Improving child tuberculosis contact identification and screening in Lesotho: Results from a mixed-methods cluster-randomized implementation science study.

BACKGROUND: Child tuberculosis (TB) contact management is recommended for preventing TB in children but its implementation is suboptimal in high TB/HIV-burden settings. The PREVENT Study was a mixed-methods, clustered-randomized implementation study that evaluated the effectiveness and acceptability of a community-based intervention (CBI) to improve child TB contact management in Lesotho, a high TB burden country. METHODS: Ten health facilities were randomized to CBI or standard of care (SOC). CBI holistically addressed the complex provider-, patient-, and caregiver-related barriers to prevention of childhood TB. Routine TB program data were abstracted from TB registers and cards for all adult TB patients aged >18 years registered during the study period, and their child contacts. Primary outcome was yield (number) of child contacts identified and screened per adult TB patient. Generalized linear mixed models tested for differences between study arms. CBI acceptability was assessed via semi-structured in-depth interviews with a purposively selected sample of 20 healthcare providers and 28 caregivers. Qualitative data were used to explain and confirm quantitative results. We used thematic analysis to analyze the data. RESULTS: From 01/2017-06/2018, 973 adult TB patients were recorded, 490 at CBI and 483 at SOC health facilities; 64% male, 68% HIV-positive. At CBI and SOC health facilities, 216 and 164 child contacts were identified, respectively (p = 0.16). Screening proportions (94% vs. 62%, p = 0.13) were similar; contact yield per TB case (0.40 vs. 0.20, p = 0.08) was higher at CBI than SOC health facilities, respectively. CBI was acceptable to caregivers and healthcare providers. CONCLUSION: Identification and screening for TB child contacts were similar across study arms but yield was marginally higher at CBI compared with SOC health facilities. CBI scale-up may enhance the ability to reach and engage child TB contacts, contributing to efforts to improve TB prevention among children.

Tuberculosis elimination: where are we now?

Tuberculosis (TB) still represents a major public health issue in spite of the significant impact of the efforts made by the World Health Organization (WHO) and partners to improve its control. In 2014 WHO launched a new global strategy (End TB) with a vision of a world free of TB, and a 2035 goal of TB elimination (defined as less than one incident case per million). The aim of this article is to summarise the theoretical bases of the End TB Strategy and to analyse progresses and persistent obstacles on the way to TB elimination.The evolution of the WHO recommended strategies of TB control (Directly Observed Therapy, Short Course (DOTS), Stop TB and End TB) are described and the concept of TB elimination is discussed. Furthermore, the eight core activities recently proposed by WHO as the milestones to achieve TB elimination are discussed in detail. Finally, the recently published experiences of Cyprus and Oman on their way towards TB elimination are described, together with the regional experience of Latin America.New prevention, diagnostic and treatment tools are also necessary to increase the speed of the present TB incidence decline.

Stakeholder perspectives for optimization of tuberculosis contact investigation in a high-burden setting.

INTRODUCTION: Optimal tuberculosis contact investigation impacts TB prevention, timely case finding and linkage to care, however data on routine implementation in high burden contexts is limited. MATERIALS AND METHODS: In a multi-method qualitative study based on individual interviews with TB patients, facility observations and focus group discussions with health workers (HWs) in 13 public health facilities, and key informant interviews with governmental and non-governmental experts, we describe TB contact investigation in the context of an urban setting in Kenya and identify opportunities for optimization. RESULTS: Invitation of TB patients to bring close contacts by HWs was key for all patient decisions that led to contact screening in addition to patients' understanding of TB transmission and desire to avoid contacts suffering from TB. Sub-optimal HW enquiry of TB patients and contacts presenting at the facility were missed opportunities which stemmed from lack of standardized operational procedures, documentation tools and HW training. Stakeholders proposed provision of fast tracked and holistic health packages for contacts seeking TB screening, and sustainable government led funding for the requisite infrastructure and workforce. CONCLUSION: TB contact invitation by HWs leading to contact screening occurs in this context. Stakeholder perspectives inform the design of an operational framework for optimized delivery.

