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Abdullahi LH, Oketch S, Komen H, Mbithi I, Millington K, Mulupi S, Chakaya J, Zulu EM. Gendered gaps to tuberculosis prevention and care in Kenya: a political economy analysis study. BMJ Open 2024; 14:e077989. [PMID: 38569714 PMCID: PMC11146361 DOI: 10.1136/bmjopen-2023-077989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 03/14/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Tuberculosis (TB) remains a public health concern in Kenya despite the massive global efforts towards ending TB. The impediments to TB prevention and care efforts include poor health systems, resource limitations and other sociopolitical contexts that inform policy and implementation. Notably, TB cases are much higher in men than women. Therefore, the political economy analysis (PEA) study provides in-depth contexts and understanding of the gender gaps to access and successful treatment for TB infection. DESIGN PEA adopts a qualitative, in-depth approach through key informant interviews (KII) and documentary analysis. SETTING AND PARTICIPANTS The KIIs were distributed among government entities, academia, non-state actors and community TB groups from Kenya. RESULTS The themes identified were mapped onto the applied PEA analysis framework domains. The contextual and institutional issues included gender concerns related to the disconnect between TB policies and gender inclusion aspects, such as low prioritisation for TB programmes, limited use of evidence to inform decisions and poor health system structures. The broad barriers influencing the social contexts for TB programmes were social stigma and cultural norms such as traditional interventions that negatively impact health-seeking behaviours. The themes around the economic situation were poverty and unemployment, food insecurity and malnutrition. The political context centred around the systemic and governance gaps in the health system from the national and devolved health functions. CONCLUSION Broad contextual factors identified from the PEA widen the disparity in targeted gender efforts toward men. Following the development of effective TB policies and strategies, it is essential to have well-planned gendered responsive interventions with a clear implementation plan and monitoring system to enhance access to TB prevention and care.
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Affiliation(s)
- Leila H Abdullahi
- Research Department, African Institute for Development Policy, Nairobi, Kenya
| | - Sandra Oketch
- African Institute for Development Policy (AFIDEP), Nairobi, Kenya
| | - Henry Komen
- African Institute for Development Policy (AFIDEP), Nairobi, Kenya
| | | | | | | | | | - Eliya M Zulu
- African Institute for Development Policy, Nairobi, Kenya
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Wagnew F, Alene KA, Kelly M, Gray D. Impacts of body weight change on treatment outcomes in patients with multidrug-resistant tuberculosis in Northwest Ethiopia. Sci Rep 2024; 14:508. [PMID: 38177234 PMCID: PMC10767082 DOI: 10.1038/s41598-023-51026-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 12/29/2023] [Indexed: 01/06/2024] Open
Abstract
Measuring body weight during therapy has received insufficient attention in poor resource settings like Ethiopia. We aimed to investigate the association between weight change during therapy and treatment outcomes among patients with multidrug-resistant tuberculosis (MDR-TB) in northwest Ethiopia. This retrospective cohort study analysed data from patients with MDR-TB admitted between May 2015 to February 2022 at four treatment facilities in Northwest Ethiopia. We used the joint model (JM) to determine the association between weight change during therapy and treatment outcomes for patients with MDR-TB. A total of 419 patients with MDR-TB were included in the analysis. Of these, 265 (63.3%) were male, and 255 (60.9%) were undernourished. Weight increase over time was associated with a decrease in unsuccessful treatment outcomes (adjusted hazard ratio (AHR): 0.96, 95% CI: 0.94 to 0.98). In addition, patients with undernutrition (AHR: 1.72, 95% CI: 1.10 to 2.97), HIV (AHR:1.79, 95% CI: 1.04 to 3.06), and clinical complications such as pneumothorax (AHR: 1.66, 95% CI: 1.03 to 2.67) were associated with unsuccessful treatment outcomes. The JM showed a significant inverse association between weight gain and unsuccessful MDR-TB treatment outcomes. Therefore, weight gain may be used as a surrogate marker for good TB treatment response in Ethiopia.
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Affiliation(s)
- Fasil Wagnew
- College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia.
- National Centre for Epidemiology and Population Health (NCEPH), College of Health and Medicine, The Australian National University, Canberra, Australia.
- Geospatial and Tuberculosis Research Team, Telethon Kids Institute, Nedlands, WA, Australia.
| | - Kefyalew Addis Alene
- Geospatial and Tuberculosis Research Team, Telethon Kids Institute, Nedlands, WA, Australia
- School of Population Health, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
| | - Matthew Kelly
- National Centre for Epidemiology and Population Health (NCEPH), College of Health and Medicine, The Australian National University, Canberra, Australia
| | - Darren Gray
- Population Health Program, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
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Raad R, Dixon J, Gorsky M, Hoddinott G. Cycles of antibiotic use and emergent antimicrobial resistance in the South African tuberculosis programme (1950-2021): A scoping review and critical reflections on stewardship. Glob Public Health 2024; 19:2356623. [PMID: 38771831 DOI: 10.1080/17441692.2024.2356623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 05/13/2024] [Indexed: 05/23/2024]
Abstract
The emergent threat of antimicrobial resistance (AMR) has resulted in debates around the use and preservation of effective antimicrobials. Concerns around AMR reflect a history of increasing dependence on antibiotics to address disease epidemics rooted in profound structural and systemic challenges. In the context of global health, this process, often referred to as pharmaceuticalisation, has commonly occurred within disease programmes, of which lessons are vital for adding nuance to conversations around antimicrobial stewardship. Tuberculosis (TB) is a notable example. A disease which accounts for one-third of AMR globally and remains the leading cause of death from a single infectious agent in many low - and middle-income countries, including South Africa. In this scoping review, we chart TB science in South Africa over 70 years of programming. We reviewed published manuscripts about the programme and critically reflected on the implications of our findings for stewardship. We identified cycles of programmatic responses to new drug availability and the emergence of drug resistance, which intersected with cycles of pharmaceuticalisation. These cycles reflect the political, economic, and social factors influencing programmatic decision-making. Our analysis offers a starting point for research exploring these cycles and drawing out implications for stewardship across the TB and AMR communities.
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Affiliation(s)
- Rene Raad
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Justin Dixon
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
- The Health Research Institute Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Martin Gorsky
- Centre for History in Public Health, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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Lecai J, Mijiti P, Chuangyue H, Qian G, Weiguo T, Jihong C. Treatment outcomes of multidrug-resistant tuberculosis patients receiving ambulatory treatment in Shenzhen, China: a retrospective cohort study. Front Public Health 2023; 11:1134938. [PMID: 37408751 PMCID: PMC10319049 DOI: 10.3389/fpubh.2023.1134938] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 05/26/2023] [Indexed: 07/07/2023] Open
Abstract
Background WHO recommended multidrug-resistant tuberculosis (MDR-TB) should be treated mainly under ambulatory model, but outcome of ambulatory treatment of MDR-TB in China was little known. Methods The clinical data of 261 MDR-TB patients treated as outpatients in Shenzhen, China during 2010-2015 were collected and analyzed retrospectively. Results Of 261 MDR-TB patients receiving ambulatory treatment, 71.1% (186/261) achieved treatment success (cured or completed treatment), 0.4% (1/261) died during treatment, 11.5% (30/261) had treatment failure or relapse, 8.0% (21/261) were lost to follow-up, and 8.8% (23/261) were transferred out. The culture conversion rate at 6 months was 85.0%. Although 91.6% (239/261) of patients experienced at least one adverse event (AE), only 2% of AEs caused permanent discontinuation of one or more drugs. Multivariate analysis showed that previous TB treatment, regimens containing capreomycin and resistance to FQs were associated with poor outcomes, while experiencing three or more AEs was associated with good outcomes. Conclusion Good treatment success rates and early culture conversions were achieved with entirely ambulatory treatment of MDR-TB patients in Shenzhen, supporting WHO recommendations. Advantageous aspects of the local TB control program, including accessible and affordable second-line drugs, patient support, active monitoring and proper management of AEs and well-implemented DOT likely contributed to treatment success rates.
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Affiliation(s)
- Ji Lecai
- Department of Tuberculosis Control, Shenzhen Center for Chronic Disease Control, Shenzhen, China
- Department of Nephrology, Affiliated Bao'an Hospital of Shenzhen, The Second School of Clinical Medicine, Southern Medical University, Shenzhen, Guangdong, China
| | - Peierdun Mijiti
- School of Public Health, Xinjiang Medical University, Urumqi, China
| | - Hong Chuangyue
- Department of Tuberculosis Control, Shenzhen Center for Chronic Disease Control, Shenzhen, China
| | - Gao Qian
- The Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, School of Basic Medical Science, Fudan University, Shanghai, China
| | - Tan Weiguo
- Department of Tuberculosis Control, Shenzhen Center for Chronic Disease Control, Shenzhen, China
| | - Chen Jihong
- Department of Nephrology, The Second Affiliated Hospital of Shenzhen University, Shenzhen, China
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Faye LM, Hosu MC, Iruedo J, Vasaikar S, Nokoyo KA, Tsuro U, Apalata T. Treatment Outcomes and Associated Factors among Tuberculosis Patients from Selected Rural Eastern Cape Hospitals: An Ambidirectional Study. Trop Med Infect Dis 2023; 8:315. [PMID: 37368733 DOI: 10.3390/tropicalmed8060315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/27/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
An essential metric for determining the efficacy of tuberculosis (TB) control programs is the evaluation of TB treatment outcomes; this study was conducted to investigate treatment outcomes and associated factors among tuberculosis patients in rural areas of Eastern Cape, South Africa. Assessing treatment outcomes is fundamental to facilitating the End TB Strategy's set target. Clinic records from 457 patients with DR-TB were examined for data collection while 101 patients were followed up prospectively. Data were analyzed using Stata version 17.0. The odds ratio and 95% confidence interval were calculated to check the association between variables. p ≤ 0.05 was considered statistically significant. Of the 427 participants, 65.8% had successful treatment whilst 34.2% had unsuccessful TB treatment. A total of 61.2% and 39% of the HIV-positive and HIV-negative participants had a successful TB treatment whilst 66% and 34% of both HIV-negative and positive participants had unsuccessful TB treatment. From the 101 patients that were followed up, smokers took longer to have treatment outcomes compared to non-smokers. In the study with HIV/TB co-infection, men predominated. HIV and tuberculosis co-infection made therapy difficult with unfavorable effects on TB management. The treatment success rate (65.8%) was lower than the WHO threshold standard with a high proportion of patients being lost to the follow up. The co-infection of tuberculosis and HIV resulted in undesirable treatment outcomes. Strengthening TB surveillance and control is recommended.
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Affiliation(s)
- Lindiwe M Faye
- Department of Laboratory Medicine and Pathology, Walter Sisulu University and National Health Laboratory Services (NHLS), Private Bag X5117, Mthatha 5099, South Africa
| | - Mojisola C Hosu
- Department of Laboratory Medicine and Pathology, Walter Sisulu University and National Health Laboratory Services (NHLS), Private Bag X5117, Mthatha 5099, South Africa
| | - Joshua Iruedo
- Department of Family Medicine, Walter Sisulu University, Private Bag X5117, Mthatha 5099, South Africa
| | - Sandeep Vasaikar
- Department of Laboratory Medicine and Pathology, Walter Sisulu University and National Health Laboratory Services (NHLS), Private Bag X5117, Mthatha 5099, South Africa
| | - Kolisa A Nokoyo
- Wits School of Public Health, 27 St Andrew Road, Parktown, Johannesburg 2193, South Africa
| | - Urgent Tsuro
- Department of Public Health, Walter Sisulu University, Private Bag X5117, Mthatha 5099, South Africa
| | - Teke Apalata
- Department of Laboratory Medicine and Pathology, Walter Sisulu University and National Health Laboratory Services (NHLS), Private Bag X5117, Mthatha 5099, South Africa
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Ma JB, Zeng LC, Ren F, Dang LY, Luo H, Wu YQ, Yang XJ, Li R, Yang H, Xu Y. Development and validation of a prediction model for unsuccessful treatment outcomes in patients with multi-drug resistance tuberculosis. BMC Infect Dis 2023; 23:289. [PMID: 37147607 PMCID: PMC10161636 DOI: 10.1186/s12879-023-08193-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 03/23/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND The World Health Organization has reported that the treatment success rate of multi-drug resistance tuberculosis is approximately 57% globally. Although new drugs such as bedaquiline and linezolid is likely improve the treatment outcome, there are other factors associated with unsuccessful treatment outcome. The factors associated with unsuccessful treatment outcomes have been widely examined, but only a few studies have developed prediction models. We aimed to develop and validate a simple clinical prediction model for unsuccessful treatment outcomes in patients with multi-drug resistance pulmonary tuberculosis (MDR-PTB). METHODS This retrospective cohort study was performed between January 2017 and December 2019 at a special hospital in Xi'an, China. A total of 446 patients with MDR-PTB were included. Least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression were used to select prognostic factors for unsuccessful treatment outcomes. A nomogram was built based on four prognostic factors. Internal validation and leave-one-out cross-validation was used to assess the model. RESULTS Of the 446 patients with MDR-PTB, 32.9% (147/446) cases had unsuccessful treatment outcomes, and 67.1% had successful outcomes. After LASSO regression and multivariate logistic analyses, no health education, advanced age, being male, and larger extent lung involvement were identified as prognostic factors. These four prognostic factors were used to build the prediction nomograms. The area under the curve of the model was 0.757 (95%CI 0.711 to 0.804), and the concordance index (C-index) was 0.75. For the bootstrap sampling validation, the corrected C-index was 0.747. In the leave-one-out cross-validation, the C-index was 0.765. The slope of the calibration curve was 0.968, which was approximately 1.0. This indicated that the model was accurate in predicting unsuccessful treatment outcomes. CONCLUSIONS We built a predictive model and established a nomogram for unsuccessful treatment outcomes of multi-drug resistance pulmonary tuberculosis based on baseline characteristics. This predictive model showed good performance and could be used as a tool by clinicians to predict who among their patients will have an unsuccessful treatment outcome.
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Affiliation(s)
- J-B Ma
- Department of Drug-resistance tuberculosis, Xi'an Chest Hospital, Xi'an, Shaanxi Province, China
| | - L-C Zeng
- Xi'an Center for Disease Control and Prevention, Xi'an, Shaanxi Province, China
| | - F Ren
- Department of Drug-resistance tuberculosis, Xi'an Chest Hospital, Xi'an, Shaanxi Province, China.
| | - L-Y Dang
- Department of Drug-resistance tuberculosis, Xi'an Chest Hospital, Xi'an, Shaanxi Province, China
| | - H Luo
- Department of Drug-resistance tuberculosis, Xi'an Chest Hospital, Xi'an, Shaanxi Province, China
| | - Y-Q Wu
- Department of Drug-resistance tuberculosis, Xi'an Chest Hospital, Xi'an, Shaanxi Province, China
| | - X-J Yang
- Department of Drug-resistance tuberculosis, Xi'an Chest Hospital, Xi'an, Shaanxi Province, China
| | - R Li
- Department of Drug-resistance tuberculosis, Xi'an Chest Hospital, Xi'an, Shaanxi Province, China
| | - H Yang
- Department of Clinical Laboratory, Xi'an Chest Hospital, Xi'an, Shaanxi Province, China
| | - Y Xu
- Department of Drug-resistance tuberculosis, Xi'an Chest Hospital, Xi'an, Shaanxi Province, China
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Peresu E, Heunis JC, Kigozi NG, De Graeve D. Knowledge, attitudes and practices of community treatment supporters administering multidrug-resistant tuberculosis injections: A cross-sectional study in rural Eswatini. PLoS One 2022; 17:e0271362. [PMID: 35834492 PMCID: PMC9282659 DOI: 10.1371/journal.pone.0271362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/28/2022] [Indexed: 11/28/2022] Open
Abstract
Background This study assessed knowledge, attitudes and practices (KAP) of lay community treatment supporters (CTSs) delegated with directly observed treatment (DOT) supervision and administration of intramuscular multidrug-resistant tuberculosis (MDR-TB) injections in the Shiselweni region in Eswatini. Methodology A cross-sectional survey among a purposive sample of 82 CTSs providing DOT and administering injections to MDR-TB patients was conducted in May 2017. Observations in the patients’ homes were undertaken to verify CTSs’ self-reported community-based MDR-TB management practices. Results Out of 82 respondents, 78 (95.1%) were female and half (n = 41; 50.0%) had primary education or lower. Over one-tenth (n = 12; 14.6%) had not attended a MDR-TB training workshop, but were administering injections. The overall KAP scores were satisfactory. Good self-reported community-based MDR-TB practices were largely verified through observation. However, substantial proportions of respondents incorrectly defined MDR-TB, were unaware of the treatment regimen, stigmatised patients, and underreported needlestick injuries. There was no statistically significant association between duration administering intramuscular injections, MDR-TB training, knowledge and attitudes, and good community-based MDR-TB management practices. Conclusions The gaps in the current KAP of CTSs in this setting raise questions about the timing, adequacy, design and content of community-based MDR-TB management training. Nonetheless, with appropriate training, lay CTSs in this region can be an option to complement an overstretched professional health workforce in providing DOT and MDR-TB injections at community level.
