Reduction of diagnostic and treatment delays reduces rifampicin-resistant tuberculosis mortality in Rwanda.

SETTING: In 2005, in response to the increasing prevalence of rifampicin-resistant tuberculosis (RR-TB) and poor treatment outcomes, Rwanda initiated the programmatic management of RR-TB, including expanded access to systematic rifampicin drug susceptibility testing (DST) and standardised treatment.OBJECTIVE: To describe trends in diagnostic and treatment delays and estimate their effect on RR-TB mortality.DESIGN: Retrospective analysis of individual-level data including 748 (85.4%) of 876 patients diagnosed with RR-TB notified to the World Health Organization between 1 July 2005 and 31 December 2016 in Rwanda. Logistic regression was used to estimate the effect of diagnostic and therapeutic delays on RR-TB mortality.RESULTS: Between 2006 and 2016, the median diagnostic delay significantly decreased from 88 days to 1 day, and the therapeutic delay from 76 days to 3 days. Simultaneously, RR-TB mortality significantly decreased from 30.8% in 2006 to 6.9% in 2016. Total delay in starting multidrug-resistant TB (MDR-TB) treatment of more than 100 days was associated with more than two-fold higher odds for dying. When delays were long, empirical RR-TB treatment initiation was associated with a lower mortality.CONCLUSION: The reduction of diagnostic and treatment delays reduced RR-TB mortality. We anticipate that universal testing for RR-TB, short diagnostic and therapeutic delays and effective standardised MDR-TB treatment will further decrease RR-TB mortality in Rwanda.

Assessment of schistosomiasis and soil-transmitted helminths prevalence in school-aged children and opportunities for integration of control in local health services in Kwilu Province, the Democratic Republic of the Congo.

OBJECTIVE: To determine the prevalence of schistosomiasis (SCH) and soil-transmitted helminths (STH) in the Democratic Republic of Congo, and to assess the capacity of the local health centres for diagnosis and treatment. METHODS: Cross-sectional school-based survey in two health districts in the Province of Kwilu. We collected a stool and a urine sample for parasitological examination. Urine filtration and duplicate Kato-Katz thick smears were used for the diagnosis of SCH. Health centres were evaluated using a structured questionnaire. RESULTS: In total, 526 children participated in the study and the overall prevalence of Schistosoma mansoni infection was 8.9% (95% CI: 3.5-13.2) in both districts. The prevalence was higher in Mosango (11.7%; 95% CI: 8.9-14.8) than Yasa Bonga district (6.2%; 95% CI: 1.1-11.4). Urine filtration showed that Schistosoma haematobium infection was not present. The combined STH infection prevalence was 58.1% in both districts; hookworm infection was the most common STH found in 52.9% (95% CI: 29.3-62.4) of subjects, followed by Ascaris lumbricoides 9.3% (95% CI: 5.8-15.5) and Trichuris trichiura 2.1% (95% CI: 0.9-4.9). Mixed STH infections were observed as well as SCH-STH coinfection. CONCLUSION: Further mapping of both SCH and STH burden is needed, and coverage of preventive chemotherapy in school-aged children should be increased.

Risk Factors associated with defaulting from visceral leishmaniasis treatment: analysis under routine programme conditions in Bihar, India.