Isoniazid Preventive Therapy among Children Living with Tuberculosis Patients: Is It Working? A Mixed-Method Study from Bhopal, India.

Objective: We assessed uptake of isoniazid preventive therapy (IPT) among child contacts of smear-positive tuberculosis (TB) patients and its implementation challenges from healthcare providers' and parents' perspectives in Bhopal, India. Methods: A mixed-method study design: quantitative phase (review of programme records and house-to-house survey of smear-positive TB patients) followed by qualitative phase (interviews of healthcare providers and parents). Results: Of 59 child contacts (<6 years) of 129 index patients, 51 were contacted. Among them, 19 of 51 (37%) were screened for TB and one had TB. Only 11 of 50 (22%) children were started and 10 of 50 (20%) completed IPT. Content analysis of interviews revealed lack of awareness, risk perception among parents, cumbersome screening process, isoniazid stock-outs, inadequate knowledge among healthcare providers and poor programmatic monitoring as main barriers to IPT implementation. Conclusion: National TB programme should counsel parents, train healthcare providers, simplify screening procedures, ensure regular drug supply and introduce an indicator to strengthen monitoring and uptake of IPT.

Optimising molecular diagnostic capacity for effective control of tuberculosis in high-burden settings.

The World Health Organization's 2035 vision is to reduce tuberculosis (TB) associated mortality by 95%. While low-burden, well-equipped industrialised economies can expect to see this goal achieved, it is challenging in the low- and middle-income countries that bear the highest burden of TB. Inadequate diagnosis leads to inappropriate treatment and poor clinical outcomes. The roll-out of the Xpert(®) MTB/RIF assay has demonstrated that molecular diagnostics can produce rapid diagnosis and treatment initiation. Strong molecular services are still limited to regional or national centres. The delay in implementation is due partly to resources, and partly to the suggestion that such techniques are too challenging for widespread implementation. We have successfully implemented a molecular tool for rapid monitoring of patient treatment response to anti-tuberculosis treatment in three high TB burden countries in Africa. We discuss here the challenges facing TB diagnosis and treatment monitoring, and draw from our experience in establishing molecular treatment monitoring platforms to provide practical insights into successful optimisation of molecular diagnostic capacity in resource-constrained, high TB burden settings. We recommend a holistic health system-wide approach for molecular diagnostic capacity development, addressing human resource training, institutional capacity development, streamlined procurement systems, and engagement with the public, policy makers and implementers of TB control programmes.

How to manage neonatal tuberculosis.

This article reports the recommendations for managing neonatal tuberculosis (TB) drawn up by a group of Italian scientific societies. The Consensus Conference method was used, and relevant publications in English were identified through a systematic review of MEDLINE and the Cochrane Database of Systematic Reviews from their inception until 31 December 2014. Group experts concluded that if suspicion is aroused, it is necessary to undertake promptly all of the investigations useful for identifying the disease not only in the newborn, but also in the mother and family contacts because a diagnosis of TB in the family nucleus can guide its diagnosis and treatment in the newborn. If the suspicion is confirmed, empirical treatment should be started. Breast-fed newborns being treated with isoniazid should be given pyridoxine supplementation at a dose of 1 mg kg(-1) day(-1). Mothers with active-phase TB can breast-feed once they have become smear negative after having received appropriate treatment.

Descentralização do atendimento dos casos de tuberculose para Atenção Primária: um relato de experiência / Decentralization of the care of tuberculosis cases for Primary Care: an experience report

Este trabalho tem como objetivo descrever a experiência do processo de descentralização do tratamento da TB para a AP de modo a contribuir com as instituições e profissionais que ainda não desencadearam esse processo. (AU)

Comisión de diagnóstico de casos sospechosos de tuberculosis con baciloscopia negativa: aceptabilidad del servicio por los médicos presentadores / Commission for the diagnosis of bacteriologically negative suspected tuberculosis cases: acceptability of the service by presenting physicians

