Use of stool swabs in molecular transport media increases access to Xpert Ultra testing for TB in children.

SETTING: Tertiary level hospital in Lusaka, Zambia.OBJECTIVE: To measure concordance between Xpert® MTB/RIF Ultra (Ultra) results of stool with and without transport media, and compare Ultra results from the two stool processing methods to Ultra and culture results using gastric aspirates (GA).DESIGN: This was a cross-sectional study collecting stool and GA from children 0-5 years presenting with signs and symptoms of TB. Stool was processed for Ultra testing by two methods: the Simple-One-Step (SOS) on an aliquot of stool and PrimeStore® MTM Molecular Transport Medium (PS-MTM) using a stool swab.RESULTS: A total of 114 children (median age: 17 months, IQR 7-30) provided both a stool and a GA sample. Stool Ultra results processed using the PS-MTM method showed high concordance with stool Ultra results processed by the SOS method, with only 1/114 discordant results. Concordance with GA Ultra was high as well, as 9/13 Mycobacterium tuberculosis (MTB) cases detected were identified by all three methods.CONCLUSION: Ultra results from stool swabs collected using PS-MTM were equivalent to results from stool using the SOS method and GA. Given that PS-MTM inactivates MTB and stabilises DNA without cold chain, using it for stool has the potential to increase access to a TB diagnosis for children in underserved areas.

SARS-CoV-2 seroprevalence and associated risk factors in periurban Zambia: a population-based study.

BACKGROUND: We nested a seroprevalence survey within the TREATS (Tuberculosis Reduction through Expanded Antiretroviral Treatment and Screening) project. We aimed to measure the seroprevalence of SARS-CoV-2 infection and investigate associated risk factors in one community (population ∼27,000) with high prevalence of TB/HIV in Zambia. METHODS: The study design was cross-sectional. A random sample of 3592 individuals aged ≥15 years enrolled in the TREATS TB-prevalence survey were selected for antibody testing. Randomly selected blocks of residence were visited between October 2020 and March 2021. Antibodies against SARS-CoV-2 were detected using Abbott- ARCHITECT SARS-CoV-2 IgG assay. RESULTS: A total of 3035/3526 (86.1%) individuals had a blood sample taken. Antibody testing results were available for 2917/3035 (96.1%) participants. Overall, 401/2977 (13.5%) individuals tested positive for IgG antibodies. Seroprevalence was similar by sex (12.7% men vs 14.0% women) and was lowest in the youngest age group 15-19 years (9.7%) and similar in ages 20 years and older (∼15%). We found no evidence of an association between seroprevalence and HIV-status or TB. There was strong evidence (p <0.001) of variation by time of enrollment, with prevalence varying from 2.8% (95% CI 0.8-4.9) among those recruited in December 2020 to 33.7% (95% CI 27.7-39.7) among those recruited in mid-February 2021. CONCLUSION: Seroprevalence was 13.5% but there was substantial variation over time, with a sharp increase to approximately 35% toward the end of the second epidemic wave.

Does tuberculosis screening improve individual outcomes? A systematic review.

BACKGROUND: To determine if tuberculosis (TB) screening improves patient outcomes, we conducted two systematic reviews to investigate the effect of TB screening on diagnosis, treatment outcomes, deaths (clinical review assessing 23 outcome indicators); and patient costs (economic review). METHODS: Pubmed, EMBASE, Scopus and the Cochrane Library were searched between 1/1/1980-13/4/2020 (clinical review) and 1/1/2010-14/8/2020 (economic review). As studies were heterogeneous, data synthesis was narrative. FINDINGS: Clinical review: of 27,270 articles, 18 (n=3 trials) were eligible. Nine involved general populations. Compared to passive case finding (PCF), studies showed lower smear grade (n=2/3) and time to diagnosis (n=2/3); higher pre-treatment losses to follow-up (screened 23% and 29% vs PCF 15% and 14%; n=2/2); and similar treatment success (range 68-81%; n=4) and case fatality (range 3-11%; n=5) in the screened group. Nine reported on risk groups. Compared to PCF, studies showed lower smear positivity among those culture-confirmed (n=3/4) and time to diagnosis (n=2/2); and similar (range 80-90%; n=2/2) treatment success in the screened group. Case fatality was lower in n=2/3 observational studies; both reported on established screening programmes. A neonatal trial and post-hoc analysis of a household contacts trial found screening was associated with lower all-cause mortality. Economic review: From 2841 articles, six observational studies were eligible. Total costs (n=6) and catastrophic cost prevalence (n=4; range screened 9-45% vs PCF 12-61%) was lower among those screened. INTERPRETATION: We found very limited patient outcome data. Collecting and reporting this data must be prioritised to inform policy and practice. FUNDING: WHO and EDCTP.

