TB Guidelines Research Articles

A Case Report on Peritoneal Tuberculosis in an Immunocompromised Patient

Background: Peritoneal tuberculosis (PTB) is one of the most challenging forms of extra pulmonary tuberculosis. Abdominal TB cases make up above 3% of all extra pulmonary TB as per the Index TB Guidelines. PTB is commonly due to reactivation of latent tuberculosis in the peritoneum. Numerous cases were still misdiagnosed due to nonspecific presentation. The golden standard for diagnosis is laparoscopic biopsy. Presenting signs and symptoms of PTB are unspecific such as ascites, abdominal pain and distension, fever, weight loss, diarrhea/constipation. Peritoneal tuberculosis is a significant cause of ascites in developing countries. The causative agent of peritoneal tuberculosis is Mycobacterium tuberculosis. Case Presentation: In this case study, a 52 year old male had complaints of progressive abdominal distension and fever for 2 weeks. Patient underwent diagnostic paracentesis, upper and lower GI endoscopy, biopsy and gene xpert to confirm peritoneal tuberculosis. Patient with peritoneal TB have gradually progressive abdominal swelling due to ascites and abdominal pain. Conclusion: Peritoneal tuberculosis should be considered in differential diagnosis. Differential diagnosis, especially in the developing countries or under developed countries. This case highlights the easy diagnosis of the condition other than the other case reports.

Cash transfers to enhance completion of TB screening among household contacts in rural Tanzania.

<sec id="st1"><title>BACKGROUND</title>Tanzanian TB guidelines recommend facility-based TB screening for symptomatic household contacts (HHCs) or those aged <5 years, but cost remains a major barrier. In this study, we evaluate the use of unconditional cash transfers (UCTs) to facilitate completion of HHC TB screening.</sec><sec id="st2"><title>METHODS</title>In this prospective interventional study, we enrolled index people diagnosed with TB (PWTB) within 8 weeks of TB treatment initiation from the TB clinic at Haydom Lutheran Hospital, Haydom, Tanzania, and surrounding TB dispensaries in rural Tanzania. The study provided at the time of enrollment an UCT up to 40,000 Tanzanian shillings (USD16.91) directly to heads of households with PWTB, covered medical costs from screening activities and provided three bi-weekly phone reminders to facilitate HHC TB screening. The primary outcome was TB screening completion for all HHCs compared to the same period of the preceding year.</sec><sec id="st3"><title>RESULTS</title>We enrolled 120 index PWTB, including 398 HHCs between July and December 2022. The median age for index PWTB was 35 years; 38% were females. Sixty-five (54%) households completed screening for all HHCs, compared to 7% during the same period of the preceding year.</sec><sec id="st4"><title>CONCLUSION</title>These interventions may considerably improve completion of HHC TB screening in rural Tanzania.</sec>.

Knowledge and Practices toward Tuberculosis Case Identification among Accredited Drug Dispensing Outlets Dispensers in Magu District, Northwestern Tanzania.

Accredited Drug Dispensing Outlets dispensers (ADDO dispensers) have a crucial role in detecting and referring TB suspects. However, several studies highlight low knowledge of TB among ADDO dispensers. To facilitate this, the National TB and Leprosy Control Program trained ADDO dispensers on case identification and referral. Hence, this was a community-based cross-sectional study to determine the knowledge and practice of ADDO dispensers in the detection of active tuberculosis suspects in Magu Districts, Mwanza, Tanzania. This was a cross-sectional study that included 133 systematically selected ADDO dispensers. Out of 133 ADDO dispensers, 88 (66.9%) had attended TB training. About 108 (81%) participants had good knowledge of TB. The majority of ADDO dispensers 104 (78.4%) had poor practice toward the identification of TB cases. Attending training (AOR 4.49, CI 1.03-19.47), longer working experience (AOR 4.64, CI 1.99-10.81), and the presence of national TB guidelines (AOR 3.85, CI 1.11-13.34) was significantly associated with good self-reported TB case identification practices. Therefore, the study revealed adequate knowledge but with poor practice. Provisions to train ADDO dispensers in tuberculosis case detection and referral could yield great results.

Quality of TB diagnostic services at primary healthcare clinics in eThekwini district, South Africa.

