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Context matters: Examining the factors impacting the implementation of tuberculosis infection prevention and control guidelines in health settings in seven high tuberculosis burden countries

About one third of the world population is estimated to be infected with Mycobacterium tuberculosis (MTB), and this proportion is expected to be higher in countries with a high tuberculosis (TB) burden. The Philippines is both a high tuberculosis burden and a high multidrug resistant tuberculosis (MDR-TB) burden country. Though TB has been extensively described in the civilian population, there is limited data on TB in the military population. The objectives are: (1) To determine MTB/MDR-TB prevalence among military and civilian patients in the Philippines presenting with clinically suspected TB in a tertiary military hospital and (2) To determine performance of direct sputum smear microscopy (DSSM) using Ziehl-Neelsen (ZN) staining compared to Xpert MTB/RIF real-time reverse transcriptase polymerase chain reaction. Sputum samples were obtained from patients, clinically suspected with TB, and/or with TB associated signs/symptoms. Sputum specimens were tested using DSSM with ZN staining and Xpert MTB/RIF assay (Cepheid, Sunnyvale, California) and patient demographic and clinical data were collected. From March 2015 to December 2018, a total of 795 (173 military personnel [164 active duty and 9 retired]; 618 civilians; and 4 with no data on military/civilian status) patients with TB associated symptoms or clinically suspected with TB were tested. Overall, MTB prevalence was 81/795 (10%). MTB prevalence among active duty and retired military personnel were 27/164 (16%) and 4/9 (44%), respectively while MTB prevalence for civilian patients was 50/618 (8%) (p value=0.0003; OR=2.48 [95% C.I. 1.5-4]). Among active and retired military personnel who tested positive for MTB, rifampin resistance was 4/27 (15%) and 1/4 (25%), respectively, while rifampin resistance for civilian patients was 9/50 (18%) (p value=1; OR=0.88 [95% C.I. 0.26-2.90]). For active duty military personnel, average MTB prevalence (based on Xpert MTB/RIF) covering years 2015-2018 was 21% and ranged from 13% to 35%, while average rifampin resistance among MTB positive active duty military personnel was 15% and ranged from 0% to 25%. Overall sensitivity and specificity of DSSM compared to Xpert MTB/RIF were 70% and 96%, respectively. Positive and negative predictive values of DSSM to accurately categorize MTB in symptomatic cases (with Xpert MTB/RIF as "true positive" reference) were 74% and 95%, respectively. Performance of DSSM varied according to MTB load detected by Xpert MTB/RIF with increasing DSSM sensitivity observed as the MTB load detected by Xpert MTB/RIF increased (p=0.02). This report describes high MTB and MDR-TB prevalence rates among symptomatic military patients with military personnel having higher odds of MTB infection compared to the civilian patients in the study. Since DSSM (ZN) sensitivity greatly varied depending on MTB load, the Xpert MTB/RIF should be used as a first-line diagnostic tool to identify MTB and detect rifampin resistance among presumptive TB cases instead of DSSM (ZN) microscopy.

Intelligent Engineering Systems

BackgroundPhilippines, Indonesia, and Bangladesh are three high tuberculosis (TB) burden countries in Asia which account for 18% of the estimated global TB incidence (1.8 million) and 15% of TB related deaths (192,000). In 2017 alone, approximately 785,000 of the incident TB cases in these countries remained missing, including diagnosed but not notified.MethodsWe reviewed the published data from the most recent TB prevalence surveys conducted in Bangladesh, Indonesia, and the Philippines. The prevalence rates established by the surveys were used to estimate the disease burden of these countries for 2017. The Global TB Report 2017 and World Health Organization’s (WHO) global TB database were sourced for collection of incidence and notification data by age groups and types of TB to estimate prevalence to notification gaps 2017.ResultsAccording to the surveys, the estimated prevalence rates of bacteriologically confirmed TB and smear-positive TB are 287 and 113 for Bangladesh (2015–16), 759 and 256 for Indonesia (2013–14) and 1159 and 434 for the Philippines (2016) per 100,000 population over the age of 15 years. The overall national TB prevalence estimates for all forms is 260 for Bangladesh, 660 for Indonesia, and 970 for the Philippines (2016). Compared with the incidence rate, the proportion of total notified cases is 67% for Bangladesh, 52% for Indonesia, and 55% for the Philippines. Bangladesh has been able to detect almost 100% of the prevalent pulmonary TB, while Indonesia and Philippines have detected only 30 and 22% of these infectious cases respectively. Although notification has been improving over the years, there is no impact on the incidence rate since a large proportion of the undiagnosed cases, and delayed diagnosis continue to feed the transmission process.ConclusionThe surveys have provided data that is critical for developing realistic strategies for these countries to eliminate TB. In general, this paper recommends interventions for strengthening diagnosis of pulmonary TB, implementing targeted communication programs and active case finding to reduce patient level delays, expanding public-private partnership to increase access to TB services, using rapid diagnostics, and providing social protection for vulnerable populations. These measures can accelerate these countries’ progress towards achieving End TB goals.

