Presumptive Tuberculosis Cases Research Articles

Rifampicin resistant tuberculosis in presumptive pulmonary tuberculosis cases in Dubti Hospital, Afar, Ethiopia.

Ethiopia stood third in drug-resistant tuberculosis (TB) in Africa, and more than 5,000 MDR-TB patients are reported each year. Greater than 90% of rifampicin (RIF) resistant strains are resistant to isoniazid (INH) and hence the objective of this study was to determine the prevalence and risk factors of RIF resistant MTB among presumptive TB cases at Dubti General Hospital, Afar, Ethiopia. In this cross-sectional study, 384 presumptive TB cases were recruited and a structured questionnaire was used to collect socio-demographic and clinical data. Sputum samples were collected and examined using X-pertMTB/RIF assay. Bivariate, multivariate logistic regressions, and fishers' exact analysis were done to assess the associations between the prevalence of TB and MDR-TB with different socio-demographic and clinical variables. In the present study, the overall prevalence of pulmonary TB was 24.5% (94/384), of this 4 (4.3%) isolates were resistant to RIF. History of anti-TB treatment (AOR = 2.4, 95% CI: 1.3-4.4 and TB contact (AOR = 3.6, 95% CI: 2.1-6.2 were significantly associated with gene X-pert MTB/RIF positive TB. Moreover, resistance to rifampicin was statistically associated with the history of TB contact with multi-drug resistant TB (P = 0.027) and khat chewer cases (P = 0.04). The overall prevalence of TB and its drug-resistant were relatively higher than that of in the general population in Ethiopia. History of anti-TB treatment and TB contact were significantly associated with X-pert MTB/RIF positive MDR-TB.

Burden of Pulmonary Tuberculosis among Tribal Population: A Cross-sectional Study in Tribal Areas of Maharashtra, India.

Background:It is very important to identify and treat infectious pulmonary tuberculosis (PTB) patients at the earliest to save the life of the patients and to prevent the transmission of infectious agent to others. As per Global Tuberculosis (TB) Report 2017, an estimated 28 lakh new TB cases occur and 4.23 lakh people die due to TB annually. Due to the poor health services and lack of awareness, particularly vulnerable tribal groups are vulnerable or at risk to many diseases including TB.Methodology:A community-based cross-sectional study was conducted to determine the burden of pulmonary TB (PTB) among adult tribal population of Maharashtra. House-to-house visit was conducted to identify the presumptive TB cases and sputum microscopy and chest X-ray were done to confirm the diagnosis.Results:In the survey, 6898 tribal adults were interviewed from 8 tribal clusters, and among them, 144 (2.1%) presumptive TB cases were identified. The most common symptom among the presumptive TB cases was cough for >2 weeks (93.1%). The prevalence of PTB in the study area estimated is 261per lakh tribal population per year.Conclusion:The current study shows that the estimated burden of PTB among tribal population is within the wide variation of prevalence reported from other studies in different tribal communities (133–3294 per lakh population) in India. The current study provides vital information on the burden of TB among the tribal population of Maharashtra which can be used as a baseline data for future epidemiological studies.

Active case-finding for tuberculosis in India.

Early identification of presumptive tuberculosis (TB) cases through active case-finding (ACF) would be an important complementary strategy to meet the national urgency in accelerating case detection to achieve the goals of 'End TB' strategy. ACF activities have yielded additional cases in different vulnerable groups in India. The yield of cases depends on the screening tool available, the characteristics of the high-risk population being screened, and most importantly, the linkage between effective diagnostic and treatment facilities. The ACF strategy could be both economically and epidemiologically relevant if it could bring down the level of transmission. This needs long-term research focusing on outcomes such as cases averted and reduction in the prevalence of the disease. Available evidence suggests that ACF is likely to be feasible in Indian settings but needs to be scaled up rapidly to create a good impact.

