Correction: Translating drug resistant tuberculosis treatment guidelines to reality in war-torn Kandahar, Afghanistan: A retrospective cohort study.

[This corrects the article DOI: 10.1371/journal.pone.0237787.].

Contents of antenatal care services in Afghanistan: findings from the national health survey 2018.

BACKGROUND: Maternal and newborn mortality is a public health concern in low- and middle-income countries (LMICs), including Afghanistan, where the evolving socio-political circumstances have added new complexities to healthcare service delivery. Birth outcomes for both pregnant women and their newborns are improved if women receive benefits of quality antenatal care (ANC). OBJECTIVES: This study aimed to assess the contents of ANC services and identify predictors of utilization of services by pregnant women during ANC visits to health facilities in Afghanistan. METHODS: In this cross-sectional study, we used data from the Afghanistan Health Survey 2018 (AHS2018). We included a total of 6,627 ever-married women, aged 14-49 years, who had given birth in the past 2 years or were pregnant at the time of survey and had consulted a health worker for ANC services in a health facility. The outcome was defined as 1-4 services and 5-8 services that a pregnant woman received during an ANC visit. The services were (i) taking a pregnant woman's blood pressure, (ii) weighing her, (iii) testing her blood, (iv) testing her urine, (v) providing advice on nutrition, (vi) advising about complicated pregnancy, (vii) advising about the availability of health services, and (viii) giving her at least one dose of Tetanus Toxoid (TT) vaccine. The binary outcome (1-4 services versus 5-8 services) was used in a multivariable logistic regression model. RESULTS: Of all 6,627 women, 31.4% (2,083) received 5-8 services during ANC visits. Only 1.3% (86) received all 8 services, with 98.7% (6,541) receiving between 1 and 7 services, and 71.6% (4,745) women had their blood pressure measured during ANC visits. The likelihood (adOR = Adjusted Odds Ratio) of receiving 5-8 services was higher in women who could read and write (adOR = 1.33: 1.15-1.54), in women whose husbands could read and write (adOR = 1.14: 1.00-1.28), in primipara women (adOR = 1.42: 1.02-1.98), in women who knew one danger sign (adOR = 5.38: 4.50-6.45), those who knew 2 danger signs (adOR = 8.51: 7.12-10.19) and those who knew ≥ 3 danger signs (adOR = 13.19: 10.67-16.29) of complicated pregnancy, and in women who had almost daily access to TV (adOR = 1.16: 1.01-1.33). However, the likelihood of receiving 5-8 services was lower in women who used private clinics (adOR = 0.64: 0.55-0.74) and who received services from nurses (adOR = 0.27 (0.08-0.88). CONCLUSION: Our findings have the potential to influence the design and implementation of ANC services of health interventions to improve the delivery of services to pregnant women during ANC visits.

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.

Person-centred care and short oral treatment for rifampicin-resistant tuberculosis improve retention in care in Kandahar, Afghanistan.

OBJECTIVES: To describe the effect of adaptations to a person-centred care with short oral regimens on retention in care for rifampicin-resistant TB (RR-TB) in Kandahar province, Afghanistan. METHODS: The study included people with RR-TB registered in the programme between 01 October 2016 and 18 April 2021. From 19 November 2019, the programme implemented a trial investigating the safety and effectiveness of short oral RR-TB regimens. During the trial, person-centred care was adapted. We included the data from people living with RR-TB treated in the period before and after the care model was adapted and applied Kaplan-Meier statistics to compare rates of retention in care. RESULTS: Of 236 patients registered in the RR-TB programme, 146 (61.9%) were registered before and 90 (38.1%) after the model of care was adapted. Before adaptations enhancing person-centred care, pre-treatment attrition was 23.3% (n = 34/146), whilst under the adapted care model it was 5.6% (n = 5/90). Attrition on treatment was 22.3% (n = 25/112) before adaptations, whilst during the study period none of the participants were lost-to-follow-up on treatment and 3.3% died (n = 3/90). CONCLUSIONS: As person-centred care delivery and treatment regimens were adapted to better fit-specific contextual challenges and the needs of the target population, retention in care improved amongst people with RR-TB in Kandahar, Afghanistan.

