Pulmonary Tuberculosis and Rifampicin Resistant Mycobacterium Tuberculosis in Children and Adolescents using Gene Xpert MTB/RIF Assay in Tigray, Northern Ethiopia

Background

Tuberculosis (TB) continues to be a global health problem. While childhood TB contributes 10% to the global TB burden, the paucibacillary nature of TB disease in children and the absence of reliable diagnostic methods have made MTB diagnosis in children to be a great challenge. This study aimed to determine the prevalence of MTB and rifampicin-resistant MTB (RR-MTB) among children using Gene Xpert MTB/RIF Assay in Tigray, Ethiopia.

Methods

A retrospective database study was conducted among children in ten governmental hospitals in the Tigray region. Gene Xpert MTB/RIF results of sputum/gastric lavage samples from children with presumptive TB from January 2016 to December 2019 were extracted using a data extraction sheet. Data were collected and analyzed using Statistical Package for the Social Sciences version 21.

Results

The prevalence of bacteriologically confirmed MTB by Gene-Xpert in children with presumptive TB was 7.3% (95% CI: 6.7%-7.9%) and the proportion of those that were Gene-Xpert MTB positive who also have rifampicin resistance was 10.9% (95% CI: 8.2-13.6%). Older children aged 11-15 years [AOR = 1.76; 95% CI = 1.33-2.33, p < 0.001] and adolescents 16-17 years [AOR = 2.18; 95% CI = 1.63-2.92, p < 0.001] were more likely to be MTB positive. Relapse cases [AOR = 1.66; 95% CI = 1.09-2.51, p = 0.017] and lost/failure cases [AOR = 8.82; 95% CI = 3.94-19.76, p < 0.001] were more likely to have MTB compared to the new cases.

Conclusion

The proportion of MTB-positive among the TB presumptive patients was 7.3%. The proportion of rifampicin-resistant TB to all positive patients was 10.9%. Female participants had more MTB than males (or younger children). The result highlights the need for due attention in children because it is very helpful in determining the future control of the disease.

The Magnitude of MTB and Rifampicin Resistance MTB Using Xpert-MTB/RIF Assay Among Tuberculosis Suspected Patients in Gedeo Zone, Southern Ethiopia

Background

Tuberculosis (TB) remains a major global health problem causing death among millions of people each year. The new barrier that challenges the control of tuberculosis is the emerging and the increasing number of drug-resistant TB that becomes a world concern. This study aimed to determine the magnitude of rifampicin-resistant Mycobacterium tuberculosis (RR-MTB) among presumptive TB patients attending Dilla University Referral Hospital, Gedeo Zone, Ethiopia.

Methods

A retrospective cross-sectional study was conducted at Dilla University Referral Hospital from January 2014 to December 2020. Sputum results were done using Xpert MTB/RIF assay and other necessary data were collected from the registration logbooks using a standardized data extraction format and analyzed using SPSS version 23 statistical software.

Results

A total of 17,745 presumptive TB patients were included, of which 62.2% were males. The overall prevalence of Mycobacterium tuberculosis (MTB) was 11.8%, of which 5.1% were confirmed to have RR-MTB. Extra-pulmonary TB was reported in 1.5% of the study participants. The highest prevalence of MTB and RR-MTB was recorded in 2017 with a prevalence of 20.1% and 8.5%, respectively. All age groups were significantly associated with a higher prevalence of MTB (p < 0.036). TB patients with a history of previous treatment and HIV positive were significantly associated with MTB (P < 0.021), while RR-MTB was only significantly associated with patients with a history of previous treatment (P < 0.018).

Conclusion

A high magnitude of MTB and RR-MTB was reported among TB patients with HIV and a history of previous treatment. Therefore, coordinated efforts should be applied to the improvement of treatment adherence of known TB cases, and appropriate control and prevention methods to reduce the emergence and increase of MTB and RR-MTB cases.

A five-year audit of gaps in HIV testing and associations with TB treatment outcomes in Armenia, 2015-2019

INTRODUCTION

Poor human immunodeficiency virus (HIV) testing practices and underreporting of HIV-related data in TB information systems remain barriers to effective care for TB-HIV co-infected patients. HIV testing and recording practices in national TB program have not been formally evaluated in Armenia. This study aimed to assess the recording completeness of HIV testing and HIV status in the national TB program electronic database, and to determine trend in HIV testing and the association between HIV testing and treatment outcomes for all TB patients registered in Armenia (2015-2019).

