1
|
Mahler B, Băiceanu D, Stoichiță A, Dendrino D, Mihai M, Ciolan G, Ibraim E, Munteanu I, Popa C, Burecu M, Rusu P, Cioacată A, Moșteanu IM, Dragomir A. Active Case-Finding: An Effective Solution for Tuberculosis Detection in Vulnerable Groups - The Romanian Experience. Risk Manag Healthc Policy 2024; 17:1115-1125. [PMID: 38778920 PMCID: PMC11110982 DOI: 10.2147/rmhp.s458722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/29/2024] [Indexed: 05/25/2024] Open
Abstract
Introduction Tuberculosis (TB) remains a global health challenge, requiring enhanced active case finding (ACF) through screening strategies. This study assesses the effectiveness of such an approach in locating TB cases among vulnerable groups, such as homeless persons, injecting drug users, those detained in prison, and people living in rural areas. Methods The study focuses on socio-economic characteristics and TB detection rates across Romanian counties using modern techniques including computer-aided detection of lesions on chest X-ray and GeneXpert tests. Results The results highlight the disproportionate burden of TB in vulnerable groups, by revealing significant differences in TB detection rates between regions. Notably, the TB detection rates among these vulnerable groups (250.85 per 100,000 population) are five times higher than the national incidence rate (46.1). Discussion These findings underscore the imperative integration of ACF into National TB Program to provide customized and efficient solutions for diverse vulnerable groups, thereby informing crucial public health initiatives and interventions.
Collapse
Affiliation(s)
- Beatrice Mahler
- Pneumology II Department, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- Pneumology Clinic, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
- Tuberculosis Screening Program, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
| | - Dragoș Băiceanu
- Tuberculosis Screening Program, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
- Research Department, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
| | - Alexandru Stoichiță
- Pneumology II Department, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- Pneumology Clinic, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
- Tuberculosis Screening Program, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
| | - Dragoș Dendrino
- Tuberculosis Screening Program, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
| | - Mihaela Mihai
- Tuberculosis Screening Program, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
- Faculty of Economic Cybernetics, Statistics and Informatics, The Bucharest University of Economic Studies, Bucharest, Romania
| | - Gina Ciolan
- Pneumology Clinic, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
| | - Elmira Ibraim
- Tuberculosis Screening Program, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
- Research Department, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
| | - Ioana Munteanu
- Pneumology Clinic, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
- Tuberculosis Screening Program, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
- Faculty of Medicine, “Titu Maiorescu” University, Bucharest, Romania
| | - Cristina Popa
- Pneumology Clinic, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
- Tuberculosis Screening Program, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
| | - Mădălina Burecu
- Pneumology Clinic, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
- Tuberculosis Screening Program, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
| | - Paula Rusu
- Tuberculosis Screening Program, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
| | - Andreea Cioacată
- Pneumology Clinic, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
| | - Ioana Mădălina Moșteanu
- Pneumology Clinic, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
- Faculty of Medicine, University of Medicine and Pharmacy Craiova, Craiova, Romania
| | - Antonela Dragomir
- Pneumology II Department, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- Pneumology Clinic, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
- Tuberculosis Screening Program, “Marius Nasta” Institute of Pneumology, Bucharest, Romania
| |
Collapse
|
2
|
Omongot S, Muttamba W, Najjingo I, Baruch Baluku J, Kitaka S, Turyahabwe S, Kirenga B. Strategies to resolve the gap in adolescent tuberculosis care at four health facilities in Uganda: The teenager's TB pilot project. PLoS One 2024; 19:e0286894. [PMID: 38603636 PMCID: PMC11008838 DOI: 10.1371/journal.pone.0286894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 01/31/2024] [Indexed: 04/13/2024] Open
Abstract
In 2021, an estimated 10.6 million people fell ill with tuberculosis (TB) globally and 11.3% were children. About 40% of children aged five to fourteen years with TB are missed annually. In Uganda, 44% of adolescents with chronic cough of more than two weeks do not seek care from health facilities. Therefore, strategies to promote health care-seeking behaviour among adolescents were urgently needed to resolve the gap. In regard to this, the research project utilized a before and after design, in which the number of adolescents (10-19years) enrolled in the project health facilities were compared before and after the intervention. The intervention package that comprised of tuberculosis awareness and screening information was developed together with adolescents, thus; a human-centred approach was used. The package consisted of TB screening cards, poster messages and a local song. The song was broadcasted in the community radios. Poster messages were deployed in the community by the village health teams (VHTS). The TB screening cards were given to TB positive and presumptive adults to screen adolescents at home. Adolescents that were found with TB symptoms were referred to the project health facilities. Socio-demographic and clinical characteristics of eligible adolescents were collected in a period of six months from Kawolo, Iganga, Gombe and Kiwoko health facilities. To determine the effectiveness of the package, before and after intervention data were equally collected. A total of 394 adolescents were enrolled, majority (76%) were school going. The intervention improved adolescent TB care seeking in the four project health facilities. The average number of adolescents screened increased from 159 to 309 (incidence rate ratio (IRR) = 1.9, P<0.001, 95% CI [1.9, 2.0]). Those presumed to have TB increased from 13 to 29(IRR = 2.2, P<0.001, 95% CI [1.9, 2.5]). The ones tested with GeneXpert increased in average from 8 to 28(IRR = 3.3, P<0.001, 95% CI [2.8, 3.8]). There was a minimal increase in the average monthly number of adolescents with a positive result of 0.8, from 1.6 to 2.4(p = 0.170) and linkage to TB care services of 1.1, from 2 to 3.1(p = 0.154). The project improved uptake of TB services among adolescents along the TB care cascade. We recommend a robust and fully powered randomized controlled trial to evaluate the effectiveness of the Package.
Collapse
Affiliation(s)
- Samson Omongot
- Makerere University Lung Institute, Makerere University, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Winters Muttamba
- Makerere University Lung Institute, Makerere University, Kampala, Uganda
- Division of Infection and Global Health, School of Medicine, University of St Andrews, St. Andrews, United Kingdom
| | - Irene Najjingo
- Makerere University Lung Institute, Makerere University, Kampala, Uganda
| | - Joseph Baruch Baluku
- Makerere University Lung Institute, Makerere University, Kampala, Uganda
- Division of Pulmonology, Kiruddu National Referral Hospital, Kampala, Uganda
| | - Sabrina Kitaka
- Department of Pediatrics, Makerere University College of Health Sciences, Kampala, Uganda
| | - Stavia Turyahabwe
- National Tuberculosis and leprosy Programme, Ministry of Health (MOH), Kampala, Uganda
| | - Bruce Kirenga
- Makerere University Lung Institute, Makerere University, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| |
Collapse
|
3
|
Ilaiwy G, Heysell SK, Lukumay S, Agustino D, Mejan P, Simeon K, Thomas TA, Mduma E. Cash transfers to enhance completion of TB screening among household contacts in rural Tanzania. Int J Tuberc Lung Dis 2024; 28:176-182. [PMID: 38563339 PMCID: PMC11027996 DOI: 10.5588/ijtld.23.0412] [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] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Tanzanian TB guidelines recommend facility-based TB screening for symptomatic household contacts (HHCs) or those aged <5 years, but cost remains a major barrier. In this study, we evaluate the use of unconditional cash transfers (UCTs) to facilitate completion of HHC TB screening.METHODS In this prospective interventional study, we enrolled index people diagnosed with TB (PWTB) within 8 weeks of TB treatment initiation from the TB clinic at Haydom Lutheran Hospital, Haydom, Tanzania, and surrounding TB dispensaries in rural Tanzania. The study provided at the time of enrollment an UCT up to 40,000 Tanzanian shillings (USD16.91) directly to heads of households with PWTB, covered medical costs from screening activities and provided three bi-weekly phone reminders to facilitate HHC TB screening. The primary outcome was TB screening completion for all HHCs compared to the same period of the preceding year.RESULTS We enrolled 120 index PWTB, including 398 HHCs between July and December 2022. The median age for index PWTB was 35 years; 38% were females. Sixty-five (54%) households completed screening for all HHCs, compared to 7% during the same period of the preceding year.CONCLUSION These interventions may considerably improve completion of HHC TB screening in rural Tanzania..
Collapse
Affiliation(s)
- Ghassan Ilaiwy
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Scott K. Heysell
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Saning’o Lukumay
- Haydom Global Health Research Center, Haydom Lutheran Hospital, Haydom, Manyara, Tanzania
| | - Domitila Agustino
- Haydom Global Health Research Center, Haydom Lutheran Hospital, Haydom, Manyara, Tanzania
| | - Paulo Mejan
- Haydom Global Health Research Center, Haydom Lutheran Hospital, Haydom, Manyara, Tanzania
| | - Kusulla Simeon
- Haydom Global Health Research Center, Haydom Lutheran Hospital, Haydom, Manyara, Tanzania
| | - Tania A. Thomas
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Estomih Mduma
- Haydom Global Health Research Center, Haydom Lutheran Hospital, Haydom, Manyara, Tanzania
| |
Collapse
|
4
|
Ajudua FI, Mash RJ. Implementing active surveillance for TB: A descriptive survey of healthcare workers in the Eastern Cape, South Africa. Afr J Prim Health Care Fam Med 2024; 16:e1-e12. [PMID: 38426777 PMCID: PMC10913162 DOI: 10.4102/phcfm.v16i1.4217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 11/27/2023] [Accepted: 11/29/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND South Africa is a tuberculosis (TB) high-burden country. In the Eastern Cape (EC), community health worker (CHW) teams implement active surveillance for TB to curb spread in disadvantaged communities. However, achieving the goals of the End-TB strategy require coordinated efforts that implement policy and strengthen health systems. AIM This survey described views of healthcare workers (HCWs) in primary care facilities on factors that influence implementation of active surveillance for TB. SETTING This survey was conducted across two districts, among healthcare workers working in TB rooms at primary health facilities. METHOD A cross-sectional survey of HCW in the EC. RESULTS The survey included 37 clinics in the OR Tambo Health District (ORTHD) and 44 clinics in the Nelson Mandela Bay Health District (NMBHD). Routine screening at primary care facilities (88.2%) and contact tracing initiatives (80.8%) were the common modes of TB screening. Tuberculosis screening services in the community were only provided by CHWs in 67.3% of instances. Although CHWs were adequately trained and motivated; the lack of transport, limited availability of outreach team leaders (OTLs) and poor security limited implementation of TB screening services in the community. Comparison between both districts revealed TB screening was limited by lack of transport in the rural district and poor security in the urban context. Community engagement provided a platform for improving acceptability. CONCLUSION Community-based TB screening was limited. Inadequate coordination of services between stakeholders in the community has limited reach. Further research should describe that coordinating resource allocation and community empowerment could improve the implementation of active surveillance for TB.Contribution: This study highlights the views of TB room HCWs who believe the opportunity for community-level TB screening is improved with effective leadership and community engagement for acceptability of these services.
Collapse
Affiliation(s)
- Febisola I Ajudua
- Department of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; and Department of Family Medicine and Rural Health, Faculty of Health Sciences, Walter Sisulu University, Gqeberha, South Africa; and Faculty of Health Sciences, Nelson Mandela University, Gqeberha.
| | | |
Collapse
|
5
|
Feasey HRA, Khundi M, Soko RN, Bottomley C, Chiume L, Burchett HED, Nliwasa M, Twabi HH, Mpunga JA, MacPherson P, Corbett EL. Impact of active case-finding for tuberculosis on case-notifications in Blantyre, Malawi: A community-based cluster-randomised trial (SCALE). PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002683. [PMID: 38051717 PMCID: PMC10697577 DOI: 10.1371/journal.pgph.0002683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 11/06/2023] [Indexed: 12/07/2023]
Abstract
Active case-finding (ACF) for tuberculosis can help find the "missing millions" with undiagnosed tuberculosis. In a cluster-randomised trial, we investigated impact of ACF on case-notifications in Blantyre, Malawi, where ACF has been intensively implemented following 2014 estimates of ~1,000 per 100,000 adults with undiagnosed TB. Following a pre-intervention prevalence survey (May 2019 to March 2020), constrained randomisation allocated neighbourhoods to either door-to-door ACF (sputum microscopy for reported cough >2 weeks) or standard-of-care (SOC). Implementation was interrupted by COVID-19. Cluster-level bacteriologically-confirmed case-notification rate (CNR) ratio within 91 days of ACF was our redefined primary outcome; comparison between arms used Poisson regression with random effects. Secondary outcomes were 91-day CNR ratios comparing all tuberculosis registrations and all non-ACF registrations. Interrupted time series (ITS) analysis of CNRs in the SOC arm examined prevalence survey impact. (ISRCTN11400592). 72 clusters served by 10 study-supported tuberculosis registration centres were randomised to ACF (261,244 adults, 58,944 person-years follow-up) or SOC (256,713 adults, 52,805 person-years). Of 1,192 ACF participants, 13 (1.09%) were smear-positive. Within 91 days, 113 (42 bacteriologically-confirmed) and 108 (33 bacteriologically-confirmed) tuberculosis patients were identified as ACF or SOC cluster residents, respectively. There was no difference by arm, with adjusted 91-day CNR ratios 1.12 (95% CI: 0.61-2.07) for bacteriologically-confirmed tuberculosis; 0.93 (95% CI: 0.68-1.28) for all tuberculosis registrations; and 0.86 (95%CI: 0.63-1.16) for non-ACF (routinely) diagnosed. Of 7,905 ACF and 7,992 SOC pre-intervention survey participants, 12 (0.15%) and 17 (0.21%), respectively, had culture/Xpert-confirmed tuberculosis. ITS analysis showed no survey impact on SOC CNRs. Despite residual undiagnosed tuberculosis of 150 per 100,000 population, there was no increase in tuberculosis notifications from this previously successful approach targeting symptomatic disease, likely due to previous TB ACF and rapid declines in TB burden. In such settings, future ACF should focus on targeted outreach and demand creation, alongside optimised facility-based screening. Trial Registration: ISRCTN11400592.
