Bacteriologically Confirmed Pulmonary Tuberculosis Research Articles

Use of a context-specific package to increase sputum smear monitoring among people with pulmonary tuberculosis in Uganda: a quality improvement study

BackgroundPeople with bacteriologically confirmed pulmonary tuberculosis (BC-PTB) require sputum smear monitoring (SSM) to ascertain response to anti-TB treatment and cure from TB disease. We aimed to increase SSM at 2,...

Accuracy of computer-aided chest X-ray in community-based tuberculosis screening: Lessons from the 2016 Kenya National Tuberculosis Prevalence Survey.

Community-based screening for tuberculosis (TB) could improve detection but is resource intensive. We set out to evaluate the accuracy of computer-aided TB screening using digital chest X-ray (CXR) to determine if this approach met target product profiles (TPP) for community-based screening. CXR images from participants in the 2016 Kenya National TB Prevalence Survey were evaluated using CAD4TBv6 (Delft Imaging), giving a probabilistic score for pulmonary TB ranging from 0 (low probability) to 99 (high probability). We constructed a Bayesian latent class model to estimate the accuracy of CAD4TBv6 screening compared to bacteriologically-confirmed TB across CAD4TBv6 threshold cut-offs, incorporating data on Clinical Officer CXR interpretation, participant demographics (age, sex, TB symptoms, previous TB history), and sputum results. We compared model-estimated sensitivity and specificity of CAD4TBv6 to optimum and minimum TPPs. Of 63,050 prevalence survey participants, 61,848 (98%) had analysable CXR images, and 8,966 (14.5%) underwent sputum bacteriological testing; 298 had bacteriologically-confirmed pulmonary TB. Median CAD4TBv6 scores for participants with bacteriologically-confirmed TB were significantly higher (72, IQR: 58-82.75) compared to participants with bacteriologically-negative sputum results (49, IQR: 44-57, p<0.0001). CAD4TBv6 met the optimum TPP; with the threshold set to achieve a mean sensitivity of 95% (optimum TPP), specificity was 83.3%, (95% credible interval [CrI]: 83.0%-83.7%, CAD4TBv6 threshold: 55). There was considerable variation in accuracy by participant characteristics, with older individuals and those with previous TB having lowest specificity. CAD4TBv6 met the optimal TPP for TB community screening. To optimise screening accuracy and efficiency of confirmatory sputum testing, we recommend that an adaptive approach to threshold setting is adopted based on participant characteristics.

Treatment Outcomes Among Notified Pulmonary Tuberculosis Cases in 67 Refugee Health Facilities in the Eastern Africa-IGAD Region: Historical Cohort, 2014-2017

Background: Refugees are at increased risk for Tuberculosis (TB). In 2020, more than 3.9 million refugees were hosted in refugee camps/settlements in member countries of Intergovernmental Authority on Development (IGAD), East Africa. Regional evidence, therefore, on treatment outcome is important to improve the quality of TB care and strengthen the monitoring and evaluation system in the refugee settings. Objective: To assess trends of pooled TB treatment outcomes at the regional level and identify factors associated with unsuccessful treatment outcome among patients with pulmonary TB (PTB), bacteriologically confirmed pulmonary TB (BCPTB) and clinically diagnosed pulmonary TB (CDPTB) in refugee camps in IGAD region from 2014 to 2017. Methods: A retrospective cohort study was conducted in 67 refugee health facilities located in four countries (Ethiopia=25, Uganda=33, Kenya=5 and Sudan=4). Demographic and clinical data of all PTB patients registered between January 1, 2014 and December 31, 2017 were used. Descriptive analysis was done on the data and multivariate logistic regression analysis was used to identify baseline covariates associated with unsuccessful treatment. Results: A total of 4,072 TB cases (42%, 28%, 12% and 19% were from Kenya, Ethiopia, Sudan, and Uganda respectively) were included with more than half (62.4%) being BCPTB. 59.2% were males and 13.5% were HIV co-infected. The pooled treatment success rate (TSR) in the period under review was 80.7%. TSR was higher among the CDPTB compared to BCPTB cases in 2014 (86.5% vs. 81.3%), 2015 (87.5% vs. 84.8%) and 2016 (81.0 vs. 80.6%); but reversed in favour of BCPTB in 2017 (77.1% vs. 74.3%). Overall, 13.6% of the cases had unsuccessful treatment (treatment failed, died, or lost to follow-up). The factors significantly associated with unsuccessful treatment were positive HIV status (aOR 2.6[CI: 1.7 - 4.2]), male gender (aOR 1.7[CI: 1.4 - 3.8]), previous TB history (aOR 1.5[CI: 1.0 - 2.2]) and older age (aOR 1.7[CI: 1.1 - 2.8]). Conclusion: TB Treatment success rate in the refugee camps remained below the global target (≥ 90). TB-HIV co-infection, Male gender, previous history of treatment and age (15-34 &amp;old age) increased the risk for unsuccessful treatment outcomes among PTB patients in the refugee camps.

