Are global tuberculosis control targets overlooking an essential indicator? Prolonged delays to diagnosis despite high case detection rates in Yunnan, China.

Delay in treating active tuberculosis (TB) impedes disease control by allowing ongoing transmission, and may explain the unexpectedly modest declines in global TB incidence. Even though China has achieved TB control targets under the global Directly Observed Treatment, Short course (DOTS) strategy, TB prevalence in western provinces, including Yunnan, is not decreasing. This cross-sectional study investigates whether prolonged delay in identifying and correctly treating TB patients, which is not routinely monitored, persists even when there is a well-functioning TB control programme and global targets are being met. Records of adult smear-positive pulmonary TB patients diagnosed with between 2006 and 2013 were extracted from the Yunnan Centre for Disease Control electronic database, which contains information on the entire population of TB patients managed across 129 diagnostic centres. Delay was investigated at three stages: delay to DOTS facility (period between symptom onset and first visit to at a CDC unit providing standardized treatment); delay to TB confirmation (period between reaching a CDC unit and confirmation of smear-positive TB) and delay to treatment (period between confirmation of TB and initiation of treatment). Data from 76 486 patients was analysed. Delay to reaching a DOTS facility was by far the largest contributor to total delay to treatment initiation. The median delay to reaching a DOTS facility, to TB confirmation and to treatment was 57 days (IQR 25-112), 2 days (IQR 1-6) and 1 day (IQR 0-1) respectively. Prolonged delays to reaching a facility providing standardized TB care occurred in a substantial subset of the population despite all TB control targets being met; overall, 32% (24 676) of patients experienced a delay of more than 90 days to reaching a DOTS facility. Policies that focus on reducing delays in accessing appropriate health services, rather than only on increasing overall case-detection rates, may result in greater progress towards reducing TB incidence.

Financial barriers and coping strategies: a qualitative study of accessing multidrug-resistant tuberculosis and tuberculosis care in Yunnan, China.

BACKGROUND: Tuberculosis (TB) and multidrug-resistance tuberculosis (MDR-TB) pose serious challenges to global health, particularly in China, which has the second highest case burden in the world. Disparities in access to care for the poorest, rural TB patients may be exacerbated for MDR-TB patients, although this has not been investigated widely. We examine whether certain patient groups experience different barriers to accessing TB services, whether there are added challenges for patients with MDR-TB, and how patients and health providers cope in Yunnan, a mountainous province in China with a largely rural population and high TB burden. METHODS: Using a qualitative study design, we conducted five focus group discussions and 47 in-depth interviews with purposively sampled TB and MDR-TB patients and healthcare providers in Mandarin, between August 2014 and May 2015. Field-notes and interview transcripts were analysed via a combination of open and thematic coding. RESULTS: Patients and healthcare providers consistently cited financial constraints as the most common barriers to accessing care. Rural residents, farmers and ethnic minorities were the most vulnerable to these barriers, and patients with MDR-TB reported a higher financial burden owing to the centralisation and longer duration of treatment. Support in the form of free or subsidised treatment and medical insurance, was deemed essential but inadequate for alleviating financial barriers to patients. Most patients coped by selling their assets or borrowing money from family members, which often strained relationships. Notably, some healthcare providers themselves reported making financial and other contributions to assist patients, but recognised these practices as unsustainable. CONCLUSIONS: Financial constraints were identified by TB and MDR-TB patients and health care professionals as the most pervasive barrier to care. Barriers appeared to be magnified for ethnic minorities and patients coming from rural areas, especially those with MDR-TB. To reduce financial barriers and improve treatment outcomes, there is a need for further research into the total costs of seeking and accessing TB and MDR-TB care. This will enable better assessment and targeting of appropriate financial support for identified vulnerable groups and geographic development of relevant services.

Are current case-finding methods under-diagnosing tuberculosis among women in Myanmar? An analysis of operational data from Yangon and the nationwide prevalence survey.

