National tuberculosis patients cost survey: research findings lead to change in policy and practice, Viet Nam

In 2016, the Viet Nam National Tuberculosis Programme (NTP) conducted the first national TB patients cost survey to identify the main cost drivers to help guide cost mitigation policies and reduce financial barriers to the treatment of TB patients. The survey findings were widely disseminated and the NTP defined a roadmap. The major components of the roadmap included 1) advocating for patients to be covered by social health insurance; 2) creating a charity fund for TB patients; 3) strengthening the collaboration between the Ministry of Health and Ministry of Labour and Social Affairs; and 4) advocating for donor support. The first national TB patients cost survey has shown that a high proportion of TB patients incurred costs that were classed as 'catastrophic'. The survey findings led to policy changes and new practices in Viet Nam.

Prevalence and associated factors of diabetes mellitus among tuberculosis patients in Hanoi, Vietnam

BACKGROUND

Diabetes mellitus (DM) is recognized as an important comorbidity for the development of tuberculosis (TB). With the increase of DM burden globally, concerns have been raised about the emerging co-epidemics of DM and TB, especially in low- and middle-income countries.

METHODS

A facility-based, cross-sectional study was carried out in all 30 district TB units in Hanoi, Vietnam. All eligible, diagnosed TB patients aged 15 years old or older were asked to provide consent and were screened for diabetes using fasting blood glucose (FBG). Pre-tested semi-structured questionnaires were used for collecting demographic data, lifestyle habits and clinical data. Identification of pre-diabetes or diabetes in TB patients was done in accordance to parameters set by the American Diabetes Association (2016).

RESULTS

Of 870 eligible TB patients, 831 (95.5%) participated in the study. Of those, 241 (29%; 95%CI: 25.9-32.1%) were prediabetic and 114 (13.7%; 95%CI: 11.4-16.1%) were found to have DM. The risk of DM was higher in patients belonging to the age group 40-64 years (OR 6.09; 95%CI 2.81-13.2); or the age group 65 years or older (OR 2.65; 95%CI 1.65-4.25) or who have a family history of DM (OR 2.71; 95%CI 1.33-5.50).

CONCLUSIONS

This study demonstrated high prevalence of DM and prediabetes among TB patients in Hanoi, Vietnam. National Tuberculosis Programme needs to establish a systematic screening process for DM among TB patients.

The effect of household poverty on tuberculosis

pSETTING: Households in Malawi, Mongolia, Myanmar, the Philippines, Rwanda, Tanzania, Viet Nam and Zambia.OBJECTIVE To assess the relationship between household socio-economic level, both relative and absolute, and individual tuberculosis (TB) disease.

DESIGN

We analysed national TB prevalence surveys from eight countries individually and in pooled multicountry models. Socio-economic level (SEL) was measured in terms of both relative household position and absolute wealth. The outcome of interest was whether or not an individual had TB disease. Logistic regression models were used to control for putative risk factors for TB disease such as age, sex and previous treatment history.

RESULTS

Overall, a strong and consistent association between household SEL and individual TB disease was not found. Significant results were found in four individual country models, with the lowest socio-economic quintile being associated with higher TB risk in Mongolia, Myanmar, Tanzania and Viet Nam.

CONCLUSIONS

TB prevalence surveys are designed to assess prevalence of disease and, due to the small numbers of cases usually detected, may not be the most efficient means of investigating TB risk factors. Different designs are needed, including measuring the SEL of individuals in nested case-control studies within TB prevalence surveys or among TB patients seeking treatment in health care facilities.

Successfully treated but not fit for purpose: paying attention to chronic lung impairment after TB treatment

In 2013, 86% of patients with newly diagnosed tuberculosis (TB) successfully completed treatment and were discharged from care. However, long-term studies in industrialised and resource-poor countries all point to a higher risk of death in TB survivors than in the general population. The likely explanation is chronic restrictive and obstructive lung disease consequent to TB. We call for better linkages between TB control programmes and respiratory medicine services, a better understanding of the burden of respiratory disability at the end of anti-tuberculosis treatment, and political, programmatic, clinical and research action to improve the quality of life of affected patients.

The role of macroscopic sputum quality assessments to optimise sputum testing for tuberculosis

SETTING

Community-wide active case finding for tuberculosis (TB) using Xpert® MTB/RIF as the primary screening tool, Ca Mau Province, Viet Nam.

