Local staff making sense of their tuberculosis data: key to quality care and ending tuberculosis.

The End TB Strategy's ambitious targets require universal health coverage, new tools and better data to monitor progress. To assess the feasibility of a novel approach, whereby facility and district staff analyse and use their tuberculosis (TB) data to strengthen the quality of patient care and data. This approach was piloted in Zimbabwe, and performance before and during the study were compared. Key indicators were defined for presumptive TB, TB disease, drug-resistant TB, TB and human immunodeficiency virus (HIV) co-infection, treatment outcomes, directly observed treatment and drug management. Staff validated, tabulated and analysed data quarterly to identify challenges and agree on action points at 'data-driven' supervision and performance review meetings. In the district that fully implemented the new approach, there was a significant increase in the identification of presumptive TB (63% vs. 30% in the rest of the province; P < 0.00001) and new smear-positive TB cases (87% vs. a decrease in the rest of the province; P < 0.0001), and a decline in the rate of pulmonary TB cases without diagnostic smear results (77% vs. 20% in the rest of the province; P = 0.037). The present study suggests that this approach led to an improvement in the quality of patient care and data, stimulated local staff to set priorities and increased 'ownership'. This approach can significantly help attain national TB goals and strengthen health systems. .

Challenges and opportunities to prevent tuberculosis in people living with HIV in low-income countries.

People living with the human immunodeficiency virus (HIV) (PLHIV) are at high risk for tuberculosis (TB), and TB is a major cause of death in PLHIV. Preventing TB in PLHIV is therefore a key priority. Early initiation of antiretroviral therapy (ART) in asymptomatic PLHIV has a potent TB preventive effect, with even more benefits in those with advanced immunodeficiency. Applying the most recent World Health Organization recommendations that all PLHIV initiate ART regardless of clinical stage or CD4 cell count could provide a considerable TB preventive benefit at the population level in high HIV prevalence settings. Preventive therapy can treat tuberculous infection and prevent new infections during the course of treatment. It is now established that isoniazid preventive therapy (IPT) combined with ART among PLHIV significantly reduces the risk of TB and mortality compared with ART alone, and therefore has huge potential benefits for millions of sufferers. However, despite the evidence, this intervention is not implemented in most low-income countries with high burdens of HIV-associated TB. HIV and TB programme commitment, integration of services, appropriate screening procedures for excluding active TB, reliable drug supplies, patient-centred support to ensure adherence and well-organised follow-up and monitoring that includes drug safety are needed for successful implementation of IPT, and these features would also be needed for future shorter preventive regimens. A holistic approach to TB prevention in PLHIV should also include other important preventive measures, such as the detection and treatment of active TB, particularly among contacts of PLHIV, and control measures for tuberculous infection in health facilities, the homes of index patients and congregate settings.

Age-stratified tuberculosis treatment outcomes in Zimbabwe: are we paying attention to the most vulnerable?

Setting: A high tuberculosis (TB) incidence, resource-limited urban setting in Zimbabwe. Objectives: To compare treatment outcomes among people initiated on first-line anti-tuberculosis treatment in relation to age and other explanatory factors. Design: This was a retrospective record review of routine programme data. Results: Of 2209 patients included in the study, 133 (6%) were children (aged <10 years), 132 (6%) adolescents (10-19 years), 1782 (81%) adults (20-59 years) and 162 (7%) were aged ⩾60 years, defined as elderly. The highest proportion of smear-negative pulmonary TB cases was among the elderly (40%). Unfavourable outcomes, mainly deaths, increased proportionately with age, and were highest among the elderly (adjusted relative risk 3.8, 95%CI 1.3-10.7). Having previous TB, being human immunodeficiency virus positive and not on antiretroviral treatment or cotrimoxazole preventive therapy were associated with an increased risk of unfavourable outcomes. Conclusion: The elderly had the worst outcomes among all the age groups. This may be related to immunosuppressant comorbidities or other age-related diseases mis-classified as TB, as a significant proportion were smear-negative. Older persons need better adapted TB management and more sensitive diagnostic tools, such as Xpert® MTB/RIF.

Contexte : Une zone urbaine aux ressources limitées avec une incidence élevée de tuberculose (TB) au Zimbabwe.Objectifs : Comparer les résultats du traitement parmi des patients mis sous traitement antituberculeux de première ligne, en relation avec leur âge et d'autres facteurs explicatifs.Schéma : Une revue rétrospective de dossiers de données de routine du programme.Résultats : Sur les 2209 patients inclus dans l'étude, 133 (6%) ont été des enfants (âgés de <10 ans), 132 (6%) des adolescents (10­19 ans), 1782 (81%) des adultes (20­59 ans) et 162 (7%) ≥60 ans, définies comme âgées. Le taux le plus élevé de cas de TB pulmonaire à frottis négatif a concerné les personnes âgées (40%). Les résultats défavorables, en particulier le décès, ont augmenté proportionnellement à l'âge et ont donc été les plus élevés parmi les personnes âgées (risque relatif ajusté 3,8 ; IC95% 1,3­10,7). Avoir des antécédents de TB, être positif pour le virus de l'immunodéficience humaine et ne pas être sous traitement antirétroviral ni sous traitement préventif par cotrimoxazole ont été associés avec un risque accru de résultat défavorable.Conclusion : Les personnes âgées ont eu de plus mauvais résultats que tous les autres groupes d'âge. Ceci peut être lié aux comorbidités immunosuppressives ou à d'autres pathologies liées à l'âge, classées à tort comme TB, puisqu'une proportion significative a eu un frottis négatif. Les personnes plus âgées ont besoin d'une prise en charge de la TB mieux adaptée et d'outils diagnostiques plus sensibles, comme l'Xpert® MTB/RIF.