Collapse
Affiliation(s)
| | - McEwen Khundi
- African Institute for Development Policy, Lilongwe, Malawi
| | - Rebecca Nzawa Soko
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Lingstone Chiume
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Marriott Nliwasa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Hussein H. Twabi
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Peter MacPherson
- School of Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | | |
Collapse
|
6
|
Bonnet M, Vasiliu A, Tchounga BK, Cuer B, Fielding K, Ssekyanzi B, Tchakounte Youngui B, Cohn J, Dodd PJ, Tiendrebeogo G, Tchendjou P, Simo L, Okello RF, Kuate Kuate A, Turyahabwe S, Atwine D, Graham SM, Casenghi M. Effectiveness of a community-based approach for the investigation and management of children with household tuberculosis contact in Cameroon and Uganda: a cluster-randomised trial. Lancet Glob Health 2023; 11:e1911-e1921. [PMID: 37918417 DOI: 10.1016/s2214-109x(23)00430-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/22/2023] [Accepted: 09/01/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Globally, the uptake of tuberculosis-preventive treatment (TPT) among children with household tuberculosis contact remains low, partly due to the necessity of bringing children to health facilities for investigations. This study aimed to evaluate the effect on TPT initiation and completion of community-based approaches to tuberculosis contact investigations in Cameroon and Uganda. METHODS We did a parallel, cluster-randomised, controlled trial across 20 clusters (consisting of 25 district hospitals and primary health centres) in Cameroon and Uganda, which were randomised (1:1) to receive a community-based approach (intervention group) or standard-of-care facility-based approach to contact screening and management (control group). The community-based approach consisted of symptom-based tuberculosis screening of all household contacts by community health workers at the household, with referral of symptomatic contacts to local facilities for investigations. Initiation of TPT (3-month course of rifampicin-isoniazid) was done by a nurse in the household, and home visits for TPT follow-up were done by community health workers. Index patients were people aged 15 years or older with bacteriologically confirmed, drug-susceptible, pulmonary tuberculosis diagnosed less than 1 month before inclusion and who declared at least one child or young adolescent (aged 0-14 years) household contact. The primary endpoint was the proportion of declared child contacts in the TPT target group (those aged <5 years irrespective of HIV status, and children aged 5-14 years living with HIV) who commenced and completed TPT, assessed in the modified intention-to-treat population (excluding enrolled index patients and their contacts who did not fit the eligibility criteria). Descriptive cascade of care assessment and generalised linear mixed modelling were used for comparison. This study is registered with ClinicalTrials.gov (NCT03832023). FINDINGS The study included nine clusters in the intervention group (after excluding one cluster that did not enrol any index patients for >2 months) and ten in the control group. Between Oct 14, 2019 and Jan 13, 2022, 2894 child contacts were declared by 899 index patients with bacteriologically confirmed tuberculosis. Among all child contacts declared, 1548 (81·9%) of 1889 in the intervention group and 475 (47·3%) of 1005 in the control group were screened for tuberculosis. 1400 (48·4%) child contacts were considered to be in the TPT target group: 941 (49·8%) of 1889 in the intervention group and 459 (45·7%) of 1005 in the control group. In the TPT target group, TPT was commenced and completed in 752 (79·9%) of 941 child contacts in the intervention group and 283 (61·7%) of 459 in the control group (odds ratio 3·06 [95% CI 1·24-7·53]). INTERPRETATION A community-based approach using community health workers can significantly increase contact investigation coverage and TPT completion among eligible child contacts in a tuberculosis-endemic setting. FUNDING Unitaid. TRANSLATION For the French translation of the abstract see Supplementary Materials section.
Collapse
Affiliation(s)
- Maryline Bonnet
- TransVIHMI, University Montpellier, Institut de Recherche pour le Développement, INSERM, Montpellier, France.
| | - Anca Vasiliu
- TransVIHMI, University Montpellier, Institut de Recherche pour le Développement, INSERM, Montpellier, France; Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | | | - Benjamin Cuer
- TransVIHMI, University Montpellier, Institut de Recherche pour le Développement, INSERM, Montpellier, France
| | | | | | | | - Jennifer Cohn
- Department of Innovation and New Technology, Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland
| | - Peter J Dodd
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Georges Tiendrebeogo
- University Montpellier, Institut de Recherche pour le Développement, INSERM, Montpellier, France
| | | | - Leonie Simo
- Elizabeth Glaser Pediatric AIDS Foundation, Yaoundé, Cameroon
| | | | | | | | - Daniel Atwine
- Clinical Research Department, Epicentre Mbarara Research Centre, Mbarara, Uganda
| | - Stephen M Graham
- Royal Children's Hospital, University of Melbourne Department of Paediatrics and Murdoch Children's Research Institute, Melbourne, Australia; International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Martina Casenghi
- Department of Innovation and New Technology, Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland
| |
Collapse
|
7
|
Katamba A, Gupta AJ, Turimumahoro P, Ochom E, Ggita JM, Nakasendwa S, Nanziri L, Musinguzi J, Hennein R, Sekadde M, Hanrahan C, Byaruhanga R, Yoeli E, Turyahabwe S, Cattamanchi A, Dowdy DW, Haberer JE, Armstrong-Hough M, Kiwanuka N, Davis JL. A user-centred implementation strategy for tuberculosis contact investigation in Uganda: protocol for a stepped-wedge, cluster-randomised trial. BMC Public Health 2023; 23:1568. [PMID: 37592314 PMCID: PMC10436440 DOI: 10.1186/s12889-023-16510-0] [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: 06/28/2023] [Accepted: 08/10/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Tuberculosis(TB) is among the leading causes of infectious death worldwide. Contact investigation is an evidence-based, World Health Organisation-endorsed intervention for timely TB diagnosis, treatment, and prevention but has not been widely and effectively implemented. METHODS We are conducting a stepped-wedge, cluster-randomised, hybrid Type III implementation-effectiveness trial comparing a user-centred to a standard strategy for implementing TB contact investigation in 12 healthcare facilities in Uganda. The user-centred strategy consists of several client-focused components including (1) a TB-education booklet, (2) a contact-identification algorithm, (3) an instructional sputum-collection video, and (4) a community-health-rider service to transport clients, CHWs, and sputum samples, along with several healthcare-worker-focused components, including (1) collaborative improvement meetings, (2) regular audit-and-feedback reports, and (3) a digital group-chat application designed to develop a community of practice. Sites will cross-over from the standard to the user-centred strategy in six, eight-week transition steps following a randomly determined site-pairing scheme and timeline. The primary implementation outcome is the proportion of symptomatic close contacts completing TB evaluation within 60 days of TB treatment initiation by the index person with TB. The primary clinical effectiveness outcomes are the proportion of contacts diagnosed with and initiating active TB disease treatment and the proportion initiating TB preventative therapy within 60 days. We will assess outcomes from routine source documents using intention-to-treat analyses. We will also conduct nested mixed-methods studies of implementation fidelity and context and perform cost-effectiveness and impact modelling. The Makerere School of Public Health IRB(#554), the Uganda National Council for Science and Technology(#HS1720ES), and the Yale Institutional Review Board(#2000023199) approved the study and waived informed consent for the main trial implementation-effectiveness outcomes. We will submit results for publication in peer-reviewed journals and disseminate findings to local policymakers and representatives of affected communities. DISCUSSION This pragmatic, quasi-experimental implementation trial will inform efforts to find and prevent undiagnosed persons with TB in high-burden settings using contact investigation. It will also help assess the suitability of human-centred design and communities of practice for tailoring implementation strategies and sustaining evidence-based interventions in low-and-middle-income countries. TRIAL REGISTRATION The trial was registered(ClinicalTrials.gov Identifier NCT05640648) on 16 November 2022, after the trial launch on 7 March 2022.
Collapse
Affiliation(s)
- Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Makerere University School of Medicine, Kampala, Uganda
| | - Amanda J Gupta
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Yale School of Public Health, New Haven, CT, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Emmanuel Ochom
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Joseph M Ggita
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Suzan Nakasendwa
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Leah Nanziri
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Johnson Musinguzi
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Rachel Hennein
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Yale School of Public Health, New Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Moorine Sekadde
- National TB and Leprosy Programme, Ministry of Health, Kampala, Uganda
| | - Colleen Hanrahan
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Erez Yoeli
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Stavia Turyahabwe
- National TB and Leprosy Programme, Ministry of Health, Kampala, Uganda
| | - Adithya Cattamanchi
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- University of California Irvine, Irvine, CA, USA
| | - David W Dowdy
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jessica E Haberer
- Massachusetts General Hospital, Boston, MA, USA
- Harvard University, Cambridge, MA, USA
| | - Mari Armstrong-Hough
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- School of Global Public Health, New York University, New York, NY, USA
| | - Noah Kiwanuka
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - J Lucian Davis
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda.
- Yale School of Public Health, New Haven, CT, USA.
- Yale School of Medicine, New Haven, CT, USA.
| |
Collapse
|
8
|
Garg T, Nonyane BAS, Mohlamonyane M, Lebina L, Martinson NA, Dowdy DW, Hanrahan CF. Investigating linkage to care between hospitals and primary care clinics for people with TB in rural South Africa. PLoS One 2023; 18:e0289830. [PMID: 37578978 PMCID: PMC10424851 DOI: 10.1371/journal.pone.0289830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/26/2023] [Indexed: 08/16/2023] Open
Abstract
People with tuberculosis (TB) are often lost to follow-up during treatment transition to another facility. These losses may result in substantial morbidity and mortality but are rarely recorded. We conducted a record review on adults diagnosed with TB at 11 hospitals in Limpopo, South Africa, who were subsequently transferred to a local clinic to initiate or continue treatment. We then performed in-depth record reviews at the primary care clinic to which they were referred and called participants who could not be identified as starting treatment. Between August 2017 and April 2018, we reviewed records of 778 individuals diagnosed with TB in-hospital and later referred to local clinics for treatment. Of the 778, 88 (11%) did not link to care, and an additional 43 (5.5%) died. Compared to people without cough, those with cough had higher odds of linking to care (aOR = 2.01, 95% CI: 1.26-3.25, p = 0.005) and were also linked more quickly [adjusted Time Ratio (aTR) = 0.53, 95% CI:0.36-0.79, p<0.001], as were those diagnosed microbiologically (aOR = 1.86, 95% CI: 1.16-3.06, p = 0.012; aTR = 0.58, 95% CI: 0.34-0.98, p = 0.04). People diagnosed with TB in hospitals often disengage following referral to local clinics. Interventions to identify and re-engage people who do not present to local clinics within days of referral might close an important gap in the TB treatment cascade.
