Threats and Interventions During the Treatment of Tuberculosis in an Inner-city District / Factores de riesgo e intervenciones durante el tratamiento de la tuberculosis en un barrio marginal

Background: Since there are active drugs against tuberculosis (TB), the most effective control measures are to assure treatment adherence and to perform contact tracing. Given the long treatment duration and characteristics of some TB patients, threats that put at risk treatment adherence may appear. Identify and address them is essential to achieve the objectives of disease control.Objectives: To identify the epidemiological characteristics of TB patients and the incidents and threats occurring during treatment, to describe the interventions performed to enhance treatment adherence and to determine if there are differences among native and foreign-born patients in the TB clinical unit of a referral hospital in the inner city of Barcelona.Methods: A descriptive, observational, cross-sectional study was performed. We recorded information on sociodemographic and clinical characteristics, incidents and interventions during treatment in all patients with TB diagnosed between September 2013 and August 2016.Results: 172 patients were included, 62.2% were foreign-born. The most common incidents and threats were medication-related complications (43.0%), missed follow-up visits (34.3%), communication problems (25.6%), comorbidities complications (23.8%), trips (19.2%), fear of social rejection (16.9%) and change of address (14.5%). The adherence-promoting interventions were: follow-up calls, directly observed treatment, medical and humanitarian reports, extra visits and cultural mediation. Incidents and interventions were more frequent in foreign-born patients, however there were no differences in treatment success among Spanish and foreign-born. (AU)

Antecedentes: Dado que existen medicamentos activos contra la tuberculosis (TB), las medidas de control más efectivas son asegurar la adherencia al tratamiento y realizar un seguimiento cercano. Debido a la larga duración del tratamiento y las características de algunos pacientes con TB, pueden entrar en juego ciertos factores que hacen peligrar la adherencia al tratamiento. Identificar estos factores y abordarlos es esencial para lograr los objetivos de control de la enfermedad.Objetivos: Identificar las características epidemiológicas de los pacientes con TB y los incidentes y factores que tienen lugar durante el tratamiento, describir las intervenciones realizadas para mejorar la adherencia al tratamiento y determinar si existen diferencias entre los pacientes nativos y extranjeros en la Unidad Clínica de TB de un hospital de referencia en el centro de la ciudad de Barcelona.Métodos: Se realizó un estudio descriptivo, observacional y transversal. Registramos las características sociodemográficas y clínicas de todos los pacientes con TB diagnosticados entre septiembre de 2013 y agosto de 2016, así como los incidentes y las intervenciones realizadas durante el tratamiento.Resultados: Se incluyeron 172 pacientes, el 62,2% eran nacidos en el extranjero. Los incidentes y los factores de riesgo más comunes fueron: complicaciones relacionadas con la medicación (43,0%), visitas de seguimiento perdidas (34,3%), problemas de comunicación (25,6%), complicaciones de las comorbilidades (23,8%), viajes (19,2%), miedo al rechazo social (16,9%) y cambio de domicilio (14,5%). Las intervenciones para el fomento de la adherencia fueron: llamadas de seguimiento, tratamiento directamente observado, informes médicos y humanitarios, visitas adicionales y mediación cultural. Los incidentes e intervenciones fueron más frecuentes en pacientes nacidos en el extranjero; sin embargo, no hubo diferencias en el éxito del tratamiento entre españoles y nacidos en el extranjero. (AU)

Threats and Interventions During the Treatment of Tuberculosis in an Inner-city District.

