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Taylor M, Medley N, van Wyk SS, Oliver S. Community views on active case finding for tuberculosis in low- and middle-income countries: a qualitative evidence synthesis. Cochrane Database Syst Rev 2024; 3:CD014756. [PMID: 38511668 PMCID: PMC10955804 DOI: 10.1002/14651858.cd014756.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
BACKGROUND Active case finding (ACF) refers to the systematic identification of people with tuberculosis in communities and amongst populations who do not present to health facilities, through approaches such as door-to-door screening or contact tracing. ACF may improve access to tuberculosis diagnosis and treatment for the poor and for people remote from diagnostic and treatment facilities. As a result, ACF may also reduce onward transmission. However, there is a need to understand how these programmes are experienced by communities in order to design appropriate services. OBJECTIVES To synthesize community views on tuberculosis active case finding (ACF) programmes in low- and middle-income countries. SEARCH METHODS We searched MEDLINE, Embase, and eight other databases up to 22 June 2023, together with reference checking, citation searching, and contact with study authors to identify additional studies. We did not include grey literature. SELECTION CRITERIA This review synthesized qualitative research and mixed-methods studies with separate qualitative data. Eligible studies explored community experiences, perceptions, or attitudes towards ACF programmes for tuberculosis in any endemic low- or middle-income country, with no time restrictions. DATA COLLECTION AND ANALYSIS Due to the large volume of studies identified, we chose to sample studies that had 'thick' description and that investigated key subgroups of children and refugees. We followed standard Cochrane methods for study description and appraisal of methodological limitations. We conducted thematic synthesis and developed codes inductively using ATLAS.ti software. We examined codes for underlying ideas, connections, and interpretations and, from this, generated analytical themes. We assessed the confidence in the findings using the GRADE-CERQual approach, and produced a conceptual model to display how the different findings interact. MAIN RESULTS We included 45 studies in this synthesis, and sampled 20. The studies covered a broad range of World Health Organization (WHO) regions (Africa, South-East Asia, Eastern Mediterranean, and the Americas) and explored the views and experiences of community members, community health workers, and clinical staff in low- and middle-income countries endemic for tuberculosis. The following five themes emerged. • ACF improves access to diagnosis for many, but does little to help communities on the edge. Tuberculosis ACF and contact tracing improve access to health services for people with worse health and fewer resources (High confidence). ACF helps to find this population, exposed to deprived living conditions, but is not sensitive to additional dimensions of their plight (High confidence) and out-of-pocket costs necessary to continue care (High confidence). Finally, migration and difficult geography further reduce communities' access to ACF (High confidence). • People are afraid of diagnosis and its impact. Some community members find screening frightening. It exposes them to discrimination along distinct pathways (isolation from their families and wider community, lost employment and housing). HIV stigma compounds tuberculosis stigma and heightens vulnerability to discrimination along these same pathways (High confidence). Consequently, community members may refuse to participate in screening, contact tracing, and treatment (High confidence). In addition, people with tuberculosis reported their emotional turmoil upon diagnosis, as they anticipated intense treatment regimens and the prospect of living with a serious illness (High confidence). • Screening is undermined by weak health infrastructure. In many settings, a lack of resources results in weak services in competition with other disease control programmes (Moderate confidence). In this context of low investment, people face repeated tests and clinic visits, wasted time, and fraught social interaction with health providers (Moderate confidence). ACF can create expectations for follow-up health care that it cannot deliver (High confidence). Finally, community education improves awareness of tuberculosis in some settings, but lack of full information impacts community members, parents, and health workers, and sometimes leads to harm for children (High confidence). • Health workers are an undervalued but important part of ACF. ACF can feel difficult for health workers in the context of a poorly resourced health system and with people who may not wish to be identified. In addition, the evidence suggests health workers are poorly protected against tuberculosis and fear they or their families might become infected (Moderate confidence). However, they appear to be central to programme success, as the humanity they offer often acts as a driving force for retaining people with tuberculosis in care (Moderate confidence). • Local leadership is necessary but not sufficient for ensuring appropriate programmes. Local leadership creates an intrinsic motivation for communities to value health services (High confidence). However, local leadership cannot guarantee the success of ACF and contact tracing programmes. It is important to balance professional authority with local knowledge and rapport (High confidence). AUTHORS' CONCLUSIONS Tuberculosis active case finding (ACF) and contact tracing bring a diagnostic service to people who may otherwise not receive it, such as those who are well or without symptoms and those who are sick but who have fewer resources and live further from health facilities. However, capturing these 'missing cases' may in itself be insufficient without appropriate health system strengthening to retain people in care. People who receive a tuberculosis diagnosis must contend with a complex and unsustainable cascade of care, and this affects their perception of ACF and their decision to engage with it.
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Affiliation(s)
- Melissa Taylor
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Nancy Medley
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Susanna S van Wyk
- Centre for Evidence-based Health Care, Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sandy Oliver
- EPPI-Centre, Social Science Research Unit, UCL Institute of Education, University College London, London, UK
- Faculty of the Humanities, University of Johannesburg, Johannesburg, South Africa
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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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Fehr J, Konigorski S, Olivier S, Gunda R, Surujdeen A, Gareta D, Smit T, Baisley K, Moodley S, Moosa Y, Hanekom W, Koole O, Ndung'u T, Pillay D, Grant AD, Siedner MJ, Lippert C, Wong EB. Computer-aided interpretation of chest radiography reveals the spectrum of tuberculosis in rural South Africa. NPJ Digit Med 2021; 4:106. [PMID: 34215836 PMCID: PMC8253848 DOI: 10.1038/s41746-021-00471-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 05/21/2021] [Indexed: 02/01/2023] Open
Abstract
Computer-aided digital chest radiograph interpretation (CAD) can facilitate high-throughput screening for tuberculosis (TB), but its use in population-based active case-finding programs has been limited. In an HIV-endemic area in rural South Africa, we used a CAD algorithm (CAD4TBv5) to interpret digital chest x-rays (CXR) as part of a mobile health screening effort. Participants with TB symptoms or CAD4TBv5 score above the triaging threshold were referred for microbiological sputum assessment. During an initial pilot phase, a low CAD4TBv5 triaging threshold of 25 was selected to maximize TB case finding. We report the performance of CAD4TBv5 in screening 9,914 participants, 99 (1.0%) of whom were found to have microbiologically proven TB. CAD4TBv5 was able to identify TB cases at the same sensitivity but lower specificity as a blinded radiologist, whereas the next generation of the algorithm (CAD4TBv6) achieved comparable sensitivity and specificity to the radiologist. The CXRs of people with microbiologically confirmed TB spanned a range of lung field abnormality, including 19 (19.2%) cases deemed normal by the radiologist. HIV serostatus did not impact CAD4TB's performance. Notably, 78.8% of the TB cases identified during this population-based survey were asymptomatic and therefore triaged for sputum collection on the basis of CAD4TBv5 score alone. While CAD4TBv6 has the potential to replace radiologists for triaging CXRs in TB prevalence surveys, population-specific piloting is necessary to set the appropriate triaging thresholds. Further work on image analysis strategies is needed to identify radiologically subtle active TB.
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Affiliation(s)
- Jana Fehr
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Digital Health & Machine Learning, Hasso Plattner Institute for Digital Engineering, Berlin, Germany
| | - Stefan Konigorski
- Digital Health & Machine Learning, Hasso Plattner Institute for Digital Engineering, Berlin, Germany
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stephen Olivier
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Resign Gunda
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | | | - Dickman Gareta
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Theresa Smit
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Kathy Baisley
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- London School of Hygiene & Tropical Medicine, London, UK
| | - Sashen Moodley
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Yumna Moosa
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Willem Hanekom
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | - Olivier Koole
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- London School of Hygiene & Tropical Medicine, London, UK
| | - Thumbi Ndung'u
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Division of Infection and Immunity, University College London, London, UK
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
- Ragon Institute of MGH, MIT and Harvard University, Cambridge, MA, USA
- Max Planck Institute for Infection Biology, Berlin, Germany
| | - Deenan Pillay
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | - Alison D Grant
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- London School of Hygiene & Tropical Medicine, London, UK
- School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Mark J Siedner
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- Harvard Medical School, Boston, MA, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Christoph Lippert
- Digital Health & Machine Learning, Hasso Plattner Institute for Digital Engineering, Berlin, Germany
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emily B Wong
- Africa Health Research Institute, KwaZulu-Natal, South Africa.
- Harvard Medical School, Boston, MA, USA.
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA.
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Bohlbro AS, Hvingelby VS, Rudolf F, Wejse C, Patsche CB. Active case-finding of tuberculosis in general populations and at-risk groups: a systematic review and meta-analysis. Eur Respir J 2021; 58:13993003.00090-2021. [PMID: 33766950 DOI: 10.1183/13993003.00090-2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/14/2021] [Indexed: 11/05/2022]
Abstract
The World Health Organization (WHO) recommends active case-finding (ACF) of Tuberculosis (TB) in certain high-risk groups; however, more evidence is needed to elucidate the scope of ACF beyond the current recommendations. In this study we aimed to systematically review yields (the prevalence of active TB) of studies on ACF in general populations and at-risk groups.The review protocol was registered with PROSPERO (registration no.: CRD42020206856). A literature search in PubMed, Embase, and CENTRAL was performed for studies concluded after 31/12/1999 and published before 01/09/2020. Screening yields were estimated and yield/prevalence ratios (ratio between yield of study and WHO estimated prevalence of TB) were calculated to assess which groups might especially benefit from ACF. Finally, risk of bias was assessed, and heterogeneity was investigated using meta-regression and sensitivity analyses.We included 197 studies, with a total of 12 372 530 screened and 53 158 cases found. Yields were high among drug users, close contacts, the poor and marginalised, people living with HIV (PLHIV), and prison inmates across incidence strata and estimated yield/prevalence ratios in screenings of general populations tended to be >1 with an overall ratio of 1.4 and ranging between 1.0 and 1.5. Sensitivity analyses suggested that inclusion of studies at high risk of bias contributed to underestimation of yields.Despite many studies using insensitive screening methods, these results suggest that more at-risk groups should be considered for inclusion in future screening recommendations and that screening of general populations may outperform current case-finding practices, providing evidence for extending ACF beyond the current recommendations.