BACKGROUND: Although there is a large increase in investment for tuberculosis control in Myanmar, there are few operational analyses to inform policies. Only 34% of nationally reported cases are from women. In this study, we investigate sex differences in tuberculosis diagnoses in Myanmar in order to identify potential health systems barriers that may be driving lower tuberculosis case finding among women. METHODS: From October 2014 to March 2015, we systematically collected data on all new adult smear positive tuberculosis cases in ten township health centres across Yangon, the largest city in Myanmar, to produce an electronic tuberculosis database. We conducted a descriptive cross-sectional analysis of sex differences in tuberculosis diagnoses at the township health centres. We also analysed national prevalence survey data to calculate additional case finding in men and women by using sputum culture when smear microscopy was negative, and estimated the sex-specific impact of using a more sensitive diagnostic tool at township health centres. RESULTS: Overall, only 514 (30%) out of 1371 new smear positive tuberculosis patients diagnosed at the township health centres were female. The proportion of female patients varied by township (from 21% to 37%, p = 0.0172), month of diagnosis (37% in February 2015 and 23% in March 2015 p = 0.0004) and age group (26% in 25-64 years and 49% in 18-25 years, p < 0.0001). Smear microscopy grading of sputum specimens was not substantially different between sexes. The prevalence survey analysis indicated that the use of a more sensitive diagnostic tool could result in the proportion of females diagnosed at township health centres increasing to 36% from 30%. CONCLUSIONS: Our study, which is the first to systematically compile and analyse routine operational data from tuberculosis diagnostic centres in Myanmar, found that substantially fewer women than men were diagnosed in all study townships. The sex ratio of newly diagnosed cases varied by age group, month of diagnosis and township of diagnosis. Low sensitivity of tuberculosis diagnosis may lead to a potential under-diagnosis of tuberculosis among women.

Late diagnosis of HIV in Europe: definitional and public health challenges.

With universal access to antiretroviral therapy (ART), people can access effective treatment but are only able to benefit from these advances if they are aware of their status and are effectively accessing testing services. Although it was anticipated in the mid-1990s that the availability of ART would lead to earlier testing, this trend has not been observed in practice, with stagnant or even increasing rates of late diagnosis in Europe. Ahead of a gathering of key European stakeholders in Brussels in November 2007, we reviewed definitions of late diagnosis and approaches to surveillance of late HIV diagnosis in Europe. We found that there is no common or consistent reporting of late diagnosis across Europe and that the multiplicity of definitions for late diagnosis is likely proving a hindrance to providing information on the magnitude of the problem, determining trends, and informing understanding of reasons for changes in trends. We also show that existing evidence points to high rates of late diagnosis across Europe - between 15 and 38% of all HIV cases - and concur that trends that are increasing or at best stagnant. We identify risk factors that are associated with individuals being more likely to present late and we explore the reasons for late presentation. We reflect on the need to review surveillance and testing policies, notably in relation for population groups that are heavily represented in late presenters and make recommendations for a coherent, cross-European approach to surveillance and monitoring in order to support improvements in service provision and, ultimately, public health.

HIV testing strategies across European countries.

With universal access to effective combination antiretroviral therapy (ART), people in need can gain effective treatment but are only able to benefit from these advances if they are aware of their serostatus and have effectively accessed testing services. Despite the expectation that ART would lead individuals to seek earlier testing, this trend has not been observed in practice, with stable or even increasing rates of late diagnosis in Europe being witnessed. Ahead of a gathering of key European stakeholders in Brussels in November 2007, we reviewed testing strategies across European countries. We show differences in policy and practices. Moreover, HIV testing strategies are changing, in line with new global guidelines issued by World Health Organization headquarters, and a number of countries are promoting an expansion of routine and opt-out testing. However, gaps in our understanding of effective testing strategies remain and, as a consequence, national policies across Europe remain incoherent and often lack an evidence base. This is likely to have serious public health implications.

Public health law and tuberculosis control in Europe.

BACKGROUND: Tuberculosis control is an important public health challenge in many European countries. Law is an important tool that policy-makers can draw upon to support control efforts and, according to the World Health Organization, represents a tangible expression of political commitment and will. Despite this, little national research, and even less cross-national comparative research, has been conducted to describe and analyse legislative approaches to tuberculosis control. METHODS: We conducted a survey of 14 European countries to identify, describe, map and analyse legislative tools used to support tuberculosis control. RESULTS: We found a wide range of legislative models. Legal measures available to nation states, such as compulsory examination, compulsory screening, compulsory detention, compulsory treatment and compulsory vaccination, vary widely in both scope and number. We identified a typology of legal frameworks, from the most authoritarian to the least restrictive. It seems likely that the application of some laws might not withstand scrutiny under the European Convention for the Protection of Human Rights and Fundamental Freedoms. CONCLUSIONS: Harmonization of legislative response to infectious diseases, based upon sound evidence, may be necessary if collaborative efforts in support of infectious disease control, as envisaged in the new International Health Regulations, are to be most effective and are to reflect more appropriately a globalized 21st century world.