Intelligent Engineering Systems

Design A cohort study using programmatic data was undertaken to assess TB diagnostic cascade in one of the study prisons for 2018. Treatment outcomes among male inmates with TB were assessed over a period of four years, in two study prisons. Results A total of 405 (11%) inmates with presumptive TB were identified, and 370 (91%) of these were evaluated for TB, mostly using rapid molecular testing of sputum specimens. Twenty-five inmates were diagnosed with TB resulting in a prevalence of 649/100,000 population. Of these, 16 (64%) were started on treatment. Nine (36%) were lost to follow-up before treatment initiation. From 2015 to 2018, 280 adult male inmates with TB were started on treatment. Of these, 212 (76%) had pulmonary disease that was bacteriologically confirmed. Almost all (276/280, 99%) had known HIV status, 65% were HIV-infected, and 80% of these were on antiretroviral treatment. The TB treatment success rate (cured or treatment completed) was recorded for 209 (75%) inmates, whilst 14 (5%) died and 11 (4%) were lost to follow-up. The frequency of unfavourable treatment outcomes (death, lost to follow-up, and not evaluated) was higher (54%) among inmates ≥ 60 years than those in the age group of 45-59 years (17%). Conclusion The findings revealed a threefold burden of TB in prisons, compared with what is reported by national survey. To decrease transmission of TB bacilli, it is essential to promote efforts that address missed opportunities in the TB diagnostic cascade, prompt treatment initiation, and ensure that tracking and documentation of treatment outcomes for all inmates are intensified.

BackgroundAs one of the top three high tuberculosis (TB) burden countries, China is a country where the overall TB incidence continues to decline. However, due to its large population and area, the increased TB burden exists in regional areas.MethodsThis retrospective study analyzed local inpatient pulmonary TB cases in the Affiliated Hospital of Zunyi Medical University (AHZMU) from January 2016 to December 2018 in a high TB incidence and economically-less-developed area of China. Four methods, acid-fast bacilli stain, culture, Xpert and LAMP, were used to detect Mycobacterium tuberculosis (M.tb), while proportional method and Xpert were used to identify rifampicin-resistant TB (RR-TB). Case number, treatment history, M.tb confirmed TB and rifampicin resistant proportion were analyzed to investigate the local TB epidemic.ResultsTotal 3,910 local inpatient cases with pulmonary TB were admitted to AHZMU during this study period. The annual numbers of total TB cases increased 26.4% (from 1,173 to 1,483), while new cases increased 29.6% (from 936 to 1,213) and RR-TB cases increased 2.7 times (from 31 to 84). Meanwhile, the percentage of previously treated cases declined from 20.2 to 18.2% and the M.tb confirmed TB proportion increased from 34.7 to 49.7%.ConclusionThe elevated M.tb confirmed TB proportion and the declined percentage of previously treated cases indicated the improved TB diagnosis and treatment of AHZMU. However, the increasing number of total TB cases, new and RR-TB cases showed an upward trend and increased TB burden in a relatively underdeveloped area of China.

