Tuberculosis Program Performance Research Articles

Progress Toward Tuberculosis Elimination and Tuberculosis Program Performance - National Tuberculosis Indicators Project, 2016-2022.

Elimination of tuberculosis (TB) is defined as reducing TB disease incidence in the United States to less than 1 case per million persons per year. In 2022, TB incidence in the United States was 2.5 TB cases per 100,000 persons. CDC's TB program developed a set of national TB indicators to evaluate progress toward TB elimination through monitoring performance of state and city TB program activities. Examining TB indicator data enables state- and city-level TB programs to identify areas for program evaluation and improvement activities. These data also help CDC identify states and cities that might benefit from technical assistance. The 5-year period for which the most recent data were available for each of five indicators: 1) overall TB incidence (2018-2022), 2) TB incidence among non-U.S.-born persons (2018-2022), 3) percentage of persons with drug susceptibility results reported (2018-2022), 4) percentage of contacts to sputum acid-fast bacillus (AFB) smear-positive TB patients with newly diagnosed latent TB infection (LTBI) who completed treatment (2017-2021), and 5) percentage of patients with completion of TB therapy within 12 months (2016-2020). The National TB Indicators Project (NTIP) is a web-based performance monitoring tool that uses national TB surveillance data reported through the National TB Surveillance System and the Aggregate Reports for TB Program Evaluation. NTIP was developed to facilitate the use of existing data to help TB program staff members prioritize activities, monitor progress, and focus program improvement efforts. The following five indicators were selected for this report because of their importance in Federal TB funding allocation and in accelerating the decline in TB cases: 1) overall TB incidence in the United States, 2) TB incidence among non-U.S.-born persons, 3) percentage of persons with drug susceptibility results reported, 4) percentage of contacts to sputum AFB smear-positive TB cases who completed treatment for LTBI, and 5) percentage of patients with completion of TB therapy within 12 months. For this report, 52 TB programs (50 states, the District of Columbia, and New York City) were categorized into terciles based on the 5-year average number of TB cases reported to National TB Surveillance System. This grouping allows comparison of TB programs that have similar numbers of TB cases and allocates a similar number of TB programs to each category. The following formula was used to calculate the relative change by TB program for each indicator: [(% from year 5 - % from year 1 ÷ % from year 1) × 100]. During the 5-year period for which the most recent data were available, most TB programs had improvements in reducing overall TB incidence (71.2%) and increasing the percentage of contacts receiving a diagnosis of LTBI who completed LTBI treatment (55.8%); the majority of programs (51.0%) also had improvements in reducing incidence among non-U.S.-born persons. The average percentage of persons with drug susceptibility results reported in most jurisdictions (28 of 52, [53.9%]) met or exceeded the 5-year national average of 97% (2018-2022). The percentage of contacts to sputum acid-fast bacillus (AFB) smear-positive TB patients with newly diagnosed latent TB infection (LTBI) who completed treatment increased in 29 of 52 (55.8%) jurisdictions from 2017 to 2021, signifying that, for most jurisdictions, steps have been taken to enhance performance in this area. The average percentage of patients with completion of TB therapy within 12 months was at or above the national average of 89.7% in approximately two-thirds (32 of 52 [61.5%]) of jurisdictions. This report is the first to describe a 5-year relative change for TB program performance. These results suggest that TB programs are making improvements in activities that help identify persons with TB and LTBI and ensure patients complete treatment in a timely manner. Use of NTIP data from individual TB programs enables a more detailed examination of trends in program performance and identification of areas for program improvement. Assessing indicator trends by TB program provides an opportunity to gain a better understanding of program performance in comparison to other programs. It can also facilitate communication between programs regarding successes and challenges in program improvement. This information is valuable for TB programs to allocate resources effectively and provide additional context on TB control for public health policymakers.

