A comparison of the yield and relative cost of active tuberculosis case-finding algorithms in Zimbabwe.

SETTING: Ten districts and three cities in Zimbabwe. OBJECTIVE: To compare the yield and relative cost of identifying a case of tuberculosis (TB) using the three WHO-recommended algorithms (WHO2b, symptom inquiry only; WHO2d, chest X-ray [CXR] after a positive symptom inquiry; WHO3b, CXR only) and the Zimbabwe active case finding (ZimACF) algorithm (symptom inquiry plus CXR) to everyone. DESIGN: Cross-sectional study using data from the ZimACF project. RESULTS: A total of 38 574 people were screened from April to December 2017; 488 (1.3%) were diagnosed with TB using the ZimACF algorithm. Fewer TB cases would have been diagnosed with the WHO-recommended algorithms. This ranged from 7% fewer (34 cases) with WHO3b, 18% fewer (88 cases) with WHO2b and 25% fewer (122 cases) with WHO2d. The need for CXR ranged from 36% (WHO2d) to 100% (WHO3b). The need for bacteriological confirmation ranged from 7% (WHO2d) to 40% (ZimACF). The relative cost per case of TB diagnosed ranged from US$180 with WHO3b to US$565 for the ZimACF algorithm. CONCLUSION: The ZimACF algorithm had the highest case yield, but at a much higher cost per case than the WHO algorithms. It is possible to switch to algorithm WHO3b, but the trade-off between cost and yield needs to be reviewed by the Zimbabwean National TB Programme.

Feasibility and yield of screening for diabetes mellitus among tuberculosis patients in Harare, Zimbabwe.

SETTING: A resource-limited urban setting in Zimbabwe with a high burden of tuberculosis (TB) and human immunodeficiency virus (HIV). OBJECTIVES: To determine the feasibility and yield of diabetes mellitus (DM) screening among TB patients in primary health care facilities. DESIGN: A descriptive study. RESULTS: Of the 1617 TB patients registered at 10 pilot facilities, close to two thirds (60%) were male and 798 (49%) were bacteriologically confirmed. The median age was 37 years; two thirds (67%) were co-infected with HIV. A total of 1305 (89%) were screened for DM, and 111 (8.5%, 95% CI 7.0-10.2) were newly diagnosed with DM. Low TB notifying sites were more likely than high TB notifying sites to screen patients using random blood glucose (RBG) (83% vs. 79%; P < 0.04). Screening increased gradually per quarter over the study period. There were, however, notable losses along the screening cascade, the reasons for which will need to be explored in future studies. CONCLUSION: The study findings indicate the feasibility of DM screening among TB patients, with considerable yield of persons newly diagnosed with DM. Scaling up of this intervention will need to address the observed losses along the screening cascade.

Local staff making sense of their tuberculosis data: key to quality care and ending tuberculosis.

The End TB Strategy's ambitious targets require universal health coverage, new tools and better data to monitor progress. To assess the feasibility of a novel approach, whereby facility and district staff analyse and use their tuberculosis (TB) data to strengthen the quality of patient care and data. This approach was piloted in Zimbabwe, and performance before and during the study were compared. Key indicators were defined for presumptive TB, TB disease, drug-resistant TB, TB and human immunodeficiency virus (HIV) co-infection, treatment outcomes, directly observed treatment and drug management. Staff validated, tabulated and analysed data quarterly to identify challenges and agree on action points at 'data-driven' supervision and performance review meetings. In the district that fully implemented the new approach, there was a significant increase in the identification of presumptive TB (63% vs. 30% in the rest of the province; P < 0.00001) and new smear-positive TB cases (87% vs. a decrease in the rest of the province; P < 0.0001), and a decline in the rate of pulmonary TB cases without diagnostic smear results (77% vs. 20% in the rest of the province; P = 0.037). The present study suggests that this approach led to an improvement in the quality of patient care and data, stimulated local staff to set priorities and increased 'ownership'. This approach can significantly help attain national TB goals and strengthen health systems. .

Challenges and opportunities to prevent tuberculosis in people living with HIV in low-income countries.