A Framework for Improving the Engagement of Medical Practitioners in an E-Training Platform for Tuberculosis Care and Prevention

We propose a new framework to improve the engagement of medical practitioners in a planned e-training platform for the successful identification and effective management of presumptive cases of tuberculosis (TB) in Pakistan. Our work is aligned with the World Health Organization’s TB-DOTS (Directly Observed Treatment Short-course) strategy for promoting the effective management of tuberculosis. We start by presenting previous work done at Mercy Corps Pakistan for training medical practitioners, then present the results of a recent survey we administered to a random sample of medical practitioners in Pakistan to learn about their requirements and readiness to embrace a new e-training platform and methodology. Informed by feedback from the survey, we formulated a detailed requirement analysis of the five key learning areas (or phases) that we believe are fundamental to the success of a TB e-training platform. Moreover, survey results revealed that an on-spot, on-demand, and competency-based learning tool can potentially improve the engagement of medical practitioners in the process. Building on the insights gained from the survey, we finally describe our initial UX (user experience) prototypes for phase 1, which corresponds to the identification of presumptive tuberculosis cases.

Urine Xpert MTB/RIF for the diagnosis of childhood tuberculosis

IntroductionXpert MTB/RIF is recommended for the simultaneous detection of tuberculosis (TB) and rifampicin resistance directly from sputum specimens. Since young children cannot always expectorate, we assessed urine as a possible specimen source to diagnose TB in children using Xpert MTB/RIF. MethodsDuring a field study to enhance childhood TB identification, spot urine samples were prospectively collected from consecutive ambulatory children aged 0 to 14 years presenting with presumptive pulmonary TB in community health centers. Urine Xpert MTB/RIF was performed by blinded technicians in 182 samples using 2ml of unprocessed urine. ResultsThe mean age of presumptive TB cases was 5.9 years (median 5.4, range 0.1 to 14.7) with more males (113, 62%) compared to females. All urine samples tested negative for Xpert MTB/RIF, regardless of whether concentration was performed or not. Out of these 182 presumptive TB cases, 50 (28%) were clinically diagnosed and 5 (3%) were bacteriologically diagnosed to have TB disease using either sputum or nasopharyngeal aspirate specimens. ConclusionsIn this community-based study, urine Xpert MTB/RIF does not appear to contribute to the diagnosis of childhood TB.

HIV status among presumptive tuberculosis cases attending tertiary care centre in South India.

In India, to increase human immunodeficiency virus (HIV) case detection, the National Technical Working Group on TB /HIV had made it mandatory to screen for HIV infection among presumptive tuberculosis (TB) cases. Our study was a cross-sectional study, conducted between June 2015 and December 2016 in a tertiary care institute (JIPMER), in South India, to estimate the prevalence of HIV among presumptive TB cases. Among the 964 presumptive TB cases who attended pulmonary medicine OPD, 189 patients were sputum acid-fast bacilli (AFB) positive. Among the 189 sputum positive cases, 9 were HIV positive. Of the 964 presumptive TB cases, 879 gave consent for HIV testing and 33 (3.7%) turned out to be HIV positive. If only sputum positive cases had been screened for HIV, we would have missed 24 new HIV positive cases. The number needed to screen was 27 among presumptive TB cases and 18 among TB patients. The uptake of HIV testing (91%) and the diagnostic yield of 3.7% of HIV positive cases among the presumptive TB patients is quite high compared to that of the Revised National Tuberculosis Control Programme (RNTCP) mechanism of Puducherry. This reinforces the need to screen all the presumptive cases for HIV infection, to increase HIV case detection so that anti-retroviral therapy (ART) can be initiated early.

Demography and the dual epidemics of tuberculosis and HIV: Analysis of cross-sectional data from Sub-Saharan Africa.

BackgroundConvergence of tuberculosis (TB) and HIV epidemics is associated with higher morbidity and mortality risks and understanding their distribution across key demographic factors is essential for prevention and control. This analysis examines the prevalence of TB, HIV and TB-HIV coinfection across age and gender in patients with presumptive TB seeking care at the National TB and Leprosy Training Center in Nigeria.MethodsSamples from 1603 presumptive pulmonary TB cases who provided informed consent were evaluated with a sequential testing algorithm that included a smear microscopy, cultures in liquid and broth media and then genotyping by Hain line probe assays. HIV was serially tested with two HIV rapid assays and retested with a third assay in non-conclusive samples.ResultsTwenty-three percent (375/1603) had confirmed pulmonary TB infection, 23.6% (378/1603) were positive for HIV infection and 26.9% (101/375) of the confirmed TB cases were HIV co-infected. Males had a higher prevalence of TB: 27.6% vs. 18.0%, p < .0001; and a lower prevalence of HIV: 19.0% vs. 29.6%, p < .0001. In the age range of 25–29 years, males were twice as likely to have TB (OR = 2.2; 95% confidence interval [CI]: 1.3–3.9, p = 0.0032) while females were five times more likely to have HIV (OR = 4.8; 95% CI: 2.6–8.9, p < .0001). Persons with TB-HIV coinfection were more likely to be young, female and less likely to be married.ConclusionYounger females with a high burden of HIV may be under-diagnosed and under-reported for TB in Nigeria. Community programs for intensified and early detection of TB and HIV targeting younger females are needed in this setting.

