TB Symptoms Research Articles

Twenty Year Experience of Thoracic Surgery in a Tertiary Institute for Post TB Sequelae

Aims & Objective: Post TB sequelae like hemoptysis and recurrent chest infections are a source of lot of morbidity around the globe. Many of these patients present to thoracic surgeons and surgical intervention is able to offer significant relief in many of these patients. Methods: Retrospective analysis was carried out for cases operated upon for post TB seqalae in the period from March 1997 to December 2017 in the Thoracic Surgery Department of the National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India. A total of 1325 cases of post TB sequelae were taken up for surgery Out of these, those operated upon primarily for troublesome hemoptysis were 1154 cases. 171 cases were taken up for surgery because they had for recurrent chest infections. Out of these, 558 had tubercular cavities or destroyed lungs, 213 had aspergilloma and post tubercular bronchiectasis was present in 554 cases. Procedures performed were pneumonectomy in 417 patients, lobectomy in 732, bilobectomy in 98, segmental and wedge resections in 16 and thoracoplasty in 62 cases. Results: A total of 60 deaths occurred in this series. There were 18 early and 42 late deaths. 7 patients died of hemorrhage, 4 of respiratory failure, 3 sudden deaths in postoperative period (possible cause-Cardiac arrhythmia or cardiac herniation) and 4 of sepsis. Bronchopleural fistula developed postoperatively in 88 cases, which was managed by tube thoracostomy, followed by thoracoplasty, if required. Other complications like wound infection, atelectasis and pneumonitis were quite manageable. Conclusion: Overall quite gratifying results are achieved if surgical intervention is offered in patients suffering from debilitating post TB symptoms in carefully selected and well prepared cases.

Factors Associated with Treatment Adherence among Tuberculosis Patients in Gandaki Province of Nepal

Introduction: Poor adherence to the treatment regimen is a major cause of treatment failure and the emergence of drug resistance among TB patients. The emergence of resistance to anti-tuberculosis drugs and particularly of multi-drug resistance (MDR), Pre-extensively drug resistance tuberculosis (Pre-XDR) and extensively drug resistance (XDR) tuberculosis have become a major public health problem in several countries and an obstacle to effective global TB control.
 Methodology: This research was health facility based cross-sectional study and carried out among TB patients registered under DOTS and receiving treatment more than or equal to 60 days from health facilities of Gandaki province of Nepal. Structured interview schedule and validated questionnaires were used for data collection. Treatment Adherence was assessed by using Nepali version of Morisky treatment adherence scale (MMSA-8) questionnaires. Data were entered in Epi-data software and analysis was performed with the help of the Statistical Package for Social Science (SPSS). The odds ratio with a 95%CI was calculated and a P-value of <0.05 was considered as cut off for statistical significance.
 Results: A total 180 TB patients were participated in this study. The overall prevalence of treatment adherence among tuberculosis participants was 79.4%. Participants who haven’t living with comorbidities were more than four times more likely to adhere with medicine compared to participants who had living with co-morbidities. Similarly, who had friendly relationship with health workers were more than forty six and half times likely to adhere to medicine with compared to participants who had unfriendly relationship with health workers.
 Conclusion: The supportive factors for treatment adherence among Tuberculosis patients were socioeconomic factors (Hilly region, hindu religion, nuclear family, literate), life style related factors (no prior alcohol consumption, not habit smokeless tobacco previously), diseases related factors (delay of confirming TB diagnosis, Not experienced side effects, aware about TB symptoms, no co-infection) and accessibility to health care facilities related factors (confirm TB diagnosis cost, favourable time for DOTS centre, health workers supervision during the medication, friendly relationship with health workers, know about the length of the treatment, TB status disclose).