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Affiliation(s)
- Anders Solitander Bohlbro
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau.,Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark.,GloHAU, Center for Global Health, Department of Public Health, Aarhus University, Denmark
| | | | - Frauke Rudolf
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau.,Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark
| | - Christian Wejse
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau.,Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark.,GloHAU, Center for Global Health, Department of Public Health, Aarhus University, Denmark
| | - Cecilie Blenstrup Patsche
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau.,GloHAU, Center for Global Health, Department of Public Health, Aarhus University, Denmark
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Medley N, Taylor M, van Wyk SS, Oliver S. Community views on active case finding for tuberculosis in low- and middle-income countries: a qualitative evidence synthesis. Hippokratia 2021. [DOI: 10.1002/14651858.cd014756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Nancy Medley
- Department of Clinical Sciences; Liverpool School of Tropical Medicine; Liverpool UK
| | - Melissa Taylor
- Department of Clinical Sciences; Liverpool School of Tropical Medicine; Liverpool UK
| | - Susanna S van Wyk
- Centre for Evidence-based Health Care, Epidemiology and Biostatistics, Department of Global Health; Faculty of Medicine and Health Sciences, Stellenbosch University; Cape Town South Africa
| | - Sandy Oliver
- EPPI-Centre, Social Science Research Unit, UCL Institute of Education; University College London; London UK
- Faculty of the Humanities; University of Johannesburg; Johannesburg South Africa
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Biermann O, Klüppelberg R, Lönnroth K, Viney K, Caws M, Atkins S. 'A double-edged sword': Perceived benefits and harms of active case-finding for people with presumptive tuberculosis and communities-A qualitative study based on expert interviews. PLoS One 2021; 16:e0247568. [PMID: 33705422 PMCID: PMC7951804 DOI: 10.1371/journal.pone.0247568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 02/09/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Active case-finding (ACF), also referred to as community-based tuberculosis screening, is a component of the World Health Organization's End TB Strategy. ACF has potential benefits but also harms, which need to be carefully assessed when developing and implementing ACF policies. While empirical evidence on the benefits of ACF is still weak, evidence on the harms is even weaker. This study aimed to explore experts' views on the benefits and harms of ACF for people with presumptive TB and communities. METHODS This was an exploratory study. Semi-structured interviews were conducted with a purposive sample of 39 experts from international, non-governmental/non-profit organizations, funders, government institutions, international societies, think tanks, universities and research institutions worldwide. Framework analysis was applied. RESULTS Findings elaborated perceived benefits of ACF, including reaching vulnerable populations, reducing patient costs, helping raise awareness for tuberculosis among individuals and engaging communities, and reducing tuberculosis transmission. Perceived harms included increasing stigma and discrimination, causing false-positive diagnoses, as well as triggering other unintended consequences related to screening for tuberculosis patients, such as deportation of migrants once confirmed to have tuberculosis. Most of the perceived benefits of ACF could be linked to its objective of finding and treating persons with tuberculosis early (theme 1), while ACF was also perceived as a "double-edged sword" and could cause harms, if inappropriately designed and implemented (theme 2). The analysis underlined the importance of considering the benefits and harms of ACF throughout the screening pathway. The study provides new insights into the perceived benefits and harms of ACF from the perspectives of experts in the field. CONCLUSION This study highlights gaps in the evidence base surrounding ACF and can stimulate further research, debate and analysis regarding the benefits and harms of ACF to inform contextual optimization of design and implementation of ACF strategies.
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Affiliation(s)
- Olivia Biermann
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Raina Klüppelberg
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Knut Lönnroth
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Kerri Viney
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Research School of Population Health, College of Health and Medicine, Australian National University, Canberra, Australia
| | - Maxine Caws
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Nepal
| | - Salla Atkins
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- New Social Research and Global Health and Development, Faculty of Social Sciences, Tampere University, Tampere, Finland
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Evrevin M, Hermet L, Guillet-Caruba C, Nivose PL, Sordoillet V, Mellon G, Dulioust A, Doucet-Populaire F. Improving tuberculosis management in prisons: Impact of a rapid molecular point-of-care test. J Infect 2020; 82:235-239. [PMID: 33285215 DOI: 10.1016/j.jinf.2020.11.042] [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: 07/09/2020] [Revised: 11/25/2020] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To improve tuberculosis (TB) diagnosis in prison, we evaluate the value of the XpertⓇMTB/RIF Ultra assay (Xpert) as point-of-care (POC) in a French prison hospital. METHODS We first validated Xpert use on raw sputum at the referent laboratory. Secondly, trained physicians at the prison hospital performed Xpert tests for each patient presenting TB symptoms. The results were compared with Xpert, microscopic examination, culture and drug susceptibility testing on the corresponding decontaminated specimens. RESULTS 76 inmates were included in 15 months and 21 were diagnosed with TB. The overall sensitivity, specificity, positive and negative predictive values of Xpert were respectively: 92.3%, 100%, 100% and 98.7% on raw sputum. The efficiency of the molecular POC was confirmed by a concordance of 97% between Xpert findings from the prison hospital and culture results. Delay of microbiological diagnosis was reduced by about 18 days for 13 inmates with smear-negative sputum that avoid the mobilization of major means (escort, transport) to perform fibroscopic samples. Repeated Xpert negative results helped to speed the lifting of inmate isolation. CONCLUSIONS The implementation of Xpert in prison could optimize the management of incarcerated patients and thus limit the spread of TB among inmates, carers and other staff.
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Affiliation(s)
- Marine Evrevin
- AP-HP, Hôpital Antoine Béclère, Service de Bactériologie-Hygiène, Université Paris-Saclay, Clamart, France
| | - Loïc Hermet
- Etablissement Public de Santé National de Fresnes (EPSNF), Fresnes, France
| | - Christelle Guillet-Caruba
- AP-HP, Hôpital Antoine Béclère, Service de Bactériologie-Hygiène, Université Paris-Saclay, Clamart, France
| | | | - Vallier Sordoillet
- AP-HP, Hôpital Antoine Béclère, Service de Bactériologie-Hygiène, Université Paris-Saclay, Clamart, France
| | - Guillaume Mellon
- Etablissement Public de Santé National de Fresnes (EPSNF), Fresnes, France
| | - Anne Dulioust
- Etablissement Public de Santé National de Fresnes (EPSNF), Fresnes, France
| | - Florence Doucet-Populaire
- AP-HP, Hôpital Antoine Béclère, Service de Bactériologie-Hygiène, Université Paris-Saclay, Clamart, France; Université Paris-Saclay, CEA, CNRS, Institut for integrative biology of the Cell (I2BC), Gif-sur-Yvette, France.
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8
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Biermann O, Tran PB, Viney K, Caws M, Lönnroth K, Sidney Annerstedt K. Active case-finding policy development, implementation and scale-up in high-burden countries: A mixed-methods survey with National Tuberculosis Programme managers and document review. PLoS One 2020; 15:e0240696. [PMID: 33112890 PMCID: PMC7592767 DOI: 10.1371/journal.pone.0240696] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 10/01/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) stresses the importance of active case-finding (ACF) for early detection of tuberculosis (TB), especially in the 30 high-burden countries that account for almost 90% of cases globally. OBJECTIVE To describe the attitudes of National TB Programme (NTP) managers related to ACF policy development, implementation and scale-up in the 30 high-burden countries, and to review national TB strategic plans. METHODS This was a mixed-methods study with an embedded design: A cross-sectional survey with NTP managers yielded quantitative and qualitative data. A review of national TB strategic plans complemented the results. All data were analyzed in parallel and merged in the interpretation of the findings. RESULTS 23 of the 30 NTP managers (77%) participated in the survey and 22 (73%) national TB strategic plans were reviewed. NTP managers considered managers in districts and regions key stakeholders for both ACF policy development and implementation. Different types of evidence were used to inform ACF policy, while there was a particular demand for local evidence. The NSPs reflected the NTP managers' unanimous agreement on the need for ACF scale-up, but not all included explicit aims and targets related to ACF. The NTP managers recognized that ACF may decrease health systems costs in the long-term, while acknowledging the risk for increased health system costs in the short-term. About 90% of the NTP managers declared that financial and human resources were currently lacking, while they also elaborated on strategies to overcome resource constraints. CONCLUSION NTP managers stated that ACF should be scaled up but reported resource constraints. Strategies to increase resources exist but may not yet have been fully implemented, e.g. generating local evidence including from operational research for advocacy. Managers in districts and regions were identified as key stakeholders whose involvement could help improve ACF policy development, implementation and scale-up.
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Affiliation(s)
- Olivia Biermann
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Phuong Bich Tran
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Kerri Viney
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Research School of Population Health, College of Health and Medicine, Australian National University, Canberra, Australia
| | - Maxine Caws
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Nepal
| | - Knut Lönnroth
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Creswell J, Khan A, Bakker MI, Brouwer M, Kamineni VV, Mergenthaler C, Smelyanskaya M, Qin ZZ, Ramis O, Stevens R, Reddy KS, Blok L. The TB REACH Initiative: Supporting TB Elimination Efforts in the Asia-Pacific. Trop Med Infect Dis 2020; 5:E164. [PMID: 33114749 PMCID: PMC7709586 DOI: 10.3390/tropicalmed5040164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 10/09/2020] [Accepted: 10/16/2020] [Indexed: 12/19/2022] Open
Abstract
After many years of TB 'control' and incremental progress, the TB community is talking about ending the disease, yet this will only be possible with a shift in the way we approach the TB response. While the Asia-Pacific region has the highest TB burden worldwide, it also has the opportunity to lead the quest to end TB by embracing the four areas laid out in this series: using data to target hotspots, initiating active case finding, provisioning preventive TB treatment, and employing a biosocial approach. The Stop TB Partnership's TB REACH initiative provides a platform to support partners in the development, evaluation and scale-up of new and innovative technologies and approaches to advance TB programs. We present several approaches TB REACH is taking to support its partners in the Asia-Pacific and globally to advance our collective response to end TB.
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Affiliation(s)
- Jacob Creswell
- Stop TB Partnership, 1218 Geneva, Switzerland; (A.K.); (M.S.); (Z.Z.Q.)
| | - Amera Khan
- Stop TB Partnership, 1218 Geneva, Switzerland; (A.K.); (M.S.); (Z.Z.Q.)
| | - Mirjam I Bakker
- KIT Royal Tropical Institute, 1092 Amsterdam, The Netherlands; (M.I.B.); (C.M.); (L.B.)
| | | | | | | | | | - Zhi Zhen Qin
- Stop TB Partnership, 1218 Geneva, Switzerland; (A.K.); (M.S.); (Z.Z.Q.)
| | | | | | - K Srikanth Reddy
- Global Affairs Canada, Global Health and Nutrition Bureau, Ottawa K1A 0G2, ON, Canada;
| | - Lucie Blok
- KIT Royal Tropical Institute, 1092 Amsterdam, The Netherlands; (M.I.B.); (C.M.); (L.B.)