Upfront Xpert MTB/RIF testing on various specimen types for presumptive infant TB cases for early and appropriate treatment initiation.

BackgroundDiagnosis of tuberculosis (TB) in infants is challenging due to non-specific clinical presentations of the disease in this age-group and low sensitivity of widely available TB diagnostic tools, which in turn delays prompt access to TB treatment. Upfront access to Xpert/MTB RIF (Xpert) testing, a highly sensitive and specific rapid diagnostic tool, could potentially address some of these challenges. Under the current project, we assessed the utility and feasibility of applying upfront Xpert for diagnosis of tuberculosis in infants, including for testing of non-sputum specimens.MethodsA high throughput lab was established in each of the four project cities, and linked to various health care providers across the city, through rapid specimen transportation and electronic reporting linkages. Free Xpert testing was offered to all infant (<2 years of age) presumptive TB cases (both pulmonary and extra-pulmonary) seeking care at public and private health facilities.ResultsA total of 7,994 presumptive infant TB cases were enrolled in the project from April 2014 to October 2016, detecting 465 (5.8%, CI: 5.3–6.4) TB cases. The majority (93.9%; CI: 93.4–94.4) of patient specimens were non-sputum and TB positivity was higher amongst non-sputum specimens. Further, a high proportion (5.6% CI 3.8–8.1) of infant TB cases were found to be rifampicin resistant. Covering large cities with a single lab per city over more than two years, the project demonstrated the feasibility of same-day diagnosis with upfront Xpert testing. This in turn led to prompt treatment initiation, with a two-day median turnaround time to treatment initiation. Case mortality observed in the project cohort of diagnosed TB cases was 11.0% (CI 8.4–14.1), the majority of which was pre- or early treatment mortality, in spite of prompt access to treatment for most diagnosed cases.ConclusionThe current project demonstrated the feasibility of applying rapid and upfront Xpert testing for presumptive infant TB cases. Rapid TB diagnosis in turn facilitates prompt and appropriate treatment initiation. Further, levels of rifampicin resistance observed in infants TB cases highlight the additional benefit of upfront resistance testing. However, high rates of early case mortality, in spite of prompt diagnosis and treatment initiation, highlight the need for further research in infant patient pathways for overall improvement in TB care for infant populations.

Detection and Diagnostic Accuracy of Rapid Urine Lipoarabinomannan Lateral-Flow Assay in Pulmonary Tuberculosis patients in Nigeria

Background: Tuberculosis (TB) is a public health challenge in both developed and developing countries. Early diagnosis is essential in preventing the further spread of the disease, but the control programs are currently facing a number of constraints and fewer than 25% of all tuberculosis cases especially childhood cases are detected. We aimed to evaluate diagnostic accuracy of a commercially available qualitative immunoassay for the detection of lipoarabinomannan (LAM) antigen of Mycobacteria in human urine by comparing its sensitivity and specificity in TB patients with the AFB and GeneXpert in individuals with presumptive tuberculosis cases. Methods: A cross-sectional study that consecutively enrolled 53 eligible TB adults’ patients attending TB Centre, Mangu, Plateau State from February to March 2017. We applied the LAM test on urine collected as a spot and early morning sample. Diagnostic accuracy was analyzed for a microbiological TB reference standard based on Gene Xpert MTB/RIF results and for a composite reference standard including clinical data. Performance of sputum smear microscopy (AFB) was included for comparison. Results: The mean age of the respondents was 41.0±17.0 years.) The male proportion was 36(68.0%) and female was 17(32.0%). The patients with HIV-1 Co-infection were 9(23.8%). Of the 53 patients, the positive testing rate of TB using LAM test was 11 (20.8 %). The proportion of those who tested positive using Gene Xpert was 9(17.0%) and AFB was 33(62.2%), and the sensitivity and specificity were 33.3% and 93.2%, respectively. Negative and positive predictive values were 87.23% and 50.0%, diagnostic accuracy was 83.02%. Conclusion: The study showed great sensitivity of urine LAM test suggesting it could be useful as point of care diagnostic test for presumptive TB cases. Its high negative predictive value suggests a role in screening out uninfected patients; though GeneXpert had superior sensitivity, but the ease of the LAM test holds operational advantage as a screening method, however larger studies are needed to further determine diagnostic accuracy.

