Evaluation of a short training course of chest X-ray interpretation for the diagnosis of paediatric TB.

BACKGROUND: Chest X-ray (CXR) interpretation is challenging for the diagnosis of paediatric TB. We assessed the performance of a three half-day CXR training module for healthcare workers (HCWs) at low healthcare levels in six high TB incidence countries. METHODS: Within the TB-Speed Decentralization Study, we developed a three half-day training course to identify normal CXR, CXR of good quality and identify six TB-suggestive features. We performed a pre-post training assessment on a pre-defined set of 20 CXR readings. We compared the proportion of correctly interpreted CXRs and the median reading score before and after the training using the McNemar test and a linear mixed model. RESULTS: Of 191 HCWs, 43 (23%) were physicians, 103 (54%) nurses, 18 (9.4%) radiology technicians and 12 (6.3%) other professionals. Of 2,840 CXRs with both assessment, respectively 1,843 (64.9%) and 2,277 (80.2%) were correctly interpreted during pre-training and post-training (P < 0.001). The median reading score improved significantly from 13/20 to 16/20 after the training, after adjusting by country, facility and profession (adjusted ß = 3.31, 95% CI 2.44-4.47). CONCLUSION: Despite some limitations of the course assessment that did not include abnormal non-TB suggestive CXR, study findings suggest that a short CXR training course could improve HCWs' interpretation skills in diagnosing paediatric TB.

CONTEXTE: L'interprétation de la radiographie thoracique (CXR) est un défi pour le diagnostic de la TB pédiatrique. Nous avons évalué la performance d'un module de formation de trois demi-journées sur la CXR destiné aux agents de santé (HCWs) dans six pays où l'incidence de la TB est élevée et où les ressources en services de santé sont limitées. MÉTHODES: Dans le cadre de l'étude de décentralisation TB-Speed, nous avons mis au point un cours de formation de trois demi-journées pour identifier une CXR normale, une CXR de bonne qualité et six caractéristiques suggestives de la TB. Nous avons effectué une évaluation avant et après la formation sur un ensemble prédéfini de 20 clichés radiologiques. Nous avons comparé la proportion de CXR correctement interprétées et le score médian de lecture avant et après la formation à l'aide du test de McNemar et d'un modèle linéaire mixte. RÉSULTATS: Sur les 191 HCWs, 43 (23%) étaient des médecins, 103 (54%) des infirmières, 18 (9,4%) des techniciens en radiologie et 12 (6,3%) d'autres professionnels. Sur 2 840 CXR avec les deux évaluations, respectivement 1 843 (64,9%) et 2 277 (80,2%) ont été correctement interprétées avant et après la formation (P < 0,001). Le score médian de lecture s'est amélioré de manière significative, passant de 13/20 à 16/20 après la formation, après ajustement par pays, établissement et profession (ß ajusté = 3,31; IC 95% 2,44­4,47). CONCLUSION: Malgré certaines limites de l'évaluation du cours qui n'incluait pas de CXR anormale non évocatrice de TB, les résultats de l'étude suggèrent qu'une formation courte sur la CXR pourrait améliorer les compétences d'interprétation des HCWs dans le diagnostic de la TB pédiatrique.

Using community health workers for facility and community based TB case finding: An evaluation in central Mozambique.

BACKGROUND: Mozambique has one of the highest incidence rates of both TB and HIV in the world and an estimated tuberculosis (TB) treatment coverage of only 57% in 2018. Numerous approaches are being tested to reduce existing gaps in coverage and the estimated number of missing cases. METHODS: Thirty Community Healthcare Workers (CHWs) were tasked with increasing TB notifications by performing verbal facility-based TB screening of all people presenting for care and TB contact tracing in the community. Using routine National TB Program data, we analyzed trends in TB notifications in five intervention districts and seven control districts in Manica province the year before this project and during a one-year intervention period. RESULTS: In the four quarters before the study, the intervention districts notified 5,219 individuals with all forms of TB, and the control districts notified 2,248 TB cases. During the study 5,982 all forms of people with TB were notified in the intervention area, an increase of 763 (14.6%) over the baseline, whereas the control districts notified 1,877 persons with TB, a decrease of -371 (-16.5%). The CHW screening activities yielded 1,502 notified and treated individuals with TB. CONCLUSIONS: Employing CHWs to promote facility-based TB screening and household contact tracing may lead to an overall increase in TB notification.

Rapid TB diagnostic service and community action to FIND.TREAT.ALL#EndTB, Maputo, Mozambique, 2013-2018.

Finding and treating all tuberculosis (TB) patients is crucial for ending TB. We investigated whether rapid diagnostic turnaround time (TAT) and patient tracking could increase TB treatment initiation in Maputo, Mozambique. Among 3329 TB patients newly diagnosed by the University Eduardo Mondlane-Anti-Persoonsmijnen Ontmijnende Product Ontwikkeling/Anti-Personnel Landmines Detection Product Development (APOPO) Laboratory between 2013 and 2018, on average 61% were verifiably linked to care. This proportion increased from 54% (first half 2013) to 79% (second half 2018) after introducing a 24-hour TAT in 2015 and patient tracking conducted by a community-based partner, Associação Kenguelekezé, in 2017. Rapid, well-connected TB diagnostic services can reduce pre-treatment loss to follow-up and support the joint initiative of WHO, Stop TB and Global Fund to 'FIND.TREAT.ALL.#EndTB'.