Comparison of chest computed tomography features between pulmonary tuberculosis patients with culture-positive and culture-negative sputum for non-mycobacteria: A retrospective observational study.

Although complication with non-mycobacterial pneumonia among patients with pulmonary tuberculosis (TB) may lead to poor prognosis, discrimination between TB complicated with and without non-mycobacterial pneumonia using radiological imaging has not been fully elucidated. We aimed to clarify the differences in chest computed tomography (CT) features between pulmonary TB patients with culture-positive and culture-negative sputum for non-mycobacteria.We retrospectively included consecutive patients admitted to our hospital from January 2013 to December 2015 for bacteriologically-confirmed pulmonary TB, who were tested by sputum culture for non-mycobacteria, and who underwent chest CT within 2 weeks before or after admission. Chest CT features were compared between pulmonary TB patients who had positive non-mycobacterial cultures and in those who had not.Of 202 patients with pulmonary TB, 186 (92%) were tested by sputum culture for non-mycobacteria and underwent chest CT. Among these, non-mycobacteria were isolated in 118 patients (63%), while 68 patients (37%) had negative cultures. Patients with a positive culture for non-mycobacteria were significantly older and had lower levels of physical activity and albumin, higher levels of C-reactive protein, and a greater number of respiratory failures. By CT, emphysematous lesions, ground-glass opacities, airspace consolidation, air-bronchogram, interlobular septal thickening, bronchiectasis, pleural effusion, pleural thickening, and lymph node enlargement were more frequently in patients with a positive culture for non-mycobacteria. These chest CT features could be helpful for detecting complication with non-mycobacterial pneumonia in patients with pulmonary TB.

Association between GeneXpert Diagnosis and Same-Day Initiation of Tuberculosis Treatment in Rural Eastern Uganda.

Diagnosis of tuberculosis with GeneXpert and same-day initiation of tuberculosis treatment (SITT) has important public health and clinical benefits. GeneXpert allows for rapid diagnosis, hence presenting an opportunity for SITT. We determined the association between GeneXpert diagnosis and SITT, and the effect of SITT on treatment success rate among adult persons with bacteriologically confirmed pulmonary tuberculosis (BC-PTB) in rural eastern Uganda. We conducted a retrospective cohort study using routinely collected data at 10 health facilities, used modified Poisson regression analysis to determine the association between GeneXpert and SITT, and expressed the results as risk ratio (RR). We used propensity score-matched analysis to match SITT participants to delayed initiation of treatment (DIT) participants and then performed logistic regression analysis to determine the independent effect of SITT on treatment success rate, expressed as odds ratio (OR). Of 1,045 participants, 764 (73.1%) had SITT. The use of GeneXpert for diagnosis of tuberculosis was associated with higher likelihood of SITT (adjusted RR [aRR], 1.28; 95% CI: 1.19-1.37) and for persons with new BC-PTB diagnosis (aRR, 1.16; 95% CI: 1.02-1.32). We successfully matched 530 participants (265 in SITT and 265 in DIT) through 1:1 nearest neighbor caliper matching. Before propensity score-matched analysis, SITT was not significantly associated with treatment success rate (adjusted OR, 0.97; 95% CI: 0.70-1.33). After propensity score-matched analysis, SITT remained nonsignificantly associated with treatment success rate (OR, 0.96; 95% CI: 0.67-1.40). GeneXpert thus increases the likelihood of SITT, but SITT has no significant effect on treatment success rate.

