Bringing state-of-the-art diagnostics to vulnerable populations: The use of a mobile screening unit in active case finding for tuberculosis in Palawan, the Philippines.

BACKGROUND: Globally, case detection of tuberculosis (TB) has stabilized in recent years. Active case finding (ACF) has regained an increased attention as a complementary strategy to fill the case detection gap. In the Philippines, the DetecTB project implemented an innovative ACF strategy that offered a one-stop diagnostic service with a mobile unit equipped with enhanced diagnostic tools including chest X-ray (CXR) and Xpert®MTB/RIF (Xpert). The project targeted the rural poor, the urban poor, prison inmates, indigenous population and high school students. METHODS: This is a retrospective review of TB screening data from 25,103 individuals. A descriptive analysis was carried out to compare screening and treatment outcomes across target populations. Univariate and multivariate analyses were performed to identify predictors of TB for each population. The composition of bacteriologically-confirmed cases by smear and symptom status was further investigated. RESULTS: The highest yield with lowest number needed to screen (NNS) was found in prison (6.2%, NNS: 16), followed by indigenous population (2.9%, NNS: 34), the rural poor (2.2%, NNS: 45), the urban poor (2.1%, NNS: 48), and high school (0.2%, NNS: 495). The treatment success rate for all populations was high with 89.5% in rifampicin-susceptible patients and 83.3% in rifampicin-resistant patients. A relatively higher loss to follow-up rate was observed in indigenous population (7.5%) and the rural poor (6.4%). Only cough more than two weeks showed a significant association with TB diagnosis in all target populations (Adjusted Odds Ratio ranging from 1.71 to 6.73) while other symptoms and demographic factors varied in their strength of association. The urban poor had the highest proportion of smear-positive patients with cough more than two weeks (72.0%). The proportion of smear-negative (Xpert-positive) patients without cough more than two weeks was the highest in indigenous population (39.3%), followed by prison inmates (27.7%), and the rural poor (22.8%). CONCLUSIONS: The innovative ACF strategy using mobile unit yielded a substantial number of TB patients and achieved successful treatment outcomes. TB screening in prison, indigenous population, and urban and rural poor communities was found to be effective. The combined use of CXR and Xpert largely contributed to increased case detection.

Factors Associated with Loss to Follow-up during Treatment for Multidrug-Resistant Tuberculosis, the Philippines, 2012-2014.

To identify factors associated with loss to follow-up during treatment for multidrug-resistant (MDR) tuberculosis (TB) in the Philippines, we conducted a case-control study of adult patients who began receiving treatment for rifampin-resistant TB during July 1-December 31, 2012. Among 91 case-patients (those lost to follow-up) and 182 control-patients (those who adhered to treatment), independent factors associated with loss to follow-up included patients' higher self-rating of the severity of vomiting as an adverse drug reaction and alcohol abuse. Protective factors included receiving any type of assistance from the TB program, better TB knowledge, and higher levels of trust in and support from physicians and nurses. These results provide insights for designing interventions aimed at reducing patient loss to follow-up during treatment for MDR TB.

Restarting the tuberculosis programme post-Haiyan.

PROBLEM: Typhoon Haiyan damaged or destroyed health infrastructure, equipment and services essential to the Philippine National Tuberculosis Programme (NTP), and it had to be re-established in the affected areas in Regions 6, 7 and 8. Continuing treatment and restoring diagnostic capacity were also challenging. CONTEXT: The Philippines has one of the highest tuberculosis (TB) burdens in the world. At the time of Typhoon Haiyan, there were an estimated 26 ,00 TB cases on treatment at directly observed treatment, short-course (DOTS) centres and 356 multidrug-resistant TB cases registered at programmatic management of drug-resistant TB (PMDT) sites. As TB was not included in the Philippines early-warning post-disaster surveillance system, tracking TB patients was difficult after Haiyan. ACTIONS AND OUTCOMES: Immediately following Haiyan, each aspect of the NTP was assessed to determine the extent of damage. TB patients were traced and services restored. We created maps showing the location of temporary TB diagnostic and treatment services, which hastened referrals. We provided new laboratory equipment, training and rapid testing capabilities in the affected regions. All TB services in the affected areas (473 DOTS, 490 TB microscopy and six PMDT facilities) were restored just two months after Haiyan. LESSONS LEARNT: Key lessons learnt from the NTP experience following Tyhoon Haiyan were: (1) the importance of having an electronic TB registry (database); (2) the need to include TB in the post-disaster surveillance system; (3) clear guidelines for TB control in disasters; and (4) the importance of coordination with all partners.

Initial drug resistance and tuberculosis treatment outcomes: systematic review and meta-analysis.

BACKGROUND: Despite the increasing prevalence of drug-resistant tuberculosis, most low- and middle-income countries use standardized regimens, without assessment of drug susceptibility. PURPOSE: To perform a systematic review and meta-analysis of the effect of initial drug resistance and treatment regimen on tuberculosis treatment outcomes. DATA SOURCES: PubMed, the Cochrane Central Database of Clinical Trials, and EMBASE were searched for studies published in English from 1965 to June 2007. Additional studies were identified from cited references. STUDY SELECTION: Randomized, controlled trials and cohort studies of standardized treatment of previously untreated patients with culture-confirmed pulmonary tuberculosis. Drug-susceptibility testing was done on pretreatment isolates from all patients and from patients with treatment failure or relapse. DATA EXTRACTION: Two authors reviewed the studies for methods, initial drug resistance, treatment regimens, and outcomes. DATA SYNTHESIS: Pooled cumulative incidences were computed with random-effects meta-analyses. Association between risk factors and outcomes were determined by using stratified analyses. The cumulative incidence of acquired drug resistance with initially pan-sensitive strains was 0.8% (95% CI, 0.5% to 1.0%) compared with 6% (CI, 4% to 8%) with initially single drug-resistant strains and 14% (CI, 9% to 20%) with initially polydrug-resistant strains. Failure and relapse were most strongly associated with initial drug resistance. Failure was also associated with shorter duration of rifampin therapy and nonuse of streptomycin, whereas the rate of relapse was higher with shorter duration of rifampin therapy and nonuse of pyrazinamide. LIMITATIONS: Few studies included HIV-infected persons, and treatment outcomes were pooled despite considerable heterogeneity. CONCLUSION: Treatment outcomes were substantially worse in the presence of initial drug resistance, which has important implications in resource-limited settings in which drug resistance is prevalent.