Care For TB Patients Research Articles

Outcome of patients with tuberculosis managed under NTEP through STEPS in a private hospital in India

ObjectiveAs the global health care commits to the ambitious goal of TB elimination, System for TB Elimination in Private Sector (STEPS) was introduced to provide appropriate standards of TB care to all patients. This study aims to assess the outcome of TB patients treated under STEPS programme in a Private hospital and find any significant factors in determining favourable and unfavourable outcomes. SettingPrivate Quaternary care hospital in South India. DesignRetrospective study which included 163 patients diagnosed with Pulmonary and Extra-Pulmonary Tuberculosis from January 2020 to June 2022. Details like clinical profile, type and site of tuberculosis, modification of ATT regimen, adverse effects and outcomes were recorded. ResultsThe study population included 62.6% males. 45.3% had Type-2 Diabetes mellitus. More than half of the cases were Extra-Pulmonary TB (52.2%) and 54.6% had microbiological confirmation. The Cure Rate in Pulmonary and Extra-Pulmonary TB cases were 76.7% and 79.2% respectively. 29 patients expired during TB treatment out of which 41.3% had renal failure. Advanced age and chronic kidney disease as a co-morbidity were significant in causing unfavourable outcomes. ConclusionProper implementation of STEPS can help in 100% TB notification and effective care of TB patients.

Socio-economic burden of TB and its impact on child contacts in The Gambia.

To determine the social impact of adult TB on child household contacts living in the Greater Banjul Area, The Gambia. This was a prospective observational cohort study among adults (≥18 years) starting treatment for drug-susceptible pulmonary TB between June 2019 and July 2021 who reported having at least one child household contact. We collected data from 51 adults and 180 child contacts at the start of TB treatment (baseline) and again at 6 months of treatment. Participants were asked about expenses for school fees, healthcare, festivities and food security of child contacts. While school attendance of the child contacts remained largely unaffected, there was a significant drop in school performance at 6 months (P < 0.001). Furthermore, child contacts faced significant food insecurity in terms of food quantity and variety available, with up to a four-fold increase in some instances at 6 months compared to baseline (P < 0.001). Child contacts face a potential decline in school performance and risk of food insecurity. While a plethora of work is being undertaken to alleviate costs of care for TB patients, further emphasis is needed to ensure educational and social prosperity for child contacts, as adults with TB have socio-economic implications for the wider household.

Covid 19: Risk factors and development of pulmonary TB in household contacts, Lima, Peru

Objectiveis to determine the risk factors associated with developing tuberculosis in household contacts of patients with pulmonary tuberculosis in the epidemiological context of the Covid 19 pandemic. MethodsIt is descriptive, analytical and cross-sectional, the population of index cases with tuberculosis is 53, and a sample of 59 household contacts of a health center of the Ministry of Health, in Lima, in the months of September and October 2021, two pre-established surveys were applied, one applied in the index case, and another to household contacts; for the association of risk factors, the Mantel and Haenszel Chi-square test was used. Resultsin the sociodemographic risk, shared housing, with a significance of 0.000; family support, with a significance of 0.006, considered P values < 0.05. Clinical factor, 27.5 % (11) of the index cases have type 2 diabetes mellitus, and 7.5 % (3) have malnutrition, and 7.5 % have alcoholism, 5 % have HIV/AIDS, arterial hypertension, and lack of application of isoniazid preventive therapy (IPT) are associated with a significance level of 0.001, (P < 0.05). Environmental risk, home lighting, hygiene and ventilation are associated with a significance level of 0.017, 0.002 and 0.011 respectively, with P < 0.05. index cases, more than 28 % were infected, 69.8 % were vaccinated; in contacts more than 13 % were infected, and vaccinated more than 47 % Conclusionshared housing, family support, associated diseases, lack of implementation of isoniazid preventive therapy (PTZ), home lighting, hygiene and ventilation were the most relevant associated with the development of tuberculosis. Tuberculosis is a global health crisis, attention should focus on controlling tuberculosis in areas where it continues to develop. Given that migration factors are a prevalent condition in the Americas, the focus must address health risk factors to improve health outcomes and care for TB patients in Peru.

