Presumptive TB Cases Research Articles

TB prevalence in Zimbabwe: a national cross-sectional survey, 2014.

BACKGROUND: We conducted the first national TB prevalence survey to provide accurate estimates of bacteriologically confirmed pulmonary TB disease among adults aged ≥15 years in 2014.METHODS: A TB symptoms screen and chest X-ray (CXR) were used to identify presumptive TB cases who submitted two sputum samples for smear microscopy, liquid and solid culture. Bacteriological confirmation included acid-fast bacilli smear positivity confirmed using Xpert® MTB/RIF and/or culture. Prevalence estimates were calculated using random effects logistic regression with multiple imputations and inverse probability weighting.RESULTS: Of 43,478 eligible participants, 33,736 (78%) were screened; of these 5,820 (17%) presumptive cases were identified. There were 107 (1.9%) bacteriologically confirmed TB cases, of which 23 (21%) were smear-positive. The adjusted prevalences of smear-positive and bacteriologically confirmed TB disease were respectively 82/100,000 population (95% CI 47-118/100,000) and 344/100,000 (95% CI 268-420/100,000), with an overall all-ages, all-forms TB prevalence of 275/100,000 population (95% CI 217-334/100,000). TB prevalence was higher in males, and age groups 35-44 and ≥65 years. CXR identified 93/107 (87%) cases vs. 39/107 (36%) using the symptom screen.CONCLUSION: Zimbabwe TB disease prevalence has decreased relative to prior estimates, possibly due to increased antiretroviral therapy coverage and successful national TB control strategies. Continued investments in TB diagnostics for improved case detection are required.

Early TB case detection by community-based mobile X-ray screening and Xpert testing in Balochistan.

This survey was conducted at 35 sites of 20 cities in 15 districts with low programmatic TB case notifications in the past years in Balochistan. To assess the effectiveness of the systemic community-based screening and diagnosis for early detection of TB; and 2) to describe the characteristics and understand the strengths and weaknesses of the intervention in Balochistan, and sociodemographic factors associated with it. This cross-sectional descriptive study was conducted using a mobile van equipped with a digital X-ray machine with computer-aided detection for TB (CAD4TB) software for screening, followed by confirmatory high sensitivity Xpert® MTB/RIF assay testing. A total of 236 (3.4%) TB cases was detected out of 6,899 screened. About 1,168 (17%) presumptive TB cases were identified and 1,065 (91%) sputum samples were tested on Xpert. Among those diagnosed, 166 (70%) were Mycobacterium tuberculosis-positive and 70 (30%) were with clinical suspicion. Of the sputum samples tested, 87% (923/1065) had a probability score of >70 on CAD4TB. Community-based screening with innovative activities, comprising sensitive screening and diagnostic tools, effectively improves TB case detection, which might suffice to reduce the prevalence of TB and break the chain of infection transmission in the at-risk population.

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.

Prevalence of active tuberculosis and associated factors among people with chronic psychotic disorders at St. Amanuel Mental Specialized Hospital and Gergesenon Mental Rehabilitation center, Addis Ababa, Ethiopia

BackgroundTuberculosis (TB) is an airborne chronic infectious disease mainly caused by Mycobacterium tuberculosis complex bacteria. Currently, about 1.7 billion (26%) of the world’s population are considered to be infected with M. tuberculosis. The risk of acquiring tuberculosis is higher on some segments of societies including people with severe mental illness. As a result, World health organization (WHO) strongly recommends screening for tuberculosis in such risk groups and setting.MethodsA cross-sectional study was conducted to assess the prevalence of active tuberculosis and associated factors among patients with chronic psychotic disorders admitted at St. Amanuel Mental Specialized Hospital and Gergesenon Mental rehabilitation center from February to June, 2020. All admitted patients were screened for any sign of TB as recommended by WHO. Presumptive TB cases were identified. Sputum samples were collected and tested by Xpert MTB/RIF assay. Data analysis was performed using SPSS version 25.0 statistical software and Chi square analysis was used to test the statistical association.ResultsFrom a total 3600 pschotic patients screened for TB, 250 (6.94%) presumptive tuberculosis cases were detected. From these, 27 (10.8%) were positive by Xpert MTB/RIF assay. Most of the patients were males (68.4%). The mean ± SD age of the participant was 36.5 ± 9.7 years. The overall prevalence of tuberculosis was found to be 750 per 100,000 population. The number of patients per room (p = 0.039) was associated with Xpert MTB/RIF positive active tuberculosis.ConclusionThe prevalence of active tuberculosis among chronic psychotic patients was high. Number of admitted patients per room was identified as risk factors for Xpert MTB/RIF positive active tuberculosis. Therefore, to control TB transmission in chronic mental health treatment facilities, efforts should be directed to periodic screening for early case detection and improving the number of patients per room.

