1
|
Lemaire JF, Cohn J, Kakayeva S, Tchounga B, Ekouévi PF, Ilunga VK, Ochieng Yara D, Lanje S, Bhamu Y, Haule L, Namubiru M, Nyamundaya T, Berset M, de Souza M, Machekano R, Casenghi M. Improving TB detection among children in routine clinical care through intensified case finding in facility-based child health entry points and decentralized management: A before-and-after study in Nine Sub-Saharan African Countries. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002865. [PMID: 38315700 PMCID: PMC10843113 DOI: 10.1371/journal.pgph.0002865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/03/2024] [Indexed: 02/07/2024]
Abstract
In 2022, an estimated 1.25 million children <15 years of age developed tuberculosis (TB) worldwide, but >50% remained undiagnosed or unreported. WHO recently recommended integrated and decentralized models of care as an approach to improve access to TB services for children, but evidence remains limited. The Catalyzing Paediatric TB Innovation project (CaP-TB) implemented a multi-pronged intervention to improve TB case finding in children in nine sub-Saharan African countries. The intervention introduced systematic TB screening in different facility-based child-health entry-points, decentralisation of TB diagnosis and management, improved sample collection with access to Xpert® MTB/RIF or MTB/RIF Ultra testing, and implementation of contact investigation. Pre-intervention records were compared with those during intervention to assess effect on paediatric TB cascade of care. The intervention screened 1 991 401 children <15 years of age for TB across 144 health care facilities. The monthly paediatric TB case detection rate increased significantly during intervention versus pre-intervention (+46.0%, 95% CI 36.2-55.8%; p<0.0001), with variability across countries. The increase was greater in the <5 years old compared to the 5-14 years old (+53.4%, 95% CI 35.2-71.9%; p<0.0001 versus +39.9%, 95% CI 27.6-52.2%; p<0.0001). Relative contribution of lower-tier facilities to total case detection rate increased from 37% (71.8/191.8) pre-intervention to 50% (139.9/280.2) during intervention. The majority (89.5%) of children with TB were identified through facility-based intensified case-finding and primarily accessed care through outpatient and inpatient departments. In this multi-country study implemented under real-life conditions, the implementation of integrated and decentralized interventions increased paediatric TB case detection. The increase was driven by lower-tier facilities that serve as the primary point of healthcare contact for most patients. The effect was greater in children < 5 years compared to 5-14 years old, representing an important achievement as the TB detection gap is higher in this subpopulation. (Study number NCT03948698).
Collapse
Affiliation(s)
| | - Jennifer Cohn
- Division of Infectious Diseases, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Shirin Kakayeva
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia, United States of America
| | - Boris Tchounga
- Elizabeth Glaser Pediatric AIDS Foundation, Yaounde, Cameroon
| | | | - Vicky Kambaji Ilunga
- Elizabeth Glaser Pediatric AIDS Foundation, Kinshasa, République Démocratique du Congo
| | | | - Samson Lanje
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - Yusuf Bhamu
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Leo Haule
- Elizabeth Glaser Pediatric AIDS Foundation, Dar es Salaam, Tanzania
| | - Mary Namubiru
- Elizabeth Glaser Pediatric AIDS Foundation, Kampala, Uganda
| | | | - Maude Berset
- Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland
| | | | - Rhoderick Machekano
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia, United States of America
| | | | | |
Collapse
|
2
|
Babo Y, Seremolo B, Bogale M, Bedru A, Wabe Y, Churako H, Bilat A, Degaga T, de Haas P, Tiemersma E, Jerene D. Comparison of Xpert MTB/RIF Ultra Results of Stool and Sputum in Children with Presumptive Tuberculosis in Southern Ethiopia. Trop Med Infect Dis 2023; 8:350. [PMID: 37505646 PMCID: PMC10384425 DOI: 10.3390/tropicalmed8070350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 07/29/2023] Open
Abstract
The introduction of stool as a readily obtainable sample and the recently developed simple one-step (SOS) stool processing method on Xpert MTB/RIF Ultra (Xpert Ultra) offer an opportunity for TB diagnosis in children. We conducted this study in secondary health facilities in Ethiopia, which are the first-level referral facilities for childhood TB diagnosis and treatment, with the aim to determine if stool-based TB diagnosis can be performed with a reasonable level of concordance with sputum tests using Xpert MTB/RIF Ultra. Eligible children 0-14 years old with presumptive pulmonary TB were asked to provide stools in addition to routinely requested sputum samples. We determined the level of agreement between the stool and sputum test results. Of the 373 children included in the study, 61% were <5 years of age and 56% were male. Thirty-six children (9.7%) were diagnosed with TB, and all started treatment. The rate of concordance between stool and sputum was high, with a kappa value of 0.83 (p < 0.001). There were more Xpert Ultra positive results on stool (n = 27 (7.2%)) than on sputum/NGA (n = 23 (6.2%)). Laboratories in secondary hospitals can perform stool-based TB diagnosis in children, with high concordance between stool and sputum test results reaffirming the applicability of the SOS stool method.