Lived Experience of Iranian Family Caregivers of Tubercular Patients: A Qualitative Study

Objective. To investigate the lived experience of family caregivers of persons with tuberculosis. Methods. In this study, the method of hermeneutic phenomenology. Data were collected through online in-depth semi-structured interviews with nine family caregivers of TB patients. The obtained data were thematically analyzed to explain the concept of home care for TB patients through van Manen's 6-step methodology. Results. After the thematic analysis, three main themes of caregivers'; mental distresses, quality care stasis, andfacilitated care were obtained from 944 primary codes and 11 categories. Conclusion. Family caregivers of these patients suffer from mental distress. This issue affects the quality and ease of caregiving for these patients. Therefore, policymakers of this area should pay attention to the family caregivers of these patients and attempt to provide support; they should try to improve their quality of life.

Lived Experience of Iranian Family Caregivers of Tubercular Patients: A Qualitative Study.

To investigate the lived experience of family caregivers of persons with tuberculosis. In this study, the method of hermeneutic phenomenology. Data were collected through online in-depth semi-structured interviews with nine family caregivers of TB patients. The obtained data were thematically analyzed to explain the concept of home care for TB patients through van Manen's 6-step methodology. After the thematic analysis, three main themes of caregivers' mental distresses, quality care stasis, and facilitated care were obtained from 944 primary codes and 11 categories. Family caregivers of these patients suffer from mental distress. This issue affects the quality and ease of caregiving for these patients. Therefore, policymakers of this area should pay attention to the family caregivers of these patients and attempt to provide support; they should try to improve their quality of life.

The impact of the COVID-19 pandemic on patients’ experiences obtaining a tuberculosis diagnosis in Peru: a mixed-methods study

BackgroundThe COVID-19 pandemic disrupted TB services worldwide, leading to diagnostic delays. There have been few published reports describing how the pandemic affected people’s pathway to diagnosis from their own perspectives. We sought to evaluate the impact on the pandemic on people’s experiences obtaining a TB diagnosis.MethodsWe performed a mixed-methods study, enrolling newly diagnosed TB patients from 12 health centers in Lima, Peru. We used structured surveys to quantify diagnostic delay, defined as the time between symptom onset and diagnosis, and in-depth interviews to understand the ways in which the pandemic affected the pathway to care. We compared diagnostic delay between patients enrolled during the first year of the pandemic to those diagnosed after using a Wilcoxon rank-sum test. We used an inductive content analysis approach to analyze interview content related to the pandemic.ResultsWe enrolled 51 patients during November 2020–April 2021 (during the first year of the pandemic) and 49 patients during October 2021–February 2022. Median diagnostic delay was longer for patients diagnosed during the first year of the pandemic (median 15 [IQR 5–26] weeks compared to 6 [IQR 3–18] weeks, p = 0.027). Qualitative analysis of 26 interviews revealed that the pandemic affected participants’ care-seeking behavior and their ability to access to TB diagnostic services, particularly for those diagnosed in the first year of the pandemic. Many participants initially had their symptoms attributed to COVID-19, resulting in delayed TB evaluation and additional costs for COVID-19 treatment.ConclusionsThe COVID-19 pandemic impacted multiple steps in the pathway to care for TB patients in Lima, causing delays in TB diagnosis. These findings demonstrate how the shifting of health care resources to prioritize COVID-19 can lead to collateral damage for people with TB and other conditions.

Stakeholder perspectives around post-TB wellbeing and care in Kenya and Malawi.

