Tuberculosis Program Research Articles

More Than a Decade of GeneXpert®Mycobacterium tuberculosis/Rifampicin (Ultra) Testing in South Africa: Laboratory Insights from Twenty-Three Million Tests.

This study seeks to describe the rollout and current state of South Africa's GeneXpert molecular diagnostic program for tuberculosis (TB). Xpert MTB/RIF was introduced in 2011 with a subsequent expansion to include extra-pulmonary and paediatric testing, followed by Xpert MTB/RIF Ultra in 2017. Through a centralised laboratory information system and the use of a standardised platform for more than a decade, over 23 million tests were analysed, describing the numbers tested, Mycobacterium tuberculosis complex detection, rifampin resistance, and the unsuccessful test rates. The stratification by province, specimen type, age, and sex identified significant heterogeneity across the program and highlighted testing gaps for men, low detection yield for paediatric pulmonary TB, and the effects of inadequate specimen quality on the detection rate. The insights gained from these data can aid in the monitoring of interventions in support of the national TB program beyond laboratory operational aspects.

Exploring programmatic indicators of tuberculosis control that incorporate routine Mycobacterium tuberculosis sequencing in low incidence settings: a comprehensive (2017–2021) patient cohort analysis

Routine whole genome sequencing of Mycobacterium tuberculosis has been implemented with increasing frequency. However, its value for tuberculosis (TB) control programs beyond individual case management and enhanced drug resistance detection has not yet been explored. We analysed routine sequencing data of culture-confirmed TB cases notified between 1st January 2017 and 31st December 2021 in New South Wales (NSW), Australia. Genomic surveillance included evidence of local TB transmission, defined by single nucleotide polymorphism (SNP) clustering over a variable (0-25) SNP threshold, and drug resistance conferring mutations. M.tuberculosis sequences from 1831 patients were examined, representing 64.8% of all notified TB cases and 96.2% of culture-confirmed cases. Applying a traditional 5-SNP cluster threshold identified 62 transmission clusters with 183 clustered cases; 101/183 (55.2%) had 0 SNP differences. Cluster assessment over a 5-year period, using a 5-SNP threshold, provided a comprehensive overview of likely recent transmission within NSW, Australia, as an indicator of local TB control. Genotypic drug susceptibility testing (DST) was highly concordant with phenotypic DST and provided a 6.8% increase in antimycobacterial resistance detection. Importantly, it detected mutations missed by routine molecular tests. Lineage 2 strains were more likely to be drug resistant (p<0.0001) and locally transmitted if drug resistant (p<0.0001). Performing routine prospective WGS in a low incidence country like Australia, provides genomically informed programmatic indicators of local TB control. A rolling 5-year cluster assessment reflects epidemic containment and progress towards 'zero TB transmission'. Genomic DST also provides valuable information for clinical care and drug resistance surveillance. NHMRC Centre for Research Excellence in Tuberculosis (www.tbcre.org.au) and NSW Health Prevention Research Support Program.

How can tuberculosis services better support patients with a diabetes co-morbidity? A mixed methods study in the Philippines