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Affiliation(s)
- Ernest Peresu
- Faculty of Economic and Management Sciences, Centre for Development Support, University of the Free State, Bloemfontein, South Africa
- * E-mail:
| | - J. Christo Heunis
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa
| | - N. Gladys Kigozi
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa
| | - Diana De Graeve
- Faculty of Applied Economics, University of Antwerp, Prinsstraat, Antwerp, Belgium
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Alene KA, Murray MB, van de Water BJ, Becerra MC, Atalell KA, Nicol MP, Clements ACA. Treatment Outcomes Among Pregnant Patients With Multidrug-Resistant Tuberculosis: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2216527. [PMID: 35687333 PMCID: PMC9187956 DOI: 10.1001/jamanetworkopen.2022.16527] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
IMPORTANCE The management of multidrug-resistant tuberculosis (MDR-TB) during pregnancy is challenging, yet no systematic synthesis of evidence has accurately measured treatment outcomes. OBJECTIVE To systematically synthesize treatment outcomes and adverse events among pregnant patients with MDR-TB. DATA SOURCES PubMed, Scopus, Web of Science, and ProQuest were searched from the inception of each database through August 31, 2021. STUDY SELECTION Studies containing cohorts of pregnant patients with a defined treatment outcome were eligible. DATA EXTRACTION AND SYNTHESIS Independent reviewers screened studies and assessed the risk of bias. The study followed the Preferring Reporting Items for Systematic Review and Meta-analyses reporting guideline. Meta-analysis was performed using random-effects models. The sources of heterogeneity were explored through metaregression. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of patients with each treatment outcome (including treatment success, death, loss to follow-up, and treatment failure), and the secondary outcomes included the proportion of patients experiencing adverse events during pregnancy. RESULTS In this systematic review and meta-analysis, 10 studies containing 275 pregnant patients with available data on treatment outcomes were included. The pooled estimate was 72.5% (95% CI, 63.3%-81.0%) for treatment success, 6.8% (95% CI, 2.6%-12.4%) for death, 18.4% (95% CI, 13.1%-24.2%) for loss to follow-up, and 0.6% (95% CI, 0.0%-2.9%) for treatment failure. Treatment success was significantly higher in studies in which the proportion of patients taking linezolid was greater than the median (20.1%) compared with studies in which this proportion was lower than the median (odds ratio, 1.22; 95% CI, 1.05-1.42). More than half of the pregnant patients (54.7%; 95% CI, 43.5%-65.4%) experienced at least 1 type of adverse event, most commonly liver function impairment (30.4%; 95% CI, 17.7%-45.7%), kidney function impairment (14.9%; 95% CI, 6.2%-28.3%), hypokalemia (11.9%; 95% CI, 3.9%-25.6%), hearing loss (11.8%; 95% CI, 5.5%-21.3%), gastrointestinal disorders (11.8%; 95% CI, 5.2%-21.8%), psychiatric disorders (9.1%; 95% CI, 2.5%-21.6%), or anemia (8.9%; 95% CI, 3.6%-17.4%). The pooled proportion of favorable pregnancy outcomes was 73.2% (95% CI, 49.4%-92.1%). The most common types of adverse pregnancy outcomes were preterm birth (9.5%; 95% CI, 0.0%-29.0%), pregnancy loss (6.0%; 95% CI, 1.3%-12.9%), low birth weight (3.9%; 95% CI, 0.0%-18.7%), and stillbirth (1.9%; 95% CI, 0.1%-5.1%). Most of the studies had low-quality (3 studies) or medium-quality (4 studies) scores. CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, high treatment success and favorable pregnancy outcomes were reported among pregnant patients with MDR-TB. Further research is needed to design shorter, more effective, and safer treatment regimens for pregnant patients with MDR-TB.
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Affiliation(s)
- Kefyalew Addis Alene
- Telethon Kids Institute, Nedlands, Western Australia, Australia
- Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
| | - Megan B. Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | | | - Mercedes C. Becerra
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | | | - Mark P. Nicol
- Institute for Infectious Diseases and Molecular Medicine, Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
- School of Biomedical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Archie C. A. Clements
- Telethon Kids Institute, Nedlands, Western Australia, Australia
- Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
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Burzynski J, Mangan JM, Lam CK, Macaraig M, Salerno MM, deCastro BR, Goswami ND, Lin CY, Schluger NW, Vernon A. In-Person vs Electronic Directly Observed Therapy for Tuberculosis Treatment Adherence: A Randomized Noninferiority Trial. JAMA Netw Open 2022; 5:e2144210. [PMID: 35050357 PMCID: PMC8777548 DOI: 10.1001/jamanetworkopen.2021.44210] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Electronic directly observed therapy (DOT) is used increasingly as an alternative to in-person DOT for monitoring tuberculosis treatment. Evidence supporting its efficacy is limited. OBJECTIVE To determine whether electronic DOT can attain a level of treatment observation as favorable as in-person DOT. DESIGN, SETTING, AND PARTICIPANTS This was a 2-period crossover, noninferiority trial with initial randomization to electronic or in-person DOT at the time outpatient tuberculosis treatment began. The trial enrolled 216 participants with physician-suspected or bacteriologically confirmed tuberculosis from July 2017 to October 2019 in 4 clinics operated by the New York City Health Department. Data analysis was conducted between March 2020 and April 2021. INTERVENTIONS Participants were asked to complete 20 medication doses using 1 DOT method, then switched methods for another 20 doses. With in-person therapy, participants chose clinic or community-based DOT; with electronic DOT, participants chose live video-conferencing or recorded videos. MAIN OUTCOMES AND MEASURES Difference between the percentage of medication doses participants were observed to completely ingest with in-person DOT and with electronic DOT. Noninferiority was demonstrated if the upper 95% confidence limit of the difference was 10% or less. We estimated the percentage of completed doses using a logistic mixed effects model, run in 4 modes: modified intention-to-treat, per-protocol, per-protocol with 85% or more of doses conforming to the randomization assignment, and empirical. Confidence intervals were estimated by bootstrapping (with 1000 replicates). RESULTS There were 173 participants in each crossover period (median age, 40 years [range, 16-86 years]; 140 [66%] men; 80 [37%] Asian and Pacific Islander, 43 [20%] Black, and 71 [33%] Hispanic individuals) evaluated with the model in the modified intention-to-treat analytic mode. The percentage of completed doses with in-person DOT was 87.2% (95% CI, 84.6%-89.9%) vs 89.8% (95% CI, 87.5%-92.1%) with electronic DOT. The percentage difference was -2.6% (95% CI, -4.8% to -0.3%), consistent with a conclusion of noninferiority. The 3 other analytic modes yielded equivalent conclusions, with percentage differences ranging from -4.9% to -1.9%. CONCLUSIONS AND RELEVANCE In this trial, the percentage of completed doses under electronic DOT was noninferior to that under in-person DOT. This trial provides evidence supporting the efficacy of this digital adherence technology, and for the inclusion of electronic DOT in the standard of care. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03266003.
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Affiliation(s)
- Joseph Burzynski
- Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, New York
| | - Joan M. Mangan
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Chee Kin Lam
- Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, New York
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Michelle Macaraig
- Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, New York
| | - Marco M. Salerno
- Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, New York
- Division of Pulmonary, Allergy & Critical Care, Columbia University, New York, New York
| | - B. Rey deCastro
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Neela D. Goswami
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Carol Y. Lin
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Neil W. Schluger
- Division of Pulmonary, Allergy & Critical Care, Columbia University, New York, New York
| | - Andrew Vernon
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention, Atlanta, Georgia
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Ausi Y, Santoso P, Sunjaya DK, Barliana MI. Between Curing and Torturing: Burden of Adverse Reaction in Drug-Resistant Tuberculosis Therapy. Patient Prefer Adherence 2021; 15:2597-2607. [PMID: 34848950 PMCID: PMC8627322 DOI: 10.2147/ppa.s333111] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 11/09/2021] [Indexed: 01/07/2023] Open
Abstract
Drug-resistant tuberculosis (DR-TB) requires prolonged and complex therapy which is associated with several adverse drug reactions (ADR). The burden of ADR can affect the quality of life (QoL) of patients that consists of physical, mental, and social well-being, and influences the beliefs and behaviors of patient related to treatment. This article reviews the burden of ADR and its association with QoL and adherence. We used PubMed to retrieve the relevant original research articles written in English from 2011 to 2021. We combined the following keywords: "tuberculosis," "Drug-resistant tuberculosis," "Side Effect," "Adverse Drug Reactions," "Adverse Event," "Quality of Life," "Adherence," "Non-adherence," "Default," and "Loss to follow-up." Article selection process was unsystematic. We included 12 relevant main articles and summarized into two main topics, namely, 1) ADR and QoL (3 articles), and 2) ADR and therapy adherence (9 articles). The result showed that patients with ADR tend to have low QoL, even in the end of treatment. Although it was torturing, the presence of ADR does not always result in non-adherence. It is probably because the perception about the benefit of the treatment dominates the perceived barrier. In conclusion, burden of ADR generally tends to degrade QoL of patients and potentially influence the adherence. A comprehensive support from family, community, and healthcare provider is required to help patients in coping with the burden of ADR. Nevertheless, the regimen safety and efficacy improvement are highly needed.
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Affiliation(s)
- Yudisia Ausi
- Department of Biological Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
- Master Program in Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
| | - Prayudi Santoso
- Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Deni Kurniadi Sunjaya
- Department of Public Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Melisa Intan Barliana
- Department of Biological Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
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11
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Sekandi JN, Kasiita V, Onuoha NA, Zalwango S, Nakkonde D, Kaawa-Mafigiri D, Turinawe J, Kakaire R, Davis-Olwell P, Atuyambe L, Buregyeya E. Stakeholders' Perceptions of Benefits of and Barriers to Using Video-Observed Treatment for Monitoring Patients With Tuberculosis in Uganda: Exploratory Qualitative Study. JMIR Mhealth Uhealth 2021; 9:e27131. [PMID: 34704961 PMCID: PMC8581755 DOI: 10.2196/27131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 08/15/2021] [Accepted: 09/07/2021] [Indexed: 01/19/2023] Open
Abstract
Background Nonadherence to treatment remains a barrier to tuberculosis (TB) control. Directly observed therapy (DOT) is the standard for monitoring adherence to TB treatment worldwide, but its implementation is challenging, especially in resource-limited settings. DOT is labor-intensive and inconvenient to both patients and health care workers. Video DOT (VDOT) is a novel patient-centered alternative that uses mobile technology to observe patients taking medication remotely. However, the perceptions and acceptability of potential end users have not been evaluated in Africa. Objective This study explores stakeholders’ acceptability of, as well as perceptions of potential benefits of and barriers to, using VDOT to inform a pilot study for monitoring patients with TB in urban Uganda. Methods An exploratory, qualitative, cross-sectional study with an exit survey was conducted in Kampala, Uganda, from April to May 2018. We conducted 5 focus group discussions, each comprising 6 participants. Groups included patients with TB (n=2 groups; male and female), health care providers (n=1), caregivers (n=1), and community DOT volunteer workers (n=1). The questions that captured perceived benefits and barriers were guided by domains adopted from the Technology Acceptance Model. These included perceived usefulness, ease of use, and intent to use technology. Eligible participants were aged ≥18 years and provided written informed consent. For patients with TB, we included only those who had completed at least 2 months of treatment to minimize the likelihood of infection. A purposive sample of patients, caregivers, health care providers, and community DOT workers was recruited at 4 TB clinics in Kampala. Trained interviewers conducted unstructured interviews that were audio-recorded, transcribed, and analyzed using inductive content analysis to generate emerging themes. Results The average age of participants was 34.5 (SD 10.7) years. VDOT was acceptable to most participants on a scale of 1 to 10. Of the participants, 70% (21/30) perceived it as highly acceptable, with scores ≥8, whereas 30% (9/30) scored between 5 and 7. Emergent themes on perceived benefits of VDOT were facilitation of easy adherence monitoring, timely follow-up on missed doses, patient-provider communication, and saving time and money because of minimal travel to meet in person. Perceived barriers included limited technology usability skills, inadequate cellular connectivity, internet access, availability of electricity, cost of the smartphone, and use of the internet. Some female patients raised concerns about the disruption of their domestic work routines to record videos. The impact of VDOT on privacy and confidentiality emerged as both a perceived benefit and barrier. Conclusions VDOT was acceptable and perceived as beneficial by most study participants, despite potential technical and cost barriers. Mixed perceptions emerged about the impact of VDOT on privacy and confidentiality. Future efforts should focus on training users, ensuring adequate technical infrastructure, assuring privacy, and performing comparative cost analyses in the local context.
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Affiliation(s)
- Juliet Nabbuye Sekandi
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, United States.,Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States
| | | | - Nicole Amara Onuoha
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States
| | - Sarah Zalwango
- School of Public Health, Makerere University, Kampala, Uganda.,Kampala Capital City Authority, Kampala, Uganda
| | | | | | - Julius Turinawe
- School of Public Health, Makerere University, Kampala, Uganda
| | - Robert Kakaire
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States
| | - Paula Davis-Olwell
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, United States.,Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States
| | - Lynn Atuyambe
- School of Public Health, Makerere University, Kampala, Uganda
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12
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Navarro PDD, Haddad JPA, Rabelo JVC, Silva CHDLE, Almeida IND, Carvalho WDS, Miranda SSD. The impact of the stratification by degree of clinical severity and abandonment risk of tuberculosis treatment. J Bras Pneumol 2021; 47:e20210018. [PMID: 34495173 PMCID: PMC8979663 DOI: 10.36416/1806-3756/e20210018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/30/2021] [Indexed: 12/01/2022] Open
Abstract
Objective: Evaluate the impact of the instrument of the “Stratification by Degree of Clinical Severity and Abandonment Risk of Tuberculosis Treatment” (SRTB) on the tuberculosis outcome. Methods: This study was a pragmatic clinical trial involving patients with a confirmed diagnosis of tuberculosis treated at one of the 152 primary health care units in the city of Belo Horizonte, Brazil, between May of 2016 and April of 2017. Cluster areas for tuberculosis were identified, and the units and their respective patients were divided into intervention (use of SRTB) and nonintervention groups. Results: The total sample comprised 432 participants, 223 and 209 of whom being allocated to the nonintervention and intervention groups, respectively. The risk of treatment abandonment in the nonintervention group was significantly higher than was that in the intervention group (OR = 15.010; p < 0.001), regardless of the number of risk factors identified. Kaplan-Meier curves showed a hazard ratio of 0.0753 (p < 0.001). Conclusions: The SRTB instrument was effective in reducing abandonment of tuberculosis treatment, regardless of the number of risk factors for that. This instrument is rapid and easy to use, and can be adapted to different realities. Its application showed characteristics predisposing to a non-adherence to the treatment and established bases to mitigate its impact.