759. Where can we find active TB? Case finding at community sites and alcohol based venues (ABVs) in rural South Africa

BackgroundCommunity-based intensive case finding (CBICF) is an effective strategy for infectious disease case detection, particularly for hard-to-reach populations. Alcohol use is increasingly recognized as a risk factor for tuberculosis. We report on the association of alcohol use with tuberculosis case detection as part of a CBICF in a rural resource limited setting.MethodsIn rural KwaZuluNatal, South Africa, community health workers stationed outside ABVs, community centers, and public events conducted health education and voluntary confidential screening in a mobile clinic. A WHO endorsed TB symptom screen (with sputum collection for GeneXpert if ≥1 symptom), HIV rapid test, random glucose (elevated >7mmol/L), and blood pressure (elevated >140 or >90mmHg) were offered. Community members with positive results were referred to their primary care clinic. Alcohol Use Disorder Identification Test (AUDIT) was used to identify hazardous drinking (score ≥8for men, ≥6for women). Here we report on TB screening results only.ResultsAmong 1438 participants, 91.2% were screened at ABV, 72.3% were male, median age was 30 (IQR 22-46), 25.9% were employed, 92.0% had electricity but only 29.4% had running water. Among those screened at all sites, 43.1% reported hazardous alcohol use, 39.3% tobacco use, and 13.9% cannabis use. Overall, 5 people with active TB were identified representing a number needed to screen of 288 to identify one case of TB. Bivariate analysis showed TB cases were more likely to be associated with older age (p=0.03), cigarette use (p=0.06), and hazardous alcohol use (p=0.01). Among only men who were screened, older age (p=0.01) and hazardous alcohol use (p=0.04) were associated with active TB disease. The mean AUDIT score among TB cases was 13.8 (SD 4.09) compared to non-TB cases 6.8 (SD 7.5) (p=0.04).ConclusionCBICF is a useful way to detect people with active TB, especially for hard-to-reach rural populations. Focusing screening efforts among those at ABVs is high yield and can be a useful adjunctive strategy for TB case finding efforts. These findings highlight a need for comprehensive substance abuse services to assist those at high risk for TB acquisition.Disclosures All Authors: No reported disclosures

Standard for TB care in India (STCI) guidelines- A study on knowledge, attitude and practice among junior doctors of a tertiary care hospital of Kolkata

Introduction: Standards for TB Care in India was produced in 2014 which set out the standard of TB treatment and TB testing & diagnosis in India that should be provided by the RNTCP in all parts of the country. Objectives: to assess the knowledge, attitude and practices regarding Standards for TB Care in India (STCI) guidelines among junior doctors in a Tertiary Care Teaching Hospital of Kolkata. Materials and Methods: An institution-based observational descriptive study, cross-sectional in design, was conducted among 244 junior doctors of a tertiary care Government Teaching Hospital of Kolkata, from May 2016 to June 2016 using a pre designed pre tested structured questionnaire. Results: Though junior doctors had satisfactory knowledge about symptoms of presumptive TB & diagnosis; they had unsatisfactory knowledge regarding drug regimen, follow up sputum, diagnosis of MDR TB, XDR- TB and TB HIV.; they had positive attitude regarding seriousness of TB and regular upgradation of TB knowledge and had discordant practices regarding drug regimen, duration of treatment and TB notification. Conclusions: Structured and periodic training and re-training to ensure continuity of correct knowledge is need of the hour. Keywords: STCI, Junior doctors, Knowledge, Attitude, Practice.

A study on awareness on tuberculosis among urban slum population of Hyderabad

Background: Tuberculosis a major public health problem in India with highest burden of cases. India accounts for about 24% of global prevalence, 23% of the global incidence cases and 21% of global TB deaths. Irregular and inappropriate treatment of persons with active TB, unawareness about TB symptoms and treatment course, illiteracy, may be the major hurdles for TB eradication.Methods: A cross sectional, community based study was conducted in urban slum dwellers (n=153). Data compilation and analysis: All the data collected was entered and analyzed with MS excel software 2007 and Epi info 3.5.3. All tests were considered significant at p<0.05 level.Results: 18.3% told that cough+expectoration+evening rise of temperature+weight loss are the signs and symptoms of TB. 55.5% know that it spreads through cough and sneezing mixed with air. 23.5% knows blood examination, sputum examination, x-ray is the mode of diagnosis of TB.Conclusions: Literacy plays major role in creating awareness on TB.

Social Enterprise Model (SEM) for private sector tuberculosis screening and care in Bangladesh

BackgroundIn Bangladesh, about 80% of healthcare is provided by the private sector. Although free diagnosis and care is offered in the public sector, only half of the estimated number of people with tuberculosis are diagnosed, treated, and notified to the national program. Private sector engagement strategies often have been small scale and time limited. We evaluated a Social Enterprise Model combining external funding and income generation at three tuberculosis screening centres across the Dhaka Metropolitan Area for diagnosing and treating tuberculosis.Methods and findingsThe model established three tuberculosis screening centres across Dhaka Metropolitan Area that carried the icddr,b brand and offered free Xpert MTB/RIF tests to patients visiting the screening centres for subsidized, digital chest radiographs from April 2014 to December 2017. A network of private and public health care providers, and community recommendation was formed for patient referral. No financial incentives were offered to physicians for referrals. Revenues from radiography were used to support screening centres’ operation. Tuberculosis patients could choose to receive treatment from the private or public sector. Between 2014 and 2017, 1,032 private facilities networked with 8,466 private providers were mapped within the Dhaka Metropolitan Area. 64, 031 patients with TB symptoms were referred by the private providers, public sector and community residents to the three screening centres with 80% coming from private providers. 4,270 private providers made at least one referral. Overall, 10,288 pulmonary and extra-pulmonary tuberculosis cases were detected and 7,695 were bacteriologically positive by Xpert, corresponding to 28% of the total notifications in Dhaka Metropolitan Area.ConclusionThe model established a network of private providers who referred individuals with presumptive tuberculosis without financial incentives to icddr,b’s screening centres, facilitating a quarter of total tuberculosis notifications in Dhaka Metropolitan Area. Scaling up this approach may enhance national and international tuberculosis response.

