Tuberculosis-tobacco integration in the South-East Asia Region: policy analysis and implementation framework

SETTING

Despite overwhelming evidence for the association between tuberculosis (TB) and tobacco use, it remains neglected in the context of policy, planning and practice. There is limited evidence about the extent of integration of TB and tobacco control programmes in South-East Asia Region (SEAR) countries.

OBJECTIVE

To assess the level of TB-tobacco integration in 11 SEAR countries.

DESIGN

Cross-sectional study using a structured questionnaire addressed to TB and tobacco focal points at the World Health Organization Country Offices.

RESULTS

Apart from India, no country in the SEAR has a formal coordination mechanism for national TB and tobacco control programmes or a system of referral for tobacco users among TB patients for treatment of tobacco dependence. There is no joint planning, joint training or joint supervision and monitoring in any country.

CONCLUSION

There is poor integration between TB and tobacco control programmes in most SEAR countries. This assessment fed into the development of a regional framework for TB-tobacco integration, which outlines three strategies: 1) integrated patient-centred care and prevention; 2) joint TB tobacco actions covering policy development, planning, training and monitoring; and 3) research and innovation. Every country in the region should adopt the TB-tobacco integration framework to improve programme performance.

The clinical utility of cycle of threshold value of GeneXpert MTB/RIF (CBNAAT) and its diagnostic accuracy in pulmonary and extra-pulmonary samples at a tertiary care center in India

BACKGROUND

There are knowledge gaps in the in-depth analysis of the most promising and robust diagnostic tool, GeneXpert MTB/RIF (CBNAAT). The cycle of threshold (CT) value of the CBNAAT test and its clinical implications has not been explored much.

AIMS AND OBJECTIVES

The study aimed at (a) estimating the diagnostic accuracy and incremental yield of Xpert MTB/RIF in various specimens (b) establishing the association between CT value category (high, medium, low, very low) and culture time-to-positivity (TTP).

METHODS

A total of 1000 samples, both pulmonary and extra-pulmonary were collected from presumptive TB cases in a large tertiary care hospital. Sensitivity and specificity of CBNAAT was calculated with culture as the gold standard. The association of CT value with culture TTP was also studied.

RESULTS

The overall sensitivity of CBNAAT was 88.5%, with bronchial washing specimen being the most sensitive (92.3%) and pleural fluid being the least (66.7%). In smear negative individuals, the sensitivity of CBNAAT was 80.9%. The additional yield of CBNAAT over smear microscopy was 10.9%. It was observed that as we move from high to very low CT category, culture positivity decreases significantly (p<0.001), whereas time taken for culture growth increases (p<0.001).

CONCLUSION

CBNAAT is a robust test for accurate diagnosis of tuberculosis both pulmonary and extra-pulmonary, smear negative as well, especially in resource-limited settings. The correlation between CT value and culture TTP has potential in predicting bacillary load, though further studies are required.

Osteonecrosis of the Jaw among Patients Receiving Antiresorptive Medication: A 4-year Retrospective Study at a Tertiary Cancer Center, Kerala, India

Purpose:

Osteonecrosis of the jaw (ONJ) is a rare but complicated side effect of antiresorptive medications. The aim of the study is to evaluate the dental and drug-related factors related to ONJ among patients on these drugs at a tertiary cancer center, India.

Methodology:

A retrospective record review of patients who received antiresorptive medication at our center from 2011 to 2014 was done. The demographic factors, type, dosage, and duration of the medication and dental history were collected, and the data were entered an analyzed using Epidata software.

Results:

A higher incidence of ONJ (8.1%) was noted in our sample (n = 183). Dental intervention after zoledronic acid (ZA) administration showed a statistical significance (P < 0.001). No significance (P value) was noted with respect to sex (0.78), age (0.28), median duration (0.9), and median dosage (0.9) of ZA.

Conclusion:

Oro-dental screening and dental monitoring shall reduce the incidence of ONJ. Within the limitations of our study, no significant relation could be pointed toward the dosage and duration of the drug and development of ONJ.

Cost of injury care in India: cross-sectional analysis of National Sample Survey 2014

BACKGROUND

Injuries account for nearly 10% of total deaths in India and this burden is likely to rise. We aimed to estimate the out-of-pocket (OOP) expenditure and catastrophic expenditure due to hospitalisation or outpatient care as a result of any injury and factors associated with incurring catastrophic expenditure.

METHODS

Secondary analysis of nationally representative data for India collected by National Sample Survey Organization in 2014, reporting on health service utilisation and healthcare-related OOP expenditure by income quintiles and by type of health facility (public or private).