Sputum smear non-conversion among adult persons with bacteriologically confirmed pulmonary tuberculosis in rural eastern Uganda

RationaleFailure to convert sputum at two months of treatment among persons with bacteriologically confirmed pulmonary tuberculosis (BC-PTB) indicates poor response to treatment but data are limited on its assessment. ObjectiveWe determined the frequency and factors associated with sputum smear non-conversion at two months among persons with BC-PTB in eastern Uganda. MethodsWe abstracted data of adult persons with BC-PTB, from routinely available records from TB registers at 10 clinics in eastern Uganda. We determined factors that are independently associated with sputum smear non-conversion using logistic regression analysis. We expressed the results as odds ratio (OR) with 95% confidence interval (CI). Measurements and main resultsOf 516 persons with BC-PTB, 81 (15.7%) did not achieve sputum smear conversion at two months of TB treatment. Higher Mycobacteria tuberculosis (MTB) load and treatment at a private-not-for-profit (PNFP) facility compared to government health facility were significantly associated with sputum smear non-conversion. A one unit (+1) increase in MTB load based on ZN stain counts was associated with a 48% increase in the odds of sputum smear non-conversion with adjusted odds ratio (AOR), 1.48 (95% CI, 1.02–2.18). TB treatment at private-not-for-profit health facility was associated with a two-fold increase in the odds of sputum smear non-conversion (AOR, 2.03; 95% CI, 1.01–3.92). ConclusionsOur study shows that sputum smear non-conversion is common at two months of treatment in this population. It is more likely among patients with higher baseline MTB load and those treated at PNFP facilities. Strategies targeting patients with these risk factors are needed to enhance sputum smear conversion.

Surveillance for multi-drug and rifampicin resistant tuberculosis and treatment outcomes among previously treated persons with tuberculosis in the era of GeneXpert in rural eastern Uganda

RationalePreviously treated persons with bacteriologically confirmed pulmonary tuberculosis (BC-PTB) have increased risk of developing multi-drug resistant or rifampicin resistant tuberculosis (MDR/RR-TB). Surveillance for resistance is critical to identify and treat MDR/RR-TB to ensure cure and prevent transmission. There are limited studies conducted on this subject. ObjectivesWe examined the frequency and factors associated with MDR/RR-TB surveillance among previously treated persons with BC-PTB, and described their treatment outcomes in rural eastern Uganda. MethodsWe reviewed treatment records for BC-PTB between January 2015 and June 2018 at 10 clinics in eastern Uganda. We collected data on demographics, surveillance for MDR/RR, use of GeneXpert and treatment outcomes. We performed bivariate and multivariate analyses. For multivariate analysis, we used the modified Poisson regression analysis with robust standard errors and stated the results as adjusted risk ratio (aRR) with 95% confidence intervals (CI). All analyses were conducted in R version 3.5.2. Measurements and main resultsWe obtained records for 135 previously treated persons with BC-PTB and of these, 41 (30.4%) had undergone surveillance for MDR/RR-TB. Treatment failures were less likely to have surveillance compared to relapses (aRR, 0.28; 95% CI, 0.08–0.95), and there was an increasing trend in the likelihood for surveillance between 2015 and 2018 (aRR, 1.77; 95% CI, 1.39–2.25). There was no difference in MDR/RR-TB surveillance rate between health facilities with and without GeneXpert on-site (aRR, 1.52; 95% CI, 0.81–2.86) and between male and female patients (aRR, 0.54; 95% CI, 0.21–1.37). Overall, 92 (68.1%) previously treated persons with BC-PTB were successfully treated for tuberculosis. ConclusionsMDR/RR-TB surveillance and treatment success rates among previously treated persons with BC-PTB in rural eastern Uganda are low. Tuberculosis programs should strengthen MDR/RR-TB surveillance and especially target those with treatment failure.

Does completion of sputum smear monitoring have an effect on treatment success and cure rate among adult tuberculosis patients in rural Eastern Uganda? A propensity score-matched analysis.

BackgroundTuberculosis is a global public health problem. Bacteriologically confirmed pulmonary tuberculosis (BC-PTB) patients require three sputum smear monitoring (SSM) tests to establish cure or treatment success, but few studies have assessed the relationship. We evaluated the effect of completing SSM on treatment success rate (TSR) among adult BC-PTB patients in rural eastern Uganda.MethodsWe conducted a propensity score-matched (PSM) analysis of a retrospective observational cohort data. Participants who completed SSM were matched to those who had not, through nearest neighbor 1:1 caliper matching. Balance of baseline characteristics between the groups was compared before and after PSM using standardized mean differences. Logistic regression analysis was performed in matched and unmatched samples, reported as odds ratio (OR) with 95% confidence intervals (CI). Robustness of the results to hidden bias was checked through sensitivity analysis. The primary outcome was TSR (treatment completion or cure), while the secondary was cure rate, measured as an individual outcome.ResultsBefore PSM, 591 (72.3%) of the 817 participants had incomplete SSM, with statistically significant differences in baseline covariates between completers and non-completers. After PSM, there were 185 participants in either group, balanced on baseline covariates. Before PSM, SSM completion was not associated with TSR, with unadjusted (OR, 0.92; 95%CI, 0.32–2.63) and adjusted analysis (Adjusted OR, 1.32; 95%CI, 0.41–4.22). For cure rate, there was a statistically significant effect before (OR, 93.34; 95%CI, 29.53–295.99) and after adjusted analysis (Adjusted OR, 86.24; 95%CI, 27.05–274.94), although imprecise. In PSM analysis, SSM completion was associated with increased odds of cure (OR, 87.00; 95%CI, 12.12–624.59) but not TSR (OR, 1.67; 95%CI, 0.40–6.97).ConclusionsCompleting SSM increases cure but has no effect on TSR among adult BC-PTB patients in eastern Uganda. Implementation of SSM should be encouraged to ensure improvement in cure rates among tuberculosis patients in rural areas.

