Case Notification Rates Research Articles

A role for community-level socioeconomic indicators in targeting tuberculosis screening interventions

Tuberculosis screening programs commonly target areas with high case notification rates. However, this may exacerbate disparities by excluding areas that already face barriers to accessing diagnostic services. We compared historic case notification rates, demographic, and socioeconomic indicators as predictors of neighborhood-level tuberculosis screening yield during a mobile screening program in 74 neighborhoods in Lima, Peru. We used logistic regression and Classification and Regression Tree (CART) analysis to identify predictors of screening yield. During February 7, 2019–February 6, 2020, the program screened 29,619 people and diagnosed 147 tuberculosis cases. Historic case notification rate was not associated with screening yield in any analysis. In regression analysis, screening yield decreased as the percent of vehicle ownership increased (odds ratio [OR]: 0.76 per 10% increase in vehicle ownership; 95% confidence interval [CI]: 0.58–0.99). CART analysis identified the percent of blender ownership (≤ 83.1% vs > 83.1%; OR: 1.7; 95% CI: 1.2–2.6) and the percent of TB patients with a prior tuberculosis episode (> 10.6% vs ≤ 10.6%; OR: 3.6; 95% CI: 1.0–12.7) as optimal predictors of screening yield. Overall, socioeconomic indicators were better predictors of tuberculosis screening yield than historic case notification rates. Considering community-level socioeconomic characteristics could help identify high-yield locations for screening interventions.

Changes in Nutritional Habits and Lifestyles during the COVID-19 Lockdown Period in Saudi Arabia: A Cross-Sectional Study

The World Health Organization (WHO) declared the coronavirus disease (COVID-19) to be a pandemic in March 2020 due to growing case notification rates worldwide. This study was designed to investigate nutritional habits and lifestyle changes among people living in the Kingdom of Saudi Arabia (KSA) during the COVID-19 lockdown. A cross-sectional study of 208 adults aged 18 to 56 years living in the KSA was conducted between March and May 2020. Participants were identified and invited to complete an online survey. Google Docs forms were used by participants to self-report their nutritional habits, lifestyles, and physical activity levels during the lockdown. Of the 208 participants, 88.9% were female. More than half of the participants (58.1%) reported an increase in their food consumption during the lockdown, which included a higher intake of fast food (47.1%), sweets (48.5%), and fruits and vegetables (49%). 30.8% of participants reported an increase in body weight during the lockdown, while 32.2% reported a decrease. Staying at home or working from home was associated with decreased levels of physical activity in 39% of participants. This study provides the first data on changes in nutritional habits and lifestyles during the COVID-19 quarantine. Our findings suggest that people should decrease their intake of foods that are high in fat and sugar and increase their physical activity levels to maintain a healthy lifestyle.

Do community-based active case-finding interventions have indirect impacts on wider TB case detection and determinants of subsequent TB testing behaviour? A systematic review.

Community-based active case-finding (ACF) may have important impacts on routine TB case-detection and subsequent patient-initiated diagnosis pathways, contributing "indirectly" to infectious diseases prevention and care. We investigated the impact of ACF beyond directly diagnosed patients for TB, using routine case-notification rate (CNR) ratios as a measure of indirect effect. We systematically searched for publications 01-Jan-1980 to 13-Apr-2020 reporting on community-based ACF interventions compared to a comparison group, together with review of linked manuscripts reporting knowledge, attitudes, and practices (KAP) outcomes or qualitative data on TB testing behaviour. We calculated CNR ratios of routine case-notifications (i.e. excluding cases identified directly through ACF) and compared proxy behavioural outcomes for both ACF and comparator communities. Full text manuscripts from 988 of 23,883 abstracts were screened for inclusion; 36 were eligible. Of these, 12 reported routine notification rates separately from ACF intervention-attributed rates, and one reported any proxy behavioural outcomes. Two further studies were identified from screening 1121 abstracts for linked KAP/qualitative manuscripts. 8/12 case-notification studies were considered at critical or serious risk of bias. 8/11 non-randomised studies reported bacteriologically-confirmed CNR ratios between 0.47 (95% CI:0.41-0.53) and 0.96 (95% CI:0.94-0.97), with 7/11 reporting all-form CNR ratios between 0.96 (95% CI:0.88-1.05) and 1.09 (95% CI:1.02-1.16). One high-quality randomised-controlled trial reported a ratio of 1.14 (95% CI 0.91-1.43). KAP/qualitative manuscripts provided insufficient evidence to establish the impact of ACF on subsequent TB testing behaviour. ACF interventions with routine CNR ratios >1 suggest an indirect effect on wider TB case-detection, potentially due to impact on subsequent TB testing behaviour through follow-up after a negative ACF test or increased TB knowledge. However, data on this type of impact are rarely collected. Evaluation of routine case-notification, testing and proxy behavioural outcomes in intervention and comparator communities should be included as standard methodology in future ACF campaign study designs.

