Improve Tuberculosis Case Detection Research Articles

Improving tuberculosis case detection through contact risk stratification by Xpert MTB/RIF Ultra and spatial parameters: Evaluation of an innovative active case finding strategy in Mozambique (Xpatial-TB)

Prompt diagnosis is critical for tuberculosis (TB) control, as it enables early treatment which in turn, reduces transmission and improves treatment outcomes. We investigated the impact on TB diagnosis of introducing Xpert Ultra as the frontline diagnostic test, combined with an innovative active-case finding (ACF) strategy (based on Xpert Ultra semi-quantitative results and spatial parameters), in a semi-rural district of Southern Mozambique. From January-December 2018 we recruited incident TB-cases (index cases, ICs) and their household contacts (HCs). Recruitment of close community contacts (CCs) depended on IC´s Xpert Ultra results, and the population density of their area. TB-contacts, either symptomatic or people living with HIV, were asked to provide a spot sputum for lab-testing. Trends on TB case notification were compared to the previous years and to those of two districts in the south of the Maputo province (control area), using an interrupted time series analysis with and without control (CITS/ITS). A total of 1010 TB ICs (37.1% laboratory-confirmed) were recruited; 3165 HCs and 4730 CCs were screened for TB. Eighty-nine additional TB cases were identified through the ACF intervention (52.8% laboratory-confirmed). The intervention increased by 8.2% all forms of TB cases detected in 2018. Xpert Ultra trace positive results accounted for a high proportion of laboratory confirmations in the ACF cohort (51.1% vs 13.7% of those passively diagnosed). The Number Needed to Screen to find a TB case differed widely among HCs (55) and CCs (153). During the intervention period, a reversal of the previous negative trend in lab-confirmed case notifications was observed in the district. However, the CITS model did not show any statistically significant difference compared to the control area. Paediatric population benefited the most from the ACF strategy and HCs screening seemed an effective intervention to find microbiological confirmed cases in early stages of the disease.

Facilitators and barriers to implementing chest radiography in tuberculosis systematic screening of clinically high-risk groups in Ethiopia: A qualitative study.

Chest X-ray has been included in national tuberculosis screening algorithms as a sensitive tuberculosis screening tool among high-risk groups. However, the implementation was influenced by multiple factors. We aimed to explore facilitators and barriers to implementing chest X-ray in systematic tuberculosis screening of clinically high-risk groups in Addis Ababa, Ethiopia. We conducted face-to-face, in-depth interviews with purposively selected participants at tertiary-level hospitals and a tuberculosis program coordinator at the Ethiopian Ministry of Health, who coordinates chest X-ray-guided systematic tuberculosis screening. A framework analysis was conducted using the consolidated framework for implementation research. We identified 11 constructs that influenced the implementation of the chest X-ray intervention. Facilitators included the relative sensitivity of chest X-ray over symptom-based screening, its potential integration into existing systems, technological advancements in the area, policies and laws supporting the screening intervention, and the quality of the evidence of the screening intervention. Barriers included implementation complexity, high costs of the intervention, knowledge gaps among healthcare providers, training gaps, low priority for chest X-ray screening at the healthcare facility level, and a lack of external support from the Ministry of Health and stakeholders. This study identified contextual factors that influence the implementation of chest X-ray guided systematic tuberculosis screening among clinically high-risk groups that healthcare facilities and health ministries may use for decision-making. Addressing the barriers identified by the study would help to improve the implementation of chest X-rays for improved tuberculosis case detection and prompt treatment in clinically high-risk groups.

Qualitative Analysis of Factors Influencing the Use of DHIS2 for Tuberculosis Surveillance: A Case Study in Guinea

Tuberculosis (TB) is a major public health problem in Guinea, where many cases are undetected and untreated. A robust health information system is needed to improve TB case detection and treatment outcomes. DHIS2 (District Health Information Software 2) is a web-based system that collects, analyses and reports data on TB indicators. However, its use and use in Guinea is affected by various factors. We explored these factors using a qualitative survey with health workers and managers who use DHIS2 for TB surveillance. We collected data through a survey with open-ended questions and analysed them using classical content analysis. We conducted a qualitative survey with 35 health workers and managers who use DHIS2 for TB surveillance at different levels of the health system in Guinea. We collected data through an online survey with open-ended questions and analysed them using classical content analysis with NVivo software. We identified four main themes: technical issues (such as internet connection, data synchronisation, and validation rules), data quality issues (such as data validation, data aberrations, and data completeness), training and support issues (such as data analysis techniques, online training, orientation on DHIS2), and organisational issues (such as integration of community data, standardisation of data elements, meetings for data validation). We discussed how these findings could inform the improvement of DHIS2 for TB surveillance in Guinea and other similar settings. Keywords: DHIS2, Health information system, Surveillance, Tuberculosis, Qualitative study.