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10
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Garg T, Bhardwaj M, Deo S. Role of community health workers in improving cost efficiency in an active case finding tuberculosis programme: an operational research study from rural Bihar, India. BMJ Open 2020; 10:e036625. [PMID: 33004390 PMCID: PMC7536783 DOI: 10.1136/bmjopen-2019-036625] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Cost-efficient active case finding (ACF) approaches are needed for their large-scale adoption in national tuberculosis (TB) programmes. Our aim was to assess if community health workers' (CHW) knowledge about families' health status can improve the cost efficiency of the ACF programme without adversely affecting the delivery of other health services for which they are responsible. DESIGN Quasi-experimental design. INTERVENTIONS We evaluated an ACF programme in the Samastipur district in Bihar, India, between July 2017 and June 2018. CHWs called Accredited Social Health Activists generated referrals of individuals at risk of TB and conducted symptom-based screening to identify patients with presumptive TB. They also helped them undergo testing and provided treatment support for confirmed TB cases. PRIMARY AND SECONDARY OUTCOME MEASURES We compared the notification rate from the intervention region with that from a control region in the same district with similar characteristics. We analysed operational data to calculate the cost per TB case diagnosed. We used routine programmatic data from the public health system to estimate the impact on other services provided by CHWs. FINDINGS CHWs identified 9895 patients with presumptive TB. Of these, 5864 patients were tested for TB, and 1236 were confirmed as TB cases. Annual public case notification rate increased sharply in the intervention region from 45.8 to 105.8 per 100 000 population, whereas it decreased from 50.7 to 45.3 in the control region. There was no practically or statistically significant impact on other output indicators of the CHWs, such as institutional deliveries (-0.04%). The overall cost of the intervention was about US$134 per diagnosed case. Main cost drivers were human resources, and commodities (drugs and diagnostics), which contributed 37.4% and 32.5% of the cost, respectively. CONCLUSIONS ACF programmes that use existing CHWs in the health system are feasible, cost efficient and do not adversely affect other healthcare services delivered by CHWs.
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Affiliation(s)
- Tushar Garg
- Research, Innovators In Health, Patna, Bihar, India
| | | | - Sarang Deo
- Operations Management, Indian School of Business, Hyderabad, Telangana, India
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11
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Shewade HD, Gupta V, Ghule VH, Nayak S, Satyanarayana S, Dayal R, Mohanty S, Singh S, Biswas M, Reddy KK, Mallick G, Bera OP, Pandey P, Pandurangan S, Rao R, Prasad BM, Kumar AMV, Chadha SS. Impact of Advocacy, Communication, Social Mobilization and Active Case Finding on TB Notification in Jharkhand, India. J Epidemiol Glob Health 2020; 9:233-242. [PMID: 31854164 PMCID: PMC7310791 DOI: 10.2991/jegh.k.190812.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 08/10/2019] [Indexed: 10/31/2022] Open
Abstract
Community-level benefits of screening for active tuberculosis (TB) disease remain uncertain. Project Axshya (meaning free of TB) conducted advocacy, communication, social mobilization, and active case finding among vulnerable/marginalized populations of India. Among 15 districts of Jharkhand state, the project was initiated in 36 subdistrict level administrative units - tuberculosis units (TUs) in a staggered manner between April 2013 and September 2014, and continued till the end of 2015. Seven TUs did not implement the project. We assessed the relative change in the quarterly TB case finding indicators (n = 4) after inclusion of a TU within the project. By fitting four multilevel models (mixed-effects maximum likelihood regression using random intercept), we adjusted for secular (over previous five quarters) and seasonal trends, baseline differences within Axshya and non-Axshya TUs, and population size and clustering within districts and within TUs. After inclusion of a TU within the project, we found a significant increase [95% confidence interval (CI)] in TU-level presumptive TB sputum examination rate, new sputum-positive TB Case Notification Rate (CNR), sputum-positive TB CNR, and all forms TB CNR by 12 (5.5, 18.5), 1.1 (0.5, 1.7), 1.3 (0.6, 2.0), and 1.2 (0.1, 2.2) per 100,000 population per quarter, respectively. Overall, the project resulted in an increase (95% CI) in sputum examination and detection of new sputum-positive TB, sputum-positive TB and all forms of TB patients by 22,410 (10,203, 34,077), 2066 (923, 3210), 2380 (1162, 3616), and 2122 (203, 4059), respectively. This provides evidence for implementing project Axshya over and above the existing passive case finding.
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Affiliation(s)
- Hemant Deepak Shewade
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France.,Department of Operational Research, The Union South-East Asia (USEA), New Delhi, India
| | - Vivek Gupta
- Dr RP Centre for Ophthalmic Sciences, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Vaibhav Haribhau Ghule
- Joint Efforts for Elimination of TB (JEET) Project, Foundation for Innovative New Diagnostics (FIND), New Delhi, India
| | - Sashikanta Nayak
- Department of TB and Communicable Disease, The Union South-East Asia (USEA), New Delhi, India
| | - Srinath Satyanarayana
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | - Rakesh Dayal
- State TB Cell, Department of Health and Family Welfare, Government of Jharkhand, Ranchi, India
| | - Subrat Mohanty
- Department of TB and Communicable Disease, The Union South-East Asia (USEA), New Delhi, India
| | - Sukhwinder Singh
- Department of TB and Communicable Disease, The Union South-East Asia (USEA), New Delhi, India
| | - Moumita Biswas
- Department of TB and Communicable Disease, The Union South-East Asia (USEA), New Delhi, India
| | - Kiran Kumar Reddy
- Department of TB and Communicable Disease, The Union South-East Asia (USEA), New Delhi, India
| | - Gayadhar Mallick
- Department of TB and Communicable Disease, The Union South-East Asia (USEA), New Delhi, India
| | - Om Prakash Bera
- Department of TB and Communicable Disease, The Union South-East Asia (USEA), New Delhi, India
| | - Prabhat Pandey
- Department of TB and Communicable Disease, The Union South-East Asia (USEA), New Delhi, India
| | - Sripriya Pandurangan
- Department of TB and Communicable Disease, The Union South-East Asia (USEA), New Delhi, India
| | - Raghuram Rao
- Central TB Division, Revised National Tuberculosis Control Programme, Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | | | - Ajay Madhugiri Venkatachalaiah Kumar
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France.,Department of Operational Research, The Union South-East Asia (USEA), New Delhi, India.,Yenepoya Medical College, Yenepoya (Deemed to be University), Mangaluru, India
| | - Sarabjit Singh Chadha
- Infectious Diseases, Foundation for Innovative New Diagnostics (FIND), New Delhi, India
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12
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van Gurp M, Rood E, Fatima R, Joshi P, Verma SC, Khan AH, Blok L, Mergenthaler C, Bakker MI. Finding gaps in TB notifications: spatial analysis of geographical patterns of TB notifications, associations with TB program efforts and social determinants of TB risk in Bangladesh, Nepal and Pakistan. BMC Infect Dis 2020; 20:490. [PMID: 32650738 PMCID: PMC7350590 DOI: 10.1186/s12879-020-05207-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 06/29/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND In order to effectively combat Tuberculosis, resources to diagnose and treat TB should be allocated effectively to the areas and population that need them. Although a wealth of subnational data on TB is routinely collected to support local planning, it is often underutilized. Therefore, this study uses spatial analytical techniques and profiling to understand and identify factors underlying spatial variation in TB case notification rates (CNR) in Bangladesh, Nepal and Pakistan for better TB program planning. METHODS Spatial analytical techniques and profiling was used to identify subnational patterns of TB CNRs at the district level in Bangladesh (N = 64, 2015), Nepal (N = 75, 2014) and Pakistan (N = 142, 2015). A multivariable linear regression analysis was performed to assess the association between subnational CNR and demographic and health indicators associated with TB burden and indicators of TB programme efforts. To correct for spatial dependencies of the observations, the residuals of the multivariable models were tested for unexplained spatial autocorrelation. Spatial autocorrelation among the residuals was adjusted for by fitting a simultaneous autoregressive model (SAR). RESULTS Spatial clustering of TB CNRs was observed in all three countries. In Bangladesh, TB CNR were found significantly associated with testing rate (0.06%, p < 0.001), test positivity rate (14.44%, p < 0.001), proportion of bacteriologically confirmed cases (- 1.33%, p < 0.001) and population density (4.5*10-3%, p < 0.01). In Nepal, TB CNR were associated with population sex ratio (1.54%, p < 0.01), facility density (- 0.19%, p < 0.05) and treatment success rate (- 3.68%, p < 0.001). Finally, TB CNR in Pakistan were found significantly associated with testing rate (0.08%, p < 0.001), positivity rate (4.29, p < 0.001), proportion of bacteriologically confirmed cases (- 1.45, p < 0.001), vaccination coverage (1.17%, p < 0.001) and facility density (20.41%, p < 0.001). CONCLUSION Subnational TB CNRs are more likely reflective of TB programme efforts and access to healthcare than TB burden. TB CNRs are better used for monitoring and evaluation of TB control efforts than the TB epidemic. Using spatial analytical techniques and profiling can help identify areas where TB is underreported. Applying these techniques routinely in the surveillance facilitates the use of TB CNRs in program planning.
