Does distance to healthcare facility affect care-seeking for TB-related symptoms in Tanzania?

BACKGROUND: In high TB burden countries, delayed diagnosis remains a big challenge in TB control. The objective of this study is to assess the role of distance between residence and healthcare facility (HCF) on care-seeking among individuals with symptoms associated with pulmonary TB in Tanzania.METHODS: In this cross-sectional study, using data from a national TB survey, coordinates of 300 (residential) sites within 62 clusters were obtained through Google searches and average distances to HCF were calculated per cluster. Univariable and multivariable logistic regression analyses were conducted, with care-seeking behaviour being the primary outcome variable.RESULTS: Distance from residence to HCF had no effect on care-seeking behaviour of individuals with TB-related symptoms in this study (OR 1.00, 95% CI 1.00-1.00). Over 85% of HCFs where care has been sought lack TB diagnostic capacity, mostly comprising dispensaries with staff less educated in TB-related symptoms.CONCLUSION: Care-seeking behaviour among individuals with TB-related symptoms in Tanzania was not found to be associated with distance to HCF. First-line diagnostics should be improved 1) by equipping local dispensaries with basic TB diagnostic capacity, and 2) by educating staff of local dispensaries more thoroughly about basic TB symptoms and the importance of swift referrals.

Association between cholera treatment outcome and nutritional status in children aged 2-4 years in Nigeria

SETTING

Cholera can aggravate or precipitate malnutrition, and children with severe acute malnutrition (SAM) have a higher incidence and longer duration of diarrhoea.

OBJECTIVE

To describe 1) characteristics of and treatment outcomes in children aged 2-4 years with cholera, 2) the case fatality rate (CFR) in all children treated, and 3) the associations between nutritional status, hydration status, treatment administered and hospital outcomes.

DESIGN

An observational cohort study of children admitted to one cholera treatment centre in Maiduguri, Nigeria, with a focus on children aged 2-4 years. CFRs were examined by cross tabulation and mean length of stay (LOS) using analysis of variance.

RESULTS

SAM was identified in 24% of children aged 2-4 years. The CFR for children aged 2-4 years was 1.4%. As the sample size was small, we did not find any association between nutritional status and death due to cholera. The proportion of children discharged within 2 days was 79%, and the longest stay was 8 days. In general, health facility LOS increased with severity of malnutrition.

CONCLUSION

Our study found that nutritional status affected the LOS, but was unable to find an association between malnutrition and fatality among children aged 2-4 years.

Characteristics of first-time family planning users and methods used at mobile clinics in rural Malawi

Setting: Malawi committed to increase modern contraceptive prevalence rate to 60% for all women by 2020, but current use ranges from 37% to 59% among women of different ages and marital status.Objectives: To describe characteristics of first-time family planning (FP) users and associations between characteristics and methods used among women of childbearing age accessing injectables, oral contraceptives and implants in rural mobile clinics in Mulanje, Malawi, in 2017–2018.Design: This was a cross-sectional retrospective study.Results: Among 2120 first-time FP users, 65% were <25 years. Half (50%) had 2–4 live children and only 1% were nulliparous. HIV infection rate among all users was 4%. Of the three methods, injectables were used most (75%), with a significantly higher use in HIV-positive clients (91%). Nearly 25% of first-time users used implants and the proportion increased from 21% in 2017 to 34% in 2018.Conclusion: This study demonstrated that FP can be provided to young women in remote areas if the availability of well-trained providers is ensured. It highlighted the need to target younger and nulliparous women with a broad mix of contraceptives to improve access to, and uptake of, FP services to reach national commitments.

Mass screening for active case finding of pulmonary tuberculosis in the Russian Federation: how to save costs

BACKGROUND: In Russia, mass chest X-ray (CXR) screening for tuberculosis (TB) is mandatory.OBJECTIVE: To compare the yield and the cost per TB case detected and the total cost of CXR screening, passive case finding and contact tracing among adolescents and adults in the Arkhangelsk Oblast, Russian Federation, 2013-2017.DESIGN: This was an analysis of costing strategies using aggregated data. Costing information was obtained from the Finance Department of the Arkhangelsk Clinical TB Dispensary, Arkhangelsk, and the Territorial Fund of Mandatory Medical Insurance, Arkhangelsk, Russian Federation.RESULTS: TB cases were detected using CXR screening (n = 684, 46%), contact tracing (n = 61, 4%) and passive case finding (n = 743, 46%). The number of cases detected using CXR screening, contact tracing and passive case finding was respectively 28,753 and 960/100 000. The mean costs/test were respectively US$3.54 (US$12 541/case), US$20.28 (US$2693/case) and US$11.85 (US$1235/case) using CXR screening, contact tracing and passive case finding The number of cases/100 000 in targeted groups was as follows: HIV-positive persons, 645; homeless persons, 461; and migrants, 441. The cost/TB case detected was respectively US$549, US$768 and US$803.CONCLUSION: Mass CXR screening (excluding HIV-positive, migrant and homeless populations) has low yield and high cost per TB case detected. It should be stopped and resources should instead be used to strengthen the screening of targeted high-risk groups, contacts and passive case finding.