Overcoming the TB epidemic requires moving past expanding the coverage of healthcare services and looking to improve the quality of TB services. During COVID-19, the suboptimal state of TB services has further deteriorated, and little is known about how these services have fared after the pandemic. The study aims to assess the quality TB diagnostic services in primary health care (PHC) clinics in the eThekwini district, South Africa. Twenty-one clinics with the lowest and highest headcounts from each region of eThekwini were purposively selected. An audit tool adapted from the United States Agency for International Development (USAID) and the national TB guidelines was used to collect data on six different audit components. To assess quality, a 3-point scale was used where clinics could get a rating of either excellent, moderate, or poor performance. Descriptive statistics were employed to summarize and analyze clinic scores in Stata v15.1. Additionally, associations between clinic scores and clinic characteristics were investigated using Pearson's pairwise correlation coefficient and a linear regression model, where p < 0.05 was the measure of statistical significance. The audit found that the quality of diagnostic services in eThekwini was moderate. The gaps that required addressing were the lack of TB training among staff, adherence to infection prevention and control practices, and contact screening. Without feasible solutions, these will hinder current TB management strategies and slow progress toward ending the TB epidemic.

INDEX guidelines for extra-pulmonary tuberculosis: knowledge and practice among clinicians in Bengaluru, Karnataka

Background: Extra-pulmonary tuberculosis (EPTB) remains a major problem in developing countries, which acquire diagnostic and management challenges. The study was conducted to characterize the diagnosed EPTB cases, and to understand the perspectives of clinicians on diagnosis and challenges in its management. Methods: A total of 150 EPTB patients' medical records were reviewed at two tertiary hospitals in Bengaluru, Karnataka for the period January 2017 to December 2017. The questionnaire-based interview was conducted among clinicians (n=42) during the study period. Results: The mean age and weight of EPTB patients (females (77, 51%) and males (73, 49%) were 32.5 (±17.5) years and 44.5 (±16.3) kilograms, respectively. Pleural TB (44, 29%), cervical lymph node TB (LNTB) (32, 21%) and abdominal TB (17, 11%) were the most common sites of EPTB involvement, followed by bones and joints TB (11, 7%), spine TB (10, 7%), hilar/mediastinal TB (9, 6%), tuberculoma (8, 5%), TB meningitis (6, 4%), abdominal LNTB (6, 4%), urinary TB (4, 3%) and others (3, 2%). We found GeneXpert was the basis of EPTB diagnosis in 43.3% of cases followed by acid-fast bacilli (AFB) smear microscopy (20.7%) and culture (12.5%). Of 150 EPTB suspected cases, 73% (110) were started anti-TB treatment (ATT), including 8% (12) having received ATT previously. According to LIKERT scale options, 90% of clinicians agreed GeneXpert as a promising diagnostic tool for diagnosis as compared to other microbiological (79%) and histopathological tests (55%). Conclusions: The quality of EPTB diagnosis and management practices at these institutions is satisfactory according to the principles laid down in INDEX TB guidelines or the national guidelines.

Health Care Providers' Knowledge of Tuberculosis and Diabetes Mellitus Comorbidity in Lubumbashi, Democratic Republic of the Congo (DRC).

Tuberculosis-Diabetes mellitus (TB-DM) co-morbidity is a growing scourge in the world. The new approaches and interventions for TB control implemented by the Tuberculosis National Control Program (TNCP) in DRC require the involvement of health care providers for their success. The objective of this study is to assess the knowledge of health care provider on different aspects of the management of TB-DM co-morbidity and to compare this knowledge according to the health care system, the type of providers and the number of years of experience. Cross-sectional and analytic study was conducted in 11 health care facilities in the Lubumbashi Health District, selected by reasoned choice, and an electronic questionnaire was administered to health care providers. These providers were interviewed on the different aspects of the management of the TB-DM comorbidity. The data were presented and compared in relation to knowledge about TB, DM, and TB-DM comorbidity. A total of 113 providers were interviewed, predominantly males and physicians. Questions related to knowledge about DM were better answered. Doctors compared to paramedics; tertiary-level providers compared to secondary-level providers had better responses to the different questions. There is a statistically significant correlation between the level of knowledge of TB, DM and the type of health care provider, the number of years of experience. The present study shows that there are gaps in the knowledge of our health care providers and community members on the recommendations of the DRC TB guidelines (Programme AntiTuberculeux Intégré 5: PATI 5) in general and on the management of TB-DM. It is therefore important and necessary to put in place strategies to improve this level of knowledge, which will focus on the extension of the guidelines, the awareness and the training of the stakeholders involved in the control.

Diagnostic Performance of Different Laboratory Methods for the Detection of Extrapulmonary Tuberculosis.

