Knowledge, attitudes, beliefs, and stigma related to latent tuberculosis infection: a qualitative study among Eritreans in the Netherlands.

BACKGROUND: Tailored and culturally appropriate latent tuberculosis (TB) infection screening and treatment programs, including interventions against TB stigma, are needed to reduce TB incidence in low TB incidence countries. However, we lack insights in stigma related to latent TB infection (LTBI) among target groups, such as asylum seekers and refugees. We therefore studied knowledge, attitudes, beliefs, and stigma associated with LTBI among Eritrean asylum seekers and refugees in the Netherlands. METHODS: We used convenience sampling to interview adult Eritrean asylum seekers and refugees: 26 semi-structured group interviews following TB and LTBI related health education and LTBI screening, and 31 semi-structured individual interviews with Eritreans during or after completion of LTBI treatment (November 2016-May 2018). We used a thematic analysis to identify, analyse and report patterns in the data. RESULTS: Despite TB/LTBI education, misconceptions embedded in cultural beliefs about TB transmission and prevention persisted. Fear of getting infected with TB was the cause of reported enacted (isolation and gossip) and anticipated (concealment of treatment and self-isolation) stigma by participants on LTBI treatment. CONCLUSION: The inability to differentiate LTBI from TB disease and consequent fear of getting infected by persons with LTBI led to enacted and anticipated stigma comparable to stigma related to TB disease among Eritreans. Additional to continuous culturally sensitive education activities, TB prevention programs should implement evidence-based interventions reducing stigma at all phases in the LTBI screening and treatment cascade.

Insights into culturally appropriate latent tuberculosis infection (LTBI) screening in NSW: perspectives of Indian and Pakistani migrants.

OBJECTIVE: Latent tuberculosis (LTBI) case-finding and treatment are a focus of TB elimination in Australia. We sought the perspectives of migrants from two high-burden countries likely to be targeted by this strategy. METHODS: To understand perceptions of migrant groups in Australia on LTBI screening, 28 in-depth interviews were conducted with Indian and Pakistani community members recruited purposively through local organisations in the Illawarra region, New South Wales. Drawing on local TB policy, data collected qualitatively was analysed using framework methodologies. RESULTS: Australia's immigration system prioritises migrants of higher socioeconomic status. Participants supported elimination but perceived TB as a disease of the poor and not relevant to them. Lack of understanding of LTBI and sensitivity to being 'targeted' are further barriers to screening participation. CONCLUSION: Information provision and targeting rationale are an essential preamble to LTBI screening. Migration appears to modify cultural attitudes to TB, but not significantly. Despite less stigma surrounding TB in Australian contexts, testing privacy and confidentiality, and limiting public identification of specific groups remain important to program acceptability. Implications for public health: Progress towards TB elimination can be enhanced by consulting with targeted communities, using existing networks for communication and service provision; emphasising prevention benefits.

Solutions to improve the latent tuberculosis Cascade of Care in Ghana: a longitudinal impact assessment.

BACKGROUND: Loss of patients in the latent tuberculosis infection (LTBI) cascade of care is a major barrier to LTBI management. We evaluated the impact and acceptability of local solutions implemented to strengthen LTBI management of household contacts (HHCs) at an outpatient clinic in Ghana. METHODS: Local solutions to improve LTBI management were informed by a baseline evaluation of the LTBI cascade and questionnaires administered to index patients, HHCs, and health care workers at the study site in Offinso, Ghana. Solutions aimed to reduce patient costs and improve knowledge. We evaluated the impact and acceptability of the solutions. Specific objectives were to: 1) Compare the proportion of eligible HHCs completing each step in the LTBI cascade of care before and after solution implementation; 2) Compare knowledge, attitude, and practices (KAP) before and after solution implementation, based on responses of patients and health care workers (HCW) to structured questionnaires; 3) Evaluate patient and HCW acceptability of solutions using information obtained from these questionnaires. RESULTS: Pre and Post-Solution LTBI Cascades included 58 and 125 HHCs, respectively. Before implementation, 39% of expected < 5-year-old HHCs and 66% of ≥5-year-old HHCs were identified. None completed any further cascade steps. Post implementation, the proportion of eligible HHCs who completed identification, assessment, evaluation, and treatment initiation increased for HHCs < 5 to 94, 100, 82, 100%, respectively, and for HHCs ≥5 to 96, 69, 67, 100%, respectively. Pre and Post-Solutions questionnaires were completed by 80 and 95 respondents, respectively. Study participants most frequently mentioned financial support and education as the solutions that supported LTBI management. CONCLUSION: Implementation of locally selected solutions was associated with an increase in the proportion of HHCs completing all steps in the LTBI cascade. Tuberculosis programs should consider prioritizing financial support, such as payment for chest x-rays, to support LTBI cascade completion.