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

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

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

Setting

Ten districts and three cities in Zimbabwe.

Objective

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

Design

Cross-sectional study using data from the ZimACF project.

Results

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

Conclusion

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

Population impact of factors associated with prevalent pulmonary tuberculosis in Tanzania

SETTING

Tanzania has an estimated tuberculosis (TB) prevalence of 295 per 100 000 adult population. There is currently no nationally representative information on factors associated with TB in Tanzania.

OBJECTIVE

To determine the demographic and clinical factors associated with bacteriologically confirmed TB in the adult general population of Tanzania.

DESIGN

A case-control study nested in a nationally representative TB prevalence survey. All patients with bacteriologically confirmed pulmonary TB (PTB) constituted cases and a representative sample of people without bacteriologically confirmed PTB constituted controls. We calculated adjusted odds ratios (aORs) to identify factors associated with TB.

RESULTS

Age groups 25-34 years (aOR 3.7, 95%CI 1.5-8.8) and 55-64 years (aOR 2.5, 95%CI 1.1-5.5), male sex (aOR 1.6, 95%CI 1.1-2.3) and low body mass index (BMI) (aOR 1.7, 95%CI 1.1-2.8) were significantly associated with TB. Association with human immunodeficiency virus (HIV) and diabetes mellitus (DM) was not statistically significant. The population attributable fraction (PAF) was 2% (95%CI -2 to 5) for DM and 3% (95%CI -2 to 8) for HIV.

CONCLUSION

Being in an older age group, being male and having a low BMI were associated with bacteriologically confirmed PTB. On the population level, classic risk factors for TB have no major effect on prevalent TB from which future transmission may occur.

Prevalence of pulmonary tuberculosis in adult population of Tanzania: a national survey, 2012

SETTING

Tanzania is classified as one of the 22 high tuberculosis (TB) burden countries; however, the true burden of TB disease in the country remains unknown.

OBJECTIVE

To assess the prevalence of bacteriologically confirmed pulmonary TB (PTB) in the adult population.

DESIGN

This was a community-based cluster randomised survey with proportional-to-population-size selection of primary sampling units (districts). Participants were screened for TB using a symptom questionnaire and chest X-ray (CXR). Those with abnormal CXR and/or at least one symptom suggestive of TB were classified as individuals with presumptive TB, and asked to submit three sputum specimens for smear microscopy and culture.

RESULTS

The weighted prevalence for sputum smear-positive TB cases was 249 per 100 000 adult population (95%CI 192-305) and that for bacteriologically confirmed TB cases was 293/100 000 (95%CI 228-358). Individuals aged ⩾45 years comprised 55% (71/129) of the identified smear-positive cases, but just 28% (6793/24 648) of the notified TB cases. CXR screening identified more TB cases than symptom screening. When weighted for human immunodeficiency virus prevalence among notified new smear-positive cases, the overall case detection of incident TB cases in 2012 was between 37% and 48%.

CONCLUSIONS

The prevalence of sputum smear-positive PTB and bacteriologically confirmed PTB in the adult population was higher than previous World Health Organization estimates. There is a potential underestimation of the number of bacteriologically confirmed PTB cases in the adult population. The age distribution of prevalent cases suggests an epidemiological shift towards the older generations, which has been a sign of successful TB control activities in the past. However, the survey shows that many infectious TB cases are currently missed by the National Tuberculosis Programme.

