Impact of the COVID-19 pandemic on quality of tuberculosis care in private facilities in Bandung, Indonesia: a repeated cross-sectional standardized patients study

BACKGROUND

Indonesia has the second highest incidence of tuberculosis in the world. While 74% of people with tuberculosis in Indonesia first accessed the private health sector when seeking care for their symptoms, only 18% of tuberculosis notifications originate in the private sector. Little is known about the impact of the COVID-19 pandemic on the private sector. Using unannounced standardized patient visits to private providers, we aimed to measure quality of tuberculosis care during the COVID-19 pandemic.

METHODS

A cross-sectional study was conducted using standardized patients in Bandung City, West Java, Indonesia. Ten standardized patients completed 292 visits with private providers between 9 July 2021 and 21 January 2022, wherein standardized patients presented a presumptive tuberculosis case. Results were compared to standardized patients surveys conducted in the same geographical area before the onset of COVID-19.

RESULTS

Overall, 35% (95% confidence interval (CI): 29.2-40.4%) of visits were managed correctly according to national tuberculosis guidelines. There were no significant differences in the clinical management of presumptive tuberculosis patients before and during the COVID-19 pandemic, apart from an increase in temperature checks (adjusted odds ratio (aOR): 8.05, 95% CI: 2.96-21.9, p < 0.001) and a decrease in throat examinations (aOR 0.16, 95% CI: 0.06-0.41, p = 0.002) conducted during the pandemic.

CONCLUSIONS

Results indicate that providers successfully identify tuberculosis in their patients yet do not manage them according to national guidelines. There were no major changes found in quality of tuberculosis care due to the COVID-19 pandemic. As tuberculosis notifications have declined in Indonesia due to the COVID-19 pandemic, there remains an urgent need to increase private provider engagement in Indonesia and improve quality of care.

Care pathways of individuals with tuberculosis before and during the COVID-19 pandemic in Bandung, Indonesia

The COVID-19 pandemic is thought to have undone years' worth of progress in the fight against tuberculosis (TB). For instance, in Indonesia, a high TB burden country, TB case notifications decreased by 14% and treatment coverage decreased by 47% during COVID-19. We sought to better understand the impact of COVID-19 on TB case detection using two cross-sectional surveys conducted before (2018) and after the onset of the pandemic (2021). These surveys allowed us to quantify the delays that individuals with TB who eventually received treatment at private providers faced while trying to access care for their illness, their journey to obtain a diagnosis, the encounters individuals had with healthcare providers before a TB diagnosis, and the factors associated with patient delay and the total number of provider encounters. We found some worsening of care seeking pathways on multiple dimensions. Median patient delay increased from 28 days (IQR: 10, 31) to 32 days (IQR: 14, 90) and the median number of encounters increased from 5 (IQR: 4, 8) to 7 (IQR: 5, 10), but doctor and treatment delays remained relatively unchanged. Employed individuals experienced shorter delays compared to unemployed individuals (adjusted medians: -20.13, CI -39.14, -1.12) while individuals whose initial consult was in the private hospitals experienced less encounters compared to those visiting public providers, private primary care providers, and informal providers (-4.29 encounters, CI -6.76, -1.81). Patients who visited the healthcare providers >6 times experienced longer total delay compared to those with less than 6 visits (adjusted medians: 59.40, 95% CI: 35.04, 83.77). Our findings suggest the need to ramp up awareness programs to reduce patient delay and strengthen private provide engagement in the country, particularly in the primary care sector.

Implementing a chest X-ray artificial intelligence tool to enhance tuberculosis screening in India: Lessons learned

Artificial Intelligence (AI) based chest X-ray (CXR) screening for tuberculosis (TB) is becoming increasingly popular. Still, deploying such AI tools can be challenging due to multiple real-life barriers like software installation, workflow integration, network connectivity constraints, limited human resources available to interpret findings, etc. To understand these challenges, PATH implemented a TB REACH active case-finding program in a resource-limited setting of Nagpur in India, where an AI software device (qXR) intended for TB screening using CXR images was used. Eight private CXR laboratories that fulfilled prerequisites for AI software installation were engaged for this program. Key lessons about operational feasibility and accessibility, along with the strategies adopted to overcome these challenges, were learned during this program. This program also helped to screen 10,481 presumptive TB individuals using informal providers based on clinical history. Among them, 2,303 individuals were flagged as presumptive for TB by a radiologist or by AI based on their CXR interpretation. Approximately 15.8% increase in overall TB yield could be attributed to the presence of AI alone because these additional cases were not deemed presumptive for TB by radiologists, but AI was able to identify them. Successful implementation of AI tools like qXR in resource-limited settings in India will require solving real-life implementation challenges for seamless deployment and workflow integration.

Tuberculosis service disruptions and adaptations during the first year of the COVID-19 pandemic in the private health sector of two urban settings in Nigeria-A mixed methods study

