Exploring the Impact of the COVID-19 Pandemic on Tuberculosis Care and Prevention.

The COVID-19 pandemic has set back the global tuberculosis (TB) response by several years. In 2020, access to TB prevention and care declined sharply, with TB notifications dropping by 18% compared to 2019. Declines were more pronounced in children, with a 24% drop in 0-14 year-olds and a 28% drop in 0-4 year-olds. As a result, in 2020 the number of deaths due to TB increased to 1.5 million across all ages, reversing a decade-long declining trend. Progress toward the UN High Level Meeting targets for 2022 is at risk, including the targets related to children for TB and drug-resistant TB treatments, and TB preventive therapy. Nonetheless, ending TB by 2030 as envisaged in the Sustainable Development Goals (SDGs) is still possible, but requires increased investments in accelerated case detection, subclinical TB, preventive therapy and an effective vaccine. Investing in TB could prepare the world better for fighting a future airborne pandemic.

Enhancing Tuberculosis Case-Finding: A Case of Quality Improvement Initiative in Tanzania.

BACKGROUND: Tanzania is 1 of the 30 high TB burden countries and 1 of the 13 countries in which 75% of people with TB are unaccounted for and that is prioritized for the Global Fund Catalytic investment and Strategic Initiative support. Tanzania decided to strengthen its National TB Programme to find these people with TB who are unaccounted for by identifying evidence-driven innovations to deliver high-quality services and to improve the efficiency of TB case-finding. A quality improvement (QI) initiative was implemented by the National Tuberculosis and Leprosy Programme to enhance TB case-finding. The initiative involved identifying gaps in the quality of services, introducing new tools, improving the work capacity of health care workers through training and mentorship sessions, strengthening laboratory and referral services, and implementing mandatory TB screening of all patients attending health facilities. We aimed to assess the effectiveness of QI initiative to enhance TB case-findings at the health facility level. METHOD: A cross-sectional design, and intervention and control facilities randomly selected for an evaluation of the QI initiative were used. Twenty facilities from the Dodoma region across all health care system levels (dispensaries, health centres, and hospitals) were involved in this evaluation. The facilities were randomly divided into either the intervention or control groups at a 1:1 ratio (10 intervention and 10 control facilities). Data routinely collected from program registers from January 2016 to June 2017 were used. RESULT: The evaluation registered a 52% increase in TB case notification in Q1 of 2017 compared with in Q1 of 2016 and, similarly, a 52% increase in Q2 of 2017 compared with in Q2 of 2016, with 9 out of 10 intervention sites reporting increases in their quarterly TB case notifications. There were no positive changes in the 'control facilities' where routine services were provided, with half of the facilities showing a decrease in TB case notification from baseline. CONCLUSION: This QI initiative has the potential to support a long-term comprehensive approach to ending TB and to improve the quality of the foundations of the health care system. This initiative sets a reliable pace for health facilities to efficiently respond to and manage TB case-finding interventions put into action. Tanzania's experience with implementing QI interventions could serve as a model for improving TB case notifications in other settings.

Pulmonary tuberculosis among women with cough attending clinics for family planning and maternal and child health in Dar Es Salaam, Tanzania.

BACKGROUND: Tuberculosis (TB) case detection in women has remained low in developing world. This study was conducted to determine the proportion of smear positive TB among women with cough regardless of the duration attending family Planning (FP) and Maternal and child health (MCH) clinics in Dar es Salaam. METHODS: We conducted a cross sectional study in all three municipal hospitals of Dar es Salaam, between October 2007 and June 2008. All women with cough attending FP and MCH clinics were screened for TB by smear microscopy. Pearson chi-square was used to compare group difference for categorical variables. Risk factors for smear positive were estimated by logistics regression with 95% confidence intervals (CI) given for odds ratios indicating statistically significant relationship if the CI did not include one. RESULTS: We enrolled a total of 749 TB suspects. Five hundred and twenty nine patients (70.6%) were from MCH clinics. Mean (SD) age was 27.6 (5.2) years. A total of 616 (82.2%) patients were coughing for less than two weeks as compared to 133 (17.8%), who coughed for two or more weeks. Among 616 TB suspects, 14 (2.3%) were smear positive TB patients, and of the 133 who had coughed for two or more weeks, 13 (9.8%) were smear positive TB patients. Risk factors associated with smear positive results were having attended more than one visit to any facility prior to diagnosis (OR = 6.8; 95%CI 2.57-18.0) and having HIV/AIDS (OR = 4.4; 95%CI 1.65-11.96). Long duration of cough was not a risk factor for being smear positive (OR = 1.6; 95%CI 0.59-4.49). CONCLUSION: The proportion of smear positive TB patients among women with cough attending MCH and FP was 3.8%. Visits to any health facility prior to Diagnosis and HIV infection were risk for having a smear positive TB.