RESULTS

The median expenditure per episode of hospitalisation due to any injury was US$156, and it was three times higher among the richest quintile compared with the poorest quintile (p<0.001). There was a significantly higher prevalence (p<0.001) of catastrophic expenditure among the poorest quintile (32%) compared with the richest (21%). Mean private sector OOP hospitalisation expenditure was five times higher than in the public sector (p<0.001). Medicines accounted for 37% and 58% of public sector hospitalisation and outpatient care, respectively. Patients treated in a private facility, hospitalised for over 7 days, in the poorest wealth quintiles and of general caste had higher odds of incurring catastrophic expenditure.

CONCLUSION

People who sustain an injury have a high risk of catastrophic household expenditure, particularly for those in lowest income quartiles. There is a clear need for publicly funded risk protection mechanisms targeting the poor. Promotion of generic medicines and subsidisation for the poorest wealth quintile may also reduce OOP expenditure in public sector facilities.

Predictors of unfavourable treatment outcome in patients with multidrug-resistant tuberculosis in India

Setting: India has one of the highest global rates of multidrug-resistant tuberculosis (MDR-TB), which is associated with poor treatment outcomes. A better understanding of the risk factors for unfavourable outcomes is needed. Objectives: To describe 1) the demographic and clinical characteristics of MDR-TB patients registered in three states of India during 2009-2011, 2) treatment outcomes, and 3) factors associated with unfavourable outcomes. Design: A retrospective cohort study involving a record review of registered MDR-TB patients. Results: Of 788 patients, 68% were male, 70% were aged 15-44 years, 90% had failed previous anti-tuberculosis treatment or were retreatment smear-positive, 60% had a body mass index < 18.5 kg/m² and 72% had additional resistance to streptomycin and/or ethambutol. The median time from sputum collection to the start of MDR-TB treatment was 128 days (IQR 103-173). Unfavourable outcomes occurred in 40% of the patients, mostly from death or loss to follow-up. Factors significantly associated with unfavourable outcomes included male sex, age ⩾ 45 years, being underweight and infection with the human immunodeficiency virus. Adverse drug reactions were reported in 24% of patients, with gastrointestinal disturbance, psychiatric morbidity and ototoxicity the most common. Conclusion: Long delays from sputum collection to treatment initiation using conventional methods, along with poor treatment outcomes, suggest the need to scale up rapid diagnostic tests and shorter regimens for MDR-TB.

Data collection using open access technology in multicentre operational research involving patient interviews

Conducting multicentre operational research is challenging due to issues related to the logistics of travel, training, supervision, monitoring and troubleshooting support. This is even more burdensome in resource-constrained settings and if the research includes patient interviews. In this article, we describe an innovative model that uses open access tools such as Dropbox, TeamViewer and CamScanner for efficient, quality-assured data collection in an ongoing multicentre operational research study involving record review and patient interviews. The tools used for data collection have been shared for adaptation and use by other researchers.

Ten tips to improve the visibility and dissemination of research for policy makers and practitioners

Effective dissemination of evidence is important in bridging the gap between research and policy. In this paper, we list 10 approaches for improving the visibility of research findings, which in turn will hopefully contribute towards changes in policy. Current approaches include using social media (Facebook, Twitter, LinkedIn); sharing podcasts and other research outputs such as conference papers, posters, presentations, reports, protocols, preprint copy and research data (figshare, Zenodo, Slideshare, Scribd); and using personal blogs and unique author identifiers (ORCID, ResearcherID). Researchers and funders could consider drawing up a systematic plan for dissemination of research during the stage of protocol development.

MDR-TB in Puducherry, India: reduction in attrition and turnaround time in the diagnosis and treatment pathway

Setting: A mixed-methods operational research (OR) study was conducted to examine the diagnosis and treatment pathway of patients with presumptive multidrug-resistant tuberculosis (MDR-TB) during 2012-2013 under the national TB programme in Puducherry, India. High pre-diagnosis and pre-treatment attrition and the reasons for these were identified. The recommendations from this OR were implemented and we planned to assess systematically whether there were any improvements. Objectives: Among patients with presumptive MDR-TB (July-December 2014), 1) to determine pre-diagnosis and pre-treatment attrition, 2) to determine factors associated with pre-diagnosis attrition, 3) to determine the turnaround time (TAT) from eligibility to testing and from diagnosis to treatment initiation, and 4) to compare these findings with those of the previous study (2012-2013). Design: This was a retrospective cohort study based on record review. Results: Compared to the previous study, there was a decrease in pre-diagnosis attrition from 45% to 24% (P < 0.001), in pre-treatment attrition from 29% to 0% (P = 0.18), in the TAT from eligibility to testing from a median of 11 days to 10 days (P = 0.89) and in the TAT from diagnosis to treatment initiation from a median of 38 days to 19 days (P = 0.04). There is further scope for reducing pre-diagnosis attrition by addressing the high risk of patients with human immunodeficiency virus and TB co-infection or those with extra-pulmonary TB not undergoing drug susceptibility testing. Conclusion: The implementation of findings from OR resulted in improved programme outcomes.