Rifampicin resistance among patients with Tuberculosis at the Olabisi Onabanjo University Teaching Hospital, Sagamu

Background: Tuberculosis (TB) is a major public health problem in Nigeria. The emergence of multidrug-resistant Tuberculosis poses a threat to global Tuberculosis control and if not effectively addressed, may wipe out the achievements of previous efforts in controlling Tuberculosis. Objectives: To determine the prevalence and factors associated with rifampicin resistance amongpatients receiving care for TB at the OlabisiOnabanjo University Teaching Hospital, Sagamu. Methods: A retrospective study of presumptive Tuberculosis cases managed between January 2013 and December 2016 at the Directly Observed Treatment clinic, OlabisiOnabanjoUniversity Teaching Hospital Sagamu, Ogun State, Nigeria,was done. One sputum sample was obtained from each patient for the Gene Xpert® test to diagnoseTB and to determine rifampicin resistance among patients with confirmed Mycobacterium tuberculosis infection. HIV screening was also carried out on all the patients using HIV Rapid Test kits. The sociodemographic data were retrieved from the presumptive Tuberculosis register. Results: A total of 1572 presumptive TB patients were screened for TB, out of which 187 (11.8%) were confirmed to be infected with Mycobacterium tuberculosis (MTB). A total of 20 (10.7%) of the 187 MTB patients had rifampicin resistance using Gene Xpert® method. Rifampicin resistance rate was significantlyassociated with re-treatment TB category but not with age, sex or HIV status. Conclusion: The study showed rifampicin drug resistance among confirmed TB patients. There is a need to decentralizethe use of Gene Xpert® test for TB to the peripheral facilities and make it a point of care test for presumptive TB patients.

Comparison of the yield of tuberculosis among contacts of multidrug-resistant and drug-sensitive tuberculosis patients in Ethiopia using GeneXpert as a primary diagnostic test

ObjectivesThis study compared the yield of tuberculosis (TB) among contacts of multidrug-resistant tuberculosis (MDR-TB) index cases with that in drug-sensitive TB (DS-TB) index cases in a program setting. MethodsA comparative cross-sectional study was conducted among contacts of sputum smear-positive new DS-TB index cases and MDR-TB index cases. After contacts were screened, GeneXpert was used for the diagnosis of TB. ResultsThe study included 111 MDR-TB and 119 DS-TB index cases. A total of 340 and 393 contacts of MDR-TB and DS-TB index cases, respectively, were traced, of whom 331 among MDR-TB contacts and 353 among DS-TB contacts were screened. There were 20 (6%) presumptive TB cases for MDR-TB contacts and 41 (11%) for DS-TB contacts. The prevalence of TB among MDR-TB contacts was 2.7% and among DS-TB contacts was 4.0%. The majority of the MDR-TB contacts diagnosed with TB had MDR-TB; the reverse was true for DS-TB. ConclusionsThe yield of TB among contacts of MDR-TB and DS-TB patients using GeneXpert was high as compared to the population-level prevalence. The likelihood of diagnosing rifampicin-resistant TB among contacts of MDR-TB index cases was higher in comparison with contacts of DS-TB index cases. The use of GeneXpert in DS-TB contact investigation has the added advantage of diagnosing rifampicin-resistant TB cases when compared to the use of the nationally recommended acid-fast bacillus (AFB) microscopy for DS-TB contact investigation.

