Presumptive Tuberculosis Cases Research Articles

Impact of the Stool-Based Xpert Test on Childhood Tuberculosis Diagnosis in Selected States in Nigeria.

In Nigeria, most children with tuberculosis (TB) present at primary health clinics where there are limited personnel skilled in collecting appropriate respiratory specimens from those who cannot produce sputum. KNCV Nigeria, in collaboration with the National Tuberculosis Control Program, implemented a modified simple, one-step (SOS), stool-based Xpert MTB/RIF method for diagnosis of TB in children who cannot expectorate sputum. We evaluated the impact of its implementation on childhood TB diagnosis. A cross-sectional study was conducted across 14 selected states using secondary data of children presumed to have TB. Stool was collected from children presumed to have TB and processed using Xpert. Out of 52,117 presumptive TB cases, 52% were male and 59.7% were under 5 years old. A total of 2440 (5%) cases were diagnosed with TB, and 2307 (95%) were placed on treatment. Annual TB notifications increased significantly after the introduction of the stool-based Xpert test when compared to those in the pre-implementation period. Increasing contributions from stool testing were observed throughout the implementation period, except in 2020 during the COVID-19 era. Overall, stool Xpert testing improved childhood TB notification in the studied states. Interventions aimed at awareness creation, capacity building, and active case finding improved the performance of the test.

Xpert-Ultra Assay in Stool and Urine Samples to Improve Tuberculosis Diagnosis in Children: The Médecins Sans Frontières Experience in Guinea-Bissau and South Sudan.

More than half of childhood tuberculosis cases remain undiagnosed yearly. The World Health Organization recommends the Xpert-Ultra assay as a first pediatric diagnosis test, but microbiological confirmation remains low. We aimed to determine the diagnostic performance of Xpert-Ultra with stool and urine samples in presumptive pediatric tuberculosis cases in 2 high-tuberculosis-burden settings. This Médecins Sans Frontières cross-sectional multicentric study took place at Simão Mendes Hospital, Guinea-Bissau (July 2019 to April 2020) and in Malakal Hospital, South Sudan (April 2021 to June 2023). Children aged 6 months to 15 years with presumptive tuberculosis underwent clinical and laboratory assessment, with 1 respiratory and/or extrapulmonary sample (reference standard [RS]), 1 stool, and 1 urine specimen analyzed with Xpert-Ultra. A total of 563 children were enrolled in the study, 133 from Bissau and 400 from Malakal; 30 were excluded. Confirmation of tuberculosis was achieved in 75 (14.1%), while 248 (46.5%) had unconfirmed tuberculosis. Of 553 with an RS specimen, the overall diagnostic yield was 12.4% (66 of 533). A total of 493 stool and 524 urine samples were used to evaluate the performance of Xpert-Ultra with these samples. Compared with the RS, the sensitivity and specificity of Xpert-Ultra were 62.5% (95% confidence interval, 49.4%-74%) and 98.3% (96.7%-99.2%), respectively, with stool samples, and 13.9% (7.5%-24.3%) and 99.4% (98.1%-99.8%) with urine samples. Nine patients were positive with stool and/or urine samples but negative with the RS. Xpert-Ultra in stool samples showed moderate to high sensitivity and high specificity compared with the RS and an added diagnostic yield when RS results were negative. Xpert-Ultra in stool samples was useful in extrapulmonary cases. Xpert-Ultra in urine samples showed low test performance. NCT06239337.

Improving Tuberculosis Active Case Finding Through the Engagement of Traditional Medicine Practitioners in Lagos State, Nigeria

