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Pivetta de Araujo RC, Martinez L, da Silva Santos A, Ferreira Lemos E, Dias de Oliveira R, Croda M, Porto Batestin Silva D, Lemes IBG, Cunha EAT, Gonçalves TO, Pereira dos Santos PC, Oliveira da Silva B, Cavalheiro Maymone Gonçalves C, Andrews J, Croda J. Serial Mass Screening for Tuberculosis Among Incarcerated Persons in Brazil. Clin Infect Dis 2024; 78:1669-1676. [PMID: 38324908 PMCID: PMC11175667 DOI: 10.1093/cid/ciae055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 10/13/2023] [Accepted: 02/01/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND An active search for tuberculosis cases through mass screening is widely described as a tool to improve case detection in hyperendemic settings. However, its effectiveness in high-risk populations, such as incarcerated people, is debated. METHODS Between 2017 and 2021, 3 rounds of mass screening were carried out in 3 Brazilian prisons. Social and health questionnaires, chest X-rays, and Xpert MTB/RIF were performed. RESULTS More than 80% of the prison population was screened. Overall, 684 cases of pulmonary tuberculosis were diagnosed. Prevalence across screening rounds was not statistically different. Among incarcerated persons with symptoms, the overall prevalence of tuberculosis per 100 000 persons was 8497 (95% confidence interval [CI], 7346-9811), 11 115 (95% CI, 9471-13 082), and 7957 (95% CI, 6380-9882) in screening rounds 1, 2, and 3, respectively. Similar to our overall results, there were no statistical differences between screening rounds and within individual prisons. We found no statistical differences in Computer-Aided Detection for TB version 5 scores across screening rounds among people with tuberculosis-the median scores in rounds 1, 2, and 3 were 82 (interquartile range [IQR], 63-97), 77 (IQR, 60-94), and 81 (IQR, 67-92), respectively. CONCLUSIONS In this environment with hyperendemic rates of tuberculosis, 3 rounds of mass screening did not reduce the overall tuberculosis burden. In prisons, where a substantial number of tuberculosis cases is undiagnosed annually, a range of complementary interventions and more frequent tuberculosis cases screening may be required.
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Affiliation(s)
| | - Leonardo Martinez
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Andrea da Silva Santos
- Health Sciences Research Laboratory, Federal University of Grande Dourados, Dourados, Brazil
| | - Everton Ferreira Lemos
- School of Medicine, Federal University of Mato Grosso do Sul, Campo Grande, Mato Grosso do Sul, Brazil
| | - Roberto Dias de Oliveira
- Nursing Course, State University of Mato Grosso do Sul, Dourados, Brazil
- Graduate Program in Health Sciences, Federal University of Grande Dourados, Dourados, Brazil
| | - Mariana Croda
- School of Medicine, Federal University of Mato Grosso do Sul, Campo Grande, Mato Grosso do Sul, Brazil
| | | | | | - Eunice Atsuko Totumi Cunha
- Laboratory of Bacteriology, Central Laboratory of Mato Grosso do Sul, Campo Grande, Mato Gross do Sul, Brazil
| | - Thais Oliveira Gonçalves
- Laboratory of Bacteriology, Central Laboratory of Mato Grosso do Sul, Campo Grande, Mato Gross do Sul, Brazil
| | | | - Bruna Oliveira da Silva
- Health Sciences Research Laboratory, Federal University of Grande Dourados, Dourados, Brazil
| | | | - Jason Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Julio Croda
- School of Medicine, Federal University of Mato Grosso do Sul, Campo Grande, Mato Grosso do Sul, Brazil
- Oswaldo Cruz Foundation, Campo Grande, Mato Grosso do Sul, Brazil
- Department of Epidemiology of Microbial Diseases, Yale University School of Public Health, New Haven, Connecticut, USA
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Berhanu RH, Lebina L, Nonyane BAS, Milovanovic M, Kinghorn A, Connell L, Nyathi S, Young K, Hausler H, Naidoo P, Brey Z, Shearer K, Genade L, Martinson NA. Yield of Facility-based Targeted Universal Testing for Tuberculosis With Xpert and Mycobacterial Culture in High-Risk Groups Attending Primary Care Facilities in South Africa. Clin Infect Dis 2023; 76:1594-1603. [PMID: 36610730 PMCID: PMC10156124 DOI: 10.1093/cid/ciac965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 12/08/2022] [Accepted: 12/19/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND We report the yield of targeted universal tuberculosis (TB) testing of clinic attendees in high-risk groups. METHODS Clinic attendees in primary healthcare facilities in South Africa with one of the following risk factors underwent sputum testing for TB: human immunodeficiency virus (HIV), contact with a TB patient in the past year, and having had TB in the past 2 years. A single sample was collected for Xpert-Ultra (Xpert) and culture. We report the proportion positive for Mycobacterium tuberculosis. Data were analyzed descriptively. The unadjusted clinical and demographic factors' relative risk of TB detected by culture or Xpert were calculated and concordance between Xpert and culture is described. RESULTS A total of 30 513 participants had a TB test result. Median age was 39 years, and 11 553 (38%) were men. The majority (n = 21734, 71%) had HIV, 12 492 (41%) reported close contact with a TB patient, and 1573 (5%) reported prior TB. Overall, 8.3% were positive for M. tuberculosis by culture and/or Xpert compared with 6.0% with trace-positive results excluded. In asymptomatic participants, the yield was 6.7% and 10.1% in symptomatic participants (with trace-positives excluded). Only 10% of trace-positive results were culture-positive. We found that 55% of clinic attendees with a sputum result positive for M. tuberculosis did not have a positive TB symptom screen. CONCLUSIONS A high proportion of clinic attendees with specific risk factors (HIV, close TB contact, history of TB) test positive for M. tuberculosis when universal testing is implemented.