Effectiveness of healthcare workers and volunteers training on improving tuberculosis case detection: A systematic review and meta-analysis.

Tuberculosis is the second most common infectious cause of death globally. Low TB case detection remains a major challenge to achieve the global End TB targets. This systematic review and meta-analysis aimed to determine whether training of health professionals and volunteers increase TB case detection. We performed a systematic review and meta-analysis of randomized control trials and non-randomized control trials reporting on the effectiveness of health professionals and volunteers training on TB case detection. We searched PubMed, SCOPUS, Cochrane Library, and reference sections of included articles from inception through to 15 February 2021, for studies published in English. Study screening, data extraction, and bias assessments were performed independently by two reviewers with third and fourth reviewers participating to resolve conflicts. The risk of bias was assessed using the Joanna Briggs Institute (JBI) checklist. Meta-analyses were performed with a random effect model to estimate the effectiveness of training intervention on TB case detection. Of the 2015 unique records identified through our search strategies, 2007 records were excluded following the screening, leaving eight studies to be included in the final systematic review and meta-analysis. The results showed that providing training to health professionals and volunteers significantly increased TB case detection (RR: 1.60, 95% CI: 1.53, 1.66). There was not a significant degree of heterogeneity across the included study on the outcome of interest (I2 = 0.00%, p = 0.667). Providing training to healthcare workers and volunteers can increase TB case detection.

Treatment outcome on pulmonary tuberculosis and extra pulmonary tuberculosis in government general hospital, ongole

Background: Tuberculosis is a global disease leading to cause death worldwide. The Revised National Tuberculosis Control Programme (RNTCP), Directly Observed Treatment Short Course (DOTS), was launched to reduce tuberculosis mortality, improve patient adherence to treatment, and prevent the development of drug resistance. The aim of this study was treatment outcome of tuberculosis. Treatment outcome is an important indication of tuberculosis control programme. Methodology: An ambispective observational study was conducted in a government general hospital from August 2019 to January 2020 on the treatment outcomes of PTB and EPTB in the 15 years and older age group, both males and females, on category I regimens. Patients with comorbidities like HIV, diabetes, and social habits like smoking were included. Record based TB diagnosed data (August 2019 to January 2020) are taken and asses their treatment outcome after 6months of complete therapy. The recorded and collected data were analysed to evaluate the success rate of treatment outcomes for PTB and EPTB. Results: A total of 350 subjects were enrolled in the study, of which 311 are included and 39 are excluded due to incomplete data. The study with age group of 15 and above years where males 218(70.10%) and females 93(29.90%). Total pulmonary tuberculosis cases are 277 (89.07%), and extrapulmonary tuberculosis cases are 34 (10.93%). Subjects with HIV 48(15.43%), Diabetes 54(17.37%) and Tobacco smoking 85(27.33%). The treatment outcome was observed as follows: cured 144 (46.30%), treatment completed 98 (31.51%), transfer out 10 (3.21%), died 27 (8.69%), treatment failure 7 (2.26%), treatment lost to follow-up 14 (4.50%), and treatment regimen changed 11 (3.53%). At the end of the treatment, the success rate was found to be 78%. Conclusion: This study shows that the TB patients' treatment success rate was 78%, which is slightly less than the RNTCP norms. The died rate was 8% which is higher than national average. Perhaps the services need to improve tuberculosis case detection in HIV patients, while cure rates have to be improved in RNTCP. EPTB case enrolment is very low, whereas the referral system has to improve its services. So that EPTB cases enrolment may increase its number. The early detection may enhance the cure rates in patients.

Improving Tuberculosis Case Detection in Children: Summary of Innovations and Findings From 18 Countries.