The Impact of COVID-19 on Tuberculosis Program Performance in the Kingdom of Lesotho

As tuberculosis (TB) is an airborne disease requiring multi-month therapy, systems of TB detection and care were profoundly impacted by the COVID-19 pandemic. The worsening economic situation, including income, food, and housing insecurity, impacted the social conditions in which TB-already a leading killer in resource-limited settings-thrives. This study assesses the impact of COVID-19 on TB detection and treatment in Lesotho. We used routine program data from 78 health facilities in Lesotho. We created time series models from July 2018 to March 2021 to quantify COVID-19-related disruptions to TB program indicators: outpatient visits; presumptive, diagnosed, treated, and HIV co-infected cases; and treatment outcomes including successful (cured and completed) and unsuccessful (death and treatment outcome unknown). We observed a significant decline in cumulative outpatient visits (-37.4%, 95% prediction interval [PI]: -40.1%, -28.7%) and new TB cases diagnosed (-38.7%, 95%PI: -47.2%, -28.4%) during the pandemic, as well as TB-HIV co-infections (-67.0%, 95%PI: -72.6%, -60.0%). However, we observed no difference in treatment success (-2.1%, 95%PI: -17.0%, 15.8%). TB case detection in Lesotho fell during the COVID-19 pandemic, likely related to the uptake of overall health services. However, treatment success rates did not change, indicating a strong health system and the success of local strategies to maintain treatment programs.

The social determinants of national tuberculosis incidence rates in 116 countries: a longitudinal ecological study between 2005–2015

BackgroundAccelerating declines in tuberculosis (TB) incidence is paramount for achieving global goals set for 2030 by the Sustainable Development Goals and the End TB Strategy. The aim of this study was to identify key country-level social determinants of national TB incidence trends.MethodsThis longitudinal ecological study used country-level data extracted from online databases from the period 2005–2015. We used multivariable Poisson regression models allowing for distinct within- and between-country effects to estimate associations between national TB incidence rates and 13 social determinants of health. The analysis was stratified by country income status.ResultsThe study sample included 48 low- and lower-middle-income countries (LLMICs) and 68 high- and upper-middle income countries (HUMICs), with a total of 528 and 748 observations between 2005–2015, respectively. National TB incidence rates declined in 108/116 countries between 2005–2015, with an average drop of 12.95% in LLMICs and 14.09% in HUMICs. Between LLMICs, higher Human Development Index (HDI), social protection spending, TB case detection, and TB treatment success were associated with lower TB incidence. Higher prevalence of HIV/AIDS was associated with higher TB incidence. Within LLMICs, increases in HDI over time were associated with lower TB incidence rates. Between HUMICs, higher HDI, health spending, and diabetes prevalence were associated with lower TB incidence, whereas higher prevalence of HIV/AIDS and alcohol-use were associated with higher TB incidence. Within HUMICs, increases in HIV/AIDS and diabetes prevalence over time were associated with higher TB incidence.ConclusionsIn LLMICs, TB incidence rates remain highest in countries with low human development, social protection spending and TB programme performance, and high rates of HIV/AIDS. Strengthening human development is likely to accelerate declines in TB incidence. In HUMICs, TB incidence rates remain highest in countries with low human development, health spending and diabetes prevalence, and high rates of HIV/AIDS and alcohol use. Here, slowing rising rates of HIV/AIDS and diabetes is likely to accelerate declines in TB incidence.

Worsening situation of tuberculosis in Chile

Recent data suggest an increase in tuberculosis (TB) incidence in Chile. To evaluate recent epidemiological trends, geographic extension and potential factors associated with TB reemergence in Chile. Data analysis from official sources and trend analysis. TB incidence rate increased from 12.3 (2014) to 14.7 (2017) per 100,000 inhabitants. Morbidity rates also increased in nine out of 15 regions. The proportion of TB cases in specific groups has also increased in the last six years: HIV/AIDS (68%), immigrants (118%), drug users/alcoholics (267%) and homeless people (370%). Several indicators of the national TB program performance have deteriorated including TB case detection, HIV co-infection study and contact tracing activities. Overall results indicate a higher than expected case-fatality ratio (> 3%), high rates of loss from follow-up (> 5%), and low percentage of cohort healing rate (< 90%). This decline is associated with a Control Program with scarce human resources whose central budget decreased by 90% from 2008 to 2014. New molecular diagnostic tools and liquid media culture were only recently implemented. TB trends and overall program performance indicators have deteriorated in recent years in Chile and several factors appear to be involved. Multiple strategies will be required to rectify this situation.