Assessment of knowledge, attitude and practice on tuberculosis among teacher trainees of Samtse College of Education, Bhutan.

BackgroundTuberculosis (TB) is a major public health problem in Bhutan despite the implementation of directly observed treatment short-course since 1997. This study aimed to assess the knowledge, attitude and practice on TB among the teacher trainees of Samtse College of Education.MethodologyA cross-sectional study was conducted among the teacher trainees of Samtse College of Education. A standardized pretested questionnaire was distributed and self-administered. The participants were selected randomly using randomization. The data was entered in Epi-data 4.4.2.1 and analysed using STATA version 13. A score of 1 point for a correct answer and 0 for wrong/don’t know answer was given. The knowledge, attitude and practice score were divided into good and poor based on 50% cut off. Logistic regression was used for the analysis to identify the significant covariates.ResultsA total of 420 trainees responded to the survey questionnaire. The average knowledge score on TB was 10.7 (Range = 0–21). Two hundred and forty respondents (58.6%) had low knowledge (mean score 7.8±2.5) on TB. Cough, chest pain and weight loss were correctly reported as the symptoms of TB by 306 (72.9%), 187(44.5%) and 187 (44.5%) participants. Eighty-nine-point five percent (376) of participants reported coughing as the main route of TB transmission and 85% (357) of the participants said that it could be prevented by covering the mouth while coughing. In multivariable analysis; the trainees in the junior years of college had good knowledge of TB compared with the senior years (adjusted odds ratio [AOR] 2.02; 95% confidence interval [CI] 1.18–3.5; p-value 0.011). Respondents previously treated for TB were more likely to have good knowledge on TB compared to those who never had TB in the past (AOR 2.39; 95% CI 1.07–5.31; p-value 0.033). The majority (93%) of respondents had a good attitude towards TB cases. Female trainees were 2.4 (95% CI 1.02–5.62; p-value 0.045) times more likely than male trainees to have a positive attitude towards TB. Eighty-eight percent of the respondents reported that they would visit the hospital if they had TB symptoms. The mean score for the practice on TB was 1.33±0.59 (Range:0–2).ConclusionIn this study, the majority of the trainees had poor knowledge on TB, especially among the trainees in senior years of college and those who had never suffered from TB. The attitude towards TB was good especially among the female trainees. However, the overall practice was poor among the participants. Therefore, the Ministry of Health should collaborate with relevant stakeholders especially the Ministry of Education to incorporate topics on TB in the syllabus of students and colleges to create awareness on it.

