Can Primary Care Drive Tuberculosis Elimination? Increasing Latent Tuberculosis Infection Testing and Treatment Initiation at a Community Health Center with a Large Non-U.S.-born Population

Community health centers (CHC) play a key role in latent tuberculosis infection (LTBI) testing and treatment. We performed a retrospective analysis of LTBI testing and treatment among pediatric and adult patients at a CHC with a large non-U.S.-born (USB) population during a series of quality improvement (QI) interventions from 2010 to 2019. Among 124,695 patients with primary care visits, 40% of patients were tested for tuberculosis (TB) infection and among those tested, 20% tested positive, including 39% of adults aged 50-79 years. Compared to adults aged 18-49 years, children aged 6-17 had increased odds of LTBI testing and treatment initiation [odds ratio and 95% confidence interval 3.23 (3.10, 3.36) and 1.41 (1.12, 1.79), respectively], while age ≥ 65 was associated with lower odds of both testing and treatment initiation. Over the analysis period, coinciding with unfunded QI interventions intended to reduce barriers to LTBI care, there was a significant increase in the proportion of patients receiving LTBI testing for both adults (6% to 47%, p < 0.001) and children (23% to 80%, p < 0.001). During the analysis period, there was also a significant increase in the proportion of patients receiving prescriptions for LTBI treatment, as well as provider use of evidence-based strategies including rifamycin-based treatment. Our study suggests that primary care interventions can reduce barriers to LTBI treatment and drive TB elimination.

Feasibility of a randomized clinical trial evaluating a community intervention for household tuberculosis child contact management in Cameroon and Uganda

Background

One of the main barriers of the management of household tuberculosis child contacts is the necessity for parents to bring healthy children to the facility. We assessed the feasibility of a community intervention for tuberculosis (TB) household child contact management and the conditions for its evaluation in a cluster randomized controlled trial in Cameroon and Uganda.

Methods

We assessed three dimensions of feasibility using a mixed method approach: (1) recruitment capability using retrospective aggregated data from facility registers; (2) acceptability of the intervention using focus group discussions with TB patients and in-depth interviews with healthcare providers and community leaders; and (3) adaptation, integration, and resources of the intervention in existing TB services using a survey and discussions with stakeholders.

Results

Reaching the sample size is feasible in all clusters in 15 months with the condition of regrouping 2 facilities in the same cluster in Uganda due to decentralization of TB services. Community health worker (CHW) selection and training and simplified tools for contact screening, tolerability, and adherence of preventive therapy were key elements for the implementation of the community intervention. Healthcare providers and patients found the intervention of child contact investigations and TB preventive treatment management in the household acceptable in both countries due to its benefits (competing priorities, transport cost) as compared to facility-based management. TB stigma was present, but not a barrier for the community intervention. Visit schedule and team conduct were identified as key facilitators for the intervention.

Conclusions

This study shows that evaluating a community intervention for TB child contact management in a cluster randomized trial is feasible in Cameroon and Uganda.

Trial registration

Clini calTr ials. gov NCT03832023. Registered on February 6^th 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-00996-3.

Repairing boundaries along pathways to tuberculosis case detection: a qualitative synthesis of intervention designs

BACKGROUND

Tuberculosis case-finding interventions often involve several activities to enhance patient pathways, and it is unclear which activity defines the type of case-finding intervention. When conducting studies to identify the most effective case-finding intervention it is important to have a clear understanding of these interventions for meaningful comparisons. This review aimed to construct a systems-based logic model of all pathways to tuberculosis case detection through a synthesis of intervention designs.

METHODS

We identified an existing systematic review on the effectiveness of interventions to increase tuberculosis case detection and updated the search from December 2016 to October 2020. We included randomized controlled trials, as these designs encourage detailed description of interventions. Taking each study in turn, intervention descriptions were read in detail. The texts were analysed qualitatively by constantly comparing emerging codes to construct patient journeys, visualized as logical chains. Actions taken as part of interventions were positioned along patient journeys to theorize the sequence of outcomes. Patient journeys formed the basis of the model, which was refined through discussion.

