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Nguyen HB, Vo LNQ, Forse RJ, Wiemers AMC, Huynh HB, Dong TTT, Phan YTH, Creswell J, Dang TMH, Nguyen LH, Shedrawy J, Lönnroth K, Nguyen TD, Dinh LV, Annerstedt KS, Codlin AJ. Is convenience really king? Comparative evaluation of catastrophic costs due to tuberculosis in the public and private healthcare sectors of Viet Nam: a longitudinal patient cost study. Infect Dis Poverty 2024; 13:27. [PMID: 38528604 DOI: 10.1186/s40249-024-01196-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/11/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND In Viet Nam, tuberculosis (TB) represents a devastating life-event with an exorbitant price tag, partly due to lost income from daily directly observed therapy in public sector care. Thus, persons with TB may seek care in the private sector for its flexibility, convenience, and privacy. Our study aimed to measure income changes, costs and catastrophic cost incurrence among TB-affected households in the public and private sector. METHODS Between October 2020 and March 2022, we conducted 110 longitudinal patient cost interviews, among 50 patients privately treated for TB and 60 TB patients treated by the National TB Program (NTP) in Ha Noi, Hai Phong and Ho Chi Minh City, Viet Nam. Using a local adaptation of the WHO TB patient cost survey tool, participants were interviewed during the intensive phase, continuation phase and post-treatment. We compared income levels, direct and indirect treatment costs, catastrophic costs using Wilcoxon rank-sum and chi-squared tests and associated risk factors between the two cohorts using multivariate regression. RESULTS The pre-treatment median monthly household income was significantly higher in the private sector versus NTP cohort (USD 868 vs USD 578; P = 0.010). However, private sector treatment was also significantly costlier (USD 2075 vs USD 1313; P = 0.005), driven by direct medical costs which were 4.6 times higher than costs reported by NTP participants (USD 754 vs USD 164; P < 0.001). This resulted in no significant difference in catastrophic costs between the two cohorts (Private: 55% vs NTP: 52%; P = 0.675). Factors associated with catastrophic cost included being a single-person household [adjusted odds ratio (aOR = 13.71; 95% confidence interval (CI): 1.36-138.14; P = 0.026], unemployment during treatment (aOR = 10.86; 95% CI: 2.64-44.60; P < 0.001) and experiencing TB-related stigma (aOR = 37.90; 95% CI: 1.72-831.73; P = 0.021). CONCLUSIONS Persons with TB in Viet Nam face similarly high risk of catastrophic costs whether treated in the public or private sector. Patient costs could be reduced through expanded insurance reimbursement to minimize direct medical costs in the private sector, use of remote monitoring and multi-week/month dosing strategies to avert economic costs in the public sector and greater access to social protection mechanism in general.
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Affiliation(s)
| | - Luan Nguyen Quang Vo
- Friends for International TB Relief, Ha Noi, Viet Nam.
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden.
| | - Rachel Jeanette Forse
- Friends for International TB Relief, Ha Noi, Viet Nam
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | | | - Huy Ba Huynh
- Friends for International TB Relief, Ha Noi, Viet Nam
| | | | | | | | | | | | - Jad Shedrawy
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | - Knut Lönnroth
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | | | | | - Kristi Sidney Annerstedt
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | - Andrew James Codlin
- Friends for International TB Relief, Ha Noi, Viet Nam
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
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2
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Nababan B, Triasih R, Chan G, Dwihardiani B, Hidayat A, Dewi SC, Unwanah L, Mustofa A, du Cros P. The Yield of Active Tuberculosis Disease and Latent Tuberculosis Infection in Tuberculosis Household Contacts Investigated Using Chest X-ray in Yogyakarta Province, Indonesia. Trop Med Infect Dis 2024; 9:34. [PMID: 38393123 PMCID: PMC10891579 DOI: 10.3390/tropicalmed9020034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/16/2024] [Accepted: 01/22/2024] [Indexed: 02/25/2024] Open
Abstract
In Indonesia, the implementation of tuberculosis (TB) contact investigation is limited, with low detection rates. We report the yield of and risk factors for TB disease and infection for household contacts (HHCs) investigated using chest X-ray (CXR) screening. We identified HHCs aged five years and above of bacteriologically confirmed index cases from 2018 to 2022 in Yogyakarta City and Kulon Progo. All HHCs were offered screening for TB symptoms; TB infection testing with either tuberculin skin testing or interferon gamma release assay; and referral for CXR. Sputum from those with symptoms or CXR suggestive of TB was tested with Xpert MTB/RIF. Risk factors for active TB disease and latent TB infection (LTBI) were identified by logistic regression models. We screened 2857 HHCs for TB between June 2020 and December 2022, with 68 (2.4%) diagnosed with active TB. Of 2621 HHCs eligible for LTBI investigation, 1083 (45.7%) were diagnosed with LTBI. The factors associated with active TB were age, being underweight, diabetes mellitus, urban living, and sleeping in the same house as an index case. Factors associated with LTBI were increasing age and male gender. Conclusions: Screening for HHC including CXR and TST/IGRA yielded a moderate prevalence of TB disease and infection.
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Affiliation(s)
- Betty Nababan
- Centre for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Sleman, Yogyakarta 55281, Indonesia
| | - Rina Triasih
- Centre for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Sleman, Yogyakarta 55281, Indonesia
- Department of Pediatric, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Dr. Sardjito Hospital, Sleman, Yogyakarta 55281, Indonesia
| | - Geoffrey Chan
- TB Elimination and Implementation Science Working Group, Burnet Institute, Melbourne, VIC 3004, Australia
| | - Bintari Dwihardiani
- Centre for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Sleman, Yogyakarta 55281, Indonesia
| | - Arif Hidayat
- Centre for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Sleman, Yogyakarta 55281, Indonesia
| | - Setyogati C. Dewi
- Yogyakarta City Health Office, Yogyakarta, Yogyakarta 55165, Indonesia
| | - Lana Unwanah
- Yogyakarta City Health Office, Yogyakarta, Yogyakarta 55165, Indonesia
| | - Arif Mustofa
- Kulon Progo District Health Office, Yogyakarta, Yogyakarta 55165, Indonesia
| | - Philipp du Cros
- TB Elimination and Implementation Science Working Group, Burnet Institute, Melbourne, VIC 3004, Australia
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Gurung SC, Dixit K, Paudel R, Sah MK, Pandit RN, Aryal TP, Khatiwada SU, Majhi G, Dhital R, Paudel PR, Shrestha G, Rai B, Budhathoki G, Khanal M, Mishra G, Levy J, Van de Rest J, Thapa A, Ramsay A, Squire SB, Lönnroth K, Basnyat B, Caws M. Comparing Additionality of Tuberculosis Cases Using GeneXpert or Smear-Based Active TB Case-Finding Strategies among Social Contacts of Index Cases in Nepal. Trop Med Infect Dis 2023; 8:369. [PMID: 37505665 PMCID: PMC10384436 DOI: 10.3390/tropicalmed8070369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/11/2023] [Accepted: 07/13/2023] [Indexed: 07/29/2023] Open
Abstract
This study compares the yield and additionality of community-based active tuberculosis (TB) active case-finding strategies using either smear microscopy or GeneXpert as the TB diagnostic test. Active case-finding strategies screened social contacts of index cases and high-risk groups in four districts of Nepal in July 2017-2019. Two districts (Chitwan and Dhanusha) applied GeneXpert testing and two districts (Makwanpur and Mahotarri) used smear microscopy. Two control districts implemented standard national TB program activities. Districts implementing GeneXpert testing screened 23,657 people for TB, tested 17,114 and diagnosed 764 TB cases, producing a yield of 4.5%. Districts implementing smear microscopy screened 19,961 people for TB, tested 13,285 and diagnosed 437 cases, producing a yield of 3.3%. The screening numbers required were 31 for GeneXpert and 45.7 for smear districts. The test numbers required were 22.4 and 30.4 for GeneXpert and smear. Using the TB REACH additionality method, social contact tracing for TB through GeneXpert testing contributed to a 20% (3958/3322) increase in district-level TB notifications, smear microscopy 12.4% (3146/2798), and -0.5% (2553/2566) for control districts. Therefore, social contact tracing of TB index cases using GeneXpert testing should be implemented throughout Nepal within the TB FREE initiative to close the notification gap and accelerate progress toward END TB strategy targets.