Yield of tuberculosis among household contacts of tuberculosis patients in Accra, Ghana

BackgroundThe End TB Strategy calls for systematic screening of selected high-risk groups including contacts of tuberculosis (TB) cases to facilitate early TB case detection. Contact investigation is not usually routinely practiced in low TB burden countries, such as Ghana, with consequent paucity of data on the yield of TB case detection from such interventions. This study’s objective was to document the outcomes and feasibility of implementing contact investigation activities under programmatic conditions in Ghana.MethodsRetrospective analyses were conducted of abstracted data from the National TB Program, following a contact investigation intervention for TB cases diagnosed in 10 facilities in Accra from June 2010 to December 2014. Various proportions and yield from number of contacts needed to screen (NNS) and number needed to test (NNT) to detect a TB case were assessed.ResultsOverall, out of the 8519 listed contacts of 3267 index cases, 8166 (96%) were screened and 614 (7.5%) were identified as presumptive TB. Out of these, 438 (71%) underwent sputum smear microscopy/evaluation and 53 TB cases were diagnosed. Of these, 56.6% were males, and 49% had sputum smear-positive TB, 38% had sputum smear-negative TB, and 7% had extra-pulmonary TB. The NNS and NNT to detect a TB case of all forms were 154 and 8, respectively. The proportion of TB cases with contacts listed and proportion of contacts screened annually were 88–96% and 83–100%, respectively. The proportion of presumptive TB cases tested and proportion of TB cases diagnosed among contacts tested that were 100% and 36%, respectively, in 2010 dropped to 40% and 14%, respectively, by 2014.ConclusionsThe study demonstrates that contact identification and prioritization components of a contact investigation were feasible, but overall yield of TB cases may have been lower due to the declining rate of clinical evaluation of presumptive TB contacts over time. Addressing barriers to accessing appropriate diagnostic tests may enhance yield from contact investigation in Ghana.

Tuberculosis in Staff and Students of Patan Hospital.

There is a high risk of occupational exposure to tuberculosis among healthcare workers in endemic countries. Regular screening for tuberculosis among healthcare workers is not carried out in Nepal. Infection control measures are also not routinely implemented. The aim of this study was to determine the prevalence of active tuberculosis among staff/students at Patan Hospital. Participants were given a self-administered questionnaire and invited to undergo chest radiography. Cases were scored and reviewed based on predetermined criteria, and presumptive tuberculosis cases were invited to undergo sputum smear and culture. Participants were categorized according to the extent of patient contact and asked about history of tuberculosis medication. Among 560 participants, 76.8% had direct contact with patients. Fifty-eight (10.4%) gave history of cough >2 weeks. Based on symptom history and chest radiography, 20.0% (n=112) cases were reviewed, and 12.5% (n=14) of those reviewed had sputum tested for acid-fast bacilli. One participant had culture-positive tuberculosis. Fifty participants (8.9%) reported tuberculosis in the past, among which 42.0% (n=21) occurred after employment at Patan Hospital and 42.0% before joining Patan Hospital. Security staff, radiology technicians and ward cleaning staff had the highest proportion of cases with a history of tuberculosis.History of tuberculosis medication had no relation with age, sex, education, body mass index and smoking.The incidence rate of tuberculosis at Patan Hospital was 3.6 per 1000 person-years. Overall incidence of tuberculosis among healthcare workers is noteworthy. However, this study suggests when symptomatic tuberculosis occurs in healthcare worker at Patan Hospital, it is diagnosed and there is not a large pool of undiagnosed tuberculosis.

Molecular detection of sputum Mycobacterium tuberculosis/rifampicin resistance among presumptive pulmonary tuberculosis cases in Borno state, North-Eastern Nigeria

Background: Drug resistance to anti-tuberculosis (anti-TB) medication and human immunodeficiency virus (HIV) infection undermines global control of TB.Aim: The aim of this study is to determine sputum mycobacteria/rifampicin resistance obtained from Xpert MTB/RIF molecular assay in five health facilities in Borno state.Methods: Records of 5518 presumptive TB cases that presented for care from September 2014 to December 2017 were retrieved from TB registers in this multicentre descriptive study.Results: A total of 5518 pulmonary TB presumptive cases, out of which 5484 were drug-sensitive TB (DSTB) and 34 drug-resistant TB (DRTB). The MTB detection rate was 19.1% and it was higher among DRTB with rate of 41.2% than DSTB of 19.0%. The prevalence of rifampicin resistance was 6.1%, with higher preponderance rate of 78.6% among DRTB cases than 5.1% among DSTB cases. Only 2566 (46.5%) had HIV counselling and testing. The MTB detection rate of 22.1% in HIV-negative patients was significantly higher than 16.5% in HIV patients, P = 0.001, 95% confidence interval (CI) = 2.27–8.93. Conversely, RIF resistance of 7.0% obtained in HIV patients was significantly higher than 4.8% in HIV-negative patients, P = 0.03, 95% CI = 0.06–4.34. Previous TB treatment was significantly associated with RIF resistance, P = 0.000, odd ratio = 1318.1, 95% CI = 302.1–6318.3.Conclusion: GeneXpert is a valuable tool for the detection of both MTB and RIF resistance. It is therefore useful for both management and TB infection prevention and control. Given the observed strong association between previous exposure to anti-TB medication and RIF resistance in this report, we advocate mandatory resistance test for TB patients with previous exposure to TB medication in addition to good adherence to TB medication.

