National Tuberculosis Programme Guidelines Research Articles

A mixed-methods study on impact of silicosis on tuberculosis treatment outcomes and need for TB-silicosis collaborative activities in India

Globally, silicosis and tuberculosis (TB) have been targeted for elimination by 2030. The study’s objectives were to determine the association of silicosis with unfavorable TB treatment outcomes, as well as to explore experts’ perspectives on improving treatment outcomes among silico-tuberculosis patients. A retrospective cohort study evaluated TB treatment outcomes in Khambhat block, the western part of India, between 138 patients with silico-tuberculosis and 2610 TB patients without silicosis in February–March 2022. ‘Unfavorable TB treatment outcomes’ was defined as a patient stopping treatment for at least one month, a positive sputum smear at the end of treatment, or, a patient dying while on treatment. During April–July 2022, fifteen in-depth interviews with experts in the field of silicosis/tuberculosis were audio-recorded, transcribed, and analyzed to generate codes (thematic analysis). On multivariable logistic regression analysis, patients with silico-tuberculosis had a 2.3 (95% CI 1.6–3.4) times higher odds of unfavorable treatment outcomes. The experts recommended collaborative TB-silicosis activities for improving treatment outcomes of patients with silico-tuberculosis. I conclude from the study’s findings that silicosis is associated with unfavorable TB treatment outcomes in this study setting. All patients with silicosis should be screened for TB and treated according to national TB program guidelines. All patients with TB who have a history of occupational dust exposure should be evaluated for silicosis and provided appropriate pulmonary/vocational rehabilitation.

Active Case Finding for Tuberculosis among Health Care Workers in a Teaching Hospital, Puducherry, India.

Health care workers (HCWs) are at risk of acquiring tuberculosis (TB) infection and disease due to occupational exposure. But there are no national guidelines on routine screening for TB (active case finding (ACF)) among HCWs and understand its implementation and feasibility. This study was conducted among HCWs in a teaching hospital in India. We used symptom screening to identify those with presumptive TB and were further evaluated for diagnosis of TB. A total of 1,001 HCWs were screened over a period of 18 months. In our study, 51 (5.1%) HCWs were found to have presumptive TB and on further evaluation, 5 (0.5%) of these patients were diagnosed with active TB. The number needed to screen (NNS) for one active TB among the HCWs was 200. Alcohol use was significantly associated with both presumptive TB (P = 0.037) and active TB (P = 0.035) among HCWs, and exposure to active TB patients (P = 0.014) in the family and workplace and increased frequency of exposures (P = <0.001) were associated with presumptive TB. ACF for TB among HCWs had a good yield in our study. ACF utilizing routine national TB program guidelines is feasible to be implemented among HCWs to aid in the early diagnosis and treatment of TB in this high-risk group.

Protocol for a randomised controlled trial to evaluate the effectiveness of improving tuberculosis patients\u2019 treatment adherence via electronic monitors and an app versus usual care in Tibet

BackgroundTreatment non-adherence is a serious challenge to effective tuberculosis (TB) control in Tibet. In this study we will pilot and evaluate the effectiveness of using new electronic monitors (e-monitors) and a smartphone app to improve treatment adherence among new pulmonary TB patients in Tibet.MethodsWe will use a multicentre, parallel-group, individually randomised controlled, superiority trial with blinded outcome evaluation and unblinded treatment. We will randomise new pulmonary TB outpatients (aged ≥ 15 years old and free from communication impairment) from Shigatse, Tibet to either the intervention or control arm in a 1:1 ratio at the time of their diagnosis. All patients will be treated according to the World Health Organisation standard 6-month TB treatment regimen and the China National TB programme guidelines. Intervention arm patients will be given their medication via e-monitors that have automatic voice reminders, and record medication adherence data and share it with health staff via Cloud connection. Intervention patients will also be encouraged to receive smartphone-based video-observed treatment if their adherence is problematic. Control arm patients will receive their medication in e-monitors that will collect medication adherence history, but will have their reminder function deactivated and are not linked to the app. The primary outcome is the rate of poor adherence, measured monthly during treatment as a binary indicator where poor adherence means missing ≥ 20% of doses in a month. We will conduct a qualitative process evaluation to explore operational questions regarding acceptability, cultural appropriateness and burden of technology use, as well as a cost-effectiveness analysis and an analysis of the long-term effects of the intervention on TB control.DiscussionOur study is one of the first trials to evaluate the use of e-monitors and smartphone apps for customised treatment support in low- and middle-income countries (LMICs). All intervention activities are designed to be embedded into routine TB care with strong local ownership. Through the trial we intend to understand the feasibility of our intervention, its effectiveness, its cost-effectiveness and its long-term impacts to inform future scale-up in remote areas of China and other LMICs.Trial registrationCurrent Controlled Trials, ID: ISRCTN52132803. Registered on 9 November 2018.

