Hearing aid support for patients with DR-TB in Ethiopia.

SETTING: Previous and current patients with drug-resistant TB (DR-TB) who had documented treatment-related hearing impairment due to second-line injectable (SLI) use were identified from different DR-TB treatment initiation centres in Ethiopia. OBJECTIVE: To assess selected patients with DR-TB for eligibility for hearing aids and provide hearing aids to 10 eligible patients. DESIGN: This was an observational cohort study. Patients were followed up for 8 months, with hearing assessments conducted at 1, 3 and 8 months to objectively assess hearing capacity. RESULTS: Of 12 patients assessed for hearing aids eligibility, 10 were fitted with hearing aids (type XTM XP P4) and followed up for 8 months. "Formal" improvement was observed only in one patient. However, "general quality of life" appeared to be improved in nine patients. CONCLUSION: Minimal "formal" improvement was observed. However, the study was too small to say whether hearing aids should, or should not, be recommended as a public health measure. This needs a larger better controlled follow-up study. The all-oral DR-TB treatment regimens should be used for all patients with DR-TB in Ethiopia. However, as a proportion of patients with DR-TB are likely to continue receiving SLIs in the foreseeable future, they will require close audiometry assessment and appropriate care.

CONTEXTE: Les patients, anciens et actuels, atteints de TB pharmacorésistante (DR-TB) ayant une déficience auditive documentée due à l'utilisation d'agents injectables de seconde ligne (SLI), ont été identifiés dans différents centres de traitement de la DR-TB en Éthiopie. OBJECTIF: Évaluer l'éligibilité des patients atteints de DR-TB sélectionnés à une aide auditive et fournir cette dernière à 10 patients éligibles. MÉTHODE: Il s'agissait d'une étude de cohorte observationnelle. Les patients ont été suivis pendant 8 mois, avec examens auditifs à 1, 3 et 8 mois pour évaluer de manière objective leur capacité auditive. RÉSULTATS: Sur 12 patients évalués pour éligibilité à une aide auditive, 10 ont été équipés (type XTM XP P4) et suivis pendant 8 mois. Une amélioration « formelle ¼ a été observée chez seulement un patient, mais la « qualité de vie globale ¼ de neuf patients semble s'être améliorée. CONCLUSION: Une amélioration « formelle ¼ minime a été observée. L'étude était cependant trop petite pour pouvoir recommander ou non les aides auditives en tant que mesure de santé publique. Une étude de suivi mieux contrôlée et plus vaste est nécessaire. Les schémas thérapeutiques entièrement par voie orale de la DR-TB doivent être utilisés chez tous les patients atteints de la maladie en Éthiopie. Cependant, puisque certains patients atteints de DR-TB sont susceptibles de continuer à recevoir des SLI dans un futur proche, un contrôle étroit par audiométrie et des soins appropriés seront nécessaires.

Introducing bedaquiline: experiences from the Challenge TB Project.

BACKGROUND: Drug-resistant tuberculosis (DR-TB) remains a global public health crisis. In 2013, the World Health Organization recommended the introduction of bedaquiline (BDQ) for eligible DR-TB patients.METHODS: We conducted a retrospective review and analyses of project reports from 2016 to mid-2019 on the processes, activities implemented, available results on enrolment and interim treatment outcomes, across the 23 Challenge TB (CTB) supported countries.RESULTS: Initial introduction of BDQ-containing regimens in the 23 CTB-supported countries took on average 2 years, with subsequent nation-wide scale-up achieved in Ethiopia and Kyrgyzstan within a short time period. Successful implementation required critical interventions including advocacy, revision of policies and guidelines, capacity building of health care workers, and strengthening of laboratory networks. The number of countries providing BDQ increased from 9 to 23; 9398 patients were enrolled on bedaquiline containing regimens; 71% were culture-negative after 6 months of treatment; and the number of countries reporting serious adverse events increased (from 5 to 18). Major challenges included limited in-country coordination with drug regulatory agencies, unrealistic quantification and drug ordering, weak laboratory networks and reporting systems for drug safety.CONCLUSION: BDQ introduction required a systematic and programmatic approach. The initial time investment helped achieve initial introduction and scale-up of coverage, ownership and sustainability by National TB Programmes.