BackgroundSouth Africa is among the seven highest tuberculosis (TB) burden countries. Harmful lifestyle behaviours, such as smoking and alcohol, and poor adherence to medication can affect clinical outcomes. Modification of these behaviours is likely to improve TB treatment outcomes and has proven possible using motivational interviewing (MI) techniques or use of short message service (SMS) text messaging. There have been no studies assessing the effect of combined MI and SMS interventions on multiple lifestyle factors and TB treatment outcomes.MethodsThis is a prospective, multicentre, two-arm individual randomised controlled trial looking at the effectiveness and cost-effectiveness of a complex behavioural intervention (the ProLife programme) on improving TB and lifestyle-related outcomes in three provinces of South Africa. The ProLife programme consists of an MI counselling strategy, delivered by lay health workers, augmented with subsequent SMS. We aim to recruit 696 adult participants (aged 18 years and over) with drug-sensitive pulmonary TB who are current smokers and/or report harmful or hazardous alcohol use. Patients will be consecutively enrolled at 27 clinics in three different health districts in South Africa. Participants randomised individually to the intervention arm will receive three MI counselling sessions one month apart. Each MI session will be followed by twice-weekly SMS messages targeting treatment adherence, alcohol use and tobacco smoking, as appropriate. We will assess the effect on TB treatment success, using standard World Health Organization (WHO) treatment outcome definitions (primary outcome), as well as on a range of secondary outcomes including smoking cessation, reduction in alcohol use, and TB medication and anti-retroviral therapy adherence. Secondary outcomes will be measured at the three-month and six-month follow-ups.DiscussionThis trial aligns with the WHO agenda of integrating TB care with the care for chronic diseases of lifestyle, such as provision of smoking cessation treatments, and with the use of digital technologies. If the ProLife programme is found to be effective and cost-effective, the programme could have significant implications for TB treatment globally and could be successfully implemented in a wide range of TB treatment settings.Trial registrationISRCTN Registry, ISRCTN62728852. Registered on 13 April 2018.

In high tuberculosis (TB) burden countries, health settings, including non-designated TB hospitals, host many patients with pulmonary TB. Bangladesh's National TB Control Program aims to strengthen TB infection prevention and control (IPC) in health settings. However, there has been no published literature to date that assessed the preparedness of hospitals to comply with the recommendations. To address this gap, our study examined healthcare workers knowledge and attitudes towards TB IPC guidelines and their perceptions regarding the hospitals' preparedness in Bangladesh. Between January to December 2019, we conducted 16 key-informant interviews and four focus group discussions with healthcare workers from two public tertiary care hospitals. In addition, we undertook a review of 13 documents [i.e., hospital policy, annual report, staff list, published manuscript]. Our findings showed that healthcare workers acknowledged the TB risk and were willing to implement the TB IPC measures but identified key barriers impacting implementation. Gaps were identified in: policy (no TB policy or guidelines in the hospital), health systems (healthcare workers were unaware of the guidelines, lack of TB IPC program, training and education, absence of healthcare-associated TB infection surveillance, low priority of TB IPC, no TB IPC monitoring and feedback, high patient load and bed occupancy, and limited supply of IPC resources) and behavioural factors (risk perception, compliance, and self and social stigma). The additional service-level gap was the lack of electronic medical record systems. These findings highlighted that while there is a demand amongst healthcare workers to implement TB IPC measures, the public tertiary care hospitals have got key issues to address. Therefore, the National TB Control Program may consider these gaps, provide TB IPC guidelines to these hospitals, assist them in developing hospital-level IPC manual, provide training, and coordinate with the ministry of health to allocate separate budget, staffing, and IPC resources to implement the control measures successfully.