Costs and outcomes of tuberculosis control in the Russian Federation: retrospective cohort analysis.

We analysed costs and outcomes of tuberculosis care for patients in a traditional Russian tuberculosis control system, using 3-year retrospective cohort data. Of 1749 cases at 3 years of follow-up, 65% were cured, 11.3% (198/1749) still had 'active' or 'chronic' disease, 10.3% had transferred out of the local civilian health care system and 12.7% had died. The mean cost of managing one case over 3 years was 886 US dollars: 1,078 US dollars for bacteriologically confirmed (BK+) cases and 718 US dollars for bacteriologically unconfirmed (BK-) cases. Approximately 60% of treatment costs were incurred in the first 12 months and 40% incurred in the remaining 2 years. Around 60% of the total cost was accounted for by hospital inpatient care. The cost, treatment and outcome of BK+ and BK- cases differed substantially. The cost of treating BK+ cases was 50% higher than treating BK- cases due to higher hospitalization rates and the additional cost of managing BK+ cases that become 'chronic'. While BK+ cases accounted for 55% of total health expenditure on tuberculosis, the share of BK- cases was 45% of the total - due to hospitalization and lengthy periods of follow up. The costs of treating tuberculosis in the Russian tuberculosis control system are very high compared with other high-burden countries due to hospitalization policies and lengthy case management periods. Much of this expenditure can be avoided if the WHO-recommended DOTS strategy is implemented. In particular, the proportion of expenditure for BK- cases is surprisingly high and can be avoided as most of these patients do not need hospitalizing or lengthy periods of follow-up.

Social factors influencing hospital utilisation by tuberculosis patients in the Russian Federation: analysis of routinely collected data.

OBJECTIVE: To establish whether admissions, discharges and hospital utilisation for tuberculosis (TB) in Russia are independent of sex, age, disability and employment status. STUDY POPULATION AND METHODS: Analysis of hospital admissions, discharges and in-patient utilisation using routinely collected data in Samara Region of the Russian Federation. RESULTS: Male, unemployed and disabled adults were significantly more likely to be hospitalised (P < 0.001). The unemployed and pensioners were more likely to have multiple admissions. Unemployed adults were more likely to have longer average lengths of stay per admission (P < 0.001), with a cumulative length of stay for unemployed and disabled adults significantly greater than for employed adults and adults with no disability. Interruption of hospital care was significantly more frequent in male, disabled and unemployed patients (P < 0.001). CONCLUSIONS: Socio-economic factors influence hospital admission patterns and the length of stay for patients when hospitalised, as the providers of TB services attempt to mitigate the lack of social care provision for patients. For the WHO DOTS strategy to be effectively implemented and sustained in the Russian Federation health system, social sector linkage issues need to be addressed.

Seasonal variation and hospital utilization for tuberculosis in Russia: hospitals as social care institutions.

BACKGROUND: Clinical management of tuberculosis in Russia involves lengthy hospitalizations, in contrast to the recommended strategy advocated by the World Health Organization. METHODS: We used Fourier transform, spectral analysis and Student's t-test to analyse periodic and seasonal variations in admission and discharge rates for tuberculosis hospitalizations in 1999-2002, using routinely captured data from the Samara Region, Russia. RESULTS: Hospital admissions in colder months were significantly higher than in warmer months. The mean monthly adjusted number of admissions in colder and warmer months for all adults was 413 and 372 (P < 0.01), for unemployed adults 218 and 198 (P < 0.02) and for pensioners 104 and 82 (P < 0.05). Hospital discharges varied seasonally. Maximum differences between admissions and discharges occurred in colder months and minimum differences were observed in warmer months. CONCLUSIONS: As hospitalizations of tuberculosis patients in colder months fulfil an important social need, shifts to ambulatory care must be carefully managed.

Health system frailties in tuberculosis service provision in Russia: an analysis through the lens of formal nutritional support.

