Tuberculosis Program Research Articles

Health worker perspectives on barriers and facilitators of tuberculosis investigation coverage among index case contacts in rural Southwestern Uganda: a qualitative study

BackgroundIn 2012, the World Health Organization recommended screening and investigation of contacts of index tuberculosis patients as a strategy to accelerate detection of tuberculosis (TB) cases. Nine years after the adoption of this recommendation, coverage of TB contact investigations in Uganda remains low. The objective of this study was to examine health care providers’ perceptions of factors influencing coverage of TB contact investigations in three selected rural health facilities in Mbarara district, southwestern Uganda.MethodsThis study identified provider opinions on the barriers and facilitators to implementation of TB contact investigation using the Consolidated Framework for Implementation Research. Using an exploratory qualitative study design, semi-structured interviews with 19 health workers involved in the TB program at district, health facility and community levels were conducted from April 2020 and July 2020. Analysis was conducted inductively using reflexive thematic analysis in six iterative steps: familiarizing with the data, creating initial codes, searching for themes, reviewing themes, developing theme definitions, and writing the report.ResultsNineteen health care workers participated in this study which translates to a 100% response rate. These included two district TB and leprosy supervisors, five nurses, five clinical officers, six village health team members and one laboratory technician. The three themes that emerged from the analysis were intervention-related, health system and contextual factors. Health system-related barriers included inadequate or delayed government funding for the TB program, shortage of human resources, insufficient personal protective equipment, and a stock-out of supplies such as Xpert MTB cartridges. Contextual barriers included steep terrain, poverty or low income, and the stigma associated with TB and COVID-19. Facilitators comprised increased knowledge and understanding of the intervention, performance review and on-the-job training of health workers.ConclusionsThis study found that most of the factors affecting TB contact investigations in this rural community were related to health system constraints such as inadequate or delayed funding and human resource shortages. This can be addressed by strengthening the foundational elements of the health system - health financing and human resources - to establish a comprehensive TB control program that will enable the efficient identification of missing TB patients.

The pattern of rpoB gene mutation of Mycobacterium tuberculosis and predictors of rifampicin resistance detected by GeneXpert MTB/RIF assay in Tanzania.

Antimicrobial resistance in Mycobacterium tuberculosis (MTB) poses a significant challenge to tuberculosis (TB) management worldwide. Rifampicin resistance (RR) has been associated with the rpoB gene mutation. No study was conducted in Tanzania to determine the commonest mutation. The inconsistent findings from various studies support the need to determine whether reported mutation patterns are applicable in our setting. We determined the frequency of rpoB gene mutation and factors associated with RR, which were detected using GeneXpert MTB/RIF assay. We conducted a retrospective cross-sectional study involving data from the National Tuberculosis and Leprosy Program database from 2020 to 2022 for cases investigated using GeneXpert MTB/RIF assay. Descriptive analysis was performed to determine the frequency of categorical variables. The chi-square test and logistic regression analysis assessed the relationship between the independent variables and outcome. The 95% confidence interval and a significance level of p<0.05 were used to assess the strength of association. A total of 56,004 participants had a status of MTB and RR, where 38,705/56,004 (69.11%) were males. Probe E mutation (codon 529-533), 89/219 (40.64%) was predominant. Human immunodeficiency virus (HIV)-positive patients had a higher gene mutation, 134/10601 (1.26%) than HIV-negative, 306/45016 (0.68%) (p<0.001). Patients with both pulmonary and extra-pulmonary TB had about four times greater odds of developing rifampicin resistance (AOR 3.88, 95%CI: 1.80-8.32). RR was nearly nine times higher in previously treated patients than new patients (AOR 8.66, 95% CI: 6.97-10.76). HIV-positive individuals had nearly twice the odds of developing RR than HIV-negative individuals (AOR 1.91, 95%CI: 1.51-2.42). The rate of RR was lower compared to other studies in Tanzania, with probe E mutations the most prevalent. Patients with disseminated TB, HIV co-infection and those with prior exposure to anti-TB had more risk of RR. The findings highlight the need to strengthen surveillance of multidrug-resistant TB among high risk patients.