Background: Tuberculosis (TB) remains a significant global health challenge, particularly in high-burden countries like Nigeria. Despite efforts to combat TB, a substantial number of cases remain undiagnosed and untreated, contributing to the continued spread of the disease. In response to this public health crisis, the USAID/Nigeria Tuberculosis Local Organization (USAID/Nigeria TB LON) project, implemented by the Equitable Health Access Initiative (EHAI) in Lagos State, initiated a novel approach to TB case finding. This journal article provides an overview of the strategies, activities, challenges, and achievements of the Program within the USAID TB LON 3 project in Lagos State, with a focus on the period from March to September 2021 Methods: This approach involves collaboration with Traditional Medicine Practitioners (TMPs) to identify and link presumptive TB cases to testing and treatment services. Result: From March to September 2021, only 30 out of the 94 TMPs trained reported a total of 8,333 clients screened for Tuberculosis infections across 7 LGAs in Lagos State. 715 presumptive TB cases were identified (representing 0.09% of screened cases) and 628 samples were further evaluated for TB (88% of identified presumptive cases) with 12 confirmed TB positive cases reported (2% of presumptive cases), 11 linked to treatment, and 1 death reported. Conclusion: This research offers compelling evidence supporting the efficacy of engaging Traditional Medicine Practitioners (TMPs) in enhancing active Tuberculosis (TB) case finding in Lagos State. The substantial and positive impact observed underscores the potential of this approach to play a pivotal role in TB control initiatives, fortifying the healthcare system's resilience in addressing TB within community outside hospital facility. Keywords: Tuberculosis (TB), Traditional Medicine Practitioners (TMP),

Community-based Advocacy Communication Social Mobilization (ACSM) intervention by empowering key community leaders: Evaluation using the RE-AIM framework.

Based on the theme of World Tuberculosis (TB) Day 2018-"Wanted Leaders for TB free world," various studies and country-level project have witnessed how training leaders on TB has helped enhance TB awareness in the community. This study was conducted to evaluate the effectiveness of Advocacy Communication and Social Mobilization (ACSM) intervention strategy through key community leaders, using Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. This study was undertaken by the Department of Community Medicine, Sri Manakula Vinayagar Medical College and Hospital (SMVMCH), Puducherry, in the field practice area of Primary Health Centre (PHC), Thirubuvanai. The STOP TB, ENGAGE-TB, and National TB Elimination Program (NTEP) guidelines were used for interventions. Key community leaders (KCL) list (N = 117) was obtained from Mannadipet commune panchayat and PHC. The study was conducted in four phases: phase 1 (baseline): quantitative data: proportion of presumptive TB cases from notification register; phase 2 (intervention): training program for staff nurses, auxiliary nurse midwife (ANM), Accredited Social Health Activist (ASHA), and Anganwadi workers (group activity), participatory rural appraisal (PRA) activity for self-help group (SHG) leaders, and health education session for religious leaders and ex-panchayat leaders; phase 3: strengthening of ongoing activity: health education session and active case finding for TB; and phase 4: end line: outcome of the intervention, evaluated using the RE-AIM framework. As an outcome of the intervention, there was a marginal increase (21 cases) in the proportion of presumptive TB cases when comparing before (2018) and after (2019) intervention. The proportion of presumptive TB cases identified and referred by KCL was 312. A total of 77 presumptive TB cases were identified through community-based active case finding (ACF). Two sputum samples (on the spot early morning) were collected and sent for Cartridge-based nucleic acid amplification testing (CBNAAT), of which three cases were positive. This study was community led and involved leaders from diverse backgrounds, optimizing the chance of success. For sustainability, we have initiated TB support group.

Active case finding of tuberculosis among nomads and semi-nomads in Puducherry.

Tuberculosis (TB), is a global epidemic and communicable disease that accounts for increased global mortality and morbidity. India is also marching towards the elimination of tuberculosis by 2025 with this background we conducted this study. To identify the undiagnosed TB cases in nomadic and semi-nomadic populations of Puducherry. A community-based cross-sectional study was done among nomads and semi-nomads in Puducherry for four months between May 2022 to September 2022 after getting the Institute's ethical committee approval. After obtaining written consent/assent, a pretested semi structured questionnaire was used to record the data. The questionnaire consists of three parts that include, sociodemographic details and history specific to tuberculosis based on operational definitions such as presumptive TB and physical examination. Those participants fulfilling the criteria for presumptive TB was provided a Falcon tube for spot sample. The participants were explained the procedure to collect the sputum and its quality was verified by the principal investigator before sending it to the laboratory. Data was analysed with Statistical Package for Social Science (SPSS Inc, Chicago, Illinois, USA) software version 16.0 and Microsoft Excel 2016. Frequencies and percentages were estimated for categorical data. Our study showed 6.25% was the proportion of presumptive TB cases in our study population. In the presumptive TB cases 60% belonged to age >45yrs 80% belonged to the male gender and all of them belonged to lower socioeconomic status. The macro-environment findings of those presumptive TB cases were 80% belonged Kutcha houses, with poor ventilation and overcrowding present. Their co-morbidity status indicates 60% were diabetics and 20% were hypertensive. Their predominant findings were 80% reported Cough and 20% fever, significant weight loss. No contact history of TB was found. When these presumptive TB cases underwent microbiological examination, none were sputum positive. This study showed ACF helped to identify presumptive TB in an effective way and needs large-scale screening to identify sputum-positive cases.