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Affiliation(s)
- Suman Chandra Gurung
- Birat Nepal Medical Trust, Kathmandu 44600, Nepal
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool L35QA, UK
| | - Kritika Dixit
- Birat Nepal Medical Trust, Kathmandu 44600, Nepal
- WHO Collaborating Centre on TB and Social Medicine, Department of Global Public Health, Karolinska Institutet, 10653 Stockholm, Sweden
| | - Rajan Paudel
- Birat Nepal Medical Trust, Kathmandu 44600, Nepal
| | | | | | | | | | - Govind Majhi
- Birat Nepal Medical Trust, Kathmandu 44600, Nepal
| | - Raghu Dhital
- Birat Nepal Medical Trust, Kathmandu 44600, Nepal
| | - Puskar Raj Paudel
- Birat Nepal Medical Trust, Kathmandu 44600, Nepal
- KNCV Tuberculosis Foundation, 2514 The Hague, The Netherlands
| | | | - Bhola Rai
- Birat Nepal Medical Trust, Kathmandu 44600, Nepal
| | | | - Mukti Khanal
- National TB Control Centre, Kathmandu 44600, Nepal
| | - Gokul Mishra
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool L35QA, UK
| | - Jens Levy
- KNCV Tuberculosis Foundation, 2514 The Hague, The Netherlands
| | - Job Van de Rest
- KNCV Tuberculosis Foundation, 2514 The Hague, The Netherlands
| | - Anchal Thapa
- Birat Nepal Medical Trust, Kathmandu 44600, Nepal
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool L35QA, UK
| | - Andrew Ramsay
- Division of Infection and Global Health, University of St Andrews, St Andrews KY169AJ, UK
| | - Stephen Bertel Squire
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool L35QA, UK
| | - Knut Lönnroth
- WHO Collaborating Centre on TB and Social Medicine, Department of Global Public Health, Karolinska Institutet, 10653 Stockholm, Sweden
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, Kathmandu 44600, Nepal
| | - Maxine Caws
- Birat Nepal Medical Trust, Kathmandu 44600, Nepal
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool L35QA, UK
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4
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Kerkhoff AD, Mwamba C, Pry JM, Kagujje M, Nyangu S, Mateyo K, Sanjase N, Chilukutu L, Christopoulos KA, Muyoyeta M, Sharma A. A mixed methods study on men's and women's tuberculosis care journeys in Lusaka, Zambia-Implications for gender-tailored tuberculosis health promotion and case finding strategies. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001372. [PMID: 37327200 DOI: 10.1371/journal.pgph.0001372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 05/16/2023] [Indexed: 06/18/2023]
Abstract
Men and women with undiagnosed tuberculosis (TB) in high burden countries may have differential factors influencing their healthcare seeking behaviors and access to TB services, which can result in delayed diagnoses and increase TB-related morbidity and mortality. A convergent, parallel, mixed-methods study design was used to explore and evaluate TB care engagement among adults (≥18 years) with newly diagnosed, microbiologically-confirmed TB attending three public health facilities in Lusaka, Zambia. Quantitative structured surveys characterized the TB care pathway (time to initial care-seeking, diagnosis, and treatment initiation) and collected information on factors influencing care engagement. Multinomial multivariable logistic regression was used to determine predicted probabilities of TB health-seeking behaviors and determinants of care engagement. Qualitative in-depth interviews (IDIs; n = 20) were conducted and analyzed using a hybrid approach to identify barriers and facilitators to TB care engagement by gender. Overall, 400 TB patients completed a structured survey, of which 275 (68.8%) and 125 (31.3%) were men and women, respectively. Men were more likely to be unmarried (39.3% and 27.2%), have a higher median daily income (50 and 30 Zambian Kwacha [ZMW]), alcohol use disorder (70.9% [AUDIT-C score ≥4] and 31.2% [AUDIT-C score ≥3]), and a history of smoking (63.3% and 8.8%), while women were more likely to be religious (96.8% and 70.8%) and living with HIV (70.4% and 36.0%). After adjusting for potential confounders, the probability of delayed health-seeking ≥4 weeks after symptom onset did not differ significantly by gender (44.0% and 36.2%, p = 0.14). While the top reasons for delayed healthcare-seeking were largely similar by gender, men were more likely to report initially perceiving their symptoms as not being serious (94.8% and 78.7%, p = 0.032), while women were more likely to report not knowing the symptoms of TB before their diagnosis (89.5% and 74.4%; p = 0.007) and having a prior bad healthcare experience (26.4% and 9.9%; p = 0.036). Notably, women had a higher probability of receiving TB diagnosis ≥2 weeks after initial healthcare seeking (56.5% and 41.0%, p = 0.007). While men and women reported similar acceptability of health-information sources, they emphasized different trusted messengers. Also, men had a higher adjusted probability of stating that no one influenced their health-related decision making (37.9% and 28.3%, p = 0.001). In IDIs, men recommended TB testing sites at convenient community locations, while women endorsed an incentivized, peer-based, case-finding approach. Sensitization and TB testing strategies at bars and churches were highlighted as promising approaches to reach men and women, respectively. This mixed-methods study found important differences between men and women with TB in Zambia. These differences suggest the need for gender-tailored TB health promotion, including addressing harmful alcohol use and smoking among men, and sensitizing HCWs to prolonged delays in TB diagnosis among women, and also using gender-specific approaches as part of community-based, active case-finding strategies to improve TB diagnosis in high burden settings.