Factors associated with incomplete tuberculosis preventive treatment: a retrospective analysis of six-years programmatic data in Cambodia

Tuberculosis (TB) preventive treatment (TPT) effectively prevents the progression from TB infection to TB disease. This study explores factors associated with TPT non-completion in Cambodia using 6-years programmatic data (2018–2023) retrieved from the TB Management Information System (TB-MIS). Out of 14,262 individuals with latent TB infection (LTBI) initiated with TPT, 299 (2.1%) did not complete the treatment. Individuals aged between 15–24 and 25–34 years old were more likely to not complete the treatment compared to those aged < 5 years old, with aOR = 1.7, p = 0.034 and aOR = 2.1, p = 0.003, respectively. Individuals initiated with 3-month daily Rifampicin and Isoniazid (3RH) or with 6-month daily Isoniazid (6H) were more likely to not complete the treatment compared to those initiated with 3-month weekly Isoniazid and Rifapentine (3HP), with aOR = 2.6, p < 0.001 and aOR = 7, p < 0.001, respectively. Those who began TPT at referral hospitals were nearly twice as likely to not complete the treatment compared to those who started the treatment at health centers (aOR = 1.95, p = 0.003). To improve TPT completion, strengthen the treatment follow-up among those aged between 15 and 34 years old and initiated TPT at referral hospitals should be prioritized. The national TB program should consider 3HP the first choice of treatment.

Assessing the impact of COVID-19 management on the workload of human resources working in India’s National Tuberculosis Elimination Program

BackgroundIn 1993, WHO declared tuberculosis (TB) as a global health emergency considering 10 million people are battling TB, of which 30% are undiagnosed annually. In 2020 the COVID-19 pandemic took an unprecedented toll on health systems in every country. Public health staff already engaged in TB control and numerous other departments were additionally tasked with managing COVID-19, stretching human resource (HR) capacity beyond its limits. As part of an assessment of HR involved in TB control in India, The World Bank Group and partners conducted an analysis of the impact of COVID-19 on TB human resources for health (HRH) workloads, with the objective of describing the extent to which TB-related activities could be fulfilled and hypothesizing on future HR requirements to meet those needs.MethodsThe study team conducted a Workload Indicators and Staffing Needs (WISN) analysis according to standard WHO methodology to classify the workloads of priority cadres directly or indirectly involved in TB control activities as over-, adequately or under-worked, in 18 districts across seven states in India. Data collection was done via telephone interviews, and questions were added regarding the proportion of time dedicated to COVID-19 related tasks. We carried out quantitative analysis to describe the time allocated to COVID-19 which otherwise would have been spent on TB activities. We also conducted key informant interviews (KII) with key TB program staff about HRH planning and task-shifting from TB to COVID-19.ResultsWorkload data were collected from 377 respondents working in or together with India’s Central TB Division (CTD). 73% of all respondents (n = 270) reported carrying out COVID-19 tasks. The average time spent on COVID-19 tasks was 4 h / day (n = 72 respondents). Multiple cadres highly instrumental in TB screening and diagnosis, in particular community outreach (ASHA) workers and CBNAAT/TrueNAAT laboratory technicians working at peripheral, block and district levels, were overworked, and spending more than 50% of their time on COVID-19 tasks, reducing time for TB case-finding. Qualitative interviews with laboratory technicians revealed that PCR machines previously used for TB testing were repurposed for COVID-19 testing.ConclusionsThe devastating impact of COVID-19 on HR capacity to conduct TB case-finding in India, as in other settings, cannot be overstated. Our findings provide clear evidence that NTEP human resources did not have time or essential material resources to carry out TB tasks during the COVID pandemic without doing substantial overtime and/or compromising on TB service delivery. To minimize disruptions to routine health services such as TB amidst future emerging infectious diseases, we would do well, during periods of relative calm and stability, to strategically map out how HRH lab staff, public health resources, such as India’s Health and Wellness Centers and public health cadre, and public-private sector collaboration can most optimally absorb shocks to the health system.

