Pre-treatment loss to follow-up in tuberculosis patients in low- and lower-middle-income countries and high-burden countries: a systematic review and meta-analysis

A methodological review of patient healthcare-seeking journeys from symptom onset to receipt of care

BACKGROUND

For many diseases, early diagnosis and treatment are more cost-effective, reduce community spread of infectious diseases and result in better patient outcomes. However, healthcare-seeking and diagnoses for several diseases are unnecessarily delayed. For example, in 2022, 3 million and 5.6 million people living with tuberculosis (TB) and HIV, respectively, were undiagnosed. Many patients never access appropriate testing, remain undiagnosed after testing or drop out shortly after treatment initiation. This underscores challenges in accessing healthcare for many individuals. Understanding healthcare-seeking obstacles can expose bottlenecks in healthcare delivery and promote equity of access. We aimed to synthesise methodologies used to portray healthcare-seeking trajectories and provide a conceptual framework for patient journey analyses.

DESIGN/METHODS

We conducted a literature search using keywords related to "patient/care healthcare-seeking/journey/pathway analysis" AND "TB" OR "infectious/pulmonary diseases" in PubMed, CINAHL, Web of Science and Global Health (OVID). From a preliminary scoping search and expert consultation, we developed a conceptual framework and honed the key data points necessary to understand patients' healthcare-seeking journeys, which then served as our inclusion criteria for the subsequent expanded review. Retained papers included at least three of these data points.

RESULTS

Our conceptual framework included five data points and seven related indicators that contribute to understanding patients' experiences during healthcare-seeking. We retained 66 studies that met our eligibility criteria. Most studies (56.3%) were in Central and Southeast Asia, explored TB healthcare-seeking experiences (76.6%), were quantitative (67.2%), used in-depth, semistructured or structured questionnaires for data collection (73.4%). Healthcare-seeking journeys were explored, measured and portrayed in different ways, with no consistency in included information.

CONCLUSIONS

We synthesised various methodologies in exploring patient healthcare-seeking journeys and found crucial data points necessary to understand challenges patients encounter when interacting with health systems and offer insights to researchers and healthcare practitioners. Our framework proposes a standardised approach to patient journey research.

Tuberculosis

Tuberculosis is a leading cause of death globally. Given the airborne transmission of tuberculosis, anybody can be infected, but people in high-incidence settings are more exposed. Risk of progression to disease is higher in the first years after infection, and in people with undernourishment, immunosuppression, or who smoke, drink alcohol, or have diabetes. Although cough, fever, and weight loss are hallmark symptoms, people with tuberculosis can be asymptomatic, so a high index of suspicion is required. Prompt diagnosis can be made by sputum examination (ideally with rapid molecular tests), but chest radiography can be helpful. Most people with disease can be treated with regimens of 6 months or less; longer regimens may be necessary for those with drug resistance. Central to successful treatment is comprehensive, person-centred care including addressing key determinants, such as undernourishment, smoking, and alcohol use, and optimising management of comorbidities, such as diabetes and HIV. Care should continue after treatment ends, as long-term sequelae are common. Prevention relies mostly on treatment with rifamycin-based regimens; current vaccines have limited efficacy. Ongoing research on shorter and safer regimens for infection and disease treatment, and simpler and more accurate diagnostic methods will be key for tuberculosis elimination.

Effects of conditional cash transfers and pre-test and post-test tuberculosis counselling on patient outcomes and loss to follow-up across the continuum of care in South Africa: a randomised controlled trial

BACKGROUND

Economic and behavioural factors lead to poor outcomes in patients with tuberculosis. We investigated the effects of a package of interventions consisting of pre-test and post-test tuberculosis counselling with conditional cash transfers on patient outcomes in adults undergoing investigation for pulmonary tuberculosis.

METHODS

This pragmatic, open-label, individual randomised controlled trial was done in nine clinics in Johannesburg, South Africa. Participants (aged ≥18 years) undergoing investigation for tuberculosis were randomly assigned (1:1) to the intervention group or control group (standard of care) via permuted block randomisation, stratified by clinic; group assignment was concealed using opaque envelopes. The intervention group received pre-test and post-test tuberculosis counselling, and for participants diagnosed with rifampicin-susceptible tuberculosis, a digital payment (R150; approximately US$10) at treatment initiation and each monthly treatment visit. Payments were contingent on timely attendance: 14 days from initial sputum sample collection and within 7 days on either side of their scheduled monthly appointment. The primary endpoint was successful patient outcome (patients who were cured or completed treatment) or unsuccessful patient outcome (pretreatment loss-to-follow-up, on-treatment loss-to-follow-up, development of rifampicin-resistant tuberculosis while on treatment, treatment failure [ie, smear or culture positive at 5 months or later after commencing treatment], or death). The primary outcome was analysed in the modified intention-to-treat population, defined as all randomly assigned participants with rifampicin-susceptible tuberculosis confirmed before the commencement of tuberculosis treatment. Weighted outcome prevalence, relative risks (RRs), and risk differences were calculated using a multivariable Poisson model with robust standard errors. This trial is registered with the Pan African Clinical Trials Registry (PACTR202410708311054) and is completed.

FINDINGS

Between Oct 25, 2018, and Dec 9, 2019, 4110 participants were enrolled and randomly assigned, 2059 to the intervention group and 2051 to the control group. 381 (9·3%) participants had microbiologically confirmed rifampicin-susceptible pulmonary tuberculosis (195 [9·5%] of 2059 in the intervention group vs 186 [9·1%] of 2051 in the control group; median age 37 years [IQR 30 to 45], 257 [67·5%] male, 124 [32·5%] female). At study closure, primary outcome data were available for 128 (65·6%) of 195 participants in the intervention group and 139 (74·7%) of 186 participants in the control group. 105 (82·0%) of 128 participants in the intervention group and 93 (66·9%) of 139 participants in the control group had a successful patient outcome; 23 (18·0%) of 128 participants in the intervention group and 46 (33·1%) of 139 participants in the control group had an unsuccessful patient outcome. The weighted regression analysis showed a substantial reduction in the risk of unsuccessful patient outcomes in the intervention group compared with the control group (weighted prevalence 15·9% vs 28·6%; RR in weighted population 0·52, 95% CI 0·33 to 0·82; risk difference in weighted population -14·1 percentage points, 95% CI -23·3 to -4·8). Pretreatment loss to follow-up was lower in the intervention group than in the control group (unweighted population: five [3·9%] of 128 participants vs 22 [15·8%] of 139 participants; risk difference in weighted population -9·6 percentage points, 95% CI -14·9 to -4·2).

INTERPRETATION

The package of interventions consisting of pre-test and post-test tuberculosis counselling with conditional cash transfers significantly reduced the risk of unsuccessful tuberculosis patient outcomes, bringing one of the 90-90-90 targets within reach (ie, achieving 90% tuberculosis treatment success). Furthermore, reduction in pretreatment loss to follow-up is expected to reduce transmission and lower incidence of the disease over time.

FUNDING

South African Medical Research Council, UK Medical Research Council, and Newton Fund.

Pretreatment attrition after rifampicin-resistant tuberculosis diagnosis with Xpert MTB/RIF or ultra in high TB burden countries: a systematic review and meta-analysis

INTRODUCTION

The WHO endorsed the Xpert MTB/RIF (Xpert) technique since 2011 as initial test to diagnose rifampicin-resistant tuberculosis (RR-TB). No systematic review has quantified the proportion of pretreatment attrition in RR-TB patients diagnosed with Xpert in high TB burden countries.Pretreatment attrition for RR-TB represents the gap between patients diagnosed and those who effectively started anti-TB treatment regardless of the reasons (which include pretreatment mortality (death of a diagnosed RR-TB patient before starting adequate treatment) and/or pretreatment loss to follow-up (PTLFU) (drop-out of a diagnosed RR-TB patient before initiation of anti-TB treatment).

METHODS

In this systematic review and meta-analysis, we queried EMBASE, PubMed and Web of science to retrieve studies published between 2011 and 22 July 2024, that described pretreatment attrition for RR-TB using Xpert in high TB burden countries. Data on RR-TB patients who did not start treatment after diagnosis and reasons for not starting were extracted in an Excel table. A modified version of the Newcastle-Ottawa scale was used to evaluate the risk of bias among all included studies. The pooled proportion of pretreatment attrition and reasons were assessed using random-effects meta-analysis. Forest plots were generated using R software.

RESULTS

Thirty eligible studies from 21 countries were identified after full-text screening and included in the meta-analysis. Most studies used routine programme data. The pooled proportion of pretreatment attrition in included studies was 18% (95% CI: 12 to 25). PTLFU and pretreatment mortality were, respectively, reported in 10 and nine studies and explained 78% (95% CI: 51% to 92%) and 30% (95% CI: 15% to 52%) of attrition.

CONCLUSION

Pretreatment attrition was widespread, with significant heterogeneity between included studies. National TB programmes should ensure accurate data collection and reporting of pretreatment attrition to enable reliable overall control strategies.

PROSPERO REGISTRATION NUMBER

CRD42022321509.

Pre-diagnosis and pre-treatment loss to follow-up and associated factors among patients with presumed tuberculosis and those diagnosed in Uganda

BACKGROUND

Loss to follow-up (LTFU) of patients with presumed tuberculosis (TB) before completing the diagnostic process (pre-diagnosis LTFU) and before initiating treatment for those diagnosed (pre-treatment LTFU) is a challenge in the realization of the End TB Strategy. We assessed the proportion of pre-diagnosis and pre-treatment LTFU and associated factors among patients with presumed TB and those diagnosed in the selected health facilities.

METHODS

This was a retrospective cohort study involving a review of routinely collected data from presumptive, laboratory and TB treatment registers from January 2019 to December 2022. The study was conducted in three general hospitals and one lower-level health center IV in Central Uganda. We defined pre-diagnosis LTFU as failure to test for TB and obtain results within 30 days from the date of being presumed and pre-treatment LTFU as failure to initiate TB treatment within 14 days from the date of diagnosis. Modified Poisson regression was used to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) of factors associated with pre-diagnosis and pre-treatment LTFU.

