Factors associated with loss to follow-up among TB patients in rural Papua New Guinea.

BACKGROUND: Papua New Guinea (PNG) is a lower middle-income country that has struggled to contain TB. The loss of patients to follow-up is a major contributing factor towards the high disease burden. OBJECTIVE: To describe persons with drug-susceptible TB (DS-TB) registered for treatment at the Gaubin Rural Hospital (GRH) on Karkar Island, Madang Province, PNG, and to investigate factors associated with patient loss to follow-up (LTFU). DESIGN: A retrospective cohort study was conducted using data from GRH DS-TB registers. Factors associated with LTFU were investigated using univariable and multivariable logistic regression. RESULTS: A total of 722 patients were registered for DS-TB treatment and eligible for inclusion between 1 January 2014 and 30 June 2018, of whom 97 (13.4%) were lost to follow-up. Male sex was associated with an increased odds of LTFU (adjusted OR [aOR] 1.9, 95% CI 1.2-3.0; P = 0.005), as was travel time to GRH >3 h (aOR 3.7, 95%, CI 2.2-6.3; P < 0.001). CONCLUSION: A high LTFU rate has been identified in patients with TB in PNG. This study found male sex and increased travel time from treatment location to be associated with unsuccessful treatment adherence, highlighting the need for further interventions to improve adherence.

CONTEXTE: La Papouasie-Nouvelle-Guinée (PNG) est située dans la tranche inférieure des pays à revenu intermédiaire, et a eu du mal à contenir la TB. Les patients perdus de vue sont un facteur contributif majeur du poids sanitaire élevé de la maladie. OBJECTIF: Décrire les personnes atteintes de TB pharmacosensible (DS-TB) enregistrées pour traitement à l'hôpital rural Gaubin (GRH) sur l'île de Karkar, province de Madang, PNG, et analyser les facteurs associés à la perte de vue des patients (LTFU). MÉTHODE: Une étude de cohorte rétrospective a été réalisée en utilisant les données des registres du GRH sur la DS-TB. Les facteurs associés à la LTFU ont été analysés en utilisant une régression logistique multivariable et univariable. RÉSULTATS: Au total, 722 patients ont été enregistrés pour traitement de la DS-TB et étaient éligibles à l'étude entre le 1er janvier 2014 et le 30 juin 2018, parmi lesquels 97 (13,4%) ont été perdus de vue. Le genre masculin a été associé à une probabilité plus élevée de LTFU (OR ajusté [ORa] 1,9 ; IC 95% 1,2­3,0 ; P = 0,005), tout comme un temps de trajet pour se rendre au GRH >3 heures (ORa 3,7 ; IC 95% 2,2­6,3 ; P < 0,001). CONCLUSION: Un taux élevé de LTFU a été identifié chez les patients atteints de TB en PNG. Cette étude révèle que le genre masculin et un temps de trajet accru pour se rendre au lieu d'administration du traitement sont associés à une mauvaise observance du traitement, ce qui souligne le besoin d'interventions supplémentaires visant à améliorer l'observance.

Impact of GxAlert on the management of rifampicin-resistant tuberculosis patients, Port Moresby, Papua New Guinea.

SETTING: GxAlert is an automatic electronic notification service that provides immediate Xpert® MTB/RIF testing results. It was implemented for the notification of patients with rifampicin resistant-tuberculosis (RR-TB) at Port Moresby General Hospital, Port Moresby, Papua New Guinea, in May 2015. OBJECTIVE: To determine if there were differences in pre-treatment attrition, the time to treatment initiation and patient outcomes in the 12 months pre- and post-introduction of GxAlert for RR-TB patients. DESIGN: This was a retrospective cohort study. RESULTS: The median time from Xpert testing to treatment initiation decreased from 35 days [IQR 13-131] prior to GxAlert to 10 days [IQR 3-29] after GxAlert (P = 0.001), with the cumulative proportion of patients initiating treatment within 30 days increasing from 25% (95%CI 17-37) to 54% (95%CI 44-64; P < 0.001) over these periods. However, our analysis of the time to treatment prior to the introduction of GxAlert suggests that a decrease had already occurred prior to implementation. There was no difference in interim clinical outcomes between the periods. CONCLUSION: Although a decrease in time to treatment initiation cannot be attributed to GxAlert, there was a significant improvement over the 2-year period, suggesting that considerable improvements have been made in timely RR-TB patient management in Port Moresby.

A retrospective study of tuberculosis outcomes in Gulf Province, Papua New Guinea.