Childhood tuberculosis in Mauritania, 2010-2015: diagnosis and outcomes in Nouakchott and the rest of the country

Setting: The National Tuberculosis Programme, Mauritania. Objective: To compare the diagnosis and treatment outcomes of childhood tuberculosis (TB) cases (aged <15 years) registered between 2010 and 2015 inside and outside Nouakchott, the capital city. Design: This was a retrospective comparative cohort study. Results: A total of 948 children with TB were registered. The registration rate was 10 times higher in Nouakchott. The proportion of children among all TB cases was higher inside than outside Nouakchott (7.5% vs. 4.6%, P < 0.01). Under-fives represented 225 (24%) of all childhood TB cases, of whom 204 (91%) were registered in Nouakchott. Extra-pulmonary TB was more common in Nouakchott, while smear-negative TB was less common. Treatment success was similar inside and outside Nouakchott (national rate 61%). The principal unsuccessful outcomes were loss to follow-up outside Nouakchott (21% vs. 11%, P < 0.01) while transfers out were more common in the city (25% vs. 14%, P = 0.01). Being aged <5 years (OR 1.2, 95%CI 1.1-1.5) was associated with an unsuccessful outcome. Conclusion: This study indicates problems in the diagnosis and treatment of childhood TB in Mauritania, especially outside the city of Nouakchott. We suggest strengthening clinical diagnosis and management, improving communications between TB treatment centres and health services and pressing the TB world to develop more accurate and easy-to-use diagnostic tools for children.

Pre-treatment loss to follow-up among smear-positive TB patients in tertiary hospitals, Quetta, Pakistan

Setting: Three public sector tertiary care hospitals in Quetta, Balochistan, Pakistan, with anecdotal evidence of gaps between the diagnosis and treatment of patients with tuberculosis (TB). Objectives: To assess the proportion of pre-treatment loss to follow-up (LTFU), defined as no documented evidence of treatment initiation or referral in TB registers, among smear-positive pulmonary TB patients diagnosed in 2015, and the associated sociodemographic factors. Design: A retrospective cohort study involving the review of laboratory and TB registers. Results: Of 1110 smear-positive TB patients diagnosed (58% female, median age 40 years, 5% from outside the province or the country), 235 (21.2%) were lost to follow-up before starting treatment. Pre-treatment LTFU was higher among males; in patients residing far away, in rural areas, outside the province or the country; and in those without a mobile phone number. Conclusion: About one fifth of the smear-positive TB patients were lost to follow-up before starting treatment. Strengthening the referral and feedback mechanisms and using information technology to improve the tracing of patients is urgently required. Further qualitative research is needed to understand the reasons for pre-treatment LTFU from the patient's perspective.

High mortality in tuberculosis patients despite HIV interventions in Swaziland

SETTING

All health facilities providing tuberculosis (TB) care in Swaziland.

OBJECTIVE

To describe the impact of human immunodeficiency virus (HIV) interventions on the trend of TB treatment outcomes during 2010-2013 in Swaziland; and to describe the evolution in TB case notification, the uptake of HIV testing, antiretroviral therapy (ART) and cotrimoxazole preventive therapy (CPT), and the proportion of TB-HIV co-infected patients with adverse treatment outcomes, including mortality, loss to follow-up and treatment failure.

DESIGN

A retrospective descriptive study using aggregated national TB programme data.

RESULTS

Between 2010 and 2013, TB case notifications in Swaziland decreased by 40%, HIV testing increased from 86% to 96%, CPT uptake increased from 93% to 99% and ART uptake among TB patients increased from 35% to 75%. The TB-HIV co-infection rate remained around 70% and the proportion of TB-HIV cases with adverse outcomes decreased from 36% to 30%. Mortality remained high, at 14-16%, over the study period, and anti-tuberculosis treatment failure rates were stable over time (<5%).

CONCLUSION

Despite high CPT and ART uptake in TB-HIV patients, mortality remained high. Further studies are required to better define high-risk patient groups, understand the reasons for death and design appropriate interventions.

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.

Health care-seeking behaviour among people with cough in Tanzania: findings from a tuberculosis prevalence survey

SETTING

The study was conducted within a nation-wide population-based tuberculosis (TB) prevalence survey in the adult population in Tanzania.

OBJECTIVE

To assess the health care-seeking behaviour of coughers presumed to have TB.

DESIGN

A survey in which participants were screened for TB using a symptom questionnaire and chest X-ray (CXR). Those with cough of ⩾ 2 weeks and/or who were coughing blood were interviewed about their health care-seeking behaviour and socio-demographic and clinical factors.

RESULTS

Of 3388 people with presumptive TB, 31.0% (1051/3388) had sought treatment for their symptoms. Of these, about 42% (445/1051) sought care at sites with TB diagnostic capacity, where sputum examination was performed in 37.1% (165/445) and CXR in 28.1% (125/445). In sites with limited TB diagnostic capacity, fewer than 1% were referred for sputum examination or CXR. Individuals with additional symptoms were more likely to seek treatment. Knowledge about TB was significantly associated with care seeking at sites with TB diagnostic capacity.