Cost of hospitalisation for non-communicable diseases in India: are we pro-poor?

OBJECTIVES

To estimate out-of-pocket (OOP) expenditure due to hospitalisation from NCDs and its impact on households in India.

METHODS

The study analysed nationwide representative data collected by the National Sample Survey Organisation in 2014 that reported health service utilisation and healthcare-related OOP expenditure by income quintiles and by type of health facility (public or private). The recall period for inpatient hospitalisation expenditure was 365 days. Consumption expenditure was collected for a recall period of 1 month. OOP expenditure amounting to >10% of annual consumption expenditure was termed as catastrophic. Weighted analysis was performed.

RESULTS

The median expenditure per episode of hospitalisation due to NCDs was USD 149 - this was ~3 times higher among the richest quintile compared to poorest quintile. There was a significantly higher prevalence of catastrophic expenditure among the poorest quintile, more so for cancers (85%), psychiatric and neurological disorders (63%) and injuries (63%). Mean private-sector OOP hospitalisation expenditure was nearly five times higher than that in the public sector. Medicines accounted for 40% and 27% of public- and private-sector OOP hospitalisation expenditure, respectively.

CONCLUSION

Strengthening of public health facilities is required at community level for the prevention, control and management of NCDs. Promotion of generic medicines, better availability of essential drugs and possible subsidisation for the poorest quintile will be measures to consider to reduce OOP expenditure in public-sector facilities.

Impact of modular training on tobacco control on the knowledge of health workers in two jurisdictions of northern India

BACKGROUND

National Tobacco Control Programme was launched in India in year 2007-08. It was realized that community health workers can play an important role of agents for positive change to bring down the tobacco morbidity and mortality in the country. Keeping this in view, a health worker guide was developed by the Government of India, Ministry of Health and Family Welfare (GOI) in collaboration with The Union South-East Asia (The Union) in the year 2010. The guide provides the information needed by the most basic level of health workers to effectively address the problem of tobacco use in the community. A modular training was conducted in two jurisdictions in India (namely, Chandigarh and Hamirpur (Himachal Pradesh)) to assess the usefulness of the guide as training material for community health workers in undertaking tobacco control activities at community and village levels.

MATERIALS AND METHODS

A total of 271 participants were trained, which included 133 from Chandigarh and 138 from Hamirpur. The pre and post-training assessment of knowledge of health worker was done.

RESULTS

There was marked increase in post-test scores as compared to the pretest scores. The health workers scoring more than 60% increased from 40% in the pretest to over 80% in the post-test. Only three workers had a post-test score of less than 30% against 54 workers in the pretest.

CONCLUSION

The understanding on tobacco control had increased significantly after the training in each group. It is strongly recommended that such training should be replicated to all community health workers across all the states in India.

Is Mid-upper Arm Circumference Alone Sufficient to Identify Severe Acute Malnutrition Correctly?

Anthropometric data of 2466 children in Haryana revealed low sensitivity (6.9%) and positive predictive value (14.3%) of Mid-upper Arm Circumference (MUAC) at 115 mm cut-off for identifying Severe acute malnutrition (SAM). This raises concerns regarding the reliability of MUAC as a screening tool to identify SAM at the community-level.

Does research through Structured Operational Research and Training (SORT IT) courses impact policy and practice?

SETTING

Structured Operational Research and Training Initiative (SORT IT) courses are well known for their output, with nearly 90% of participants completing the course and publishing in scientific journals.

OBJECTIVE

We assessed the impact of research papers on policy and practice that resulted from six SORT IT courses initiated between July 2012 and March 2013.

DESIGN

This was a cross-sectional study involving e-mail-based, self-administered questionnaires and telephone/skype/in-person responses from first and/or senior co-authors of course papers. A descriptive content analysis of the responses was performed and categorised into themes.

RESULTS

Of 72 participants, 63 (88%) completed the course. Course output included 81 submitted papers, of which 76 (94%) were published. Of the 81 papers assessed, 45 (55%) contributed to a change in policy and/or practice: 29 contributed to government policy/practice change (20 at national, 4 at subnational and 5 at hospital level), 11 to non-government organisational policy change and 5 to reinforcing existing policy. The changes ranged from modifications of monitoring and evaluation tools, to redrafting of national guidelines, to scaling up existing policies.