Despite a growing focus on the plight of tuberculosis (TB) among children, 56% of the 1.2 million children who develop TB annually are not detected and notified. TB REACH is a platform of the Stop TB Partnership that supports innovative interventions to improve TB case detection and preventative treatment. We present summary findings from 27 TB REACH-supported projects in 18 countries. Interventions were designed around intensified case-finding approaches (facility-based systematic screening and contact investigation), capacity building (including decentralized care delivery and supported decision-making), and improving diagnostic methods (ie, introduction of alternative respiratory specimens and new tools to aid the diagnosis). These interventions were evaluated on how they worked to identify children with TB, prevent further transmission of TB among children, and strengthen the health system involved with childhood TB care. Overall, 13 715 children were detected with TB, improving case notifications by 34%. In addition, nearly 5000 eligible contacts were enrolled on TB preventive treatment through these interventions. Focusing efforts and funding on childhood TB can produce marked improvements in case detection.

Interventions to improve linkage along the HIV-tuberculosis care cascades in low- and middle-income countries: A systematic review and meta-analysis.

In support of global targets to end HIV/AIDS and tuberculosis (TB) by 2030, we reviewed interventions aiming to improve TB case-detection and anti-TB treatment among people living with HIV (PLHIV) and HIV testing and antiretroviral treatment initiation among people with TB disease in low- and middle-income countries (LMICs). We conducted a systematic review of comparative (quasi-)experimental interventional studies published in Medline or EMBASE between January 2003-July 2021. We performed random-effects effect meta-analyses (DerSimonian and Laird method) for interventions that were homogenous (based on intervention descriptions); for others we narratively synthesized the intervention effect. Studies were assessed using ROBINS-I, Cochrane Risk-of-Bias, and GRADE. (PROSPERO #CRD42018109629). Of 21,516 retrieved studies, 23 were included, contributing 53 arms and 84,884 participants from 4 continents. Five interventions were analyzed: co-location of test and/or treatment services; patient education and counselling; dedicated personnel; peer support; and financial support. A majority were implemented in primary health facilities (n = 22) and reported on HIV outcomes in people with TB (n = 18). Service co-location had the most consistent positive effect on HIV testing and treatment initiation among people with TB, and TB case-detection among PLHIV. Other interventions were heterogenous, implemented concurrent with standard-of-care strategies and/or diverse facility-level improvements, and produced mixed effects. Operational system, human resource, and/or laboratory strengthening were common within successful interventions. Most studies had a moderate to serious risk of bias. This review provides operational clarity on intervention models that can support early linkages between the TB and HIV care cascades. The findings have supported the World Health Organization 2020 HIV Service Delivery Guidelines update. Further research is needed to evaluate the distinct effect of education and counselling, financial support, and dedicated personnel interventions, and to explore the role of community-based, virtual, and differentiated service delivery models in addressing TB-HIV co-morbidity.

Tuberculosis treatment outcomes and associated factors in two states in Nigeria

To determine the treatment success rate among TB patients and associated factors in Anambra and Oyo, the two states with the largest burden of tuberculosis in Nigeria. A health facility record review for 2016 was conducted in the two states (Anambra and Oyo). A checklist was used to extract relevant information from the records kept in each of the selected DOTS facilities to determine TB treatment success rates. Treatment success rate was defined as the proportion of new smear-positive TB cases registered under DOTS in a given year that successfully completed treatment, whether with bacteriologic evidence of success ('cured') or without ('treatment completed'). Treatment success rate was classified into good (≥85%) and poor (<85%) success rates using the 85% national target for TB treatment outcome. Data were analysed using descriptive statistics and chi-square at P<0.05. There were 1281TB treatment enrollees in 2016 in Anambra and 3809 in Oyo (total=4835). An overall treatment success rate of 75.8% was achieved (Anambra-57.5%; Oyo-82.0%). The percentage cure rates were 61.5% for Anambra and 85.2% for Oyo. Overall, only 28.6% of the facilities in both states (Anambra-0.0%; Oyo-60.0%) had a good treatment success rate. More facilities in Anambra (100.0%) than Oyo (40.0%) had a poor treatment success rate (p<0.001), as did more private/FBO (100.0%) than public health facilities (60.0%) (p=0.009). All tertiary facilities had a poor treatment success rate followed by 87.5% of secondary health facilities and 56.5% of primary healthcare facilities (P=0.035). Treatment success and cure rates in Anambra state were below the 85.0% of the recommended target set by the WHO. Geographical location, and level/tier and type of facility were factors associated with this. Interventions are recommended to address these problems.

