TB Notification Research Articles

Impact of COVID-19 pandemic on tuberculosis notification and outcome in a district of South Gujarat

ABSTRACT Context/Background: The COVID-19 pandemic affected the health care services worldwide, with the target of END TB 2025; it was important to make sure that the TB notification and linkage services were not hampered. The current study aims to document the overall impact of COVID-19 on TB notification and treatment services. Aims/Objectives: To document the impact of COVID-19 on notification and comparison of their outcome between pre-COVID-19 and COVID-19 era. Methodology: Programmatic data of 9893 notified TB cases reported from Surat rural between 2019 and 2021 were collected from Nikshay portal through DTO Surat. Detailed comparison of pre- and COVID-19 era was performed using stratified analysis. Results: There was a significant (P = 0.02) 29% decline in cases reported in 2020 as compared to the cases reported in the previous year. The impact of COVID-19 was also seen on mortality of the reported cases (18% increase). The overall proportion of treatment failure was increased (28%), whereas difference of 20% was seen in cases where treatment regimen was required to be changed. Conclusions: Despite the overall impact of COVID-19 on TB services (2020), the health department has proactively countered and bounce back in 2021 with an overall increase in notification and treatment services.

The International Consensus for Early TB framework (ICE-TB): Implications from a low-incidence setting.

<sec><title>BACKGROUND</title>In recent years, there has been increasing recognition of the public health significance of the spectrum of TB disease presentation, and the existing classification systems of asymptomatic infection and symptomatic TB have been limited in terms of explanatory power. Accordingly, in 2022-2023, a new International Consensus framework for Early TB (ICE-TB) was developed, categorising the spectrum of TB infection and disease into five states based on the presence or absence of macroscopic pathology, host infectiousness, and symptoms and signs.</sec><sec><title>METHODS</title>We used the ICE-TB framework to re-analyse existing notification data for 2022 within a low-incidence setting to explore the potential utility and future challenges for its public health application.</sec><sec><title>RESULTS</title>Existing notification data were sufficient to allow substantial reclassification of currently recognised active disease states, but did not systematically capture Mycobacterium tuberculosis infection or subclinical TB. Fifty percent of existing TB notifications would be classified as 'Clinical, infectious', with the potential need to consider further subclassification.</sec><sec><title>CONCLUSION</title>Our exploration highlighted limitations in existing classification systems and diagnostic approaches and should encourage researchers and programmatic implementers to emphasise person-centred and programmatic needs in the development of new tools for TB management.</sec>.

The impact of COVID-19 national lockdowns on drug-resistant tuberculosis in KwaZulu-Natal, South Africa: A spatial analysis

PurposeWe sought to understand the impact of the initial COVID-19 mitigation strategies in 2020 on drug-resistant (DR) TB diagnoses in KwaZulu-Natal province (KZN), South Africa. MethodsWe compared the number, spatial distribution, and characteristics of DR TB diagnoses before and after the initial COVID-19 lockdown on March 26th, 2020. Information on DR TB diagnoses was collected from the CONTEXT prospective cohort study and municipality characteristics were collected from Statistics South Africa. We used Bayesian conditional autoregressive models and relative-risk surface maps to examine spatial correlates and patterns of DR TB notifications. ResultsBetween October 2018 and February 2022, there were 693 individuals diagnosed with DR TB in KZN, South Africa. The rate of diagnoses per year was 274 and 155 prior and after to the initial lockdowns, respectively, corresponding to a 43 % decrease in the notification rate of cases. Compared to cases diagnosed before the lockdown, cases diagnosed after were less likely to have a fuel source for heating, piped water, a flush toilet, or own a phone (p-values≤0.02). Changes in notifications were not homogenously distributed, with predominantly rural northeastern and southwestern municipalities having significantly greater relative-risks after the lockdown. ConclusionsWe found a reduction in the rate of DR TB diagnoses after the COVID-19 pandemic lockdowns and observed that individuals diagnosed after the lockdowns had worse living conditions, fewer household resources, and more adults living in their household compared to before the pandemic.

TB notifications among citizens and non-citizens in Taiwan.