Development and validation of a risk prediction model for pulmonary tuberculosis among presumptive tuberculosis cases in Ethiopia

BackgroundEarly diagnosis and treatment of tuberculosis (TB) is one of the key strategies to achieve the WHO End TB targets. This study aimed to develop and validate a simple, convenient...

The magnitude of health care seeking delay and associated factors for tuberculosis suggestive symptoms in Sidama Region Ethiopia: Community-based cross-sectional study

BackgroundHealth care seeking delay for tuberculosis suggestive symptoms is a great challenge for controlling the disease. Therefore, the study aimed to determine the magnitude and identify factors associated with delayed healthcare seeking among presumptive tuberculosis cases for suggestive tuberculosis symptoms. MethodsA community-based cross-sectional study was conducted among 476 subjects with symptoms suggestive of tuberculosis. Data were collected using a structured questionnaire, entered into Epi-data software version 3.1, and exported to SPSS software version 25.0 for analysis. The multivariable logistic regression models included variables like sex, marital status, knowledge, education level, and distance from health facility that show a significant association with health care seeking delay in the binary logistic regression at a P value 0.25. Tables, graphs, and charts were then used to display the results. ResultThe proportion of delayed health care seeking was found to be 46.7 % (95 % CI, 43.5–48.9). The study also revealed that being married, not attending formal education, having a lower monthly income, and having poor knowledge of tuberculosis were significantly associated with delayed tuberculosis-suggestive symptoms. ConclusionIn this study, delays in health care seeking among TB-suspected patients were high compared to the Ethiopian Ministry of Health target. Different systems should be built to increase community awareness of health care.

Incremental yield of serial sputum examinations in the diagnosis of pulmonary tuberculosis in Taiwan: Findings of a pragmatic trial

BackgroundPresumptive tuberculosis (TB) cases commonly had two to three sputum examinations in Taiwan. The incremental yield of serial sputum examinations has not been assessed before. MethodsIn a pragmatic trial, presumptive TB patients with a frontline nucleic acid amplification test (NAAT) were classified as group A. Those without a frontline NAAT were randomized into group B frontline NAAT as intervention, and group C usual care. We investigated expected incremental yields and the number of examinations required for detection of one additional TB case from each serial sputum smear and culture. ResultsOf 6835 presumptive TB cases, 395 (5.8%) were smear positive for acid-fast bacilli, and 195 (2.8%) culture positive for M tuberculosis. The expected incremental yield from a third smear was 3.5% and examination of 1712 (95% credibility interval 586–4706) third smears was required to detected one additional TB case. Sensitivity of one smear with an NAAT in group B was 46.8% (95% confidence interval 32.1%–61.9%), and that of two smears in Group C 40.0% (95% confidence interval 25.7%–55.7%). The expected incremental yield from a third culture was 8.4%, and the number of third cultures required to detect one additional TB case was 394 (95% credibility interval 231–670). ConclusionsThe incremental yield of the third sputum smear was negligible. It may be reasonable to perform an NAAT, smear and culture on the first specimen and culture alone on the second. The utility of the third serial culture for the detection of additional TB case is debatable.

Impact of the use of GeneXpert on TB diagnosis and anti-TB treatment outcome at health facilities in Addis Ababa, Ethiopia in the post-millennium development years.