Time to Drug-Resistant Tuberculosis Treatment in a Prospective South African Cohort.

This study examined time to treatment initiation by age among a prospective cohort with drug-resistant tuberculosis (DR-TB). Participants aged 13 years or older nested within a cluster-randomized trial in 2 South African provinces were evaluated. Outcomes were treatment initiation within 5 days of DR-TB diagnosis (National Tuberculosis Program guidelines) and days from diagnosis to treatment. A total of 521 participants met inclusion criteria. Eighty-two patients (16%) met national guidelines; median time to treatment was 11 days (range = 0-180). No patient (age, sex, prior TB history, HIV status) or health system characteristics (geographic urban/rural location, province) were associated with treatment initiation per guidelines except geographic location (t = 3.64, degrees of freedom = 1, P = .0003). One in 6 individuals with DR-TB received treatment per guidelines, and average time to treatment was 11 days. Strategies are needed to decrease treatment delays and meet the recommended guidelines for treatment for patients of all ages.

High Sensitivity C-Reactive Protein (hsCRP) as a Biomarker of Treatment Response After the Intensive Phase Among Pediatric Patients With TB

SESSION TITLE: Pediatrics SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM PURPOSE: Childhood tuberculosis has an increasing incidence worldwide. Its occurrence represents an important event indicating a recent transmission usually from an infectious adult. The identification of a surrogate biomarker for treatment response and risk for poor outcome in tuberculosis will be a beneficial tool in the patient’s management. Thus, a biomarker like high sensitivity C-reactive protein (hsCRP) was proposed to be a prognostic marker in this study. METHODS: Children diagnosed with tuberculosis based on the Philippine Pediatric Society and National Tuberculosis Program guidelines were included in the study. Clinical data were reviewed and recorded, and blood samples were collected for serum hsCRP determination at 2 point of time (before treatment, and after the intensive phase). Data analysis was done using Stata SE version 12. Mean, standard deviation, frequency, percent distribution, paired T test and scatter plot were used. The level of significance is set at 0.05. RESULTS: There were 40 subjects diagnosed with pulmonary tuberculosis who participated the study. Twenty-three were male (57.5%) and 17 were female (42.5%). The age ranges from 1 to 18 years with a mean age of 8.6 + 5.5. Out of the 40 participants, 32 had completed the study. In this study, the analysis of data showed that the level of serum hsCRP after the intensive phase of treatment is significantly lower compared to the level before treatment (p value of 0.0002). On the other hand, body mass index (BMI), which is being used as one of the objective parameters of treatment response in children, demonstrated a statistically significant difference before and after the intensive phase at a p value of 0.0007. High sensitivity C-reactive protein and BMI were indirectly correlated, however, it was statistically insignificant before and after 2 months of treatment at p value of 0.26 and 0.35, respectively. CONCLUSIONS: This study has shown that there is a statistically significant lower serum hsCRP level and statistically significant improvement in BMI after the intensive phase of treatment among pediatric patients with tuberculosis, however, there is a weak indirect correlation between the 2 parameters. It is the therefore concluded that hsCRP can only be an additional tool to evaluate treatment response after the intensive phase of therapy. CLINICAL IMPLICATIONS: It is important for the clinicians to have good monitoring parameters on treatment efficacy in patients with tuberculosis. The inability to do so will contribute to the poor outcome and continued disease transmission. DISCLOSURE: The following authors have nothing to disclose: Annalee de Leon-Manalo, Ma. Dulce Requiron-Sy, Maria Encarnita Limpin No Product/Research Disclosure Information

'That's when I struggle' … Exploring challenges faced by care givers of children with tuberculosis in Botswana.