CONCLUSIONS

A third of the persons with cough symptoms consistent with TB had sought health care. About 42% sought care in sites with TB diagnostic capacity, but most did not undergo TB diagnostic procedures, precluding a timely diagnosis.

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.

Active and passive case detection strategies for the control of leishmaniasis in Bangladesh

SETTING

Two subdistricts in Bangladesh, Fulbaria and Trishal, which are hyperendemic for leishmaniasis.

OBJECTIVE

To determine 1) the numbers of patients diagnosed with visceral leishmaniasis (VL) and post-kala azar dermal leishmaniasis (PKDL) using an active case detection (ACD) strategy in Fulbaria and a passive case detection (PCD) strategy in Trishal, and 2) the time taken from symptoms to diagnosis in the ACD subdistrict.

DESIGN

A cross-sectional descriptive study of patients diagnosed from May 2010 to December 2011. The ACD strategy involved community education and outreach workers targeting households of index patients using symptom-based screening and rK-39 tests for suspected cases.

RESULTS

In the ACD subdistrict (Fulbaria) and PCD sub-district (Trishal), respectively 1088 and 756 residents were diagnosed with VL and 1145 and 37 with PKDL. In the ACD subdistrict, the median time to diagnosis for patients directly referred by outreach workers or self-referred was similar, at 60 days for VL and respectively 345 and 360 days for PKDL.

CONCLUSION

An ACD strategy at the subdistrict level resulted in an increased yield of VL and a much higher yield of PKDL. As PKDL acts as a reservoir for infection, a strategy of ACD and treatment can contribute to the regional elimination of leishmaniasis in the Indian sub-continent.

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.

Open access for operational research publications from low- and middle-income countries: who pays?

Open-access journal publications aim to ensure that new knowledge is widely disseminated and made freely accessible in a timely manner so that it can be used to improve people's health, particularly those in low- and middle-income countries. In this paper, we briefly explain the differences between closed- and open-access journals, including the evolving idea of the 'open-access spectrum'. We highlight the potential benefits of supporting open access for operational research, and discuss the conundrum and ways forward as regards who pays for open access.

Severe acute maternal morbidity and associated deaths in conflict and post-conflict settings in Africa

SETTING

Five hospitals in four conflict and post-conflict countries (Democratic Republic of Congo, Somaliland, Sierra Leone and Burundi).

OBJECTIVES

To report among hospital deliveries: 1) the proportion of severe acute maternal morbidity (SAMM), 2) the pattern of SAMM, and 3) maternal deaths according to type of SAMM.

METHODS

An audit of data from a standardised database implemented in all the sites in the study.

RESULTS

Of the 18 675 deliveries, there were 6314 (34%) known SAMM cases with 63 associated deaths, implying that for every 100 SAMM cases there was one maternal death. In descending order, the death-to-SAMM ratios per 1000 deliveries were: 1:7 for sepsis, 6 for haemorrhage 1:70 for hypertensive disorder and 1:398 for obstructed labour. A substantial proportion of deaths (38%) that occurred in hospitals could not be categorised into the standardised SAMM conditions available in the database.

CONCLUSION

As this is the first study using multi-centre data from conflict and post-conflict countries, these findings are relevant to improving maternal health in such settings. Findings, implications and possible ways forward in addressing various challenges are discussed.

Are sputum samples of retreatment tuberculosis reaching the reference laboratories? A 9-year audit in Tanzania

SETTING

One reference and three zonal laboratories and 500 health facilities managing retreatment tuberculosis (TB) patients in Tanzania.

OBJECTIVES

The National Tuberculosis and Leprosy Programme (NTLP) requires that all notified cases of retreatment TB in Tanzania have sputum samples sent for culture and drug susceptibility testing (DST). This study determined 1) if the number of annually notified retreatment patients corresponded to the number of sputum samples received by the reference laboratories, and 2) the number of culture-positive samples and the number of cases undergoing DST.

DESIGN

Nine-year audit of country-wide programme data from 2002 to 2010.

RESULTS

Of the 40 940 retreatment TB patients notified by the NTLP, 3871 (10%) had their sputum samples received at the reference and zonal laboratories for culture and DST. A total of 3761 (97%) sputum samples were processed for culture, of which 1589 (42%) were found to be culture-positive and 1415 (89%) had DST performed.

CONCLUSIONS

There is a >90% shortfall between notified retreatment cases and numbers of sputum samples received, cultured and assessed for DST at reference and zonal laboratories. Steps needed to address this problem are discussed.