BackgroundPeople with diabetes mellitus (DM) have an estimated two- to three-times greater risk of adverse tuberculosis (TB) treatment outcomes compared to those without DM. Blood glucose control is a primary aim of managing DM during TB treatment, yet TB programmes are not generally adapted to provide DM services. The purpose of this study was to understand perceptions and the lived experiences of diabetic patients in TB treatment in the Philippines, with a view to informing the development of disease co-management strategies.MethodsThis mixed methods study was conducted within a prospective cohort of adults newly-starting treatment for drug-sensitive and drug-resistant TB at 13 public TB clinics in three regions of the Philippines. Within the subset of 189 diabetic persons who self-reported a prior DM diagnosis, or were diagnosed by screenings conducted through the TB clinic, longitudinal blood glucose data were used to ascertain individuals’ glycaemic control (controlled or uncontrolled). Univariable logistic regression analyses exploring associations between uncontrolled glycaemia and demographic and clinical factors informed purposive sampling of 31 people to participate in semi-structured interviews. All audio-recorded data were transcribed and thematic analysis performed.ResultsParticipants — both with controlled and uncontrolled blood glucose — were knowledgeable about diabetes and its management. However, a minority of participants were aware of the impact of DM on TB treatment and outcomes. Many participants newly-diagnosed with DM at enrolment in TB treatment had not perceived any diabetic symptoms prior and would have likely not sought clinical consult otherwise. Access to free glucose-lowering medications through TB clinics was a key enabling resource. However, participants expressed fear of side effects and interrupted access to glucose-lowering medications, and a preference for phytotherapy. Many participants felt that physical and financial impacts of TB and its treatment were challenges to DM management.Conclusions and recommendationsResults of this study indicate that public TB clinics can provide diabetic patients with additional health care resources and education to address co-morbidity. TB programmes might consider identifying patients with complicated DM, and offering diabetic monitoring and management, as DM and diabetic complications may compound the burden of TB and its treatment.

Strategy to Reduce the Incidence of Pulmonary Tuberculosis (TB) Through Spatial Analysis and Literacy Studies in Batang Regency, Indonesia

Every year, around 2 million people in the world die from TB, and 9 million become infected with TB. Indonesia is located in position third after India and China. Batang Regency is one of the locations with a high prevalence of TB in Central Java. In 2021, there were 840 TB cases recorded in Batang Regency, increasing sharply in 2022 to 1192 cases. Seeing this trend, it is necessary to carry out research on strategies to reduce the incidence of pulmonary TB using literacy studies and spatial analysis in Batang Regency, Indonesia, in 2023. This study is a descriptive study using spatial analysis. This research is accompanied by an in-depth look at answers to TB program holders at the Batang Regency Health Service. The subjects in this study were patients with pulmonary TB in Batang Regency. The data analysis used the ArcView GIS program to obtain a map of the distribution of pulmonary TB cases in Batang Regency. Research results show that there were 831 pulmonary TB cases in 2020, 840 cases in 2021, and a sharp increase in 2022 with 1192 cases. The highest number of cases was in Batang District, with 279 cases, followed by Warungasem District, with 123 cases, and Bandar District, with 111 cases. These three districts are lowland and densely populated areas. Therefore, the Batang Regency Health Service needs to prioritize TB control programs in areas with the most cases.

Utilizing Rapid Molecular Tests (RMT/RIF) in Tuberculosis Drug-Sensitive/Resistant Discovery in Indonesia: A Pilot Study

The underdiagnosis and underreporting of tuberculosis (TB) indicators are unresolved problems. The rapid molecular test (RMT) is one of the breakthroughs for TB case finding by using safer and more sensitive equipment; it is even believed to help find drug-resistant TB. The results of several webinars held regularly by a TB program as well as its evaluation and the use of RMT formed the basis of this study. This initial pilot study aimed to provide an overview of case finding for both drug-sensitive and drug-resistant TB using RMT. A cross-sectional study was conducted on samples in several provinces in Indonesia that have used RMT, both in remote or non-remote island borders areas and fiscal capacity. Regarding the use of RMT for drug-sensitive TB case finding, the largest contributors were males aged above 15 years, while in the drug-resistant TB case finding group, the biggest contributor was the use of RMT in 2017 and 2018. Overall, the findings could only describe the situation in the study area. The use of RMT in drug-sensitive TB case finding would be maximized if the detected cases are males aged above 15 years, while RMT can help find cases of drug-resistant TB.