Introducción: en etapa de eliminación de la tuberculosis, resulta de gran interés la identificación temprana de estos enfermos en cualquiera de sus formas, incluyendo aquellos con manifestaciones clínicas-radiológicas y microscopía negativa. Objetivos: conocer la frecuencia con que los médicos de diferentes servicios de salud presentan los expedientes clínicos de enfermos sospechosos de tuberculosis en la Comisión de Diagnóstico de enfermos de Tuberculosis con Baciloscopias Negativas (CODIBAARNE) del Hospital Neumológico Benéfico Jurídico de La Habana, la procedencia de dichos facultativos y sus opiniones sobre este servicio científico-técnico. Métodos: estudio descriptivo exploratorio. Para precisar la procedencia de los médicos presentadores, se aplicó un único formulario de encuesta. Resultados: en el 2004-05 se encuestaron 181 médicos y en el 2011, 40. De los primeros 181 encuestados, 118 (65,2 por ciento) procedían de 44 policlínicos de la atención primaria de salud y 63 (34,8 por ciento) de 17 hospitales de atención secundaria. Del primer grupo, 142 (78,5 por ciento) consideraron bueno y útil el servicio científico-técnico y 34 (19 por ciento) expresaron que era instructivo y aprendían con el servicio brindado. Del segundo grupo, 33 (82,5 por ciento) son Médicos Generales Integrales, y expresaron opiniones muy similares a las del primer grupo entrevistado. Conclusión: CODIBAARNE brinda extensa cobertura de servicios científico-técnicos a médicos de atención primaria y secundaria, que suscitan opiniones muy favorables de la gran mayoría de sus usuarios, considerándola como una herramienta complementaria para el diagnóstico de la tuberculosis con baciloscopia negativa(AU)

Introduction: in tuberculosis elimination an important role is played by early identification of all patients, including those with negative clinical-radiological and microscopy results. Objectives: determine the frequency with which physicians from various health services submit the medical records of patients with suspected tuberculosis to the Commission for the Diagnosis of Bacteriologically Negative Tuberculosis (CODIBAARNE) of Havana Benéfico Jurídico Pneuological Hospital, the institutional affiliation of those physicians and their opinions about this technical-scientific service. Methods: a descriptive exploratory study was conducted to determine the place of origin of presenting doctors. A unique survey form was used. Results: 181 doctors were surveyed in the period 2004-2005 and 40 in 2011. Of the former 181 doctors, 118 (65.2 percent) were from 44 primary health care polyclinics and 63 (34.8 percent) from 17 secondary health care hospitals. 142 (78.5 percent) evaluated the technical and scientific service as good and useful, and 34 (19 percent) said it was instructive. Of the second group 33 (82.5 percent) were comprehensive general physicians. Their opinions were very similar to those of the first group. Conclusion: CODIBAARNE provides extensive coverage of technical and scientific services to primary and secondary health care physicians, generating very favorable opinions among most of its users, who view it as a complementary tool for the diagnosis of bacteriologically negative tuberculosis(AU)

Outbreak of primary inoculation tuberculosis in an acupuncture clinic in southeastern China.

Outbreak of Mycobacterium tuberculosis infections associated with acupuncture has not been reported. Thirteen patients with a painful swollen lump were referred to our hospital. The index patient received acupuncture and paraspinal muscular injection at a local acupuncture clinic in April 2011 and was diagnosed with M. tuberculosis 1 month later. From May 2011 to August 2011, 12 more patients with a swollen lump on the nuchal region or in the lower back or the buttocks region were referred to our hospital. Tuberculin skin test (TST), T-SPOT.TB, acid-fast stain, M. tuberculosis culture, chest radiograph, and lump magnetic resonance imaging (MRI) were performed and the patients were diagnosed with tuberculous abscess of the lump. All 13 patients received intramuscular injection at the paraspinal muscle by two acupuncturists at a local clinic and reported a swollen lump at the injection site. The needles and syringes were reused after autoclave sterilization. The TST was positive in all patients. Twelve patients had positive acid-fast stains. Mycobacterial cultures of abscess specimens were positive in all 13 patients. T-SPOT.TB tests were positive in all patients who underwent the test. The lesions and biopsies were subjected to polymerase chain reaction (PCR) and gene sequencing by the Disease Control Center of Zhejiang Province, China and the causative agent was identified as M. tuberculosis, Beijing type. In conclusion, physicians should consider the possibility of mycobacterial infections, apart from other bacterial agents, in patients with a swollen paraspinal lump following intramuscular injection.

