Screening tools to exclude active pulmonary TB in high TB burden countries: systematic review and meta-analysis.

To examine the use of symptoms, chest X-ray (CXR) abnormalities, and combinations of symptoms and CXR in excluding active pulmonary tuberculosis (TB) before treating for latent tuberculous infection (LTBI) in high TB burden countries. We updated a systematic review and meta-analysis of studies on the sensitivities, specificities, predictive values, diagnostic odds ratios and areas under the curve for index tests. The analysis was conducted using the hierarchical summary receiver operating characteristic method in R software. We included 24 publications in the systematic review and meta-analysis. 'Any CXR abnormality' had the highest sensitivity (94.1%, 95%CI 85.8-97.7) among all index tests. 'CXR abnormality suggestive of TB' had a higher specificity (92.2%, 95%CI 89.7-94.1) than 'any CXR abnormality' (86.8%, 95%CI 79.7-91.7). The sensitivity for 'any TB symptom' was 73.0% (95%CI 64.1-80.4), while 'prolonged cough' of ≥2 weeks had a specificity of 94.3% (95%CI 92.2-95.9). There was no significant difference in the sensitivity and specificity of all screening tools stratified by human immunodeficiency virus (HIV) settings, with the exception of 'CXR abnormality suggestive of TB', which had a significantly higher sensitivity in low than in high HIV prevalence settings (effect estimate 2.26, 95%CI 0.69-3.82; P = 0.002). In countries with a high TB burden, the absence of any TB symptom and any CXR abnormality can be used to exclude active pulmonary TB before initiating treatment for LTBI in household contacts aged ≥5 years of patients with bacteriologically confirmed pulmonary TB. .

Factors associated with the length of stay in emergency departments in Southern-Ethiopia.

OBJECTIVES: This cross-sectional study was conducted on 399 patients at Hawassa University Comprehensive Specialized Hospital from February 15 to March 30/2018 to assess the length of stay (LOS) and its associated factors in emergency departments (EDs). RESULT: About 91.5% patients were stayed in the EDs for greater than 24 h in different reasons. Inadequacy of beds in inpatient wards, overcrowding, absence of different laboratory test profiles and delay in radiological services were showed a significant differences in LOS greater than 24 h when compared to LOS ≤ 24 h in EDs (p < 0.05 for all). In addition, admission beds [adjusted odds ratio: 8.7 (95% CI 3.2-23.2)]; overcrowding [adjusted odds ratio: 3.6 (95% CI 1.6-8.3)]; laboratory test profiles [adjusted odds ratio: 5.1 (95% CI 1.9-14.1)], and radiology services [adjusted odds ratio: 3.7 (95% CI 1.5-9.2)] were significantly and positively associated with LOS greater than 24 h in EDs. Further, a significant proportion of patients were stayed for unnecessary extended length of time in EDs due to different factors. Therefore, the commitment of organization is crucial to provide sufficient number of admission beds, to scale-up laboratory test profiles and to decrease radiology service turn-around time in order to improve LOS in EDs.

Policies and practices on the programmatic management of LTBI: a survey in the African Region.

BACKGROUND: Although the management of latent tuberculous infection (LTBI) is a core component of the End TB Strategy, there is limited information about the status of implementation of such interventions in most African countries. METHODS: A web-based survey involving the 47 countries of the African Region was conducted between November 2016 and April 2017. RESULTS: The questionnaire was completed by 32/47 (68.1%) National TB Programme managers or their delegates. LTBI guidelines were available in four countries (12.5%), while 13 (40.6%) had an LTBI section in their national TB guidelines; there was no significant association with socio-economic conditions and funding allocation. LTBI diagnosis was mostly based on clinical evaluation to rule out active disease, rather than on systematic use of the tuberculin skin test. Respectively 23 (71.8%) and 17 countries (53.1%) reported providing treatment to child contacts aged <5 years and people living with the human immunodeficiency virus (PLHIV). Over two thirds of respondent countries had ongoing activities targeting at least one of the aforementioned high-risk groups. A recording and reporting system for LTBI-related data on child contacts and PLHIV was available in respectively 14 and 12 countries; 7 countries had an LTBI monitoring and evaluation plan. CONCLUSIONS: These data suggest that greater effort is needed to appropriately scale up LTBI policies in the African Region.

Three-month weekly rifapentine plus isoniazid for tuberculosis preventive treatment: a systematic review.