RESULTS

Of the 13,064 patients with presumed TB, 39.9% were aged 25 to 44 years, and 57.1% were females. Almost a third, 28.3% (3,699/13.064) experienced pre-diagnosis LTFU and 13.7% (163/1187) did not initiate treatment within 14 days from being diagnosed. Pre-diagnosis LTFU was more likely to occur among patients aged 0-14 years (adj PR 1.1, 95% CI: 1.06,1.24), females (adj.PR=1.06, 95% CI: 1.01, 1.12) and those with no record of place of residence (adj. PR=2.7, 95% CI: 2.54, 2.93). In addition, patients with no record of phone contact were more likely to be LTFU, (adj. PR=1.1, 95% CI: 1.05, 1.17). Pre-treatment LTFU was also more likely among patients with no record of place of residence (adj PR 7.1, 95% CI: 5.13,9.85) and those with no record of phone contact (adj PR 2.2, 95% CI: 1.63,2.86). Patients presumed from the HIV clinics were 40% less likely to experience pre-treatment LTFU compared to those in the outpatient departments (adj PR 0.6, 95% CI: 0.41,0.88).

CONCLUSION

High proportions of pre-diagnosis and pre-treatment LTFU were observed in this study. This calls for urgent interventions at these time points in the TB care cascade to be able to realise the End TB Strategy.

Interventions and implementation considerations for reducing pre-treatment loss to follow-up in adults with pulmonary tuberculosis: A scoping review

Background

Tuberculosis (TB) is a leading cause of death worldwide with over 90% of reported cases occurring in low- and middle-income countries (LMICs). Pre-treatment loss to follow-up (PTLFU) is a key contributor to TB mortality and infection transmission.

Objectives

We performed a scoping review to map available evidence on interventions to reduce PTLFU in adults with pulmonary TB, identify gaps in existing knowledge, and develop a conceptual framework to guide intervention implementation.

Methods

We searched eight electronic databases up to February 6 2024, medRxiv for pre-prints, and reference lists of included studies. Two review authors independently selected studies and extracted data using a predesigned form. We analysed data descriptively, presented findings in a narrative summary and developed a conceptual framework based on the Practical, Robust Implementation, and Sustainability Model to map the factors for effective intervention implementation.

Results

We reviewed 1262 records and included 17 studies. Most studies were randomized controlled trials (8/17, 47%). Intervention barriers included stigma and inadequate resources; enablers included mobile phones and TB testing and results on the same day. We identified eight interventions that reduced PTLFU: treatment support groups; mobile notifications; community health workers; integrated HIV/TB services; Xpert MTB/RIF as the initial diagnostic test; computer-aided detection with chest radiography screening; active linkage to care; and multi-component strategies.

Conclusion

Given the variation of healthcare settings, TB programs should consider contextual factors such as user acceptability, political commitment, resources, and infrastructure before adopting an intervention. Future research should utilize qualitative study designs, be people-centred, and include social and economic factors affecting PTLFU.

Sputum and tongue swab molecular testing for the in-home diagnosis of tuberculosis in unselected household contacts: a cost and cost-effectiveness analysis

Background

Delayed and missed diagnosis are a persistent barrier to tuberculosis control, partly driven by limitations associated with sputum collection and an unmet need for decentralized testing. Household contact investigation with point-of-care testing of non-invasive specimens like tongue swabs are hitherto undescribed and may be a cost-effective solution to enable community-based active case finding.

Methods

In-home, molecular point-of-care testing was conducted using sputum and tongue specimens collected from all household contacts of confirmed tuberculosis cases. A health economic assessment was executed to estimate and compare the cost and cost-effectiveness of different in-home, point-of-care testing strategies. Incremental cost effectiveness ratios of strategies utilizing different combination testing algorithms using sputum and/or tongue swab specimens were compared.

Findings

The total implementation cost of delivering the standard of care for a 2-year period was $84 962. Strategies integrating in-home point-of-care testing ranged between $87 844 - $93 969. The cost-per-test for in-home, POC testing of sputum was the highest at $20·08 per test. Two strategies, Point-of-Care Sputum Testing and Point-of-Care Combined Sputum and Individual Tongue Swab Testing were the most cost-effective with ICERs of $543·74 and $547·29 respectively, both below a $2,760 willingness-to-pay threshold.

Interpretation

An in-home, point-of-care molecular testing strategy utilizing combination testing of tongue swabs and sputum specimens would incur an additional 10.6% program cost, compared to SOC, over a 2-year period. The increased sample yield from tongue swabs combined with immediate result notification following, in-home POC testing would increase the number of new TB cases detected and linked to care by more than 800%.

Tuberculosis treatment loss to follow-up in children exposed at home: A prospective cohort study

Background

Loss to follow-up (LTFU) from tuberculosis (TB) treatment and care is a significant public health problem. It is important to understand what drives LTFU in children - a population whose treatment and management depend on an adult caregiver - to better provide support services to families affected by TB.

Methods

We conducted a prospective cohort study of household contacts in Lima, Peru (2009-12). Using multilevel logistic regression analysis, we explored individual-level characteristics of children and their adult household members with TB disease to identify risk factors for LTFU among children initiated on treatment for TB.

Results

A total of 154 child (0-14 years) household contacts were diagnosed with TB and initiated on treatment. While most (n = 133, 86.4%) had a successful outcome, 20 (13.0%) children were LTFU. Six (30.0%) children were LTFU within three months, nine (45.0%) between five to seven months, and three (15.0%) after seven months of treatment being initiated. In univariable analysis, children with index patients above 25 years of age had decreased odds of being LTFU (odds ratio = 0.26; 95% confidence interval = 0.08-0.84) compared to children with index patients 25 years or younger.

Conclusions

In this cohort, more than 10% of children sick with TB who were exposed to the disease at home were LTFU. An integrated, family-centred TB prevention and management approach may reduce barriers to a child completing their course of TB treatment.

Uncertainty in tuberculosis clinical decision-making: An umbrella review with systematic methods and thematic analysis

Tuberculosis is a major infectious disease worldwide, but currently available diagnostics have suboptimal accuracy, particularly in patients unable to expectorate, and are often unavailable at the point-of-care in resource-limited settings. Test/treatment decision are, therefore, often made on clinical grounds. We hypothesized that contextual factors beyond disease probability may influence clinical decisions about when to test and when to treat for tuberculosis. This umbrella review aimed to identify such factors, and to develop a framework for uncertainty in tuberculosis clinical decision-making. Systematic reviews were searched in seven databases (MEDLINE, CINAHL Complete, Embase, Scopus, Cochrane, PROSPERO, Epistemonikos) using predetermined search criteria. Findings were classified as barriers and facilitators for testing or treatment decisions, and thematically analysed based on a multi-level model of uncertainty in health care. We included 27 reviews. Study designs and primary aims were heterogeneous, with seven meta-analyses and three qualitative evidence syntheses. Facilitators for decisions to test included providers' advanced professional qualification and confidence in tests results, availability of automated diagnostics with quick turnaround times. Common barriers for requesting a diagnostic test included: poor provider tuberculosis knowledge, fear of acquiring tuberculosis through respiratory sampling, scarcity of healthcare resources, and complexity of specimen collection. Facilitators for empiric treatment included patients' young age, severe sickness, and test inaccessibility. Main barriers to treatment included communication obstacles, providers' high confidence in negative test results (irrespective of negative predictive value). Multiple sources of uncertainty were identified at the patient, provider, diagnostic test, and healthcare system levels. Complex determinants of uncertainty influenced decision-making. This could result in delayed or missed diagnosis and treatment opportunities. It is important to understand the variability associated with patient-provider clinical encounters and healthcare settings, clinicians' attitudes, and experiences, as well as diagnostic test characteristics, to improve clinical practices, and allow an impactful introduction of novel diagnostics.

Community tuberculosis screening, testing and care, Uganda

Objective

To assess the effectiveness of a community-based tuberculosis and leprosy intervention in which village health teams and health workers conduct door-to-door tuberculosis screening, targeted screenings and contact tracing.

Methods

We conducted a before-and-after implementation study in Uganda to assess the effectiveness of the community tuberculosis intervention by looking at reach, outputs, adoption and effectiveness of the intervention. Campaign 1 was conducted in March 2022 and campaign 2 in September 2022. We calculated percentages of targets achieved and compared case notification rates during the intervention with corresponding quarters in the previous year. We also assessed the leprosy screening.

Findings

Over 5 days, campaign 1 screened 1 289 213 people (2.9% of the general population), of whom 179 144 (13.9%) fulfilled the presumptive tuberculosis criteria, and 4043 (2.3%) were diagnosed with bacteriologically-confirmed tuberculosis; 3710 (91.8%) individuals were linked to care. In campaign 2, 5 134 056 people (11.6% of the general population) were screened, detecting 428 444 (8.3%) presumptive tuberculosis patients and 8121 (1.9%) bacteriologically-confirmed tuberculosis patients; 5942 individuals (87.1%) were linked to care. The case notification rate increased from 48.1 to 59.5 per 100 000 population in campaign 1, with a case notification rate ratio of 1.24 (95% confidence interval, CI: 1.22-1.26). In campaign 2, the case notification rate increased from 45.0 to 71.6 per 100 000 population, with a case notification rate ratio of 1.59 (95% CI: 1.56-1.62). Of the 176 patients identified with leprosy, 137 (77.8%) initiated treatment.

Conclusion

This community tuberculosis screening initiative is effective. However, continuous monitoring and adaptations are needed to overcome context-specific implementation challenges.

New Manual Quantitative Polymerase Chain Reaction Assay Validated on Tongue Swabs Collected and Processed in Uganda Shows Sensitivity That Rivals Sputum-based Molecular Tuberculosis Diagnostics

BACKGROUND

Sputum-based testing is a barrier to increasing access to molecular diagnostics for tuberculosis (TB). Many people with TB are unable to produce sputum, and sputum processing increases assay complexity and cost. Tongue swabs are emerging as an alternative to sputum, but performance limits are uncertain.

METHODS

From June 2022 to July 2023, we enrolled 397 consecutive adults with cough >2 weeks at 2 health centers in Kampala, Uganda. We collected demographic and clinical information, sputum for TB testing (Xpert MTB/RIF Ultra and 2 liquid cultures), and tongue swabs for same-day quantitative polymerase chain reaction (qPCR) testing. We evaluated tongue swab qPCR diagnostic accuracy versus sputum TB test results, quantified TB targets per swab, assessed the impact of serial swabbing, and compared 2 swab types (Copan FLOQSWAB and Steripack spun polyester).

RESULTS

Among 397 participants, 43.1% were female, median age was 33 years, 23.5% were diagnosed with human immunodeficiency virus, and 32.0% had confirmed TB. Sputum Xpert Ultra and tongue swab qPCR results were concordant for 98.2% (95% confidence interval [CI]: 96.2-99.1) of participants. Tongue swab qPCR sensitivity was 92.6% (95% CI: 86.5 to 96.0) and specificity was 99.1% (95% CI: 96.9 to 99.8) versus microbiological reference standard. A single tongue swab recovered a 7-log range of TB copies, with a decreasing recovery trend among 4 serial swabs. Swab types performed equivalently.