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Affiliation(s)
- Pedro Daibert de Navarro
- . Secretaria Municipal de Saúde, Prefeitura de Belo Horizonte, Belo Horizonte (MG) Brasil.,. Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte (MG) Brasil
| | - João Paulo Amaral Haddad
- . Departamento de Medicina Veterinária Preventiva, Escola de Veterinária, Universidade Federal de Minas Gerais, Belo Horizonte (MG) Brasil
| | | | | | - Isabela Neves de Almeida
- . Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte (MG) Brasil.,. Faculdade de Farmácia, Universidade Federal de Ouro Preto, Ouro Preto (MG) Brasil
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13
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Wang S. Development of a nomogram for predicting treatment default under facility-based directly observed therapy short-course in a region with a high tuberculosis burden. Ther Adv Infect Dis 2021; 8:20499361211034066. [PMID: 34377465 PMCID: PMC8330448 DOI: 10.1177/20499361211034066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 07/03/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Poor adherence to tuberculosis (TB) treatment is a substantial barrier to global TB control. The aim of this study was to construct a nomogram for predicting the probability of TB treatment default. Methods: A total of 1185 TB patients who had received treatment between 2010 and 2011 in Peru were analyzed in this study. Patient demographics, social, and medical information were recorded. Predictors were selected by least absolute shrinkage and selection operator (LASSO) regression analysis, and a nomogram for predicting TB treatment default was constructed by using multivariable logistic regression analysis. Bootstrapping method was applied for internal validation. Calibration and clinical utility of the nomogram was also evaluated. Results: The incidence of TB treatment default among the study patients was 11.6% (138/1185). Six predictors (secondary education status, alcohol use, illegal drug use, body mass index, multidrug-resistant tuberculosis, and human immunodeficiency virus serostatus) were selected through the LASSO regression analysis. A nomogram was developed based on the six predictors and it yielded an area under the curve (AUC) value of 0.797 [95% confidence interval (CI), 0.755–0.839]. In the internal validation, the AUC achieved 0.805 (95% CI, 0.759–0.844). Additionally, the nomogram was well-calibrated, and it showed clinical utility in decision curve analysis. Conclusion: A nomogram was constructed that incorporates six characteristics of the TB patients, which provides a good reference for predicting TB treatment default.
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Affiliation(s)
- Saibin Wang
- Department of Respiratory Medicine, Jinhua Municipal Central Hospital, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, No. 365, East Renmin Road, Jinhua, Zhejiang Province 321000, China
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14
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Woldeyohannes D, Tekalegn Y, Sahiledengle B, Assefa T, Aman R, Hailemariam Z, Mwanri L, Girma A. Predictors of mortality and loss to follow-up among drug resistant tuberculosis patients in Oromia Hospitals, Ethiopia: A retrospective follow-up study. PLoS One 2021; 16:e0250804. [PMID: 33956812 PMCID: PMC8101723 DOI: 10.1371/journal.pone.0250804] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/14/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Drug resistance tuberculosis (DR-TB) patients' mortality and loss to follow-up (LTF) from treatment and care is a growing worry in Ethiopia. However, little is known about predictors of mortality and LTF among drug-resistant tuberculosis patients in Oromia region, Ethiopia. The current study aimed to identify predictors of mortality and loss to follow-up among drug resistance tuberculosis patients in Oromia Hospitals, Ethiopia. METHODS A retrospective follow up study was carried out from 01 November 2012 to 31 December 2017 among DR-TB patients after calculating sample size using single proportion population formula. Mean, median, Frequency tables and bar charts were used to describe patients' characteristics in the cohort. The Kaplan-Meier curve was used to estimate the probability of death and LTF after the treatment was initiated. The log-rank test was used to compare time to death and time to LTF. The Cox proportional hazard model was used to determine predictors of mortality and LTF after DR-TB diagnosis. The Crude and adjusted Cox proportional hazard ratio was used to measure the strength of association whereas p-value less than 0.05 were used to declare statistically significant predictors. RESULT A total of 406 DR-TB patients were followed for 7084 person-months observations. Among the patients, 71 (17.5%) died and 32 (7.9%) were lost to follow up (LTF). The incidence density of death and LTF in the cohort was 9.8 and 4.5 per 1000 person-months, respectively. The median age of the study participants was 28 years (IQR: 27.1, 29.1). The overall cumulative survival probability of patients at the end of 24 months was 77.5% and 84.5% for the mortality and LTF, respectively. The independent predictors of death was chest radiographic findings (AHR = 0.37, 95% CI: 0.17-0.79) and HIV serostatus 2.98 (95% CI: 1.72-5.19). Drug adverse effect (AHR = 6.1; 95% CI: 2.5, 14.34) and culture test result (AHR = 0.1; 95% CI: 0.1, 0.3) were independent predictors of LTF. CONCLUSION This study concluded that drug-resistant tuberculosis mortality and LTF remains high in the study area. Continual support of the integration of TB/HIV service with emphasis and work to identified predictors may help in reducing drug-resistant tuberculosis mortality and LTF.
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Affiliation(s)
- Demelash Woldeyohannes
- Department of Public Health, Collage of Medicine and Health Science, Wachemo University, Hossana, Ethiopia
- * E-mail:
| | - Yohannes Tekalegn
- Department of Public Health, School of Health Science, Madda Walabu University, Bale Goba, Ethiopia
| | - Biniyam Sahiledengle
- Department of Public Health, School of Health Science, Madda Walabu University, Bale Goba, Ethiopia
| | - Tesfaye Assefa
- Department of Nursing, School of Health Science, Goba Referral Hospital, Madda Walabu University, Bale Goba, Ethiopia
| | - Rameto Aman
- Department of Public Health, School of Health Science, Madda Walabu University, Bale Goba, Ethiopia
| | - Zeleke Hailemariam
- Department of Public Health, Collage of Medicine and Health Science, Arba Minch University, Arba Minch, Ethiopia
| | - Lillian Mwanri
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Alemu Girma
- Department of Surgery, School of Health Science, Goba Referral Hospital, Madda Walabu University, Bale Goba, Ethiopia
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15
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Kimani E, Muhula S, Kiptai T, Orwa J, Odero T, Gachuno O. Factors influencing TB treatment interruption and treatment outcomes among patients in Kiambu County, 2016-2019. PLoS One 2021; 16:e0248820. [PMID: 33822794 PMCID: PMC8023511 DOI: 10.1371/journal.pone.0248820] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 03/07/2021] [Indexed: 11/22/2022] Open
Abstract
Tuberculosis (TB) is the leading cause of mortality as a single infectious agent globally with increasing numbers of case notification in developing countries. This study seeks to investigate the clinical and socio-demographic factors of time to TB treatment interruption among Tuberculosis patients in Kiambu County, 2016–2019. We retrospectively analyzed data for all treatment outcomes patients obtained from TB tracing form linked with the Tuberculosis Information Basic Unit (TIBU) of patients in Kiambu County health facilities using time to treatment interruption as the main outcome. Categorical variables were presented using frequency and percentages. Kaplan-Meir curve was used to analyze probabilities of time to treatment interruptions between intensive and continuation phases. Log-rank test statistics was used to compare the equality of the curves. Cox proportion model was used to determine determinants of treatment interruption. A total of 292 participants were included in this study. Males were 68%, with majority (35%) of the participants were aged 24–35 years; 5.8% were aged 0–14 years and 5.1% aged above 55 years. The overall treatment success rate was 66.8% (cured, 34.6%; completed 32.2%), 60.3% were on intensive phase of treatment. Lack of knowledge and relocation were the major reasons of treatment interruptions. Patients on intensive phase were 1.58 times likely to interrupt treatment compared to those on continuation phase (aHR: 1.581; 95%CI: 1.232–2.031). There is need to develop TB interventions that target men and middle aged population in order to reduce treatment interruption and increase the treatment success rates in the County and Country.
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Affiliation(s)
- Evelyn Kimani
- Department of Health, Tuberculosis, Leprosy and Lung Disease Program-Kiambu County, Kiambu, Kenya
- * E-mail:
| | | | | | - James Orwa
- University of Nairobi – School of Medicine, Nairobi, Kenya
| | - Theresa Odero
- University of Nairobi – School of Medicine, Nairobi, Kenya
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16
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Sekandi JN, Onuoha NA, Buregyeya E, Zalwango S, Kaggwa PE, Nakkonde D, Kakaire R, Atuyambe L, Whalen CC, Dobbin KK. Using a Mobile Health Intervention (DOT Selfie) With Transfer of Social Bundle Incentives to Increase Treatment Adherence in Tuberculosis Patients in Uganda: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2021; 10:e18029. [PMID: 32990629 PMCID: PMC7815451 DOI: 10.2196/18029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/10/2020] [Accepted: 09/16/2020] [Indexed: 12/13/2022] Open
Abstract
Background The World Health Organization’s End TB Strategy envisions a world free of tuberculosis (TB)—free of deaths, disease, and suffering due to TB—by 2035. Nonadherence reduces cure rates, prolongs infectiousness, and contributes to the emergence of multidrug-resistant TB (MDR-TB). Moreover, MDR-TB is a growing, complex, and costly problem that presents a major obstacle to TB control. Directly observed therapy (DOT) for treatment adherence monitoring is the recommended standard; however, it is challenging to implement at scale because it is labor-intensive. Mobile health interventions can facilitate remote adherence monitoring and minimize the costs and inconveniences associated with standard DOT. Objective The study aims to evaluate the effectiveness of using video directly observed therapy (VDOT) plus incentives to improve medication adherence in TB treatment versus usual-care DOT in an African context. Methods The DOT Selfie study is an open-label, randomized controlled trial (RCT) with 2 parallel groups, in which 144 adult patients with TB aged 18-65 years will be randomly assigned to receive the usual-care DOT monitoring or VDOT as the intervention. The intervention will consist of a smartphone app, a weekly internet subscription, translated text message reminders, and incentives for those who adhere. The participant will use a smartphone to record and send time-stamped encrypted videos showing their daily medication ingestion. This video component will directly substitute the need for daily face-to-face meetings between the health provider and patients. We hypothesize that the VDOT intervention will be more effective because it allows patients to swallow their pills anywhere, anytime. Moreover, patients will receive mobile-phone–based “social bundle” incentives to motivate adherence to continued daily submission of videos to the health system. The health providers will log into a secured computer system to verify treatment adherence, document missed doses, investigate the reasons for missed doses, and follow prespecified protocol measures to re-establish medication adherence. The primary endpoint is the adherence level as measured by the fraction of expected doses observed over the treatment period. The main secondary outcome will be time-to-treatment completion in both groups. Results This study was funded in 2019. Enrollment began in July and is expected to be completed by November 2020. Data collection and follow-up are expected to be completed by June 2021. Results from the analyses based on the primary endpoint are expected to be submitted for publication by December 2021. Conclusions This random control trial will be among the first to evaluate the effectiveness of VDOT within an African setting. The results will provide robust scientific evidence on the implementation and adoption of mobile health (mHealth) tools, coupled with incentives to motivate TB medication adherence. If successful, VDOT will apply to other low-income settings and a range of chronic diseases with lifelong treatment, such as HIV/AIDs. Trial Registration ClinicalTrials.gov NCT04134689; http://clinicaltrials.gov/ct2/show/NCT04134689 International Registered Report Identifier (IRRID) DERR1-10.2196/18029
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Affiliation(s)
- Juliet Nabbuye Sekandi
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States.,Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, United States
| | - Nicole Amara Onuoha
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States
| | | | - Sarah Zalwango
- School of Public Health, Makerere University, Kampala, Uganda.,Department of Public Health Service and Environment, Kampala Capital City Authority, Kampala, Uganda
| | | | | | - Robert Kakaire
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States
| | - Lynn Atuyambe
- School of Public Health, Makerere University, Kampala, Uganda
| | - Christopher C Whalen
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States.,Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, United States
| | - Kevin K Dobbin
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, United States
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17
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Wen S, Yin J, Sun Q. Impacts of social support on the treatment outcomes of drug-resistant tuberculosis: a systematic review and meta-analysis. BMJ Open 2020; 10:e036985. [PMID: 33033087 PMCID: PMC7545632 DOI: 10.1136/bmjopen-2020-036985] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To assess the effectiveness of social support on treatment success promotion or lost to follow-up (LTFU) reduction for patients with drug-resistant tuberculosis (DR-TB). DESIGN We searched Pubmed, Web of Science, Embase, Scopus and Medline databases until 18 June 2020 for interventional or mixed-method studies which reported social support and treatment outcomes of DR-TB patients. Two independent reviewers extracted data and disagreements were resolved by consensus with a third reviewer. Random-effects meta-analysis was performed to calculate the OR and 95% CI for the effects of social support on the improvement of treatment outcomes and the heterogeneity and risk of bias were assessed. SETTING Low-income and middle-income countries. PARTICIPANTS DR-TB patients. OUTCOMES Treatment success is defined as the combination of the cured and treatment completion, and LTFU is measured as treatment being interrupted for two consecutive months or more. RESULTS Among 173 articles selected for full-text review, 162 were excluded through independent review (kappa=0.87) and 10 studies enrolling 1621 DR-TB patients in eight countries were included for qualitative analysis. In these studies, the most frequently introduced social support was material support (10 studies), followed by informational (eight studies), emotional (seven studies) and companionship support (four studies). Seven studies that reported treatment outcomes in both intervention arm and control arm are qualified for meta-analysis. An encouraging improvement on treatment success rate (OR: 2.58; 95% CI: 1.80 to 3.69) was found when material support was integrated into social support packages and no heterogeneity was observed (I1 of 0%, Q test p=0.72). Reduction on LTFU rate (OR: 0.17; 95% CI: 0.05 to 0.55) was also noted when material support was available but substantial heterogeneity was found (I2 of 80%, Q test p=0.002). CONCLUSION Material support appeared feasible and effective to improve treatment success for DR-TB patients combined with other social support interventions. PROSPERO REGISTRATION NUMBER CRD42019140824.
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Affiliation(s)
- Shuqin Wen
- Centre for Health Management and Policy Research, School of Public Health, Shandong University Cheeloo College of Medicine, Jinan, Shandong, China
- NHC Key Lab of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China
| | - Jia Yin
- Centre for Health Management and Policy Research, School of Public Health, Shandong University Cheeloo College of Medicine, Jinan, Shandong, China
- NHC Key Lab of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China
| | - Qiang Sun
- Centre for Health Management and Policy Research, School of Public Health, Shandong University Cheeloo College of Medicine, Jinan, Shandong, China
- NHC Key Lab of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China
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18
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Aisyah DN, Ahmad RA, Artama WT, Adisasmito W, Diva H, Hayward AC, Kozlakidis Z. Knowledge, Attitudes, and Behaviors on Utilizing Mobile Health Technology for TB in Indonesia: A Qualitative Pilot Study. Front Public Health 2020; 8:531514. [PMID: 33123508 PMCID: PMC7573209 DOI: 10.3389/fpubh.2020.531514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 08/27/2020] [Indexed: 11/13/2022] Open
Abstract
Tuberculosis (TB) infections remain a global health burden with a high incidence rate in South-East Asia, including Indonesia. TB control strategy is founded on early case detection and complete treatment to minimize transmission and prevent the emergence of drug resistance. However, many patients face challenges to comply with daily medication, causing many to adhere inconsistently or stop prematurely. Technological solutions could enhance adherence to treatment and support national screening and follow-up policies. These include telephone video communication, enabling health professionals to watch patients take their medication, address patients' concerns, and provide advice and support. This manuscript describes the outcome of a qualitative pilot study, based on a series of focus group discussions to assess the knowledge, attitudes, and behaviors, on the potential utilization of mobile technology for health purposes with a particular focus on TB treatment follow-up. The findings illustrate that general knowledge of mobile health technologies, of their legal framework of operations, and of their exact potential within the healthcare system is incomplete or poor. The novel findings are as follows: (a) the willingness of participants to learn about these technologies, (b) the open and welcoming attitude toward receiving such information even within frontline community settings, and (c) the willingness to back a government-supported, healthcare-driven set of such initiatives. Potential implementation barriers have also been highlighted. This study is an important first step toward understanding the attitudes and behaviors on utilizing mobile health technology for TB in Indonesia.
