Feasibility, enablers and challenges of using timeliness metrics for household contact tracing and TB preventive therapy in Pakistan.

INTRODUCTION: Screening household contacts of TB patients and providing TB preventive therapy (TPT) is a key intervention to end the TB epidemic. Global and timely implementation of TPT in household contacts, however, is dismal. We adapted the 7-1-7 timeliness metric designed to evaluate and respond to infectious disease outbreaks or pandemics, and assessed the feasibility, enablers and challenges of implementing this metric for screening and management of household contacts of index patients with bacteriologically-confirmed pulmonary TB in Karachi city, Pakistan. METHODS: We conducted an explanatory mixed methods study with a quantitative component (cohort design) followed by a qualitative component (descriptive design with focus group discussions). RESULTS: From January-June 2023, 92% of 450 index patients had their household contacts line-listed within seven days of initiating anti-TB treatment ("first 7"). In 84% of 1342 household contacts, screening outcomes were ascertained within one day of line-listing ("next 1"). In 35% of 256 household contacts eligible for further evaluation by a medical officer (aged ≤5 years or with chest symptoms), anti-tuberculosis treatment, TPT or a decision for no drugs was made within seven days of symptom screening ("second 7"). The principal reason for not starting anti-tuberculosis treatment or TPT was failure to consult a medical officer: only 129(50%) of 256 contacts consulted a medical officer. Reasons for poor performance in the "second 7" component included travel costs to see a medical officer, loss of daily earnings and fear of a TB diagnosis. Field staff reported that timeliness metrics motivated them to take prompt action in household contact screening and TPT provision and they suggested these be included in national guidelines. CONCLUSIONS: Field staff found "7-1-7" timeliness metrics to be feasible and useful. Integration of these metrics into national guidelines could improve timeliness of diagnosis, treatment and prevention of TB within households of index patients.

Surgical Antibiotic Prophylaxis Administration Improved after introducing Dedicated Guidelines: A Before-and-After Study from Dhulikhel Hospital in Nepal (2019-2023).

(1) Background: Surgical antibiotic prophylaxis (SAP) is important for reducing surgical site infections. The development of a dedicated hospital SAP guideline in the Dhulikhel Hospital was a recommendation from a baseline study on SAP compliance. Compliance with this new guideline was enhanced through the establishment of a hospital committee, the establishment of an antibiotic stewardship program and the funding and training of healthcare professionals. Using the baseline and a follow-up study after introducing dedicated hospital SAP guidelines, we compared: (a) overall compliance with the SAP guidelines and (b) the proportion of eligible and non-eligible patients who received initial and redosing of SAP; (2) Methods: A before-and-after cohort study was conducted to compare SAP compliance between a baseline study (July 2019-December 2019) and a follow-up study (January 2023-April 2023); (3) Results: A total of 874 patients were in the baseline study and 751 in the follow-up study. Overall SAP compliance increased from 75% (baseline) to 85% in the follow-up study (p < 0.001). Over 90% of those eligible for the initial dose of SAP received it in both studies. Inappropriate use for those not eligible for an initial dose was reduced from 50% to 38% (p = 0.04). For those eligible for redosing, this increased from 14% to 22% but was not statistically significant (p = 0.272); (4) Conclusions: Although there is room for improvement, introduction of dedicated SAP guidelines was associated with improved overall SAP compliance. This study highlights the role of operational research in triggering favorable interventions in hospital clinical care.

Contact Tracing and Tuberculosis Preventive Therapy for Household Child Contacts of Pulmonary Tuberculosis Patients in the Kyrgyz Republic: How Well Are We Doing?

Early identification, screening and investigation for tuberculosis (TB), and provision of TB preventive therapy (TPT), reduces risk of TB among child household contacts of pulmonary TB patients (index patients). A cohort study was conducted to describe the care cascade and timeliness of contact tracing and TPT initiation among child household contacts (aged < 15 years) of index patients initiated on TB treatment in Bishkek, the Kyrgyz Republic during October 2021-September 2022. In the register, information on the number of child household contacts was available for 153 (18%) of 873 index patients. Of 297 child household contacts identified, data were available for 285, of whom 261 (92%) were screened for TB. More than 50% were screened after 1 month of the index patient initiating TB treatment. TB was diagnosed in 23/285 (9%, 95% CI: 6-13%) children. Of 238 TB-free children, 130 (55%) were eligible for TPT. Of the latter, 64 (49%) were initiated on TPT, of whom 52 (81%) completed TPT. While TPT completion was excellent, there was deficiency in contact identification, timely screening and TPT initiation. Thus, healthcare providers should diligently request and record details of child household contacts, adhere to contact tracing timelines and counsel caregivers regarding TPT.