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Affiliation(s)
- Rebecca H Berhanu
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Limakatso Lebina
- Perinatal HIV Research Unit (PHRU), University of Witwatersrand, Soweto, South Africa
| | - Bareng A S Nonyane
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, USA
| | - Minja Milovanovic
- Perinatal HIV Research Unit (PHRU), University of Witwatersrand, Soweto, South Africa
| | - Anthony Kinghorn
- Perinatal HIV Research Unit (PHRU), University of Witwatersrand, Soweto, South Africa
| | | | | | | | - Harry Hausler
- TB HIV Care, Cape Town, South Africa
- Department of Family Medicine, University of Pretoria, Pretoria, South Africa
| | - Pren Naidoo
- Public Health Management Consultant, Cape Town, South Africa
| | - Zameer Brey
- Bill and Melinda Gates Foundation–South Africa, Johannesburg, South Africa
| | - Kate Shearer
- Department of Medicine, Division of Infectious Diseases, Baltimore, Maryland, USA
- Centre for TB Research, Johns Hopkins University, Baltimore, Maryland, USA
| | - Leisha Genade
- Perinatal HIV Research Unit (PHRU), University of Witwatersrand, Soweto, South Africa
| | - Neil A Martinson
- Perinatal HIV Research Unit (PHRU), University of Witwatersrand, Soweto, South Africa
- Centre for TB Research, Johns Hopkins University, Baltimore, Maryland, USA
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Garg T, Chaisson LH, Naufal F, Shapiro AE, Golub JE. A systematic review and meta-analysis of active case finding for tuberculosis in India. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2022; 7:100076. [PMID: 37383930 PMCID: PMC10305973 DOI: 10.1016/j.lansea.2022.100076] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Background Active case finding (ACF) for tuberculosis (TB) is the cornerstone case-finding strategy in India's national TB policy. However, ACF strategies are highly diverse and pose implementation challenges in routine programming. We reviewed the literature to characterise ACF in India; assess the yield of ACF for different risk groups, screening locations, and screening criteria; and estimate losses to follow-up (LTFU) in screening and diagnosis. Methods We searched PubMed, EMBASE, Scopus, and the Cochrane library to identify studies with ACF for TB in India from November 2010 to December 2020. We calculated 1) weighted mean number needed to screen (NNS) stratified by risk group, screening location, and screening strategy; and 2) the proportion of screening and pre-diagnostic LTFU. We assessed risk of bias using the AXIS tool for cross-sectional studies. Findings Of 27,416 abstracts screened, we included 45 studies conducted in India. Most studies were from southern and western India and aimed to diagnose pulmonary TB at the primary health level in the public sector after screening. There was considerable heterogeneity in risk groups screened and ACF methodology across studies. Of the 17 risk groups identified, the lowest weighted mean NNS was seen in people with HIV (21, range 3-89, n=5), tribal populations (50, range 40-286, n=3), household contacts of people with TB (50, range 3-undefined, n=12), people with diabetes (65, range 21-undefined, n=3), and rural populations (131, range 23-737, n=5). ACF at facility-based screening (60, range 3-undefined, n=19) had lower weighted mean NNS than at other screening locations. Using the WHO symptom screen (135, 3-undefined, n=20) had lower weighted mean NNS than using criteria of abnormal chest x-ray or any symptom. Median screening and pre-diagnosis loss-to-follow-up was 6% (IQR 4.1%, 11.3%, range 0-32.5%, n=12) and 9.5% (IQR 2.4%, 34.4%, range 0-86.9%, n=27), respectively. Interpretation For ACF to be impactful in India, its design must be based on contextual understanding. The narrow evidence base available currently is insufficient for effectively targeting ACF programming in a large and diverse country. Achieving case-finding targets in India requires evidence-based ACF implementation. Funding WHO Global TB Programme.
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Affiliation(s)
- Tushar Garg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Lelia H. Chaisson
- Division of Infectious Diseases, Department of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Fahd Naufal
- Wilmer Eye Institute, Johns Hopkins Medicine, Baltimore, MD, United States
| | - Adrienne E. Shapiro
- Department of Global Health and Department of Medicine, University of Washington, Seattle, WA, United States
| | - Jonathan E. Golub
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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Cox SR, Kadam A, Atre S, Gupte AN, Sohn H, Gupte N, Sawant T, Mhadeshwar V, Thompson R, Kendall E, Hoffmann C, Suryavanshi N, Kerrigan D, Tripathy S, Kakrani A, Barthwal MS, Mave V, Golub JE. Tuberculosis (TB) Aftermath: study protocol for a hybrid type I effectiveness-implementation non-inferiority randomized trial in India comparing two active case finding (ACF) strategies among individuals treated for TB and their household contacts. Trials 2022; 23:635. [PMID: 35932062 PMCID: PMC9354295 DOI: 10.1186/s13063-022-06503-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/01/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Approximately 7% of all reported tuberculosis (TB) cases each year are recurrent, occurring among people who have had TB in the recent or distant past. TB recurrence is particularly common in India, which has the largest TB burden worldwide. Although patients recently treated for TB are at high risk of developing TB again, evidence around effective active case finding (ACF) strategies in this population is scarce. We will conduct a hybrid type I effectiveness-implementation non-inferiority randomized trial to compare the effectiveness, cost-effectiveness, and feasibility of two ACF strategies among individuals who have completed TB treatment and their household contacts (HHCs). METHODS We will enroll 1076 adults (≥ 18 years) who have completed TB treatment at a public TB unit (TU) in Pune, India, along with their HHCs (averaging two per patient, n = 2152). Participants will undergo symptom-based ACF by existing healthcare workers (HCWs) at 6-month intervals and will be randomized to either home-based ACF (HACF) or telephonic ACF (TACF). Symptomatic participants will undergo microbiologic testing through the program. Asymptomatic HHCs will be referred for TB preventive treatment (TPT) per national guidelines. The primary outcome is rate per 100 person-years of people diagnosed with new or recurrent TB by study arm, within 12 months following treatment completion. The secondary outcome is proportion of HHCs < 6 years, by study arm, initiated on TPT after ruling out TB disease. Study staff will collect socio-demographic and clinical data to identify risk factors for TB recurrence and will measure post-TB lung impairment. In both arms, an 18-month "mop-up" visit will be conducted to ascertain outcomes. We will use the RE-AIM framework to characterize implementation processes and explore acceptability through in-depth interviews with index patients, HHCs and HCWs (n = 100). Cost-effectiveness will be assessed by calculating the incremental cost per TB case detected within 12 months and projected for disability-adjusted life years averted based on modeled estimates of morbidity, mortality, and time with infectious TB. DISCUSSION This novel trial will guide India's scale-up of post-treatment ACF and provide an evidence base for designing strategies to detect recurrent and new TB in other high burden settings. TRIAL REGISTRATION NCT04333485 , registered April 3, 2020. CTRI/2020/05/025059 [Clinical Trials Registry of India], registered May 6 2020.
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Affiliation(s)
- Samyra R Cox
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA.
