Tuberculosis yield among contacts of non-pulmonary bacteriologically confirmed index TB patients in the urban setting of central Uganda.

BACKGROUND: The World Health Organization (WHO) recommends systematic and active investigation of TB contacts. However, lower priority is given to contact investigation among other non-pulmonary bacteriologically confirmed (PBC) cases; it thus contributes to the scarce information on the yield of TB among contacts of index TB patients without microbiological confirmation (non-PBC patients). This study therefore aimed at establishing the yield of TB among contacts of PBC and non-PBC index TB patients in the urban setting of central Uganda. METHODS: We abstracted data from the Uganda national TB contact investigation registers present at 48 health facilities for the period January 2018 to August 2020. The screening yield for both PBC and non-PBC, timing of TB diagnosis among contacts were determined. Logistic regression was used to examine predictors for diagnosing contacts as non PBC TB patients. RESULTS: From January 2018 to August 2020, 234 persons were diagnosed with TB from a total of 14,275 contacts traced for both PBC and non-PBC TB index patients at 48 facilities. Of these, 100(42.7%) were contacts of non-PBC index patients. TB screening yield was higher among contacts of non PBC 100(2.0%) compared to 134(1.4%) among contacts of PBC index patients. For both groups, over 80% of their contacts were diagnosed with TB within 3 months from the day of TB treatment start of the index case. On multivariate logistic regression the only predictor for diagnosing contacts as non PBC TB patients was age under15 years (adjusted odds ratio [aOR] 7.53, 95% CI [3.27-17.3] p = <0.05). CONCLUSION: The yield of TB among contacts of non-PBC index case is nearly the same for contacts of PBC index cases and most contacts were diagnosed with TB disease during the intensive TB treatment phase of the index case. There was no association between the type of TB (PBC, non-PBC) disease diagnosed in the contacts, and that of index TB patients. To improve TB case-finding, emphasis should be placed on contact investigation for household and close contacts of all other index cases with pulmonary tuberculosis regardless of whether PBC or non-PBC during the intensive phase of treatment.

Improving TB case notification in northern Uganda: evidence of a quality improvement-guided active case finding intervention.

BACKGROUND: Strategies to identify and treat undiagnosed prevalent cases that have not sought diagnostic services on their own, are necessary to treat TB in patients earlier and interrupt transmission. Late presentation for medical services of symptomatic patients require special efforts to detect early and notify TB in high risk populations. An intervention that combined quality improvement with facility-led active case finding (QI-ACF) was implemented in 10 districts of Northern Uganda with the highest TB burden to improve case notification among populations at highest risk of TB. METHODS: Using QI-ACF intervention approach in 48 facilities, we; 1) targeted key vulnerable populations, 2) engaged district and facility teams in TB systems strengthening, 3) conducted systematic screening and diagnosis in vulnerable groups (people living with HIV, fishing communities, and prisoners), and 4) trained health workers on national x-ray diagnosis guidelines for smear-negative patients. Facility-led QI-ACF meant that health care providers identified the target population, mobilized and massively screened suspects, and addressed gaps in documentation. Chest X-ray diagnosis was promoted for smear-negative TB among those suspects whose sputum examination was negative. The effect of the intervention on case notification was then assessed separately over the post intervention period. RESULTS: Over all TB case notification in the intervention districts increased from 171 to 223 per 100,000 population between the baseline months of October-December 2016 and end line month of April-June 2017. TB patient contacts had the majority of TB positive cases identified during active case finding (40, 6.1%). Fishing communities had the highest TB positivity rate at 6.8%. Prisoners accounted for the lowest number of TB positive cases at 34 (2.3%). CONCLUSION: Targeting should be applied at all levels of TB intervention to improve yield: targeting districts and facilities with the lowest rates of case notification and targeting index patient contacts, HIV clients, and fishing communities. Screening tools are useful to guide health workers to identify presumptive cases. Efforts to improve availability of x-ray for TB diagnosis contributed to almost half of the new cases identified. Having all HIV patients who were eligible for viral load provide sputum for TB screening proved easy to implement.

Cost-effectiveness of implementing the chronic care model for HIV care in Uganda.

OBJECTIVE: The chronic care model (CCM) is an integrated, population-based approach for treating those with chronic diseases that involves patient self-management, delivery system design and decision support for clinicians to ensure evidence-based care. We sought to determine effectiveness and cost-effectiveness of implementing the CCM for HIV care in Uganda. DESIGN: This controlled, pre/post-intervention study used difference-in-differences analysis to evaluate effectiveness of the CCM to improve patient adherence to antiretroviral therapy (ART) and CD4 counts. SETTING: One district hospital and two smaller facilities each in one intervention and one control district in Uganda. PARTICIPANTS: About 46 randomly sampled patients receiving HIV services at three control sites and 56 patients from three intervention sites. INTERVENTION: Two group training sessions and monthly coaching visits from improvement experts over 1 year, implementing the CCM. MAIN OUTCOME MEASURE(S): Patient adherence to ART prescriptions (pill counts) and CD4 counts were measured at baseline and en dline. RESULTS: The odds of increased CD4 in the intervention group was 3.2 times higher than controls (P = 0.022). Clinician-reported ART adherence was 60% (P = 0.001) higher in the intervention group. The intervention cost $11 740 and served 7016 patients ($1.67 per patient). Incremental cost-effectiveness ratios of the intervention compared to business-as-usual was $6.90 per additional patient with improved CD4 and $3.40 per additional ART patient with stable or improved adherence. CONCLUSION: For modest expenditure, it is possible to improve indicators of HIV care quality using the CCM. We recommended implementing the CCM in Uganda; it may be applicable in similar settings in other countries.