Managing Comorbidities, Determinants and Disability at Start and End of TB Treatment under Routine Program Conditions in China.

Many patients with tuberculosis (TB) have comorbidities, risk determinants and disability that co-exist at diagnosis, during and after TB treatment. We conducted an observational cohort study in 11 health facilities in China to assess under routine program conditions (i) the burden of these problems at the start and end of TB treatment and (ii) whether referral mechanisms for further care were functional. There were 603 patients registered with drug-susceptible TB who started TB treatment: 84% were symptomatic, 14% had diabetes, 14% had high blood pressure, 19% smoked cigarettes, 10% drank excess alcohol and in 45% the 6 min walking test (6MWT) was abnormal. Five patients were identified with mental health disorders. There were 586 (97%) patients who successfully completed TB treatment six months later. Of these, 18% were still symptomatic, 12% had diabetes (the remainder with diabetes failed to complete treatment), 5% had high blood pressure, 5% smoked cigarettes, 1% drank excess alcohol and 25% had an abnormal 6MWT. Referral mechanisms for the care of comorbidities and determinants worked well except for mental health and pulmonary rehabilitation for disability. There is need for more programmatic-related studies in other countries to build the evidence base for care of TB-related conditions and disability.

Antibiotic resistance and consumption before and during the COVID-19 pandemic in Valle del Cauca, Colombia.

Objective: To assess changes in antibiotic resistance of eight of the World Health Organization priority bug-drug combinations and consumption of six antibiotics (ceftriaxone, cefepime, piperacillin/tazobactam, meropenem, ciprofloxacin, vancomycin) before (March 2018 to July 2019) and during (March 2020 to July 2021) the COVID-19 pandemic in 31 hospitals in Valle del Cauca, Colombia. Methods: This was a before/after study using routinely collected data. For antibiotic consumption, daily defined doses (DDD) per 100 bed-days were compared. Results: There were 23 405 priority bacterial isolates with data on antibiotic resistance. The total number of isolates increased from 9 774 to 13 631 in the periods before and during the pandemic, respectively. While resistance significantly decreased for four selected bug-drug combinations (Klebsiella pneumoniae, extended spectrum beta lactamase [ESBL]-producing, 32% to 24%; K. pneumoniae, carbapenem-resistant, 4% to 2%; Pseudomonas aeruginosa, carbapenem-resistant, 12% to 8%; Acinetobacter baumannii, carbapenem-resistant, 23% to 9%), the level of resistance for Enterococcus faecium to vancomycin significantly increased (42% to 57%). There was no change in resistance for the remaining three combinations (Staphylococcus aureus, methicillin-resistant; Escherichia coli, ESBL-producing; E. coli, carbapenem-resistant). Consumption of all antibiotics increased. However, meropenem consumption decreased in intensive care unit settings (8.2 to 7.1 DDD per 100 bed-days). Conclusions: While the consumption of antibiotics increased, a decrease in antibiotic resistance of four bug-drug combinations was observed during the pandemic. This was possibly due to an increase in community-acquired infections. Increasing resistance of E. faecium to vancomycin must be monitored. The findings of this study are essential to inform stewardship programs in hospital settings of Colombia and similar contexts elsewhere.

