Public Health Action最新文献

Introduction: Despite the effectiveness of TB preventive treatment (TPT) in reducing TB incidence and mortality among people living with HIV (PLHIV), uptake has been low. We conducted a cluster randomised trial to evaluate a choice architecture-based intervention for prescribing TPT (the 'CAT' study) to PLHIV in Mozambique, nested within the short-course 3HP regimen roll-out, and qualitatively assessed intervention acceptability and feasibility with healthcare workers (HCWs).

Methods: The CAT intervention comprised training on default TPT prescribing and prescribing stickers integrated into antiretroviral therapy (ART) stationery. We assessed intervention acceptability and feasibility to increase TPT prescribing through 25 in-depth interviews (IDIs) with HCWs from participating clinics between August and September 2022. Thematic analysis of the IDIs identified key themes.

Results: Participants reported a positive impact of the intervention on patient care, though workload opinions varied. Participants reported that CAT did not significantly alter routine TPT prescribing processes but highlighted the need for reminders and decision-support tools. CAT was viewed to streamline patient management, particularly identifying eligible TPT patients and simplifying documentation.

Conclusion: The CAT strategy could enhance TPT delivery to PLHIV and integrate it into preventive care for other diseases.

An electronic dashboard for oxygen monitoring and stockout prevention was implemented during the COVID-19 pandemic in 2022 by Jhpiego through the United States Agency for International Development Reaching Impact, Saturation, and Epidemic Control program and Government of Lesotho across 12 hospitals in Lesotho. Nurses documented patient blood oxygen levels, oxygen usage, and facility-level stocks on a daily checklist, which populated a dashboard that estimated oxygen demand usage and visualized facility-level oxygen stocks and impending stockouts. During 359 facility days evaluated, dashboard data reported 82/1,796 patients (4.6%) as hypoxemic, 186,802 L/day average oxygen usage, and successful prevention of all 14 potential stockouts.

Setting: An established response to an outbreak of drug-resistant TB (DR-TB) on Daru Island, South Fly District (SFD), Western Province, Papua New Guinea (PNG).

Objective: To describe and evaluate the trends in TB case notification disaggregated by demographic and clinical characteristics, programmatic interventions for TB and COVID-19 and treatment outcomes in 2017-2022.

Design: A cohort study of routinely collected programmatic data of all patients registered for TB treatment in SFD comparing pre-COVID (2017-2019) to COVID (2020-2022) periods.

Results: Of the 3,751 TB cases registered, 19.6% had DR-TB, and the case notification rate was 1,792/100,000 for Daru and 623/100,000 for SFD. There was a 29.2% reduction in case notifications from 2019 to 2021, with recovery in 2022. During COVID, the healthcare workforce was adversely impacted, and active TB case-finding was stopped. During COVID, compared to pre-COVID, bacteriological confirmation increased (62.3% to 71.9%), whereas rates of child TB notifications (11.6% to 9.1%), pulmonary TB (60.8% to 57.4%) and DR-TB (20.7% to 18.6%) decreased. High rates of treatment success were maintained for both drug-susceptible (86.5%) and DR-TB (83.6%).

Conclusion: Health systems strengthening and community engagement before COVID likely contributed to resilience and mitigated potential impacts on TB in this remote and resource-limited setting. Case notifications remain very high, and additional interventions are needed to interrupt transmission.

Setting: Linezolid (LZD) has emerged as a critical agent and core component of regimens to treat drug-resistant TB (DR-TB); however, there are ongoing uncertainties regarding its safety and the optimal dosing approach. Since 2016, linezolid has been used in the treatment of patients diagnosed with DR-TB at Daru Provincial Hospital, PNG.

Objective: To describe the patient characteristics, treatment outcomes, and tolerability of linezolid-containing regimens used to treat DR-TB in Daru, Western Province.

Design: This was a retrospective analysis of programmatic data.

Results: A total of 632 eligible patients were diagnosed with DR-TB during the study period. Of these, 580 (91.8%) were commenced on a LZD-containing regimen. Among patients with baseline haemoglobin results available (380/632, 60.1%), the median value was 10.1 g/dL, with a mean corpuscular volume of 70.7 fL, 78.1% of those with haemoglobin results were anaemic at baseline. Despite this, 242/580 (41.7%) patients were able to complete the full LZD course of treatment (typically 18 months) without dose reduction or interruption. Treatment success was observed in 87.9% of the cohort. Neurotoxicity was not commonly reported, but adverse events were likely under-reported.

Conclusion: In this cohort, with high rates of baseline anaemia, prolonged therapy with LZD was relatively well tolerated.

Setting: In sub-Saharan Africa, the syndemic of HIV and non-communicable diseases (NCDs) poses a significant challenge. To address this, leading global think tanks like the WHO advocate for integrated HIV/NCD care at primary healthcare levels. However, comparative empirical data on the costs of integrated care are limited. South Africa, with the largest HIV programme globally, was purposively selected for our comparative case study.

Objective: To determine the cost of integrated HIV/NCD care from the providers' perspective at two 'ideal status' public healthcare facilities in South Africa as case studies.

Design: A multi-pronged methodology was used to collect provider cost data via retrospective documentary sources or records and a question-and-answer session with facility managers who provided key information on cost-related data. Data analysis utilised an activity-based costing (ABC) method.