Collapse
Affiliation(s)
- Tushar Garg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Bareng Aletta Sanny Nonyane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Mbali Mohlamonyane
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Limakatso Lebina
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Neil A. Martinson
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - David W. Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Colleen F. Hanrahan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| |
Collapse
|
9
|
Kagujje M, Nyangu S, Maimbolwa MM, Shuma B, Mutti L, Somwe P, Sanjase N, Chungu C, Kerkhoff AD, Muyoyeta M. Strategies to increase childhood tuberculosis case detection at the primary health care level: Lessons from an active case finding study in Zambia. PLoS One 2023; 18:e0288643. [PMID: 37467209 PMCID: PMC10355435 DOI: 10.1371/journal.pone.0288643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 07/01/2023] [Indexed: 07/21/2023] Open
Abstract
INTRODUCTION In high TB burden settings, it is estimated that 10-20% of total notifications should be children, however, currently only 6-8% of the total TB notifications in Zambia are children. We assessed whether the implementation of a multicomponent strategy, at primary healthcare facilities, that systematically targets barriers at each step of the childhood TB diagnostic cascade can increase childhood TB case detection. METHODS We conducted a controlled, interrupted time series analysis to compare childhood TB case notifications before (January 2018-December 2019), and during implementation (January 2020-September 2021) in two intervention and two control Level 1 hospitals in Lusaka, Zambia. At each of the intervention facilities, we implemented a multicomponent strategy constituting: (1) capacity development on childhood TB and interpretation of chest x-ray, (2) TB awareness-raising and demand creation activities, (3) setting up fast track TB services, (4) strengthening of household contact tracing, and (5) improving access to digital chest X-ray for TB screening and Xpert MTB/Rif Ultra for TB diagnosis, through strengthening sample collection in children. FINDINGS Among 5,150 children < 15 years screened at the two intervention facilities during the study period, 503 (9.8% yield) were diagnosed with TB. Of these, 433 (86.1%) were identified through facility-based activities (10.5% yield) and 70 (13.9%) were identified through household contact tracing (6.9% yield). Overall, 446 children (88.7%) children with TB were clinically diagnosed. Following implementation of the multicomponent strategy, the proportion children contributed to total TB notifications immediately changed by +1.5% (95%CI: -3.5, 6.6) and -4.4% (95%CI: -7.5, 1.4) at the intervention and control sites, respectively (difference 6.0% [95%CI: -0.7, 12.7]), p = 0.08); the proportion of childhood notifications increased 0.9% (95%CI: -0.7, 2.5%) each quarter at the intervention sites relative to pre-implementation trends, while declining 1.2% (-95%CI: -1.8, -0.6) at the control sites (difference 2.1% [95%CI: 0.1, 4.2] per quarter between, p = 0.046); this translated into 352 additional and 85 fewer childhood TB notifications at the intervention and control sites, respectively, compared to the pre-implementation period. CONCLUSION A standardized package of strategies to improve childhood TB detection at primary healthcare facilities was feasible to implement and was associated with a sustained improvement in childhood TB notifications.
Collapse
Affiliation(s)
- Mary Kagujje
- Tuberculosis Department, Centre of Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Sarah Nyangu
- Tuberculosis Department, Centre of Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Minyoi M. Maimbolwa
- Tuberculosis Department, Centre of Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Brian Shuma
- Tuberculosis Department, Centre of Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Lilungwe Mutti
- Tuberculosis Department, Centre of Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Paul Somwe
- Strategic Information Department, Centre of Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Nsala Sanjase
- Tuberculosis Department, Centre of Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Andrew D. Kerkhoff
- Department of Medicine, University of San Francisco California, San Francisco, California, United States of America
| | - Monde Muyoyeta
- Tuberculosis Department, Centre of Infectious Disease Research in Zambia, Lusaka, Zambia
| |
Collapse
|
10
|
Katamba A, Gupta AJ, Turimumahoro P, Ochom E, Ggita JM, Nakasendwa S, Nanziri L, Musinguzi J, Hennein R, Sekadde M, Hanrahan C, Byaruhanga R, Yoeli E, Turyahabwe S, Cattamanchi A, Dowdy DW, Haberer JE, Armstrong-Hough M, Kiwanuka N, Davis JL. A user-centred implementation strategy for tuberculosis contact investigation in Uganda: Protocol for a stepped-wedge, cluster-randomised trial. RESEARCH SQUARE 2023:rs.3.rs-3121275. [PMID: 37461631 PMCID: PMC10350172 DOI: 10.21203/rs.3.rs-3121275/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
Background Tuberculosis (TB) is among the leading causes of infectious death worldwide. Contact investigation is an evidence-based, World Health Organisation-endorsed intervention for timely TB diagnosis, treatment, and prevention but has not been widely and effectively implemented. Methods We are conducting a stepped-wedge, cluster-randomised, hybrid Type III implementation-effectiveness trial comparing a user-centred to a standard strategy for implementing TB contact investigation in 12 healthcare facilities in Uganda. The user-centred strategy consists of several client-focused components including 1) a TB-education booklet, 2) a contact-identification algorithm, 3) an instructional sputum-collection video, and 4) a community-health-rider service to transport clients, CHWs, and sputum samples, along with several healthcare-worker-focused components, including 1) collaborative improvement meetings, 2) regular audit-and-feedback reports, and 3) a digital group-chat application designed to develop a community of practice. Sites will cross from the standard to the user-centred strategy in six, eight-week transition steps following a randomly determined site-pairing scheme and timeline. The primary implementation outcome is the proportion of symptomatic close contacts completing TB evaluation within 60 days of TB treatment initiation by the index person with TB. The primary clinical effectiveness outcomes are the proportion of contacts diagnosed with and initiating active TB disease treatment and the proportion initiating TB preventative therapy within 60 days. We will assess outcomes from routine source documents using intention-to-treat analyses. We will also conduct nested mixed-methods studies of implementation fidelity and context and perform cost-effectiveness and impact modelling. The Makerere School of Public Health IRB (#554), the Uganda National Council for Science and Technology (#HS1720ES), and the Yale Institutional Review Board (#2000023199) approved the study with a waiver of informed consent for the main trial implementation-effectiveness outcomes. We will submit trial results for publication in a peer-reviewed journal and disseminate findings to local shareholders, including policymakers and representatives of affected communities. Discussion This pragmatic, quasi-experimental implementation trial will inform efforts to find and prevent undiagnosed persons with TB in high-burden setting using contact investigation. It will help assess the suitability of human-centred design and communities of practice for tailoring implementation strategies and sustain evidence-based interventions in low-and-middle-income countries. Trial registration number ClinicalTrials.gov Identifier: NCT05640648.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Leah Nanziri
- Uganda Tuberculosis Implementation Research Consortium
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Gupta AJ, Turimumahoro P, Ochom E, Ggita JM, Babirye D, Ayakaka I, Mark D, Okello DA, Cattamanchi A, Dowdy DW, Haberer JE, Armstrong-Hough M, Katamba A, Davis JL. mHealth to improve implementation of TB contact investigation: a case study from Uganda. Implement Sci Commun 2023; 4:71. [PMID: 37340456 PMCID: PMC10280918 DOI: 10.1186/s43058-023-00448-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 06/01/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Implementation science offers a systematic approach to adapting innovations and delivery strategies to new contexts but has yet to be widely applied in low- and middle-income countries. The Fogarty Center for Global Health Studies is sponsoring a special series, "Global Implementation Science Case Studies," to address this gap. METHODS We developed a case study for this series describing our approach and lessons learned while conducting a prospective, multi-modal study to design, implement, and evaluate an implementation strategy for TB contact investigation in Kampala, Uganda. The study included formative, evaluative, and summative phases that allowed us to develop and test an adapted contact investigation intervention involving home-based sample collection for TB and HIV testing. We concurrently developed a multi-component mHealth implementation strategy involving fingerprint scanning, electronic decision support, and automated reporting of test results via text message. We then conducted a household-randomized, hybrid implementation-effectiveness trial comparing the adapted intervention and implementation strategy to usual care. Our assessment included nested quantitative and qualitative studies to understand the strategy's acceptability, appropriateness, feasibility, fidelity, and costs. Reflecting on this process with a multi-disciplinary team of implementing researchers and local public health partners, we provide commentary on the previously published studies and how the results influenced the adaptation of international TB contact investigation guidelines to fit the local context. RESULTS While the trial did not show improvements in contact investigation delivery or public health outcomes, our multi-modal evaluation strategy helped us identify which elements of home-based, mHealth-facilitated contact investigation were feasible, acceptable, and appropriate and which elements reduced its fidelity and sustainability, including high costs. We identified a need for better tools for measuring implementation that are simple, quantitative, and repeatable and for greater attention to ethical issues in implementation science. CONCLUSIONS Overall, a theory-informed, community-engaged approach to implementation offered many learnings and actionable insights for delivering TB contact investigation and using implementation science in low-income countries. Future implementation trials, especially those incorporating mHealth strategies, should apply the learnings from this case study to enhance the rigor, equity, and impact of implementation research in global health settings.
Collapse
Affiliation(s)
- Amanda J Gupta
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Patricia Turimumahoro
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Emmanuel Ochom
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Joseph M Ggita
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Diana Babirye
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Irene Ayakaka
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - David Mark
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | | | - Adithya Cattamanchi
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA, USA
- Division of Pulmonary Diseases and Critical Care Medicine, University of California, Irvine, Irvine, CA, USA
| | - David W Dowdy
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jessica E Haberer
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mari Armstrong-Hough
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
- Department of Social and Behavioral Sciences, New York University School of Global Public Health, New York, NY, USA
- Department of Epidemiology, New York University School of Global Public Health, New York, NY, USA
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
- Clinical Epidemiology Unit, Department of Medicine, Makerere University, Kampala, Uganda
| | - J Lucian Davis
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA.
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda.
- Pulmonary, Critical Care, and Sleep Medicine Section, Yale School of Medicine, New Haven, CT, USA.
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, CT, USA.
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Hanrahan CF, Nonyane BAS, Lebina L, Mmolawa L, Siwelana T, West NS, Albaugh N, Martinson N, Dowdy DW. Household- Versus Incentive-Based Contact Investigation for Tuberculosis in Rural South Africa: A Cluster-Randomized Trial. Clin Infect Dis 2023; 76:1164-1172. [PMID: 36458857 PMCID: PMC10319771 DOI: 10.1093/cid/ciac920] [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: 05/17/2022] [Revised: 11/16/2022] [Accepted: 11/23/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Household contact investigation for people newly diagnosed with tuberculosis (TB) is poorly implemented, particularly in low- and middle-income countries. Conditional cash incentives may improve uptake. METHODS We conducted a pragmatic, cluster-randomized, crossover trial of 2 TB contact investigation approaches (household-based and incentive-based) in 28 public primary care clinics in South Africa. Each clinic used 1 approach for 18 months, followed by a 6-month washout period, after which the opposite approach was used. Fourteen clinics were randomized to each approach. In the household-based arm, we conducted TB screening and testing of contacts at the household. In the incentive-based arm, both index patients and ≤10 of their close contacts (either within or outside the household) were given small cash incentives for presenting to study clinics for TB screening. The primary outcome was the number of people with incident TB who were diagnosed and started on treatment at study clinics. RESULTS From July 2016 to January 2020, we randomized 28 clinics to each study arm, and enrolled 782 index TB patients and 1882 contacts in the household-based arm and 780 index patients and 1940 contacts in the incentive-based arm. A total of 1413 individuals started on TB treatment in the household-based arm and 1510 in the incentive-based arm. The adjusted incidence rate ratio of TB treatment initiation in the incentive- versus household-based arms was 1.05 (95% confidence interval: .97-1.13). CONCLUSIONS Incentive-based contact investigation for TB has similar effectiveness to traditional household-based approaches and may be a viable alternative or complementary approach to household-based investigation.