Antibiotic resistance and consumption before and during the COVID-19 pandemic in Valle del Cauca, Colombia / Resistencia antibiótica y consumo de antibióticos antes y durante la pandemia de COVID-19 en el Valle del Cauca, Colombia / Resistência a antibióticos e consumo de antibióticos antes e durante a pandemia de COVID-19 no Valle del Cauca, Colômbia

ABSTRACT Objective. To assess changes in antibiotic resistance of eight of the World Health Organization priority bug-drug combinations and consumption of six antibiotics (ceftriaxone, cefepime, piperacillin/tazobactam, meropenem, ciprofloxacin, vancomycin) before (March 2018 to July 2019) and during (March 2020 to July 2021) the COVID-19 pandemic in 31 hospitals in Valle del Cauca, Colombia. Methods. This was a before/after study using routinely collected data. For antibiotic consumption, daily defined doses (DDD) per 100 bed-days were compared. Results. There were 23 405 priority bacterial isolates with data on antibiotic resistance. The total number of isolates increased from 9 774 to 13 631 in the periods before and during the pandemic, respectively. While resistance significantly decreased for four selected bug-drug combinations (Klebsiella pneumoniae, extended spectrum beta lactamase [ESBL]-producing, 32% to 24%; K. pneumoniae, carbapenem-resistant, 4% to 2%; Pseudomonas aeruginosa, carbapenem-resistant, 12% to 8%; Acinetobacter baumannii, carbapenem-resistant, 23% to 9%), the level of resistance for Enterococcus faecium to vancomycin significantly increased (42% to 57%). There was no change in resistance for the remaining three combinations (Staphylococcus aureus, methicillin-resistant; Escherichia coli, ESBL-producing; E. coli, carbapenem-resistant). Consumption of all antibiotics increased. However, meropenem consumption decreased in intensive care unit settings (8.2 to 7.1 DDD per 100 bed-days). Conclusions. While the consumption of antibiotics increased, a decrease in antibiotic resistance of four bug-drug combinations was observed during the pandemic. This was possibly due to an increase in community-acquired infections. Increasing resistance of E. faecium to vancomycin must be monitored. The findings of this study are essential to inform stewardship programs in hospital settings of Colombia and similar contexts elsewhere.

RESUMEN Objetivo. Evaluar los cambios en la resistencia a los antibióticos de ocho de las combinaciones de fármacos y agentes patógenos incluidos en la lista prioritaria de la Organización Mundial de la Salud y el consumo de seis antibióticos (ceftriaxona, cefepima, piperacilina/tazobactam, meropenem, ciprofloxacina, vancomicina) antes de la pandemia de COVID-19 (de marzo del 2018 a julio del 2019) y durante la pandemia (de marzo del 2020 a julio del 2021) en 31 hospitales del Valle del Cauca (Colombia). Métodos. En este estudio se analiza el antes y el después empleando datos recopilados de forma rutinaria. Para el consumo de antibióticos, se compararon las dosis diarias definidas (DDD) por 100 días-cama. Resultados. Hubo 23 405 cepas bacterianas aisladas prioritarias con datos sobre la resistencia a los antibióticos. El número total de cepas aisladas aumentó de 9 774 antes de la pandemia a 13 631 durante la pandemia. Si bien la resistencia disminuyó significativamente en las cuatro combinaciones seleccionadas de agentes patógenos y fármacos (Klebsiella pneumoniae, productora de betalactamasa de espectro extendido [BLEE], de 32% a 24%; K. pneumoniae, resistente a los carbapenémicos, de 4% a 2%; Pseudomonas aeruginosa, resistente a los carbapenémicos, de 12% a 8%; Acinetobacter baumannii, resistente a los carbapenémicos, de 23% a 9%), el nivel de resistencia de Enterococcus faecium a la vancomicina aumentó significativamente (de 42% a 57%). No hubo cambios en la resistencia en las tres combinaciones restantes (Staphylococcus aureus, resistente a la meticilina; Escherichia coli, productora de BLEE; E. coli, resistente a los carbapenémicos). El consumo de todos los antibióticos aumentó. Sin embargo, el consumo de meropenem disminuyó en los entornos de las unidades de cuidados intensivos (de 8,2 a 7,1 DDD por 100 días-cama). Conclusiones. Aunque el consumo de antibióticos aumentó, se observó una disminución en la resistencia a los antibióticos de cuatro combinaciones de agentes patógenos y medicamentos durante la pandemia, que posiblemente se debió a un aumento en las infecciones adquiridas en la comunidad. Es necesario vigilar el aumento de la resistencia de E. faecium a la vancomicina. Los resultados de este estudio son esenciales para que sirvan de orientación en los programas de optimización del uso de los antibióticos en los entornos hospitalarios de Colombia y en contextos similares en otros lugares.