There is growing awareness of the burden of post-TB morbidity, and its impact on the lives and livelihoods of TB affected households. However little work has been done to determine how post-TB care might be delivered in a feasible and sustainable way, within existing National TB Programmes (NTPs) and health systems, in low-resource, high TB-burden settings. In this programme of stakeholder engagement around post-TB care, we identified actors with influence and interest in TB care in Kenya and Malawi, including TB-survivors, healthcare providers, policy-makers, researchers and funders, and explored their perspectives on post-TB morbidity and care. Stakeholder mapping was completed to identify actors with interest and influence in TB care services in each country, informed by the study team's local, regional and international networks. Key international TB organisations were included to provide a global perspective. In person or online one-to-one interviews were completed with purposively selected stakeholders. Snowballing was used to expand the network. Data were recorded, transcribed and translated, and a coding frame was derived. Data were coded using NVivo 12 software and were analysed using thematic content analysis. Online workshops were held with stakeholders from Kenya and Malawi to explore areas of uncertainty and validate findings. The importance of holistic care for TB patients, which addresses both TB comorbidities and sequelae, was widely recognised by stakeholders. Key challenges to implementation include uncertainty around the burden of post-TB morbidity, leadership of post-TB services, funding constraints, staff and equipment limitations, and the need for improved integration between national TB and non-communicable disease (NCD) programmes for care provision and oversight. There is a need for local data on the burden and distribution of morbidity, evidence-informed clinical guidelines, and pilot data on models of care. Opportunities to learn from existing HIV-NCD services were emphasised. This work addresses important questions about the practical implementation of post-TB services in two African countries, exploring if, how, where, and for whom these services should be provided, according to a broad range of stakeholders. We have identified strong interest in the provision of holistic care for TB patients in Kenya and Malawi, and key evidence gaps which must be addressed to inform decision making by policy makers, TB programmes, and funders around investment in post-TB services. There is a need for pilot studies of models of integrated TB care, and for cross-learning between countries and from HIV-NCD services.

Policy framework for building integrated care for TB patients in Romania: setting up the scene

Abstract Problem Romania put many efforts for TB control, but despite a constant decreasing trend since almost two decades, TB remained a public health concern, due to the notification rate (highest in EU), the number of resistant cases and the mortality. A national strategy for TB control has been issues for 2015-2020, but its implementation was fragmentary. Description of the Problem Benefiting for a series of programs financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria, Romania performed a detailed analysis of the national context, on four pillars (governance and accountability, service delivery, organizational capacity, resources). Quantitative data collected through routine systems were combined to interviews with key informers and focus groups with medical staff, patients and NGOs active in supporting key vulnerable population. Results A national framework for strengthening the implementation of the strategy was set up under a Tailored to Transition Global Fund Grant. This framework put together the policy and the technical levels and the civil society sector. Main interventions aimed to strengthen the governance, to improve the procurement and supply mechanism, to develop the ambulatory patient-centered model of care and to create tools for improving the access of key vulnerable population to basic integrated medical and social services. Lessons Translating the good practice models developed by the NGO sector to permanent (governmental) structures was difficult due to more rigorous legislative framework for public systems. Key messages Multisectoral approach is essential for building integrated care for TB patients. Integration of services should focus not only to complex medical needs, but also to the social ones.

Nurses' Safety in Caring for Tuberculosis Patients at a Teaching Hospital in South West Nigeria.

Background Tuberculosis remains the leading cause of death due to infectious diseases worldwide ranking above HIV/AIDS, and Nigeria is rated as the 7th worldwide and the 2nd in Africa among the 30 countries highly burdened with tuberculosis worldwide. Aim To investigate the challenges encountered by nurses in the care of TB patients in a Federal Teaching Hospital in Nigeria. Setting. Ekiti State, Southwest Nigeria. Methods A qualitative contextual method was utilized with the sample size determined by data saturation. Data collection was done through an audiotaped, semistructured interview. The study sample consisted of 20 professional nurses working in the medical and paediatric wards of a selected Federal Teaching Hospital in South West, Nigeria. Data was analysed using Tesch's content analysis approach. Results The majority of the participants were females within the age group of 31–40 years. Challenges included inadequate availability of personal protective equipment (PPE), lack of isolation wards, delegating the care of tuberculosis patients to young inexperienced nurses, long process in diagnosing patients with tuberculosis, lack of policies protecting the nurses from exposure to tuberculosis, and inadequate training. The major concern was the fear of contracting tuberculosis. Conclusion The study suggested that there should be a provision of adequate personal protective equipment; tuberculosis designated wards and provision of periodic training to update the nurses on care of tuberculosis patients. Establishment and execution of hospital policies and practices along with support are equally essential in facilitating a safe workplace for nurses.