OBJECTIVES

To determine whether macroscopic sputum quality characteristics (sputum colour and volume) can be used to predict Xpert MTB-negative sputum and hence exclude sputum samples from testing.

DESIGN

Field staff conducted household visits to approximately 51,200 adults in 58 villages randomly selected from throughout the province. Sputum samples from all screened participants who were able to produce ⩾1 ml sputum underwent macroscopic sputum assessment and were tested with Xpert.

RESULTS

Of the 21,624 sputum samples tested, 159 (0.74%) were Xpert MTB-positive; 93% of the samples were 1-2 ml and nearly all were mucoid (93%) or mucopurulent (5.7%). One salivary sample was Xpert MTB-positive (2.0% of all salivary samples). The lowest positive predictive value for any sputum volume or colour characteristic was 0.66%. This was not substantially different from the overall prevalence of positive sputum Xpert MTB (0.74%).

CONCLUSION

Sputum colour and volume cannot be used to predict the presence or absence of M. tuberculosis in sputum detected using Xpert. These sputum quality parameters cannot therefore be used to exclude sputum samples from testing for TB.

The effects of placing an operational research fellow within the Viet Nam National Tuberculosis Programme

In April 2009, an operational research fellow was placed within the Viet Nam National Tuberculosis Control Programme (NTP). Over the 6 years from 2010 to 2015, the OR fellow co-authored 21 tuberculosis research papers (as principal author in 15 [71%]). This constituted 23% of the 91 tuberculosis papers published in Viet Nam during this period. Of the 21 published papers, 16 (76%) contributed to changes in policy (n = 8) and practice (n = 8), and these in turn improved programme performance. Many papers also contributed important evidence for better programme planning. Highly motivated OR fellows embedded within NTPs can facilitate high-quality research and research uptake.

Collaborative activities and treatment outcomes in patients with HIV-associated tuberculosis in Viet Nam

SETTING

The National Tuberculosis (TB) Programme in Viet Nam and Ho Chi Minh City (HCMC).

OBJECTIVES

To determine 1) at national level between 2011 and 2013, the relationship between human immunodeficiency virus (HIV) testing, uptake of TB-HIV interventions and adverse treatment outcomes among TB-HIV patients; and 2) in HCMC in 2013, patient characteristics associated with adverse outcomes.

DESIGN

An ecological study reviewing aggregate nationwide data and a retrospective cohort review in HCMC.

RESULTS

Nationwide, from 2011 to 2013, HIV testing increased in TB patients from 58% to 68% and antiretroviral therapy (ART) increased in TB-HIV patients from 54% to 63%. Adverse treatment outcomes in TB-HIV patients increased from 24% to 27%, largely due to transfer out (5-9% increase) and death. The Northern and Highland regions showed poor uptake of TB-HIV interventions. In HCMC, 303 (27%) of 1110 TB-HIV patients had adverse outcomes, with higher risks observed in those with previously treated TB, those diagnosed as HIV-positive before TB onset and those never placed on cotrimoxazole or ART.

CONCLUSION

Despite improving HIV testing rates and TB-HIV interventions, adverse outcomes in TB-HIV patients remain at about 26%. Characteristics predicting higher risk of adverse outcomes must be addressed if Viet Nam wishes to end the TB epidemic by 2030.

Management and treatment outcomes of patients enrolled in MDR-TB treatment in Viet Nam

SETTING

The programmatic management of drug-resistant tuberculosis (TB) in Viet Nam has been rapidly scaled up since 2009.

OBJECTIVES

To document the annual numbers of patients enrolled for multidrug-resistant tuberculosis (MDR-TB) treatment during 2010-2014 and to determine characteristics and treatment outcomes of patients initiating treatment during 2010-2012.

DESIGN

A retrospective cohort study using national reports and data from the national electronic data system for drug-resistant TB.

RESULTS

The number of patients enrolled annually for MDR-TB treatment increased from 97 in 2010 to 1522 in 2014. The majority of patients were middle-aged men who had pulmonary disease and had failed a retreatment regimen; 77% had received ⩾2 courses of TB treatment. Favourable outcomes (cured and treatment completed) were attained in 73% of patients. Unfavourable outcomes included loss to follow-up (12.5%), death (8%) and failure (6.3%). Having had ⩾2 previous treatment courses and being human immunodeficiency virus-positive were associated with unfavourable outcomes.