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Affiliation(s)
- Dewi Nur Aisyah
- Indonesia One Health University Network (INDOHUN), Depok, Indonesia
- Infectious Disease Informatics, Institute of Health Informatics, University College London, London, United Kingdom
| | - Riris Andono Ahmad
- Center for Tropical Medicine, Gadjah Mada University, Yogyakarta, Indonesia
| | - Wayan Tunas Artama
- Center for Tropical Medicine, Gadjah Mada University, Yogyakarta, Indonesia
- One Health Collaborating Center (OHCC), Faculty of Veterinary Medicine Gadjah Mada University, Yogyakarta, Indonesia
| | - Wiku Adisasmito
- Indonesia One Health University Network (INDOHUN), Depok, Indonesia
- Faculty of Public Health, Universitas Indonesia, Depok, Indonesia
| | - Haniena Diva
- Indonesia One Health University Network (INDOHUN), Depok, Indonesia
| | - Andrew C. Hayward
- Infectious Disease Informatics, Institute of Health Informatics, University College London, London, United Kingdom
- Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Zisis Kozlakidis
- International Agency for Research on Cancer, World Health Organization, Lyon, France
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19
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Sekandi JN, Buregyeya E, Zalwango S, Dobbin KK, Atuyambe L, Nakkonde D, Turinawe J, Tucker EG, Olowookere S, Turyahabwe S, Garfein RS. Video directly observed therapy for supporting and monitoring adherence to tuberculosis treatment in Uganda: a pilot cohort study. ERJ Open Res 2020; 6:00175-2019. [PMID: 32280670 PMCID: PMC7132038 DOI: 10.1183/23120541.00175-2019] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 02/11/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Nonadherence to treatment remains an obstacle to tuberculosis (TB) control worldwide. The aim of this study was to evaluate the feasibility of using video directly observed therapy (VDOT) for supporting TB treatment adherence in Uganda. Methods From May to December 2018, we conducted a pilot cohort study at a TB clinic in Kampala City. We enrolled patients aged 18–65 years with ≥3 months remaining of their TB treatment. Participants were trained to use a smartphone app to record videos of medication intake and submit them to a secured system. Trained health workers logged into the system to watch the submitted videos. The primary outcome was adherence measured as the fraction of expected doses observed (FEDO). In a secondary analysis, we examined differences in FEDO by sex, age, phone ownership, duration of follow-up, reasons for missed videos and patients' satisfaction at study exit. Results Of 52 patients enrolled, 50 were analysed. 28 (56%) were male, the mean age was 31 years (range 19–50 years) and 35 (70%) owned smartphones. Of the 5150 videos expected, 4231 (82.2%) were received. The median FEDO was 85% (interquartile range 66%–94%) and this significantly differed by follow-up duration. Phone malfunction, uncharged battery and VDOT app malfunctions were the commonest reasons for missed videos. 92% of patients reported being very satisfied with using VDOT. Conclusion VDOT was feasible and acceptable for monitoring and supporting TB treatment. It resulted in high levels of adherence, suggesting that digital technology holds promise in improving patient monitoring in Uganda. Video directly observed therapy is feasible and acceptable for supporting and monitoring TB treatment adherence in a low-resource setting like Uganda. Digital health interventions hold promise as alternative methods for improving patient care.http://bit.ly/2Hxnvwu
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Affiliation(s)
- Juliet N Sekandi
- Dept of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA.,Global Health Institute, College of Public Health, University of Georgia, Athens, GA, USA
| | | | - Sarah Zalwango
- School of Public Health, Makerere University, Kampala, Uganda.,Kampala Capital City Authority, Dept of Public Health Service and Environment, Kampala, Uganda
| | - Kevin K Dobbin
- Dept of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | - Lynn Atuyambe
- School of Public Health, Makerere University, Kampala, Uganda
| | | | - Julius Turinawe
- School of Public Health, Makerere University, Kampala, Uganda
| | - Emma G Tucker
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, USA
| | - Shade Olowookere
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, USA
| | | | - Richard S Garfein
- School of Medicine, University of California, San Diego, La Jolla, CA, USA
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20
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Verma M, Vishwanath K, Eweje F, Roxhed N, Grant T, Castaneda M, Steiger C, Mazdiyasni H, Bensel T, Minahan D, Soares V, Salama JAF, Lopes A, Hess K, Cleveland C, Fulop DJ, Hayward A, Collins J, Tamang SM, Hua T, Ikeanyi C, Zeidman G, Mule E, Boominathan S, Popova E, Miller JB, Bellinger AM, Collins D, Leibowitz D, Batra S, Ahuja S, Bajiya M, Batra S, Sarin R, Agarwal U, Khaparde SD, Gupta NK, Gupta D, Bhatnagar AK, Chopra KK, Sharma N, Khanna A, Chowdhury J, Stoner R, Slocum AH, Cima MJ, Furin J, Langer R, Traverso G. A gastric resident drug delivery system for prolonged gram-level dosing of tuberculosis treatment. Sci Transl Med 2020; 11:11/483/eaau6267. [PMID: 30867322 PMCID: PMC7797620 DOI: 10.1126/scitranslmed.aau6267] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 02/01/2019] [Indexed: 12/12/2022]
Abstract
Multigram drug depot systems for extended drug release could transform our capacity to effectively treat patients across a myriad of diseases. For example, tuberculosis (TB) requires multimonth courses of daily multigram doses for treatment. To address the challenge of prolonged dosing for regimens requiring multigram drug dosing, we developed a gastric resident system delivered through the nasogastric route that was capable of safely encapsulating and releasing grams of antibiotics over a period of weeks. Initial preclinical safety and drug release were demonstrated in a swine model with a panel of TB antibiotics. We anticipate multiple applications in the field of infectious diseases, as well as for other indications where multigram depots could impart meaningful benefits to patients, helping maximize adherence to their medication.
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Affiliation(s)
- Malvika Verma
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Tata Center for Technology and Design, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Karan Vishwanath
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Feyisope Eweje
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Niclas Roxhed
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Micro and Nanosystems, KTH Royal Institute of Technology, Stockholm 10044, Sweden
| | - Tyler Grant
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Macy Castaneda
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Christoph Steiger
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.,Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Hormoz Mazdiyasni
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Taylor Bensel
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Daniel Minahan
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Vance Soares
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - John A F Salama
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Aaron Lopes
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Kaitlyn Hess
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Cody Cleveland
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Daniel J Fulop
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Alison Hayward
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Division of Comparative Medicine, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Joy Collins
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Siddartha M Tamang
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Tiffany Hua
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Chinonyelum Ikeanyi
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Gal Zeidman
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Elizabeth Mule
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Sooraj Boominathan
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Ellena Popova
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Biology, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Jonathan B Miller
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Andrew M Bellinger
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Cardiovascular Division, Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - David Collins
- Management Sciences for Health, Medford, MA 02155, USA.,Boston University School of Public Health, Boston, MA 02118, USA
| | - Dalia Leibowitz
- Tata Center for Technology and Design, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | | | | | | | | | - Rohit Sarin
- National Institute of Tuberculosis and Respiratory Diseases, New Delhi 110030, India
| | - Upasna Agarwal
- National Institute of Tuberculosis and Respiratory Diseases, New Delhi 110030, India
| | - Sunil D Khaparde
- Former Deputy Director General and Head of Central TB Division, Government of India, New Delhi 110011, India
| | - Neeraj K Gupta
- Department of Respiratory Medicine, Safdarjung Hospital, New Delhi 110029, India
| | - Deepak Gupta
- Division of Pulmonary and Critical Care Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Anuj K Bhatnagar
- Rajan Babu Institute for Pulmonary Medicine and Tuberculosis, New Delhi 110009, India
| | | | - Nandini Sharma
- Department of Community Medicine, Maulana Azad Medical College, New Delhi 110002, India
| | - Ashwani Khanna
- Lok Nayak Hospital Chest Clinic, New Delhi 110002, India
| | | | - Robert Stoner
- Tata Center for Technology and Design, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,MIT Energy Initiative, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Alexander H Slocum
- Tata Center for Technology and Design, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Michael J Cima
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Tata Center for Technology and Design, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Materials Science and Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Robert Langer
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA. .,Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Tata Center for Technology and Design, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Media Lab, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Giovanni Traverso
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA. .,Tata Center for Technology and Design, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.,Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
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21
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Intermittent treatment interruption and its effect on multidrug resistant tuberculosis treatment outcome in Ethiopia. Sci Rep 2019; 9:20030. [PMID: 31882784 PMCID: PMC6934462 DOI: 10.1038/s41598-019-56553-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/12/2019] [Indexed: 11/21/2022] Open
Abstract
Treatment interruption is one of the main risk factors of poor treatment outcome and occurrence of additional drug resistant tuberculosis. This study is a national retrospective cohort study with 10 years follow up period in MDR-TB patients in Ethiopia. We included 204 patients who had missed the treatment at least for one day over the course of the treatment (exposed group) and 203 patients who had never interrupted the treatment (unexposed group). We categorized treatment outcome into successful (cured or completed) and unsuccessful (lost to follow up, failed or died). We described treatment interruption by the length of time between interruptions, time to first interruption, total number of interruption episodes and percent of missed doses. We used Poisson regression model with robust standard error to determine the association between treatment interruption and outcome. 82% of the patients interrupted the treatment in the first six month of treatment period, and considerable proportion of patients demonstrated long intervals between two consecutive interruptions. Treatment interruption was significantly associated with unsuccessful treatment outcome (Adjusted Risk Ratio (ARR) = 1.9; 95% CI (1.4–2.6)). Early identification of patients at high risk of interruption is vital in improving successful treatment outcome.
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22
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Projecting the impact of variable MDR-TB transmission efficiency on long-term epidemic trends in South Africa and Vietnam. Sci Rep 2019; 9:18099. [PMID: 31792289 PMCID: PMC6889300 DOI: 10.1038/s41598-019-54561-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/10/2019] [Indexed: 12/12/2022] Open
Abstract
Whether multidrug-resistant tuberculosis (MDR-TB) is less transmissible than drug-susceptible (DS-)TB on a population level is uncertain. Even in the absence of a genetic fitness cost, the transmission potential of individuals with MDR-TB may vary by infectiousness, frequency of contact, or duration of disease. We used a compartmental model to project the progression of MDR-TB epidemics in South Africa and Vietnam under alternative assumptions about the relative transmission efficiency of MDR-TB. Specifically, we considered three scenarios: consistently lower transmission efficiency for MDR-TB than for DS-TB; equal transmission efficiency; and an initial deficit in the transmission efficiency of MDR-TB that closes over time. We calibrated these scenarios with data from drug resistance surveys and projected epidemic trends to 2040. The incidence of MDR-TB was projected to expand in most scenarios, but the degree of expansion depended greatly on the future transmission efficiency of MDR-TB. For example, by 2040, we projected absolute MDR-TB incidence to account for 5% (IQR: 4–9%) of incident TB in South Africa and 14% (IQR: 9–26%) in Vietnam assuming consistently lower MDR-TB transmission efficiency, versus 15% (IQR: 8–27%)and 41% (IQR: 23–62%), respectively, assuming shrinking transmission efficiency deficits. Given future uncertainty, specific responses to halt MDR-TB transmission should be prioritized.
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23
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Kassa GM, Teferra AS, Wolde HF, Muluneh AG, Merid MW. Incidence and predictors of lost to follow-up among drug-resistant tuberculosis patients at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia: a retrospective follow-up study. BMC Infect Dis 2019; 19:817. [PMID: 31533661 PMCID: PMC6751642 DOI: 10.1186/s12879-019-4447-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 09/09/2019] [Indexed: 11/18/2022] Open
Abstract
Background The emergence of Drug-Resistance Tuberculosis (DR-TB) is an increasing global public health problem. Lost to Follow-up (LTFU) from DR-TB treatment remains a major barrier to tuberculosis epidemic control and better treatment outcome. In Ethiopia, evidences on the incidence and predictors of LTFU are scarce. Thus, this study aimed to determine the incidence and identify the predictors of LTFU among DR-TB patients. Methods A retrospective follow-up study was conducted among a total of 332 DR-TB patients at the University of Gondar comprehensive specialized hospital. Data were retrieved from patient records from September 2010 to December 2017 and entered in to Epi-data 4.2.0.0 and analysed using Stata14.1 software. The risk was estimated using the Nelson-Aalen cumulative hazard curve. A log-rank test was used for survival comparisons between categories of independent variables. The Gompertz regression model was fitted, and hazard ratio with a 95% confidence interval (CI) was used to measure the strength of associations. Variables with less than 0.05 p-values in the multivariable model were considered as significantly associated with LTFU. Results Among a total of 332 patient records reviewed, 206 (62.05%) were male. The median age was 30 years (Inter Quartile Range (IQR): 23–40). Forty-one (12.35%) of the participants had no history of TB treatment, while a quarter of were TB-HIV co-infected. Closely all (92.17%) of the patients had pulmonary tuberculosis. The median follow up time was 20.37 months (IQR: 11.02, 21.80). Thirty-six (10.84%) patients were lost from follow-up with an incidence rate of 6.47 (95% CI: 4.67, 8.97)/1000 Person Months (PM). Homelessness (Adjusted Hazard Ratio (AHR) =2.51, 95%CI: 1.15, 5.45) and treatment enrolment year from 2013 to 2014 (AHR = 3.25, 95% CI: 1.30, 8.13) were significant predictors of LTFU. Conclusion This study indicated that LTFU among DR-TB registered patients was high in the first six months compared to subsequent months. Homelessness and year of treatment enrolment were independent predictors of LTFU, requiring more economic support to patients in order to ensure treatment completion. This result can be generalized to patients who are using DR-TB treatment in similar settings.
