Private pharmacy and community health worker engagement in the provision of TB services.

Engaging private health providers and community healthcare workers (CHWs) in the provision of TB care services can increase TB case notification and limit community transmission. We determined whether private pharmacy and community engagement could affect access to TB diagnostic and treatment services in Uganda.We conducted a cross-sectional study on patients diagnosed with TB through three different pathways; by private pharmacies, CHWs, and public health facilities. We collected data on patient demographics, time between symptom recognition and TB treatment initiation, and the amount of money spent on TB care seeking.We collected data from 325 participants; 65.2% were male, with a mean age of 35 years (SD 11.50). The time in days between the onset of symptoms and initiation of treatment was significantly different: respectively 149 (IQR 65.5-295), 119 (IQR 51-200), and 106.5 (IQR 60-201) days for CHWs, pharmacies, and public facilities (P = 0.04). The longest time was between the first contact with a health provider and the TB diagnosis (51 days, IQR 19-104). Participants diagnosed at public health facilities incurred the highest costs.Although the use of CHWs and pharmacies did not shorten the TB treatment pathway, the costs incurred were lower than those in private health facilities..

Mapping TB incidence across districts in Uganda to inform health program activities.

BACKGROUND: Identifying spatial variation in TB burden can help national TB programs effectively allocate resources to reach and treat all people with TB. However, data limitations pose challenges for subnational TB burden estimation. METHODS: We developed a small-area modeling approach using geo-positioned prevalence survey data, case notifications, and geospatial covariates to simultaneously estimate spatial variation in TB incidence and case notification completeness across districts in Uganda from 2016-2019. TB incidence was estimated using 1) cluster-level data from the national 2014-2015 TB prevalence survey transformed to incidence, and 2) case notifications adjusted for geospatial covariates of health system access. The case notification completeness surface was fit jointly using observed case notifications and estimated incidence. RESULTS: Estimated pulmonary TB incidence among adults varied >10-fold across Ugandan districts in 2019. Case detection increased nationwide from 2016 to 2019, and the number of districts with case detection rates >70% quadrupled. District-level estimates of TB incidence were five times more precise than a model using TB prevalence survey data alone. CONCLUSION: A joint spatial modeling approach provides useful insights for TB program operation, outlining areas where TB incidence estimates are highest and health programs should concentrate their efforts. This approach can be applied in many countries with high TB burden.

CONTEXTE: L'identification des variations spatiales de la charge de morbidité de la TB peut aider les programmes nationaux de lutte contre la TB à allouer efficacement les ressources pour atteindre et traiter toutes les personnes atteintes de TB. Cependant, les limites des données posent des problèmes pour l'estimation de la charge de morbidité infranationale. MÉTHODES: Nous avons développé une approche de modélisation à petite échelle en utilisant des données d'enquête de prévalence géolocalisées, des notifications de cas et des covariables géospatiales pour estimer simultanément la variation spatiale de l'incidence de la TB et l'exhaustivité de la notification des cas dans les districts de l'Ouganda de 2016 à 2019. L'incidence de la TB a été estimée à l'aide 1) des données au niveau des grappes de l'enquête nationale sur la prévalence de la TB de 2014­2015, transformées en incidence, et 2) des notifications de cas ajustées pour tenir compte des covariables géospatiales de l'accès au système de santé. La surface de complétude des notifications de cas a été ajustée conjointement à l'aide des notifications de cas observés et de l'incidence estimée. RÉSULTATS: L'incidence estimée de la TB pulmonaire chez les adultes a été multipliée par >10 dans les districts ougandais en 2019. La détection des cas a augmenté à l'échelle nationale entre 2016 et 2019, et le nombre de districts avec des taux de détection des cas >70% a quadruplé. Les estimations de l'incidence de la TB au niveau des districts étaient cinq fois plus précises qu'un modèle utilisant uniquement les données de l'enquête sur la prévalence de la TB. CONCLUSION: Une approche conjointe de modélisation spatiale fournit des informations utiles pour le fonctionnement des programmes de lutte contre la TB, en décrivant les domaines où les estimations de l'incidence de la TB sont les plus élevées et où les programmes de santé devraient concentrer leurs efforts. Cette approche peut être appliquée dans de nombreux pays où la charge de morbidité de la TB est élevée.

Impact of on-site Xpert on TB diagnosis and mortality trends in Uganda.