CONCLUSIONS

Tongue swabs are a promising alternative to sputum for molecular diagnosis of TB, with sensitivity approaching sputum-based molecular tests. Our results provide valuable insights for developing successful tongue swab-based TB diagnostics.

Pre-treatment loss to follow-up in adults with pulmonary TB in Kenya

SETTING

County referral hospital in western Kenya.

OBJECTIVES

To ascertain the proportion of pre-treatment loss to follow-up (PTLFU) and associated patient factors in adults with pulmonary TB (PTB) in western Kenya.

DESIGN

A retrospective data review of laboratory and treatment registers for adults with bacteriologically confirmed PTB between January 2018 to December 2021. We defined PTLFU as failure to initiate treatment within 14 days of diagnosis. We used multivariable logistic regression modelling to identify patient factors associated with PTLFU.

RESULTS

Of 476 patients with PTB, 67.2% were male; the mean age was 36.1 years; 37.0% were HIV-positive; 5.7% had a history of anti-TB treatment; 40.6% were not traceable in the treatment register; 202 (42.4%, 95% CI 38.1-46.9) experienced PTLFU. Age ≥55 years (aOR 2.6, 95% CI 1.0-6.7) and providing only an address (aOR 34.2, 95% CI 18.7-62.5) or only a telephone contact number (aOR 22.3, 95% CI 3.5-141.1) were associated with PTLFU. Sex, HIV status, history of anti-TB treatment and place of residence were not associated with PTLFU.

CONCLUSION

PTLFU contributes markedly to TB patient losses in western Kenya. Strengthening systems for documenting patient information and actively monitoring PTLFU are crucial for attrition reduction.

Sustained high fatality during TB therapy amid rapid decline in TB mortality at population level: A retrospective cohort and ecological analysis from Shiselweni, Eswatini

OBJECTIVES

Despite declining TB notifications in Southern Africa, TB-related deaths remain high. We describe patient- and population-level trends in TB-related deaths in Eswatini over a period of 11 years.

METHODS

Patient-level (retrospective cohort, from 2009 to 2019) and population-level (ecological analysis, 2009-2017) predictors and rates of TB-related deaths were analysed in HIV-negative and HIV-coinfected first-line TB treatment cases and the population of the Shiselweni region. Patient-level TB treatment data, and population and HIV prevalence estimates were combined to obtain stratified annual mortality rates. Multivariable Poisson regressions models were fitted to identify patient-level and population-level predictors of deaths.

RESULTS

Of 11,883 TB treatment cases, 1302 (11.0%) patients died during treatment: 210/2798 (7.5%) HIV-negative patients, 984/8443 (11.7%) people living with HIV (PLHIV), and 108/642 (16.8%) patients with unknown HIV-status. The treatment case fatality ratio remained above 10% in most years. At patient-level, fatality risk was higher in PLHIV (aRR 1.74, 1.51-2.02), and for older age and extra-pulmonary TB irrespective of HIV-status. For PLHIV, fatality risk was higher for TB retreatment cases (aRR 1.38, 1.18-1.61) and patients without antiretroviral therapy (aRR 1.70, 1.47-1.97). It decreases with increasing higher CD4 strata and the programmatic availability of TB-LAM testing (aRR 0.65, 0.35-0.90). At population-level, mortality rates decreased 6.4-fold (-147/100,000 population) between 2009 (174/100,000) and 2017 (27/100,000), coinciding with a decline in TB treatment cases (2785 in 2009 to 497 in 2017). Although the absolute decline in mortality rates was most pronounced in PLHIV (-826/100,000 vs. HIV-negative: -23/100,000), the relative population-level mortality risk remained higher in PLHIV (aRR 4.68, 3.25-6.72) compared to the HIV-negative population.

CONCLUSIONS

TB-related mortality rapidly decreased at population-level and most pronounced in PLHIV. However, case fatality among TB treatment cases remained high. Further strategies to reduce active TB disease and introduce improved TB therapies are warranted.

The Impact of Preventive Treatment for Multidrug- and Rifampin-Resistant Tuberculosis Exceeds Trial-Based Estimates

BACKGROUND

Several clinical trials of tuberculosis preventive treatment (TPT) for household contacts of patients with multidrug- or rifampin-resistant tuberculosis (MDR/RR-TB) are nearing completion. The potential benefits of delivering TPT to MDR/RR-TB contacts extend beyond the outcomes that clinical trials can measure.

METHODS

We developed an agent-based, household-structured TB and MDR/RR-TB transmission model, calibrated to an illustrative setting in India. We simulated contact investigation in households of patients with MDR/RR-TB, comparing an MDR/RR-TPT regimen (assuming 6-month duration, 70% efficacy) and associated active case finding against alternatives of contact investigation without TPT or no household intervention. We simulated the TB and MDR/RR-TB incidence averted relative to placebo over 2 years, as measurable by a typical trial, as well as the incidence averted over a longer time horizon, in the broader population, and relative to no contact investigation.

RESULTS

Observing TPT and placebo recipients for 2 years as in a typical trial, MDR/RR-TPT was measured to prevent 72% (interquartile range, 45%-100%) of incident MDR/RR-TB among recipients; the median number needed to treat (NNT) to prevent 1 MDR/RR-TB case was 73, compared to placebo. This NNT decreased to 54 with 13-18 years of observation, to 27 when downstream transmission effects were also considered, and to 12 when the effects of active TB screening were included by comparing to a no-household-contact-intervention scenario.

CONCLUSIONS

If forthcoming trial results demonstrate efficacy, the long-term population impact of TPT for MDR/RR-TB-including the large effect of increased active TB detection among MDR/RR-TB contacts-could be much greater than suggested by trial outcomes alone.

Reducing Initial Loss to Follow-up Among People With Bacteriologically Confirmed Tuberculosis: LINKEDin, a Quasi-experimental Study in South Africa

Every person diagnosed with tuberculosis (TB) needs to initiate treatment. The World Health Organization estimated that 61% of people who developed TB in 2021 were included in a TB treatment registration system. Initial loss to follow-up (ILTFU) is the loss of persons to care between diagnosis and treatment initiation/registration. LINKEDin, a quasi-experimental study, evaluated the effect of 2 interventions (hospital recording and an alert-and-response patient management intervention) in 6 subdistricts across 3 high-TB burden provinces of South Africa. Using integrated electronic reports, we identified all persons diagnosed with TB (Xpert MTB/RIF positive) in the hospital and at primary health care facilities. We prospectively determined linkage to care at 30 days after TB diagnosis. We calculated the risk of ILTFU during the baseline and intervention periods and the relative risk reduction in ILTFU between these periods. We found a relative reduction in ILTFU of 42.4% (95% CI, 28.5%-53.7%) in KwaZulu Natal (KZN) and 22.3% (95% CI, 13.3%-30.4%) in the Western Cape (WC), with no significant change in Gauteng. In KZN and the WC, the relative reduction in ILTFU appeared greater in subdistricts where the alert-and-response patient management intervention was implemented (KZN: 49.3%; 95% CI, 32.4%-62%; vs 32.2%; 95% CI, 5.4%-51.4%; and WC: 34.2%; 95% CI, 20.9%-45.3%; vs 13.4%; 95% CI, 0.7%-24.4%). We reported a notable reduction in ILTFU in 2 provinces using existing routine health service data and applying a simple intervention to trace and recall those not linked to care. TB programs need to consider ILTFU a priority and develop interventions specific to their context to ensure improved linkage to care.

Factors contributing to pre-treatment loss to follow-up in adults with pulmonary tuberculosis: a qualitative evidence synthesis of patient and healthcare worker perspectives

BACKGROUND

Since 2018, over 14 million people have been treated for tuberculosis (TB) globally. However, pre-treatment loss to follow-up (PTLFU) has been shown to contribute substantially to patient losses in the TB care cascade with subsequent high community transmission and mortality rates.

OBJECTIVE

To identify, appraise, and synthesise evidence on the perspectives of patients and healthcare workers on factors contributing to PTLFU in adults with pulmonary TB.

METHODS

We registered the title with PROSPERO (CRD42021253212). We searched nine relevant databases up to 24 May 2021 for qualitative studies. Two review authors independently reviewed records for eligibility and extracted data. We assessed methodological quality with the Evidence for Policy and Practice Information Centre tool and synthesised data using the Supporting the Use of Research Evidence framework. We assessed confidence in our findings using Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual).

RESULTS

We reviewed a total of 1239 records and included five studies, all from low- and middle-income countries. Key themes reported by patients and healthcare workers were communication challenges among healthcare workers and between healthcare workers and patients; knowledge, attitudes, and behaviours about TB and its management; accessibility and availability of facilities for TB care; and human resource and financial constraints, weakness in management and leadership in TB programmes. Patients' change of residence, long waiting times, and poor referral systems were additional factors that contributed to patients disengaging from care. We had moderate confidence in most of our findings.

CONCLUSION

Findings from our qualitative evidence synthesis highlight multiple factors that contribute to PTLFU. Central to addressing these factors will be the need to strengthen health systems and offer people-centred care.

Health worker views on pre-treatment loss to follow-up in adults with pulmonary TB in Western Kenya

SETTING

County referral hospital in Western Kenya.

OBJECTIVES

To explore factors contributing to pre-treatment loss to follow-up (PTLFU) in adults with pulmonary TB and propose solutions to address PTLFU from healthcare worker (HCW) perspectives.

DESIGN

This was an exploratory qualitative study using thematic analysis.

RESULTS

We conducted 19 key informant interviews with HCWs representing laboratory, clinical care, management and the community. Participant age ranged from 26 to 62 years; 14 (74%) were females; and most (74%) had worked in TB care for ⩽5 years. They reported that patients experienced stigma and had misconceptions about TB that contributed to PTLFU. HCWs were hesitant to work in the TB clinic, which contributed to suboptimal patient care, leading to PTLFU. Unclear linkage between laboratory and clinician, and limited financial resources to track patients were among the healthcare system factors that led to PTLFU. HCWs suggested having proper patient preparation, assigning resources to track patients and holding regular interdisciplinary meetings as practical solutions to address PTLFU.

CONCLUSION

HCWs reported multiple factors that may influence PTLFU and recommended various solutions to address these. Knowledge of TB management, patient preparation, resources to track patients and multidisciplinary meetings will be central to addressing PTLFU.

