-driven activity-based costing as a management tool for provider cost estimation: lessons from the national TB control program in Zimbabwe in 2018

Background

Insufficient cost data and limited capacity constrains the understanding of the actual resources required for effective TB control. This study used process maps and time-driven activity-based costing to document TB service delivery processes. The analysis identified the resources required to sustain TB services in Zimbabwe, as well as several opportunities for more effective and efficient use of available resources.

Methods

A multi-disciplinary team applied time-driven activity-based costing (TDABC) to develop process maps and measure the cost of clinical pathways used for Drug Susceptible TB (DS-TB) at urban polyclinics, rural district and provincial hospitals, and community based targeted screening for TB (Tas4TB). The team performed interviews and observations to collect data on the time taken by health care worker-patient pairs at every stage of the treatment pathway. The personnel’s practical capacity and capacity cost rates were calculated on five cost domains. An MS Excel model calculated diagnostic and treatment costs.

Findings

Twenty-five stages were identified in the TB care pathway across all health facilities except for community targeted screening for TB. Considerable variations were observed among the facilities in how health care professionals performed client registration, taking of vital signs, treatment follow-up, dispensing medicines and processing samples.

The average cost per patient for the entire DS-TB care was USD324 with diagnosis costing USD69 and treatment costing USD255. The average cost for diagnosis and treatment was higher in clinics than in hospitals (USD392 versus USD256). Nurses in clinics were 1.6 time more expensive than in hospitals. The main cost components were personnel (USD130) and laboratory (USD119). Diagnostic cost in Tas4TB was twice that of health facility setting (USD153 vs USD69), with major cost drivers being demand creation (USD89) and sputum specimen transportation (USD5 vs USD3).

Conclusion

TDABC is a feasible and effective costing and management tool in low-resource settings. The TDABC process maps and treatment costs revealed several opportunities for innovative improvements in the NTP under public health programme settings. Re-engineering laboratory testing processes and synchronising TB treatment follow-up with antiretroviral treatments could produce better and more uniform TB treatments at significantly lower cost in Zimbabwe.

Prevalence, risk factors and treatment outcomes of isoniazid resistant TB in Bulawayo city, Zimbabwe: A cohort study

Introduction:

The isoniazid-resistant TB poses a threat to TB control efforts. Zimbabwe, one of the high TB burden countries, has not explored the burden of isoniazid resistant TB. Hence among all bacteriologically-confirmed TB patients diagnosed in Bulawayo City during March 2017 and December 2018, we aimed to assess the proportion with isoniazid resistant TB and associated factors. Also, we aimed to describe the TB treatment outcomes.

Methodology:

A cohort study involving routinely collected data by the National TB Reference Laboratory (NTBRL) in Bulawayo City and National TB programme of Zimbabwe. The percentage with 95% confidence interval (CI) was used to express the proportion with isoniazid-resistant TB. The modified Poisson regression was used to assess the association of demographic and clinical characteristics with isoniazid mono-resistant TB.

Results:

Of 2160 bacteriologically-confirmed TB patients, 1612 (74.6%) had their sputum received at the NTBRL and 743 (46.1%) had culture growth. Among those with culture growth, 34 (4.6%, 95% CI: 3.5–6.7) had isoniazid mono-resistant TB, 25 (3.3%, 95% CI: 2.2–4.9) had MDR-TB. Thus, 59 (7.9%, 95% CI: 6.1–10.1) had isoniazid-resistant TB. Children < 15 years had a higher prevalence of isoniazid mono-resistant TB (aPR= 3.93; 95% CI: 1.24–12.45). Among those with rifampicin sensitive TB, patients with isoniazid-sensitive TB had higher favourable treatment outcomes compared to those with isoniazid-resistant TB (86.3% versus 75.5%, p = 0.039).

Conclusions:

The prevalence of isoniazid-resistant TB was low compared to neighbouring countries with high burden of TB-HIV. However, Zimbabwe should consider reviewing treatment guidelines for isoniazid mono-resistant TB due to the observed poor treatment outcomes.

Treatment outcomes of multi drug resistant and rifampicin resistant Tuberculosis in Zimbabwe: A cohort analysis of patients initiated on treatment during 2010 to 2015

Background

Zimbabwe is one of the thirty countries globally with a high burden of multidrug-resistant tuberculosis (TB) or rifampicin-resistant TB (MDR/RR-TB). Since 2010, patients diagnosed with MDR/RR-TB are being treated with 20–24 months of standardized second-line drugs (SLDs). The profile, management and factors associated with unfavourable treatment outcomes of MDR/RR TB have not been systematically evaluated in Zimbabwe.