OBJECTIVE: To assess the rate of default from treatment in the visceral leishmaniasis (VL) elimination programme and to identify risk factors and its underlying causes. METHODS: Case-control study conducted between December 2009 and June 2012 in three primary health centres (PHCs) of Muzaffarpur district, India. Patients who defaulted from treatment from the PHCs were considered as 'cases' and those who completed their treatment as 'controls'. Two controls were included in the study for each case. Respondents' opinion and satisfaction with the services provided at the PHCs were also elicited. Logistic regression was performed to assess the contribution of sociodemographic variables on patient status, and a discriminant analysis was used (after decomposing the original data) to identify factors that can predict the patient status as defaulter or not, based on factor scores of the components as predictor variables. RESULTS: During the study period, 16.3% (89/544) of patients defaulted; 87 cases and 188 controls were interviewed through a semistructured questionnaire. Women tended to be more at risk for default (OR, 1.6, 95% CI (0.9 -2.9). Treatment received was miltefosine in 55.6% and sodium stibogluconate (SSG) in 44.4%. Most (86%) defaulters completed their treatment at other healthcare facilities; 70% of them preferred non-governmental institutions. Most cited reasons for default were seeking a second opinion for VL treatment and preferring to be treated in specialised VL centres. Discriminant analysis showed only one significant predictor: dissatisfaction with the medical care received in PHCs. CONCLUSION: Efforts are needed to enhance the quality of VL care at PHC level, which will be beneficial in increasing treatment completion rates.

'They prefer hidden treatment': anti-tuberculosis drug-taking practices and drug regulation in Karakalpakstan.

SETTING: The joint Médecins Sans Frontières/Ministry of Health Multidrug-Resistant Tuberculosis (MDR-TB) Programme, Karakalpakstan, Uzbekistan. OBJECTIVE: Uzbekistan has high rates of MDR-TB. We aimed to understand patients' and prescribers' attitudes to anti-tuberculosis drug prescription, regulation and drug-taking behaviour. METHODS: Participants (12 patients, 12 practitioners) were recruited purposively. Data were gathered qualitatively using field notes and in-depth interviews and analysed thematically. FINDINGS: Our analysis highlighted two main themes. First, shame and stigma were reported to increase the likelihood of self-treatment and incorrect use of anti-tuberculosis drugs, most commonly at the initial stages of illness. A health system failure to promote health information was perceived, leading to wrong diagnoses and inappropriate therapies. Motivated by shame, patients hid their condition by resorting to drug treatment options outside the programme, compounding the risk of chaotic management and dissemination of erroneous information through lay networks. Second, positive influences on treatment were reported through patients, practitioners and peers working effectively together to deliver the correct information and support, which acted to normalise TB, reduce stigma and prevent misuse of anti-tuberculosis drugs. CONCLUSION: Effective case finding, patient support and community education strategies are essential. Patients, practitioners and peers working together can help reduce stigma and prevent misuse of anti-tuberculosis drugs.

Integration of diagnosis and treatment of sleeping sickness in primary healthcare facilities in the Democratic Republic of the Congo.

BACKGROUND: Control of human African trypanosomiasis (HAT) in the Democratic Republic of Congo (DRC) has always been a vertical programme, although attempts at integration in general health services were made in recent years. Now that HAT prevalence is declining, the integration question becomes even more crucial. We studied the level of attainment of integration of HAT case detection and management in primary care centres in two high-prevalence districts in the province of Bandundu, DRC. METHODS: We visited all 43 first-line health centres of Mushie and Kwamouth districts, conducted structured interviews and inspected facilities using a standardised checklist. We focused on: availability of well trained staff - besides HAT, we also tested for knowledge on tuberculosis; availability of equipment, consumables and supplies; and utilisation of the services. RESULTS: All health centres were operating but most were poorly equipped, and attendance rates were very low. We observed a median of 14 outpatient consultations per facility (IQR 8-21) in the week prior to our visit, that is two patients per day. The staff had good knowledge on presenting symptoms, diagnosis and treatment of both HAT and tuberculosis. Nine centres were accredited by the national programme as HAT diagnosis and treatment centres, but the most sensitive diagnostic confirmation test, the mini-anion exchange centrifugation technique (mAECT), was not present in any. Although all nine were performing the CATT screening test, only two had the required cold chain in working order. CONCLUSION: In these high-prevalence districts in DRC, staff is well-acquainted with HAT but lack the tools required for an adequate diagnostic procedure. Attendance rates of these primary care centres are extremely low, making timely recognition of a resurgence of HAT unlikely in the current state of affairs.

Village health workers in Bihar, India: an untapped resource in the struggle against kala-azar.