Usefulness and effectiveness of community pharmacists-led mobile phone communication in identification and referral of presumptive tuberculosis cases in a selected district of Tamil Nadu

BackgroundCommunity pharmacists’ usually are not able to be actively involved in the identification and referral of presumptive TB cases approaching their pharmacy for over-the-counter (OTC) drugs. The main barriers from their perspective were increased patient volume and work burden. Therefore, a new methodology was adopted by appointing an auxiliary pharmacist who will be actively involved in the identification and referral of presumptive TB cases. The present study aimed to assess the usefulness and effectiveness of community pharmacists-led mobile phone communication in identification and referral of presumptive tuberculosis cases in a selected district of Tamil Nadu. MethodsA community intervention trial with pre and post-test comparison study was conducted among the community pharmacists in Tiruvallur district of Tamil Nadu. Knowledge about TB and referral practice of community pharmacists were captured and the same were taught to them. Details of the cases with the complaints of TB who came to the enrolled pharmacists for OTC drugs during the intervention period were collected by the community pharmacists and given to auxiliary pharmacist through WhatsApp. Auxiliary pharmacist called each patient and educated about TB and followed the patients. ResultsA total of 191 pharmacists were included in the study. 389 patients who approached pharmacy for OTC medications were suspected as TB by the community pharmacists based on their symptoms. 32 patients were not willing to give their details, while the details of others were collected by the community pharmacists and forwarded to auxiliary pharmacist through WhatsApp. 217 patients responded to phone calls made by the auxiliary pharmacist. Of them, 189 patients’ health conditions were improved, while 28 patients suffered with symptoms and they had visited PHC and 2 patients were diagnosed as TB by clinician. ConclusionUse of auxiliary pharmacist in collaboration with community pharmacists through phone communication is a useful and comfortable mode of collection of presumptive TB cases from the community pharmacies. Similarly, health education and follow-up of the presumptive cases via phone call is an effective way in the identification and referral of presumptive tuberculosis cases.

‘Student centered approach’ in implementing community based active case finding for tuberculosis in rural, Puducherry – A qualitative evaluation

BackgroundAs a part of Competency Based Medical Education (CBME) the competencies related to Communication skills, survey technique, can be improvised by exposing the students in community based Active Case Finding for Tuberculosis which helps in sustaining the activity. MethodsCommunity based house-to-house survey using “Student centered approach” was carried out to identify Presumptive TB cases as per the program definition among fourteen villages covered by Thirubhuvanai, Primary Health Centre. The team comprised of trained MBBS student, medical interns supervised by Post graduates, Medical social workers posted at the Department of Community Medicine, of a medical college, Puducherry. After training Mobile based application (Epicollect5) was used for survey. Feedback from students were obtained to explore their experience from ACF. Free listing and pile sorting was done among interns to explore their experience on Epicollect using Visual Anthropic software. ResultsThe major learning of the medical students from ACF activities were communication skills, rapport building with the community people, Screening for TB and their problem. Free listing identified 14 salient variables depending on the cut-off value of 0.083 (Smith's Salience Score) and subjected to pile sorting. Cognitive map identified their experiences into three categories namely knowledge on TB screening, uses of Epicollect and paper-based questionnaire. Totally 19,134 households were screened, among them 77 presumptive TB cases were identified, three positive pulmonary TB cases were detected and linked to TB care pathway. Conclusion“Student centered approach” proved to be effective strategy in ACF for TB from student's reflection. This rigorous ACF outreach activity shares dual benefits individual and community level benefit and also programme level benefits. Implementing this approach of involving MBBS students in ACF activity was successful and it is feasible to continue every year propounded by National TB Elimination Program (NTEP) guidelines.