Comparison of chest radiographic findings among HIV positive and negative adults with smear positive Pulmonary Tuberculosis in Dar-es-salaam

Background: Chest X-ray radiography is a widely available and cheap imaging modality used for identification of pulmonary tuberculosis (PTB) in suspected patients. Knowledge of discriminatory features of PTB among HIV infected patient is of utmost importance to improve tuberculosis case detection and consequently reduce morbidity and mortality associated with TB among HIV infected individuals. We aimed to describe chest radiographic findings among PTB patients and their association with HIV co-infection and CD4 levels among HIV positive patients.Methodology: A total of 170 newly diagnosed consented smear positive PTB patients underwent postero-anterior Chest radiographs (PA - CXR) and HIV testing. Determination of CD4 count was performed among HIV positive patients. The radiographs were interpreted using glossary of terms for thoracic radiology by two independent radiologists who were blinded to HIV diagnosis.Results: Study participants included 100 (58.9%) males and 70 (41.1%) females. Among these 54 (31.8%) had HIV/PTB co-infection. The pattern of radiographic findings among patients with PTB/HIV compared to PTB only were: pulmonary cavities 44.4% vs 61.2%, (p=0.04), alveolar consolidation 64.9% vs 81.7%, (p=0.04), upper zone consolidation 40.7% vs 57.8%, (p=0.039), middle zone consolidation 25.9% vs 44.8%, (p=0.019) and typical PTB 40.7% vs 57.8%, (p=0.039), respectively. Therefore, lesions were less likely to be observed among PTB/HIV compared to PTB only and the differences were statistically significant. When compared to PTB patients only HIV/PTB co-infected patients had more nodules on the left lung field 85.2% vs 60.9% (p=0.023); on each left lung zone upper 59.3% vs 34.4% (p=0.028); mid 77.8% vs 54.7% (p-value=0.039); lower 66.7% vs 34.4% (p=0.005) and miliary nodules 44.4% vs 15.6% (p=0.003), respectively. HIV/PTB co-infected patients with CD4 &gt; 200 cells/μL had more mid zone consolidation (42.9% vs 15.2%, p=0.024).Conclusion: The commonest chest radiographic findings in HIV/PTB co-infected patients were pulmonary cavities and alveolar consolidation are associated with HIV negative status. HIV/PTB co-infected patients with severe immunosuppression had mid zone consolidation. Patients with severe immunosuppression showed less chest radiographic findings. HIV/PTB co-infection was highly associated with mid and lower zone pulmonary nodules and miliary nodules.&#x0D; Key words: PTB, HIV, CXR

Predictive utility of tuberculosis symptom screening for children and adolescents living with HIV in six high HIV/TB burden countries in eastern and southern Africa.

BACKGROUND: The World Health Organization (WHO) estimates tuberculosis (TB) accounted for 40,000 deaths in children living with HIV in 2017. Early detection and treatment of TB reduces mortality in children and adolescents living with HIV (CALHIV). Despite limited evidence, the WHO recommends that CALHIV are actively screened for TB symptoms at every clinical encounter in order to improve TB case detection. As more CALHIV access care and …

A yield and cost comparison of tuberculosis contact investigation and intensified case finding in Uganda.