BACKGROUND: Uptake of preventive treatment for tuberculosis (TB) remains poor. A 3-month regimen of rifapentine (RPT) plus isoniazid (INH) (3HP) could facilitate its scale-up. We conducted a systematic review to assess the effects of 3HP compared with daily 6- or 9-month INH monotherapy. METHODS: We searched the following databases to identify randomised controlled trials: PubMed, Embase, the Web of Science, Cochrane Central Register of Controlled Trials, three ongoing trial registers and conference abstracts up to 24 January 2017. Where possible, we pooled data using a random-effects model. RESULTS: Four studies were included. Of those, we included two studies that compared 3HP with daily 6- or 9-month INH (6/9H) among adults with human immunodeficiency virus (HIV) co-infection, one among HIV-negative adults and one among predominantly HIV-negative children and adolescents. Risk of active TB was not significantly different between 3HP and 6/9H (risk ratio [RR] 0.73, 95%CI 0.23-2.29, in adults with HIV; RR 0.44, 95%CI 0.18-1.07, in adults without HIV; RR 0.13, 95%CI 0.01-2.54, in children and adolescents). Risk of hepatotoxicity was significantly lower in the 3HP group among adults with HIV (RR 0.26, 95%CI 0.12-0.55) and those without HIV (RR 0.16, 95%CI 0.10-0.27). 3HP was also associated with a higher completion rate in all subgroups. CONCLUSIONS: HP was shown to have a preventive effect similar to that of INH monotherapy, with fewer adverse events and higher completion rates. 3HP can contribute significantly to the scale-up of preventive treatment.

Policies and practices on the programmatic management of latent tuberculous infection: global survey.

SETTING: Global survey among low tuberculosis (TB) burden countries, which are primary target countries for the World Health Organization (WHO) guidelines on the programmatic management of latent tuberculous infection (LTBI). OBJECTIVE: To perform a baseline assessment of policies and practices for the programmatic management of LTBI. DESIGN: Online and paper-based pre-tested questionnaire filled out by national TB programme managers or their equivalents from 108 countries. RESULTS: Of 74 respondent countries, 75.7% (56/74) had a national policy on LTBI. The majority of the countries (67/74, 90.5%) provided LTBI testing and treatment for child contacts of TB cases, while almost two thirds (49/74, 66%) reported provision of LTBI testing and treatment to people living with the human immunodeficiency virus (PLHIV). Six countries (8.1%) did not report providing LTBI management to child contacts and PLHIV. Among countries that reported both the availability of policy and practice of testing and treatment of LTBI for at-risk populations, a system for recording and reporting data was available in 62% (33/53) for child contacts and in 53% (21/40) for PLHIV. CONCLUSION: Countries need to ensure that national LTBI policies and a standardised monitoring and evaluation system are in place to promote the programmatic management of LTBI.

Rifampicin resistance after treatment for latent tuberculous infection: a systematic review and meta-analysis.

SETTING: Treatment for latent tuberculous infection (LTBI) reduces the risk of tuberculosis (TB) disease. Shorter, rifamycin-containing regimens have been shown to be as effective as 6 months of isoniazid and superior with regard to safety and completion rate. It is unknown whether preventive therapy with rifamycins increases resistance to the drugs used. OBJECTIVE: To determine whether treatment for LTBI with rifamycin-containing regimens leads to significant development of resistance against rifamycins. DESIGN: Systematic review and meta-analysis. RESULTS: We included six randomised-controlled trials of rifamycin-containing regimens for LTBI treatment that reported drug resistance. There was no statistically significant increased risk of rifamycin resistance after LTBI treatment with rifamycin-containing regimens compared to non-rifamycin-containing regimens (RR 3.45, 95%CI 0.72-16.56; P = 0.12) or placebo (RR 0.20, 95%CI 0.02-1.66; P = 0.13). CONCLUSION: Preventive treatment with rifamycin-containing regimens does not significantly increase rifamycin resistance. Programmatic management of LTBI requires the creation of sound surveillance systems to monitor drug resistance.

Expanding human immunodeficiency virus testing and counseling to reach tuberculosis clients' partners and families.

Recent years have shown important increases in human immunodeficiency virus (HIV) testing and counseling (HTC), diagnosis, and coverage of antiretroviral therapy (ART) among HIV-infected tuberculosis (TB) patients. Expansion of HTC for partners and families are critical next steps to increase earlier HIV diagnoses and access to ART, and to achieve international goals for reduced TB and HIV-related morbidity, mortality, transmission and costs. TB and HIV programs should develop and evaluate feasible and effective strategies to increase access to HTC among the partners and families of TB patients, and ensure that newly diagnosed people living with HIV and HIV-infected TB patients who complete anti-tuberculosis treatment are successfully linked to ongoing HIV clinical care.

Community-based multi-disease prevention campaigns for controlling human immunodeficiency virus-associated tuberculosis.