Bacteriologically-confirmed pulmonary tuberculosis in an Ethiopian prison: Prevalence from screening of entrant and resident prisoners.

BackgroundPulmonary Tuberculosis (PTB) is a major health problem in prisons. Multiple studies of TB in regional Ethiopian prisons have assessed prevalence and risk factors but have not examined recently implemented screening programs for TB in prisons. This study compares bacteriologically-confirmed PTB (BC-PTB) prevalence in prison entrants versus residents and identifies risk factors for PTB in Kality prison, a large federal Ethiopian prison located in Addis Ababa, through a study of an enhanced TB screening program.MethodsParticipating prisoners (n = 13,803) consisted of 8,228 entrants screened continuously and 5,575 residents screened in two cross-sectional waves for PTB symptoms, demographics, TB risk factors, and medical history. Participants reporting at least one symptom of PTB were asked to produce sputum which was examined by microscopy for acid-fast bacilli, Xpert MTB/RIF assay and MGIT liquid culture. Prevalence of BC-PTB, defined as evidence of Mycobacterium tuberculosis (MTB) in sputum by the above methods, was compared in entrants and residents for the study. Descriptive analysis of prevalence was followed by bivariate and multivariate analyses of risk factors.ResultsPrisoners were mainly male (86%), young (median age 26 years) and literate (89%). Prevalence of TB symptoms by screening was 17% (2,334/13,803) with rates in residents >5-fold higher than entrants. Prevalence of BC-PTB detected by screening in participating prisoners was 0.16% (22/13,803). Prevalence in residents increased in the second resident screening compared to the first (R1 = 0.10% and R2 = 0.39%, p = 0.027), but remained higher than in entrants (4.3-fold higher during R1 and 3.1-fold higher during R2). Drug resistance (DR) was found in 38% (5/13) of culture-isolated MTB. Risk factors including being ever diagnosed with TB, history of TB contact and low Body Mass Index (BMI) (<18.5) were significantly associated with BC-PTB (p<0.05).ConclusionsBC-PTB prevalence was strikingly lower than previously reported from other Ethiopian prisons. PTB appears to be transmitted within this prison based on its higher prevalence in residents than in entrants. Whether a sustained program of PTB screening of entrants and/or residents reduces prevalence of PTB in prisons is not clear from this study, but our findings suggest that resources should be prioritized to resident, rather than entrant, screening due to higher BC-PTB prevalence. Detection of multi- and mono-DR TB in both entrant and resident prisoners warrants regular screening for active TB and adoption of methods to detect drug resistance.

Treatment supporters and level of health facility influence completion of sputum smear monitoring among tuberculosis patients in rural Uganda: A mixed-methods study

ObjectivesTo investigate whether treatment supporters influence the completion of sputum smear monitoring (SSM) among adult persons with bacteriologically confirmed pulmonary tuberculosis (BC-PTB), and to explore the reasons for incomplete SSM according to healthcare workers, persons with BC-PTB, and their treatment supporters in rural eastern Uganda. MethodsA mixed-methods design was used. Quantitative data were abstracted from tuberculosis unit registers, while qualitative data were obtained through key informant interviews with healthcare workers and in-depth interviews with persons with BC-PTB and their treatment supporters. Quantitative data were analyzed with Stata. Qualitative data were transcribed verbatim and analyzed using a thematic content approach. ResultsRecords were abstracted for 817 patients. Of these, 226 (27.7%) completed SSM. Factors independently associated with SSM completion included having a treatment supporter (adjusted risk ratio (ARR) 2.40, 95% confidence interval (CI) 1.23–4.70), treatment at a district hospital (ARR 1.61, 95% CI 1.04–2.49), treatment at a regional referral hospital (ARR 2.00, 95% CI 1.46–2.73), and every additional year since 2015 (ARR 1.29, 95% CI 1.17–1.43). Reasons for incomplete SSM related to health system, patient, treatment supporter, and healthcare provider factors. ConclusionsCompletion of SSM was low. Persons with BC-PTB who have a treatment supporter were more likely to complete SSM compared to those without, and those receiving treatment at higher level facilities were more likely to complete SSM compared to those at lower level ones.