IntroductionResource constraints in Low and Middle-Income Countries (LMICs) limit tuberculosis (TB) contact investigation despite evidence its benefits could outweigh costs, with increased efficiency when compared with intensified case finding (ICF). However, there is limited data on yield and cost per TB case identified. We compared yield and cost per TB case identified for ICF and Tuberculosis-Contact Investigation (TB-CI) in Uganda.MethodsA retrospective cohort study based on data from 12 Ugandan hospitals was done between April and September 2017. Two methods of TB case finding (i.e. ICF and TB-CI) were compared. Regarding ICF, patients either self-reported their signs and symptoms or were prompted by health care workers, while TB-CI was done by home-visiting and screening contacts of TB patients. Patients who were presumed to have tuberculosis were requested to produce a sample for examination. TB yield was defined as a ratio of diagnoses to tests, and this was computed per method of diagnosis. The cost per TB case identified (medical, personnel, transportation and training) for each diagnosis method were computed using the activity-based approach, from the health care perspective. Cost data were analyzed using Windows Excel.Results454 index TB cases and 2,707 of their household contacts were investigated. Thirty-one per cent of contacts (840/2707) were found to be presumptive TB cases. A total of 7,685 tests were done, 6,967 for ICF and 718 for TB-CI. The yields were 18.62% (1297/6967) and 5.29% (38/718) for ICF and TB-CI, respectively. It cost US$ 120.60 to diagnose a case of TB using ICF compared to US$ 877.57 for TB-CI.ConclusionThe yield of TB-CI was found to be four-times lower and seven-times costlier compared to ICF. These findings suggest that ICF can improve TB case detection at a low cost, particularly in high TB prevalent settings.

Low Tuberculosis (TB) Case Detection: A Health Facility-Based Study of Possible Obstacles in Kaffa Zone, Southwest District of Ethiopia.

Background In Ethiopia, the national TB case detection rate is becoming improved; still some districts are not able to meet their case detection targets which leads to ongoing spread of TB infections to family members and communities. This study was intended to assess possible obstacles contributing to low TB case detection in Kaffa zone, Southwest Ethiopia. Methods A cross-sectional descriptive study involving qualitative and quantitative data was conducted from Mar. to Sep. 2019. Sociodemographic characteristics and data on duration of cough, whether sputum smear microscopy was requested or not, and data on TB knowledge and health care-seeking practice were collected from outpatients. Health care delivery barrier for TB case detection was also explored by using in-depth interview and FGD of health staff. Results From 802 outpatients with coughing for 2 or more weeks of duration, 334 (41.6%) of them were not requested to have TB microscopic diagnosis. Of these, 11/324 (3.4%) of them were positive for TB after sputum smear microscopy. Only 24.2% of the outpatients were aware as they have had health education on TB disease. Twenty-eight percent of patients perceived that TB was due to exposure to cold air, and 13.5% could not mention any sign or symptom of TB. Amazingly, 54.2% of them did not have any information as current TB diagnosis and treatment is free. Thirty-five percent of the patients were taking antibiotics before visiting the health facility. The interrupted supply of TB diagnostic reagents, frequent electricity interruption, shortage of trained TB care providers, weak health information system, and weak active case finding practice were explored as the factors contributing to low TB case detection. Conclusion Interrupted functioning of diagnostic centers, shortage of trained care providers, limited active TB case finding practice, weak health information system, and inadequate knowledge and health care-seeking practice of the patients were identified as contributors for low TB case detection. Thus, improving functioning of diagnostic centers, active TB case finding activities, and expanding health education on TB disease will help to improve TB case detection in the districts.

An evaluation of a tuberculosis case-finding and treatment program among Syrian refugees\u2014Jordan and Lebanon, 2013\u20132015

BackgroundThe displacement crisis in Syria poses challenges for tuberculosis (TB) control across the region. Since 2012 in Jordan and 2013 in Lebanon, the International Organization for Migration (IOM) has supported the National TB Program (NTP) in detecting and treating TB among Syrian refugees. In December 2016, IOM asked US Centers for Disease Control and Prevention (CDC) staff to evaluate its program of support to Jordan and Lebanon’s NTPs for TB control among Syrian refugees. This manuscript focuses on case-finding, including contact investigations, and treatment components of the IOM program during 2013–2015 in Jordan and 2015 in Lebanon.MethodsThe evaluation consisted of a retrospective review of de-identified Jordan and Lebanon line lists of TB cases and of investigated contacts (Lebanon only). Syrian refugee TB cases were categorized by sex, age group (age < 5 years, 5–14 years, ≥15 years), TB type (pulmonary versus extra-pulmonary), and additionally in Jordan, by refugee camp status (residence in versus outside a refugee camp), to evaluate differences in treatment completion and contact investigation.ResultsIn Jordan, Syrian refugee cases represented 24.4% of TB cases in 2013, when Syrian refugees made up 6.8% of the country’s population, and 13.8% of TB cases in 2015, when Syrians made up 8.3% of the total population. In Lebanon in 2015, Syrian refugee cases represented 21.4% of TB cases, when Syrians made up 20.1% of the total population. In Jordan, the proportion of Syrian TB cases residing in refugee camps (29.3%) was higher than the proportion of Syrians refugees residing in camps (17.1%). Of Syrian TB cases in 2015, 94.8% in Jordan and 87.8% in Lebanon completed treatment. In Lebanon, among Syrian TB cases with household contacts listed, contact investigation was completed for 77.8% of cases.ConclusionIOM’s program of NTP support provides critical TB services for Syrian refugees with high treatment completion rates. More community and health practitioner outreach for enhanced active case finding among community-based Syrian refugees in Jordan may improve TB case detection in populations outside of refugee camps. Thorough contact investigations need continued emphasis, including completely recording investigations in both countries, to find active TB cases.