RESUMO Objetivo. Avaliar as mudanças na resistência a antibióticos em oito das combinações microrganismo/antimicrobiano prioritárias da Organização Mundial da Saúde e o consumo de seis antibióticos (ceftriaxona, cefepima, piperacilina/tazobactam, meropeném, ciprofloxacino, vancomicina) antes (março de 2018 a julho de 2019) e durante (março de 2020 a julho de 2021) a pandemia de COVID-19 em 31 hospitais em Valle del Cauca, Colômbia. Métodos. Este foi um estudo antes/depois utilizando dados coletados rotineiramente. Para avaliar o consumo de antibióticos, foram comparadas doses diárias definidas (DDD) por 100 leitos-dias. Resultados. Havia dados sobre resistência a antibióticos para 23.405 isolados bacterianos prioritários. O número total de isolados aumentou de 9.774 para 13.631 antes e durante a pandemia, respectivamente. Embora a resistência tenha diminuído significativamente para quatro das combinações microrganismo/antimicrobiano selecionadas (Klebsiella pneumoniae, produtora de betalactamase de espectro estendido [ESBL], 32% a 24%; K. pneumoniae, resistente a carbapenêmicos, 4% a 2%; Pseudomonas aeruginosa, resistente a carbapenêmicos, 12% a 8%; Acinetobacter baumannii, resistente a carbapenêmicos, 23% a 9%), o nível de resistência de Enterococcus faecium a vancomicina aumentou significativamente (42% a 57%). Não houve mudança na resistência para as três combinações restantes (Staphylococcus aureus, resistente a meticilina; Escherichia coli, produtora de ESBL; E. coli, resistente a carbapenêmicos). O consumo de todos os antibióticos aumentou. Entretanto, o consumo de meropeném nas unidades de terapia intensiva diminuiu (de 8,2 para 7,1 DDD por 100 leitos-dias). Conclusões. Embora o consumo de antibióticos tenha aumentado, observou-se uma diminuição na resistência a antibióticos de quatro combinações microrganismo/antimicrobiano durante a pandemia. Isso ocorreu possivelmente devido a um aumento nas infecções adquiridas na comunidade. O aumento da resistência de E. faecium à vancomicina deve ser monitorado. Os achados deste estudo são essenciais para guiar os programas de gerenciamento de antimicrobianos em ambientes hospitalares da Colômbia e em outros contextos similares.

Quality, Equity and Partnerships in Mixed Methods and Qualitative Research during Seven Years of Implementing the Structured Operational Research and Training Initiative in 18 Countries.

Introduction: Qualitative studies are often inadequately reported, making it difficult to judge their appropriateness for decision making in public health. We assessed the publication characteristics and quality of reporting of qualitative and mixed-method studies from the Structured Operational Research and Training Initiative (SORT IT), a global partnership for operational research capacity building. Methods: A cross-sectional analysis of publications to assess the qualitative component using an adapted version of the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Results: In 67 publications involving 18 countries, 32 journals and 13 public health themes, 55 were mixed-methods studies and 12 were qualitative studies. First authorship from low-and-middle-income (LMIC) countries was present in 64 (96%), LMIC last authorship in 55 (82%), and female first authorship in 30 (45%). The mean LMIC institutions represented per publication was five (range 1-11). Sixty-three (94%) publications were open access. Reporting quality was graded as 'good' to 'excellent' in 60 (89%) publications, 'fair' in five (8%) and 'poor' in two (3%). Conclusion: Most SORT IT publications adhered to COREQ standards, while supporting gender equity in authorship and the promotion of LMIC research leadership. SORT IT plays an important role in ensuring quality of evidence for decision making to improve public health.

High Levels of Outpatient Antibiotic Prescription at a District Hospital in Ghana: Results of a Cross Sectional Study.