<sec><title>BACKGROUND</title>Substantial under-notification of TB among non-citizens has been noted previously. Foreign workers with TB who were deported previously could stay for anti-TB treatment since 2014. We assessed whether TB notification improved.</sec><sec><title>METHODS</title>We used the National Health Insurance (NHI) reimbursement database to identify potential TB cases that required notification. We matched potential TB cases with the national TB registry to determine whether they had been notified. Cases notified within 7 days of the initiation of anti-TB treatment were classified as having timely notification.</sec><sec><title>RESULTS</title>Of 53,208 potential TB cases identified in 2016-2020, 96.6% had been notified. The notification proportion increased from 95.5% in 2016 to 97.1% in 2020 among citizens and from 89.0% in 2016 to 96.9% in 2020 among non-citizens. Factors significantly associated with non-notification among non-citizens were previously notified TB (aOR 35.5, 95% CI 17.7-70.9), without health insurance (aOR 15.4, 95% CI 9.3-25.2) and having only one visit to health care facilities in 6 months (aOR 2.3, 95% CI 1.4-3.8). The proportion of TB cases notified within 7 days was 87% overall, 86.2% among citizens, and 96.5% among non-citizens.</sec><sec><title>CONCLUSION</title>TB notification has improved, especially among non-citizens, following a policy change that allows foreign workers to stay for anti-TB treatment.</sec>.

The impact of COVID-19 on tuberculosis in most populated state of India: A geospatial meta-analysis.

Tuberculosis is one of the major burdens to developing nations. India is among the countries categorized by the World Health Organization (WHO) as experiencing a significant burden of TB, HIV-associated TB, and MDR/RR-TB within the context of low- and middle-income nations. Globally South East Asian and African region alone accounted for 82% of death (HIV negative), where India accounts for 36% of TB fatalities. The data was extracted from NIKSHAY web portal on TB notification cases in UP, India. The random effects meta-analysis was performed to estimate pooled proportion of TB cases in public and private notified during both the periods. Spatial analysis was used to display the spread of TB cases across the state, during both the periods. A total 75 districts data on TB notified cases were available for current investigation. The pooled proportion of TB cases were 0.24 (0.21, 0.27) and 0.76 (0.73, 0.79) during COVID-19 period for private and public hospitals, respectively. Similarly, the pooled proportion of TB cases were 0.26 (0.23, 0.29) and 0.74 (0.71, 0.77) post-COVID-19 for private and public hospitals, respectively. The proportion of TB cases were more in public hospital as compared to private hospitals during COVID-19 period. Similarly, result was obtained in post-COVID-19 period.

The impact of the COVID-19 pandemic on TB notifications in Ukraine in 2020.

We assessed the impact of the COVID-19 pandemic on TB notifications in Ukraine, stratified by multiple subgroups. We analyzed data from Ukraine's National TB Program from January 2015 to December 2020 using interrupted time series models. We compared observed cases to counterfactual estimated cases had the pandemic not occurred and estimated trends through December 2020 nationally and by various demographics. We compared the proportions of individuals who underwent drug susceptibility testing (DST) in February 2020 and April 2020 to assess the pandemic impact on drug resistance testing. In April 2020, there were 39% (95% CI 36-42) fewer TB notifications than the estimated counterfactual (3,060 estimated; 95% CI 2,918-3,202; 1,872 observed). We observed a greater decrease in notifications among refugees/migrants compared with non-refugees/migrants (64%, 95% CI 60-67 vs. 39%, 95% CI 36-42), and individuals aged <15 years compared with those aged ≥15 years (60%, 95% CI 57-64 vs. 38%, 95% CI 36-41). We also observed a decrease in the proportion of individuals receiving DST for several drugs. These findings underscore the challenges to TB prevention and care during disruption and may be generalizable to the current wartime situation, especially considering the substantial increase in refugees within and leaving Ukraine.

Incidence of tuberculous infection in a TB-endemic city.