Collapse
Affiliation(s)
- Yohannes Babo
- KNCV Tuberculosis Foundation, P.O. Box 703 Code 1110, Addis Ababa, Ethiopia
| | - Bihil Seremolo
- KNCV Tuberculosis Foundation, P.O. Box 703 Code 1110, Addis Ababa, Ethiopia
| | - Mamush Bogale
- KNCV Tuberculosis Foundation, P.O. Box 703 Code 1110, Addis Ababa, Ethiopia
| | - Ahmed Bedru
- KNCV Tuberculosis Foundation, P.O. Box 703 Code 1110, Addis Ababa, Ethiopia
| | - Yasin Wabe
- Worabe Comprehensive Specialized Hospital, Worabe, Ethiopia
| | - Haba Churako
- Wolaita Sodo University Hospital, Wolaita, Ethiopia
| | - Alemu Bilat
- Nigist Eleni Memorial Comprehensive Specialized Hospital, Hossana, Ethiopia
| | - Tamiru Degaga
- College of Medicine & Health Sciences, Arba Minch University, Arbaminch, Ethiopia
| | - Petra de Haas
- KNCV Tuberculosis Foundation, Maanweg 174, 2516 AB The Hague, The Netherlands
| | - Edine Tiemersma
- KNCV Tuberculosis Foundation, Maanweg 174, 2516 AB The Hague, The Netherlands
| | - Degu Jerene
- KNCV Tuberculosis Foundation, Maanweg 174, 2516 AB The Hague, The Netherlands
| |
Collapse
|
3
|
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
|
4
|
Engel N, Ochodo EA, Karanja PW, Schmidt BM, Janssen R, Steingart KR, Oliver S. Rapid molecular tests for tuberculosis and tuberculosis drug resistance: a qualitative evidence synthesis of recipient and provider views. Cochrane Database Syst Rev 2022; 4:CD014877. [PMID: 35470432 PMCID: PMC9038447 DOI: 10.1002/14651858.cd014877.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Programmes that introduce rapid molecular tests for tuberculosis and tuberculosis drug resistance aim to bring tests closer to the community, and thereby cut delay in diagnosis, ensure early treatment, and improve health outcomes, as well as overcome problems with poor laboratory infrastructure and inadequately trained personnel. Yet, diagnostic technologies only have an impact if they are put to use in a correct and timely manner. Views of the intended beneficiaries are important in uptake of diagnostics, and their effective use also depends on those implementing testing programmes, including providers, laboratory professionals, and staff in health ministries. Otherwise, there is a risk these technologies will not fit their intended use and setting, cannot be made to work and scale up, and are not used by, or not accessible to, those in need. OBJECTIVES To synthesize end-user and professional user perspectives and experiences with low-complexity nucleic acid amplification tests (NAATs) for detection of tuberculosis and tuberculosis drug resistance; and to identify implications for effective implementation and health equity. SEARCH METHODS We searched MEDLINE, Embase, CINAHL, PsycInfo and Science Citation Index Expanded databases for eligible studies from 1 January 2007 up to 20 October 2021. We limited all searches to 2007 onward because the development of Xpert MTB/RIF, the first rapid molecular test in this review, was completed in 2009. SELECTION CRITERIA We included studies that used qualitative methods for data collection and analysis, and were focused on perspectives and experiences of users and potential users of low-complexity NAATs to diagnose tuberculosis and drug-resistant tuberculosis. NAATs included Xpert MTB/RIF, Xpert MTB/RIF Ultra, Xpert MTB/XDR, and the Truenat assays. Users were people with presumptive or confirmed tuberculosis and drug-resistant tuberculosis (including multidrug-resistant (MDR-TB)) and their caregivers, healthcare providers, laboratory technicians and managers, and programme officers and staff; and were from any type of health facility and setting globally. MDR-TB is tuberculosis caused by resistance to at least rifampicin and isoniazid, the two most effective first-line drugs used to treat tuberculosis. DATA COLLECTION AND ANALYSIS We used a thematic analysis approach for data extraction and synthesis, and assessed confidence in the findings using GRADE CERQual approach. We developed a conceptual framework to illustrate how the findings relate. MAIN RESULTS We found 32 studies. All studies were conducted in low- and middle-income countries. Twenty-seven studies were conducted in high-tuberculosis burden countries and 21 studies in high-MDR-TB burden countries. Only one study was from an Eastern European country. While the studies covered a diverse use of low-complexity NAATs, in only a minority of studies was it used as the initial diagnostic test for all people with presumptive tuberculosis. We identified 18 review findings and grouped them into three overarching categories. Critical aspects users value People with tuberculosis valued reaching diagnostic closure with an accurate diagnosis, avoiding diagnostic delays, and keeping diagnostic-associated cost low. Similarly, healthcare providers valued aspects of accuracy and the resulting confidence in low-complexity NAAT results, rapid turnaround times, and keeping cost to people seeking a diagnosis low. In addition, providers valued diversity of sample types (for example, gastric aspirate specimens and stool in children) and drug resistance information. Laboratory professionals appreciated the improved ease of use, ergonomics, and biosafety of low-complexity NAATs compared to sputum microscopy, and increased staff satisfaction. Challenges reported to realizing those values