Detection of pulmonary tuberculosis among patients with cough attending outpatient departments in Dar Es Salaam, Tanzania: does duration of cough matter?

BACKGROUND: According to WHO estimates, tuberculosis case detection rate in Tanzania is less than 50% and this poses a major challenge to control tuberculosis in the country. Currently, one of the defining criteria for suspecting tuberculosis is cough for two weeks or more. We wanted to find out whether the prevalence of tuberculosis was different in patients who reported cough for two weeks or more, compared to patients with cough for less than two weeks. METHODS: We conducted a cross sectional study in six health facilities in Dar es Salaam, between September and October 2007. All patients aged five years and above with cough were screened for pulmonary tuberculosis (PTB) by smear microscopy. Patients were divided into two groups, those who coughed for less than two weeks (<2 wks) and those who coughed for two weeks or more (> or = 2 wks). RESULTS: A total of 65,530 patients attended outpatients department (OPD). Out of these, 2274 (3.5%) patients reported cough. Among patients who reported cough, 2214 (97.4%) remembered their cough duration. One thousand nine hundred and seventy three patients (89.1%) coughed for >/= 2 wks as compared to 241 (10.9%) patients who coughed for <2 wks. Of those who coughed for two weeks or more, 250 (12.7%) had smear positive PTB, and of those who had coughed for less than two weeks, 21 (8.7%) had smear positive PTB. There was no statistically significant difference in prevalence of smear positive tuberculosis among the two groups (Pearson Chi-Square 3.2; p = 0.074). CONCLUSION: Detection of smear positive PTB among patients who coughed for less than two weeks was as high as for those who coughed for two weeks or more.

Delay in tuberculosis case detection in Pwani region, Tanzania. A cross sectional study.

BACKGROUND: Delay in Tuberculosis (TB) case detection may worsen the disease and increase TB transmission. It is also a challenge to the National TB and Leprosy control Program (NTLP). METHODS: We conducted a cross sectional study in four out of six districts in Pwani region to estimate the extent and factors responsible for delay in TB case detection in Pwani region. Delays were divided into patient, health facility and total delay. RESULTS: We enrolled a total of 226 smear positive TB patients. Out of 226 patient's results were available for 206. The majority (66.5%) of the patients were males. Mean age for males and females were 37.3 and 33.7 years respectively. Mean (SD) total delay was 125.5 (98.5) days (median 90). Out of 206 patients, 79 (38.35%) delayed to seek TB health care. Health facility delay was observed among 121 (58.7%) patients.Risk factors for delay was poor knowledge that chest pain may be a TB symptom (OR = 2.9; 95%CI 1.20- 7.03) and the belief that TB is always associated with HIV/AIDS (OR = 2.7; 95%CI 1.39-5.23). Risk for delay was low among patients who first presented to a government health facility (OR = 0.3; 95%CI 0.12- 0.71) and those presenting with chest pain (OR = 0.2; 95%CI 0.10-0.61). CONCLUSION: There is a considerable delay in TB case detection in Pwani mainly contributed by patients. Risk factors for delay include misconception about TB/HIV and poor knowledge of TB symptoms.

Acceptability of community and health facility-based directly observed treatment of tuberculosis in Tanzanian urban setting.

SETTING: An urban district in Dar es Salaam, Tanzania. OBJECTIVE: To assess the acceptability of community and health facility-based direct observation of treatment (DOT) of tuberculosis (TB) patients in Temeke district. DESIGN: Both quantitative and qualitative study methodologies were used. Eight focus group discussions were carried out with TB patients, treatment supporters, health workers and community members. Quantitative study was also carried out among TB patients and treatment supporters. RESULTS: A total of 268 patients and 103 treatment supporters were enrolled in the study. The majority of the patients (75%) were satisfied with the DOT options they received. Males were more satisfied with community-based DOT (84%) than females (67%) (OR 4.96, 95% CI 1.38-17.86). The majority (81%) were willing to supervise another TB patient. The results of the qualitative study demonstrated that community-based DOT was preferred because it was found to be convenient, reduced costs, saved time of the patients and reduced workload in health services. The main challenge of community-based DOT was to ensure effective supervision and monitoring of patients and treatment supporters in the community. CONCLUSION: The results from the quantitative and qualitative studies indicate that both DOT options were acceptable. The study has also identified key challenges and opportunities for effective implementation of community-based DOT interventions that are relevant, sensitive and acceptable to the population. Community-based DOT is a viable option and can complement and strengthen the existing health facility-based DOT, especially in countries like Tanzania where the health system is overwhelmed with increasing number of TB and HIV/AIDS patients.