References for scientific papers: why not standardise to one global style?

The different reference styles demanded by journals, both for in-text citations and manuscript bibliographies, require that significant time and attention be paid to minute detail that constitute a tedious obstacle on the road to publication for all authors, but especially for those from resource-limited countries and/or writing in a second language. To illustrate this, we highlight different reference styles requested by five popular journals to which operational research papers are often submitted. We call for a simpler, standardised format for in-text and bibliography reference citations, so that researchers can concentrate on the science and its interpretation rather than fonts and punctuation.

Why ethics is indispensable for good-quality operational research

This article outlines challenges encountered when ethics is taught and promoted in the Operational Research courses of the International Union Against Tuberculosis and Lung Disease, with a focus on ethical issues related to studies that involve health records reviews. Problems observed by the Ethics Advisory Group include engagement of all stakeholders, maintenance of confidentiality and authorship. The omission of ethics in the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement and its explanatory commentary published in 2007 is highlighted and questioned.

Tuberculosis treatment outcomes among retreatment patients registered by private practitioners in Myanmar

The objectives of this retrospective cohort study were to report treatment outcomes and identify factors associated with treatment failure among all retreatment tuberculosis (TB) patients registered in the public-private mix DOTS programme of Populations Services International-Myanmar over 6 years. Among 3643 retreatment patients, 2657 (73%) were successfully treated and 309 (8.5%) failed. This study shows that retreatment patients who have failed treatment for their first TB episode are almost twice as likely to fail a second time (13.5%). We have identified some key programmatic challenges associated with retreatment TB in the private sector, and steps are being taken to address this issue.

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.

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.

Oops, what about ethics?

Ethics approval of research studies is essential for the protection and rights of study subjects, whether this is for prospective research or record reviews. This article shares a painful lesson learned from a field experience where the appropriate steps for obtaining ethics approval were not followed by a young researcher. This researcher had embarked on an operational research project, but had omitted to seek ethics approval from a local ethics committee. Young researchers, particularly from low- and middle-income countries, need to learn about the importance and value of ethics.

The burden and outcomes of childhood tuberculosis in Cotonou, Benin

SETTING

The National Tuberculosis Programme (NTP) and the paediatric ward of the General Hospital (GH), Cotonou, Benin.

OBJECTIVE

To describe the burden of tuberculosis (TB), characteristics and outcomes among children treated in Cotonou from 2009 to 2011.

DESIGN

Cross-sectional cohort study consisting of a retrospective record review of all children with TB aged <15 years.

RESULTS

From 2009 to 2011, 182 children with TB were diagnosed and treated (4.5% of total cases), 153 (84%) by the NTP and 29 (16%) by the GH; the latter were not notified to the NTP. The incidence rate of notified TB cases was between 8 and 13 per 100 000 population, and was higher in children aged >5 years. Of 167 children tested, 29% were HIV-positive. Treatment success was 72% overall, with success rates of 86%, 62% and 74%, respectively, among sputum smear-positive, sputum smear-negative and extra-pulmonary patients. Treatment success rates were lower in children with sputum smear-negative TB (62%) and those with HIV infection (58%).

CONCLUSION

The number of children being treated for TB is low, and younger children in particular are underdiagnosed. There is a need to improve the diagnosis of childhood TB, especially among younger children, and to improve treatment outcomes among HIV-TB infected children, with better follow-up and monitoring.

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.

Timing of antiretroviral therapy and effects on tuberculosis treatment outcomes in HIV-co-infected patients in Malawi

SETTING

Queen Elizabeth Central Hospital, Blantyre, Malawi.

OBJECTIVES

To determine 1) the proportion of human immunodeficiency virus (HIV) infected tuberculosis (TB) patients started on antiretroviral therapy (ART), 2) the timing of ART and 3) the effect of the timing on TB treatment outcomes.

DESIGN

A retrospective record review of HIV-infected TB patients registered from January to December 2009.

RESULTS

A total of 3376 TB patients were registered, of whom 2665 (79%) were HIV-tested and 2042 (77%) were HIV-infected. A total of 1190 HIV-infected TB patients who were not on ART at the time of starting TB treatment were studied. Of 688 (58%) who started ART, 61% started therapy within 2 months of anti-tuberculosis treatment and 39% started later (≥2 months). Treatment success for patients with TB who started ART within 2 months was higher than for those starting ART later (RR 1.6, 95%CI 1.4-1.8), and death rates were lower (RR 0.25, 95%CI 0.19-0.35).