INTRODUCTION: In 2005 a visceral leishmaniasis (VL) elimination initiative was launched on the Indian subcontinent; important components of early case finding and treatment are entrusted to the primary health care system (PHC). In an earlier study in Bihar, India, we discovered some major shortcomings in implementation, in particular related to monitoring of treatment and treatment outcomes. These shortcomings could be addressed through involvement of village health workers. In the current study we assessed knowledge, attitude and practice of these village health workers in relation to VL. Main objective was to assess the feasibility of their involvement in VL control. METHODS: We obtained a list of auxiliary nurses/midwives and accredited social health activists for the highly endemic district of Muzaffarpur. We randomly sampled 100 auxiliary nurses and 100 activists, who were visited in their homes for an interview. Questions were asked on knowledge, attitude and practice related to visceral leishmaniasis and to tuberculosis. RESULTS: Auxiliary nurses and activists know the presenting symptoms of visceral leishmaniasis, they know how it is diagnosed but they are not aware of the recommended first-line treatment. Many are already involved in tuberculosis control and are very well aware of the treatment modalities of tuberculosis, but few are involved in control of visceral leishmaniasis control. They are well organised, have strong links to the primary healthcare system and are ready to get more involved in visceral leishmaniasis control. CONCLUSION: To ensure adequate monitoring of visceral leishmaniasis treatment and treatment outcomes, the control programme urgently needs to consider involving auxiliary nurses and activists.

Treatment outcomes for human African Trypanosomiasis in the Democratic Republic of the Congo: analysis of routine program data from the world's largest sleeping sickness control program.

OBJECTIVE: To enable the human African trypanosomiasis (HAT) control program of the Democratic Republic of the Congo to generate data on treatment outcomes, an electronic database was developed. The database was piloted in two provinces, Bandundu and Kasai Oriental. In this study, we analysed routine data from the two provinces for the period 2006-2008. METHODS: Data were extracted from case declaration cards and monthly reports available at national and provincial HAT coordination units and entered into the database. RESULTS: Data were retrieved for 15 086 of 15 741 cases reported in the two provinces for the period (96%). Compliance with post-treatment follow-up was very poor in both provinces; only 25% had undergone at least one post-treatment follow-up examination, <1% had undergone the required four follow-up examinations. Relapse rates among those presenting for follow-up were high in Kasai (18%) but low in Bandundu (0.3%). CONCLUSIONS: High relapse rates in Kasai and poor compliance with post-treatment follow-up in both provinces are important problems that the HAT control program urgently needs to address. Moreover, in analogy to tuberculosis control programs, HAT control programs need to adopt a recording and reporting routine that includes reporting on treatment outcomes.

Monitoring drug effectiveness in kala-azar in Bihar, India: cost and feasibility of periodic random surveys vs. a health service-based reporting system.

OBJECTIVE: In 2009, a random survey was conducted in Muzaffarpur district to document the clinical outcomes of visceral leishmaniasis patients (VL) treated by the public health care system in 2008, to assess the effectiveness of miltefosine against VL. We analysed the operational feasibility and cost of such periodic random surveys as compared with health facility-based routine monitoring. METHODS: A random sample of 150 patients was drawn from registers kept at Primary Health Care centres. Patient records were examined, and the patients were located at their residence. Patients and physicians were interviewed with the help of two specifically designed questionnaires by a team of one supervisor, one physician and one field worker. Costs incurred during this survey were properly documented, and vehicle log books maintained for analysis. RESULTS: Hundred and 39 (76.7%) of the patients could be located. Eleven patients were not traceable. Per patient, follow-up cost was US$ 15.51 and on average 2.27 patients could be visited per team-day. Human resource involvement constituted 75% of the total cost whereas involvement of physician costs 51% of the total cost. CONCLUSION: A random survey to document clinical outcomes is costly and labour intensive but gives probably the most accurate information on drug effectiveness. A health service-based retrospective cohort reporting system modelled on the monitoring system developed by tuberculosis programmes could be a better alternative. Involvement of community health workers in such monitoring would offer the additional advantage of treatment supervision and support.