Collapse
Affiliation(s)
- Colleen F Hanrahan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Bareng Aletta Sanny Nonyane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Lesego Mmolawa
- Perinatal HIV Research Unit, Chris Hani Baragwanath Hospital, Diepkloof, Soweto, South Africa
| | - Tsundzukani Siwelana
- Perinatal HIV Research Unit, Chris Hani Baragwanath Hospital, Diepkloof, Soweto, South Africa
| | - Nora S West
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nicholas Albaugh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Neil Martinson
- Perinatal HIV Research Unit, Chris Hani Baragwanath Hospital, Diepkloof, Soweto, South Africa
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| |
Collapse
|
14
|
Yuen CM, Szkwarko D, Dubois MM, Shahbaz S, Yuengling KA, Urbanowski ME, Bain PA, Brands A, Masini T, Verkuijl S, Viney K, Hirsch-Moverman Y, Hussain H. Tuberculosis care models for children and adolescents: a scoping review. Bull World Health Organ 2022; 100:777-788L. [PMID: 36466210 PMCID: PMC9706349 DOI: 10.2471/blt.22.288447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 08/02/2022] [Accepted: 08/10/2022] [Indexed: 12/05/2022] Open
Abstract
Objective To map which tuberculosis care models are best suited for children and adolescents. Methods We conducted a scoping review to assess the impact of decentralized, integrated and family-centred care on child and adolescent tuberculosis-related outcomes, describe approaches for these care models and identify key knowledge gaps. We searched seven literature databases on 5 February 2021 (updated 16 February 2022), searched the references of 18 published reviews and requested data from ongoing studies. We included studies from countries with a high tuberculosis burden that used a care model of interest and reported tuberculosis diagnostic, treatment or prevention outcomes for an age group < 20 years old. Findings We identified 28 studies with a comparator group for the impact assessment and added 19 non-comparative studies to a qualitative analysis of care delivery approaches. Approaches included strengthening capacity in primary-level facilities, providing services in communities, screening for tuberculosis in other health services, co-locating tuberculosis and human immunodeficiency virus treatment, offering a choice of treatment location and providing social or economic support. Strengthening both decentralized diagnostic services and community linkages led to one-to-sevenfold increases in case detection across nine studies and improved prevention outcomes. We identified only five comparative studies on integrated or family-centred care, but 11 non-comparative studies reported successful treatment outcomes for at least 71% of children and adolescents. Conclusion Strengthening decentralized services in facilities and communities can improve tuberculosis outcomes for children and adolescents. Further research is needed to identify optimal integrated and family-centred care approaches.
Collapse
Affiliation(s)
- Courtney M Yuen
- Division of Global Health Equity, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA02115, United States of America (USA)
| | - Daria Szkwarko
- Warren Alpert Medical School, Brown University, Providence, USA
| | - Melanie M Dubois
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, USA
| | | | | | - Michael E Urbanowski
- T.H. Chan School of Medicine, University of Massachusetts Chan Medical School, Worcester, USA
| | - Paul A Bain
- Countway Library, Harvard Medical School, Boston, USA
| | - Annemieke Brands
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Tiziana Masini
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Sabine Verkuijl
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Kerri Viney
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | | | - Hamidah Hussain
- Interactive Research and Development Global, Singapore, Singapore
| |
Collapse
|
15
|
ter Ellen F, Tielens K, Fenenga C, Mieras L, Schoenmakers A, Arif MA, Veldhuijzen N, Peters R, Ignotti E, Kasang C, Quao B, Steinmann P, Banstola NL, Oraga J, Budiawan T. Implementation approaches for leprosy prevention with single-dose rifampicin: A support tool for decision making. PLoS Negl Trop Dis 2022; 16:e0010792. [PMID: 36251696 PMCID: PMC9612816 DOI: 10.1371/journal.pntd.0010792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 10/27/2022] [Accepted: 09/06/2022] [Indexed: 11/05/2022] Open
Abstract
Background In the past 15 years, the decline in annually detected leprosy patients has stagnated. To reduce the transmission of Mycobacterium leprae, the World Health Organization recommends single-dose rifampicin (SDR) as post-exposure prophylaxis (PEP) for contacts of leprosy patients. Various approaches to administer SDR-PEP have been piloted. However, requirements and criteria to select the most suitable approach were missing. The aims of this study were to develop an evidence-informed decision tool to support leprosy programme managers in selecting an SDR-PEP implementation approach, and to assess its user-friendliness among stakeholders without SDR-PEP experience. Methodology The development process comprised two phases. First, a draft tool was developed based on a literature review and semi-structured interviews with experts from various countries, organisations and institutes. This led to: an overview of existing SDR-PEP approaches and their characteristics; understanding the requirements and best circumstances for these approaches; and, identification of relevant criteria to select an approach. In the second phase the tool’s usability and applicability was assessed, through interviews and a focus group discussion with intended, inexperienced users; leprosy programme managers and non-governmental organization (NGO) staff. Principal findings Five SDR-PEP implementation approaches were identified. The levels of endemicity and stigma, and the accessibility of an area were identified as most relevant criteria to select an approach. There was an information gap on cost-effectiveness, while successful implementation depends on availability of resources. Five basic requirements, irrespective of the approach, were identified: stakeholder support; availability of medication; compliant health system; trained health staff; and health education. Two added benefits of the tool were identified: its potential value for advocacy and for training. Conclusion An evidence-informed SDR-PEP decision tool to support the selection of implementation approaches for leprosy prevention was developed. While the tool was evaluated by potential users, more research is needed to further improve the tool, especially health-economic studies, to ensure efficient and cost-effective implementation of SDR-PEP. The chance of contacts of leprosy patients developing leprosy can be reduced by providing a single dose of rifampicin. The implementation of this type of post-exposure prophylaxis can be done in various ways. This study led to the development of the SDR-PEP decision support tool to select the most suitable approach. It was developed in two phases; first, a tool was drafted based on a literature review and expert interviews, this was followed by phase 2 in which interviews and a focus group discussion with intended users of the tool were held. Five SDR-PEP implementation approaches that have been developed so far were identified. Apart from the characteristics of these approaches, the tool lists five basic requirements for the successful implementation of any approach, and criteria that help to select the best approach in a given context. A flowchart supports the selection process. The study found that the tool can also be used for lobby and advocacy, to clarify SDR-PEP implementation and the choice for an approach, and in training on SDR-PEP implementation. Information about costs and cost-effectiveness of the approaches is limited. Further research will help to continue to improve the tool.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Benedict Quao
- National Leprosy Control Programme, Ghana Health Service, Accra, Ghana
| | - Peter Steinmann
- Swiss Tropical and Public Health Institute, Allschwil Switzerland, University of Basel, Basel, Switzerland
| | | | | | | |
Collapse
|
16
|
Woodard L, Liaw W, Adepoju OE, Prabhu S, Chae M, Matuk-Villazon O, Beech BM. Evaluating a contact tracing course: How universities can develop the public health workforce. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2022:1-7. [PMID: 35981316 DOI: 10.1080/07448481.2022.2103380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 05/27/2022] [Accepted: 07/12/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES To describe the participants of a university-based COVID-19 contact tracing course and determine whether the course changed knowledge, attitudes, and intention to participate in contact tracing. PARTICIPANTS Faculty, staff, and students were eligible. METHODS Surveys evaluated the impact of the course on participant intentions to engage in contact tracing. Logistic regression identified characteristics associated with increased likelihood of participating in contact tracing. RESULTS Nearly 800 individuals participated, of whom 26.2% identified as Hispanic/Latino and 14.0% as Black. Nearly half (48.8%) planned to conduct contact tracing. While attitudes did not change, knowledge improved (67.9% vs. 93.8% scores on assessments; p < 0.001). Younger participants and Black individuals were more more likely to be confident that they would participate in contact tracing. CONCLUSIONS Course completion was associated with increased knowledge. Participants were racially and ethnically diverse, highlighting how universities can partner with health departments to develop workforces that reflect local communities.
Collapse
Affiliation(s)
- LeChauncy Woodard
- Department of Health Systems and Population Health Sciences, University of Houston Tilman J. Fertitta Family College of Medicine, Houston, Texas, USA
- Humana Integrated Health System Sciences Institute, University of Houston, Houston, Texas, USA
| | - Winston Liaw
- Department of Health Systems and Population Health Sciences, University of Houston Tilman J. Fertitta Family College of Medicine, Houston, Texas, USA
| | - Omolola E Adepoju
- Department of Health Systems and Population Health Sciences, University of Houston Tilman J. Fertitta Family College of Medicine, Houston, Texas, USA
| | | | - Minji Chae
- Department of Biostatistics and Data Science, University of Texas Health Science Center School of Public Health, Houston, Texas, USA
| | - Omar Matuk-Villazon
- Department of Decision and Information Sciences, C.T. Bauer College of Business, University of Houston, Houston, TX, USA
| | - Bettina M Beech
- Department of Health Systems and Population Health Sciences, University of Houston Tilman J. Fertitta Family College of Medicine, Houston, Texas, USA
| |
Collapse
|
17
|
Zulu DW, Silumbwe A, Maritim P, Zulu JM. Integration of systematic screening for tuberculosis in outpatient departments of urban primary healthcare facilities in Zambia: a case study of Kitwe district. BMC Health Serv Res 2022; 22:732. [PMID: 35655301 PMCID: PMC9160503 DOI: 10.1186/s12913-022-08043-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Tuberculosis (TB) is the leading cause of death from a single infectious agent globally, killing about 1.5 million people annually, yet 3 million cases are missed every year. The World Health Organization recommends systematic screening of suspected active TB patients among those visiting the healthcare facilities. While many countries have scaled-up systematic screening of TB, there has been limited assessment of the extent of its integration into the health system. This study sought to explore factors that shape the integration of systematic screening of TB in outpatient departments of primary healthcare facilities in Kitwe district, Zambia.
Methods
This was a qualitative case study with health providers including district managers, TB focal point persons and laboratory personnel working in six purposively selected primary healthcare facilities. Data was collected through key informant (n = 8) and in-depth (n = 15) interviews. Data analysis was conducted using QDA Miner software and guided by Atun’s Integration framework.
Results
The facilitators to integration of systematic screening for TB into out patient departments of primary health facilities included the perceived high burden TB, compatibility of the systematic screening for TB program with healthcare workers training and working schedules, stakeholder knowledge of each others interest and values, regular performance management and integrated outreach of TB screening services. Constraining factors to integration of systematic screening for TB into outpatient departments included complexity of screening for TB in children, unbalanced incentivization mechanisms, ownership and legitimacy of the TB screening program, negative health worker attitudes, social cultural misconceptions of TB and societal stigma as well as the COVID-19 pandemic.
Conclusion
Systematic screening of TB is not fully integrated into the primary healthcare facilities in Zambia to capture all those suspected with active TB that make contact with the health system. Finding the missing TB cases will, therefore, require contextual adaptation of the systematic screening for TB program to local needs and capacities as well as strengthening the health system.
Collapse
|
18
|
Kay AW, Sandoval M, Mtetwa G, Mkhabela M, Ndlovu B, Devezin T, Sikhondze W, Vambe D, Sibanda J, Dube GS, Stevens RH, Lukhele B, Mandalakas AM. Vikela Ekhaya: A Novel, Community-based, Tuberculosis Contact Management Program in a High Burden Setting. Clin Infect Dis 2022; 74:1631-1638. [PMID: 34302733 PMCID: PMC9070808 DOI: 10.1093/cid/ciab652] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The prevention of tuberculosis (TB) in child contacts of TB cases and people living with human immunodeficiency virus (HIV) is a public health priority, but global access to TB preventive therapy (TPT) remains low. In 2019, we implemented Vikela Ekhaya, a novel community-based TB contact management program in Eswatini designed to reduce barriers to accessing TPT. METHODS Vikela Ekhaya offered differentiated TB and HIV testing for household contacts of TB cases by using mobile contact management teams to screen contacts, assess their TPT eligibility, and initiate and monitor TPT adherence in participants' homes. RESULTS In total, 945 contacts from 244 households were screened for TB symptoms; 72 (8%) contacts reported TB symptoms, and 5 contacts (0.5%) were diagnosed with prevalent TB. A total of 322 of 330 (98%) eligible asymptomatic household contacts initiated TPT. Of 322 contacts initiating TPT, 248 children initiated 3 months of isoniazid and rifampicin and 74 children and adults living with HIV initiated 6 months of isoniazid; 298 (93%) completed TPT. In clustered logistic regression analyses, unknown HIV status (adjusted odds ratio [aOR] 5.7, P = .023), positive HIV status (aOR 21.1, P = .001), urban setting (aOR 5.6, P = .006), and low income (aOR 5.9, P = .001) predicted loss from the cascade of care among TPT-eligible contacts. CONCLUSION Vikela Ekhaya demonstrated that community-based TB household contact management is a feasible, acceptable, and successful strategy for TB screening and TPT delivery. The results of this study support the development of novel, differentiated, community-based interventions for TB prevention and control.