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA.
| | - Abhay Kadam
- Johns Hopkins India, G-4 & G-5, PHOENIX Building, OPP. to Residency Club, Pune, Maharashtra, 411001, India
| | - Sachin Atre
- Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Maharashtra, 411018, India
| | - Akshay N Gupte
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Hojoon Sohn
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Nikhil Gupte
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
- Johns Hopkins India, G-4 & G-5, PHOENIX Building, OPP. to Residency Club, Pune, Maharashtra, 411001, India
| | - Trupti Sawant
- Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Maharashtra, 411018, India
| | - Vishal Mhadeshwar
- Johns Hopkins India, G-4 & G-5, PHOENIX Building, OPP. to Residency Club, Pune, Maharashtra, 411001, India
| | - Ryan Thompson
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | - Emily Kendall
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Christopher Hoffmann
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Nishi Suryavanshi
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
- Johns Hopkins India, G-4 & G-5, PHOENIX Building, OPP. to Residency Club, Pune, Maharashtra, 411001, India
| | - Deanna Kerrigan
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- George Washington University, 2121 I St NW, Washington, D.C., 20052, USA
| | - Srikanth Tripathy
- Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Maharashtra, 411018, India
| | - Arjunlal Kakrani
- Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Maharashtra, 411018, India
| | - Madhusudan S Barthwal
- Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Maharashtra, 411018, India
| | - Vidya Mave
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
- Johns Hopkins India, G-4 & G-5, PHOENIX Building, OPP. to Residency Club, Pune, Maharashtra, 411001, India
| | - Jonathan E Golub
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
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A clinical score for identifying active tuberculosis while awaiting microbiological results: Development and validation of a multivariable prediction model in sub-Saharan Africa. PLoS Med 2020; 17:e1003420. [PMID: 33170838 PMCID: PMC7654801 DOI: 10.1371/journal.pmed.1003420] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 10/14/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In highly resource-limited settings, many clinics lack same-day microbiological testing for active tuberculosis (TB). In these contexts, risk of pretreatment loss to follow-up is high, and a simple, easy-to-use clinical risk score could be useful. METHODS AND FINDINGS We analyzed data from adults tested for TB with Xpert MTB/RIF across 28 primary health clinics in rural South Africa (between July 2016 and January 2018). We used least absolute shrinkage and selection operator regression to identify characteristics associated with Xpert-confirmed TB and converted coefficients into a simple score. We assessed discrimination using receiver operating characteristic (ROC) curves, calibration using Cox linear logistic regression, and clinical utility using decision curves. We validated the score externally in a population of adults tested for TB across 4 primary health clinics in urban Uganda (between May 2018 and December 2019). Model development was repeated de novo with the Ugandan population to compare clinical scores. The South African and Ugandan cohorts included 701 and 106 individuals who tested positive for TB, respectively, and 686 and 281 randomly selected individuals who tested negative. Compared to the Ugandan cohort, the South African cohort was older (41% versus 19% aged 45 years or older), had similar breakdown of biological sex (48% versus 50% female), and had higher HIV prevalence (45% versus 34%). The final prediction model, scored from 0 to 10, included 6 characteristics: age, sex, HIV (2 points), diabetes, number of classical TB symptoms (cough, fever, weight loss, and night sweats; 1 point each), and >14-day symptom duration. Discrimination was moderate in the derivation (c-statistic = 0.82, 95% CI = 0.81 to 0.82) and validation (c-statistic = 0.75, 95% CI = 0.69 to 0.80) populations. A patient with 10% pretest probability of TB would have a posttest probability of 4% with a score of 3/10 versus 43% with a score of 7/10. The de novo Ugandan model contained similar characteristics and performed equally well. Our study may be subject to spectrum bias as we only included a random sample of people without TB from each cohort. This score is only meant to guide management while awaiting microbiological results, not intended as a community-based triage test (i.e., to identify individuals who should receive further testing). CONCLUSIONS In this study, we observed that a simple clinical risk score reasonably distinguished individuals with and without TB among those submitting sputum for diagnosis. Subject to prospective validation, this score might be useful in settings with constrained diagnostic resources where concern for pretreatment loss to follow-up is high.
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Lau LL, Hung N, Dodd W, Lim K, Ferma JD, Cole DC. Social trust and health seeking behaviours: A longitudinal study of a community-based active tuberculosis case finding program in the Philippines. SSM Popul Health 2020; 12:100664. [PMID: 33015308 PMCID: PMC7522854 DOI: 10.1016/j.ssmph.2020.100664] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 12/18/2022] Open
Abstract
Introduction Social trust is an important driver of health seeking behaviours and plays a particularly important role for diseases that have a high degree of stigma associated with them, such as tuberculosis (TB). Individuals experiencing poverty also face additional social and financial barriers in accessing care for TB. We examined an active case finding (ACF) initiative embedded in a program targeting those living in poverty (Transform) implemented by International Care Ministries (ICM), a Philippine-based non-governmental organization (NGO), and analyzed how different forms of social trust may affect the initial uptake of ACF. Methods Program monitoring data and a cross-sectional survey conducted at the beginning of Transform included six dimensions of social trust: satisfaction with family life, satisfaction with friendships, and level of trust in relatives, neighbours, pastor or religious leader, and local government officials. Amongst individuals suspected of having TB who received referrals post-screening, multilevel modelling examined the effects of social trust on rural health unit (RHU) attendance. Results Among the subset of 3350 individuals who received TB screening in 51 communities, 889 (26.5%) were symptom positive and required referral to the RHU, but only 24.1% of those who received referrals successfully attended the RHU. Multilevel regression analysis showed that for each unit increase on the Likert scale in baseline level of family satisfaction and level of trust in relatives, the odds of attending an RHU was 1.03 times (95% CI: 0.99, 1.07) and 1.06 times greater (95% CI: 1.00, 1.11), respectively, independent of other factors. Conclusion These results suggest that social trust in family members could play a valuable role in addressing stigma and rejection, both cited as barriers to higher screening rates. It is recommended that ACF programs that target TB, or other diseases that are stigmatized, prioritize trust-building as an important component of their intervention. Role of social trust on health clinic attendance among extreme poor examined. Effect of five relationship types in supporting tuberculosis testing explored. Trust in family relationships predicted greater health clinic testing. Health interventions for stigmatized diseases should prioritize trust-building.