The effect of systematic screening of the general population on TB case notification rates.

BACKGROUND: Understanding how TB case notification rates (TB-CNR) change with TB screening and their association with underlying TB incidence/prevalence could inform how they are best used to monitor screening impact.METHODS: We undertook a systematic review to identify articles published between 1 January 1980 and 13 April 2020 on TB-CNR trends associated with TB screening in the general-population. Using a simple compartmental TB transmission model, we modelled TB-CNRs, incidence and prevalence dynamics during 5 years of screening.RESULTS: Of 27,282 articles, seven before/after studies were eligible. Two involved population-wide screening, while five used targeted screening. The data suggest screening was associated with initial increases in TB-CNRs. Increases were greatest with population-wide screening, where screening identified a large proportion of notified people with TB. Only one study reported on sustained screening; TB-CNR trends were compatible with model simulations. Model simulations always showed a peak in TB-CNRs with screening. Following the peak, TB-CNRs declined but were typically sustained above baseline during the intervention. Incidence and prevalence decreased during the intervention; the relative decline in incidence was smaller than the decline in prevalence.CONCLUSIONS: Published data on TB-CNR trends with TB screening are limited. These data are needed to identify generalisable patterns and enable method development for inferring underlying TB incidence/prevalence from TB-CNR trends.

A Randomized Control Trial to Test Effect of Cash Incentives and Training on Active Casefinding for Tuberculosis among Community Health Workers in Nigeria

Background: Case detection for Tuberculosis remains low in high burden communities. Community Health Workers (CHWs) are the first point of contact for many Nigerians in the rural areas and have been found useful in active case finding. This study assessed the effect of cash incentives and training on tuberculosis case detection by CHWs in six Local Government Areas in Nigeria. Materials and Methods: A randomised control trial was conducted in three PHC clusters. The intervention Arm (A) received cash incentives for every presumptive case referred. The Training Arm(B) had no cash incentives and the control had neither training nor cash incentives. Case notification rates from the TB program were used to assess the effect of cash incentives on TB case finding. Data was analyzed using Graph Pad Prism. Descriptive data was presented in tables and bivariate data was analyzed using chi square. Mean increases in case notification rates was calculated Statistical significance was set as P=0.05. Results: The intervention identified 394 presumptive TB cases, contributing 30.3% of all presumptive cases notified in the LGAs. Findings also showed an increase of 14.4% (ꭓ2=2.976, P value=0.2258) in case notification rates for the Arm A that received cash incentives alongside training, there was also an increase of 7.4% (ꭓ2= 1.999, P value=0.1575) in Arm B that received Training only. Secondary outcomes indicated a 144.8%(ꭓ2= 4.147, P value=0.1258) increase in community outreaches conducted in the Arm that were given cash incentives. Conclusion: The study demonstrated an increase in TB control activities of case notification and outreaches among community health workers that received cash incentives and training. These findings support the use training and cash incentives for CHWs in high burden TB settings to improve TB case detection rates.