<sec id="st1"><title>BACKGROUND</title>Current metrics for TB transmission include TB notifications, disease mortality, and prevalence surveys. These metrics are helpful to national TB programs to assess the burden of disease, but they do not directly measure incident infection in the community.</sec><sec id="st2"><title>METHODS</title>To estimate incidence of Mycobacterium tuberculosis infection in Kampala, Uganda, we performed a prospective cohort study between 2014 and 2017 which enrolled of 1,275 adult residents without signs of tuberculous infection (tuberculin skin test [TST] <5 mm and no signs of TB disease) and followed them for conversion of TST at 1 year.</sec><sec id="st3"><title>RESULTS</title>During follow-up, 194 participants converted the TST and 158 converted by one year. The incidence density of TST conversion was 13.2 conversions/100 person-year (95% CI 11.6-15.1), which corresponds to an annual cumulative incidence of tuberculous infection of 12.4% (95% CI 10.7-14.3). Cumulative incidence was greater among older participants and among men. Among participants who reported prior exposure to TB cases, the cumulative risk was highest among those reporting exposure during follow-up.</sec><sec id="st4"><title>CONCLUSIONS</title>The high annual incidence of infection suggests that residents of Kampala have adequate contact for infection with undetected, infectious cases of TB as they go about their daily lives.</sec>.

Leveraging Global Fund's investments to expand innovative public-private provider engagement in TB.

TB remains a significant global health threat, claiming 1.3 million lives annually. The COVID-19 pandemic disrupted progress in the global TB response. Most patients with TB initially seek care from private providers, whereas only a small proportion are engaged by national programmes. The Global Fund is the major international source of funding for TB responses and supports the scale-up of innovative private-public mix (PPM) models in TB. We collected programmatic and financial data on TB from 11 priority countries implementing PPM activities. Country examples and trends in the budget of Global Fund grants were analysed. These countries account for 60% of the global TB burden and Global Fund TB portfolio. PPM contributed 29% of national TB notifications in 2022 (range: 8% to 49%). During 2021-2023, US$1.4 billion was allocated for TB and US$155 million (11%) for PPM, while PPM contributed to 35% of national TB notification targets. PPM budgets increased over time from US$43 million (2002 to 2014) to US$129 million (2024 to 2026). The Global Fund's investments facilitated the expansion of innovative PPM models, improved access, and enhanced TB responses. Our indicative analysis underscores the need for evidence-based planning, collaboration, and increased domestic investment to accelerate the end of TB.

TB among refugees from Ukraine in European countries.

Since the Russian Federation's invasion of Ukraine, millions of refugees have moved to neighbouring European countries. We assessed the burden of TB in these refugees and surveyed screening approaches. We conducted a survey among 30 European Union/European Economic Area and 13 other European countries, requesting population data on migrant residents and refugees with country of birth (COB) Ukraine, the number of TB notifications among people with COB Ukraine and countries' screening policies for refugees from Ukraine. In 2021, the number of migrants born in Ukraine was 1.7 million in the 34 responding countries, and increased with 5.2 million refugees from Ukraine to 6.9 million in 2022. These countries notified 207 TB cases in people with COB Ukraine in 2021 (TB notification rate 12.0/100,000) and 887 in 2022 (TB notification rate 12.8/100,000), of which 228 (26%) had multidrug-resistant/rifampicin-resistant TB (MDR/RR-TB). TB notification rates were higher in countries advising screening for all (16.9/100,000) or specific groups of refugees from Ukraine (14.7/100,000) compared to those without screening (7.2/100,000). TB rates found in people from Ukraine were lower than the expected rate of 44 per 100,000, but higher in host countries recommending screening. Our study underscores the need for adequate TB health services for refugees from Ukraine to ensure tailored diagnosis and treatment, especially for MDR/RR-TB.

IJCM_310A: Active Case Finding for Tuberculosis in outreach centres of a medical college in Puducherry, India: A Mixed Methods Study on Outcomes and Implementation Challenges