HIV prevalence and TB in migrant miners communities of origin in Gaza Province, Mozambique: The need for increasing awareness and knowledge.

BACKGROUND: As part of ongoing efforts to generate evidence needed on HIV and tuberculosis (TB) to inform policies and programs aimed to improve the health outcomes of migrants and communities affected by migration and mining, a preliminary investigation was conducted through a biological and behavioral (BBS) approach related to HIV and TB in two communities of origin of migrant mineworkers in Gaza Province. The main objective was to determine the prevalence of HIV and the rates of asymptomatic infection by TB, and the social and behavioral risk factors associated. METHODS: A cross-sectional survey was conducted from May to June 2017 using a simple random sampling methodology. Eligible participants were individuals who were living in the community at the time the survey was conducted, which included adult mine workers and members of their families aged 18 and above. A socio-behavioral questionnaire was administered, blood specimens were collected for HIV testing (Determine/Unigold) and sputum for TB (GeneXpert MTB/RIF) was collected. The statistical analysis was performed using the R studio software to produce means, proportion and odds ratio at 95% confidence intervals. RESULTS: A total of 1012 participants were enrolled, 75.2% were females, with a median age of 34. The overall prevalence of HIV found in the two communities was 24.2% (CI: 21.6-27.0) and was higher in the rural community (31.6%; 95% CI: 27.0-35.3). The prevalence of active TB was found to be 0.3% (n = 3) while 7.5% of the participants self-reported to have been previously diagnosed with TB at some point in their life. Only 2.8% of participants had knowledge of the basic principles of TB transmission. Condom use at last sexual intercourse with a regular partner was low among both sexes (17.3% male and 12.6% female). A considerable proportion of participants had not been aware of their HIV positive serostatus(31.1% female and 25.0% male). About 1/3 of the participants had had a history of STIs. CONCLUSION: The results of this survey confirm a high prevalence of HIV in communities of origin of migrant miners in Gaza province. Findings also demonstrated low levels of awareness/ knowledge and prevention of TB and HIV. It is important to strengthen strategies that encourage regular HIV testing and TB screening. Appropriate communication interventions on methods of transmission and prevention of HIV and TB in these communities must be intensified, as well as ensuring ongoing linkage to TB and HIV social and healthcare services.

HIV prevalence and TB in migrant miners communities of origin in Gaza Province, Mozambique: the need for increasing awareness and knowledge