Results: Despite the difference in the size of the clinics, the cost per patient in terms of ABC is similar between the two primary healthcare facilities, USD261.60 and USD226.30, respectively.

Conclusion: The ABC method can be utilised to cost integrated care, foster health economic data availability for future research, and inform health policymakers.

Setting: Papua New Guinea (PNG) is a high-burden country for multidrug-resistant or rifampicin-resistant TB (MDR/RR-TB). There are limited data on MDR/RR-TB notifications and treatment from the most populous province.

Objective: Describe MDR/RR-TB detection and treatment outcomes in Morobe Province, the impact of the COVID-19 pandemic and factors associated with unfavourable treatment outcomes.

Design: Retrospective cohort study of MDR/RR-TB notifications between 2012 and 2021 using routine programme registration data. Favourable outcomes were compared to unfavourable outcomes using multivariable regression.

Results: Between 2012 and 2021, 160 cases of MDR/RR-TB were bacteriologically confirmed. Few diagnoses were made among children (2.5%), extrapulmonary cases (0.6%) or rural residents (38%). Case notifications rose sharply from 2016 after the introduction of GeneXpert to 5.6 cases per 100,000 population in 2020 before a reduction in 2021 coinciding with COVID-19 disruptions. Loss to follow-up (27.5%) and death (8.1%) were common. Unfavourable treatment outcomes were more common among male participants (aOR 3.00, 95% CI 1.38-6.45) and those treated with longer injectable-containing regimens (aOR 3.39, 95% CI 1.30-8.80).

Conclusion: MDR/RR-TB detection has increased overall, but enhanced and decentralised diagnostic capacity is needed, including in important sub-populations. Persisting low treatment success rates must be urgently addressed to minimise the further emergence of drug-resistant TB in Morobe Province.

Setting: Papua New Guinea is a high-burden multidrug-resistant TB (MDR/RR-TB) country that reports low rates of bacteriological confirmation. Sputum drug susceptibility testing for second-line drugs is important. Access to culture is limited.

Objective: To evaluate the prevalence of mycobacterial sputum sample culture contamination and determine factors associated with contamination.

Design: A retrospective analysis of data from a TB diagnostic accuracy study that used culture as the diagnostic reference standard. Data included characteristics of people with presumptive pulmonary TB who provided sputum, sputum quality and culture results.

Results: Sputum (1-3 samples) was collected from 174 adults. The median age was 33 years (IQR 24-47). Of 337 samples sent for culture, 28% were contaminated. Contamination was strongly associated with samples self-collected by participants outside clinic hours (aOR 5.69; 95% CI 2.62-12.38). Contamination risk increased with delays in shipping to the reference laboratory (aOR 1.19 per day, 95% CI 1.10-1.29) beyond the minimum 3 days. Contamination was less frequent among people aged 35-44 years compared to 18-24 years (aOR 0.27, 95% CI 0.10-0.73). Sputum quality was not associated with culture contamination.

Conclusion: Culture contamination could be reduced using spot sputum collection, expedited submission to laboratories and faster shipping when required.

Objective: We adapted a mobile TB screening unit to create an integrated screening program for noncommunicable diseases and TB, using community health worker (CHW) navigators to support linkage to care. We piloted the model in underserved communities of Lima, Peru, evaluating its feasibility, acceptability, and ability to continue supporting TB case detection.

Design: The program provided screening for TB, hypertension, diabetes, and depression and was rebranded to avoid TB-associated stigma. CHW navigators were trained to link people to care for all four conditions. Implementation barriers and facilitators were identified from the implementation team's meeting minutes.

Results: During August-December 2023, we screened 1,000 adults, of whom 254 (25%) were referred for evaluation and paired with CHW navigators. Of these, 197 (78%) underwent evaluation at a health center, and 151 (59%) initiated some form of treatment, including 4 for TB. Completion of the linkage cascade was 93% for TB, 81% for hypertension, 71% for diabetes and 69% for depression. Limitations in equipment and staff were implementation barriers, while multiple flexibility-related facilitators were identified.

Conclusion: The integrated screening program was acceptable and feasible and still identified people with TB. CHW navigators were effective in supporting linkage to primary care services.

Setting: Three health facilities: Chongwe Health Centre (CHC), Chongwe District Hospital (CDH), and Ngwerere Health Centre (NHC) in Chongwe District, Lusaka Province, Zambia.

Objective: To describe the epidemiological trend of TB in 2015-2018, with the 2014 data as baseline.

Design: This was an observational study.

Results: At CHC, CDH, and NHC, 457, 851 and 85 cases, respectively, of all types of TB were registered in 2014-2018. The numbers of patients with presumptive TB at CHC and CDH increased from 606 and 406, respectively, in 2014 to 1068 and 1848, respectively, in 2018. The proportion of patients with bacteriologically positive TB among patients with presumptive TB decreased at CHC and CDH from over 10% in 2014 to less than 5% in late 2018. The treatment success rates decreased at CHC and CDH in 2017 from respectively 93.7% and 93.0% in 2014 to 69.1% and 73.0% in 2017. GeneXpert equipment was installed at CHC in 2016 and CDH in 2017.

Conclusion: After introducing GeneXpert equipment at CHC and CDH, the proportion of bacteriologically-positive TB among presumptive TB significantly decreased because of the high number of patients with presumptive TB screened; however, it may have also caused treatment success rates to have stumbled.