Resilience of elective cancer surgery systems during COVID-19 lockdowns: an international, multicentre, prospective cohort study

BackgroundSurgery is the main modality of cure for solid cancers and was prioritised to continue during SARS-CoV-2 outbreaks. This study aimed to identify areas for health system strengthening by comparing the delivery of elective cancer surgery during COVID-19 in periods of lockdown versus light restriction. MethodsIn this international, multicentre, prospective cohort study, we enrolled patients with 15 cancer types who had a decision for surgery during the SARS-CoV-2 pandemic (between Jan 21, 2020 and April 14, 2020) to Aug 31, 2020. Any hospital worldwide providing elective cancer surgery was eligible. The primary outcome was the non-operation rate (proportion of patients who did not undergo planned surgery). Reasons for non-operation were classified as COVID-19 related (societal, operational, or personal) or unrelated. Average national Oxford COVID-19 Stringency Index scores were calculated for each patient during their wait for surgery and classified into light restrictions (index <20), moderate lockdowns (20–60), and full lockdowns (>60). Cox proportional-hazards regression models were used to explore associations between lockdowns and non-operation. This study was registered at ClinicalTrials.gov, NCT04384926. FindingsWe enrolled 27 700 participants, of whom 20 006 patients (8526 men and 11480 women) from 466 hospitals and 61 countries did not receive surgery after a minimum of 3-months' follow up (median 23 weeks [IQR 16–30]). All patients had a COVID-19-related reason for non-operation. Light restrictions were associated with a 0·6% reference non-operation rate, moderate lockdowns with a 5·5% rate (HR 0·81, 95% CI 0·77–0·84, p<0·0001), and full lockdowns with a 15·0% rate (0·51, 0·50– 0·53, p<0·0001). In sensitivity analyses, including adjustment for SARS-COV-2 case notification rates, moderate (0·84, 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001) remained independently associated with non-operation. Frail patients with advanced cancer, particularly those from low-income and middle-income countries and those requiring postoperative critical care, were more likely to not have an operation. InterpretationCancer surgery systems worldwide were affected by lockdowns, including in the UK, with one in seven patients not undergoing planned surgery. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which could include protected elective surgical pathways and long-term investment in surge capacity for acute care during public health emergencies. In the UK, a whole-health system approach is required to mitigate against further harm for NHS patients. FundingNational Institute for Health Research (NIHR) Global Health Research Unit, Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, Economic and Social Research Council, European Society of Coloproctology, Medtronic, NIHR Academy, Sarcoma UK, The Urology Foundation, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.

Effect of COVID-19 pandemic lockdowns on planned cancer surgery for 15 tumour types in 61 countries: an international, prospective, cohort study

SummaryBackgroundSurgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction.MethodsThis international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index <20), moderate lockdowns (20–60), and full lockdowns (>60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov, NCT04384926.FindingsOf eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays.InterpretationCancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include protected elective surgical pathways and long-term investment in surge capacity for acute care during public health emergencies to protect elective staff and services.FundingNational Institute for Health Research Global Health Research Unit, Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, Medtronic, Sarcoma UK, The Urology Foundation, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.

Retrospective epidemiological analysis of SARS-CoV-2 wastewater surveillance and case notifications data – New South Wales, Australia, 2020

This epidemiological study analysed SARS-CoV-2 wastewater surveillance and case notifications data to inform evidence-based public health action in NSW. We investigated measures of association between SARS-CoV-2 RNA fragments detected in wastewater samples (n = 100) and case notifications (n = 1,367, as rates per 100,000 population) within wastewater catchment areas (n = 6); and evaluated the performance of wastewater testing as a population-level diagnostic tool. Furthermore, we modelled SARS-CoV-2 RNA fragment detection in wastewater given the case notification rate using logistic regression. The odds of a viral detection in wastewater samples increased by a factor of 5.68 (95% CI: 1.51-32.1, P = 0.004) with rates of one or more notified cases within a catchment. The diagnostic specificity of wastewater viral detection results was 0.88 (95% CI: 0.69-0.97); the overall diagnostic sensitivity was 0.44 (95% CI: 0.33-0.56). The probability of a viral detection result in wastewater exceeded 50% (95% CI: 36-64%) once the case rate within a catchment exceeded 10.5. Observed results suggest that in a low prevalence setting, wastewater viral detections are a more reliable indicator of the presence of recent virus shedding cases in a catchment, than non-detect results are of the absence of cases in a catchment.