Annual risk of tuberculosis infection among tribal population of central India.

OBJECTIVE: To estimate the annual risk of tuberculosis infection (ARTI) among tribal children of Madhya Pradesh, central India. METHODS: Community-based, cross-sectional tuberculin survey among children aged 1-9 years in the tribal population of Madhya Pradesh. Multistage stratified cluster sampling was used to select a representative random sample of villages predominated by tribal population from selected districts. A total of 4802 children were tuberculin-tested with 1TU of PPD RT 23 and the reaction sizes read after 72 h. RESULTS: A total of 3062 (64%) children had no BCG scar. The frequency distribution of children by reaction sizes indicated a fair mode at 18 mm in the right hand side of the distribution. By mirror-image technique, the prevalence of infection among children with no recognizable BCG scar was estimated as 6.8% (95% CI: 4.8-8.9%). The ARTI was computed as 1.3% (0.9-1.7%). The corresponding figures for children irrespective of scar status were 7.1% (95% CI: 5.5-8.8%) and 1.3% (1.0-1.7%) respectively. CONCLUSIONS: The risk of tuberculosis infection in tribal population of Madhya Pradesh, central India is not different from other areas of the country. There is, however, a need to further intensify tuberculosis control measures on a sustained and long-term basis.

Cross-referral between voluntary HIV counselling and testing centres and TB services, Maharashtra, India, 2003-2004.

SETTING: India has a high tuberculosis (TB) burden, with 1.8 million new cases per year. Although an estimated 2.5 million people are infected with human immunodeficiency virus (HIV), the national HIV prevalence is <1%. India's size and diverse TB-HIV epidemiology pose a major challenge to the implementation of links between TB and HIV/AIDS programme services. METHODS: A pilot cross-referral initiative was instituted between voluntary counselling and testing centres (VCT) and the diagnostic and treatment facilities of the Revised National TB Control Programme (RNTCP) in four districts of Maharashtra, India. OBJECTIVE: To detect TB disease among VCT patients and selectively screen TB patients for referral to VCT services. RESULTS: Between July 2003 and June 2004, 336 (3%) of 9921 VCT patients were identified as TB suspects and 83 (29%) were diagnosed with TB disease. Of the 765 selectively referred TB cases, 181 (24%) were found to be HIV-positive, representing 11% of the newly detected persons living with HIV in the four districts. CONCLUSIONS: The pilot cross-referral initiative yielded significant numbers of active TB cases among VCT patients and HIV-positive persons among TB patients. Collaborative activities between HIV/AIDS and TB programmes need to be rapidly scaled up to other states in India.

Smoking and alcohol consumption: Risk factors for pulmonary tuberculosis among the tribal community in central India.

Smoking and alcohol consumption are important risk factors for pulmonary tuberculosis (PTB). A cross-sectional survey was undertaken among the Gond tribe in Jabalpur district of Madhya Pradesh, and information on smoking and alcohol consumption was collected. As compared to females, males had an increased odds for PTB prevalence (odds ratio (OR) 3.2; 95% CI 486.4-1358.4; p=0.01). Similarly smokers and alcohol consumers had an increased odds for PTB compared to non-smokers and non-alcohol consumers, respectively [(OR 3.2; 95% CI 516.4-1986.4; p=0.003); (OR 3.2; 95% CI 480.8-2254.8; p=0.009)]. Persons who were both smokers and alcohol consumers had an equally increased odds of PTB than those who did not smoke and consumed alcohol (OR 4.1; 95% CI 477.6-2581.6; p=0.001). The study findings highlight the need to develop and implement culturally appropriate awareness raising activities among the tribal community to support TB control efforts.

Source of retreatment cases under the revised national TB control programme in Rajasthan, India, 2003.