Objective

To assess treatment outcomes and factors associated with unfavourable outcomes among MDR/RR-TB patients registered and treated under the National Tuberculosis Programme in all the district hospitals and urban healthcare facilities in Zimbabwe between January 2010 and December 2015.

Methods

A cohort study using routinely collected programme data. The ‘death’, ‘loss to follow-up’ (LTFU), ‘failure’ and ‘not evaluated’ were considered as “unfavourable outcome”. A generalized linear model with a log-link and binomial distribution or a Poisson distribution with robust error variances were used to assess factors associated with “unfavourable outcome”. The unadjusted and adjusted relative risks were calculated as a measure of association. A 𝑝value< 0.05 was considered statistically significant.

Results

Of the 473 patients in the study, the median age was 34 years [interquartile range, 29–42] and 230 (49%) were males. There were 352 (74%) patients co-infected with HIV, of whom 321 (91%) were on antiretroviral therapy (ART). Severe adverse events (SAEs) were recorded in 118 (25%) patients; mostly hearing impairments (70%) and psychosis (11%). Overall, 184 (39%) patients had ‘unfavourable’ treatment outcomes [125 (26%) were deaths, 39 (8%) were lost to follow-up, 4 (<1%) were failures and 16 (3%) not evaluated]. Being co-infected with HIV but not on ART [adjusted relative risk (aRR) = 2.60; 95% CI: 1.33–5.09] was independently associated with unfavourable treatment outcomes.

Conclusion

The high unfavourable treatment outcomes among MDR/RR-TB patients on standardized SLDs were coupled with a high occurrence of SAEs in this predominantly HIV co-infected cohort. Switching to individualized all oral shorter treatment regimens should be considered to limit SAEs and improve treatment outcomes. Improving the ART uptake and timeliness of ART initiation can reduce unfavourable outcomes.

Trend analysis of tuberculosis case notifications with scale-up of antiretroviral therapy and roll-out of isoniazid preventive therapy in Zimbabwe, 2000-2018

OBJECTIVES

Antiretroviral therapy (ART) and isoniazid preventive therapy (IPT) are known to have a tuberculosis (TB) protective effect at the individual level among people living with HIV (PLHIV). In Zimbabwe where TB is driven by HIV infection, we have assessed whether there is a population-level association between IPT and ART scale-up and annual TB case notification rates (CNRs) from 2000 to 2018.

DESIGN

Ecological study using aggregate national data.

SETTING

Annual aggregate national data on TB case notification rates (stratified by TB category and type of disease), numbers (and proportions) of PLHIV in ART care and of these, numbers (and proportions) ever commenced on IPT.

RESULTS

ART coverage in the public sector increased from <1% (8400 PLHIV) in 2004 to ~88% (>1.1 million PLHIV patients) by December 2018, while IPT coverage among PLHIV in ART care increased from <1% (98 PLHIV) in 2012 to ~33% (373 917 PLHIV) by December 2018. These HIV-related interventions were associated with significant declines in TB CNRs: between the highest CNR prior to national roll-out of ART (in 2004) to the lowest recorded CNR after national IPT roll-out from 2012, these were (1) for all TB case (510 to 173 cases/100 000 population; 66% decline, p<0.001); (2) for those with new TB (501 to 159 cases/100 000 population; 68% decline, p<0.001) and (3) for those with new clinically diagnosed PTB (284 to 63 cases/100 000 population; 77.8% decline, p<0.001).

CONCLUSIONS

This study shows the population-level impact of the continued scale-up of ART among PLHIV and the national roll-out of IPT among those in ART care in reducing TB, particularly clinically diagnosed TB which is largely associated with HIV. There are further opportunities for continued mitigation of TB with increasing coverage of ART and in particular IPT which still has a low coverage.

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>.

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.

How well does the process of screening and diagnosis work for HIV-infected persons identified with presumptive tuberculosis who are attending HIV care and treatment clinics in Harare city, Zimbabwe?