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Affiliation(s)
| | - Ente Rood
- KIT Royal Tropical Instituter, Amsterdam, Netherlands
| | - Razia Fatima
- National TB Control Program, Islamabad, Pakistan
| | | | | | | | - Lucie Blok
- KIT Royal Tropical Instituter, Amsterdam, Netherlands
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13
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Shewade HD, Gupta V, Satyanarayana S, Kumar S, Pandey P, Bajpai UN, Tripathy JP, Kathirvel S, Pandurangan S, Mohanty S, Ghule VH, Sagili KD, Prasad BM, Singh P, Singh K, Jayaraman G, Rajeswaran P, Biswas M, Mallick G, Naqvi AJ, Bharadwaj AK, Sathiyanarayanan K, Pathak A, Mohan N, Rao R, Kumar AMV, Chadha SS. Active versus passive case finding for tuberculosis in marginalised and vulnerable populations in India: comparison of treatment outcomes. Glob Health Action 2020; 12:1656451. [PMID: 31475635 PMCID: PMC6735288 DOI: 10.1080/16549716.2019.1656451] [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] [Indexed: 11/06/2022] Open
Abstract
Background: Community-based active case finding (ACF) for tuberculosis (TB) implemented among marginalised and vulnerable populations in 285 districts of India resulted in reduction of diagnosis delay and prevalence of catastrophic costs due to TB diagnosis. We were interested to know whether this translated into improved treatment outcomes. Globally, there is limited published literature from marginalised and vulnerable populations on the independent effect of community-based ACF on treatment outcomes when compared to passive case finding (PCF). Objectives: To determine the relative differences in unfavourable treatment outcomes (death, loss-to-follow-up, failure, not evaluated) of ACF and PCF-diagnosed people. Methods: Cohort study involving record reviews and interviews in 18 randomly selected districts. We enrolled all ACF-diagnosed people with new smear-positive pulmonary TB, registered under the national TB programme between March 2016 and February 2017, and an equal number of randomly selected PCF-diagnosed people in the same settings. We used log binomial models to adjust for confounders. Results: Of 572 enrolled, 275 belonged to the ACF and 297 to the PCF group. The proportion of unfavourable outcomes were 10.2% (95% CI: 7.1%, 14.3%) in the ACF and 12.5% (95% CI: 9.2%, 16.7%) in the PCF group (p = 0.468). The association between ACF and unfavourable outcomes remained non-significant after adjusting for confounders available from records [aRR: 0.83 (95% CI: 0.56, 1.21)]. Due to patient non-availability at their residence, interviews were conducted for 465 (81.3%). In the 465 cohort too, there was no association after adjusting for confounders from records and interviews [aRR: 1.05 (95% CI: 0.62, 1.77)]. Conclusion: We did not find significant differences in the treatment outcomes. Due to the wide CIs, studies with larger sample sizes are urgently required. Studies are required to understand how to translate the benefits of ACF to improved treatment outcomes.
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Affiliation(s)
- Hemant Deepak Shewade
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union) , Paris , France.,Department of Operational Research , The Union South-East Asia (USEA) , New Delhi, India.,Karuna Trust , Bengaluru , India
| | - Vivek Gupta
- Dr RP Centre for Ophthalmic Sciences, All India Institute of Medical Sciences (AIIMS) , New Delhi , India
| | - Srinath Satyanarayana
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union) , Paris , France
| | - Sunil Kumar
- State TB Cell , Department of Health & Family Welfare, Government of Kerala, Thiruvananthapuram , India
| | - Prabhat Pandey
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | - U N Bajpai
- Voluntary Health Association of India (VHAI) , New Delhi , India
| | - Jaya Prasad Tripathy
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union) , Paris , France.,Department of Operational Research , The Union South-East Asia (USEA) , New Delhi, India
| | - Soundappan Kathirvel
- Department of Operational Research , The Union South-East Asia (USEA) , New Delhi, India.,Department of Community Medicine and School of Public Health , Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh , India
| | - Sripriya Pandurangan
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | - Subrat Mohanty
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | - Vaibhav Haribhau Ghule
- Joint Efforts for Elimination of TB (JEET) Project , Foundation for Innovate New Diagnostics (FIND), New Delhi , India
| | - Karuna D Sagili
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | | | - Priyanka Singh
- MAMTA Health Institute for Mother and Child , New Delhi , India
| | - Kamlesh Singh
- Catholic Health Association of India (CHAI) , Telangana , India
| | - Gurukartick Jayaraman
- Resource Group for Education & Advocacy for Community Health (REACH) , Chennai , India
| | - P Rajeswaran
- Resource Group for Education & Advocacy for Community Health (REACH) , Chennai , India
| | - Moumita Biswas
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | - Gayadhar Mallick
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | - Ali Jafar Naqvi
- MAMTA Health Institute for Mother and Child , New Delhi , India
| | | | - K Sathiyanarayanan
- Resource Group for Education & Advocacy for Community Health (REACH) , Chennai , India
| | - Aniruddha Pathak
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | - Nisha Mohan
- Karuna Trust , Bengaluru , India.,IIHMR University, Jaipur , India
| | - Raghuram Rao
- Central TB Division, Revised National Tuberculosis Control Programme, Ministry of Health and Family Welfare , Government of India , New Delhi, India
| | - Ajay M V Kumar
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union) , Paris , France.,Department of Operational Research , The Union South-East Asia (USEA) , New Delhi, India.,Yenepoya Medical College, Yenepoya (Deemed to be University), Mangaluru , India
| | - Sarabjit Singh Chadha
- Infectious Diseases, Foundation for Innovate New Diagnostics (FIND), New Delhi , India
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14
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Machekera SM, Wilkinson E, Hinderaker SG, Mabhala M, Zishiri C, Ncube RT, Timire C, Takarinda KC, Sengai T, Sandy C. A comparison of the yield and relative cost of active tuberculosis case-finding algorithms in Zimbabwe. Public Health Action 2019; 9:63-68. [PMID: 31417855 DOI: 10.5588/pha.18.0098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/09/2019] [Indexed: 11/10/2022] Open
Abstract
Setting Ten districts and three cities in Zimbabwe. Objective To compare the yield and relative cost of identifying a case of tuberculosis (TB) using the three WHO-recommended algorithms (WHO2b, symptom inquiry only; WHO2d, chest X-ray [CXR] after a positive symptom inquiry; WHO3b, CXR only) and the Zimbabwe active case finding (ZimACF) algorithm (symptom inquiry plus CXR) to everyone. Design Cross-sectional study using data from the ZimACF project. Results A total of 38 574 people were screened from April to December 2017; 488 (1.3%) were diagnosed with TB using the ZimACF algorithm. Fewer TB cases would have been diagnosed with the WHO-recommended algorithms. This ranged from 7% fewer (34 cases) with WHO3b, 18% fewer (88 cases) with WHO2b and 25% fewer (122 cases) with WHO2d. The need for CXR ranged from 36% (WHO2d) to 100% (WHO3b). The need for bacteriological confirmation ranged from 7% (WHO2d) to 40% (ZimACF). The relative cost per case of TB diagnosed ranged from US$180 with WHO3b to US$565 for the ZimACF algorithm. Conclusion The ZimACF algorithm had the highest case yield, but at a much higher cost per case than the WHO algorithms. It is possible to switch to algorithm WHO3b, but the trade-off between cost and yield needs to be reviewed by the Zimbabwean National TB Programme.
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Affiliation(s)
- S M Machekera
- International Union Against Tuberculosis and Lung Diseases, Harare, Zimbabwe
| | - E Wilkinson
- Institute of Medicine, University of Chester, Chester, UK
| | - S G Hinderaker
- Centre of International Health, University of Bergen, Bergen, Norway
| | - M Mabhala
- Department of Public Health and Wellbeing, University of Chester, Chester, UK
| | - C Zishiri
- International Union Against Tuberculosis and Lung Diseases, Harare, Zimbabwe
| | - R T Ncube
- International Union Against Tuberculosis and Lung Diseases, Harare, Zimbabwe
| | - C Timire
- International Union Against Tuberculosis and Lung Diseases, Harare, Zimbabwe.,Ministry of Health and Child Care, Harare, Zimbabwe
| | - K C Takarinda
- International Union Against Tuberculosis and Lung Diseases, Harare, Zimbabwe.,Ministry of Health and Child Care, Harare, Zimbabwe
| | - T Sengai
- Family AIDS Caring Trust, Mutare, Zimbabwe
| | - C Sandy
- Ministry of Health and Child Care, Harare, Zimbabwe
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15
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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: 212] [Impact Index Per Article: 42.4] [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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Shewade HD, Gupta V, Satyanarayana S, Pandey P, Bajpai UN, Tripathy JP, Kathirvel S, Pandurangan S, Mohanty S, Ghule VH, Sagili KD, Prasad BM, Nath S, Singh P, Singh K, Singh R, Jayaraman G, Rajeswaran P, Srivastava BK, Biswas M, Mallick G, Bera OP, Sahai KN, Murali L, Kamble S, Deshpande M, Kumar N, Kumar S, Jaisingh AJJ, Naqvi AJ, Verma P, Ansari MS, Mishra PC, Sumesh G, Barik S, Mathew V, Lohar MRS, Gaurkhede CS, Parate G, Bale SY, Koli I, Bharadwaj AK, Venkatraman G, Sathiyanarayanan K, Lal J, Sharma AK, Rao R, Kumar AMV, Chadha SS. Patient characteristics, health seeking and delays among new sputum smear positive TB patients identified through active case finding when compared to passive case finding in India. PLoS One 2019; 14:e0213345. [PMID: 30865730 PMCID: PMC6415860 DOI: 10.1371/journal.pone.0213345] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 02/20/2019] [Indexed: 11/18/2022] Open
Abstract
Background Axshya SAMVAD is an active tuberculosis (TB) case finding (ACF) strategy under project Axshya (Axshya meaning ‘free of TB’ and SAMVAD meaning ‘conversation’) among marginalized and vulnerable populations in 285 districts of India. Objectives To compare patient characteristics, health seeking, delays in diagnosis and treatment initiation among new sputum smear positive TB patients detected through ACF and passive case finding (PCF) under the national TB programme in marginalized and vulnerable populations between March 2016 and February 2017. Methods This observational analytic study was conducted in 18 randomly sampled Axshya districts. We enrolled all TB patients detected through ACF and an equal number of randomly selected patients detected through PCF in the same settings. Data on patient characteristics, health seeking and delays were collected through record review and patient interviews (at their residence). Delays included patient level delay (from eligibility for sputum examination to first contact with any health care provider (HCP)), health system level diagnosis delay (from contact with first HCP to TB diagnosis) and treatment initiation delays (from diagnosis to treatment initiation). Total delay was the sum of patient level, health system level diagnosis delay and treatment initiation delays. Results We included 234 ACF-diagnosed and 231 PCF-diagnosed patients. When compared to PCF, ACF patients were relatively older (≥65 years, 14% versus 8%, p = 0.041), had no formal education (57% versus 36%, p<0.001), had lower monthly income per capita (median 13.1 versus 15.7 USD, p = 0.014), were more likely from rural areas (92% versus 81%, p<0.002) and residing far away from the sputum microscopy centres (more than 15 km, 24% versus 18%, p = 0.126). Fewer patients had history of significant loss of weight (68% versus 78%, p = 0.011) and sputum grade of 3+ (15% versus 21%, p = 0.060). Compared to PCF, HCP visits among ACF patients was significantly lower (median one versus two HCPs, p<0.001). ACF patients had significantly lower health system level diagnosis delay (median five versus 19 days, p = 0.008) and the association remained significant after adjusting for potential confounders. Patient level and total delays were not significantly different. Conclusion Axshya SAMVAD linked the most impoverished communities to TB care and resulted in reduction of health system level diagnosis delay.
