Contact tracing for tuberculosis, Thailand.

PROBLEM: Despite implementation of universal health coverage in Thailand, gaps remain in the system for screening contacts of tuberculosis patients. APPROACH: We designed broader criteria for contact investigation and new screening practices and assessed the approach in a programme-based operational research study in 2017-2018. Clinic staff interviewed 100 index patients and asked them to give household and non-household contacts an invitation for a free screening and chest X-ray. Contact persons who attended received 250 Thai baht (about 8 United States dollars) allowance for transport. LOCAL SETTING: Chiang Rai province, Thailand, has high rates of tuberculosis notification and a high number of people living in poverty. The coverage of contact investigation in under 5-year-olds was only 33.2% (222 screened out of 668 contacts) over 2011-2015. RELEVANT CHANGES: Index patients identified 440 contacts in total and gave invitation cards to 227 of them. The contact investigation coverage was 81.1% (184/227) and tuberculosis detection among contacts screened was 6.0% (11/184). Of the 11 contacts with active tuberculosis, three did not have tuberculosis symptoms, three were non-household contacts and three were contacts of non-smear-positive tuberculosis patients. The contact investigation coverage of the contacts younger than 5 years was 100% (14/14) and the yield of tuberculosis detection in this age group was 21.4% (3/14). LESSONS LEARNT: High coverage of contact investigation with a high yield of tuberculosis detection among contacts can be achieved by applying broader criteria for contact investigation and providing financial support for transportation.

Characteristics and treatment outcomes of tuberculosis cases by risk groups, Japan, 2007-2010.

INTRODUCTION: We studied the characteristics and treatment outcomes of the following risk groups for tuberculosis (TB): those with HIV and diabetes mellitus (DM), contact cases, the homeless, foreigners, health care workers (HCW) and the elderly. METHOD: A descriptive cross-sectional study was conducted by analysing the Japanese tuberculosis surveillance data of all cases registered between 2007 and 2010 (n = 96 689). RESULTS: The annual proportion of TB cases by risk group was stable over the study period, although there was a slight but significant increase observed for foreigners and elderly cases. Homeless and elderly TB cases had the highest DM co-morbidity (16.6% and 15.3%). HIV co-infection was low in all TB cases (0.2%) yet highest in foreigners (1.3%). HIV status of 45% of TB cases was unknown. The proportion of multi drug resistant (MDR) TB was similar among all risk groups (0.0-0.9%) except foreigners, at 3.4%. Males in most risk groups had higher mortality than females; the mortality of all TB cases in all age groups for both males and females were 3.6-24 times higher than the general population. DISCUSSION: Reasons for the high proportion of "HIV status unknown" should be investigated and improved. Contact tracing among foreign cases with MDR-TB should be a priority. Homeless persons should be screened for DM together with TB. Programs to enhance health and nutrition status may benefit tuberculosis prevention among the elderly. Tuberculosis screening and TB education are important for HCW.

Engaging women volunteers of high socioeconomic status in supporting socioeconomically disadvantaged tuberculosis patients in Chiang Rai, Thailand.

PROBLEM: The 2008 tuberculosis (TB) surveillance of Chiang Rai Hospital, Chiang Rai, Thailand reported that 8.4% of Thai, 22.7% of hill tribe minority and 25% of migrant patients (n = 736) defaulted from treatment. CONTEXT: TB patient management in Chiang Rai is complicated due to poverty and HIV stigma. A previous study shows unaffordable travel expense was one of the reasons of patient default. ACTION: We engaged Chiang Rai women's organizations whose members are of high socioeconomic status to support poor TB patients financially and socially. A group of women formed a team to support these TB patients (n = 192) by raising and sustaining funds and providing home visits (n = 37). TB surveillance and patient-fund register data were used to evaluate TB treatment outcomes. OUTCOME: THE SUCCESS OF TB TREATMENT WAS SIGNIFICANTLY HIGHER FOR PATIENTS RECEIVING FINANCIAL SUPPORT (RELATIVE RISK [RR]: 1.351; 95% confidence interval [CI] 1.20-1.53; P < 0.000). Lower death rates in all groups were observed among patients receiving financial support. However, financial assistance alone did not improve treatment outcomes for migrant patients. Thirty-seven patients (25 Thai, eight hill tribe, four migrants) who were visited by women volunteers at home achieved 95% TB treatment success. DISCUSSION: It is possible to involve volunteers to support poor TB patients. Willingness to support TB patients was driven by presenting provincial TB epidemiology information, research data on the experience of poor patients and the inspiring experiences of other women volunteers. Future research should investigate the reasons for the high treatment success among patients who received home visits.