Background: Tuberculosis is the leading cause of death from a curable infectious disease and is responsible for 9.9 million new cases and 1.3 million deaths. Over 95% of TB deaths occur in low and middle-income countries. The WHO TB statistics for India for 2021 give an estimated incidence figure of 2,590,000 million cases. In Puducherry, 4500 cases were notified in the same year, with a TB notification rate of 226 per lakh population. ACF has potential benefits but also challenges, which need to be carefully assessed when developing and implementing ACF policies. Objectives: 1) To understand the experiences of healthcare workers during the implementation of Active Case Finding (ACF) activities 2) To assess the implementation of ACF using the feasibility indicators. Methodology: Qualitative interviews (IDI &amp; FGD) were conducted among healthcare workers (Nodal Officers, Medical Officers, and Medical Interns) involved in the ACF to enumerate their experiences during the survey and the implementation challenges they faced. Additionally, a set of feasibility indicators from the literature (Hemant et al.2023) was identified to assess the implementation of ACF in outreach centres of a medical college in Puducherry. Results: Three overarching themes emerged through qualitative interviews: awareness of ACF and TB, implementation challenges, and mechanisms to overcome the challenges. Feasibility indicators will be elicited upon completion of data curation and analysis. Conclusion: The intricate details involved in the implementation of ACF would be understood through the experiences of Health Care Workers as well as quantitative estimation of ACF implementation.

Engagement of private health care facilities in TB management in Lusaka district of Zambia: lessons learned and achievements

BackgroundGlobally, at least 3 million TB patients are missed every year. In Zambia, the TB treatment coverage increased from 66% in 2020 to 92% in 2022. Involvement of all levels of health care service delivery is critical to finding all the missing TB patients.MethodsA survey was undertaken in 15 private facilities in Lusaka district of Zambia using a structured tool administered by project team and a district health team member. Data collected during the survey was analysed and results were used to determine the type of TB services that were offered as well as barriers and enablers to TB service provision. This was followed by a set of interventions that included; training and mentorship on active case finding and systematic TB screening, increased diagnostic capacity, provision of national recording and reporting tools and provision of TB medication through linkage with the National TB program (NTP). We report findings from the baseline survey and changes in presumptive TB identification and notification following interventions.ResultsMajor barriers to TB service delivery were the high cost of TB diagnostic testing and treatment in facilities where services were not supported by the National TB program; the mean cost was 33 (SD 33) and 93 (SD 148) for GeneXpert testing and a full course of treatment respectively. Pre-intervention, presumptive TB identification appeared to increase monthly by 4 (P = 0.000, CI=[3.00–5.00]). The monthly trends of presumptive TB identification during the intervention period increased by 5.32 (P = 0.000, [CI 4.31–6.33. Pre-intervention, the notification of TB appeared to decrease every month by -4.0 (P = 0.114, CI=[-9.00-0.10]) followed by an immediate increase in notifications of 13.94 TB patients (P = 0.001, CI [6.51, 21.36] in the first month on intervention. The monthly trends of notification during the intervention period changed by 0.34 (P = 0.000 [CI 0.19–0.48]). Private facility contribution to TB notification increased from 3 to 7%.ConclusionEngagement and inclusion of private health facilities in TB service provision through a systems strengthening approach can increase contribution to TB notification by private health facilities.

Outcome of patients with tuberculosis managed under NTEP through STEPS in a private hospital in India

ObjectiveAs the global health care commits to the ambitious goal of TB elimination, System for TB Elimination in Private Sector (STEPS) was introduced to provide appropriate standards of TB care to all patients. This study aims to assess the outcome of TB patients treated under STEPS programme in a Private hospital and find any significant factors in determining favourable and unfavourable outcomes. SettingPrivate Quaternary care hospital in South India. DesignRetrospective study which included 163 patients diagnosed with Pulmonary and Extra-Pulmonary Tuberculosis from January 2020 to June 2022. Details like clinical profile, type and site of tuberculosis, modification of ATT regimen, adverse effects and outcomes were recorded. ResultsThe study population included 62.6% males. 45.3% had Type-2 Diabetes mellitus. More than half of the cases were Extra-Pulmonary TB (52.2%) and 54.6% had microbiological confirmation. The Cure Rate in Pulmonary and Extra-Pulmonary TB cases were 76.7% and 79.2% respectively. 29 patients expired during TB treatment out of which 41.3% had renal failure. Advanced age and chronic kidney disease as a co-morbidity were significant in causing unfavourable outcomes. ConclusionProper implementation of STEPS can help in 100% TB notification and effective care of TB patients.

Impact of annual TB screening on stone quarry workers in high-incidence Portuguese municipalities.