Accurate and appropriate extrapulmonary tuberculosis (EPTB) diagnosis remains challenging due to its paucibacillary nature, requirement of invasive collection procedures, and lack of sensitive tests. This study investigated the diagnostic performance of different methods for the diagnosis of EPTB. A total of 1340 EPTB specimens were collected from presumptive EPTB patients from four different hospitals between November 2015 and March 2017. The collected specimens were tested with AFB microscopy, culture, Xpert MTB/RIF assay (Xpert), and MTBDRplus assay. Among the 1340 EPTB specimens, 49 (3.66%), 141 (10.52%), 166 (12.39%), and 154 (11.49%) were positive in AFB microscopy, culture, Xpert MTB/RIF, and MTBDRplus assay, respectively. A total of 194 (14.9%) cases were found positive in at least one of these methods. Using culture as a reference standard, the sensitivity and specificity of AFB microscopy, Xpert MTB/RIF, and MTBDRplus assay were: 27.0%/99.1%, 83.7%/96.0%, and 79.4%/96.5%, respectively. Compared to the composite reference standard, the sensitivity of culture, AFB microscopy, Xpert MTB/RIF, and MTBDRplus assay was 72.7%, 25.3%, 85.6%, and 79.4%, respectively, with a specificity of 100% for all the methods. The Xpert MTB/RIF assay showed the highest sensitivity compared to other methods. Considering the short turnaround time and promising findings, Xpert MTB/RIF assay should be integrated into national TB guidelines as a routine diagnostic test.

Clinical Profile and Quality of Life of Patients With Post-pulmonary Tuberculosis Sequelae Presenting to a Tertiary Care Hospital.

Background and objective There is a dearth of studies on the clinical presentation of patients with post-pulmonary tuberculosis (PTB) sequelae and its impact on their quality of life (QoL). In light of this, we conducted this study to analyze the clinical profile and QoL in patients with post-PTB sequelae. Methods Patients with a history of treated PTB and evidence of radiological damage were enrolled prospectively from November 2018 till June 2020 to study their clinical profile and QoL as per the eligibility criteria. A detailed clinical history was taken along with posteroanterior-view chest X-rays and CT scans of the thorax with bronchial angiography in patients with hemoptysis. QoL was assessed using theHindi version of St. George's Respiratory Questionnaire (SGRQ) for which permission was obtained from the St. George's University of London. SGRQ scores were calculated using score calculation algorithms (Microsoft Excel-based) and missing data imputation as recommended by its developer. Results A total of174 patients were included in the analysis. The analyzed population was relatively younger (mean age: 44.27 years) with BMIs leaning toward the lower side of normal (median: 19.6 kg/m²); the majority of the patients were males (59%) and non-smokers (77%). PTB had been diagnosed clinico-radiologically in the majority (68%) of patients with non-compliance to antitubercular treatment (ATT) being reported by only 9% of patients. Multiple courses of ATT were received by about one-third of patients, mainly on a clinico-radiologic basis. Systemic hypertension (HTN) (11%) and diabetes mellitus (DM) (9%) were the most common comorbidities. The most common symptom complex found was cough, expectoration, and dyspnea (n=102, 59%). At least one incidence of massive hemoptysis was reported by 20% of patients. Bronchial artery embolization (BAE) was performed for moderate to massive hemoptysis in 26% of patients with a success rate of >90%. One-fifth of the study participants required hospitalization for exacerbation of respiratory symptoms with more than half of these (59%) requiring ventilatory support. Health-related QoL was significantly impaired as reflected by amedian SGRQ total score of 45.53. The most affected domain of QoLwas the activity domain (mean score: 45.47). Females had worse QoL as compared to males (p=0.0062), and so did underweight patients (p=0.048). The prolonged duration of the illness also significantly impaired the QoL (p<0.001, r=0.313). Conclusion The sequelae of PTB are under-recognized even among physicians and are frequently misdiagnosed as active PTB. The QoL is more severely affecteddue to residual damage. This study highlights the clinical profile of this patient population and underscores the need to recognize post-PTB sequelae as a separate entity. An important remedy to mitigate its long-term consequences is its inclusion and recognition in national and international TB guidelines to facilitate its early identification and promote further research to address its evidence-based management.