GeneXpert is an effective and rapid molecular system used for tuberculosis (TB) diagnosis. It is expected to improve the detection rate and treatment outcomes needed to meet the sustainable development goals (SDG) and End TB strategy targets set for 2030. This study aimed to evaluate the impact of GeneXpert on diagnosis and anti-TB treatment outcomes in the post-millennium development goals (MDGs) in the capital city of Ethiopia. Hence, the global priority indicator based on the End TB Strategy for TB treatment success rate was met early in 2018 in Addis Ababa, Ethiopia, which was anticipated to be met by 2025. A retrospective health facilities-based study was conducted in Addis Ababa, Ethiopia. Records of all TB cases diagnosed and treated in selected health facilities from January 1st, 2015 to December 31st, 2018 were reviewed and included in the study. Data analysis of descriptive and inferential statistics was conducted using SPSS version 20. The reviewed records have shown that a total of 45,158 presumptive pulmonary TB (PTB) cases had accessed TB diagnosis services. Of which, 28.9% (13072/45158) were tested by AFB microscopy and 71.1% (32086/45158) were tested by GeneXpert. During the study period, the coverage of Xpert MTB/RIF testing increased to 94.9% in 2018 compared to 1.6% in 2015. The number of presumptive PTB cases tested with the GeneXpert system showed a significant increase compared to smear microscopy. The odds of positivity were detected in males compared to females. The odds of detecting TB cases were much higher among study participants aged 15-44 years compared to younger than 15 years. Treatment success rate showed a relative improvement each year between 2015 and 2018 with a mean of 92.6%. Reduced odds of treatment successes were observed in age categories older than 35 years, and in TB/HIV co-infected patients. Increased odds of treatment successes were reported in the years between 2016 and 2018 compared to 2015. Scaling up the Xpert MTB/RIF assay as a point-of-care test for presumptive TB cases in resource-limited settings would have a significant impact to meet the SDG and End TB strategy both in TB detection and treatment success rates.

Incidental radiological findings during clinical tuberculosis screening in Lesotho and South Africa: a case series

BackgroundChest X-ray offers high sensitivity and acceptable specificity as a tuberculosis screening tool, but in areas with a high burden of tuberculosis, there is often a lack of radiological expertise to interpret chest X-ray. Computer-aided detection systems based on artificial intelligence are therefore increasingly used to screen for tuberculosis-related abnormalities on digital chest radiographies. The CAD4TB software has previously been shown to demonstrate high sensitivity for chest X-ray tuberculosis-related abnormalities, but it is not yet calibrated for the detection of non-tuberculosis abnormalities. When screening for tuberculosis, users of computer-aided detection need to be aware that other chest pathologies are likely to be as prevalent as, or more prevalent than, active tuberculosis. However, non­-tuberculosis chest X-ray abnormalities detected during chest X-ray screening for tuberculosis remain poorly characterized in the sub-Saharan African setting, with only minimal literature.Case presentationIn this case series, we report on four cases with non-tuberculosis abnormalities detected on CXR in TB TRIAGE + ACCURACY (ClinicalTrials.gov Identifier: NCT04666311), a study in adult presumptive tuberculosis cases at health facilities in Lesotho and South Africa to determine the diagnostic accuracy of two potential tuberculosis triage tests: computer-aided detection (CAD4TB v7, Delft, the Netherlands) and C-reactive protein (Alere Afinion, USA). The four Black African participants presented with the following chest X-ray abnormalities: a 59-year-old woman with pulmonary arteriovenous malformation, a 28-year-old man with pneumothorax, a 20-year-old man with massive bronchiectasis, and a 47-year-old woman with aspergilloma.ConclusionsSolely using chest X-ray computer-aided detection systems based on artificial intelligence as a tuberculosis screening strategy in sub-Saharan Africa comes with benefits, but also risks. Due to the limitation of CAD4TB for non-tuberculosis-abnormality identification, the computer-aided detection software may miss significant chest X-ray abnormalities that require treatment, as exemplified in our four cases. Increased data collection, characterization of non-tuberculosis anomalies and research on the implications of these diseases for individuals and health systems in sub-Saharan Africa is needed to help improve existing artificial intelligence software programs and their use in countries with high tuberculosis burden.

Simultaneous screening for COVID-19 and tuberculosis, India.