Health care-seeking behaviour and diagnostic delays for Human African Trypanosomiasis in the Democratic Republic of the Congo.

OBJECTIVE: About half of the patients with Human African trypanosomiasis (HAT) reported in the Democratic Republic of the Congo (DRC) are currently detected by fixed health facilities and not by mobile teams. Given the recent policy to integrate HAT control into general health services, we studied health seeking behaviour in these spontaneously presenting patients. METHODS: We took a random sample from all patients diagnosed with a first-time HAT episode through passive case finding between 1 October 2008 and 30 September 2009 in the two most endemic provinces of the DRC. Patients were approached at their homes for a structured interview. We documented patient delay (i.e. time between onset of symptoms and contacting a health centre) and health system delay (i.e. time between first contact and correct diagnosis of HAT). RESULTS: Median patient delay was 4 months (IQR 1-10 months, n = 66); median health system delay was 3 months (IQR 0.5-11 months). Those first presenting to public health centres had a median systems delay of 7 months (IQR 2-14 months, n = 23). On median, patients were diagnosed upon the forth visit to a health facility (IQR 3rd-7th visit). CONCLUSIONS: Substantial patient as well as health system delays are incurred in HAT cases detected passively. Public health centres are performing poorly in the diagnostic work-up for HAT, mainly because HAT is a relatively rare disease with few and non-specific early symptoms. Integration of HAT diagnosis and treatment into general health services requires strong technical support and well-organized supervision and referral mechanisms.

Why do tuberculosis patients default in Tashkent City, Uzbekistan? A qualitative study.

BACKGROUND: Tuberculosis (TB) control in Tashkent City, Uzbekistan, is organised in accordance with the DOTS strategy. Intensive phase treatment is provided in hospital, while the continuation phase is given on an ambulatory basis. In 2005, the defaulter rate was 21%. An earlier quantitative study explored when patients default and identified some of the risk factors associated with default, but did not answer the question: 'Why do patients default?' OBJECTIVE: To investigate reasons for defaulting and to identify possible solutions. METHODS: We conducted a qualitative follow-up study consisting of 32 in-depth interviews with defaulters, patients who had completed treatment and health care providers. RESULTS: Communication between patients and health care staff is poor. Patients lack proper information on TB and its treatment. There is a widespread belief that TB is not curable. Hospitalisation is problematic due to poor general conditions in TB hospitals, costs incurred by patients during hospitalisation and because TB patients need to earn a living or take care of their families. CONCLUSION: Poor communication between health care staff and TB patients is a key issue underlying several of the causes of default identified, and needs to be addressed. Reducing the period of hospitalisation may also improve adherence to TB treatment.

Management of visceral leishmaniasis in rural primary health care services in Bihar, India.

OBJECTIVE: In 2005 a visceral leishmaniasis (VL) elimination initiative was launched on the Indian subcontinent, with early diagnosis based on a rapid diagnostic test and treatment with the oral drug miltefosine as its main strategy. Several recent studies have signaled underreporting of VL cases in the region. Information on treatment outcomes is scanty. Our aim was to document VL case management by the primary health care services in India. METHODS: We took a random sample of all VL patients registered in rural primary health care (PHC) facilities of Muzaffarpur district, Bihar, India during 2008. Patients were traced at home for an interview and their records were reviewed. We recorded patient and doctor delay, treatment regimens, treatment outcomes and costs incurred by patients. RESULTS: We could review records of all 150 patients sampled and interview 139 patients or their guardian. Most patients (81%) had first presented to unqualified practitioners; median delay before reaching the appropriate primary healthcare facility was 40 days (IQR 31-59 days). Existing networks of village health workers were under-used. 48% of VL patients were treated with antimonials; 40% of those needed a second treatment course. Median direct expenditure by patients was 4000 rupees per episode (IQR 2695-5563 rupees), equivalent to almost 2 months of household income. CONCLUSION: In 2008 still critical flaws remained in VL case management in the primary health care services in Bihar: obsolete use of antimonials with high failure rates and long patient delay. To meet the target of the VL elimination, more active case detection strategies are needed, and village health worker networks could be more involved. Costs to patients remain an obstacle to early case finding.