Quality of tuberculosis care in the private health sector

As countries move towards achieving universal health coverage, efforts to engage all care providers have gained more significance. Over a third of people estimated to have developed TB in 2018 were not detected and notified by national TB programs (NTPs). This gap is more pronounced in countries with large private sectors, especially those with a high burden of TB. Health care providers outside the scope of NTPs, including the private and informal sector, are often the first point of care for TB patients. However, these providers are not fully engaged despite evidence from country experiences and projects that demonstrate increased detection and good treatment outcomes through publicprivate mix (PPM) approaches. While there are often concerns about quality of care in public facilities, there is also increasing evidence that quality of TB care in the private sector falls short of international standards in many places and urgently needs improvement. Failure to engage the full range of health care providers for TB has serious consequences in terms of access to quality care, resulting in increased transmission as a result of delayed diagnosis and treatment; excess mortality and morbidity as a result of inappropriate treatment; and increased drug resistance as a result of incomplete treatment. Recent attention to this issue has led to significant increases in private TB notifications, especially in India, Indonesia and the Philippines, but the gap between notification and the extension of quality program services for provision of treatment and care appears to be growing.

Professional skills for health promotion in caring for tuberculosis patients.

to understand the health promotion skills found in the speeches of health practitioners in care for TB patients. qualitative study, developed with seven practitioners involved in care for TB patients, identified from a sociocentric approach, whose speeches were submitted to analysis based on the health promotion skills model in the Galway Consensus. there were four domains: Catalyzing change; Leadership; Planning; and Partnerships. These domains resulted from health education actions, contribution of management nursing practitioners, seeking to meet patients' needs and articulation of professional sectors. there were some skill domains in the speeches of health practitioners, with the nurse being quoted in the development of essential skills for health promotion activities, such as catalyzing change and leading care for TB patients.

Continuity of care for TB patients at a South African hospital: A qualitative participatory study of the experiences of hospital staff.

BackgroundEnsuring effective clinical management and continuity of TB care across hospital and primary health-care services remains challenging in South Africa. The high burden of TB, coupled with numerous health system problems, influence the TB care delivered by hospital staff.ObjectiveTo understand factors from the perspectives of hospital staff that influence the clinical management and discharge of TB patients, and to elicit recommendations to improve continuity of care for TB patients.DesignParticipatory action research was used to engage hospital staff working with TB patients admitted to a central public hospital in the Western Cape province, South Africa. Data were collected through eight focus group discussions with nurses, junior doctors and ward administrators. Data analysis was done using Miles and Huberman’s framework to identify emerging patterns and to develop categories with themes and sub-themes. The participants influenced all phases of the research process to inform better practices in TB clinical management and discharge planning at the hospital.ResultsThe emerging themes and sub-themes were categorized into two overall sections: The clinical care management process and the discharge and referral process. Nurses expressed a fear of exposure to TB and MDR-TB due to challenges in clinical and infection-prevention control. Clinical hierarchies, poor interdisciplinary teamwork, limited task shifting and poor communication interfered with effective clinical and discharge processes. A high workload, staff shortages and inadequate skills resulted in insufficient information and health education for TB patients and their caregivers. Despite awareness of the patients’ socio-economic challenges, some aspects of care were not patient-centered, and caregivers were not included in discharge planning. Communication between the hospital and referral points was inefficient and poorly supported by information systems. Hospital staff recommended improved infection prevention and control practices and interdisciplinary teamwork in the hospital, that TB education for patients be integrated with hospital staff functions, with more patient-centered discharge planning, and improved communication across hospitals and primary health care levels.ConclusionsInterdisciplinary teamwork, more patient-centered care, and better communication within the hospital and with primary health-care services are needed for improved continuity of care for TB patients. Further studies on factors contributing to, and interventions to improve, continuity of TB care in similar hospital settings are needed.