Tuberculosis with Immune Thrombocytopenia an Unusual Association

Introduction Tuberculosis (TB) and is the leading infectious cause of death in adult's worldwide.TB can have a wide variety of presentations manifestation. Hematological manifestations of tuberculosis have different forms and one of the rare associated is TB with isolated thrombocytopenia. ITP is relatively common autoimmune bleeding disorder.. However, ITP is very rarely associated with TB with only a few cases reported. Isolated Thrombocytopenia in TB is multifactorial and could be explained by different mechanisms as follows Immune-mediated platelet destruction through antiplatelet antibodies as mycobacterium TB may share antibodies with platelets or platelet-associated immunoglobulin, Tuberculosis-induced hemophagocytosis, Defective platelet production due to bone marrow (BM) infiltration, Hypersplenism, intravascular coagulation, anti-tuberculous treatment (ATT) induced thrombocytopenia. Methodology We reviewed the literature using PubMed, google scholar and English language articles only. We have included all the reported cases of tuberculosis and immune thrombocytopenia if it is associations or initial presentations using the keyword: tuberculosis. Pulmonary tuberculosis, immune thrombocytopenia, Idiopathic thrombocytopenia purpura and we excluded drug induced thrombocytopenia. Our review identified forty-two cases in total, in our review Baseline and clinical characteristics are provided. Results Of the forty-two cases identified, more than one quarter of cases (n=12) were from India; the remainder of the reported cases from thirteen different countries. Gender was nearly equally distributed (males n= 21, females n=20, one case unknown); age ranged from 4 to 74 years. The most reported sites of TB as follows; lung (n=20), disseminated (n=8), lymph nodes (n=6), abdomen (n=4), mediastinum (n=2), spleen (n=1) and knee (n=1). Bone marrow aspiration and biopsy done in 27 cases, three of them (7%) found granuloma and 14 (32%) found to have normal to hyprecellular marrow with increased number of megakaryocytes. Of the forty-two cases, ITP was the first presentation of TB with or without typical TB symptoms and signs in more than three quarters of the cases (n=33), while ITP was discovered in TB patients in routine investigations without obvious bleeding symptoms or signs in only four cases. Hemorrhagic symptoms were reported in most of the cases (n=31), skin manifestations (petechiae/purpura/ecchymosis) being the most common (n=28). The therapeutic approach to TB-associated ITP showed significant heterogeneity with Anti tuberculous treatment and first- and/or second-line treatment for ITP given with or without platelets transfusion. Most of the cases (n=36) achieved full recovery with Anti-tuberculous treatment(ATT) and IVIG ± Steroids. Of the 42 cases, six cases were treated with blood and platelet transfusion for thrombocytopenia which did not normalize the platelet count as thrombocytopenia as expected as this is most likely an immune mediated phenomenon. Conclusion Unfortunately, there are no clear guidelines for management of TB-associated ITP and is anecdotal or observational at best. This highlights the importance of conducting prospective and standardized studies in the future. We found that Anti tuberculous treatment could have play pivotal role in management of ITP in TB Patients. Figure Disclosures No relevant conflicts of interest to declare.

Tuberculosis symptom screening for children and adolescents living with HIV in six high HIV/TB burden countries in Africa.

Objectives:The WHO recommends that children and adolescents living with HIV (CALHIV) complete TB symptom screening at every clinical encounter but evidence supporting this recommendation is limited. We evaluated the performance of the recommended TB symptom screening in six high-burden TB/HIV countries.Design:Retrospective longitudinal cohort.Methods:We extracted data from electronic medical records of CALHIV receiving care from clinics in Botswana, Eswatini, Lesotho, Malawi, Tanzania, and Uganda from January 2014 to June 2017. We defined incident TB cases as those prescribed TB treatment within 30 days of TB diagnosis. We analyzed the most recent symptom screen preceding a TB diagnosis. In accordance with WHO guidelines, positive screens were defined as current fever, cough, poor weight gain, or recent TB contact. Odds of TB disease was modeled by screen result and age at which screening was conducted.Results:Twenty thousand seven hundred and six patients collectively had 316 740 clinic visits, of which 240 161 (75.8%) had documented TB symptom screens. There were 35 701 (14.9%) positive TB symptom screens, and 1212 incident TB diagnoses. Sensitivity and specificity of the TB symptom screen to diagnose TB were 61.2% (95% CI 58.4--64.0) and 88.8% (95% CI 88.7--88.9), respectively. Log odds of documented TB for positive or negative screens was statistically different only for screens conducted at ages 7--17.Conclusion:Although specificity was high, the sensitivity of the TB symptom screen to detect TB in CALHIV was low. More accurate screening approaches are needed to optimally identify TB disease in CALHIV.

Active TB case finding in a high burden setting; comparison of community and facility-based strategies in Lusaka, Zambia.

We conducted an implementation science study to increase TB case detection through a combination of interventions at health facility and community levels. We determined the impact of the study in terms of additional cases detected and notification rate and compared the yield of bacteriologically confirmed TB of facility based and community based case finding. Over a period of 18 months, similar case finding activities were conducted at George health facility in Lusaka Zambia and its catchment community, an informal peri-urban settlement. Activities included awareness and demand creation activities, TB screening with digital chest x-ray or symptom screening, sputum evaluation using geneXpert MTB/RIF, TB diagnosis and linkage to treatment. A total of 18,194 individuals were screened of which 9,846 (54.1%) were screened at the facility and 8,348 (45.9%) were screened in the community. The total number of TB cases diagnosed during the intervention period were 1,026, compared to 759 in the pre-intervention period; an additional 267 TB cases were diagnosed. Of the 563 bacteriologically confirmed TB cases diagnosed under the study, 515/563 (91.5%) and 48/563 (8.5%) were identified at the facility and in the community respectively (P<0.0001). The TB notification rate increased from 246 per 100,000 population pre-intervention to 395 per 100,000 population in the last year of the intervention. Facility active case finding was more effective in detecting TB cases than community active case finding. Strengthening health systems to appropriately identify and evaluate patients for TB needs to be optimised in high burden settings. At a minimum, provider initiated TB symptom screening with completion of the TB screening and diagnostic cascade should be provided at the health facility in high burden settings. Community screening needs to be systematic and targeted at high risk groups and communities with access barriers.