RESULTS

Based on intervention descriptions from 17 randomized controlled trials, our model distinguishes two care-seeking pathways and four screening pathways. An open invitation to people with tuberculosis symptoms creates care-seeking pathways. On care-seeking pathways, systematic screening can be conducted at general health services, but not at specific TB care services. People invited to tuberculosis services regardless of symptoms follow tuberculosis screening pathways and may be identified with presumptive tuberculosis even if they do not seek care for tuberculosis symptoms. Tuberculosis screening pathways include screening offered to all people accessing care at general health services, screening at a mobile clinic or health facility with open invitation to a whole population or tuberculosis contacts, screening personally offered to a whole population or tuberculosis contacts at home, work or school, and screening offered to people receiving care for human immunodeficiency virus or other clinical risk-group care.

CONCLUSION

This systems-based logic model of tuberculosis case-finding pathways may support standardized terminology, consistency, transparency and improved communication among researchers, policy-makers, health workers and community members when implementing and evaluating interventions to improve tuberculosis case detection.

"We have to learn to cooperate with each other": a qualitative study to explore integration of traditional healers into the provision of HIV self-testing and tuberculosis screening in Eswatini

BACKGROUND

Traditional healing plays an important role in healthcare in Eswatini, and innovative collaborations with traditional healers may enable hard-to-reach men to access HIV and tuberculosis diagnostic services. This study explored attitudes towards integration of traditional healers into the provision of HIV self-testing kits and sputum collection containers.

METHODS

A qualitative study was conducted in 2019-2020 in Shiselweni region, Eswatini. Eight male traditional healers were trained on HIV and tuberculosis care including distribution of HIV self-testing kits and sputum collection containers. Attitudes towards the intervention were elicited through in-depth interviews with the eight traditional healers, ten clients, five healthcare workers and seven focus group discussions with community members. Interviews and group discussions were conducted in SiSwati, audio-recorded, translated and transcribed into English. Data were coded inductively and analysed thematically.

RESULTS

81 HIV self-testing kits and 24 sputum collection containers were distributed by the healers to 99 clients, with 14% of participants reporting a reactive HIV self-test result. The distribution of sputum containers did not result in any tuberculosis diagnoses, as samples were refused at health centres. Traditional healers perceived themselves as important healthcare providers, and after training, were willing and able to distribute HIV self-test kits and sputum containers to clients. Many saw themselves as peers who could address barriers to health-seeking among Swazi men that reflected hegemonic masculinities and patriarchal attitudes. Traditional healers were considered to provide services that were private, flexible, efficient and non-judgemental, although some clients and community members expressed concerns over confidentiality breaches. Attitudes among health workers were mixed, with some calling for greater collaboration with traditional healers and others expressing doubts about their potential role in promoting HIV and tuberculosis services. Specifically, many health workers did not accept sputum samples collected outside health facilities.

CONCLUSIONS

Offering HIV self-testing kits and sputum containers through traditional healers led to high HIV yields, but no TB diagnoses. The intervention was appreciated by healers' clients, due to the cultural literacy of traditional healers and practical considerations. Scaling-up this approach could bridge testing gaps if traditional healers are supported, but procedures for receiving sputum samples at health facilities need further strengthening.

The burden and predictors of latent tuberculosis infection among immigrants in South Korea: a retrospective cross-sectional study

BACKGROUND

Approximately one-fourth of the global population is latently infected with Mycobacterium tuberculosis. An understanding of the burden of latent tuberculosis infection (LTBI) among immigrants compared with the general Korean population should be the first step in identifying priority groups for LTBI diagnosis and treatment. The study aimed to compute the age-standardized LTBI prevalence and predictors among immigrants with LTBI in South Korea.