The long-term effects of domestic and international tuberculosis service improvements on tuberculosis trends within the USA: a mathematical modelling study

For settings with low tuberculosis incidence, disease elimination is a long-term goal. We investigated pathways to tuberculosis pre-elimination (incidence <1·0 cases per 100 000 people) and elimination (incidence <0·1 cases per 100 000 people) in the USA, where incidence was estimated at 2·9 per 100 000 people in 2023. Using a mathematical modelling framework, we simulated how US tuberculosis incidence could be affected by changes in tuberculosis services in the countries of origin for future migrants to the USA, as well as changes in tuberculosis services inside the USA. To do so, we used a linked set of transmission dynamic models, calibrated to demographic and epidemiological data for each setting. We constructed intervention scenarios representing improvements in tuberculosis services internationally and within the USA, individually and in combination, plus a base-case scenario representing continuation of current services. We simulated health and economic outcomes until 2100, using a Bayesian approach to quantify uncertainty in these outcomes. Under the base-case scenario, US tuberculosis incidence was projected to decline to 1·8 cases per 100 000 (95% uncertainty interval [UI] 1·5-2·1) in the total population by 2050. Intervention scenarios produced substantial reductions in tuberculosis incidence, with the combination of all domestic and international interventions projected to achieve pre-elimination by 2033 (95% UI 2031-2037). Compared with the base-case scenario, this combination of interventions could avert 101 000 tuberculosis cases (95% UI 84 000-120 000) and 13 300 tuberculosis deaths (95% UI 10 500-16 300) in the USA from 2025 to 2050. Tuberculosis elimination was not projected before 2100. Strengthening tuberculosis services domestically, promoting the development of more effective technologies and interventions, and supporting tuberculosis programmes in countries with a high tuberculosis burden are key strategies for accelerating progress towards tuberculosis elimination in the USA. US Centers for Disease Control and Prevention.

Effect of COVID-19 on paediatric TB service delivery and patients’ comfort receiving TB services in Cameroon and Kenya during COVID: a qualitative assessment

BackgroundThe outbreak of COVID-19 has caused a setback to the gains achieved in tuberculosis (TB) control by impairing TB diagnosis, delaying treatment initiation and aggravating TB deaths. This study explored...

Characteristics and contributing factors of adverse drug reactions: an analytical study of patients with tuberculosis receiving treatment under the National TB Program of India

Background Tuberculosis (TB) continues to pose a serious threat to the public health system in India. Although the National Tuberculosis Elimination Program (NTEP) is providing a wide range of interventions from early diagnosis to complete treatment to reduce morbidity and mortality from TB, adverse drug reactions (ADR) remain a challenge in treatment adherence and completion. Methods An observational cross-sectional study was conducted in selected districts of Gujarat state. A total of 593 reported TB patients were recruited with an adjusted unified distribution based on the type of cases, site of diseases, and service facility through a simple random sampling method. A semi-structured questionnaire tool was used to collect socio-demographic, clinical, and ADR-related data from the TB patients. Data was analyzed for the frequency, percentage, chi-squared, and adjusted odds ratio to find the association between the variables. Results The majority of the study participants were male (87.2%), aged 15 to 60 (57.8%), daily laborers (22.4%), and married (64.2%). Over 75% of individuals had pulmonary TB, with 87% having experienced their first episode, 83% being new cases, and 44.7% having a history of addiction. ADR with mild symptoms was reported by more than a quarter (29%) of TB patients during the intensive phase (77%). The association between ADR experience and drug susceptibility was significant (p&lt;0.005) and drug-resistant TB patients experience two times more ADRs than drug-sensitive TB patients (OR 2.04). Binomial logistic regression was carried out to describe the association between various variables and occurrence of ADRs. Conclusion The study highlighted a need to enhance health care providers’ capacity and program structure for managing ADRs among TB patients. In order to completely eliminate TB across the country, it also emphasized the attention for a holistic and all-encompassing strategy for managing TB patients at the field level.

Epidemiological analysis of pulmonary tuberculosis and extra-pulmonary tuberculosis in Saudi Arabia: a cross-sectional study

Tuberculosis (TB) is a serious disease that affects people worldwide, including in Saudi Arabia. The study analyzed the frequency of diagnosed TB cases, age-specific incidence rate, year of diagnosis, and prevalence of TB in Saudi Arabia from 2014 to 2020. Based on the National Tuberculosis Program (NTP) data, 21,120 patients were diagnosed with TB. The mean incidence rate of pulmonary TB and extra-pulmonary TB was approximately 6.92 and 2.33 per 100,000 population, respectively. The highest age-specific incidence rate was observed in the 25–35 year age group. The non-Saudi population (11,086 cases; 52.50%) was significantly more affected by both types of TB compared to the Saudi population (10,034 cases; 47.50%). The male population of Saudi and non-Saudi was significantly more affected by both types of TB. The highest overall mean incidence rate per 100,000 population was observed in the Jeddah and Jazan regions. The study's findings may have implications for supporting public health interventions and implementing a more effective TB control strategy program in Saudi Arabia. It suggests that immigrants from TB-endemic countries and religious visitors from high-risk countries should undergo pre and post-arrival screening for TB to reduce its incidence.