Collapse
Affiliation(s)
- Alexander W Kay
- The Global Tuberculosis Program, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
- Baylor College of Medicine Children’s Foundation-Eswatini, Mbabane, Eswatini
| | - Micaela Sandoval
- The Global Tuberculosis Program, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
- UTHealth School of Public Health, Houston, Texas, USA
| | - Godwin Mtetwa
- Baylor College of Medicine Children’s Foundation-Eswatini, Mbabane, Eswatini
| | - Musa Mkhabela
- Baylor College of Medicine Children’s Foundation-Eswatini, Mbabane, Eswatini
| | - Banele Ndlovu
- Baylor College of Medicine Children’s Foundation-Eswatini, Mbabane, Eswatini
| | - Tara Devezin
- The Global Tuberculosis Program, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Welile Sikhondze
- Eswatini National Tuberculosis Control Program, Manzini, Eswatini
| | - Debrah Vambe
- Eswatini National Tuberculosis Control Program, Manzini, Eswatini
| | - Joyce Sibanda
- Eswatini National Tuberculosis Control Program, Manzini, Eswatini
| | - Gloria S Dube
- Eswatini National Tuberculosis Control Program, Manzini, Eswatini
| | - Robert H Stevens
- Independent Consultant to StopTB Partnership, Geneva, Switzerland
| | - Bhekumusa Lukhele
- The Global Tuberculosis Program, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
- Baylor College of Medicine Children’s Foundation-Eswatini, Mbabane, Eswatini
| | - Anna M Mandalakas
- The Global Tuberculosis Program, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
- UTHealth School of Public Health, Houston, Texas, USA
| |
Collapse
|
19
|
Mmolawa L, Siwelana T, Hanrahan CF, Lebina L, Martinson NA, Dowdy D, Nonyane BAS. Time to care-seeking for TB symptoms. Int J Tuberc Lung Dis 2022; 26:268-275. [PMID: 35197167 PMCID: PMC9636494 DOI: 10.5588/ijtld.21.0447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND: Early presentation to healthcare facilities is critical for early diagnosis and treatment of TB. We studied self-reported time to care-seeking from the onset of TB symptoms among primary healthcare clinic (PHC) attendees in Limpopo Province, South Africa.METHODS: We used data from participants enrolled in a cluster-randomized trial of TB case finding in 56 PHC clinics across two health districts. We fitted log-normal accelerated failure time regression models and we present time ratios (TRs) for potential risk factors.RESULTS: We included 2,160 participants. Among the 1,757 (81%) diagnosed with active TB, the median time to care-seeking was 30 days (IQR 14-60); adults sought care later than children/adolescents (adjusted TR aTR 1.47, 95% CI 1.10-1.96). Among those not diagnosed with TB, the median was 14 days (IQR 7-60); being HIV-positive (aTR 1.57, 95% CI 1.03-2.40); having less than grade 8 education and currently smoking were associated with longer time to care-seeking. In the combined analysis, living with HIV and having underlying active TB was associated with faster care-seeking (TB status x HIV interaction: TR 0.68, 95% CI 0.48-0.96).CONCLUSION: Delay in care-seeking was associated with age, lower education and being a current smoker. TB awareness campaigns targeting these population groups may improve care-seeking behavior and reduce community TB transmission.
Collapse
Affiliation(s)
- L Mmolawa
- Perinatal HIV Research Unit, South Africa Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
| | - T Siwelana
- Perinatal HIV Research Unit, South Africa Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
| | - C F Hanrahan
- Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - L Lebina
- Perinatal HIV Research Unit, South Africa Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
| | - N A Martinson
- Perinatal HIV Research Unit, South Africa Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa, Johns Hopkins University, Center for TB Research, Baltimore, MD, USA
| | - D Dowdy
- Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, Johns Hopkins University, Center for TB Research, Baltimore, MD, USA
| | - B A S Nonyane
- Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, Perinatal HIV Research Unit, South Africa Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
20
|
Hossain AD, Jarolimova J, Elnaiem A, Huang CX, Richterman A, Ivers LC. Effectiveness of contact tracing in the control of infectious diseases: a systematic review. THE LANCET PUBLIC HEALTH 2022; 7:e259-e273. [PMID: 35180434 PMCID: PMC8847088 DOI: 10.1016/s2468-2667(22)00001-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/23/2021] [Accepted: 01/04/2022] [Indexed: 11/06/2022] Open
Abstract
Background Contact tracing is used for multiple infectious diseases, most recently for COVID-19, but data regarding its effectiveness in disease control are scarce. To address this knowledge gap and inform public health decision making for COVID-19, we systematically reviewed the existing literature to determine the effectiveness of contact tracing in the control of communicable illness. Methods We searched PubMed, Embase, and the Cochrane Library from database inception up to Nov 22, 2021, for published studies evaluating associations between provider-initiated contact tracing for transmissible infectious diseases and one of three outcomes of interest: case detection rates among contacts or at the community level, overall forward transmission, or overall disease incidence. Clinical trials and observational studies were eligible, with no language or date restrictions. Reference lists of reviews were searched for additional studies. We excluded studies without a control group, using only mathematical modelling, not reporting a primary outcome of interest, or solely examining patient-initiated contact tracing. One reviewer applied eligibility criteria to each screened abstract and full-text article, and two reviewers independently extracted summary effect estimates and additional data from eligible studies. Only data reported in published manuscripts or supplemental material was extracted. Risk of bias for each included study was assessed with the Cochrane Risk of Bias 2 tool (randomised studies) or the Newcastle–Ottawa Scale (non-randomised studies). Findings We identified 9050 unique citations, of which 47 studies met the inclusion criteria: six were focused on COVID-19, 20 on tuberculosis, eight on HIV, 12 on curable sexually transmitted infections (STIs), and one on measles. More than 2 million index patients were included across a variety of settings (both urban and rural areas and low-resource and high-resource settings). Of the 47 studies, 29 (61·7%) used observational designs, including all studies on COVID-19, and 18 (38·3%) were randomised controlled trials. 40 studies compared provider-initiated contact tracing with other interventions or evaluated expansions of provider-initiated contact tracing, and seven compared programmatic adaptations within provider-initiated contact tracing. 29 (72·5%) of the 40 studies evaluating the effect of provider-initiated contact tracing, including four (66·7%) of six COVID-19 studies, found contact tracing interventions were associated with improvements in at least one outcome of interest. 23 (48·9%) studies had low risk of bias, 22 (46·8%) studies had some risk of bias, and two (4·3%) studies (both randomised controlled trials on curable STIs) had high risk of bias. Interpretation Provider-initiated contact tracing can be an effective public health tool. However, the ability of authorities to make informed choices about its deployment might be limited by heterogenous approaches to contact tracing in studies, a scarcity of quantitative evidence on its effectiveness, and absence of specificity of tracing parameters most important for disease control. Funding The Sullivan Family Foundation, Massachusetts General Hospital Executive Committee on Research, and US National Institutes of Health.
Collapse
|
21
|
Dovel K, Balakasi K, Gupta S, Mphande M, Robson I, Khan S, Amberbir A, Stilson C, van Oosterhout JJ, Doi N, Nichols BE. Frequency of visits to health facilities and HIV services offered to men, Malawi. Bull World Health Organ 2021; 99:618-626. [PMID: 34475599 PMCID: PMC8381098 DOI: 10.2471/blt.20.278994] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 05/07/2021] [Accepted: 05/07/2021] [Indexed: 11/27/2022] Open
Abstract
Objective To determine how often men in Malawi attend health facilities and if testing for human immunodeficiency virus (HIV) is offered during facility visits. Methods We conducted a cross-sectional, community-representative survey of men (15–64 years) from 36 villages in Malawi. We excluded men who ever tested HIV-positive. Primary outcomes were: health facility visits in the past 12 months (for their own health (client visit) or to support the health services of others (guardian visit)); being offered HIV testing during facility visits; and being tested that same day. We disaggregated all results by HIV testing history: tested ≤ 12 months ago, or in need of testing (never tested or tested > 12 months before). Findings We included 1116 men in the analysis. Mean age was 34 years (standard deviation: 13.2) and 55% (617/1116) of men needed HIV testing. Regarding facility visits, 82% (920/1116) of all men and 70% (429/617) of men in need of testing made at least one facility visit in the past 12 months. Men made a total of 1973 visits (mean two visits): 39% (765/1973) were as guardians and 84% (1657/1973) were to outpatient departments. Among men needing HIV testing, only 7% (30/429) were offered testing during any visit. The most common reason for not testing was not being offered services (37%; 179/487). Conclusion Men in Malawi attend health facilities regularly, but few of those in need of HIV testing are offered testing services. Health screening services should capitalize on men’s routine visits to outpatient departments as clients and guardians.
Collapse
Affiliation(s)
- Kathryn Dovel
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Ave, Los Angeles, CA 90095, United States of America (USA)
| | | | - Sundeep Gupta
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Ave, Los Angeles, CA 90095, United States of America (USA)
| | | | | | | | | | | | | | - Naoko Doi
- Clinton Health Access Initiative, Boston, USA
| | - Brooke E Nichols
- Department of Global Health, School of Public Health, Boston University, Boston, USA
| |
Collapse
|
22
|
Kerkhoff AD, Kagujje M, Nyangu S, Mateyo K, Sanjase N, Chilukutu L, Eshun-Wilson I, Geng EH, Havlir DV, Muyoyeta M. Pathways to care and preferences for improving tuberculosis services among tuberculosis patients in Zambia: A discrete choice experiment. PLoS One 2021; 16:e0252095. [PMID: 34464392 PMCID: PMC8407587 DOI: 10.1371/journal.pone.0252095] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/21/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Delays in the diagnosis of tuberculosis (TB) contribute to a substantial proportion of TB-related mortality, especially among people living with HIV (PLHIV). We sought to characterize the diagnostic journey for HIV-positive and HIV-negative patients with a new TB diagnosis in Zambia, to understand drivers of delay, and characterize their preferences for service characteristics to inform improvements in TB services. METHODS We assessed consecutive adults with newly microbiologically-confirmed TB at two public health treatment facilities in Lusaka, Zambia. We administered a survey to document critical intervals in the TB care pathway (time to initial care-seeking, diagnosis and treatment initiation), identify bottlenecks and their reasons. We quantified patient preferences for a range of characteristics of health services using a discrete choice experiment (DCE) that assessed 7 attributes (distance, wait times, hours of operation, confidentiality, sex of provider, testing incentive, TB test speed and notification method). RESULTS Among 401 patients enrolled (median age of 34 years, 68.7% male, 46.6% HIV-positive), 60.9% and 39.1% were from a first-level and tertiary hospital, respectively. The median time from symptom onset to receipt of TB treatment was 5.0 weeks (IQR: 3.6-8.0) and was longer among HIV-positive patients seeking care at a tertiary hospital than HIV-negative patients (6.4 vs. 4.9 weeks, p = 0.002). The time from symptom onset to initial presentation for evaluation accounted for the majority of time until treatment initiation (median 3.0 weeks, IQR: 1.0-5.0)-an important minority of 11.0% of patients delayed care-seeking ≥8 weeks. The DCE found that patients strongly preferred same-day TB test results (relative importance, 37.2%), facilities close to home (18.0%), and facilities with short wait times (16.9%). Patients were willing to travel to a facility up to 7.6 kilometers further away in order to access same-day TB test results. Preferences for improving current TB services did not differ according to HIV status. CONCLUSIONS Prolonged intervals from TB symptom onset to treatment initiation were common, especially among PLHIV, and were driven by delayed health-seeking. Addressing known barriers to timely diagnosis and incorporating patients' preferences into TB services, including same-day TB test results, may facilitate earlier TB care engagement in high burden settings.