Evaluating the integration of tuberculosis screening and contact investigation in tuberculosis clinics in Ethiopia: A mixed method study.

BACKGROUND: Aligned with global childhood tuberculosis (TB) road map, Ethiopia developed its own in 2015. The key strategies outlined in the Ethiopian roadmap are incorporating TB screening in Integrated Maternal, Neonatal and Child Illnesses (IMNCI) clinic for children under five years (U5) and intensifying contact investigations at TB clinic. However, these strategies have never been evaluated. OBJECTIVE: To evaluate the integration of tuberculosis (TB) screening and contact investigation into Integrated Maternal, Neonatal and Child Illnesses (IMNCI) and TB clinics in Addis Ababa, Ethiopia. METHODS: The study used mixed methods with stepped-wedge design where 30 randomly selected health care facilities were randomized into three groups of 10 during August 2016-November 2017. The integration of TB screening into IMNCI clinic and contact investigation in TB clinic were introduced by a three-day childhood TB training for health providers. An in-depth interview was used to explore the challenges of the interventions and supplemented data on TB screening and contact investigation. RESULTS: Overall, 180896 children attended 30 IMNCI clinics and145444 (80.4%) were screened for TB. A total of 688 (0.4%) children had presumptive TB and 47(0.03%) had TB. During the pre-intervention period, 51873 of the 85278 children (60.8%) were screened for TB as compared to 93570 of the 95618 children (97.9%) in the intervention (p<0.001). This had resulted in 149 (0.30%) and 539 (0.6%) presumptive TB cases in pre-intervention and intervention periods (p<0.001), respectively. Also, nine TB cases (6.0%) in pre-intervention and 38 (7.1%) after intervention were identified (p = 0.72). In TB clinics, 559 under-five (U5) contacts were identified and 419 (80.1%) were screened. In all, 51(9.1%) presumed TB cases and 12 (2.1%) active TB cases were identified from the traced contacts. TB screening was done for 182 of the 275 traced contacts (66.2%) before intervention and for 237 of the 284 of the traced (83.5%) under intervention (p<0.001). Isoniazid prevention therapy (IPT) was initiated for 69 of 163 eligible contacts (42.3%) before intervention and for 159 of 194 eligible children (82.0%) under intervention (p<0.001). Over 95% of health providers indicated that the integration of TB screening into IMNCI and contact investigation in TB clinic is acceptable and practical. Gastric aspiration to collect sputum using nasogastric tube was reported to be difficult. CONCLUSIONS: Integrating TB screening into IMNCI clinics and intensifying contact investigation in TB clinics is feasible improving TB screening, presumed TB cases, TB cases, contact screening and IPT coverage during the intervention period. Stool specimen could be non-invasive to address the challenge of sputum collection.

Blood donation barriers and facilitators of Sub-Saharan African migrants and minorities in Western high-income countries: a systematic review of the literature.