SETTING: Gulf Province, a rural area of mainland Papua New Guinea, is known to have one of the highest burdens of tuberculosis (TB) in the country. OBJECTIVES: To describe the characteristics and outcomes of TB patients registered for first-line treatment in Kerema General Hospital in Gulf Province between January and December 2016. DESIGN: This was a retrospective cohort study using routinely collected programme data. RESULTS: Of 347 cases with a recorded TB site, 54% were male and 32% were aged <15 years. No human immunodeficiency virus (HIV) status was recorded for 51% of cases. TB was bacteriologically confirmed in 23% of cases. Among the cohort, there were 145 extrapulmonary TB cases (42%); the site of disease was unknown in 56% of these cases. Of the 297 cases with treatment outcome evaluated, 56% had a favourable outcome and 26% were lost to follow-up. On multivariable analysis, extrapulmonary TB (adjusted OR [aOR] 0.51, 95%CI 0.30-0.88, P = 0.02) and bacteriologically confirmed TB (aOR 0.40, 95%CI 0.21-0.77, P < 0.01) were associated with decreased odds of an unfavourable treatment outcome. CONCLUSION: The study findings highlight the need to improve TB diagnosis, access to HIV testing, treatment adherence, patient support and the quality of TB programme data in Gulf Province.

Challenges in TB diagnosis and treatment: the Kavieng Provincial Hospital experience, Papua New Guinea.

SETTING: The Tuberculosis (TB) Basic Management Unit at Kavieng Provincial Hospital, New Ireland Province, Papua New Guinea. OBJECTIVE: To assess the linkage between laboratory diagnosis and treatment initiation and describe the characteristics and treatment outcomes of TB patients. DESIGN: This was a retrospective cohort study of 1) sputum smear-positive TB patients recorded in the laboratory register, and 2) TB patients recorded in the treatment register in 2015 and 2016. RESULTS: Of the 221 patients registered for TB treatment, 173 (78%) were clinically diagnosed; extrapulmonary TB was common (36% of all patients). Unfavourable treatment outcomes were seen in more than 40% of patients, including death (10%) and loss to follow-up (26%), and were significantly more common in smear-negative vs. smear-positive pulmonary TB patients (RR 1.69 [95%CI 1.02-2.80]). Only 4 (<2%) TB patients had undergone testing for HIV. Twelve (21%) of 58 sputum smear-positive TB patients were not registered as undergoing treatment for TB. CONCLUSION: This study identifies diagnostic and treatment gaps in the TB treatment cascade at the Kavieng Basic Management Unit. The TB programme requires strengthening to address the high proportions of clinically diagnosed TB, of patients not tested for HIV and of loss to follow-up.

Gaps in tuberculosis care in West Sepik Province of Papua New Guinea.

SETTING: Papua New Guinea (PNG), a low-resource country with a high tuberculosis (TB) burden. OBJECTIVE: To describe the characteristics, treatment outcomes and risk factors for unfavourable outcomes among patients registered for first-line tuberculosis (TB) treatment between 1 January 2014 and 31 December 2016 in West Sepik Province. DESIGN: This was a retrospective cohort study of routinely collected programme data. RESULTS: Of 1058 cases, 50.7% were male and 38.8% were aged <15 years; 43.1% were extrapulmonary TB cases and 280 (26.5%) were bacteriologically confirmed. No human immunodeficiency virus (HIV) status was recorded for 74.7% of cases. Of 1019 (96.3%) patients with a recorded outcome, 779 (76.4%) were favourable and 240 (23.6%) were unfavourable. On multivariable logistic regression, increasing age was associated with an increased odds of an unfavourable outcome (adjusted OR [aOR] 1.06 per every 5-year increase, 95%CI 1.02-1.11; P = 0.006) and being a retreatment case was associated with a reduced odds of an unfavourable outcome compared to new cases (aOR 0.54, 95%CI 0.31-0.93; P = 0.027). CONCLUSION: This study identified substantial gaps in TB care, including low rates of bacteriological diagnosis and HIV testing, and high rates of loss to follow-up, highlighting the need to strengthen TB control efforts, including support for new cases.

A mortality review of adult inpatients with tuberculosis in Mendi, Papua New Guinea.

