Community-supported self-administered tuberculosis treatment combined with active tuberculosis screening: a pilot experience in Conakry, Guinea.

Directly observed treatment (DOT) for tuberculosis (TB) is recommended by the World Health Organization. However, DOT does not always meet patients' preferences, burdens health facilities, and is hard to implement in settings where access to healthcare services is regularly interrupted. A model addressing these limitations of DOT is community-supported self-administered treatment (CS-SAT), in which patients who self-administer TB treatment receive regular visits from community members. Guinea is a country with a high TB burden, recurrent epidemics, and periodic socio-political unrest. We piloted a CS-SAT model for drug-susceptible TB patients in Conakry, led by community volunteers, who also conducted active TB case finding among household contacts and referrals for isoniazid preventive treatment (IPT) in children below 5 years old. We aimed to assess TB treatment outcomes of patients on CS-SAT and describe the number of patients identified with TB case finding and IPT provision. Prospectively enrolled bacteriologically confirmed TB patients, presenting to two facilities, received monthly TB medication. Community volunteers performed bi-weekly (initiation phase) and later monthly (continuation phase) home visits to verify treatment adherence, screen household contacts for TB, and assess IPT uptake in children under five. Among 359 enrolled TB patients, 237 (66.0%) were male, and 37 (10.3%) were HIV-positive. Three hundred forty (94.7%) participants had treatment success, seven (1.9%) died, seven (1.9%) experienced treatment failure, and five (1.4%) were lost-to-follow-up. Among 1585 household contacts screened for TB, 26 (1.6%) had TB symptoms, of whom five (19.2%) were diagnosed with pulmonary TB. IPT referral was done for 376 children from 198 households. In a challenging setting, where DOT is often not feasible, CS-SAT led to successful TB treatment outcomes and created an opportunity for active TB case finding and IPT referral. We recommend the Guinean CS-SAT model for implementation in similar settings.

Face mask sampling (FMS) for tuberculosis shows lower diagnostic sensitivity than sputum sampling in Guinea.

BACKGROUND: Pulmonary tuberculosis (PTB) diagnosis relies on sputum examination, a challenge in sputum-scarce patients. Alternative non-invasive sampling methods such as face mask sampling (FMS) have been proposed. OBJECTIVE: To evaluate the value of FMS for PTB diagnosis by assessing its agreement with sputum samples processed by GeneXpert MTB/RIF (Ultra)(Xpert) testing, and describe FMS sensitivity and specificity. METHODS: This was a prospective study conducted at the Carrière TB clinic in Guinea. Presumptive TB patients willing to participate were asked to wear a surgical mask containing a polyvinyl alcohol (PVA) strip for thirty minutes. Subsequently, two spot sputum samples were collected, of which one was processed by microscopy on site and the other by Xpert in Guinea's National Reference Laboratory of Mycobacteriology (LNRM). The first 30 FMS were processed at the Supranational Reference Laboratory in Antwerp, Belgium, and the following 118 FMS in the LNRM. RESULTS: One hundred fifty patients participated, of whom 148 had valid results for both mask and sputum. Sputum smear microscopy was positive for 47 (31.8%) patients while sputum-Xpert detected MTB in 54 (36.5%) patients. Among the 54 patients testing sputum-Xpert positive, 26 (48.1%) yielded a positive FMS-Xpert result, while four sputum-Xpert negative patients tested positive for FMS and 90 patients were Xpert-negative for both sputum and mask samples, suggesting a moderate level of agreement (k-value of 0.47). The overall mask sensitivity was 48.1%, with 95.7% specificity. CONCLUSION: In our setting, Xpert testing on FMS did not yield a high level of agreement to sputum sample.

Four-Month High-Dose Rifampicin Regimens for Pulmonary Tuberculosis.

High-Dose Rifampicin Regimen for Pulmonary TuberculosisThis randomized, controlled trial tested the efficacy and safety of high-dose rifampicin (1200 or 1800 mg/d) as part of the treatment regimen for pulmonary tuberculosis. Four-month high-dose rifampicin regimens had no dose-limiting side effects but failed to meet noninferiority criteria compared with the standard 6-month control regimen.

Health-Related Quality of Life of Tuberculosis Patients during the COVID-19 Pandemic in Conakry, Guinea: A Mixed Methods Study.

The COVID-19 pandemic has had a significant impact on all facets of life and has exacerbated many challenges faced by people living with tuberculosis (TB). This study aimed to assess the health-related quality of life (HRQoL) of TB patients in Guinea during the first wave of the COVID-19 pandemic. A mixed methods study was conducted using two validated tools to assess HRQoL and qualitative interviews among TB patients enrolled in treatment at 11 health centers in Conakry, Guinea. Logistic regression was used to identify factors associated with the deterioration of HRQoL. We included 439 participants in the study, among whom 44% and 31% experienced pain and anxiety, respectively. We found that an increase in the number of household size and the distance from participants' residence to the health centers were significantly associated with lower HRQoL. Qualitative interviews highlighted nutritional and financial issues, which were exacerbated during the COVID-19 pandemic and beliefs that the Guinean Government's assistance plan was insufficient. This study supports the implementation of specific relief plans for TB patients, which includes nutritional and psychological support, especially those whose movements are limited by travel restrictions, preventing access to TB care, reducing work opportunities and exacerbating financial needs and stress.