Treatment success rate among adult pulmonary tuberculosis patients in sub-Saharan Africa: a systematic review and meta-analysis

ObjectivesTo summarise treatment success rate (TSR) among adult bacteriologically confirmed pulmonary tuberculosis (BC-PTB) patients in sub-Saharan Africa (SSA).DesignWe searched MEDLINE, EMBASE, Google Scholar and Web of Science electronic databases for...

Enhancing TB case detection: experience in offering upfront Xpert MTB/RIF testing to pediatric presumptive TB and DR TB cases for early rapid diagnosis of drug sensitive and drug resistant TB.

BackgroundDiagnosis of pulmonary tuberculosis (PTB) in children is challenging due to difficulties in obtaining good quality sputum specimens as well as the paucibacillary nature of disease. Globally a large proportion of pediatric tuberculosis (TB) cases are diagnosed based only on clinical findings. Xpert MTB/RIF, a highly sensitive and specific rapid tool, offers a promising solution in addressing these challenges. This study presents the results from pediatric groups taking part in a large demonstration study wherein Xpert MTB/RIF testing replaced smear microscopy for all presumptive PTB cases in public health facilities across India.MethodsThe study covered a population of 8.8 million across 18 programmatic sub-district level tuberculosis units (TU), with one Xpert MTB/RIF platform established at each study TU. Pediatric presumptive PTB cases (both TB and Drug Resistant TB (DR-TB)) accessing any public health facilities in study area were prospectively enrolled and tested on Xpert MTB/RIF following a standardized diagnostic algorithm.Results4,600 pediatric presumptive pulmonary TB cases were enrolled. 590 (12.8%, CI 11.8–13.8) pediatric PTB were diagnosed. Overall 10.4% (CI 9.5–11.2) of presumptive PTB cases had positive results by Xpert MTB/RIF, compared with 4.8% (CI 4.2–5.4) who had smear-positive results. Upfront Xpert MTB/RIF testing of presumptive PTB and presumptive DR-TB cases resulted in diagnosis of 79 and 12 rifampicin resistance cases, respectively. Positive predictive value (PPV) for rifampicin resistance detection was high (98%, CI 90.1–99.9), with no statistically significant variation with respect to past history of treatment.ConclusionUpfront access to Xpert MTB/RIF testing in pediatric presumptive PTB cases was associated with a two-fold increase in bacteriologically-confirmed PTB, and increased detection of rifampicin-resistant TB cases under routine operational conditions across India. These results suggest that routine Xpert MTB/RIF testing is a promising solution to present-day challenges in the diagnosis of PTB in pediatric patients.

Detection of Mycobacterium tuberculosis DNA by PCR in Peripheral Blood of Patients with Pulmonary Tuberculosis

Background: Although pulmonary tuberculosis (TB) is a respiratory disease, the presence of Mycobacterium tuberculosis (Mtb) DNA or Mtb itself has been reported in the peripheral blood (PB) of several patients with pulmonary TB. Additionally, it was recently announced that active pulmona ry TB patients donated PB, and that this blood was then transfused to other individuals in Korea. Methods: Sixty-nine patients with bacteriologically-confirmed pulmonary TB (35), non-tuberculous mycobacterial (NTM) lung disease (6), and other lung diseases (28) were enrolled in this study, which was conducted to determine if Mtb DNA could be detected in the PB by PCR. In addition, 10 pulmonary TB patients with high-burden bacilli were also enrolled in this study for the culture of Mtb in PB. Results: PCR detected the presence of Mtb in 22.8% (8/35) of the pulmonary TB patients, in 16.7% (1/6) of the patients with NTM lung disease, and in none of the patients with other diseases (0%). In addition, no Mtb was cultured from the PB of the 10 pulmonary TB patients. Conclusion: Although Mtb DNA was detected in the PB of some patients with pulmonary TB, viable Mtb was not isolated from the PB of those patients, which indicates that pa tients that viable Mth may not be transmitted via trasfusion of blood of pulmonary TB patients. (Tuberc Respir Dis 2007; 63: 331-336)