Public Health Action最新文献

Objective: To evaluate the impact of Truenat assays on the diagnosis of TB at peripheral facilities in Nigeria.

Methods: This was a retrospective cross-sectional study across 34 out of 38 Truenat-implementing facilities in Nigeria. These facilities offer DOTS services. Information on turnaround time (TAT) for TB diagnosis and time to commencement of treatment was obtained. Also, trends in TB case notifications at the facilities 9 months prior to and 9 months during Truenat implementation were compared.

Results: Of 2,335 entries, 70.1% (1,636) were used to determine TAT, while 45.8% (n = 1,070) were used for time to treatment initiation. The median time to diagnosis was <24 hours (IQR 0-1 days). The majority (57.9%) were diagnosed in <24 hours. The median time to treatment initiation was 1.5 days (IQR 0-3). In 9 months before the introduction of Truenat, 8% of 20,424 presumptives evaluated were positive for TB, while during the implementation, 9% of 37,087 presumptives were positive for TB.

Conclusion: Truenat deployment led to an increase in TB and DR-TB case detection in peripheral facilities in Nigeria. It also decreased TAT and time to TB treatment initiation. These have positive implications in the fight against TB, and Truenat is relevant in finding missing TB cases in Nigeria.

Setting: Daru Island in Papua New Guinea (PNG) has a high prevalence of TB and multidrug-resistant TB (MDR-TB).

Objective: To evaluate the early implementation of a community-wide project to detect and treat TB disease and infection, outline the decision-making processes, and change the model of care.

Design: A continuous quality improvement (CQI) initiative used a plan-do-study-act (PDSA) framework for prospective implementation. Care cascades were analysed for case detection, treatment, and TB preventive treatment (TPT) initiation.

Results: Of 3,263 people screened for TB between June and December 2023, 13.7% (447/3,263) screened positive (CAD4TB or symptoms), 77.9% (348/447) had Xpert Ultra testing, 6.9% (24/348) were diagnosed with TB and all initiated treatment. For 5-34-year-olds without active TB (n = 1,928), 82.0% (1,581/1,928) had tuberculin skin testing (TST), 96.1% (1,519/1,581) had TST read, 23.0% (350/1,519) were TST-positive, 95.4% (334/350) were TPT eligible, and 78.7% (263/334) initiated TPT. Three PDSA review cycles informed adjustments to the model of care, including CAD4TB threshold and TPT criteria. Key challenges identified were meeting screening targets, sputum unavailability from asymptomatic individuals with high CAD4TB scores, and consumable stock-outs.

Conclusion: CQI improved project implementation by increasing the detection of TB disease and infection and accelerating the pace of screening needed to achieve timely community-wide coverage.

Introduction: India's National TB Elimination Programme (NTEP) aims to eliminate TB-related catastrophic expenditure by offering free diagnosis and treatment. However, 3.9% of TB patients have drug-resistant TB (DR-TB) and are facing higher costs.

Objective: To assess DR-TB patients' diagnosis and pre-treatment evaluation costs, catastrophic cost incidence, and its relation to patient characteristics.

Methods: The study included DR-TB patients from three District Drug-Resistant TB Centres in Delhi and Faridabad (October 2021-June 2022). Socio-economic and clinical characteristics and direct medical and non-medical costs from drug susceptibility testing eligibility to the start of DR-TB treatment were collected using patient interviews and records. Indirect costs were calculated via the human capital approach, defining catastrophic costs as expenses over 20% of household annual income. Multivariable regression was used to estimate the effects of patient characteristics on catastrophic costs.

Results: Of 158 patients, 37.3% were aged 19-30 years, and 55.7% were women. Median total cost was USD326.6 (IQR 132.7-666.7), with 48.2% for diagnosis and 66.0% indirect. 32% faced catastrophic costs, with manual labourers at higher risk (adjusted OR 4.4).

Conclusion: Despite free diagnosis and treatment, a significant portion of DR-TB households in India incur catastrophic costs, mainly from indirect expenses, indicating a need for targeted policy and programme interventions.

Setting: Madang Province is located on the northern coast of Papua New Guinea (PNG), a critical mixing point between the populous highlands and more remote regions. Madang Province faces challenges with limited capacity to diagnose and treat TB.

Objective: To describe the TB caseload and investigate factors associated with known unfavourable treatment outcomes.

Design: This is a retrospective cohort study using routinely collected TB programmatic data for treatments commenced 1 January 2019 to 31 December 2021. Using multivariable logistic regression, factors associated with known unfavourable treatment outcomes-death, failure after treatment, and loss to follow-up (LTFU)-were evaluated.

Results: Of the 4,668 registered and treated, 3,755 had an evaluated outcome, and 33% had unfavourable outcomes, most commonly LTFU (23%). Unfavourable treatment outcomes were significantly associated with HIV-untested (aOR 2.82 compared to HIV-negative; 95% CI 2.39-3.33), having drug-resistant TB (aOR 3.26 compared to drug-susceptible TB, 95% CI 1.18-9.00), and travel time to the health facility 1-<3 hours by foot (aOR 3.53 compared to <1 hour by foot; 95% CI 1.04-12.06).

Conclusion: High LTFU from TB treatment was associated with factors that indicate barriers to access to care and treatment completion. Decentralisation and strengthening of TB services for improved person-centred care and treatment support are urgently required in Madang Province.

Setting: Bacteriological confirmation of TB diagnosis remains a key operational challenge in Papua New Guinea. Sandaun Provincial Hospital (SPH) is the main TB diagnostic and treatment centre of West Sepik Province.

Objective: To evaluate TB caseload, patient characteristics, and quality of diagnosis at SPH between 2016 and 2021.

Design: A retrospective descriptive study using TB treatment, laboratory, and presumptive TB registers to collect data on all TB patients. We used multivariable logistic regression to determine factors associated with bacteriological confirmation.