As part of ongoing efforts to generate evidence needed on HIV and tuberculosis (TB) to inform policies and programs aimed to improve the health outcomes of migrants and communities affected by migration and mining, a preliminary investigation was conducted through a biological and behavioral (BBS) approach related to HIV and TB in two communities of origin of migrant mineworkers in Gaza Province. The main objective was to determine the prevalence of HIV and the rates of asymptomatic infection by TB, and the social and behavioral risk factors associated. Methods A cross-sectional survey was conducted from May to June 2017 using a simple random sampling methodology. Eligible participants were individuals who were living in the community at the time the survey was conducted, which included adult mine workers and members of their families aged 18 and above. A socio-behavioral questionnaire was administered, blood specimens were collected for HIV testing (Determine/Unigold) and sputum for TB (GeneXpert MTB/RIF) was collected. The statistical analysis was performed using the R studio software to produce means, proportion and odds ratio at 95% confidence intervals. Results A total of 1012 participants were enrolled, 75.2% were females, with a median age of 34. The overall prevalence of HIV found in the two communities was 24.2% (CI: 21.6­27.0) and was higher in the rural community (31.6%; 95% CI: 27.0­35.3). The prevalence of active TB was found to be 0.3% (n = 3) while 7.5% of the participants self-reported to have been previously diagnosed with TB at some point in their life. Only 2.8% of participants had knowledge of the basic principles of TB transmission. Condom use at last sexual intercourse with a regular partner was low among both sexes (17.3% male and 12.6% female). A considerable proportion of participants had not been aware of their HIV positive serostatus(31.1% female and 25.0% male). About 1/3 of the participants had had a history of STIs. Conclusion The results of this survey confirm a high prevalence of HIV in communities of origin of migrant miners in Gaza province. Findings also demonstrated low levels of awareness/ knowledge and prevention of TB and HIV. It is important to strengthen strategies that encourage regular HIV testing and TB screening. Appropriate communication interventions on methods of transmission and prevention of HIV and TB in these communities must be intensified, as well as ensuring ongoing linkage to TB and HIV social and healthcare services.

Quality of life of patients on treatment for latent tuberculosis infection: a mixed-method study in Stockholm, Sweden.

BACKGROUND: Unlike active tuberculosis, latent tuberculosis infection (LTBI) is asymptomatic and often considered not to affect the health-related quality of life (HRQoL) of patients. However, being diagnosed with and treated for LTBI can be associated with adverse clinical evens such side effects of treatment as well as psychosocial challenges. Therefore, the aims of this study were to qualitatively explore patients' experiences during diagnosis and treatment of LTBI in Stockholm measure their HRQoL, and contrast and merge the results to better understand how the HRQoL of these patients is affected. METHODS: LTBI patients who were treated in Stockholm during September 2017 and June 2018and who fulfilled the inclusion criteria were invited to fill a survey that included a HRQoL instrument, EQ-5D-3 L, and a mental health screening instrument, RHS-15. After filling the survey, a subset of these patients was asked to participate in an interview with open-ended questions that focused on their experiences during the diagnosis and treatment. RESULTS: In total 108 participants filled that survey and interviews were conducted with 20 patients. Patients scored relatively high on EQ-5D: the scores of utility and VAS scale are similar to those reported by the general population of Stockholm. Very few patients reported problems on the physical health domains of EQ-5D which was supported by the quantitative data that showed no effect on physical health and usual activity. Thirty-eight percent screened positive for RHS-15 and 27.8% reported problems with anxiety/depression domain of EQ-5D which could be related to many stressing factors mentioned in the interviews such as: fear and distress related to lack of clarity about LTBI diagnosis, perceived risk of infecting others and uncertainties about the future. CONCLUSION: The quantified HRQoL of LTBI patients in Stockholm is similar to the general population and there is thus no HRQoL decrements that is detectable with EQ-5D. However, the study reinforces the importance of tackling anxiety and fear and ensuring good health information for persons diagnosed with and treated for LTBI.

High Completion Rate for 12 Weekly Doses of Isoniazid and Rifapentine as Treatment for Latent Mycobacterium tuberculosis Infection in the Federal Bureau of Prisons.

CONTEXT: Correctional facilities provide unique opportunities to diagnose and treat persons with latent tuberculosis infection (LTBI). Studies have shown that 12 weekly doses of isoniazid and rifapentine (INH-RPT) to treat LTBI resulted in high completion rates with good tolerability. OBJECTIVE: To evaluate completion rates and clinical signs or reported symptoms associated with discontinuation of 12 weekly doses of INH-RPT for LTBI treatment. SETTING/PARTICIPANTS: During July 2012 to February 2015, 7 Federal Bureau of Prisons facilities participated in an assessment of 12 weekly doses of INH-RPT for LTBI treatment among 463 inmates. MAIN OUTCOME MEASURES: Fisher exact test was used to assess the associations between patient sociodemographic characteristics and clinical signs or symptoms with discontinuation of treatment. RESULTS: Of 463 inmates treated with INH-RPT, 424 (92%) completed treatment. Reasons for discontinuation of treatment for 39 (8%) inmates included the following: 17 (44%) signs/symptoms, 9 (23%) transfer or release, 8 (21%) treatment refusal, and 5 (13%) provider error. A total of 229 (49.5%) inmates reported experiencing at least 1 sign or symptom during treatment; most frequently reported were fatigue (16%), nausea (13%), and abdominal pain (7%). Among these 229 inmates, signs/symptoms significantly associated with discontinuation of treatment included abdominal pain (P < .001), appetite loss (P = .02), fever/chills (P = .01), nausea (P = .03), sore muscles (P = .002), and elevation of liver transaminases 5× upper limits of normal or greater (P = .03). CONCLUSIONS: The LTBI completion rates were high for the INH-RPT regimen, with few inmates discontinuing because of signs or symptoms related to treatment. This regimen also has practical advantages to aid in treatment completion in the correctional setting and can be considered a viable alternative to standard LTBI regimens.