Tuberculosis among northern Manitoba First Nations, 2008-2012: program performance on- and off-reserve.

The objectives of this study were to:(1) report tuberculosis (TB) program performance for northern First Nations in the province of Manitoba; (2) present methods for TB program performance measurement using routinely collected surveillance data; and (3) advance dialogue on performance measurement of Canadian TB programs. Data on a retrospective cohort of people diagnosed with TB in Manitoba between January 1, 2008 and December 31, 2010, and their contacts,were extracted from theManitoba TB Registry. Performance measures based on US-CDC were analyzed. Adjusted probability ratios (aPR) and 95% confidence intervals (CIs) werereported with comparisons between on-/off-reserve First Nations, adjusted for age, sex, and treatment history. A cohort of n = 149 people diagnosed with TB and n = 3560 contactswereidentified. Comparisons off-/on-reserve: Treatment completion (aPR = 1.03; 95% CI 0.995-1.07); early detection (aPR = 0.87; 95% CI 0.57-1.33); HIV testing and reporting (aPR = 0.42; 95% CI 0.21-0.83); pediatric TB (age < 15years) (aPR = 1.20; 95% CI 0.47-3.06); retreatment for TB (aPR = 0.93; 95% CI 0.89-0.97); contact elicitation (aPR = 0.94; 95% CI 0.84-1.05); contact assessment (aPR = 0.69; 95% CI 0.50-0.94). Pediatric (ages < 15years) TB incidence in northern Manitoba was 37.1 per 100,000/year. TB program performance varies depending on residence in a reserve or non-reserve community. Action is urgently needed to address TB program performance in terms of contact investigation and HIV testing/reporting for First Nations off-reserve and to address high rates of pediatric TB in northern Manitoba. First Nations collaboration and models of care should be considered both on- and off-reserve to improve TB program performance.

Health systems performance in managing tuberculosis: analysis of tuberculosis care cascades among high-burden and non-high-burden countries.

BackgroundTuberculosis (TB) is a major global health burden, which has been inadequately addressed. This study aims to analyze different patterns and gaps of care along the care cascade across countries and to develop a model to examine the relationship between performance of tuberculosis programmes in high and low burden countries along the tuberculosis care cascade and tuberculosis disease burden.MethodsWe used the World Health Organization’s Global TB Database for the year 2016 to construct tuberculosis care cascade consisting of four steps: incidence, diagnosed, treatment started and treatment completed. Based on the constructed care cascades, we analyzed the relationship between health system performance indicators and tuberculosis cascades performance: diagnosed rate, treatment started rate, and treatment completed rate.ResultsThere are wide differences in access to diagnosis and treatment between high-burden countries and non-high-burden countries. The largest gap was found between incidence and diagnosed rate, with 65% of diagnosed rate for high burden countries and 80% of diagnosed rate for non-high burden countries. We found variations in care performance among high-burden countries. We found a negative relationship between the population health indicators related to the mortality rate and TB care cascade performance. There was a positive relationship between immunization coverage rate and antenatal care indicators and TB care cascade performance.ConclusionsWell-functioning tuberculosis care cascades and effective health systems are important for the successful management of tuberculosis. While improving screening performance is essential for tuberculosis control especially for high-burden countries, resource should be allocated to improve health system performance, which is weak in high-burden countries. Performance of TB programmes across care cascade could be used as a useful tracer to measure performance of health systems.