OBJECTIVES: The present study aimed to gain more insight into, and summarise, blood donation determinants among migrants or minorities of Sub-Saharan heritage by systematically reviewing the current literature. BACKGROUND: Sub-Saharan Africans are under-represented in the blood donor population in Western high-income countries. This causes a lack of specific blood types for transfusions and prevention of alloimmunisation among Sub-Saharan African patients. METHODS/MATERIALS: Medline, EMBASE, PsycINFO and BIOSIS were searched for relevant empirical studies that focused on barriers and facilitators of blood donation among Sub-Saharan Africans in Western countries until 22 June 2017. Of the 679 articles screened by title and abstract, 152 were subsequently screened by full text. Paired reviewers independently assessed the studies based on predefined eligibility and quality criteria. RESULTS: Of the 31 included studies, 24 used quantitative and 7 used qualitative research methods. Target cohorts varied from Black African Americans and refugees from Sub-Sahara Africa to specific Sub-Saharan migrant groups such as Comorians or Ethiopians. Main recurring barriers for Sub-Saharan Africans were haemoglobin deferral, fear of needles and pain, social exclusion, lack of awareness, negative attitudes and accessibility problems. Important recurring facilitators for Sub-Saharan Africans were altruism, free health checks and specific recruitment and awareness-raising campaigns. CONCLUSION: The findings of this review can be used as a starting point to develop recruitment and retention strategies for Sub-Saharan African persons. Further research is needed to gain more insight in the role of these determinants in specific contexts as socioeconomic features, personal histories and host country regulations may differ per country.

Reasons to end the donor career: a quantitative study among stopped blood donors in the Netherlands.

BACKGROUND AND OBJECTIVES: Previous work has studied barriers to donating blood or plasma among current, lapsed and non-donors. Still, it remains unclear why donors stop donating and end their donor career voluntarily. A thorough understanding of why donors stop is necessary to develop more effective retention strategies and manage the decline in whole-blood donors. METHODS: An online questionnaire that contained questions about reasons to stop donation was sent out to 7098 Dutch whole-blood donors who deregistered from the donor pool in 2015 but who were not permanently deferred for medical reasons (response: N = 2490, 35%). RESULTS: The final sample consisted of 1865 stopped blood donors. Of the stopped blood donors, 28·4% reported that negative physical experiences were (partly) the reason to stop. This stopping reason was more often reported by women than men, those aged 19-33 years compared to older groups and those who had donated five times or less compared to those with more donations. Inconvenient opening times (26·1%) was a stopping reason more frequently reported by men compared to women, those aged 34-50 years compared to their younger and older counterparts and those who had donated more than five times. CONCLUSIONS: We found that the stopping reasons for blood donors are dependent on gender, age and the number of donations. Stopping reasons differ substantially from barriers experienced by current, lapsed and non-donors. More research on preventing negative physical experiences and implementing more flexible opening hours are advised.

Tuberculosis and latent tuberculous infection screening of migrants in Europe: comparative analysis of policies, surveillance systems and results.

Migration patterns into and within Europe have changed over the last decade. In 2015, European Union (EU) countries received over 1.2 million asylum requests, more than double the number registered in the previous year. This review compares the published literature on policies for tuberculosis (TB) and latent tuberculous infection (LTBI) screening in EU and European Free Trade Association (EFTA) countries with the existing TB/LTBI screening programmes for migrants in 11 EU/EFTA countries based on a survey of policy and surveillance systems. In addition, we provide a systematic review of the literature on the yield of screening migrants for active TB and LTBI in Europe. Published studies provide limited information about screening coverage and the yield of screening evaluations in EU/EFTA countries. Furthermore, countries use different screening strategies and settings, and different definitions for coverage and yield of screening for active TB and LTBI. We recommend harmonising case definitions, reporting standards and policies for TB/LTBI screening. To achieve TB elimination targets, a European platform for multi-country data collection and analysis, sharing of countries' policies and practices, and harmonisation of migrant screening strategies is needed.

Community referral for presumptive TB in Nigeria: a comparison of four models of active case finding.

