Risk factors for unfavourable treatment outcome among new smear-positive pulmonary tuberculosis cases in China

Setting: Three projects of the Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB. Objectives: To assess unfavourable treatment outcomes (UTOs), including failure, died, loss to follow-up (LTFU), transferred out and unknown outcome, and to identify risk factors associated with UTOs. Design: This was a cross-sectional study using routine programme data. Results: Of 30 277 new smear-positive tuberculosis (TB) patients, 4261 (14.1%) had UTOs: 2048 (6.8%) LTFU, 1418 (4.7%) transferred out, 390 (1.3%) died, 340 (1.1%) failed and 65 (0.2%) had an unknown outcome. Risk factors for LTFU (including LTFU, transfer out and unknown outcome) were residing in Anhui, age > 55 years, service delay > 10 days, patient delay < 30 days, directly observed treatment (DOT) provided by a family member or others and unknown DOT provider. The outcome of 'died' was associated with residing in Shaanxi, age > 55 years, male sex, patient delay > 30 days and unknown DOT provider. 'Failed' was associated with having unlimited access to health services, patient delay of >30 days and unknown DOT provider. Conclusion: This study highlights the predominance of lost patients among UTOs. Patients with family members or other non-medical DOT providers or unknown DOT providers had a high risk of a UTO. There is an urgent need to address these service-related factors.

Success of active tuberculosis case detection among high-risk groups in urban slums in Pakistan

BACKGROUND

In Pakistan, patients with symptoms suggestive of tuberculosis (TB) seek care from a wide array of health care providers, many of whom do not notify cases to the National TB Programme (NTP).

SETTING

We evaluated an active case detection intervention in five randomly selected districts in urban slums of Sindh Province, Pakistan.

OBJECTIVE

To evaluate the increase in case notification of smear-positive TB by active case finding at community-based chest camps by engaging the private providers.

DESIGN

A cross-sectional study of TB case detection associated with a project using integrated intervention and chest camps.

RESULTS

From April 2011 to September 2012, the total number of clients seen in the camps was 165 280. Of all the attendees, 13 481 (12.7%) were examined by sputum smear microscopy. The proportion of smear-positive results was significantly higher among those from engaged private providers than among those referred from camps (OR 1.54, 95%CI 1.42-1.66). During the project, the total number of smear-positive TB notifications increased over the intervention period from 5158 to 8275.

CONCLUSION

Active case detection by engaging private providers and chest camps can significantly increase the number of smear-positive TB case notifications.

Can the number of patients with presumptive tuberculosis lost in the general health services in Pakistan be reduced?

The frequency of patients with presumptive tuberculosis (TB) who are not investigated by sputum smear microscopy is unknown in Pakistan. Using a simple intervention comparing patient and laboratory registers, patients with presumptive TB were identified in two districts from July to December 2013, a list of missing patients was prepared and the patients traced. The intervention significantly reduced the number of patients with presumptive TB lost, from 8.5% before the intervention to 6.9% after. A systematic comparison of out-patient and laboratory registers, followed by tracing missing persons, can reduce the proportion of patients with presumptive TB lost before diagnosis.

Investigation of presumptive tuberculosis cases by private health providers: lessons learnt from a survey in Pakistan

Pakistan's National Tuberculosis Control Programme (NTP) is missing data on many tuberculosis (TB) cases who visit private providers. A survey on the incidence and under-reporting of TB in Pakistan provided a database for exploring the investigation and referral of presumptive TB cases by private health providers. The survey showed that private health providers requested both sputum smear and X-ray for diagnostic investigations. Of 2161 presumptive TB cases referred, 1189 (55%) were sent for investigations to a district NTP TB centre, of whom only 314 (26.4%) were registered. This indicates an urgent need to strengthen the link between private health providers and NTP to enhance TB notification.

The Structured Operational Research and Training Initiative for public health programmes

In 2009, the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins sans Frontières Brussels-Luxembourg (MSF) began developing an outcome-oriented model for operational research training. In January 2013, The Union and MSF joined with the Special Programme for Research and Training in Tropical Diseases (TDR) at the World Health Organization (WHO) to form an initiative called the Structured Operational Research and Training Initiative (SORT IT). This integrates the training of public health programme staff with the conduct of operational research prioritised by their programme. SORT IT programmes consist of three one-week workshops over 9 months, with clearly-defined milestones and expected output. This paper describes the vision, objectives and structure of SORT IT programmes, including selection criteria for applicants, the research projects that can be undertaken within the time frame, the programme structure and milestones, mentorship, the monitoring and evaluation of the programmes and what happens beyond the programme in terms of further research, publications and the setting up of additional training programmes. There is a growing national and international need for operational research and related capacity building in public health. SORT IT aims to meet this need by advocating for the output-based model of operational research training for public health programme staff described here. It also aims to secure sustainable funding to expand training at a global and national level. Finally, it could act as an observatory to monitor and evaluate operational research in public health. Criteria for prospective partners wishing to join SORT IT have been drawn up.

Patient delay in the diagnosis and treatment of tuberculosis in China: findings of case detection projects

OBJECTIVE

1) To assess patient delay among new smear-positive pulmonary tuberculosis (PTB) patients in accessing health services in seven FIDELIS (Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB) projects from 2003 to 2008 in China; 2) to compare treatment delay by province; and 3) to assess factors associated with delay.

METHOD

Records of new smear-positive PTB patients were reviewed. Data sources were the consultation book, laboratory register, patient record, treatment card and the PWLAHS (people with limited access to health services) evaluation form. Data were collected using a standard questionnaire, cross-checked by staff from the sites and by the International Union Against Tuberculosis and Lung Disease (The Union) and analysed by The Union.

RESULTS

Of the 75 401 new smear-positive PTB patients included in the study, 63-89% were PWLAHS. The average gross domestic product of the project sites and at national level were respectively US$557 and US$998. The median patient delay was 93 days (range 68-128). Delays were longer among females, older patients, rural residents and PWLAHS. Delayed access to health services was significantly associated with a greater number of symptoms.