CONCLUSION

Under routine programme conditions in Malawi, a higher proportion of HIV-infected TB patients who started ART did so within 2 months of starting TB treatment, and early ART intervention was associated with better treatment outcomes. This confirms recommendations that co-infected TB patients should start ART early.

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.

Sexual violence in post-conflict Liberia: survivors and their care

Using routine data from three clinics offering care to survivors of sexual violence (SV) in Monrovia, Liberia, we describe the characteristics of SV survivors and the pattern of SV and discuss how the current approach could be better adapted to meet survivors' needs. There were 1500 survivors seeking SV care between January 2008 and December 2009. Most survivors were women (98%) and median age was 13 years (Interquartile range: 9-17 years). Sexual aggression occurred during day-to-day activities in 822 (55%) cases and in the survivor's home in 552 (37%) cases. The perpetrator was a known civilian in 1037 (69%) SV events. Only 619 (41%) survivors sought care within 72 h. The current approach could be improved by: effectively addressing the psychosocial needs of child survivors, reaching male survivors, targeting the perpetrators in awareness and advocacy campaigns and reducing delays in seeking care.

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.

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.

Intensified tuberculosis case finding among people living with the human immunodeficiency virus in a hospital clinic in Ethiopia

Intensified tuberculosis case finding (ICF) is used in people living with the human immunodeficiency virus (PLHIV) to reduce the burden of tuberculosis (TB). We conducted a retrospective study in 300 PLHIV attending an HIV care clinic in Ethiopia to assess ICF performance during a 12-month period. Between 80% and 95% of patients were screened for TB at enrolment and at each 3-month follow-up visit. Thirty-four (11%) patients were diagnosed with TB, of whom 27 (79%) were identified in the first 6 months. This study assessed serial ICF in routine settings, showing that TB screening had its largest diagnostic yield in the first 6 months.

The Union and Médecins Sans Frontières approach to operational research

Operational research (OR) has become a hot topic at national meetings, international conferences and donor fora. The International Union Against Tuberculosis and Lung Disease (The Union) and Médecins Sans Frontières (MSF) Operational Centre Brussels strongly promote and implement OR with colleagues in low- and middle-income countries. Here we describe how the two organisations define OR, and explain the guiding principles and methodology that underpin the strategy for developing and expanding OR in those countries. We articulate The Union's and MSF's approach to supporting OR, highlighting the main synergies and differences. Then, using the Malawi National Tuberculosis Control Programme as an example, we show how OR can be embedded within tuberculosis control activities, leading to changes in policy and practice at the national level. We discuss the difficult, yet vitally important, issue of capacity building, and share our vision of a new paradigm of product-related training and performance-based OR fellowships as two ways of developing the necessary skills at country level to ensure research is actually performed. Finally, we highlight the need to consider and incorporate into practice the ethical components of OR. This is a key moment to be involved in OR. We are confident that in partnership with interested stakeholders, including the World Health Organization, we can stimulate the implementation of quality, relevant OR as an integral part of health service delivery that in turn will lead to better health for people, particularly for those living in the poorer parts of the world.

Performance of culture and drug susceptibility testing in pulmonary tuberculosis patients in northern China

Multidrug-resistant tuberculosis (MDR-TB) is a growing problem in China. In 2008, all smear-positive pulmonary TB patients in a city in northern China were expected to undergo routine culture and drug susceptibility testing (DST). We assessed the performance of this system. There were 915 patients, of whom 356 (39%) had culture performed; 275 (30%) had positive cultures and 236 (26%) had DST. Of the 236 patients with DST, 6% of new and 32% of previously treated patients had MDR-TB. Culture and DST is an important service for the correct management of patients, and solutions to improve the current system need to be considered.

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.

Diagnosis and outcome of childhood tuberculosis: implementing public health policy in three districts of Pakistan

SETTING

All nine public sector hospitals in three districts of Pakistan.

OBJECTIVE

To estimate case notifications of children with tuberculosis (TB) and their outcomes.

DESIGN

A retrospective cohort following all children aged <15 years placed on TB treatment under the National TB Control Programme (NTP) in public hospitals. The study period was 2 years before and 2 years after the implementation of new NTP policy guidelines for childhood TB. Data were collected from hospital TB registers, patient treatment cards and quarterly reports.