BACKGROUND: Three years after state-wide DOTS coverage and achievement of global targets for detection and cure, the proportion of sputum-positive retreatment cases remained high in the north Indian state of Rajasthan. AIM: To determine source, accuracy of categorisation and treatment outcomes in Category II sputum-positive retreatment cases registered from January to March 2003 in five districts of Rajasthan. MATERIAL AND METHODS: Two hundred consecutive Category II sputum-positive retreatment cases were identified from the tuberculosis register and interviewed using a semi-structured questionnaire. RESULTS: Categorisation was correct in 195 (97.5%) of retreatment cases interviewed. Treatment after default (TAD) comprised 84.6% (165/195) of interviewees, with 13.3% (n = 26) relapses and 2.1% (n = 4) failure cases. Of the TAD cases, 84.8% (n = 140) had defaulted from previous treatment in the private sector. Only 6.1% (n = 10) had defaulted from Category II DOTS treatment. The most unfavourable treatment outcome seen amongst interviewees was default, as also described in the national data. CONCLUSION: TADs constituted the majority of interviewed retreatment cases (84.6%), and were overwhelmingly being generated by irregular treatment in the private sector. Further involvement of the private sector in the DOTS programme in Rajasthan is needed to stop the creation of further retreatment cases.

Yield of pulmonary tuberculosis cases by symptoms: Findings from a community survey in Madhya Pradesh, central India.

A cross-sectional tuberculosis prevalence survey was undertaken in Jabalpur district, Madhya Pradesh, central India. All individuals were questioned for chest symptoms. Sputum samples were collected and examined for microscopy and culture. Overall prevalence of sputum positive pulmonary tuberculosis was found to be 255.3 per 100,000 population. Cough, with or without other symptoms, was present in 75.5% individuals and yielded 88.2% of the detected pulmonary tuberculosis cases. Elicitation of a previous history of treatment yielded 5.9%, and chest pain 4.5% cases. History of fever alone yielded no cases. The findings suggest that a history of fever alone may be safely excluded from the list of symptoms to be elicited in future TB prevalence surveys in India.

DOT for patients with limited access to health care facilities in a hill district of eastern Nepal.

SETTING: The hill district in Nepal, where access to health care facilities is difficult. OBJECTIVE: To compare results before and after a decentralised directly observed treatment (DOT) intervention. DESIGN: Prospective study of patients registered in Dhankuta district, Nepal, 1996-1999. Patients received their intensive phase treatment under health worker supervision via one of three DOT options: 1) ambulatory from the peripheral government health facilities; 2) ambulatory from an international non-governmental organisation (INGO) TB clinic in district centre; or 3) resident in INGO TB hostel in district centre. Historical data from 1995-1996, with unsupervised short-course chemotherapy, were used for comparison. RESULTS: Of 307 new cases, respectively 126 (41%), 86 (28%) and 95 (31%) took their intensive phase treatment via options 1, 2 and 3. Smear conversion (at 2 months) and cure rates in new smear-positive pulmonary tuberculosis cases were respectively 81.6% (vs. 58.8% historical, P = 0.001) and 84.9% (vs. 76.7% historical, P = 0.03). Overall costs to the INGO provider fell by 7%, mainly as a result of staffing reductions in the INGO services made possible by rationalisation with government services during the intervention. CONCLUSION: By offering varied DOT delivery routes, including an in-patient option, satisfactory results are possible with DOT even in areas where access to health care facilities is difficult. Provision of in-patient care via an INGO TB hostel allowed a significant proportion of new cases (31%) to receive their intensive phase treatment who otherwise may have had difficulty accessing treatment, due either to the distance to the nearest health facility or to disease severity. Substitution of government hospital beds or local hotel beds for the INGO hostel beds may allow the model to be reproduced elsewhere in similar geographical conditions in Nepal, but further studies should be performed in a non-INGO supported district beforehand.

Non-adherence to tuberculosis treatment in the eastern Tarai of Nepal.