To evaluate the implementation of new operational workflows for simultaneous screening of coronavirus disease 2019 (COVID-19) and tuberculosis at four high-volume COVID-19 testing centres located in tertiary hospitals in Mumbai, India. Each centre already offering antigen-detecting rapid diagnostic tests were equipped with a rapid molecular testing platform for COVID-19 and tuberculosis, sufficient laboratory staff, and reagents and consumables for screening. Using a verbal tuberculosis questionnaire, a patient follow-up agent screened individuals visiting the COVID-19 testing centres. Presumptive tuberculosis patients were asked to provide sputum samples for rapid molecular testing. Subsequently, we reversed our operational workflow to also screen patients visiting tuberculosis outpatient departments for COVID-19, using rapid diagnostic tests. From March to December 2021, we screened 14 588 presumptive COVID-19 patients for tuberculosis, of whom 475 (3.3%) were identified as having presumptive tuberculosis. Of these, 288 (60.6%) were tested and 32 individuals (11.1%) were identified as tuberculosis positive (219 cases per 100 000 individuals screened). Of the tuberculosis-positive individuals, three had rifampicin-resistant tuberculosis. Among the remaining 187 presumptive tuberculosis cases not tested, 174 reported no symptoms at follow-up and 13 individuals either refused testing or could not be traced. Of the 671 presumptive tuberculosis cases screened for COVID-19, 17 (2.5%) were positive by antigen rapid diagnostic tests, and five (0.7%) who tested negative, later tested positive on the molecular testing platform (2483 COVID-19 cases per 100 000 individuals screened). Simultaneous screening for COVID-19 and tuberculosis in India is operationally feasible and can improve real-time on-site detection of COVID-19 and tuberculosis.

High non-compliance rate among presumptive tuberculosis cases referred from peripheral health facilities in silti district of Southern Ethiopia: a mixed methods study

BackgroundFor presumptive Tuberculosis (TB) case referral to be effective, most of the referred cases need to present themselves to health facilities for assessment and testing. Otherwise, cases of TB could be missed, and these cases are at an increased risk of delayed diagnosis, complications and death. Further, their care incurs significantly higher costs. This study assessed referral compliance as well as factors attributable to compliance/non-compliance to referral of presumptive TB cases in Silti district, Southern Ethiopia.MethodWe applied a mixed design involving both quantitative and qualitative methods. A randomly selected sample of 384 presumptive TB cases referred between January, 2014 and July 2021 were included in this study from the records of 12 health posts. Purposefully selected presumptive TB cases and Health Extension Workers were also interviewed to get in-depth information on the reasons for compliance and non-compliance to referral. STATA version 14 was employed to model the data using logistic regression. Qualitative data were analyzed using thematic content analysis.ResultsOf the 384 referred presumptive TB cases, close to 49% did not present themselves to the referral facilities. About 66% (n = 249) of the referred cases were women, and 62% (n = 119) of those who complied to referral were women. In multivariate analysis, cough [AOR = 3.4, 95%CI: 1.54–7.32], and chest pain [AOR = 2.7, 95%CI: 1.45–5.05] were independent predictors of compliance to referral. Nearly 5.5% (n = 21) of TB cases of all types were identified. The qualitative data analysis revealed that severe disease symptoms, HEW’s recommendations, and social issues as reasons improving compliance while personal and social factors, financial problems, lack of awareness about TB and transportation were reasons impeding compliance to referral.ConclusionOur study showed a high level of non-compliance to referral among referred presumptive TB cases. We also found that more women were referred and also complied with the referral. Strengthening community awareness about the disease symptoms and the existence of free treatment, addressing misconceptions about TB, supporting the elderly and disabled, and checkup house visits after referral could improve compliance to referral.

Burden of Mycobacterium tuberculosis and Associated Factors among Presumptive Extra pulmonary Tuberculosis Patients from Selected Health Facilities, Addis Ababa, Ethiopia