Implementation of The Pulmonary Tuberculosis Control Program at Sikumana Public Health Center

Introduction: According to the East Nusa Tenggara Provincial Health Office, Kupang City is the city with the highest contribution to pulmonary TB cases in 2021 with 491 cases and the Sikumana Health Center is the Public Health Center with the highest number of TB cases with 88 cases, patient recovery rate of 68.2%, and not reached the national target of 100%. The purpose of this study was to analyze the implementation of the pulmonary TB control program at the Sikumana Health Center. Methods : The research study was qualitative research using in-depth interview techniques. The number of informants was 11 informants. This research was conducted at the Sikumana Health Center, District Maulafa, City of Kupang from February to April 2023.Results: In the input aspect, the funds program, and human resources are sufficient, and the facilities for implementing the TB program are incomplete. In the process aspect, the planning and implementation stages have been going according to the proposed activity plan, but in the monitoring and supervision activities, it is still lacking because it is administrative and based on recording and reporting only. In the output aspect, the coverage of case detection in 2022 is 58.5%, the notification rate for all cases is 22.8%, the treatment success rate is 94.2%, and the cure rate is 98.2%.Conclusion: The Pulmonary Tuberculosis program implementation in Sikumana Health Center wasn’t implemented successfully because of process and input problems such as facilities and human resources. There should be regular training for TB program implementing officers, a special room for sputum collection, and routine supervision to the laboratory.

Impact on Tuberculosis Notification During COVID-19 Pandemic in India: A Narrative Review.

Various programs are being weakened due to the COVID-19 pandemic, and the tuberculosis (TB) program is no exception. TB case detection and notification is one of the worst affected areas. The study aims to assess India's TB reporting status during this pandemic and find possible solutions. Data analysis has been obtained from the India TB notification open-source database. Relevant literature research has been done to determine the measures based on various efforts made by different Indian states. There was a review of all TB notifications in 2019, 2020, and 2021 and a deficiency in notifications. Between 2019 and 2021, the country's TB notification ratio experienced a significant adaptation. In 2020, all states reported a decline in private and public TB case reports. In the nation, only a few private TB notifications were lost. In April 2020, there were the fewest notifications, which began to decline in February 2020. When states began implementing cutting-edge programs like the Integrated TB COVID Case Search and Active Case Finding (ACF), the notification trend improved in May 2020. The notifications of TB cases decreased significantly due to the present COVID-19 pandemic, which has consequences for the disease's stealthy spread throughout homes and communities. However, the situation may be better with an integrated strategy for managing TB-COVID cases.

Impact of the COVID-19 pandemic on tuberculosis control in Indonesia: a nationwide longitudinal analysis of programme data

The impact of the COVID-19 pandemic on tuberculosis control in high-burden countries has not been adequately assessed. We aimed to estimate the impact of the COVID-19 pandemic on the national tuberculosis programme in Indonesia, in association with indicators of human development and health-system capacity across all 514 districts in 34 provinces. We did a nationwide longitudinal analysis to compare tuberculosis case notification, treatment coverage, and mortality rates in Indonesia before (2016-19) and during (2020-21) the COVID-19 pandemic. The following outcomes were assessed: the district-level quarterly reported tuberculosis case notification rate (number of all reported tuberculosis cases per 100 000 population), treatment coverage (proportion of tuberculosis patients who started treatment), and all-cause mortality rate in patients with tuberculosis (number of reported deaths per 100 000 population). District-level data on COVID-19 incidence and deaths, health-system capacity, and human development and sociodemographics were also analysed. Multilevel linear spline regression was done to assess quarterly time trends for the three outcomes. During the COVID-19 pandemic, the tuberculosis case notification rate declined by 26% (case notification rate ratio 0·74, 95% CI 0·72-0·77) and treatment coverage declined by 11% (treatment coverage ratio 0·89, 95% CI 0·88-0·90), but there was no significant increase in all-cause mortality (all-cause mortality rate ratio 0·97, 95% CI 0·91-1·04) compared with the pre-pandemic period. In the second year of the pandemic, we observed a partial recovery of the case notification rate from Q1 to Q4 of 2021, a persistent decrease in treatment coverage, and a decrease in the all-cause mortality rate from Q2 of 2020 to Q4 of 2021. The multivariable analysis showed that the reduction in the tuberculosis case notification rate was associated with a higher COVID-19 incidence rate (adjusted odds ratio 3·1, 95% CI 1·1-8·6, for the highest compared with the lowest group) and fewer GeneXpert machines for tuberculosis diagnosis (3·1, 1·0-9·4, for the lowest compared with the highest group) per 100 000 population. The reduction in tuberculosis treatment coverage was associated with higher COVID-19 incidence (adjusted odds ratio 11·7, 95% CI 1·5-93·4, for the highest compared with the lowest group), fewer primary health centres (10·6, 4·1-28·0, for the lowest compared with the middle-high group), and a very low number of doctors (0·3, 0·1-0·9, for the low-middle compared with the lowest group) per 100 000 population. No factors were shown to be significantly associated with all-cause mortality. The COVID-19 pandemic adversely and unevenly affected the national tuberculosis programme across Indonesia, with the greatest impacts observed in districts with the lowest health-system capacity. These disruptions could lead to an escalation in tuberculosis transmission in the coming years, warranting the need for intensified efforts to control tuberculosis and strengthen local health systems. Wellcome Africa Asia Programme Vietnam. For the Bahasa translation of the abstract see Supplementary Materials section.

