Variability in distribution and use of tuberculosis diagnostic tests in Kenya: a cross-sectional survey.

BACKGROUND: Globally, 40% of all tuberculosis (TB) cases, 65% paediatric cases and 75% multi-drug resistant TB (MDR-TB) cases are missed due to underreporting and/or under diagnosis. A recent Kenyan TB prevalence survey found that a significant number of TB cases are being missed here. Understanding spatial distribution and patterns of use of TB diagnostic tests as per the guidelines could potentially help improve TB case detection by identifying diagnostic gaps. METHODS: We used 2015 Kenya National TB programme data to map TB case notification rates (CNR) in different counties, linked with their capacity to perform diagnostic tests (chest x-rays, smear microscopy, Xpert MTB/RIF®, culture and line probe assay). We then ran hierarchical regression models for adults and children to specifically establish determinants of use of Xpert® (as per Kenyan guidelines) with county and facility as random effects. RESULTS: In 2015, 82,313 TB cases were notified and 7.8% were children. The median CNR/100,000 amongst 0-14yr olds was 37.2 (IQR 20.6, 41.0) and 267.4 (IQR 202.6, 338.1) for ≥15yr olds respectively. 4.8% of child TB cases and 12.2% of adult TB cases had an Xpert® test done, with gaps in guideline adherence. There were 2,072 microscopy sites (mean microscopy density 4.46/100,000); 129 Xpert® sites (mean 0.31/100,000); two TB culture laboratories and 304 chest X-ray facilities (mean 0.74/100,000) with variability in spatial distribution across the 47 counties. Retreatment cases (i.e. failures, relapses/recurrences, defaulters) had the highest odds of getting an Xpert® test compared to new/transfer-in patients (AOR 7.81, 95% CI 7.33-8.33). Children had reduced odds of getting an Xpert® (AOR 0.41, CI 0.36-0.47). HIV-positive individuals had nearly twice the odds of getting an Xpert® test (AOR 1.82, CI 1.73-1.92). Private sector and higher-level hospitals had a tendency towards lower odds of use of Xpert®. CONCLUSIONS: We noted under-use and gaps in guideline adherence for Xpert® especially in children. The under-use despite considerable investment undermines cost-effectiveness of Xpert®. Further research is needed to develop strategies enhancing use of diagnostics, including innovations to improve access (e.g. specimen referral) and overcoming local barriers to adoption of guidelines and technologies.

Gender differences in treatment outcomes among 15-49 year olds with smear-positive pulmonary tuberculosis in Kenya.

OBJECTIVE: To determine gender differences in treatment outcomes among 15-49 year olds with smear-positive pulmonary tuberculosis (PTB) and factors associated with poor outcomes in Kenya. DESIGN: Retrospective descriptive cohort. RESULTS: Of 16 056 subjects analysed, 38% were female and 62% male. Females had a higher risk of poor treatment outcome than males (12% vs. 10%, P < 0.001; adjusted OR 1.29, 95%CI 1.16-1.44, P < 0.001). In the first multivariate model, restricting the analysis to human immunodeficiency virus (HIV) positive patients and adjusting for risk factors and clustering, females had a non-significantly lower risk of poor outcome (OR 0.99, 95%CI 0.86-1.13, P = 0.844). In the model restricted to HIV-negative patients, a non-significantly lower risk was found (OR 0.89, 95%CI 0.73-1.09, P = 0.267). In the second model, restricting analysis to patients on antiretroviral therapy (ART) and adjusting for risk factors and clustering, females had a non-significantly lower risk of poor PTB treatment outcomes (OR 0.98, 95%CI 0.84-1.14, P = 0.792). In the model restricted to HIV-positive patients not on ART, a non-significantly higher risk was found (OR 1.15, 95%CI 0.79-1.67, P = 0.461). CONCLUSION: Females of reproductive age are likely to have poorer treatment outcomes than males. Among females, not commencing ART during anti-tuberculosis treatment seemed to be associated with poor outcomes.

Antenatal care and pregnancy outcomes in a safe motherhood health voucher system in rural Kenya, 2007-2013.