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Affiliation(s)
- Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, California, United States of America
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Jake M Pry
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Division of Epidemiology, University of California Davis, Davis, California, United States of America
| | - Mary Kagujje
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Sarah Nyangu
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Kondwelani Mateyo
- Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Nsala Sanjase
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Katerina A Christopoulos
- Division of HIV, Infectious Diseases and Global Medicine Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, California, United States of America
| | - Monde Muyoyeta
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Anjali Sharma
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
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5
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Quang Vo LN, Forse RJ, Tran J, Dam T, Driscoll J, Codlin AJ, Creswell J, Sidney-Annerstedt K, Van Truong V, Thi Minh HD, Huu LN, Nguyen HB, Nguyen NV. Economic evaluation of a community health worker model for tuberculosis care in Ho Chi Minh City, Viet Nam: a mixed-methods Social Return on Investment Analysis. BMC Public Health 2023; 23:945. [PMID: 37231468 DOI: 10.1186/s12889-023-15841-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 05/08/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND There is extensive evidence for the cost-effectiveness of programmatic and additional tuberculosis (TB) interventions, but no studies have employed the social return on investment (SROI) methodology. We conducted a SROI analysis to measure the benefits of a community health worker (CHW) model for active TB case finding and patient-centered care. METHODS This mixed-method study took place alongside a TB intervention implemented in Ho Chi Minh City, Viet Nam, between October-2017 - September-2019. The valuation encompassed beneficiary, health system and societal perspectives over a 5-year time-horizon. We conducted a rapid literature review, two focus group discussions and 14 in-depth interviews to identify and validate pertinent stakeholders and material value drivers. We compiled quantitative data from the TB program's and the intervention's surveillance systems, ecological databases, scientific publications, project accounts and 11 beneficiary surveys. We mapped, quantified and monetized value drivers to derive a crude financial benefit, which was adjusted for four counterfactuals. We calculated a SROI based on the net present value (NPV) of benefits and investments using a discounted cash flow model with a discount rate of 3.5%. A scenario analysis assessed SROI at varying discount rates of 0-10%. RESULTS The mathematical model yielded NPVs of US$235,511 in investments and US$8,497,183 in benefits. This suggested a return of US$36.08 for each dollar invested, ranging from US$31.66-US39.00 for varying discount rate scenarios. CONCLUSIONS The evaluated CHW-based TB intervention generated substantial individual and societal benefits. The SROI methodology may be an alternative for the economic evaluation of healthcare interventions.
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Affiliation(s)
- Luan Nguyen Quang Vo
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam.
| | - Rachel Jeanette Forse
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | - Jacqueline Tran
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | - Thu Dam
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | - Jenny Driscoll
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | - Andrew James Codlin
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | | | - Kristi Sidney-Annerstedt
- Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Solna, Sweden
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6
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Marley G, Zou X, Nie J, Cheng W, Xie Y, Liao H, Wang Y, Tao Y, Tucker JD, Sylvia S, Chou R, Wu D, Ong J, Tang W. Improving cascade outcomes for active TB: A global systematic review and meta-analysis of TB interventions. PLoS Med 2023; 20:e1004091. [PMID: 36595536 PMCID: PMC9847969 DOI: 10.1371/journal.pmed.1004091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 01/18/2023] [Accepted: 12/13/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND To inform policy and implementation that can enhance prevention and improve tuberculosis (TB) care cascade outcomes, this review aimed to summarize the impact of various interventions on care cascade outcomes for active TB. METHODS AND FINDINGS In this systematic review and meta-analysis, we retrieved English articles with comparator arms (like randomized controlled trials (RCTs) and before and after intervention studies) that evaluated TB interventions published from January 1970 to September 30, 2022, from Embase, CINAHL, PubMed, and the Cochrane library. Commentaries, qualitative studies, conference abstracts, studies without standard of care comparator arms, and studies that did not report quantitative results for TB care cascade outcomes were excluded. Data from studies with similar comparator arms were pooled in a random effects model, and outcomes were reported as odds ratio (OR) with 95% confidence interval (CI) and number of studies (k). The quality of evidence was appraised using GRADE, and the study was registered on PROSPERO (CRD42018103331). Of 21,548 deduplicated studies, 144 eligible studies were included. Of 144 studies, 128 were from low/middle-income countries, 84 were RCTs, and 25 integrated TB and HIV care. Counselling and education was significantly associated with testing (OR = 8.82, 95% CI:1.71 to 45.43; I2 = 99.9%, k = 7), diagnosis (OR = 1.44, 95% CI:1.08 to 1.92; I2 = 97.6%, k = 9), linkage to care (OR = 3.10, 95% CI = 1.97 to 4.86; I2 = 0%, k = 1), cure (OR = 2.08, 95% CI:1.11 to 3.88; I2 = 76.7%, k = 4), treatment completion (OR = 1.48, 95% CI: 1.07 to 2.03; I2 = 73.1%, k = 8), and treatment success (OR = 3.24, 95% CI: 1.88 to 5.55; I2 = 75.9%, k = 5) outcomes compared to standard-of-care. Incentives, multisector collaborations, and community-based interventions were associated with at least three TB care cascade outcomes; digital interventions and mixed interventions were associated with an increased likelihood of two cascade outcomes each. These findings remained salient when studies were limited to RCTs only. Also, our study does not cover the entire care cascade as we did not measure gaps in pre-testing, pretreatment, and post-treatment outcomes (like loss to follow-up and TB recurrence). CONCLUSIONS Among TB interventions, education and counseling, incentives, community-based interventions, and mixed interventions were associated with multiple active TB care cascade outcomes. However, cost-effectiveness and local-setting contexts should be considered when choosing such strategies due to their high heterogeneity.
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Affiliation(s)
- Gifty Marley
- Dermatology Hospital of Southern Medical University, Guangzhou, China
- University of North Carolina Project-China, Guangzhou, China
| | - Xia Zou
- Global Health Research Center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Juan Nie
- Department of Research and Education, Guangzhou Concord Cancer Center, Guangzhou, China
| | - Weibin Cheng
- Institute for Healthcare Artificial Intelligence Application, Guangdong Second Provincial General Hospital, Guangzhou, China
- School of Data Science, City University of Hong Kong, Hong Kong, China
| | - Yewei Xie
- University of North Carolina Project-China, Guangzhou, China
| | - Huipeng Liao
- University of North Carolina Project-China, Guangzhou, China
| | - Yehua Wang
- University of North Carolina Project-China, Guangzhou, China
| | - Yusha Tao
- University of North Carolina Project-China, Guangzhou, China
| | - Joseph D. Tucker
- University of North Carolina Project-China, Guangzhou, China
- Faculty of Infectious and Tropical Diseases, London School of Health and Tropical Medicine, London, United Kingdom
| | - Sean Sylvia
- University of North Carolina Project-China, Guangzhou, China
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Roger Chou
- Oregon Health & Science University, Portland, Oregon, United States of America
| | - Dan Wu
- University of North Carolina Project-China, Guangzhou, China
- Faculty of Infectious and Tropical Diseases, London School of Health and Tropical Medicine, London, United Kingdom
| | - Jason Ong
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Weiming Tang
- Dermatology Hospital of Southern Medical University, Guangzhou, China
- University of North Carolina Project-China, Guangzhou, China
- * E-mail:
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7
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Cox SR, Kadam A, Atre S, Gupte AN, Sohn H, Gupte N, Sawant T, Mhadeshwar V, Thompson R, Kendall E, Hoffmann C, Suryavanshi N, Kerrigan D, Tripathy S, Kakrani A, Barthwal MS, Mave V, Golub JE. Tuberculosis (TB) Aftermath: study protocol for a hybrid type I effectiveness-implementation non-inferiority randomized trial in India comparing two active case finding (ACF) strategies among individuals treated for TB and their household contacts. Trials 2022; 23:635. [PMID: 35932062 PMCID: PMC9354295 DOI: 10.1186/s13063-022-06503-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/01/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Approximately 7% of all reported tuberculosis (TB) cases each year are recurrent, occurring among people who have had TB in the recent or distant past. TB recurrence is particularly common in India, which has the largest TB burden worldwide. Although patients recently treated for TB are at high risk of developing TB again, evidence around effective active case finding (ACF) strategies in this population is scarce. We will conduct a hybrid type I effectiveness-implementation non-inferiority randomized trial to compare the effectiveness, cost-effectiveness, and feasibility of two ACF strategies among individuals who have completed TB treatment and their household contacts (HHCs). METHODS We will enroll 1076 adults (≥ 18 years) who have completed TB treatment at a public TB unit (TU) in Pune, India, along with their HHCs (averaging two per patient, n = 2152). Participants will undergo symptom-based ACF by existing healthcare workers (HCWs) at 6-month intervals and will be randomized to either home-based ACF (HACF) or telephonic ACF (TACF). Symptomatic participants will undergo microbiologic testing through the program. Asymptomatic HHCs will be referred for TB preventive treatment (TPT) per national guidelines. The primary outcome is rate per 100 person-years of people diagnosed with new or recurrent TB by study arm, within 12 months following treatment completion. The secondary outcome is proportion of HHCs < 6 years, by study arm, initiated on TPT after ruling out TB disease. Study staff will collect socio-demographic and clinical data to identify risk factors for TB recurrence and will measure post-TB lung impairment. In both arms, an 18-month "mop-up" visit will be conducted to ascertain outcomes. We will use the RE-AIM framework to characterize implementation processes and explore acceptability through in-depth interviews with index patients, HHCs and HCWs (n = 100). Cost-effectiveness will be assessed by calculating the incremental cost per TB case detected within 12 months and projected for disability-adjusted life years averted based on modeled estimates of morbidity, mortality, and time with infectious TB. DISCUSSION This novel trial will guide India's scale-up of post-treatment ACF and provide an evidence base for designing strategies to detect recurrent and new TB in other high burden settings. TRIAL REGISTRATION NCT04333485 , registered April 3, 2020. CTRI/2020/05/025059 [Clinical Trials Registry of India], registered May 6 2020.