The impact of increased reimbursement rates under the new cooperative medical scheme on the financial burden of tuberculosis patients

BackgroundTuberculosis (TB) is still a major public health problem in China. To scale up TB control, an innovative programme entitled the ‘China-Gates Foundation Collaboration on TB Control in China was initiated in 2009. During the second phase of the project, a policy of increased reimbursement rates under the New Cooperative Medical Scheme (NCMS) was implemented. In this paper, we aim to explore how this reform affects the financial burden on TB patients through comparison with baseline data.MethodsIn two cross-sectional surveys, quantitative data were collected before (January 2010 to December 2012) and after (April 2014 to June 2015) the intervention in the existing NCMS routine data system. Information on all 313 TB inpatients, among which 117 inpatients in the project was collected. Qualitative data collection included 11 focus group discussions. Three main indicators, non-reimbursable expenses rate (NER), effective reimbursement rate (ERR), and out-of-pocket payment (OOP) as a percentage of per capita household income, were used to measure the impact of intervention by comprising post-intervention data with baseline data. The quantitative data were analysed by descriptive analysis and non-parametric tests (Mann-Whitney U test) using SPSS 22.0, and qualitative data were subjected to thematic framework analysis using Nvivo10.ResultsThe nominal reimbursement rates for inpatient care were no less than 80% for services within the package. Total inpatient expenses greatly increased, with an average growth rate of 11.3%. For all TB inpatients, the ERR for inpatient care increased from 52 to 66%. Compared with inpatients outside the project, for inpatients covered by the new policy, the ERR was higher (78%), and OOP showed a sharper decline. In addition, their financial burden decreased significantly.ConclusionsAlthough the nominal reimbursement rates for inpatient care of TB patients greatly increased under the new reimbursement policy, inpatient OOP expenditure was still a major financial problem for patients. Limited diagnosis and treatment options in county general hospitals and inadequate implementation of the new policy resulted in higher inpatient expenditures and limited reimbursement. Comprehensive control models are needed to effectively decrease the financial burden on all TB patients.

Facilitators and Barriers to Self-Management of Tuberculosis Patients: A Qualitative Study

Introduction: Patient self-management improves health and well-being. In 2015, 10.4 million was infected with Tuberculosis TB. TB is curable but treatment is ineffective without patient self-management. When patient perform self-management, it reduces treatment abandonment, prevents hospital admissions, and increases confidence and sense of control. TB self-management involves managing medication regimens, monitoring laboratory indicators, maintaining nutrition, coping to the psychological and social demands, and lifestyle regulation. However, little has been known about the conditions that facilitate or inhibit self-management of TB patients. Therefore, the purpose of this paper is to describe the facilitators and barriers of self-management of TB patients receiving treatment in an urban community health center. Methods: Qualitative data were collected through individual interview conducted at the dwelling place of the participants. The participants were recruited through maximum variation sampling from 15 adults with pulmonary TB with different gender, education, and occupation receiving treatment in an urban community health center in the Philippines. Data were analyzed using content analysis. Trustworthiness was established through respondent validation to check for accuracy and credibility of analysis. The respondents evaluated the interview transcript for the correctness and consistency of the identified categories between the researcher’s view and the participants. Bracketing and audit trailing from the verbatim transcriptions were done to establish trustworthiness. Results: Facilitators of self-management of TB patients are the self, family support, health care providers, environment, and spirituality. On the other hand, the barriers to self-management are the physical and emotional stress, social stigma, dissatisfaction to the healthcare system, and the self. Discussions: The self is the most important facilitator of self-management because it is voluntary and conscious will of the patient to improve their health and well-being. However, the self may also be the barrier especially if there is no support of the family, acceptance of the community, and the over-all health care system. Conclusions: Identification of the facilitators and barriers to self-management is a prerequisite in order to develop an integrated care model that will improve the over-all care of TB patients. Health care providers must educate patients about the importance of self-management, use therapeutic communication with patients, and engage patients to spiritual activities that promote healing. Moreover, involving the family in the care, and ensuring accessible, available, appropriate, and acceptable services of health and care system are also important to promote self-management of patients. Lessons learned: Patient self-management is not a one-way process. It involves participation of the family, health care providers, and the different factors that interact with the patient. Limitations: The study is limited to qualitative data derived from pulmonary TB patients living in an urban community in the Philippines. Suggestions for future research: Qualitative data may be triangulated using quantitative data for future research using a large number of participants.