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Affiliation(s)
- Getahun Molla Kassa
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences and Specialized Comprehensive Hospital, University of Gondar, Gondar, Ethiopia.
| | - Alemayehu Shimeka Teferra
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences and Specialized Comprehensive Hospital, University of Gondar, Gondar, Ethiopia
| | - Haileab Fekadu Wolde
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences and Specialized Comprehensive Hospital, University of Gondar, Gondar, Ethiopia
| | - Atalay Goshu Muluneh
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences and Specialized Comprehensive Hospital, University of Gondar, Gondar, Ethiopia
| | - Mehari Woldemariam Merid
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences and Specialized Comprehensive Hospital, University of Gondar, Gondar, Ethiopia
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24
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McNally TW, de Wildt G, Meza G, Wiskin CMD. Improving outcomes for multi-drug-resistant tuberculosis in the Peruvian Amazon - a qualitative study exploring the experiences and perceptions of patients and healthcare professionals. BMC Health Serv Res 2019; 19:594. [PMID: 31438958 PMCID: PMC6704631 DOI: 10.1186/s12913-019-4429-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 08/13/2019] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Thomas W McNally
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
| | - Gilles de Wildt
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Graciela Meza
- Facultad de Medicina Humana, Universidad Nacional de la Amazonia Peruana, Iquitos, Peru
| | - Connie M D Wiskin
- Facultad de Medicina Humana, Universidad Nacional de la Amazonia Peruana, Iquitos, Peru
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25
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Viana PVDS, Codenotti SB, Bierrenbach AL, Basta PC. [Tuberculosis in indigenous children and adolescents in Brazil: factors associated with death and treatment dropout]. CAD SAUDE PUBLICA 2019; 35Suppl 3:e00074218. [PMID: 31433033 DOI: 10.1590/0102-311x00074218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 01/11/2019] [Indexed: 11/22/2022] Open
Abstract
The study aimed to describe clinical and sociodemographic characteristics, estimate incidence, and analyze factors associated with dropout and death during treatment of TB cases reported in indigenous children and adolescents in Brazil from 2006 to 2016. A historical case series was performed on incidence according to age bracket and major geographic region, and multinomial logistic regression was used to explain factors associated with treatment dropout and death. Of the 2,096 reported cases, 88.2% evolved to cure, 7.2% dropped out of treatment, and 4.6% evolved to death. There was a predominance of cases in boys 15-19 years of age and a higher proportion of deaths (55.7%) in children < 4 years. Considering indigenous children and adolescents with TB in Brazil as a whole, mean incidence was 49.1/100,000, ranging from 21.5/100,000 to 97.6/100,000 in the Northeast and Central, respectively. Cases with insufficient and irregular follow-up showed higher odds of dropout (OR = 11.1; 95%CI: 5.2-24.8/OR = 4.4; 95%CI: 1.9-10.3) and death (OR = 20.3; 95%CI: 4.9-84.9/OR = 5.1; 95%CI: 1.2-22.7). Cases in retreatment (OR = 2.4; 95%CI: 2.08-8.55) and with HIV coinfection (OR = 8.2; 95%CI: 2.2-30.9) were also associated with dropout. Extrapulmonary (OR = 1.8; 95%CI: 1.1-3.3) and mixed clinical forms (OR = 5.6; 95%CI: 2.8-11.4), age < 4 years (OR = 3.1; 95%CI: 1.5-6.4), and cases from the North (OR = 2.8; 95%CI: 1.1-7.1) and Central (OR = 2.8; 95%CI: 1.1-7.0) were associated with death. TB control in indigenous children and adolescents cannot be achieved without investments in research and development and without reducing social inequalities.
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Affiliation(s)
| | | | | | - Paulo Cesar Basta
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
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26
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Abandonment of therapy in multidrug-resistant tuberculosis: Associated factors in a region with a high burden of the disease in Perú. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2019; 39:44-57. [PMID: 31529833 DOI: 10.7705/biomedica.v39i3.4564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Indexed: 11/21/2022]
Abstract
Introduction: In the context of multidrug-resistant tuberculosis, abandonment of therapy represents a serious public health problem that affects the quality of life of patients, families, and communities. Managing this phenomenon places a burden on health systems since it causes free sources of transmission in the community, thereby increasing prevalence and mortality. Thus, there is a need to study factors associated with this problem.
Objective: This study sought to identify risk factors associated with the abandonment of therapy by patients with multidrug-resistant tuberculosis in the Peruvian region of Callao.
Materials and methods: We conducted an analytical case-control study (cases=80; controls=180) in patients under treatment from January 1st, 2010, to December 31, 2012. Risk factors were identified using logistic regression; odds ratios (OR) and 95% confidence intervals (CI) were calculated.
Results: The multivariate analysis identified the following risk factors: Being unaware of the disease (OR=23.10; 95% CI 3.6-36.79; p=0.002); not believing in healing (OR=117.34; 95% CI 13.57-124.6; p=0.000); not having social support (OR=19.16; 95% CI 1.32-27.77; p=0.030); considering the hours of attention to be inadequate (OR=78.13; 95% CI 4.84-125.97; p=0.002), and not receiving laboratory reports (OR=46.13; 95% CI 2.85-74.77; p=0.007).
Conclusion: Health services must focus on the early detection of conditions that may represent risk factors to proactively implement effective, rapid and high-impact interventions.
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27
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Inhaled Antibiotics for Mycobacterial Lung Disease. Pharmaceutics 2019; 11:pharmaceutics11070352. [PMID: 31331119 PMCID: PMC6680843 DOI: 10.3390/pharmaceutics11070352] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 07/09/2019] [Accepted: 07/15/2019] [Indexed: 12/22/2022] Open
Abstract
Mycobacterial lung diseases are an increasing global health concern. Tuberculosis and nontuberculous mycobacteria differ in disease severity, epidemiology, and treatment strategies, but there are also a number of similarities. Pathophysiology and disease progression appear to be relatively similar between these two clinical diagnoses, and as a result these difficult to treat pulmonary infections often require similarly extensive treatment durations of multiple systemic drugs. In an effort to improve treatment outcomes for all mycobacterial lung diseases, a significant body of research has investigated the use of inhaled antibiotics. This review discusses previous research into inhaled development programs, as well as ongoing research of inhaled therapies for both nontuberculous mycobacterial lung disease, and tuberculosis. Due to the similarities between the causative agents, this review will also discuss the potential cross-fertilization of development programs between these similar-yet-different diseases. Finally, we will discuss some of the perceived difficulties in developing a clinically utilized inhaled antibiotic for mycobacterial diseases, and potential arguments in favor of the approach.
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28
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Bezerra SS, Guerreiro MP, Sobrinho JLS. Consensual improvement actions for the Tuberculosis Control Programme in Pernambuco state, Brazil: an e-Delphi study. AIMS Public Health 2019; 6:229-241. [PMID: 31637273 PMCID: PMC6779604 DOI: 10.3934/publichealth.2019.3.229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 06/25/2019] [Indexed: 11/18/2022] Open
Abstract
Objectives: Tuberculosis (TB) remains a major public health problem, particularly in low and middle-income countries. The aim of this study is to consensualise improvement actions for the Tuberculosis Control Programme of the Pernambuco state (SPTC), Brazil. Methods: Firstly, a preliminary workshop was conducted with experts (n = 8), including key stakeholders and health professionals, to select structure and process indicators pertaining to the tuberculosis control programme. Then, an e-Delphi was carried out with a purposive sample of 11 local TB experts. The first-round questionnaire was comprised of 19 open-ended questions on possible improvement actions, based on programme indicators obtained in the previous stage. In the second-round experts rated each action for relevance and feasibility, using a four-point scale. In the last round the participants rated the actions again, in the light of group's answers. We used published criteria to define consensus at the outset of the study. Key findings: Eighty-nine improvement actions achieved a high degree of consensus in both feasibility and relevance in round three. Eighty-six actions were grouped under 19 structure and process indicators, while three were consideredcross-sectional in scope (i.e. related to more than one indicator). Ten out of the 86 actions obtained at least 70% of ratings on the highest score of the scale both for relevance and feasibility. These included: “Request and availability of sputum pots can be made by any health professional in the health unit”. Conclusions: The wide array of actions obtained in this Delphi represent a resource from which local SPTC services can select the actions most suitable for each context. The ten most relevant and feasible actions represent a particularly useful starting point to streamline change and potentially improve programme indicators.
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Affiliation(s)
- Simone Santos Bezerra
- Center of Biological Sciences, Post-graduation Programme in Therapeutic Innovation, Federal University of Pernambuco, Cidade Universitária, Recife, Pernambuco, Brazil
| | - Mara Pereira Guerreiro
- Unidade de Investigação e Desenvolvimento em Enfermagem (ui&de), Escola Superior de Enfermagem de Lisboa, Parque das Nações, Av. D. João II, 1990-096, Lisbon, Portugal.,Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Instituto Universitário Egas Moniz,Quinta da Granja, 2829, 511 Monte de Caparica, Almada, Portugal
| | - José Lamartine Soares Sobrinho
- Department of Pharmacy Health Sciences Center, Federal University of Pernambuco-Av. MoraesRego, 123, Cidade Universitária, Recife, Pernambuco, Brazil
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29
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Lester R, Park JJ, Bolten LM, Enjetti A, Johnston JC, Schwartzman K, Tilahun B, Delft AV. Mobile phone short message service for adherence support and care of patients with tuberculosis infection: Evidence and opportunity. J Clin Tuberc Other Mycobact Dis 2019; 16:100108. [PMID: 31720432 PMCID: PMC6830136 DOI: 10.1016/j.jctube.2019.100108] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
To attain the Global End Tuberculosis (TB) goals, the treatment of persons with TB requires advancements in coordinated approaches that are low-cost and highly accessible. Treating TB successfully requires prolonged medication regimens with good adherence, which in turn requires patients to be adequately supported. Furthermore, TB care-providers often wish to monitor treatment-taking by patients in order to track the success of their programs and ensure adequate completion of therapies by individuals. The standard-of-care for treatment monitoring in TB programs often includes directly observed therapy (DOT). Video observed therapy (VOT) has emerged as a method to mimic in-person visits or observations, especially in the smartphone era with internet data connections, but remains simply inaccessible to patients in areas where TB is most endemic. Both approaches may be considered more intensive than necessary for many patients, leaving an opportunity for more affordable and acceptable approaches. The rapid increase in mobile phone penetration provides an opportunity to reach patients between clinical visits. Short message services (SMS) are available on almost every mobile phone and are supported by first generation cellular communication networks, thus providing the farthest reach and penetration globally. Evidence from non-TB conditions suggests SMS, used in a variety of ways, may support outpatients for better medication adherence and quality of care but the evidence in TB remains limited. In this paper, we discuss how basic mobile phones and SMS-related services may be used in supporting global care of persons with TB, with a focus on patient-centered approaches.
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Affiliation(s)
| | - Jay Jh Park
- University of British Columbia, Vancouver, Canada
| | | | | | - James C Johnston
- University of British Columbia, Vancouver, Canada.,Provincial TB Services, British Columbia Centre for Disease Control, Vancouver, Canada
| | - Kevin Schwartzman
- Respiratory Division, Montreal Chest Institute, Respiratory Epidemiology and Clinical Research Unit, and McGill International Tuberculosis Centre, McGill University, Montreal, Quebec, Canada
| | | | - Arne von Delft
- TB Proof, 29 Almond Drive, Somerset West, Western Cape 7130, South Africa.,School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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30
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Indira Krishnan AK, Mini GK, Aravind LR. Evidence based interventions and implementation gaps in control of tuberculosis: A systematic review in low and middle-income countries with special focus on India. Indian J Tuberc 2019; 66:268-278. [PMID: 31151496 DOI: 10.1016/j.ijtb.2019.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 04/04/2019] [Indexed: 10/27/2022]
Abstract
We synthesised the findings of intervention studies on Tuberculosis control (TC) in low- and middle-income countries with specific reference to India through a systematic review during the period 2000-2017 in order to identify the implementation gap. The research questions were framed using PICOS (population, intervention, comparison, outcomes and study design) framework and PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines were used for study selection. The search was mainly carried out in MEDLINE/PubMed, Web of Knowledge and Cochrane libraries. DOTS was found to be the most effective intervention program for control of Tuberculosis. Lack of utilization of the capacity of various level health staff, accessibility in utilizing health facilities and insufficient community involvement was identified as the major gaps for TC. In the case of India, each state has its own priority and applicability for different TC interventions. Most of the studies on implementation of the TC program supported the encouraging effect of the intervention in the control of Tuberculosis. The specific need of each country is clearly reflected in many of the selected studies. In order to establish the association of intervention and its implementation gaps on TB control, more rigorous evaluation methods are needed including meta-analysis. REGISTRATION: PROSPERO registration number: CRD42018070406.
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Affiliation(s)
- Anil Kumar Indira Krishnan
- School of Public Health, 3rd Floor, Medical College, SRM University, Kattankulathur, Kancheepuram, Tamilnadu, 603203, India
| | - G K Mini
- Global Institute of Public Health, Ananthapuri Hospitals and Research Institute, Trivandrum, 695024, India; Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 695011, Kerala, India.
| | - L R Aravind
- Health System Research India Initiative (HSRII), S-10, Vrindavan Gardens, Pattom P.O, Thiruvananthapuram, 695004, India
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31
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Collin SM, Wurie F, Muzyamba MC, de Vries G, Lönnroth K, Migliori GB, Abubakar I, Anderson SR, Zenner D. Effectiveness of interventions for reducing TB incidence in countries with low TB incidence: a systematic review of reviews. Eur Respir Rev 2019; 28:28/152/180107. [PMID: 31142548 DOI: 10.1183/16000617.0107-2018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/22/2019] [Indexed: 12/18/2022] Open
Abstract
AIMS What is the evidence base for the effectiveness of interventions to reduce tuberculosis (TB) incidence in countries which have low TB incidence? METHODS We conducted a systematic review of interventions for TB control and prevention relevant to low TB incidence settings (<10 cases per 100 000 population). Our analysis was stratified according to "direct" or "indirect" effects on TB incidence. Review quality was assessed using AMSTAR2 criteria. We summarised the strength of review level evidence for interventions as "sufficient", "tentative", "insufficient" or "no" using a framework based on the consistency of evidence within and between reviews. RESULTS We found sufficient review level evidence for direct effects on TB incidence/case prevention of vaccination and treatment of latent TB infection. We also found sufficient evidence of beneficial indirect effects attributable to drug susceptibility testing and adverse indirect effects (measured as sub-optimal treatment outcomes) in relation to use of standardised first-line drug regimens for isoniazid-resistant TB and intermittent dosing regimens. We found insufficient review level evidence for direct or indirect effects of interventions in other areas, including screening, adherence, multidrug-resistant TB, and healthcare-associated infection. DISCUSSION Our review has shown a need for stronger evidence to support expert opinion and country experience when formulating TB control policy.
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Affiliation(s)
- Simon M Collin
- TB Unit, National Infection Service, Public Health England, London, UK
| | - Fatima Wurie
- TB Unit, National Infection Service, Public Health England, London, UK
| | - Morris C Muzyamba
- TB Unit, National Infection Service, Public Health England, London, UK
| | | | | | | | | | - Sarah R Anderson
- TB Unit, National Infection Service, Public Health England, London, UK
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32
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Kendall EA, Sahu S, Pai M, Fox GJ, Varaine F, Cox H, Cegielski JP, Mabote L, Vassall A, Dowdy DW. What will it take to eliminate drug-resistant tuberculosis? Int J Tuberc Lung Dis 2019; 23:535-546. [PMID: 31097060 PMCID: PMC6600801 DOI: 10.5588/ijtld.18.0217] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Drug-resistant tuberculosis (DR-TB) is challenging to diagnose, treat, and prevent, but this situation is slowly changing. If the world is to drastically reduce the incidence of DR-TB, we must stop creating new DR-TB as an essential first step. The DR-TB epidemic that is ongoing should also be directly addressed. First-line drug resistance must be rapidly detected using universal molecular testing for resistance to at least rifampin and, preferably, other key drugs at initial TB diagnosis. DR-TB treatment outcomes must also improve dramatically. Effective use of currently available, new, and repurposed drugs, combined with patient-centered treatment that aids adherence and reduces catastrophic costs, are essential. Innovations within sight, such as short, highly effective, broadly indicated regimens, paired with point-of-care drug susceptibility testing, could accelerate progress in treatment outcomes. Preventing or containing resistance to second-line and novel drugs is also critical and will require high-quality systems for diagnosis, regimen selection, and treatment monitoring. Finally, earlier detection and/or prevention of DR-TB is necessary, with particular attention to airborne infection control, case finding, and preventive therapy for contacts of patients with DR-TB. Implementing these strategies can overcome the barrier that DR-TB represents for global TB elimination efforts, and could ultimately make global elimination of DR-TB (fewer than one annual case per million population worldwide) attainable. There is a strong cost-effectiveness case to support pursuing DR-TB elimination; however, achieving this goal will require substantial global investment plus political and societal commitment at national and local levels.