Background

Intensified TB case finding is recommended for all HIV-infected persons regularly attending HIV care and treatment clinics. The authors aimed to determine how well this system worked among HIV-infected patients diagnosed with presumptive TB in 14 health facilities of Harare province, Zimbabwe, between January and December 2016.

Methods

Retrospective review using routine programme records.

Results

Of 47 659 HIV-infected persons enrolled in HIV care, 102 were identified with presumptive TB through the programmatic electronic database. Of these, 23% (23/102) were recorded in presumptive TB registers and, of these 65% (15/23) were traced to laboratory registers. Of 79 patients not recorded in presumptive TB registers, 9% (7/79) were traced to laboratory registers. Of 22 patients in the laboratory register, all had negative sputum smears for acid-fast bacilli and 45% (10/22) had Xpert MTB/RIF assays with one positive result. Six patients altogether started anti-tuberculosis treatment, the median time from presumptive tuberculosis diagnosis to treatment being 12 days. The only significant risk factor for loss-to-follow-up between presumptive TB diagnosis and laboratory registration was not being recorded in presumptive TB registers.

Conclusions

Follow-up mechanisms for presumptive TB cases diagnosed in HIV care clinics in Harare city need strengthening, particularly through improved documentation in presumptive TB registers and better Xpert MTB/RIF use.

Targeted active screening for tuberculosis in Zimbabwe: are field digital chest X-ray ratings reliable?

SETTING

Fifteen purposively selected districts in Zimbabwe in which targeted active screening for tuberculosis (Tas4TB) was conducted among TB high-risk groups (HRGs). There were 230 patients started on TB treatment on the basis of chest X-ray (CXR) results without corresponding bacteriological confirmation.

OBJECTIVES

To determine 1) the percentage of agreements in digital CXR ratings by medical officers against final ratings by radiologist(s), 2) inter-rater agreement in CXR ratings between medical officers and radiologists, and 3) number (and proportion) of patients belonging to HRGs who were over-treated during Tas4TB.

DESIGN

This was a cross-sectional study using programme data.

RESULTS

A total of 168 patients had their CXRs rated by two independent radiologists. Discordances among the radiologists were resolved by a third index radiologist, who provided the final rating. κ scores were 0.01 (field ratings vs. Radiologist A); 0.02 (field ratings vs. Radiologist B); 0.74 (Radiologists A vs. B). The percentage agreement for field and final radiologist rating was 70% (95%CI 64-78). Around 29% (95%CI 23-36) of the patients were potentially over-treated during Tas4TB.

CONCLUSION

Over a quarter of patients with presumptive TB are potentially over-treated during Tas4TB. Over-treatment is highest among those with previous contact with TB patients. Trainings of radiographers and medical officers may improve CXR ratings.

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.

Access to second-line drug susceptibility testing results among patients with Rifampicin resistant tuberculosis after introduction of the Hain® Line Probe Assay in Southern provinces, Zimbabwe

OBJECTIVES

To determine the proportion of rifampicin-resistant tuberculosis (RR-TB) patients who accessed second-line drug susceptibility testing (SL-DST) results following introduction of the Hain technology in southern provinces, Zimbabwe.

DESIGN

Cohort study using secondary data.

RESULTS

Xpert MTB/RIF results were used to identify 133 RR-TB patients for this study. Their mean age (SD) was 37.9 (11.1) years, 83 (62%) were males and 106 (80%) were HIV-infected. There were 6 (5%) participants who had pre-treatment attrition. Of the 133 pulmonary TB (PTB) patients, 117 (80%) had additional sputum specimens collected; 96 (72%) specimens reached the National TB Reference Laboratory (NTBRL); 95 (71%) were processed; 68 (51%) had SL-DST results. Only 53 (40%) SL-DST results reached the peripheral facilities. Median time from specimen reception at the NTBRL to SL-DSTs was 40 days, interquartile range (IQR: 28-67). Median time from presumptive diagnosis of RR-TB by health care worker to SL-DST results was 50days (IQR: 39-80), and increased to 79days (IQR: 39-101) in facilities >250km from the NTBRL. The proportion with any fluoroquinolone resistance was 9 (13.2%).

CONCLUSION

Although RR-TB patients with PTB were initiated timely on treatment, access to SL-DSTs by facilities needs improvement. Health inequities exist as remote areas are less likely to get SL-DST results in time.

Has the utilisation of Xpert® MTB/RIF in Manicaland Province, Zimbabwe, improved with new guidance on whom to test?