CONCLUSION

Patient delay in accessing health care in China was lengthy; TB care and control needs to be improved.

Notified tuberculosis among Singapore residents by ethnicity, 2002-2011

SETTING

The National Tuberculosis Programme in Singapore where, among resident cases, higher tuberculosis (TB) rates have been reported in ethnic Malays.

OBJECTIVE

To describe the socio-demographic and clinical characteristics of resident TB cases by ethnicity, and to assess whether Malays differ from other groups in terms of the above parameters.

DESIGN

Cross-sectional review of records from the tuberculosis registry's electronic database.

RESULTS

Among 15 622 resident cases notified, 72.2% were Chinese, 18.7% Malay, 5.8% Indian and 2.9% were from other minorities. Compared to other ethnicities, Malays were more likely to be incarcerated at the time of notification (odds ratio [OR] 3.70, 95%CI 3.03-4.52) and clustered at the same residential address (OR 1.65, 95%CI 1.44-1.89), but were less likely to be aged ≥65 years (OR 0.61, 95%CI 0.54-0.70) or to reside in high-cost housing (OR 0.11, 95%CI 0.07-0.17). In terms of disease characteristics, more Malays had diabetes mellitus (OR 1.54, 1.37-1.73), a highly-positive acid-fast bacilli smear (OR 1.64, 95%CI 1.47-1.83) and cavitary disease on chest X-ray (OR 1.41, 95%CI 1.28-1.55).

CONCLUSION

Compared to other ethnicities, reported TB cases among Malays were more severe and were likely to be more infectious. Increased vigilance in case management and contact investigations, as well as an improvement in the socio-economic conditions of this community, are required to reduce TB rates in this ethnic group.

High quit rate among smokers with tuberculosis in a modified smoking cessation programme in Dhaka, Bangladesh

SETTING

BRAC, a non-governmental organisation, implemented a modified smoking cessation programme for tuberculosis (TB) patients based on International Union Against Tuberculosis and Lung Disease (The Union) guidelines in 17 peri-urban centres of Dhaka, Bangladesh.

OBJECTIVE

To determine whether a modified version of The Union's smoking cessation intervention was effective in promoting cessation among TB patients and determinants associated with quitting smoking.

DESIGN

Cohort study of routinely collected data.

RESULTS

A total of 3134 TB patients were registered from May 2011 to April 2012. Of these, 615 (20%) were current smokers, with a mean age of 38 years (±13.8). On treatment completion, 562 patients were analysed, with 53 (9%) lost to follow-up or dead, while 82% of smokers had quit. Patients with extra-pulmonary TB were less likely to quit than those with pulmonary TB. Patients with high-intensity dependence were less likely to quit than those with low-intensity dependence.

CONCLUSION

This study suggests that a simplified smoking cessation intervention can be effective in promoting smoking cessation among TB patients in Bangladesh. This is encouraging for other low-resource settings; the Bangladesh National Tuberculosis Control Programme should consider nationwide scaling up and integration of this smoking cessation plan.

Effectiveness of a community-based observation of anti-tuberculosis treatment in Bangalore City, India, 2010-2011

SETTING

The Revised National Tuberculosis Control Programme in an urban setting of Bangalore City, India.

OBJECTIVES

To compare treatment outcomes and smear conversion rates among new smear-positive tuberculosis (TB) patients undergoing treatment administered by community directly observed treatment (DOT) providers with those undergoing treatment administered by institutional DOT providers in Bangalore City in 2010-2011.

METHOD

Cohort study of routine data recorded from treatment cards of TB patients undergoing treatment under the public health services from 1 October 2010 to 30 September 2011.

RESULT

Treatment records of 1864 new smear-positive TB patients registered during this period were evaluated. Among those evaluated, 604 (32%) had been administered treatment by community DOT providers and the remainder by institutional DOT providers. The treatment success rate in those undergoing community DOT was 93% (n = 564) and that of those undergoing institutional DOT was 75% (n = 951; RR 1.23, 95%CI 1.19-1.28). The sputum smear conversion rate of patients who underwent community DOT was 92% and that of those who underwent institutional DOT was 71% at the end of 2 months.

CONCLUSION

We conclude that community DOT for treatment supervision of TB patients is more effective than institutional DOT and that it should be reinforced.

Routine programmatic delivery of isoniazid preventive therapy to children in Cape Town, South Africa

SETTING

Fourteen primary health care facilities in Cape Town, South Africa.

OBJECTIVE

To determine the proportion and characteristics of infectious adult tuberculosis (TB) cases that identify children aged <5 years who qualify for isoniazid preventive therapy (IPT), and to determine the proportion of children who initiate and complete IPT.

DESIGN

A retrospective clinical record review conducted as a stratified cluster survey.

RESULTS

Of 1179 records of infectious adult cases, 33.3% had no documentation of contacts. Of the remaining 786 records, 525 contacts aged <5 years were identified, representing 0.7 child contacts per infectious adult case. Older age, male, human immunodeficiency virus (HIV) positive, smear-negative and retreatment TB cases were all associated with no documentation of contacts. Of the 525 child contacts identified, less than half were screened for TB, 141 initiated IPT and 19 completed it.

CONCLUSION

Less than 67% of infectious TB case records had documentation of contacts. Younger, female, HIV-negative and new smear-positive TB cases were more likely to have had contacts identified. Less than 14% of children already initiated on IPT completed 6 months of treatment.

Non-adherence to standard treatment guidelines in a rural paediatric hospital in Sierra Leone

SETTING

A rural paediatric hospital in Bo, Sierra Leone.

OBJECTIVES

To assess the level of adherence to standard treatment guidelines among clinicians prescribing treatment for children admitted with a diagnosis of malaria and/or lower respiratory tract infection (LRTI), and determine the association between (non) adherence and hospital outcomes, given that non-rational use of medicines is a serious global problem.

DESIGN

Secondary analysis of routine programme data.