Mind the gap! Risk factors for poor continuity of care of TB patients discharged from a hospital in the Western Cape, South Africa.

BackgroundTB patients discharged from hospitals in South Africa experience poor continuity of care, failing to continue TB treatment at other levels of care. Factors contributing to poor continuity of TB care are insufficiently described to inform interventions.ObjectiveTo describe continuity of care and risk factors in TB patients discharged from a referral hospital in the Western Cape, South Africa.DesignThis retrospective observational study used routine information to describe continuity of care and risk factors in TB patients discharged from hospital.Results788 hospitalized TB patients were identified in 6 months. Their median age was 32 years, 400 (51%) were male, and 653 (83%) were urban. A bacteriological TB test was performed for 74%, 25% were tested for HIV in hospital, and 32% of all TB patients had documented evidence of HIV co-infection. Few (13%) were notified for TB; 375 (48%) received TB medication; 284 (36%) continued TB treatment after discharge; 91 (24%) had a successful TB treatment outcome, and 166 (21%) died. Better continuity of care was associated with adults, urban residence, bacteriological TB tests in hospital and TB medication on discharge. Fragmented hospital TB data systems did not provide continuity with primary health care information systems.ConclusionsDischarged TB patients experienced poor continuity of care, with children, rural patients, those not tested for TB in hospital or discharged without TB medication at greatest risk. Suboptimal quality of hospital TB care and a fragmented hospital information system without linkages to other levels underpinned poor continuity of care.

Prevalence and correlates of depressive symptoms in adult patients with pulmonary tuberculosis in the Southwest Region of Cameroon.

BackgroundTuberculosis (TB) remains a global health challenge and depression is a significant contributor to the global burden of disease. Current evidence suggests that there is an association between depressive symptoms and TB, lower adherence to treatment, and increased morbidity and mortality. However, there is paucity of data regarding these associations in Cameroon. This study aimed to determine the prevalence and correlates of depression in adult patients with pulmonary TB (PTB) in the Southwest Region of Cameroon.MethodsA hospital-based cross-sectional study involving 265 patients with PTB was conducted from 2nd January to 31st March 2015 in the Limbe Regional Hospital and the Kumba District Hospital. Depression was diagnosed using the standard nine-item Patient Health Questionnaire, and classified as none, mild or moderate. Logistic regressions were used to investigate correlates of depression in these patients.ResultsOf the 265 patients (mean age 36.9 ± 10 years) studied, 136 (51.3 %) were female. The prevalence of depression was 61.1 % (95 % CI: 55.1–66.8), with a significant proportion (36.6 %) having mild depression. Multivariable logistic regression analysis showed that being female (aOR = 3.0, 95 % CI (1.7–5.5), P < 0.001), having a family history of mental illness (aOR = 2.5, 95 % CI: 1.3–5.4, P > 0.05), being on retreatment for TB (aOR = 11.2, 95 % CI: 5.2–31.1, P < 0.001), having discontinued treatment (aOR = 8.2, 95 % CI: 1.1–23.3, P < 0.05) and having a HIV/TB co-infection (aOR = 2.5, 95 % CI: 1.2–6.5, P < 0.001) were factors associated with having a higher chance of being depressed.ConclusionOur study suggests that there is a high prevalence of depression among PTB patients, with more than one in two patients affected. Multidisciplinary care for TB patients involving mental health practitioners is highly encouraged, especially for high-risk groups.Electronic supplementary materialThe online version of this article (doi:10.1186/s40249-016-0145-6) contains supplementary material, which is available to authorized users.