Effects of COVID-19 on national tuberculosis elimination programme strategies during March to May 2020 on Tumkur district, India

Background: the nation-wide lockdown due global pandemic has disrupted a vital strategic intervention resulting in overall 60% decrease in presumptive and diagnostic TB cases during the lockdown period.Methods: A discrete choice experimental (DCE) exploratory operational research conducted during March to May 2020.Results: Health care services were affected 25% reduction in the outpatient department (OPD) in comparison to the previous year the same period. A gradual reduction in negative sputum cases undergoing chest radiography from 54% to 14%. Due to restricted movement LPA tests have been reduced 25% among the diagnosed TB cases, and private referrals to cartridge based nucleic acid amplification test (CBNAAT) services were reduced to 20%.Conclusions: Health services, including national programmes to combat TB, need to be actively engaged in ensuring an effective and rapid response to COVID-19 while ensuring that TB services are maintained. While experience on COVID-19 infection in TB patients remains limited, it is anticipated that people ill with both TB and COVID-19 may have poorer treatment outcomes, especially if TB treatment is interrupted. TB patients should take precautions as advised by health authorities to be protected from COVID-19 and continue their TB treatment as prescribed.

Understanding health care-seeking behaviour of the tribal population in India among those with presumptive TB symptoms.

Background and objectivesUnderstanding the drivers for care-seeking among those who present with symptoms of TB is crucial for early diagnosis of TB and prompt treatment, which will in turn halt further TB transmission. While TB is a challenge among the tribal population, little is known about the care-seeking behaviour and the factors influencing care-seeking behaviour among the tribal population across India.MethodologyThis community-based descriptive study was carried out in 17 states of India across 6 zones, covering 88 villages from tribal districts with over 70% tribal population. The sample population included individuals ≥15 years old who were screened through an interview for symptoms suggestive of pulmonary TB (PTB), currently and/or previously on anti-TB treatment. Those with symptoms were then assessed on their health-seeking behavior using a semi-structured interview schedule.ResultsAmong 74532 eligible participants screened for symptoms suggestive of TB, 2675 (3.6%) were found to be presumptive TB cases. Of them, 659 (24.6%) sought care for their symptoms. While 48.2% sought care after a week, 19.3% sought care after one month or more, with no significant difference in the first point of care; 46.9% approaching a private and 46.7% a public facility. The significant factors influencing care-seeking behaviour were knowledge on TB (OR: 4.64 (3.70–5.83), p < 0.001), age<35 years (OR: 1.60 (1.28–2.00), p < 0.001), co-morbidities like asthma (OR: 1.80 (1.38–2.35), p < 0.001) and blood pressure (OR: 2.59 (1.75–3.85), p < 0.001), symptoms such as blood in sputum (OR: 1.69 (1.32–2.16), p < 0.001), shortness of breath (OR: 1.43 (1.19–1.72), p < 0.001) and weight loss (OR: 1.59 (1.33–1.89), p < 0.001). The cough was the most often reported symptom overall. There were gender differences in symptoms that prompted care-seeking: Males were more likely to seek care for weight loss (OR: 1.78 (1.42–2.23), p<0.001), blood in the sputum (OR: 1.69 (1.25–2.28), p<0.001), shortness of breath (OR: 1.49 (1.18–1.88), p<0.001) and fever (OR: 1.32 (1.05–1.65), p = 0.018). Females were more likely to seek care for blood in sputum (OR: 1.68 (1.10–2.58), p = 0.018) and shortness of breath (OR = 1.35, (1.01–1.82), p = 0.048). The cough did not feature as a significant symptom that prompted care-seeking.ConclusionDelayed healthcare-seeking behaviour among those with symptoms presumptive of TB in the tribal population is a major concern. Findings point to differences across gender about symptoms that prompt care-seeking in this population. Gender-sensitive interventions with health system strengthening are urgently needed to facilitate early diagnosis and treatment among this population.

The Role of Cartridge-Based Nucleic Acid Amplification Test (CBNAAT), Line Probe Assay (LPA), Liquid Culture, Acid-Fast Bacilli (AFB) Smear and Histopathology in the Diagnosis of Osteoarticular Tuberculosis.