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Affiliation(s)
- Hemant Deepak Shewade
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- * E-mail:
| | - Vivek Gupta
- All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Srinath Satyanarayana
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | - Prabhat Pandey
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - U. N. Bajpai
- Voluntary Health Association of India (VHAI), New Delhi, India
| | - Jaya Prasad Tripathy
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | - Soundappan Kathirvel
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
- Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sripriya Pandurangan
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Subrat Mohanty
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Vaibhav Haribhau Ghule
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Karuna D. Sagili
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Banuru Muralidhara Prasad
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Sudhi Nath
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Priyanka Singh
- MAMTA Health Institute for Mother and Child, New Delhi, India
| | - Kamlesh Singh
- Catholic Health Association of India (CHAI), Telangana, India
| | - Ramesh Singh
- Voluntary Health Association of India (VHAI), New Delhi, India
| | - Gurukartick Jayaraman
- Resource Group for Education & Advocacy for Community Health (REACH), Chennai, India
| | - P. Rajeswaran
- Resource Group for Education & Advocacy for Community Health (REACH), Chennai, India
| | | | - Moumita Biswas
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Gayadhar Mallick
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Om Prakash Bera
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - K. N. Sahai
- State TB Cell, Department of Health & Family Welfare, Government of Bihar, Patna, India
| | - Lakshmi Murali
- State TB Cell, Department of Health & Family Welfare, Government of Tamil Nadu, Chennai, India
| | - Sanjeev Kamble
- State TB Cell, Health Department, Government of Maharashtra, Pune, India
| | - Madhav Deshpande
- State TB Cell, Department of Health & Family Welfare, Government of Chattisgarh, Raipur, India
| | - Naresh Kumar
- State TB Cell, Department of Health & Family Welfare, Government of Punjab, Chandigarh, India
| | - Sunil Kumar
- State TB Cell, Department of Health & Family Welfare, Government of Kerala, Thiruvananthapuram, India
| | | | - Ali Jafar Naqvi
- MAMTA Health Institute for Mother and Child, New Delhi, India
| | - Prafulla Verma
- MAMTA Health Institute for Mother and Child, New Delhi, India
| | | | - Prafulla C. Mishra
- Catholic Bishops’ Conference of India-Coalition for AIDS and Related Diseases (CBCI-CARD), New Delhi, India
| | - G Sumesh
- Resource Group for Education & Advocacy for Community Health (REACH), Chennai, India
| | - Sanjeeb Barik
- Emmanuel Hospital Association (EHA), New Delhi, India
| | - Vijesh Mathew
- Catholic Health Association of India (CHAI), Telangana, India
| | | | | | - Ganesh Parate
- MAMTA Health Institute for Mother and Child, New Delhi, India
| | | | - Ishwar Koli
- Catholic Health Association of India (CHAI), Telangana, India
| | | | - G. Venkatraman
- Resource Group for Education & Advocacy for Community Health (REACH), Chennai, India
| | - K. Sathiyanarayanan
- Resource Group for Education & Advocacy for Community Health (REACH), Chennai, India
| | - Jinesh Lal
- Catholic Health Association of India (CHAI), Telangana, India
| | | | - Raghuram Rao
- Central TB Division, Revised National Tuberculosis Control Programme, Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - Ajay M. V. Kumar
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | - Sarabjit Singh Chadha
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
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Dixon J, Tameris M. A disease beyond reach: nurse perspectives on the past and present of tuberculosis control in South Africa. ANTHROPOLOGY SOUTHERN AFRICA 2018. [DOI: 10.1080/23323256.2018.1526096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Justin Dixon
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Michèle Tameris
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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The performance and yield of tuberculosis testing algorithms using microscopy, chest x-ray, and Xpert MTB/RIF. J Clin Tuberc Other Mycobact Dis 2018; 14:1-6. [PMID: 31720409 PMCID: PMC6830149 DOI: 10.1016/j.jctube.2018.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 11/19/2018] [Accepted: 11/26/2018] [Indexed: 12/14/2022] Open
Abstract
Setting The introduction of Xpert MTB/RIF (Xpert) and renewed interest in chest x-ray (CXR) for tuberculosis testing has provided additional choices to the smear-based diagnostic algorithms used by TB programs previously. More programmatic data is needed to better understand the implications of possible approaches. Objective We sought to evaluate how different testing algorithms using microscopy, Xpert and CXR impacted the number of people detected with TB in a district hospital in Nepal. Design Consecutively recruited patients with TB-related symptoms were offered smear microscopy, CXR and Xpert. We tested six hypothetical algorithms and compared yield, bacteriologically positive (Bac+) cases missed, and tests conducted. Results Among 929 patients, Bac+ prevalence was 17.3% (n = 161). Smear microscopy detected 121 (75.2% of Bac+). Depending on the radiologists' interpretation of CXR, Xpert testing could be reduced by (31%-60%). Smear microscopy reduced Xpert cartridge need slightly, but increased the overall diagnostic tests performed. Conclusion Xpert detected a large proportion of Bac+ TB cases missed by microscopy. CXR was useful in greatly reducing the number of diagnostic tests needed even among presumptive TB patients. Loose CXR readings should be used to identify more people for TB testing. More analysis of costs and standardized CXR reading should be considered.
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Boudarene L, James R, Coker R, Khan MS. Are scientific research outputs aligned with national policy makers' priorities? A case study of tuberculosis in Cambodia. Health Policy Plan 2018; 32:i3-i11. [PMID: 29028223 DOI: 10.1093/heapol/czx041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2017] [Indexed: 11/13/2022] Open
Abstract
With funding for tuberculosis (TB) research decreasing, and the high global disease burden persisting, there are calls for increased investment in TB research. However, justification of such investments is questionable, when translation of research outputs into policy and health care improvements remains a challenge for TB and other diseases. Using TB in Cambodia as a case study, we investigate how evidence needs of national policy makers are addressed by topics covered in research publications. We first conducted a systematic review to compile all studies on TB in Cambodia published since 2000. We then identified priority areas in which evidence for policy and programme planning are required from the perspective of key national TB control stakeholders. Finally, results from the literature review were analysed in relation to the priority research areas for national policy makers to assess overlap and highlight gaps in evidence. Priority research areas were: TB-HIV co-infection; childhood TB; multidrug resistant TB (MDR-TB); and universal and equitable access to quality diagnosis and treatment. On screening 1687 unique papers retrieved from our literature search, 253 were eligible publications focusing on TB in Cambodia. Of these, only 73 (29%) addressed one of the four priority research areas. Overall, 30 (11%), five (2%), seven (2%) and 37 (14%) studies reported findings relevant to TB-HIV, childhood TB, MDR-TB and access to quality diagnosis and treatment respectively. Our analysis shows that a small proportion of the research outputs in Cambodia address priority areas for informing policy and programme planning. This case study illustrates that there is substantial room for improvement in alignment between research outputs and evidence gaps that national policy makers would like to see addressed; better coordination between researchers, funders and policy makers' on identifying priority research topics may increase the relevance of research findings to health policies and programmes.
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Affiliation(s)
- Lydia Boudarene
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore 117549, Singapore.,University of Health Science, 73 Preah Monivong Blvd (93), Phnom Penh, Cambodia
| | - Richard James
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore 117549, Singapore.,University of Health Science, 73 Preah Monivong Blvd (93), Phnom Penh, Cambodia
| | - Richard Coker
- Communicable Diseases Research and Policy Group, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK.,Mahidol University, 420/1 Ratchawithi RD, Ratchathewi District, Bangkok, Thailand
| | - Mishal S Khan
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore 117549, Singapore.,Communicable Diseases Research and Policy Group, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK
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Efficacy of district tuberculosis co-ordinating team on health service performance for suspected TB patient in district hospital. JOURNAL OF HEALTH RESEARCH 2018. [DOI: 10.1108/jhr-05-2018-026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose
The purpose of this paper is to study the efficacy of a district tuberculosis (TB) co-ordinating team on health service performance for suspected TB patients in a district hospital in northeastern Thailand.
Design/methodology/approach
A comparison study of pre- and post-evaluations of TB system improvement was conducted in a district hospital in northeastern Thailand between October 2016 and June 2017. Data collection reviewed the record of suspected TB cases reported in the district hospital in the past nine months as a base line for describing the health service performance in term of received investigation for TB diagnosis. Participants from a TB clinic, district health office and health center set up a TB co-ordinating team to explore situations and systematic gaps. The TB co-ordinating team gave recommendations of health service performance for suspected TB patients over a nine-month period. Records of suspected TB cases health service performance were collected nine months after intervention. Data analysis by descriptive statistics and to test the effect of intervention was performed.
Findings
The records from 324 and 379 suspected TB cases reported in the hospital from the 9 months preceding and 9 months, respectively, after intervention were reviewed. A TB co-ordinating team was set up to improve the system and health service performance in terms of investigation for TB diagnosis. The results revealed that health service performance in terms of complete microscopy and investigation in both chest radiography and microscopy increased after intervention. When comparing between pre- and post-intervention, suspected cases received both chest radiography and microscopy in 176 cases and 283 cases, respectively (p-value=0.001). There were 27 cases diagnosed for smear positive TB in pre-intervention and 51 cases diagnosed in post-intervention (p-value=0.011). There were 21 cases pre- and 36 cases post-intervention that had referral documents from health center with no statistically significant difference.
Originality/value
The TB co-ordinating team had the role to improve health service performance for suspected TB cases to enroll in investigation process for increase TB diagnosis in district hospital.