Tuberculosis Control Laws in the U.S.-Mexico Border Region: Legal Framework in the United States

Multidrug-resistant tuberculosis (MDR TB), designated by the CDC as a serious threat within the United States, can occur when TB drugs are misused or mismanaged. Examples include when patients do not complete their full course of treatment; when health-care providers prescribe the wrong treatment, the wrong dose, or length of time for taking the drugs; when the supply of drugs is not available; or when the drugs are of poor quality.In the U.S., MDR-TB rates are highest along the U.S.-Mexico border. Populations in this region are mobile. TB patients who live on one side of the border might have their disease diagnosed or treated in the adjacent country; therefore, investigation of close contacts often involves school, work, and social settings on both sides of the border. Laws and governmental practices can impede optimal TB case management even within the U.S., which includes prompt disease diagnosis, close monitoring of medical regimens, adherence to treatment, and identification and evaluation of close contacts. Each of these strategies becomes more difficult when case management must be coordinated among multiple health jurisdictions.The United States-Mexico Border Health Commission (BHC) was created in 2000 to provide international leadership to optimize health and quality of life along the U.S.-Mexico border. Due to its impact in the border region, TB prevention and barriers to TB control are key BHC priorities. To reduce the burden of TB in binational border communities, the BHC facilitates and supports various activities intended to advance cross-border cooperation in TB surveillance, control, education, prevention, and case management.Beginning in 2012, the BHC’s TB Consortium began discussion of legal barriers to continuity of care in the region. This draft legal guide, prepared with support from the Robert Wood Johnson Foundation, discusses legal barriers to continuity of care for TB patients. Not only does drug-resistant tuberculosis present uniquely immigration-driven challenges, it also exposes weaknesses in the U.S. public health system that concern citizens and non-citizens equally.Repatriation of Mexican nationals by U.S. immigration authorities poses distinct issues with respect to continuity of care for bi-national tuberculosis cases. At present, U.S. repatriation policy specifies advance notification to Mexican officials along with transfer of medical records and an initial supply of medication for persons with active cases of tuberculosis. The paper examines current U.S. immigration policy for the treatment and release of such persons, along with the administrative difficulties that can impede continuity of care.

Implementation of a new model for TB-care in a low endemic setting: A challenge in vain?