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Affiliation(s)
- Lincoln L.H. Lau
- Dalla Lana School of Public Health, University of Toronto, Canada
- International Care Ministries Foundation Inc, Philippines
- School of Public Health and Health Systems, University of Waterloo, Canada
- Corresponding author. Unit 2001 Antel Global Corporate Center Julia Vargas Ave Ortigas Center Pasig City NCR Philippines.
| | - Natalee Hung
- International Care Ministries Foundation Inc, Philippines
| | - Warren Dodd
- School of Public Health and Health Systems, University of Waterloo, Canada
| | - Krisha Lim
- International Care Ministries Foundation Inc, Philippines
| | | | - Donald C. Cole
- Dalla Lana School of Public Health, University of Toronto, Canada
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Sander MS, Laah SN, Titahong CN, Lele C, Kinge T, de Jong BC, Abena JLF, Codlin AJ, Creswell J. Systematic screening for tuberculosis among hospital outpatients in Cameroon: The role of screening and testing algorithms to improve case detection. J Clin Tuberc Other Mycobact Dis 2019; 15:100095. [PMID: 31720422 PMCID: PMC6830146 DOI: 10.1016/j.jctube.2019.100095] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Better screening and testing approaches are needed to improve TB case finding, particularly in health facilities where many people with TB seek care but are not diagnosed using the existing approaches. OBJECTIVE We aimed to evaluate the performance of various TB screening and testing approaches among hospital outpatients in a setting with a high prevalence of HIV/TB. METHODS We screened outpatients at a large hospital in Cameroon using both chest X-ray and a symptom questionnaire including current cough, fever, night sweats and/or weight loss. Participants with a positive screen were tested for TB using smear microscopy, the Xpert MTB/RIF assay, and culture. RESULTS Among 2051 people screened, 1137 (55%) reported one or more TB symptom and 389 (19%) had an abnormal chest X-ray. In total, 1255 people (61%) had a positive screen and 31 of those screened (1.5%) had bacteriologically confirmed TB. To detect TB, screening with cough >2 weeks had a sensitivity of 61% (95% CI, 44-78%). Screening for a combination of cough >2 -weeks and/or abnormal chest X-ray had a sensitivity of 81% (95% CI, 67-95%) and specificity of 71% (95% CI, 69-73%), while screening for a combination of cough >2 weeks or any of 2 or more symptoms had a similar performance. Smear microscopy and Xpert MTB/RIF detected 32% (10/31) and 55% (17/31), respectively, of people who had bacteriologically-confirmed TB. CONCLUSIONS Screening hospital outpatients for cough >2 weeks or for at least 2 of current cough, fever, night sweats or weight loss is a feasible strategy that had a high relative yield to detect bacteriologically-confirmed TB in this population. Clinical diagnosis of TB is still an important need, even where Xpert MTB/RIF testing is available.
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Affiliation(s)
- Melissa S. Sander
- Tuberculosis Reference Laboratory Bamenda, PO Box 586, Bamenda, Cameroon
| | | | | | | | | | - Bouke C. de Jong
- Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium
| | | | - Andrew J. Codlin
- Stop TB Partnership, Chemin du Pommier 40, 1218 Le Grand-Saconnex, Geneva, Switzerland
| | - Jacob Creswell
- Stop TB Partnership, Chemin du Pommier 40, 1218 Le Grand-Saconnex, Geneva, Switzerland
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Adane K, Spigt M, Winkens B, Dinant GJ. Tuberculosis case detection by trained inmate peer educators in a resource-limited prison setting in Ethiopia: a cluster-randomised trial. LANCET GLOBAL HEALTH 2019; 7:e482-e491. [PMID: 30824364 DOI: 10.1016/s2214-109x(18)30477-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 09/11/2018] [Accepted: 10/12/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND To improve tuberculosis case detection, interventions that are feasible with available resources are needed. We investigated whether involving trained prison inmates in a tuberculosis control programme improved tuberculosis case detection, shortened pre-treatment symptom duration, and increased treatment success in a resource-limited prison setting in Ethiopia. METHODS In this cluster-randomised trial we randomly assigned prisons in the regions Amhara and Tigray of Ethiopia to an intervention group or a control group, after matching them into pairs based on their geographical proximity and size. Larger prisons were considered eligible whereas smaller prisons were excluded. We selected three to six prison inmates in each intervention prison. The recruited prison inmates who received a 3-day training course and were capable of identifying presumptive tuberculosis cases then provided health education to all other prison inmates about tuberculosis prevention and control every 2 weeks for 1 year. They also actively searched for symptomatic prison inmates and undertook routine symptom-based tuberculosis screening. The control prisons followed the existing passive case finding system. The primary outcome was the mean case detection rate at the end of the year, measured at cluster (prison) level. This trial is registered at ClinicalTrials.gov, number NCT02744521. FINDINGS We randomly assigned 16 prisons with a total population of 18 032 inmates to either the intervention group (n=8) or the control group (n=8) from April 1, 2016, to March 31, 2017. During the 1-year study period, 75 new tuberculosis cases (1% of 8874 total inmates) were detected in the intervention prisons and 25 new cases (<1% of 9158 total inmates) were detected in the control prisons. The mean case detection rate was significantly higher in the intervention group than in the control group (mean difference 52·9 percentage points, 95% CI 17·5-88·3, p=0·010). INTERPRETATION Involving trained inmate peer educators in the tuberculosis control programme in Ethiopian prisons significantly improved the tuberculosis case detection rate. The findings have important implications for clinical and public health policy, particularly in prisons of low-income countries where tuberculosis burden is high and the recommended tuberculosis diagnostic and treatment algorithms have generally not been implemented. FUNDING Nuffic, Mekelle University.
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Affiliation(s)
- Kelemework Adane
- Department of Medical Microbiology and Immunology, College of Health Sciences, Mekelle University, Mekelle, Ethiopia; Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands.