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Berkowitz N, Okorie A, Goliath R, Levitt N, Wilkinson RJ, Oni T. The prevalence and determinants of active tuberculosis among diabetes patients in Cape Town, South Africa, a high HIV/TB burden setting. Diabetes Res Clin Pract 2018; 138:16-25. [PMID: 29382589 PMCID: PMC5931785 DOI: 10.1016/j.diabres.2018.01.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 12/23/2017] [Accepted: 01/23/2018] [Indexed: 11/19/2022]
Abstract
AIMS Studies addressing the association between diabetes mellitus (DM) and tuberculosis (TB) in sub-Saharan Africa are limited. We assessed the prevalence of active TB among DM patients at a primary care clinic, and identified risk factors for prevalent TB. METHODS A cross-sectional study was conducted in adult DM patients attending a clinic in Khayelitsha, Cape Town. Participants were screened for active TB (symptom screening and microbiological diagnosis) and HIV. RESULTS Among 440 DM patients screened, the active TB prevalence was 3.0% (95% CI 1.72-5.03). Of the 13 prevalent TB cases, 53.9% (n = 7; 95% CI 27.20-78.50) had no TB symptoms, and 61.5% (n = 8; 95% CI 33.30-83.70) were HIV-1 co-infected. There were no significant differences in either fasting plasma glucose or HbA1c levels between TB and non-TB participants. On multivariate analysis, HIV-1 infection (OR 11.3, 95% CI 3.26-39.42) and hemoptysis (OR 31.4, 95% CI 3.62-273.35) were strongly associated with prevalent active TB, with no differences in this association by age or gender. CONCLUSIONS The prevalence of active TB among DM patients was 4-fold higher than the national prevalence; suggesting the need for active TB screening, particularly if hemoptysis is reported. Our results highlight the importance of HIV screening in this older population group. The high prevalence of sub-clinical TB among those diagnosed with TB highlights the need for further research to determine how best to screen for active TB in high-risk TB/HIV population groups and settings.
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Affiliation(s)
- Natacha Berkowitz
- Clinical Infectious Disease Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town 7925, South Africa
| | - Adaeze Okorie
- Division of Public Health Medicine, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
| | - Rene Goliath
- Clinical Infectious Disease Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town 7925, South Africa
| | - Naomi Levitt
- Division of Diabetes and Endocrinology, Department of Medicine, Groote Schuur Hospital, Cape Town 7925, South Africa
| | - Robert J Wilkinson
- Clinical Infectious Disease Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town 7925, South Africa; The Francis Crick Institute Mill Hill Laboratory, London NW7 1AA, United Kingdom
| | - Tolu Oni
- Clinical Infectious Disease Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town 7925, South Africa; Division of Public Health Medicine, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa.
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Kigozi G, Engelbrecht M, Heunis C, Janse van Rensburg A. Household contact non-attendance of clinical evaluation for tuberculosis: a pilot study in a high burden district in South Africa. BMC Infect Dis 2018; 18:106. [PMID: 29506488 PMCID: PMC5838997 DOI: 10.1186/s12879-018-3010-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 02/22/2018] [Indexed: 11/21/2022] Open
Abstract
Background In 2012, the World Health Organization launched guidelines for systematically investigating contacts of persons with infectious tuberculosis (TB) in low- and middle-income countries. As such, it is necessary to understand factors that would influence successful scale-up. This study targeted household contacts of newly-diagnosed infectious TB patients in the Mangaung Metropolitan district to explore factors associated with non-attendance of clinical evaluation. Method In September–October 2016, a pilot study of household contacts was conducted. At each of the 40 primary health care (PHC) facilities in the district, at least one out of four types of TB index cases were purposefully selected. These included children <5 years, smear-positive cases, HIV co-infected cases, and multidrug-resistant TB (MDR-TB) cases. Trained fieldworkers administered questionnaires and screened contacts for TB symptoms. Those with TB symptoms as well as children <5 years were referred for clinical evaluation at the nearest PHC facility. Contacts’ socio-demographic and clinical characteristics, TB knowledge and perception about TB-related discrimination are described. Logistic regression analysis was used to investigate factors associated with non-attendance of clinical evaluation. Results Out of the 259 participants, approximately three in every five (59.5%) were female. The median age was 20 (interquartile range: 8–41) years. While the large majority (87.3%) of adult contacts correctly described TB aetiology, almost three in every five (59.9%) thought that it was hereditary, and almost two-thirds (65.5%) believed that it could be cured by herbal medicine. About one-fifth (22.9%) of contacts believed that TB patients were subjected to discrimination. Two in every five (39.4%) contacts were referred for clinical evaluation of whom more than half (52.9%) did not attend the clinic. Non-attendance was significantly associated with inter alia male gender (AOR: 3.4; CI: 1.11–10.24), prior TB diagnosis (AOR: 5.6; CI: 1.13–27.90) and sharing of a bedroom with the index case (AOR: 3.4: CI: 1.07–10.59). Conclusion The pilot study identified gaps in household contacts’ knowledge of TB. Further research on important individual, clinical and structural factors that can influence and should be considered in the planning, implementation and scale-up of household contact TB investigation is warranted.
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Affiliation(s)
- Gladys Kigozi
- Centre for Health Systems Research & Development, University of the Free State, P. O. Box 339, Bloemfontein, 9300, South Africa.
| | - Michelle Engelbrecht
- Centre for Health Systems Research & Development, University of the Free State, P. O. Box 339, Bloemfontein, 9300, South Africa
| | - Christo Heunis
- Centre for Health Systems Research & Development, University of the Free State, P. O. Box 339, Bloemfontein, 9300, South Africa
| | - André Janse van Rensburg
- Centre for Health Systems Research & Development, University of the Free State, P. O. Box 339, Bloemfontein, 9300, South Africa
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Rivera VR, Jean-Juste MA, Gluck SC, Reeder HT, Sainristil J, Julma P, Peck M, Joseph P, Ocheretina O, Perodin C, Secours R, Duran-Mendicuti M, Hashiguchi L, Cremieux PY, Koenig SP, Pape JW. Diagnostic yield of active case finding for tuberculosis and HIV at the household level in slums in Haiti. Int J Tuberc Lung Dis 2017; 21:1140-1146. [PMID: 29037294 PMCID: PMC5902800 DOI: 10.5588/ijtld.17.0049] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Haiti has the highest burden of tuberculosis (TB) in the Americas, with an estimated prevalence of 254 per 100 000 population. The Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (Groupe Haïtien d'Etude du Sarcome de Kaposi et des Infections Opportunistes, GHESKIO) conducted active case finding (ACF) for TB at the household level in nine slums in Port-au-Prince. OBJECTIVE We report on the prevalence of undiagnosed TB detected through GHESKIO's ACF campaign. DESIGN From 1 August 2014 to 31 July 2015, we conducted a retrospective cohort analysis using GHESKIO's ACF campaign data. All individuals who reported chronic cough (cough 2 weeks) were tested for TB at GHESKIO, and those aged 10 years were included in the analyses. RESULTS Of 104 097 individuals screened in the community, 5598 (5%) reported chronic cough and satisfied the study inclusion criteria. A total of 1110 (20%) were diagnosed with active TB disease (prevalence of 1066/100 000). Of the 5472 (98%) patients tested for human immunodeficiency virus (HIV), 528 (10%) were HIV-positive; 143 (3%) patients were diagnosed with both diseases. CONCLUSION Household-level screening for cough with TB and HIV testing for symptomatic patients was a high-yield strategy, leading to the detection of a prevalence of undiagnosed disease exceeding national estimates by more than four-fold for TB, and by five-fold for HIV.
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Affiliation(s)
- V R Rivera
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti, Center for Global Health, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - M-A Jean-Juste
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - S C Gluck
- Analysis Group, Boston, Massachusetts
| | | | - J Sainristil
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - P Julma
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - M Peck
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - P Joseph
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - O Ocheretina
- Center for Global Health, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - C Perodin
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - R Secours
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - L Hashiguchi
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - S P Koenig
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - J W Pape
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti, Center for Global Health, Department of Medicine, Weill Cornell Medical College, New York, New York
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James R, Khim K, Boudarene L, Yoong J, Phalla C, Saint S, Koeut P, Mao TE, Coker R, Khan MS. Tuberculosis active case finding in Cambodia: a pragmatic, cost-effectiveness comparison of three implementation models. BMC Infect Dis 2017; 17:580. [PMID: 28830372 PMCID: PMC5568199 DOI: 10.1186/s12879-017-2670-8] [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: 02/03/2017] [Accepted: 08/07/2017] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Globally, almost 40% of tuberculosis (TB) patients remain undiagnosed, and those that are diagnosed often experience prolonged delays before initiating correct treatment, leading to ongoing transmission. While there is a push for active case finding (ACF) to improve early detection and treatment of TB, there is extremely limited evidence about the relative cost-effectiveness of different ACF implementation models. Cambodia presents a unique opportunity for addressing this gap in evidence as ACF has been implemented using different models, but no comparisons have been conducted. The objective of our study is to contribute to knowledge and methodology on comparing cost-effectiveness of alternative ACF implementation models from the health service perspective, using programmatic data, in order to inform national policy and practice. METHODS We retrospectively compared three distinct ACF implementation models - door to door symptom screening in urban slums, checking contacts of TB patients, and door to door symptom screening focusing on rural populations aged above 55 - in terms of the number of new bacteriologically-positive pulmonary TB cases diagnosed and the cost of implementation assuming activities are conducted by the national TB program of Cambodia. We calculated the cost per additional case detected using the alternative ACF models. RESULTS Our analysis, which is the first of its kind for TB, revealed that the ACF model based on door to door screening in poor urban areas of Phnom Penh was the most cost-effective (249 USD per case detected, 737 cases diagnosed), followed by the model based on testing contacts of TB patients (308 USD per case detected, 807 cases diagnosed), and symptomatic screening of older rural populations (316 USD per case detected, 397 cases diagnosed). CONCLUSIONS Our study provides new evidence on the relative effectiveness and economics of three implementation models for enhanced TB case finding, in line with calls for data from 'routine conditions' to be included in disease control program strategic planning. Such cost-effectiveness comparisons are essential to inform resource allocation decisions of national policy makers in resource constraint settings. We applied a novel, pragmatic methodological approach, which was designed to provide results that are directly relevant to policy makers, costing the interventions from Cambodia's national TB program's perspective and using case finding data from implementation activities, rather than experimental settings.