Twenty years of rifampicin resistance surveillance in Bangladesh: periodic vs. continuous monitoring.

To analyse 20 years of tuberculosis (TB) drug resistance surveillance, comparing conventional periodic random drug resistance surveys with continuous monitoring, in Damien Foundation-supported districts of Bangladesh. Retrospective study of data on TB drug resistance from five periodic surveys among newly registered patients vs. continuous monitoring of retreatment patients from 1996 to 2016. Periodic surveys and continuous monitoring showed similar trends in rifampicin (RMP) resistance; with all smear-positives registered as denominator, prevalence in new cases was found to be at approximately the same level as incidence in retreatment cases. Changes in trends observed using continuous monitoring preceded those detected in periodic surveys by a few years. The accurate interpretation of trend changes requires detailed knowledge of changes in treatment regimens, referral criteria, testing methods and operational factors. Low rates of resistance to RMP, isoniazid and the fluoroquinolones were maintained over the two decades, indicating excellent TB programme performance, including highly active standard first- and second-line treatment regimens. Continuous monitoring is feasible, but requires rigorous application of referral guidelines and data maintenance. Contrary to random surveys, continuous monitoring provides early indications of programme performance, essential for individual patient management, and is more efficient and cost-effective.

Performance measurement of a Canadian provincial tuberculosis programme: Manitoba, 2008-2012.

Performance measurement assists tuberculosis (TB) programmes in understanding areas of strength and weakness, and planning for improvements. Canada currently does not have a national comprehensive system for the measurement and analysis of TB programme performance. To analyse the performance of a Canadian provincial TB programme using measures and targets based on those published by the US Centers for Disease Prevention and Control for 2015. Using provincial surveillance data from the Canadian province of Manitoba, we analysed key programme performance outcome measures (treatment completion, early detection, human immunodeficiency virus [HIV] testing, paediatric TB, retreatment, and contact elicitation and assessment) for people diagnosed with TB between 2008 and 2010. Significant outcome variation was found between Indigenous and non-Indigenous populations as well as within populations. The reporting rate of HIV testing was low. High rates of paediatric TB among Indigenous populations, particularly in rural areas, were found. Significantly better performance in HIV testing and reporting as well as in contact investigation was found for rural compared with urban Indigenous populations. Foreign-born persons had the lowest contact assessment rate. This study of TB programme performance in Manitoba demonstrates the viability of the approach in the Canadian context, and could help to identify key areas for TB programme improvement.

Accessibility to tuberculosis control services and tuberculosis programme performance in southern Ethiopia

BackgroundDespite the expansion of health services and community-based interventions in Ethiopia, limited evidence exists about the distribution of and access to health facilities and their relationship with the performance of tuberculosis (TB) control programmes. We aim to assess the geographical distribution of and physical accessibility to TB control services and their relationship with TB case notification rates (CNRs) and treatment outcome in the Sidama Zone, southern Ethiopia.DesignWe carried out an ecological study to assess physical accessibility to TB control facilities and the association of physical accessibility with TB CNRs and treatment outcome. We collected smear-positive pulmonary TB (PTB) cases treated during 2003–2012 from unit TB registers and TB service data such as availability of basic supplies for TB control and geographic locations of health services. We used ArcGIS 10.2 to measure the distance from each enumeration location to the nearest TB control facilities. A linear regression analysis was employed to assess factors associated with TB CNRs and treatment outcome.ResultsOver a decade the health service coverage (the health facility–to-population ratio) increased by 36% and the accessibility to TB control facilities also improved. Thus, the mean distance from TB control services was 7.6 km in 2003 (ranging from 1.8 to 25.5 km) between kebeles (the smallest administrative units) and had decreased to 3.2 km in 2012 (ranging from 1.5 to 12.4 km). In multivariate linear regression, as distance from TB diagnostic facilities (b-estimate=−0.25, p<0.001) and altitude (b-estimate=−0.31, p<0.001) increased, the CNRs of TB decreased, whereas a higher population density was associated with increased TB CNRs. Similarly, distance to TB control facilities (b-estimate=−0.27, p<0.001) and altitude (b-estimate=−0.30, p<0.001) were inversely associated with treatment success (proportion of treatment completed or cured cases).ConclusionsAccessibility to TB control services improved despite the geographic variations. TB CNRs were higher in areas where people had better access to diagnostic and treatment centres. Community-based interventions also played an important role for the increased CNRs in most areas.