1432. Exploring Cell Wall Targets to Overcome Mycobacterium tuberculosis (Mtb): Ceftriaxone (CRO) Inhibits LdtMt2, a Major Peptidoglycan (PG) Synthase

Abstract Background Drug-resistant tuberculosis (DR TB) is a deadly, difficult-to-treat infection, and new treatment strategies are needed. Despite the wide success of β-lactams (BLs), DR TB guidelines only include meropenem (MEM) and imipenem (IPM), given with clavulanate (CLA). BlaC, the Mtb β-lactamase, hydrolyzes CRO less efficiently than other cephems and β-lactamase inhibitors improve the in vitro susceptibility of Mtb to CRO. Surprisingly, CRO has not been evaluated in DR TB clinical studies. Moreover, the mechanisms by which CRO disrupts Mtb PG synthesis are not well characterized. CRO inhibits LdtMt1­, but activity against LdtMt2, an important Mtb PG synthase, is unknown. To explore this knowledge gap, we examined CRO inhibition of LdtMt2. In addition, we investigated if combining CRO with MEM or IPM would lower minimum inhibitory concentrations (MICs) more than each agent alone. Methods A panel of Mtb isolates was selected for susceptibility testing with a broth microdilution method. Timed electrospray ionization-mass spectrometry (ESI-MS) and inhibition kinetic assays were performed. Results CRO MICs ranged 0.25 to 16 µg/mL and lowered ≤ 0.06 to 2 µg/mL with CLA (Table 1). Fractional inhibitory concentration indices for CRO + MEM or IPM was &amp;lt; 0.5 for six isolates, suggesting synergy. ESI-MS captured CRO-LdtMt2­ acyl-complexes at timepoints 5 to 120 min, and a 158 Da fragment loss was observed; MEM and IPM were unchanged (Table 2, Figure 1). When LdtMt2 was co-incubated with MEM and CRO together, only MEM complexes were captured. Interestingly, Kiapp­ with CRO (0.07 ± 0.01 µM) was comparable to that with MEM (0.09 ± 0.01 µM). Figure 1Mass spectrometry chromatograms with LdtMt2 (A) alone incubated with ceftriaxone at (B) 5 min, (C) 15 min, (D) 30 min, (E) 120 min. [Ldt¬Mt2] = 13.2 µM and [ceftriaxone] = 264 µM. Changes in MW are also listed in Table 1. (F) shows the structure of ceftriaxone with the proposed leaving group in red, leaving the remaining bound structure accounting for the observed change in MW. Conclusion CRO was effective in lowering MICs with MEM, IPM, and CLA for our Mtb isolates. Based upon ESI-MS, we found that CRO forms a stable complex with LdtMt2 and the R2 side chain is eliminated, while kinetic observations support inhibition of LdtMt2 by CRO (Figure 2). Previous work found MEM and IPM also inhibit multiple other PG synthases (e.g., PonA1, LdtMt1, LdtMt3). We hypothesize that CRO + MEM/IPM inhibits the growth of Mtb by the combined inactivation of multiple cell wall enzymes. Our observations support the further exploration of the notion of “target redundancy” as an approach to treat multidrug-resistant mycobacteria with BLs. Figure 2.Ceftriaxone-LdtMt2 adduct formation leading to release of the R2 side group Disclosures Krisztina Papp-Wallace, Ph.D, Merck: Grant/Research Support|Venatorx: Grant/Research Support|Wockhardt: Advisor/Consultant Robert A. Bonomo, MD, NIH VA: Grant/Research Support|VenatoRx Merck Wockhardt Cystic Fibrosis Foundation: Grant/Research Support.

Addressing TB multimorbidity in policy and practice: An exploratory survey of TB providers in 27 high-TB burden countries.

In people with TB, co-existence of long-term conditions (e.g., depression, diabetes and HIV) and risk factors (e.g.,alcohol misuse, malnutrition, and smoking) are associated with increased mortality and poor treatment outcomes including delayed recovery, TB treatment failure and relapse. However, it is unclear as to what extent these comorbidities are addressed in TB policy and practice. Between August and October 2021, we conducted an online cross-sectional survey in high-TB burden countries. We recruited a purposive sample of TB health workers, managers, policy makers, advisors and advocates from these countries. The survey enquired about the extent to which various comorbid conditions are: (a) mentioned in TB policies, plans, and guidelines; (b) screened, diagnosed, treated or referred to specialist services by TB healthcare workers. We summarised using descriptive analysis. Of the 1100 potential respondents contacted in 33 countries, 543 responded but only 446 (41%) from 27 countries provided sufficient data for inclusion in the study. We found no notable differences between these providing insufficient data and those completing the survey. HIV, diabetes mellitus, depression and tobacco and alcohol use disorders were identified as the most common and concerning comorbid conditions in TB. HIV was screened for and managed by TB services in most countries. Screening for diabetes and/or tobacco and alcohol use disorders was offered by almost half of all TB services but only a few offered relevant treatments. Depression was rarely screened for, almost never treated, and only infrequently referred to specialist services. Most respondents felt confident in screening/diagnosing these comorbid conditions but not in treating these conditions. With the exception of HIV, chronic comorbid conditions are only partially screened for and rarely managed within TB services. Mental health conditions are for the most part neglected. Given their adverse impact on TB outcomes, integrating screening and management of these comorbidities within TB programmes offers a significant opportunity to meet TB targets, address non-communicable diseases and improve patient well-being.

