Increase in rifampicin resistance among people previously treated for TB

People previously treated for TB are at a higher risk of rifampicin-resistant or multidrug-resistant TB (RR/MDR-TB). Uganda's recent RR-TB estimates were not updated, including during the COVID-19 pandemic. Using programmatic data (2012-2021), we report on the distribution and trends in RR-TB among people previously treated for bacteriologically confirmed pulmonary TB (BC-PTB) across six TB clinics in Kampala, Uganda. The RR-TB prevalence between 2012 and 2015 was 0% (95% CI 0-2.3). The prevalence rose significantly in recent years to 7.0% (95% CI 4.4-10.8) between 2016 and 2021 (P < 0.001). RR-TB is increasing among people previously treated for BC-PTB in Kampala; surveillance for RR-TB should be enhanced.

Delivery of long-term-injectable agents for TB by lay carers: pragmatic randomised trial

BACKGROUND

People with recurrent or drug-resistant TB require long courses of intramuscular injections. We evaluate a novel system in which patient-nominated lay carers were trained to deliver intramuscular injections to patients in their own homes.

METHODS

A pragmatic, individually randomised non-inferiority trial was conducted at two hospitals in Malawi. Adults starting TB retreatment were recruited. Patients randomised to the intervention received home-based care from patient-nominated lay people trained to deliver intramuscular streptomycin. Patients receiving standard care were admitted to hospital for 2 months of streptomycin. The primary outcome was successful treatment (alive and on treatment) at the end of the intervention.

RESULTS

Of 456 patients screened, 204 participants were randomised. The trial was terminated early due to futility. At the end of the intervention, 97/101 (96.0%) in the hospital arm were still alive and on treatment compared with 96/103 (93.2%) in the home-based arm (risk difference -0.03 (95% CI -0.09 to 0.03); p value 0.538). There were no differences in the proportion completing 8 months of anti-TB treatment; or the proportion experiencing 2-month sputum culture conversion. The mean cost of hospital-based management was US$1546.3 per person, compared to US$729.2 for home-based management. Home-based care reduced risk of catastrophic household costs by 84%.

CONCLUSIONS

Although this trial failed to meet target recruitment, the available data demonstrate that training patient-nominated lay people has potential to provide a feasible solution to the operational challenges associated with delivering long-term-injectable drugs to people with recurrent or drug-resistant TB in resource-limited settings, and substantially reduce costs. Further data under operational conditions are required.

TRIAL REGISTRATION NUMBER

ISRCTN05815615.

Has TB CARE I sputum transport improved access to culture services for retreatment tuberculosis patients in Zimbabwe?

Setting: Retreatment tuberculosis (TB) patients in Zimbabwe are investigated using microscopy, Xpert^® MTB/RIF and culture + drug susceptibility testing (CDST). TB CARE I, a sputum transport service using motorcycles, was introduced to transport specimens between peripheral health facilities and laboratories, including National Reference Laboratories (NRLs). Objectives: To compare access to CDST and treatment outcomes among retreatment TB patients in facilities with and those without TB CARE I support. Design: This was a retrospective cohort study. Results: There were 187 patients from TB CARE I-supported facilities and 116 from non-TB CARE I facilities, with no difference in demographic characteristics. Altogether, specimens from 22 (12%) retreatment TB patients had successful CDST from TB CARE I facilities, which was not statistically significantly different from non-supported facilities (n = 14, 12%; P = 0.94). The median number of days from sputum collection to receipt at the NRL was lower in TB CARE I facilities than in non-supported facilities (median 6, interquartile range [IQR] 4-8 vs. median 8, IQR 6-13.5; P = 0.000). Favourable treatment outcomes were documented in 65% of patients under TB CARE I, significantly more than among patients in non-supported facilities (47%, P < 0.01). Conclusion: The process of sputum specimen collection for CDST was not different between TB CARE I and non-TB CARE I-supported health facilities, apart from a slightly shorter time. Ways to improve the current system are discussed.

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.