Experiences with latent TB cascade of care strengthening for household contacts in Calgary, Canada.

SETTING: Identification, assessment, and treatment of latent TB infection (LTBI), collectively known as the LTBI cascade of care, is critical for TB prevention. OBJECTIVE: The objective of this research, conducted within the ACT4 trial, was to assess and strengthen the LTBI cascade of care for household contacts at Calgary TB Services, a clinic serving a predominately foreign-born population in Western Canada. DESIGN: Baseline assessment consisted of a retrospective LTBI cascade analysis of 32 contact investigations, and questionnaires administered to patients and health care workers. Four solutions were implemented in response to identified gaps. Solution impact was measured for 6 months using descriptive statistics. RESULTS: Pre-implementation, 56% of household contacts initiated treatment. Most contacts were lost to care because the tuberculin skin test (TST) was not initiated, or physicians did not recommend treatment. Evening clinics, a patient education pamphlet, a nursing workshop, and treatment recommendation guidelines were implemented. Post-implementation, losses due to LTBI treatment non-recommendation were reduced; however, the overall proportion of household contacts initiating treatment did not increase. CONCLUSION: Close engagement between researchers and TB programmes can reduce losses in the LTBI cascade. To see sustained improvement in overall outcomes, long-term engagement and data collection for ongoing problem-solving are required.

CONTEXTE: L'identification, l'évaluation et le traitement de l'infection tuberculeuse latente (LTBI) ­ collectivement connus sous le nom de « cascade de soins de la LTBI ¼ ­ sont essentiels à la prévention de la TB. OBJECTIF: L'objectif de cette étude, réalisée dans le cadre de l'essai ACT4, était d'évaluer et de renforcer la cascade de soins de la LTBI pour les contacts domestiques au Calgary TB Services, une clinique traitant principalement une population née à l'étranger dans l'ouest du Canada. PLAN: Il s'agissait d'une évaluation initiale comprenant une analyse rétrospective de la cascade de soins de la LTBI de 32 recherches de contacts et des questionnaires administrés aux patients et aux professionnels de santé. Quatre solutions ont été mises en place en réponse aux lacunes identifiées. L'impact des solutions a été mesuré pendant 6 mois à l'aide de statistiques descriptives. RÉSULTATS: Avant la mise en place des solutions, 56% des contacts domestiques avaient démarré un traitement. La plupart des contacts ont été perdus de vue car l'intradermoréaction à la tuberculine (TST) n'avait pas été effectuée ou car les médecins ne recommandaient pas de traitement. Des solutions ont été mises en place, telles que l'ouverture des cliniques en soirée, un dépliant informatif pour les patients, un atelier de travail à destination des infirmiers et des directives thérapeutiques. Après la mise en place des solutions, les pertes dues à l'absence de recommandation de traitement contre la LTBI ont été réduites, mais la proportion globale de contacts domestiques démarrant un traitement n'a pas augmenté. CONCLUSION: Une collaboration étroite entre chercheurs et programmes de lutte contre la TB peut réduire les pertes observées au cours de la cascade de soins de la LTBI. Afin d'obtenir une amélioration durable des résultats globaux, un engagement de long terme et un recueil des données sont requis pour résoudre les problèmes actuels.

Interventions to reduce losses in the cascade of care for latent tuberculosis: a systematic review and meta-analysis.

BACKGROUND: Losses can occur throughout the latent tuberculosis infection (LTBI) cascade of care. This can result in suboptimal rates of effective treatment for LTBI. We conducted a systematic review and meta-analysis to estimate the effect of different interventions to reduce losses in the LTBI cascade before treatment completion.METHODS: We searched several databases for articles reporting outcomes for interventions designed to strengthen the LTBI cascade. We included papers published in English from January 1990 until February 2018. Where possible, estimates were pooled using random-effects meta-analysis.RESULTS: We identified 30 studies that evaluated 32 different interventions aimed at reducing losses in the LTBI cascade. In pooled analysis, interventions that improved completion of cascade steps included patient incentives (respectively 42 [95% CI 34-51] and 48 [95% CI 15-81] additional patients completing initial assessment and medical evaluation per 100 starting); health care worker education (28 [95% CI 4-52] additional patients initiating initial assessment per 100 identified; home visits (additional 13 [95% CI 4-21] patients completing initial assessment per 100 starting); digital solutions (additional 11 [95% CI 4-21] patients initiating initial assessment per 100 identified); and patient reminders (additional 7 [95% CI 0.3-13] patients completing initial assessment per 100 starting). Several other interventions reduced losses at specific cascade steps, but evidence for these interventions came from single studies and could not be pooled.CONCLUSIONS: Although there is limited evidence that any single intervention significantly improves the LTBI cascade, many studies provide information about effective ways to strengthen it.