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Affiliation(s)
- Samyra R Cox
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA.
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA.
| | - Abhay Kadam
- Johns Hopkins India, G-4 & G-5, PHOENIX Building, OPP. to Residency Club, Pune, Maharashtra, 411001, India
| | - Sachin Atre
- Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Maharashtra, 411018, India
| | - Akshay N Gupte
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Hojoon Sohn
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Nikhil Gupte
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
- Johns Hopkins India, G-4 & G-5, PHOENIX Building, OPP. to Residency Club, Pune, Maharashtra, 411001, India
| | - Trupti Sawant
- Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Maharashtra, 411018, India
| | - Vishal Mhadeshwar
- Johns Hopkins India, G-4 & G-5, PHOENIX Building, OPP. to Residency Club, Pune, Maharashtra, 411001, India
| | - Ryan Thompson
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | - Emily Kendall
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Christopher Hoffmann
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Nishi Suryavanshi
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
- Johns Hopkins India, G-4 & G-5, PHOENIX Building, OPP. to Residency Club, Pune, Maharashtra, 411001, India
| | - Deanna Kerrigan
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- George Washington University, 2121 I St NW, Washington, D.C., 20052, USA
| | - Srikanth Tripathy
- Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Maharashtra, 411018, India
| | - Arjunlal Kakrani
- Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Maharashtra, 411018, India
| | - Madhusudan S Barthwal
- Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Maharashtra, 411018, India
| | - Vidya Mave
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
- Johns Hopkins India, G-4 & G-5, PHOENIX Building, OPP. to Residency Club, Pune, Maharashtra, 411001, India
| | - Jonathan E Golub
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
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Tovar M, Aleta A, Sanz J, Moreno Y. Modeling the impact of COVID-19 on future tuberculosis burden. COMMUNICATIONS MEDICINE 2022; 2:77. [PMID: 35784445 PMCID: PMC9243113 DOI: 10.1038/s43856-022-00145-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 06/16/2022] [Indexed: 01/09/2023] Open
Abstract
Background The ongoing COVID-19 pandemic has greatly disrupted our everyday life, forcing the adoption of non-pharmaceutical interventions in many countries and putting public health services and healthcare systems worldwide under stress. These circumstances are leading to unintended effects such as the increase in the burden of other diseases. Methods Here, using a data-driven epidemiological model for tuberculosis (TB) spreading, we describe the expected rise in TB incidence and mortality if COVID-associated changes in TB notification are sustained and attributable entirely to disrupted diagnosis and treatment adherence. Results Our calculations show that the reduction in diagnosis of new TB cases due to the COVID-19 pandemic could result in 228k (CI 187-276) excess deaths in India, 111k (CI 93-134) in Indonesia, 27k (CI 21-33) in Pakistan, and 12k (CI 9-18) in Kenya. Conclusions We show that it is possible to reverse these excess deaths by increasing the pre-covid diagnosis capabilities from 15 to 50% for 2 to 4 years. This would prevent almost all TB-related excess mortality that could be caused by the COVID-19 pandemic if no additional preventative measures are introduced. Our work therefore provides guidelines for mitigating the impact of COVID-19 on tuberculosis epidemic in the years to come.
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Affiliation(s)
- Mario Tovar
- grid.11205.370000 0001 2152 8769Institute for Biocomputation and Physics of Complex Systems (BIFI), University of Zaragoza, 50009 Zaragoza, Spain ,grid.11205.370000 0001 2152 8769Department of Theoretical Physics, University of Zaragoza, 50009 Zaragoza, Spain
| | - Alberto Aleta
- grid.418750.f0000 0004 1759 3658ISI Foundation, Via Chisola 5, 10126 Torino, Italy
| | - Joaquín Sanz
- grid.11205.370000 0001 2152 8769Institute for Biocomputation and Physics of Complex Systems (BIFI), University of Zaragoza, 50009 Zaragoza, Spain ,grid.11205.370000 0001 2152 8769Department of Theoretical Physics, University of Zaragoza, 50009 Zaragoza, Spain
| | - Yamir Moreno
- grid.11205.370000 0001 2152 8769Institute for Biocomputation and Physics of Complex Systems (BIFI), University of Zaragoza, 50009 Zaragoza, Spain ,grid.11205.370000 0001 2152 8769Department of Theoretical Physics, University of Zaragoza, 50009 Zaragoza, Spain ,grid.418750.f0000 0004 1759 3658ISI Foundation, Via Chisola 5, 10126 Torino, Italy
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Dam TA, Forse RJ, Tran PMT, Vo LNQ, Codlin AJ, Nguyen LP, Creswell J. What makes community health worker models for tuberculosis active case finding work? A cross-sectional study of TB REACH projects to identify success factors for increasing case notifications. HUMAN RESOURCES FOR HEALTH 2022; 20:25. [PMID: 35279166 PMCID: PMC8917377 DOI: 10.1186/s12960-022-00708-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/10/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND In the field of tuberculosis (TB), Community Healthcare Workers (CHWs) have been engaged for advocacy, case detection, and patient support in a wide range of settings. Estimates predict large-scale shortfalls of healthcare workers in low- and middle-income settings by 2030 and strategies are needed to optimize the health workforce to achieve universal availability and accessibility of healthcare. In 2018, the World Health Organization (WHO) published guidelines on best practices for CHW engagement, and identified remaining knowledge gaps. Stop TB Partnership's TB REACH initiative has supported interventions using CHWs to deliver TB care in over 30 countries, and utilized the same primary indicator to measure project impact at the population-level for all TB active case finding projects, which makes the results comparable across multiple settings. This study compiled 10 years of implementation data from the initiative's grantee network to begin to address key knowledge gaps in CHW networks. METHODS We conducted a cross-sectional study analyzing the TB REACH data repository (n = 123) and primary survey responses (n = 50) of project implementers. We designed a survey based on WHO guidelines to understand projects' practices on CHW recruitment, training, activities, supervision, compensation, and sustainability. We segmented projects by TB notification impact and fitted linear random-effect regression models to identify practices associated with higher changes in notifications. RESULTS Most projects employed CHWs for advocacy alongside case finding and holding activities. Model characteristics associated with higher project impact included incorporating e-learning in training and having the prospect of CHWs continuing their responsibilities at the close of a project. Factors that trended towards being associated with higher impact were community-based training, differentiated contracts, and non-monetary incentives. CONCLUSION In line with WHO guidelines, our findings emphasize that successful implementation approaches provide CHWs with comprehensive training, continuous supervision, fair compensation, and are integrated within the existing primary healthcare system. However, we encountered a great degree of heterogeneity in CHW engagement models, resulting in few practices clearly associated with higher notifications.