Crossing the Last Mile of TB Care in Rural Southern Madagascar: A Multistakeholder Initiative.

Despite a free TB care policy, access to TB care in rural Madagascar is limited due to a markedly underfunded health care system. The World Health Organization estimated the yearly TB incidence in Madagascar at 238 cases per 100,000 people in 2020; only half of the patients with TB are being notified and treated. We describe the development, implementation, and lessons learned of an intervention to improve TB care services in a remote, rural district in southern Madagascar. We involved national, regional, and local stakeholders in assessing the multifaceted challenges in a remote, rural area and codesigning activities to address them. The overarching principles of the intervention were to (1) promote national TB guidelines, (2) build on best practices, and (3) prioritize low-cost activities to enable scale-up. An in-depth assessment of challenges in accessing and delivering TB care resulted in the following prioritization of activities: (1) fostering community engagement, (2) decentralizing service provision, (3) improving quality of care, (4) providing nutritional support, and (5) ensuring staff support and supervision. The intervention was launched in September 2019 and is ongoing as of October 2022. During mobile TB clinics conducted between September 2019 and December 2020, 4,982 presumptive patients were screened and 1,706 (34.2%) have been diagnosed with TB. Based on 2010-2020 official TB notification data, we calculated trend-adjusted additional TB notifications during the intervention, resulting in a 2.6-fold increase in cases in 2019-2020. The intervention district's TB notification rate increased from 178 cases per 100,000 people in 2018 to 424 cases per 100,000 people in 2020. Involving stakeholders from all levels of care was perceived as a key to success. The unexpected increase in the number of patients with TB in the intervention district overburdened the current paper-based TB notification system and emphasized the need for expanded diagnostics and social support services.

Comparing the usability of the World Health Organization's conventional tuberculosis guidelines to the eTB recommendations map: A two-arm superiority randomised controlled trial.

Best practices for the dissemination of global health guidelines has not undergone rigorous research. We used a new approach to digitizing World Health Organization (WHO) global tuberculosis guideline recommendations (eTB RecMap) and compared its usability to the conventional method of accessing TB recommendations using the WHO website. We conducted a two-arm superiority randomised controlled trial using a survey among global stakeholders who were past or planned future users of TB guidelines, recommendations, or policy advice. We assigned participants randomly (1:1) to complete an activity using the WHO eTB RecMap or the conventional website. The primary outcome was the accessibility of information and secondary outcomes understanding, satisfaction, and preference for one of the two formats. Between February 26 and August 29, 2021, we received 478 responses from stakeholders, of whom 244 (122 per group) were eligible and provided analysable results. Participants rated the eTB RecMap as more accessible, on average, when compared to the conventional website (on a seven-point scale, the mean difference {MD} was 0.9; 95% confidence interval {CI}: 0.6, 1.2; p < 0.001) and were more likely to correctly answer understanding questions. This is the first trial comparing digitized dissemination formats of health guideline recommendations. Stakeholders rated the WHO eTB RecMap as more accessible than the conventional WHO website for the tested recommendations. They also understood presented information better. The findings support better usability of TB information through the eTB RecMap and contribute to the effort to end the TB epidemic. Trial registration: This trial was registered with ClinicalTrials.gov (NCT04745897) on February 9, 2021.

Global Outsourcing and Local Tendering Supply Chain Systems in the Public Healthcare Sector: A Cost Comparison Analysis, Namibia