METHODS

In 2018, the Korea Disease Control and Prevention Agency implemented a pilot LTBI screening project for immigrants using a chest radiography and the QuantiFERON Gold In-Tube assay. A standardized prevalence ratio (SPR) was computed to compare the LTBI burden in immigrants and the general Korean population.

RESULTS

During the duration of the project, a total of 8108 immigrants (5134 males and 2974 females) underwent LTBI screening. The SPR of 1.547 (95% confidence interval [CI] 1.468-1.629) in males and 1.261 (95% CI 1.177-1.349) in females were both higher than the Korean reference population. Furthermore, among the immigrants, those aged < 40 years and Korean diaspora visa holders had a higher SPR.

CONCLUSION

This study found a higher LTBI prevalence among immigrant population in South Korea compared to that in the general Korean population, and the SPR was higher among those aged < 40 years and the Korean diaspora. The findings can be used as baseline evidence for including immigrants in South Korea in the at-risk group with a priority need for LTBI screening and treatment.

Coverage of tuberculosis and diabetes mellitus screening among household contacts of tuberculosis patients: a household-based cross-sectional survey from Southern Thailand

Background

The comorbid presence of tuberculosis and diabetes mellitus has become an increasingly important public health threat to the prevention and control of both diseases. Thus, household contact investigation may serve a dual purpose of screening for both tuberculosis and diabetes mellitus among household contacts. We therefore aimed to evaluate the coverage of screening for tuberculosis and diabetes mellitus among household contacts of tuberculosis index cases and to determine predictors of tuberculosis screening.

Methods

A household-based survey was conducted in February 2019 in Muang district of Phatthalung Province, Thailand where 95 index tuberculosis patients were newly diagnosed with pulmonary or pleural tuberculosis between October 2017 and September 2018. Household contacts of the index patients were interviewed using a structured questionnaire to ascertain their past-year history of tuberculosis screening and, if appropriate, diabetes mellitus screening. For children, the household head or an adult household member was interviewed as a proxy. Coverage of tuberculosis screening at the household level was regarded as households having all contacts screened for tuberculosis. Logistic regression and mixed-effects logistic regression models were used to determine predictors of tuberculosis screening at the household and individual levels, respectively, with the strengths of association presented as adjusted odds ratios (AOR) and 95% confidence intervals (CI).

Results

Of 61 responding households (64%), complete coverage of tuberculosis screening at the household level was 34.4% and among the 174 household contacts was 46.6%. About 20% of contacts did not receive any recommendation for tuberculosis screening. Households were more likely to have all members screened for tuberculosis if they were advised to be screened by a healthcare professional rather than someone else. At the individual level, contacts aged ≥35 years (AOR: 30.6, 95% CI: 2.0–466.0), being an employee (AOR: 0.1, 95% CI: 0.0–0.8) and those who had lived more than 5 years in the same household (AOR: 0.1, 95% CI: 0.0–0.8) were independent predictors for tuberculosis screening. Coverage of diabetes mellitus screening was 80.6% with lack of awareness being the main reason for not being screened.

Conclusions

Compared to diabetes screening, the coverage of tuberculosis screening was low. A better strategy to improve coverage of tuberculosis contact screening is needed.

A transcriptional blood signature distinguishes early tuberculosis disease from latent tuberculosis infection and uninfected individuals in a Vietnamese cohort

OBJECTIVES

Global tuberculosis (TB) control is restricted by the failure to detect an estimated 3.3 million TB cases annually. In the majority of TB endemic settings, sputum smear microscopy is used to diagnose TB, but this test is insensitive for TB in its early stages. The objective of this study is to establish a concise gene signature that discriminates between individuals with early TB disease, latent TB infection (LTBI) and those without infection.

METHODS

This is a case control study nested within a cluster-randomised trial of population screening for active TB using Xpert MTB/RIF. Whole blood samples from 303 participants with active TB (97), LTBI (92) and uninfected individuals (114) were subject to transcriptomic analysis of selected target genes based on a systematic review of previous studies.