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Affiliation(s)
- Thu A Dam
- Friends for International TB Relief, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Hanoi, Vietnam
| | - Rachel J Forse
- Friends for International TB Relief, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Hanoi, Vietnam.
- Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Solnavägen 1, 171 77, Solna, Sweden.
| | - Phuong M T Tran
- Friends for International TB Relief, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Hanoi, Vietnam
| | - Luan N Q Vo
- Friends for International TB Relief, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Hanoi, Vietnam
- IRD VN, 68B Nguyen Van Troi, Ward 8, Phu Nhuan District, Ho Chi Minh City, Vietnam
| | - Andrew J Codlin
- Friends for International TB Relief, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Hanoi, Vietnam
| | - Lan P Nguyen
- Centre for Development of Community Health Initiatives, 1/21 Le Van Luong St., Nhan Chin Ward, Thanh Xuan District, Hanoi, Vietnam
| | - Jacob Creswell
- Stop TB Partnership, Chemin du Pommier 40, 1218 Le Grand-Saconnex, Geneva, Switzerland
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Vasiliu A, Tiendrebeogo G, Awolu MM, Akatukwasa C, Tchakounte BY, Ssekyanzi B, Tchounga BK, Atwine D, Casenghi M, Bonnet M. Feasibility of a randomized clinical trial evaluating a community intervention for household tuberculosis child contact management in Cameroon and Uganda. Pilot Feasibility Stud 2022; 8:39. [PMID: 35148800 PMCID: PMC8832743 DOI: 10.1186/s40814-022-00996-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/27/2022] [Indexed: 11/30/2022] Open
Abstract
Background One of the main barriers of the management of household tuberculosis child contacts is the necessity for parents to bring healthy children to the facility. We assessed the feasibility of a community intervention for tuberculosis (TB) household child contact management and the conditions for its evaluation in a cluster randomized controlled trial in Cameroon and Uganda. Methods We assessed three dimensions of feasibility using a mixed method approach: (1) recruitment capability using retrospective aggregated data from facility registers; (2) acceptability of the intervention using focus group discussions with TB patients and in-depth interviews with healthcare providers and community leaders; and (3) adaptation, integration, and resources of the intervention in existing TB services using a survey and discussions with stakeholders. Results Reaching the sample size is feasible in all clusters in 15 months with the condition of regrouping 2 facilities in the same cluster in Uganda due to decentralization of TB services. Community health worker (CHW) selection and training and simplified tools for contact screening, tolerability, and adherence of preventive therapy were key elements for the implementation of the community intervention. Healthcare providers and patients found the intervention of child contact investigations and TB preventive treatment management in the household acceptable in both countries due to its benefits (competing priorities, transport cost) as compared to facility-based management. TB stigma was present, but not a barrier for the community intervention. Visit schedule and team conduct were identified as key facilitators for the intervention. Conclusions This study shows that evaluating a community intervention for TB child contact management in a cluster randomized trial is feasible in Cameroon and Uganda. Trial registration Clini calTr ials. gov NCT03832023. Registered on February 6th 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s40814-022-00996-3.
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Affiliation(s)
- Anca Vasiliu
- University of Montpellier, IRD, INSERM, TransVIHMI, Montpellier, France.
| | | | | | | | | | | | | | | | | | - Maryline Bonnet
- University of Montpellier, IRD, INSERM, TransVIHMI, Montpellier, France
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11
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Tran PMT, Dam TA, Huynh HB, Codlin AJ, Forse RJ, Dang HMT, Truong VV, Nguyen LH, Nguyen HB, Nguyen NV, Creswell J, Meralli F, Morishita F, Dong TTT, Nguyen GH, Vo LNQ. Evaluating novel engagement mechanisms, yields and acceptability of tuberculosis screening at retail pharmacies in Ho Chi Minh City, Viet Nam. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000257. [PMID: 36962503 PMCID: PMC10021543 DOI: 10.1371/journal.pgph.0000257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 08/28/2022] [Indexed: 03/26/2023]
Abstract
Pharmacies represent a key health system entry point for people with TB in Viet Nam, but high fragmentation hinders their broader engagement. Professional networking apps may be able to facilitate pharmacy engagement for systematic TB screening and referral. Between September and December 2019, we piloted the use of a social networking app, SwipeRx, to recruit pharmacists for a TB referral scheme across four districts of Ho Chi Minh City, Viet Nam. We measured chest X-ray (CXR) referrals and TB detection yields at participating pharmacies and fielded 100 acceptability surveys, divided into pharmacists who did and did not make a CXR referral. We then fitted mixed-effect odds proportional models to explore acceptability factors that were associated with making a CXR referral. 1,816 push notifications were sent to pharmacists via the SwipeRx app and 78 indicated their interest in participating; however, only one was within the pilot's intervention area. Additional in-person outreach resulted in the recruitment of 146 pharmacists, with 54 (37.0%) making at least one CXR referral. A total of 182 pharmacy customers were referred, resulting in a total of 64 (35.2%) CXR screens and seven people being diagnosed with TB. Compared to pharmacists who did not make any CXR referrals, pharmacists making at least one CXR referral understood the pilot's objectives more clearly (aOR = 2.6, 95% CI: 1.2-5.8) and they believed that TB screening increased customer trust (aOR = 2.7, 95% CI: 1.2-5.8), benefited their business (aOR = 2.8, 95% CI: 1.3-6.2) and constituted a competitive advantage (aOR = 4.4, 95% CI: 1.9-9.9). They were also more confident in using mHealth apps (aOR = 3.1, 95 CI%: 1.4-6.8). Pharmacies can play an important role in early and increased TB case finding. It is critical to highlight the value proposition of TB referral schemes to their business during recruitment. Digital networking platforms, such as SwipeRx, can facilitate referrals for TB screening by pharmacists, but their ability to identify and recruit pharmacists requires optimization, particularly when targeting specific segments of a nation-wide digital network.