ObjectivesTo compare supplier prices for local tendering and global outsourcing supply chain systems that are used to purchase pharmaceutical products by the Ministry of Health in Namibia and to compare the supplier prices for both systems to the international reference buyer median prices. MethodsThis study was quantitative in design and compared local and international supplier prices for a basket of vaccines, antiretrovirals, and anti-tuberculosis (TB) drugs from 2015 to 2020. Prices were retrieved from the procurement documents obtained from the Central Medical Stores division of the Ministry of Health, Namibia. The study also compared local and international supplier prices with the international reference buyer median prices obtained from the Management Sciences for Health International Drug Price Indicator Guide (2015 edition). ResultsIt was found that 77% of all the pharmaceutical products in the study were more expensive when obtained from the local suppliers than from international suppliers—that is, vaccines (70%), antiretrovirals (86.6%), and anti-TB drugs (67%). More than 50% of all the pharmaceutical products had local and international supplier prices, which were higher than the international reference buyer median prices. The price differentials were found to be higher for pharmaceutical products that were newly introduced into TB and human immunodeficiency virus treatment guidelines. ConclusionsThe study has concluded that local suppliers were costlier than international suppliers for vaccines, antiretrovirals, and anti-TB drugs. The international price comparisons have shown that there is a need for improving the pricing mechanisms in Namibia to reduce the prices of several essential medicines.

Assessment of awareness of workers of the forensic medical service of the Republic of Tatarstan (bureau) about tuberculosis infection

Introduction. Forensic workers are at high risk of contracting Koch's bacillus infection. Significant risk factors for infections are a high microbial load, increased traumatism, and the absence of lifetime medical records of tuberculosis in cadavers admitted for examination. In addition, sporadic cases of infection continue to be reported, necessitating measures to improve the prevention of personnel infection. In view of the above, there is a great need for research into the awareness of bureau personnel, on the basis of which preventive measures will be developed. Purpose of the study — to examine the awareness of bureau personnel about the main issues of tuberculosis infection, its prevention, ways of infection, diagnosis, and clinical manifestations. Materials and methods. The main method of research was an anonymous questionnaire survey of 262 employees of the Kazan bureau of the Republic of Tatarstan. The obtained data were counted on the service onlinetestpad, where the questionnaire was posted. Results. According to the results of the study, 12 employees (4.6%) out of those interviewed in the bureau had tuberculosis. Forty-three employees (16.4%) reported contact with a sick person at their place of work (training). A total of 147 respondents (56.1%) think that it is possible to get infected by a sick person; 39 respondents (14.9%) think that it is possible to get infected while doing professional duties. Some respondents did not consider important aspects in preventing the formation and spread of TB: a significant part of workers (96 workers, 36.6%) wash dirty work clothes at home by themselves and about the same number of respondents (95 workers, 36.3%) do not consider it important to change work clothes when moving from a "dirty" zone to a "clean" one and vice versa. Discussion. Positive results of the questionnaire were associated with a high degree of competence of the staff, dissemination of TB guidelines, training, and supervision by supervisory authorities. Conclusion. Based on the results, it was found that staff at the Bureau of Forensic Medicine are sufficiently informed about methods of specific and non-specific prevention of tuberculosis and have information about the modes of transmission. However, there is a lack of awareness among certain staff members on how to prevent the spread of tuberculosis infection.

Adherence of HIV clinics to guidelines for the delivery of TB screening among people living with HIV/AIDS in Ghana

BackgroundTuberculosis screening of people living with HIV (PLHIV) – an intervention to reduce the burden of TB among PLHIV – is being implemented at HIV clinics in Ghana since 2007, but TB screening coverage remains low. Facility adherence to intervention guidelines may be a factor but is missing in implementation science literature. This study assesses the level of HIV clinic adherence to the guidelines and related facility characteristics in selected district hospitals in Ghana.MethodsThis cross-sectional study was conducted in all 27 district hospitals with HIV clinics, X-ray and geneXpert machines in Ghana. These hospitals are in 27 districts representing about 27% of the 100 district hospitals with HIV clinics in Ghana. A data collection tool with 18-items (maximum score of 29) was developed from the TB/HIV collaborative guidelines to assess facility adherence to four interrelated components of the TB screening programme as stated in the guidelines: intensive TB case-finding among PLHIV (ITCF), Isoniazid preventive therapy initiation (IPT), TB infection control (TIC), and programme review meetings (PRM). Data were collected through record review and interviews with 27 key informants from each hospital. Adherence scores per component were summed to determine an overall adherence score per facility and summarized using medians and converted to proportions. Facility characteristics were assessed and compared across facilities with high (above median) versus low (below median) overall adherence scores, using nonparametric test statistics.ResultsFrom the 27 key interviews and facility records reviewed, the median adherence scores for ITCF, IPT, TIC, and PRM components were 85.7% (IQR: 85.5–100.0), 0% (IQR: 0–66.7), 33.3% (IQR: 33.3–50.0), and 90.0% (IQR: 70.0–90.0), respectively. The overall median adherence score was 62.1% (IQR: 58.6–65.1), and 17 clinics (63%) with overall adherence score above the median were categorized as high adherence. Compared to low adherence facilities, high adherence facilities had statistically significant lower PLHIV clinic attendees per month (256 (IQR: 60–904) vs. 900 (IQR: 609–2622); p = 0.042), and lower HIV provider workloads (28.6 (IQR: 8.6–113) vs. 90 (IQR: 66.7–263.5); p = 0.046), and most had screening guidelines (76%, p < 0.01) and questionnaire (80%, p < 0.01) available on-site.ConclusionPRM had highest score while the IPT component had the lowest score. Almost a third of the facilities implemented the TB screening programme activities with a high level of adherence to the guidelines. We suggest to ensure adherence to all four components, reducing staff workloads and making TB screening questionnaires and guidelines available on-site would increase facility adherence to the intervention and ultimately achieve intervention targets.