Government-funded public health clinics in and around Gaborone, Botswana. To explore the challenges faced by care givers of children on treatment for tuberculosis (TB) to inform a more child-friendly approach to Botswana's National TB Programme (NTP) strategy. Qualitative study using 28 in-depth interviews with care givers of children receiving anti-tuberculosis treatment. Care givers identified five main challenges: long delays in their child's diagnosis, difficulty attending clinic for daily treatment, difficulty administering TB medications, stock-outs of TB medications leading to treatment interruptions, and inadequate TB education. Care givers prioritized these same five areas to improve the overall management of their child's TB. Our findings suggest that despite accessing care through an NTP that adheres to World Health Organization guidelines, care givers for children on treatment in Botswana continue to encounter significant challenges. While each of these represents a potential threat to successful treatment, they can be addressed with relatively small systematic and programmatic adjustments. These results will inform the next version of the Botswana NTP guidelines towards a more child- and care giver-centered approach.

Diagnosis of smear-negative tuberculosis in Nigeria: Do health care workers adhere to the national guidelines?

ObjectiveThe study sought to assess the extent to which healthcare workers (HCWs) adhere to the National Tuberculosis Program (NTP) guidelines for the diagnosis of smear negative tuberculosis in Nigeria. MethodThis was a cross-sectional retrospective desk analysis of case files of 280 smear negative pulmonary TB in six States in southern Nigeria. ResultsAbout 93% of the 280 patients had their first set of sputum smear microscopy tests done, but only 3.6% had the second set of diagnostic tests as prescribed by the NTP guidelines. Only 45.7% (128/280) received broad spectrum antibiotics after their first smear microscopy. 98% had a chest X-ray done, while 93.6% (262/280) had HIV counseling and testing (HCT), out of which 45.0% were HIV positive. Overall, only 2 patients (0.7%) were diagnosed in strict compliance with the NTP guidelines. There was no significant difference in the pattern of diagnosis of smear negative TB cases and smear positive TB cases. ConclusionThe adherence of HCWs to the NTP guidelines for diagnosis of smear negative TB is apparently sub-optimal and needs improvement.

Quality of Tuberculosis Care in Private Health Facilities of Addis Ababa, Ethiopia

Ensuring provision of good quality tuberculosis (TB) care, especially in private for profit health facilities, is an important component of TB control strategy to reduce poor medical practice which results in multidrug resistant TB (MDR-TB). The aim of this study was to investigate quality of TB care in private health facilities of Addis Ababa. A facility based cross-sectional study was conducted based on Donabedian's structure-process-outcome model of health care quality. Quality of care was determined by adherence to National TB Program guidelines, treatment success rate, and client satisfaction. Exit interview was conducted on 292 patients on the intensive phase of treatment and 384 patient records were reviewed in eight private health facilities. Initial diagnostic AFB test was done for 95.4% of pulmonary TB patients. Most important components of TB care recommended by national guidelines were delivered for a significant proportion of patients. Majority (75%) of the clients were found to be satisfied with each component of TB care. The treatment success rate was 90.9%. The quality of TB care was fairly good. However, only 77.7% of the patients were counseled for HIV testing. Strengthening HIV counseling and testing, tackling shortage of streptomycin and laboratory reagent at private TB clinic is crucial.

Advances in tuberculosis diagnostics: the Xpert MTB/RIF assay and future prospects for a point-of-care test

Rapid progress has been made in the development of new diagnostic assays for tuberculosis in recent years. New technologies have been developed and assessed, and are now being implemented. The Xpert MTB/RIF assay, which enables simultaneous detection of Mycobacterium tuberculosis (MTB) and rifampicin (RIF) resistance, was endorsed by WHO in December, 2010. This assay was specifically recommended for use as the initial diagnostic test for suspected drug-resistant or HIV-associated pulmonary tuberculosis. By June, 2012, two-thirds of countries with a high tuberculosis burden and half of countries with a high multidrug-resistant tuberculosis burden had incorporated the assay into their national tuberculosis programme guidelines. Although the development of the Xpert MTB/RIF assay is undoubtedly a landmark event, clinical and programmatic effects and cost-effectiveness remain to be defined. We review the rapidly growing body of scientific literature and discuss the advantages and challenges of using the Xpert MTB/RIF assay in areas where tuberculosis is endemic. We also review other prospects within the developmental pipeline. A rapid, accurate point-of-care diagnostic test that is affordable and can be readily implemented is urgently needed. Investment in the tuberculosis diagnostics pipeline should remain a major priority for funders and researchers.