Infection control for extrapulmonary tuberculosis at a tertiary care cancer center.

Extrapulmonary tuberculosis (TB) can be infectious when diagnostic or therapeutic procedures are performed on infected lesions. We retrospectively describe infection control and evaluate isolation failure rates during the manipulation of active extrapulmonary TB lesions at a comprehensive cancer center over a 5-year period. Among patients with a high suspicion of cancer, extrapulmonary TB was not suspected, and airborne precautions often were not used when manipulating infected lesions.

Pre-Columbian mycobacterial genomes reveal seals as a source of New World human tuberculosis.

Modern strains of Mycobacterium tuberculosis from the Americas are closely related to those from Europe, supporting the assumption that human tuberculosis was introduced post-contact. This notion, however, is incompatible with archaeological evidence of pre-contact tuberculosis in the New World. Comparative genomics of modern isolates suggests that M. tuberculosis attained its worldwide distribution following human dispersals out of Africa during the Pleistocene epoch, although this has yet to be confirmed with ancient calibration points. Here we present three 1,000-year-old mycobacterial genomes from Peruvian human skeletons, revealing that a member of the M. tuberculosis complex caused human disease before contact. The ancient strains are distinct from known human-adapted forms and are most closely related to those adapted to seals and sea lions. Two independent dating approaches suggest a most recent common ancestor for the M. tuberculosis complex less than 6,000 years ago, which supports a Holocene dispersal of the disease. Our results implicate sea mammals as having played a role in transmitting the disease to humans across the ocean.

Outbreak of pyrazinamide-monoresistant tuberculosis identified using genotype cluster and social media analysis.

SETTING: Monoresistance to pyrazinamide (PZA) has infrequently been associated with Mycobacterium tuberculosis. OBJECTIVE: To report an outbreak of PZA-monoresistant M. tuberculosis in Virginia involving two genotype clusters from December 2004 to August 2010. RESULTS: Thirty cases were identified involving a predominantly young, US-born population with histories of substance use and incarceration and a large proportion of children aged <15 years (n= 6, 20%); of these, 23 cases (77%) were culture-confirmed as M. tuberculosis complex. DNA fingerprinting and molecular analysis of the PZA resistance gene, pncA, demonstrated a clonal strain that was not M. bovis. Genotypic data provided the initial link between seemingly unrelated cases, and helped reveal a historic genotype cluster of cases from 2004. Further genotype cluster and contact investigation procedures, including the novel use of the social networking website Facebook.com, revealed additional links between the 2004 and 2009 genotype clusters and described an ongoing, extensive outbreak necessitating an enhanced screening and treatment protocol for contacts. CONCLUSIONS: This outbreak demonstrates how tuberculosis can spread through a young, vulnerable population. The use of genotypic data and the novel incorporation of social media investigations were critical to understanding the settings and context of infectivity.

"Phthisiophobia": the difficult recognition of transmission of tuberculosis to health care workers.