BACKGROUND: Engagement of communities and civil society organizations is a critical part of the Post-2015 End TB Strategy. Since 2007, many models of community referral have been implemented to boost TB case detection in Nigeria. Yet clear insights into the comparative TB yield from particular approaches have been limited. METHODS: We compared four models of active case finding in three Nigerian states. Data on presumptive TB case referral by community workers (CWs), TB diagnoses among referred clients, active case finding model characteristics, and CWs compensation details for 2012 were obtained from implementers and CWs via interviews and log book review. Self-reported performance data were triangulated against routine surveillance data to assess concordance. Analysis focused on assessing the predictors of presumptive TB referral. RESULTS: CWs referred 4-22% of presumptive TB clients tested, and 4-24% of the total TB cases detected. The annual median referral per CW ranged widely among the models from 1 to 48 clients, with an overall average of 13.4 referrals per CW. The highest median referrals (48 per CW/yr) and mean TB diagnoses (7.1/yr) per CW (H =70.850, p < 0.001) was obtained by the model with training supervision, and $80/quarterly payments (Comprehensive Quotas-Oriented model). The model with irregularly supervised, trained, and compensated CWs contributed the least to TB case detection with a median of 13 referrals per CW/yr and mean of 0.53 TB diagnoses per CW/yr. Hours spent weekly on presumptive TB referral made the strongest unique contribution (Beta = 0.514, p < 0.001) to explaining presumptive TB referral after controlling for other variables. CONCLUSION: All community based TB case-finding projects studied referred a relative low number of symptomatic individuals. The study shows that incentivized referral, appropriate selection of CWs, supportive supervision, leveraged treatment support roles, and a responsive TB program to receive clients for testing were the key drivers of community TB case finding.

Does decentralisation of tuberculosis care influence treatment outcomes? The case of Oromia Region, Ethiopia.

SETTING: Oromia Region, Ethiopia. OBJECTIVE: To investigate the effect of decentralised care on anti-tuberculosis treatment outcomes and identify factors affecting outcome among new smear-positive tuberculosis (TB) patients. DESIGN: This was a retrospective cohort study comparing patients treated in the community during the continuation phase with those managed throughout treatment in health facilities. Data were collected from TB registers and patient cards using a pre-tested data capture form. RESULTS: Of the 2226 new smear-positive TB patients registered from July 2010 to June 2012 who were included in the study, 1599 (72.6%) received treatment in health facilities, and the rest in the community. Overall treatment success was 94.7%. Patients treated in the community had comparable treatment success with those managed in health facilities (aOR 1.7, 95%CI 0.80-3.57). Missing doses (OR 0.22, 95%CI 0.08-0.55), supervision during the continuation phase (OR 2.6, 95%CI 1.34-5.05), positive sputum at month 2 (OR 0.07, 95%CI 0.04-0.13) and human immunodeficiency virus infection (OR 0.25, 95%CI 0.13-0.46) were independent predictors of treatment success. CONCLUSION: Overall treatment success is high in new smear-positive TB patients in Oromia. Patients receiving treatment in the community during the continuation phase have treatment success comparable with that of patients managed in health facilities.

Contexte : Région d'Oromia, Ethiopie.Objectif : Examiner l'effet d'un traitement décentralisé de la tuberculose (TB) sur les résultats de ce traitement et identifier les facteurs affectant les résultats parmi des patients tuberculeux nouveaux à frottis positif.Schéma : Etude rétrospective de cohorte comparant les patients traités en communauté pendant la phase de continuation avec ceux traités dans les structures de santé. Des données ont été recueillies à partir des registres de TB et des cartes de traitement des patients grâce à un formulaire de recueil de données prétesté.Résultats : De 2226 patients tuberculeux nouveaux à frottis positif enregistrés entre juillet 2010 et juillet 2012, et inclus dans cette étude, 1599 (72,6%) ont été traités dans des structures de santé et le reste en communauté. Le succès d'ensemble du traitement a été de 94,7%. Les patients traités en communauté ont eu un taux de réussite comparable à ceux traités dans les structures de santé (OR ajusté 1,7 ; IC95% 0,80­3,57). Des doses manquées (OR 0,22 ; IC95% 0,08­0,55), une supervision pendant la phase de prolongation (OR 2,6 ; IC95% 1,34­5,05), des crachats positifs au deuxième mois (OR 0,07 ; IC95% 0,04­0,13) et l'infection au virus de l'immunodéficience humaine (OR 0,25 ; IC95% 0,13­0,46) étaient des facteurs prédictifs indépendants de succès du traitement.Conclusion : Le succès d'ensemble du traitement est élevé chez les patients tuberculeux nouveaux à frottis positif de la région d'Oromia. Les patients traités en communauté pendant la phase de continuation ont un taux de réussite du traitement comparable à celui des patients traités dans des structures de santé.