Combined assessment of tuberculosis case notification rate and infection control at health facilities of Dale districts, Sidama Zone, Southern Ethiopia.

BackgroundMycobacterium tuberculosis (TB) is the deadliest disease that claims millions of deaths globally. Ethiopia is among the countries heavily hit by the disaster. Despite the effective directly observed treatment and TB infection control (TBIC) measures provided by the world health organization (WHO), the rate of new cases increased daily throughout the country. Healthcare workers (HCWs) are at highest risk serving without having the necessary facility in place while overcrowding of patients exacerbated TB transmission. The study aimed to assess TBIC implementation and analyze case notification rate (CNR) of smear-positive pulmonary TB in the selected health facilities at Dale district, Sidama Zone, Southern Ethiopia.MethodsSeven health care facilities have been visited in the study area and smear-positive pulmonary TB notification rate was determined retrospectively during the years 2012 to 2014. Data on smear positive test results and demographic characteristics were collected from the TB unit registries. A structured questionnaire, facility survey, and observation checklists were used to assess the presence of TBIC plans at the health care facilities.ResultsThe overall case notification rate of smear-positive pulmonary tuberculosis was 5.3% among all 7696 TB suspected patients. The odds of being diagnosed with smear-positive TB were 24% more in males than in females (adj OR = 1.24, 95% CI: (1.22, 1.55). Moreover, in the study area, only 28% of the facilities have been practiced TB infection control and 71% of the facilities assigned a focal person for the TBIC plan. The implementation of environmental control measures in the facilities was ranged between 16–83%. N95 particulate respirators were found only in 14% of the facilities.ConclusionTB CNR in Dale district was low. Moreover, implementations of TBIC in Dale district health facilities were poor when the survey was done. Hence, urgent measures should be taken to reverse the burden of TB.

Analyzing the reach of public health campaigns based on multidimensional aspects: the case of the syphilis epidemic in Brazil

BackgroundPublic health campaigns aim to promote awareness, increase knowledge, and encourage a target population to adopt desirable attitudes and behaviors. Assessing their reach from a multidimensional perspective through information technology can facilitate the development of more effective campaigns in public health response.MethodsWe scrutinized seven data sources from different perspectives to assess a health campaign launched in Brazil named “Syphilis No!”. This campaign is part of an Agenda for strategic actions to reduce syphilis in Brazil which includes dissemination of educommunication materials to remind people of the importance of syphilis prevention, emphasizing “test, treat and cure” concept. We developed a multidimensional analysis framework and implemented an information system to process the data from a time series perspective, and assessed the effects over time, both before and after the campaign. We descriptively analyzed data related to the campaign, including e-news, search engine activity, online courses, serological tests, medication distribution and case notification rates.FindingsRegarding search engine activity, we observed the highest volume of search during the first week of campaigns in 2018 (between November 25th and December 7th). Nevertheless, analyzing this data in a trend plot revealed sustained growth until the end of 2019. From March 2018, the amount of e-news posts related to syphilis in Brazil, indexed by Google, followed an increasing slope, with a record peak in October 2019. In addition, data showed that 12 new online courses related to syphilis disease were available on the AVASUS Platform Learning Management System (LMS), to support efforts to promote lifelong learning for health professionals, teachers, and students. These courses reached more than 22,000 students between February 2019 and September 2020. Serological test data showed that the number of tests carried out in 2019 were 375·18% more than in 2015, even accounting for population growth. Finally, starting from the middle of 2018, the syphilis case notification rates followed a decreasing curve.InterpretationFrom this perspective, the “Syphilis No!” Project was a positive influence, inducing policy to fight syphilis in Brazil by supporting the implementation of a testing, treatment, and cure agenda (#TesteTrateCure). Certainly, this inference was made by analyzing multidimensional aspects and because, prior to 2018, the country had largely neglected this disease, with no records of communication actions during that period.

