Contact screening and management in a high-transmission MDR-TB setting in Papua New Guinea: Progress, challenges and future directions

Daru, South Fly District, Papua New Guinea is a high transmission setting for multidrug-resistant tuberculosis (MDR-TB). An emergency response by the Government in 2014 established a high-quality model for treatment and care. Household contact screening and management commenced in 2016 with TB preventive treatment (TPT) for well young child (<5 years) contacts of people with drug-susceptible TB and later expanded to young child contacts of MDR-TB. The model of care is community-based and led by non-specialist health workers, under supervision. An electronic medical record system supports care, reporting and operational research. Community engagement and education has been central, with a concerted focus on peer-led counselling and patient-centred services to improve TPT uptake and completion. Challenges include the application of households as the unit of intervention for detection of active TB and TPT provision. Our implementation experience in Daru has highlighted significant population mixing dynamics with most transmission likely occurring outside the household. We propose a community-wide screening approach with the provision of TPT based on testing to include older children, adolescents, and young adults. As there is the possibility of MDR-TB infection irrespective of the drug susceptibility of the household index case, a novel option is a combination TPT regimen of 6 months of daily isoniazid and levofloxacin (6HLfx). A sensitive aged-related algorithm to detect and exclude active TB is being developed. Ongoing community engagement, quality data systems with operational research to evaluate approaches are critical in high transmission MDR-TB settings.

Risk factors for TB in Australia and their association with delayed treatment completion

BACKGROUND: Australia has a low incidence of TB and has committed to eliminating the disease. Identification of risk factors associated with TB is critical to achieving this goal.METHODS: We undertook a prospective cohort study involving persons receiving TB treatment in four Australian jurisdictions. Risk factors and their association with delayed treatment completion (treatment delayed by at least 1 month) were analysed using univariate analyses and multivariate logistic regression.RESULTS: Baseline surveys were completed for 402 persons with TB. Most (86.1%) were born overseas. Exposure to a person with TB was reported by 19.4%. Diabetes mellitus (10.2%), homelessness (9.2%), cigarette smoking (8.7%), excess alcohol consumption (6.0%) and mental illness (6.2%) were other common risk factors. At follow-up, 24.8% of patients had delayed treatment completion, which was associated with adverse events (34.1%, aOR 6.67, 95% CI 3.36-13.27), excess alcohol consumption (6.0%, aOR 21.94, 95% CI 6.03-79.85) and HIV co-infection (2.7%, aOR 8.10, 95% CI 1.16-56.60).CONCLUSIONS: We identified risk factors for TB and their association with delayed treatment completion, not all of which are routinely collected for surveillance purposes. Recognition of these risk factors should facilitate patient-centred care and assist Australia in reaching TB elimination.

Tuberculosis related disability: a systematic review and meta-analysis

BACKGROUND

The sustainable development goals aim to improve health for all by 2030. They incorporate ambitious goals regarding tuberculosis (TB), which may be a significant cause of disability, yet to be quantified. Therefore, we aimed to quantify the prevalence and types of TB-related disabilities.

METHODS

We performed a systematic review of TB-related disabilities. The pooled prevalence of disabilities was calculated using the inverse variance heterogeneity model. The maps of the proportions of common types of disabilities by country income level were created.

RESULTS

We included a total of 131 studies (217,475 patients) that were conducted in 49 countries. The most common type of disabilities were mental health disorders (23.1%), respiratory impairment (20.7%), musculoskeletal impairment (17.1%), hearing impairment (14.5%), visual impairment (9.8%), renal impairment (5.7%), and neurological impairment (1.6%). The prevalence of respiratory impairment (61.2%) and mental health disorders (42.0%) was highest in low-income countries while neurological impairment was highest in lower middle-income countries (25.6%). Drug-resistant TB was associated with respiratory (58.7%), neurological (37.2%), and hearing impairments (25.0%) and mental health disorders (26.0%), respectively.

CONCLUSIONS

TB-related disabilities were frequently reported. More uniform reporting tools for TB-related disability and further research to better quantify and mitigate it are urgently needed.

PROSPERO REGISTRATION NUMBER

CRD42019147488.

A pilot model of patient education and counselling for drug-resistant tuberculosis in Daru, Papua New Guinea

Education and counselling for people with drug-resistant tuberculosis (DR-TB) is recommended by the World Health Organization, given the arduous treatment journey. A model of education and counselling involving counsellors and peer counsellors, standard sessions and novel education tools was piloted in the high DR-TB burden context of Daru, Papua New Guinea. The pilot contributed to high retention in care, highlighting the need for investment in scalable models. Future models will need to be adapted as better tolerated regimens are introduced. A focus on patient-centred care requires prioritisation in order to meet the End TB Strategy targets.

Assessing the costs of mobile voluntary counseling and testing at the work place versus facility based voluntary counseling and testing in Namibia

INTRODUCTION

Bophelo! is a mobile voluntary counseling and testing (VCT) and wellness screening program operated by PharmAccess at workplaces in Namibia, funded from both public and private resources. Publicly funded fixed site New Start centers provide similar services in Namibia. At this time of this study, no comparative information on the cost effectiveness of mobile versus fixed site service provision was available in Namibia to inform future programming for scale-up of VCT. The objectives of the study were to assess the costs of mobile VCT and wellness service delivery in Namibia and to compare the costs and effectiveness with fixed site VCT testing in Namibia.

METHODS

The full direct costs of all resources used by the mobile and fixed site testing programs and data on people tested and outcomes were obtained from PharmAccess and New Start centers in Namibia. Data were also collected on the source of funding, both public donor funding and private funding through contributions from employers. The data were analyzed using Microsoft Excel to determine the average cost per person tested for HIV.

RESULTS

In 2009, the average cost per person tested for HIV at the Bophelo! mobile clinic was an estimated US$60.59 (US$310,451 for the 5124 people tested). Private employer contributions to the testing costs reduced the public cost per person tested to US$37.76. The incremental cost per person associated with testing for conditions other than HIV infection was US$11.35, an increase of 18.7%, consisting of the costs of additional tests (US$8.62) and staff time (US$2.73). The cost of testing one person for HIV in 2009 at the New Start centers was estimated at US$58.21 (US$4,082,936 for the 70 143 people tested).

CONCLUSIONS

Mobile clinics can provide cost-effective wellness testing services at the workplace and have the potential to mobilize local private funding sources. Providing wellness testing in addition to VCT can help address the growing issue of non-communicable diseases.