BackgroundExtra pulmonary tuberculosis (EPTB) accounts for a significant proportion of tuberculosis (TB), a devastating disease of public health concern. The complexity of the cases, the involvement of many organs, resource constraints, and concerns regarding drug resistance make disease diagnosis and treatment difficult. This study aimed to determine the burden of tuberculosis and associated factors among presumptive EPTB patients in selected hospitals in Addis Ababa. Material and methodsA cross-sectional study was conducted from February to August 2022 in selected public hospitals in Addis Ababa. Those who attended the hospitals and were presumptively diagnosed as EPTB patient were included in the study. Sociodemographic and clinical data were collected using a semistructured questionnaire. The GeneXpert MTB/RIF assay, Mycobacterium Growth Indicator Tube (MGIT) culture, and solid culture using Löwenstein–Jensen (LJ) medium were used. The data were entered and analyzed using SPSS version 23, and a p-value ≤ 0.05 was considered as statistically significant. ResultsFrom a total of 308 participants enrolled in this study, the measured burdens of extrapulmonary tuberculosis using the Xpert MTB/RIF assay, liquid culture, and solid culture were 54 (17.5%), 45 (14.6%), and 39 (12.7%), respectively. In this study, sex, contact history with known TB cases, having a purulent type of aspirate, and being HIV positive had statistically significant associations with EPTB. ConclusionsThe burden of extrapulmonary tuberculosis among presumptive extrapulmonary tuberculosis cases was found to be significant. Sex, contact history with a known TB case, having apurulent type of aspirate, and being HIV positive were found to be associated with extrapulmonary tuberculosis infection. Strict adherence to the national tuberculosis diagnosis and treatment guidelines is important, while the true burden of the disease should be ascertained using standard diagnostic tests for better prevention and control interventions.

Epidemiology of tuberculosis in Mongolia: analysis of surveillance data, 2015-2019.

Mongolia has a high tuberculosis (TB) burden. Data from routine paper-based surveillance were used to describe the epidemiology of TB in Mongolia; the data included testing presumptive TB cases, TB notifications, drug-resistant cases, treatment outcomes and notifications in prisoners. The proportion of the population tested for TB increased between 2015 and 2019. The number and rate per 100 000 population of TB notifications decreased between 2015 and 2018 and then increased in 2019. Most TB notifications in 2019 were in the capital, Ulaanbaatar (59.3%), followed by the central (16.8%), Khangai (10.4%), east (8.5%) and west (5.0%) regions. About half of TB notifications nationally were bacteriologically confirmed (45.4% in 2015, 48.1% in 2019), with the proportion of bacteriologically confirmed TB per province or district varying from 0% to 66%. High TB notification rates were observed in 2019 for males aged 15-54 years (202 per 100 000 population) and females aged 15-34 years (190 per 100 000 population). Treatment success for all forms of TB was 90% in 2019 but was below the 90% target for bacteriologically confirmed cases. Between 2015 and 2019, the number of RR/MDR-TB notifications ranged from 265 to 211. The Mongolian National Tuberculosis Programme needs to continue its efforts in TB control, to further increase the programmatic impact and reduce the TB burden. It is recommended that Mongolia continue to increase TB screening, the use of Xpert testing, contact investigations and preventive treatments, and targeting interventions to the high-burden areas identified in this subnational analysis.

Effect of a training intervention for finding the missed cases of tuberculosis amongst patent medicine vendors in Delta State, Nigeria.

The undiagnosed and untreated tuberculosis (TB) cases underpin the experience of accelerating deaths. Everyone should be engaged in managing TB patients to revert the current trend. In this context, we assessed the outcome of an education intervention on the knowledge of TB and referral practice of presumptive TB cases to directly observed therapy strategy amongst patent medicine vendors (PMVs). The study was quasi-experimental, conducted amongst 647 PMVs in Delta State, Nigeria. A structured questionnaire was administered to obtain baseline data on knowledge of TB. An educational intervention on knowledge of TB was then given. A post-intervention assessment of TB knowledge was subsequently conducted using the same questionnaire. The exact number of referrals of presumptive TB cases by PMVs and the number that tested positive amongst the referred presumptive TB cases, 3 months before and after the training were obtained from the state TB database. SPSS v. 26 was used for data analysis. The pre-training knowledge average score was 15.45 ± 6.45, while the post-training average score was 19.44 ± 7.03 (P < 0.001). The pre-training average number of presumptive cases referred was 146 ± 124.7, and the post-training was 205.67 ± 255.4, P = 0.41. The pre-training average number of cases that turned out positive was 9.5 ± 6.3, and the post-training was 13.5 ± 11.3, P = 0.42. There was a significant improvement in PMVs' knowledge of TB post-intervention. However, while an increase in the number of cases referred and positives detected was observed, this was not significant. Periodic training and updates to PMVs in keeping with current trends and best practices in TB management are recommended.