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Affiliation(s)
| | - Thu A Dam
- Friends for International TB Relief, Ha Noi, Viet Nam
| | - Huy B Huynh
- Friends for International TB Relief, Ha Noi, Viet Nam
| | | | | | - Ha M T Dang
- Pham Ngoc Thach Hospital, Ho Chi Minh City, Viet Nam
| | - Vinh V Truong
- Pham Ngoc Thach Hospital, Ho Chi Minh City, Viet Nam
| | - Lan H Nguyen
- Pham Ngoc Thach Hospital, Ho Chi Minh City, Viet Nam
| | | | | | | | | | - Fukushi Morishita
- World Health Organization Regional Office for the Western Pacific, Manila, Philippines
| | - Thuy T T Dong
- Friends for International TB Relief, Ha Noi, Viet Nam
| | | | - Luan N Q Vo
- Friends for International TB Relief, Ha Noi, Viet Nam
- IRD VN, Ho Chi Minh City, Viet Nam
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12
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Andom AT, Gilbert HN, Ndayizigiye M, Mukherjee JS, Nthunya J, Marole TA, Smith Fawzi MC, Yuen CM. Understanding reasons for suboptimal tuberculosis screening in a low-resource setting: A mixed-methods study in the Kingdom of Lesotho. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000249. [PMID: 36962295 PMCID: PMC10021370 DOI: 10.1371/journal.pgph.0000249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/13/2022] [Indexed: 11/19/2022]
Abstract
Lesotho has one of the highest tuberculosis (TB) incidence rates in the world, estimated at 654/100,000 population. However, TB detection remains low, with only 51% of people with TB being diagnosed and treated. The aim of this study was to evaluate implementation of TB screening and identify drivers of suboptimal TB screening in Lesotho. We used a convergent mixed methods study design. We collected data on the number of health facility visits and the number of clients screened for TB during March-August, 2019 from one district hospital and one health center. We conducted interviews and focus group discussions with patients and health workers to elucidate the mechanisms associated with suboptimal screening. Out of an estimated 70,393 visitors to the two health facilities, only 22% of hospital visitors and 48% of health center visitors were asked about TB symptoms. Only 2% of those screened at each facility said that they had TB symptoms, comprising a total of 510 people. Lack of training on tuberculosis screening, overall staff shortages, barriers faced by patients in accessing care, and health care worker mistrust of tuberculosis screening procedures were identified as drivers of suboptimal TB screening. TB screening could be improved by ensuring the availability of well-trained, incentivized, and dedicated screeners at health facilities, and by providing TB screening services in community settings.
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Affiliation(s)
- Afom T Andom
- Partners In Health-Lesotho, Maseru, Lesotho
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Hannah N Gilbert
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
| | | | - Joia S Mukherjee
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, United States of America
- Partners in Health, Boston, MA, United States of America
| | | | | | - Mary C Smith Fawzi
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Courtney M Yuen
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, United States of America
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13
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Independent evaluation of 12 artificial intelligence solutions for the detection of tuberculosis. Sci Rep 2021; 11:23895. [PMID: 34903808 PMCID: PMC8668935 DOI: 10.1038/s41598-021-03265-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/30/2021] [Indexed: 11/13/2022] Open
Abstract
There have been few independent evaluations of computer-aided detection (CAD) software for tuberculosis (TB) screening, despite the rapidly expanding array of available CAD solutions. We developed a test library of chest X-ray (CXR) images which was blindly re-read by two TB clinicians with different levels of experience and then processed by 12 CAD software solutions. Using Xpert MTB/RIF results as the reference standard, we compared the performance characteristics of each CAD software against both an Expert and Intermediate Reader, using cut-off thresholds which were selected to match the sensitivity of each human reader. Six CAD systems performed on par with the Expert Reader (Qure.ai, DeepTek, Delft Imaging, JF Healthcare, OXIPIT, and Lunit) and one additional software (Infervision) performed on par with the Intermediate Reader only. Qure.ai, Delft Imaging and Lunit were the only software to perform significantly better than the Intermediate Reader. The majority of these CAD software showed significantly lower performance among participants with a past history of TB. The radiography equipment used to capture the CXR image was also shown to affect performance for some CAD software. TB program implementers now have a wide selection of quality CAD software solutions to utilize in their CXR screening initiatives.
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14
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Ayabina DV, Gomes MGM, Nguyen NV, Vo L, Shreshta S, Thapa A, Codlin AJ, Mishra G, Caws M. The impact of active case finding on transmission dynamics of tuberculosis: A modelling study. PLoS One 2021; 16:e0257242. [PMID: 34797864 PMCID: PMC8604297 DOI: 10.1371/journal.pone.0257242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/26/2021] [Indexed: 11/18/2022] Open
Abstract
Background In the last decade, active case finding (ACF) strategies for tuberculosis (TB) have been implemented in many diverse settings, with some showing large increases in case detection and reporting at the sub-national level. There have also been several studies which seek to provide evidence for the benefits of ACF to individuals and communities in the broader context. However, there remains no quantification of the impact of ACF with regards to reducing the burden of transmission. We sought to address this knowledge gap and quantify the potential impact of active case finding on reducing transmission of TB at the national scale and further, to determine the intensification of intervention efforts required to bring the reproduction number (R0) below 1 for TB. Methods We adopt a dynamic transmission model that incorporates heterogeneity in risk to TB to assess the impact of an ACF programme (IMPACT TB) on reducing TB incidence in Vietnam and Nepal. We fit the models to country-level incidence data using a Bayesian Markov Chain Monte Carlo approach. We assess the impact of ACF using a parameter in our model, which we term the treatment success rate. Using programmatic data, we estimate how much this parameter has increased as a result of IMPACT TB in the implementation districts of Vietnam and Nepal and quantify additional efforts needed to eliminate transmission of TB in these countries by 2035. Results Extending the IMPACT TB programme to national coverage would lead to moderate decreases in TB incidence and would not be enough to interrupt transmission by 2035. Decreasing transmission sufficiently to bring the reproduction number (R0) below 1, would require a further intensification of current efforts, even at the sub-national level. Conclusions Active case finding programmes are effective in reducing TB in the short term. However, interruption of transmission in high-burden countries, like Vietnam and Nepal, will require comprehensive incremental efforts. Complementary measures to reduce progression from infection to disease, and reactivation of latent infection, are needed to meet the WHO End TB incidence targets.