OBJECTIVE: The aim of this study was to describe health system challenges faced by tuberculosis (TB) treatment facilities in Russia through an analysis of formal institutional dietary provisions to patients in an inpatient facility that provides care for poor patients. METHODS: Analysis of formal dietary provisions by institutions and financing data from TB hospitals in Samara Oblast, Russia. RESULTS: Formal dietary provision for inpatients with TB has fallen substantially in recent years. In a hospital providing inpatient care for the poorest patients with fewest social support networks, this has been very pronounced. The likely reason for this is that financial support for other budget lines, principally salaries, has required protection. CONCLUSION: Formal institutional nutritional support in institutions providing care for the poorest patients with TB is unlikely to be enhancing the speed of recovery, or reducing the duration of infectiousness. Furthermore, the role that hospital may have played in the past in enabling patients to regain weight lost before admission may have been limited by reductions in formal financing. Reductions in state provision of food for patients may serve as an important illustration of wider TB control system frailties in the Russian Federation.

Barriers to sustainable tuberculosis control in the Russian Federation health system.

The Russian Federation has the eleventh highest tuberculosis burden in the world in terms of the total estimated number of new cases that occur each year. In 2003, 26% of the population was covered by the internationally recommended control strategy known as directly observed treatment (DOT) compared to an overall average of 61% among the 22 countries with the highest burden of tuberculosis. The Director-General of WHO has identified two necessary starting points for the scaling-up of interventions to control emerging infectious diseases. These are a comprehensive engagement with the health system and a strengthening of the health system. The success of programmes aimed at controlling infectious diseases is often determined by constraints posed by the health system. We analyse and evaluate the impact of the arrangements for delivering tuberculosis services in the Russian Federation, drawing on detailed analyses of barriers and incentives created by the organizational structures, and financing and provider-payment systems. We demonstrate that the systems offer few incentives to improve the efficiency of services or the effectiveness of tuberculosis control. Instead, the system encourages prolonged supervision through specialized outpatient departments in hospitals (known as dispensaries), multiple admissions to hospital and lengthy hospitalization. The implementation, and expansion and sustainability of WHO-approved methods of tuberculosis control in the Russian Federation are unlikely to be realized under the prevailing system of service delivery. This is because implementation does not take into account the wider context of the health system. In order for the control programme to be sustainable, the health system will need to be changed to enable services to be reconfigured so that incentives are created to reward improvements in efficiency and outcomes.

Increased risk of tuberculosis among health care workers in Samara Oblast, Russia: analysis of notification data.

SETTING: Samara Oblast, Russia. OBJECTIVE: To compare the rates of tuberculosis (TB) in health care workers (HCWs) working in TB services, general health services (GHS) and the general population in a region of the Russian Federation. DESIGN: Analysis of notification rates of TB among HCWs, GHS workers and the general population during the 9-year period from 1994 to 2002. RESULTS: During 1994-2002, TB incidence among staff employed at the TB services in Samara Oblast was ten times higher than among the general population, reaching 741.6/100 000 person years at risk. Staff working at in-patient TB facilities were found to be at highest risk, with an incidence rate ratio of 17.7 (95% CI 11.6-27.0) compared to HCWs at the GHS. CONCLUSIONS: HCWs at TB services in the Russian Federation are at substantially increased risk for TB, suggesting significant risks from nosocomial transmission. Control of institutional spread of TB in the Russian Federation is an area that requires urgent attention, especially given the epidemic of human immunodeficiency virus that Russia is currently witnessing.

A framework and toolkit for capturing the communicable disease programmes within health systems: tuberculosis control as an illustrative example.

The frameworks and methods used for analysis, monitoring and evaluation of communicable disease control vary greatly. Although a number of manuals exist instruments for a detailed analysis of wider health system context are lacking. This is surprising given that the success of vertical programmes is often determined by the constraints of health systems. The importance of the context and the health system in determining the successful implementation of national tuberculosis programmes is well recognized by the WHO, which recommends analysis of national tuberculosis programmes within the context of health care system, health reform and the economic status of the country. However, current approaches inadequately capture intelligence on the health systems variables impacting on programme efficacy, limiting the ability of policy makers to draw lessons for wider use. A recent WHO report highlights the major systemic constraints to DOTS implementation and recommends a comprehensive and multi-sectoral approach to tuberculosis control. This obviates the need for tools that take into account health systems issues as well as focusing on a particular vertical programme but no such comprehensive tool exists. This paper outlines the conceptual basis for a model and a toolkit for rapid assessment, monitoring, and evaluation of the context, the elements of the health system and vertical communicable disease programme. It describes the framework, the potential strengths and weaknesses, approach and piloting of the toolkit and its two elements: first for 'horizontal assessment' of the health system within which the programme is embedded and second for 'vertical assessment' of the infectious disease-specific programme.