Collapse
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, 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
- University Teaching Hospital, Department of Internal Medicine, Lusaka, Zambia
| | - Nsala Sanjase
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Elvin H. Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases and Global Medicine Zuckerberg San Francisco General Hospital and Trauma Center University of California, San Francisco, California, United States of America
| | - Monde Muyoyeta
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| |
Collapse
|
23
|
Lungu P, Kerkhoff AD, Kasapo CC, Mzyece J, Nyimbili S, Chimzizi R, Silumesii A, Kagujje M, Subbaraman R, Muyoyeta M, Malama K. Tuberculosis care cascade in Zambia - identifying the gaps in order to improve outcomes: a population-based analysis. BMJ Open 2021; 11:e044867. [PMID: 34376439 PMCID: PMC8356169 DOI: 10.1136/bmjopen-2020-044867] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Tuberculosis (TB) remains a leading cause of morbidity and mortality in Zambia, especially for people living with HIV (PLHIV). We undertook a care cascade analysis to quantify gaps in care and align programme improvement measures with areas of need. DESIGN Retrospective, population-based analysis. SETTING We derived national-level estimates for each step of the TB care cascade in Zambia. Estimates were informed by WHO incidence estimates, nationally aggregated laboratory and notification registers, and individual-level programme data from four provinces. PARTICIPANTS Participants included all individuals with active TB disease in Zambia in 2018. We characterised the overall TB cascade and disaggregated by drug susceptibility results and HIV status. RESULTS In 2018, the total burden of TB in Zambia was estimated to be 72 495 (range, 40 495-111 495) cases. Of these, 43 387 (59.8%) accessed TB testing, 40 176 (55.4%) were diagnosed with TB, 36 431 (50.3%) were started on treatment and 32 700 (45.1%) completed treatment. Among all persons with TB lost at any step along the care cascade (n=39 795), 29 108 (73.1%) were lost prior to accessing diagnostic services, 3211 (8.1%) prior to diagnosis, 3745 (9.4%) prior to initiating treatment and 3731 (9.4%) prior to treatment completion. PLHIV were less likely than HIV-negative individuals to successfully complete the care cascade (42.8% vs 50.2%, p<0.001). Among those with rifampicin-resistant TB, there was substantial attrition at each step of the cascade and only 22.8% were estimated to have successfully completed treatment. CONCLUSIONS Losses throughout the care cascade resulted in a large proportion of individuals with TB not completing treatment. Ongoing health systems strengthening and patient-centred engagement strategies are needed at every step of the care cascade; however, scale-up of active case finding strategies is particularly critical to ensure individuals with TB in the population reach initial stages of care. Additionally, a renewed focus on PLHIV and individuals with drug-resistant TB is urgently needed to improve TB-related outcomes in Zambia.
Collapse
Affiliation(s)
- Patrick Lungu
- National Tuberculosis and Leprosy Control Programme, Lusaka, Zambia
- Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
| | - 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, USA
| | - Clara C Kasapo
- National Tuberculosis and Leprosy Control Programme, Lusaka, Zambia
| | - Judith Mzyece
- National Tuberculosis and Leprosy Control Programme, Lusaka, Zambia
| | - Sulani Nyimbili
- National Tuberculosis and Leprosy Control Programme, Lusaka, Zambia
| | - Rhehab Chimzizi
- National Tuberculosis and Leprosy Control Programme, Lusaka, Zambia
| | - Andrew Silumesii
- Department of Public Health and Research, Ministry of Health, Lusaka, Zambia
| | - Mary Kagujje
- Tuberculosis Department, Center for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Ramnath Subbaraman
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Monde Muyoyeta
- Tuberculosis Department, Center for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | |
Collapse
|
24
|
Izco S, Murias‐Closas A, Jordan AM, Greene G, Catorze N, Chiconela H, Garcia JI, Blanco‐Arevalo A, Febrer A, Casellas A, Saavedra B, Chiller T, Nhampossa T, Garcia‐Basteiro A, Letang E. Improved detection and management of advanced HIV disease through a community adult TB-contact tracing intervention with same-day provision of the WHO-recommended package of care including ART initiation in a rural district of Mozambique. J Int AIDS Soc 2021; 24:e25775. [PMID: 34347366 PMCID: PMC8336616 DOI: 10.1002/jia2.25775] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 06/02/2021] [Accepted: 07/05/2021] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION AIDS-mortality remains unacceptably high in sub-Saharan Africa, largely driven by advanced HIV disease (AHD). We nested a study in an existing tuberculosis (TB) contact-tracing intervention (Xpatial-TB). The aim was to assess the burden of AHD among high-risk people living with HIV (PLHIV) identified and to evaluate the provision of the WHO-recommended package of care to this population. METHODS All PLHIV ≥14 years old identified between June and December 2018 in Manhiça District by Xpatial-TB were offered to participate in the study if ART naïve or had suboptimal ART adherence. Consenting individuals were screened for AHD. Patients with AHD (CD4 < 200 cells/μL or WHO stage 3 or 4) were offered a package of interventions in a single visit, including testing for cryptococcal antigen (CrAg) and TB-lipoarabinomannan (TB-LAM), prophylaxis and treatment for opportunistic infections, adherence support or accelerated ART initiation. We collected information on follow-up visits carried out under routine programmatic conditions for six months. RESULTS A total of 2881 adults were identified in the Xpatial TB-contact intervention. Overall, 23% (673/2881) were HIV positive, including 351 TB index (64.2%) and 322 TB contacts (13.8%). Overall, 159/673 PLHIV (24%) were ART naïve or had suboptimal ART adherence, of whom 155 (97%, 124 TB index and 31 TB-contacts) consented to the study and were screened for AHD. Seventy percent of TB index-patients (87/124) and 16% of TB contacts (5/31) had CD4 < 200 cells/µL. Four (13%) of the TB contacts had TB, giving an overall AHD prevalence among TB contacts of 29% (9/31). Serum-CrAg was positive in 4.6% (4/87) of TB-index patients and in zero TB contacts. All ART naïve TB contacts without TB initiated ART within 48 hours of HIV diagnosis. Among TB cases, ART timing was tailored to the presence of TB and cryptococcosis. Six-month mortality was 21% among TB-index cases and zero in TB contacts. CONCLUSIONS A TB contact-tracing outreach intervention identified undiagnosed HIV and AHD in TB patients and their contacts, undiagnosed cryptococcosis among TB patients, and resulted in an adequate provision of the WHO-recommended package of care in this rural Mozambican population. Same-day and accelerated ART initiation was feasible and safe in this population including among those with AHD.
Collapse
Affiliation(s)
- Santiago Izco
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
| | | | - Alexander M Jordan
- Mycotic Diseases BranchUnited States Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | - Gregory Greene
- Mycotic Diseases BranchUnited States Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | - Nteruma Catorze
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
| | | | - Juan Ignacio Garcia
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
- PhD Program in Methodology of Biomedical ResearchFaculty of MedicineUniversity of BarcelonaBarcelonaSpain
| | | | - Anna Febrer
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
| | - Aina Casellas
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
| | - Belén Saavedra
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
| | - Tom Chiller
- Mycotic Diseases BranchUnited States Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | | | - Alberto Garcia‐Basteiro
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
| | - Emilio Letang
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Department of Infectious Diseases Hospital del MarHospital del Mar Research Institute (IMIM)BarcelonaSpain
| |
Collapse
|
25
|
Baik Y, Hanrahan CF, Mmolawa L, Nonyane BAS, Albaugh NW, Lebina L, Siwelana T, Martinson N, Dowdy DW. Conditional cash transfers to incentivize tuberculosis screening: Description of a novel strategy for contact investigation in rural South Africa. Clin Infect Dis 2021; 74:957-964. [PMID: 34212181 PMCID: PMC8946721 DOI: 10.1093/cid/ciab601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Providing incentives to screen close contacts for tuberculosis (TB) is an alternative to traditional household-based contact investigation. We aimed to characterize patients and contexts for which this incentive-based strategy might be preferred. METHODS This is a secondary analysis of a cluster randomized trial of TB contact investigation in Limpopo District, South Africa, conducted between 2016-2020. Twenty-eight clinics were randomly allocated to household-based versus incentive-based contact investigation. In the incentive-based arm, index participants and contacts received transport reimbursement and incentives for TB screening and microbiological diagnosis of contacts. We estimated the absolute difference in mean number of contacts per index participant with household-based versus incentive-based contact investigation, overall and within sub-groups of index participants. RESULTS A total of 3776 contacts (1903 in the incentive-based and 1873 in the household-based arm) were referred by 2501 index participants. A higher proportion of contacts in the incentive-based than household-based arm were adults (72% vs 59%) and reported chronic TB symptoms (25% vs 16%) or ever smoking (23% vs 11%). Index participants who walked or bicycled to clinic referred 1.03 more contacts per index (95%CI:0.48-1.57) through incentive-based than household-based investigation. Index participants living with >5 household members referred 0.48 more contacts per index (95%CI:0.03-0.94) through household-based than incentive-based investigation. CONCLUSIONS Relative to household-based contact investigation, incentive-based investigation identifies contacts who appear to be at higher risk for active TB. Incentive-based investigation may be more appropriate for index participants who can easily access the clinic, whereas household-based investigation should be prioritized for patients with large households.
Collapse
Affiliation(s)
- Yeonsoo Baik
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Colleen F Hanrahan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Lesego Mmolawa
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa
| | - Bareng A S Nonyane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Nicholas W Albaugh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Limakatso Lebina
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa
| | - Tsundzukani Siwelana
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa
| | - Neil Martinson
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| |
Collapse
|
26
|
Vonasek B, Ness T, Takwoingi Y, Kay AW, van Wyk SS, Ouellette L, Marais BJ, Steingart KR, Mandalakas AM. Screening tests for active pulmonary tuberculosis in children. Cochrane Database Syst Rev 2021; 6:CD013693. [PMID: 34180536 PMCID: PMC8237391 DOI: 10.1002/14651858.cd013693.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Globally, children under 15 years represent approximately 12% of new tuberculosis cases, but 16% of the estimated 1.4 million deaths. This higher share of mortality highlights the urgent need to develop strategies to improve case detection in this age group and identify children without tuberculosis disease who should be considered for tuberculosis preventive treatment. One such strategy is systematic screening for tuberculosis in high-risk groups. OBJECTIVES To estimate the sensitivity and specificity of the presence of one or more tuberculosis symptoms, or symptom combinations; chest radiography (CXR); Xpert MTB/RIF; Xpert Ultra; and combinations of these as screening tests for detecting active pulmonary childhood tuberculosis in the following groups. - Tuberculosis contacts, including household contacts, school contacts, and other close contacts of a person with infectious tuberculosis. - Children living with HIV. - Children with pneumonia. - Other risk groups (e.g. children with a history of previous tuberculosis, malnourished children). - Children in the general population in high tuberculosis burden settings. SEARCH METHODS We searched six databases, including the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase, on 14 February 2020 without language restrictions and contacted researchers in the field. SELECTION CRITERIA Cross-sectional and cohort studies where at least 75% of children were aged under 15 years. Studies were eligible if conducted for screening rather than diagnosing tuberculosis. Reference standards were microbiological (MRS) and composite reference standard (CRS), which may incorporate symptoms and CXR. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality using QUADAS-2. We consolidated symptom screens across included studies into groups that used similar combinations of symptoms as follows: one or more of cough, fever, or poor weight gain and one or more of cough, fever, or decreased playfulness. For combination of symptoms, a positive screen was the presence of one or more than one symptom. We used a bivariate model to estimate pooled sensitivity and specificity with 95% confidence intervals (CIs) and performed analyses separately by reference standard. We assessed certainty of evidence using GRADE. MAIN RESULTS Nineteen studies assessed the following screens: one symptom (15 studies, 10,097 participants); combinations of symptoms (12 studies, 29,889 participants); CXR (10 studies, 7146 participants); and Xpert MTB/RIF (2 studies, 787 participants). Several studies assessed more than one screening test. No studies assessed Xpert Ultra. For 16 studies (84%), risk of bias for the reference standard domain was unclear owing to concern about incorporation bias. Across other quality domains, risk of bias was generally low. Symptom screen (verified by CRS) One or more of cough, fever, or poor weight gain in tuberculosis contacts (4 studies, tuberculosis prevalence 2% to 13%): pooled sensitivity was 89% (95% CI 52% to 98%; 113 participants; low-certainty evidence) and pooled specificity was 69% (95% CI 51% to 83%; 2582 participants; low-certainty evidence). Of 1000 children where 50 have pulmonary tuberculosis, 339 would be screen-positive, of whom 294 (87%) would not have pulmonary tuberculosis (false positives); 661 would be screen-negative, of whom five (1%) would have pulmonary tuberculosis (false negatives). One or more of cough, fever, or decreased playfulness in children aged under five years, inpatient or outpatient (3 studies, tuberculosis prevalence 3% to 13%): sensitivity ranged from 64% to 76% (106 participants; moderate-certainty evidence) and specificity from 37% to 77% (2339 participants; low-certainty evidence). Of 1000 children where 50 have pulmonary tuberculosis, 251 to 636 would be screen-positive, of whom 219 to 598 (87% to 94%) would not have pulmonary tuberculosis; 364 to 749 would be screen-negative, of whom 12 to 18 (2% to 3%) would have pulmonary tuberculosis. One or more of cough, fever, poor weight gain, or tuberculosis close contact (World Health Organization four-symptom screen) in children living with HIV, outpatient (2 studies, tuberculosis prevalence 3% and 8%): pooled sensitivity was 61% (95% CI 58% to 64%; 1219 screens; moderate-certainty evidence) and pooled specificity was 94% (95% CI 86% to 98%; 201,916 screens; low-certainty evidence). Of 1000 symptom screens where 50 of the screens are on children with pulmonary tuberculosis, 88 would be screen-positive, of which 57 (65%) would be on children who do not have pulmonary tuberculosis; 912 would be screen-negative, of which 19 (2%) would be on children who have pulmonary tuberculosis. CXR (verified by CRS) CXR with any abnormality in tuberculosis contacts (8 studies, tuberculosis prevalence 2% to 25%): pooled sensitivity was 87% (95% CI 75% to 93%; 232 participants; low-certainty evidence) and pooled specificity was 99% (95% CI 68% to 100%; 3281 participants; low-certainty evidence). Of 1000 children, where 50 have pulmonary tuberculosis, 63 would be screen-positive, of whom 19 (30%) would not have pulmonary tuberculosis; 937 would be screen-negative, of whom 6 (1%) would have pulmonary tuberculosis. Xpert MTB/RIF (verified by MRS) Xpert MTB/RIF, inpatient or outpatient (2 studies, tuberculosis prevalence 1% and 4%): sensitivity was 43% and 100% (16 participants; very low-certainty evidence) and specificity was 99% and 100% (771 participants; moderate-certainty evidence). Of 1000 children, where 50 have pulmonary tuberculosis, 31 to 69 would be Xpert MTB/RIF-positive, of whom 9 to 19 (28% to 29%) would not have pulmonary tuberculosis; 969 to 931 would be Xpert MTB/RIF-negative, of whom 0 to 28 (0% to 3%) would have tuberculosis. Studies often assessed more symptoms than those included in the index test and symptom definitions varied. These differences complicated data aggregation and may have influenced accuracy estimates. Both symptoms and CXR formed part of the CRS (incorporation bias), which may have led to overestimation of sensitivity and specificity. AUTHORS' CONCLUSIONS We found that in children who are tuberculosis contacts or living with HIV, screening tests using symptoms or CXR may be useful, but our review is limited by design issues with the index test and incorporation bias in the reference standard. For Xpert MTB/RIF, we found insufficient evidence regarding screening accuracy. Prospective evaluations of screening tests for tuberculosis in children will help clarify their use. In the meantime, screening strategies need to be pragmatic to address the persistent gaps in prevention and case detection that exist in resource-limited settings.