Tuberculosis case detection by trained inmate peer educators in a resource-limited prison setting in Ethiopia: a cluster-randomised trial

To improve tuberculosis case detection, interventions that are feasible with available resources are needed. We investigated whether involving trained prison inmates in a tuberculosis control programme improved tuberculosis case detection, shortened pre-treatment symptom duration, and increased treatment success in a resource-limited prison setting in Ethiopia. In this cluster-randomised trial we randomly assigned prisons in the regions Amhara and Tigray of Ethiopia to an intervention group or a control group, after matching them into pairs based on their geographical proximity and size. Larger prisons were considered eligible whereas smaller prisons were excluded. We selected three to six prison inmates in each intervention prison. The recruited prison inmates who received a 3-day training course and were capable of identifying presumptive tuberculosis cases then provided health education to all other prison inmates about tuberculosis prevention and control every 2 weeks for 1 year. They also actively searched for symptomatic prison inmates and undertook routine symptom-based tuberculosis screening. The control prisons followed the existing passive case finding system. The primary outcome was the mean case detection rate at the end of the year, measured at cluster (prison) level. This trial is registered at ClinicalTrials.gov, number NCT02744521. We randomly assigned 16 prisons with a total population of 18 032 inmates to either the intervention group (n=8) or the control group (n=8) from April 1, 2016, to March 31, 2017. During the 1-year study period, 75 new tuberculosis cases (1% of 8874 total inmates) were detected in the intervention prisons and 25 new cases (<1% of 9158 total inmates) were detected in the control prisons. The mean case detection rate was significantly higher in the intervention group than in the control group (mean difference 52·9 percentage points, 95% CI 17·5-88·3, p=0·010). Involving trained inmate peer educators in the tuberculosis control programme in Ethiopian prisons significantly improved the tuberculosis case detection rate. The findings have important implications for clinical and public health policy, particularly in prisons of low-income countries where tuberculosis burden is high and the recommended tuberculosis diagnostic and treatment algorithms have generally not been implemented. Nuffic, Mekelle University.

A Spatial Analysis Framework to Monitor and Accelerate Progress towards SDG 3 to End TB in Bangladesh

Global efforts to end the tuberculosis (TB) epidemic by 2030 (SDG3.3) through improved TB case detection and treatment have not been effective to significantly reduce the global burden of the TB epidemic. This study presents an analytical framework to evaluate the use of TB case notification rates (CNR) to monitor and to evaluate TB under-detection and under-diagnoses in Bangladesh. Local indicators of spatial autocorrelation (LISA) were calculated to assess the presence and scale of spatial clusters of TB CNR across 489 upazilas in Bangladesh. Simultaneous autoregressive models were fit to the data to identify associations between TB CNR and poverty, TB testing rates and retreatment rates. CNRs were found to be significantly spatially clustered, negatively correlated to poverty rates and positively associated to TB testing and retreatment rates. Comparing the observed pattern of CNR with model-standardized rates made it possible to identify areas where TB under-detection is likely to occur. These results suggest that TB CNR is an unreliable proxy for TB incidence. Spatial variations in TB case notifications and subnational variations in TB case detection should be considered when monitoring national TB trends. These results provide useful information to target and prioritize context specific interventions.