Screening programmes for tuberculosis in new entrants across Europe.

Screening foreign-born groups with high rates of tuberculosis may help to ensure that they can benefit from early treatment and minimise onward transmission. In January 2003, we surveyed new entrant screening programmes in Europe. Of the 26 countries from whom a response was received, 13 (50%) conducted no specific tuberculosis screening. Of 13 countries with programmes, none conducted pre-entry screening, three conducted screening at ports of entry, and nine screened in other centres. All 13 principally screened refugees. All programmes used chest X-rays as a screening tool, but no two countries took the same specific clinical approach.

Compulsory detention of recalcitrant tuberculosis patients in the context of a new tuberculosis control programme in Israel.

OBJECTIVE: To analyse the use of compulsory detention in the context of a new national tuberculosis (TB) control programme launched in 1997. METHODS: A retrospective review was made of the use of compulsory detention in the management of infectious TB before and after the initiation of a new TB control programme, using data from the central TB registry in the Ministry of Health and the charts of each patient. RESULTS: Between 1994 and 2001, 13 recalcitrant patients out of 3056 (0.43%) cases of pulmonary TB were brought to trial. Eleven patients were detained. All were either hospitalized under a court order and, when failing to comply with the order, hospitalized in prison, or referred directly to a prison hospital. Twelve of 13 (92%) patients were new immigrants. After the new programme was launched, proportionately fewer patients were brought to trial [6/943 (0.64%) in 1994-1996 compared with 7/2113 (0.33%) in 1997-2001]. CONCLUSION: The reduction in the number of individuals detained could be viewed as an improvement in TB control due to the new TB control programme. It remains to be shown whether these individuals, most of whom had drug-resistant strains of TB, posed a sufficient threat to public health to justify detention.

Tuberculosis control in Samara Oblast, Russia: institutional and regulatory environment.

SETTING: Tuberculosis control programme in Samara Oblast, Russia, funded in part by the government of the United Kingdom. OBJECTIVE: To identify and evaluate institutional and regulatory influences as well as incentives and disincentives that might be amenable to change in the promotion of the DOTS strategy. DESIGN: Multidisciplinary situational analysis through in-depth interviews of stakeholders and review of official federal and oblast documents. RESULTS: Interpretation of traditional notification data is complex because classification and reporting systems differ from World Health Organization principles. Regulations governing financing encourage lengthy hospitalisations and interventions, and provide few incentives to shift policy to ambulatory care. CONCLUSION: Accurate comparability of epidemiological trends and programmatic successes requires equivalent classification and reporting systems. If the DOTS strategy is to be sustainable, changes to financing systems will be needed.

Public health impact of detention of individuals with tuberculosis: systematic literature review.

As the world witnesses ever-increasing rates of tuberculosis, particularly of drug-resistant strains affecting some of society's most marginalized individuals, policy makers and legislators may again visit the statute books in order to strengthen their armamentarium of tools to protect public health. This paper assesses the evidence in support of the sanction to detain those with tuberculosis who are perceived as posing a public health threat, and shows that little research has been conducted to inform policy, probably because traditional epidemiological methods used to assess the impact of interventions are not feasible.

The law, human rights, and the detention of individuals with tuberculosis in England and Wales.

BACKGROUND: Tuberculosis poses a global public health threat, and individuals who fail to comply with treatment risk developing drug-resistant strains, which are a serious public health concern. A number of individuals who have been deemed to pose a 'serious risk of infection' to others have been detained in recent years in England and Wales under the Public Health Act 1984. With the incorporation of the European Convention on Human Rights (ECHR) into British law due to take effect shortly this paper examines the justness of Sections 37 and 38 of the Act, and asks whether the Act stands up to scrutiny under the ECHR. METHODS: A critical review, including an examination of recently opened relevant files at the Public Record Office, was carried out on Sections 37 and 38 of the Public Health Act 1984. RESULTS: Sections 37 and 38 of the Public Health Act 1984 fail to provide sufficient safeguards from abuse and fall short of the requirements of the ECHR. CONCLUSIONS: Sections 37 and 38 should be replaced. Greater safeguards to protect the rights of those with infectious diseases are needed.