People living with the human immunodeficiency virus (HIV) (PLHIV) are at high risk for tuberculosis (TB), and TB is a major cause of death in PLHIV. Preventing TB in PLHIV is therefore a key priority. Early initiation of antiretroviral therapy (ART) in asymptomatic PLHIV has a potent TB preventive effect, with even more benefits in those with advanced immunodeficiency. Applying the most recent World Health Organization recommendations that all PLHIV initiate ART regardless of clinical stage or CD4 cell count could provide a considerable TB preventive benefit at the population level in high HIV prevalence settings. Preventive therapy can treat tuberculous infection and prevent new infections during the course of treatment. It is now established that isoniazid preventive therapy (IPT) combined with ART among PLHIV significantly reduces the risk of TB and mortality compared with ART alone, and therefore has huge potential benefits for millions of sufferers. However, despite the evidence, this intervention is not implemented in most low-income countries with high burdens of HIV-associated TB. HIV and TB programme commitment, integration of services, appropriate screening procedures for excluding active TB, reliable drug supplies, patient-centred support to ensure adherence and well-organised follow-up and monitoring that includes drug safety are needed for successful implementation of IPT, and these features would also be needed for future shorter preventive regimens. A holistic approach to TB prevention in PLHIV should also include other important preventive measures, such as the detection and treatment of active TB, particularly among contacts of PLHIV, and control measures for tuberculous infection in health facilities, the homes of index patients and congregate settings.

Age-stratified tuberculosis treatment outcomes in Zimbabwe: are we paying attention to the most vulnerable?

Setting: A high tuberculosis (TB) incidence, resource-limited urban setting in Zimbabwe. Objectives: To compare treatment outcomes among people initiated on first-line anti-tuberculosis treatment in relation to age and other explanatory factors. Design: This was a retrospective record review of routine programme data. Results: Of 2209 patients included in the study, 133 (6%) were children (aged <10 years), 132 (6%) adolescents (10-19 years), 1782 (81%) adults (20-59 years) and 162 (7%) were aged ⩾60 years, defined as elderly. The highest proportion of smear-negative pulmonary TB cases was among the elderly (40%). Unfavourable outcomes, mainly deaths, increased proportionately with age, and were highest among the elderly (adjusted relative risk 3.8, 95%CI 1.3-10.7). Having previous TB, being human immunodeficiency virus positive and not on antiretroviral treatment or cotrimoxazole preventive therapy were associated with an increased risk of unfavourable outcomes. Conclusion: The elderly had the worst outcomes among all the age groups. This may be related to immunosuppressant comorbidities or other age-related diseases mis-classified as TB, as a significant proportion were smear-negative. Older persons need better adapted TB management and more sensitive diagnostic tools, such as Xpert® MTB/RIF.

Contexte : Une zone urbaine aux ressources limitées avec une incidence élevée de tuberculose (TB) au Zimbabwe.Objectifs : Comparer les résultats du traitement parmi des patients mis sous traitement antituberculeux de première ligne, en relation avec leur âge et d'autres facteurs explicatifs.Schéma : Une revue rétrospective de dossiers de données de routine du programme.Résultats : Sur les 2209 patients inclus dans l'étude, 133 (6%) ont été des enfants (âgés de <10 ans), 132 (6%) des adolescents (10­19 ans), 1782 (81%) des adultes (20­59 ans) et 162 (7%) ≥60 ans, définies comme âgées. Le taux le plus élevé de cas de TB pulmonaire à frottis négatif a concerné les personnes âgées (40%). Les résultats défavorables, en particulier le décès, ont augmenté proportionnellement à l'âge et ont donc été les plus élevés parmi les personnes âgées (risque relatif ajusté 3,8 ; IC95% 1,3­10,7). Avoir des antécédents de TB, être positif pour le virus de l'immunodéficience humaine et ne pas être sous traitement antirétroviral ni sous traitement préventif par cotrimoxazole ont été associés avec un risque accru de résultat défavorable.Conclusion : Les personnes âgées ont eu de plus mauvais résultats que tous les autres groupes d'âge. Ceci peut être lié aux comorbidités immunosuppressives ou à d'autres pathologies liées à l'âge, classées à tort comme TB, puisqu'une proportion significative a eu un frottis négatif. Les personnes plus âgées ont besoin d'une prise en charge de la TB mieux adaptée et d'outils diagnostiques plus sensibles, comme l'Xpert® MTB/RIF.