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.

Active household contact screening for tuberculosis and provision of isoniazid preventive therapy to under-five children in Afghanistan.

OBJECTIVES: This observational study analyzed the performance of the National TB Control Program (NTP) in Afghanistan in household contact screening from 2011 to 2018 and its use as an entry point for isoniazid preventive therapy (IPT), as well as the IPT completion rates for children under age five. METHODS: From 2011 to 2018, the Afghanistan NTP released guidelines for passive and active contact screening of bacteriologically confirmed TB cases. Health workers were trained in contact screening. Presumptive TB cases gave sputum for AFB smear microscopy; other diagnostics were used if patients could not produce sputum. Children under five (excluding those with active TB) were treated for latent TB infection. We calculated the yield and the number needed to screen and number needed to test to find a case of TB, as well as the rates of IPT initiation and completion. RESULTS: From 2011 to 2018, 142,797 bacteriologically confirmed TB cases were diagnosed in Afghanistan. The number of household members eligible for screening was estimated to be 856,782, of whom 586,292 (81%) were screened for TB and 117,643 (20.1%) were found to be presumptive TB cases. Among the cases screened, 10,896 TB cases (all forms) were diagnosed (1.85%, 95% CI 1.82-1.89), 54.4% in females. The number needed to screen to diagnose a single case of TB (all forms) was 53.8; the number needed to test was 10.7. Out of all children under five, 101,084 (85.9%) were initiated on IPT, and 69,273 (68.5%) completed treatment. CONCLUSIONS: Program performance in contact screening in Afghanistan is high, at 81%, and the yield of TB is also high-close to 10 times higher than the national TB incidence rate. IPT initiation and completion rates are also high as compared to those of many other countries but need further improvement, especially for completion.

Translating drug resistant tuberculosis treatment guidelines to reality in war-torn Kandahar, Afghanistan: A retrospective cohort study.

INTRODUCTION: Afghanistan is affected by one of the world's longest protracted armed conflicts, frequent natural disasters, disease outbreaks and large population movements and it suffers from a high burden of tuberculosis (TB), including rifampicin-resistant TB (RR-TB). The study shows Médecins Sans Frontières' experiences with care for patients with RR-TB in Kandahar Province. We describe the uptake of RR-TB treatment, how World Health Organisation criteria for the choice between the short and an individualized regimen were implemented, and treatment outcomes. METHODS: This is a retrospective cohort analysis of routinely collected data from RR-TB patients enrolled in care from 2016 until 2019. Descriptive analysis was performed to present characteristics of patients and treatment outcomes. Multivariable Cox analysis was performed to identify risk factors for having an unfavourable treatment outcome. RESULTS: Out of 146 enrolled RR-TB patients, 112 (76.7%) started treatment: 41 (36.6%) and 71 (63.4%) with the short and individualized treatment regimen, respectively. Of 82 with results for fluoroquinolone susceptibility, 39 (47.6%) had fluoroquinolone-resistant TB. Seven patients with initially fluoroquinolone-resistant TB and three pregnant women started the short regimen and 18 patients eligible for the short regimen started the injectable-free individualized regimen. Overall, six-month smear and culture conversion were 98.7% and 97.1%, respectively; treatment success was 70.1%. Known initial fluoroquinolone resistance (aHR 3.77, 95%CI:1.53-9.27) but not choice of regimen predicted having an unfavourable outcome. CONCLUSION: Even though criteria for the choice of treatment regimen were not applied strictly, we have achieved acceptable outcomes in this cohort. To expand RR-TB care, treatment regimens should fit provision at primary health care level and take patient preferences into account.