RESULTS

Data were collected for 865 children admitted with an entry diagnosis of malaria and 690 children with LRTI during the period January to April 2011; some patients were classified in both categories. Non-adherence to guidelines comprised use of non-standard drug regimens, dosage variations, non-standard frequency of administration and treatment duration. Cumulative non-adherence to guidelines for LRTI cases was 86%. For malaria, this involved 12% of patients. Potentially harmful non-adherence was significantly associated with an unfavourable hospital outcome, both for malaria and for LRTI cases.

CONCLUSIONS

Overall non-adherence to standard treatment guidelines by clinicians in a routine hospital setting is very high and influences hospital outcomes. This study advocates for the implementation of routine measures to monitor and improve rational drug use and the quality of clinical care in such hospitals.

Incomplete registration and reporting of culture-confirmed childhood tuberculosis diagnosed in hospital

SETTING

The South African National Tuberculosis Programme (NTP) recommends the registration of tuberculosis (TB) patients at community clinics. TB in children is often diagnosed at referral hospitals, and there are concerns as to whether these children are accurately reflected in routine NTP reporting.

OBJECTIVE

To assess the completeness of registration of children with culture-confirmed TB diagnosed in a referral hospital, in the routine provincial electronic TB register (ETR.Net), and to describe TB treatment outcomes.

DESIGN

A retrospective cohort study including children aged <13 years diagnosed with culture-confirmed TB at Tygerberg Children's Hospital from July 2007 to June 2009. Data on demographic, clinical and referral factors were collated from hospital data sources. Electronic matching was used to identify children in the provincial ETR.Net.

RESULTS

Only 166 of 267 (62%) children were registered in ETR.Net. Children with TB meningitis and death prior to referral were significantly less likely to be registered. Treatment outcome data were available for only 70% of children; favourable outcomes were reported in 56%.

CONCLUSIONS

A large proportion of children diagnosed with confirmed TB at a referral hospital were not registered, resulting in underreporting of the burden and severity of childhood TB. Routine surveillance of childhood TB should include linkage of hospital data.

Severe malnutrition in children presenting to health facilities in an urban slum in Bangladesh

SETTING

An urban slum in Kamrangirchar, Bangladesh.

OBJECTIVES

Among children aged 6-59 months seeking medical care from the two Médecins Sans Frontières-supported primary health centres, to determine 1) the prevalence of severe acute malnutrition (SAM) and severe chronic malnutrition (SCM), and 2) the extent of overlap between SAM and SCM.

DESIGN

In a retrospective record review, data were analysed from out-patient registers on age, sex, height, weight and mid-upper arm circumference (MUAC) of children attending for medical care from April to September 2011. SAM was defined as weight for height < -3 Z scores of the median and/or MUAC <115 mm. SCM was defined as height for age < -3 Z scores of the median. World Health Organization growth standards were used as reference.

RESULTS

Data were complete in the records of 7318 (98%) children, of whom 322 (4%) had SAM and 1698 (23%) had SCM. Among the 322 children with SAM, 162 (50%) also had SCM.

CONCLUSION

In an urban Bangladesh slum, SAM and SCM co-exist, with a predominance of SCM. The current national guidelines for severe malnutrition, which focus on identification and management only for SAM, urgently need to be expanded to include SCM if substantial childhood morbidity and mortality are to be reduced.

Operational research training: the course and beyond

Insufficient operational research (OR) is generated within programmes and health systems in low- and middle-income countries, partly due to limited capacity and skills to undertake and publish OR in peer-reviewed journals. To address this, a three-module course was piloted by the International Union Against Tuberculosis and Lung Disease and Médecins Sans Frontières in 2009-2010, with 12 participants. Five received mentorship and financial support as OR Fellows. Eleven of 12 participants submitted a paper to a peer-reviewed journal within 4 weeks of the end of the course. Evaluation shows that participants continued OR activities beyond the course. During the subsequent year, they submitted and/or published 19 papers, made 10 posters and/or presentations, and many participated in training, mentoring and/or paper reviewing. Some described changes in policy and practice influenced by their research, and changes in their organisation's approach to OR. They provided recommendations for improving and expanding OR. We conclude that participants can, with certain enabling conditions, take research questions through to publication, use skills gained to undertake and promote OR thereafter and contribute to improvement in policy and practice. An internet-based network will provide participants and graduates with a platform for collection of course outcomes and ongoing mentor- and peer-based support, resources and incentives.

Management of asthma in resource-limited settings: role of low-cost corticosteroid/β-agonist combination inhaler

The management of asthma requires medicines that are effective in relaxing airway smooth muscles and in reducing airway inflammation. Rapid-acting β₂ agonist is a bronchodilator that provides quick symptom relief in patients with asthma. However, it does not effectively address the underlying problem of airway inflammation. Excess use of inhaled bronchodilators alone for symptom relief may result in delay in seeking health care, which in turn may result in delayed use of anti-inflammatory agents. Inhaled corticosteroid (ICS) is critical in the treatment of airway inflammation; it reduces the risk of life-threatening asthma attacks and the need for hospitalisation. ICS is underused, however, and a substantial proportion of patients with persistent asthma in resource-limited settings have no access to affordable ICS for long-term treatment. International guidelines recommend the use of rapid-acting β-agonists as needed as rescue treatment when symptoms occur. Studies have shown that the use of both ICS and rapid-acting β-agonist as needed for symptom relief might be a better option. The combination of ICS and rapid-acting bronchodilator in a single inhaler is currently too expensive and is not affordable for the poor. Although ICS and short-acting β₂ agonist (SABA) for rescue treatment can be obtained to a certain extent by using separate ICS and SABA inhalers, the first step is to ensure access to affordable, quality-assured essential asthma medicine in resource-limited settings.

Results at 30 months of a randomised trial of FDCs and separate drugs for the treatment of tuberculosis

Study C was an open-label, non-inferiority, randomised controlled trial of fixed-dose combination (FDC) or separate drugs given during the intensive phase of treatment to 1585 patients with smear-positive pulmonary tuberculosis conducted at 11 sites in Africa, Asia and Latin America. Thirty months post-randomisation, the failure/relapse rates in the per protocol population were 7.4% of 591 patients on FDCs and 6.5% of 587 patients on separate drugs; the site-adjusted difference was 0.3% (90%CI -1.8 to 2.3). In the modified intention-to-treat analysis, the corresponding results were respectively 17.9% of 683 and 16.1% of 671; the site-adjusted difference was 2.0% (90%CI -1.2 to 5.2).