| | - Mark Spigt
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands; Department of Community Medicine, General Practice Research Unit, UiT The Arctic University of Norway, Tromsø, Norway
| | - Bjorn Winkens
- Department of Methodology and Statistics, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands
| | - Geert-Jan Dinant
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands
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Gabardo BMA, Maluf EMCP, Freitas MBFD, Gabardo BA. Should active case finding be conducted among patients with respiratory symptoms independently of local epidemiological settings? J Bras Pneumol 2019; 45:e20190171. [PMID: 31618299 PMCID: PMC7447534 DOI: 10.1590/1806-3713/e20190171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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10
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Ohene SA, Bonsu F, Hanson-Nortey NN, Toonstra A, Sackey A, Lonnroth K, Uplekar M, Danso S, Mensah G, Afutu F, Klatser P, Bakker M. Provider initiated tuberculosis case finding in outpatient departments of health care facilities in Ghana: yield by screening strategy and target group. BMC Infect Dis 2017; 17:739. [PMID: 29191155 PMCID: PMC5709967 DOI: 10.1186/s12879-017-2843-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Accepted: 11/21/2017] [Indexed: 11/22/2022] Open
Abstract
Background Meticulous identification and investigation of patients presenting with tuberculosis (TB) suggestive symptoms rarely happen in crowded outpatient departments (OPDs). Making health providers in OPDs diligently follow screening procedures may help increase TB case detection. From July 2010 to December 2013, two symptom based TB screening approaches of varying cough duration were used to screen and test for TB among general outpatients, PLHIV, diabetics and contacts in Accra, Ghana. Methods This study was a retrospective analysis comparing the yield of TB cases using two different screening approaches, allocated to selected public health facilities. In the first approach, the conventional 2 weeks cough duration with or without other TB suggestive symptoms was the criterion to test for TB in attendants of 7 general OPDs. In the second approach the screening criteria cough of >24 hours, as well as a history of at least one of the following symptoms: fever, weight loss and drenching night sweats were used to screen and test for TB among attendants of 3 general OPDs, 7 HIV clinics and 2 diabetes clinics. Contact investigation was initiated for index TB patients. The facilities documented the number of patients verbally screened, with presumptive TB, tested using smear microscopy and those diagnosed with TB in order to calculate the yield and number needed to screen (NNS) to find one TB case. Case notification trends in Accra were compared to those of a control area. Results In the approach using >24-hour cough, significantly more presumptive TB cases were identified among outpatients (0.82% versus 0.63%), more were tested (90.1% versus 86.7%), but less smear positive patients were identified among those tested (8.0% versus 9.4%). Overall, all forms of TB cases identified per 100,000 screened were significantly higher in the >24-hour cough approach at OPD (92.7 for cough >24 hour versus 82.7 for cough >2 weeks ), and even higher in diabetics (364), among contacts (693) and PLHIV (995). NNS (95% Confidence Interval) varied from 100 (93-109) for PLHIV, 144 (112-202) for contacts, 275 (197-451) for diabetics and 1144 (1101-1190) for OPD attendants. About 80% of the TB cases were detected in general OPDs. Despite the intervention, notifications trends were similar in the intervention and control areas. Conclusion The >24-hour cough approach yielded more TB cases though required TB testing for a larger number of patients. The yield of TB cases per 100,000 population screened was highest among PLHIV, contacts, and diabetics, but the majority of cases were detected in general OPDs. The intervention had no discernible impact on general case notification.
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Affiliation(s)
- Sally-Ann Ohene
- World Health Organization Country Office, 29 Volta Street Airport, Airport Residential Area, P.O. Box MB 142, Accra, Ghana.
| | - Frank Bonsu
- National Tuberculosis Control Program, Accra, Ghana
| | | | - Ardon Toonstra
- KIT Health, Royal Tropical Institute (KIT), Amsterdam, The Netherlands
| | | | | | | | - Samuel Danso
- National Tuberculosis Control Program, Accra, Ghana
| | | | - Felix Afutu
- National Tuberculosis Control Program, Accra, Ghana
| | - Paul Klatser
- Department of Global Health, Academic Medical Centre, Amsterdam Institute of Global Health and Development, Amsterdam, The Netherlands
| | - Mirjam Bakker
- KIT Health, Royal Tropical Institute (KIT), Amsterdam, The Netherlands
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McAllister S, Wiem Lestari B, Sujatmiko B, Siregar A, Sihaloho ED, Fathania D, Dewi NF, Koesoemadinata RC, Hill PC, Alisjahbana B. Feasibility of two active case finding approaches for detection of tuberculosis in Bandung City, Indonesia. Public Health Action 2017; 7:206-211. [PMID: 29226096 DOI: 10.5588/pha.17.0026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 05/06/2017] [Indexed: 11/10/2022] Open
Abstract
Setting: A community health clinic catchment area in the eastern part of Bandung City, Indonesia. Objective: To evaluate the feasibility of two different screening interventions using community health workers (CHWs) in detecting tuberculosis (TB) cases. Design: This was a feasibility study of 1) house-to-house TB symptom screening of five randomly selected 'neighbourhoods' in the catchment area, and 2) selected screening of household contacts of TB index patients and their neighbouring households. Acceptability was assessed through focus group discussions with key stakeholders. Results: Of 5100 individuals screened in randomly selected neighbourhoods, 48 (0.9%) reported symptoms, of whom 38 provided sputum samples; no positive TB was found. No TB cases were found among the 88 household contacts or the 423 neighbourhood contacts. With training, regular support and supervision from research staff and local community health centre staff, CHWs were able to undertake screening effectively, and almost all householders were willing to participate. Conclusion: The use of CHWs for TB screening could be integrated into routine practice relatively easily in Indonesia. The effectiveness of this would need further exploration, particularly with the use of improved diagnostics such as chest X-ray and sputum culture.
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Affiliation(s)
- S McAllister
- Centre for International Health, Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - B Wiem Lestari
- TB-HIV Research Centre, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - B Sujatmiko
- TB-HIV Research Centre, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - A Siregar
- Centre for Economics and Development Studies, Department of Economics, Faculty of Economics and Business, Universitas Padjadjaran, Bandung, Indonesia
| | - E D Sihaloho
- Centre for Economics and Development Studies, Department of Economics, Faculty of Economics and Business, Universitas Padjadjaran, Bandung, Indonesia
| | - D Fathania
- TB-HIV Research Centre, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - N F Dewi
- TB-HIV Research Centre, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - R C Koesoemadinata
- TB-HIV Research Centre, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - P C Hill
- Centre for International Health, Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - B Alisjahbana
- TB-HIV Research Centre, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
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Appleton SC, Connell DW, Singanayagam A, Bradley P, Pan D, Sanderson F, Cleaver B, Rahman A, Kon OM. Evaluation of prediagnosis emergency department presentations in patients with active tuberculosis: the role of chest radiography, risk factors and symptoms. BMJ Open Respir Res 2017; 4:e000154. [PMID: 28123749 PMCID: PMC5253606 DOI: 10.1136/bmjresp-2016-000154] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/24/2016] [Accepted: 10/26/2016] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION London has a high rate of tuberculosis (TB) with 2572 cases reported in 2014. Cases are more common in non-UK born, alcohol-dependent or homeless patients. The emergency department (ED) presents an opportunity for the diagnosis of TB in these patient groups. This is the first study describing the clinico-radiological characteristics of such attendances in two urban UK hospitals for pulmonary TB (PTB) and extrapulmonary TB (EPTB). METHODS We conducted a retrospective cohort study using the London TB Register (LTBR) and hospital records to identify patients who presented to two London ED's in the 6 months prior to their ultimate TB diagnosis 2011-2012. RESULTS 397 TB cases were identified. 39% (154/397) had presented to the ED in the 6 months prior to diagnosis. In the study population, the presence of cough, weight loss, fever and night sweats only had prevalence rates of 40%, 34%, 34% and 21%, respectively. Chest radiography was performed in 76% (117/154) of patients. For cases where a new diagnosis of TB was suspected, 73% (41/56) had an abnormal radiograph, compared with 36% (35/98) of patients where it was not. There was an abnormality on a chest radiograph in 73% (55/75) of PTB cases and also in 40% (21/52) of EPTB cases where a film was requested. CONCLUSIONS A large proportion of patients with TB present to ED. A diagnosis was more likely in the presence of an abnormal radiograph, suggesting opportunities for earlier diagnosis if risk factors, symptoms and chest radiograph findings are combined.