Comparative Sero-Epidemiological Prevalence of TB with Acid Fast Bacilli sputum Positive Cases in TB Suspects of Lower Dir

Background: Tuberculosis is an infection of lungs accompanied by coughing more than two weeks, fever, and night sweat, loss of appetite, weight loss and anorexia. Approximately 33% of the entire world population has infected the incidence of TB is 9 lac new cases each year with mortality rate of 1.3 million. There are 22 high risk burden countries accounting for nearly 80% entire TB of the globe. Materials and Methods: A cross sectional investigation was carried out to analyze patients by both immune chromatographic test and direct sputum smear microscopy. Patients were asked through a questionnaire mentioning the age, name, gender, location, and symptoms of TB. Thrusfield formula was used from veterinary microbiology to calculate the sample number. So, with 95% confidence interval, 5% absolute precision, I analyzed only 324 subjects of interest. Results: The entire positivity rate was 25% in which 79.5% was the rate of positivity by ICT and 20.5% by sputum smear microscopy. Higher positivity by Age range 20-40 showed 40.9% by ICT and by sputum it was found in age group 1-20 years 17.5%. Based on gender, higher positivity rate was found by both tests in females as compared to males. Females were 31.8% positive by ICT and 10% by sputum test. Males were 22.8% positive by ICT and 5% by sputum test. Marital status based higher positivity by ICT was found in married which is 29.11% while positivity in unmarried which is 12.5%. Conclusion: Tuberculosis is still a prevalent disease in lower Dir Khyber Pukhtunkhwa province of Pakistan. The more positivity rate has found in females as compared to males. It requires further sophisticated investigation to acquire a more accurate result in case of tuberculosis prevalence in lower Dir region of KP province of Pakistan. As the DOTS strategy states, Directly observed treatment and short course is a better way to early case detection and treatment otherwise the disease can become more exaggerated in short period of time because the bacteria is an airborne pathogen so it can freely transmit to the lungs.

A clinical algorithm for same-day HIV treatment initiation in settings with high TB symptom prevalence in South Africa: The SLATE II individually randomized clinical trial

BackgroundMany countries encourage same-day initiation of antiretroviral therapy (ART), but evidence on eligibility for same-day initiation, how best to implement it, and its impact on outcomes remains scarce. Building on the Simplified Algorithm for Treatment Eligibility (SLATE) I trial, in which nearly half of participants were ineligible for same-day initiation mainly because of TB symptoms, the study evaluated the revised SLATE II algorithm, which allowed same-day initiation for patients with mild TB symptoms and other less serious reasons for delay.Methods and findingsSLATE II was a nonblinded, 1:1 individually randomized pragmatic trial at three primary healthcare clinics in Johannesburg, South Africa. It randomized adult patients presenting for an HIV test or any HIV care but not yet on ART. Intervention arm patients were assessed with a symptom screen, medical history, brief physical examination, and readiness questionnaire to distinguish between patients eligible for immediate ART dispensing and those requiring further care before initiation. Standard arm patients received usual care. Follow-up was by review of routine clinic records. Primary outcomes were (1) ART initiation in ≤7 days and (2) ART initiation in ≤28 days and retention in care at 8 months (composite outcome). From 14 March to 18 September 2018, 593 adult HIV+, nonpregnant patients were enrolled (median interquartile range [IQR] age 35 [29–43]; 63% (n = 373) female; median CD4 count 293 [133–487]). Half of study patients (n = 295) presented with TB symptoms, whereas only 13 (4%) standard arm and 7 (2%) intervention arm patients tested positive for TB disease. Among 140 intervention arm patients with TB symptoms, 72% were eligible for same-day initiation. Initiation was higher in the intervention (n = 296) versus standard arm (n = 297) by 7 days (91% versus 68%; risk difference [RD] 23% [95% confidence interval (CI) 17%–29%]) and 28 days (94% versus 82%; RD 12% [7%–17%]) after enrollment. In total, 87% of intervention and 38% of standard arm patients initiated on the same day. By 8 months after study enrollment, 74% (220/296) of intervention and 59% (175/297) of standard arm patients had both initiated ART in ≤28 days and been retained in care (RD 15% [7%–23%]). Among the 41% of participants with viral load results available, suppression was 90% in the standard arm and 92% in the intervention arm among patients initiated in ≤28 days. No ART-associated adverse events were reported after initiation; two intervention and four standard arm patients were reported to have died during passive follow-up. Limitations of the study included limited geographic generalizability, exclusion of patients too sick to consent, fluctuations in procedures in the standard arm over the course of the study, high fidelity to the trial protocol by study staff, and the possibility of overestimating loss to follow-up due to data constraints.ConclusionsMore than 85% of patients presenting for HIV testing or care, including those newly diagnosed, were eligible and ready for same-day initiation under the SLATE II algorithm. The algorithm increased initiation within 7 days without appearing to compromise retention and viral suppression at 8 months, offering a practical and acceptable approach that can be widely and immediately utilized by existing providers.Trial registrationClinicaltrials.gov NCT03315013, registered 19 October 2017. First participant enrolled 14 March 2018.

