Does distance to healthcare facility affect care-seeking for TB-related symptoms in Tanzania?

BACKGROUND: In high TB burden countries, delayed diagnosis remains a big challenge in TB control. The objective of this study is to assess the role of distance between residence and healthcare facility (HCF) on care-seeking among individuals with symptoms associated with pulmonary TB in Tanzania.METHODS: In this cross-sectional study, using data from a national TB survey, coordinates of 300 (residential) sites within 62 clusters were obtained through Google searches and average distances to HCF were calculated per cluster. Univariable and multivariable logistic regression analyses were conducted, with care-seeking behaviour being the primary outcome variable.RESULTS: Distance from residence to HCF had no effect on care-seeking behaviour of individuals with TB-related symptoms in this study (OR 1.00, 95% CI 1.00-1.00). Over 85% of HCFs where care has been sought lack TB diagnostic capacity, mostly comprising dispensaries with staff less educated in TB-related symptoms.CONCLUSION: Care-seeking behaviour among individuals with TB-related symptoms in Tanzania was not found to be associated with distance to HCF. First-line diagnostics should be improved 1) by equipping local dispensaries with basic TB diagnostic capacity, and 2) by educating staff of local dispensaries more thoroughly about basic TB symptoms and the importance of swift referrals.

Association between cholera treatment outcome and nutritional status in children aged 2-4 years in Nigeria.

SETTING: Cholera can aggravate or precipitate malnutrition, and children with severe acute malnutrition (SAM) have a higher incidence and longer duration of diarrhoea. OBJECTIVE: To describe 1) characteristics of and treatment outcomes in children aged 2-4 years with cholera, 2) the case fatality rate (CFR) in all children treated, and 3) the associations between nutritional status, hydration status, treatment administered and hospital outcomes. DESIGN: An observational cohort study of children admitted to one cholera treatment centre in Maiduguri, Nigeria, with a focus on children aged 2-4 years. CFRs were examined by cross tabulation and mean length of stay (LOS) using analysis of variance. RESULTS: SAM was identified in 24% of children aged 2-4 years. The CFR for children aged 2-4 years was 1.4%. As the sample size was small, we did not find any association between nutritional status and death due to cholera. The proportion of children discharged within 2 days was 79%, and the longest stay was 8 days. In general, health facility LOS increased with severity of malnutrition. CONCLUSION: Our study found that nutritional status affected the LOS, but was unable to find an association between malnutrition and fatality among children aged 2-4 years.

CONTEXTE: Le choléra peut aggraver ou précipiter la malnutrition et les enfants atteints de malnutrition aiguë grave (SAM) ont une incidence plus élevée et une durée plus longue de diarrhée. OBJECTIF: Décrire 1) les caractéristiques et les résultats du traitement d'enfants de 2­4 ans atteints de choléra, 2) le taux de mortalité de tous les enfants traités, et 3) les associations entre état nutritionnel, hydratation, traitement administré et évolution à l'hôpital. SCHÉMA: Cohorte d'observation d'enfants admis au centre de traitement du choléra de Maiduguri, Nigeria, avec un focus sur les enfants de 2­4 ans. Les taux de létalité ont été examinés par tabulation croisée et la durée moyenne de séjour par analyse de la variance. RÉSULTATS: Une SAM a été identifiée chez 24% des enfants de 2­4 ans. Le taux de létalité des enfants de 2­4 ans était de 1,4%. La petite taille de la population n'a pas permis d'observer d'association entre état nutritionnel et décès dû au choléra. La proportion d'enfants sortis en 48h a été de 79% et la durée la plus longue de séjour de 8 jours. En général, la durée de séjour en structure de santé augmentait avec la gravité de la malnutrition. CONCLUSION: Notre étude a constaté que l'état nutritionnel affectait la durée de séjour mais n'a pas permis de trouver une association entre malnutrition et létalité parmi les enfants de 2­4 ans.

An alumni study of a Master's in international health.