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Affiliation(s)
- S C Appleton
- Tuberculosis Service , Imperial College Healthcare NHS Trust , London , UK
| | - D W Connell
- Tuberculosis Service , Imperial College Healthcare NHS Trust , London , UK
| | - A Singanayagam
- Tuberculosis Service , Imperial College Healthcare NHS Trust , London , UK
| | - P Bradley
- Department of Emergency Medicine , Imperial College Healthcare NHS Trust , London , UK
| | - D Pan
- Department of Emergency Medicine , Imperial College Healthcare NHS Trust , London , UK
| | - F Sanderson
- Tuberculosis Service , Imperial College Healthcare NHS Trust , London , UK
| | - B Cleaver
- Department of Emergency Medicine , Imperial College Healthcare NHS Trust , London , UK
| | - A Rahman
- Department of Emergency Medicine , Imperial College Healthcare NHS Trust , London , UK
| | - O M Kon
- Tuberculosis Service , Imperial College Healthcare NHS Trust , London , UK
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13
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Clinical-Laboratory Prediction Rule Derivation for Pulmonary Tuberculosis Diagnosis in General Hospitals in a High-Burden Country. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2016. [DOI: 10.1097/ipc.0000000000000391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Otero L, Shah L, Verdonck K, Battaglioli T, Brewer T, Gotuzzo E, Seas C, Van der Stuyft P. A prospective longitudinal study of tuberculosis among household contacts of smear-positive tuberculosis cases in Lima, Peru. BMC Infect Dis 2016; 16:259. [PMID: 27278655 PMCID: PMC4898451 DOI: 10.1186/s12879-016-1616-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 06/03/2016] [Indexed: 11/24/2022] Open
Abstract
Background Household contacts (HHCs) of TB cases are at increased risk for TB disease compared to the general population but the risk may be modified by individual or household factors. We conducted a study to determine incident TB among HHCs over two years after exposure and to identify individual and household level risk factors. Methods Adults newly diagnosed with a first episode of smear-positive pulmonary TB (index cases) between March 2010 and December 2011 in eastern Lima, were interviewed to identify their HHC and household characteristics. TB registers were reviewed for up to two years after the index case diagnosis and house visits were made to ascertain TB cases among HHC. The TB incidence rate ratio among HHCs as a function of risk factors was determined using generalized linear mixed models. Results The 1178 index cases reported 5466 HHCs. In 402/1178 (34.1 %) households, at least one HHC had experienced a TB episode ever. The TB incidence among HHCs was 1918 (95%CI 1669–2194) per 100,000 person-years overall, and was 2392 (95%CI 2005–2833) and 1435 (95%CI 1139–1787) per 100,000 person-years in the first and second year, respectively. Incident TB occurred more than six months following the index case’s TB diagnosis in 121/205 (59.0 %) HHCs. In HHCs, bacillary load and time between symptoms and treatment initiation in the index case, as well as the relationship to the index case and the sex of the HHC all had a significant association with TB incidence in HHCs. Conclusions Incidence of TB among HHCs was more than ten times higher than in the general population. Certain HHC and households were at higher risk of TB, we recommend studies to compare HHC investigation to households at highest risk versus current practice, in terms of efficiency. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1616-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Larissa Otero
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado 430, San Martín de Porres, Lima 31, Peru. .,Department of Public Health, Unit of General Epidemiology and Disease Control, Institute of Tropical Medicine, Antwerp, Belgium.
| | - Lena Shah
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Kristien Verdonck
- Department of Public Health, Unit of Epidemiology and Control of Tropical Diseases, Institute of Tropical Medicine, Antwerp, Belgium
| | - Tullia Battaglioli
- Department of Public Health, Unit of General Epidemiology and Disease Control, Institute of Tropical Medicine, Antwerp, Belgium
| | - Timothy Brewer
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Eduardo Gotuzzo
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado 430, San Martín de Porres, Lima 31, Peru
| | - Carlos Seas
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado 430, San Martín de Porres, Lima 31, Peru
| | - Patrick Van der Stuyft
- Department of Public Health, Unit of General Epidemiology and Disease Control, Institute of Tropical Medicine, Antwerp, Belgium.,Department of Public Health, Ghent University, Ghent, Belgium
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van Hest R, de Vries G. Active tuberculosis case-finding among drug users and homeless persons: after the outbreak. Eur Respir J 2016; 48:269-71. [PMID: 27103393 DOI: 10.1183/13993003.00284-2016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 03/18/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Rob van Hest
- Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, The Netherlands Municipal Public Health Service Groningen, Groningen, The Netherlands
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Implementation of Tuberculosis Intensive Case Finding, Isoniazid Preventive Therapy, and Infection Control ("Three I's") and HIV-Tuberculosis Service Integration in Lower Income Countries. PLoS One 2016; 11:e0153243. [PMID: 27073928 PMCID: PMC4830552 DOI: 10.1371/journal.pone.0153243] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 03/27/2016] [Indexed: 11/19/2022] Open
Abstract
SETTING World Health Organization advocates for integration of HIV-tuberculosis (TB) services and recommends intensive case finding (ICF), isoniazid preventive therapy (IPT), and infection control ("Three I's") for TB prevention and control among persons living with HIV. OBJECTIVE To assess the implementation of the "Three I's" of TB-control at HIV treatment sites in lower income countries. DESIGN Survey conducted between March-July, 2012 at 47 sites in 26 countries: 6 (13%) Asia Pacific, 7 (15%), Caribbean, Central and South America, 5 (10%) Central Africa, 8 (17%) East Africa, 14 (30%) Southern Africa, and 7 (15%) West Africa. RESULTS ICF using symptom-based screening was performed at 38% of sites; 45% of sites used symptom-screening plus additional diagnostics. IPT at enrollment or ART initiation was implemented in only 17% of sites, with 9% of sites providing IPT to tuberculin-skin-test positive patients. Infection control measures varied: 62% of sites separated smear-positive patients, and healthcare workers used masks at 57% of sites. Only 12 (26%) sites integrated HIV-TB services. Integration was not associated with implementation of TB prevention measures except for IPT provision at enrollment (42% integrated vs. 9% non-integrated; p = 0.03). CONCLUSIONS Implementation of TB screening, IPT provision, and infection control measures was low and variable across regional HIV treatment sites, regardless of integration status.