Results: Of 1,305 TB patients registered, 25% were children (<15 years) and 30% had extrapulmonary TB. The quality of sputum was associated with a positive smear microscopy result (P = 0.002). The proportion bacteriologically confirmed was low (37.3%), being higher in young adults 15-44 years (50.6%, 377/745) than in children <15 years (6.3%, 20/319) or older adults ≥45 years (37.6%, 68/181). Bacteriological confirmation was less likely in people travelling ≥3 hours to a health facility (adjusted OR 0.58, 95% CI 0.34-0.97) and extrapulmonary TB (aOR 0.01, 95% CI 0.00-0.03) but more likely for retreatment cases (aOR 1.59, 95% CI 1.00-2.51).

Conclusion: Diagnostic services in West Sepik Province need strengthening to achieve a higher proportion of bacteriological confirmation in new pulmonary and extrapulmonary TB cases of all ages and improve access for the rural population.

Setting: Japan: a low-TB-burden country.

Objective: To characterise TB-related technical enquiries received in 2020-2022, and share the lessons learnt.

Design: This was a descriptive study.

Results: We received 1,898 communications, of which 1,447 (40.2 per month) were classified as technical enquiries, 34% fewer than the 2,197 enquiries received in 2017-2019. The enquiry rates were highest for Shimane (4.32/100,000 population) and Yamanashi (2.59/100,000 population) prefectures, and lowest in Ehime (0.00/100,000 population) and Yamagata (0.09/100,000 population) prefectures. The main organisations the enquirers belonged to were local governments (n = 989, 68.3%) and healthcare facilities (n = 242, 16.7%). The enquirers included medical doctors (n = 236, 16.3%), nurses (n = 814, 56.3%), and the general public (n = 141, 9.7%). The most frequent enquiries were about TB diagnosis and treatment, including laboratory diagnosis (n = 442, 30.6%), followed by the regulatory framework (n = 216, 14.9%), contact investigation (n = 151, 10.8%), and TB in foreigners (n = 112, 7.9%).

Conclusion: During the COVID-19 era, we received two-thirds of technical enquiries compared with 2017-2019, because local health offices were overwhelmed by the pandemic. Since the most frequent enquiries were about diagnosis and treatment of TB, the health ministry of Japan should maintain a few specialised TB institutions with TB physicians to provide technical assistance.

Setting: Multidrug-resistant/rifampicin-resistant TB (MDR/RR-TB) is now endemic in the National Capital District (NCD), Papua New Guinea. Loss to follow-up (LTFU) is a challenge.

Objective: To evaluate and identify risk factors for LTFU, including pre-treatment LTFU, in adults with MDR/RR-TB at Port Moresby General Hospital (PMGH).

Design: A retrospective analysis of treatment initiation in adults diagnosed with MDR/RR-TB (2018-2022) and outcomes for a cohort treated for MDR/RR-TB (2014-2019). We assessed the factors associated with LTFU using multivariate logistic regression.

Results: Of 95 patients diagnosed with MDR/RR-TB at PMGH from 2018 to 2022, 21 (22%) were lost to follow-up before treatment. Of the 658 adults who initiated treatment for MDR/RR-TB at PMGH from 2014 to 2019, 161 (24%) were lost to follow-up during treatment. A higher proportion of patients on injectable-containing long regimens (110/404, 27%) were lost to follow-up than those on the all-oral regimen containing bedaquiline (13/66, 12%). Treatment loss to follow-up was associated with age (35-54 years age group: aOR 0.49, 95% CI 0.32-0.77; 55-75 years age group: aOR 0.42, 95% CI 0.19-0.90; compared to the 15-34 years age group), residence outside of NCD (aOR 1.79, 95% CI 1.04-3.06), and year of treatment initiation.

Conclusion: Pre-treatment LTFU requires programmatic focus. Shorter oral regimens and decentralised services may address the reasons for higher LTFU in younger people and people living outside NCD.

Papua New Guinea (PNG) is a high-burden country for TB, with an estimated annual TB incidence rate of 432 per 100,000 population. There are major challenges to the provision of quality care for TB patients with high rates of loss to follow-up, and multidrug-resistant TB is increasingly detected. In 2022-2023, the second Structured Operational Research Training IniTiative (SORT-IT) for TB was undertaken. Eight participants completed the course, and the outputs from these research projects highlight important current operational issues for the PNG TB programme in a range of settings. The first four articles in the series are published in this issue of Public Health Action, with the remainder to follow in subsequent issues.

Background: Quantifying quality of life (QoL) in extrapulmonary TB patients is crucial yet often overlooked. This study examines the impact of tuberculous lymphadenitis and pleuritis on patients' QoL, associated factors, and recurrence.

Methods: Data were collected prospectively from patients using a pre-designed questionnaire at baseline, post-treatment, and 2 years after treatment. Health domains are essential to overall health and well-being and can be assessed to understand health status. We included mobility for physical well-being, usual activities for self-care, pain/discomfort for disease manifestations, and anxiety/depression for emotional health.

Results: Of the 376 patients, 53% had TB lymphadenitis, and 47% had TB pleuritis, with a mean age of 25 years (SD ±12.95). The most commonly reported issues at baseline were pain/discomfort and restricted usual activities. After treatment, over 90% experienced improvement, but 8% re-developed symptoms after 2 years, and two patients required retreatment for recurrent EPTB. Predictors negatively impacting QoL included private income sources, residence outside the city, and marriage, with the first two primarily affecting emotional health.

Conclusion: Tuberculous lymphadenitis and pleuritis significantly impact patients' physical and emotional health, necessitating healthcare providers to address non-medical factors affecting QoL to reduce morbidity and mortality and improve QoL.