Investing to end epidemics: the role of the Global Fund to control TB by 2030.

The Global Fund to fight AIDS, Tuberculosis and Malaria provides over three-quarters of all international financing towards TB programs with US$4.7 billion disbursed, supporting provision of treatment for 13.2 million patients with smear-positive TB and 210 000 patients with multidrug-resistant TB in over 100 countries since 2002. In 2013, the Global Fund launched a new funding model that, among others, is advancing strategic investments to maximize impact, addressing 'missing' TB cases, enhancing a synergistic response to TB/HIV dual epidemics, and building resilient and sustainable systems for health. A new Global Fund Strategy is under development through consultation with various stakeholders, with which the Global Fund will work to play a more catalytic role and foster innovations to end the TB epidemic.

Cost and cost-effectiveness of community based and health facility based directly observed treatment of tuberculosis in Dar es Salaam, Tanzania.

BACKGROUND: Identifying new approaches to tuberculosis treatment that are effective and put less demand to meagre health resources is important. One such approach is community based direct observed treatment (DOT). The purpose of the study was to determine the cost and cost effectiveness of health facility and community based directly observed treatment of tuberculosis in an urban setting in Tanzania. METHODS: Two alternative strategies were compared: health facility based directly observed treatment by health personnel and community based directly observed treatment by treatment supervisors. Costs were analysed from the perspective of health services, patients and community in the year 2002 in USD using standard methods. Treatment outcomes were obtained from a randomised-controlled trial which was conducted alongside the cost study. Smear positive, smear negative and extra-pulmonary TB patients were included. Cost-effectiveness was calculated as the cost per patient successfully treated. RESULTS: The total cost of treating a patient with conventional health facility based DOT and community based DOT were 145 dollars and 94 dollars respectively. Community based DOT reduced cost by 35%. Cost fell by 27% for health services and 72% for patients. When smear positive and smear negative patients were considered separately, community DOT was associated with 45% and 19% reduction of the costs respectively. Patients used about 43 dollars to follow their medication to health facility which is equivalent to their monthly income. Indirect costs were as important as direct costs, contributing to about 49% of the total patient's cost. The main reason for reduced cost was fewer number of visits to the TB clinic. Community based DOT was more cost-effective at 128 dollars per patient successfully treated compared to 203 dollars for a patient successfully treated with health facility based DOT. CONCLUSION: Community based DOT presents an economically attractive option to complement health facility based DOT. This is particularly important in settings where TB clinics are working beyond capacity under limited resources.

Collaboration between the national tuberculosis programme and a non governmental organisation in TB/HIV care at a district level: experience from Tanzania.

BACKGROUND: The increase in tuberculosis and HIV/AIDS patients in many countries in Africa including Tanzania, is outstripping the ability of public health services to cope. This calls for a closer collaboration between tuberculosis programmes and other stakeholders involved in HIV/AIDS care. OBJECTIVE: To determine the feasibility of establishing collaboration between the tuberculosis programme and an NGO in TB/ HIV care at a district level in Tanzania. METHODS: Quantitative and qualitative study designs involving TB as well as HIV suspects and patients together with health workers, were conducted between December, 2001 and September, 2002. RESULTS: A total of 72 patients and 28 key informants were involved. The collaboration was in the following areas; voluntary counselling and testing for HIV, diagnosis and treatment of TB, referral and follow up of patients and suspects, home based care, psychological support and training. Both the tuberculosis programme and NGO benefited from the collaboration. TB case detection among PLWA increased more than three folds and TB treatment was integrated in home based care of NGO. The main barriers identified in this study were; poor communication, poor referral system and lack of knowledge and skills among health staff. CONCLUSION: The study has shown that it is possible for a tuberculosis programme and a non governmental organisation to collaborate in TB/HIV care. The study has also identified potential areas of collaboration and barriers that needed to be overcome in order to provide such comprehensive services at a district level.