In high tuberculosis (TB) burden countries, health settings, including non-designated TB hospitals, host many patients with pulmonary TB. Bangladesh’s National TB Control Program aims to strengthen TB infection prevention and control (IPC) in health settings. However, there has been no published literature to date that assessed the preparedness of hospitals to comply with the recommendations. To address this gap, our study examined healthcare workers knowledge and attitudes towards TB IPC guidelines and their perceptions regarding the hospitals’ preparedness in Bangladesh. Between January to December 2019, we conducted 16 key-informant interviews and four focus group discussions with healthcare workers from two public tertiary care hospitals. In addition, we undertook a review of 13 documents [i.e., hospital policy, annual report, staff list, published manuscript]. Our findings showed that healthcare workers acknowledged the TB risk and were willing to implement the TB IPC measures but identified key barriers impacting implementation. Gaps were identified in: policy (no TB policy or guidelines in the hospital), health systems (healthcare workers were unaware of the guidelines, lack of TB IPC program, training and education, absence of healthcare-associated TB infection surveillance, low priority of TB IPC, no TB IPC monitoring and feedback, high patient load and bed occupancy, and limited supply of IPC resources) and behavioural factors (risk perception, compliance, and self and social stigma). The additional service-level gap was the lack of electronic medical record systems. These findings highlighted that while there is a demand amongst healthcare workers to implement TB IPC measures, the public tertiary care hospitals have got key issues to address. Therefore, the National TB Control Program may consider these gaps, provide TB IPC guidelines to these hospitals, assist them in developing hospital-level IPC manual, provide training, and coordinate with the ministry of health to allocate separate budget, staffing, and IPC resources to implement the control measures successfully.

Background: India is one of the top most country among the high tuberculosis (TB) burden countries and ranks the third highest human immunodeficiency virus (HIV) burden country in the world contributing to 23% of the total global load. Mycobacterium tuberculosis (MTB) and HIV are known to act synergistically and result in higher mortality rates. TB-HIV coinfection and emergence of drug resistant forms of MTB can impact positively on treatment outcomes. Aims and Objectives: The aim of this study was to determine of the prevalence of TB-HIV co-infection among MTB and to determine the prevalence of rifampicin (RIF) resistant TB among HIV seropositive patients. Materials and Methods: It was a retrospective and observational study carried out in the Department of Microbiology, Malda Medical College, Malda, West Bengal. Records of all patients that tested using CBNAAT during March 2016–December 2019 in the CBNAAT laboratory of Malda Medical College were assessed. Data generated during this period were collected and analyzed. The statistical analysis was done in tabulation form and different charts and tables were used for displaying data. Results: A total of 6503 samples were tested in CBNAAT laboratory during March 2016–December 2019. Out of 6503, 3098 samples were positive for CBNAAT (MTB detected).Of 3098 MTB, 8.91% (276/3098) were RIF resistant. Among 3098 MTB, 91.22% (2826/3098) were pulmonary TB (PTB) and 8.78% (272/3098) were extra PTB. Out of 6503 total samples, 664 were reported patients living with HIV. The prevalence of TB-HIV coinfection was 3.91% (121/3098) among MTB positive cases. Of all TB-HIV coinfected cases, most of the patients (67.77%) were in the age group of 20–39 years and males (77.69%) contributed to more than females. Of 121 TB-HIV coinfected, 88.43% (107/121) were sensitive to RIF and 11.57% (14/121) were resistant to RIF. Conclusion: The present study reported that the prevalence of TB-HIV coinfection was 3.91% and the prevalence of RIF resistant TB in HIV seropositive patients was higher than HIV seronegative patients. Thus, all TB patients should be screened for HIV and all HIV-positive individuals should be screened for TB along with drug resistance for better management.

Despite being the world's highest tuberculosis (TB) burden country, India still misses millions of TB cases annually. To address this issue, the India National Strategic Plan, following WHO strategy, promotes combining active case finding (ACF) with passive case finding (PCF) activities. National TB Elimination Programme (NTEP) began ACF campaigns thrice a year, targeting vulnerable populations. However, states like Manipur faced challenges in implementing and sustaining ACF activities due to resource constraints. To assess the impact of engaging student and women organizations (SAWOs) in improving TB case notifications, treatment adherence, and completion rate in NTEP, as well as to estimate the cost-effectiveness of the ACF intervention. A quasi-experimental pre-post study is being conducted among individuals ≥15 years residing in Senapati District, Manipur, having two phases: preparatory and enhanced case finding and implementation of the ACF. Data is being collected and compared on TB case notification, treatment adherence, and outcomes beforeand after the intervention. Chi-square test will be used to test the statistical significance and logistic regression to identify the factors independently associated with the impact of intervention. Potential confounders at both patient and facility levels will be identified based on expert opinion and bivariate analysis. A multi-level logistic regression model will be used to control the confounding, with sensitivity analysis to ensure result robustness.Cost analysis will cover direct, indirect, medical, and non-medical costs for patients and health system. Incremental cost-effectiveness ratio per quality-adjusted life years gained will be evaluated. This study introduces a novel community-led model involving SAWOsto improve TB case detection and treatment support, comprehensively addressing allfour pillars of 'END TB' strategy. The intervention is a community-based participatory research, emphasizing collaboration between researchers andcommunity to address TB control. The main activities of this intervention include community TB sensitization, ECF, ACF, treatment support and monitoring. This model could significantly impact TB control efforts, especially in resource-constrained settings like Manipur, offering valuable insights into ACF implementation and its economic implications.