Collapse
Affiliation(s)
- Bryan Vonasek
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Department of Pediatrics, Division of Infectious Diseases, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Tara Ness
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Alexander W Kay
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine , Houston, Texas, USA
| | - Susanna S van Wyk
- Centre for Evidence-based Health Care, Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Ben J Marais
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
- Children's Hospital at Westmead, University of Sydney, Sydney, Australia
| | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Anna M Mandalakas
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine , Houston, Texas, USA
| |
Collapse
|
27
|
Velen K, Shingde RV, Ho J, Fox GJ. The effectiveness of contact investigation among contacts of tuberculosis patients: a systematic review and meta-analysis. Eur Respir J 2021; 58:13993003.00266-2021. [PMID: 34016621 DOI: 10.1183/13993003.00266-2021] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/29/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND We aimed to evaluate the effectiveness of contact investigation in comparison to passive case-detection alone and estimated the yield of co-prevalent and incident tuberculosis (TB), and latent tuberculosis infection (LTBI) among contacts of patients with TB. METHODS A systematic search was undertaken of studies published between January 1, 2011 and October 1, 2019 in the English language. The proportion of contacts diagnosed with co-prevalent TB, incident TB and/or LTBI was estimated. Evaluation of the effectiveness of contact investigation included randomised trials, while the yield of contact investigation (co-prevalent and incident TB and LTBI) was assessed in non-randomised studies. RESULTS Data were extracted from 244 studies, of which 187 studies measured the proportion of contacts diagnosed with TB disease and 135 studies measured LTBI prevalence. Individual randomised trials demonstrated that contact investigation increased TB case notification (RR 2.5 [95% CI: 2.0-3.2]), TB case detection (OR 1.34 [95% CI: 0.43-4.24]) and decreased mortality (RR 0.6 [95% CI: 0.4-0.8]) and population TB prevalence (risk ratio 0.82 [95% CI: 0.64-1.04]).The overall pooled prevalence of TB was 3.6% (95% CI: 3.3-4.0%; I2=98.9%, 181 studies). The pooled prevalence of microbiologically-confirmed TB was 3.2% (95% CI: 2.6-3.7%; I2=99.5%, 106 studies). The pooled incidence of TB was highest in the first year after exposure to index patients (2.0%, 95% CI: 1.1-3.3%; I2=96.2%, 14 studies) and substantially lower five years after exposure to index patient (0.5%, 95% CI: 0.3-0.9%; 1 study). The pooled prevalence of LTBI among contacts was 42.4% (95% CI: 38.5-46.4%; I2=99.8%, 135 studies). CONCLUSIONS AND RELEVANCE This systematic review and meta-analysis found that contact investigation was effective in high-burden settings. The higher pooled prevalence estimates of microbiologically-confirmed TB compared to previous reviews suggests newer rapid molecular diagnostics contribute to increased case detection.
Collapse
Affiliation(s)
- Kavindhran Velen
- Sydney Medical School, The University of Sydney, Sydney, Australia.,The Aurum Institute, Parktown, South Africa
| | | | - Jennifer Ho
- Woolcock Institute of Medical Research, Sydney, Australia
| | - Greg James Fox
- Sydney Medical School, The University of Sydney, Sydney, Australia.,Woolcock Institute of Medical Research, Sydney, Australia
| |
Collapse
|
28
|
Brief Report: Proportion and Predictors of Adult TB Contacts Accepting HIV Testing During an Active TB Case Finding Intervention in South Africa. J Acquir Immune Defic Syndr 2021; 85:525-529. [PMID: 33031156 DOI: 10.1097/qai.0000000000002509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Many individuals at risk for HIV may be reached through active TB case finding interventions in areas with highly prevalent co-epidemics of TB/HIV. METHODS We analyzed data from a cluster-randomized trial of 2 TB case finding strategies: facility-based screening and contact investigation of newly identified TB cases. In both arms, on-site rapid HIV testing was offered to all contacts older than 18 months who did not self-report HIV-positive status. Those who were HIV infected were referred appropriately. All contacts 15 years and older were included in this analysis. RESULTS Among 2179 contacts identified, 50% (1092) accepted HIV testing and counselling, of whom 6.3% (68) tested HIV-positive. Contacts who were unemployed [adjusted prevalence ratio (aPR) 1.14, 95% confidence interval (CI): 1.04 to 1.25], had not been to a clinic (aPR 1.09, 95% CI: 1.02 to 1.18) or HIV tested (aPR 1.25, 95% CI: 1.14 to 1.39) 6 months before, and those reporting gastrointestinal symptoms (aPR 1.22, 95% CI: 0.98 to 1.52) and genitourinary symptoms (aPR 1.30, 95% CI: 1.17 to 1.45) were significantly associated with accepting HIV testing. Women [adjusted odds ratio (aOR) 2.19, 95% CI: 1.26 to 3.81], individuals with a past history of tuberculosis (aOR 1.96, 95% CI: 0.93 to 4.14), and those not HIV tested 6 months before (aOR 2.20, 95% CI: 1.28 to 3.79) were significantly associated with testing HIV-positive. CONCLUSION Offering HIV testing in the context of active tuberculosis case finding represents an opportunity to identify a large proportion of previously undiagnosed individuals with HIV in a population that might otherwise not seek testing.
Collapse
|
29
|
Medina-Marino A, de Vos L, Bezuidenhout D, Denkinger CM, Schumacher SG, Shin SS, Stevens W, Theron G, van der Walt M, Daniels J. "I got tested at home, the help came to me": acceptability and feasibility of home-based TB testing of household contacts using portable molecular diagnostics in South Africa. Trop Med Int Health 2021; 26:343-354. [PMID: 33289194 DOI: 10.1111/tmi.13533] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The effectiveness of household contact investigations is limited by low referral uptake for clinic-based TB testing by symptomatic household contacts. We qualitatively investigated the acceptability and perceived benefits of home-based TB testing using a portable GeneXpert-I instrument (GX-I) in an urban South African township. METHODS In-depth interviews were conducted with household contacts tested and those that observed testing. Semi-structured interviews explored household contact's understanding of TB, perceptions of the GX-I device and testing procedures, confidentiality, willingness to refer others, and views on home- vs. clinic-based testing. Focus group discussions with home-based TB testing implementing staff assessed operational considerations for scale-up. Data were analysed using a constant comparison approach to qualitatively evaluate the acceptability and feasibility of home-based TB testing. RESULTS Thirty in-depth interviews and two focus group discussions were conducted. Observing one's own sputum being tested resulted in an emergent trust in home-based TB testing, the GX-I device and one's test results. Home-based TB testing was considered convenient, helped to overcome apathy towards testing and mitigated barriers to clinic-based testing. Perceptions that home-based TB testing contributes to improved household and community health resulted in an emergent theme of alleviation of health insecurities. Operational concerns regarding inadvertent disclosure of one's diagnosis to household members and time spent in people's homes were identified. CONCLUSIONS Home-based TB testing was acceptable and feasible. Individuals expressed belief in the machine by being able to witness the testing process. Though most themes mirrored qualitative studies of home-based HIV testing, the alleviation of health insecurities theme is unique to home-based TB testing. Future research must evaluate the impact of home-based TB testing on case finding yield, time-to-treatment initiation and household outcomes.
Collapse
Affiliation(s)
- Andrew Medina-Marino
- Research Unit, Foundation for Professional Development, East London, South Africa.,Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lindsey de Vos
- Research Unit, Foundation for Professional Development, East London, South Africa
| | - Dana Bezuidenhout
- Research Unit, Foundation for Professional Development, East London, South Africa
| | - Claudia M Denkinger
- Foundation for Innovative New Diagnostics, Geneva, Switzerland.,Division of Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Sanghyuk S Shin
- Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, CA, USA
| | - Wendy Stevens
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa
| | - Grant Theron
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Cape Town, South Africa
| | | | - Joseph Daniels
- Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
| |
Collapse
|
30
|
Case finding strategies under National Tuberculosis Elimination Programme (NTEP). Indian J Tuberc 2020; 67:S101-S106. [PMID: 33308653 PMCID: PMC7526527 DOI: 10.1016/j.ijtb.2020.09.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/24/2020] [Indexed: 11/23/2022]
Abstract
Case finding, an important parameter in fight against Tuberculosis (TB) has always remained a challenge despite advances in diagnostic modalities, access to health care and administrative commitment. We are still far from reaching the goals so set as per End TB Strategy and National Strategic Plan 2017–2025, and case finding is of paramount importance for achieving the said targets. This article, after identifying the obstacles faced in case finding, explores the various case finding strategies in the perspective of diagnostics, feasibility, resource utilization and current recommendations. Need for prioritization of case finding in different settings with involvement and active participation of one and all has been discussed. Role of health education in an individual, general public and health care worker in the context of case finding has been highlighted. Research areas to strengthen case finding have been enumerated. The review concludes by bringing out the need for heightened efforts for case finding in TB as the resources are significantly diverted as the world is facing the corona virus disease 2019 (COVID-19) pandemic. Early case finding and prompt treatment is very important for eliminating Tuberculosis but has always remained a challenge. Ongoing passive case finding needs to be strictly complemented with active case finding especially in vulnerable population. Efforts for case finding in TB should not be neglected despite the present corona virus disease 2019 (COVID-19) pandemic.