How culturally unique are pandemic effects? Evaluating cultural similarities and differences in effects of age, biological sex, and political beliefs on COVID impacts.

Despite being bio-epidemiological phenomena, the causes and effects of pandemics are culturally influenced in ways that go beyond national boundaries. However, they are often studied in isolated pockets, and this fact makes it difficult to parse the unique influence of specific cultural psychologies. To help fill in this gap, the present study applies existing cultural theories via linear mixed modeling to test the influence of unique cultural factors in a multi-national sample (that moves beyond Western nations) on the effects of age, biological sex, and political beliefs on pandemic outcomes that include adverse financial impacts, adverse resource impacts, adverse psychological impacts, and the health impacts of COVID. Our study spanned 19 nations (participant N = 14,133) and involved translations into 9 languages. Linear mixed models revealed similarities across cultures, with both young persons and women reporting worse outcomes from COVID across the multi-national sample. However, these effects were generally qualified by culture-specific variance, and overall more evidence emerged for effects unique to each culture than effects similar across cultures. Follow-up analyses suggested this cultural variability was consistent with models of pre-existing inequalities and socioecological stressors exacerbating the effects of the pandemic. Collectively, this evidence highlights the importance of developing culturally flexible models for understanding the cross-cultural nature of pandemic psychology beyond typical WEIRD approaches.

Malnutrition prevalence and associated biochemical factors among drug-resistance tuberculosis (DR-TB) patients at key treatment sites in Conakry City, Republic of Guinea.

INTRODUCTION: drug-resistant tuberculosis is a major global health problem and a threat to health security given the increase in the number of cases and the challenges associated with care. Besides, the relationship between poor nutritional status and tuberculosis is clearly established. For relevant and evidence-based public health decision-making regarding the management of malnutrition in patients with drug-resistant tuberculosis in the initial phase, it is essential to estimate the prevalence of malnutrition and understand the risk factors associated with it. METHODS: we performed a retrospective cohort study in drug-resistant tuberculosis patients aged 18 years and older, among which the nutritional status was assessed through BMI. All predictors were included in a prediction model using the multivariate logistic model according to the lowest Akaike criterion. Discrimination and model calibration was evaluated using receiver performance analysis, and the Hosmer and Lemeshow test. RESULTS: this study revealed a prevalence of malnutrition of 64.7% in drug-resistant tuberculosis patients in our 218-patient series. The factors associated with malnutrition were: unsuccessful treatment, the active presence of mycobacterium tuberculosis, increased bacteriological conversion time, increased serum creatinine, increased transaminase SGPT of the liver, and anaemia. Some of the factors not associated with malnutrition included the history of anti-tuberculosis treatment, vomiting, hepatic SGPT, initial AFB count, smear and culture conversion time, depression, and chest X-ray. CONCLUSION: malnutrition remains a concern among drug-resistant tuberculosis patients in Guinea as it affects more than half of them with a negative impact on the outcome of treatment. Implementing specific interventions for these high-risk patients, including nutritional supplementation, psychosocial support, and treatment for tuberculosis, can improve management for better treatment outcomes.

Psychosocial impacts of COVID-19 in the Guinean population. An online cross-sectional survey.

Guinea, like many other African countries, has been facing an unprecedented COVID-19 outbreak, since March 2020. In April 2020, Guinean National agency for health security recorded 1351 confirmed cases of COVID-19, including 313 recoveries and 07 deaths. To address this health crisis, some drastic measures were implemented to prevent the spread of COVID-19. Those measures might potentially cause some psychological problems among Guineans. Thus, we conducted this study to assess the psychosocial impacts of COVID-19 in the Guinean population. We carried out an online cross-sectional survey among internet users in Guinea. A free e-survey platform was used, and questionnaires were sent to internet users. The study ran from May 1 through May 10 2020. Participation in the study was voluntary. Data collection was based on sociodemographic information and self-reported questionnaires: Impact of Event Scale-Revised (IES-R) for stress evaluation, Penn state worry questionnaire (PSWQ), and an adapted Social Psychological Measurements of COVID-19. A total of 280 participants took part in the study; responses from 5 participants were deleted because of incompleteness. The average age of participants was 28.9 [95% CI: 28.1;29.6]. Most of participants were male 65.5% [95% CI: 59.5%;71.1%]. Unemployed participants stood for 48.7% [95% CI: 42.7%;54.8%]. IES-R scale for stress evaluation yielded the following findings: 19.6% (mild), 5.23% (moderate) and 9.15% (severe); 82.8% and 17.2% of participants had respectively reported low and moderate worry. No significant statistical association was found between sociodemographic variables and traumatic events (IES-R and PSWQ). However, 82% of our participants had to cope with the negative impacts of COVID-19. Although there were few cases of traumatic events, negative impacts of COVID-19 on study participants deserve to be underlined. So, further investigations are necessary to identify and disentangle specific psychosocial problems in different Guinean socio-cultural contexts.