Setting: Manicaland Province, Zimbabwe. Objectives: To compare the utilisation and results of deploying Xpert^® MTB/RIF in 13 (one provincial, six district and six rural) hospitals between January and June 2016, when Xpert was recommended only for those with presumptive multidrug-resistant tuberculosis (MDR-TB) and coinfection with human immunodeficiency virus (HIV), and between January and June 2017, when Xpert was recommended for all presumptive TB patients. Design: This was a cross-sectional study. Results: Xpert assays averaged 759 monthly in 2016 and 1430 monthly in 2017 (88% increase). Utilisation of Xpert averaged 22% monthly in 2016 and 42% in 2017 (88% increase). In 2017, utilisation of Xpert was significantly higher in provincial (82%) than in district (51%) and rural (26%) hospitals (P < 0.001). The proportion of successful assays that detected TB decreased significantly from 13% in 2016 to 7% in 2017 (a 46% decrease, P < 0.001); this phenomenon was observed in all types of hospital. The proportion of persons detected with rifampicin-resistant TB was similar between hospitals (4% in 2016 and 3% in 2017). The proportion of registered TB cases with bacteriological confirmation increased from 48% in 2016 to 53% in 2017 (P = 0.04). Conclusion: Xpert use in all presumptive TB patients led to a significant increase in assay numbers and utilisation of Xpert instruments, resulting in more bacteriological confirmation of cases.

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.

How has the Zimbabwe mycobacterial culture and drug sensitivity testing system among re-treatment tuberculosis patients functioned during the scale-up of the Xpert MTB/RIF assay?

Background

In Zimbabwe, while the Xpert MTB/RIF assay is being used for diagnosing tuberculosis and rifampicin-resistance, re-treatment tuberculosis (TB) patients are still expected to have culture and drug sensitivity testing (CDST) performed at national reference laboratories for confirmation. The study aim was to document the Xpert MTB/RIF assay scale-up and assess how the CDST system functioned for re-treatment TB patients.

Methods

We performed an ecologic study using national aggregate data.

Results

Use of the Xpert MTB/RIF assay increased from 11 829 to 68 153 between 2012 and 2016. Xpert assays worked well, with successful tests in more than 90% of cases, TB detection rates at 15–17% and rifampicin resistance in <10%. During Xpert scale-up, the number of sputum specimens from re-treatment TB patients reaching national reference laboratories for CDST increased from 12% to 51%. In terms of laboratory performance, culture contamination increased from 3% to 17%, positive cultures from 13% to 17% and successful CDST from 6% to 14%: the proportion of CDST showing any resistance to rifampicin averaged 44%. From 2009 to 2016, the proportion of notified re-treatment TB patients with successful CDST increased from <1% to 7%.

Conclusions

While components of Zimbabwe’s CDST system for re-treatment TB patients showed some changes during the scale-up of the Xpert MTB/RIF assay, overall performance was poor. The country must either invest in improving CDST performance or in advanced molecular diagnostic technology.

Xpert(®) MTB/RIF detection of rifampin resistance and time to treatment initiation in Harare, Zimbabwe

BACKGROUND

Patients at elevated risk of drug-resistant tuberculosis (TB) are prioritized for Xpert(®) MTB/RIF testing; however, the clinical usefulness of the test in this population is understudied.

DESIGN

From November 2011 to June 2014, consecutive out-patients with a history of previous TB in high-density suburbs of Harare, Zimbabwe, were tested using Xpert, solid and liquid culture, and the microscopic observation drug susceptibility assay. Diagnostic accuracy for rifampin (RMP) resistance and time to initiation of second-line regimens were ascertained. The rpoB gene was sequenced in cases with culture-confirmed RMP resistance and genotypic susceptibility.

RESULTS

Among 352 retreatment patients, 71 (20%) were RMP-resistant, 98 (28%) RMP-susceptible, 64 (18%) culture-negative/Xpert-positive, and 119 (34%) culture-negative/Xpert-negative. Xpert had a sensitivity of 86% (95%CI 75-93) and a specificity of 98% (95%CI 92-100) for RMP-resistant TB. The positive predictive value of Xpert-determined RMP resistance for multidrug-resistant TB (MDR-TB) was 82% (95%CI 70-91). Of 71 (83%) participants, 59 initiated treatment with second-line drugs, with a median time to treatment initiation of 18 days (IQR 10-44).