SETTING: Since 2012, Uganda expanded the Xpert® MTB/RIF network for diagnosis of TB. OBJECTIVES: We compared TB care cascades at health facilities with on-site Xpert vs. facilities that accessed the assay through specimen referral. DESIGN: We analysed secondary aggregate data of the National TB and Leprosy Program (NTLP) from 2016 to 2019. We computed the proportions of notified TB cases and mortality ratios in relation to the estimated TB burden. RESULTS: TB case notifications per annum increased from 24,287 in 2016 to 30,739 in 2019, and the proportion of cases diagnosed at facilities with on-site Xpert testing increased from 62% (15,070/24,287) to 81% (24,829/30,739) (P < 0.001). TB mortality at facilities with on-site Xpert decreased from 8.6% (1,302/15,070) to 7.8% (1,938/24,829) (P = 0.41), while it increased at facilities without on-site Xpert from 6.9% (638/9,217) to 8.8% (521/5,910) (P = 0.23). Furthermore, mortality among TB-HIV co-infected patients at facilities with on-site Xpert dropped from 5.0% (760/15,070) in 2016 to 4.8% (1,187/24,826) in 2019 (P = 0.84) compared to 4.4% (407/9,217) in 2016 to 5.3% (315/5,910) in 2019 (P = 0.57). CONCLUSION: Wider installation and decentralisation of Xpert leads to increased case-finding. However, the impact on reduction in mortality remains limited. Interventions to address TB-related mortality in addition to Xpert roll-out are required.

CONTEXTE: Depuis 2012, l'Ouganda a élargi son réseau de tests Xpert® MTB/RIF destinés au diagnostic de la TB. Nous avons comparé les cascades de soins de la TB dans des centres en mesure de réaliser les tests Xpert « sur place ¼ et dans des centres ayant accès à ces tests par un système d'adresse des prélèvements. MÉTHODES: Nous avons analysé les données agrégées secondaires du programme national de lutte contre la TB (NTLP) de 2016 à 2019. Nous avons calculé les pourcentages de cas de TB ayant fait l'objet d'une notification et les taux de mortalité par rapport au poids sanitaire estimé de la TB. RÉSULTATS: Les notifications annuelles de cas de TB ont augmenté de 24 287 en 2016 à 30 739 en 2019, et la proportion de cas diagnostiqués dans les centres avec tests Xpert sur place a augmenté de 62% (15 070/24 287) à 81% (24 829/30 739) ; P < 0,001. La mortalité liée à la TB dans les centres avec tests Xpert sur place a diminué de 8,6% (1 302/15 070) à 7,8% (1 938/24 829) (P = 0,41), alors qu'elle a augmenté dans les centres sans tests Xpert sur place, de 6,9% (638/9 217) à 8,8% (521/5 910) (P = 0,23). Par ailleurs, la mortalité des patients coinfectés par la TB et le VIH dans les centres avec tests Xpert sur place a diminué de 5,0% (760/15 070) en 2016 à 4,8% (1 187/24 826) en 2019 (P = 0,84), contre une hausse de 4,4% (407/9 217) en 2016 à 5,3% (315/5 910) en 2019 (P = 0,57) dans les centres sans tests Xpert sur place. CONCLUSIONS: La décentralisation et l'élargissement du déploiement des tests Xpert a permis d'accroître le nombre de cas détectés. Toutefois, l'impact sur la réduction de la mortalité reste limité. Des interventions visant à réduire la mortalité liée à la TB, audelà du déploiement des tests Xpert, sont nécessaires.

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.

Xpert® MTB/RIF associated with improved treatment initiation among patients with smear-negative tuberculosis.

BACKGROUND: Delayed diagnosis and treatment initiation of smear-negative tuberculosis (TB) patients can lead to increased morbidity and mortality, particularly among those co-infected with the human immunodeficiency virus (HIV). OBJECTIVE: To compare TB treatment initiation among smear-negative presumptive TB patients in the 6 months before and after the introduction of Xpert® MTB/RIF testing at five rural tertiary hospitals in Uganda. METHODS: Patient records of the dates and results of sputum analysis were extracted from TB laboratory registers and linked to those on treatment initiation as indicated in the TB treatment registers. The proportion of smear-negative presumptive patients who initiated anti-tuberculosis treatment was compared before and after Xpert implementation using χ² tests. Time to treatment was analysed using Kaplan-Meier survival analysis. RESULTS: Records from 3658 patients were analysed, 1894 before and 1764 after the introduction of Xpert testing. After the introduction of Xpert, 25% (437/1764) of smear-negative presumptive TB patients underwent testing. The proportion initiated on anti-tuberculosis treatment increased from 5.9% (112/1894) to 10.8% (190/1764) (P < 0.01). However, 37% (32/87) of patients with a confirmed TB diagnosis did not initiate treatment. Time to TB treatment initiation improved from 8 to 3.5 days between the study periods. CONCLUSION: Xpert testing was associated with improved TB treatment initiation among smear-negative presumptive TB patients. Improved utilisation and linkage to treatment could improve the impact of this test on patient-centred outcomes.