Human immunodeficiency virus (HIV) infection increases the risk of tuberculosis (TB) 21-34 fold, and has fuelled the resurgence of TB in sub-Saharan Africa. The World Health Organization (WHO) recommends the Three I's for HIV/TB (infection control, intensified case finding [ICF] and isoniazid preventive therapy) and earlier initiation of antiretroviral therapy for preventing TB in persons with HIV. Current service delivery frameworks do not identify people early enough to maximally harness the preventive benefits of these interventions. Community-based campaigns were essential components of global efforts to control major public health threats such as polio, measles, guinea worm disease and smallpox. They were also successful in helping to control TB in resource-rich settings. There have been recent community-based efforts to identify persons who have TB and/or HIV. Multi-disease community-based frameworks have been rare. Based on findings from a WHO meta-analysis and a Cochrane review, integrating ICF into the recent multi-disease prevention campaign in Kenya may have had implications in controlling TB. Community-based multi-disease prevention campaigns represent a potentially powerful strategy to deliver prevention interventions, identify people with HIV and/or TB, and link those eligible to care and treatment.

WHO guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update.

The production of guidelines for the management of drug-resistant tuberculosis (TB) fits the mandate of the World Health Organization (WHO) to support countries in the reinforcement of patient care. WHO commissioned external reviews to summarise evidence on priority questions regarding case-finding, treatment regimens for multidrug-resistant TB (MDR-TB), monitoring the response to MDR-TB treatment, and models of care. A multidisciplinary expert panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to develop recommendations. The recommendations support the wider use of rapid drug susceptibility testing for isoniazid and rifampicin or rifampicin alone using molecular techniques. Monitoring by sputum culture is important for early detection of failure during treatment. Regimens lasting ≥ 20 months and containing pyrazinamide, a fluoroquinolone, a second-line injectable drug, ethionamide (or prothionamide), and either cycloserine or p-aminosalicylic acid are recommended. The guidelines promote the early use of antiretroviral agents for TB patients with HIV on second-line drug regimens. Systems that primarily employ ambulatory models of care are recommended over others based mainly on hospitalisation. Scientific and medical associations should promote the recommendations among practitioners and public health decision makers involved in MDR-TB care. Controlled trials are needed to improve the quality of existing evidence, particularly on the optimal composition and duration of MDR-TB treatment regimens.

Community tuberculosis care through "TB clubs" in rural North Ethiopia.

Non-compliance is a major problem in the treatment of tuberculosis (TB). This paper assesses the effectiveness of "TB clubs" in improving compliance with TB treatment and their impact in improving societal attitudes associated with TB. The study utilised both quantitative (cohort study) and qualitative (focus group discussion and an in-depth interview) methods. The cohort study was conducted in two rural districts of Northern Ethiopia. A total of 128 sputum positive pulmonary patients were enrolled and followed, 64 in the TB club and 64 in the comparison groups, to determine treatment outcome of anti-TB therapy. The impact of the TB clubs in changing societal attitudes and behaviour associated with TB was assessed using qualitative methods. The treatment completion rate was significantly better (X2=5.41, P<0.02) in the TB club group, 44 out of 64 patients (68.7%) completed treatment in TB club while only 30 of the 64 (46.8%) completed treatment in the comparison group. The defaulter rate was also significantly lower (X2=11.57, P<0.001) in the TB club group 8/64 (12.5%) compared to 26/64 (40.6%) in the comparison group. The qualitative part of the study also demonstrated remarkable changes in patients' understanding of TB, patients' initial reaction to a TB diagnosis, misconceptions as to the cause and treatment of TB, the social isolation and compliance and belief in the modern health care in the TB club area. The complementary results obtained from the quantitative and qualitative components of the study indicate that the TB club approach has a significant impact in improving patients' compliance to anti-TB treatment and in building positive attitudes and practice in the community regarding TB. This study, thus, provides convincing evidences that the TB club approach is useful in delivering TB treatment successfully in rural populations. Further large-scale studies are needed to find out whether this approach is applicable on a national scale and to other developing countries.

Marriage through abduction ('Telefa') in rural north west Ethiopia.

A community based cross sectional study was conducted in a rural district of North West Ethiopia between February and April 1997 to determine the magnitude of marriage through abduction ('Telefa') and identify problems associated with it. Randomly selected and currently married 1,168 women were interviewed. The prevalence of marriage through abduction was 6.2% (72/1168). All the abductions reported were only once in lifetime during the first marriage. The median age at first marriage of abducted women was 13 years with a range of 13 (Minimum = 7 and Maximum 20). About two third (66.7%) of abducted women had been married more than once in their life time. Following a multivariate analysis in a logistic regression model abducted women were likely to be victims of abortion [Adjusted OR (95% CI) = 1.71 (1.10-3.05)], marital instability [Adjusted OR (95% CI) = 1.87 (1.10-3.18)], rape [Adjusted OR (95% CI) = 7.77 (3.78-15.95)] and domestic violence [Adjusted OR (95% CI) = 1.69 (1.11-2.81)]. The recognition of the magnitude and the associated health problems of marriage through abduction (Telefa) is important. Appropriate strategies that address the health needs of abducted women must be designed. Enforcing the judiciary system to discourage this harmful practice and empowerment of young girls and rural women is needed.