Assessment of Tuberculosis Prevalence in Newly Diagnosed Human Immunodeficiency Virus-Infected Adults Attending Care and Treatment Center in Gujarat, India.

Background:Tuberculosis (TB) is first opportunistic infection and leading cause of death among human immunodeficiency virus (HIV)/AIDS. Certainly, the prevalence of TB is expected to differ between general population and HIV-infected persons. This study was conducted to determine the prevalence of TB among newly diagnosed HIV-infected adults attending antiretroviral therapy (ART) center in the state of Gujarat, India.Materials and Methods:Cross-sectional study was carried out among newly diagnosed HIV-infected persons attending ART center from July 2012 to September 2012. Screening of TB symptoms and chest X-ray was done for those who consented. Sputum samples were collected for microscopy with Ziehl–Neelsen method for all presumptive TB cases and those diagnosed as pulmonary TB, culture, and drug susceptibility test was done. Blood samples were collected for CD4+ T-cells count and hemoglobin.Results:Out of 2021 eligible HIV-infected persons, 63.5% were males and 68.2% were in the age group of 26–45 years. The prevalence of TB was 17.8%. Among 360 patients with TB, 102 (28%) had smear positive TB, 86 (24%) had smear-negative TB, and 172 (48%) were diagnosed as extrapulmonary TB. Two hundred and thirty-eight (27%) TB patients with CD4+ T-Cell count below 200 compared to 122 (11%) patients above 200.Conclusion:A high prevalence of TB was found among newly diagnosed HIV-infected adults attending ART center for care and treatment. The prevalence of pulmonary and extrapulmonary TB was almost equal. Chances of TB disease were more with depletion of CD4 counts. The study highlights urgent need of intensive case finding as well as periodic screening of newly diagnosed HIV-infected individuals.

Provider initiated tuberculosis case finding in outpatient departments of health care facilities in Ghana: yield by screening strategy and target group

BackgroundMeticulous identification and investigation of patients presenting with tuberculosis (TB) suggestive symptoms rarely happen in crowded outpatient departments (OPDs). Making health providers in OPDs diligently follow screening procedures may help increase TB case detection. From July 2010 to December 2013, two symptom based TB screening approaches of varying cough duration were used to screen and test for TB among general outpatients, PLHIV, diabetics and contacts in Accra, Ghana.MethodsThis study was a retrospective analysis comparing the yield of TB cases using two different screening approaches, allocated to selected public health facilities. In the first approach, the conventional 2 weeks cough duration with or without other TB suggestive symptoms was the criterion to test for TB in attendants of 7 general OPDs. In the second approach the screening criteria cough of >24 hours, as well as a history of at least one of the following symptoms: fever, weight loss and drenching night sweats were used to screen and test for TB among attendants of 3 general OPDs, 7 HIV clinics and 2 diabetes clinics. Contact investigation was initiated for index TB patients. The facilities documented the number of patients verbally screened, with presumptive TB, tested using smear microscopy and those diagnosed with TB in order to calculate the yield and number needed to screen (NNS) to find one TB case. Case notification trends in Accra were compared to those of a control area.ResultsIn the approach using >24-hour cough, significantly more presumptive TB cases were identified among outpatients (0.82% versus 0.63%), more were tested (90.1% versus 86.7%), but less smear positive patients were identified among those tested (8.0% versus 9.4%). Overall, all forms of TB cases identified per 100,000 screened were significantly higher in the >24-hour cough approach at OPD (92.7 for cough >24 hour versus 82.7 for cough >2 weeks ), and even higher in diabetics (364), among contacts (693) and PLHIV (995). NNS (95% Confidence Interval) varied from 100 (93-109) for PLHIV, 144 (112-202) for contacts, 275 (197-451) for diabetics and 1144 (1101-1190) for OPD attendants. About 80% of the TB cases were detected in general OPDs. Despite the intervention, notifications trends were similar in the intervention and control areas.ConclusionThe >24-hour cough approach yielded more TB cases though required TB testing for a larger number of patients. The yield of TB cases per 100,000 population screened was highest among PLHIV, contacts, and diabetics, but the majority of cases were detected in general OPDs. The intervention had no discernible impact on general case notification.