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Affiliation(s)
- E A Kendall
- Johns Hopkins University, Baltimore, Maryland, USA
| | - S Sahu
- Stop TB Partnership, Geneva, Switzerland
| | - M Pai
- McGill International TB Center, McGill University, Montreal, Quebec, Canada
| | - G J Fox
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - F Varaine
- Médecins Sans Frontières, Paris, France
| | - H Cox
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; **Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - L Mabote
- AIDS and Rights Alliance for Southern Africa, Cape Town, South Africa
| | - A Vassall
- London School of Hygiene & Tropical Medicine, London, UK
| | - D W Dowdy
- Johns Hopkins University, Baltimore, Maryland, USA
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33
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El Hamdouni M, Bourkadi JE, Benamor J, Hassar M, Cherrah Y, Ahid S. Treatment outcomes of drug resistant tuberculosis patients in Morocco: multi-centric prospective study. BMC Infect Dis 2019; 19:316. [PMID: 30975090 PMCID: PMC6458640 DOI: 10.1186/s12879-019-3931-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 03/21/2019] [Indexed: 11/12/2022] Open
Abstract
Background Drug resistant tuberculosis is a major public health problem in Morocco and worldwide. Treatment outcome of drug resistant tuberculosis is poor and requires a long period of treatment with many toxic and expensive antituberculosis drugs. The aim of this study is to evaluate treatment outcomes of drug resistant tuberculosis and to determine predictors of poor treatment outcomes in a large region of Morocco. Methods It is a multi-centric observational cohort study conducted from January 01, 2014 to January 01, 2016. A questionnaire was established to collect data from clinical charts of patients with confirmed resistant TB. The study was carried out in all the 11 centers located in the Rabat-Salé-Kénitra region of Morocco where drug resistant tuberculosis is treated. Treatment outcomes were reported and the definitions and classifications of these outcomes were defined according to the WHO guidelines. Univariate and multivariate logistic regression were conducted to determine factors associated with poor drug resistant tuberculosis treatment outcomes in Morocco. Results In our study, 101 patients were treated for drug resistant tuberculosis between January 01, 2014 and January 01, 2016. Patients’ age ranged from 9.5 to70 years; 72patients (71.3%) were male and 80 patients (79.2%) were living in urban areas. Thirty two patients were smokers, 74 patients had multidrug-resistant tuberculosis, 25 patients had rifampicin resistance and 2 patients had isoniazid resistance. Treatment outcomes of tuberculosis patients were as follows: 45 patients were cured (44.5%), 9 completed treatment (8.9%), 5 patients died before completing the treatment, 35 patients were lost to follow up (34.6%) and 7 patients had treatment failure. In the multivariate analysis, being a smoker is an independent risk factor for poor treatment outcomes, (p-value = 0.015, OR = 4.355, IC [1.327–14.292]). Conclusion Treatment success outcomes occurred in more than half of the cases, which is lower than the World Health Organization target of at least a 75% success rate. A significant number of patients abandoned their treatment before its completion. These dropouts are a serious public health hazard that needs to be addressed urgently.
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Affiliation(s)
- Mariam El Hamdouni
- Equipe de Recherche de Pharmacoéconomie & Pharmacoépidémiologie. Laboratoire de Pharmacologie & Toxicologie, Faculté de Médecine et de Pharmacie, Université Mohammed V, Rabat, Morocco.
| | | | - Jouda Benamor
- Service de Pneumologie, Hôpital My Youssef, Rabat, Morocco
| | - Mohammed Hassar
- Equipe de Recherche de Pharmacoéconomie & Pharmacoépidémiologie. Laboratoire de Pharmacologie & Toxicologie, Faculté de Médecine et de Pharmacie, Université Mohammed V, Rabat, Morocco
| | - Yahia Cherrah
- Equipe de Recherche de Pharmacoéconomie & Pharmacoépidémiologie. Laboratoire de Pharmacologie & Toxicologie, Faculté de Médecine et de Pharmacie, Université Mohammed V, Rabat, Morocco
| | - Samir Ahid
- Equipe de Recherche de Pharmacoéconomie & Pharmacoépidémiologie. Laboratoire de Pharmacologie & Toxicologie, Faculté de Médecine et de Pharmacie, Université Mohammed V, Rabat, Morocco
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34
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Reid MJA, Arinaminpathy N, Bloom A, Bloom BR, Boehme C, Chaisson R, Chin DP, Churchyard G, Cox H, Ditiu L, Dybul M, Farrar J, Fauci AS, Fekadu E, Fujiwara PI, Hallett TB, Hanson CL, Harrington M, Herbert N, Hopewell PC, Ikeda C, Jamison DT, Khan AJ, Koek I, Krishnan N, Motsoaledi A, Pai M, Raviglione MC, Sharman A, Small PM, Swaminathan S, Temesgen Z, Vassall A, Venkatesan N, van Weezenbeek K, Yamey G, Agins BD, Alexandru S, Andrews JR, Beyeler N, Bivol S, Brigden G, Cattamanchi A, Cazabon D, Crudu V, Daftary A, Dewan P, Doepel LK, Eisinger RW, Fan V, Fewer S, Furin J, Goldhaber-Fiebert JD, Gomez GB, Graham SM, Gupta D, Kamene M, Khaparde S, Mailu EW, Masini EO, McHugh L, Mitchell E, Moon S, Osberg M, Pande T, Prince L, Rade K, Rao R, Remme M, Seddon JA, Selwyn C, Shete P, Sachdeva KS, Stallworthy G, Vesga JF, Vilc V, Goosby EP. Building a tuberculosis-free world: The Lancet Commission on tuberculosis. Lancet 2019; 393:1331-1384. [PMID: 30904263 DOI: 10.1016/s0140-6736(19)30024-8] [Citation(s) in RCA: 215] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 12/20/2018] [Accepted: 12/25/2018] [Indexed: 11/22/2022]
Affiliation(s)
- Michael J A Reid
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA.
| | - Nimalan Arinaminpathy
- School of Public Health, Imperial College London, London, UK; Faculty of Medicine, Imperial College London, London, UK
| | - Amy Bloom
- Tuberculosis Division, United States Agency for International Development, Washington, DC, USA
| | - Barry R Bloom
- Department of Global Health and Population, Harvard University, Cambridge, MA, USA
| | | | - Richard Chaisson
- Departments of Medicine, Epidemiology, and International Health, Johns Hopkins School of Medicine, Baltimore, MA, USA
| | | | | | - Helen Cox
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Mark Dybul
- Department of Medicine, Centre for Global Health and Quality, Georgetown University, Washington, DC, USA
| | | | - Anthony S Fauci
- National Institute of Allergy and Infectious Diseases, US National Institutes of Health, Maryland, MA, USA
| | | | - Paula I Fujiwara
- Department of Tuberculosis and HIV, The International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Timothy B Hallett
- School of Public Health, Imperial College London, London, UK; Faculty of Medicine, Imperial College London, London, UK
| | | | | | - Nick Herbert
- Global TB Caucus, Houses of Parliament, London, UK
| | - Philip C Hopewell
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Chieko Ikeda
- Department of GLobal Health, Ministry of Heath, Labor and Welfare, Tokyo, Japan
| | - Dean T Jamison
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Aamir J Khan
- Interactive Research & Development, Karachi, Pakistan
| | - Irene Koek
- Global Health Bureau, United States Agency for International Development, Washington, DC, USA
| | - Nalini Krishnan
- Resource Group for Education and Advocacy for Community Health, Chennai, India
| | - Aaron Motsoaledi
- South African National Department of Health, Pretoria, South Africa
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada; McGill International TB Center, McGill University, Montreal, QC, Canada
| | - Mario C Raviglione
- University of Milan, Milan, Italy; Global Studies Institute, University of Geneva, Geneva, Switzerland
| | - Almaz Sharman
- Academy of Preventive Medicine of Kazakhstan, Almaty, Kazakhstan
| | - Peter M Small
- Global Health Institute, School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | | | - Zelalem Temesgen
- Department of Infectious Diseases, Mayo Clinic, Rochester, MI, USA
| | - Anna Vassall
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK; Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, Netherlands
| | | | | | - Gavin Yamey
- Center for Policy Impact in Global Health, Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Bruce D Agins
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Sofia Alexandru
- Institutul de Ftiziopneumologie Chiril Draganiuc, Chisinau, Moldova
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Naomi Beyeler
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Stela Bivol
- Center for Health Policies and Studies, Chisinau, Moldova
| | - Grania Brigden
- Department of Tuberculosis and HIV, The International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Adithya Cattamanchi
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Danielle Cazabon
- McGill International TB Center, McGill University, Montreal, QC, Canada
| | - Valeriu Crudu
- Center for Health Policies and Studies, Chisinau, Moldova
| | - Amrita Daftary
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada; McGill International TB Center, McGill University, Montreal, QC, Canada
| | - Puneet Dewan
- Bill & Melinda Gates Foundation, New Delhi, India
| | - Laurie K Doepel
- National Institute of Allergy and Infectious Diseases, US National Institutes of Health, Maryland, MA, USA
| | - Robert W Eisinger
- National Institute of Allergy and Infectious Diseases, US National Institutes of Health, Maryland, MA, USA
| | - Victoria Fan
- T H Chan School of Public Health, Harvard University, Cambridge, MA, USA; Office of Public Health Studies, University of Hawaii, Mānoa, HI, USA
| | - Sara Fewer
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Jennifer Furin
- Division of Infectious Diseases & HIV Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Jeremy D Goldhaber-Fiebert
- Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
| | - Gabriela B Gomez
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Stephen M Graham
- Department of Tuberculosis and HIV, The International Union Against Tuberculosis and Lung Disease, Paris, France; Department of Paediatrics, Center for International Child Health, University of Melbourne, Melbourne, VIC, Australia; Burnet Institute, Melbourne, VIC, Australia
| | - Devesh Gupta
- Revised National TB Control Program, New Delhi, India
| | - Maureen Kamene
- National Tuberculosis, Leprosy and Lung Disease Program, Ministry of Health, Nairobi, Kenya
| | | | - Eunice W Mailu
- National Tuberculosis, Leprosy and Lung Disease Program, Ministry of Health, Nairobi, Kenya
| | | | - Lorrie McHugh
- Office of the Secretary-General's Special Envoy on Tuberculosis, United Nations, Geneva, Switzerland
| | - Ellen Mitchell
- International Institute of Social Studies, Erasmus University Rotterdam, The Hague, Netherland
| | - Suerie Moon
- Department of Global Health and Population, Harvard University, Cambridge, MA, USA; Global Health Centre, The Graduate Institute Geneva, Geneva, Switzerland
| | | | - Tripti Pande
- McGill International TB Center, McGill University, Montreal, QC, Canada
| | - Lea Prince
- Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
| | | | - Raghuram Rao
- Ministry of Health and Family Welfare, New Delhi, India
| | - Michelle Remme
- International Institute for Global Health, United Nations University, Kuala Lumpur, Malaysia
| | - James A Seddon
- Department of Medicine, Imperial College London, London, UK; Faculty of Medicine, Imperial College London, London, UK; Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Casey Selwyn
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Priya Shete
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Juan F Vesga
- School of Public Health, Imperial College London, London, UK; Faculty of Medicine, Imperial College London, London, UK
| | | | - Eric P Goosby
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
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Law S, Daftary A, O'Donnell M, Padayatchi N, Calzavara L, Menzies D. Interventions to improve retention-in-care and treatment adherence among patients with drug-resistant tuberculosis: a systematic review. Eur Respir J 2019; 53:13993003.01030-2018. [PMID: 30309972 DOI: 10.1183/13993003.01030-2018] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 09/20/2018] [Indexed: 11/05/2022]
Abstract
The global loss to follow-up (LTFU) rate among drug-resistant tuberculosis (DR-TB) patients remains high at 15%. We conducted a systematic review to explore interventions to reduce LTFU during DR-TB treatment.We searched for studies published between January 2000 and December 2017 that provided any form of psychosocial or material support for patients with DR-TB. We estimated point estimates and 95% confidence intervals of the proportion LTFU. We performed subgroup analyses and pooled estimates using an exact binomial likelihood approach.We included 35 DR-TB cohorts from 25 studies, with a pooled proportion LTFU of 17 (12-23)%. Cohorts that received any form of psychosocial or material support had lower LTFU rates than those that received standard care. Psychosocial support throughout treatment, via counselling sessions or home visits, was associated with lower LTFU rates compared to when support was provided through a limited number of visits or not at all.Our review suggests that psychosocial support should be provided throughout DR-TB treatment in order to reduce treatment LTFU. Future studies should explore the potential of providing self-administered therapy complemented with psychosocial support during the continuation phase.
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Affiliation(s)
- Stephanie Law
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Amrita Daftary
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.,McGill International TB Centre, McGill University, Montreal, QC, Canada.,CAPRISA-MRC TB-HIV Pathogenesis and Treatment Unit, Durban, South Africa
| | - Max O'Donnell
- CAPRISA-MRC TB-HIV Pathogenesis and Treatment Unit, Durban, South Africa.,Division of Pulmonary, Allergy and Critical Care Medicine, and Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
| | - Nesri Padayatchi
- CAPRISA-MRC TB-HIV Pathogenesis and Treatment Unit, Durban, South Africa
| | - Liviana Calzavara
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Dick Menzies
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.,McGill International TB Centre, McGill University, Montreal, QC, Canada
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36
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Jain S, Bhagyalaxmi A, Patel P, Barot D. Reasons for the delay in the initiation of treatment and initial default among drug-resistant tuberculosis patients in Ahmedabad corporation area. Indian J Public Health 2019; 63:377-379. [DOI: 10.4103/ijph.ijph_26_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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37
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Saleh Jaber AA, Khan AH, Syed Sulaiman SA. Evaluation of tuberculosis defaulters in Yemen from the perspective of health care service. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2018. [DOI: 10.1111/jphs.12259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Ammar Ali Saleh Jaber
- Department of Clinical Pharmacy; School of Pharmaceutical Sciences; Universiti Sains Malaysia; Penang Malaysia
| | - Amer Hayat Khan
- Department of Clinical Pharmacy; School of Pharmaceutical Sciences; Universiti Sains Malaysia; Penang Malaysia
| | - Syed Azhar Syed Sulaiman
- Department of Clinical Pharmacy; School of Pharmaceutical Sciences; Universiti Sains Malaysia; Penang Malaysia
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Priedeman Skiles M, Curtis SL, Angeles G, Mullen S, Senik T. Evaluating the impact of social support services on tuberculosis treatment default in Ukraine. PLoS One 2018; 13:e0199513. [PMID: 30092037 PMCID: PMC6084809 DOI: 10.1371/journal.pone.0199513] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 06/09/2018] [Indexed: 01/10/2023] Open
Abstract
Ukraine is among the top 20 highest drug-resistant tuberculosis burden countries in the world. Driving the high drug-resistant tuberculosis rates is an unchecked treatment default rate. This evaluation measures the effect of social support provided to tuberculosis patients at risk of defaulting on treatment during outpatient treatment. Five tuberculosis patient cohorts, served in three oblasts from 2011 and 2012, were constructed from medical records to compare risk factors for default, receipt of social services, and treatment outcome. Regression analyses were used to identify risk factors predictive of treatment default and to estimate the impact of the social support program on treatment default, controlling for risk, disease status, and demographics. In 2012, tuberculosis patients receiving social support in Ukraine reduced their probability of defaulting on continuation treatment by 10 percentage points compared to high-risk patients who did not receive social support in 2012 or 2011. Treatment success rates for the high-risk patients receiving social support were comparable to the low-risk cohorts and significantly improved over the high-risk comparison cohorts. Further research is recommended to quantify the costs and benefits for scaling-up social support services, evaluate social support program fidelity, identify which populations respond best to select services, and what barriers might still exist to achieve better adherence. With that information, tailoring programs to most effectively reach and serve clients in a patient-centered approach may reap substantial rewards for Ukraine.
