Clinical standards for the diagnosis, treatment and prevention of TB infection.

BACKGROUND: Tuberculosis (TB) preventive therapy (TPT) decreases the risk of developing TB disease and its associated morbidity and mortality. The aim of these clinical standards is to guide the assessment, management of TB infection (TBI) and implementation of TPT.METHODS: A panel of global experts in the field of TB care was identified; 41 participated in a Delphi process. A 5-point Likert scale was used to score the initial standards. After rounds of revision, the document was approved with 100% agreement.RESULTS: Eight clinical standards were defined: Standard 1, all individuals belonging to at-risk groups for TB should undergo testing for TBI; Standard 2, all individual candidates for TPT (including caregivers of children) should undergo a counselling/health education session; Standard 3, testing for TBI: timing and test of choice should be optimised; Standard 4, TB disease should be excluded prior to initiation of TPT; Standard 5, all candidates for TPT should undergo a set of baseline examinations; Standard 6, all individuals initiating TPT should receive one of the recommended regimens; Standard 7, all individuals who have started TPT should be monitored; Standard 8, a TBI screening and testing register should be kept to inform the cascade of care.CONCLUSION: This is the first consensus-based set of Clinical Standards for TBI. This document guides clinicians, programme managers and public health officers in planning and implementing adequate measures to assess and manage TBI.

Examining the cost of community-based tuberculosis treatment in South Africa.

SETTING: While South Africa has improved access to tuberculosis (TB) treatment and care, the 2015 treatment success rate for multidrug-resistant TB (MDR-TB) remains low, at 55%. Community-based TB treatment and care improves patient retention compared to the standard of care alone.OBJECTIVE: To assess the cost of a USAID-funded community-based TB model in Nelson Mandela Bay Health District (NMBHD), Eastern Cape Province, South Africa compared to the national standard of care alone.DESIGN: We estimated the cost of community-based DR-TB treatment and adherence support compared to the standard of care alone.RESULTS: Average overall costs were US$2827 lower per patient on the community-based model than the standard of care alone.CONCLUSION: The per-patient cost of the community-based model is lower than the standard of care alone. Assuming the costs and effects of a community-based model implemented in NMBHD were observed at a larger scale, implementing the model could reduce overall health system costs.

Process measure of FAST tuberculosis infection control demonstrates delay in likely effective treatment.

SETTING: The tuberculous infection control strategy, FAST (Find cases Actively, Separate safely and Treat effectively), recommends prompt initiation of likely effective anti-tuberculosis treatment informed by Xpert® MTB/RIF results.OBJECTIVE: To describe FAST implementation at Quang Nam Provincial TB and Lung Disease Hospital (QNH), Tam Ky, Viet Nam, using time to initiation of effective TB treatment as a process measure. DESIGN: Hospital logs were used to calculate the time to likely effective treatment in patients with pulmonary TB (PTB) hospitalised during the study period. RESULTS: Between 1 January and 31 December 2016, of 858 patients treated for PTB, 493 (57.5%) received likely effective treatment. The median time to likely effective treatment was 3 days (interquartile range 2.0-6.0), with 213 (43.2%) patients receiving likely effective treatment within 2 days. Of 81 patients receiving likely effective treatment for drug-susceptible TB with a positive Xpert result as their initial in-patient diagnostic test, 64 (79.0%) received likely effective treatment within 2 days compared with 10 (5.7%) who were initially smear-negative then found to be Xpert-positive (P < 0.0001). CONCLUSIONS: A 'time to' process measure of the FAST tuberculous infection control strategy indicates delays in the initiation of likely effective anti-tuberculosis treatment in a resource-limited hospital. Expanding access to Xpert may speed time to likely effective treatment.

[Role of ST2 biomarker for the evaluation of myocardial remodeling in patients with ischemic heart failure with preserved ejection fraction].