New manual qPCR assay validated on tongue swabs collected and processed in Uganda shows sensitivity that rivals sputum-based molecular TB diagnostics

Background

Reliance on sputum-based testing is a key barrier to increasing access to molecular diagnostics for tuberculosis (TB). Many people with TB are unable to produce and sputum processing increases the complexity and cost of molecular assays. Tongue swabs are emerging as an alternative to sputum, but performance limits are uncertain.

Methods

From June 2022 to July 2023, we enrolled 397 consecutive adults with cough >2 weeks at two health centers in Kampala, Uganda. We collected routine demographic and clinical information, sputum for routine TB testing (one Xpert MTB/RIF Ultra® and two liquid cultures), and up to four tongue swabs for same-day qPCR. We evaluated tongue swab qPCR diagnostic accuracy in reference to sputum TB test results, quantified TB targets per swab, assessed the impact of serial swabbing, and compared two swab types (Copan FLOQSWAB® and Steripack® spun polyester swabs).

Results

Among 397 participants, 43.1% were female, median age was 33 years, 23.5% were living with HIV (PLHIV) and 32.3% had confirmed TB. Sputum Xpert Ultra and tongue swab qPCR results were concordant for 98.2% [96.2-99.1] of participants. Tongue swab qPCR sensitivity was 91.0% [84.6-94.9] and specificity 98.9% [96.2-99.8] vs. microbiological reference standard (MRS). A single tongue swab recovered a seven-log range of TB copies, with a decreasing recovery trend among four serial swabs. We found no difference between swab types.

Conclusions

Tongue swabs show promise as an alternative to sputum for TB diagnosis, with sensitivity approaching sputum-based molecular tests. Our results provide valuable insights for developing successful tongue swab-based TB diagnostics.

An mHealth App (eSkinHealth) for Detecting and Managing Skin Diseases in Resource-Limited Settings: Mixed Methods Pilot Study

BACKGROUND

In sub-Saharan Africa, the disease burden from skin diseases, including skin-related neglected tropical diseases (skin NTDs), is extremely high. These diseases often are overlooked due to limited access to health care stemming from, for example, remote geographical locations and a lack of experts. To address these gaps, we developed a mobile health app, eSkinHealth, which is a field-adapted platform to serve as a portable electronic patient chart and for teledermatology.

OBJECTIVE

The purpose of the study is to evaluate the usability and effectiveness of the app in rural Côte d'Ivoire for diagnosing and managing skin NTDs and other skin diseases.

METHODS

A 2-arm trial with local health care providers and patients with skin diseases was implemented over a 3-month period. The providers were assigned to an intervention receiving the eSkinHealth app or control with usual care. Four nurses and 8 community health care workers participated in each arm. The training was provided on the use of the app to the intervention arm only, while both arms were trained on skin diseases. For the usability study, we evaluated our approach with the System Usability Scale (SUS) and in-depth interviews. For the effectiveness study, our primary outcome was to evaluate the detection and management of 5 skin NTDs as our targeted diseases, namely, Buruli ulcer, leprosy, lymphatic filariasis, scabies, and yaws, using the eSkinHealth app. Procedures of our methods were reviewed and approved by the institutional review board of the Ministry of Health and by Tulane University.

RESULTS

The mean age of our participants (providers) was 40.5 and 42.5 years for the intervention and control arms, respectively, and all were male (n=24). The average SUS scores taken from the intervention arm at baseline, the midpoint (6 weeks), and the end of study (12 weeks) were 72.3 (SD 11.5), 72.3 (SD 12.4), and 86.3 (SD 10.8), respectively. All participants interviewed, including 4 dermatologists and program managers, were satisfied with the app. Especially community health care workers felt empowered by being equipped with the tool. A total of 79 cases of skin NTDs were reported in the intervention arm as compared to 17 cases in the control arm (P=.002). Besides the skin NTDs, more skin diseases and conditions were reported from the control than from the intervention arm (P<.001). However, 100 cases (66%) were not given any particular diagnosis in the control arm and were documented only as a "dermatosis." In the intervention arm, 151 cases (72.9%) were diagnosed within the eSkinHealth platform, and the remaining were diagnosed on-site by dermatologists.

CONCLUSIONS

The study provided evidence for the usability and effectiveness of the eSkinHealth app embedded into our surveillance approach to improve the detection and management of skin NTDs and other skin diseases in Côte d'Ivoire and, furthermore, is expected to contribute to knowledge on mobile health approaches in the control of skin diseases in resource-limited settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05300399; https://clinicaltrials.gov/ct2/show/NCT05300399.

"Together against Tuberculosis": Cascade of Care of Patients Referred by the Private Health Care Providers in the Kyrgyz Republic

Until 2021, in the Kyrgyz Republic, tuberculosis (TB) was diagnosed and treated only in the public sector. With funding support of the STOP-TB partnership, the private providers in four regions of the country and Bishkek city were mapped, trained and incentivized to screen for and identify presumptive TB patients and refer them to the public facilities for diagnosis and treatment. In this study, we describe the cascade of care of such patients. This was a cohort study involving secondary analysis of routine data. Of 79,352 patients screened during February 2021-March 2022, 2511 (3%) had presumptive TB, of whom 903 (36%) were not tested for TB [pre-diagnostic loss to follow-up]. A total of 323 (13%) patients were diagnosed with TB, of whom, 42 (13%) were not started on treatment [pre-treatment loss to follow-up]. Among 257 patients eligible for outcome assessment, 197 (77%) had treatment success, 29 (11%) were lost-to-follow-up, 13 (5%) died, 4 (2%) had treatment failure and 14 (5%) were not evaluated. While this donor-funded, pioneering initiative was successful in engaging the private sector, we recommend that the national TB programme scales up the initiative nationally with dedicated budgets, activities and plans to monitor progress. Qualitative research is urgently needed to understand the reasons for the gaps in the care cascade.

Under-Reporting of Tuberculosis Disease among Children and Adolescents in Low and Middle-Income Countries: A Systematic Review

Under-reporting of tuberculosis (TB) disease in children and adolescents is a significant global concern, as many children are missing from TB notification data. A systematic literature review was conducted to understand the global reporting gap of child and adolescent TB as well as current interventions to close this gap in Low- and Middle- Income Countries (LMIC). Our study found large and variable gaps in child and adolescent TB reporting, due to various factors. Interventions to close this gap exist but are limited. Future studies are necessary to improve global surveillance systems to improve TB care delivery for children and adolescents.

Economic evaluation of a community health worker model for tuberculosis care in Ho Chi Minh City, Viet Nam: a mixed-methods Social Return on Investment Analysis

BACKGROUND

There is extensive evidence for the cost-effectiveness of programmatic and additional tuberculosis (TB) interventions, but no studies have employed the social return on investment (SROI) methodology. We conducted a SROI analysis to measure the benefits of a community health worker (CHW) model for active TB case finding and patient-centered care.

METHODS

This mixed-method study took place alongside a TB intervention implemented in Ho Chi Minh City, Viet Nam, between October-2017 - September-2019. The valuation encompassed beneficiary, health system and societal perspectives over a 5-year time-horizon. We conducted a rapid literature review, two focus group discussions and 14 in-depth interviews to identify and validate pertinent stakeholders and material value drivers. We compiled quantitative data from the TB program's and the intervention's surveillance systems, ecological databases, scientific publications, project accounts and 11 beneficiary surveys. We mapped, quantified and monetized value drivers to derive a crude financial benefit, which was adjusted for four counterfactuals. We calculated a SROI based on the net present value (NPV) of benefits and investments using a discounted cash flow model with a discount rate of 3.5%. A scenario analysis assessed SROI at varying discount rates of 0-10%.

RESULTS

The mathematical model yielded NPVs of US$235,511 in investments and US$8,497,183 in benefits. This suggested a return of US$36.08 for each dollar invested, ranging from US$31.66-US39.00 for varying discount rate scenarios.

CONCLUSIONS

The evaluated CHW-based TB intervention generated substantial individual and societal benefits. The SROI methodology may be an alternative for the economic evaluation of healthcare interventions.

Factors associated with loss to follow-up before and after treatment initiation among patients with tuberculosis: A 5-year observation in China

Background

Loss to follow-up (LTFU) is a significant barrier to the completion of anti-tuberculosis (TB) treatment and a major predictor of TB-associated deaths. Currently, research on LTFU-related factors in China is both scarce and inconsistent.

Methods

We collected information from the TB observation database of the National Clinical Research Center for Infectious Diseases. The data of all patients who were documented as LTFU were assessed retrospectively and compared with those of patients who were not LTFU. Descriptive epidemiology and multivariable logistic regression analyses were conducted to identify the factors associated with LTFU.

Results

A total of 24,265 TB patients were included in the analysis. Of them, 3,046 were categorized as LTFU, including 678 who were lost before treatment initiation and 2,368 who were lost afterwards. The previous history of TB was independently associated with LTFU before treatment initiation. Having medical insurance, chronic hepatitis or cirrhosis, and providing an alternative contact were independent predictive factors for LTFU after treatment initiation.

Conclusion

Loss to follow-up is frequent in the management of patients with TB and can be predicted using patients' treatment history, clinical characteristics, and socioeconomic factors. Our research illustrates the importance of early assessment and intervention after diagnosis. Targeted measures can improve patient engagement and ultimately treatment adherence, leading to better health outcomes and disease control.

Use of light-emitting diode fluorescence microscopy to detect acid-fast bacilli in sputum as proficient alternative tool in the diagnosis of pulmonary tuberculosis in countries with limited resource settings

Background

Despite recent advances in the development of more sensitive technologies for the diagnosis of tuberculosis (TB), in resource-limited settings, the diagnosis continues to rely on sputum smear microscopy. This is because smear microscopy is simple, cost-efficient and the most accessible tool for the diagnosis of TB. Our study evaluated the performance of light-emitting diode fluorescence microscopy (LED-FM) using auramine/rhodamine (auramine) and the fluorescein di-acetate (FDA) vital stain in the diagnostic of pulmonary TB in Bamako, Mali.

Methods

Sputum smear microscopy was conducted using the FDA and auramine/rhodamine staining procedures on fresh samples using LED-FM to evaluate the Mycobacterium TB (MTB) metabolic activity and to predict contagiousness. Mycobacterial culture assay was utilized as a gold standard method.