Indoor air pollution from solid fuel and tuberculosis: a systematic review and meta-analysis

OBJECTIVE

To conduct an updated systematic review and meta-analysis on the association between indoor air pollution and tuberculosis (TB).

DESIGN

We searched for English or Chinese articles using PubMed and EMBASE up to 28 February 2013. We aimed to identify randomised controlled trials and observational epidemiological studies that reported the association between domestic use of solid fuel and TB. Two reviewers independently extracted the information from included studies and assessed the risk of bias of these studies using pre-defined criteria. The effect sizes of eligible studies were pooled using a random-effects model; the heterogeneity across studies was quantified using I(2) statistics.

RESULTS

We identified 15 studies on solid fuel use and active TB and one on solid fuel use and latent tuberculous infection. The summary odds ratios from case-control and cross-sectional studies were respectively 1.17 (95%CI 0.83 - 1.65) and 1.62 (95%CI 0.89 - 2.93), with substantial between-study heterogeneity (I(2) 56.2% and 80.5%, respectively). Subgroup analysis and meta-regression analysis did not identify any study-level factors that could explain the heterogeneity observed.

CONCLUSION

The level of evidence for the association between domestic use of solid fuels and TB was very low. High-quality studies are badly needed to clarify this association and to estimate the magnitude of the problem.

Factors influencing increased expertise for a sustainable workforce at a research centre in South Africa

SETTING

The Desmond Tutu Tuberculosis (TB) Centre (DTTC), Stellenbosch University, South Africa.

OBJECTIVES

1) To determine whether access to designated funding is associated with the development of expertise in employees, and 2) which other factors are associated with the development of expertise in employees.

DESIGN

This was a retrospective study. The target population consisted of all employees at the DTTC during the period 1 January 2004 to 31 December 2011. Improvement in expertise during employment was the primary outcome; the secondary outcome was an increase in educational level linked to the National Qualifications Framework.

RESULTS

There was no association between access to funding and expertise development, but an association between the number of months employed and improvement of expertise during employment was observed (OR 1.03, 95%CI 1.02-1.04, P < 0.001), controlling for age at appointment, sex, access to designated funding and education level.

CONCLUSION

The study shows that almost a third of employees increased their expertise, more than 90% had access to designated funding and personnel employed for a longer duration were more likely to experience improvements in expertise. We encourage research organisations in low- and middle-income countries to implement strategies to retain employees in order to build their expertise.

Symptom reporting among prevalent tuberculosis cases who smoke, are HIV-positive or have hyperglycaemia

Data from a tuberculosis (TB) prevalence survey conducted in 24 communities in Zambia and the Western Cape, South Africa, January-December 2010, were analysed to determine the influence of smoking, hyperglycaemia and human immunodeficiency virus (HIV) infection on TB symptom reporting in culture-confirmed TB cases. Of 123 790 adults eligible for enrolment, 90 601 (73%) consented and 64 463 had evaluable sputum samples. ORs and 95%CIs were calculated using a robust standard errors logistic regression model adjusting for clustering at community level. HIV-positive TB cases were more likely to report cough, weight loss, night sweats and chest pain than non-HIV-positive TB cases. TB cases who smoked or had hyperglycaemia did not report symptoms differently from cases without these comorbidities.

Estimating tuberculosis burden and case detection in Pakistan

BACKGROUND

The National Tuberculosis Control Programme (NTP) in Pakistan has officially achieved a tuberculosis (TB) case detection rate of 64% in 2011, with an estimated incidence rate of 230 per 100 000 population, but is likely to be missing an unknown number of patients, particularly in the private sector.

SETTING

All public and private sector providers in 12 randomly selected districts of Pakistan were included.

OBJECTIVE

To estimate TB incidence and TB notification rates in Pakistan in 2012.

DESIGN

A surveillance system was established among all eligible non-NTP providers in selected districts from January to March 2012. Record linkage and capture-recapture analysis was conducted.

RESULTS

Of 8346 TB cases identified after record linkage, 6061 were registered with the NTP. The estimated number of unobserved TB cases was 10 030 (95%CI 7800-12 910), which meant that the proportion of notified cases was 32% (95%CI 17-49). The calculated annual incidence was 878 000 cases (95%CI 573 000-1 675 000), corresponding to a rate of 497/100 000 (95%CI 324-948) annually in the population.

CONCLUSION

The study estimated that the proportion of cases notified to the NTP was low, with actual incidence rates being higher than official estimates. TB surveillance should be strengthened to reduce under-reporting.

Does task shifting in tuberculosis microscopy services to non-certified technicians in Afghanistan affect quality?

SETTING

Tuberculosis microscopy centres in 30 provinces in Afghanistan.

OBJECTIVE

To compare the quality of sputum smear examinations in microscopy centres with microscopists who are fully certified as laboratory technicians with those performed in centres with technicians who do not have such certification (high school graduates).

DESIGN

Cross-sectional record review of sputum smear microscopy slides examined by technicians and cross-checked by trained assessors as part of routine external quality assurance between July and September 2009.

RESULTS

Of 129 non-certified technicians, 118 (91%) were stationed in rural health centres compared with 217/257 (84%) certified technicians. From 386 microscopy centres, 7313 slides were cross-checked. Of 257 microscopy centres with certified technicians, 42 (16%) had at least one slide with a major error compared to 23 (18%) of 129 microscopy centres staffed with non-certified technicians. The difference was not statistically significant (OR 1.11, 95%CI 0.64-1.94). The number of slides showing major errors was also similar between the centres with both certified and non-certified technicians.

CONCLUSION

This study confirms the deployment of non-certified microscopy technicians to peripheral health centres throughout the country and that their performance with sputum smear microscopy is similar to that of certified technicians with 3 years of training.