Risk factors for visceral leishmaniasis in India: further evidence on the role of domestic animals.

OBJECTIVE: Studies investigating risk factors for visceral leishmaniasis (VL) on the Indian Subcontinent have shown contradictory results related to the role of domestic animals. In some studies having animals in or around the house was a risk factor, in others it was protective. We investigated the specific hypothesis that keeping domestic animals inside the house at night is a risk factor for VL. METHODS: Individually matched case-control study. All patients with VL diagnosed in the study area in Bihar, India between March 1st, 2007 and December 1st, 2008 were eligible. For each case, we selected two random controls, with no history of previous VL; matched on sex, age group and neighbourhood. Patients and controls were subjected to a structured interview on the main exposure of interest and potential confounders; a conditional logistic regression model was used to analyse the data. RESULTS: We enrolled 141 patients and 282 controls. We found no significant associations between VL and keeping domestic animals inside the house (OR of 0.88 for bovines and 1.00 for 'any animal') or ownership of domestic animals (OR of 0.97 for bovines and 1.02 for 'any animal'). VL was associated with housing conditions. Living in a thatched house (OR 2.60, 95% CI 1.50-4.48) or in a house with damp floors (OR 2.60, 95% CI 1.25-5.41) were risk factors, independently from socio economic status. CONCLUSION: Keeping animals inside the house is not a risk factor for VL in Bihar, India. Improving housing conditions for the poor has the potential to reduce VL incidence.

A new format of the CATT test for the detection of human African Trypanosomiasis, designed for use in peripheral health facilities.

OBJECTIVES: To test the reproducibility and thermostability of a new format of the Card-Agglutination Test for Trypanosomiasis (CATT) test for Human African Trypanosomiasis (HAT), designed for use at primary health care facility level in endemic countries. METHODS: A population of 4217 from highly endemic villages was screened using the existing format of the CATT test (CATT-R250) on whole blood. All those testing positive (220) and a random sample of negatives (555) were retested in the field with the new format (CATT-D10). Inter-format reproducibility was assessed by calculating kappa. All samples testing positive on whole blood with either method were further evaluated in Belgium by CATT titration of serum by two observers, using both old and new format. CATT-D10 test kits were incubated under four temperature regimens (4, 37, 45 degrees C and fluctuating) with regular assessments of reactivity over 18 months. RESULTS: Inter-format reproducibility of CATT-D10 vs. CATT-R250 on whole blood performed by laboratory technicians in the field was excellent with kappa values of 0.83-0.89. Both inter- and intra-format reproducibility assessed by CATT titration were excellent, with 96.5-100% of all differences observed falling within the limits of +/-1 titration step. After 18 months, reactivity of test kits incubated under all four temperature regimens was still well above the minimum threshold considered acceptable. CONCLUSION: The CATT-D10 is thermostable and can be used interchangeably with the old format of the CATT test. It is highly suitable for use in peripheral health facilities in HAT-endemic countries.

Drug prescribing practices for tuberculosis in Uzbekistan.

SETTING: Uzbekistan has had 100% DOTS coverage since 2005; however, the treatment success rate has remained at around 80% for the last 4 years. Surveys from the capital city of Tashkent and from western Uzbekistan have shown high levels of primary multidrug resistance. OBJECTIVE: To assess treatment regimens prescribed for new cases of tuberculosis (TB), including the prescription of additional non-TB drugs, and the cost implications for the patient. DESIGN: We randomly sampled 30 clusters of seven new TB patients. Enrolled patients were interviewed and their medical records were reviewed. RESULTS: In general, the treatment regimens prescribed were correct; doses were high rather than low. Second-line anti-tuberculosis drugs were rarely prescribed. In addition to anti-tuberculosis drugs, patients were prescribed on average seven to eight non-TB drugs. The rationale for prescribing the non-TB drugs was, however, questionable. Patients incurred substantial costs for these drugs, some of which were not without risk. CONCLUSION: Prescriptions of anti-tuberculosis drugs for new TB patients are adequate; however, the practice of prescribing additional non-TB drugs needs to be reconsidered.