Results

Out of 1401 TB suspected patients, 1354 (96.65%) were retrieved from database, which were MTB complex culture positive, and 47 (3.40%) were culture negative (no mycobacterial growth observed). Out of the 1354 included patients, 1343 (95.86%), were acid-fast bacillus (AFB) positive after direct FDA staining, 1352 (96.50%) AFB positive after direct Auramine, and 1354 (96.65%) AFB positive with indirect auramine after digestion and centrifugation. Overall, the FDA staining method has a sensitivity of 98.82%, while the sensitivity of Auramine with direct observation was 99.48%, and 99.56% with the indirect examination.

Conclusion

This study showed that, using fresh sputum both auramine/rhodamine and FDA are highly sensitive methods in diagnosing pulmonary TB and could be easily used in countries with limited resource settings.

A systematic review of risk factors for mortality among tuberculosis patients in South Africa

BACKGROUND

Tuberculosis (TB)-associated mortality in South Africa remains high. This review aimed to systematically assess risk factors associated with death during TB treatment in South African patients.

METHODS

We conducted a systematic review of TB research articles published between 2010 and 2018. We searched BioMed Central (BMC), PubMed®, EBSCOhost, Cochrane, and SCOPUS for publications between January 2010 and December 2018. Searches were conducted between August 2019 and October 2019. We included randomised control trials (RCTs), case control, cross sectional, retrospective, and prospective cohort studies where TB mortality was a primary endpoint and effect measure estimates were provided for risk factors for TB mortality during TB treatment. Due to heterogeneity in effect measures and risk factors evaluated, a formal meta-analysis of risk factors for TB mortality was not appropriate. A random effects meta-analysis was used to estimate case fatality ratios (CFRs) for all studies and for specific subgroups so that these could be compared. Quality assessments were performed using the Newcastle-Ottawa scale or the Cochrane Risk of Bias Tool.

RESULTS

We identified 1995 titles for screening, 24 publications met our inclusion criteria (one cross-sectional study, 2 RCTs, and 21 cohort studies). Twenty-two studies reported on adults (n = 12561) and two were restricted to children < 15 years of age (n = 696). The CFR estimated for all studies was 26.4% (CI 18.1-34.7, n = 13257 ); 37.5% (CI 24.8-50.3, n = 5149) for drug-resistant (DR) TB; 12.5% (CI 1.1-23.9, n = 1935) for drug-susceptible (DS) TB; 15.6% (CI 8.1-23.2, n = 6173) for studies in which drug susceptibility was mixed or not specified; 21.3% (CI 15.3-27.3, n = 7375) for people living with HIV/AIDS (PLHIV); 19.2% (CI 7.7-30.7, n = 1691) in HIV-negative TB patients; and 6.8% (CI 4.9-8.7, n = 696) in paediatric studies. The main risk factors associated with TB mortality were HIV infection, prior TB treatment, DR-TB, and lower body weight at TB diagnosis.

CONCLUSIONS

In South Africa, overall mortality during TB treatment remains high, people with DR-TB have an elevated risk of mortality during TB treatment and interventions to mitigate high mortality are needed. In addition, better prospective data on TB mortality are needed, especially amongst vulnerable sub-populations including young children, adolescents, pregnant women, and people with co-morbidities other than HIV. Limitations included a lack of prospective studies and RCTs and a high degree of heterogeneity in risk factors and comparator variables.

SYSTEMATIC REVIEW REGISTRATION

The systematic review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42018108622. This study was funded by the Bill and Melinda Gates Foundation (Investment ID OPP1173131) via the South African TB Think Tank.

Multicomponent strategy with decentralised molecular testing for tuberculosis in Uganda: a cost and cost-effectiveness analysis

BACKGROUND

Decentralised molecular testing for tuberculosis could reduce missed diagnoses and losses to follow-up in high-burden settings. The aim of this study was to evaluate the cost and cost-effectiveness of the Xpert Performance Evaluation for Linkage to Tuberculosis Care (XPEL-TB) study strategy, a multicomponent strategy including decentralised molecular testing for tuberculosis, in Uganda.

METHODS

We conducted a costing and cost-effectiveness analysis nested in a pragmatic cluster-randomised trial of onsite (decentralised) versus hub-and-spoke (centralised) testing for tuberculosis with Xpert MTB/RIF Ultra (Xpert) in 20 community health centres in Uganda. We collected empirical data on the cost of the XPEL-TB strategy (decentralised Xpert testing, workflow redesign, and performance feedback) and routine tuberculosis testing (onsite smear microscopy with specimen transport for centralised Xpert testing) from the health system perspective. Time-and-motion studies were performed to estimate activity-based service costs. Cost-effectiveness was assessed as the incremental cost (2019 US$) per tuberculosis diagnosis and per 14-day treatment initiation.

FINDINGS

The XPEL-TB study ran from Oct 22, 2018, to March 1, 2020. Effectiveness and cost-effectiveness outcomes were assessed from Dec 1, 2018, to Nov 30, 2019 and included 4867 women and 3139 men. On a per-test basis, the cost of decentralised ($20·46, range $17·85-25·72) and centralised ($18·20, range $16·58-24·25) Xpert testing was similar. However, decentralised testing resulted in more patients receiving appropriate Xpert testing, so the per-patient cost of decentralised testing was higher: $20·28 (range $17·68-25·48) versus $9·59 (range $7·62-14·34). The XPEL-TB strategy was estimated to cost $1332 (95% uncertainty range $763-5558) per incremental tuberculosis diagnosis and $687 ($501-1207) per incremental patient initiating tuberculosis treatment within 14 days. Cost-effectiveness was reduced in sites performing fewer than 150-250 tests annually.

INTERPRETATION

The XPEL-TB strategy facilitated higher rates of Xpert testing for tuberculosis at a similar per-test cost and modest incremental cost per tuberculosis diagnosis and treatment initiation. Decentralised Xpert testing, with appropriate implementation supports, should be scaled up to clinics with sufficient testing volume to support a single-module device.

FUNDING

The National Heart, Lung, and Blood Institute.

Missing Cases of Bacteriologically Confirmed TB/DR-TB from the National Treatment Registers in West and North Sumatra Provinces, Indonesia

This study aimed to assess the percentage of confirmed drug-sensitive (DS) TB and drug-resistant (DR) TB patients who were missing in the national treatment registration in North Sumatra and West Sumatra, where treatment services for DR-TB in North Sumatra are relatively well established compared with West Sumatra, where the system recently started. Confirmed DS/DR-TB records in the laboratory register at 40 government health facilities in 2017 and 2018 were traced to determine whether they were in the treatment register databases. A Jaro-Winkler soundexed string distance analysis enhanced by socio-demographic information matching had sensitivity and specificity over 98% in identifying the same person in the same or different databases. The laboratory data contained 5885 newly diagnosed records of bacteriologically confirmed TB cases. Of the 5885 cases, 1424 of 5353 (26.6%) DS-TB cases and 133 of 532 (25.0%) DR-TB cases were missing in the treatment notification database. The odds of missing treatment for DS-TB was similar for both provinces (AOR = 1.0 (0.9, 1.2), but for DR-TB, North Sumatra had a significantly lower missing odds ratio (AOR = 0.4 (0.2, 0.7). The system must be improved to reduce this missing rate, especially for DR-TB in West Sumatra.

The Impact of the COVID-19 Pandemic on Tuberculosis Case Notification and Treatment Outcomes in Eswatini

Objectives: We investigated the impact of COVID-19 on tuberculosis (TB) case notification and treatment outcomes in Eswatini.

Methods: A comparative retrospective cohort study was conducted using TB data from eight facilities. An interrupted time series analysis, using segmented Poisson regression was done to assess the impact of COVID-19 on TB case notification comparing period before (December 2018-February 2020, n = 1,560) and during the pandemic (March 2020–May 2021, n = 840). Case notification was defined as number of TB cases registered in the TB treatment register. Treatment outcomes was result assigned to patients at the end of treatment according to WHO rules.

Results: There was a significant decrease in TB case notification (IRR 0.71, 95% CI: 0.60–0.83) and a significant increase in death rate among registrants during the pandemic (21.3%) compared to pre-pandemic (10.8%, p < 0.01). Logistic regression indicated higher odds of unfavorable outcomes (death, lost-to-follow-up, and not evaluated) during the pandemic than pre-pandemic (aOR 2.91, 95% CI: 2.17–3.89).

Conclusion: COVID-19 negatively impacted TB services in Eswatini. Eswatini should invest in strategies to safe-guard the health system against similar pandemics.

An Evaluation of The Diagnostic Value of Sputum Smears Microscopy and Pcr Relative to Sputum Culture in The Diagnosis of Pulmonary Tuberculosis: A Systematic Review and Meta-Analysis in Iran

Background: Tuberculosis is one of the oldest known diseases in humans, and early detection of tuberculosis is one of the main measures to decrease the spread of tuberculosis. In many parts of the world, including Iran, the diagnosis of tuberculosis is based on the detection of acid-fast bacillus in sputum smear microscopy and PCR. this study aimed to synthesize evidence on the diagnostic accuracy of sputum smear and PCR compared to sputum culture for the diagnosis of PT in Iranian patients. Methods: This systematic review and meta-analysis was conducted based on PRISMA guideline for systematic review and meta-analysis. Eligible studies were cross-sectional original diagnostic studies published in English and Persian in Iran which examined the sensitivity or specificity(study outcome) of sputum smear microscopy or PCR( as the test) relative to sputum culture (as the gold standard/comparator) among Iranian patients suspected of having tuberculosis( study population). Studies whose data were not complete or extractable were excluded. Results: A total of 3518 subjects were evaluated from 15 eligible studies. The pooled sensitivity of sputum smear and PCR was 75.12 (95% CI: 66.68-83.56) and 88.02 (95% CI: 82.87-93.27), respectively. The specificity for sputum smear and PCR was 93.94 (95% CI: 91.26-96.63) and 91.82 (95% CI: 87.29-96.35) respectively. The sensitivity of both sputum smears was higher in studies published after 2010, and had higher quality. The specificity of sputum smear was a bit lower in studies published after2010 but higher in studies with higher quality. The specificity of PCR was higher in studies published after 2010 but higher in studies with higher quality. Conclusion:The increased sensitivity of sputum smear and PCR during recent years suggests the improvement of preparation and laboratory methods in recent years. However, the imperfect sensitivity of these tests highlights the need for a more accurate diagnostic method for the detection of pulmonary tuberculosis in Iran.