Improved performance of Xpert MTB/RIF assay on sputum sediment samples obtained from presumptive pulmonary tuberculosis cases at Kibong\u2019oto infectious diseases hospital in\xa0Tanzania

BackgroundThe introduction of Xpert MTB/RIF assay (Xpert) has significantly improved diagnosis of Tuberculosis (TB) in resource limited human immunodeficiency virus (HIV) endemic settings. We aimed to modify the Xpert protocol to improve the detection of Mycobacterium tuberculosis (MTB).MethodsThis cross sectional study was conducted among presumptive pulmonary tuberculosis (PTB) patients at Kibong’oto Infectious Diseases Hospital between August and November 2015. Each patient consented to provide 2 samples of raw sputa. One-sputum sample was sedimented using the Petroff’s method and divided into two portions. One portion of sediment was inoculated on Lowenstein-Jensen culture media and observed for any growth for up to 8 weeks. Both, raw sputum and the portions of sediments were tested separately using Xpert with a sample reagent ratio of 1:2. Mean age of patients, prevalence of MTB, Xpert sensitivity, specificity, positive and negative predictive value were calculated. An incremental sensitivity was determined. Pearson chi-square and either an independent T or Mann-Whitney U-test were used to compared categorical and continuous variables respectively. A p- value of ≤0.05 was considered significant.ResultsOf the 270 presumptive PTB cases, 262 were eligible for analysis. Eight (3%) were excluded due to contaminated culture. Patients’ mean age was 42.9 (±SD 15.1) years of which 173 (66%) were female. The overall prevalence of PTB was 112 (43%), of which the Xpert detected 105 (40%) in sediments and 98 (37%) in raw sputa as compared to culture which detected 85 (32%) cases of PTB. Sensitivity, specificity, positive and negative predictive values of Xpert on sputum sediments were 92%, 85%, 74% and 96% respectively. Overall, the incremental sensitivity of Xpert on sediment over raw sputum was 6%. In HIV infected Presumptive PTB, the incremental sensitivity was 12%.ConclusionLowering the sample reagent to sediment dilution ratio increases sensitivity of Xpert on MTB detection among presumptive PTB cases, especially in HIV infected individuals.

Characteristics and management of presumptive tuberculosis in public health facilities in Malawi, 2014-2016.

Setting: Public health facilities providing tuberculosis (TB) and human immunodeficiency virus (HIV) services in Malawi. Objectives: Using routinely collected health service delivery data to describe trends in HIV ascertainment and use of the Xpert® MTB/RIF assay to diagnose TB among HIV-positive presumptive TB cases. Design: This was an implementation study of presumptive TB cases who sought care from 21 facilities between April 2014 and June 2016. Descriptive statistics were used to summarise patient, facility and service level characteristics. Results: Of 28 567 presumptive TB cases analysed, 23 198 (81%) had known HIV status. The proportion of ascertained HIV status in presumptive TB cases increased over the study period. HIV prevalence was 49%, with 73% of HIV-positive presumptive TB cases on antiretroviral therapy. Access to Xpert ranged between 37% and 63% per quarter among HIV-positive presumptive TB patients with smear-negative sputum results. Of 7829 patients with documented Xpert results, 68% were HIV-positive. Conclusion: After the introduction of registers with HIV-related variables, HIV ascertainment among presumptive TB cases increased over time. Access to Xpert was suboptimal among HIV-positive presumptive TB cases. Further collaboration between national TB and HIV programmes may facilitate increased use of Xpert for HIV-positive patients with presumptive TB who seek care in public health facilities.