Marco de referencia: Un entorno urbano con alta incidencia de tuberculosis (TB) y recursos limitados en Zimbabwe.Objetivos: Comparar los desenlaces terapéuticos de las personas que habían iniciado el tratamiento antituberculoso de primera línea, según la edad y otras variables explicativas.Métod: Un estudio retrospectivo con análisis de los datos corrientes del registro del programa.Resultados: De los 2209 pacientes incluidos en el estudio, 133 eran niños (6%, <10 años de edad), 132 adolescentes (10­19 años, 6%), 1782 adultos (20­59 años, 81%) y 162 eran personas de ≥60 años (7%), definidas como ancianas. La más alta proporción de casos de TB pulmonar con baciloscopia negativa se observó en el grupo de ancianos (40%). Los desenlaces desfavorables, en la mayoría de los casos por muerte, aumentaron de manera proporcional con la edad y fueron más frecuentes en los ancianos (riesgo relativo ajustado 3,8; IC95% 1,3­10,7). Los factores asociados con un mayor riesgo de alcanzar desenlaces desfavorables fueron el antecedente de TB, la positividad frente al virus de la inmunodeficiencia humana y el hecho de no recibir tratamiento antirretrovírico ni tratamiento preventivo con cotrimoxazol.Conclusión: Los pacientes ancianos presentaron los desenlaces más desfavorables en comparación con los demás grupos etarios. Esto se podría explicar por las enfermedades concomitantes que provocan inmunodepresión u otras enfermedades asociadas con la edad, designadas de manera errada como TB, pues en una proporción considerable la baciloscopia fue negativa en este grupo. Las personas ancianas necesitan un tratamiento antituberculoso mejor adaptado e instrumentos diagnósticos más sensibles, como la prueba Xpert® MTB/RIF.

Diagnosis and treatment of TB patients with rifampicin resistance detected using Xpert(®) MTB/RIF in Zimbabwe.

SETTING: In Zimbabwe, there are concerns about the management of tuberculosis (TB) patients with rifampicin (RMP) resistance diagnosed using Xpert(®) MTB/RIF. OBJECTIVE: To assess linkages between diagnosis and treatment for these patients in Harare and Manicaland provinces in 2014. DESIGN: A retrospective cohort study. RESULTS: Of 20 329 Xpert assays conducted, 90% were successful, 11% detected Mycobacterium tuberculosis and 4.5% showed RMP resistance. Of 77 patients with RMP-resistant TB diagnosed by Xpert, 70% had samples sent to the reference laboratory for culture and drug susceptibility testing (CDST); 53% of the samples arrived. In 21% the samples showed M. tuberculosis growth, and in 17% the DST results were recorded, all of which confirmed RMP resistance. Of the 77 patients, 34 (44%) never started treatment for multidrug-resistant (MDR) TB, with documented reasons being death, loss to follow-up and incorrect treatment. Of the 43 patients who started MDR-TB treatment, 12 (71%) in Harare and 17 (65%) in Manicaland started within 2 weeks of diagnosis. CONCLUSION: Xpert has been rolled out successfully in two Zimbabwe provinces. However, the process of confirming CDST for Xpert-diagnosed RMP-resistant TB works poorly, and many patients are either delayed or never initiate MDR-TB treatment. These shortfalls must be addressed at the programmatic level.

Contexte : Au Zimbabwe, la prise en charge des patients tuberculeux ayant une résistance à la rifampicine (RMP) diagnostiqués par Xpert® MTB/RIF est préoccupante.Objectif : Evaluer les liens entre le diagnostic et le traitement de ces patients dans les provinces de Harare et de Manicaland en 2014.Schéma : Etude rétrospective de cohorte.Résultats : Sur 20 329 tests Xpert, 90% ont été réussis, 11% ont détecté Mycobacterium tuberculosis et 4,5% ont mis en évidence une résistance à la RMP. Il y a eu 77 patients atteints d'une tuberculose (TB) résistante à la RMP diagnostiqués par Xpert. Parmi eux, 70% ont bénéficié d'un envoi d'échantillon au laboratoire de référence pour une culture et un test de pharmacosensibilité (CDST) ; pour 53% d'entre eux, les échantillons sont arrivés à bon port ; pour 21%, les échantillons ont mis en évidence une croissance de M. tuberculosis ; et chez 17%, les résultats du CDST ont été enregistrés et tous ont confirmé la résistance à la RMP. Sur 77 patients, 34 (44%) n'ont jamais mis en route un traitement pour le TB multirésistante (TB-MDR) ; les motifs documentés étaient le décès, la perte de vue ou un traitement incorrect. Des 43 patients qui ont débuté le traitement de TB-MDR, 12 (71%) à Harare et 17 (65%) au Manicaland ont commencé dans les 2 semaines suivant le diagnostic.Conclusion : L'Xpert a été lancé avec succès dans deux provinces du Zimbabwe. Cependant, le processus de confirmation du CDST pour une TB résistante à la RMP diagnostiquée par Xpert ne fonctionne pas bien, et de nombreux patients sont soit traités avec retard, soit ne démarrent jamais le traitement de TB-MDR. Ces problèmes doivent être examinés par le programme.