Testing indicators to monitor the COVID-19 pandemic

Testing indicators to monitor the COVID-19 pandemic

Additional Yield of Active Case Finding Through House Hold Survey in Selected District of Kabul, Afghanistan, 2018

Every year, 10.4 million people get sick with Tuberculosis (TB) and 40 percent of them do not receive treatment care - they are “missed” to identify by the health systems. Missing TB cases is major challenge in fighting the disease; pose a serious threat to global health security. As per World Health organization estimation, in 2018, Afghanistan missed 27 percent TB case notification. Thus we conducted an active case finding through house hold survey from June – November, 2018 in Kabul city, districts of Afghanistan.&#x0D; This descriptive cross sectional study included all the residence of 21 sub-districts in Kabul City Afghanistan. After obtaining written consent, data was collected using a structured questionnaire from all presumptive TB cases. Sputum was collected from eligible participants and tested for AFB, Gene-Xpart and Chest X-ray was done. Standard test algorithm and case categorization was done according to WHO recommendations. Descriptive analysis of demographic, clinical and laboratory data was done.&#x0D; A total of 22,596 participants were included and among them 6740 were eligible. Among them 1614(24.3%) individuals were screened positive to have presumptive TB and 105 (6.5%) had laboratory confirmed TB. Thus the case notification rate was 465 in 100,000 populations. Among the presumptive TB cases, mean age was 38.6 + 18.5 years; 74% were female; 72% were housewives/unemployed; 2.6% were smokers.&#x0D; The case notification rate and the point prevalence showed increase numbers than the actual reports by the Afghanistan National TB program, which signifies the program was missing significant numbers of TB cases. Hence active TB case finding might be an effective approach in terms of case notification in Afghanistan. We recommend extending active community TB surveillance of the country.

Public-Private Mix Implementation and Achievements of Tuberculosis Control Program at Puskesmas in Pekanbaru

Public-Private Mix (PPM) is a strategy implemented in countries with a high burden of tuberculosis, including Indonesia. This study aims to identify PPM implementation at the Puskesmas and the success of the TB control program at the Puskesmas that have implemented the PPM strategy. The research was conducted in 2019 in Pekanbaru Municipality. It was an observational study that collected quantitative and qualitative data. The implementation of PPM was assessed through guided interviews. The success of the Tuberculosis control program was assessed through the Case Notification Rate and Success Rate using secondary data from 2010 to 2017. The results showed that PPM had been implemented in six health centers in Pekanbaru. However, there were obstacles such as a lack of human resources, NGOs, private clinics, and local governments. The Case Notification Rate and Success Rate showed an increasing trend after the PPM implementation. However, these indicators had not yet reached the national target. It can be concluded that PPM in Pekanbaru had been implemented but needed to be improved at all Puskesmas by involving more partnerships and following up on obstacles encountered. Furthermore, the Tuberculosis Control Indicator had shown an increasing trend, but it needed to reach the national target.

V5 Preoperative nasopharyngeal swab testing and postoperative pulmonary complications in patients undergoing elective surgery during the SARS-CoV-2 pandemic

BackgroundSurgical services are preparing to scale up in areas affected by COVID-19. This study aimed to evaluate the association between preoperative SARS-CoV-2 testing and postoperative pulmonary complications in patients undergoing elective cancer surgery.MethodsThis international cohort study included adult patients undergoing elective surgery for cancer in areas affected by SARS-CoV-2 up to 19 April 2020. Patients suspected of SARS-CoV-2 infection before operation were excluded. The primary outcome measure was postoperative pulmonary complications at 30 days after surgery. Preoperative testing strategies were adjusted for confounding using mixed-effects models.ResultsOf 8784 patients (432 hospitals, 53 countries), 2303 patients (26.2 per cent) underwent preoperative testing: 1458 (16.6 per cent) had a swab test, 521 (5.9 per cent) CT only, and 324 (3.7 per cent) swab and CT. Pulmonary complications occurred in 3.9 per cent, whereas SARS-CoV-2 infection was confirmed in 2.6 per cent. After risk adjustment, having at least one negative preoperative nasopharyngeal swab test (adjusted odds ratio 0.68, 95 per cent confidence interval 0.68 to 0.98; P = 0.040) was associated with a lower rate of pulmonary complications. Swab testing was beneficial before major surgery and in areas with a high 14-day SARS-CoV-2 case notification rate, but not before minor surgery or in low-risk areas. To prevent one pulmonary complication, the number needed to swab test before major or minor surgery was 18 and 48 respectively in high-risk areas, and 73 and 387 in low-risk areas.ConclusionPreoperative nasopharyngeal swab testing was beneficial before major surgery and in high SARS-CoV-2 risk areas. There was no proven benefit of swab testing before minor surgery in low-risk areas.