Marco de referencia: La región de Oromia en Etiopía.Objtivo: Investigar el efecto de la descentralización de la atención de la tuberculosis (TB) sobre los desenlaces terapéuticos y definir los factores que modifican estos resultados en los pacientes con diagnóstico reciente de TB y baciloscopia positiva.Método: Se llevó a cabo un estudio retrospectivo de cohortes, en el cual se compararon los pacientes que recibieron el régimen antituberculoso durante la fase de continuación en la comunidad y los pacientes atendidos durante todo el tratamiento en los establecimientos de salud. Los datos se recogieron a partir de los registros de TB de los pacientes y de las tarjetas de tratamiento, mediante un formulario de captura de datos, que se ensayó previamente.Resultados: Se incluyeron en el estudio 2226 casos nuevos de TB con baciloscopia positiva registrados de junio del 2010 a junio del 2012, de los cuales 1599 recibieron el tratamiento en los establecimientos de salud (72,6%) y el resto en la comunidad. La tasa global de éxito terapéutico fue 94,7%. Los pacientes tratados en la comunidad presentaron una tasa de éxito equivalente la de los pacientes atendidos en los centros sanitarios (OR ajustado 1,7; IC95% 0,80­3,57). Aparecieron como factores pronósticos independientes del éxito terapéutico las siguientes variables: las dosis no administradas (OR 0,22; IC95% 0,08­0,55), la supervisión durante la fase de continuación (OR 2,6; IC95% 1,34­5,05), la positividad del esputo al segundo mes (OR 0,07; IC95% 0,04­0,13) y la infección por el virus de la inmunodeficiencia humana (OR 0,25; IC95% 0,13­0,46).Conclusión: Los casos nuevos de TB pulmonar y baciloscopia positiva alcanzaron globalmente una alta tasa de éxito terapéutico en Oromia. Los resultados de los pacientes que recibieron el tratamiento en la comunidad durante la fase de continuación fueron comparables con los desenlaces de los pacientes tratados en los establecimientos sanitarios.

Assigning focal persons to notify more tuberculosis patients: lessons learned in southern Ethiopia.

SETTING: Health centres in Southern Ethiopia. OBJECTIVE: To determine factors contributing to the large variations in the notification of smear-positive tuberculosis (TB) cases. DESIGN: A cross-sectional study in selected health centres from areas with high and low case notification was conducted and health system and health care worker (HCW) related determinants were examined. RESULTS: A total of 50 (61.0%) health centres and 172 (65.2%) HCWs from high case notification areas, and 32 (39.0%) health centres and 92 (33.8%) HCWs from low case notification areas were included in the study. Assignment of a full-time TB focal person at the TB clinic (adjusted odds ratio [aOR] 5.8, 95%CI 1.5-22.4) and availability of TB recording tools (aOR 7.0, 95%CI 1.5-32.5) were independent predictors of high case notification rates. HCW knowledge about TB screening, diagnosis and treatment was positively associated with case notification (aOR 2.53, 95%CI 1.42-4.48). CONCLUSION: Increased TB case notification was associated with the presence of a full-time focal person, availability of TB recording tools and good knowledge about TB among HCWs. Putting in place these measures in all health centres could increase TB notification in the region.