OBJECTIVES: The objective of the study was to clarify the reasons why students who graduated from a Master's programme in international health were joining the programme. Another objective was to document how the Master's degree had influenced the careers of the graduates. STUDY DESIGN: An online survey of students who graduated from a Master's programme in international health, including oral science, between 2010 and 2015. METHOD: The study used an anonymous questionnaire that contained 28 items. Topics included information such as demographics, questions about the reasons for joining the Master's programme and the benefits and influence of the programme on the career of the students. RESULTS: Of the 102 alumni who were invited to participate, 70 responded. The response rate was 69%, and we have no information about the non-responders. The results showed that the main reasons for students enrolling in the programme were to improve their competence and develop their career. Around 63% of the respondents reported that the programme had increased their competencies in the jobs they had, whereas 24% answered that their increased qualifications had enabled them to acquire new positions. Thus successfully completing the programme had a positive influence on the graduates' careers in international health. Most of the graduates, who were working, were typically employed at hospitals and universities. Several graduates had proceeded to gain further qualifications by now being enrolled in a PhD programme. CONCLUSIONS: Among the 70% of responders in this survey, the master's programme had benefitted the alumni and the programme had fulfilled their expectations. The programme had a positive influence on the alumni in areas such as increased competency, development of their careers, new positions and better salaries.

A comparison of the yield and relative cost of active tuberculosis case-finding algorithms in Zimbabwe.

SETTING: Ten districts and three cities in Zimbabwe. OBJECTIVE: To compare the yield and relative cost of identifying a case of tuberculosis (TB) using the three WHO-recommended algorithms (WHO2b, symptom inquiry only; WHO2d, chest X-ray [CXR] after a positive symptom inquiry; WHO3b, CXR only) and the Zimbabwe active case finding (ZimACF) algorithm (symptom inquiry plus CXR) to everyone. DESIGN: Cross-sectional study using data from the ZimACF project. RESULTS: A total of 38 574 people were screened from April to December 2017; 488 (1.3%) were diagnosed with TB using the ZimACF algorithm. Fewer TB cases would have been diagnosed with the WHO-recommended algorithms. This ranged from 7% fewer (34 cases) with WHO3b, 18% fewer (88 cases) with WHO2b and 25% fewer (122 cases) with WHO2d. The need for CXR ranged from 36% (WHO2d) to 100% (WHO3b). The need for bacteriological confirmation ranged from 7% (WHO2d) to 40% (ZimACF). The relative cost per case of TB diagnosed ranged from US$180 with WHO3b to US$565 for the ZimACF algorithm. CONCLUSION: The ZimACF algorithm had the highest case yield, but at a much higher cost per case than the WHO algorithms. It is possible to switch to algorithm WHO3b, but the trade-off between cost and yield needs to be reviewed by the Zimbabwean National TB Programme.

Mass screening for active case finding of pulmonary tuberculosis in the Russian Federation: how to save costs.

BACKGROUND: In Russia, mass chest X-ray (CXR) screening for tuberculosis (TB) is mandatory.OBJECTIVE: To compare the yield and the cost per TB case detected and the total cost of CXR screening, passive case finding and contact tracing among adolescents and adults in the Arkhangelsk Oblast, Russian Federation, 2013-2017.DESIGN: This was an analysis of costing strategies using aggregated data. Costing information was obtained from the Finance Department of the Arkhangelsk Clinical TB Dispensary, Arkhangelsk, and the Territorial Fund of Mandatory Medical Insurance, Arkhangelsk, Russian Federation.RESULTS: TB cases were detected using CXR screening (n = 684, 46%), contact tracing (n = 61, 4%) and passive case finding (n = 743, 46%). The number of cases detected using CXR screening, contact tracing and passive case finding was respectively 28,753 and 960/100 000. The mean costs/test were respectively US$3.54 (US$12 541/case), US$20.28 (US$2693/case) and US$11.85 (US$1235/case) using CXR screening, contact tracing and passive case finding The number of cases/100 000 in targeted groups was as follows: HIV-positive persons, 645; homeless persons, 461; and migrants, 441. The cost/TB case detected was respectively US$549, US$768 and US$803.CONCLUSION: Mass CXR screening (excluding HIV-positive, migrant and homeless populations) has low yield and high cost per TB case detected. It should be stopped and resources should instead be used to strengthen the screening of targeted high-risk groups, contacts and passive case finding.