There is a paucity of data on the role of molecular methods in the diagnosis of osteoarticular tuberculosis. The present study was conducted to define the role of molecular (CBNAAT, LPA), phenotypic (AFB smear and culture) and histopathological evaluation in the diagnosis of osteoarticular TB. Seventy-seven consecutive cases of osteoarticular tuberculosis were grouped into presumptive TB cases (group A) and presumptive drug-resistant cases (group B). Tissue samples obtained were submitted for CBNAAT, LPA, AFB smear, liquid culture and histological examinations. The diagnostic accuracy of each test was reported against histologically diagnosed cases and in all tests in tandem. Group A and group B had 65 and 12 cases, respectively. The diagnostic accuracy for tuberculosis was 84.62% by CBNAAT, 70.77% by LPA, 86.15% by molecular tests (combined), 47.69% by AFB smear, 50.77% by liquid culture and 87.69% by histology in group A, and 91.67% for CBNAAT, 83.33% for LPA, 91.67% for molecular tests (combined), 25% for AFB smear, 16.67% for liquid culture and 83.33% for histology in group B. The drug resistance detection rate was 4.62% on CBNAAT, 3.08% on LPA, 6.15% on molecular tests (combined) and 1.54% on DST in group A, while it was 33.33% on CBNAAT, 58.33% on LPA, 58.33% on molecular tests (combined) and 16.67% on DST among group B cases. Similar sensitivity rates for the various tests were obtained among both the groups on comparison with histology (taken as denominator). The addition of molecular methods increased the overall diagnostic accuracy (all tests in tandem) from 93.8 to 100% in group A and from 83.3 to 100% in group B cases. No single tests could diagnose tuberculosis in all cases; hence, samples should be evaluated by molecular tests (CBNAAT and LPA), AFB smear, culture and histological examinations simultaneously. The molecular tests have better demonstration of drug resistance from mycobacterial culture. The online version contains supplementary material available at 10.1007/s43465-020-00326-w.

STUDY OF CLINICO-RADIOLOGICAL PARAMETERS IN DIAGNOSIS OF PEDIATRIC TUBERCULOSIS AT TERTIARY CARE HOSPITAL

Background: Global TB burden in India in children is about 2.2 lakh per year, among which pulmonary TB is most common presentation. Childhood TB contributes to about 10-20% of all TB in high burden countries and accounting for 8-20% TB related deaths. Children up to 14 years constitute about 35% of the population in our country and are expected to contribute about 10% of the case load. In order to achieve ‘Zero death by TB’, additional focus has to be directed towards TB in children. Paediatric clinical feature is variable in tuberculosis. Many cases of primary TB infection in children are asymptomatic and remain completely unnoticed or accidentally discovered at a later stage. In this study we looked for clinical and radiological presentation of childhood TB and its correlation in diagnosis within a period of 1 year in a tertiary care hospital. Methods: Total 254 children suspected of having tuberculosis were enrolled in the study and various microbiological, laboratory and radiological tests were used to diagnose the patients. Clinical samples were processed using standardized protocols. CBNAAT was the initial test of choice for microbiological confirmation. Results: Among 254 children, 69(27%) had pulmonary tuberculosis, extrapulmonary tuberculosis was found in 76(30%) children. Fever was the most common (in 100% cases) symptom in pulmonary TB. Most common radiological presentation was segmental consolidation (44%). Amongst 69 pulmonary TB patients, 16(23%) were Rifampicin resistant by CBNAAT method. Conclusion: Primary childhood TB being paucibacillary, makes microbiological diagnosis (gold standard) difficult. In relevant clinical setting, certain radiological lesions may be highly suggestive of tuberculosis: miliary pattern, hilar and/or paratracheal lymphadenopathy with or without parenchymal involvement and fibro-cavitatory lesions. All presumptive TB cases with these radiological patterns are considered to be probable TB and should be subjected to microbiological testing to confirm the diagnosis.