CONCLUSION

Increasing numbers of patients are being treated for MDR-TB each year with good treatment outcomes under national programme management in Viet Nam. However, there is a need to increase case detection-currently at 30% of the estimated 5100 MDR-TB cases per year, reduce adverse outcomes and improve monitoring and evaluation.

The fourth national anti-tuberculosis drug resistance survey in Viet Nam

SETTING

Viet Nam's Fourth National Anti-Tuberculosis Drug Resistance Survey was conducted in 2011.

OBJECTIVE

To determine the prevalence of resistance to the four main first-line anti-tuberculosis drugs in Viet Nam.

METHODS

Eighty clusters were selected using a probability proportion to size approach. Drug susceptibility testing (DST) against the four main first-line anti-tuberculosis drugs was performed.

RESULTS

A total of 1629 smear-positive tuberculosis (TB) patients were eligible for culture. Of these, DST results were available for 1312 patients, including 1105 new TB cases, 195 previously treated TB cases and 12 cases with an unknown treatment history. The proportion of cases with resistance to any drug was 32.7% (95%CI 29.1-36.5) among new cases and 54.2% (95%CI 44.3-63.7) among previously treated cases. The proportion of multidrug-resistant TB (MDR-TB) cases was 4.0% (95%CI 2.5-5.4) in new cases and 23.3 (95%CI 16.7-29.9) in previously treated cases.

CONCLUSIONS

The fourth drug resistance survey in Viet Nam found that the proportion of MDR-TB among new and previously treated cases was not significantly different from that in the 2005 survey. The National TB Programme should prioritise the detection and treatment of MDR-TB to reduce transmission of MDR-TB in the community.

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.

Adequacy of anti-tuberculosis drug prescriptions in Viet Nam

SETTING

National Tuberculosis Program, Viet Nam, 2008.

OBJECTIVES

To determine drug prescription adherence to national guidelines, to examine factors associated with an erroneous dosage of rifampin (RMP) and to evaluate the impact of an insufficient RMP dosage on treatment outcome.

METHODS

A representative sample of 30 treatment units was randomly selected. All patient treatment cards enrolled in these units were obtained, and data were double-entered and validated before calculating the adequacy of the individual drug prescriptions.

RESULTS

Of 3412 tuberculosis treatment cards, 3225 (94.5%) had information on treatment regimen and the patient's weight. Treatment was successful in 89.4%. Prescriptions of tablets/vials conforming to recommendations were found for respectively 91.2%, 89.9%, 92.3% and 94.6% of the patients for RMP/isoniazid, pyrazinamide, ethambutol and streptomycin. Patients in the 25-39 kg weight bracket received insufficient dosages. This was almost entirely attributable to patients at the end of the weight bracket. Nevertheless, no significant association was found between treatment failure and death, body weight and insufficient RMP dosage.

CONCLUSIONS

Adherence to national recommendations was high. RMP was given in insufficient dosage for patients at the end of a weight range bracket, but the under-dosage was small and did not measurably affect treatment outcome.

Time to unsuccessful tuberculosis treatment outcome, Cambodia, China, and Viet Nam

OBJECTIVE

To determine the frequency and characteristics of patients with unsuccessful tuberculosis (TB) treatment.

METHODS

Random selection of TB case registers among all treatment units in Cambodia, two provinces in China, and Viet Nam. The data of two calendar years were analyzed to assess unsuccessful outcomes and their time of occurrence.

RESULTS

Among the 33 309 TB patients, treatment was unsuccessful in respectively 10.1%, 3.0% and 9.1% of patients in Cambodia, China and Viet Nam. The risk of death was highest in Cambodia, higher among males than females, increased with age, and was more common among retreatment cases than new cases, and among patients with a high than a low sputum smear microscopy grade. Half of all deaths occurred in the first 2 months in Cambodia and within 11 weeks in China and Viet Nam. Median time to default was 3 months in Cambodia and Viet Nam, and about 2 months in China.

CONCLUSIONS

Treatment was highly successful in the three study countries, with a low proportion of death and default. As the majority of defaulting occurs at the beginning of treatment, all countries should critically review their current policy of treatment support in this period.

Free tuberculosis diagnosis and treatment are not enough: patient cost evidence from three continents

SETTING

The National Tuberculosis Programs of Ghana, Viet Nam and the Dominican Republic.