Variability in distribution and use of tuberculosis diagnostic tests in Kenya: a cross-sectional survey

BackgroundGlobally, 40% of all tuberculosis (TB) cases, 65% paediatric cases and 75% multi-drug resistant TB (MDR-TB) cases are missed due to underreporting and/or under diagnosis. A recent Kenyan TB prevalence survey found that a significant number of TB cases are being missed here. Understanding spatial distribution and patterns of use of TB diagnostic tests as per the guidelines could potentially help improve TB case detection by identifying diagnostic gaps.MethodsWe used 2015 Kenya National TB programme data to map TB case notification rates (CNR) in different counties, linked with their capacity to perform diagnostic tests (chest x-rays, smear microscopy, Xpert MTB/RIF®, culture and line probe assay). We then ran hierarchical regression models for adults and children to specifically establish determinants of use of Xpert® (as per Kenyan guidelines) with county and facility as random effects.ResultsIn 2015, 82,313 TB cases were notified and 7.8% were children. The median CNR/100,000 amongst 0-14yr olds was 37.2 (IQR 20.6, 41.0) and 267.4 (IQR 202.6, 338.1) for ≥15yr olds respectively. 4.8% of child TB cases and 12.2% of adult TB cases had an Xpert® test done, with gaps in guideline adherence. There were 2,072 microscopy sites (mean microscopy density 4.46/100,000); 129 Xpert® sites (mean 0.31/100,000); two TB culture laboratories and 304 chest X-ray facilities (mean 0.74/100,000) with variability in spatial distribution across the 47 counties. Retreatment cases (i.e. failures, relapses/recurrences, defaulters) had the highest odds of getting an Xpert® test compared to new/transfer-in patients (AOR 7.81, 95% CI 7.33-8.33). Children had reduced odds of getting an Xpert® (AOR 0.41, CI 0.36-0.47). HIV-positive individuals had nearly twice the odds of getting an Xpert® test (AOR 1.82, CI 1.73-1.92). Private sector and higher-level hospitals had a tendency towards lower odds of use of Xpert®.ConclusionsWe noted under-use and gaps in guideline adherence for Xpert® especially in children. The under-use despite considerable investment undermines cost-effectiveness of Xpert®. Further research is needed to develop strategies enhancing use of diagnostics, including innovations to improve access (e.g. specimen referral) and overcoming local barriers to adoption of guidelines and technologies.

Prospects for Tuberculosis Elimination in the United States: Results of a Transmission Dynamic Model.

We estimated long-term tuberculosis (TB) trends in the US population and assessed prospects for TB elimination. We used a detailed simulation model allowing for changes in TB transmission, immigration, and other TB risk determinants. Five hypothetical scenarios were evaluated from 2017 to 2100: 1) maintain current TB prevention and treatment activities (base case); 2) provision of latent TB infection testing and treatment for new legal immigrants; 3) increased uptake of latent TB infection screening and treatment among high-risk populations, including a 3-month isoniazid-rifapentine regimen; 4) improved TB case detection; and 5) improved TB treatment quality. Under the base case, we estimate that by 2050, TB incidence will decline to 14 cases per million, a 52% (95% posterior interval (PI): 35, 67) reduction from 2016, and 82% (95% posterior interval: 78, 86) of incident TB will be among persons born outside of the United States. Intensified TB control could reduce incidence by 77% (95% posterior interval: 66, 85) by 2050. We predict TB may be eliminated in US-born but not non-US-born persons by 2100. Results were sensitive to numbers of people entering the United States with latent or active TB, and were robust to alternative interpretations of epidemiologic evidence. TB elimination in the United States remains a distant goal; however, strengthening TB prevention and treatment could produce important health benefits.

Improving tuberculosis case detection in underdeveloped multi-ethnic regions with high disease burden: a case study of integrated control program in China