Collapse
|
31
|
A clinical score for identifying active tuberculosis while awaiting microbiological results: Development and validation of a multivariable prediction model in sub-Saharan Africa. PLoS Med 2020; 17:e1003420. [PMID: 33170838 PMCID: PMC7654801 DOI: 10.1371/journal.pmed.1003420] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 10/14/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In highly resource-limited settings, many clinics lack same-day microbiological testing for active tuberculosis (TB). In these contexts, risk of pretreatment loss to follow-up is high, and a simple, easy-to-use clinical risk score could be useful. METHODS AND FINDINGS We analyzed data from adults tested for TB with Xpert MTB/RIF across 28 primary health clinics in rural South Africa (between July 2016 and January 2018). We used least absolute shrinkage and selection operator regression to identify characteristics associated with Xpert-confirmed TB and converted coefficients into a simple score. We assessed discrimination using receiver operating characteristic (ROC) curves, calibration using Cox linear logistic regression, and clinical utility using decision curves. We validated the score externally in a population of adults tested for TB across 4 primary health clinics in urban Uganda (between May 2018 and December 2019). Model development was repeated de novo with the Ugandan population to compare clinical scores. The South African and Ugandan cohorts included 701 and 106 individuals who tested positive for TB, respectively, and 686 and 281 randomly selected individuals who tested negative. Compared to the Ugandan cohort, the South African cohort was older (41% versus 19% aged 45 years or older), had similar breakdown of biological sex (48% versus 50% female), and had higher HIV prevalence (45% versus 34%). The final prediction model, scored from 0 to 10, included 6 characteristics: age, sex, HIV (2 points), diabetes, number of classical TB symptoms (cough, fever, weight loss, and night sweats; 1 point each), and >14-day symptom duration. Discrimination was moderate in the derivation (c-statistic = 0.82, 95% CI = 0.81 to 0.82) and validation (c-statistic = 0.75, 95% CI = 0.69 to 0.80) populations. A patient with 10% pretest probability of TB would have a posttest probability of 4% with a score of 3/10 versus 43% with a score of 7/10. The de novo Ugandan model contained similar characteristics and performed equally well. Our study may be subject to spectrum bias as we only included a random sample of people without TB from each cohort. This score is only meant to guide management while awaiting microbiological results, not intended as a community-based triage test (i.e., to identify individuals who should receive further testing). CONCLUSIONS In this study, we observed that a simple clinical risk score reasonably distinguished individuals with and without TB among those submitting sputum for diagnosis. Subject to prospective validation, this score might be useful in settings with constrained diagnostic resources where concern for pretreatment loss to follow-up is high.
Collapse
|
32
|
Kagujje M, Chilukutu L, Somwe P, Mutale J, Chiyenu K, Lumpa M, Mwanza W, Muyoyeta M. Active TB case finding in a high burden setting; comparison of community and facility-based strategies in Lusaka, Zambia. PLoS One 2020; 15:e0237931. [PMID: 32911494 PMCID: PMC7482928 DOI: 10.1371/journal.pone.0237931] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 08/03/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION We conducted an implementation science study to increase TB case detection through a combination of interventions at health facility and community levels. We determined the impact of the study in terms of additional cases detected and notification rate and compared the yield of bacteriologically confirmed TB of facility based and community based case finding. METHODOLOGY Over a period of 18 months, similar case finding activities were conducted at George health facility in Lusaka Zambia and its catchment community, an informal peri-urban settlement. Activities included awareness and demand creation activities, TB screening with digital chest x-ray or symptom screening, sputum evaluation using geneXpert MTB/RIF, TB diagnosis and linkage to treatment. RESULTS A total of 18,194 individuals were screened of which 9,846 (54.1%) were screened at the facility and 8,348 (45.9%) were screened in the community. The total number of TB cases diagnosed during the intervention period were 1,026, compared to 759 in the pre-intervention period; an additional 267 TB cases were diagnosed. Of the 563 bacteriologically confirmed TB cases diagnosed under the study, 515/563 (91.5%) and 48/563 (8.5%) were identified at the facility and in the community respectively (P<0.0001). The TB notification rate increased from 246 per 100,000 population pre-intervention to 395 per 100,000 population in the last year of the intervention. CONCLUSIONS Facility active case finding was more effective in detecting TB cases than community active case finding. Strengthening health systems to appropriately identify and evaluate patients for TB needs to be optimised in high burden settings. At a minimum, provider initiated TB symptom screening with completion of the TB screening and diagnostic cascade should be provided at the health facility in high burden settings. Community screening needs to be systematic and targeted at high risk groups and communities with access barriers.
Collapse
Affiliation(s)
- Mary Kagujje
- Tuberculosis Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- * E-mail:
| | - Lophina Chilukutu
- Tuberculosis Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Paul Somwe
- Strategic Information Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Jacob Mutale
- Strategic Information Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Kanema Chiyenu
- Strategic Information Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Mwansa Lumpa
- Strategic Information Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Winfrida Mwanza
- Tuberculosis Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Monde Muyoyeta
- Tuberculosis Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| |
Collapse
|
33
|
Brennan A, Maskew M, Larson BA, Tsikhutsu I, Bii M, Vezi L, Fox M, Venter WDF, Ehrenkranz PD, Rosen S. Prevalence of TB symptoms, diagnosis and treatment among people living with HIV (PLHIV) not on ART presenting at outpatient clinics in South Africa and Kenya: baseline results from a clinical trial. BMJ Open 2020; 10:e035794. [PMID: 32895266 PMCID: PMC7476481 DOI: 10.1136/bmjopen-2019-035794] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE We used screening data and routine clinic records for intervention arm patients in the Simplified Algorithm for Treatment Eligibility (SLATE) trials to describe the prevalence of tuberculosis (TB) symptoms, diagnosis and treatment among people living with HIV (PLHIV), not on antiretroviral therapy (ART) and presenting at outpatient clinics in South Africa and Kenya. We compared the performance of the WHO four-symptom TB screening tool with a baseline Xpert test. SETTING Outpatient HIV clinics in South Africa and Kenya. PARTICIPANTS Eligible patients were non-pregnant, PLHIV, >18 years of age, not on ART, willing to provide written informed consent. A total of 594 patients in South Africa and 240 in Kenya were eligible. RESULTS Prevalence of any TB symptom was 38% in Kenya, 35% (SLATE I) and 47% (SLATE II) in South Africa. During SLATE I, 70% of patients in Kenya and 57% in South Africa with ≥1 TB symptom were tested for TB. In SLATE II, 79% of patients with ≥1 TB symptom were tested. Of those, 19% tested positive for TB in Kenya, 15% (SLATE I) and 5% (SLATE II) tested positive in South Africa. Of the 28 patients who tested positive in both trials, 20 initiated TB treatment. The lowest median CD4 counts were among those with active TB (Kenya 124 cells/mm3; South Africa 193 cells/mm3). When comparing the WHO four-symptom screening tool to the Xpert test (SLATE II), we found that increasing the number of symptoms required for a positive screen from one to three or four decreased sensitivity but increased the positive predictive value to >30%. CONCLUSIONS 80% of patients assessed for ART initiation presented with ≥1 TB symptoms. Reconsideration of the 'any symptom' rule may be appropriate, with ART initiation among patients with fewer/milder symptoms commencing while TB test results are pending. TRIAL REGISTRATION NUMBER NCT02891135 and NCT03315013.
Collapse
Affiliation(s)
- Alana Brennan
- Departments of Epidemiology, Boston University, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University, Boston, Massachusetts, USA
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bruce A Larson
- Department of Global Health, Boston University, Boston, Massachusetts, USA
| | - Isaac Tsikhutsu
- Kenya Medical Research Institute, Nairobi, Kenya
- Henry M. Jackson Foundation Medical Research International, Inc, Nairobi, Kenya
| | - Margaret Bii
- Kenya Medical Research Institute, Nairobi, Kenya
- Henry M. Jackson Foundation Medical Research International, Inc, Nairobi, Kenya
| | - Lungisile Vezi
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew Fox
- Departments of Epidemiology, Boston University, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University, Boston, Massachusetts, USA
| | | | | | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University, Boston, Massachusetts, USA
| |
Collapse
|
34
|
Ross AM, Zerden LDS, Ruth BJ, Zelnick J, Cederbaum J. Contact Tracing: An Opportunity for Social Work to Lead. SOCIAL WORK IN PUBLIC HEALTH 2020; 35:533-545. [PMID: 32781912 DOI: 10.1080/19371918.2020.1806170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Since the novel coronavirus disease (COVID-19) first emerged in December 2019, there have been unprecedented efforts worldwide to contain and mitigate the rapid spread of the virus through evidence-based public health measures. As a component of pandemic response in the United States, efforts to develop, launch, and scale-up contact tracing initiatives are rapidly expanding, yet the presence of social work is noticeably absent. In this paper, we identify the specialized skill set necessary for high quality contact tracing in the COVID-19 era and explore its alignment with social work competencies and skills. Described are current examples of contact tracing efforts, and an argument for greater social work leadership, based on the profession's ethics, competencies and person-in-environment orientation is offered. In light of the dire need for widespread high-quality contact tracing, social work is well-positioned to participate in interprofessional efforts to design, oversee and manage highly effective front-line contact tracing efforts.
Collapse
Affiliation(s)
- Abigail M Ross
- Graduate School of Social Service, Fordham University , New York, New York, USA
| | - Lisa De Saxe Zerden
- School of Social Work-Chapel Hill, University of North Carolina , Chapel Hill, North Carolina, USA
| | - Betty J Ruth
- School of Social Work, Boston University , Boston, Massachusetts, USA
| | - Jennifer Zelnick
- Graduate School of Social Work, Touro College , New York, New York, USA
| | - Julie Cederbaum
- Suzanne Dworak-Peck School of Social Work, University of Southern California , Los Angeles, California, USA
| |
Collapse
|
35
|
Erlinger S, Stracker N, Hanrahan C, Nonyane B, Mmolawa L, Tampi R, Tucker A, West N, Lebina L, Martinson N, Dowdy D. Tuberculosis patients with higher levels of poverty face equal or greater costs of illness. Int J Tuberc Lung Dis 2019; 23:1205-1212. [PMID: 31718757 PMCID: PMC6890494 DOI: 10.5588/ijtld.18.0814] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
SETTING: Fifty-six public clinics in Limpopo Province, South Africa.OBJECTIVE: To evaluate the association between tuberculosis (TB) patient costs and poverty as measured by a multidimensional poverty index.DESIGN: We performed cross-sectional interviews of consecutive patients with TB. TB episode costs were estimated from self-reported income, travel costs, and care-seeking time. Poverty was assessed using the South African Multidimensional Poverty Index (SAMPI) deprivation score (a 12-item household-level index), with higher scores indicating greater poverty. We used multivariable linear regression to adjust for age, sex, human immunodeficiency virus status and travel time.RESULTS: Among 323 participants, 108 (33%) were 'deprived' (deprivation score >0.33). For each 0.1-unit increase in deprivation score, absolute TB episode costs were 1.11 times greater (95%CI 0.97-1.26). TB episode costs were 1.19 times greater with each quintile of higher deprivation score (95%CI 1.00-1.40), but lower by a factor of 0.54 with each quintile of lower self-reported income (higher poverty, 95%CI 0.46-0.62).CONCLUSION: Individuals experiencing multidimensional poverty and the cost of tuberculosis illness in Limpopo, South Africa faced equal or higher costs of TB than non-impoverished patients. Individuals with lower self-reported income experienced higher costs as a proportion of household income but lower absolute costs. Targeted interventions are needed to reduce the economic burden of TB on patients with multidimensional poverty.
Collapse
Affiliation(s)
- S. Erlinger
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.
| | - N. Stracker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.
| | - C. Hanrahan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.
| | - B.A.S. Nonyane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.
| | - L. Mmolawa
- Perinatal HIV Research Unit (PHRU), Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, South Africa. Johns Hopkins University Center for TB Research, Baltimore, MD
| | - R. Tampi
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.
| | - A. Tucker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.
| | - N. West
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.
| | - L. Lebina
- Perinatal HIV Research Unit (PHRU), Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, South Africa. Johns Hopkins University Center for TB Research, Baltimore, MD
| | - N.A. Martinson
- Perinatal HIV Research Unit (PHRU), Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, South Africa. Johns Hopkins University Center for TB Research, Baltimore, MD
| | - D. Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.
| |
Collapse
|
36
|
Hatherill M, Chaisson RE, Denkinger CM. Addressing critical needs in the fight to end tuberculosis with innovative tools and strategies. PLoS Med 2019; 16:e1002795. [PMID: 31039150 PMCID: PMC6490887 DOI: 10.1371/journal.pmed.1002795] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
This month in PLOS Medicine we launched a Special Issue on New Tools and Strategies for Tuberculosis Diagnosis, Care, and Elimination. In this issue's Editorial, the Guest Editors Claudia Denkinger, Richard Chaisson, and Mark Hatherill highlight some of the research that will publish and how these studies focusing on discovery, clinical trials and implementation research collectively add to the prospects for reaching the EndTB targets of the WHO by 2035.
Collapse
Affiliation(s)
- Mark Hatherill
- South African Tuberculosis Vaccine Initiative (SATVI), University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Richard E. Chaisson
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Claudia M. Denkinger
- Center of Infectious Diseases, University of Heidelberg, Heidelberg, Germany
- FIND, Geneva, Switzerland
| |
Collapse
|