Improving “Fast” Indicators of TB Infection Control through Targeted Health Workers Training; Findings from Facility Based Studies in Abia State, Nigeria

Aim: The aim of this study was to assess the effect of health workers training and implementation of the FAST strategy on the “FAST” indicators at Abia State University Teaching Hospital (ABSUTH); a tertiary referral facility. ”FAST” strategy; a focused approach to stopping TB spread in congregate settings developed by TB Care1 stands for Finding TB cases Actively, Separating safely, and Treating effectively.&#x0D; Study Design: This was a facility based interventional study using control group design methods with ABSUTH as the intervention facility while Federal Medical Centre Umuahia (FMCU) was the control.&#x0D; Methodology: Health workers (74 across cadres; doctors, nurses, laboratory scientist and medical record staff) selected through stratified random sampling were trained to ensure daily cough surveillance and screening for TB among patients at the General outpatient, medical wards and HIV clinic of ABSUTH under supervision of a “FAST” focal person.Baseline “Fast Indicators” in the facility TB records of newly diagnosed TB patients 3 months before and 3 months after the training intervention were obtained.&#x0D; Results: At baseline the “FAST” strategy indicators recorded in the study facility include time to diagnosis &gt; 1 week, time to treatment 3.5 days, presumptive TB cases 92, number of cases commenced on treatment were 22 while presumptive DRTB cases was 0.33. This study observed a significant positive difference in all the “FAST” indicators following the intervention. Time to diagnosis decreased by 52%, time to treatment decreased by 17% while the number of presumptive TB cases increased by over 100%. Number of TB cases diagnosed also increased by 100% as well as the cases commenced on treatment by 91%, while number of diagnosed DRTB cases increased by over 100%.These were all statistically significant ( P=.013,.03, .032, and .049 except time to treatment P= 0.053).&#x0D; Conclusion: The training intervention on ‘FAST” strategy of TB infection Control significantly improved FAST Indicators in the intervention facility with attendant reduction in diagnostic delays and increased case notification.

Impact of Xpert MTB/RIF scale up in improving Rifampicin resistance TB detection - Experience from 5 regions in Tanzania

Background: The WHO recommends the use of Xpert MTB/RIF technology rather than conventional microscopy, culture and DST as the initial diagnostic test for all presumptive TB cases. In 2017, there were an estimated 640 MDR/RR-TB cases, but only 200 cases of MDR-TB were identified in Tanzania, representing about 31% of the total estimated cases in the country. Tanzania has also revised the policy guideline to include Xpert MTB/RIF as primary diagnostic test among all presumptive TB cases although due to financial constraints the coverage of Xpert diagnostic facilities has remained low. USAID Boresha Afya Southern Zone program a comprehensive HIV Care project with support from USAID providing services in 5 regions has supported scale up of Gene X-pert machine in TB and RR-TB case detection. We document impact of Xpert scale up in improving RR-TB case detection. Methods and materials: The program mapped the number and location of Xpert machines available at all 35 district councils and only 11 councils had Xpert Machines. The program supported the efforts by the ministry to scale up Xpert machine availability by adding 27 new Xpert machines which increased a coverage to at least one Xpert machine per council. Furthermore, the program started supporting transport of sputum samples to X-pert sites by integrating sputum samples transportation with HIV Viral Load sample transportation system. Results: The number of RR-TB notifications increased by more than two folds from 21 cases in 2017 to 47 cases in 2018.Further more, the total number of TB cases notified increased from 8681 cases notified in 2017 to 9824 cases in 2018.Tabled 1PeriodJan-March 2017Apr-June 2017July-Sept 2017Oct -Dec 2017Jan-March 2018Apr-June 2018July-Sept 2018Oct- Dec 2018Number of RR-TB cases Detected44855101715 Open table in a new tab Conclusion: Use of Xpert MTB/RIF has demonstrated effectiveness in addressing the first pillar of the END TB Strategy; early diagnosis of TB including universal drug susceptibility testing. While there is a need to scale up Xpert machine to cover more sites, strengthening sputum sample transportation system to sites with Xpert machines will improve TB case detection in remote constrained settings.

Active household contact screening for tuberculosis and provision of isoniazid preventive therapy to under-five children in Afghanistan.