Mass incarceration as a driver of the tuberculosis epidemic in Latin America and projected impacts of policy alternatives: A mathematical modeling study.

Tuberculosis incidence is increasing in Latin America, where the incarcerated population has nearly quadrupled since 1990. The full impact of incarceration on the tuberculosis epidemic, accounting for effects beyond prisons, has never been quantified. We calibrated dynamic compartmental transmission models to historical and contemporary data from Argentina, Brazil, Colombia, El Salvador, Mexico, and Peru, which comprise approximately 80% of the region's incarcerated population and tuberculosis burden. Using historical counterfactual scenarios, we estimated the transmission population attributable fraction (tPAF) for incarceration and the excess population-level burden attributable to increasing incarceration prevalence since 1990. We additionally projected the impact of alternative incarceration policies on future population tuberculosis incidence. Population tuberculosis incidence in 2019 was 29.4% (95% UI, 23.9-36.8) higher than expected without the rise in incarceration since 1990, corresponding to 34,393 (95% UI, 28,295-42,579) excess incident cases across countries. The incarceration tPAF in 2019 was 27.2% (95% UI, 20.9-35.8), exceeding estimates for other risk factors like HIV, alcohol use disorder, and undernutrition. Compared to a scenario where incarceration rates remain stable at current levels, a gradual 50% reduction in prison admissions and duration of incarceration by 2034 would reduce population tuberculosis incidence by over 10% in all countries except Mexico. The historical rise in incarceration in Latin America has resulted in a large excess tuberculosis burden that has been under-recognized to-date. International health agencies, ministries of justice, and national tuberculosis programs should collaborate to address this health crisis with comprehensive strategies, including decarceration. National Institutes of Health.

Tuberculosis Information System: Evaluation Approach with HOT-FIT Framework

Background: The increase in the number of pulmonary TB cases increases the risk of illness and death, which indicates the need for TB prevention and control efforts through online recording and reporting of cases using the Tuberculosis Information System (SITB). However, there are several challenges in implementing the use of SITB, which results in delays in reporting TB cases and disrupts TB prevention and treatment efforts. Purpose: The purpose of this study was to describe the use of SITB with the HOT-FIT Framework in the UPT Puskesmas Lemo area, North Barito District, Central Kalimantan. Methods: This research applies qualitative research methods with a phenomenological approach. The study population consisted of five informants who were selected deliberately (purposive sampling), including the Head of Puskesmas, TB Program Manager, TB Program Management Assistant, General Practitioner, and Laboratory Officer. Results: The results highlight that the use of Tuberculosis Information System (SITB) applications faces a number of supporting and inhibiting factors, which eventually lead to delays in reporting. Although the availability of adequate human resources (HR) is one of the supporting factors for reporting tuberculosis (TB) cases through the SITB application, the unstable internet network and lack of facilities and infrastructure such as inadequate software are also inhibiting factors. Conclusion: Puskesmas Lemo has participated in the successful implementation of TB case recording and reporting activities using SITB, but there are several aspects that still need to be improved and followed up. Thus, the Lemo Health Center still needs regular guidance and monitoring by the Health Office in carrying out its functions.

‘We did not even know it was tuberculosis’: a qualitative evaluation of integrating tuberculosis services into paediatric entry points in the CaP-TB programme in Cameroon and Kenya

IntroductionPaediatric tuberculosis (TB) is often undiagnosed and under-reported. The Catalysing Paediatric TB (CaP-TB) programme provided integrated and decentralised TB screening and diagnosis services through multiple paediatric care entry points. This...