AIM: 1) To study the role of soluble ST2 (sST2) in evaluation of left ventricular (LV) myocardial remodeling and 2) to evaluate the predictive value of sST2 for development of adverse cardiovascular events (CVE) during 12 months following myocardial revascularization in patients with ischemic heart disease (IHD) and chronic heart failure (CHF) with preserved LV ejection fraction (EF). MATERIALS AND METHODS: The study included 55 patients (42 men) with IHD and NYHA FC I-III CHF with LV EF 63 [59; 65] % aged 65 [58; 69] who were scheduled for myocardial revascularization. Echocardiographic evaluation of myocardial stress and myocardial remodeling indexes was performed for all patients. Content of sST2 was measured using enzyme immunoassay. RESULTS: Group 1 included patients with sST2 overexpression (≥35 ng/ml) (n=26; sST2-43.75 ng/ml) and group 2 - patients with the sST2 expression.

TB preventive therapy for people living with HIV: key considerations for scale-up in resource-limited settings.

Tuberculosis (TB) is the leading cause of death for persons living with the human immunodeficiency virus (PLHIV). TB preventive therapy (TPT) works synergistically with, and independently of, antiretroviral therapy to reduce TB morbidity, mortality and incidence among PLHIV. However, although TPT is a crucial and cost-effective component of HIV care for adults and children and has been recommended as an international standard of care for over a decade, it remains highly underutilized. If we are to end the global TB epidemic, we must address the significant reservoir of tuberculous infection, especially in those, such as PLHIV, who are most likely to progress to TB disease. To do so, we must confront the pervasive perception that barriers to TPT scale-up are insurmountable in resource-limited settings. Here we review available evidence to address several commonly stated obstacles to TPT scale-up, including the need for the tuberculin skin test, limited diagnostic capacity to reliably exclude TB disease, concerns about creating drug resistance, suboptimal patient adherence to therapy, inability to monitor for and prevent adverse events, a 'one size fits all' option for TPT regimen and duration, and uncertainty about TPT use in children, adolescents, and pregnant women. We also discuss TPT delivery in the era of differentiated care for PLHIV, how best to tackle advanced planning for drug procurement and supply chain management, and how to create an enabling environment for TPT scale-up success.

Evaluation of the Tuberculosis Infection Control Training Center, Tajikistan, 2014-2015.

SETTING: Training center on tuberculosis (TB) infection control (IC) for health care workers in the Central Asian Republics region. OBJECTIVE: To assess the effects of TB IC training courses conducted at the Tuberculosis Infection Control Training Center in Machiton, Tajikistan. DESIGN: Participants who participated in training (n = 89) during the first year of operation (April 2014-February 2015) were invited to participate in a post-training interview. RESULTS: Of the 89 participants, 84 (94%) completed the interview and expressed satisfaction with the training. Eighty (95%) participants reported meeting with workplace leadership to discuss the training. Of these, 69 (85%) reported discussing changes required to meet TB IC standards. Self-reported changes in TB IC practices at work facilities post training included the creation of TB IC committees, designation of a TB IC focal person, TB IC planning, policies to separate infectious patients in waiting rooms, provision of masks for infectious patients, development of cough etiquette policies, improved glove availability, hand hygiene programs, and TB IC posters in waiting rooms. CONCLUSIONS: Participant satisfaction and reported changes in TB IC activities illustrate the potential of these training courses to improve TB IC in the region. Future training courses may be tailored to specific audiences using a structured conceptual framework to impact administration, budgeting, and facilities management of TB IC practices.

TIME Impact - a new user-friendly tuberculosis (TB) model to inform TB policy decisions.