[Compliance of latent tuberculosis infection treatment in a cohort of TB contacts]. / Cumplimiento del tratamiento de la infección tuberculosa latente en una cohorte de contactos de enfermos de tuberculosis.

OBJECTIVE: Compliance with the treatment of Latent Tuberculous Infection (ITL) is a determining factor in the control of tuberculosis. The objective of this study was to estimate the acceptance and compliance of the ITL treatment, and associated factors in contacts of patients with tuberculosis in Lleida. METHODS: Epidemiological analytical observational study, of a retrospective cohort follow-up, since the 1 January 2015 to 31 December 2016. The Participants were contacts of patients with tuberculosis in Lleida. Variables of the index case and independent and dependent variables (acceptance and compliance of the treatment) of contacts were studied through univariate and bivariate analysis. The strength of association was studied with odds ratio (OR) and confidence interval (IC) of 95% they were adjusted by a multivariate regression model. RESULTS: 69.1% of tuberculosis cases had a contact study, and 47.5% had at least one contact with prescription of preventive treatment. The treatment was accepted by 94.5% of contacts, and only 70.3% finalized this treatment. The completion was more frequent in patients who knew the meaning of latent tuberculosis infection treatment (ORa: 2.0; CI: 95% 1.0-4.1).

OBJETIVO: El cumplimiento del tratamiento de la Infección Tuberculosa Latente (ITL) es un factor determinante del control de la tuberculosis. El objetivo de este trabajo fue estimar la aceptación y el cumplimiento del tratamiento de la ITL y factores asociados en contactos de enfermos con tuberculosis en Lleida. METODOS: Estudio epidemiológico analítico observacional de seguimiento de una cohorte retrospectiva, desde el 1 de enero de 2015 al 31 de diciembre de 2016. Los participantes fueron los contactos de enfermos con tuberculosis de Lleida. Se estudiaron variables del caso índice y variables independientes y dependientes (aceptación y cumplimiento de la ITL) de los contactos, a través del análisis univariado y multivariado. La fuerza de asociación se estudió con el odds ratio (OR) y su intervalo de confianza (IC) del 95% y se ajustaron mediante modelos de regresión logística. RESULTADOS: El 69,1% de los casos de tuberculosis poseían estudio de contactos, y el 47,5% tenían algún contacto con prescripción de tratamiento preventivo. El 94,5% de los contactos aceptó el tratamiento de la ITL, y éste fue finalizado por el 70,3%. El cumplimiento fue más frecuente en los pacientes que conocían el significado del tratamiento de la ITL (ORa: 2,0; IC: 95% 1,0-4,1). CONCLUSIONES: En relación a la aceptación/cumplimiento del tratamiento de la ITL, destaca la influencia positiva de poseer conocimientos sobre la infección y su tratamiento. Los profesionales de Atención Primaria deberían proporcionar mayor educación sanitaria con el fin de mejorar el cumplimiento terapéutico de la ITL.

Acceptability of latent tuberculosis testing of migrants in a college environment in England.