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Affiliation(s)
- Richard James
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | | | - Lydia Boudarene
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Joanne Yoong
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.,Center for Economic and Social Research, University of Southern California, 635 Downey Way, VPD, Los Angeles, CA, 90089, USA
| | - Chea Phalla
- University of Health Science, Phnom Penh, Cambodia
| | - Saly Saint
- National Center for Tuberculosis and Leprosy Control, Phnom Penh, Cambodia
| | - Pichenda Koeut
- National Center for Tuberculosis and Leprosy Control, Phnom Penh, Cambodia
| | - Tan Eang Mao
- National Center for Tuberculosis and Leprosy Control, Phnom Penh, Cambodia
| | - Richard Coker
- Communicable Diseases Policy Research Group, London School of Hygiene & Tropical Medicine, Bangkok, Thailand.,Faculty of Public Health, Mahidol University, Bangkok, Thailand
| | - Mishal Sameer Khan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore. .,Communicable Diseases Policy Research Group, London School of Hygiene & Tropical Medicine, Bangkok, Thailand.
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Extending 'Contact Tracing' into the Community within a 50-Metre Radius of an Index Tuberculosis Patient Using Xpert MTB/RIF in Urban, Pakistan: Did It Increase Case Detection? PLoS One 2016; 11:e0165813. [PMID: 27898665 PMCID: PMC5127497 DOI: 10.1371/journal.pone.0165813] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 10/18/2016] [Indexed: 11/19/2022] Open
Abstract
Background Currently, only 62% of incident tuberculosis (TB) cases are reported to the national programme in Pakistan. Several innovative interventions are being recommended to detect the remaining ‘missed’ TB cases. One such intervention involved expanding contact investigation to the community using the Xpert MTB/RIF test. Methods This was a before and after intervention study involving retrospective record review. Passive case finding and household contact investigation was routinely done in the pre-intervention period July 2011-June 2013. Four districts with a high concentration of slums were selected as intervention areas; Lahore, Rawalpindi, Faisalabad and Islamabad. Here, in the intervention period, July 2013-June 2015, contact investigation beyond household was conducted: all people staying within a radius of 50 metres (using Geographical Information System) from the household of smear positive TB patients were screened for tuberculosis. Those with presumptive TB were investigated using smear microscopy and the Xpert MTB/RIF test was performed on smear negative patients. All the diagnosed TB patients were linked to TB treatment and care. Results A total of 783043 contacts were screened for tuberculosis: 23741(3.0%) presumptive TB patients were identified of whom, 4710 (19.8%) all forms and 4084(17.2%) bacteriologically confirmed TB patients were detected. The contribution of Xpert MTB/RIF to bacteriologically confirmed TB patients was 7.6%. The yield among investigated presumptive child TB patients was 5.1%. The overall yield of all forms TB patients among investigated was 22.3% among household and 19.1% in close community. The intervention contributed an increase of case detection of bacteriologically confirmed tuberculosis by 6.8% and all forms TB patients by 7.9%. Conclusion Community contact investigation beyond household not only detected additional TB patients but also increased TB case detection. However, further long term assessments and cost-effectiveness studies are required before national scale-up.
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Sanaie A, Mergenthaler C, Nasrat A, Seddiq MK, Mahmoodi SD, Stevens RH, Creswell J. An Evaluation of Passive and Active Approaches to Improve Tuberculosis Notifications in Afghanistan. PLoS One 2016; 11:e0163813. [PMID: 27701446 PMCID: PMC5049786 DOI: 10.1371/journal.pone.0163813] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 09/14/2016] [Indexed: 11/19/2022] Open
Abstract
Background In Afghanistan, improving TB case detection remains challenging. In 2014, only half of the estimated incident TB cases were notified, and notifications have decreased since peaking in 2007. Active case finding has been increasingly considered to improve TB case notifications. While access to health services has improved in Afghanistan, it remains poor and many people seeking health services won’t receive proper care. Methods From October 2011 through December 2012 we conducted three separate case finding strategies in six provinces of Afghanistan and measured impact on TB case notification. Systematically screening cough among attendees at 47 health facilities, active household contact investigation of smear-positive index TB patients, and active screening at 15 camps for internally displaced people were conducted. We collected both intervention yield and official quarterly notification data. Additional TB notifications were calculated by comparing numbers of cases notified during the intervention with those notified before the intervention, then adjusting for secular trends in notification. Results We screened 2,022,127 people for TB symptoms during the intervention, tested 59,838 with smear microscopy and detected 5,046 people with smear-positive TB. Most cases (81.7%, 4,125) were identified in health facilities while nearly 20% were found through active case finding. A 56% increase in smear-positive TB notifications was observed between the baseline and intervention periods among the 47 health facilities, where cases detected by all three strategies were notified. Discussion While most people with TB are likely to be identified through health facility screening, there are many people who remain without a proper diagnosis if outreach is not attempted. This is especially true in places like Afghanistan where access to general services is poor. Targeted active case finding can improve the number of people who are detected and treated for TB and can push towards the targets of the Stop TB Global Plan and End TB Strategy.
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Affiliation(s)
- A. Sanaie
- Anti-TB Association Afghanistan, Kabul, Afghanistan
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27
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Delva GJ, Francois I, Claassen CW, Dorestan D, Bastien B, Medina-Moreno S, Fort DS, Redfield RR, Buchwald UK. Active Tuberculosis Case Finding in Port-au-Prince, Haiti: Experiences, Results, and Implications for Tuberculosis Control Programs. Tuberc Res Treat 2016; 2016:8020745. [PMID: 27668093 PMCID: PMC5030475 DOI: 10.1155/2016/8020745] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 07/10/2016] [Indexed: 11/24/2022] Open
Abstract
Background. Haiti has the highest tuberculosis (TB) prevalence in the Americas with 254 cases per 100,000 persons. Case detection relies on passive detection and TB services in many regions suffer from poor diagnostic and clinical resources. Methods. Mache Chache ("Go and Seek") was a TB REACH Wave 3 funded TB case finding project in Port-au-Prince between July 2013 and September 2014, targeting four intervention areas with insufficient TB diagnostic performance. Results. Based on a verbal symptom screen emphasizing the presence of cough, the project identified 11,150 (11.75%) of all screened persons as TB subjects and 2.67% as smear-positive (SS+) TB cases. Enhanced case finding and strengthening of laboratory services led to a 59% increase in bacteriologically confirmed cases in the evaluation population. In addition, smear grades dropped significantly, suggesting earlier case detection. Xpert® MTB/RIF was successfully introduced and improved TB diagnosis in HIV-infected, smear-negative clinic patients, but not in HIV-negative, smear-negative TB suspects in the community. However, the number needed to screen for one additional SS+ case varied widely between clinic and community screening activities. Conclusion. Enhanced and active TB case finding in Haiti can improve TB diagnosis and care. However, screening algorithms have to be tailored to individual settings, necessitating long-term commitment.
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Affiliation(s)
- Guesly J. Delva
- Department of Medicine, Institute of Human Virology, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD 21201, USA
- Division of Infectious Diseases, Department of Medicine, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD 21201, USA
| | - Ingrid Francois
- Institute of Human Virology, University of Maryland School of Medicine, 4, Delmas 81, Port-au-Prince, Haiti
| | - Cassidy W. Claassen
- Department of Medicine, Institute of Human Virology, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD 21201, USA
- Division of Infectious Diseases, Department of Medicine, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD 21201, USA
| | - Darwin Dorestan
- Institute of Human Virology, University of Maryland School of Medicine, 4, Delmas 81, Port-au-Prince, Haiti
| | - Barbara Bastien
- Institute of Human Virology, University of Maryland School of Medicine, 4, Delmas 81, Port-au-Prince, Haiti
| | - Sandra Medina-Moreno
- Department of Medicine, Institute of Human Virology, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD 21201, USA
| | - Dumesle St. Fort
- Institute of Human Virology, University of Maryland School of Medicine, 4, Delmas 81, Port-au-Prince, Haiti
| | - Robert R. Redfield
- Department of Medicine, Institute of Human Virology, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD 21201, USA
- Division of Infectious Diseases, Department of Medicine, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD 21201, USA
| | - Ulrike K. Buchwald
- Department of Medicine, Institute of Human Virology, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD 21201, USA
- Division of Infectious Diseases, Department of Medicine, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD 21201, USA
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Adetifa IM, Kendall L, Bashorun A, Linda C, Omoleke S, Jeffries D, Maane R, Alorse BD, Alorse WD, Okoi CB, Mlaga KD, Kinteh MA, Donkor S, de Jong BC, Antonio M, d'Alessandro U. A tuberculosis nationwide prevalence survey in Gambia, 2012. Bull World Health Organ 2016; 94:433-41. [PMID: 27274595 PMCID: PMC4890202 DOI: 10.2471/blt.14.151670] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 01/20/2016] [Accepted: 01/25/2016] [Indexed: 11/27/2022] Open
Abstract
Objective To estimate the population prevalence of active pulmonary tuberculosis in Gambia. Methods Between December 2011 and January 2013, people aged ≥ 15 years participating in a nationwide, multistage cluster survey were screened for active pulmonary tuberculosis with chest radiography and for tuberculosis symptoms. For diagnostic confirmation, sputum samples were collected from those whose screening were positive and subjected to fluorescence microscopy and liquid tuberculosis cultures. Multiple imputation and inverse probability weighting were used to estimate tuberculosis prevalence. Findings Of 100 678 people enumerated, 55 832 were eligible to participate and 43 100 (77.2%) of those participated. A majority of participants (42 942; 99.6%) were successfully screened for symptoms and by chest X-ray. Only 5948 (13.8%) were eligible for sputum examination, yielding 43 bacteriologically confirmed, 28 definite smear-positive and six probable smear-positive tuberculosis cases. Chest X-ray identified more tuberculosis cases (58/69) than did symptoms alone (43/71). The estimated prevalence of smear-positive and bacteriologically confirmed pulmonary tuberculosis were 90 (95% confidence interval, CI: 53–127) and 212 (95% CI: 152–272) per 100 000 population, respectively. Tuberculosis prevalence was higher in males (333; 95% CI: 233–433) and in the 35–54 year age group (355; 95% CI: 219–490). Conclusion The burden of tuberculosis remains high in Gambia but lower than earlier estimates of 490 per 100 000 population in 2010. Less than half of all cases would have been identified based on smear microscopy results alone. Successful control efforts will require interventions targeting men, increased access to radiography and more accurate, rapid diagnostic tests.