The Effect of the COVID-19 Pandemic on Pulmonary Tuberculosis Control in the Selected Upazila Health Complexes of Dhaka Division, Bangladesh.

Despite the enormous disruption of tuberculosis (TB) services reported globally, Bangladesh's impact is not well documented. We aimed to assess the effect of the COVID-19 pandemic on the TB control program in Bangladesh from patients' and service providers' perspectives. We conducted a cross-sectional study from November-December 2021 at six conveniently selected Upazila Health Complexes (UHC) of the Dhaka division, Bangladesh. We conducted face-to-face interviews among 180 pulmonary TB service recipients and all TB service providers working in the selected UHC. We also reviewed TB registries from each UHC. All data were summarized using descriptive statistics tools. We found a 31% reduction in presumptive TB cases during 2021 compared to 2020. Other TB services, such as testing, were reduced by 16-36% during the same period. Service receivers reported a lack of transportation (95%), and a lack of adequate human resources (89%) as critical barriers to receiving and providing TB service, respectively. The findings of our study showed substantial interruption of TB service delivery during the COVID-19 pandemic, threatening the recent progress and pushback from achieving the 2035 End TB targets. Early mitigation of TB service delivery through adopting remote follow-ups using digital health technology and integrating COVID-19 and TB screening is essential for the continuity of essential TB services and achieving global TB targets.

Magnitude and factors associated with pre-diagnosis loss to follow-up among tuberculosis presumptive patients in the Cycle of Health Care, Musoma, Tanzania: Cross-sectional study

Background: Despite National Tuberculosis (TB) Program efforts on tuberculosis control in the country, pre-diagnosis loss to follow-up is still a major problem. The study aims at exploring the magnitude and risk factors of presumptive TB cases who either do not submit a second sputum sample or do not show up for their laboratory results.&#x0D; Methods: The study included presumptive TB registered at the Musoma Regional Referral Hospital between May and November 2014. Lost to follow up presumptive TB were then traced and interviewed from December 2014 to April 2015. One hundred and thirty-two among those who submitted both samples and showed up for their results were randomly selected as a comparison group. &#x0D; Results: A total of 620 presumptive TB was registered at the Musoma Regional Referral Hospital (MRRH), of which 521 (84.0%) completed TB testing in accordance with the national TB diagnostic algorithm while 99 (16.0%) did not complete. Out of those who did not complete, 65 (65.7%) submitted only one spot sample and 34 (34.3%) submitted both but all of these did not pick-up their results. The Mean age of participants was 45.3 years (Standard deviation 17.7). The main reasons for loss to follow-up were: 23 (23.2%) opted to go to other health care facilities; 23 (23.2%) lack of transport fare; and 20 (20.2%) long distance to the hospital. Males were 1.6 (95%CI1.02-2.90) more likely to complete TB diagnostic algorithm.

Training program for tuberculosis (TB) patients to improve referrals of presumptive TB cases and sputum in Denpasar, Bali, Indonesia

Background and purpose: Tuberculosis (TB) is a global healthproblem and one of the top ten causes of deaths in the world. TB case finding is an important component of TB control. In Indonesia, most case findings were done passively so that the referral coverage for TB sputum was lower than the target. This study aims to determine the effectiveness of training for TB patients as volunteers to increase the active referral of presumptive TB cases. Methods: The pretest-posttest design intervention study was conducted in five public health centers (PHCs) which had the highest number of TB patients in Denpasar. The intervention was carried out for seven weeks (February May 2020). A total of 35 TB patients, who were currently undergoing treatment at the PHCs, met the study criteria and willing to volunteer, were trained through meetings, discussions and demonstrations about the risk of TB transmission, contact investigations and how to collect sputum samples. Before and after the interventions, data on volunteers’ knowledge, the number of presumptive TB and sputum referrals by volunteers were collected through interviews and daily records. A regular reminder was sent in the form of a WhatsApp message once a week. Bivariate data analysis was performed with Chi-square and Wilcoxon Signed Rank Test. Results: Volunteers’ knowledge scores increased significantly after training, with a median score of 13.0 to 15.0 (p&lt;0.001), and there was a significant difference in knowledge improvement amongthose who actively responded to regular reminders compared to those who were less active (p=0.002). A total of 31 presumptive TB cases were successfully referred during the study period (7 weeks). Volunteers managed to refer as many as 30 sputum preparations with good quality, but no positive sputum was found. Conclusion: Recruitment and training of TB patients as volunteers can increase the knowledge and skills of volunteers to identify and refer presumptive TB cases and quality sputum samples. More TB patients should be trained as volunteers with a longer observation time to increase TB patient detectio