Community-based active case-finding interventions for tuberculosis: a systematic review

SummaryBackgroundCommunity-based active case-finding interventions might identify and treat more people with tuberculosis disease than standard case detection. We aimed to assess whether active case-finding interventions can affect tuberculosis epidemiology in the wider community.MethodsWe did a systematic review by searching PubMed, Embase, Scopus, and Cochrane Library for studies that compared tuberculosis case notification rates, tuberculosis disease prevalence, or tuberculosis infection prevalence or incidence in children, between populations exposed and unexposed to active case-finding interventions. We included studies published in English between Jan 1, 1980, and April 13, 2020. Studies of active case-finding in the general population, in populations perceived to be at high risk for tuberculosis, and in closed settings were included, whereas studies of tuberculosis screening at health-care facilities, among household contacts, or among children only, and studies that screened fewer than 1000 people were excluded. To estimate effectiveness, we extracted or calculated case notification rates, prevalence of tuberculosis disease, and incidence or prevalence of tuberculosis infection in children, and compared ratios of these outcomes between groups that were exposed or not exposed to active case-finding interventions.Results27 883 abstracts were screened and 988 articles underwent full text review. 28 studies contributed data for analysis of tuberculosis case notifications, nine for prevalence of tuberculosis disease, and two for incidence or prevalence of tuberculosis infection in children. In one cluster-randomised trial in South Africa and Zambia, an active case-finding intervention based on community mobilisation and sputum drop-off did not affect tuberculosis prevalence, whereas, in a cluster-randomised trial in Vietnam, an active case-finding intervention based on sputum tuberculosis tests for everyone reduced tuberculosis prevalence in the community. We found inconsistent, low-quality evidence that active case-finding might increase the number of cases of tuberculosis notified in populations with structural risk factors for tuberculosis.InterpretationCommunity-based active case-finding for tuberculosis might be effective in changing tuberculosis epidemiology and thereby improving population health if delivered with high coverage and intensity. If possible, active case-finding projects should incorporate a well designed, robust evaluation to contribute to the evidence base and help elucidate which delivery methods and diagnostic strategies are most effective.FundingWHO Global TB Programme.

The trend of tuberculosis case notification and predictors of unsuccessful treatment outcomes in Samdrup Jongkhar district, Bhutan: A fourteen-year retrospective study

Tuberculosis (TB) continues to be an important public health issue in Bhutan. This study aims to describe the trend of tuberculosis and investigate factors associated with a unsuccessful treatment outcome in Samdrup Jongkhar District in Bhutan.A fourteen-year (2004–2017) case records in two TB centres of Dewathang and Samdrup Jongkhar Hospitals were reviewed and analyzed to examine trends in case notification and treatment outcomes. Univariable and multivariable logistic regression analysis was undertaken to identify covariates of unsuccessful TB treatment.Of the total of 820 TB cases registered in surveillance record, 729 cases were analysed. Males made up 53.8% (397) of total cases and the median age was 29 years (range: 2–87 years). A gradual downward trend in TB case notification was noticed in the district with overall case notification rate of 139/100,000 during the study period. The annual treatment success rate was over 90% except for years 2013–2015 with overall treatment success rate for the study period at 93%. A re-treatment TB patient, sputum-positive at the second month of treatment and being of Indian nationality were significant correlates of unsuccessful treatment outcomes. The overall TB inclidence has declined and TB treatment success rate was above WHO recommended 90% in Samdrup Jongkhar District during the study period. A special attention should be paid to the poor treatment outcome predictors including re-treatment cases and failed sputum conversion at the second month of treatment.