This observational study analyzed the performance of the National TB Control Program (NTP) in Afghanistan in household contact screening from 2011 to 2018 and its use as an entry point for isoniazid preventive therapy (IPT), as well as the IPT completion rates for children under age five. From 2011 to 2018, the Afghanistan NTP released guidelines for passive and active contact screening of bacteriologically confirmed TB cases. Health workers were trained in contact screening. Presumptive TB cases gave sputum for AFB smear microscopy; other diagnostics were used if patients could not produce sputum. Children under five (excluding those with active TB) were treated for latent TB infection. We calculated the yield and the number needed to screen and number needed to test to find a case of TB, as well as the rates of IPT initiation and completion. From 2011 to 2018, 142,797 bacteriologically confirmed TB cases were diagnosed in Afghanistan. The number of household members eligible for screening was estimated to be 856,782, of whom 586,292 (81%) were screened for TB and 117,643 (20.1%) were found to be presumptive TB cases. Among the cases screened, 10,896 TB cases (all forms) were diagnosed (1.85%, 95% CI 1.82-1.89), 54.4% in females. The number needed to screen to diagnose a single case of TB (all forms) was 53.8; the number needed to test was 10.7. Out of all children under five, 101,084 (85.9%) were initiated on IPT, and 69,273 (68.5%) completed treatment. Program performance in contact screening in Afghanistan is high, at 81%, and the yield of TB is also high-close to 10 times higher than the national TB incidence rate. IPT initiation and completion rates are also high as compared to those of many other countries but need further improvement, especially for completion.

Differential yield of universal versus selective drug susceptibility testing of patients with tuberculosis in high-burden countries: a systematic review and meta-analysis

IntroductionAlthough universal drug susceptibility testing (DST) is a component of the End-TB Strategy, over 70% of drug-resistant tuberculosis (DR-TB) cases globally remain undetected. This detection gap reflects difficulties in DST...

Impact and operational feasibility of TrueNat™ MTB/Rif under India's RNTCP.

The Revised National Tuberculosis Control Programme (RNTCP) in Andhra Pradesh, India, introduced TrueNat™ MTB/Rif, a rapid molecular test for detecting Mycobacterium tuberculosis (MTB) and rifampicin (RIF) resistance at 193 TB units (TUs) in October 2018. We evaluated its impact on TB diagnosis and assessed the operational feasibility of its deployment at point-of-care (POC) settings. We compared the number of presumptive TB cases tested and the number (proportion) of microbiologically positive before (January-August 2018) and after (January-August 2019) the deployment of TrueNat. We interviewed laboratory technicians and Senior TB Laboratory Supervisor from 25 randomly selected TUs to assess operational feasibility. In 2018, 10.5% (range 8.9-13.1) of 245,989 presumptive cases tested were positive. In 2019, of the 185,435 presumptive cases tested, 13.7% (range 9.6-18.9) were positive. The proportion of presumptive TB cases in whom MTB was detected using TrueNat was 14.4% (range 10.0-21.2). TrueNat significantly increased case detection (incidence rate ratio [IRR] 1.30; 95%CI 1.15-1.46), yielding an additional 18 TB cases per 100 000 population. Laboratory technicians became comfortable in performing TrueNat after a median of 10 tests (interquartile range 5-17.5). Invalid reports declined from 6.8% to 3.6%. The deployment of TrueNat as POC diagnostic test improved case detection and was operationally feasible under RNTCP.

Upfront Xpert MTB/RIF for diagnosis of pediatric TB-Does it work? Experience from India.

BackgroundDiagnosis of TB in pediatric population poses several challenges. A novel initiative was implemented in several major cities of India aimed at providing upfront access to free-of-cost Xpert MTB/RIF to presumptive pediatric TB cases. This paper aims to describe the experience of implementing this large initiative and assess feasibility of the intervention in high TB burden settings.MethodsData were drawn from the pediatric TB project implemented in 10 major cities of India between April 2014 and March 2018. In each city, providers, both public and private, were engaged and linked with a high throughput Xpert MTB/RIF lab (established in that city) through rapid specimen transportation and electronic reporting system. Rates and proportions were estimated to describe the characteristics of this cohort.ResultsOf the total 94,415 presumptive pediatric TB cases tested in the project, 6,270 were diagnosed positive for MTB (6.6%) on Xpert MTB/RIF (vs 2% on smear microscopy). Among MTB positives, 545 cases were rifampicin resistant (8.7%). The median duration between collection of specimens and reporting of results was 0 days (same day) and >89% cases were initiated on treatment. Approximately 50% of the specimens tested were non-sputum. The number of providers/facilities engaged under the project increased >10-fold (from 124 in Q2’14 to 1416 in Q1’18).ConclusionThis project, which was one of the largest initiatives globally among pediatric population, demonstrated the feasibility of sustaining rapid and upfront access to free-of-cost Xpert MTB/RIF testing. The project underscores the efficiency of this rapid diagnostic assay in tackling several challenges in pediatric TB diagnosis, identifies opportunities for further interventions as well as brings to light scope for effective engagement with healthcare providers. The findings have facilitated a policy decision by National TB Programme mandating the use of Xpert MTB/RIF as a primary diagnostic tool for TB diagnosis in children, which is being scaled-up.