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Affiliation(s)
- Ifedayo Mo Adetifa
- Department of Infectious Diseases Epidemiology, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, England
| | - Lindsay Kendall
- Disease Control and Elimination Theme, Medical Research Council Unit, Banjul, Gambia
| | - Adedapo Bashorun
- Disease Control and Elimination Theme, Medical Research Council Unit, Banjul, Gambia
| | - Christopher Linda
- Disease Control and Elimination Theme, Medical Research Council Unit, Banjul, Gambia
| | - Semeeh Omoleke
- Disease Control and Elimination Theme, Medical Research Council Unit, Banjul, Gambia
| | - David Jeffries
- Disease Control and Elimination Theme, Medical Research Council Unit, Banjul, Gambia
| | - Rahmatulai Maane
- Clinical Services Department, Medical Research Council Unit, Banjul, Gambia
| | | | | | | | - Kodjovi D Mlaga
- Vaccinology Theme, Medical Research Council Unit, Banjul, Gambia
| | - Ma Ansu Kinteh
- Disease Control and Elimination Theme, Medical Research Council Unit, Banjul, Gambia
| | - Simon Donkor
- Disease Control and Elimination Theme, Medical Research Council Unit, Banjul, Gambia
| | - Bouke C de Jong
- Mycobacteriology Unit, Institute of Tropical Medicine, Antwerp, Belgium
| | - Martin Antonio
- Vaccinology Theme, Medical Research Council Unit, Banjul, Gambia
| | - Umberto d'Alessandro
- Disease Control and Elimination Theme, Medical Research Council Unit, Banjul, Gambia
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Van Rie A, Clouse K, Hanrahan C, Selibas K, Sanne I, Williams S, Kim P, Bassett J. High uptake of systematic HIV counseling and testing and TB symptom screening at a primary care clinic in South Africa. PLoS One 2014; 9:e105428. [PMID: 25268851 PMCID: PMC4182031 DOI: 10.1371/journal.pone.0105428] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 07/23/2014] [Indexed: 11/28/2022] Open
Abstract
Background Timely diagnosis and treatment of tuberculosis (TB) and HIV is important to reduce morbidity and mortality, and break the cycle of ongoing transmission. Methods We performed an implementation research study to develop a model for systematic TB symptom screening and HIV counseling and testing (HCT) for all adult clients at a primary care clinic and prospectively evaluate the 6-month coverage and yield, and 18-month sustainability at a primary care clinic in Johannesburg, South Africa. Results During the first 6 months, 26,515 visits occurred among 12,078 adults. The proportion of adults aware of their HIV status was 43.7% at the start of the first visit, increased to 84.6% at the end of the first visit, and to 90% at end of any visit during the first 6 months. During these 6 months, 1042 clients were newly diagnosed with HIV. HIV prevalence was 22.9% among those newly tested, and 58.9% among all adult clinic clients. High coverage of systematic HCT was sustained across all 18 months. Coverage of systematic HIV-stratified TB symptom screening during first 6-months was also high (89.6%) but only 35.0% of those symptomatic were screened by sputum. During these 6-months, 90 clients had a positive Xpert MTB/RIF assay, corresponding to a TB prevalence of 0.4% among all 23,534 clients TB symptom-screened and 2.8% among the 3,284 clients with a positive TB symptom screen. The initial high coverage of TB symptom screening was not sustained, with coverage of TB symptom screening dropping after the first six months to 70% and assessment by sputum dropping to 15%. Conclusion Routine, systematic HCT and HIV-stratified TB symptom screening is feasible at primary care level. Systematic HCT doubled the proportion of clients with known HIV status. While HCT was sustainable, coverage of systematic TB screening dropped significantly after the first 6 months of implementation.
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Affiliation(s)
- Annelies Van Rie
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | - Kate Clouse
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Colleen Hanrahan
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Katerina Selibas
- Clinical HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Ian Sanne
- Clinical HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Sharon Williams
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Peter Kim
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Jean Bassett
- Witkoppen Health and Welfare Center, Johannesburg, South Africa
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Breuninger M, van Ginneken B, Philipsen RHHM, Mhimbira F, Hella JJ, Lwilla F, van den Hombergh J, Ross A, Jugheli L, Wagner D, Reither K. Diagnostic accuracy of computer-aided detection of pulmonary tuberculosis in chest radiographs: a validation study from sub-Saharan Africa. PLoS One 2014; 9:e106381. [PMID: 25192172 PMCID: PMC4156349 DOI: 10.1371/journal.pone.0106381] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 08/06/2014] [Indexed: 11/21/2022] Open
Abstract
Background Chest radiography to diagnose and screen for pulmonary tuberculosis has limitations, especially due to inter-reader variability. Automating the interpretation has the potential to overcome this drawback and to deliver objective and reproducible results. The CAD4TB software is a computer-aided detection system that has shown promising preliminary findings. Evaluation studies in different settings are needed to assess diagnostic accuracy and practicability of use. Methods CAD4TB was evaluated on chest radiographs of patients with symptoms suggestive of pulmonary tuberculosis enrolled in two cohort studies in Tanzania. All patients were characterized by sputum smear microscopy and culture including subsequent antigen or molecular confirmation of Mycobacterium tuberculosis (M.tb) to determine the reference standard. Chest radiographs were read by the software and two human readers, one expert reader and one clinical officer. The sensitivity and specificity of CAD4TB was depicted using receiver operating characteristic (ROC) curves, the area under the curve calculated and the performance of the software compared to the results of human readers. Results Of 861 study participants, 194 (23%) were culture-positive for M.tb. The area under the ROC curve of CAD4TB for the detection of culture-positive pulmonary tuberculosis was 0.84 (95% CI 0.80–0.88). CAD4TB was significantly more accurate for the discrimination of smear-positive cases against non TB patients than for smear-negative cases (p-value<0.01). It differentiated better between TB cases and non TB patients among HIV-negative compared to HIV-positive individuals (p<0.01). CAD4TB significantly outperformed the clinical officer, but did not reach the accuracy of the expert reader (p = 0.02), for a tuberculosis specific reading threshold. Conclusion CAD4TB accurately distinguished between the chest radiographs of culture-positive TB cases and controls. Further studies on cost-effectiveness, operational and ethical aspects should determine its place in diagnostic and screening algorithms.
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Affiliation(s)
- Marianne Breuninger
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- Ifakara Health Institute, Bagamoyo, United Republic of Tanzania
- Center for Infectious Diseases and Travel Medicine, University Hospital Freiburg, Freiburg, Germany
- * E-mail:
| | - Bram van Ginneken
- Diagnostic Image Analysis Group, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rick H. H. M. Philipsen
- Diagnostic Image Analysis Group, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Jerry J. Hella
- Ifakara Health Institute, Bagamoyo, United Republic of Tanzania
| | - Fred Lwilla
- Ifakara Health Institute, Bagamoyo, United Republic of Tanzania
| | | | - Amanda Ross
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Levan Jugheli
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- Ifakara Health Institute, Bagamoyo, United Republic of Tanzania
- University of Basel, Basel, Switzerland
| | - Dirk Wagner
- Center for Infectious Diseases and Travel Medicine, University Hospital Freiburg, Freiburg, Germany
| | - Klaus Reither
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- Ifakara Health Institute, Bagamoyo, United Republic of Tanzania
- University of Basel, Basel, Switzerland
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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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Creswell J, Khowaja S, Codlin A, Hashmi R, Rasheed E, Khan M, Durab I, Mergenthaler C, Hussain O, Khan F, Khan AJ. An evaluation of systematic tuberculosis screening at private facilities in Karachi, Pakistan. PLoS One 2014; 9:e93858. [PMID: 24705600 PMCID: PMC3976346 DOI: 10.1371/journal.pone.0093858] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 03/06/2014] [Indexed: 12/03/2022] Open
Abstract
Background In Pakistan, like many Asian countries, a large proportion of healthcare is provided through the private sector. We evaluated a systematic screening strategy to identify people with tuberculosis in private facilities in Karachi and assessed the approaches' ability to diagnose patients earlier in their disease progression. Methods and Findings Lay workers at 89 private clinics and a large hospital outpatient department screened all attendees for tuberculosis using a mobile phone-based questionnaire during one year. The number needed to screen to detect a case of tuberculosis was calculated. To evaluate early diagnosis, we tested for differences in cough duration and smear grading by screening facility. 529,447 people were screened, 1,010 smear-positive tuberculosis cases were detected and 942 (93.3%) started treatment, representing 58.7% of all smear-positive cases notified in the intervention area. The number needed to screen to detect a smear-positive case was 124 (prevalence 806/100,000) at the hospital and 763 (prevalence 131/100,000) at the clinics; however, ten times the number of individuals were screened in clinics. People with smear-positive TB detected at the hospital were less likely to report cough lasting 2–3 weeks (RR 0.66 95%CI [0.49–0.90]) and more likely to report cough duration >3 weeks (RR 1.10 95%CI [1.03–1.18]). Smear-positive cases at the clinics were less likely to have a +3 grade (RR 0.76 95%CI [0.63–0.92]) and more likely to have +1 smear grade (RR 1.24 95%CI [1.02–1.51]). Conclusions Tuberculosis screening at private facilities is acceptable and can yield large numbers of previously undiagnosed cases. Screening at general practitioner clinics may find cases earlier than at hospitals although more people must be screened to identify a case of tuberculosis. Limitations include lack of culture testing, therefore underestimating true TB prevalence. Using more sensitive and specific screening and diagnostic tests such as chest x-ray and Xpert MTB/RIF may improve results.
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Affiliation(s)
| | - Saira Khowaja
- Interactive Research and Development, Karachi, Pakistan
| | - Andrew Codlin
- Interactive Research and Development, Karachi, Pakistan
| | - Rabia Hashmi
- Interactive Research and Development, Karachi, Pakistan
| | - Erum Rasheed
- Interactive Research and Development, Karachi, Pakistan
| | - Mubashir Khan
- Interactive Research and Development, Karachi, Pakistan
| | - Irfan Durab
- Interactive Research and Development, Karachi, Pakistan
| | | | - Owais Hussain
- Interactive Research and Development, Karachi, Pakistan
| | - Faisal Khan
- Interactive Research and Development, Karachi, Pakistan
| | - Aamir J. Khan
- Interactive Research and Development, Karachi, Pakistan
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