BACKGROUND: Monitoring of antibiotic prescription practices in hospitals is essential to assess and facilitate appropriate use. This is relevant to halt the progression of antimicrobial resistance. METHODS: Assessment of antibiotic prescribing patterns and completeness of antibiotic prescriptions among out-patients in 2021 was conducted at the University Hospital of Kwame Nkrumah University of Science and Technology in the Ashanti region of Ghana. We reviewed electronic medical records (EMR) of 49,660 patients who had 110,280 encounters in the year. RESULTS: The patient encounters yielded 350,149 prescriptions. Every month, 33-36% of patient encounters resulted in antibiotic prescription, higher than the World Health Organization's (WHO) recommended optimum of 27%. Almost half of the antibiotics prescribed belonged to WHO's Watch group. Amoxicillin-clavulanic acid (50%), azithromycin (29%), ciprofloxacin (28%), metronidazole (21%), and cefuroxime (20%) were the most prescribed antibiotics. Antibiotic prescribing parameters (indication, name of drug, duration, dose, route, and frequency) were documented in almost all prescriptions. CONCLUSIONS: Extending antimicrobial stewardship to the out-patient settings by developing standard treatment guidelines, an out-patient specific drug formulary, and antibiograms can promote rational antibiotic use at the hospital. The EMR system of the hospital is a valuable tool for monitoring prescriptions that can be leveraged for future audits.

COVID-19 Amongst Travelers at Points of Entry in Nepal: Screening, Testing, Diagnosis and Isolation Practices.

WHO recommends surveillance for COVID-19 among travelers at Points of Entry (POE) to countries. At 13 selected POE at the Nepal-India border, between March 2021 and July 2021, we describe the screening, testing, diagnosis and isolation practices of COVID-19 amongst travelers. Those who stayed in India or elsewhere for > one day and those who did not have a negative RT-PCR result within the last 72 h of travel were tested for COVID-19 with rapid antigen diagnostic tests. Daily surveillance reports maintained at POE were used for analysis. Of 337,338 travelers screened, 69,886 (21%) were tested and 3907 (6%) were diagnosed with COVID-19. The proportions tested averaged 15% during April-May when screened numbers were high and increased to 35% in July when screened numbers had decreased. The proportions diagnosed positive peaked at 10% in April-May, but decreased to below 1% in June and July. Testing coverage varied from 0−99% in the different POE. Most COVID-19 cases were Nepalese, male, <60 years of age, migrant workers and presented with fever. Of COVID-19 cases, 32% had home-based isolation, 64% underwent community-based isolation and the remainder either went to hospital or returned to India. In conclusion, about one fifth of travelers overall were tested, with coverage varying considerably over time and among different POE. Strengthening surveillance processes at POE is needed.

Compliance with Medication amongst Persons with Diabetes Mellitus during the COVID-19 Pandemic, Kerala, India: A Cross Sectional Study.

Compliance with medication in persons with diabetes mellitus (DM) has been a challenge during the COVID-19 pandemic, leading to poor glycemic control and higher risk of complications. In the state of Kerala, India, 20−25% of adults have DM. Our cross-sectional study aimed to assess medication compliance and factors associated with poor compliance in DM persons attending selected primary care government facilities in Kerala during the COVID-19 pandemic. Persons registered with DM for >6 months were consecutively interviewed between August and September 2021. Poor compliance was defined as answering "No" to one or more of three questions related to access and intake of medication two weeks prior to and the day before the interview. Factors independently associated with poor compliance were assessed using adjusted prevalence ratios (aPr) and 95% confidence intervals. Of the 560 DM persons included, 209 (37%) exhibited poor compliance. Factors associated with poor compliance were age 19−45 years (aPr 1.4, 1.1−1.9); inability to be blood glucose tested during the COVID-19 pandemic (aPr 3.6, 2.9−4.3); not having COVID-19 (aPr 1.4, 1.0−1.9); and being double vaccinated against COVID-19 (aPr 1.4, 1.1−2.0). Focused attention must be paid to these groups to improve medication compliance and prevent DM complications and severe COVID-19-related disease.

Epidemiology and Response to the COVID-19 Pandemic in Kerala, India, 2020-2021: A Cross-Sectional Study.