Reforming tuberculosis control in Ukraine: results of pilot projects and implications for the national scale-up of DOTS.

The period of economic transition has had severe consequences for health and health systems in Ukraine. The tuberculosis (TB) situation illustrates this. The strategy recommended by the World Health Organization (WHO) for TB, directly observed treatment short-course (DOTS), has the potential to provide real improvements in TB services, forming the basis of the response to the growing epidemic. In 2002, Ukraine, financially supported by USAID and the European Community (EC), began to introduce DOTS through pilot projects in Mariupol and Kyiv City. The aim of this study is to assess the feasibility, effectiveness, health service cost, patient cost, and the cost-effectiveness of these pilots, in order to inform the national scale-up of DOTS. The study finds that DOTS is feasible and has the potential to be both effective and cost-effective in Ukraine. Following this study, Ukraine adopted DOTS as a national TB control strategy in 2005. However, the pilots also found that there are several evidence-related concerns and perverse economic incentives to both providers and patients that will need to be addressed if national scale-up is to be successful. These include concerns related to the treatment of MDR-TB, economic benefits to some patients to remain hospitalized, and payments to providers and health facilities that support current practices. These will need to be addressed if Ukraine is to develop an effective response to its emerging TB epidemic.

Health care seeking behaviour for tuberculosis symptoms in Kiev City, Ukraine.

SETTING: Tuberculosis (TB) doctors in Kiev City have the impression that TB patients often present with advanced TB disease, and the mortality rate among TB patients is high. Delay in seeking health care may explain these observations. OBJECTIVE: To assess the magnitude of patient delay and evaluate risk factors for delay. DESIGN: We included 190 newly diagnosed pulmonary TB patients. For each patient, information was gathered through interviews and from the medical records. RESULTS: The median time between the start of symptoms and the first visit to a health care provider (patient delay) was 30.0 days. Individuals reporting unemployment, cough or loss of weight before seeking health care had a longer patient delay. The same applies to individuals with the risk factors homelessness, joblessness or alcohol abuse. The main reasons for delay among those who presented late were 'thought symptoms would go away' and 'symptoms not considered serious'. CONCLUSION: For most TB patients, the time between start of symptoms and first health care seeking action was acceptable. Long patient delay was reported by individuals who were homeless, jobless or abused alcohol. Specific activities will have most effect if they are targeted at these vulnerable and difficult to reach groups.

HIV testing practices of TB patients after introduction of a new testing policy in Kiev City, Ukraine.

SETTING: The Kiev City Health Administration published a new policy for human immunodeficiency virus (HIV) testing of tuberculosis (TB) patients. According to this policy, all TB patients should be offered voluntary HIV testing after counselling. OBJECTIVE: To evaluate the implementation of the new HIV testing policy and to determine the HIV prevalence in TB patients in Kiev City. DESIGN: TB patient medical records were retrieved from eight TB facilities in Kiev City. They were reviewed for information about offering an HIV test, accepting to be HIV tested and outcome of the HIV test. Information was collected about patient characteristics and TB risk groups. RESULTS: Of 914 patients, 75% were offered HIV testing. Females were less frequently and alcohol abusers more frequently offered HIV testing. Of the patients who were offered HIV testing, 84% accepted. Of the 574 who were HIV tested, 36 (6.3%) had a positive test result. CONCLUSION: Not all TB facilities adhere strictly to the new policy. HIV testing seemed to be targeted to individuals with a high risk for HIV infection. To improve adherence to the new policy we recommend training of TB physicians in voluntary counselling and testing. The HIV prevalence among TB patients in Kiev City was 6.3%.