Delays in Treatment Initiation and Treatment Outcomes in Patients with Tuberculosis in the Kyrgyz Republic: Are There Differences between Migrants and Non-Migrants?

Migrants are at increased risk of developing tuberculosis (TB) and have poor treatment outcomes. The National TB program (NTP) of the Kyrgyz Republic recognizes two types of migrants: internal (intra-country) and external (inter-country) migrants. This cohort study compared the characteristics, timeliness of diagnosis and treatment initiation, and treatment outcomes of TB patients (internal migrant vs. external migrant vs. non-migrant) identified during treatment in the country in 2021. The TB treatment register and treatment cards of 5114 patients (156 internal, 430 external, and 4528 non-migrants) were reviewed. Risk factors (unemployment, smoking, alcohol use, and homelessness) were higher (p-value < 0.001) in internal (84%) than in external migrants (66%) and non-migrants (43%). The median delay in seeking care post-symptom onset was longer (p-value= 0.03) in external (30 days) than in internal migrants (21 days) and non-migrants (25 days). Successful treatment outcomes for drug-sensitive TB were higher in internal (89%, p-value = 0.012) and external migrants (86%, p-value = 0.001) than in non-migrants (78%). Internal and external migrants should be separately considered with respect to TB care and monitoring under the NTP. Success rates seem to be high in migrants, but our findings may be biased, as migrants with poor healthcare access may remain undetected and untreated and have undocumented poor outcomes.

Rapid Utilizing Molecular Tests (RMT/RIF) in Tuberculosis Drug-Sensitive/Resistant Discovery in Indonesia: A Pilot Study

The underdiagnosis and underreporting of tuberculosis (TB) indicators are unresolved problems. The rapid molecular test (RMT) is one of the breakthroughs for TB case finding by using safer and more sensitive equipment; it is even believed to help find drug-resistant TB. The results of several webinars held regularly by a TB program as well as its evaluation and the use of RMT formed the basis of this study. This initial pilot study aimed to provide an overview of case finding for both drug-sensitive and drug-resistant TB using RMT. A cross-sectional study was conducted on samples in several provinces in Indonesia that have used RMT, both in remote or non-remote island borders areas and fiscal capacity. Regarding the use of RMT for drug-sensitive TB case finding, the largest contributors were males aged above 15 years, while in the drug-resistant TB case finding group, the biggest contributor was the use of RMT in 2017 and 2018. Overall, the findings could only describe the situation in the study area. The use of RMT in drug-sensitive TB case finding would be maximized if the detected cases are males aged above 15 years, while RMT can help find cases of drug-resistant TB.

Barriers and Facilitators to Integrating Depression Treatment Within a TB Program and Primary Care in Brazil.