Profile and treatment outcomes of elderly patients with tuberculosis in Delhi, India: implications for their management

BACKGROUND

Given India's high rate of TB, rising burden of non-communicable diseases (NCDs) and growing elderly population, elderly TB patients may be at higher risk of adverse outcomes including death, loss-to-follow-up (LTFU) and treatment failure. This may call for modifications in their management. This study thus aimed to compare the profile and treatment outcomes between elderly (≥60 years) and non-elderly (15-59 years) TB patients.

METHODS

This was a retrospective cohort study using routinely-collected programme data from a chest clinic in Delhi, India. It included all elderly and selected non-elderly TB patients registered for treatment between 2005 and 2010. Data on patients' clinical and demographic characteristics and treatment outcomes were analysed.

RESULTS

There were 812 elderly and 1624 non-elderly TB patients. Elderly patients were more likely to be male (63.2% vs 51.1%) and have smear-positive TB (56.0% vs 47.4%). Adverse outcomes were more frequent among elderly patients (adjusted OR 1.9, 95% CI: 1.5-2.4), specifically deaths (adjusted OR 5.0, 95% CI: 3.1-8.1) and lost-to-follow-up (adjusted OR 1.4, 95% CI: 1.0-1.9).

CONCLUSIONS

The profile and worse outcomes of elderly Indian TB patients may be indicative of co-existing NCDs. This needs further investigation and likely calls for a more comprehensive and intensive approach to their management.

Tuberculosis patients in primary care do not start treatment. What role do health system delays play?

SETTING

Primary health care facilities in five provinces of South Africa.

OBJECTIVE

To investigate the association between the proportion of sputum results with a prolonged smear turnaround time and the proportion of smear-positive tuberculosis (TB) cases initially lost to follow-up.

DESIGN

The unit of investigation was a primary health care facility and the outcome was the initial loss to follow-up rate per facility, which was calculated by comparing the sputum register with the TB treatment register. A prolonged turnaround time was defined as more than 48 h from when the sputum sample was documented in the sputum register to receipt of the result at the facility.

RESULTS

The mean initial loss to follow-up rate was 25% (95%CI 22-28). Smear turnaround time overall was inversely associated with initial loss to follow-up (P = 0.008), when comparing Category 2 (33-66% turnaround time within 48 h) with Category 1 (0-32%) (OR 0.73, 95%CI 0.48-1.13, P = 0.163) and when comparing Category 3 (67-100%) with Category 1 (OR 0.62, 95%CI 0.39-0.99, P = 0.045). The population preventable fraction of initial loss to follow-up (when turnaround time was <48 h in ≥67% of smear results) was 21%.

CONCLUSION

Initial loss to follow-up should be reported as part of the TB programme to ensure that patients are initiated on treatment to prevent transmission within communities.

Standard case management of asthma in Sudan: a pilot project

SETTING

A pilot project for asthma management in selected hospitals in Khartoum and Gezira States, Sudan.

OBJECTIVE

To assess standard case management of asthma in 2007-2008.

DESIGN

Local adaptation of guidelines, followed by situational analysis, pre-intervention study, training and implementation. Treatment outcome was assessed 1 year after patient enrolment.

RESULTS

Situational analysis revealed that inhaled beclometasone was not available in the public sector. During the project, 2068 patients were enrolled: severity of asthma was intermittent in 185 (9.0%), mild persistent in 231 (11.2%), moderate persistent in 640 (31.0%), severe persistent in 812 (39.3%) and unclassified in 200 (9.7%). Of the 1654 patients with persistent asthma who were treated with inhaled corticosteroids, 1157 (70.0%) had treatment cards available for outcome assessment. Of these, 652 (56.4%) did not attend their annual evaluation, among whom 1 (0.1%) died and 651 (56.3%) were lost to follow-up. Of the 505 patients who attended their annual evaluation, 417 (82.6%) improved, 32 (6.3%) were stable and 56 (11.1%) were worse. The frequency of emergency visits and hospitalisation decreased substantially among those who presented for the 1 year follow-up assessment.

CONCLUSION

The results of standard case management of asthma were encouraging; however, a high proportion of patients did not return for long-term management.

Management of asthma in Benin: the challenge of loss to follow-up

SETTING

An asthma pilot project in Benin.

OBJECTIVE

To assess the implementation of standard case management of asthma at three referral centres and three primary care centres.

METHODS

The project began with local adaptation of international asthma guidelines, followed by situation analysis, pre-intervention, training and intervention. The initial dosage of inhaled beclometasone was determined by asthma severity. Outcome of treatment was assessed annually, starting from one year after enrolment.

RESULTS

Of 103 asthma patients identified during situation analysis, only 11 (11%) were prescribed inhaled corticosteroids. After health worker training, a total of 430 asthma patients were identified in 2008, of whom 273 (63.5%) returned after initial management with 7-day oral prednisolone. Of the 273 patients, 261 (95.6%) had persistent asthma, 231 (86.2%) had peak flow measurement variability of ≥20%, and 155 (56.8%) had had one or more unplanned visits to health facilities in the previous year. Outcome at one year evaluation was as follows: 63 (24.1%) had improved, 48 (18.4%) remained stable, 14 (5.4%) were worse and 136 (52.4%) were lost to follow-up.

CONCLUSION

It is feasible to train health workers to manage asthma patients in a standardised manner. However, a high proportion of patients were lost to follow-up during treatment.

Does the 65 cm height cut-off as age proxy exclude children eligible for nutritional assessment in Bangladesh?

SETTING

Kamrangirchar slum, Dhaka, Bangladesh.

OBJECTIVE

During nutritional surveys and in circumstances when it is difficult to ascertain children's age, length/height cut-offs are used as proxy for age to sample children aged 6-59 months. In a context of prevalent stunting, using data from primary health care centres where age and height parameters were well-recorded, we assessed the proportion of children aged between 6 and 59 months who would be excluded from nutritional assessment using a height cut-off of 65 cm as a proxy for age ≥6 months.