Nigeria has the second largest share of undiagnosed TB cases in the world and a large private health sector estimated to be the point of initial care-seeking for 67% of TB patients. There is evidence that COVID-19 restrictions disrupted private healthcare provision, but insufficient data on how private healthcare provision changed as a result of the pandemic. We conducted qualitative interviews and a survey to assess the impact of the pandemic, and government response on private healthcare provision, and the disruptions providers experienced, particularly for TB services. Using mixed methods, we targeted policymakers, and a network of clinical facilities, laboratories, community pharmacies, and medicine vendors in Kano and Lagos, Nigeria. We interviewed 11 policymakers, surveyed participants in 2,412 private facilities. Most (n = 1,676, 70%) facilities remained open during the initial lockdown period, and most (n = 1,667, 69%) offered TB screening. TB notifications dipped during the lockdown periods but quickly recovered. Clinical facilities reported disruptions in availability of medical supplies, staff, required renovations, patient volume and income. Few private providers (n = 119, 11% in Kano; n = 323, 25% in Lagos) offered any COVID-19 screening up to the time of the survey, as these were only available in designated facilities. These findings aligned with the interviews as policymakers reported a gradual return to pre-COVID services after initial disruptions and diversion of resources to the pandemic response. Our results show that COVID-19 and control measures had a temporary impact on private sector TB care. Although some facilities saw decreases in TB notifications, private facilities continued to provide care for individuals with TB who otherwise might have been unable to seek care in the public sector. Our findings highlight resilience in the private sector as they recovered fairly quickly from pandemic-related disruptions, and the important role private providers can play in supporting TB control efforts.

Most common reasons for primary care visits in low- and middle-income countries: A systematic review

With the Covid-19 pandemic and the introduction of the WHO's Essential Diagnostics List (EDL), increasing global attention is focused on the crucial role of diagnostics in achieving universal health coverage. To create national EDLs and to aid health system planning, it is vital to understand the most common conditions with which people present at primary care health facilities. We undertook a systematic review of the most common reasons for primary care visits in low- and middle-income countries. Six databases were searched for articles published between January 2009 and December 2019, with the search updated on MEDLINE to January 2021. Data on the most common patient reasons for encounter (RFEs) and provider diagnoses were collected. 17 of 22,279 screened articles were included. Most studies used unvalidated diagnostic classification systems or presented provider diagnosis data grouped by organ system, rather than presenting specific diagnoses. No studies included data from low-income countries. Only four studies (from Brazil, India, Nigeria and South Africa) using the ICPC-2 classification system contained RFE and provider diagnosis data and could be pooled. The top five RFEs from the four studies were headache, fever, back or low back symptom, cough and pain general/multiple sites. The top five diagnoses were uncomplicated hypertension, upper respiratory tract infection, type 2 diabetes, malaria and health maintenance/prevention. No psychological symptoms were among the top 10 pooled RFEs. There was more variation in top diagnoses between studies than top RFEs, showing the importance of creating location-specific lists of essential diagnostics for primary care. Future studies should aim to sample primary care facilities from across their country of study and use ICPC-3 to report both patient RFEs and provider diagnoses.

The Endocannabinoid System and Eating Behaviours: a Review of the Current State of the Evidence

PURPOSE OF THE REVIEW

The endocannabinoid system (ENS) has emerged as an important factor in food intake and may have implications for nutrition research. The objective of the current report is to summarise the available evidence on the ENS and eating behaviour from both animal and human studies.

RECENT FINDINGS

The literature reviewed demonstrates a clear link between the ENS and eating behaviours. Overall, studies indicate that 2-arachidonoylglycerol (2-AG) and N-arachidonoylethanolamine (AEA) via cannabinoid receptor-1 (CNR1) binding may stimulate hunger and food intake while oleylethanolamide (OEA) may inhibit hunger. Mechanisms of these associations are not yet well understood, although the evidence suggests that there may be interactions with other physiological systems to consider. Most studies have been conducted in animal models, with few human studies available. Additional research is warranted among human populations into the ENS and eating behaviour. Evaluation of relationships between variation in ENS genes and dietary outcomes is an important area for investigation.

Do nutrition and cash-based interventions and policies aimed at reducing stunting have an impact on economic development of low-and-middle-income countries? A systematic review

BACKGROUND

Childhood stunting is the most common manifestation of chronic malnutrition. A growing body of literature indicates that stunting can have negative repercussions on physical and cognitive development. There are increasing concerns that low- and middle-income countries (LMICs) are particularly susceptible to adverse consequences of stunting on economic development. The aim of this review is to synthesize current evidence on interventions and policies that have had success in reducing stunting and explore the impact of successes on economic indicators.

METHODS

This review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles were searched through MEDLINE via PubMed and Ovid, Cochrane Library, Web of Science and ProQuest. Only articles that addressed the effects of nutrition and cash-based interventions and/or policies on stunting and reported effects on childhood mortality and/or human capital indicators were included. Two reviewers independently abstracted data and assessed quality.

RESULTS

Seventeen studies from Africa (47%), South America (41%), and South Asia (12%) met the eligibility criteria: 8 cohort studies, 4 case studies, 4 Randomized Control Trials (RCTs) and 1 quasi-trial. Three types of interventions/policies were evaluated: multisectoral policies, nutritional supplementations and cash-based interventions (CCT). Overall, 76% of the included studies were successful in reducing stunting and 65% of interventions/policies reported successes on stunting reductions and economic successes. Five of the 11 successful studies reported on nutritional supplementation, 4 reported on multisectoral policies, and 2 reported on CCT interventions. Average Annual Rate of Reduction (AARR) was calculated to assess the impact of multisectoral policies on childhood mortality. AARR for under 5 mortality ranged from 5.2 to 6.2% and all countries aligned with the global target of 4.4% AARR. Quality assessment yielded positive results, with the biggest concerns being attrition bias for cohort studies, blinding for trials and generalizability of results for case studies.

CONCLUSIONS

Evidence suggests that investment in fighting chronic malnutrition through multisectoral policies, multi-year nutritional supplementation (protein or multiple micronutrient supplementation) and possibly CCTs can have a long-term impact on economic development of LMICs. More evidence is needed to inform practices in non-represented regions while prioritizing standardization of economic indicators in the literature.