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Affiliation(s)
- Diepreye Victoria Ayabina
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - M. Gabriela M. Gomes
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- CIBIO-InBIO, Centro de Investiga¸c˜ao em Biodiversidade e Recursos Gen´eticos, and CMUP, Centro de Matem´atica da Universidade do Porto, Porto, Portugal
| | - Nhung Viet Nguyen
- National Tuberculosis Control Programme of Vietnam- National Lung Hospital (VNTP-NLH), Hanoi, Vietnam
| | - Luan Vo
- Friends for International TB Relief (FIT), Ho Chi Minh City, Vietnam
| | | | - Anil Thapa
- National TB Control Centre, Thimi, Kathmandu, Nepal
| | | | - Gokul Mishra
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Birat Nepal Medical Trust, Kathmandu, Nepal
| | - Maxine Caws
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Birat Nepal Medical Trust, Kathmandu, Nepal
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15
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Biermann O, Tran PB, Forse RJ, Vo LNQ, Codlin AJ, Viney K, Caws M, Lönnroth K. Capitalizing on facilitators and addressing barriers when implementing active tuberculosis case-finding in six districts of Ho Chi Minh City, Vietnam: a qualitative study with key stakeholders. Implement Sci 2021; 16:54. [PMID: 34011353 PMCID: PMC8135167 DOI: 10.1186/s13012-021-01124-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 05/03/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Vietnam has a high burden of undetected tuberculosis (TB). The Vietnamese National TB Strategic Plan highlights active case-finding (ACF) as one strategy to find people with TB who are currently unreached by the existing government health services. The IMPACT TB (Implementing proven community-based active TB case-finding intervention) project was implemented across six districts of Ho Chi Minh City, 2017-2019. We aimed to explore the facilitators and barriers for ACF implementation during the IMPACT TB project to understand how and why the intervention achieved high yields. METHODS This was an exploratory qualitative study based on 39 semi-structured key-informant interviews with TB patients who were diagnosed through ACF, employees and volunteers who implemented ACF, and leaders from district, national, or international institutions and organizations in Vietnam. Thematic analysis was applied, using an implementation science framework by Grol and Wensing. RESULTS We generated three main themes: (1) the studied ACF model used in Vietnam provided a conducive social and organizational context for ACF implementation with areas for improvement, including communication and awareness-raising, preparation and logistics, data systems and processes, and incentives; (2) employees and volunteers capitalized on their strengths to facilitate ACF implementation, e.g., experience, skills, and communication; and (3) employees and volunteers were in a position to address patient-level barriers to ACF implementation, e.g., stigma, discrimination, and mistrust. These themes covered a variety of facilitators and barriers, which we divided into 17 categories. All categories were mentioned by employees and volunteers, except the category of having a network that facilitates ACF implementation, which was only mentioned by volunteers. This study also highlighted examples and ideas of how to address facilitators and barriers. CONCLUSIONS IMPACT TB provided a favorable social and organizational context for ACF implementation. Individual employees and volunteers still determined the success of the project, as they had to be able to capitalize on their own strengths and address patient-level barriers. Volunteers especially used their networks to facilitate ACF. Knowledge of both facilitators and barriers, and how to address them can inform the planning and implementation ACF in Vietnam and similar contexts across low- and middle-income countries worldwide.
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Affiliation(s)
- Olivia Biermann
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
| | - Phuong Bich Tran
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Rachel Jeanette Forse
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Friends for International Tuberculosis Relief, Ho Chi Minh City, Vietnam
| | | | | | - Kerri Viney
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Research School of Population Health, College of Health and Medicine, Australian National University, Canberra, Australia
| | - Maxine Caws
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Nepal
| | - Knut Lönnroth
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Singh AA, Creswell J, Bhatia V. Framework for planning and monitoring active TB case finding interventions to meet the global targets in the COVID-19 era and beyond: South-East Asia perspective. PLOS GLOBAL PUBLIC HEALTH 2021; 1:e0000073. [PMID: 36962114 PMCID: PMC10021227 DOI: 10.1371/journal.pgph.0000073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There was an estimated 20-40% decline in tuberculosis (TB) case detection in the South-East Asia Region (SEA Region) during 2020 due to COVID-19 outbreak. This is over and above a million people with TB who were missed each year, prior to the pandemic. Active case finding (ACF) for TB has been gaining considerable interest and investment in the SEA Region and will be even more essential for finding people with TB missed due to the COVID-19 pandemic. Many countries in the Region have incorporated ACF activities into national strategic plans and are conducting large scale activities with varying results. ACF can reach people with TB earlier than routine approaches, can lead to increases in the numbers of people diagnosed, and is often needed for certain key populations who face stigma, social, and economic barriers. However, ACF is not a one size fits all approach, and has higher costs than routine care. So, planning interventions in consultation with relevant stakeholders including the affected communities is critical. Furthermore, continuous monitoring during the intervention and after completion is crucial as national TB programmes review progress and decide on the effective utilization of limited resources. Planning and monitoring become more relevant in the COVID-19 era because of constraints posed by resource diversion towards pandemic control. Here, we summarize different aspects of planning and monitoring of ACF approaches to inform national TB programmes and partners based on experiences in the SEA Region, as programmes look to reach those who are missed and catch-up on progress towards ending TB.
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Affiliation(s)
| | | | - Vineet Bhatia
- South-East Asia Regional Office, World Health Organization, New Delhi, India
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17
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Nguyen LH, Codlin AJ, Vo LNQ, Dao T, Tran D, Forse RJ, Vu TN, Le GT, Luu T, Do GC, Truong VV, Minh HDT, Nguyen HH, Creswell J, Caws M, Nguyen HB, Nguyen NV. An Evaluation of Programmatic Community-Based Chest X-ray Screening for Tuberculosis in Ho Chi Minh City, Vietnam. Trop Med Infect Dis 2020; 5:tropicalmed5040185. [PMID: 33321696 PMCID: PMC7768495 DOI: 10.3390/tropicalmed5040185] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/28/2020] [Accepted: 11/12/2020] [Indexed: 02/08/2023] Open
Abstract
Across Asia, a large proportion of people with tuberculosis (TB) do not report symptoms, have mild symptoms or only experience symptoms for a short duration. These individuals may not seek care at health facilities or may be missed by symptom screening, resulting in sustained TB transmission in the community. We evaluated the yields of TB from 114 days of community-based, mobile chest X-ray (CXR) screening. The yields at each step of the TB screening cascade were tabulated and we compared cohorts of participants who reported having a prolonged cough and those reporting no cough or one of short duration. We estimated the marginal yields of TB using different diagnostic algorithms and calculated the relative diagnostic costs and cost per case for each algorithm. A total of 34,529 participants were screened by CXR, detecting 256 people with Xpert-positive TB. Only 50% of those diagnosed with TB were detected among participants reporting a prolonged cough. The study’s screening algorithm detected almost 4 times as much TB as the National TB Program’s standard diagnostic algorithm. Community-based, mobile chest X-ray screening can be a high yielding strategy which is able to identify people with TB who would likely otherwise have been missed by existing health services.
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Affiliation(s)
- Lan Huu Nguyen
- Pham Ngoc Thach Hospital, Ho Chi Minh City 700 000, Vietnam; (L.H.N.); (G.C.D.); (V.V.T.); (H.D.T.M.)
| | - Andrew J. Codlin
- Friends for International TB Relief, Ho Chi Minh City 700 000, Vietnam; (L.N.Q.V.); (D.T.); (R.J.F.)
- Correspondence: ; Tel.: +84-352512847
| | - Luan Nguyen Quang Vo
- Friends for International TB Relief, Ho Chi Minh City 700 000, Vietnam; (L.N.Q.V.); (D.T.); (R.J.F.)
- Interactive Research and Development, Singapore 238884, Singapore
| | - Thang Dao
- IRD VN, Ho Chi Minh City 700 000, Vietnam;
| | - Duc Tran
- Friends for International TB Relief, Ho Chi Minh City 700 000, Vietnam; (L.N.Q.V.); (D.T.); (R.J.F.)
| | - Rachel J. Forse
- Friends for International TB Relief, Ho Chi Minh City 700 000, Vietnam; (L.N.Q.V.); (D.T.); (R.J.F.)
| | - Thanh Nguyen Vu
- Ho Chi Minh City Public Health Association, Ho Chi Minh City 700 000, Vietnam; (T.N.V.); (G.T.L.)
| | - Giang Truong Le
- Ho Chi Minh City Public Health Association, Ho Chi Minh City 700 000, Vietnam; (T.N.V.); (G.T.L.)
| | - Tuan Luu
- Clinton Health Access Initiative Vietnam, Ha Noi 100 000, Vietnam;
| | - Giang Chau Do
- Pham Ngoc Thach Hospital, Ho Chi Minh City 700 000, Vietnam; (L.H.N.); (G.C.D.); (V.V.T.); (H.D.T.M.)
| | - Vinh Van Truong
- Pham Ngoc Thach Hospital, Ho Chi Minh City 700 000, Vietnam; (L.H.N.); (G.C.D.); (V.V.T.); (H.D.T.M.)
| | - Ha Dang Thi Minh
- Pham Ngoc Thach Hospital, Ho Chi Minh City 700 000, Vietnam; (L.H.N.); (G.C.D.); (V.V.T.); (H.D.T.M.)
| | - Hung Huu Nguyen
- Ho Chi Minh City Department of Health, Ho Chi Minh City 700 000, Vietnam;
| | | | - Maxine Caws
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK;
- Birat Nepal Medical Trust Nepal, Kathmandu 44600, Nepal
| | - Hoa Binh Nguyen
- Viet Nam National Lung Hospital, Ha Noi 100 000, Vietnam; (H.B.N.); (N.V.N.)
| | - Nhung Viet Nguyen
- Viet Nam National Lung Hospital, Ha Noi 100 000, Vietnam; (H.B.N.); (N.V.N.)
