Concordance of programmatic and laboratory-based multidrug-resistant tuberculosis treatment outcomes in Peru

Concordance of three approaches for operationalizing outcome definitions for multidrug-resistant TB

BACKGROUND: The WHO provides standardized outcome definitions for rifampicin-resistant (RR) and multidrug-resistant (MDR) TB. However, operationalizing these definitions can be challenging in some clinical settings, and incorrect classification may generate bias in reporting and research. Outcomes calculated by algorithms can increase standardization and be adapted to suit the research question. We evaluated concordance between clinician-assigned treatment outcomes and outcomes calculated based on one of two standardized algorithms, one which identified failure at its earliest possible recurrence (i.e., failure-dominant algorithm), and one which calculated the outcome based on culture results at the end of treatment, regardless of early occurrence of failure (i.e., success-dominant algorithm).METHODS: Among 2,525 patients enrolled in the multi-country endTB observational study, we calculated the frequencies of concordance using cross-tabulations of clinician-assigned and algorithm-assigned outcomes. We summarized the common discrepancies.RESULTS: Treatment success calculated by algorithms had high concordance with treatment success assigned by clinicians (95.8 and 97.7% for failure-dominant and success-dominant algorithms, respectively). The frequency and pattern of the most common discrepancies varied by country.CONCLUSION: High concordance was found between clinician-assigned and algorithm-assigned outcomes. Heterogeneity in discrepancies across settings suggests that using algorithms to calculate outcomes may minimize bias.

Improving outcomes for multi-drug-resistant tuberculosis in the Peruvian Amazon - a qualitative study exploring the experiences and perceptions of patients and healthcare professionals

BACKGROUND

Management for multi-drug-resistant tuberculosis (MDR-TB) is challenging and has poor patient outcomes. Peru has a high burden of MDR-TB. The Loreto region in the Peruvian Amazon is worst affected for reasons including high rates of poverty and poor healthcare access. Current evidence identifies factors that influence MDR-TB medication adherence, but there is limited understanding of the patient and healthcare professional (HCP) perspective, the HCP-patient relationship and other factors that influence outcomes. A qualitative investigation was conducted to explore and compare the experiences and perceptions of MDR-TB patients and their dedicated HCPs to inform future management strategies.

METHOD

Twenty-six, semi-structured in-depth interviews were conducted with 15 MDR-TB patients and 11 HCPs who were purposively recruited from 4 of the worst affected districts of Iquitos (capital of the Loreto region). Field notes and transcripts of the two groups were analysed separately using thematic content analysis. Ethics approval was received from the Institutional Research Ethics Committee, Department of Health, Loreto, and the University of Birmingham Internal Research Ethics Committee.

RESULTS

Four key themes influencing patient outcomes emerged in each participant group: personal patient factors, external factors, clinical factors, and the HCP-patient relationship. Personal factors included high standard patient and population knowledge and education, which can facilitate engagement with treatment by encouraging belief in evidence-based medicine, dispelling belief in natural medicines, health myths and stigma. External factors included the adverse effect of the financial impact of MDR-TB on patients and their families. An open, trusting and strong HCP-patient relationship emerged as a vitally important clinical factor influencing of patient outcomes. The results also provide valuable insight into the dynamic of the relationship and ways in which a good relationship can be fostered.

CONCLUSIONS

This study highlights the importance of financial support for patients, effective MDR-TB education and the role of the HCP-patient relationship. These findings add to the existing evidence base and provide insight into care improvements and policy changes that could improve outcomes if prioritised by local and national government.

Santa Clara de Nanay: the MAL-ED cohort in Peru

The Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) cohort study communities in Peru are located in Loreto province, in a rural area 15 km from the city of Iquitos. This riverine population of approximately 5000 individuals is fairly representative of Loreto. The province lags behind the rest of the country in access to water and sanitation, per capita income, and key health indicators including infant mortality (43.0 vs 16.0 per 1000 nationwide) and under-5 mortality (60.6 vs 21.0 per 1000). Total fertility rates are higher than elsewhere in the country (4.3 vs 2.6). Nationwide, the prevalence of human immunodeficiency virus is estimated at 0.45%, the prevalence of tuberculosis is 117 per 100 000, and the incidence of malaria is 258 per 100 000. Stunting in this community is high, whereas acute undernutrition is relatively uncommon. The population suffers from high rates of diarrheal disease. Prevalent enteric pathogens include Ascaris, Giardia, enterotoxigenic Escherichia coli, Shigella, and Campylobacter.