Barriers of community pharmacists in identification and referral of presumptive tuberculosis cases in Tiruvallur district of Tamil Nadu

BackgroundTuberculosis (TB) still continues to be a major public health threat. Early diagnosis is the cornerstone in combating TB. Community pharmacists are the front line health care providers among the health care system. The present study aimed to identify the barriers of community pharmacists in the identification and referral of presumptive pulmonary tuberculosis cases. MethodsProspective, cross-sectional study was conducted among the community pharmacists in Tiruvallur district of Tamil Nadu. One pharmacist from each pharmacy was interviewed using semi-structured questionnaire. Knowledge component, practice and barriers of identification and referral in presumptive TB cases were captured. ResultsA total of 143 pharmacists were included in the study. Barriers in identification and referral by pharmacists’ perception were patient volume (32%), pharmacy workload (22%), difficulty in identifying the cases (16%), etc. Research team also identified few barriers such as pharmacists do not have adequate knowledge about TB (34%), pharmacists are not trained enough to identify and refer presumptive TB cases (26%), etc. All the pharmacists (100%) refer the presumptive TB cases, if they come across for OTC medications. Pharmacists also provided health education to their community (45.7%). ConclusionAdequate training of community pharmacists and a follow-up system for the presumptive TB cases identified by the community pharmacist are essential in reducing the barriers of pharmacists in TB case detection.

Diagnosis of tuberculosis from smear-negative presumptive TB cases using Xpert MTB/Rif assay: a cross-sectional study from Nepal

BackgroundIn most developing countries, smear-negative pulmonary TB (SNPT) often gets missed from the diagnosis of consideration, though it accounts 30–65% of total PTB cases, due to deficient or inaccessible molecular diagnostic modalities.MethodsThe cross-sectional study enrolled 360 patients with clinical-radiological suspicion of SNPT in Tribhuvan University Teaching Hospital (TUTH). The patient selection was done as per the algorithm of Nepal’s National Tuberculosis Program (NTP) for Xpert MTB/RIF testing. Participants’ demographic and clinical information were collected using a pre-tested questionnaire. The specimens were collected, processed directly for Xpert MTB/RIF test according to the manufacturer’s protocol. The same samples were stained using the Ziehl-Neelsen technique then observed microscopically. Both findings were interpreted; rifampicin-resistant, if obtained, on Xpert testing was confirmed with a Line Probe Assay.ResultOf 360 smear-negative sputum samples analyzed, 85(23.61%) found positive while 3(0.8%) of them were rifampicin resistance. The infection was higher in males, i.e. 60(25.3%) compared to female 25(20.3%). The age group, > 45(nearly 33%) with median age 42 ± 21.5, were prone to the infection. During the study period, 4.6% (515/11048) sputum samples were reported as smear-positive in TUTH. Consequently, with Xpert MTB/RIF assay, the additional case 16.5% (n = 85/515) from smear-negative presumptive TB cases were detected. Among the most occurring clinical presentations, cough and chest pain were positively associated with SNPT. While upper lobe infiltrates (36.4%) and pleural effusion (40.4%) were the most peculiar radiological impression noted in PTB patient. 94 multi-drug resistant(MDR) suspected cases were enrolled; of total suspects, 29(30.8%) samples were rifampicin sensitive, 1(1.06%) indeterminate, 3(3.19%) rifampicin-resistant while remaining of them were negative. 2(2.2%) MDR cases were recovered from the patient with a previous history of ATT, of total 89 previously treated cases enrolled However, a single rifampicin-resistant from the new suspects.ConclusionWith an application of the assay, the additional cases, missed with smear microscopy, could be sought and exact incidence of the diseases could be revealed.