BackgroundIn the underdeveloped multi-ethnic regions of China, high tuberculosis (TB) burden and regional inequity in access to healthcare service increase the challenge of achieving the End TB goals. Among all the provinces, the highest TB burden is reported in Xinjiang, where ethnic minorities and older people have suffered most. However, current case-finding strategy is inadequate given the complex social determinants and suboptimal case detection rates. Thus, we developed an integrated TB control program to improve case detection and conducted a pilot in Xinjiang from 2014 to 2015. In this case study, we summarized the activities and key findings. We also shared the experiences and challenges of implementing interventions and provided recommendations to inform the TB control program in the future.Case presentationThe pilot interventions were implemented in one selected town in Yining based on local TB control programs. By applying tailor-made educational materials, outreach TB educational activities were conducted in diverse ways. In 22 Masjids, the trained imams promoted TB education to the Muslims, covering 20,440 person-times in 88 delivered preaching sessions. In seven schools, 1944 students were educated by the teachers and contributed to educating 6929 family members. In the village communities, 13,073 residents participated in household education and screening. Among them, 12,292 people aged under 65 years were investigated for suspicious pulmonary TB symptoms, where six TB patients were diagnosed out of 89 TB suspects; 781 older people were mobilized for screening directly by chest X-ray, where 10 patients were diagnosed out of 692 participants. Supportive healthcare system, multi-sectoral cooperation and multi-channel financing mechanism were the successful experiences of implementation. The interventions were proved to be more effective than the previous performance: the number of TB suspects consulting doctors and patients detected increased by 50% and 26%, respectively. The potential challenges, implications and recommendations should been taken into account for further program improvement.ConclusionsIn underdeveloped multi-ethnic regions with high TB burden, improving case detection is necessary and the interventions can be feasible and effective within a supportive system. More intensive educational and training approaches, a high index of TB suspicion and prioritization of older people in screening are recommended. To sustain and scale up the program, the impacts, cost-effectiveness, feasibility and acceptability of interventions warrant further research and evaluation in each specific context.

An evaluation of innovative community-based approaches and systematic tuberculosis screening to improve tuberculosis case detection in Ebonyi State, Nigeria

National tuberculosis (TB) programmes globally rely heavily on passive case finding for detecting TB in the community as advocated by the World Health Organization (WHO). TB case detection is low in Nigeria despite improvement in TB services and coverage. A retrospective evaluation of an active case-finding intervention utilizing community-based approaches and targeted systematic TB screening in Ebonyi State, Nigeria was done. The analysis was performed using Epi Info. Using community-based and health-facility-based systematic screening strategies, 218,751 persons were screened, with 19.7% of them being presumptive TB cases. Among these, 23,729 (55.1%) submitted sputum samples for microscopy, and 764 (3.2%) had smear-positive TB. In addition, 683 individuals were diagnosed with other forms of TB using X-ray and clinical evaluation giving a total of 1447 all forms of TB cases. The overall number needed to screen (NNS) to find one person with all forms of TB through the project was 151. The NNS was 53 for general outpatients, 88 through contact tracing, and 110 among HIV-infected persons. Active case-finding strategies achieved good yields though early loss to follow-up was high. Active case finding is recommended for integration into national TB control policy and practice.

Household Contact Screening and Yield of Tuberculosis Cases-A Clinic Based Study in Chennai, South India.

BackgroundContact investigation is an active case finding strategy to increase detection of Tuberculosis (TB) and a key component of TB control programs. The household contacts are at a higher risk of exposure than members of the general population. The information on the value and yield of household contact screening and the approaches used in high incidence settings like India is limited.ObjectiveTo evaluate the yield of active case finding in household contacts of newly diagnosed smear positive TB patients and the factors associated with increased yield.MethodRetrospective record review of the household contacts of newly diagnosed sputum smear positive patients (index case) enrolled in a clinical trial at National Institute of Research in Tuberculosis, Chennai during the period 2007–2014. A sequential screening algorithm with chest x-ray followed by symptom screen was employed to identify presumptive TB patients.Results643 household contacts of 280 index TB patients were identified out of which 544 (85%) consented for screening. 71/544 (13%) patients had an abnormal chest radiograph and out of them 70% were symptomatic. A total of 29/544 (5.3%) contacts were found to have TB among whom 23/29 (79%) were sputum smear positive. The number needed to screen (NNS) to identify a new TB case among all household contacts was 19 and among those with an abnormal CXR was 02. Age group > 44 years, male gender and siblings of the index case was associated with abnormal chest radiograph whereas age group between 15–44 was significantly associated with developing TB disease among household contacts.ConclusionActive screening among household contacts is an effective way to improve TB case detection. The yield for new TB cases among contacts with abnormal x-ray was high in this study and the use of Chest X-rays in combination with symptom screen is recommended.