Impact of the Ebola virus disease outbreak (2014-2016) on tuberculosis surveillance activities by Guinea's National Tuberculosis Control Program: a time series analysis.

BACKGROUND: Most countries in Subsaharan Africa have well-established National Tuberculosis Control Programs with relatively stable routine performances. However, major epidemiological events may result in significant disruptions. In March 2014, the World Health Organization announced the outbreak of Ebola virus disease in Guinea, a country with a high incidence of TB and HIV. Our study aimed to assess the impact of the Ebola virus disease outbreak on TB notification, treatment, and surveillance, using main indicators. METHODS: This is a retrospective cohort study that compared TB trends using surveillance data from the periods before (2011-2013), during (2014-2016), and after (2017-2018) Ebola virus disease outbreak. A time-series analysis was conducted to investigate the linkages between the decline in TB notification and the Ebola virus disease outbreak through cross-correlation. The lag in the cross-correlation test was evaluated using ANCOVA type II delayed variable dependent model. The surveillance system was assessed using TB surveillance standards and benchmarks and vital registration systems recommended by WHO, compared with those of 2015 during the Ebola virus disease. RESULTS: The rate of reporting of TB declined from 120 cases per 100,000 in 2011 to 100 cases per 100,000 in 2014, at the peak of the Ebola virus disease outbreak. The time-series cross-correlation test of all notified cases of TB and Ebola showed a significant lag of - 0.4 (40%), reflecting a drop in the rate of notification (F-value = 5.7 [95% CI: 0.2-21.3]). The Ebola virus disease had no negative impact on patient treatment outcomes (F-value = 1.3 [95% CI: 0.0-8.8]). Regarding the surveillance system, five out of 13 WHO standards and benchmarks were met following their evaluation in 2019, after the Ebola virus disease outbreak, compared to three in 2015. CONCLUSION: Major epidemics such as the Ebola virus disease outbreak may have a significant impact on well-established TB control programs as shown in the example of Guinea. Sudden disruptions of routine performance may lead programs to improve their surveillance system. The experience acquired in the fight against EVD and the investments made should make it possible to prepare the health system in a coherent manner for the other probable episodes.

Better programmatic outcome with the shorter regimen for the treatment of multidrug-resistant tuberculosis (MDR-TB) in Guinea: A retrospective cohort study.

SETTING: Since August 2016, after the Ebola outbreak, the Guinean National Tuberculosis Programme and Damien Foundation implemented the shorter treatment regimen (STR) for multidrug-resistant tuberculosis (MDR-TB) in the three MDR-TB sites of Conakry. Previously, the longer regimen was used to treat MDR-TB. OBJECTIVES: In a post-Ebola context, with a weakened health system, we describe the MDR-TB treatment uptake, patients characteristics, treatment outcomes and estimate the effect of using the longer versus STR on having a programmatically adverse outcome. DESIGN: This is a retrospective cohort study in RR-TB patients treated with either the longer regimen or STR. RESULTS: In Conakry, in 2016 and 2017, 131 and 219 patients were diagnosed with rifampicin-resistant tuberculosis (RR-TB); and 108 and 163 started treatment, respectively. Of 271 patients who started treatment, 75 were treated with the longer regimen and 196 with the STR. Patients characteristics were similar regardless of the regimen except that the median age was higher among those treated with a longer regimen (30 years (IQR:24-38) versus 26 years (IQR:21-39) for the STR. Patients treated with a STR were more likely to obtain a programmatically favorable outcome (74.0% vs 58.7%, p = 0.01) as lost to follow up was higher among those treated with a longer regimen (20.0% vs 8.2%, p = 0.006). Patients on a longer regimen were more than 2 times more likely (aOR: 2.5; 95%CI:1.3,4.7) to have a programmatically adverse outcome as well as being 45 years or older (aOR: 2.8; 95%CI:1.3,6.2), HIV positive (aOR:3.3; 95%CI:1.6,6.6) and attendance at a clinic without NGO support (aOR:3.0; 95%:1.6,5.7). CONCLUSION: In Guinea, patients treated with the STR were more likely to have a successful outcome than those treated with the longer MDR-TB treatment regimen. Lost to follow-up was higher in patients on the longer regimen. However, STR treatment outcomes were less good than those reported in the region.