RESULTS

Analysis of 82 genes identified a pattern of differentially expressed genes in TB disease. A seven gene signature was identified that distinguished between TB disease and no TB disease with an AUC of 0.86 (95% CI: 0.80-0.91), and between TB disease from LTBI with an AUC of 0.88 (95% CI: 0.82-0.93).

CONCLUSION

This gene signature accurately distinguishes early TB disease from those without TB disease or infection, in the context of community-wide TB screening. It could be used as a non-sputum based screening tool or triage test to detect prevalent cases of TB in the community.

Implementation status of household contact tuberculosis screening by health extension workers: assessment findings from programme implementation in Tigray region, northern Ethiopia

Background

In the Tigray region of Ethiopia, Health Extension Workers (HEWs) conduct Tuberculosis (TB) screening for all household (HH) contacts. However, there is limited evidence on implementation status of HH contact TB screening by HEWs. The aim of this program assessment was to describe the implementation status and associated factors of HH contact TB screening by HEWs.

Methods

This programme assessment was conducted in three randomly selected districts from March to April 2018. Data was collected by using pre-tested structured questionnaire. Descriptive statistics was carried out using frequency tables. Logistic regression analysis was done to identify factors associated with HH contacts screening by HEWs.

Results

In this programme assessment a total of HHs of 411 index TB cases were included. One-fifth (21.7%) of index TB cases had at least one HH contact screened for TB by HEWs. Having TB treatment supporter (TTS) during intensive phase of index TB case (AOR = 2.55, 95% CI: 1.06–6.01), health education on TB to HH contacts by HEWs (AOR = 4.28, 95% CI: 2.04–9.00), HH visit by HEWs within 6 months prior to the programme assessment (AOR = 5.84, 95% CI: 2.81–12.17) and discussions about TB activities by HEWs with Women Development Army (WDA) leaders (AOR = 9.51, 95% CI: 1.49–60.75) were significantly associated with household contact TB screening by HEWs.

Conclusions

Our finding revealed that the proportion of HH contact TB screened by HEWs was low. Therefore, HEWs should routinely visit HHs of index TB cases and provide regular health education to improve contact screening practice. In addition, it is highly recommended to strengthen HEWs regular discussion about TB activities with WDA leaders and TB TTS.

Tuberculosis (TB) outbreak in a closed Aotus monkey breeding colony: Epidemiology, diagnosis and TB screening using antibody and interferon-gamma release testing

Tuberculosis (TB) caused by Mycobacterium tuberculosis (MTB) is a devastating and terminal disease in non-human primates (NHPs). Regular TB screenings using the intradermal tuberculin test (TST) have been the mainstay of TB surveillance and control in NHPs. Historically, Aotus monkeys have been considered less susceptible to TB than other NHPs. Here we present the diagnosis and epidemiology of a TB outbreak at The Gorgas Memorial Institute Aotus colony in Panama, and the results of two cross-sectional randomized TB screening studies, using antibody (Ab) and IFN-gamma release assay testing.

RESULTS

Epidemiological and spatial analysis confirmed that the outbreak was the result of a continuing intermittent exposure, with human to monkey transmission as the most likely source. During the outbreak that lasted five months (January-June 2015), Mycobacterium kansassi and MTB were isolated from lung caseous granulomas in 1/7 and 3/7 TB suspicious animals respectively. Furthermore, MTB was detected by qRT-PCR in formalin fixed lung and liver granulomas in 2/7 and 1/6 monkeys respectively, suggesting an aerosol route of infection. Likewise, a random sample that included 63 / 313 adult (>2 year-old) monkeys, screened for latent TB with the Primagam® IFN-gamma release assay, between March-May, 2016, were all non-reactors; indicating that the outbreak was self-limiting and the colony was likely free or latent TB infection. Control measures included, quarantine, disinfection and TST screening of all personnel. In conclusion, this study demonstrates that Aotus are highly susceptible to TB, therefore, TB prevention measures should be strictly enforced in Aotus monkey colonies.