<sec id="st1"><title>SETTING</title>The Portuguese municipalities of Penafiel and Marco de Canaveses are high TB incidence areas, where stone quarry workers represent a vulnerable population.</sec><sec id="st2"><title>OBJECTIVE</title>To assess the annual rate of TB infection (ARI) in stone quarry workers and to compare it with the TB notification rate in the general community.</sec><sec id="st3"><title>DESIGN</title>An annual TB infection screening strategy using interferon-gamma release assay (IGRA) was implemented in 2018 for workers from high-risk stone quarries. A prospective cohort was enrolled and workers screened in periods of 2 years were included. IGRA-positive workers were referred for preventive treatment. ARI was calculated as the proportion of workers with IGRA conversion.</sec><sec id="st4"><title>RESULTS</title>Of the 232 IGRA-negative workers in 2018, 20 tested positive in 2019 (8.6% ARI). Of 171 IGRA-negative workers in 2019, eight tested positive in 2021 (4.7% in 2 years). Two of the 150 IGRA-negative workers in 2021 tested positive in 2022 (1.3% ARI). ARI decreased by 84.9% between 2019 and 2022. In the two municipalities, the TB notification rate declined 23.9% between 2018 and 2021.</sec><sec id="st5"><title>CONCLUSION</title>A more pronounced reduction in ARI was observed among stone quarry workers regularly screened for TB infection compared to the notification rate among the general population in high-incidence municipalities. A screening strategy for high-risk populations, together with enforced community measures, could foster risk reduction in the community.</sec>.

A social enterprise model for TB detection and treatment through the private sector in Pakistan.

Existing models to increase TB case notifications from the private sector in Pakistan are financially unsustainable and have achieved modest success due to limited coverage. To evaluate the impact of a social enterprise model (SEM) intervention on TB case detection in Karachi, Pakistan, and to assess its financial sustainability. Purpose-built centres were established within the private sector that integrated TB screening, diagnostics and treatment and operated 12 hours per day with convenient locations to improve access. TB services were offered free of cost, and revenue generation took place through user fees from other diagnostics. Private providers with a focus on the informal sector were engaged through community workers to generate screening referrals. Overall 171,488 people were screened and 18,683 cases were notified, including 197 individuals with drug-resistant TB. Annual TB notifications in Karachi increased from 18,105 in 2014 to a maximum of 25,840 (40% increase). The proportion of cases in Karachi notified by the centres grew to 27% in 2020. Commercial revenue reached USD288,065 and enabled operating cost recovery of 15%. Average cost per TB case notified was USD203. The SEM intervention contributed a large proportion of notifications in Karachi and achieved modest cost recovery.

Improving TB Case Detection Through Active Case-Finding: Results of Multiple Intervention Strategies in Hard-to-Reach Riverine Areas of Southern Nigeria.

A major challenge to TB control globally is low case detection, largely due to routine health facility-based passive case-finding employed by national TB control programs. Active case-finding is a risk-population-based screening approach that has been established to be effective in TB control. This intervention aimed to increase TB case detection in hard-to-reach areas in southern Nigeria. Using a descriptive cross-sectional design, we conducted implementation research in 15 hard-to-reach riverine local government areas with historically recognized low TB case notification rates. Individuals with TB symptoms were screened using multiple strategies. Data were collected quarterly over a 4-year period using reporting tools and checklists. Descriptive analysis was done with Microsoft Excel spreadsheet 2019. A total of 1,089,129 individuals were screened: 16,576 in 2017; 108,102 in 2018; 697,165 in 2019; and 267,286 in 2020. Of those screened, 24,802 (2.3%) were identified as presumptive TB, of which 88.8% were tested and 10% were diagnosed with TB (0.23% of those screened). TB notifications more than doubled, increasing by 183.3% and 137.5% in the initial implementation and scale-up, respectively. On average, 441 individuals needed to be screened to diagnose 1 TB case. The cases, predominantly males (56.1%) and aged 15 years and older (77.4%), comprised 71.9% bacteriologically confirmed drug-sensitive TB, 25.8% clinically diagnosed drug-sensitive TB, and 2.3% drug-resistant cases. Detection sources included community outreach (1,786), health facilities (505), people living with HIV (57), and household contacts of bacteriologically confirmed TB cases (123). Remarkably, 98.1% of diagnosed TB cases commenced treatment. We found a significant yield in TB case notifications, more than doubling the baseline figures. Given these successful results, we recommend prioritizing resources to support active case-finding strategies in national programs, especially in hard-to-reach areas with high-risk populations, to address TB more comprehensively.