SETTING: Mendi Provincial Hospital, Southern Highlands Province, Papua New Guinea (PNG). BACKGROUND: PNG is a high burden country for tuberculosis (TB) and TB-human immunodeficiency virus (HIV). TB is the second most common cause of death in PNG. OBJECTIVE: To identify the number of adult inpatients with TB who died between 1 January 2015 and 30 August 2017; describe these patients' characteristics and identify contributing factors that could be modified. DESIGN: This was a retrospective case series review. RESULTS: Among 905 inpatients with TB during the study period, there were 90 deaths. The patients who died were older than those who survived (median age 40 years vs. 32 years, P = 0.011). The majority of patients who died lived less than 3 hours from the hospital (71%), were diagnosed after admission (79%) and were clinically diagnosed (77%). HIV status was not known in 50% of the deaths. Of patients with a known status, 27% (12/45) were HIV-positive. The median symptom duration prior to presentation was 28 days, with females presenting later than males (84 vs. 28 days, P = 0.008). CONCLUSION: This study highlights areas where community and hospital-based management of TB could be improved to potentially reduce TB mortality, including earlier detection and treatment, improved bacteriological diagnosis and increased HIV testing.

The Vivax Surveyor: Online mapping database for Plasmodium vivax clinical trials.

INTRODUCTION: Recurrent P. vivax infections are associated with significant morbidity and mortality. Although radical cure can reduce recurrent infection, it is confounded by antimalarial resistance and the lack of safe and effective hypnozoitocidal treatment. This study documents the available literature of published clinical trials of P. vivax, providing an up to date, online, open access tool to view and download available information. METHODS: A systematic review was conducted according to PRISMA guidelines to identify prospective P. vivax therapeutic clinical trials with at least 28 days follow-up published between 1st January 1960 and 12th October 2016. Treatment arms and evidence of chloroquine resistance were mapped to trial sites. RESULTS: Since 1960, a total of 1152 antimalarial clinical trials with a minimum 28 days follow-up have been published, of which 230 (20.0%) enrolled patients with P. vivax and were included. Trials were conducted in 38 countries: 168 (73.0%) in the Asia-Pacific, 13 (5.7%) in Africa and 43 (18.7%) in the Americas. The proportion of antimalarial trials assessing P. vivax rose from 10.7% (12/112) in 1991-1995, to 24.9% (56/225) in 2011-2015. Overall, 188 (81.7%) P. vivax trials included a chloroquine treatment arm, either alone or in combination with primaquine, and 107 (46.5%) trials included a chloroquine treatment arm with early primaquine to assess radical cure. There has been a recent increase in treatment arms with artemisinin derivatives. Of the 131 sites in which chloroquine resistance could be quantified, resistance was present in 59 (45.0%) sites in 15 endemic countries. CONCLUSIONS: Over the last 20 years there has been a substantial increase in clinical research on the treatment of P. vivax, which has generated a greater awareness of the global extent of chloroquine resistance. The WWARN open access, online interactive map provides up to date information of areas where drug resistant P. vivax is emerging.

Melioidosis in a patient on monoclonal antibody therapy for psoriatic arthritis.

Melioidosis is caused by the environmental bacterium Burkholderia pseudomallei and can present with severe sepsis. Predisposing risk factors are present in 80% of cases. Monoclonal antibodies are increasingly prescribed for varied medical conditions. This report describes the first known case of melioidosis in a patient whose only risk factor for disease is treatment with a monoclonal antibody. Prescribers of monoclonal antibodies and other immunosuppressants should ensure that their patients are aware of the potential risk of melioidosis prior to travel and the precautions that should be taken.

Triaging pandemic flu: pneumonia severity scores are not the answer.

SETTING: The 2009 H1N1 influenza pandemic caused significant strain on health systems worldwide. A tool to triage patients at low risk of requiring intensive care services would assist practitioners in safely reducing hospital admission rates during pandemic influenza outbreaks. Community-acquired pneumonia severity scores have not been validated for use in pandemic influenza. OBJECTIVE: To assess the accuracy of the pneumonia severity index (PSI), CURB-65 and SMRT-CO severity scores in predicting patients at low risk of requiring intensive care services. DESIGN: Between May and July 2009, 105 patients admitted with laboratory-confirmed pandemic (H1N1) 2009 influenza to Melbourne public hospitals were assessed on admission to determine their pneumonia severity scores and subsequent need for intensive care unit (ICU) support and length of stay. RESULTS: SMRT-CO was the most accurate score at predicting ICU admission, with an area under the curve of the receiver operating characteristic of 0.826. No score provided good discrimination of low-risk patients, with respectively 19%, 21% and 12% requiring ICU admission as predicted by PSI, CURB-65 and SMRT-CO. CONCLUSION: Current pneumonia severity scores have insufficient predictive ability to safely identify low-risk patients with pandemic (H1N1) 2009 influenza.