SETTING: Tarai districts, eastern Nepal. OBJECTIVES: To identify potential methods of increasing adherence to tuberculosis (TB) treatment by determining factors that patients felt influenced adherence. METHODS: New pulmonary TB patients registered from July to November 1998 with an outcome of non-adherence to treatment (NA) were identified from District TB Registers, traced and interviewed using a semi-structured questionnaire. An equivalent number of adherent (A) patients were interviewed. RESULTS: Of 81 NA patients traced, 30 were interviewed, 16 had been incorrectly classified, age was incorrectly recorded in four, 13 had migrated and 18 were not found. The groups were similar in demographics, type and knowledge of TB. More A patients knew their diagnosis (P = 0.07) and reported haemoptysis as an initial symptom (P = 0.03). NA patients had longer travel to a health facility (P < 0.001), and fewer had been informed by health care workers (HCW) about the consequences of not completing treatment. The most common reasons given for stopping treatment were side-effects, HCWs' mistakes or behaviour, and health service failure. Desire for cure and knowledge that TB was curable were most the important reasons for completing treatment. CONCLUSION: Non-adherence seemed related to treatment delivery failures. The health system needs strengthening in Nepal. Intensified HCW training and supervision, better health education for patients and families, more flexibility for treatment supervisors, adequate supplies for treatment centres and decentralisation of treatment delivery to the lowest health service level practicable are urgently needed.

Is TB contact screening relevant in a developing country setting? Experiences from eastern Nepal, 1996-1998.

SETTING: A tuberculosis programme run by a non-governmental organisation in eight hill and mountain districts of eastern Nepal. OBJECTIVE: To assess the impact of contact screening on case-finding. DESIGN: A retrospective cohort study of contacts of smear-positive, smear-negative and extra-pulmonary tuberculosis patients diagnosed and registered during 1996-1998 ('index cases'). Contacts, defined as household members identified by index cases, were screened by sputum examination; two positive smears were taken to indicate smear-positive pulmonary disease. RESULTS: Approximately 50% (668) of registered cases identified contacts; 75% (2298) of the contacts identified provided one or more sputum specimens. An overall smear-positive case yield of 0.61% (14) was obtained from contacts tested, all except one of which were contacts of smear-positive index cases. For smear-positive index cases with a smear grading of > or = 2+, the yield was 7.2 times greater (P = 0.04) than for those with a grading of 1+. CONCLUSION: In this setting, sputum examination of household contacts of smear-negative and extrapulmonary tuberculosis cases is not justified. Further assessment is needed to evaluate the utility of testing contacts of smear-positive cases without symptom screening, and whether cost effectiveness can be improved by restricting testing to contacts of cases with high bacterial (> or = 2+) loads.

Effectiveness of urban community volunteers in directly observed treatment of tuberculosis patients: a field report from Haryana, North India.

A tuberculosis (TB) unit covering a population of 600000 in Gurgaon District of Haryana State, India, where the DOTS-based RNTCP has been implemented since April 2000. Treatment success rate, as recorded in the TB register, of new sputum smear-positive patients receiving directly observed treatment (DOT) from community volunteers was comparable with that of patients receiving DOT from government health workers (78% vs. 77%). The proportion of patients with community volunteers increased significantly with time (13% in 2000 to 25% in 2002), even in the absence of financial incentives. In this model of community volunteer involvement in an urban TB control programme, the primary responsibility for returning late patients to treatment was with the staff of the District TB Centre.

Developing nursing practice as part of the collaborative TB control programme, Tomsk, Siberia.

SETTING: Review of nursing practice, identification of training needs and implementation of training for nurses working in the Tomsk Oblast' Tuberculosis Services (TOTBS), Russia. OBJECTIVE: Preparation of TOTBS nurses for the implementation of a WHO-style TB control programme in January 1997. METHODS: Nursing services and training needs were assessed through observation visits to a number of institutions providing care for TB patients, semi-structured interviews, and discussions at staff meetings. Training sessions focused on the WHO DOTS strategy, patient education and default tracing. An evaluation visit focused on nurses' attitudes and levels of treatment completion. RESULTS: Out of a total of 165 TB cases notified in Tomsk Oblast' between January and March 1997, 53 were started on DOTS on an ambulatory basis. Five patients who defaulted returned to treatment within five days (range 2-5) and no patients were lost to follow up. Improved compliance was attributed to better patient education offered by nurses and a reliable supply of medication. Quarterly reports continue to show satisfactory levels of treatment completion. CONCLUSIONS: Obstacles to the development of nursing practice included resistance to change and low morale due to enormous workloads, no pay and staff shortages. Motivation improved through the setting of achievable targets.