DESIGN

This was a secondary data analysis of primary health centre data.

RESULTS

A total of 2060 children were included in the analysis, with a median age of 24 months and a median height of 78 cm (SD 12.1, range 50-109 cm). There were 240 (12%, 95%CI 10-13) children aged between 6 and 29 months, with a height <65 cm. The majority (59%) of these children were females; 97.5% were aged 6-17 months.

CONCLUSION

In an urban slum setting in Bangladesh, the use of the current height cut-off as a proxy for age excludes vulnerable children from nutritional assessment and could also lead to underestimation of the prevalence of malnutrition in nutritional surveys.

Important co-morbidity in patients with diabetes mellitus in three clinics in Western Kenya

SETTING

Diabetes clinics in three hospitals in Western Kenya: Moi Teaching and Referral Hospital and two associated district hospitals.

OBJECTIVE

To determine the proportion of diabetes patients with a history of tuberculosis (  TB), human immunodeficiency virus (HIV  ) infection and tobacco smoking.

DESIGN

A descriptive study using routinely collected data from patient records in the three diabetes clinics.

RESULTS

Of 1376 patients analyzed, 750 (55%) were female. The mean age of the patients in the clinics was 53.5 years (95%CI 52.2-54.8), with an average duration of diabetes of 8.1 years (95%CI 7.6-8.7). Of all patients, 5.6% reported a history of TB, similar to the frequency about 20 years earlier (1990) in Tanzania. Only 30% of the patients reported knowing their HIV status; 6% were HIV-positive. A history of tobacco smoking was reported by 3.8% of the patients.

CONCLUSION

The HIV epidemic does not seem to have significantly changed the relationship between TB and diabetes mellitus (DM) in this cohort of diabetes patients. The frequency of HIV and TB in this special population was comparable to that in the general population, and only a small proportion of patients reported a history of tobacco smoking.

Language in tuberculosis services: can we change to patient-centred terminology and stop the paradigm of blaming the patients?

The words 'defaulter', 'suspect' and 'control' have been part of the language of tuberculosis (TB) services for many decades, and they continue to be used in international guidelines and in published literature. From a patient perspective, it is our opinion that these terms are at best inappropriate, coercive and disempowering, and at worst they could be perceived as judgmental and criminalising, tending to place the blame of the disease or responsibility for adverse treatment outcomes on one side-that of the patients. In this article, which brings together a wide range of authors and institutions from Africa, Asia, Latin America, Europe and the Pacific, we discuss the use of the words 'defaulter', 'suspect' and 'control' and argue why it is detrimental to continue using them in the context of TB. We propose that 'defaulter' be replaced with 'person lost to follow-up'; that 'TB suspect' be replaced by 'person with presumptive TB' or 'person to be evaluated for TB'; and that the term 'control' be replaced with 'prevention and care' or simply deleted. These terms are non-judgmental and patient-centred. We appeal to the global Stop TB Partnership to lead discussions on this issue and to make concrete steps towards changing the current paradigm.

Asthma as a hidden disease in rural China: opportunities and challenges of standard case management

OBJECTIVE

To assess the implementation of standard case management of asthma in Huaiyuan County, Anhui Province, China, in 2008.

DESIGN

The study project began with the local adaptation of international asthma guidelines, followed by a situation analysis, pre-intervention study, training and intervention. Inhaled beclomethasone (US$15 for a 200-puff [250 µg/puff] inhaler) was prescribed for patients with persistent asthma. Treatment outcome was assessed at 1 year after enrolment.

RESULTS

Asthma was never diagnosed in the participating facilities before the project was introduced. Of the 95 patients diagnosed with persistent asthma, 72 (75.8%) were prescribed inhaled beclomethasone, and 23 (24.2%) were not, because they either refused to use inhaled beclomethasone or did not return after the initial visit. At 1 year evaluation, of the 72 patients with persistent asthma treated with inhaled corticosteroids, 12 (16.7%) improved, 7 (9.7%) remained stable, none were worse, 1 (1.4%) had died, and 52 (72.2%) were lost to follow-up. Of the 52 patients lost to follow-up, 25 (48%) were found to be alive but had stopped using inhaled beclomethasone.

CONCLUSION

Asthma is more frequently disabling and costly than had been recognised earlier. Asthma patients can be provided the care that they require, but affordable access to inhaled corticosteroids remains a challenge.

Tuberculosis contact investigation in a high-burden setting: house or household?

SETTING

A high tuberculosis (TB) burden setting, South Africa. Two frequently used definitions for 'household' are 1) 'all dwellings on the same plot of land that share the same residential address'; and 2) 'a group of persons who live together in the same dwelling unit and who have the same eating arrangements'.

OBJECTIVE

To characterise a household and the outcome of investigations in household child contacts using definition 1 compared to definition 2 during a TB contact investigation.

DESIGN

Access to a household (definition 1) was gained via an adult TB case. Children were assessed for TB infection and disease.

RESULTS

Household enumeration indicated 25 members of three families living in a main house and a fourth family living in an adjacent structure. Three children were diagnosed with TB and two referred for isoniazid preventive therapy. Families living in the main house shared the main kitchen, while the yard house family used its own kitchen. This household would have been classified as two separate households if definition 2 had been used, and children with TB disease and infection would have been missed.

CONCLUSION

The definition of household in TB contact investigation should provide a framework that is broad enough to capture the majority of children at risk.

Longer delay in accessing treatment among current smokers with new sputum smear-positive tuberculosis in Nepal

SETTING

Kathmandu, Nepal, which has 7% of the national population and 18% of the tuberculosis (TB) burden.

OBJECTIVES

To determine the association of smoking with total delay among new sputum smear-positive TB patients.

METHODS

Direct interviews were conducted among 605 TB patients registered in 37 randomly selected clinics within 30 days of initiating anti-tuberculosis treatment using a semi-structured questionnaire. Total delay was calculated from the date of the first reported symptom to the commencement of treatment. Logistic regression analyses were performed to determine the factors associated with total delay.