OBJECTIVE

To assess the direct and indirect costs of tuberculosis (TB) diagnosis and treatment for patients and households.

DESIGN

Each country translated and adapted a structured questionnaire, the Tool to Estimate Patients' Costs. A random sample of new adult patients treated for at least 1 month was interviewed in all three countries.

RESULTS

Across the countries, 27-70% of patients stopped working and experienced reduced income, 5-37% sold property and 17-47% borrowed money due to TB. Hospitalisation costs (US$42-118) and additional food items formed the largest part of direct costs during treatment. Average total patient costs (US$538-1268) were equivalent to approximately 1 year of individual income.

CONCLUSION

We observed similar patterns and challenges of TB-related costs for patients across the three countries. We advocate for global, united action for TB patients to be included under social protection schemes and for national TB programmes to improve equitable access to care.

Changes in body weight and tuberculosis treatment outcome in Viet Nam

SETTING

National Tuberculosis Programme, Viet Nam, 2008.

OBJECTIVE

To assess the relationship between changes in body weight and tuberculosis (TB) treatment outcome.

METHODS

All treatment cards of patients from a sample of 30 randomly selected treatment units in the country were analysed.

RESULTS

Of 2609 patients, 2506 (96.1%) had a successful treatment outcome. The median body weight of all patients at diagnosis was 46.0 kg (25th and 75th percentiles 41-51). New sputum smear-positive TB patients with a successful treatment outcome gained an average of 2.6 kg during treatment. Patients with weight loss during the first 2 months of treatment were more likely to have an unsuccessful outcome than patients without (OR 4.9, 95%CI 3.0-7.9). Patients weighing <40 kg at treatment start who gained more than 5% of their body weight after 2 months of treatment had a significantly smaller risk of an unsuccessful treatment outcome than patients who did not (OR 0.2, 95%CI 0.05-0.96).

CONCLUSIONS

Patients failing to gain weight or losing weight, particularly during the first 2 months of treatment, require particular attention, as they appear to be at an increased risk of unsuccessful treatment outcome.

Yield of interview screening and chest X-ray abnormalities in a tuberculosis prevalence survey

BACKGROUND

Tuberculosis (TB) prevalence surveys generally rely on a combination of screening methods to identify suspects eligible for sputum culture.

OBJECTIVE

To assess the yield of screening methods applied in a recent prevalence survey in Viet Nam and estimate the proportion of TB cases missed due to incomplete participation.

METHODS

TB suspects were identified based on self-reported TB history or productive cough by interview and chest X-ray (CXR). We calculated the case yield of these two screening methods by dividing the number of cases detected per method by the total number of cases detected. As not all participants underwent the full screening procedure, we recalculated the maximum yield of the screening methods using multiple imputation methods.

RESULTS

The yield from screening by interview and CXR were respectively 38% and 91%. Adjusting for missing data by multiple imputation, we estimated that we missed 9.9% (95%CI 6.8-14.2) of expected TB cases.

CONCLUSION

In prevalence surveys, screening by pre-structured interview is insufficient, and should be supplemented with CXR to achieve sufficient identification of TB cases. The effect of incomplete participation in the full screening procedure may be substantial and should be adjusted for in the analysis.

Health-seeking behaviour among adults with prolonged cough in Vietnam

OBJECTIVE

To assess health-seeking behaviour among adults with prolonged cough in a population-based, nationally representative sample in Vietnam.

METHODS

Cross-sectional survey conducted from September 2006 to July 2007. All inhabitants aged ≥15 years were invited for screening for cough, history of tuberculosis (TB) treatment and chest X-ray (CXR) examination. TB suspects, defined as any survey participant with CXR abnormalities consistent with TB, or productive cough for more than 2 weeks or TB treatment either currently or in the preceding 2 years submitted sputum specimens for smear examination and culture and provided information on health-seeking behaviour in an in-depth interview.

RESULTS

Of 94 179 persons participating in the survey, 4.6% had prolonged productive cough. Forty-four percentage of those had sought health care and reported pharmacies (35%), commune health posts (29%), public hospitals (24%) and private physicians (10%) as first point of contact. Only 7% had undergone sputum smear examination. Of TB suspects with prolonged productive cough, 2.9% were diagnosed with TB; 10.2% of these reported smear and 21.9% reported X-ray examination when visiting a health care facility. The average patient delay was 4.1 weeks (95% CI: 3.9-4.4) among cough suspects and 4.0 weeks (95% CI: 3.1-4.9) among TB cases.