To Assess the Knowledge and Awareness of Interns Regarding the Management of Tuberculosis as per Recent RNTCP (2017-2025) Guidelines – A Cross Sectional Study

India has been engaged in Tuberculosis control activities for more than 50 years as India is the highest TB burdened country in the world. One such initiative is Revised National Tuberculosis Control Programme (RNTCP) which has been rechristened as National Tuberculosis Elimination Programme (NTEP). The change in name is in line with the larger goal of eliminating the disease by 2025. Objective: The aim of this cross-sectional study is to assess the knowledge and awareness of interns regarding the management of tuberculosis as per recent RNTCP guidelines. Materials &amp; Methods: A structured questionnaire was provided to 111 interns to be filled in a stipulated time. The data collected was analyzed using descriptive statistical parameters and expressed in percentage. Result: Out of a total of 111 interns, 48 (43.24%) were males and 63 (56.75%) were females. Good knowledge was seen among the interns regarding the cardinal symptoms of TB as well as definition of MDR-TB. 92.79% of the participants responded rightly about two sputum samples being taken for diagnosis of TB. Only 76.57% of interns knew the principle of treatment of TB as daily administration of fixed-dose combination of first-line anti-tubercular drugs as per appropriate weight bands and 61.27% of interns were unfamiliar of chemoprophylaxis of tuberculosis according to the recent RNTCP guidelines. Only 71.17% of the participants were updated about the follow-up procedure according to new guidelines. But only 36.93% of participants could answer Cotrimoxazole as the effective drug used in HIV-TB co-infection apart from routine TB drugs to reduce mortality. Conclusion: This survey is providing valuable information that there is deficiency of knowledge among the interns regarding management of tuberculosis according to recent RNTCP guidelines which can lead to treatment failure and thereby causing a hindrance to elimination of TB from our country by 2025

Knowledge and stigma of latent tuberculosis infection in Brazil: implications for tuberculosis prevention strategies

BackgroundTuberculosis (TB) elimination requires treatment of millions of persons with latent M. tuberculosis infection (LTBI). LTBI treatment acceptance depends on population-wide TB knowledge and low stigma, but limited data are available on the relationship between stigma and knowledge. We assessed knowledge of TB disease and LTBI throughout Brazil and examined their association with TB stigma and incidence.MethodsWe performed a nationwide survey with multi-stage probability design through AmericasBarometer from April–May 2017; the sample was representative of Brazil at regional and national levels. Knowledge of and stigma toward TB were assessed by validated survey questions.ResultsSurvey-weighted responses of 1532 individuals suggest that 57% of the population knew LTBI can occur, and 90% would seek treatment for it. Regarding active TB, 85% knew TB symptoms, 70% reported they should avoid contact with someone with active TB, and 24% had stigma toward persons with TB (i.e., thought persons with tuberculosis should feel ashamed, or deserved their illness). In regression models adjusting for clinical and demographic variables, knowledge of LTBI was associated with increased stigma toward persons with TB (adjusted odds ratio [OR] = 2.13, 95% confidence interval [CI]: 1·25–3.63, for “should feel ashamed”; OR = 1·82, 95% CI: 1·15–2·89, for “deserve illness”). Adjusting for regional TB incidence did not affect this association.ConclusionsHigh proportions of this representative Brazilian population had knowledge of LTBI and were willing to seek treatment for it. However, such knowledge was associated with TB-specific stigma. Strategies to educate and implement treatment of latent tuberculosis must include efforts to decrease TB stigma.