Key drivers of the TB epidemic in Suriname and priority actions to reduce incidence and mortality.

The WHO has recently published updated guidance for national strategic planning for TB. To address the TB epidemic comprehensively, it is necessary to conduct an epidemiological review as part of the situation analysis in the national strategic plan. A descriptive epidemiological study was conducted using data from the national TB register for the period of 2010-2020. Simple frequencies were calculated for demographic and clinical variables. Trends in TB notification rates for the period 2010-2020 were also calculated. TB notification rates between 2011 (24.3/100,000) and 2019 (23.9/100,000) remained almost the same. The HIV status was known for 97.1% of TB cases, 22.7% of whom had HIV co-infection; 10.9% of patients with detected Mycobacterium tuberculosis were also resistant to rifampicin. Case fatality rate for all cases was 13.0%. Of the identified contacts, 66% were screened; 28.3-47.5% of those with TB infection started treatment, 63.3-75.9% of whom completed treatment. The review identified the following areas of concern: no decline in TB rates, high proportion of TB-HIV co-infection, high rate of resistance to rifampicin, high case-fatality rates and suboptimal contact investigation care cascade . The review was used to inform interventions and key actions to reduce TB morbidity and mortality in Suriname.

Who found it easy to avail nutritional support through direct benefit transfer under national TB elimination programme in Eastern India: an early evidence from Jharkhand

Background: National TB Programme of India launched Nikshay Poshan Yojana (NPY) through Direct Benefit Transfer (DBT) in April 2018, to provide financial support for additional nutritional requirement during TB treatment. This study aims to understand the enabling attributes in availing Nikshay Poshan Yojana (NPY) through Direct Benefit Transfer (DBT) among notified TB patients from the Indian state of Jharkhand for the year 2019. Methods: This is a retrospective cross sectional descriptive study using secondary data obtained from Nikshay web portal for the Indian state of Jharkhand in the year 2019. State level data on TB Notification and NPY DBT scheme is downloaded from the Nikshay portal in excel format and analysed using Excel 2016 version. Odds Ratio and P value are calculated and analysed to prove any statistically significant associations. Results: The study found higher odds (1.08, 95% CI: 1.03, 1.14; P value 0.004) of having patients who belong to 15 to 65 years, female sex (odds ratio 1.05, 95% CI: 1.01, 1.09; P value 0.018), seeking care in public sector (odds ratio 4.05, 95% CI: 3.83, 4.27; P value &lt;0.00001) and with drug sensitive TB (DS TB) (odds ratio 1.39, 95% CI: 1.1, 1.59; P value &lt;0.00001), among those who received at least one instalment of DBT. Conclusions: TB patients belonging to productive age group, female sex, seeking care in public sector and with DS TB have higher odds of receiving NPY among the study population.

Impact of Nikshay Poshan Yojana on tuberculosis outcomes: preliminary evidence from eastern India

Background: National TB programme of India implemented Nikshay Poshan Yojana (NPY) through direct benefit transfer (DBT) in April 2018. This is to address the dual evils of under nutrition and unfavourable outcomes among tuberculosis patients in the country. This study aimed to understand the impact of Nikshay Poshan Yojana (NPY) through direct benefit transfer (DBT) on the outcomes of notified TB patients from the Indian state of Jharkhand for the year 2019. Methods: This was a retrospective cross sectional descriptive study using secondary data obtained from Nikshay web portal for the Indian state of Jharkhand for the year 2019. State level data on TB notification and NPY DBT scheme was downloaded in excel format and analysed using Excel 2016 version. Results: The study found higher odds (odds ratio 3.14, 95% CI: 2.97, 3.33; p value &lt;0.00001) of having successful outcomes, among those who received at least one instalment of NPY. The risk of lost to follow up (LTFU) was 2.44 times (95% CI: 2.2-2.8, p value: 3.9×10-43) higher among those who did not receive any DBT payments as compared to those who received at least one DBT instalment. Conclusions: The ‘individual and health system enablers’ have a crucial role to play in successful TB treatment outcomes than NPY. However, LTFU rate reduces significantly with timely payment of NPY. This would facilitate improved treatment adherence and thus a favourable outcome.