Identifier et traiter tous les patients atteints de tuberculose (TB) est crucial pour mettre fin à la TB. Nous avons vérifié si un délai plus court de diagnostic (TAT) et un système de recherche des patients augmentait la mise en œuvre du traitement de la TB à Maputo, Mozambique. Parmi 3329 patients TB nouvellement diagnostiqués par le laboratoire UEM-APOPO (2013­2018), en moyenne 61% ont été réellement connectés à la prise en charge. Le pourcentage a augmenté de 54% (première moitié de 2013) à 79% (deuxième moitié de 2018) après l'introduction du TAT en 24h en 2015 et la surveillance des patients effectuée par notre partenaire l'association à base communautaire Kenguelekezé en 2017. Notre expérience suggère que des services de diagnostic de TB rapides, bien connectés peuvent réduire les abandons avant le traitement et soutenir les tentatives mondiales « FIND.TREAT.ALL.#EndTB ¼.

La búsqueda y el tratamiento de todos los pacientes con tuberculosis (TB) son primordiales para poner fin a esta enfermedad. Se investigó si con un lapso corto de obtención del diagnóstico y el seguimiento de los pacientes aumentaría el inicio del tratamiento antituberculoso en Maputo, Mozambique. En promedio, en 61% de los 3329 casos nuevos de TB diagnosticados en el laboratorio UEM-APOPO (2013­2018) se confirmó la vinculación de los pacientes con los servicios de atención. El porcentaje aumentó de 54% (primer semestre del 2013) a 79% (segundo semestre del 2018), después de haber introducido un plazo de obtención del diagnóstico de 24 horas en el 2015 y la localización de los pacientes por parte de la asociación comunitaria Kenguelekezé en el 2017. Esta experiencia indica que los servicios diagnósticos de la TB que son rápidos y mantienen vínculos adecuados disminuyen la pérdida durante el seguimiento antes de comenzar el tratamiento y fortalecen los esfuerzos de la iniciativa 'FIND.TREAT.ALL.#EndTB'.

Effects of Xpert® MTB/RIF testing and GxAlert on MDR-TB diagnosis and linkage to care in Mozambique.

SETTING: The diagnosis of multidrug-resistant tuberculosis (MDR-TB) and gaps in linkage to care are the principal health challenges in Mozambique. Five GeneXpert machines and GxAlert, an eHealth platform, were installed in Sofala and Manica Provinces between 2012 and 2014. OBJECTIVE: To test the effects of Xpert® MTB/RIF testing and GxAlert on rifampin-resistant TB (RR-TB) diagnosis and second-line treatment initiation rates. DESIGN: We conducted a retrospective clinical review of patients with RR-TB from March 2012 to September 2015 at these five sites. Time-series analyses were conducted to investigate the impact of Xpert on case detection and treatment. Pre- and post- analyses were conducted to investigate the impact of GxAlert. RESULTS: A total of 32 182 Xpert tests were conducted: 4010 (12.5%) detected TB without rifampin resistance, and 306 (7.1%) had RR-TB. Of the RR-TB cases, 161 (52.6%) were started on MDR-TB treatment, 6.9% had documented culture results, and time from diagnosis to treatment initiation decreased over time. The absolute number of patients diagnosed and started on MDR-TB treatment increased by 0.26 (95%CI 0.15-0.38, P < 0.001) and 0.16 (95%CI 0.089-0.24, P < 0.001) every 6 months. GxAlert did not affect treatment initiation rates. CONCLUSION: Implementation of Xpert testing was associated with increases in the number of patients diagnosed and started on MDR-TB treatment.

Remote monitoring of Xpert® MTB/RIF testing in Mozambique: results of programmatic implementation of GxAlert.

SETTING: Electronic diagnostic tests, such as the Xpert® MTB/RIF assay, are being implemented in low- and middle-income countries (LMICs). However, timely information from these tests available via remote monitoring is underutilized. The failure to transmit real-time, actionable data to key individuals such as clinicians, patients, and national monitoring and evaluation teams may negatively impact patient care. OBJECTIVE: To describe recently developed applications that allow for real-time, remote monitoring of Xpert results, and initial implementation of one of these products in central Mozambique. DESIGN: In partnership with the Mozambican National Tuberculosis Program, we compared three different remote monitoring tools for Xpert and selected one, GxAlert, to pilot and evaluate at five public health centers in Mozambique. RESULTS: GxAlert software was successfully installed on all five Xpert computers, and test results are now uploaded daily via a USB internet modem to a secure online database. A password-protected web-based interface allows real-time analysis of test results, and 1200 positive tests for tuberculosis generated 8000 SMS result notifications to key individuals. CONCLUSION: Remote monitoring of diagnostic platforms is feasible in LMICs. While promising, this effort needs to address issues around patient data ownership, confidentiality, interoperability, unique patient identifiers, and data security.