Assessing the capacity of primary health care centres to provide tuberculosis services in Kaduna State, North-Western Nigeria

Background: Despite earlier successes achieved in combating it, cases of tuberculosis in Nigeria are now on the increase, affecting more people and communities. Primary health care in Nigeria is through ward health system, designed to provide minimum health package to the communities including TB services. This study aimed to ascertain the capacity of PHC centres to provide TB services in Kaduna North senatorial district, Kaduna State, Nigeria.Methods: Four out of eight local Government areas in the district were randomly selected and one PHC per ward was recruited in the study. In each facility, questionnaires developed from the TB tracer items of the WHO service availability and readiness assessment tool were administered to the facility in-charges and TB/DOTS focal persons.Results: Forty four facilities were selected from Zaria, Sabon Gari, Makarfi and Kudan LGAs. Almost all facilities (98%) diagnosed TB clinically and 39 (90%) had anti-TB drugs available. National TB guidelines were lacking in 23 (52%) facilities and only 5 (11%) had additional capacity for sputum microscopy. While 35 (80%) TB/DOTS focal persons had received training on TB diagnosis and treatment, only 24 (55%)received training on TB/HIV co-infection and only 8 (18%) received training on multi-drug resistant TB.Conclusions: While TB services are widely available in the district, urgent need exists for all stakeholders to work together towards equipping those facilities with critical infrastructure that will improve their overall capacity, particularly with regards to comprehensive TB guidelines, laboratory diagnosis and personnel training for effective TB management.

Factors Contributing to Low Tuberculosis Detection Rates among Children Accessing Health Services in Selected Public Sector Health Facilities in Zimbabwe

Introduction: Zimbabwe is one of 8 African countries with high per capita incidence of TB, TB/HIV and multi-drug resistant TB. Zimbabwe experienced a proportionate decline in childhood TB contribution to all notifications from 9% in 2011 to 5% in 2017. Methodology: Analytical cross-sectional study was conducted in 20 public sector health facilities. Data were collected from healthcare workers (HCWs) using structured questionnaires, interview guide for health managers and data abstraction tool for childhood TB data in registers. Protocol received ethical approval and written informed consent was obtained from participants. Results: Eighty-one HCWs and 18 managers were interviewed; data for 21,791 children were abstracted. About 3.1% of children were screened for TB, and 63.2% of presumptive TB children had TB diagnostic tests. A majority (71.9%) of TB tests were conducted on the Gen Xpert MTB Rif platform. Thirty-one out of 335 children with TB tests were diagnosed with TB, and 93.5% were initiated on treatment. Seven facilities offered TB testing, 5 had TB guidelines and 5 had pediatric TB job aides. Five out of 7 microscopes and 4/7 GeneXpert machines were functional. About 64.1% of HCWs had childhood TB training, 51% had ever received mentorship on childhood TB management, 53.1% had ever collected childhood TB diagnosis specimen and 23.3% had ever initiated children on TB treatment. Discussion: Childhood TB screening and diagnosis was suboptimal, and this was a result of low healthcare worker capacity, shortage and breakdown of TB diagnostic machines and weak TB diagnostic sample transportation system.