Enhancing the impact of antiretroviral scale-up on the HIV-associated tuberculosis epidemic in Malawi.

In the June 2014 issue of this Journal, Kanyerere and colleagues presented a valuable analysis of routinely collected national programme data from Malawi, providing evidence of an impact of antiretroviral treatment (ART) scale-up on the human immunodeficiency virus (HIV) associated tuberculosis (TB) epidemic at a country level.1 Between 2004 and 2012, ART was scaled up rapidly, such that 41% of all Malawians estimated to be living with HIV were receiving treatment in 2012. During the same period, national TB notifications decreased by an average of approximately 4% per year. A causal relationship with ART scale-up cannot be proven. However, the strong temporal relationship between ART scale-up and trends in TB notifications, and also the disproportionate reductions in HIV-positive notifications, new smear-negative cases and recurrent disease collectively, make this very plausible. Potential confounders could include an improvement in TB programme performance in this time period,2 with higher cure rates resulting in reduced TB transmission and secondary cases. However, any such improvements could conceivably be mediated in part by ART scale-up, representing an additional mechanism whereby ART may confer a beneficial impact on TB control. Immune recovery during treatment of HIV-positive TB cases may improve sputum smear conversion rates and reduce treatment failures and deaths, with a corresponding improvement in the overall cure/completion rate.3 Using an ecological analysis of data from different districts or regions in Malawi, the relationships between ART coverage, TB programme outcomes and trends in TB notification rates could be further explored. The reported findings are encouraging, and provide the first evidence of the impact of ART on the HIV-associated TB epidemic at a national level in Africa.4 However, as approximately 60% of TB notifications in Malawi in 2012 were people living with HIV,1,2 how might the impact of ART on TB prevention be enhanced? While the median CD4 cell count at which ART is started has increased over time in many African countries, including Malawi, the majority of patients still present with low CD4 counts, and often with TB as the first manifestation. There is therefore a critical need for high HIV testing coverage so that HIV is diagnosed earlier during the natural history of the disease, thereby allowing ART to be started before TB develops. The earlier ART is started, the greater the TB preventive effect.4 Although ART reduces the risk of TB substantially in treated cohorts, rates remain above background, even among those with optimum CD4 count recovery.5 TB incidence rates during ART could be reduced by starting ART at higher baseline CD4 counts, by optimising CD4 count recovery through adherence support and by adjunctive use of isoniazid preventive therapy (IPT). The latter can be readily co-administered with ART, providing an additive impact.6 To guide and monitor the implementation of these strategies, useful indicators to collect (nationally or at sentinel sites) include the proportions of new HIV diagnoses that are made due to patients presenting with TB (i.e., HIV diagnosed too late) and the proportions of HIV-associated TB cases that occur either pre-ART (i.e., ART started too late) or during ART. In addition, the timing of the latter would be informative, as TB cases presenting during the first 3 months of ART largely reflect failure of baseline TB screening, whereas later incident disease represents that which is potentially preventable by improving ART outcomes and by use of adjunctive IPT.4 Such data may provide further insights into how ART can be better implemented to control the HIV-associated TB epidemic.

Resurrecting social infrastructure as a determinant of urban tuberculosis control in Delhi, India.