Challenges and opportunities to prevent tuberculosis in people living with HIV in low-income countries.

People living with the human immunodeficiency virus (HIV) (PLHIV) are at high risk for tuberculosis (TB), and TB is a major cause of death in PLHIV. Preventing TB in PLHIV is therefore a key priority. Early initiation of antiretroviral therapy (ART) in asymptomatic PLHIV has a potent TB preventive effect, with even more benefits in those with advanced immunodeficiency. Applying the most recent World Health Organization recommendations that all PLHIV initiate ART regardless of clinical stage or CD4 cell count could provide a considerable TB preventive benefit at the population level in high HIV prevalence settings. Preventive therapy can treat tuberculous infection and prevent new infections during the course of treatment. It is now established that isoniazid preventive therapy (IPT) combined with ART among PLHIV significantly reduces the risk of TB and mortality compared with ART alone, and therefore has huge potential benefits for millions of sufferers. However, despite the evidence, this intervention is not implemented in most low-income countries with high burdens of HIV-associated TB. HIV and TB programme commitment, integration of services, appropriate screening procedures for excluding active TB, reliable drug supplies, patient-centred support to ensure adherence and well-organised follow-up and monitoring that includes drug safety are needed for successful implementation of IPT, and these features would also be needed for future shorter preventive regimens. A holistic approach to TB prevention in PLHIV should also include other important preventive measures, such as the detection and treatment of active TB, particularly among contacts of PLHIV, and control measures for tuberculous infection in health facilities, the homes of index patients and congregate settings.

Childhood tuberculosis in Mauritania, 2010-2015: diagnosis and outcomes in Nouakchott and the rest of the country.

Setting: The National Tuberculosis Programme, Mauritania. Objective: To compare the diagnosis and treatment outcomes of childhood tuberculosis (TB) cases (aged <15 years) registered between 2010 and 2015 inside and outside Nouakchott, the capital city. Design: This was a retrospective comparative cohort study. Results: A total of 948 children with TB were registered. The registration rate was 10 times higher in Nouakchott. The proportion of children among all TB cases was higher inside than outside Nouakchott (7.5% vs. 4.6%, P < 0.01). Under-fives represented 225 (24%) of all childhood TB cases, of whom 204 (91%) were registered in Nouakchott. Extra-pulmonary TB was more common in Nouakchott, while smear-negative TB was less common. Treatment success was similar inside and outside Nouakchott (national rate 61%). The principal unsuccessful outcomes were loss to follow-up outside Nouakchott (21% vs. 11%, P < 0.01) while transfers out were more common in the city (25% vs. 14%, P = 0.01). Being aged <5 years (OR 1.2, 95%CI 1.1-1.5) was associated with an unsuccessful outcome. Conclusion: This study indicates problems in the diagnosis and treatment of childhood TB in Mauritania, especially outside the city of Nouakchott. We suggest strengthening clinical diagnosis and management, improving communications between TB treatment centres and health services and pressing the TB world to develop more accurate and easy-to-use diagnostic tools for children.

Contexte : Programme National Tuberculose, Mauritanie.Objectif : Comparer les résultats en termes de diagnostic et de traitement des cas de tuberculose (TB) de l'enfant (<15 ans) enregistrés entre 2010 et 2015 dans la capitale, Nouakchott, et à l'extérieur de la capitale.Schéma : Une étude rétrospective comparative de cohorte.Résultats : Au total, 948 enfants atteints de TB ont été enregistrés. Le taux d'enregistrement a été 10 fois plus élevé à Nouakchott. La proportion des enfants parmi tous les cas de TB a été plus élevée à Nouakchott qu'à l'extérieur (7,5% contre 4,6% ; P < 0,01). Les enfants âgés de <5 ans ont constitué 225 cas, soit 24% de tous les cas de TB de l'enfant, dont 204 (91%) ont été enregistrés à Nouakchott. La TB extra-pulmonaire a été plus fréquente à Nouakchott, tandis que la TB à frottis négatif a été moins fréquente. Le taux de réussite du traitement a été similaire à Nouakchott et à l'extérieur (taux national de 61%). Les principaux résultats défavorables ont été les pertes de vue à l'extérieur de Nouakchott (21% vs. 11% ; P < 0,01), tandis que les transferts ont été plus fréquents dans la capitale (25% vs. 14% ; P = 0,01). L'âge inférieur à 5 ans a été associé à un résultat défavorable (OR 1,2 ; IC95% 1,1­1,5).Conclusion : Cette étude a mis en évidence les problèmes de diagnostic et de traitement de la TB de l'enfant en Mauritanie, surtout hors de Nouakchott. Nous suggérons de renforcer le diagnostic clinique et la prise en charge, d'améliorer la communication entre les centres de traitement de la TB et les services de santé et de pousser le milieu de la TB à élaborer des outils de diagnostic plus précis et faciles à utiliser pour les enfants.