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Affiliation(s)
- Martha Priedeman Skiles
- MEASURE Evaluation Project, Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | - Siân L. Curtis
- MEASURE Evaluation Project, Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Gustavo Angeles
- MEASURE Evaluation Project, Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | - Tatyana Senik
- International Research Agency IFAK Institut, Kyiv, Ukraine
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Yates TA, Nunn AJ. Efficacy and safety of regimens for drug-resistant tuberculosis. THE LANCET. INFECTIOUS DISEASES 2018; 16:1218-1219. [PMID: 27788973 DOI: 10.1016/s1473-3099(16)30390-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 09/19/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Tom A Yates
- Institute for Global Health, University College London, London WC1N 1EH, UK.
| | - Andrew J Nunn
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, UK
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Court RG, Wiesner L, Chirehwa MT, Stewart A, de Vries N, Harding J, Gumbo T, McIlleron H, Maartens G. Effect of lidocaine on kanamycin injection-site pain in patients with multidrug-resistant tuberculosis. Int J Tuberc Lung Dis 2018; 22:926-930. [PMID: 29991403 PMCID: PMC6040239 DOI: 10.5588/ijtld.18.0091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 03/18/2018] [Indexed: 11/10/2022] Open
Abstract
SETTING Reducing pain from intramuscular injection of kanamycin (KM) could improve the tolerability of multidrug-resistant tuberculosis (MDR-TB) treatment. Lidocaine has been shown to be an effective anaesthetic diluent for some intramuscular injections, but has not been investigated with KM in the treatment of adult patients with MDR-TB. OBJECTIVE AND DESIGN We performed a randomised single-blinded crossover study to determine if lidocaine reduces KM injection-site pain. We recruited patients aged 18 years on MDR-TB treatment at two TB hospitals in Cape Town, South Africa. KM pharmacokinetic parameters and a validated numeric pain scale were used at intervals over 10 h following the injection of KM with and without lidocaine on two separate occasions. RESULTS Twenty participants completed the study: 11 were males, the median age was 36 years, 11 were HIV-infected, and the median body mass index was 17.5 kg/m2. The highest pain scores occurred early, and the median pain score was 0 by 30 min. The use of lidocaine with KM significantly reduced pain at the time of injection and 15 min post-dose. On multiple regression analysis, lidocaine halved pain scores (adjusted OR 0.5, 95%CI 0.3-0.9). The area under the curve at 0-10 h of KM with and without lidocaine was respectively 147.7 and 143.6 μg·h/ml. CONCLUSION Lidocaine significantly reduces early injection-site pain and has no effect on KM pharmacokinetics.
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Affiliation(s)
- R G Court
- Division of Clinical Pharmacology, Department of Medicine
| | - L Wiesner
- Division of Clinical Pharmacology, Department of Medicine
| | - M T Chirehwa
- Division of Clinical Pharmacology, Department of Medicine
| | - A Stewart
- Clinical Research Centre, Faculty of Health Sciences, University of Cape Town, Cape Town
| | | | - J Harding
- D P Marais Hospital, Cape Town, South Africa
| | - T Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - H McIlleron
- Division of Clinical Pharmacology, Department of Medicine
| | - G Maartens
- Division of Clinical Pharmacology, Department of Medicine
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Alipanah N, Jarlsberg L, Miller C, Linh NN, Falzon D, Jaramillo E, Nahid P. Adherence interventions and outcomes of tuberculosis treatment: A systematic review and meta-analysis of trials and observational studies. PLoS Med 2018; 15:e1002595. [PMID: 29969463 PMCID: PMC6029765 DOI: 10.1371/journal.pmed.1002595] [Citation(s) in RCA: 215] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 05/29/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Incomplete adherence to tuberculosis (TB) treatment increases the risk of delayed culture conversion with continued transmission in the community, as well as treatment failure, relapse, and development or amplification of drug resistance. We conducted a systematic review and meta-analysis of adherence interventions, including directly observed therapy (DOT), to determine which approaches lead to improved TB treatment outcomes. METHODS AND FINDINGS We systematically reviewed Medline as well as the references of published review articles for relevant studies of adherence to multidrug treatment of both drug-susceptible and drug-resistant TB through February 3, 2018. We included randomized controlled trials (RCTs) as well as prospective and retrospective cohort studies (CSs) with an internal or external control group that evaluated any adherence intervention and conducted a meta-analysis of their impact on TB treatment outcomes. Our search identified 7,729 articles, of which 129 met the inclusion criteria for quantitative analysis. Seven adherence categories were identified, including DOT offered by different providers and at various locations, reminders and tracers, incentives and enablers, patient education, digital technologies (short message services [SMSs] via mobile phones and video-observed therapy [VOT]), staff education, and combinations of these interventions. When compared with DOT alone, self-administered therapy (SAT) was associated with lower rates of treatment success (CS: risk ratio [RR] 0.81, 95% CI 0.73-0.89; RCT: RR 0.94, 95% CI 0.89-0.98), adherence (CS: RR 0.83, 95% CI 0.75-0.93), and sputum smear conversion (RCT: RR 0.92, 95% CI 0.87-0.98) as well as higher rates of development of drug resistance (CS: RR 4.19, 95% CI 2.34-7.49). When compared to DOT provided by healthcare providers, DOT provided by family members was associated with a lower rate of adherence (CS: RR 0.86, 95% CI 0.79-0.94). DOT delivery in the community versus at the clinic was associated with a higher rate of treatment success (CS: RR 1.08, 95% CI 1.01-1.15) and sputum conversion at the end of two months (CS: RR 1.05, 95% CI 1.02-1.08) as well as lower rates of treatment failure (CS: RR 0.56, 95% CI 0.33-0.95) and loss to follow-up (CS: RR 0.63, 95% CI 0.40-0.98). Medication monitors improved adherence and treatment success and VOT was comparable with DOT. SMS reminders led to a higher treatment completion rate in one RCT and were associated with higher rates of cure and sputum conversion when used in combination with medication monitors. TB treatment outcomes improved when patient education, healthcare provider education, incentives and enablers, psychological interventions, reminders and tracers, or mobile digital technologies were employed. Our findings are limited by the heterogeneity of the included studies and lack of standardized research methodology on adherence interventions. CONCLUSION TB treatment outcomes are improved with the use of adherence interventions, such as patient education and counseling, incentives and enablers, psychological interventions, reminders and tracers, and digital health technologies. Trained healthcare providers as well as community delivery provides patient-centered DOT options that both enhance adherence and improve treatment outcomes as compared to unsupervised, SAT alone.
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Affiliation(s)
- Narges Alipanah
- University of California San Francisco, Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General, San Francisco, California, United States of America
- Santa Clara Valley Medical Center, Department of Internal Medicine, San Jose, California, United States of America
| | - Leah Jarlsberg
- University of California San Francisco, Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General, San Francisco, California, United States of America
| | - Cecily Miller
- University of California San Francisco, Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General, San Francisco, California, United States of America
| | - Nguyen Nhat Linh
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Dennis Falzon
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | | | - Payam Nahid
- University of California San Francisco, Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General, San Francisco, California, United States of America
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Yin J, Wang X, Zhou L, Wei X. The relationship between social support, treatment interruption and treatment outcome in patients with multidrug-resistant tuberculosis in China: a mixed-methods study. Trop Med Int Health 2018; 23:668-677. [PMID: 29691959 DOI: 10.1111/tmi.13066] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Multidrug-resistant tuberculosis (MDR-TB) has been a major threat for successful TB control. We examined the relationship between social support and treatment outcomes in MDR-TB patients and evaluated barriers to social support. METHODS Retrospective cohort study with MDR-TB patients enrolled in the Global Fund programme between 1 January 2009 and 30 June 2014 in Zhejiang, China. We reviewed all MDR-TB patients' diagnoses and treatment outcomes. In-depth interviews were conducted with 10 community health workers and 10 patients. Pathway analysis was employed to examine the association between social support and treatment outcomes, and the mediating effect of medication adherence on their relationship. RESULTS Of 218 participants, 144 (66%) were successfully treated and 59 (27%) had poor treatment adherence. Directly observed therapy (DOT) had an indirect positive effect on treatment success, mediating through medication adherence (β = 0.541, P = 0.008; β = 0.538, P < 0.001). Financial support had both a direct (β = 0.769, P < 0.001) and an indirect positive effect on treatment success, which was mediated by a self-reported social support scale (β = 0.541, P = 0.008; β = 0.538, P < 0.001). The interviews indicated poor performance of DOT. Patients often suffered from substantial stigma, but were not provided with psychological support. CONCLUSION DOT and financial support were effective strategies for improving successful treatment outcomes in MDR-TB patients, but they were delivered not considering patients' perspectives. There is an urgent need for consistent and specific psychological support for MDR-TB patients in their communities.
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Affiliation(s)
- Jia Yin
- School of Health Care Management, Shandong University, Shandong, China.,Key Laboratory of Health Economics and Policy Research, NHFPC, Shandong University, Shandong, China.,Center for Health Management and Policy Research, Shandong University, Shandong, China
| | - Xiaomeng Wang
- TB Department, Zhejiang Centre for Disease Control and Prevention, Hangzhou, China
| | - Lin Zhou
- TB Department, Zhejiang Centre for Disease Control and Prevention, Hangzhou, China
| | - Xiaolin Wei
- Division of Clinical Public Health and Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Viana PVDS, Redner P, Ramos JP. Factors associated with loss to follow-up and death in cases of drug-resistant tuberculosis (DR-TB) treated at a reference center in Rio de Janeiro, Brazil. CAD SAUDE PUBLICA 2018; 34:e00048217. [PMID: 29768580 DOI: 10.1590/0102-311x00048217] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 10/31/2017] [Indexed: 11/21/2022] Open
Abstract
Drug-resistant tuberculosis (DR-TB) poses a serious threat to tuberculosis (TB) control in Brazil and worldwide. The current study investigated factors associated with loss to follow-up and death in the course of treatment for DR-TB in a tertiary reference center in the city of Rio de Janeiro, Brazil. This was a retrospective cohort study of cases reported to the Information System on Special Treatments for Tuberculosis (SITETB) from January 1, 2012, to December 31, 2013. A total of 257 patients were reported to the SITETB and initiated treatment for DR-TB. Of this total, 139 (54.1%) achieved treatment success as the outcome, 54 (21%) were lost to follow-up, and 21 (8.2%) died. Following a multiple multinomial logistic regression analysis, the age bracket older than 50 years was the only protective factor against loss to follow-up, whereas less than eight years of schooling and reentry after loss to follow-up were considered risk factors. Reentry after loss to follow-up, relapse, and treatment failure appeared as risk factors. Our data reinforce the concept that loss to follow-up in drug-resistant tuberculosis is a serious public health problem, and that adequate follow-up of treatment is necessary in patients with this history and low schooling. A social support network for patients is also indispensable for avoiding unfavorable outcomes.
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Affiliation(s)
| | - Paulo Redner
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | - Jesus Pais Ramos
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
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Scheffer MC, Prim RI, Wildner LM, Medeiros TF, Maurici R, Kupek E, Bazzo ML. Performance of centralized versus decentralized tuberculosis treatment services in Southern Brazil, 2006-2015. BMC Public Health 2018; 18:554. [PMID: 29699537 PMCID: PMC5922025 DOI: 10.1186/s12889-018-5468-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 04/17/2018] [Indexed: 11/16/2022] Open
Abstract
Background Tuberculosis (TB) control programs face the challenges of decreasing incidence, mortality rates, and drug resistance while increasing treatment adherence. The Brazilian TB control program recommended the decentralization of patient care as a strategy for combating the disease. This study evaluated the performance of this policy in an area with high default rates, comparing epidemiological and operational indicators between two similar municipalities. Methods This study analyzed epidemiological and operational indicators on new cases of pulmonary tuberculosis reported in the Brazilian Notifiable Diseases Information System between 2006 and 2015. In addition, to characterize differences between the populations of the two studied municipalities, a prospective cohort study was conducted between 2014 and 2015, in which patients with new cases of culture-confirmed pulmonary tuberculosis were interviewed and monitored until the disease outcome. A descriptive analysis, the chi-square test, and a Poisson regression model were employed to compare TB treatment outcomes and health care indicators between the municipalities. Results Two thousand three hundred nine cases were evaluated, of which 207 patients were interviewed. Over the 2006–2015 period, TB incidence per 100,000 population in the municipality with decentralized care was significantly higher (39%, 95% CI 27–49%) in comparison to that of the municipality with centralized care. TB treatment default rate (45%, 95% CI 12–90%) was also higher in the municipality with decentralized care. During the two-year follow-up, significant differences were found between patients in centralized care and those in decentralized care regarding treatment success (84.5 vs. 66.1%), treatment default (10.7 vs. 25.8%), illicit drug use (27.7 vs. 45.9%), and homelessness (3.6 vs. 12.9%). The operational indicators revealed that the proportion of control smear tests, medical imaging, and HIV tests were all significantly higher in the centralized care. However, a significantly higher proportion of patients started treatment in the early stages of the disease in the municipality with decentralized care. Conclusions These data showed a low success rate in TB treatment in both municipalities. Decentralization of TB care, alone, did not improve the main epidemiological and operational indicators related to disease control when compared to centralized care. Full implementation of strategies already recommended is needed to improve TB treatment success rates.
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Affiliation(s)
- Mara Cristina Scheffer
- Departamento de Análises Clínicas for Programa de Pós-Graduação em Farmácia da, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Rodrigo Ivan Prim
- Departamento de Análises Clínicas for Programa de Pós-Graduação em Farmácia da, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Leticia Muraro Wildner
- Departamento de Análises Clínicas for Programa de Pós-Graduação em Farmácia da, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Taiane Freitas Medeiros
- Departamento de Análises Clínicas for Programa de Pós-Graduação em Farmácia da, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Rosemeri Maurici
- Departamento de Clínica Médica, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Emil Kupek
- Departamento de Saúde Pública, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Maria Luiza Bazzo
- Departamento de Análises Clínicas for Programa de Pós-Graduação em Farmácia da, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil. .,Laboratório de Biologia Molecular, Sorologia e Micobactérias, Departamento de Análises Clínicas, Centro de Ciências da Saúde, Universidade Federal de Santa Catarina, Campos Universitário- Trindade, Florianopolis, SC, 88040-900, Brazil.
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MDR-TB patients in KwaZulu-Natal, South Africa: Cost-effectiveness of 5 models of care. PLoS One 2018; 13:e0196003. [PMID: 29668748 PMCID: PMC5906004 DOI: 10.1371/journal.pone.0196003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 04/04/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND South Africa has a high burden of MDR-TB, and to provide accessible treatment the government has introduced different models of care. We report the most cost-effective model after comparing cost per patient successfully treated across 5 models of care: centralized hospital, district hospitals (2), and community-based care through clinics or mobile injection teams. METHODS In an observational study five cohorts were followed prospectively. The cost analysis adopted a provider perspective and economic cost per patient successfully treated was calculated based on country protocols and length of treatment per patient per model of care. Logistic regression was used to calculate propensity score weights, to compare pairs of treatment groups, whilst adjusting for baseline imbalances between groups. Propensity score weighted costs and treatment success rates were used in the ICER analysis. Sensitivity analysis focused on varying treatment success and length of hospitalization within each model. RESULTS In 1,038 MDR-TB patients 75% were HIV-infected and 56% were successfully treated. The cost per successfully treated patient was 3 to 4.5 times lower in the community-based models with no hospitalization. Overall, the Mobile model was the most cost-effective. CONCLUSION Reducing the length of hospitalization and following community-based models of care improves the affordability of MDR-TB treatment without compromising its effectiveness.