Aim and objectivesTo evaluate the implementation of an outpatient TB-clinic in a low-endemic setting. BackgroundIn May 2014 the World Health Organization (WHO) approved the post-2015 global tuberculosis (TB) strategy including the plan for elimination of TB in low-endemic countries. Sweden is a low-endemic country, but accepts large numbers of immigrants (e.g. 116,000 in 2013) and a majority from countries where TB is common.In order to prevent TB and ensure accessibility a new outpatient clinic for adults was initiated at a specialist hospital in a suburb of Gothenburg, Sweden, in February 2014. The population living in this suburd is overrepresented among the active cases of TB and in some subgroups the incidence is equal or even higher than in high-endemic countries. The objective is early detection and treatment of active disease and latent TB infection (LTBI) in a social medical perspective. MethodsA descriptive approach made from the experiences of the authors. ResultsThe TB-care in Gothenburg has, before 2014, been centralized to the university hospital. A political decision was taken in 2012, in line with the global TB strategy, to start an outpatient clinic where TB is overrepresented in the population. The decision was to be implemented through collaboration with all healthcare providers. The new clinic was aiming to promote redistribution of patients between the hospitals with an emphasis on accessibility for the patient. The decision was made without the involvement of management and clinical staff. As a result the clinic has solely been able to focus its care on finding LTBI and spreading knowledge and awareness of TB in high-risk groups. ConclusionA new approach of specialist healthcare is decentralization with emphasis on accessibility, improved preventive possibility and knowledge about the setting. This approach is well suited for TB elimination in order to target high-risk groups. The transition does not occur automatically, and commitment and knowledge is needed on every level in the healthcare system. A political basis is necessary, but for success and change the decision has to be established and anchored among management and healthcare staff. To treat TB-patients at an outpatient specialist clinic is economically beneficial and above all causes a positive effect on the patient’s psychosocial well-being and adherence to treatment. Unfortunately, the present infrastructure of TB-care in Sweden, as well as the will and knowledge of the staff to adapt and change according to the political decision, is preventing optimal care for TB-patients based on the global TB strategy for elimination. AcknowledgementNone to declare.

Treatment and care of TB across Europe.

There continues to be profound differences in TB incidences as well as in TB treatment and care across Europe in recent years. High TB incidences are observed in Eastern Europe and especially among injecting drug users (IDUs), and there are large overlaps with a HIV epidemic, which is also far from being under control in this region. Further, mortality rates among HIV-positive patients with TB in Eastern Europe were in the 2000s 3–5 fold higher compared with other parts of Europe. As of 2014, there remain many challenges in the organizational set-up of TB care in Eastern Europe and often only limited possibilities of support for the vulnerable IDU populations, including in particular opioid substitution therapy. Further, high prevalences of multi-drug-resistant TB (MR-TB) are an increasing problem in Eastern Europe which in several settings reached beyond 50% among patients previously treated for TB. Obviously, this causes problems for immediate therapy of the individual patients and for development of secondary resistance during therapy. The panel of TB drugs available in TB clinics in Eastern Europe is often limited, and a quick TB diagnosis and acknowledgement of the resistance pattern to guide initial therapy seems to be a priority. For HIV-positive patients in particular, better access to cART may also be an important tool to reduce the TB incidence among these patients. Thus, treatment and care of TB patients in especially Eastern Europe are facing a variety of diagnostic and therapeutic challenges in the coming years.

Factors influencing integration of TB services in general hospitals in two regions of China: a qualitative study.

BackgroundIn the majority of China, the Centre for Disease Control (CDC) at the county level provides both clinical and public health care for TB cases, with hospitals and other health facilities referring suspected TB cases to the CDC. In recent years, an integrated model has emerged, where the CDC remains the basic management unit for TB control, while a general hospital is designated to provide clinical care for TB patients. This study aims to explore the factors that influence the integration of TB services in general hospitals and generate knowledge to aid the scale-up of integration of TB services in China.MethodsThis study adopted a qualitative approach using interviews from sites in East and West China. Analysis was conducted using a thematic framework approach.ResultsThe more prosperous site in East China was more coordinated and thus had a better method of resource allocation and more patient-orientated service, compared with the poorer site in the West. The development of public health organizations appeared to influence how effectively integration occurred. An understanding from staff that hospitals had better capacity to treat TB patients than CDCs was a strong rationale for integration. However, the economic and political interests might act as a barrier to effective integration. Both sites shared the same challenges of attracting and retaining a skilled workforce for the TB services. The role of the health bureau was more directive in the Western site, while a more participatory and collaborative approach was adopted in the Eastern site.ConclusionThe process of integration identifies similarities and differences between sites in more affluent East China and poorer West China. Integration of TB services in the hospitals needs to address the challenges of stakeholder motivations and resource allocation. Effective inter-organizational collaboration could help to improve the efficiency and quality of TB service. Key words: TB control, service delivery, integration, hospitals, China.