RESULTS

With the introduction of the new NTP policy, case notification of childhood TB increased from 189 (2004-2005) to 731 for the 2 years 2006-2007. The annual notification rate of childhood TB cases increased from 1.4 (2004-2005) to 5.2 per 100 000 population (2006-2007). Of the total 920 childhood TB cases registered, 610 were pulmonary, 202 extra-pulmonary and the remaining 108 unclassified. The three-fold increase in case notification was accompanied by a lack of follow-up, resulting in an increase in unknown treatment outcomes from 21.7% to 73.3%.

CONCLUSION

Managing children with TB in routine NTP practice is possible, but without adequate operational guidelines, expanding services and follow-up, it can lead to suboptimal results.

Indoor solid fuel combustion and tuberculosis: is there an association?

OBJECTIVES

To assess the strength of evidence in published articles for an association between indoor solid fuel combustion and tuberculosis.

METHODS

PubMed, a private database and Google Scholar were searched up to May 2008, as was the Cochrane Library (2008, issue 4), to identify articles on the association between indoor air pollution and tuberculous infection, tuberculosis disease and tuberculosis mortality. Each article initially chosen as acceptable for inclusion was reviewed for data extraction by three different reviewers using a standard format. Strength of evidence was determined by pre-determined criteria.

RESULTS

The full texts of 994 articles were examined for a final selection of 10 possible articles, of which six met the inclusion criteria. All articles investigated the association between exposure to solid fuel (coal and biomass) smoke and tuberculosis disease. Three (50%) of the six studies included in the systematic review showed a significant effect of exposure to solid fuel combustion and tuberculosis disease-one high-quality case-control study and two cross-sectional studies.

CONCLUSION

Despite the plausibility of an association, available original studies looking at this issue do not provide sufficient evidence of an excess risk of tuberculosis due to exposure to indoor coal or biomass combustion. Because the number of studies identified was small, new studies are needed before more definitive conclusions can be reached.

Serious adverse reactions in a tuberculosis programme setting in Kyrgyzstan

Serious adverse reactions among new smear-positive patients were studied in a programme setting in Kyrgyzstan. Two per cent of patients on tuberculosis (TB) treatment had to interrupt treatment for > or =1 week, and more than 80% of the reactions occurred during the first month of treatment. Pyrazinamide was the most common causative agent, followed by rifampicin.

Isoniazid preventive therapy for people living with HIV: public health challenges and implementation issues

Isoniazid preventive therapy (IPT) is recognised as an important component of collaborative tuberculosis (TB) and human immunodeficiency virus (HIV) activities to reduce the burden of TB in people living with HIV (PLHIV). However, there has been little in the way of IPT implementation at country level. This failure has resulted in a recent call to arms under the banner title of the 'Three I's' (infection control to prevent nosocomial transmission of TB in health care settings, intensified TB case finding and IPT). In this paper, we review the background of IPT. We then discuss the important challenges of IPT in PLHIV, namely responsibility and accountability for the implementation, identification of latent TB infection, exclusion of active TB and prevention of isoniazid resistance, length of treatment and duration of protective efficacy. We also highlight several research questions that currently remain unanswered. We finally offer practical suggestions about how to scale up IPT in the field, including the need to integrate IPT into a package of care for PLHIV, the setting up of operational projects with the philosophy of 'learning while doing', the development of flow charts for eligibility for IPT, the development and implementation of care prior to antiretroviral treatment, and finally issues around procurement, distribution, monitoring and evaluation. We support the implementation of IPT, but only if it is done in a safe and structured way. There is a definite risk that 'sloppy' IPT will be inefficient and, worse, could lead to the development of multidrug-resistant TB, and this must be avoided at all costs.

Registering initial defaulters and reporting on their treatment outcomes

This Unresolved Issues article highlights three original articles that appeared last year in the Journal discussing the phenomenon of initial defaulters. There are three important challenges with patients that appear in the laboratory sputum register but are not recorded in the tuberculosis (TB) patient register: the first is how to identify these patients, trace them and get them on to treatment as soon as possible; the second is how to register and report on these cases as part of the case-finding component of TB control; and the third is whether to include these initial default patients in the cohort analysis of treatment outcomes. We recommend a step-wise approach to these challenges and advocate that these patients be included, wherever possible, in the TB patient register and in the cohort analysis of treatment outcomes.

High success rate of TB treatment among Bhutanese refugees in Nepal

SETTING

Camps for refugees from Bhutan in south-east Nepal.

OBJECTIVES

To evaluate the outcome of treatment of tuberculosis (TB) cases in the refugee camps.

DESIGN

Cohort analysis of results of treatment of cases started on treatment from mid-July 1999 to mid-July 2004.