Kerala, a southern state in India, experienced a slightly different COVID-19 pandemic than the rest of India. Using data from daily COVID-19 bulletins and two other Kerala health information systems, this study reported on epidemiological characteristics and response measures of the COVID-19 pandemic between January 2020 and December 2021. After the first six months, Kerala experienced three distinct phases, with COVID-19 cases peaking in October 2020, May 2021, and August 2021. This contrasts with India, which experienced two main peaks in September 2020 and May 2021. The demographic profile of cases aligned with the national profile except for a slight increase of COVID-19 in persons aged ≥60 years. Monthly COVID-19 deaths increased dramatically from May 2021 onwards in line with case numbers but also reflecting changes in definitions of COVID-19 deaths. Case fatality for the two years was significantly higher in males than females, increased with increasing age groups, and varied between districts (p < 0.001). Trends in bed occupancy in field hospitals, hospitals for severe disease, intensive care units, and mechanical ventilation mirrored the different phases of the pandemic. The monitoring system in Kerala allowed certain aspects of the pandemic to be mapped, but it would benefit from further strengthening.

The Structured Operational Research and Training Initiative for Strengthening Health Systems to Tackle Antimicrobial Resistance and Improve Public Health in Low-and-Middle Income Countries.

If research is to have an impact and change health outcomes for the better, the findings of the research should be translated into recommendations and actions that can influence policy and/or practice [...].

Antibiotic Use in Suspected and Confirmed COVID-19 Patients Admitted to Health Facilities in Sierra Leone in 2020-2021: Practice Does Not Follow Policy.

Inappropriate use of antibiotics during the COVID-19 pandemic has the potential to increase the burden of antimicrobial resistance. In this study, we report on the prevalence of antibiotic use and its associated factors among suspected and confirmed COVID-19 patients admitted to 35 health facilities in Sierra Leone from March 2020-March 2021. This was a cross-sectional study using routinely collected patient data. Of 700 confirmed COVID-19 patients, 47% received antibiotics. The majority (73%) of the antibiotics belonged to the 'WATCH' group of antibiotics, which are highly toxic and prone to resistance. The most frequently prescribed antibiotics were azithromycin, ceftriaxone, amoxicillin, metronidazole, and amoxicillin-clavulanic acid. Antibiotic use was significantly higher in patients aged 25-34 years than in those with severe disease. Of 755 suspected COVID-19 patients, 61% received antibiotics, of which the majority (58%) belonged to the 'WATCH' category. The most frequently prescribed antibiotics were ceftriaxone, metronidazole, azithromycin, ciprofloxacin, and amoxycillin. The prevalence of antibiotic use among suspected and confirmed COVID-19 patients admitted to healthcare facilities in Sierra Leone was high and not in line with national and WHO case management guidelines. Training of health care providers, strengthening of antimicrobial stewardship programs, and microbiological laboratory capacity are urgently needed.

Going virtual for research training during the COVID-19 pandemic and beyond: e-SORT IT.

The Structured Operational Research and Training Initiative (SORT IT) model has contributed to building research capacity and has produced evidence for improving public health program performance in countries with limited research capacity. The model involves hands-on mentorship and consists of three modules/weeks. It is recognized to be an innovative research capacity building model. In a world changed by COVID-19, where bringing people together is not viable, an innovative, interactive, web-based, knowledge-transfer platform (e-SORT IT) for virtual implementation of SORT IT modules was created. The platform design imitated the residential course as closely as possible with the same lectures, plenary sessions, and breakout rooms. Despite the challenges, the platform performed well and even though participants and mentors were located in eight different time zones, the course was successful; 90% of participants achieved their milestones and 10 manuscripts were successfully completed. Participant evaluation revealed a satisfaction level that was nearly equivalent to the residential module. However, mentor evaluation indicated a number of shortcomings including capacity building, professional networking, communication, engagement, and contribution by participants, as well as overall module success. In conclusion, COVID-19 stimulated the creation of the e-SORT IT platform that provided a functional alternative to the residential version. Despite the limitations of reduced capacity building and networking, the e-SORT IT platform should be considered a success - it delivered the goods. This is an example of innovation and flexibility, two attributes that are sorely needed to maintain activities during the pandemic and beyond.

Does optimized adherence support improve treatment outcomes in RR / MDR-TB patients on 18-20 months regimen in Tbilisi, Georgia?