Application of Geographical Information System in Iranian National Tuberculosis Program

Application of Geographical Information System in Iranian National Tuberculosis Program

Spatio-temporal characteristics of Tuberculosis in Ghana

Background Tuberculosis (TB) remains a key contributor to global mortality; ranks second as the most fatal infectious disease and seventh among the top ten causes of death in Ghana. There is insufficient literature regarding the utilization of Bayesian hierarchical models for examining the spatial and spatio-temporal dynamics of tuberculosis risk in Ghana. Aim This study addresses this gap by determining TB hotspots regions in Ghana using the Bayesian modeling framework. Methods TB data were obtained from the Ghana Health Service and National Tuberculosis Programme for the 10 administrative regions of Ghana, from 2008 to 2017. Spatial and spatio-temporal TB relative risk for each region were estimated under the Bayesian modeling frameworks. Maps for TB risks were created to visualized regions with TB hotspots. Model fitting and parameter estimation were conducted using integrated nested Laplace approximation via R version 4.3.2. Results Among the baseline predictors, TB cure rate, TB success rate, knowledge about TB, human immunodeficiency virus (HIV) prevalence, percentage of literacy, and high income were found to be most significant predictors of TB risk in Ghana. We noted an increased risk of TB infection in the Northern zone and the Eastern and Greater Accra regions in the Southern zone. Spatio-temporal distribution of TB infection risk was predominantly concentrated in the Southern zone. Clustering of TB risk was observed among neighboring regions. Conclusion Factors influencing tuberculosis (TB) risk in Ghana are TB cure rate, TB success rate, knowledge about TB, HIV prevalence, literacy rate, and income level. The risk distribution was mainly concentrated in the Southern zone, with clusters of TB risk observed among neighboring regions. To achieve a significant reduction in TB cases, it is essential to allocate resources to TB hotspots regions and also implement measures to control significant predictors of TB infection risk.

Dietary Assessment of Tuberculosis Patients Receiving Treatment at a Tertiary Care Center in New Delhi

Introduction: Undernutrition and tuberculosis (TB) are interrelated, with a bidirectional relationship. Despite its potential impact on nutritional status and TB patient outcomes, there is limited information available on the dietary patterns of TB patients in the Indian TB program. This study aims to address this knowledge gap by evaluating dietary patterns and factors associated with reduced dietary intake among TB patients in a tertiary care center. Methodology: This was a cross-sectional study conducted in a directly observed treatment short center working under the National Tuberculosis Elimination Program. A semi-structured, pretested interviewer-administered questionnaire was used to collect data related to the demographic profile and dietary patterns of 49 patients. Results: The mean calorie intake among the patients was 1525.2 (±897) kcal, whereas the required mean calorie intake was 2231.6 (±409.2) kcal. The mean protein requirement was 66.9 (±15.2) g, whereas the mean protein intake was only 39.2 (±15.4) g. Conclusion: To strive toward the goal of TB elimination in India, the nutritional care of the patient cannot be undermined. The need of the hour is to enforce the nutritional supplementation as well as support program by the government at the national level.

Evaluation of Tuberculosis program implementation in Primary Health Care, Semarang, Indonesia

Evaluation of Tuberculosis program implementation in Primary Health Care, Semarang, Indonesia

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 Burden of Drug-Resistant Tuberculosis among Kenya's Devolved Health Units and Associated Treatment Outcomes

Background: A devolution is a form of decentralisation or the transfer of authority and responsibility from central to lower levels of government for a range of public functions. The drafters of the 2010 Kenyan constitution chose to devolve functions to 47 newly created counties. In Kenya, health is a devolved function that county governments run. Tuberculosis is managed at the county level in coordination with the National Leprosy Tuberculosis and Lung Disease Program (NLTP) with a mission of End TB Strategy to achieve a 95% decline in deaths due to tuberculosis compared with the 2015 baseline and reach an equivalent 90% reduction in tuberculosis incidence rate. Methods: This was a retrospective cohort study that collected data from health facilities accredited by the NLTP for drug-resistant tuberculosis treatment. The study population included patients who tested positive for drug-resistant tuberculosis from 2014 to 2019. Data was sourced from NLTP Electronic Medical Records (TIBU-System). After abstraction, the data was entered into Excel and analysed through STATA software version 13. Results: Of the 2674 enrolled patients in total, there were more males affected with DRTB at 64 % compared to the female patients. The public facilities carried the immense burden of diagnosis and treatment of the patient, having a cumulative number of 83 %, while the prison sector had the lowest number. For the resistance pattern, the new, relapse, and failure of first-line drugs accounted for most drug-resistant cases at 80 %, with only 65 % of the total cases having been done a gene-expert test at the point of screening. Conclusion: With a devolved health unit in Kenya, there needs to be a more coordinated support system from the national government to the county health units in terms of surveillance of TB disease. Regional centralised laboratories for diagnosis and monitoring of TB would reduce the time it takes for samples to come to Nairobi for testing, which takes time before patents are initiated on treatment.