RESULT

A total of 1214 patients with TB were notified in the programme. Among these, 631 (52%) were new smear-positive pulmonary tuberculosis (PTB) cases, 175 (14%) new smear-negative PTB cases, 290 (24%) new extra-pulmonary TB (EPTB) cases and 118 (10%) smear-positive retreatment cases. Treatment success was achieved in 1061 (94%). The proportion of new non-smear-positive cases who died on treatment was significantly higher than the corresponding figure for new smear-positive cases (RR 7.57, 95%CI 3.74-15.32 for new smear-negative and 4.22, 95%CI 2.08-8.55 for EPTB).

CONCLUSION

High cure rates and low bacteriological failure rates can be achieved in refugee settings if there is close coordination and collaboration between the local health agencies and the National Tuberculosis Programme of the host country.

Do doctors in north-western Somalia follow the national guidelines for tuberculosis management?

A cross-sectional study assessed the knowledge and practices of registered practitioners in management of tuberculosis [TB] in north-western Somalia. Of 100 registered doctors, 53 were interviewed. Of these, 32 [64%] had treated TB patients during the previous year, but only 1 had notified the authorities, 33 [66%] knew the most important symptoms and 32 [64%] identified sputum smear microscopy as the most important diagnostic test. Only 4 doctors prescribed the correct regimen and only 7 advocated direct observation. Suboptimal knowledge was more common among doctors working in private practice [relative risk: 2.1; 95% CI: 1.1-4.3]. Patients are being treated in the private sector, but few doctors follow national treatment guidelines. Training in diagnosis and case management is needed to improve TB control in Somalia

Do doctors in north-western Somalia follow the national guidelines for tuberculosis management?

A cross-sectional study assessed the knowledge and practices of registered practitioners in management of tuberculosis (TB) in north-western Somalia. Of 100 registered doctors, 53 were interviewed. Of these, 32 (64%) had treated TB patients during the previous year, but only 1 had notified the authorities, 33 (66%) knew the most important symptoms and 32 (64%) identified sputum smear microscopy as the most important diagnostic test. Only 4 doctors prescribed the correct regimen and only 7 advocated direct observation. Suboptimal knowledge was more common among doctors working in private practice (relative risk: 2.1; 95% CI: 1.1-4.3). Patients are being treated in the private sector, but few doctors follow national treatment guidelines. Training in diagnosis and case management is needed to improveTB control in Somalia.

Anemia in pregnancy in rural Tanzania: associations with micronutrients status and infections

OBJECTIVE

We studied the association between anemia in pregnancy and characteristics related to nutrition and infections.

DESIGN

Cross-sectional study.

SETTING

Four antenatal clinics in rural northern Tanzania.

SUBJECTS/METHODS

A total of 2547 women were screened for hemoglobin (Hb) and malaria plasmodia in capillary blood and for infections in urine. According to their Hb, they were assigned to one of five groups and selected accordingly, Hb<70 g/l (n=10), Hb=70-89 g/l (n=61), Hb=90-109 g/l (n=86), Hb=110-149 g/l (n=105) and Hb> or =150 g/l (n=50). The 312 selected subjects had venous blood drawn, were interviewed, and their arm circumference was measured. The sera were analyzed for ferritin, iron, total iron binding capacity (TIBC), cobalamin, folate, vitamin A, C-reactive protein (CRP), and lactate dehydrogenase (LD). Transferrin saturation (TFsat) was calculated. Urine was examined by dipsticks for nitrite.

MAIN OUTCOME MEASURES

Unadjusted and adjusted odds ratio (OR and AOR) of anemia with Hb<90 g/l.

RESULTS

Anemia (Hb<90 g/l) was associated with iron deficiency (low s-ferritin; AOR 3.4). The association with vitamin deficiencies were significant in unadjusted analysis (low s-folate; OR 3.1, low s-vitamin A; OR 2.6). Anemia was also associated with markers of infections (elevated s-CRP; AOR 3.5, urine nitrite positive; AOR 2.4) and hemolysis (elevated s-LD; AOR 10.1). A malaria positive blood slide was associated with anemia in unadjusted analysis (OR 2.7). An arm circumference less than 25 cm was associated with anemia (AOR 4.0). The associations with less severe anemia (Hb 90-109 g/l) were similar, but weaker.

CONCLUSIONS

Anemia in pregnancy was associated with markers of infections and nutritional deficiencies. This should be taken into account in the management of anemia at antenatal clinics.

SPONSORSHIP

The study was supported by the Norwegian Research Council (NFR) and the Centre for International Health, University of Bergen.