Marco de referencia: En Zimbabwe, el tratamiento de los pacientes cuyo diagnóstico de tuberculosis (TB) resistante a la rifampicina (RMP) se determina mediante la prueba Xpert® MTB/RIF es fuente de inquietud.Objetivo: Evaluar los nexos entre el diagnóstico y el tratamiento de los pacientes diagnosticados mediante la prueba Xpert en las provincias de Harare y Manicaland en el 2014.Método: Fue este un estudio retrospectivo de cohortes.Resultados: Se obtuvieron resultados satisfactorios en el 90% de las 20 329 pruebas Xpert realizadas; se detectó Mycobacterium tuberculosis en el 11% y el 4,5% reveló resistencia a RMP. Con la prueba Xpert se diagnosticaron 77 casos de TB resistente a RMP y se enviaron muestras del 70% de estos casos al laboratorio de referencia, con el fin de practicar el cultivo y las pruebas se sensibilidad (CDST) a los medicamentos antituberculosos. El 53% de estas muestras llegaron al laboratorio, en un 21% se obtuvo crecimiento de M. tuberculosis y en el 17% de los casos existía un registro de los resultados de la CDST; todos los resultados confirmaron la resistencia a RMP. De los 77 pacientes, 34 nunca comenzaron el tratamiento contra la TB multidrogorresistente (TB-MDR) (44%); las causas documentadas fueron el fallecimiento, la pérdida durante el seguimiento y un tratamiento inadecuado. De los 43 pacientes que iniciaron el tratamiento por TB-MDR, 12 casos en Harare (71%) y 17 casos en Manicaland (65%) lo comenzaron en las 2 primeras semanas después del diagnóstico.Conclusión: El despliegue de la prueba Xpert en dos provincias de Zimbabwe fue satisfactorio. Sin embargo, el mecanismo de confirmación de la resistencia a RMP mediante el CDST en los casos diagnosticados por la prueba Xpert fue deficiente y en muchos pacientes se retrasó el tratamiento de la TB-MDR o nunca se comenzó. Es preciso abordar estas deficiencias en el marco programático.

Treatment outcomes of patients on antiretrovirals after six months of treatment, Khami Clinic, Bulawayo, Zimbabwe.

OBJECTIVE: To describe treatment outcomes of patients on anti-retrovirals at six months of treatment. STUDY DESIGN: We conducted pre-intervention post intervention surveys using a pretest-post test design. SETTING: Khami Municipal Clinic, Bulawayo. SUBJECTS: We interviewed consecutive patients eligible to receive antiretroviral drugs (ARVs). All patients had a history of TB treatment and a CD4 count less than 200 cells/mm. MAIN OUTCOME MEASURES: Mean change in CD4 count, weight, body mass index, and Karnofsky performance measured before and at six months ofantiretroviral treatment. RESULTS: 72 subjects were interviewed at baseline, their median age was 38 years (Q1, 32 years, Q3, 43 years). Of these, 17 (24%) died before six months of treatment. Three (4%) defaulted treatment follow up. A total of 52 respondents were alive and interviewed at six months though only 50, had repeat CD4 counts at six months. Among the 50 survivors, the mean CD4 count at six months was significantly higher than at baseline (p = 0.0003). There was a 4.2 point statistical significant increase in the mean weight from baseline (p = 0.0005). Similarly, the mean Body Mass Index (BMI) significantly increased by 1.5 kg/m2 from baseline, (p = 0.001). The mean Karnofsky performance increased from 89% at baseline to 95% at six months (p = 0004). The researchers noted that patients on TB treatment were being deferred antiretroviral therapy until they completed TB treatment. CONCLUSION: The Khami project bears testimony that even in a resource poor setting; treatment of HIV/AIDS with antiretroviral drugs is feasible. We recommend early treatment initiation for those on TB treatment in line with national guidelines.