Tuberculosis (TB) and depression is common and is associated with poor TB outcomes. The World Health Organization End TB Strategy explicitly calls for the integration of TB and mental health services. Interpersonal Counseling (IPC) is a brief evidence-based treatment for depression that can be delivered by non-mental health specialists with expert supervision. The goal of this study was to explore potential barriers and facilitators to training non-specialist providers to deliver IPC within the TB Control Program and primary care in Itaboraí, Rio de Janeiro state. Data collection consisted of six focus groups (n = 42) with health professionals (n = 29), program coordinators (n = 7), and persons with TB (n = 6). We used open coding to analyze the data, followed by deductive coding using the Chaudoir multi-level framework for implementation outcomes. The main structural barriers identified were poverty, limited access to treatment, political instability, violence, and social stigma. Organizational barriers included an overburdened and under-resourced health system with high staff turnover. Despite high levels of stress and burnout among health professionals, several provider-level facilitators emerged including a high receptivity to, and demand for, mental health training; strong community relationships through the community health workers; and overall acceptance of IPC delivered by any type of health provider. Patients were also receptive to IPC being delivered by any type of professional. No intervention-specific barriers or facilitators were identified. Despite many challenges, integrating depression treatment into primary care in Itaboraí using IPC was perceived as acceptable, feasible, and desirable.

Comparing Additionality of Tuberculosis Cases Using GeneXpert or Smear-Based Active TB Case-Finding Strategies among Social Contacts of Index Cases in Nepal.

This study compares the yield and additionality of community-based active tuberculosis (TB) active case-finding strategies using either smear microscopy or GeneXpert as the TB diagnostic test. Active case-finding strategies screened social contacts of index cases and high-risk groups in four districts of Nepal in July 2017-2019. Two districts (Chitwan and Dhanusha) applied GeneXpert testing and two districts (Makwanpur and Mahotarri) used smear microscopy. Two control districts implemented standard national TB program activities. Districts implementing GeneXpert testing screened 23,657 people for TB, tested 17,114 and diagnosed 764 TB cases, producing a yield of 4.5%. Districts implementing smear microscopy screened 19,961 people for TB, tested 13,285 and diagnosed 437 cases, producing a yield of 3.3%. The screening numbers required were 31 for GeneXpert and 45.7 for smear districts. The test numbers required were 22.4 and 30.4 for GeneXpert and smear. Using the TB REACH additionality method, social contact tracing for TB through GeneXpert testing contributed to a 20% (3958/3322) increase in district-level TB notifications, smear microscopy 12.4% (3146/2798), and -0.5% (2553/2566) for control districts. Therefore, social contact tracing of TB index cases using GeneXpert testing should be implemented throughout Nepal within the TB FREE initiative to close the notification gap and accelerate progress toward END TB strategy targets.

An Investigation into Implications of Tuberculosis Control Efforts in Pakistan: A Comparative Approach

Objective: To investigate the difference of Tuberculosis (TB) related information in diagnosed TB patients and healthy individuals in relation to the implications of National Tuberculosis Program (NTP) control efforts. Study Design and Setting: This comparative case-control study was conducted from May to December 2022 in public sector tertiary care setups of Karachi. Methodology: In this case control study, 100 hospitalized diagnosed patients of TB were compared with 155 healthy individuals from May to December 2022. We analyzed sociodemographic characteristics of both groups related to the information for transmission and prevention of TB, as a basic element for the disease control. Result: TB patients were more likely to be uneducated, have low household income and positive family history of TB as compared to non-TB (OR 0.52, 0.30, 0.40). 18% of TB patients believed that TB infected person cannot be a source of spread to cause TB disease (OR=4.7; P=0.006). There was a statistically significant association among both the groups deemed to malnutrition and multiple households as the risk factors of tuberculosis (P=0.002 and &lt;0.001 respectively Conclusion: TB related information with respect to its cause, preventive and treatment was insufficient in both study groups leading to delay in TB treatment and increase mortality from the disease. Health education interventional strategies, focused on primitive and advanced TB related information are needed in general population with special attention on low socioeconomic groups of community, and the population living in isolated and remote areas.