BackgroundThe key to universal coverage in tuberculosis (TB) management lies in community participation and empowerment of the population. Social infrastructure development generates social capital and addresses the crucial social determinants of TB, thereby improving program performance. Recently, there has been renewed interest in the concept of social infrastructure development for TB control in developing countries. This study aims to revive this concept and highlight the fact that documentation on ways to operationalize urban TB control is required from a holistic development perspective. Further, it explains how development of social infrastructure impacts health and development outcomes, especially with respect to TB in urban settings.MethodsA wide range of published Government records pertaining to social development parameters and TB program surveillance, between 2001 and 2011 in Delhi, were studied. Social infrastructure development parameters like human development index along with other indicators reflecting patient profile and habitation in urban settings were selected as social determinants of TB. These include adult literacy rates, per capita income, net migration rates, percentage growth in slum population, and percentage of urban population living in one-room dwelling units. The impact of the Revised National Tuberculosis Control Program on TB incidence was assessed as an annual decline in new TB cases notified under the program. Univariate linear regression was employed to examine the interrelationship between social development parameters and TB program outcomes.ResultsThe decade saw a significant growth in most of the social development parameters in the State. TB program performance showed 46% increment in lives saved among all types of TB cases per 100,000 population. The 7% reduction in new TB case notifications from the year 2001 to 2011, translates to a logarithmic decline of 5.4 new TB cases per 100,000 population. Except per capita income, literacy, and net migration rates, other social determinants showed significant correlation with decline in new TB cases per 100,000 population.ConclusionsSocial infrastructure development leads to social capital generation which engenders positive growth in TB program outcomes. Strategies which promote social infrastructure development should find adequate weightage in the overall policy framework for urban TB control in developing countries.

Improved Outcomes Found after Implementing a Systematic Evaluation and Program Improvement Process for Tuberculosis

California's state and local tuberculosis (TB) programs collaborated to develop the Tuberculosis Indicators Project (TIP), a program evaluation and improvement process. In TIP, local and state staff review data, identify program gaps, implement plans to improve local TB program performance, and evaluate outcomes. After 10 years of project implementation, indicator performance changes and patient outcomes were measured. Eighty-seven percent of participating programs showed a performance increase in targeted indicators after three years compared with 57% of comparison groups. Statistically significant performance change was more common in the intervention local health departments (LHDs) than in comparison groups. The most notable performance changes were in the contact investigation and case management indicators. These results indicate that this systematic evaluation and program improvement project was associated with improved LHD TB control performance and may be useful to inform improvement projects in other public health programs.

Tuberculosis in prisons in sub-Saharan Africa – a potential time bomb

The World Health Organization (WHO) estimates that there are 10 million new cases of tuberculosis (TB) reported worldwide each year, and 1.7 million people die from the disease. The incidence of TB in sub-Saharan Africa (SSA) remains very high at over 300 new cases of TB per 100 000 population in 2007. The TB epidemic in SSA is fuelled by the HIV epidemic, and up to 70% of adults with TB are co-infected with HIV. There are few data on drug-resistant TB from SSA, probably owing to poor TB programme performance, inadequate laboratory facilities for drug susceptibility testing (DST), and poor surveillance, data collection and reporting procedures. The WHO estimated that 69 000 cases of MDR-TB emerged in 2008 in Africa, which is most probably an underestimate

Not just pretty pictures: Geographical Information Systems in TB control

Geographical Information Systems (GIS) is becoming a useful tool in disease control by health planners. However little is known about its potential in tuberculosis (TB) control. In 2000 the National TB Programme (NTP) in Malawi assessed its usefulness. Routinely collected case-finding data from the 3 previous years (1997 to 1999) were entered into a system containing a digital map of Malawi. District performance was mapped. We concluded that GIS may be complementary in monitoring TB programme performance, and may be useful for target setting, advocacy, and research. World Health Organisation (WHO) now provides free GIS software (Health Mapper) and training. However, the use of GIS in TB control still needs further piloting and expansion without constraining the locally available resources or disrupting the present TB data management system. Malawi Medical Journal Vol. 17(2) 2005: 33-35