Role of empiric treatment in hospitalized patients with Xpert MTB/RIF-negative presumptive pulmonary tuberculosis: A prospective cohort study

ObjectivesThe ability of clinical algorithms to identify tuberculosis disease and the impact of empiric treatment on survival in people with a negative Xpert MTB/RIF (Xpert) result remains poorly documented. MethodsHospitalized Xpert-negative patients (125 initiated on empiric tuberculosis treatment based on a clinical algorithm and 125 in whom tuberculosis treatment was not started) were enrolled. Sputum samples were evaluated for Mycobacterium tuberculosis by culture. All study participants were followed up for 6 months. ResultsXpert-negative inpatients in whom empiric tuberculosis treatment was initiated were more likely to have microbiological confirmed tuberculosis compared to those in whom empiric tuberculosis treatment was not started (24.8% vs 6.4%, p=0.0001). Six-month risk of death was 5.2%, but the risk was twice as high in people with bacteriological confirmation of TB (10.3% vs 4.3%, p=0.12). Cardinal symptoms of TB were associated with bacteriological confirmation and a decision to start empiric treatment. The positive predictive value of the clinical algorithm was 24.8% and empiric treatment did not affect 6-month risk of death (5.6% vs 4.8%, p=0.78). ConclusionsClinical algorithm identifies the majority of confirmed tuberculosis cases among Xpert-negative inpatients. Empiric treatment did not impact survival and resulted in substantial overtreatment. The more sensitive Xpert Ultra assay should be used to eliminate the need for empiric tuberculosis treatment.

Determinants of isoniazid preventive therapy completion among people living with HIV attending care and treatment clinics from 2013 to 2017 in Dar es Salaam Region, Tanzania. A cross-sectional analytical study

BackgroundTuberculosis (TB) disease is a common opportunistic infection among people living with HIV (PLHIV). WHO recommends at least 6 months of isoniazid Preventive Therapy (IPT) to reduce the risk of active TB. It is important to monitor the six-month IPT completion since a suboptimal dose may not protect PLHIV from TB infection. This study determined the six-month IPT completion and factors associated with six-month IPT completion among PLHIV aged 15 years or more in Dar es Salaam region, Tanzania.MethodsSecondary analysis of routine data from PLHIV attending 58 care and treatment clinics in Dar es Salaam region was used. PLHIV, aged 15 years and above, who screened negative for TB symptoms and initiated IPT from January, 2013 to June, 2017 were recruited. Modified Poisson regression with robust standard errors was used to estimate prevalence ratios (PR) and 95% confidence interval (CI) for factors associated with IPT completion. Multilevel analysis was used to account for health facility random effects in order to estimate adjusted PR (APR) for factors associated with IPT six-month completion.ResultsA total of 29,382 PLHIV were initiated IPT, with 21,808 (74%) female. Overall 17,092 (58%) six-month IPT completion, increasing from 42% (773/1857) in year 2013 to 76% (2929/3856) in 2017. Multilevel multivariable model accounting for health facilities as clusters, showed PLHIV who were not on ART had 46% lower IPT completion compared to those were on ART (APR: 0.54: 95%CI: 0.45–0.64). There was 37% lower IPT completion among PLHIV who transferred from another clinic (APR: 0.63: 95% CI (0.54–0.74) compared to those who did not transfer. PLHIV aged 25–34 years had a 6% lower prevalence of IPT completion as compared to those aged 15 to 24 years (APR:0.94 95%CI:0.89–0.98).ConclusionThe IPT completion rate in PLHIV increased over time, but there was lower IPT completion in PLHIV who transferred from other clinics, who were aged 25 to 34 years and those not on ART. Interventions to support IPT in these groups are urgently needed.

Outcomes of Community-Based Systematic Screening of Household Contacts of Patients with Multidrug-Resistant Tuberculosis in Myanmar.

Screening of household contacts of patients with multidrug-resistant tuberculosis (MDR-TB) is a crucial active TB case-finding intervention. Before 2016, this intervention had not been implemented in Myanmar, a country with a high MDR-TB burden. In 2016, a community-based screening of household contacts of MDR-TB patients using a systematic TB-screening algorithm (symptom screening and chest radiography followed by sputum smear microscopy and Xpert-MTB/RIF assays) was implemented in 33 townships in Myanmar. We assessed the implementation of this intervention, how well the screening algorithm was followed, and the yield of active TB. Data collected between April 2016 and March 2017 were analyzed using logistic and log-binomial regression. Of 620 household contacts of 210 MDR-TB patients enrolled for screening, 620 (100%) underwent TB symptom screening and 505 (81%) underwent chest radiography. Of 240 (39%) symptomatic household contacts, 71 (30%) were not further screened according to the algorithm. Children aged <15 years were less likely to follow the algorithm. Twenty-four contacts were diagnosed with active TB, including two rifampicin- resistant cases (yield of active TB = 3.9%, 95% CI: 2.3%–6.5%). The highest yield was found among children aged <5 years (10.0%, 95% CI: 3.6%–24.7%). Household contact screening should be strengthened, continued, and scaled up for all MDR-TB patients in Myanmar.