Marco de referencia: El Programa Nacional contra la Tuberculosis de Mauritania.Objetivo: Comparar los diagnósticos y los desenlaces terapéuticos de los casos de TB en los niños (<15 años de edad) registrados del 2010 al 2015 en la capital Nouakchot y fuera de esta ciudad.Método: Estudio de cohortes retrospectivo comparativo.Resultados: En general, se registraron 948 niños con TB. La tasa de registro fue 10 veces más alta en Nouakchot. La proporción de niños en todos los casos de TB fue más alta en Nouakchot que fuera de la capital (7,5% contra 4,6%; P < 0,01). De todos los casos de TB en la infancia, 225 fueron niños <5 años de edad (24%), de los cuales 204 se registraron en Nouakchot (9%). La TB extrapulmonar fue más frecuente en la capital y se observó allí una menor frecuencia de casos con baciloscopia negativa. La tasa de éxito terapéutico fue equivalente en Nouakchot y fuera de la ciudad (tasa nacional 61%). Fuera de la capital, el principal desenlace desfavorable fue la pérdida durante el seguimiento (21% contra 11%; P < 0,01) y en Nouakchot fueron las transferencias a otros centros (25% contra 14%; P = 0,01). La edad <5 años se asoció con un desenlace desfavorable (cociente de posibilidades 1,2; IC95% 1,1­1,5).Conclusión: El presente estudio pone de manifiesto los problemas del diagnóstico y el tratamiento de la TB en Mauritania, sobre todo fuera de la capital Nouakchot. Se recomienda fortalecer el diagnóstico clínico y el tratamiento, con una mejor comunicación entre los centros de tratamiento de la TB y los servicios de salud y urgir en el mundo de la TB el desarrollo de medios diagnósticos dirigidos a los niños que sean más exactos y de utilización sencilla.

Pre-treatment loss to follow-up among smear-positive TB patients in tertiary hospitals, Quetta, Pakistan.

Setting: Three public sector tertiary care hospitals in Quetta, Balochistan, Pakistan, with anecdotal evidence of gaps between the diagnosis and treatment of patients with tuberculosis (TB). Objectives: To assess the proportion of pre-treatment loss to follow-up (LTFU), defined as no documented evidence of treatment initiation or referral in TB registers, among smear-positive pulmonary TB patients diagnosed in 2015, and the associated sociodemographic factors. Design: A retrospective cohort study involving the review of laboratory and TB registers. Results: Of 1110 smear-positive TB patients diagnosed (58% female, median age 40 years, 5% from outside the province or the country), 235 (21.2%) were lost to follow-up before starting treatment. Pre-treatment LTFU was higher among males; in patients residing far away, in rural areas, outside the province or the country; and in those without a mobile phone number. Conclusion: About one fifth of the smear-positive TB patients were lost to follow-up before starting treatment. Strengthening the referral and feedback mechanisms and using information technology to improve the tracing of patients is urgently required. Further qualitative research is needed to understand the reasons for pre-treatment LTFU from the patient's perspective.