BACKGROUND: Even if the contagious nature of tuberculosis was universally accepted during the nineteenth century, its transmission to health care workers (HCWs) was initially denied by the scientific community. Working among TB patients was not considered dangerous for healthy adults, so the potential risks for HCWs were branded as unwarranted "phthisiophobia" (fear of contracting tuberculosis). OBJECTIVES: This study aims at analyzing the problem of tuberculosis transmission among health care workers from an historical perspective, particularly highlighting the contribution made by the Italian Occupational Medicine community. METHODS: Scientific literature and historical sources on different theories regarding tuberculosis transmission were investigated, specially focusing on the period at the turn of the 19th and 20th centuries. RESULTS: At the beginning of the twentieth century, Luigi Devoto (1864-1936), an Italian pioneer in the field of Occupational Medicine, was one of the first scientists to conduct research on the transmission of tuberculosis among nurses. Since the 1920s several studies, conducted mainly on medical and nursing students, confirmed the risk for HCWs. However an international consensus on this issue was only achieved during the 1950s, when the institution of mandatory chest radiographs on admission for all patients significantly decreased the cases of tuberculosis among HCWs. CONCLUSIONS: Devoto was one of the first scholars who postulated the transmission of tuberculosis to HCWs. He also theorized that hospital personnel with active disease could also be a source of contagion to patients. Nowadays, "third party risk" and latent tuberculosis infection pose a new challenge for occupational physicians in hospitals.

Perception of tuberculosis in Pakistan: findings of a nation-wide survey.

OBJECTIVE: To assess knowledge about symptoms, diagnosis, treatment, transmission, and impact of tuberculosis in Pakistan. METHODS: This nationwide survey was carried out by face to face interviews with 2742 men and women from December 2009 to June 2010. Multiple stage random area probability sampling was used for this purpose. Trained interviewers conducted interviews using structured questionnaire focusing knowledge, diagnosis, treatment, and impact of TB. Data was weighted to correspond with census distribution of population across rural and urban areas of all four provinces. SPSS 10 was used for data analysis. RESULTS: Ninety percent (2478) of the respondents were familiar with the term TB. Common symptoms associated by respondents were cough (59%), haemoptysis (51%) and fever (40%). Majority (61%) mentioned that TB can be diagnosed by clinical examination by a doctor, 45% laboratory analysis of sputum, and 33% Xray chest as a diagnostic modality. Ninety-three percent were of the opinion that TB is treatable; 90% were in favour of treatment by doctor, and 16% by homeopathic or hakim treatment. About 91% favoured to continue TB treatment according to doctor's advice, 4% thought it can be stopped within 1-2 months of resolution of symptoms, while 73% regarded TB as a communicable disease. More than 33% respondents considered that TB affects education, occupation, getting married, and having children. CONCLUSION: Pakistani population has deficient knowledge and misconceptions regarding symptoms, diagnosis, treatment, and impact of TB.

Knowledge and awareness of tuberculosis among Roma population in Belgrade: a qualitative study.

BACKGROUND: Tuberculosis (TB) remains an important health problem in the Roma population in Serbia. Recent studies have highlighted the importance of increasing awareness of TB and reducing the associated stigmas to reduce the incidence of TB and enable earlier diagnosis and effective treatment. This study investigated the knowledge and beliefs about transmission, symptoms and treatment of TB as well as attitudes towards patients with TB among the Roma population in Belgrade. METHODS: The focus-group method was considered to be appropriate for investigating knowledge and beliefs about TB. A total of 24 Roma people aged 19-55 years participated in three focus-group discussions. RESULTS: All participants knew that TB was a pulmonary disease and could be contagious. Saliva was the most commonly mentioned mode of transmission. Some individuals thought, albeit hesitantly, that TB could be transmitted by shaking hands with an infected individual. Of factors contributing to TB, participants mentioned bad living conditions, low quality and lack of food, and stress. Participants quoted chest pain, cough, haemoptysis, loss of appetite, loss of weight, weakness and sweating as basic symptoms of TB. Participants believed that effective treatment should include resting, taking prescribed medicines, inhaling fresh air and eating "strong" food such as bacon and pork; these approaches were considered as important as taking antibiotics). In addition, participants mentioned that they use some folk medicines.Relatives and friends, and to a lesser extent television, were the main sources of information about TB. Participants most appreciate personal contact with doctors as a source of information. CONCLUSIONS: We concluded that participants were aware of the seriousness TB as well as some of the modes of transmission; however, they had some misconceptions. An important finding was the confidence in doctors expressed by the Roma people.