OBJECTIVES: The majority of tuberculosis (TB) cases in England occur from reactivation of latent tuberculosis infection (LTBI) in the settled migrant population. The National Institute for Health and Clinical Excellence recommends that new entrants from high-incidence countries are screened to detect LTBI. This article seeks to describe an outreach programme and testing for LTBI in an innovative setting-ESOL (English for Speakers of Other Languages) classes at a community college (CC) with evaluation of acceptability. STUDY DESIGN: Partnership working with mixed methods used for evaluation of acceptability. METHODS: A pre-existing network from the local TB partnership designed an outreach intervention and screening for LTBI among students from an ESOL programme at a CC. Screening for LTBI with interferon gamma release assay was the culmination of a programme of health improvement activities across the college. Any student on the ESOL programme younger than the age of 35 years and resident in the UK for less than 5 years was eligible for testing. LTBI testing was carried out on-site, and the experience was evaluated by questionnaires to staff, students and partners. A facilitated debrief among the partners gave further data. RESULTS: A total of 440 eligible students were tested. One hundred and seventy-two student feedback questionnaires were completed, and 36 partner questionnaires were received with 18 CC staff responding. Students, tutors and healthcare professionals found the setting acceptable with some concerns about insufficient resource for timely follow-up. CONCLUSIONS: Students, tutors, community organisations and health professionals found the exercise worthwhile and the method and setting acceptable. There were resource issues for the clinical team in follow-up of students with positive results for such a large screening event. Unexpected barriers were found by the CC as this kind of activity was not recognised for external quality review purposes. There were concerns about reputational loss and stigma of being involved in a TB project. As current initiatives aim to divert workload from stretched general practice surgeries, this may be an important addition to primary care screening.

Knowing about you: eliciting dimensions of personhood within tuberculosis care.

BACKGROUND: Knowing someone with tuberculosis (TB) as a person, rather than defining them by their illness, is part of recognising their dignity and unique individuality, and a requirement for effective care. OBJECTIVE: An adaptation of the Patient Dignity Question (PDQ) was formalised for persons receiving treatment for active TB or latent tuberculous infection (LTBI), and its impact was evaluated for both the person and health care providers (HCPs). DESIGN: Individuals with active TB or LTBI receiving treatment in Winnipeg, MB, Canada, were asked the PDQ as part of routine care. Patients and HCPs were subsequently invited to evaluate the application of the PDQ. RESULTS: Of the 58 participants who responded to the PDQ, 97% felt both that it was important to ask about them as an individual, and that the PDQ should be asked of all patients, while 55% thought it made a difference to their care. Thirty-eight per cent of HCPs said they learned something new about their patient, and 31% said it influenced their sense of connectedness with and sense of empathy for patients, as well as their personal satisfaction in providing care. CONCLUSION: Formalising a dignity question as part of person-centred care provides a mechanism to create a respectful environment that is caring of the most marginalised who carry the burden of TB.

Screening and Treatment of Latent Tuberculosis Among Patients Receiving Biologic Agents: A National and International Survey of Rheumatologists.

OBJECTIVE: We sought to understand the current practice patterns of both US and international members of the American College of Rheumatology (ACR) in this regard. METHODS: A set of questionnaires developed by a focus group of faculties and fellows of the Rheumatology Division of University of Tennessee Health Science Center, Memphis, TN, was sent electronically using an online survey tool to 4433 rheumatologists who are ACR members in the United States and internationally. RESULTS: Seven hundred sixty-eight physicians out of 4433 ACR members responded to the electronic survey, with a response rate of 17.32%. The preferred screening method by most of the respondents was either tuberculin skin test (19%) or interferon γ release assay (32%) or both. For treatment of latent tuberculosis infection (LTBI) overall, 49% of the respondents would refer management to infectious disease specialist or the health department, 37% would initiate isoniazid for 9 or 12 months, and 14% would use isoniazid for 6 months. Approximately 60% of respondents would initiate anti-tumor necrosis factor therapy after being on LTBI treatment for 1 month. The other respondents were almost equally divided among the 3 responses: 2, 3, 6, or 9 months. CONCLUSIONS: There is a large disagreement regarding the method used and how often to screen for LTBI after initiating biologic therapy and how soon biologic treatment would be started after initiating LTBI therapy. Another disagreement exists regarding the duration of LTBI therapy. The information obtained from the survey can be taken into account when ACR or other international member organizations formulate future recommendations regarding screening and treatment of LTBI.