Eliminating the category II retreatment regimen from national tuberculosis programme guidelines: the Georgian experience

The category II retreatment regimen for management of tuberculosis in previously treated patients was first introduced in the early 1990s. It consists of 8 months of total therapy with the addition of streptomycin to standard first-line medications. A review of 6500 patients on category II therapy in Georgia showed poor outcomes and high rates of streptomycin resistance. The National Tuberculosis Program used an evidence-based analysis of national data to convince policy-makers that category II therapy should be eliminated from national guidelines in Georgia. The World Health Organization tuberculosis case-notification rate in Georgia is 102 per 100,000 population. All patients receive culture and drug susceptibility testing as a standard part of tuberculosis diagnosis. In 2009, routine surveillance found multidrug-resistant tuberculosis in 10.6% of newly diagnosed patients and 32.5% of previously treated cases. Category II retreatment regimen is no longer used in Georgia. Treatment is guided by results of drug susceptibility testing--using rapid, molecular tests where possible--for all previously treated tuberculosis patients. There was little resistance to policy change because the review was initiated and led by the National Tuberculosis Program. This experience can serve as a successful model for other countries to make informed decisions about the use of category II therapy.

Medical interns' knowledge of tuberculosis and DOTS strategy in northern Islamic Republic of Iran.

The increasing incidence of tuberculosis (TB) is a major concern to public health policy-makers. To assess knowledge about TB and the DOTS strategy among medical students in a high incidence area of the Islamic Republic of Iran, a questionnaire designed around the national TB programme guidelines was given to 80 interns in Golestan and Mazandaran medical schools in December 2007. The overall mean knowledge score was 1.80 (SD 1.61) items correct out of 15. Knowledge about diagnosis, treatment and monitoring was especially poor. There were no significant differences between the knowledge of interns who had completed their internships in the infectious diseases or community health departments compared with those who had not.

Public‐Private Partnership for TB Control in Bangladesh: Role of Private Medical Practitioners in the Management of TB Patients

AbstractBackground: Despite enormous efforts, Bangladesh has one of the highest burdens of tuberculosis (TB) in the world. Treatment in the private sector is common and popular among TB patients in South‐Asian countries, including Bangladesh, even though the quality of diagnosis and treatment of TB patients has been shown to be poor in several such countries. The Bangladesh National Tuberculosis Programme (NTP) has recently shown considerable interest in exploring policy options to address this problem. Consequently, the NTP and Non‐Governmental Organisation (NGO) partners planned to develop a public‐private partnership (PPP) model for effective involvement of private medical practitioners (PMPs) in TB control. However, there was a lack of solid data on TB case management practice by PMPs which was needed to appraise the potential role and contribution of PMPs in TB control. The purpose of the study is therefore to assess the knowledge, attitudes and practices of PMPs on TB control in an urban setting in Bangladesh in order to inform development of a public‐private collaboration model. Methods: A cross sectional study was carried out in four areas of Dhaka city involving the NTP and three NGO partners. A mapping of PMPs was carried out: of the 250 PMPs identified, 97 showed an interest in becoming involved in the public‐private collaboration model and agreed to be interviewed. Information was also collected from focus group discussions with PMPs, and through a workshop. Results: PMPs were not aware of the NTP‐recommended regimen for treating TB: their prescribing patterns varied widely and were not related to the TB case categorisation. X‐ray was the preferred investigation of PMPs, who sent TB suspects to their preferred private‐run laboratory for diagnostic tests. Virtually no PMP had knowledge of the Bangladesh national policy for TB control (based on the WHO DOTS strategy), and the great majority did not know the locations of neighbouring DOTS centres. The quality of care provided by the public sector was perceived as poor by PMPs, who were therefore reluctant to refer TB patients to the NTP. Conclusions: There is enormous potential for improving TB treatment and control through partnerships between the NTP and PMPs, if the issues identified in this study are adequately addressed. PMPs must be encouraged to follow NTP guidelines for diagnosis and treatment. They should be motivated to refer patients to nearby DOTS centres. Proper training is required for PMPs to enhance their knowledge on diagnosis, treatment, and follow‐up. Appropriate tools and protocols and customised training packages need to be developed, focusing on appropriate diagnosis and treatment, including ways to refer patients to DOTS centres for diagnosis and treatment supervision.