Barriers to tuberculosis treatment adherence in high-burden tuberculosis settings in Ashanti region, Ghana: a qualitative study from patient’s perspective

BackgroundDespite having an effective community-based Directly Observed Therapy Short-course (DOTS) strategy for tuberculosis (TB) care, treatment adherence has been a major challenge in many developing countries including Ghana. Poor adherence results in discontinuity of treatment and leads to adverse treatment outcomes which pose an increased risk of drug resistance. This study explored barriers to TB treatment adherence and recommended potential patient-centered strategies to improve treatment adherence in two high-burden TB settings in the Ashanti region of Ghana.MethodsThe study was conducted among TB patients who defaulted on treatment in the Obuasi Municipal and Obuasi East districts in the Ashanti region. A qualitative phenomenology approach was used to explore the barriers to TB treatment adherence. Purposive sampling was adopted to select study participants with different sociodemographic backgrounds and experiences with TB care. Eligible participants were selected by reviewing the medical records of patients from health facility TB registers (2019–2021). Sixty-one (61) TB patients met the eligibility criteria and were contacted via phone call. Out of the 61 patients, 20 were successfully reached and consented to participate. In-depth interviews were conducted with participants using a semi-structured interview guide. All interviews were audio recorded and transcribed verbatim. The transcripts were imported into Atlas.ti version 8.4 software and analyzed using thematic content analysis.ResultsFood insecurity, cost of transportation to the treatment center, lack of family support, income insecurity, long distance to the treatment center, insufficient knowledge about TB, side effect of drugs, improvement in health after the intensive phase of the treatment regimen, and difficulty in accessing public transportation were the main co-occurring barriers to treatment adherence among the TB patients.ConclusionThe main barriers to TB treatment adherence identified in this study reveal major implementation gaps in the TB programme including gaps related to social support, food security, income security, knowledge, and proximity to treatment centers. Hence, to improve treatment adherence there is a need for the government and the National Tuberculosis Programme (NTP) to collaborate with different sectors to provide comprehensive health education, social and financial support as well as food aid to TB patients.

A machine learning approach to explore individual risk factors for tuberculosis treatment non-adherence in Mukono district.

Despite the availability and implementation of well-known efficacious interventions for tuberculosis treatment by the Ministry of Health, Uganda (MoH), treatment non-adherence persists. Moreover, identifying a specific tuberculosis patient at risk of treatment non-adherence is still a challenge. Thus, this retrospective study, based on a record review of 838 tuberculosis patients enrolled in six health facilities, presents, and discusses a machine learning approach to explore the individual risk factors predictive of tuberculosis treatment non-adherence in the Mukono district, Uganda. Five classification machine learning algorithms, logistic regression (LR), artificial neural networks (ANN), support vector machines (SVM), random forest (RF), and AdaBoost were trained, and evaluated by computing their accuracy, F1 score, precision, recall, and the area under the receiver operating curve (AUC) through the aid of a confusion matrix. Of the five developed and evaluated algorithms, SVM (91.28%) had the highest accuracy (AdaBoost, 91.05% performed better than SVM when AUC is considered as evaluation parameter). Looking at all five evaluation parameters globally, AdaBoost is quite on par with SVM. Individual risk factors predictive of non-adherence included tuberculosis type, GeneXpert results, sub-country, antiretroviral status, contacts below 5 years, health facility ownership, sputum test results at 2 months, treatment supporter, cotrimoxazole preventive therapy (CPT) dapsone status, risk group, patient age, gender, middle and upper arm circumference, referral, positive sputum test at 5 and 6 months. Therefore, machine learning techniques, specifically classification types, can identify patient factors predictive of treatment non-adherence and accurately differentiate between adherent and non-adherent patients. Thus, tuberculosis program management should consider adopting the classification machine learning techniques evaluated in this study as a screening tool for identifying and targeting suited interventions to these patients.

Psychosocial support interventions to improve treatment outcomes for people living with tuberculosis: a mixed methods systematic review and meta-analysis.