Undernotification and underreporting of tuberculosis in Zambia: a national data quality assessment

BACKGROUND

Despite national implementation of several high impact interventions and innovations to bolster tuberculosis (TB) detection and improve quality of TB services in Zambia, notifications have been declining since 2004. A countrywide data quality assessment (DQA) of Zambia's National TB and Leprosy Programme (NTLP) was undertaken to quantify the degree to which undernotification and underreporting of TB notifications may be occurring.

METHODS

The NTLP conducted a retrospective DQA of health facilities in high burden districts in all ten Zambian provinces. Multiple routine programmatic data sources were triangulated through a multi-step verification process to enumerate the total number of unique TB patients diagnosed between 1st January and 31st August 2019; both bacteriologically confirmed and clinically diagnosed TB patients were included. Undernotification was defined as the number of TB patients identified through the DQA that were not documented in facility treatment registers, while underreporting was defined as the number of notified TB cases not reported to the NTLP.

RESULTS

Overall, 265 health facilities across 55 districts were assessed from which 28,402 TB patients were identified; 94.5% of TB patients were ≥ 15 years old, 65.1% were male, 52.0% were HIV-positive, and 89.6% were a new/relapse case. Among all TB cases, 32.8% (95%CI: 32.2-33.3) were unnotified. Undernotification was associated with age ≥ 15 years old (adjusted prevalence odds ratio [aPOR] = 2.4 [95%CI: 2.0-2.9]), HIV-positive status (aPOR = 1.6 [95%CI: 1.5-1.8]), being a new/relapse TB case (aPOR = 17.5 [95%CI: 13.4-22.8]), being a clinically diagnosed TB case (aPOR = 4.2 [95%CI:3.8-4.6]), and being diagnosed at a hospital (range, aPOR = 1.5 [95%CI: 1.3-1.6] to 2.6 [95%CI: 2.3-2.9]). There was substantial heterogeneity in the proportion of unnotified TB cases by province (range, 18.2% to 43.6%). In a sub-analysis among 22,199 TB patients with further data available, 55.9% (95%CI: 55.2-56.6) were notified and reported to the NTLP, 32.8% (95%CI: 32.2-33.4) were unnotified, and 11.3% (95%CI: 10.9-11.7) went unreported to the NTLP.

CONCLUSIONS

The findings from Zambia's first countrywide TB programme DQA demonstrate substantial undernotification and underreporting of TB cases across all provinces. This underscores the urgent need to implement a robust and integrated data management system to facilitate timely registration and reporting of all TB patients who are diagnosed and treated.

Female Genital Tuberculosis Among Infertile Women and Its Contributions to Primary and Secondary Infertility: A systematic review and meta-analysis

Female genital tuberculosis (FGTB) is a widespread infectious disease among young women. This meta-analysis aimed to investigate the prevalence of FGTB among infertile women and its contribution to primary and secondary infertility. PubMed, MEDLINE®, WorldCat, The Lens, direct Google search, Google Scholar and ResearchGate were searched from 1971 to July 17, 2021 using the following terms: "prevalence", "epidemiology", "urogenital tuberculosis", "FGTB", "infertile women", "infertility complaints" and "FGTB testing methods". Data were extracted and a meta-analysis was performed. A total of 42 studies were selected with a total of 30,918 infertile women. Of these, the pooled prevalence of FGTB was 20% (95% confidence interval: 15-25%, I2 = 99.94%) and the prevalence of overall infertility, primary infertility and secondary infertility among FGTB population were 88%, 66% and 34%, respectively. The proportion of FGTB is remarkable among infertile women globally. The biggest burden of the disease is present in low-income countries followed by lower-to-middle- and upper-to-middle-income countries.

A synthesized model of tuberculosis transmission featuring treatment abandonment

In this paper, we propose and justify a synthesized version of the tuberculosis transmission model featuring treatment abandonment. In contrast to other models that account for the treatment abandonment, our model has only four state variables or classes (susceptible, latent, infectious, and treated), while people abandoning treatment are not gathered into an additional class. The proposed model retains the core properties that are highly desirable in epidemiological modeling. Namely, the disease transmission dynamics is characterized by the basic reproduction number $ \mathscr{R}_0 $, a threshold value that determines the number of possible steady states and their stability properties. It is shown that the disease-free equilibrium is globally asymptotically stable (GAS) only if $ \mathscr{R}_0 < 1 $, while a strictly positive endemic equilibrium exists and is GAS only if $ \mathscr{R}_0 > 1. $ Analysis of the dependence of $ \mathscr{R}_0 $ on the treatment abandonment rate shows that a reduction of the treatment abandonment rate has a positive effect on the disease incidence and results in avoiding disease-related fatalities.

An explanation of the 15-year trend and investigation of the tuberculosis cascade in Kurdistan province

Objective

This study's objectives were to describe the 15-year trend from 2005 to 2019 and examine the tuberculosis cascade in the Kurdistan province from 21 march 2018-20 march 2019.

Methods

This retrospective study was in 2744 patients with tuberculosis from 2005 to 2019 who were registered in Kurdistan disease registration centers. For the initial evaluation of demographic data, we utilized SPSS software version 20 and excel. Additionally, to design a care cascade, we utilized draw.io software for registered patients between March 21, 2018, and March 20, 2019. As a result, 2489 new cases of tuberculosis remained in our study.

Results

The results showed that the mean of age of people with tuberculosis was 58 years and sex distribution were 1441 (57.9) female and 1048 (42.1) male. Additionally, a cascade model showed that in Kurdistan Province, an estimated 112 new cases of smear-positive pulmonary tuberculosis in 2018, of which 90% (101 people) were sent to medical facilities and underwent diagnostic testing, with 80% of these patients (81 people). Infection was identified in 81 individuals, all of whom had their diagnoses recorded in the medical database. 82% (67 patients) of the patients who were enrolled in the treatment system received access to treatment, and 65 patients, or 97 percent, experienced no recurrence for at least a year after treatment. Correct diagnosis and therapy represented the biggest gap.

Conclusion

Cascade can enhance surveillance program and focus activities to better cases, diagnose, connect to care, and help TB patients survive without recurrence.

Patient and health system level barriers to and facilitators for tuberculosis treatment initiation in Uganda: a qualitative study

BACKGROUND

The WHO END TB strategy targets to place at least 90% of all patients diagnosed with Tuberculosis (TB) on appropriate treatment. In Uganda, approximately 20% of patients diagnosed with TB are not initiated on TB treatment. We sought to identify the patient and health system level barriers to and facilitators for TB treatment initiation in Uganda.

METHODS

We conducted the study at ten public health facilities (three primary care, four district and three tertiary referral hospitals). We carried out in-depth interviews with patients diagnosed with TB and key informant interviews with health managers. In addition, we held focus group discussions with healthcare workers involved in TB care. Data collection and thematic analysis of transcripts was informed by the Capability, Opportunity, Motivation and Behavior (COM-B) model. We identified relevant intervention functions using the Behavior Change Wheel.

RESULTS

We interviewed 79 respondents (31 patients, 10 health managers and 38 healthcare workers). Common barriers at the health facility level included; lack of knowledge about the proportion of patients not initiated on TB treatment (psychological capability); difficulty accessing sputum results from the laboratory as well as difficulty tracing patients due to inadequate recording of patient addresses (physical opportunity). At the patient level, notable barriers included long turnaround time for sputum results and lack of transport funds to return to health facilities (physical opportunity); limited TB knowledge (psychological capability) and stigma (social opportunity). The most important facilitators identified were quick access to sputum test results either on the date of first visit (same-day diagnosis) or on the date of first return and availability of TB treatment (physical opportunity). We identified education, restructuring of the service environment to improve sputum results turnaround time and enablement to improve communication of test results as relevant intervention functions to alleviate these barriers to and enhance facilitators for TB treatment initiation.

CONCLUSION

We found that barriers to treatment initiation existed at both the patient and health facility-level across all levels of the (Capability, Opportunity and Motivation) model. The intervention functions identified here should be tested for feasibility.

The intersecting pandemics of tuberculosis and COVID-19: population-level and patient-level impact, clinical presentation, and corrective interventions

The global tuberculosis burden remains substantial, with more than 10 million people newly ill per year. Nevertheless, tuberculosis incidence has slowly declined over the past decade, and mortality has decreased by almost a third in tandem. This positive trend was abruptly reversed by the COVID-19 pandemic, which in many parts of the world has resulted in a substantial reduction in tuberculosis testing and case notifications, with an associated increase in mortality, taking global tuberculosis control back by roughly 10 years. Here, we consider points of intersection between the tuberculosis and COVID-19 pandemics, identifying wide-ranging approaches that could be taken to reverse the devastating effects of COVID-19 on tuberculosis control. We review the impact of COVID-19 at the population level on tuberculosis case detection, morbidity and mortality, and the patient-level impact, including susceptibility to disease, clinical presentation, diagnosis, management, and prognosis. We propose strategies to reverse or mitigate the deleterious effects of COVID-19 and restore tuberculosis services. Finally, we highlight research priorities and major challenges and controversies that need to be addressed to restore and advance the global response to tuberculosis.

Increasing TB/HIV Case Notification through an Active Case-Finding Approach among Rural and Mining Communities in Northwest Tanzania

While Tanzania is among the high TB burden countries to reach the WHO's End TB 2030 milestones, 41% of the people estimated to have had TB in 2020 were not diagnosed and notified. As part of the response to close the TB treatment coverage gap, SHDEPHA+ Kahama conducted a TB REACH active case-finding (ACF) intervention among rural and mining communities in Northwest Tanzania to increase TB/HIV case notification from July 2017 to June 2020. The intervention successfully linked marginalized mining communities with integrated TB/HIV screening, diagnostic, and referral services, screening 144,707 people for TB of whom 24,200 were tested for TB and 4,478 were tested for HIV, diagnosing 1,499 people with TB and 1,273 people with HIV (including at least 154 people with TB/HIV coinfection). The intervention revealed that community-based ACF can ensure high rates of linkage to care among hard-to-reach populations for TB. Providing integrated TB and HIV screening and diagnostic services during evening hours (Moonlight Events) in and around mining settlements can yield a large number of people with undiagnosed TB and HIV. For TB, this is true not only amongst miners but also FSW living in the same communities, who appear to be at similar or equally high risk of infection. Local NGOs can help to bridge the TB treatment coverage gap and to improve TB and HIV health outcomes by linking these marginalized groups with public sector services. Capturing the number of referrals arriving at CTCs is an important next step to identify how well the integrated TB/HIV outreach services operate and how they can be strengthened.