METHODOLOGY

A cohort study of TB patients using routine programmatic data from the national TB program of Armenia.

RESULTS

From 2015 to 2019, the electronic database was completed for HIV testing and HIV status by 48.1% and 97.5%, respectively. Of all registered TB patients 93.6% were tested for HIV. Of a total 4,674 patients, 1,085 (23.2%) had unsuccessful outcomes. Patients with HIV status "not tested" and "not recorded" compared to HIV "negatives" had 1.76 (95%CI 1.42-2.11) and 1.6 (95%CI 1.20-2.06) times higher risk of unsuccessful outcomes, respectively. Lost to follow-up was the most frequent unsuccessful outcome in HIV status "not tested" group.

CONCLUSIONS

An analysis of nationwide data revealed incompleteness of the national TB electronic database for HIV data. Patients with HIV status "not tested" and "not recorded" had higher risk of unsuccessful TB treatment outcomes. Upgrade of the electronic database with information on key indicators of TB-HIV services will facilitate improved monitoring and reporting.

Impact and operational feasibility of TrueNat™ MTB/Rif under India's RNTCP

BACKGROUND

The Revised National Tuberculosis Control Programme (RNTCP) in Andhra Pradesh, India, introduced TrueNat™ MTB/Rif, a rapid molecular test for detecting Mycobacterium tuberculosis (MTB) and rifampicin (RIF) resistance at 193 TB units (TUs) in October 2018. We evaluated its impact on TB diagnosis and assessed the operational feasibility of its deployment at point-of-care (POC) settings.

METHODS

We compared the number of presumptive TB cases tested and the number (proportion) of microbiologically positive before (January-August 2018) and after (January-August 2019) the deployment of TrueNat. We interviewed laboratory technicians and Senior TB Laboratory Supervisor from 25 randomly selected TUs to assess operational feasibility.

RESULTS

In 2018, 10.5% (range 8.9-13.1) of 245,989 presumptive cases tested were positive. In 2019, of the 185,435 presumptive cases tested, 13.7% (range 9.6-18.9) were positive. The proportion of presumptive TB cases in whom MTB was detected using TrueNat was 14.4% (range 10.0-21.2). TrueNat significantly increased case detection (incidence rate ratio [IRR] 1.30; 95%CI 1.15-1.46), yielding an additional 18 TB cases per 100 000 population. Laboratory technicians became comfortable in performing TrueNat after a median of 10 tests (interquartile range 5-17.5). Invalid reports declined from 6.8% to 3.6%.

CONCLUSION

The deployment of TrueNat as POC diagnostic test improved case detection and was operationally feasible under RNTCP.

Use of Xpert Contributes to Accurate Diagnosis, Timely Initiation, and Rational Use of Anti-TB Treatment Among Childhood Tuberculosis Cases in South Central Ethiopia

Background

Childhood tuberculosis (TB) was under-prioritized, and only 15% of childhood TB cases are microbiologically confirmed. Hence, most childhood TB diagnoses are made on a clinical basis and prone to over- or under-treatment. Xpert is a rapid method for the diagnosis of childhood TB with high sensitivity.

Objective

To assess the use of Xpert for accurate diagnosis, timely initiation, and rational use of anti-TB treatment among childhood TB.

Methods

In 2016, the hospital facilitated the installation of the Xpert machine. We reviewed data trends over four consecutive years; two years before the arrival of the machine and two years following the implementation of Xpert. Data were extracted retrospectively from electronically stored databases and medical records and entered to SPSS 21 for analysis.

Results

In the pre-intervention period (2014–2015), 404 cases of children presenting with symptoms or signs suggestive of TB (“presumptive TB”) were evaluated using AFB microscopy. A total of 254 (62.8%) TB diagnoses were made, of which 54 (21.3%) were confirmed by smear AFB while 200 (78.7%) were treated as smear-negative TB cases. The mean waiting time to start anti-TB treatment was 6.95 days [95% CI (3.71–10.90)]. During the intervention period (2016–2017), 371 children with presumptive TB were evaluated using Xpert. A total of 199 (53.6%) childhood TB cases were notified, of which 88 (44.2%) were Xpert positive and 111 (55.8%) were treated as Xpert-negative probable TB cases. The tendency to initiate anti-TB treatment for unconfirmed TB cases was reduced by a third. Compared with smear AFB, Xpert improved accuracy of diagnosing pediatric TB cases two-fold. The average waiting time to start anti-TB treatment was 1.33 days [95% CI (0.95–1.71)]. There was a significant reduction in the waiting time to start anti-TB treatment, with a mean time difference before and during intervention of 5.62 days [95% CI (1.68–9.56)].