Different profiles of body mass index variation among patients with multidrug-resistant tuberculosis: a retrospective cohort study.

BACKGROUND: Despite the predictive role of body weight variation in treatment outcome in multidrug-resistant tuberculosis (MDR-TB), few corroborating data are available. We studied weight variation in patients with MDR-TB to identify groups of weight change and to determine factors that influence these changes. METHODS: We analyzed patients with rifampicin resistance who were treated with an MDR-TB treatment regimen between June 07, 2016 and June 22, 2018 at three major drug-resistant TB centers in Guinea. Patients were seen monthly until the end of treatment. Clinical outcome was the body mass index (BMI). We used a linear mixed model to analyze trajectories of BMI and a latent class mixed model to identify groups of BMI trajectories. RESULTS: Of 232 patients treated for MDR-TB during the study period, 165 were analyzed. These patients had a total of 1387 visits, with a median of 5 visits (interquartile range, 3-8 visits). Monthly BMI increase was 0.24 (SE 0.02) per kg/m2. Factors associated with faster BMI progression were success of MDR-TB treatment (0.24 [SE 0.09] per kg/m2; p = 0.0205) and absence of lung cavities on X-ray (0.18 [0.06] per kg/m2; p = 0.0068). Two groups of BMI change were identified: rapid BMI increase (n = 121; 85%) and slow BMI increase (n = 22; 15%). Patients in the slow BMI increase group were mostly female (68%) had no history of TB treatment (41%), had a positive HIV infection (59%), and had a more severe clinical condition at baseline, characterized by a higher frequency of symptoms including depression (18%), dyspnea (68%), poor adherence to MDR-TB treatment (64%), lower platelet count, and higher SGOT. These patients also had a longer time to initial culture conversion (log-rank test: p = 0.0218). CONCLUSION: Quantitative BMI data on patients with MDR-TB treated with a short regimen allowed the identification of subgroups of patients with different trajectories of BMI and emphasized the usefulness of BMI as a biomarker for the monitoring of MDR-TB treatment outcome.

The effects of nutritional supplementation on body mass index and CD4 count among adult people living with HIV AIDS on antiretroviral treatment in Conakry, Guinea.

Whereas the HIV prevalence in Guinea is among the lowest in Africa, many PLHIV in Guinea are malnourished. This study assessed the effect of a nutritional supplementation program on body mass index and CD4 count among adult PLHIV on ART. Study participants were PLHIV who came for consultation in the study sites between May and July 2016. The data came from two sources: retrospectively from participants' medical records and interviews at the time of recruitment into the study. About six months before they were recruited into the study, some of the PLHIV started to receive a monthly nutritional supplementation consisting of Corn-Soy Blend and oil. Analytic methods included bivariate and multivariable methods. The intervention increased the mean BMI by 7.4% and the average current CD4 count by 4.7% compared to nonintervention (P<0.001). Programs in low resource settings should consider nutrition assistance as part of a comprehensive strategy to ensure optimal metabolic and immunological functions among PLHIV.

Upholding Tuberculosis Services during the 2014 Ebola Storm: An Encouraging Experience from Conakry, Guinea.

SETTING: Ten targeted health facilities supported by Damien Foundation (a Belgian Non Governmental Organization) and the National Tuberculosis (TB) Program in Conakry, Guinea. OBJECTIVES: To uphold TB program performance during the Ebola outbreak in the presence of a package of pre-emptive additional measures geared at reinforcing the routine TB program, and ensuring Ebola infection control, health-workers safety and motivation. DESIGN: A retrospective comparative cohort study of a TB program assessing the performance before (2013) and during the (2014) Ebola outbreak. RESULTS: During the Ebola outbreak, all health facilities were maintained opened, there were no reported health-worker Ebola infections, drug stockouts or health staff absences. Of 2,475 presumptive pulmonary TB cases, 13% were diagnosed with TB in both periods (160/1203 in 2013 and 163/1272 in 2014). For new TB, treatment success improved from 84% before to 87% during the Ebola outbreak (P = 0.03). Adjusted Hazard-ratios (AHR) for an unfavorable outcome was alwo lower during the Ebola outbreak, AHR = 0.8, 95% CI:0.7-0.9, P = 0.04). Treatment success improved for HIV co-infected patients (72% to 80%, P<0.01). For retreatment patients, the proportion achieving treatment success was maintained (68% to 72%, P = 0.05). Uptake of HIV-testing and Cotrimoxazole Preventive Treatment was maintained over 85%, and Anti-Retroviral Therapy uptake increased from 77% in 2013 to 86% in 2014 (P<0.01). CONCLUSION: Contingency planning and health system and worker support during the 2014 Ebola outbreak was associated with encouraging and sustained TB program performance. This is of relevance to future outbreaks.