Tuberculosis detection and the challenges of integrated care in rural China: A cross-sectional standardized patient study.

BackgroundDespite recent reductions in prevalence, China still faces a substantial tuberculosis (TB) burden, with future progress dependent on the ability of rural providers to appropriately detect and refer TB patients for further care. This study (a) provides a baseline assessment of the ability of rural providers to correctly manage presumptive TB cases; (b) measures the gap between provider knowledge and practice and; (c) evaluates how ongoing reforms of China’s health system—characterized by a movement toward “integrated care” and promotion of initial contact with grassroots providers—will affect the care of TB patients.Methods/FindingsUnannounced standardized patients (SPs) presenting with classic pulmonary TB symptoms were deployed in 3 provinces of China in July 2015. The SPs successfully completed 274 interactions across all 3 tiers of China’s rural health system, interacting with providers in 46 village clinics, 207 township health centers, and 21 county hospitals. Interactions between providers and standardized patients were assessed against international and national standards of TB care. Using a lenient definition of correct management as at least a referral, chest X-ray or sputum test, 41% (111 of 274) SPs were correctly managed. Although there were no cases of empirical anti-TB treatment, antibiotics unrelated to the treatment of TB were prescribed in 168 of 274 interactions or 61.3% (95% CI: 55%–67%). Correct management proportions significantly higher at county hospitals compared to township health centers (OR 0.06, 95% CI: 0.01–0.25, p < 0.001) and village clinics (OR 0.02, 95% CI: 0.0–0.17, p < 0.001). Correct management in tests of knowledge administered to the same 274 physicians for the same case was 45 percentage points (95% CI: 37%–53%) higher with 24 percentage points (95% CI: −33% to −15%) fewer antibiotic prescriptions. Relative to the current system, where patients can choose to bypass any level of care, simulations suggest that a system of managed referral with gatekeeping at the level of village clinics would reduce proportions of correct management from 41% to 16%, while gatekeeping at the level of the township hospital would retain correct management close to current levels at 37%. The main limitations of the study are 2-fold. First, we evaluate the management of a one-time new patient presenting with presumptive TB, which may not reflect how providers manage repeat patients or more complicated TB presentations. Second, simulations under alternate policies require behavioral and statistical assumptions that should be addressed in future applications of this method.ConclusionsThere were significant quality deficits among village clinics and township health centers in the management of a classic case of presumptive TB, with higher proportions of correct case management in county hospitals. Poor clinical performance does not arise only from a lack of knowledge, a phenomenon known as the “know-do” gap. Given significant deficits in quality of care, reforms encouraging first contact with lower tiers of the health system can improve efficiency only with concomitant improvements in appropriate management of presumptive TB patients in village clinics and township health centers.

Evaluation of Mycobacterium tuberculosis viability in OMNIgene-SPUTUM reagent upon multi-day transport at ambient temperature

BackgroundMaintaining the quality of clinical specimens for tuberculosis (TB) testing is a major challenge in many high TB burden-limited resources countries. Sample referral systems in low and middle income countries are often weak and the maintenance of the cold-chain challenging and very costly for TB programs. The development of transport media allowing the preservation of samples without refrigeration is critical for increasing access to TB diagnostic services and for reducing the costs related to testing.MethodsWe evaluated the performance of OMNIgene-SPUTUM (OM-S) reagent for the maintenance of Mycobacterium tuberculosis (MTB) viability in sputum samples in the absence of refrigeration and its capacity to stabilize nucleic acid for molecular testing. A total of 329 sputum specimens from presumptive TB cases collected at the National Reference Laboratory in Tirana, Albania, were either decontaminated by a conventional method or processed with OM-S reagent and stored at room temperature. Samples in OM-S were shipped to the Supranational Reference Laboratory in Milan, Italy, at various times and processed for liquid culture.ResultsOur data show that OM-S maintains MTB viability for at least three weeks in the absence of refrigeration and improves the quality of culture resulting in a contamination rate lower than 0.5%. However, a significant delay in the time to culture positivity was observed for samples stored for more than two weeks in OM-S.ConclusionsOverall, OM-S offers multiple benefits both at laboratory and TB national program level by increasing the availability to quality diagnostics, promoting access to health care services and strengthening TB patient care especially in hard to reach populations.