Tuberculosis in rural northwest Ethiopia: community perspective.

A community based cross sectional study was conducted in April 1997 to assess the perspective of the rural community towards Tuberculosis (TB) and TB patients and identify prevailing misconceptions and other problems related with TB in the south Gonder administrative zone of the Amhara region. A total of 1000 heads of household were interviewed and disease information was obtained for 5078 family members. The prevalence of productive cough lasting more than 3 weeks was 4.6% (233/5078) and cervical, axillary or inguinal swelling with or with out a sinus tract that lasted more than 12 months was 1.0% (52/5078). TB treatment defaulters were found in 10% of the rural households. Apparent clinical improvement after the intensive phase was the commonest reason for defaulting (45%) followed by far distance of the health institution (25.3%). Evil spirit and sexual intercourse were incriminated as a cause for TB in 19.9% and 4.7% of respondents respectively. TB was believed as curable disease by 66.7% of the respondents. The rural community exhibited a great deal of ostracism towards TB patients. Majority (76.2%) of the respondents have heard about HIV/AIDS out of whom 19.4% disclosed that there could be an association between HIV/AIDS and TB. It was demonstrated that misconceptions about TB, its treatment, patients and families were prevalent among the communities in South Gonder. Community based awareness creating strategies should be designed and dissemination of TB information and education are strongly recommended.

Contribution of 'TB clubs' to tuberculosis control in a rural district in Ethiopia.

SETTING: A rural district (Estie) in South Gonder, Ethiopia. OBJECTIVE: To describe the contribution of 'TB clubs' (small support groups of patients based on where they live) to the performance of the tuberculosis control programme in Estie District. DESIGN: A descriptive study of the formation of 'TB clubs', their contribution to case-finding and the treatment outcomes before and after formation of the 'TB clubs'. RESULTS: The proportion of actual among expected attendances of tuberculosis patients for follow-up during treatment at health facilities significantly increased (P < 0.001) after the introduction of the TB clubs. Community elders, community health agents and local health workers helped TB clubs to refer tuberculosis suspects, promote treatment adherence and trace defaulters as an integral part of a district tuberculosis programme. The TB clubs referred 181 tuberculosis suspects in the community for investigation, of whom 65% subsequently had a diagnosis of tuberculosis. TB clubs identified 69% of all patients and 76% of new sputum smear-positive pulmonary patients diagnosed in the district. Treatment success rates in new sputum smear-positive, smear-negative and extra-pulmonary tuberculosis patients were 83%, 79% and 81%, respectively. CONCLUSION: The formation of TB clubs contributed to the effective implementation of a district tuberculosis programme. Further evaluation is needed to assess the sustainability and applicability of the approach in other settings.

Epidemic of neurolathyrism in Ethiopia.

After a drought and famine, overconsumption of the drought-tolerant grasspea triggered an epidemic of neurodegenerative neurolathyrism in Northeast Ethiopia. Environmental, nutritional, and medical factors seem to affect the susceptibility.

Medical and social consequences of tuberculosis in rural Ethiopia.

An institution based cross sectional study was conducted in June 1996 at a rural health centre in South Gonder Administrative Zone of Northern Ethiopia. Interview and respective review of medical records of patients were done. A total of 211 tuberculosis (TB) patients were included in the study, 133 (63%) males and 78 (37%) females. Majority (79.6%) of patients had pulmonary disease. Clinical observation based on symptoms and signs suggestive of tuberculosis was used as a sole criteria to prescribe anti-tuberculosis treatment in 54.1% (114/211) of all the patients. Acid fast staining of sputum was done for 51.2% (86/168) of the pulmonary patients out of whom only 31.4% were smear positive. Social ostracism was observed to have been affecting tuberculosis patients and their families to a great extent. Divorce rate due to tuberculosis among patients was 29.1% (37/127). Patients have reported loss or threat to lose their job. Dietary misconceptions were rampant. The TB control activities were ineffective and poorly organised. Starting anti-tuberculosis treatment without proper diagnosis was observed to have negative consequences on the patients and the control programme. Appropriate counselling service along with the medical treatment was provided to patients with eventual family reunions. Patients were also organised into local 'TB clubs' by their residential locations so as to improve treatment adherence and the level of TB awareness among the patients and the community. It is strongly recommended that the political system and health authorities of Ethiopia should have to give much more attention and commitment to the TB control activities in Ethiopia.