Contexte : Trois hôpitaux publics tertiaires à Quetta, Baloutchistan, Pakistan, avec des preuves empiriques d'un fossé entre le diagnostic et le traitement des patients tuberculeux (TB).Objectif : Evaluer la proportion de patients perdus de vue avant le traitement (pas de preuve documentée de mise en route du traitement ou de référence dans les registres TB) parmi les patients atteints de TB pulmonaire à frottis positif diagnostiqués en 2015, et identifier les facteurs sociodémographiques associés.Schéma : Etude rétrospective de cohorte impliquant une revue des registres de laboratoire et de TB.Résultats : Sur 1110 patients TB à frottis positif diagnostiqués (58% de femmes, d'âge médian 40 ans, 5% venant de l'extérieur de la province ou du pays), 235 (21,2%) ont été perdus de vue avant de démarrer le traitement. Cette perte de vue avant le traitement a été plus élevée parmi les hommes ; parmi les patients résidant loin, en zone rurale, hors de la province ou du pays ; et parmi ceux ne possédant pas de téléphone portable.Conclusion : Environ un cinquième des patients TB à frottis positif ont été perdus de vue avant la mise en route du traitement. Il est nécessaire de manière urgente de renforcer les mécanismes de référence et de retro-information et d'avoir une meilleure traçabilité des patients grâce aux techniques d'information. Une autre recherche qualitative est requise afin de comprendre les raisons de cette perte de vue avant le traitement selon la perspective des patients.

Marco de referencia: Tres hospitales de atención terciaria del sector público de Quetta, en la provincia de Balochistán del Pakistán, donde existen datos anecdóticos de un desfase entre el diagnóstico y el tratamiento de los pacientes con tuberculosis (TB).Objetivos: Evaluar la proporción de pérdidas durante el seguimiento antes de comenzar el tratamiento (falta de documentación de la iniciación del tratamiento o la remisión a otros centros en los registros de TB) de los pacientes con TB pulmonar y baciloscopia positiva diagnosticados en el 2015 y analizar los factores socioeconómicos determinantes.Métodos: Un estudio retrospectivo de cohortes a partir del examen de los registros de laboratorio y los registros de TB.Resultados: De los 1110 pacientes con baciloscopia positiva diagnosticados (58% de sexo femenino, mediana de la edad 40 años y 5% procedente de otra provincia o país), 235 (21,2%) se perdieron durante el seguimiento antes de iniciar el tratamiento. Estas pérdidas fueron mayores en los pacientes de sexo masculino; los pacientes que residían en zonas rurales remotas, fuera de la provincia o del país; y en las personas que no contaban con un número de teléfono celular.Conclusión: Cerca de un quinto de los pacientes con diagnóstico de TB y baciloscopia positiva se perdió durante el seguimiento antes de comenzar el tratamiento. Es urgente fortalecer el mecanismo de remisiones y de retroinformación de los resultados y mejorar la localización de los pacientes haciendo uso de la tecnología de la información. Se precisan nuevas investigaciones cualitativas que favorezcan la comprensión de las razones de esta pérdida durante el seguimiento desde la perspectiva de los pacientes.

Population impact of factors associated with prevalent pulmonary tuberculosis in Tanzania.

SETTING: Tanzania has an estimated tuberculosis (TB) prevalence of 295 per 100 000 adult population. There is currently no nationally representative information on factors associated with TB in Tanzania. OBJECTIVE: To determine the demographic and clinical factors associated with bacteriologically confirmed TB in the adult general population of Tanzania. DESIGN: A case-control study nested in a nationally representative TB prevalence survey. All patients with bacteriologically confirmed pulmonary TB (PTB) constituted cases and a representative sample of people without bacteriologically confirmed PTB constituted controls. We calculated adjusted odds ratios (aORs) to identify factors associated with TB. RESULTS: Age groups 25-34 years (aOR 3.7, 95%CI 1.5-8.8) and 55-64 years (aOR 2.5, 95%CI 1.1-5.5), male sex (aOR 1.6, 95%CI 1.1-2.3) and low body mass index (BMI) (aOR 1.7, 95%CI 1.1-2.8) were significantly associated with TB. Association with human immunodeficiency virus (HIV) and diabetes mellitus (DM) was not statistically significant. The population attributable fraction (PAF) was 2% (95%CI -2 to 5) for DM and 3% (95%CI -2 to 8) for HIV. CONCLUSION: Being in an older age group, being male and having a low BMI were associated with bacteriologically confirmed PTB. On the population level, classic risk factors for TB have no major effect on prevalent TB from which future transmission may occur.