Latent tuberculosis infection screening prior to biological treatment in Tunisian patients

OBJECTIVES

The screening of latent tuberculosis infection (LTBI) is necessary to prevent infection in patients with chronic inflammatory disease (CID) undergoing biological treatment. We aimed to assess the efficacy of LTBI screening prior to biological treatment in Tunisia, considered as a high-incidence area of active TB disease.

METHODS

We conducted a retrospective study over a period of 8 years [2007-2014] including patients with chronic inflammatory rheumatism receiving biologic agents since at least 6 months. The screening of LTBI was performed according to national Tunisian guidelines.

RESULTS

There were 35 men and 78 women. The mean age was 47.67±13.50 years. Rheumatoid arthritis (70.8%) was the most common cause of CID. The diagnosis of LTBI was established in 23 cases. Among these 23 patients, 12 patients had negative tuberculin skin test (TST) associated with positive QuantiFERON-TB Gold (QFT-G), 10 had TST more than 10mm, one patient had a TST between 5 and 10mm associated with positive QFT-G and one patient had a history of tuberculosis inadequately treated. Preventive anti-tuberculous therapy was prescribed before biological therapy initiation in cases of LTBI. During the follow-up period (3.91 years), no case of tuberculosis reactivation has been reported among patients diagnosed with LTBI. However, 2 cases of active pulmonary tuberculosis were reported in patients with initially negative TST and QFT-G.

CONCLUSION

Our study showed that the Tunisian recommendations allowed detecting a LTBI in 20% of biologic therapy candidates. Preventive measures including screening of LTBI and eventually a prophylactic treatment improve the safety of biological treatments.

Assessment of national tuberculosis and HIV collaborative program implementation status in health care settings of Ethiopia

BACKGROUND

Ethiopia has adopted the World Health Organization recommendation for TB and HIV collaborative activities since 2004. These collaborative activities have been scaled up in a phased manner and covered large number of health facilities across the nation. However, there is scarcity of information on implementation of these collaborative activities in Ethiopia.

OBJECTIVE

To assess the status of implementation of TB and HIV collaborative activities in health facility settings of Ethiopia.

METHODS

A cross sectional study mainly quantitative supplemented by qualitative methods was undertaken from May 10 to July 10, 2014 in 132 selected health facilities. Statistical analysis was performed using SPSS version 20.

RESULT

About 81% of the respondents in the selected health facilities reported the screening of People Living with HIV in care for TB at every follow up visit, whereas, only 28.7% of those health facilities reported the screening of PLWHIV for TB at enrolment to HIV chronic care. About half of the public health facilities assessed were not implementing Isoniazid Preventive Therapy and only 18.2% of eligible clients were getting this Preventive Therapy. Among the co-infected patients, 32% were not linked to chronic care services and 45.3% were not getting ART during TB treatment. On the other hand, about two thirds of the co-infected patients are getting the Cotrimoxazole Prophylaxis Therapy.

CONCLUSION

Most of anti-TB and HIV collaborative activities were not implemented as expected in the health facilities. Thus it needs integration from the ministry to the health facilities level in order to improve the collaborative activities.

Factors associated with performing tuberculosis screening of HIV-positive patients in Ghana: LASSO-based predictor selection in a large public health data set

Background

The purpose of this study is to propose the Least Absolute Shrinkage and Selection Operators procedure (LASSO) as an alternative to conventional variable selection models, as it allows for easy interpretation and handles multicollinearities. We developed a model on the basis of LASSO-selected parameters in order to link associated demographical, socio-economical, clinical and immunological factors to performing tuberculosis screening in HIV-positive patients in Ghana.

Methods

Applying the LASSO method and multivariate logistic regression analysis on a large public health data set, we selected relevant predictors related to tuberculosis screening.