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Morishita F, Eang MT, Nishikiori N, Yadav RP. Increased Case Notification through Active Case Finding of Tuberculosis among Household and Neighbourhood Contacts in Cambodia. PLoS One 2016; 11:e0150405. [PMID: 26930415 PMCID: PMC4773009 DOI: 10.1371/journal.pone.0150405] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 02/12/2016] [Indexed: 11/25/2022] Open
Abstract
Background Globally, there has been growing evidence that suggests the effectiveness of active case finding (ACF) for tuberculosis (TB) in high-risk populations. However, the evidence is still insufficient as to whether ACF increases case notification beyond what is reported in the routine passive case finding (PCF). In Cambodia, National TB Control Programme has conducted nationwide ACF with Xpert MTB/RIF that retrospectively targeted household and neighbourhood contacts alongside routine PCF. This study aims to investigate the impact of ACF on case notifications during and after the intervention period. Methods Using a quasi-experimental cluster randomized design with intervention and control arms, we compared TB case notification during the one-year intervention period with historical baseline cases and trend-adjusted expected cases, and estimated additional cases notified during the intervention period (separately for Year 1 and Year 2 implementation). The proportion of change in case notification was compared between intervention and control districts for Year 1. The quarterly case notification data from all intervention districts were consolidated, aligning different implementation quarters, and separately analysed to explore the additionality. The effect of the intervention on the subsequent case notification during the post-intervention period was also assessed. Results In Year 1, as compared to expected cases, 1467 cases of all forms (18.5%) and 330 bacteriologically-confirmed cases (9.6%) were additionally notified in intervention districts, whereas case notification in control districts decreased by 2.4% and 2.3%, respectively. In Year 2, 2737 cases of all forms (44.3%) and 793 bacteriologically-confirmed cases (38%) were additionally notified as compared to expected cases. The proportions of increase in case notifications from baseline cases and expected cases to intervention period cases were consistently higher in intervention group than in control group. The consolidated quarterly data showed sharp rises in all forms and bacteriologically-confirmed cases notified during the intervention quarter, with 64.6% and 68.4% increases (compared to baseline cases), and 46% and 52.9% increases (compared to expected cases), respectively. A cumulative reduction of case notification for five quarters after ACF reached more than -200% of additional cases. Conclusions The Cambodia’s ACF with Xpert MTB/RIF that retrospectively targeted household and neighbourhood contacts resulted in the substantial increase in case notification during the intervention period and reduced subsequent case notification during the post-intervention period. The applicability of retrospective contact investigation in other high-burden settings should be explored.
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Affiliation(s)
- Fukushi Morishita
- World Health Organization Regional Office for the Western Pacific, Manila, Philippines
- * E-mail:
| | - Mao Tan Eang
- National Center for Tuberculosis and Leprosy Control, Ministry of Health, Phnom Penh, Cambodia
| | - Nobuyuki Nishikiori
- World Health Organization Regional Office for the Western Pacific, Manila, Philippines
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Abouda M, Hamzaoui A, Drira E, Djebeniani R, Othmani S, Ben Kheder A. The effect of an integrated syndromic respiratory disease guideline in primary health care settings. J Eval Clin Pract 2015; 21:976-81. [PMID: 26153537 DOI: 10.1111/jep.12420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2015] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES The use of integrated syndromic guidelines (ISG) aims to improve the quality of care for patients with respiratory diseases. The impact of such ISG in clinical practice can be potentially significant in primary health care (PHC) settings. We report the impact of the use by general practitioners (GPs) of a Tunisian ISG for respiratory diseases in management of respiratory patients in PHC. METHODS The short-term impact was assessed through the results of the feasibility study. This study included a baseline survey, before training on ISG, and an impact survey, after training on ISG. The same 73 GPs practicing within 28 PHCs were involved in the two surveys at an interval of 6 weeks. Information on each patient mentioned gender, age, underlying conditions, symptoms, referral, diagnosis and drug prescription details. RESULTS During the periods of the baseline and impact surveys, 36.0 and 31.1% of PHC attendees, respectively, sought care for respiratory symptoms. Acute respiratory infection (ARI) cases accounted for more than 85% of patients with respiratory disease. In the impact survey, chronic respiratory disease (CRD) diagnosis increased by approximately 50%. In the same way, the proportion of tuberculosis suspects increased 5.5 times. The number of drugs prescribed per patient decreased by 18.8%, and the proportion of patients who were prescribed antibiotics decreased by 19.0%. The prescription of steroids also significantly decreased while inhaled β-agonist prescription increased. The average cost of drug prescription was reduced by 19%. CONCLUSION Training on ISG for respiratory diseases improved the diagnosis of CRD and tuberculosis, and lead to a more rational use of drugs for ARIs in PHCs.
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Affiliation(s)
- Maher Abouda
- Respiratory Diseases Department, FSI Hospital, La Marsa, Tunisia
| | | | - Ekram Drira
- Abderrahmen Mami Hospital, d'Ariana, Tunisia
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O’Hara NN, Roy L, O’Hara LM, Spiegel JM, Lynd LD, FitzGerald JM, Yassi A, Nophale LE, Marra CA. Healthcare Worker Preferences for Active Tuberculosis Case Finding Programs in South Africa: A Best-Worst Scaling Choice Experiment. PLoS One 2015. [PMID: 26197344 PMCID: PMC4511419 DOI: 10.1371/journal.pone.0133304] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective Healthcare workers (HCWs) in South Africa are at a high risk of developing active tuberculosis (TB) due to their occupational exposures. This study aimed to systematically quantify and compare the preferred attributes of an active TB case finding program for HCWs in South Africa. Methods A Best–Worst Scaling choice experiment estimated HCW’s preferences using a random-effects conditional logit model. Latent class analysis (LCA) was used to explore heterogeneity in preferences. Results “No cost”, “the assurance of confidentiality”, “no wait” and testing at the occupational health unit at one’s hospital were the most preferred attributes. LCA identified a four class model with consistent differences in preference strength. Sex, occupation, and the time since a previous TB test were statistically significant predictors of class membership. Conclusions The findings support the strengthening of occupational health units in South Africa to offer free and confidential active TB case finding programs for HCWs with minimal wait times. There is considerable variation in active TB case finding preferences amongst HCWs of different gender, occupation, and testing history. Attention to heterogeneity in preferences should optimize screening utilization of target HCW populations.