CONCLUSION

The diagnostic accuracy of Xpert for RMP resistance is high, although the predictive value for MDR-TB was lower than anticipated. Xpert allows for faster initiation of second-line treatment than culture-based drug susceptibility testing under programmatic conditions.

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.

Trends of sputum-smear positive tuberculosis in Zimbabwe: 2008-2011

BACKGROUND

Tuberculosis (TB) has remained one of the major public health problems in Zimbabwe with an estimated incidence rate of 552 per 100,000 persons in 2013. The aim of this study was to describe the trends in acid-fast bacilli (AFB) sputum-smear positive (SSP) TB overall and within subpopulations for the period during 2008-2011 in Zimbabwe. Results of this study will contribute towards the evaluation and implementation of targeted TB control interventions.

METHODS

A cross-sectional study design was used to analyze 40, 110 SSP TB patient records routinely collected during 2008-2011. Incidence trends of SSP TB were described by province, sex, and age group. A Mantel-Haenszel Chi Statistic was calculated to compare each provincial SSP TB notification rate to the national SSP TB notification rate.

RESULTS

SSP TB notification rates were higher in the two main urban provinces, the western provinces and Manicaland. The 25-44 year age group accounted for the largest proportion of notified SSP TB. However, the 55-64 year and 65+ age groups had SSP TB notification rates in 2011 higher than the 2008 value. Finally, the average SSP TB notification rate in males was 23% higher than in females.

CONCLUSION

The findings of this study suggest that TB control has successfully decreased the notification rate of SSP TB in Zimbabwe during 2008-2011. However, the disproportionate distribution of SSP TB among different regions and subpopulations of the country highlights the need for more targeted interventions to accelerate the decline of TB in Zimbabwe.

Tuberculosis treatment delays and associated factors within the Zimbabwe national tuberculosis programme

BACKGROUND

Delayed presentation of pulmonary TB (PTB) patients for treatment from onset of symptoms remains a threat to controlling individual disease progression and TB transmission in the community. Currently, there is insufficient information about treatment delays in Zimbabwe, and we therefore determined the extent of patient and health systems delays and their associated factors in patients with microbiologically confirmed PTB.

METHODS

A structured questionnaire was administered at 47 randomly selected health facilities in Zimbabwe by trained health workers to all patients aged ≥18 years with microbiologically confirmed PTB who were started on TB treatment and entered in the health facility TB registers between 01 January and 31 March 2013. Multivariate logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CIs) for associations between patient/health system characteristics and patient delay >30 days or health system delay >4 days.

RESULTS

Of the 383 recruited patients, 211(55%) were male with an overall median age of 34 years (IQR, 28-43). There was a median of 28 days (IQR, 21-63) for patient delays and 2 days (IQR, 1-5) for health system delays with 184 (48%) and 118 (31%) TB patients experiencing health system delays >30 days and health system delays >4 days respectively. Starting TB treatment at rural primary healthcare vs district/mission facilities [aOR 2.70, 95% CI 1.27-5.75, p = 0.01] and taking self-medication [aOR 2.33, 95% CI 1.23-4.43, p = 0.01] were associated with encountering patient delays. Associated with health system delays were accessing treatment from lower level facilities [aOR 2.67, 95% CI 1.18-6.07, p = 0.019], having a Gene Xpert TB diagnosis [aOR 0.21, 95% CI 0.07-0.66, p = 0.008] and >4 health facility visits prior to TB diagnosis [(aOR) 3.34, 95% CI 1.11-10.03, p = 0.045].

CONCLUSION

Patient delays were longer and more prevalent, suggesting the need for strategies aimed at promoting timely seeking of appropriate medical consultation among presumptive TB patients. Health system delays were uncommon, suggesting a fairly efficient response to microbiologically confirmed PTB cases. Identified risk factors should be explored further and specific strategies aimed at addressing these factors should be identified in order to lessen patient and health system delays.

Drug-resistant tuberculosis in high-risk groups, Zimbabwe

To estimate prevalence of multidrug-resistant tuberculosis (MDR TB) in Harare, Zimbabwe, in 2012, we performed microbiologic testing on acid-fast bacilli smear-positive sputum samples from patients previously treated for TB. Twenty (24%) of 84 specimens were consistent with MDR TB. A national drug-resistance survey is needed to determine MDR TB prevalence in Zimbabwe.