Results

One Thousand Ninety Five patients infected with HIV were enrolled into this study with 691 (63.2 %) of them having tuberculosis screening documented in their patient folders. Predictors found to be significantly associated with performance of tuberculosis screening can be classified into factors related to the clinician’s perception of the clinical state, as well as those related to PLHIV’s awareness. These factors include newly diagnosed HIV infections (n = 354 (32.42 %), aOR 1.84), current CD4+ T cell count (aOR 0.92), non-availability of HIV type (n = 787 (72.07 %), aOR 0.56), chronic cough (n = 32 (2.93 %), aOR 5.07), intake of co-trimoxazole (n = 271 (24.82 %), aOR 2.31), vitamin supplementation (n = 220 (20.15 %), aOR 2.64) as well as the use of mosquito bed nets (n = 613 (56.14 %), aOR 1.53).

Conclusions

Accelerated TB screening among newly diagnosed HIV-patients indicates that application of the WHO screening form for intensifying tuberculosis case finding among HIV-positive individuals in resource-limited settings is increasingly adopted. However, screening for TB in PLHIV is still impacted by clinician’s perception of patient’s health state and PLHIV’s health awareness. Education of staff, counselling of PLHIV and sufficient financing are needed for further improvement in implementation of TB screening for all PLHIV. The LASSO approach proved a convenient method for automatic variable selection in a large public health data set that requires efficient and fast algorithms.

Trials registration

ClinicalTrials.gov NCT01897909 (July 5, 2013).

Demonstration of mycobacterium tuberculosis in sputum and saliva smears of tuberculosis patients using ziehl neelsen and flurochrome staining- a comparative study

BACKGROUND

Early detection of tuberculosis is important for reducing its morbidity and mortality especially in the patients with non-productive cough. To overcome the cumbersome process involved in collection and processing of the sputum specimen, the time consumed for reporting of sputum by Ziehl Neelsen (ZN) method and to introduce a routine screening test in suspected, symptomless tuberculosis patients, the present study was designed using saliva as diagnostic medium and Auramine Rhodamine (AR) as staining method. On review of literature, there was no study which has tried diagnosing tuberculosis using saliva with flurochrome stain; hence the present study was designed.

AIM

To introduce a routine screening test for tuberculosis patient using saliva and to determine the diagnostic efficacy of routine ZN staining method and AR fluorescent staining method in sputum and saliva smears of pulmonary tuberculosis patients.

SETTINGS AND DESIGN

Laboratory settings and Experimental design.

MATERIALS AND METHOD

Fifty smears samples of sputum and saliva of known cases of pulmonary tuberculosis were stained with routine ZN stain and other with AR fluorescent stain. All the specimens were inoculated into Lowenstein-Jensen culture media. The smears were subjected for scanning of Mycobacterium tuberculous bacilli under X 1000 magnification for ZN stain and X 400 magnification for AR stain by grid pattern proposed by National tuberculosis institute and graded by RNTCP grading system.

RESULTS

All 50 sputum samples showed 100% positivity by ZN and AR stain while only 76% positivity was seen by culture. Of the 50 saliva samples 10% cases were positive by ZN, 76% were positive by AR & 70% by culture method. Statistical analysis using chi square test was done, and the value was found to be statistically highly significant for AR staining technique. (p<0.001) CONCLUSION: Saliva can prove to be an important tool for the diagnosis as well as screening of the patients with pulmonary tuberculosis when aided with flurochrome staining method.

Tuberculosis and the obstetrician-gynecologist: a global perspective

Tuberculosis (TB) infection poses substantial challenges for obstetricians and gynecologists globally, as gynecologic involvement may cause infertility, irregular bleeding, and pelvic pain. If TB-infected women are able to conceive, obstetric complications include intrauterine growth restriction and, more rarely, congenital transmission. Appropriate screening for high-risk populations is crucial for diagnosis and treatment of latent and active TB infection, which may prevent reproductive sequelae for individual patients and, eventually, contribute to complete eradication of the disease.