Treatment initiation among tuberculosis patients: the role of short message service (SMS) technology and Ward-based outreach teams (WBOTs)

Background

In South Africa, tuberculosis (TB) is a public health problem with treatment initiation failure rates varying between 14.9 and 25%. Lack of proper provider/patient communication on next steps after testing, not being aware that results are ready; and other competing priorities are some of the reasons for this failure. We aimed to assess the effectiveness of Short Message Service (SMS) technology and ward-based outreach teams (WBOTs) in improving TB treatment initiation. A 3-arm randomized controlled trial (Standard of care-SOC, SMS technology or WBOTs) was conducted between September 2018 and April 2020. Newly diagnosed TB patients randomly allocated to SMS and WBOTs groups were sent reminder messages (text message or paper slip respectively) that results were ready. Due to unforeseen challenges (financial and impact of the COVID 19 pandemic), implementation was only in two of the eight clinics planned.

Results

314 TB patients were assigned to one of three groups (SOC = 104, WBOTs = 105, and SMS = 105). Chi-square tests were used to compare proportions starting treatment (primary outcome). More patients in the SMS group (92/105; 88%) initiated treatment than in the SOC group (81/104; 78%), although this difference did not reach statistical significance (P = 0.062). The time to treatment initiation was significantly shorter in the SMS group than in the SOC group (P < 0.001). The proportions of patients initiated on treatment in the WBOTs group (45/62; 73%) and in the SOC group (44/61; 72%) were similar (P = 0.956). The times to treatment initiation for these two groups were also similar. The 3 group analysis yielded similar proportions initiated on treatment (P = 0.048 for SMS/SOC comparison and P = 0.956 for WBOTs/SOC comparison) but analysis of times to treatment initiation yielded some variations.

Conclusion

Reminder SMS messages sent to newly diagnosed TB patients improved the time to treatment initiation. Further research is required to show effect of the WBOTs intervention.

Trial registration

Retrospectively registered with the Pan African Clinical Trial Registry (PACTR202101914895981).

The trial was registered with the Pan African Clinical Trial Registry on 25 January, 2021 (ref: PACTR202101914895981; https://pactr.samrc.ac.za). The registration was retrospective due to an oversight. Nevertheless, the protocol details outlined in our ethics application were strictly adhered to.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12736-6.

Feasibility of a multifaceted intervention to improve treatment initiation among patients diagnosed with TB using Xpert MTB/RIF testing in Uganda

BACKGROUND

One in five patients diagnosed with TB in Uganda are not initiated on TB treatment within two weeks of diagnosis. We evaluated a multifaceted intervention for improving TB treatment initiation among patients diagnosed with TB using Xpert® MTB/RIF testing in Uganda.

METHODS

This was a pre-post interventional study at one tertiary referral hospital. The intervention was informed by the COM-B model and included; i) medical education sessions to improve healthcare worker knowledge about the magnitude and consequences of pretreatment loss to follow-up; ii) modified laboratory request forms to improve recording of patient contact information; and iii) re-designed workflow processes to improve timeliness of sputum testing and results dissemination. TB diagnostic process and outcome data were collected and compared from the period before (June to August 2019) and after (October to December 2019) intervention initiation.

RESULTS

In September 2019, four CME sessions were held at the hospital and were attended by 58 healthcare workers. During the study period, 1242 patients were evaluated by Xpert® MTB/RIF testing at the hospital (679 pre and 557 post intervention). Median turnaround time for sputum test results improved from 12 hours (IQR 4-46) in the pre-intervention period to 4 hours (IQR 3-6) in the post-intervention period. The proportion of patients started on treatment within two weeks of diagnosis improved from 59% (40/68) to 89% (49/55) (difference 30%, 95% CI 14%-43%, p<0.01) while the proportion of patients receiving a same-day diagnosis increased from 7.4% (5/68) to 25% (14/55) (difference 17.6%, 95% CI 3.9%-32.7%, p<0.01).

CONCLUSION

The multifaceted intervention was feasible and resulted in a higher proportion of patients initiating TB treatment within two weeks of diagnosis.

Multicomponent Strategy with Decentralized Molecular Testing for Tuberculosis

BACKGROUND

Effective strategies are needed to facilitate the prompt diagnosis and treatment of tuberculosis in countries with a high burden of the disease.

METHODS

We conducted a cluster-randomized trial in which Ugandan community health centers were assigned to a multicomponent diagnostic strategy (on-site molecular testing for tuberculosis, guided restructuring of clinic workflows, and monthly feedback of quality metrics) or routine care (on-site sputum-smear microscopy and referral-based molecular testing). The primary outcome was the number of adults treated for confirmed tuberculosis within 14 days after presenting to the health center for evaluation during the 16-month intervention period. Secondary outcomes included completion of tuberculosis testing, same-day diagnosis, and same-day treatment. Outcomes were also assessed on the basis of proportions.

RESULTS

A total of 20 health centers underwent randomization, with 10 assigned to each group. Of 10,644 eligible adults (median age, 40 years) whose data were evaluated, 60.1% were women and 43.8% had human immunodeficiency virus infection. The intervention strategy led to a greater number of patients being treated for confirmed tuberculosis within 14 days after presentation (342 patients across 10 intervention health centers vs. 220 across 10 control health centers; adjusted rate ratio, 1.56; 95% confidence interval [CI], 1.21 to 2.01). More patients at intervention centers than at control centers completed tuberculosis testing (adjusted rate ratio, 1.85; 95% CI, 1.21 to 2.82), received a same-day diagnosis (adjusted rate ratio, 1.89; 95% CI, 1.39 to 2.56), and received same-day treatment for confirmed tuberculosis (adjusted rate ratio, 2.38; 95% CI, 1.57 to 3.61). Among 706 patients with confirmed tuberculosis, a higher proportion in the intervention group than in the control group were treated on the same day (adjusted rate ratio, 2.29; 95% CI, 1.23 to 4.25) or within 14 days after presentation (adjusted rate ratio, 1.22; 95% CI, 1.06 to 1.40).

CONCLUSIONS

A multicomponent diagnostic strategy that included on-site molecular testing plus implementation supports to address barriers to delivery of high-quality tuberculosis evaluation services led to greater numbers of patients being tested, receiving a diagnosis, and being treated for confirmed tuberculosis. (Funded by the National Heart, Lung, and Blood Institute; XPEL-TB ClinicalTrials.gov number, NCT03044158.).

Factors associated with loss to follow-up among TB patients in rural Papua New Guinea

BACKGROUND

Papua New Guinea (PNG) is a lower middle-income country that has struggled to contain TB. The loss of patients to follow-up is a major contributing factor towards the high disease burden.

OBJECTIVE

To describe persons with drug-susceptible TB (DS-TB) registered for treatment at the Gaubin Rural Hospital (GRH) on Karkar Island, Madang Province, PNG, and to investigate factors associated with patient loss to follow-up (LTFU).

DESIGN

A retrospective cohort study was conducted using data from GRH DS-TB registers. Factors associated with LTFU were investigated using univariable and multivariable logistic regression.

RESULTS

A total of 722 patients were registered for DS-TB treatment and eligible for inclusion between 1 January 2014 and 30 June 2018, of whom 97 (13.4%) were lost to follow-up. Male sex was associated with an increased odds of LTFU (adjusted OR [aOR] 1.9, 95% CI 1.2-3.0; P = 0.005), as was travel time to GRH >3 h (aOR 3.7, 95%, CI 2.2-6.3; P < 0.001).

CONCLUSION

A high LTFU rate has been identified in patients with TB in PNG. This study found male sex and increased travel time from treatment location to be associated with unsuccessful treatment adherence, highlighting the need for further interventions to improve adherence.

Controlling Droplet Marangoni Flows to Improve Microscopy-Based TB Diagnosis

In developing countries, the most common diagnostic method for tuberculosis (TB) is microscopic examination sputum smears. Current assessment requires time-intensive inspection across the microscope slide area, and this contributes to its poor diagnostic sensitivity of ≈50%. Spatially concentrating TB bacteria in a smaller area is one potential approach to improve visual detection and potentially increase sensitivity. We hypothesized that a combination of magnetic concentration and induced droplet Marangoni flow would spatially concentrate Mycobacterium tuberculosis on the slide surface by preferential deposition of beads and TB–bead complexes in the center of an evaporating droplet. To this end, slide substrate and droplet solvent thermal conductivities and solvent surface tension, variables known to impact microfluidic flow patterns in evaporating droplets, were varied to select the most appropriate slide surface coating. Optimization in a model system used goniometry, optical coherence tomography, and microscope images of the final deposition pattern to observe the droplet flows and maximize central deposition of 1 μm fluorescent polystyrene particles and 200 nm nanoparticles (NPs) in 2 μL droplets. Rain-X^® polysiloxane glass coating was identified as the best substrate material, with a PBS-Tween droplet solvent. The use of smaller, 200 nm magnetic NPs instead of larger 1 μm beads allowed for bright field imaging of bacteria. Using these optimized components, we compared standard smear methods to the Marangoni-based spatial concentration system, which was paired with magnetic enrichment using iron oxide NPs, isolating M. bovis BCG (BCG) from samples containing 0 and 10³ to 10⁶ bacilli/mL. Compared to standard smear preparation, paired analysis demonstrated a combined volumetric and spatial sample enrichment of 100-fold. With further refinement, this magnetic/Marangoni flow concentration approach is expected to improve whole-pathogen microscopy-based diagnosis of TB and other infectious diseases.

Linkage to TB care: A qualitative study to understand linkage from the patients' perspective in the Western Cape Province, South Africa

BACKGROUND

Delayed linkage to tuberculosis (TB) treatment leads to poor patient outcomes and increased onward transmission. Between 12% and 25% of people diagnosed with TB are never linked to a primary health care facility for continued care. The TB health program is for creating processes that promote and facilitates easy access to care. We explored how TB patients experience TB services and how this influenced their choices around linkage to TB care and treatment.

METHODS

We enrolled 20 participants routinely diagnosed with TB in hospital or at primary health care facilities (PHC) in a high TB/HIV burdened peri-urban community in South Africa. Using the Western Cape Provincial Health Data centre (PHDC) which consolidates person-level clinical data, we used dates of diagnosis and treatment initiation to select participants who had been linked (immediately, after a delay, or never). Between June 2019 and January 2020, we facilitated in-depth discussions to explore both the participants' experience of their TB diagnosis and their journey around linking to TB care at a primary health care facility. We analysed the data using case descriptions.