CONCLUSIONS

In this Vietnamese survey, nearly half of persons with cough for more than 2 weeks had visited a health care provider. The commonest first health facility contacted was the pharmacy. Sputum smears were rarely examined, except in the provincial TB hospital. Our findings highlight the need to improve diagnostic practices by retraining health staff on the performance of sputum examination for TB suspects.

Household expenditure and tuberculosis prevalence in VietNam: prediction by a set of household indicators

OBJECTIVE

To study the association between TB and household expenditure in a nationwide TB prevalence survey in Viet Nam using nine household characteristics.

METHOD

To assess the prevalence of TB in Viet Nam, a nationwide stratified cluster sample survey was conducted from 2006 to 2007. Nine household characteristics used in the second Viet Nam Living Standards Survey (VLSS) were scored per household. In the VLSS dataset, we regressed these nine characteristics against household expenditure per capita, and used the coefficients to predict household expenditure level (in quintiles) in our survey and assess its relation with TB prevalence.

RESULTS

The prevalence of bacteriologically confirmed TB was 307 per 100,000 population in persons aged ≥ 15 years (95%CI 249-366). After adjustment for confounders, prevalence was found to be associated with household expenditure level: the rate was 2.5 times higher for those in the lowest household expenditure quintile (95%CI 1.6-3.9) than those in the highest quintile.

CONCLUSION

With a set of nine household characteristics, we were able to predict household expenditure level fairly accurately. There was a significant association between TB prevalence rates and estimated household expenditure level, showing that TB is related to poverty in Viet Nam.

Completeness and consistency in recording information in the tuberculosis case register, Cambodia, China and Viet Nam

SETTING

Tuberculosis (TB) case registers in Cambodia, two provinces in China and in Viet Nam.

OBJECTIVE

To determine completeness and consistency of information for quarterly reports on case finding and treatment outcome.

METHODS

A representative sample of TB case registers was selected in Cambodia, in two provinces in China and in Viet Nam. Quarterly reports were reproduced from double-entered, validated data to determine completeness and consistency.

RESULTS

The dataset comprised 37,635 patient records in 2 calendar years. Only 0.2%, 3.6% and 1.1% of cases, respectively, in Cambodia, the two China provinces, and Viet Nam did not allow classification for the quarterly report on case finding. If the treatment outcome was reported as cured, it was correct in 99.9%, 85.7%, and 98.5% of the respective three jurisdictions: errors were mostly due to misclassification of completion as cure. Under-reporting of failures was more frequent than over-reporting in Cambodia and Viet Nam, while in the two provinces in China 84% of reported failures did not actually meet the bacteriological criterion.

CONCLUSIONS

This evaluation demonstrates that recording essential information is exemplary in all three countries. It will be essential to carefully supervise the ability of staff to correctly define TB treatment outcome results in all three countries.

Low tuberculosis notification in mountainous Vietnam is not due to low case detection: a cross-sectional survey

BACKGROUND

Studies show that tuberculosis notification declines with increasing altitude. This can be due to declining incidence or declining case detection. In Vietnam notification rates of new smear-positive tuberculosis in the central mountainous provinces (26/100,000 population) are considerably lower than in Vietnam in general (69/100,000 population). In order to clarify whether this is explained by low incidence or low case detection, we aimed to assess the prevalence of new smear-positive tuberculosis among adults with prolonged cough in three mountainous provinces in central Vietnam.

METHODS

A house-to-house survey of persons (> or = 15 years) was carried out in twelve randomly selected districts in 2003. Three sputum specimens were microscopically examined of persons reporting a prolonged cough (> or = 3 weeks). Case detection was assessed by the ratio between notification and prevalence.

RESULTS

Of 68,946 included persons (95% response), 1,298 (1.9% 95%CI 1.8-2.2) reported a prolonged cough. Of these, eighteen were sputum smear-positive of whom two had had anti-tuberculosis treatment. The prevalence of new smear-positive tuberculosis was 27/100,000 (95%CI 11-44/100,000) and the notification rate was 44/100,000 among persons > or = 15 years. The estimated case detection rate was 76%.

CONCLUSION

Low tuberculosis notification in this mountainous setting is probably a true reflection of low tuberculosis incidence. Possible causes for low incidence in mountainous areas include low transmission rates or altitude-related differences in pathology.