Using Spatial Disease Patterns and Patient-Level Characteristics to Describe Prevalence Elastic Behavior in Treatment for Latent Tuberculosis Infection (LTBI).

OBJECTIVE: Individual adherence to a 9-month regimen of isoniazid (9INH) for treatment of latent tuberculosis infection (LTBI) was hypothesized to reflect a prevalent elastic health behavior pattern, or prevention behavior correlated with relevant disease burden. METHOD: Log-rank tests were used to compare survival functions among raw prevalence tertiles for diseases including TB, diabetes, and obesity. Own and cross-prevalence elasticities were calculated and spatially characterized behavioral response to diseases that may impact TB re-infection and/or re-activation. Discrete choice models were used to assess the significance of the spatial elasticities among an ethnically diverse clinic population of 552 patients in an urban American county in 2010. RESULTS: Log-rank results revealed a statistical association between dropout and chronic disease prevalence (p < .01), but not TB prevalence (p = .13). Discrete choice models incorporating spatial elasticities and controlling for patient- and treatment-level characteristics demonstrated significant associations with adherence (p < .01), an effect robust to various alternative treatment definitions. CONCLUSION: Individual LTBI adherence tracks a prevalence elastic pattern that may represent a potential risk for re-infection and re-activation.

Understanding of latent tuberculosis, its treatment and treatment side effects in immigrant and refugee patients.

BACKGROUND: Isoniazid treatment of latent tuberculosis infection (LTBI) is commonly prescribed in refugees and immigrants. We aimed to assess understanding of information provided about LTBI, its treatment and potential side effects. METHODS: A questionnaire was administered in clinics at a tertiary hospital. Total Knowledge (TKS) and Total Side Effect Scores (TSES) were derived. Logistic regression analyses were employed to correlate socio-demographic factors with knowledge. RESULTS: Fifty-two participants were recruited, 20 at isoniazid commencement and 32 already on isoniazid. The average TKS were 5.04/9 and 6.23/9 respectively and were significantly associated with interpreter use. Approximately half did not know how tuberculosis was transmitted. The average TSES were 5.0/7 and 3.5/7 respectively, but were not influenced by socio-demographic factors. CONCLUSIONS: There was suboptimal knowledge about LTBI. Improvements in health messages delivered via interpreters and additional methods of distributing information need to be developed for this patient population.

Barriers to and motivations for the implementation of a treatment programme for latent tuberculosis infection using isoniazid for people living with HIV, in upper northern Thailand.

BACKGROUND: Isoniazid Preventive Therapy (IPT) has been recommended by WHO/UNAIDS for people living with HIV (PLWH) since 1993; however the uptake of IPT implementation has been very low globally. This study aims to assess the barriers to and motivations for the implementation of IPT for PLWH in upper northern Thailand, an area with a high tuberculosis (TB) and human immunodeficiency virus (HIV) burden. METHODS: A survey was carried out via self-administered questionnaires mailed to healthcare workers (HCW) in all 95 public hospitals in the upper northern region of Thailand. A reminding phone call, one month after sending the mail, was made. RESULTS: The response rate from the hospitals was 94% and from the HCW's, 70%. IPT programme was being implemented at only 18 (20%) out of the 89 public hospitals. The main barriers as reported by 144 HCWs working in hospitals without IPT programme, were: (1) unclear direction of national policy (60%), (2) fear of emerging Isoniazid resistant tuberculosis (52%), and (3) fear of poor adherence (30%). The 38 HCWs from hospitals implementing IPT programme, were motivated by (1) knowledge that IPT can prevent TB (63%), (2) the following of national guideline (34%), (3) concern for TB prevention even after the expansion of access to antiretroviral therapy (ART) (32%). CONCLUSION AND RECOMMENDATION: To implement an IPT programme for PLWH, giving a clear national policy and straightforward direction are necessary. Furthermore, provision of public health information and updated evidences may enhance HCW's comprehension of benefits and risks of IPT, thus it may increase the IPT programme implementation.