Does the type of treatment supporter influence tuberculosis treatment outcomes in Zimbabwe?

Zimbabwe National Tuberculosis Guidelines advise that direct observation of anti-tuberculosis treatment (DOT) can be provided by a family member/relative as a last resort. In 2011, in Nkayi District, of 763 registered tuberculosis (TB) patients, 59 (8%) received health facility-based DOT, 392 (51%) received DOT from a trained community worker and 306 (40%) from a family member/relative. There were no differences in TB treatment outcomes between the three DOT groups, apart from a higher frequency rate of 'no reported outcomes' for those receiving family-based DOT. Family members should be trained to use a suitable DOT support package.

Characteristics and treatment outcomes of tuberculosis patients who "transfer-in" to health facilities in Harare City, Zimbabwe: a descriptive cross-sectional study

Background

Zimbabwe is among the 22 Tuberculosis (TB) high burden countries worldwide and runs a well-established, standardized recording and reporting system on case finding and treatment outcomes. During TB treatment, patients transfer-out and transfer-in to different health facilities, but there are few data from any national TB programmes about whether this process happens and if so to what extent. The aim of this study therefore was to describe the characteristics and outcomes of TB patients that transferred into Harare City health department clinics under the national TB programme. Specific objectives were to determine i) the proportion of a cohort of TB patients registered as transfer-in, ii) the characteristics and treatment outcomes of these transfer-in patients and iii) whether their treatment outcomes had been communicated back to their respective referral districts after completion of TB treatment.

Methods

Data were abstracted from patient files and district TB registers for all transfer-in TB patients registered from January to December 2010 within Harare City. Descriptive statistics were calculated.

Results

Of the 7,742 registered TB patients in 2010, 263 (3.5%) had transferred-in: 148 (56%) were males and overall median age was 33 years (IQR, 26–40). Most transfer-in patients (74%) came during the intensive phase of TB treatment, and 58% were from rural health-facilities. Of 176 patients with complete data on the time period between transfer-in and transfer-out, only 85 (48%) arrived for registration in Harare from referral districts within 1 week of being transferred-out. Transfer-in patients had 69% treatment success, but in 21% treatment outcome status was not evaluated. Overall, 3/212 (1.4%) transfer-in TB patients had their TB treatment outcomes reported back to their referral districts.

Conclusion

There is need to devise better strategies of following up TB patients to their referral Directly Observed Treatment (DOT) centres from TB diagnosing centres to ensure that they arrive promptly and on time. Recording and reporting of information must improve and this can be done through training and supervision. Use of mobile phones and other technology to communicate TB treatment outcomes back to the referral districts would seem the obvious way to move forward on these issues.

ART uptake, its timing and relation to anti-tuberculosis treatment outcomes among HIV-infected TB patients

SETTING

All public health facilities in two provinces of Zimbabwe.

OBJECTIVE

To determine, among tuberculosis (TB) patients with human immunodeficiency virus (HIV) registered in 2010, 1) the proportion started on antiretroviral treatment (ART), 2) the timing of ART in relation to the start of anti-tuberculosis treatment, and 3) whether timing of ART influenced anti-tuberculosis treatment outcomes.

DESIGN

Retrospective cohort study.

RESULTS

Of the 2655 HIV-positive TB patients, 1115 (42%) were documented as receiving ART. Of these, 178 (16%) started ART prior to anti-tuberculosis treatment. Of those who started after anti-tuberculosis treatment, 17% started within 2 weeks, 43% between 2 and 8 weeks and 40% after 8 weeks. Treatment success in the cohort was 82%, with 14% deaths before completion of anti-tuberculosis treatment. Not receiving ART during anti-tuberculosis treatment was associated with lower anti-tuberculosis treatment success (adjusted RR 0.70, 95%CI 0.53-0.91) and more deaths (adjusted RR 3.43, 95%CI 2.2-5.36). There were no differences in TB treatment outcomes by timing of ART initiation.

CONCLUSION

ART uptake is low given the improved treatment outcomes in those put on ART during anti-tuberculosis treatment. Better integration of HIV and TB services is needed to ensure increased coverage and earlier ART uptake.

