The contribution of private health facilities to the urban tuberculosis program of Afghanistan.

SETTING: Although the prevalence of tuberculosis (TB) is generally higher in urban areas than in rural areas, coordination between the private and public sectors for TB control is weak. OBJECTIVE: To share experience from an urban DOTS program in five cities of Afghanistan. DESIGN: An urban DOTS project was designed in 2009 in Kabul, Afghanistan, and later expanded to Kandahar, Jalalabad, Herat, Mazari-i-Sharif, and Paul-i-Khomri cities. RESULTS: In total, 57 public health facilities and 49 private facilities provided DOTS services in the five cities from 2015 to 2018. A total of 28,542 (10.6%) adults (aged ≥15) screened were diagnosed with TB (all forms). The private sector contributed 5,618 (19.7%) of those. Positivity rates among presumptive TB cases in public facilities were 18.9%, 12.5%, 14.4%, and 4.8% in 2015, 2016, 2017, and 2018, respectively. In private facilities, positivity rates were 25.8%, 39.5%, and 27.4% in 2016, 2017, and 2018, respectively. CONCLUSION: The private sector's contribution to case detection was very high and the TB positivity rate among people screened in the private sector was high, which could be due to more selective screening rather than all health facility visitors done by public health facilities.

Trends in malaria indicators after scale-up of community-based malaria management in Afghanistan.

BACKGROUND: The Community-Based Malaria Management (CBMM) strategy, introduced in 2013 and expanded to all health facilities and health posts in Afghanistan by 2016, aimed to deliver rapid diagnostic testing and more timely treatment to all communities nationwide. In this study, trends for several malaria outcome indicators were compared before and after the expansion of the CBMM strategy, using cross-sectional analysis of surveillance data. METHODS: Generalized estimating equation (GEE) models with a Poisson distribution were used to assess trends of three key outcomes before (2012-2015) and after (2016-2019) CBMM expansion. These outcomes were annual malaria incidence rate (both all and confirmed malaria incidence), malaria death rate, and malaria test positivity rate. Additional variables assessed included annual blood examination rates (ABER) and malaria confirmation rate. RESULTS: Average malaria incidence rates decreased from 13.1 before CBMM expansion to 10.0 per 1000 persons per year after CBMM expansion (P < 0.001). The time period after CBMM was expanded witnessed a 339% increase in confirmed malaria incidence as compared to the period before (IRR 3.39, 95% CI 2.18, 5.27; P < 0.001). In the period since the expansion of CBMM (2016-2019), overall malaria incidence rate declined by 19% each year (IRR 0.81, 95% CI 0.71,0.92; P = 0.001) and the malaria death rate declined by 85% each year (IRR 0.15, 95% CI 0.12, 0.20; P < 0.001). In comparing the before period to the after period, the ABER increased from 2.3 to 3.5 per 100 person/year, the malaria test positivity rate increased from 12.2 to 20.5%, and the confirmation rate increased from 21% before to 71% after CBMM. CONCLUSIONS: Afghanistan's CBMM expansion to introduce rapid diagnostic tests and provide more timely treatment for malaria through all levels of care temporally correlates with significant improvement in multiple indicators of malaria control.

Prevalence of latent tuberculosis infection among health workers in Afghanistan: A cross-sectional study.

BACKGROUND: About 26% of the world's population may have latent tuberculosis infection (LTBI). Health care workers are a high-risk category because of their professional exposure. METHODS: This cross-sectional study assessed the LTBI burden among health care workers in Afghanistan, a high-TB-burden country. We selected health facilities using a systematic sampling technique and invited all workers at the targeted health facilities to participate. Participants were interviewed about sociodemographic and exposure variables and received tuberculin skin tests for LTBI. RESULTS: Of the 4,648 health care workers invited to participate, 3,686 had tuberculin skin tests. The prevalence of LTBI was found to be 47.2% (1,738 workers). Multivariate analysis showed that a body mass index of ≥ 30 and marriage were associated with an increased risk of LTBI. Underweight (body mass index of ≤ 18 and below) and normal body mass index had no association with increased risk of LTBI. CONCLUSION: LTBI is high among health care workers in Afghanistan. We recommend instituting infection control measures in health facilities and screening workers for timely TB diagnosis.