BACKGROUND: Since there are active drugs against tuberculosis (TB), the most effective control measures are to assure treatment adherence and to perform contact tracing. Given the long treatment duration and characteristics of some TB patients, threats that put at risk treatment adherence may appear. Identify and address them is essential to achieve the objectives of disease control. OBJECTIVES: To identify the epidemiological characteristics of TB patients and the incidents and threats occurring during treatment, to describe the interventions performed to enhance treatment adherence and to determine if there are differences among native and foreign-born patients in the TB clinical unit of a referral hospital in the inner city of Barcelona. METHODS: A descriptive, observational, cross-sectional study was performed. We recorded information on sociodemographic and clinical characteristics, incidents and interventions during treatment in all patients with TB diagnosed between September 2013 and August 2016. RESULTS: 172 patients were included, 62.2% were foreign-born. The most common incidents and threats were medication-related complications (43.0%), missed follow-up visits (34.3%), communication problems (25.6%), comorbidities complications (23.8%), trips (19.2%), fear of social rejection (16.9%) and change of address (14.5%). The adherence-promoting interventions were: follow-up calls, directly observed treatment, medical and humanitarian reports, extra visits and cultural mediation. Incidents and interventions were more frequent in foreign-born patients, however there were no differences in treatment success among Spanish and foreign-born. CONCLUSION: In this inner city several incidents occurred during TB treatment that can threaten adherence and are more common among foreign-born patients. Coordination among professionals from different healthcare settings was able to overcome obstacles in most cases and achieve TB treatment completion.

Correction: Epidemiology of Tuberculosis in Immigrants in a Large City with Large-Scale Immigration (1991-2013).

[This corrects the article DOI: 10.1371/journal.pone.0164736.].

Epidemiology of Tuberculosis in Immigrants in a Large City with Large-Scale Immigration (1991-2013).

BACKGROUND: The increase in immigration in Barcelona between 2000 and 2008 forced a reorganization of the control of tuberculosis (TB). TB clinical units (TBCU) were created and community health workers (CHW) were gradually included. OBJECTIVE: To understand trends in the incidence of TB among immigrants, their main characteristics and treatment compliance during the period 1991-2013. DESIGN: We conducted a cross-sectional population-based study of cases detected among immigrants by the Tuberculosis Program in Barcelona, Spain. Sociodemographic, clinical characteristics and risk factors were described. The annual incidence was calculated for various periods and geographical areas of origin. In the linear trend analysis, a p-value of <0.05 was considered statistically significant. RESULTS: We detected 3,284 cases. Incidence decreased from 144.8/100,000 inhabitants in 1991 to 53.4/100,000 in 2013. Individuals born in Pakistan-India-Bangladesh had the highest average annual incidence (675/100,000). In all, 2,156 cases (65.7%) were male. 2,272 (69.2%) had pulmonary TB, of which 48.2% were smear-positive. 33% of the cases (1,093) lived in the inner city. Contact tracing (CT) coverage in smear-positive individuals rose from 56.8% in 1991-1999 to 81.4% in 2000-2013 (p<0.01); this value was less than 50% in people from Africa and Eastern European countries. The case fatality rate was 3.6% overall and 9.8% among those born in high-income countries (p<0.01). The highest rate of treatment default (12.8%) was observed among cases from the Maghreb. The rate of successful treatment increased from 69.9% in 1991-1999 to 87.5% in 2000-2013 (p<0.01). CONCLUSION: The incidence of TB in immigrants is decreasing in Barcelona. Organizational actions, such as incorporating CHWs and TBCUs, have been decisive for the observed improvements.

Restricting Access to Health Care to Immigrants in Barcelona: A Mixed-Methods Study With Immigrants Who Have Experienced an Infectious Disease.

Austerity policies implemented in Spain in response to the ongoing economic crisis may have detrimental consequences for the health of immigrant populations and for public health in general. A mixed-methods study by the Public Health Agency of Barcelona and the University of Michigan indicates that the Real Decreto-ley 16/2012 (RDL) threatens the health of individuals and the population, especially in the case of infectious diseases. The study sought to determine the percentage of foreign-born persons with an infectious disease who had an Individual Health Card (IHC) prior to the RDL and to determine whether foreign-born persons with an infectious disease in Barcelona encountered problems accessing health care after the RDL. Results indicate that immigrants used the IHC to seek medical attention for infectious diseases and chronic conditions. Results also show that 66% of respondents, including 54% of unemployed respondents, 3% of respondents working without contracts, and those in informal employment (9%), may be at risk of losing at least part of their health coverage. Universal health care access in Spain has been crucial for the control of communicable diseases among immigrant populations. Reducing access to a significant percentage of the total population may have deleterious effects on public health.