Characteristics and treatment outcomes of tuberculosis cases by risk groups, Japan, 2007-2010

Introduction: We studied the characteristics and treatment outcomes of the following risk groups for tuberculosis (TB): those with HIV and diabetes mellitus (DM), contact cases, the homeless, foreigners, health care workers (HCW) and the elderly. Method: A descriptive cross-sectional study was conducted by analysing the Japanese TB surveillance data of all cases registered between 2007 and 2010 (N = 96 689). Results: The annual proportion of TB cases by risk group was stable over the study period, although there was a slight but significant increase observed for foreigner and elderly cases. Homeless and elderly TB cases had the highest DM co-morbidity (16.6% and 15.3%), respectively. HIV co-infection was low in all TB cases (0.2%) yet highest in foreigners (1.3%). HIV status of 45% of TB cases was unknown. The proportion of multidrug-resistant TB (MDR-TB) was similar among all risk groups (0.0%–0.9%) except foreigner, at 3.4%. Males in most risk groups had higher mortality than females; the mortality of all TB cases in all age groups for both males and females was 3.6–24 times higher than the general population. Discussion: Reasons for the high proportion of “HIV status unknown” should be investigated and improved. Contact tracing among foreign cases with MDR-TB should be a priority. Homeless persons should be screened for DM together with TB. Programmes to enhance health and nutrition status may benefit TB prevention among the elderly. Tuberculosis screening and TB education are important for HCW.

Engaging women volunteers of high socioeconomic status in supporting socioeconomically disadvantaged tuberculosis patients in Chiang Rai, Thailand

Problem: The 2008 tuberculosis (TB) surveillance of Chiang Rai Hospital, Chiang Rai, Thailand reported that 8.4% of Thai, 22.7% of hill tribe minority and 25% of migrant patients (n = 736) defaulted from treatment. Context: TB patient management in Chiang Rai is complicated due to poverty and HIV stigma. A previous study shows unaffordable travel expense was one of the reasons of patient default. Action: We engaged Chiang Rai women’s organizations whose members are of high socioeconomic status to support poor TB patients financially and socially. A group of women formed a team to support these TB patients (n = 192) by raising and sustaining funds and providing home visits (n = 37). TB surveillance and patient-fund register data were used to evaluate TB treatment outcomes. Outcome: The success of TB treatment was significantly higher for patients receiving financial support (relative risk [RR]: 1.351; 95% confidence interval [CI] 1.20–1.53; P < 0.000). Lower death rates in all groups were observed among patients receiving financial support. However, financial assistance alone did not improve treatment outcomes for migrant patients. Thirty-seven patients (25 Thai, eight hill tribe, four migrants) who were visited by women volunteers at home achieved 95% TB treatment success. Discussion: It is possible to involve volunteers to support poor TB patients. Willingness to support TB patients was driven by presenting provincial TB epidemiology information, research data on the experience of poor patients and the inspiring experiences of other women volunteers. Future research should investigate the reasons for the high treatment success among patients who received home visits.

"If we have to die, we just die": challenges and opportunities for tuberculosis and HIV/AIDS prevention and care in northern Thailand.

In this study, the authors identify opportunities for and challenges in reducing the risks of tuberculosi (TB) and HIV/AIDS transmission in Thailand. They carried out more than six repeated in-depth interviews with each of 13 participants who have been newly diagnosed with TB, 7 of whom were HIV positive, and their caregivers, until the patient recovered from TB or died. They performed extensive observations during relevant private and public activities and analyzed the data using grounded theory, focusing on behaviors affecting risk of transmission. Out of strong virtue, many caregivers felt a responsibility to care for their ill loved ones, thus putting themselves at risk of transmission. For the older generation, this was unimportant, as they had already completed their life cycle ("let it be"). However, strong human bonds encouraged the patients to complete TB treatment until cured or deceased. The authors discuss strategies to build on appropriate behaviors.