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Vo LNQ, Codlin AJ, Forse RJ, Nguyen NT, Vu TN, Le GT, Van Truong V, Do GC, Dang HM, Nguyen LH, Nguyen HB, Nguyen NV, Levy J, Lonnroth K, Squire SB, Caws M. Evaluating the yield of systematic screening for tuberculosis among three priority groups in Ho Chi Minh City, Viet Nam. Infect Dis Poverty 2020; 9:166. [PMID: 33292638 PMCID: PMC7724701 DOI: 10.1186/s40249-020-00766-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/15/2020] [Indexed: 01/30/2023] Open
Abstract
Background In order to end tuberculosis (TB), it is necessary to expand coverage of TB care services, including systematic screening initiatives. However, more evidence is needed for groups among whom systematic screening is only conditionally recommended by the World Health Organization. This study evaluated concurrent screening in multiple target groups using community health workers (CHW). Methods In our two-year intervention study lasting from October 2017 to September 2019, CHWs in six districts of Ho Chi Minh City, Viet Nam verbally screened three urban priority groups: (1) household TB contacts; (2) close TB contacts; and (3) residents of urban priority areas without clear documented exposure to TB including hotspots, boarding homes and urban slums. Eligible persons were referred for further screening with chest radiography and follow-on testing with the Xpert MTB/RIF assay. Symptomatic individuals with normal or without radiography results were tested on smear microscopy. We described the TB care cascade and characteristics for each priority group, and calculated yield and number needed to screen. Subsequently, we fitted a mixed-effect logistic regression to identify the association of these target groups and secondary patient covariates with TB treatment initiation. Results We verbally screened 321 020 people including 24 232 household contacts, 3182 social and close contacts and 293 606 residents of urban priority areas. This resulted in 1138 persons treated for TB, of whom 85 were household contacts, 39 were close contacts and 1014 belonged to urban priority area residents. The yield of active TB in these groups was 351, 1226 and 345 per 100 000, respectively, corresponding to numbers needed to screen of 285, 82 and 290. The fitted model showed that close contacts [adjusted odds ratio (aOR) = 2.07; 95% CI: 1.38–3.11; P < 0.001] and urban priority area residents (aOR = 2.18; 95% CI: 1.69–2.79; P < 0.001) had a greater risk of active TB than household contacts. Conclusions The study detected a large number of unreached persons with TB, but most of them were not among persons in contact with an index patient. Therefore, while programs should continue to optimize screening in contacts, to close the detection gap in high TB burden settings such as Viet Nam, coverage must be expanded to persons without documented exposure such as residents in hotspots, boarding homes and urban slums.
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Affiliation(s)
- Luan Nguyen Quang Vo
- Friends for International TB Relief, 68B Nguyen Van Troi, 8, Phu Nhuan, Ho Chi Minh City, Viet Nam. .,Interactive Research and Development, Ho Chi Minh City, Viet Nam.
| | - Andrew James Codlin
- Friends for International TB Relief, 68B Nguyen Van Troi, 8, Phu Nhuan, Ho Chi Minh City, Viet Nam
| | - Rachel Jeanette Forse
- Friends for International TB Relief, 68B Nguyen Van Troi, 8, Phu Nhuan, Ho Chi Minh City, Viet Nam
| | - Nga Thuy Nguyen
- Friends for International TB Relief, 68B Nguyen Van Troi, 8, Phu Nhuan, Ho Chi Minh City, Viet Nam
| | - Thanh Nguyen Vu
- Ho Chi Minh City Public Health Association, Ho Chi Minh City, Viet Nam
| | - Giang Truong Le
- Ho Chi Minh City Public Health Association, Ho Chi Minh City, Viet Nam
| | | | - Giang Chau Do
- Pham Ngoc Thach Hospital, Ho Chi Minh City, Viet Nam
| | - Ha Minh Dang
- Pham Ngoc Thach Hospital, Ho Chi Minh City, Viet Nam
| | | | | | | | - Jens Levy
- KNCV Tuberculosefonds, The Hague, The Netherlands
| | - Knut Lonnroth
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - S Bertel Squire
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Maxine Caws
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.,Birat Nepal Medical Trust, Lazimpat, Kathmandu, Nepal
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19
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Creswell J, Khan A, Bakker MI, Brouwer M, Kamineni VV, Mergenthaler C, Smelyanskaya M, Qin ZZ, Ramis O, Stevens R, Reddy KS, Blok L. The TB REACH Initiative: Supporting TB Elimination Efforts in the Asia-Pacific. Trop Med Infect Dis 2020; 5:E164. [PMID: 33114749 PMCID: PMC7709586 DOI: 10.3390/tropicalmed5040164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 10/09/2020] [Accepted: 10/16/2020] [Indexed: 12/19/2022] Open
Abstract
After many years of TB 'control' and incremental progress, the TB community is talking about ending the disease, yet this will only be possible with a shift in the way we approach the TB response. While the Asia-Pacific region has the highest TB burden worldwide, it also has the opportunity to lead the quest to end TB by embracing the four areas laid out in this series: using data to target hotspots, initiating active case finding, provisioning preventive TB treatment, and employing a biosocial approach. The Stop TB Partnership's TB REACH initiative provides a platform to support partners in the development, evaluation and scale-up of new and innovative technologies and approaches to advance TB programs. We present several approaches TB REACH is taking to support its partners in the Asia-Pacific and globally to advance our collective response to end TB.
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Affiliation(s)
- Jacob Creswell
- Stop TB Partnership, 1218 Geneva, Switzerland; (A.K.); (M.S.); (Z.Z.Q.)
| | - Amera Khan
- Stop TB Partnership, 1218 Geneva, Switzerland; (A.K.); (M.S.); (Z.Z.Q.)
| | - Mirjam I Bakker
- KIT Royal Tropical Institute, 1092 Amsterdam, The Netherlands; (M.I.B.); (C.M.); (L.B.)
| | | | | | | | | | - Zhi Zhen Qin
- Stop TB Partnership, 1218 Geneva, Switzerland; (A.K.); (M.S.); (Z.Z.Q.)
| | | | | | - K Srikanth Reddy
- Global Affairs Canada, Global Health and Nutrition Bureau, Ottawa K1A 0G2, ON, Canada;
| | - Lucie Blok
- KIT Royal Tropical Institute, 1092 Amsterdam, The Netherlands; (M.I.B.); (C.M.); (L.B.)
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