Tuberculosis case notifications in Malawi have strong seasonal and weather-related trends

Seasonal trends in tuberculosis (TB) notifications have been observed in several countries but are poorly understood. Explanatory factors may include weather, indoor crowding, seasonal respiratory infections and migration. Using enhanced citywide TB surveillance data collected over nine years in Blantyre, Malawi, we set out to investigate how weather and seasonality affect temporal trends in TB case notification rates (CNRs) across different demographic groups. We used data from prospective enhanced surveillance between April 2011 and December 2018, which systematically collected age, HIV status, sex and case notification dates for all registering TB cases in Blantyre. We retrieved temperature and rainfall data from the Global Surface Summary of the Day weather station database. We calculated weekly trends in TB CNRs, rainfall and temperature, and calculated 10-week moving averages. To investigate the associations between rainfall, temperature and TB CNRs, we fitted generalized linear models using a distributed lag nonlinear framework. The estimated Blantyre population increased from 1,068,151 in April 2011 to 1,264,304 in December 2018, with 15,908 TB cases recorded. Overall annual TB CNRs declined from 222 to 145 per 100,000 between 2012 and 2018, with the largest declines seen in HIV-positive people and adults aged over 20 years old. TB CNRs peaks occurred with increasing temperature in September and October before the onset of increased rainfall, and later in the rainy season during January-March, after sustained rainfall. When lag between a change in weather and TB case notifications was accounted for, higher average rainfall was associated with an equivalent six weeks of relatively lower TB notification rates, whereas there were no changes in TB CNR associated with change in average temperatures. TB CNRs in Blantyre have a seasonal pattern of two cyclical peaks per year, coinciding with the start and end of the rainy season. These trends may be explained by increased transmission at certain times of the year, by limited healthcare access, by patterns of seasonal respiratory infections precipitating cough and care-seeking, or by migratory patterns related to planting and harvesting during the rainy season.

The Impact of the Evolving Human Immunodeficiency Virus Response on the Epidemiology of Tuberculosis in South African Children and Adolescents.

Few studies have evaluated tuberculosis control in children and adolescents. We used routine tuberculosis surveillance data to quantify age- and human immunodeficiency virus (HIV)-stratified trends over time and investigate the relationship between tuberculosis, HIV, age, and sex. All children and adolescents (0-19 years) routinely treated for drug-susceptible tuberculosis in South Africa and recorded in a de-duplicated national electronic tuberculosis treatment register (2004-2016) were included. Age- and HIV-stratified tuberculosis case notification rates (CNRs) were calculated in four age bands: 0-4, 5-9, 10-14, and 15-19 years. The association between HIV infection, age, and sex in children and adolescents with tuberculosis was evaluated using multivariable logistic regression. Of 719 400 children and adolescents included, 339 112 (47%) were 0-4 year olds. The overall tuberculosis CNR for 0-19 year olds declined by 54% between 2009 and 2016 (incidence rate ratio [IRR] = 0.46; 95% confidence interval [CI], .45-.47). Trends varied by age and HIV, with the smallest reductions (2013-2016) in HIV-positive 0-4 year olds (IRR = 0.90; 95% CI, .85-.95) and both HIV-positive (IRR = .84; 95% CI, .80-.88) and HIV-negative (IRR = 0.89; 95% CI, .86-.92) 15-19 year olds. Compared with 0- to 4-year-old males, odds of HIV coinfection among 15-19 year olds were nearly twice as high in females (adjusted odds ratio [aOR] = 2.49; 95% CI, 2.38-2.60) than in males (aOR = 1.35; 95% CI, 1.29-1.42). South Africa's national response to the HIV epidemic has made a substantial contribution to the observed declining trends in tuberculosis CNRs in children and adolescents. The slow decline of tuberculosis CNRs in adolescents and young HIV-positive children is concerning. Understanding how tuberculosis affects children and adolescents beyond conventional age bands and by sex can inform targeted tuberculosis control strategies.

Spatial-temporal clustering of notified pulmonary tuberculosis and its predictors in East Gojjam Zone, Northwest Ethiopia.