Diagnostic accuracy of CBNAAT (Gene-Xpert) Vs liquid culture in clinically diagnosed presumptive childhood tuberculosis admitted in Pt. J.N.M. Medical College &amp; Dr. Bhim Rao Ambedkar Memorial Hospital, Raipur (C.G.)

Background: Paediatric tuberculosis comprises 10% of all tuberculosis in developing countries. Smear microscopy is diagnostic for Pulmonary TB whereas for extra-pulmonary TB, CBNAAT (Gene-Xpert) and liquid-culture are available choices. Objectives: To establish the comparative diagnostic efficacy of CBNAAT and Liquid-culture in clinically presumptive childhood Tuberculosis. Outcome: Assess sensitivity and specificity of CBNAAT Vs Liquid-culture in clinically diagnosed presumptive childhood tuberculosis. Material &amp; Method: After approval from institutional ethical committee this Cross-sectional study was performed in department of paediatrics Pt. J. N. M. Medical College, Raipur C.G. Total 97 paediatric presumptive TB cases were enrolled for systematic screening from June-2017 to July-2018. Samples were collected and analysed by CBNAAT and liquid-culture. Data for Diagnostic efficacy of both techniques were analysed with appropriate statistical method. Results: Among study subject group 41.2% belongs to 11-15 age-group and 53.6% were female. Majority of them belongs to joint family (81.4%) and low-socioeconomic (85.6%) status. Among 97 presumptive cases CBNAAT was positive in 24.7% whereas liquid-culture was positive in 22.7%. CBNNAT has sensitivity (100%) and specificity (98.61%) when compared with liquid-culture as gold-standard. It has 95.65% positive and 100% negative predictive values. CBNAAT had 100% of sensitivity and specificity in diagnosis of abdominal-tuberculosis and TB-meningitis. In Pulmonary-TB diagnosis its specificity reduced to 98%. Conclusion: CBNAAT is equally efficacious diagnostic tool to diagnose clinically presumptive TB cases and it should be used in public health system for early diagnosis of paediatric tuberculosis.

Performance and impact of GeneXpert MTB/RIF\xae and Loopamp MTBC Detection Kit\xae assays on tuberculosis case detection in Madagascar

BackgroundTuberculosis rapid molecular assays, including GeneXpert MTB/RIF® and Loopamp MTBC Detection Kit®, are highly sensitive and specific. Such performance does not automatically translate in improved disease control and highly depends on their use, local epidemiology and the diagnostic algorithms they’re implemented within. We evaluate the performance of both assays and assess their impact on additional cases notification when implemented within WHO recommended tuberculosis diagnostic algorithms in Madagascar.MethodsFive hundred forty eight presumptive pulmonary tuberculosis patients were prospectively recruited between November 2013 and December 2014 in Antananarivo, Madagascar, a high TB incidence sub-Saharan African urban setting. Both molecular assays were evaluated as first line or add-on testing following negative smear microscopy. Based on locally defined assay performance characteristics we measure the impact of both assays and WHO-recommended diagnostic algorithms on additional tuberculosis case notifications.ResultsHigh sensitivity and specificity was confirmed for both GeneXpert MTB/RIF® (86.6% (95% CI 81.1–90.7%) and 97.4% (95% CI 94.9–98.8%)) and Loopamp MTBC Detection Kit® (84.6% (95% CI 78.9–89.0%) and 98.4% (95% CI 96.2–99.4%)). Implementation of GeneXpert MTB/RIF® and Loopamp MTBC Detection Kit® increased tuberculosis diagnostic algorithms sensitivity from 73.6% (95% CI 67.1–79.3%) up to 88.1% (95% CI 82.8–91.9%). This increase was highest when molecular assays were used as add-on testing following negative smear microscopy. As add-on testing, GeneXpert MTB/RIF® and Loopamp MTBC Detection Kit® respectively improved case detection by 23.8 and 21.2% (p < 0.05).ConclusionIncluding GeneXpert MTB/RIF® or Loopamp MTBC Detection Kit® molecular assays for TB detection on sputum samples from presumptive TB cases can significantly increase case notification in TB diagnostic centers. The TB case detection rate is further increased when those tests are use as second-line follow-on testing following negative smear microscopy results. A country wide scale-up and digital integration of molecular-based TB diagnosis assays shows promises for TB control in Madagascar.