Tobacco smoking: a major risk factor for pulmonary tuberculosis--evidence from a cross-sectional study in central India.

BACKGROUND: This paper provides information on the association of tobacco smoking and alcohol consumption with pulmonary TB (PTB) in central India. METHODS: A community based cross-sectional TB prevalence survey was conducted in Jabalpur district of the central Indian state of Madhya Pradesh. The information on tobacco smoking and alcohol consumption was collected from individuals aged ≥15 years. Using logistic regression analysis, the risk factors for PTB were identified. RESULTS: A total of 94 559 individuals provided information on tobacco smoking and alcohol consumption. Persons aged 35-54 years and 55 years and above had, respectively, a 2.19 (95% CI 1.57-3.07) and a 3.26 (95% CI 2.23-4.77) times higher risk of developing PTB compared to persons aged below 35 years. Males had a 2.35 (95% CI 1.66-3.32) times higher risk than females. Tribals (indigenous population) had a 2.32 (95% CI 1.68-3.21) times higher risk than non-tribal population. The adjusted prevalence odds ratio for mild, moderate and heavy tobacco smokers were 2.28, 2.51 and 2.74 respectively as compared to non-smokers. Alcohol consumption was not found to be a risk factor on multivariate analysis. CONCLUSION: Tobacco smoking is significantly associated with PTB in this central Indian district. Smoking cessation services need to be integrated into the activities of the TB control programme.

Safety of cycloserine and terizidone for the treatment of drug-resistant tuberculosis: a meta-analysis.

Although cycloserine (CS) is recommended by the World Health Organization as a second-line agent for the treatment of multidrug-resistant tuberculosis (MDR-TB), safety concerns have impeded its uptake by several national TB programmes. Terizidone (TRD), a structural analogue of cycloserine, may be better tolerated. To assess the safety of CS and TRD for TB treatment, a systematic review and meta-analysis were conducted. From articles published up to December 2011, 27 studies with 2164 patients were included in our review of CS use. The pooled estimate for the frequencies of any adverse drug reaction (ADR) from CS was 9.1% (95%CI 6.4-11.7); it was 5.7% (95%CI 3.7-7.6) for psychiatric ADRs, and 1.1% (95%CI 0.2-2.1) for central nervous system (CNS) related ADRs. TRD showed no better to moderately better safety than CS in a systematic review of the available literature. The published evidence suggests that CS is associated with a higher frequency of psychiatric and CNS-related ADRs than other second-line drugs. While data were limited, treatment discontinuation rates appeared to be manageable. There were no significant differences in tolerability by region, study period or combination. As countries review and revise their treatment programmes, CS, and potentially TRD, should be included in MDR-TB treatment regimens. Adequate information on possible ADRs should be provided to patients, their families and attending health care workers. Greater attention to MDR-TB patients' mental health and a significant increase in resources devoted to pharmacovigilance and treatment of MDR-TB are essential.

Capilia test for identification of Mycobacterium tuberculosis in MGIT™-positive cultures.