BackgroundTuberculosis (TB) remains a key health menace in Ethiopia and its districts. This study aimed to assess the spatial-temporal clustering of notified pulmonary TB (PTB) cases in East Gojjam Zone, Northwest Ethiopia.MethodsA retrospective study was conducted among all PTB cases reported from 2013–2019. Case notification rates (CNRs) of PTB cases at Kebele (the lowest administrative unit), woreda, and zone levels were estimated. The PTB clustering was done using global Moran’s I statistics on Arc GIS 10.6. We used Kulldorff SaTScan 9.6 with a discrete Poisson model to identify statistically significant spatial-temporal clustering of PTB cases at Kebele level. Similarly, a negative binomial regression analysis was used to identify factors associated with the incidence of PTB cases at kebele level.ResultsA total of 5340 (52%) smear-positive and 4928 (48%) smear-negative PTB cases were analyzed. The overall mean CNR of PTB cases at zone, woreda and Kebele levels were 58(47–69), 82(56–204), and 69(36–347) per 100,000 population, respectively. The purely spatial cluster analysis identified eight most likely clusters (one for overall and one per year for seven reporting years) and 47 secondary clusters. Similarly, the space-time scan analysis identified one most likely and seven secondary clusters. The purely temporal analysis also detected one most likely cluster from 2013–2015. Rural residence, distance from the nearest health facility, and poor TB service readiness were factors (p-value <0.05) to PTB incidence at kebele level.ConclusionThe distribution of PTB cases was clustered. The PTB CNR was low and showed a decreasing trend during the reporting periods. Rural residence, distance from the health facilities, and poor facility readiness were factors of PTB incidence. Improving accessibility and readiness of health facilities mainly to rural and hotspot areas is vital to increase case detection and reduce TB transmission.

High prevalence of pulmonary tuberculosis among female sex workers, men who have sex with men, and transgender women in Papua New Guinea

BackgroundPapua New Guinea (PNG) has a tuberculosis (TB) case notification rate of 333 cases per 100,000 population in 2016 and is one of the 14 countries classified by the World Health Organization (WHO) as “high-burden” for TB, multi-drug-resistant TB (MDR-TB), and TB/HIV. HIV epidemic is mixed with a higher prevalence among key populations, female sex workers (FSW), men who have sex with men (MSM), and transgender women (TGW).MethodsWe conducted a cross-sectional HIV biobehavioral survey (BBS) using respondent-driven sampling method among FSW, MSM, and TGW in Port Moresby, Lae, and Mt. Hagen (2016–2017). As part of the study, participants were screened for the four symptoms suggestive of TB infection using the WHO TB screening algorithm. Sputum and venous whole blood samples were collected and tested for pulmonary TB and HIV infection, respectively. Pulmonary TB testing was performed using GeneXpert®MTB/RIF molecular point-of-care test, and HIV testing was done following the PNG national HIV testing algorithm. All data discussed are weighted unless otherwise mentioned.ResultsAmong FSW, 72.6%, 52.0%, and 52.9% in Port Moresby, Lae, and Mt. Hagen, respectively, experienced at least one symptom suggestive of TB infection. Among MSM and TGW, 69% and 52.6% in Port Moresby and Lae, respectively, experienced at least one symptom suggestive of TB infection. Based on GeneXpert®MTB/RIF results, the estimated TB prevalence rate among FSW was 1200, 700, and 200 per 100,000 in Port Moresby, Lae, and Mt. Hagen, respectively. Among MSM and TGW, the estimated TB prevalence rate was 1000 and 1200 per 100,000 in Port Moresby and Lae, respectively. Co-prevalence of TB/HIV among FSW was 0.1% in Port Moresby and 0.2% in Lae. There were no co-prevalent cases among FSW in Mt. Hagen or among MSM and TGW in Port Moresby and Lae.ConclusionsKey populations have a higher estimated rate of pulmonary TB than the national rate of pulmonary and extra-pulmonary TB combined. This showed that screening key populations for TB should be integrated into HIV programs regardless of HIV status in PNG’s national TB response.