RESULTS

Of the 605 TB patients interviewed, 271 (44.8%) were current smokers, 33 (5.5%) were ex-smokers and 301 (49.8%) were never smokers. The median total delay was 103 days (current smokers 133 days, ex-smoker 103 days and never smokers 80 days). Longer delay was more common among current smokers (aOR 2.03, 95%CI 1.24-3.31). Covariates with significantly more delay were female sex, lower levels of education and higher degrees of sputum smear positivity.

CONCLUSION

Total delay was unacceptably longer in current smokers. Anti-smoking interventions are needed as an integral part of the TB programme to address this problem.

Why are tuberculosis patients not treated earlier? A study of informal health practitioners in Bangladesh

SETTING

Five districts and four cities of Bangladesh.

OBJECTIVE

To study the role of informal health practitioners in delays in initiating tuberculosis (TB) treatment in new smear-positive TB patients.

DESIGN

A cross-sectional study of all patients registered within specific projects in Bangladesh using routine records from projects. Definitions were as follows: 1) total delay: duration from onset of symptoms to initiation of treatment; 2) patient delay: onset of symptoms to first visit to any practitioner; and 3) health system delay: first visit to practitioner to treatment initiation.

RESULTS

A total of 7280 cases were enrolled. Prolonged delay was calculated as ≥ 5 weeks for patient delay, ≥ 10 weeks for health system delay and ≥ 13 weeks for total delay. Prolonged patient delay was less frequent when patients first consulted informal as compared to qualified health practitioners (30% vs. 68%). Similar figures for prolonged health system delay were respectively 52% and 16%, while those for total delay were 47% and 27%. The differences were statistically significant (P < 0.05).

CONCLUSION

Patients seeking care from informal practitioners access care more promptly, but have prolonged delays in initiating treatment. Further investigation on how to involve these practitioners in the programme should be evaluated.

Consulting private health care providers aggravates treatment delay in urban South African tuberculosis patients

SETTING

An urban primary health care facility in Khayelitsha, South Africa.

OBJECTIVES

To determine the difference in total tuberculosis (TB) treatment delay in patients who initially seek care at National TB Control Programme (NTP) facilities after the onset of TB-related symptoms, compared to patients who initially seek care from non-NTP health care practitioners (HCP); and to describe the relative contributions of diagnostic, treatment initiation, patient and health system (HS) delay.

DESIGN

A cross-sectional study of adult TB patients treated by the NTP.

RESULTS

A total of 210 patients (median age 31 years) were enrolled from May to December 2009: 46% were male, and 58% were human immunodeficiency virus (HIV) infected. The median duration of total delay was 31 days, diagnostic delay 26, treatment initiation delay 0, patient delay 8 and HS delay 17 days. Initial visit to a non-NTP HCP was independently associated with total (P = 0.007), HS (P = 0.014) and diagnostic delays (P = 0.012). HIV infection was an independent risk factor for total (P = 0.047) and HS delay (P = 0.021); 27% of patients reported first going to a non-NTP HCP.

CONCLUSION

Initial care sought from non-NTP HCP was the main determinant of total, HS and diagnostic delays. Engagement and education of private HCPs is recommended.

Translating childhood tuberculosis case management research into operational policies

The control of childhood tuberculosis (TB) has been of low priority in TB programmes in high-burden settings. The objective of this paper was to describe the development and testing of tools for the management of childhood TB. The Pakistan National TB Control Programme embarked on a number of activities, including the establishment of policy guidelines for the management of childhood TB and later a guidance document, 'Case Management Desk Guide and Structured Monitoring', to demonstrate the implementation of childhood TB interventions in a programme context. Initial results showed improved case finding and treatment outcome in implementation sites compared with control districts. However, further programme attention is required to improve quality.

Capture-recapture to estimate completeness of tuberculosis surveillance in two communities in South Africa

BACKGROUND

Reliable surveillance is essential for any tuberculosis (TB) control programme; however, under-registration of TB cases due to under-notification of patients on treatment or failure to initiate treatment has been well-documented internationally.

OBJECTIVE

To determine the contribution of capture-recapture methods in estimating the completeness of bacteriologically confirmed pulmonary TB registration in two high-incident communities in South Africa.

METHODS

Record linkage between the TB treatment register and two laboratory sputum TB result registers and three-source log-linear capture-recapture analysis.

RESULTS

The number of bacteriologically confirmed pulmonary TB cases in the TB treatment register was 243, with an additional 63 cases identified in the two laboratory databases, resulting in 306 TB cases. The observed completeness of the TB treatment register was 79%. The log-linear model estimated 326 (95%CI 314-355) TB cases, resulting in an estimated completeness of registration of 75% (95%CI 68-77).

CONCLUSION

Capture-recapture can be useful in evaluating the completeness of TB control surveillance and registration, including in resource-limited settings; however, methodology and results should be carefully assessed. Interventions are needed to increase the completeness of registration and to reduce the number of initial defaulters.

Comprehensiveness of primary services in the care of infectious tuberculosis patients in Rawalpindi, Pakistan

SETTING

All tuberculosis (TB) diagnostic centres of Rawalpindi District, Pakistan, including five tertiary care hospitals and 16 rural health centres.

OBJECTIVE

To identify among sputum smear-positive patients registered during 2009 in the laboratory register those who had not been recorded in a treatment register, defined in the study as 'initial loss to follow-up'.

DESIGN

A retrospective record review of routine TB data.

RESULTS

There were 16 145 suspects screened for TB and recorded in the laboratory registers. Of 1698 smear-positive patients identified in the laboratory registers, 101 (6%) could not be identified in the treatment registers. Eighty-six (10%) of 842 patients in tertiary care hospitals and 15/856 (2%) in rural health centres were not recorded (OR 6.4, 95%CI 3.6-11.6, P < 0.01).

CONCLUSION

The study shows a significant association between type of health facility and initial loss to follow-up. In rural health centres, the proportion lost to follow-up is low, reflecting more efficient care than in tertiary care hospitals. Strategies are urgently needed to improve the registration and follow-up of smear-positive cases in tertiary care institutions.