SETTING: A rural private health facility, Ruby Medical Centre (RMC), participating in a safe motherhood health voucher system for poor women in Kiambu County, Kenya. OBJECTIVES: Between 2007 and 2013, to determine 1) the number of women who delivered at the RMC, their characteristics and pregnancy-related outcomes, and 2) the number of women who received an incomplete antenatal care (ANC) package and associated factors. DESIGN: Retrospective cross-sectional study using routine programme data. RESULTS: During the study period, 2635 women delivered at the RMC: 50% were aged 16-24 years, 60% transferred in from other facilities and 59% started ANC in the third trimester of pregnancy. Of the 2635 women, 1793 (68%) received an incomplete ANC package: 347 (13%) missed essential blood tests, 312 (12%) missed the tetanus toxoid immunisation and 1672 (65%) had fewer than four visits. Presenting late and starting ANC elsewhere were associated with an incomplete package. One pregnancy-related mortality occurred; the stillbirth rate was 10 per 1000 births. CONCLUSION: This first assessment of the health voucher system in rural Kenya showed problems in ANC quality. Despite favourable pregnancy-related outcomes, increased efforts should be made to ensure earlier presentation of pregnant women, comprehensive ANC, and more consistent and accurate monitoring of reproductive indicators and interventions.

Contexte : Une structure de santé privée rurale, le Ruby Medical Centre (RMC), participant à un système de bons de traitement de Maternité sans risques destiné à des femmes pauvres du conté de Kiambu au Kenya.Objectifs : Entre 2007 et 2013, déterminer 1) le nombre de femmes qui ont accouché au RMC, leurs caractéristiques et le devenir de leur grossesse, et 2) le nombre ne bénéficiant que d'un paquet de soins anténataux (ANC) incomplets et les facteurs associés.Schéma : Etude rétrospective transversale basée sur les données recueillies en routine dans les programmes.Résultats : Au cours de la période d'étude, 2635 femmes ont accouché au RMC : 50% étaient âgées de 16 à 24 ans, 60% avaient été transférées d'autres structures et 59% avaient débuté les ANC au cours du 3e trimestre. De ces 2635 femmes, 1793 (68%) avaient un paquet d'ANC incomplet : 347 (13%) ont manqué les principaux tests sanguins, 312 (12%) n'ont pas eu de vaccination anti-tétanique et 1672 (65%) ont eu moins de quatre consultations. Un démarrage tardif et des ANC débutés ailleurs étaient associés à un paquet d'ANC incomplet. Un décès lié à la grossesse est survenu et le taux de mortinatalité a été de 10/1000 naissances.Conclusion : Cette première évaluation du système de bons de traitement dans les zones rurales du Kenya a mis en évidence des problèmes de qualité des ANC. En dépit de l'évolution favorable des grossesses, il est nécessaire d'accroitre les efforts pour faire venir les femmes enceintes plus tôt, offrir des ANC complets et un suivi plus cohérent et précis des indicateurs et des interventions de santé reproductive.

Marco de referencia: El Ruby Medical Centre (RMC) es un centro de atención de salud privado en zona rural, que participa en el sistema de cupones por una maternidad sin riesgo en el condado de Kiambu, en Kenia.Objetivos: Determinar entre el 2007 y el 2013: 1) la cantidad de mujeres cuyo parto se atendió en el RMC, las características de las mujeres y los desenlaces relacionados con el embarazo; y 2) el número de mujeres que recibieron una atención prenatal (ANC) incompleta y los factores asociados con esta situación.Métodos: Fue este un estudio transversal retrospectivo a partir de los datos del programa corriente.Resultados: Durante el período del estudio, se atendió el parto de 2635 mujeres en el RMC, el 50% de las cuales tenía entre 16 y 24 años de edad, el 60% acudió como remisión de otros centros de atención y el 59% había comenzado la ANC durante el tercer trimestre del embarazo. De las 2635 mujeres, 1793 recibieron una ANC incompleta (68%) a saber: en 347 no se practicaron los principales exámenes sanguíneos (13%); 312 no recibieron la vacuna con el toxoide antitetánico (12%); y 1672 acudieron a menos de cuatro citas de control (65%). Los factores asociados con una ANC incompleta fueron una presentación tardía al programa y el inicio de la ANC en un centro diferente. Se presentó un caso de mortalidad relacionada con el embarazo y la tasa de mortinatalidad fue de 10 por 1000 nacimientos.Conclusión: El presente estudio es la primera evaluación del sistema de cupones por una maternidad sin riesgo en la zona rural de Kenia y puso en evidencia problemas en materia de calidad de la ANC. Pese a los desenlaces favorables del embarazo, se precisan iniciativas que fomenten una presentación más temprana de las embarazadas al programa, la ANC integral, y una vigilancia más regular y exacta de los indicadores y las intervenciones en materia de salud reproductiva.