Treatment outcomes of adult patients with recurrent tuberculosis in relation to HIV status in Zimbabwe: a retrospective record review

Background

Zimbabwe is a Southern African country with a high HIV-TB burden and is ranked 19^th among the 22 Tuberculosis high burden countries worldwide. Recurrent TB is an important problem for TB control, yet there is limited information about treatment outcomes in relation to HIV status. This study was therefore conducted in Chitungwiza, a high density dormitory town outside the capital city, to determine in adults registered with recurrent TB how treatment outcomes were affected by type of recurrence and HIV status.

Methods

Data were abstracted from the Chitungwiza district TB register for all 225 adult TB patients who had previously been on anti-TB treatment and who were registered as recurrent TB from January to December 2009. The Chi-square and Fischer's exact tests were used to establish associations between categorical variables. Multivariate relative risks for associations between the various TB treatment outcomes and HIV status, type of recurrent TB, sex and age were calculated using Poisson regression with robust error variance.

Results

Of 225 registered TB patients with recurrent TB, 159 (71%) were HIV tested, 135 (85%) were HIV-positive and 20 (15%) were known to be on antiretroviral treatment (ART). More females were HIV-tested (75/90, 83%) compared with males (84/135, 62%). There were 103 (46%) with relapse TB, 32 (14%) with treatment after default, and 90 (40%) with "retreatment other" TB. There was one failure patient. HIV-testing and HIV-positivity were similar between patients with different types of TB. Overall, treatment success was 73% with transfer-outs at 14% being the most common adverse outcome. TB treatment outcomes did not differ by HIV status. However those with relapse TB had better treatment success compared to "retreatment other" TB patients, (adjusted RR 0.81; 95% CI 0.68 - 0.97, p = 0.02).

Conclusions

No differences in treatment outcomes by HIV status were established in patients with recurrent TB. Important lessons from this study include increasing HIV testing uptake, a better understanding of what constitutes "retreatment other" TB, improved follow-up of true outcomes in patients who transfer-out and better recording practices related to HIV care and treatment especially for ART.

Treatment outcomes of new adult tuberculosis patients in relation to HIV status in Zimbabwe

SETTING

All public health facilities in Chitungwiza District, Zimbabwe.

OBJECTIVE

To determine, in new tuberculosis (TB) patients registered in 2009, 1) the proportion of persons human immunodeficiency virus (HIV) tested, stratified by age, sex and type of TB, and 2) treatment outcomes in relation to type of TB and HIV status.

DESIGN

Retrospective cohort study.

RESULTS

Of 1800 TB patients, 1100 (61%) were tested, of whom 877 (80%) were HIV-positive and 75 (9%) were documented as receiving antiretroviral treatment (ART). HIV testing and HIV positivity were similar between patients with different types of TB. Overall, the treatment success rate was 70%, and 17% had transferred out. Being HIV-positive on ART was associated with better treatment success and lower transfer out; age ≥55 years was associated with poor treatment success and higher death rates. Defaulting was more common in those who did not undergo smear testing or in extra-pulmonary TB patients, while deaths were higher in males.

CONCLUSION

In a Zimbabwe district, less than two thirds of TB patients were tested. Better treatment success was observed in patients documented as HIV-positive and on ART. Important lessons for improved TB control include increasing HIV testing uptake for better access to ART, more comprehensive recording practices on ART and better reporting on true outcomes of transfer-out patients.

Mild Optic Nerve Hypoplasia with Retinal Venous Tortuosity in Aarskog (Facial-Digital-Genital) Syndrome

Aarskog syndrome (faciogenital dysplasia) is an X-linked recessive genetic growth disorder characterized by short stature, dysmorphic facies, shawl scrotum, and digital anomalies. The condition was first described in 1970 and the gene responsible is FGD1 (MIM#305400). There are several reported ophthalmic findings associated with Aarskog syndrome which are discussed. We describe a case of Aarskog syndrome with venous tortuosity, optic nerve hypoplasia, and a type-2 antithrombin deficiency.

Bilateral chronic fungal dacryocystitis caused by Candida dubliniensis in a neutropenic patient

In recent years, candida species other than Candida albicans have emerged as causes of human candidiasis, particularly in HIV-infected and other immunocompromised people. C. dubliniensis, a recently described species closely related to C. albicans, first isolated from patients with AIDS in Dublin, has been implicated as an agent of oral candidiasis in HIV-positive people. However, it has also been recovered from HIV-negative people, with clinical signs of oral candidiasis and from the genital tract of some women with vaginitis. The first case of bilateral chronic fungal dacryocystitis caused by C. dubliniensis is described in an HIV-negative woman.