CONCLUSION

More than half of the SORT IT course papers contributed to a change in policy and/or practice. Future assessments should include more robust and independent verification of the reported change(s) with all stakeholders.

MDR-TB screening in a setting with molecular diagnostic techniques: who got tested, who didn't and why?

SETTING

The Revised National Tuberculosis Control Programme, Puducherry, India, which has facilities for molecular diagnostic technique.

OBJECTIVE

To determine pre-diagnostic and pre-treatment attrition among presumptive multidrug-resistant tuberculosis (MDR-TB) patients and reasons for attrition.

METHODS

In this mixed-methods study, the quantitative component consisted of retrospective cohort analysis through record review of all presumptive MDR-TB patients recorded between October 2012 and September 2013. The qualitative component included in-depth interviews with key informants involved in programmatic management of drug-resistant tuberculosis services.

RESULTS

Of 341 eligible presumptive MDR-TB patients, pre-diagnostic and pre-treatment attrition was respectively 45.5% (155/341) and 29% (2/7). Patients with extra-pulmonary TB (RR = 2.3), those with human immuno-deficiency and TB co-infection (RR = 1.7), those registered during October-December 2012 (RR = 1.3) and those identified from primary/secondary health centres (RR = 1.8) were less likely to be tested. Themes that emerged during the analysis of the qualitative data were 'lack of a systematic mechanism to track referrals for culture and drug susceptibility testing', 'absence of courier service to transport sputum', 'lack of knowledge and ownership among staff of general health system', 'shortage of diagnostic kits' and 'patient non-adherence'.

CONCLUSION

Despite the introduction of molecular diagnostic techniques, operational issues in MDR-TB screening remain a concern and require urgent attention.

Is physical access an impediment to tuberculosis diagnosis and treatment? A study from a rural district in North India

SETTING

All designated microscopy centres (DMCs) in Fatehgarh Sahib District, Punjab, India.

OBJECTIVE

To study the association of distance (physical access) to DMCs with loss to follow-up (LTFU) of presumptive tuberculosis (TB) cases while undergoing diagnostic sputum examination and failure to initiate treatment among smear-positive TB patients after diagnosis.

DESIGN

A cross-sectional, record-based study was undertaken to analyse patient records from routine laboratory registers in all DMCs from January to June 2012.

RESULT

More than 50% of presumptive TB cases had to travel >7 km to reach the DMC, totalling >28 km for two sputum examinations for the evaluation of an episode. The distance (>10 km) to the diagnostic facility was found to be significantly associated (P < 0.01), both with LTFU during diagnosis and with a delay (>7 days) in initiating treatment after diagnosis. There was a significant correlation (r = 0.7) between distance to the DMC and time to initiate treatment among smear-positive TB cases.

CONCLUSION

Distance from the nearest facility represents a significant risk for LTFU during diagnosis and delayed initiation of treatment after diagnosis. Further decentralisation of TB care services to the community level is required by expanding the network of DMCs or by organising sputum collection and transportation.

Follow-up examinations: are multidrug-resistant tuberculosis patients in Uttar Pradesh, India, on track?

SETTING

All multidrug-resistant tuberculosis (MDR-TB) patients who had completed 6 months of treatment under the Revised National Tuberculosis Control Programme (RNTCP) in Uttar Pradesh, the largest state in northern India.

OBJECTIVE

To determine the proportion of MDR-TB patients with regular follow-up examinations, and underlying provider and patient perspectives of follow-up services.

METHODS

A retrospective cohort study was undertaken involving record reviews of 64 eligible MDR-TB patients registered during April-June 2013 in 11 districts of the state. Patients and programme personnel from the selected districts were interviewed using a semi-structured questionnaire.

RESULTS

A total of 34 (53.1%) patients underwent follow-up sputum culture at month 3, 43 (67.2%) at month 4, 36 (56.3%) at month 5 and 37 (57.8%) at month 6. Themes associated with irregular follow-up that emerged from the interviews were multiple visits, long travel distances, shortages of equipment at the facility and lack of knowledge among patients regarding the follow-up schedule.

CONCLUSION

The majority of the MDR-TB patients had irregular follow-up visits. Provider-related factors outweigh patient-related factors on the poor follow-up examinations. The programme should focus on the decentralisation of follow-up services and ensure logistics and patient-centred counselling to improve the regularisation of follow up.