People with tuberculosis (TB) face multi-dimensional barriers when accessing and engaging with care. There is evidence that providing psychosocial support within people-centered models of care can improve TB outcomes, however, there is limited consensus on what works. It remains important for such interventions to be rigorously assessed, and mixed methods systematic reviews are one way of synthesising data for policy makers to be able to access such evidence. Mixed methods reviews take a complexity perspective, with qualitative data being used to contextualise the quantitative findings and giving an insight into how interventions are contingent on variations in design and context. Five electronic databases were searched from January 1 2015 to 14 January 2023 for randomised controlled trials, quasi-experimental trials, cohort studies and qualitative studies of interventions providing psychosocial support (material and/or psychological-based support) to adults with any clinical form of active TB. Studies with inpatient treatment as the standard of care were excluded. Quantitative studies reporting pre-specified standard TB outcomes were eligible. In line with established mixed methods review methodology, a convergent parallel-results synthesis design was followed: quantitative and qualitative syntheses were distinct and carried out using appropriate methods. A convergent coding matrix was then used to integrate the results. The protocol was registered on PROSPERO (CRD42021235211). Twenty-three studies of interventions were included (12 quantitative, 10 qualitative, and 1 mixed methods study) were included. Most studies were conducted in low-and middle-income countries with a high-burden of TB. Three explanatory and contextual middle-range theories from the integration of qualitative and quantitative data were developed: effective interventions provide multi-dimensional support; psychological-based support is transformative but there is insufficient evidence that it improves treatment outcomes on its own; intervention delivery shapes a logic of care. This review takes a complexity perspective to provide actionable and timely insight to inform the design and implementation of locally-appropriate and people-centered psychosocial support interventions within national TB programmes. There was no funding source for this study.

Implementation, feasibility, and acceptability of 99DOTS-based supervision of treatment for drug-susceptible TB in Uganda.

99DOTS is a low-cost digital adherence technology that allows people with tuberculosis (TB) to self-report treatment adherence. There are limited data on its implementation, feasibility, and acceptability from sub-Saharan Africa. We conducted a longitudinal analysis and cross-sectional surveys nested within a stepped-wedge randomized trial at 18 health facilities in Uganda between December 2018 and January 2020. The longitudinal analysis assessed implementation of key components of a 99DOTS-based intervention, including self-reporting of TB medication adherence via toll-free phone calls, automated text message reminders and support actions by health workers monitoring adherence data. Cross-sectional surveys administered to a subset of people with TB and health workers assessed 99DOTS feasibility and acceptability. Composite scores for capability, opportunity, and motivation to use 99DOTS were estimated as mean Likert scale responses. Among 462 people with pulmonary TB enrolled on 99DOTS, median adherence was 58.4% (inter-quartile range [IQR] 38.7-75.6) as confirmed by self-reporting dosing via phone calls and 99.4% (IQR 96.4-100) when also including doses confirmed by health workers. Phone call-confirmed adherence declined over the treatment period and was lower among people with HIV (median 50.6% vs. 63.7%, p<0.001). People with TB received SMS dosing reminders on 90.5% of treatment days. Health worker support actions were documented for 261/409 (63.8%) people with TB who missed >3 consecutive doses. Surveys were completed by 83 people with TB and 22 health workers. Composite scores for capability, opportunity, and motivation were high; among people with TB, composite scores did not differ by gender or HIV status. Barriers to using 99DOTS included technical issues (phone access, charging, and network connection) and concerns regarding disclosure. 99DOTS was feasible to implement and highly acceptable to people with TB and their health workers. National TB Programs should offer 99DOTS as an option for TB treatment supervision.

Health-Seeking Behavior Regarding Coughs in Urban Slums in Lagos, Nigeria.