Depression and Anxiety among Tuberculosis Patients: A Systematic Review and Meta-analysis

Abstract Background: Tuberculosis (TB) patients often experience depressive and anxiety symptoms, which can significantly impact their quality of life, treatment adherence, and outcomes. Understanding the magnitude of these mental health issues is crucial for improving TB programs and achieving successful treatment outcomes. Materials and Methods: We conducted a systematic review and meta-analysis, to assess the prevalence of depressive and anxiety symptoms among TB patients. Relevant studies were identified through a search of the PubMed database. Studies were assessed for quality using the Newcastle–Ottawa Quality Assessment Scale (NOS). Data extraction was performed, and a random-effects meta-analysis was conducted to estimate pooled prevalence rates. Results: Forty studies were included in the analysis. The pooled estimated prevalence of depression among TB patients was 11% (95% confidence interval [CI]: 11–12), while the pooled estimated prevalence of anxiety was 28% (95% CI: 26–29). Subgroup analyses revealed variations in the prevalence rates among drug-sensitive (DS-TB), drug-resistant, and extensively drug-resistant patients, as well as across continents and settings. Conclusions: The review indicates that there was a considerable burden of depressive and anxiety symptoms among TB patients worldwide. The findings emphasize the need for routine screening, integrated care approaches, and targeted interventions to address the mental health needs of TB patients.

Tuberculosis Immunoreactivity Surveillance in Malawi (Timasamala)-A protocol for a cross-sectional Mycobacterium tuberculosis immunoreactivity survey in Blantyre, Malawi.

Tuberculosis (TB) transmission and prevalence are dynamic over time, and heterogeneous within populations. Public health programmes therefore require up-to-date, accurate epidemiological data to appropriately allocate resources, target interventions, and track progress towards End TB goals. Current methods of TB surveillance often rely on case notifications, which are biased by access to healthcare, and TB disease prevalence surveys, which are highly resource-intensive, requiring many tens of thousands of people to be tested to identify high-risk groups or capture trends. Surveys of "latent TB infection", or immunoreactivity to Mycobacterium tuberculosis (Mtb), using tests such as interferon-gamma release assays (IGRAs) could provide a way to identify TB transmission hotspots, supplementing information from disease notifications, and with greater spatial and temporal resolution than is possible to achieve in disease prevalence surveys. This cross-sectional survey will investigate the prevalence of Mtb immunoreactivity amongst young children, adolescents and adults in Blantyre, Malawi, a high HIV-prevalence city in southern Africa. Through this study we will estimate the annual risk of TB infection (ARTI) in Blantyre and explore individual- and area-level risk factors for infection, as well as investigating geospatial heterogeneity of Mtb infection (and its determinants), and comparing these to the distribution of TB disease case-notifications. We will also evaluate novel diagnostics for Mtb infection (QIAreach QFT) and sampling methodologies (convenience sampling in healthcare settings and community sampling based on satellite imagery), which may increase the feasibility of measuring Mtb infection at large scale. The overall aim is to provide high-resolution epidemiological data and provide new insights into methodologies which may be used by TB programmes globally.

Cycles of antibiotic use and emergent antimicrobial resistance in the South African tuberculosis programme (1950-2021): A scoping review and critical reflections on stewardship

ABSTRACT The emergent threat of antimicrobial resistance (AMR) has resulted in debates around the use and preservation of effective antimicrobials. Concerns around AMR reflect a history of increasing dependence on antibiotics to address disease epidemics rooted in profound structural and systemic challenges. In the context of global health, this process, often referred to as pharmaceuticalisation, has commonly occurred within disease programmes, of which lessons are vital for adding nuance to conversations around antimicrobial stewardship. Tuberculosis (TB) is a notable example. A disease which accounts for one-third of AMR globally and remains the leading cause of death from a single infectious agent in many low – and middle-income countries, including South Africa. In this scoping review, we chart TB science in South Africa over 70 years of programming. We reviewed published manuscripts about the programme and critically reflected on the implications of our findings for stewardship. We identified cycles of programmatic responses to new drug availability and the emergence of drug resistance, which intersected with cycles of pharmaceuticalisation. These cycles reflect the political, economic, and social factors influencing programmatic decision-making. Our analysis offers a starting point for research exploring these cycles and drawing out implications for stewardship across the TB and AMR communities.