Lax eyelid syndrome or 'progeria' of eyelid tissues

PURPOSE

The lax eyelid syndrome was described by Van den Bosch and Lemij as an uncommon disorder seen in non-obese elderly people and characterised by chronic ocular surface irritation symptoms and a "floppy upper eyelid". The authors present some new features of the lax eyelid syndrome.

METHODS

The authors report five patients, belonging to a younger age group, who presented with premature laxity of all the eyelid tissues. This caused medial and lateral canthal dystopia and eyelid malposition including ptosis, entropion and ectropion. Initial surgical correction was often followed by recurrence after some time.

CONCLUSIONS

The authors highlight the differences between lax eyelid syndrome, cutis laxa, floppy eyelid syndrome and the blepharochalasis syndrome and suggest that lax eyelid syndrome can be thought of as "progeria" or premature ageing of the eyelid tissues to distinguish it clearly from these other conditions.

Clinical and radiologic characteristics of the imploding antrum, or "silent sinus," syndrome

OBJECTIVES

To present the clinical and radiologic details of a series of patients with the imploding antrum, or silent sinus, syndrome, together with examples of the surgical findings and management.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

Fourteen patients assessed in the Orbital Service at Moorfields Eye Hospital.

MAIN OUTCOME MEASURES

Changes of clinical signs, symptoms, and radiologic signs.

RESULTS

Seven men and seven women, between the ages of 25 and 78 years (mean, 41.3 years), had unilateral enophthalmos, their having noted the anomaly for an average of 8 months (range, 1-36 months). All patients were nonsmokers. There was no evidence of progression of the condition in eight cases followed up for up to 63 months. On the affected side, there was 1 to 4 mm enophthalmos and up to 4 mm hypoglobus, with secondary narrowing of the vertical palpebral aperture in some cases, but no effect on visual function, and there was significant disturbance of ocular motility in only one case. The condition is characterized radiologically by a smooth inward bowing of the walls of the maxillary antrum on the affected side, with secondary enophthalmos and hypoglobus. In all 14 cases, the maxillary roof (orbital floor) was drawn downwards, and the medial and posterolateral walls of the maxilla were concave in 13 cases where it could be assessed. In one patient, there was associated inward collapse of the ipsilateral ethmoid complex. There was a patchy loss of mineral from the maxillary roof in 9 of 13 cases and, where the posterolateral maxillary wall was affected, there was a concomitant increase in the radiolucency (fat) of the pterygopalatine fossa. Some soft-tissue changes were present in the affected antrum in all 14 patients, and there was an air-fluid level in three patients. In 12 patients where septal deviation was present, this was to the affected side in 10 (83%), and an abnormally directed middle turbinate was also frequently observed (10 of 14 cases).

CONCLUSIONS

The silent sinus syndrome mainly presents as unilateral enophthalmos in younger people and has very characteristic clinical and radiologic signs with, in many cases, abnormal intranasal anatomic characteristics on the affected side. The condition may be exclusive to nonsmokers. The acute onset and long-term stability of the condition suggests that, although chronic and largely asymptomatic sinus disease may be the underlying cause, an acute event precipitates collapse of the orbital floor or (in fact) a widespread "implosion" of all antral walls resulting from maxillary atelectasis. Therefore, we prefer the term imploding antrum syndrome-describing the relatively acute, symptomatic, event-rather than the name silent sinus syndrome, which relates to a putative underlying mechanism.

Primary orbital melanoma masquerading as vascular anomalies

PURPOSE

To review two cases of primary orbital melanoma presenting like orbital vascular anomalies.

METHODS

Retrospective review of clinical presentation, treatment, radiology and pathology for two patients under the care of the Orbital Clinic at Moorfields Eye Hospital.

RESULTS

Both lesions presented with the appearance and behaviour of vascular anomalies. In one case, a spindle cell melanoma appeared to be a low flow vascular anomaly with a loculated secondary haemorrhage and, in the other case, a melanoma of soft parts was considered to be an arteriovenous malformation and responded partially to embolisation.

CONCLUSION

Primary malignant melanoma may present as a secondary vascular lesion of the orbit and this very rare tumour should be considered in the differential diagnosis of any vascular anomaly.