INTRODUCTION: Adherence to second-line antituberculosis drug is challenging. A combination of strategies needs to be implemented to achieve adherence. In Georgia an optimized adherence support (OAS) - a package of education, psychosocial support and adherence counselling - was added to the already existing package of adherence support (supervised treatment, adherence incentives, transport cost reimbursement) to improve adherence and increase treatment success. We assessed the additive benefits of OAS on adherence and treatment outcomes. METHODOLOGY: This was a before and after cohort study using routine programme data in the National Center for Tuberculosis and Lung Diseases in Tbilisi. All adult rifampicin- and multidrug-resistant tuberculosis (RR/MDR-TB) patients enrolled for treatment under directly observed therapy in the NCTLD during the period before (June 2015 - January 2016) and after (June 2017 - January 2018) were included in the study. Primary outcomes were: i) adequate adherence defined as ≥ 85% of days covered by TB medication during the whole treatment period; ii) final treatment outcomes. RESULTS: Of 221 RR/MDR-TB, most patients were male (76%, N = 167) with a mean age of 41 ± 14 years. Adherence data was available for 111 patients in the 'before' and 97 patients in the 'after' cohort. Adequate adherence was achieved by 62% (69/111) in the 'before' and 70% (68/97) in the 'after' cohort (p = 0.290). Overall treatment success was 64% (73/114) and 63% (67/107) in the 'before' and 'after' cohorts respectively (p = 0.937). CONCLUSIONS: Implementation of OAS had modest effect on adherence and had no additive benefits on treatment outcomes among RR/MDR-TB patients on 18-20 months regimen.

Real-Time Operational Research: Case Studies from the Field of Tuberculosis and Lessons Learnt.

Real-time operational research can be defined as research on strategies or interventions to assess if they are feasible, working as planned, scalable and effective. The research involves primary data collection, periodic analysis during the conduct of the study and dissemination of the findings to policy makers for timely action. This paper aims to illustrate the use of real-time operational research and discuss how to make it happen. Four case studies are presented from the field of tuberculosis. These include (i) mis-registration of recurrent tuberculosis in Malawi; (ii) HIV testing and adjunctive cotrimoxazole to reduce mortality in TB patients in Malawi; (iii) screening TB patients for diabetes mellitus in India; and (iv) mitigating the impact of COVID-19 on TB case detection in capital cities in Kenya, Malawi and Zimbabwe. The important ingredients of real-time operational research are sound ethics; relevant research; adherence to international standards of conducting and reporting on research; consideration of comparison groups; timely data collection; dissemination to key stakeholders; capacity building; and funding. Operational research can improve the delivery of established health interventions and ensure the deployment of new interventions as they become available, irrespective of diseases. This is particularly important when public health emergencies, including pandemics, threaten health services.

Bacteria and Their Antibiotic Resistance Profiles in Ambient Air in Accra, Ghana, February 2020: A Cross-Sectional Study.

Inappropriate use of antibiotics has led to the presence of antibiotic-resistant bacteria in ambient air. There is no published information about the presence and resistance profiles of bacteria in ambient air in Ghana. We evaluated the presence and antibiotic resistance profiles of selected bacterial, environmental and meteorological characteristics and airborne bacterial counts in 12 active air quality monitoring sites (seven roadside, two industrial and three residential) in Accra in February 2020. Roadside sites had the highest median temperature, relative humidity, wind speed and PM10 concentrations, and median airborne bacterial counts in roadside sites (115,000 CFU/m3) were higher compared with industrial (35,150 CFU/m3) and residential sites (1210 CFU/m3). Bacillus species were isolated in all samples and none were antibiotic resistant. There were, however, Pseudomonas aeruginosa, Escherichia coli, Pseudomonas species, non-hemolytic Streptococci, Coliforms and Staphylococci species, of which six (50%) showed mono-resistance or multidrug resistance to four antibiotics (penicillin, ampicillin, ciprofloxacin and ceftriaxone). There was a positive correlation between PM10 concentrations and airborne bacterial counts (rs = 0.72), but no correlations were found between PM10 concentrations and the pathogenic bacteria nor their antibiotic resistance. We call for the expansion of surveillance of ambient air to other cities of Ghana to obtain nationally representative information.