IntroductionDespite being the world’s highest tuberculosis (TB) burden country, India still misses millions of TB cases annually. To address this issue, the India National Strategic Plan, following WHO strategy, promotes combining active case finding (ACF) with passive case finding (PCF) activities. National TB Elimination Programme (NTEP) began ACF campaigns thrice a year, targeting vulnerable populations. However, states like Manipur faced challenges in implementing and sustaining ACF activities due to resource constraints.ObjectiveTo assess the impact of engaging student and women organizations (SAWOs) in improving TB case notifications, treatment adherence, and completion rate in NTEP, as well as to estimate the cost-effectiveness of the ACF intervention.MethodA quasi-experimental pre-post study is being conducted among individuals ≥15 years residing in Senapati District, Manipur, having two phases: preparatory and enhanced case finding and implementation of the ACF. Data is being collected and compared on TB case notification, treatment adherence, and outcomes beforeand after the intervention. Chi-square test will be used to test the statistical significance and logistic regression to identify the factors independently associated with the impact of intervention. Potential confounders at both patient and facility levels will be identified based on expert opinion and bivariate analysis. A multi-level logistic regression model will be used to control the confounding, with sensitivity analysis to ensure result robustness.Cost analysis will cover direct, indirect, medical, and non-medical costs for patients and health system. Incremental cost-effectiveness ratio per quality-adjusted life years gained will be evaluated.DiscussionThis study introduces a novel community-led model involving SAWOsto improve TB case detection and treatment support, comprehensively addressing allfour pillars of ‘END TB’ strategy. The intervention is a community-based participatory research, emphasizing collaboration between researchers andcommunity to address TB control. The main activities of this intervention include community TB sensitization, ECF, ACF, treatment support and monitoring. This model could significantly impact TB control efforts, especially in resource-constrained settings like Manipur, offering valuable insights into ACF implementation and its economic implications.

Background: The pandemic COVID-19 impacts a major global health crisis in the whole world including Bangladesh. Bangladesh is one of the world’s high tuberculosis (TB) burden countries and TB is a major public health concern in the country. It also observed that respiratory disease presented with similar features of coronavirus disease, unfortunately and regrettably overlooked by the physicians worldwide due to the pandemic crisis. We presented a case of pulmonary tuberculosis and coronavirus disease (COVID-19) co-infection which has not been reported much.Case report: A 55 years old female presented with acute respiratory symptoms superimposed on chronic respiratory symptoms as she was suffering from bronchial asthma, diagnosed with severe pneumonia. Oropharyngeal and nasal swab sample were found positive for coronavirus by RT-PCR assay. Assessments of the previous history and clinical scenario also suggested investigation for tuberculosis and finding positive of Sputum for acid fast bacilli (AFB) and Gene X pert detected Mycobacterium tuberculosis complex with rifampicin sensitivity. Patient was treated concomitantly for COVID-19 pneumonia and starting anti-tubercular drugs. So physicians should suspect COVID-19 co infections with pulmonary tuberculosis while treating the patient presented with respiratory and systemic features .It should keep in consideration for early diagnosis of Pulmonary tuberculosis to reduce the morbidity and mortality of the patients and to prevent transmission in the community from active sputum positive pulmonary tuberculosis.