Did FIDELIS projects contribute to the detection of new smear-positive pulmonary tuberculosis cases in China?

Setting: The first phase of the Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB (FIDELIS) projects in China started in 2003. Objective: To determine whether the FIDELIS projects contributed to the increased case detection rate for new smear-positive pulmonary tuberculosis (PTB) in China. Methods: We compared the case notification rates (CNRs) in the intervention year with those of the previous year in the FIDELIS areas, then compared the difference between the CNRs of the intervention year and the previous year in the FIDELIS areas with those in the non-FI-DELIS areas within the province. Results: There was an increase in the CNR in the intervention year compared with the previous year for all the project sites. The differences between the CNR in the intervention year and the previous year ranged from 6.4 to 31.1 per 100 000 population in the FIDELIS areas and from 2.9 to 20.4/100 000 in the non-FIDELIS areas. Differences-in-differences analysis shows that the differences in the CNRs in the FIDELIS areas were not statistically significantly different from those in the non-FIDELIS areas (P = 0.393). Conclusion: The FIDELIS projects may have contributed to the increase in case detection of new smear-positive PTB in China, but the level of evidence is low.

Objectif : Déterminer si les projets de la « Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB ¼ (FIDELIS), commencés en 2003, ont contribué à une augmentation de la détection des cas de tuberculose pulmonaire (TBP) à frottis positif en Chine.Méthodes : Nous avons comparé le taux de notification des cas (CNR) pendant l'année d'intervention avec celui de l'année précédente dans les zones FIDELIS. Nous avons également comparé la différence du CNR de l'année d'intervention et de l'année précédente dans les zones FIDELIS et les zones non FIDELIS à l'intérieur de la province.Résultats : Il y a eu une augmentation du CNR pendant l'année d'intervention comparée à l'année précédente dans tous les sites du projet. Cette différence de CNR entre l'année d'intervention et l'année précédente allait de 6,4 à 31,1 par 100 000 habitants dans les zones FIDELIS et de 2,9 à 20,4/100 000 dans les zones non FIDELIS. L'analyse des écarts dans les différences a montré que les différences de CNR dans les zones FIDELIS n'étaient pas statistiquement significatives par rapport à aux zones non FIDELIS (P = 0,393).Conclusions : Les projets FIDELIS pourraient avoir contribué à l'augmentation de la détection des cas nouveaux de TBP à frottis positif en Chine, mais le niveau de preuves reste faible.

Marco de referencia: La primera fase de ejecución del Fondo para la Expansión Innovadora de DOTS mediante Iniciativas Locales para Detener la Tuberculosis (FIDELIS, por su acrónimo en inglés), en la China, comenzó en 2003.Objetivo: Determinar si los proyectos de la iniciativa FIDELIS contribuían a aumentar la detección de casos nuevos de tuberculosis pulmonar (TBP) con baciloscopia positiva en la China.Métodos: Se comparó la tasa de notificación de casos (CNR) durante el año de la intervención, con la tasa del año anterior en las zonas vinculadas con el proyecto FIDELIS, y se examinó además la diferencia de la CNR durante el año de la intervención y el año anterior en zonas de la provincia que no participaron en el proyecto.Resultados: Durante el año de la intervención, se observó un aumento de la CNR con respecto al año anterior en todos los centros del proyecto. Las diferencias de la CNR en ambos períodos en las zonas que participaron en el proyecto FIDELIS oscilaron entre 6,4 y 31,1 por 100 000 habitantes; en las zonas donde no hubo intervención las diferencias de la tasa de notificación oscilaron entre 2,9 y 20,4/100 000. Al comparar estos resultados, no se puso en evidencia una diferencia significativa en las CNR al comparar las zonas que practicaron la intervención y las zonas fuera del proyecto FIDELIS (P = 0,393).Conclusión: Es posible que los proyectos FIDELIS hayan contribuido a mejorar la tasa de detección de casos nuevos de TBP con baciloscopia positiva en la China, pero la fuerza demostrativa de las pruebas científicas es escasa.