National Antibiotic Consumption for Human Use in Sierra Leone (2017-2019): A Cross-Sectional Study.

Monitoring antibiotic consumption is crucial to tackling antimicrobial resistance. However, currently there is no system in Sierra Leone for recording and reporting on antibiotic consumption. We therefore conducted a cross-sectional study to assess national antibiotic consumption expressed as defined daily dose (DDD) per 1000 inhabitants per day using all registered and imported antibiotics (categorized under the subgroup J01 under the anatomical and therapeutic classification (ATC) system) as a proxy. Between 2017-2019, total cumulative consumption of antibiotics was 19 DDD per 1000 inhabitants per day. The vast majority consisted of oral antibiotics (98.4%), while parenteral antibiotics made up 1.6%. According to therapeutic/pharmacological subgroups (ATC level 3), beta-lactam/penicillins, quinolones, and other antibacterials (mainly oral metronidazole) comprised 65% of total consumption. According to WHO Access, Watch, and Reserve (AWaRe), 65% of antibiotics consumed were Access, 31% were Watch, and no Reserve antibiotics were reported. The top ten oral antibiotics represented 97% of total oral antibiotics consumed, with metronidazole (35%) and ciprofloxacin (15%) together constituting half of the total. Of parenteral antibiotics consumed, procaine penicillin (32%) and ceftriaxone (19%) together comprised half of the total. Policy recommendations at global and national levels have been made to improve monitoring of antibiotic consumption and antibiotic stewardship.

Assessing the Real-Time Impact of COVID-19 on TB and HIV Services: The Experience and Response from Selected Health Facilities in Nairobi, Kenya.

There was concern that the COVID-19 pandemic would adversely affect TB and HIV programme services in Kenya. We set up real-time monthly surveillance of TB and HIV activities in 18 health facilities in Nairobi so that interventions could be implemented to counteract anticipated declining trends. Aggregate data were collected and reported monthly to programme heads during the COVID-19 period (March 2020-February 2021) using EpiCollect5 and compared with monthly data collected during the pre-COVID period (March 2019-February 2020). During the COVID-19 period, there was an overall decrease in people with presumptive pulmonary TB (31.2%), diagnosed and registered with TB (28.0%) and in those tested for HIV (50.5%). Interventions to improve TB case detection and HIV testing were implemented from August 2020 and were associated with improvements in all parameters during the second six months of the COVID-19 period. During the COVID-19 period, there were small increases in TB treatment success (65.0% to 67.0%) and referral of HIV-positive persons to antiretroviral therapy (91.2% to 92.9%): this was more apparent in the second six months after interventions were implemented. Programmatic interventions were associated with improved case detection and treatment outcomes during the COVID-19 period, suggesting that monthly real-time surveillance is useful during unprecedented events.

Assessing the Impact of COVID-19 on TB and HIV Programme Services in Selected Health Facilities in Lilongwe, Malawi: Operational Research in Real Time.

When the COVID-19 pandemic was announced in March 2020, there was concern that TB and HIV programme services in Malawi would be severely affected. We set up real-time monthly surveillance of TB and HIV activities in eight health facilities in Lilongwe to see if it was possible to counteract the anticipated negative impact on TB case detection and treatment and HIV testing. Aggregate data were collected monthly during the COVID-19 period (March 2020-February 2021) using an EpiCollect5 application and compared with monthly data collected during the pre-COVID-19 period (March 2019-February 2020); these reports were sent monthly to programme directors. During COVID-19, there was an overall decrease in persons presenting with presumptive pulmonary TB (45.6%), in patients registered for TB treatment (19.1%), and in individuals tested for HIV (39.0%). For presumptive TB, children and females were more affected, but for HIV testing, adults and males were more affected. During COVID-19, the TB treatment success rate (96.1% in pre-COVID-19 and 96.0% during COVID-19 period) and referral of HIV-positive persons to antiretroviral therapy (100% in pre-COVID-19 and 98.6% during COVID-19 period) remained high and largely unchanged. Declining trends in TB and HIV case detection were not redressed despite real-time monthly surveillance.