BACKGROUND: The performance of the Capilia test for rapid identification of Mycobacterium tuberculosis complex (MTC) in Mycobacterium Growth Indicator Tube (MGIT) positive samples with contaminating organisms is not well documented. OBJECTIVE: To assess the diagnostic yield of the Capilia test in the rapid identification of MTC in MGIT-positive cultures. DESIGN: A total of 459 selected sputum samples were cultured using BACTEC™ MGIT™ 960. Tubes flagged positive by the MGIT instrument (MGIT-positive) were examined for acid-fast bacilli and cording in smears, spotted on blood agar (BA), subcultured for biochemical tests and tested using the Capilia test. Based on smear and growth on BA, MGIT-positive tubes were grouped into MGIT true-positive, MGIT-positive with contamination and MGIT contamination. Performance parameters of Capilia test such as sensitivity, specificity, efficiency, and positive and negative predictive values (PPV, NPV) for each of these groups were determined against biochemical tests as gold standard. RESULTS: Of the 346 MGIT-positives, respectively 233, 73 and 40 were MGIT true-positive, MGIT-positive with contamination and MGIT contamination. For the three groups, the PPV and NPV of the Capilia test were respectively 97%, 96% and 100%, and 32%, 27% and 60%. CONCLUSION: In settings with high contamination of MGIT cultures, the performance of the Capilia test is diminished.

Annual risk of tuberculosis infection among the tribal children of Jhabua, Madhya Pradesh.

A cross sectional tuberculin survey was undertaken to estimate the Annual Risk of Tuberculosis Infection (ARTI) amongst tribal children aged 1-9 years in Jhabua district, Madhya Pradesh, India. Of the 1056 test-read children, 774 (73.3%) had no BCG scar. The prevalence of infection was estimated as 6.3% (95% CI: 4.8-7.7) and ARTI as 1.2% (95% CI: 0.9-1.5). The findings suggest that the tuberculosis situation in the tribal population of Jhabua district is not that different from the situation among the non-tribal population in the country. However, there is a need to further intensify tuberculosis control measures in the area.

Yield of culture of Mycobacterium tuberculosis complex in sputum samples transported from tribal areas.

BACKGROUND: There is little information on the recovery of Mycobacterium tuberculosis complex from sputum samples collected in the field for bacteriological examination. SETTING: Tribal areas in the State of Madhya Pradesh, in central India. METHODS: Sputum specimens collected from subjects with chest symptoms in a disease prevalence survey were refrigerated until transportation to the laboratory. The specimens were processed for microscopy and culture. The samples were grouped based on the delay in processing for culture from the day of collection into three groups: 0-3, 4-7 and ≥8 days, and the recovery of M. tuberculosis complex in these groups was analysed. The statistical analysis was performed using χ(2) test. RESULTS: Of the 3651 processed specimens, 114 were positive for M. tuberculosis complex by culture and 96 by smear microscopy. The differences in the proportion of 'smear-positive, culture-positive', 'smear-positive, culture-negative' and 'smear-negative, culture-positive' samples between the three groups were not significant. CONCLUSION: In difficult-to-reach areas with limited resources, refrigeration of sputum specimens until they are transported for processing at a reference laboratory for culture seems not to significantly affect the recovery of M. tuberculosis complex isolates.

Prevalence of pulmonary tuberculosis amongst the Baigas--a primitive tribe of Madhya Pradesh, Central India.

BACKGROUND: A community-based cross-sectional tuberculosis (TB) disease prevalence survey was undertaken amongst the Baiga primitive tribal community of Baiga Chak in central India. MATERIAL AND METHODS: A population of 2,359 was covered under the study. Sputum samples were collected from chest symptomatics and examined for smear microscopy and culture. RESULTS: Overall prevalence of PTB was 146 (95% C.I: 0-318) per 100,000 population. CONCLUSION: The findings suggest that TB is not a major public health problem amongst this tribal group. However, there is still the need to maintain and further strengthen TB control measures on a sustained and long term basis in the area.

Prevalence of pulmonary tuberculosis among the Bharia, a primitive tribe of Madhya Pradesh, central India.

A cross-sectional survey was undertaken to estimate the prevalence of pulmonary tuberculosis (TB) among the primitive Bharia tribe of Madhya Pradesh, India. Virtually the entire community in Patalkot valley of Chhindwara District was covered. Individuals aged > or =15 years were questioned about chest symptoms relating to TB. Sputum samples were collected and examined by smear microscopy and culture. The overall prevalence of pulmonary TB was found to be 432 per 100 000 population-not dissimilar to that seen in the wider population in India. There is, however, an urgent need to strengthen TB services in the area to improve access for this group.