Tuberculosis (TB) is the leading cause of death from infectious disease worldwide, predominantly affecting low- and middle-income countries (LMICs), where resources are limited. As such, countries need to be able to choose the most efficient interventions for their respective setting. Mathematical models can be valuable tools to inform rational policy decisions and improve resource allocation, but are often unavailable or inaccessible for LMICs, particularly in TB. We developed TIME Impact, a user-friendly TB model that enables local capacity building and strengthens country-specific policy discussions to inform support funding applications at the (sub-)national level (e.g. Ministry of Finance) or to international donors (e.g. the Global Fund to Fight AIDS, Tuberculosis and Malaria).TIME Impact is an epidemiological transmission model nested in TIME, a set of TB modelling tools available for free download within the widely-used Spectrum software. The TIME Impact model reflects key aspects of the natural history of TB, with additional structure for HIV/ART, drug resistance, treatment history and age. TIME Impact enables national TB programmes (NTPs) and other TB policymakers to better understand their own TB epidemic, plan their response, apply for funding and evaluate the implementation of the response.The explicit aim of TIME Impact's user-friendly interface is to enable training of local and international TB experts towards independent use. During application of TIME Impact, close involvement of the NTPs and other local partners also builds critical understanding of the modelling methods, assumptions and limitations inherent to modelling. This is essential to generate broad country-level ownership of the modelling data inputs and results. In turn, it stimulates discussions and a review of the current evidence and assumptions, strengthening the decision-making process in general.TIME Impact has been effectively applied in a variety of settings. In South Africa, it informed the first South African HIV and TB Investment Cases and successfully leveraged additional resources from the National Treasury at a time of austerity. In Ghana, a long-term TIME model-centred interaction with the NTP provided new insights into the local epidemiology and guided resource allocation decisions to improve impact.

Three cases of donor-derived pulmonary tuberculosis in lung transplant recipients and review of 12 previously reported cases: opportunities for early diagnosis and prevention.

INTRODUCTION: Solid organ transplant recipients have a higher frequency of tuberculosis (TB) than the general population, with mortality rates of approximately 30%. Although donor-derived TB is reported to account for <5% of TB in solid organ transplants, the source of Mycobacterium tuberculosis infection is infrequently determined. METHODS: We report 3 new cases of pulmonary TB in lung transplant recipients attributed to donor infection, and review the 12 previously reported cases to assess whether cases could have been prevented and whether any cases that might occur in the future could be detected and investigated more quickly. Specifically, we evaluate whether opportunities existed to determine TB risk on the basis of routine donor history, to expedite diagnosis through routine mycobacterial smears and cultures of respiratory specimens early post transplant, and to utilize molecular tools to investigate infection sources epidemiologically. FINDINGS: On review, donor TB risk was present among 7 cases. Routine smears and cultures diagnosed 4 asymptomatic cases. Genotyping was used to support epidemiologic findings in 6 cases. CONCLUSION: Validated screening protocols, including microbiological testing and newer technologies (e.g., interferon-gamma release assays) to identify unrecognized M. tuberculosis infection in deceased donors, are warranted.

Evaluation of program performance and expenditures in a report of performance measures (RPM) via a case study of two Florida county tuberculosis programs.

Health Department (HD) managers at both state and local levels are in desperate need of tools to assist in monitoring and evaluating programs. The purpose of this study is to assess the feasibility and utility of linking program performance scores and expenditures into a Report of Performance Measures (RPM). We analyzed secondary data on performance indicators, selected by HD staff, and expenditures, related to six surveillance activities, from two, similar, high-incidence, tuberculosis (TB) programs in Florida from 2002 to 2003. We compared the findings between the county HDs as an illustration of basic cost-effectiveness benchmarking, based on the cost-effectiveness grid. Data included here provide examples of: (1) two instances in which one county was operating relatively inefficiently compared to the other; (2) two instances in which performance and expenditures were similar for the counties; and (3) two instances in which one county spent more for higher performance scores than the other. These data illustrate how the RPM can be used to facilitate benchmarking, a basic evaluation tool. They also demonstrate ways to identify potential operational inefficiencies in a single time period and ultimately over time. It is thus likely to be a feasible and useful management tool.