The looming epidemic of diabetes-associated tuberculosis: learning lessons from HIV-associated tuberculosis

The prevalence of diabetes mellitus is increasing at a dramatic rate, and countries in Asia, particularly India and China, will bear the brunt of this epidemic. Persons with diabetes have a significantly increased risk of active tuberculosis (TB), which is two to three times higher than in persons without diabetes. In this article, we argue that the epidemiological interactions and the effects on clinical presentation and treatment resulting from the interaction between diabetes and TB are similar to those observed for human immunodeficiency virus (HIV) and TB. The lessons learned from approaches to reduce the dual burden of HIV and TB, and especially the modes of screening for the two diseases, can be adapted and applied to the screening, diagnosis, treatment and prevention of diabetes and TB. The new World Health Organization (WHO) and The Union Collaborative Framework for care and control of TB and diabetes has many similarities to the WHO Policy on Collaborative Activities to reduce the dual burden of TB and HIV, and aims to guide policy makers and implementers on how to move forward and combat this looming dual epidemic. The response to the growing HIV-associated TB epidemic in the 1980s and 1990s was slow and uncoordinated, despite clearly articulated warnings about the scale of the forthcoming problem. We must not make the same mistake with diabetes and TB. The Framework provides a template for action, and it is now up to donors, policy makers and implementers to apply the recommendations in the field and to 'learn by doing'.

Accuracy and completeness of recording of confirmed tuberculosis in two South African communities

BACKGROUND

Although tuberculosis (TB) treatment registers and laboratory records are essential tools for recording and reporting in TB control programmes, the accuracy and completeness of routinely collected data are seldom monitored.

OBJECTIVE

To assess the accuracy and completeness of TB treatment register data in two South African urban communities using record linkage.

METHODS

All cases of bacteriologically confirmed TB, defined as two smear-positive results and/or at least one culture-positive result, were included. Record linkage was performed between three data sources: 1) TB treatment registers, 2) the nearest central laboratory, and 3) the referral hospital laboratory.

RESULTS

The TB treatment registers had 435 TB cases recorded, of which 204 (47%) were bacteriologically confirmed. An additional 39 cases recorded as non-bacteriological cases in the TB treatment registers were reclassified as bacteriologically confirmed, and 63 bacteriologically confirmed cases were identified from the laboratory databases that were not recorded in the TB treatment registers. The final number of bacteriologically confirmed TB cases was 306, giving an increase of 50%.

CONCLUSIONS

The accuracy and completeness of the TB treatment register and central laboratory data were inadequate. A high percentage of bacteriologically confirmed cases from both laboratories were not recorded in the TB treatment registers. We are developing an electronic result management system to improve the management of laboratory results.

The FIDELIS initiative: innovative strategies for increased case finding

SETTING

Low-income, high tuberculosis (TB) burden countries.

OBJECTIVE

To compare case finding of new smear-positive pulmonary TB patients in projects funded to apply innovative approaches.

DESIGN

Prospective application of innovative approaches to case finding within routine services to determine the numbers of additional cases detected and the cost per additional case detected, according to the type of approach applied.

RESULTS

Between 2003 and 2007, 51 FIDELIS projects were implemented in 18 countries; 273,239 cases were reported, of which 85,267 were additional to the number reported in the previous year. The median cost per additional case was US$103. The interventions employed were: 1) social mobilisation and information, education and communication; 2) engagement of the private sector; 3) innovative approaches for microscopy services; 4) enhanced or semi-active case finding; 5) health systems strengthening; and 6) use of incentives. None of these was significantly more likely to detect additional cases or to have a lower cost per additional case than any of the others.

CONCLUSION

While there was a substantial increase in cases detected, at a moderate cost per additional case, we were unable to show that any single intervention had an advantage over the others.

Tuberculosis among community-based health care researchers

BACKGROUND

Occupational tuberculosis (TB) in hospital-based health care workers is reported regularly, but TB in community-based health care researchers has not often been addressed.

OBJECTIVE

To investigate TB incidence in health care researchers in a high TB and human immunodeficiency virus prevalent setting in the Western Cape, South Africa. The health care researchers were employed at the Desmond Tutu TB Centre, Stellenbosch University.

METHODS

A retrospective analysis was performed of routine information concerning employees at the Desmond Tutu TB Centre. The Centre has office-based and community-based employees.

RESULTS

Of 180 researchers included in the analysis, 11 TB cases were identified over 250.4 person-years (py) of follow-up. All cases were identified among community-based researchers. TB incidence was 4.39 per 100 py (95%CI 2.45-7.93). The standardised TB morbidity ratio was 2.47 (95%CI 1.25-4.32), which exceeded the standard population rate by 147%.

CONCLUSIONS

TB incidence in South Africa was 948 per 100,000 population per year in 2007; in the communities where the researchers worked, it was 1875/100,000. Community-based researchers in the study population have a 2.34 times higher TB incidence than the community. It is the responsibility of principal investigators to implement occupational health and infection control guidelines to protect researchers.

Authorship affiliations in original articles submitted to the International Journal of Tuberculosis and Lung Disease

OBJECTIVE

To ascertain whether the first (principal) and last (senior) authors of articles are affiliated to an organisation belonging to the study country in an analysis of high- and upper-middle-income countries, and low- and lower-middle-income countries.

DESIGN

Prospective review of all original articles (n = 911) submitted to the International Journal of Tuberculosis and Lung Disease (IJTLD) from June 2006 to May 2008.

RESULTS

In 81% of the submitted articles both the first and the last authors were affiliated to the country of the study. Slightly more articles from low (10%) than from lower-middle-income, high- and upper-middle-income countries (all 4%) had neither the first author nor the last author affiliated to the study country. For 17% of articles from low-income countries the senior author was not from the study country.

CONCLUSION

Although acceptance of articles for publication in the IJTLD is not dependent on this criterion, we find that a substantial proportion of authors from low- and middle-income countries were listed as principal and senior authors in articles submitted.