Barriers and Enablers to Implementing TB Control Strategies in EU and EEA Countries: A Systematic Review

Background: Meeting the 2035 WHO targets of reducing TB incidence by 90% requires the implementation of country-specific TB control strategies. This systematic review aims to identify factors which facilitate or impede the implementation of such strategies in EU/EEA settings. Focusing on providers of care, health system constraints and social and political factors, this review complements available evidence on the accessibility of TB services to recipients of care. Methods: We included publications that analysed empirical data on TB policies, strategies, guidelines or interventions. Databases were searched for papers published in EU/EEA countries between January 1997 and May 2017. Relevant phrases were coded and analysed using descriptive, thematic and network plot techniques. Findings: Of the 1,471 papers screened, 49 were included. The most common barrier to TB control strategies described the divergence of healthcare practices from guidelines. This often related to limited knowledge or perceived usefulness of the guideline by clinicians. Lack of appropriate human resources was another common barrier. The most commonly identified enabler to TB control strategies was the documented positive attitudes of healthcare workers towards TB programmes. Interpretation: Divergence between clinical practice and guidelines was described in most EU/EEA settings, indicating the need for a focused review of guideline adherence. Strengths of this study involve its broad inclusion criteria and wide range of TB control strategies analysed. Funding Statement: This study is part of the E-DETECT TB project (ref. 709624) which has received funding from the European Union’s Health Programme (2014-2020). PROSPERO (CRD42017060100). Declaration of Interests: We declare no competing interests.

General and tuberculosis-specific service readiness in two states in Nigeria

BackgroundTuberculosis is the world’s deadliest infectious disease and a leading cause of death in Nigeria. The availability of a functional healthcare system is critical for effective TB service delivery and attainment of national and global targets. This study was designed to assess readiness for TB service delivery in Oyo and Anambra states of Nigeria.MethodsThis was a facility-based study with a mixed-methods convergent parallel design. A multi-stage sampling technique was used to select 42 primary, secondary, and tertiary healthcare facilities in two TB high burden states. Data were collected using key informant interviews, a semi-structured instrument adapted from the WHO Service Availability and Readiness Assessment tool and facility observation using a checklist. Quantitative data were analysed using descriptive and inferential statistics while qualitative data were transcribed and analysed thematically. Data from both sources were integrated to generate conclusions.ResultsThe domain score for basic amenities in both states was 48.8%; 47.0% in Anambra and 50.8% in Oyo state with 95% confidence interval [− 15.29, 7.56]. In Oyo, only half of the facilities (50%) had access to constant power supply compared to 72.7% in Anambra state. The overall general service readiness index for both states was 69.2% with Oyo state having a higher value (73.3%) compared to Anambra with 65.4% (p = 0.56). The domain score for availability of staff and TB guidelines was 57.1% for both states with 95% confidence interval [− 13.8, 14.4]. Indicators of this domain with very low values were staff training for the management of HIV and TB co-infection and training on MDR -TB. Almost half (47.6%) of the facilities experienced a stock out of TB drugs in the 3 months preceding the study. The overall tuberculosis-specific service readiness index for both states was 75%; this was higher in Oyo (76.5%) than Anambra state (73.6%) (p = 0.14). Qualitative data revealed areas of deficiencies for TB service delivery such as inadequate infrastructure, poor staffing, and gaps with continuing education on TB management.ConclusionsThe weak health system remains a challenge and there must be concerted actions and funding by the government and donors to improve the TB healthcare systems.

Post-tuberculosis mortality risk among immigrants to British Columbia, Canada, 1985-2015: a time-dependent Cox regression analysis of linked immigration, public health, and vital statistics data.

To compare non-tuberculosis (non-TB)-cause mortality risk overall and cause-specific mortality risks within the immigrant population of British Columbia (BC) with and without TB diagnosis through time-dependent Cox regressions. All people immigrating to BC during 1985-2015 (N = 1,030,873) were included with n = 2435TB patients, and the remaining as non-TB controls. Outcomes were time-to-mortality for all non-TB causes, respiratory diseases, cardiovascular diseases, cancers, and injuries/poisonings, and wereascertained using ICD-coded vital statistics data. Cox regressions were used, with a time-varying exposure variable for TB diagnosis. The non-TB-cause mortality hazard ratio (HR) was 4.01 (95% CI 3.57-4.51) with covariate-adjusted HR of 1.69 (95% CI 1.50-1.91). Cause-specific covariate-adjusted mortality risk was elevated for respiratory diseases (aHR = 2.96; 95% CI 2.18-4.00), cardiovascular diseases (aHR = 1.63; 95% CI 1.32-2.02), cancers (aHR = 1.40; 95% CI 1.13-1.75), and injuries/poisonings (aHR = 1.85; 95% CI 1.25-2.72). In any given year, if an immigrant to BC was diagnosed with TB, their risk of non-TB mortality was 69% higher than if they were not diagnosed with TB. Healthcare providers should consider multiple potential threats to the long-term health of TB patients during and after TB treatment. TB guidelines in high-income settings should address TB survivor health.