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Bastos ML, Cosme LB, Fregona G, do Prado TN, Bertolde AI, Zandonade E, Sanchez MN, Dalcolmo MP, Kritski A, Trajman A, Maciel ELN. Treatment outcomes of MDR-tuberculosis patients in Brazil: a retrospective cohort analysis. BMC Infect Dis 2017; 17:718. [PMID: 29137626 PMCID: PMC5686842 DOI: 10.1186/s12879-017-2810-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 11/02/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multidrug-resistant tuberculosis (MDR-TB) is a threat for the global TB epidemic control. Despite existing evidence that individualized treatment of MDR-TB is superior to standardized regimens, the latter are recommended in Brazil, mainly because drug-susceptibility tests (DST) are often restricted to first-line drugs in public laboratories. We compared treatment outcomes of MDR-TB patients using standardized versus individualized regimens in Brazil, a high TB-burden, low resistance setting. METHODS The 2007-2013 cohort of the national electronic database (SITE-TB), which records all special treatments including drug-resistance, was analysed. Patients classified as MDR-TB in SITE-TB were eligible. Treatment outcomes were classified as successful (cure/treatment completed) or unsuccessful (failure/relapse/death/loss to follow-up). The odds for successful treatment according to type of regimen were controlled for demographic and clinical variables. RESULTS Out of 4029 registered patients, we included 1972 recorded from 2010 to 2012, who had more complete outcome data. The overall success proportion was 60%. Success was more likely in non-HIV patients, sputum-negative at baseline, with unilateral disease and without prior DR-TB. Adjusted for these variables, those receiving standardized regimens had 2.7-fold odds of success compared to those receiving individualized treatments when failure/relapse were considered, and 1.4-fold odds of success when death was included as an unsuccessful outcome. When loss to follow-up was added, no difference between types of treatment was observed. Patients who used levofloxacin instead of ofloxacin had 1.5-fold odds of success. CONCLUSION In this large cohort of MDR-TB patients with a low proportion of successful outcomes, standardized regimens had superior efficacy than individualized regimens, when adjusted for relevant variables. In addition to the limitations of any retrospective observational study, database quality hampered the analyses. Also, decision on the use of standard or individualized regimens was possibly not random, and may have introduced bias. Efforts were made to reduce classification bias and confounding. Until higher-quality evidence is produced, and DST becomes widely available in the country, our findings support the Brazilian recommendation for the use of standardized instead of individualized regimens for MDR-TB, preferably containing levofloxacin. Better quality surveillance data and DST availability across the country are necessary to improve MDR-TB control in Brazil.
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Affiliation(s)
- Mayara Lisboa Bastos
- Social Medicine Institute, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Lorrayne Beliqui Cosme
- Public Health Post-Graduation Program, Federal University of Espírito Santo, Vitória, ES, Brazil
| | - Geisa Fregona
- Public Health Post-Graduation Program, Federal University of Espírito Santo, Vitória, ES, Brazil
| | | | | | - Eliana Zandonade
- Public Health Post-Graduation Program, Federal University of Espírito Santo, Vitória, ES, Brazil.,Statistical Department, Federal University of Espírito Santo, Vitória, ES, Brazil
| | - Mauro N Sanchez
- Public Health Department, Brasília Federal University, Brasília, DF, Brazil
| | | | - Afrânio Kritski
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Brazilian Tuberculosis Network, Rio de Janeiro, Brazil
| | - Anete Trajman
- Social Medicine Institute, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil. .,Brazilian Tuberculosis Network, Rio de Janeiro, Brazil. .,McGill University, Montreal, Canada. .,, Rua Macedo Sobrinho 74/203, Humaitá 22271-080, Rio de Janeiro, Brazil.
| | - Ethel Leonor Noia Maciel
- Public Health Post-Graduation Program, Federal University of Espírito Santo, Vitória, ES, Brazil.,Brazilian Tuberculosis Network, Rio de Janeiro, Brazil
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Wanyonyi AW, Wanjala PM, Githuku J, Oyugi E, Kutima H. Factors associated with interruption of tuberculosis treatment among patients in Nandi County, Kenya 2015. Pan Afr Med J 2017; 28:11. [PMID: 30167036 PMCID: PMC6113692 DOI: 10.11604/pamj.supp.2017.28.1.9347] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 09/22/2016] [Indexed: 11/26/2022] Open
Abstract
Introduction Kenya is ranked 15th on the list of 22 high-tuberculosis (TB) burden countries with a case notification rate of 440 cases per 100,000 persons. Interruption of TB treatment is one of the major obstacles to effective TB treatment and control. Since 2009, emphasis has been on direct observation treatment short-course (DOTS) to ensure adherence. This study assessed the factors associated with interruption of treatment among patients on DOTS in Nandi County, Kenya. Methods we reviewed medical records and interviewed randomly selected persons from the County TB register, among those initiated on TB treatment between 1st January 2013 and 30th June 2014. Data on socio-demographics, clinical characteristics, behavioral factors, family support, health system factors, income, and lifestyle and treatment interruption (i.e., therapy discontinuation ≥ 2 weeks) were collected. We calculated odds ratios (OR) and 95% confidence intervals (CI) to evaluate factors associated with TB interruption and performed multivariable logistic regression to examine independent risk factors. Results from a total of 1,287 records in the TB register, we randomly selected 280 patients for interview, out of whom 252 were traced. Of the 252 participants interviewed, 149 (59.1%) were males and the mean age was 40.0 (SD ± 15.3) years. Seventy-eight (31.0%) interrupted treatment. Treatment interruption was associated with personal monthly income ≤ 10,000 Kenya shillings ($100) (AOR 4.3, CI = 2.13-8.62) compared to income > 10,000 Kenya shillings, daily alcohol consumption of > 3 days per week (AOR 3.3, CI = 1.72-6.23) compared to consumption of ≤ 3 days per week and average waiting time at the health facility ≥ 1 hour (AOR 3.5 CI = 1.86-6.78) compared to waiting time < 1 hour. Conclusion we suggest expanding DOTS services to increase the number of service points for patients. This will probably reduce the waiting time by distributing the work load across many facilities. Intensifying patient counseling and education prior to initiation of treatment could also be adopted to cover effects of alcohol use during treatment and teach patients to take up some income generating activities.
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Affiliation(s)
- Alfred Wandeba Wanyonyi
- Jomo Kenyatta University of Agriculture and Technology, Kenya.,Field Epidemiology and Laboratory Training Program, Ministry of Health, Kenya
| | | | - Jane Githuku
- Field Epidemiology and Laboratory Training Program, Ministry of Health, Kenya
| | - Elvis Oyugi
- Jomo Kenyatta University of Agriculture and Technology, Kenya.,Field Epidemiology and Laboratory Training Program, Ministry of Health, Kenya
| | - Hellen Kutima
- Jomo Kenyatta University of Agriculture and Technology, Kenya
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Dheda K, Cox H, Esmail A, Wasserman S, Chang KC, Lange C. Recent controversies about MDR and XDR-TB: Global implementation of the WHO shorter MDR-TB regimen and bedaquiline for all with MDR-TB? Respirology 2017; 23:36-45. [PMID: 28850767 DOI: 10.1111/resp.13143] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/26/2017] [Accepted: 07/10/2017] [Indexed: 12/29/2022]
Abstract
Tuberculosis (TB) is now the biggest infectious disease killer worldwide. Although the estimated incidence of TB has marginally declined over several years, it is out of control in some regions including in Africa. The advent of multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) threatens to further destabilize control in several regions of the world. Drug-resistant TB constitutes a significant threat because it underpins almost 25% of global TB mortality, is associated with high morbidity, is a threat to healthcare workers and is unsustainably costly to treat. The advent of highly resistant TB with emerging bacillary resistance to newer drugs has raised further concern. Encouragingly, in addition to preventative strategies, several interventions have recently been introduced to curb the drug-resistant TB epidemic, including newer molecular diagnostic tools, new (bedaquiline and delamanid) and repurposed (linezolid and clofazimine) drugs and shorter and individualized treatment regimens. However, there are several controversies that surround the use of new drugs and regimens, including whether, how and to what extent they should be used, and who specifically should be treated so that outcomes are optimally improved without amplifying the burden of drug resistance, and other potential drawbacks, thus sustaining effectiveness of the new drugs. The equipoise surrounding these controversies is discussed and some recommendations are provided.
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Affiliation(s)
- Keertan Dheda
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Helen Cox
- Division of Medical Microbiology, and the Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Aliasgar Esmail
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Sean Wasserman
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kwok Chiu Chang
- Department of Health, Tuberculosis and Chest Service, Centre for Health Protection, Hong Kong, China
| | - Christoph Lange
- Division of Clinical Infectious Diseases, German Center for Infection Research (DZIF), Research Center Borstel, Borstel, Germany
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49
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Ramalho DMP, Miranda PFC, Andrade MK, Brígido T, Dalcolmo MP, Mesquita E, Dias CF, Gambirasio AN, Ueleres Braga J, Detjen A, Phillips PPJ, Langley I, Fujiwara PI, Squire SB, Oliveira MM, Kritski AL. Outcomes from patients with presumed drug resistant tuberculosis in five reference centers in Brazil. BMC Infect Dis 2017; 17:571. [PMID: 28810911 PMCID: PMC5558720 DOI: 10.1186/s12879-017-2669-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 08/07/2017] [Indexed: 11/10/2022] Open
Abstract
Background The implementation of rapid drug susceptibility testing (DST) is a current global priority for TB control. However, data are scarce on patient-relevant outcomes for presumptive diagnosis of drug-resistant tuberculosis (pDR-TB) evaluated under field conditions in high burden countries. Methods Observational study of pDR-TB patients referred by primary and secondary health units. TB reference centers addressing DR-TB in five cities in Brazil. Patients age 18 years and older were eligible if pDR-TB, culture positive results for Mycobacterium tuberculosis and, if no prior DST results from another laboratory were used by a physician to start anti-TB treatment. The outcome measures were median time from triage to initiating appropriate anti-TB treatment, empirical treatment and, the treatment outcomes. Results Between February,16th, 2011 and February, 15th, 2012, among 175 pDR TB cases, 110 (63.0%) confirmed TB cases with DST results were enrolled. Among study participants, 72 (65.5%) were male and 62 (56.4%) aged 26 to 45 years. At triage, empirical treatment was given to 106 (96.0%) subjects. Among those, 85 were treated with first line drugs and 21 with second line. Median time for DST results was 69.5 [interquartile - IQR: 35.7–111.0] days and, for initiating appropriate anti-TB treatment, the median time was 1.0 (IQR: 0–41.2) days. Among 95 patients that were followed-up during the first 6 month period, 24 (25.3%; IC: 17.5%–34.9%) changed or initiated the treatment after DST results: 16/29 MDRTB, 5/21 DR-TB and 3/45 DS-TB cases. Comparing the treatment outcome to DS-TB cases, MDRTB had higher proportions changing or initiating treatment after DST results (p = 0.01) and favorable outcomes (p = 0.07). Conclusions This study shows a high rate of empirical treatment and long delay for DST results. Strategies to speed up the detection and early treatment of drug resistant TB should be prioritized.
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Affiliation(s)
- D M P Ramalho
- Tuberculosis Academic Program, Medical School and Hospital Complex HUCFF-IDT, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - P F C Miranda
- Tuberculosis Academic Program, Medical School and Hospital Complex HUCFF-IDT, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - M K Andrade
- Tuberculosis Academic Program, Medical School and Hospital Complex HUCFF-IDT, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Helio Fraga Reference Center - ENSP -Fiocruz, Rio de Janeiro, Brazil
| | - T Brígido
- Messejana Hospital -State Secretary of Health, Fortaleza, Ceará, Brazil
| | - M P Dalcolmo
- Helio Fraga Reference Center - ENSP -Fiocruz, Rio de Janeiro, Brazil
| | - E Mesquita
- Ary Parreiras Institute - State Secretary of Health, Rio de Janeiro, Brazil
| | - C F Dias
- Sanatório Partenon Hospital - State Secretary of Health, Porto Alegre, Rio Grande do Sul, Brazil
| | - A N Gambirasio
- Clemente Ferreira Institute - State Secretary of Health, Sao Paulo, Brazil
| | - J Ueleres Braga
- Helio Fraga Reference Center - ENSP -Fiocruz, Rio de Janeiro, Brazil
| | - A Detjen
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | | | - I Langley
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - P I Fujiwara
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - S B Squire
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - M M Oliveira
- Tuberculosis Academic Program, Medical School and Hospital Complex HUCFF-IDT, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - A L Kritski
- Tuberculosis Academic Program, Medical School and Hospital Complex HUCFF-IDT, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
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50
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Wohlleben J, Makhmudova M, Saidova F, Azamova S, Mergenthaler C, Verver S. Risk factors associated with loss to follow-up from tuberculosis treatment in Tajikistan: a case-control study. BMC Infect Dis 2017; 17:543. [PMID: 28778187 PMCID: PMC5545046 DOI: 10.1186/s12879-017-2655-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 07/31/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are very few studies on reasons for loss to follow-up from TB treatment in Central Asia. This study assessed risk factors for LTFU and compared their occurrence with successfully treated (ST) patients in Tajikistan. METHODS This study took place in all TB facilities in the 19 districts with at least 5 TB patients registered as loss to follow-up (LTFU) from treatment. With a matched case control design we included all LTFU patients registered in the selected districts in 2011 and 2012 as cases, with ST patients from the same districts being controls. Data were copied from patient records and registers. Conditional logistic regressions were run to analyse associations between collected variables and LTFU as dependent variable. RESULTS Three hundred cases were compared to 592 controls. Half of the cases had migrated or moved. In multivariate analysis, risk factors associated with increased LTFU were migration to another country (OR 10.6, 95% CI 6.12-18.4), moving within country (OR 11.0, 95% CI 3.50-34.9), having side effects of treatment (OR 3.67, 95% CI 1.68-8.00) and being previously treated for TB (OR 2.03, 95% CI 1.05-3.93). Medical staff also mentioned patient refusal, stigma and family problems as risk factors. CONCLUSIONS LTFU of TB patients in Tajikistan is largely a result of migration, and to a lesser extent associated with side-effects and previous treatment. There is a need to strengthen referral between health facilities within Tajikistan and with neighbouring countries and support patients with side effects and/or previous TB to prevent loss to follow-up from treatment.
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Affiliation(s)
- Jessica Wohlleben
- KNCV Tuberculosis Foundation, Evidence team, The Hague, The Netherlands.,Department of International Health, University Maastricht, Maastricht, The Netherlands
| | | | - Firuza Saidova
- KNCV TB Foundation, country office Tajikistan, Dushanbe, Tajikistan
| | - Shahnoza Azamova
- Republican Center for protection of population from TB, Dushanbe, Tajikistan
| | - Christina Mergenthaler
- KNCV Tuberculosis Foundation, Evidence team, The Hague, The Netherlands.,Present address: Royal Tropical Institute (KIT), Amsterdam, The Netherlands
| | - Suzanne Verver
- KNCV Tuberculosis Foundation, Evidence team, The Hague, The Netherlands. .,Academic Medical Centre, AIGHD, Amsterdam, the Netherlands. .,Present address: Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
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