Barriers and motivation for presumptive tuberculosis case referral: qualitative analysis among operators of community medicine outlets in Ghana

BackgroundCommunity medicine outlets (CMOs) are the first point of call for individuals presenting with cough in Ghana. Although operators of CMOs comprising pharmacists and over-the-counter (OTC) medicine sellers largely support the public–private mix strategy which seeks to engage pharmacies in tuberculosis (TB) case detection, a significant proportion is not involved in TB referral services. The study explores the barriers to and motivation for presumptive TB case referral among CMO operators.MethodsWe used open- and close-ended questions nested in a telephone survey which assessed factors associated with presumptive TB case referral among CMO operators (n = 465). We interviewed participants using computer assisted telephone interviews and analysed the qualitative data using adjusted Mayring’s structured qualitative content analysis.ResultsBased on participants’ own experiences, non-referral was attributed to negative attitudes of presumed cases (48.2%) and inability to meet the financial demands of referred presumed cases (26.3%). Regarding their perception of barriers to TB referral for their professional colleagues, an assumed lack of TB training (44.5%) and an assumed negative attitude of operators (43.6%) were mentioned. From close-ended questions, most chosen barriers to referral were: the assumption of not having seen a presumptive TB case yet (31.8%), lack of TB training (22.2%) and no monetary motivation for operators (10.5%). Most operators (81.6%) view TB referral services as their social responsibility and feel self-motivated to refer cases in order to control the spread of TB in their communities. Of 152 further comments extracted as recommendations to improve referral, 101 (66.4%) of respondents would only refer with the availability of support systems in the form of TB training and making TB diagnostic testing more accessible.ConclusionOperators of CMOs are predominantly self-motivated to refer presumptive TB cases. Barriers to referral might be mitigated by providing more training to operators and specific financial support such as reimbursement of travel costs to presumptive cases.

Bayesian latent class analysis produced diagnostic accuracy estimates that were more interpretable than composite reference standards for extrapulmonary tuberculosis tests

BackgroundEvaluating the accuracy of extrapulmonary tuberculosis (TB) tests is challenging due to lack of a gold standard. Latent class analysis (LCA), a statistical modeling approach, can adjust for reference tests’ imperfect accuracies to produce less biased test accuracy estimates than those produced by commonly used methods like composite reference standards (CRSs). Our objective is to illustrate how Bayesian LCA can address the problem of an unavailable gold standard and demonstrate how it compares to using CRSs for extrapulmonary TB tests.MethodsWe re-analyzed a dataset of presumptive extrapulmonary TB cases in New Delhi, India, for three forms of extrapulmonary TB. Results were available for culture, smear microscopy, Xpert MTB/RIF, and a non-microbiological test, cytopathology/histopathology, or adenosine deaminase (ADA). A diagram was used to define assumed relationships between observed tests and underlying latent variables in the Bayesian LCA with input from an inter-disciplinary team. We compared the results to estimates obtained from a sequence of CRSs defined by increasing numbers of positive reference tests necessary for positive disease status.ResultsData were available from 298, 388, and 230 individuals with presumptive TB lymphadenitis, meningitis, and pleuritis, respectively. Using Bayesian LCA, estimates were obtained for accuracy of all tests and for extrapulmonary TB prevalence. Xpert sensitivity neared that of culture for TB lymphadenitis and meningitis but was lower for TB pleuritis, and specificities of all microbiological tests approached 100%. Non-microbiological tests’ sensitivities were high, but specificities were only moderate, preventing disease rule-in. CRSs’ only provided estimates of Xpert and these varied widely per CRS definition. Accuracy of the CRSs also varied by definition, and no CRS was 100% accurate.ConclusionUnlike CRSs, Bayesian LCA takes into account known information about test performance resulting in accuracy estimates that are easier to interpret. LCA should receive greater consideration for evaluating extrapulmonary TB diagnostic tests.