Conclusion

Xpert use was associated with a significant increase in the accuracy of identifying confirmed TB cases, reduced unnecessary anti-TB prescription, and shortened the time taken to start TB treatment.

Private primary health care provider delay in tuberculosis diagnosis and treatment in Georgia

Setting

One national and two regional tuberculosis (TB) hospitals in Georgia.

Objectives

To define the factors associated with private primary health care (PPHC) provider delay in TB diagnosis and treatment.

Design

This was a cross-sectional study of data collected from consecutive patients with pulmonary TB from July 2015 to August 2016, complemented by qualitative data collected among PPHC providers/managers, TB patients and policy makers.

Results

PPHC provider delay (>2 weeks from the first medical consultation for TB symptoms to the initiation of TB treatment) occurred in 43.8% of 320 TB patients. Modifiable factors significantly associated with PPHC provider delay included receiving any non-specific treatment before diagnosis of TB (adjusted OR [aOR] 9.45, 95%CI 5.10-17.51), adequate knowledge of TB (aOR 0.35, 95%CI 0.12-0.99) and lower TB-related stigma (aOR 0.47, 95%CI 0.28-0.81). Inappropriate referral of presumptive TB patients to general health facilities for chest X-ray examination, often followed by misinterpretation of X-ray results in these facilities, might mislead PPHC providers to initiate presumptive TB patients on non-specific treatment.

Conclusion

PPHC provider delay in TB diagnosis and treatment is common in Georgia, highlighting a need for targeted interventions to improve identification and referral of presumptive TB patients to specialised TB services and Xpert testing.

Should sputum-negative presumptive TB patients be actively followed to identify missing cases in India?

Setting: Sputum smear microscopy, the primary diagnostic tool used for diagnosis of tuberculosis (TB) in India's Revised National TB Control Programme (RNTCP), has low sensitivity, resulting in a significant number of TB cases reported as sputum-negative. As the revised guidelines pose challenges in implementation, sputum-negative presumptive TB (SNPT) patients are subjected to 2 weeks of antibiotics, followed by chest X-ray (CXR), resulting in significant loss to care among these cases. Objective: To determine whether reducing delays in CXR would yield additional TB cases and reduce initial loss to follow-up for diagnosis among SNPT cases. Methods: In an ongoing intervention in five districts of Maharashtra, SNPT patients were offered upfront CXR. Results: Of 119 male and 116 female SNPT patients with a mean age of 45 years who were tested by CXR, 32 (14%) were reported with CXR suggestive of TB. Administering upfront CXR in SNPT patients yielded twice as many additional cases, doubling the proportion of cases detected among all those tested as against administering CXR 2 weeks after smear examination. Conclusion: Our interventional study showed that the yield of TB cases was significantly greater when upfront CXR examination was undertaken without waiting for a 2-week antibiotic trial.

Uptake of HIV testing and HIV positivity among presumptive tuberculosis patients at Puducherry, South India

SETTING

Puducherry, a district in South India with a low prevalence of human immunodeficiency virus (HIV) infection (<1% among antenatal women).

OBJECTIVES

1) To estimate the proportion of patients with known HIV status who were HIV-positive, 2) to describe the demographic and clinical characteristics of patients with unknown HIV status among presumptive TB patients, and 3) to assess the additional workload at HIV testing centres.

DESIGN

In this cross-sectional study, consecutive presumptive TB patients attending microscopy centres for diagnosis during March-May 2013 were asked if they knew their HIV status. Patients with unknown HIV status were offered voluntary counselling and HIV testing.

RESULTS

Of 1886 presumptive TB patients, HIV status was ascertained for 842 (44.6%); 28 (3.3%) were HIV-positive. The uptake of HIV testing was significantly higher in younger age groups, males, residents of Puducherry and smear-positive TB patients. The median increase in the number of clients tested for HIV per day per testing centre was 1 (range 0-6).

CONCLUSION

The uptake of HIV testing was low. HIV prevalence was higher among presumptive TB patients than in antenatal women, and as high as in TB patients. With minimal increase in workload at HIV testing centres, HIV testing could be implemented using existing resources.