Mobile targeted screening for tuberculosis in Zimbabwe: diagnosis, linkage to care and treatment outcomes.

Targeted active screening for tuberculosis (Tas4TB) using mobile trucks in the community was implemented in 15 high TB burden districts in Zimbabwe. At-risk populations were screened for TB based on symptoms and chest radiography (CXR) results. Those with any positive symptom and/or an abnormal CXR had sputum collected for investigation and diagnosis and were linked to care and treatment if found to have TB. To determine 1) the proportion and characteristics of those screened and diagnosed with TB; 2) the relationship between TB symptoms, CXR and diagnostic yields; and 3) the relationship between initiation of anti-TB treatment and treatment outcomes. Cohort study using routinely collected data. A total of 39 065 persons were screened, of whom 663 (1.7%) were diagnosed with TB; 126/663 (19.0%) were bacteriologically confirmed. The highest TB diagnostic yields were in symptomatic persons with CXRs suggestive of TB (19.4%), asymptomatic persons with CXRs suggestive of TB (8.4%) and persons at high-risk of TB (3.2%). For all diagnosed TB patients, pre-treatment loss to follow-up was 18.9% and treatment success was 59.9%. Tas4TB resulted in high diagnostic yields; however, linkage of diagnosis to care was poor. Reasons for loss to follow-up need to be better understood and rectified.

Bacteriologically-confirmed pulmonary tuberculosis in an Ethiopian prison: Prevalence from screening of entrant and resident prisoners.

BackgroundPulmonary Tuberculosis (PTB) is a major health problem in prisons. Multiple studies of TB in regional Ethiopian prisons have assessed prevalence and risk factors but have not examined recently implemented screening programs for TB in prisons. This study compares bacteriologically-confirmed PTB (BC-PTB) prevalence in prison entrants versus residents and identifies risk factors for PTB in Kality prison, a large federal Ethiopian prison located in Addis Ababa, through a study of an enhanced TB screening program.MethodsParticipating prisoners (n = 13,803) consisted of 8,228 entrants screened continuously and 5,575 residents screened in two cross-sectional waves for PTB symptoms, demographics, TB risk factors, and medical history. Participants reporting at least one symptom of PTB were asked to produce sputum which was examined by microscopy for acid-fast bacilli, Xpert MTB/RIF assay and MGIT liquid culture. Prevalence of BC-PTB, defined as evidence of Mycobacterium tuberculosis (MTB) in sputum by the above methods, was compared in entrants and residents for the study. Descriptive analysis of prevalence was followed by bivariate and multivariate analyses of risk factors.ResultsPrisoners were mainly male (86%), young (median age 26 years) and literate (89%). Prevalence of TB symptoms by screening was 17% (2,334/13,803) with rates in residents >5-fold higher than entrants. Prevalence of BC-PTB detected by screening in participating prisoners was 0.16% (22/13,803). Prevalence in residents increased in the second resident screening compared to the first (R1 = 0.10% and R2 = 0.39%, p = 0.027), but remained higher than in entrants (4.3-fold higher during R1 and 3.1-fold higher during R2). Drug resistance (DR) was found in 38% (5/13) of culture-isolated MTB. Risk factors including being ever diagnosed with TB, history of TB contact and low Body Mass Index (BMI) (<18.5) were significantly associated with BC-PTB (p<0.05).ConclusionsBC-PTB prevalence was strikingly lower than previously reported from other Ethiopian prisons. PTB appears to be transmitted within this prison based on its higher prevalence in residents than in entrants. Whether a sustained program of PTB screening of entrants and/or residents reduces prevalence of PTB in prisons is not clear from this study, but our findings suggest that resources should be prioritized to resident, rather than entrant, screening due to higher BC-PTB prevalence. Detection of multi- and mono-DR TB in both entrant and resident prisoners warrants regular screening for active TB and adoption of methods to detect drug resistance.

Increased Case Finding among high risk groups by Mobilizing Frontline Health workforces in Kathmandu Valley

Among garbage collectors, people living with TB symptoms, street children and contacts with Tuberculosis Patients...