People with tuberculosis and healthcare workers were reluctant to test for tuberculosis (including MDR-TB) due to fears, stigma, or cost concerns. Thus, low-complexity NAAT testing is not implemented with sufficient support or discretion to overcome barriers that are common to other approaches to testing for tuberculosis. Delays were reported at many steps of the diagnostic pathway owing to poor sample quality; difficulties with transporting specimens; lack of sufficient resources; maintenance of low-complexity NAATs; increased workload; inefficient work and patient flows; over-reliance on low-complexity NAAT results in lieu of clinical judgement; and lack of data-driven and inclusive implementation processes. These challenges were reported to lead to underutilization. Concerns for access and equity The reported concerns included sustainable funding and maintenance and equitable use of resources to access low-complexity NAATs, as well as conflicts of interest between donors and people implementing the tests. Also, lengthy diagnostic delays, underutilization of low-complexity NAATs, lack of tuberculosis diagnostic facilities in the community, and too many eligibility restrictions hampered access to prompt and accurate testing and treatment. This was particularly the case for vulnerable groups, such as children, people with MDR-TB, or people with limited ability to pay. We had high confidence in most of our findings. AUTHORS' CONCLUSIONS Low-complexity diagnostics have been presented as a solution to overcome deficiencies in laboratory infrastructure and lack of skilled professionals. This review indicates this is misleading. The lack of infrastructure and human resources undermine the added value new diagnostics of low complexity have for recipients and providers. We had high confidence in the evidence contributing to these review findings. Implementation of new diagnostic technologies, like those considered in this review, will need to tackle the challenges identified in this review including weak infrastructure and systems, and insufficient data on ground level realities prior and during implementation, as well as problems of conflicts of interest in order to ensure equitable use of resources.
Collapse
Affiliation(s)
- Nora Engel
- Department of Health, Ethics & Society, School of Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, Netherlands
| | - Eleanor A Ochodo
- Centre for Evidence-based Health Care, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Bey-Marrié Schmidt
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Ricky Janssen
- Department of Health, Ethics & Society, School of Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, Netherlands
| | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sandy Oliver
- EPPI-Centre, Social Science Research Unit, UCL Institute of Education, University College London, London, UK
- Africa Centre for Evidence, Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa
| |
Collapse
|
5
|
Zawedde-Muyanja S, Reuter A, Tovar MA, Hussain H, Loando Mboyo A, Detjen AK, Yuen CM. Provision of Decentralized TB Care Services: A Detect-Treat-Prevent Strategy for Children and Adolescents Affected by TB. Pathogens 2021; 10:1568. [PMID: 34959523 PMCID: PMC8705395 DOI: 10.3390/pathogens10121568] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 11/16/2022] Open
Abstract
In this review, we discuss considerations and successful models for providing decentralized diagnosis, treatment, and prevention services for children and adolescents. Key approaches to building decentralized capacity for childhood TB diagnosis in primary care facilities include provider training and increased access to child-focused diagnostic tools and techniques. Treatment of TB disease should be managed close to where patients live; pediatric formulations of both first- and second-line drugs should be widely available; and any hospitalization should be for as brief a period as medically indicated. TB preventive treatment for child and adolescent contacts must be greatly expanded, which will require home visits to identify contacts, building capacity to rule out TB, and adoption of shorter preventive regimens. Decentralization of TB services should involve the private sector, with collaborations outside the TB program in order to reach children and adolescents where they first enter the health care system. The impact of decentralization will be maximized if programs are family-centered and designed around responding to the needs of children and adolescents affected by TB, as well as their families.
Collapse
Affiliation(s)
- Stella Zawedde-Muyanja
- The Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala P.O. Box 22418, Uganda
| | - Anja Reuter
- Médecins Sans Frontières, Cape Town 7784, South Africa;
| | - Marco A. Tovar
- Socios En Salud Sucursal Perú, Lima 15001, Peru;
- Faculty of Health Sciences, Universidad Peruana de Ciencias Aplicadas, Lima 15067, Peru
| | - Hamidah Hussain
- Interactive Research and Development Global, Singapore 238884, Singapore;
| | - Aime Loando Mboyo
- Elizabeth Glaser Pediatric AIDS Foundation, Kinshasa B.P. 1002030, Democratic Republic of the Congo;
| | - Anne K. Detjen
- United Nations Children’s Fund, New York, NY 10017, USA;
| | - Courtney M. Yuen
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA;
| |
Collapse
|