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Affiliation(s)
- Nathan N. O’Hara
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lilla Roy
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lyndsay M. O’Hara
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jerry M. Spiegel
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Larry D. Lynd
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - J. Mark FitzGerald
- Institute for Heart and Lung Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Annalee Yassi
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Letshego E. Nophale
- Department of Community Health, Faculty Of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Carlo A. Marra
- School of Pharmacy, Memorial University, St. John’s, Newfoundland, Canada
- * E-mail:
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Oliveira LGDD, Natal S, Camacho LAB. [Analysis of the implementation of the Tuberculosis Control Program in Brazilian prisons]. CAD SAUDE PUBLICA 2015; 31:543-54. [PMID: 25859721 DOI: 10.1590/0102-311x00042914] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 09/29/2014] [Indexed: 11/22/2022] Open
Abstract
Tuberculosis control measures in Brazil's prison population have been regulated for ten years under the National Prison Health System Plan. Brazilian states have different organizational models for the Tuberculosis Control Program (TCP) in their prison systems. This study evaluated TCP implementation in prisons in two Brazilian states, using a multiple case study design with a qualitative approach and a log-frame analysis and assessment. According to predefined criteria, two state cases were selected, with two analytical units for each case and one prison hospital in Case 2. We identified partial program implementation in the Case 1 prisons and prison hospital and low implementation in non-hospital prison health services in Case 2. Lack of financial investment and resources, lack of integration between the courts and law enforcement system and health institutions, and poor access to health services in prisons were adverse factors for program implementation.
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Blok L, Creswell J, Stevens R, Brouwer M, Ramis O, Weil O, Klatser P, Sahu S, Bakker MI. A pragmatic approach to measuring, monitoring and evaluating interventions for improved tuberculosis case detection. Int Health 2014; 6:181-8. [PMID: 25100402 PMCID: PMC4153747 DOI: 10.1093/inthealth/ihu055] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 07/09/2014] [Accepted: 07/11/2014] [Indexed: 11/23/2022] Open
Abstract
The inability to detect all individuals with active tuberculosis has led to a growing interest in new approaches to improve case detection. Policy makers and program staff face important challenges measuring effectiveness of newly introduced interventions and reviewing feasibility of scaling-up successful approaches. While robust research will continue to be needed to document impact and influence policy, it may not always be feasible for all interventions and programmatic evidence is also critical to understand what can be expected in routine settings. The effects of interventions on early and improved tuberculosis detection can be documented through well-designed program evaluations. We present a pragmatic framework for evaluating and measuring the effect of improved case detection strategies using systematically collected intervention data in combination with routine tuberculosis notification data applying historical and contemporary controls. Standardized process evaluation and systematic documentation of program implementation design, cost and context will contribute to explaining observed levels of success and may help to identify conditions needed for success. Findings can then guide decisions on scale-up and replication in different target populations and settings.
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Affiliation(s)
- Lucie Blok
- KIT Health, Royal Tropical Institute, 1090 HA, Amsterdam, Netherlands
| | - Jacob Creswell
- Stop TB Partnership, Secretariat 20 Ave Appia, Geneva 1211, Switzerland
| | | | | | | | | | - Paul Klatser
- KIT Biomedical Research, Royal Tropical Institute, 1105 AZ, Amsterdam, Netherlands
| | - Suvanand Sahu
- Stop TB Partnership, Secretariat 20 Ave Appia, Geneva 1211, Switzerland
| | - Mirjam I Bakker
- KIT Biomedical Research, Royal Tropical Institute, 1105 AZ, Amsterdam, Netherlands
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Lorent N, Choun K, Thai S, Kim T, Huy S, Pe R, van Griensven J, Buyze J, Colebunders R, Rigouts L, Lynen L. Community-based active tuberculosis case finding in poor urban settlements of Phnom Penh, Cambodia: a feasible and effective strategy. PLoS One 2014; 9:e92754. [PMID: 24675985 PMCID: PMC3968028 DOI: 10.1371/journal.pone.0092754] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 02/24/2014] [Indexed: 01/29/2023] Open
Abstract
Background In light of the limitations of the current case finding strategies and the global urgency to improve tuberculosis (TB) case-detection, a renewed interest in active case finding (ACF) has risen. The WHO calls for more evidence on innovative ways of TB screening, especially from low-income countries, to inform global guideline development. We aimed to assess the feasibility of community-based ACF for TB among the urban poor in Cambodia and determine its impact on case detection, treatment uptake and outcome. Methods Between 9/2/2012-31/3/2013 the Sihanouk Hospital Center of HOPE conducted a door-to-door survey for TB in deprived communities of Phnom Penh. TB workers and community health volunteers performed symptom screening, collected sputum and facilitated specimen transport to the laboratories. Fluorescence microscopy was introduced at three referral hospitals. The GeneXpert MTB/RIF assay (Xpert) was performed at tertiary level for individuals at increased risk of HIV-associated, drug-resistant or smear-negative TB. Mobile phone/short message system (SMS) was used for same-day issuing of positive results. TB workers contacted diagnosed patients and referred them for care at their local health centre. Results In 14 months, we screened 315.874 individuals; we identified 12.201 aged ≥15 years with symptoms suggestive of TB; 84% provided sputum. We diagnosed 783, including 737 bacteriologically confirmed, TB cases. Xpert testing yielded 41% and 48% additional diagnoses among presumptive HIV-associated and multidrug-resistant TB cases, respectively. The median time from sputum collection to notification (by SMS) of the first positive (microscopy or Xpert) result was 3 days (IQR 2–6). Over 94% commenced TB treatment and 81% successfully completed it. Conclusion Our findings suggest that among the urban poor ACF for TB, using a sensitive symptom screen followed by smear-microscopy and targeted Xpert, contributed to improved case detection of drug-susceptible and drug-resistant TB, shortening the diagnostic delay, and successfully bringing patients into care.
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Affiliation(s)
- Natalie Lorent
- Infectious Diseases Department, Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia; Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium
| | - Kimcheng Choun
- Infectious Diseases Department, Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia
| | - Sopheak Thai
- Infectious Diseases Department, Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia
| | - Tharin Kim
- Mycobacteriology Laboratory, Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia
| | - Sopheaktra Huy
- Infectious Diseases Department, Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia
| | - Reaksmey Pe
- Infectious Diseases Department, Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia
| | - Johan van Griensven
- Infectious Diseases Department, Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia; Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium
| | - Jozefien Buyze
- Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium
| | - Robert Colebunders
- Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium; Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium
| | - Leen Rigouts
- Mycobacteriology Unit, Institute of Tropical Medicine, Antwerp, Belgium; Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Lutgarde Lynen
- Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium
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