Marco de referencia: Un entorno urbano con alta incidencia de tuberculosis (TB) y recursos limitados en Zimbabwe.Objetivos: Comparar los desenlaces terapéuticos de las personas que habían iniciado el tratamiento antituberculoso de primera línea, según la edad y otras variables explicativas.Métod: Un estudio retrospectivo con análisis de los datos corrientes del registro del programa.Resultados: De los 2209 pacientes incluidos en el estudio, 133 eran niños (6%, <10 años de edad), 132 adolescentes (10­19 años, 6%), 1782 adultos (20­59 años, 81%) y 162 eran personas de ≥60 años (7%), definidas como ancianas. La más alta proporción de casos de TB pulmonar con baciloscopia negativa se observó en el grupo de ancianos (40%). Los desenlaces desfavorables, en la mayoría de los casos por muerte, aumentaron de manera proporcional con la edad y fueron más frecuentes en los ancianos (riesgo relativo ajustado 3,8; IC95% 1,3­10,7). Los factores asociados con un mayor riesgo de alcanzar desenlaces desfavorables fueron el antecedente de TB, la positividad frente al virus de la inmunodeficiencia humana y el hecho de no recibir tratamiento antirretrovírico ni tratamiento preventivo con cotrimoxazol.Conclusión: Los pacientes ancianos presentaron los desenlaces más desfavorables en comparación con los demás grupos etarios. Esto se podría explicar por las enfermedades concomitantes que provocan inmunodepresión u otras enfermedades asociadas con la edad, designadas de manera errada como TB, pues en una proporción considerable la baciloscopia fue negativa en este grupo. Las personas ancianas necesitan un tratamiento antituberculoso mejor adaptado e instrumentos diagnósticos más sensibles, como la prueba Xpert® MTB/RIF.

Does the type of treatment supporter influence tuberculosis treatment outcomes in Zimbabwe?

Zimbabwe National Tuberculosis Guidelines advise that direct observation of anti-tuberculosis treatment (DOT) can be provided by a family member/relative as a last resort. In 2011, in Nkayi District, of 763 registered tuberculosis (TB) patients, 59 (8%) received health facility-based DOT, 392 (51%) received DOT from a trained community worker and 306 (40%) from a family member/relative. There were no differences in TB treatment outcomes between the three DOT groups, apart from a higher frequency rate of 'no reported outcomes' for those receiving family-based DOT. Family members should be trained to use a suitable DOT support package.

Les directives nationales en matière de tuberculose au Zimbabwe conseillent que l'observation directe du traitement antituberculeux (DOT) puisse être fournie par un membre de la famille ou par un autre parent, et ce en dernier ressort. En 2011, dans le District de Nkayi, 762 patients tuberculeux ont été enregistrés, parmi lesquels 59 (8%) ont reçu un DOT à partir des services de santé, 392 (51%) un DOT provenant d'un travailleur formé de la collectivité et 306 (40%) d'un membre de la famille ou d'un autre parent. Il n'y a pas eu de différences en matière de résultats du traitement de la TB entre ces trois groupes DOT, à l'exception d'une fréquence plus élevée de non-signalement des résultats chez ceux recevant un DOT par un membre de leur famille. Les membres de la famille devraient être formés à utiliser un ensemble adéquat de soutien au DOT.

Las directrices nacionales sobre la tuberculosis (TB) en Zimbabue recomiendan que, como último recurso, un miembro de la familia nuclear o extensa se pueda encargar de la observación directa del tratamiento antituberculoso (DOT). En el 2011, en el Distrito de Nkayi se registraron 763 pacientes con diagnóstico de TB, de los cuales 59 (8%) recibieron el DOT en un establecimiento de salud, 392 (51%) lo recibieron de un trabajador comunitario capacitado y 306 pacientes (40%) lo recibieron de un miembro de su familia nuclear o extensa. No se observaron diferencias en los desenlaces terapéuticos entre los tres grupos, con la excepción de una mayor frecuencia de desenlaces no comunicados en el grupo donde un familiar suministraba el tratamiento. Es preciso capacitar a los miembros de la familia sobre la utilización de un módulo apropiado de apoyo al DOT.