Endogenous reactivation and true treatment failure as causes of recurrent tuberculosis in a high incidence setting with a low HIV infection

To determine the relative frequencies of reinfection vs. reactivation or treatment failure in patients from a high tuberculosis incidence setting with a low prevalence of HIV infection. We performed DNA fingerprinting on serial isolates from one and multiple TB episodes from 97 retreatment patients; 35 patients had been previously cured, whereas 62 had not. DNA fingerprinting patterns of recurrence Mycobacterium tuberculosis isolates of 5 of the 35 previously cured patients did not match with those of the corresponding initial isolates, indicating reinfection. We did not document reinfection during treatment. Isolates from each of the remaining 30 previously cured patients had identical DNA fingerprinting results, indicating reactivation. DNA fingerprinting patterns of isolates from the 62 patients with persistently positive sputum smears were identical, suggesting treatment failure. These findings suggest that reinfection is not a common cause of relapse and treatment failure in this rural predominantly HIV-free population despite the high incidence of TB.

Risk factors for TB infection and disease in young childhood contacts in Malawi

Screening of children in household contact with smear-positive tuberculosis (TB) is universally recommended but seldom practiced in resource-poor settings. It has huge potential to reduce the burden of TB disease in children, particularly if streamlined to focus on those at greatest risk. To assess the prevalence of infection and disease amongst children aged < or = 5 yrs in household contact with smear-positive TB. To identify which source case characteristics are risk factors for infection. A prospective, hospital-based audit was conducted over a 17-mth period in Southern Malawi. Smear-positive adults were identified and encouraged to bring their children to the outpatient clinic, in accordance with the national TB programme guidelines. Full assessment was performed, including tuberculin skin test. 195 children aged < or = 5 yrs who were contacts of 161 source cases were assessed. Prevalences of TB infection and disease were high (45% and 23%, respectively). The likelihood of a child being infected was significantly greater with increasing smear-positivity of the source case, and also if the source case were female (OR 2.25, 95% CI 1.19-4.27, p = 0.01). The high prevalence of TB infection and disease in child contacts attending this hospital-based clinic supports the current policy of contact-screening in Malawi. However, community-based studies are needed to provide a more accurate assessment of prevalence and risks for child contacts.

Private practitioners and tuberculosis control in the Philippines: strangers when they meet?

To investigate the knowledge, attitudes and perspectives of the Filipino private physicians (PPs) on tuberculosis (TB) control issues in the Philippines and their implications for future governmental public health policies. Cross-sectional telephone survey from June to October 2001. In each of the 78 provinces of the Philippines we randomly selected 10 PPs from the provincial capital city, five PPs from an urban centre with more than 50,000 population, and one PP from 15 rural villages with <50,000 population, making a total of 30 PPs per province. These data were complemented with information from focus group discussions with health workers and policy makers working in TB control, and through personal interviews with PPs. We interviewed 1355 (57.9%) of 2340 PPs identified. TB was diagnosed mainly through X-ray (87.9%) and usually treated with inappropriate regimens of anti-TB drugs (89.3%). The PPs did not follow-up their TB patients, did not trace the defaulters (97.9%) and did not identify contacts (91.4%). Only 24.2% knew the National Tuberculosis Programme (NTP) policies in depth. They defined the NTP's weakest points as diagnosis through sputum microscopy (59.2%) and the management of smear negative patients (29.7%). Most PPs were willing to collaborate with the NTP (83.3%) provided they were paid (38.4%). More than a half (51.5%) objected to obligatory reporting of new TB cases. The PPs based their success in attracting TB patients to their offices on confidentiality (46.1%) and on the kind treatment and flexibility given (43.7%). Diagnosis and treatment of TB patients is a daily issue for the PPs in the Philippines, although they did not follow usually the NTP guidelines. The majority of the PPs wished to collaborate with the NTP provided they were paid.