Disability, comorbidities and risk determinants at end of TB treatment in Kenya, Uganda, Zambia and Zimbabwe.

BACKGROUND: We examined the feasibility of assessing and referring adults successfully completing TB treatment for comorbidities, risk determinants and disability in health facilities in Kenya, Uganda, Zambia and Zimbabwe. METHODS: This was a cross-sectional study within national TB programmes. RESULTS: Health workers assessed 1,063 patients (78% of eligible) in a median of 22 min [IQR 16-35] and found it useful and feasible to accomplish in addition to other responsibilities. For comorbidities, 476 (44%) had HIV co-infection, 172 (16%) had high blood pressure (newly detected in 124), 43 (4%) had mental health disorders (newly detected in 33) and 36 (3%) had diabetes mellitus. The most common risk determinants were 'probable alcohol dependence' (15%) and malnutrition (14%). Disability, defined as walking <400 m in 6 min, was found in 151/882 (17%). Overall, 763 (72%) patients had at least one comorbidity, risk determinant and/or disability. At least two-thirds of eligible patients were referred for care, although 80% of those with disability needed referral outside their original health facility. CONCLUSIONS: Seven in 10 patients completing TB treatment had at least one comorbidity, risk determinant and/or disability. This emphasises the need for offering early patient-centred care, including pulmonary rehabilitation, to improve quality of life, reduce TB recurrence and increase long-term survival.

CONTEXTE: Nous avons examiné la faisabilité d'évaluer et de référer les adultes ayant terminé avec succès le traitement de la TB pour les comorbidités, les déterminants de risque et l'invalidité dans les établissements de santé au Kenya, en Ouganda, en Zambie et au Zimbabwe. MÉTHODES: Il s'agissait d'une étude transversale menée dans le cadre des programmes nationaux de lutte contre la TB. RÉSULTATS: Les agents de santé ont évalué 1 063 patients (78% des personnes éligibles) en médiane de 22 min (IQR 16­35) et ont jugé utile et réalisable d'accomplir cette tâche en plus de leurs autres responsabilités. Pour les comorbidités, 476 (44%) étaient co-infectés par le VIH, 172 (16%) souffraient d'hypertension artérielle (dont 124 nouvellement diagnostiqués), 43 (4%) présentaient des troubles de santé mentale (dont 33 nouvellement diagnostiqués) et 36 (3%) étaient diabétiques. Les déterminants de risque les plus courants étaient une « dépendance probable à l'alcool ¼ (15%) et la malnutrition (14%). L'invalidité, définie comme une marche <400 m en 6 min, a été observée chez 151/882 (17%) des patients. Dans l'ensemble, 763 (72%) des patients présentaient au moins une comorbidité, un déterminant de risque et/ou une invalidité. Au moins deux tiers des patients éligibles ont été référés pour des soins, bien que 80% de ceux souffrant d'invalidité aient besoin d'être référés en dehors de leur établissement de santé d'origine. CONCLUSIONS: Sept patients sur 10 ayant terminé le traitement de la TB présentaient au moins une comorbidité, un déterminant de risque et/ou une invalidité. Cela souligne la nécessité d'offrir des soins précoces centrés sur le patient, y compris une réadaptation pulmonaire, pour améliorer la qualité de vie, réduire la récurrence de la TB et augmenter la survie à long terme.

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.

Decentralisation of child tuberculosis services increases case finding and uptake of preventive therapy in Uganda.

BACKGROUND: A lack of capacity to diagnose tuberculosis (TB) in children at peripheral health facilities and limited contact screening and management contribute to low case finding in TB-endemic settings. OBJECTIVE: To evaluate the implementation of a pilot project that strengthened diagnosis, treatment and prevention of child TB at peripheral health facilities in Uganda. METHODS: In June 2015, health care workers at peripheral health facilities were trained to diagnose and treat child TB. Community health care workers were trained to screen household TB contacts. Before-and-after analysis as well as comparisons with non-intervention districts were used to evaluate impact on caseload and treatment outcomes. RESULTS: By December 2016, the average number of children (age < 15 years) diagnosed with TB increased from 45 to 108 per quarter. The proportion of child TB among all TB cases increased from 8.8% to 15%, and the proportion completing treatment increased from 65% to 82%. Of 2270 child TB contacts screened, 55 (2.4%) were diagnosed with TB. Of 910 eligible child contacts, 670 (74%) started preventive therapy, 569 (85%) of whom completed therapy. CONCLUSION: The strengthening of child TB services at peripheral health facilities in Uganda was associated with increased case finding, improved treatment outcomes and the successful implementation of contact screening and management.