RESULTS

Twelve of twenty (12/20) participants interviewed who experienced a delay linking were diagnosed at the hospital. Participants who experienced delays in linking or never linked explained this as a result of lack of information and support from health care providers. Unpleasant previous TB treatment episodes made it difficult to 'face' TB again and being uncertain of their TB diagnosis. In contrast, participants said the main motivator for linking was a personal will to get better.

CONCLUSION

The health care system, especially in hospitals, should focus on strengthening patient-centred care. Communication and clear messaging on TB processes is key, to prepare patients in transitioning from a hospital setting to PHC facilities for continuation of care. This should not just include a thorough explanation of their TB diagnosis but ensure that patients understand treatment processes. Former TB patients may require additional counselling and support to re-engage in care.

Durations of asymptomatic, symptomatic, and care-seeking phases of tuberculosis disease with a Bayesian analysis of prevalence survey and notification data

BACKGROUND

Ratios of bacteriologically positive tuberculosis (TB) prevalence to notification rates are used to characterise typical durations of TB disease. However, this ignores the clinical spectrum of tuberculosis disease and potentially long infectious periods with minimal or no symptoms prior to care-seeking.

METHODS

We developed novel statistical models to estimate progression from initial bacteriological positivity including smear conversion, symptom onset and initial care-seeking. Case-detection ratios, TB incidence, durations, and other parameters were estimated by fitting the model to tuberculosis prevalence survey and notification data (one subnational and 11 national datasets) within a Bayesian framework using Markov chain Monte Carlo methods.

RESULTS

Analysis across 11 national datasets found asymptomatic tuberculosis durations in the range 4-8 months for African countries; three countries in Asia (Cambodia, Lao PDR, and Philippines) showed longer durations of > 1 year. For the six countries with relevant data, care-seeking typically began half-way between symptom onset and notification. For Kenya and Blantyre, Malawi, individual-level data were available. The sex-specific durations of asymptomatic bacteriologically-positive tuberculosis were 9.0 months (95% credible interval [CrI]: 7.2-11.2) for men and 8.1 months (95% CrI: 6.2-10.3) for women in Kenya, and 4.9 months (95% CrI: 2.6-7.9) for men and 3.5 months (95% CrI: 1.3-6.2) for women in Blantyre. Age-stratified analysis of data for Kenya showed no strong age-dependence in durations. For Blantyre, HIV-stratified analysis estimated an asymptomatic duration of 1.3 months (95% CrI: 0.3-3.0) for HIV-positive people, shorter than the 8.5 months (95% CrI: 5.0-12.7) for HIV-negative people. Additionally, case-detection ratios were higher for people living with HIV than HIV-negative people (93% vs 71%).

CONCLUSION

Asymptomatic TB disease typically lasts around 6 months. We found no evidence of age-dependence, but much shorter durations among people living with HIV, and longer durations in some Asian settings. To eradicate TB transmission, greater gains may be achieved by proactively screening people without symptoms through active case finding interventions.

Cost-effectiveness of household contact investigation for detection of tuberculosis in Pakistan

OBJECTIVES

Despite WHO guidelines recommending household contact investigation, and studies showing the impact of active screening, most tuberculosis (TB) programmes in resource-limited settings only carry out passive contact investigation. The cost of such strategies is often cited as barriers to their implementation. However, little data are available for the additional costs required to implement this strategy. We aimed to estimate the cost and cost-effectiveness of active contact investigation as compared with passive contact investigation in urban Pakistan.

METHODS

We estimated the cost-effectiveness of 'enhanced' (passive with follow-up) and 'active' (household visit) contact investigations compared with standard 'passive' contact investigation from providers and the programme's perspective using a simple decision tree. Costs were collected in Pakistan from a TB clinic performing passive contact investigation and from studies of active contact tracing interventions conducted. The effectiveness was based on the number of patients with TB identified among household contacts screened.

RESULTS

The addition of enhanced contact investigation to the existing passive mode detected 3.8 times more cases of TB per index patient compared with passive contact investigation alone. The incremental cost was US$30 per index patient, which yielded an incremental cost of US$120 per incremental patient identified with TB. The active contact investigation was 1.5 times more effective than enhanced contact investigation with an incremental cost of US$238 per incremental patient with TB identified.

CONCLUSION

Our results show that enhanced and active approaches to contact investigation effectively identify additional patients with TB among household contacts at a relatively modest cost. These strategies can be added to the passive contact investigation in a high burden setting to find the people with TB who are missed and meet the End TB strategy goals.

Who is more likely to return for TB test results? A survey at three high-burden primary healthcare facilities in Cape Town, South Africa

BACKGROUND

In low- and middle-income countries with a high burden of tuberculosis (TB), a large proportion of people who are tested for TB do not return to the health facility to collect their test results and initiate treatment, thus putting themselves at increased risk of adverse outcomes.

METHODS

This prospective study aimed to identify predictors of returning to the primary health care (PHC) facility to collect TB test results. From 15 August to 15 December 2017, 1105 people who tested for pulmonary TB at three Cape Town PHC facilities were surveyed. Using multi-variate logistic regressions on an analysis sample of 1097 people, three groups of predictors were considered: (i) demographics, health and socio-economic status; (ii) costs and benefits; and (iii) behavioural factors.

RESULTS

Forty-four percent of people tested returned to the PHC facility to collect their test results within the stipulated 2 days, and 68% returned before the end of the study period. Return was strongly and positively correlated with expecting a TB-positive result, cognitive avoidance and postponement behaviour.

CONCLUSION

Interventions to improve pre-treatment loss to follow-up should target patients who think they do not have TB, and those with a history of postponement behaviour and cognitive avoidance.

Does tuberculosis screening improve individual outcomes? A systematic review

BACKGROUND

To determine if tuberculosis (TB) screening improves patient outcomes, we conducted two systematic reviews to investigate the effect of TB screening on diagnosis, treatment outcomes, deaths (clinical review assessing 23 outcome indicators); and patient costs (economic review).

METHODS

Pubmed, EMBASE, Scopus and the Cochrane Library were searched between 1/1/1980-13/4/2020 (clinical review) and 1/1/2010-14/8/2020 (economic review). As studies were heterogeneous, data synthesis was narrative.

FINDINGS

Clinical review: of 27,270 articles, 18 (n=3 trials) were eligible. Nine involved general populations. Compared to passive case finding (PCF), studies showed lower smear grade (n=2/3) and time to diagnosis (n=2/3); higher pre-treatment losses to follow-up (screened 23% and 29% vs PCF 15% and 14%; n=2/2); and similar treatment success (range 68-81%; n=4) and case fatality (range 3-11%; n=5) in the screened group. Nine reported on risk groups. Compared to PCF, studies showed lower smear positivity among those culture-confirmed (n=3/4) and time to diagnosis (n=2/2); and similar (range 80-90%; n=2/2) treatment success in the screened group. Case fatality was lower in n=2/3 observational studies; both reported on established screening programmes. A neonatal trial and post-hoc analysis of a household contacts trial found screening was associated with lower all-cause mortality. Economic review: From 2841 articles, six observational studies were eligible. Total costs (n=6) and catastrophic cost prevalence (n=4; range screened 9-45% vs PCF 12-61%) was lower among those screened.

INTERPRETATION

We found very limited patient outcome data. Collecting and reporting this data must be prioritised to inform policy and practice.

FUNDING

WHO and EDCTP.

A qualitative study of perspectives on access to tuberculosis health services in Xigaze, China

Background

Tuberculosis (TB) is a major global health threat and the leading infectious disease cause of death worldwide. Access to and retention in TB care remains a challenge for patients, particularly those living in rural and remote settings. This qualitative study explored barriers and facilitators to accessing and maintaining contact with TB care services in communities in Xigaze (Shigatse) prefecture, Xizang Autonomous Region (Tibet Autonomous Region), China from the perspective of persons impacted by TB.

Methods

We conduced in-depth interviews with 23 participants impacted by TB in four rural districts in Xigaze prefecture, Xizang Autonomous Region, China between April 2019 and November 2020. Interviews were conducted in Tibetan and Mandarin, transcribed in Mandarin and translated into English. Transcripts were checked against recordings by native Tibetan and Mandarin speakers. QSR NVivo12 software was used for framework analysis guided by an access to care conceptual framework by Levesque et al.

Results

Overall patients reported low awareness of and an indifferent attitude towards TB, although all reported understanding the need to adhere to treatment. Participants reported complex pathways to care, often requiring visits to multiple healthcare facilities. Some participants reported visiting traditional Tibetan medicine (TTM) providers. Participants reported various barriers to accessing care including challenges physically reaching care, out-of-pocket payments for tests, diagnostics and transport. Barriers to maintaining care included medication side effects and worry about treatment effectiveness. Enablers to accessing care identified included knowledge or past experience with TB, integrated models of TTM and western care, supportive village doctors who conducted home visits, free TB treatment and other subsidies, as well as having family support with care and social support as barriers and facilitators to maintaining treatment.

Conclusions

We identified barriers and facilitators to accessing services in rural communities in Xigaze from the perspective of persons impacted by TB. Challenges include complex pathways to care, travel distances, wait times and low awareness. Tuberculosis care in the region could be strengthened by ongoing culturally tailored educational campaigns to increase awareness, partnerships with TTM providers, providing comprehensive treatment subsidies and strengthening the role of family members in comprehensive TB care.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-021-00906-4.

Early Evaluation of an Ultra-Portable X-ray System for Tuberculosis Active Case Finding

X-ray screening is an important tool in tuberculosis (TB) prevention and care, but access has historically been restricted by its immobile nature. As recent advancements have improved the portability of modern X-ray systems, this study represents an early evaluation of the safety, image quality and yield of using an ultra-portable X-ray system for active case finding (ACF). We reported operational and radiological performance characteristics and compared image quality between the ultra-portable and two reference systems. Image quality was rated by three human readers and by an artificial intelligence (AI) software. We deployed the ultra-portable X-ray alongside the reference system for community-based ACF and described TB care cascades for each system. The ultra-portable system operated within advertised specifications and radiologic tolerances, except on X-ray capture capacity, which was 58% lower than the reported maximum of 100 exposures per charge. The mean image quality rating from radiologists for the ultra-portable system was significantly lower than the reference (3.71 vs. 3.99, p < 0.001). However, we detected no significant differences in TB abnormality scores using the AI software (p = 0.571), nor in any of the steps along the TB care cascade during our ACF campaign. Despite some shortcomings, ultra-portable X-ray systems have significant potential to improve case detection and equitable access to high-quality TB care.

Tuberculosis care cascade in Zambia - identifying the gaps in order to improve outcomes: a population-based analysis

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.