Sustained high fatality during TB therapy amid rapid decline in TB mortality at population level: A retrospective cohort and ecological analysis from Shiselweni, Eswatini.

Despite declining TB notifications in Southern Africa, TB-related deaths remain high. We describe patient- and population-level trends in TB-related deaths in Eswatini over a period of 11 years. Patient-level (retrospective cohort, from 2009 to 2019) and population-level (ecological analysis, 2009-2017) predictors and rates of TB-related deaths were analysed in HIV-negative and HIV-coinfected first-line TB treatment cases and the population of the Shiselweni region. Patient-level TB treatment data, and population and HIV prevalence estimates were combined to obtain stratified annual mortality rates. Multivariable Poisson regressions models were fitted to identify patient-level and population-level predictors of deaths. Of 11,883 TB treatment cases, 1302 (11.0%) patients died during treatment: 210/2798 (7.5%) HIV-negative patients, 984/8443 (11.7%) people living with HIV (PLHIV), and 108/642 (16.8%) patients with unknown HIV-status. The treatment case fatality ratio remained above 10% in most years. At patient-level, fatality risk was higher in PLHIV (aRR 1.74, 1.51-2.02), and for older age and extra-pulmonary TB irrespective of HIV-status. For PLHIV, fatality risk was higher for TB retreatment cases (aRR 1.38, 1.18-1.61) and patients without antiretroviral therapy (aRR 1.70, 1.47-1.97). It decreases with increasing higher CD4 strata and the programmatic availability of TB-LAM testing (aRR 0.65, 0.35-0.90). At population-level, mortality rates decreased 6.4-fold (-147/100,000 population) between 2009 (174/100,000) and 2017 (27/100,000), coinciding with a decline in TB treatment cases (2785 in 2009 to 497 in 2017). Although the absolute decline in mortality rates was most pronounced in PLHIV (-826/100,000 vs. HIV-negative: -23/100,000), the relative population-level mortality risk remained higher in PLHIV (aRR 4.68, 3.25-6.72) compared to the HIV-negative population. TB-related mortality rapidly decreased at population-level and most pronounced in PLHIV. However, case fatality among TB treatment cases remained high. Further strategies to reduce active TB disease and introduce improved TB therapies are warranted.

Active screening for tuberculosis among high-risk populations in high-burden areas in Zhejiang province, China

ObjectivesTuberculosis (TB) is a major global public health concern. Although the incidence of TB in China is declining, the country continues to face many challenges regarding TB control. This study aimed to develop an active case finding (ACF) strategy for high-risk populations in areas with high TB burden and evaluate the effectiveness of the ACF strategy for early TB detection in patients to reduce TB transmission. Study designThis was a descriptive study. MethodsFrom May to October 2019, active TB screening was conducted in Zhejiang Province, China. Overall, 24 high-burden townships were chosen as study sites. Residents aged ≥65 years, suffering from diabetes, diagnosed with HIV/AIDS, or with a history of TB were mobilized for screening. Chest radiography was performed for all participants in the community. Sputum specimens were collected for sputum smear tests and cultures at county-level TB-designed hospitals. A professional medical team performed the final diagnoses. ResultsOverall, 130,643 residents were included, accounting for 8.85% of the total population in the selected areas. After screening, 89 confirmed cases and 419 suspected cases were identified. The detection rates for suspected and confirmed cases were 320.72/100,000 and 68.12/100,000, respectively. Individuals with a history of TB accounted for a large proportion of detected cases, and the detection rate was higher among males than in females. This study identified 10.5% of reported cases in the selected areas in 2019. In Zhejiang province, compared with the previous year, the rates of TB notification in 2019 and 2020 declined by 7.0% and 7.4%, respectively, compared with the previous year. However, the TB notification rate in 2019 was almost the same as that in 2018 (a decline of 2.5%) but sharply declined in 2020 (14.4%) in the screened areas. ConclusionsOur findings suggest that the ACF strategy may have helped to maintain the downward trends in TB notification rates by detecting patients with TB and suspected cases in the short term.