TB is a major cause of morbidity and mortality, with slum residents being disproportionately affected. This study aimed to assess health-seeking behavior among adult residents of slum communities presenting with coughs in Lagos, Nigeria. A community-based, cross-sectional study was conducted across six urban slums in Nigeria as part of community outreaches to mark World TB Day. A structured, pretested questionnaire was used to capture relevant sociodemographic details and questions regarding symptoms of coughs and related symptoms as well as care-seeking behavior. Data were explored, analyzed, and presented using descriptive statistics. A total of 632 respondents participated in this study. The majority were 25-34 years old (24.7%), male (65.8%), Christian (55.7%), married (73.7%), with secondary education (37.8%), with 3-4 persons per household (41%) and with 1-2 persons per room (44.5%). In total, 26.6% had had a cough for two weeks or more and were considered as presumptive TB patients. Overall, 37.2% of respondents with a cough visited patent proprietary medicine vendors (PPMVs) as the first port of call. Good health-seeking behavior was exhibited by only 36.2% of respondents. In total, 38.9% delayed seeking care from a health facility (government or private) more than one month after the onset of symptoms. None of the factors included in the multivariate analysis showed a significant association with good health-seeking behavior (i.e., visiting government or private hospitals/clinics). The poor health-seeking behavior, delay in seeking TB care and preference for PPMVs emphasizes the need for National tuberculosis programs (NTPs) to further engage these informal providers in TB prevention, diagnosis and treatment services in urban slum communities.

Competing risk models to evaluate the factors for time to loss to follow-up among tuberculosis patients at Ambo General Hospital

BackgroundA major challenge for most tuberculosis programs is the inability of tuberculosis patients to complete treatment for one reason or another. Failure to complete the treatment contributes to the emergence of multidrug-resistant TB. This study aimed to evaluate the risk factors for time to loss to follow-up treatment by considering death as a competing risk event among tuberculosis patients admitted to directly observed treatment short course at Ambo General Hospital, Ambo, Ethiopia.MethodsData collected from 457 tuberculosis patients from January 2018 to January 2022 were used for the analysis. The cause-specific hazard and sub-distribution hazard models for competing risks were used to model the outcome of interest and to identify the prognostic factors associated to treatment loss to follow-up. Loss to follow-up was used as an outcome measure and death as a competing event.ResultsOf the 457 tuberculosis patients enrolled, 54 (11.8%) were loss to follow-up their treatment and 33 (7.2%) died during the follow up period. The median time of loss to follow-up starting from the date of treatment initiation was 4.2 months. The cause-specific hazard and sub-distribution hazard models revealed that sex, place of residence, HIV status, contact history, age and baseline weights of patients were significant risk factors associated with time to loss to follow-up treatment. The findings showed that the estimates of the covariates effects were different for the cause specific and sub-distribution hazard models. The maximum relative difference observed for the covariate between the cause specific and sub-distribution hazard ratios was 12.2%.ConclusionsPatients who were male, rural residents, HIV positive, and aged 41 years or older were at higher risk of loss to follow-up their treatment. This underlines the need that tuberculosis patients, especially those in risk categories, be made aware of the length of the directly observed treatment short course and the effects of discontinuing treatment.

Comparative Case Study On Tuberculosis Patients Between Rural And Urban Areas

The recent recurrence of tuberculosis (TB) has forced us to re-evaluate the disease's pre-existing theories. Social scientists have looked at numerous cultural, environmental, and politico-economic aspects, but biomedical literature frequently explains tuberculosis in terms of biological reasons (such as bacterial infection). The design and implementation of programmes to meet the requirements of patients who have or are at risk for both diseases are influenced by the numerous linkages between TB and HIV infection. The World Health Organisation and other international organisations have promoted collaboration between national TB and HIV programmes and some amount of local service integration, and these initiatives are acknowledged as necessary in regions where the two illnesses are common. The field where their impact would be seen and the anticipation of improving both diseases' outcomes will be realised, however, is yet relatively untapped for most of these strategies. In this article, comparative case study is performed between TB patients of rural and urban areas. The method used was conducting survey using questionnaires to be answered by the patients. The conclusion drawn from the study was that the people who are older, less educated, female, and live far from medical facilities experience the greatest delays in receiving TB care and receiving a diagnosis.