Contexte : Centres de santé dans le Sud de l'Ethiopie.Objectif : Déterminer les facteurs contribuant aux importantes variations dans la déclaration des cas de tuberculose (TB) à frottis positif.Schéma : Une étude transversale a été réalisée dans des centres de santé sélectionnés dans des régions à déclaration de cas élevée ou faible et a examiné les déterminants liés au système de santé et au personnel.Résultats : Un total de 50 (61,0%) centres de santé et de 172 (65,2%) membres du personnel de santé ont été inclus dans la région à déclaration élevée de cas, tandis que 32 (39,0%) centres de santé et 92 (33,8%) membres du personnel de santé venaient de la région à faible déclaration de cas. Le recrutement d'une personne focale TB à temps plein dans le centre anti-tuberculeux (odds ratio ajusté [aOR] 5,8 ; IC95% 1,5­22,4) et la disponibilité d'outils d'enregistrement de la TB (aOR 7,0 ; IC95% 1,5­32,5) étaient des facteurs prédictifs indépendants d'un taux élevé de déclaration des cas. Les connaissances du personnel de santé en matière de dépistage, diagnostic et traitement de la TB étaient positivement associées à la déclaration des cas (aOR 2,53 ; IC95% 1,42­4,48).Conclusion : Une augmentation de la déclaration des cas de TB était associée à la présence d'une personne focale à plein temps, à la disponibilité des outils d'enregistrement de la TB et aux bonnes connaissances du personnel de santé. La mise en place de ces mesures dans tous les centres de santé pourrait augmenter la déclaration des cas dans cette région.

Marco de referencia: Algunos centros de salud en el sur de Etiopía.Objetivo: Determinar los factores que contribuyen a la amplia variación observada en materia de notificación de casos de tuberculosis (TB) con baciloscopia positiva.Método: Fue este un estudio transversal llevado a cabo en centros de salud escogidos en zonas con diferentes tasas de notificación de casos de TB, en el cual se examinaron los factores que determinan el grado de notificación y que dependen del sistema y de los profesionales sanitarios.Resultados: Se incluyeron en el estudio 50 centros de salud (61,0%) y 172 profesionales sanitarios (65,2%) de la zona con altas tasas de notificación y 32 centros (39,0%) y 92 profesionales (33,8%) de la zona con bajas tasas de notificación. Aparecieron como factores pronósticos independientes de una alta notificación, la asignación de una persona de contacto en materia de TB en jornada completa en el consultorio (OR ajustado [aOR] 5,8; IC95% 1,5­22,4) y la existencia de materiales de registro de la TB (ORa 7,0; IC95% 1,5­32,5). El grado de conocimiento de los profesionales de salud en materia de detección, diagnóstico y tratamiento de la TB se relacionó positivamente con la tasa de notificación (ORa 2,53; IC95% 1,42­4,48).Conclusión: Una mayor notificación de los casos de TB se asoció con la presencia en horario completo de una persona de contacto en el consultorio, con la disponibilidad de instrumentos de registro de la TB y con el buen conocimiento de los profesionales sanitarios sobre la enfermedad. La puesta en práctica de estas medidas en todos los establecimientos de salud aumentaría la notificación de los casos de TB de la región.

The Ethiopian initiative to build sustainable capacity for operational research: overview and lessons learned.

SETTING: Programme-based operational research is instrumental for the enhancement of tuberculosis (TB) control. In 2012, the Ethiopian Federal Ministry of Health launched an initiative for capacity building in operational research (OR). OBJECTIVE: To develop sustainable capacity for OR in Ethiopia in a multiyear initiative. DESIGN: The initiative was developed in collaboration with regional, national and international experts. Teams representing regions in Ethiopia conducted OR addressing national and regional priorities. To make use of local expertise and increase sustainability, a domestic mentor training programme was included. Existing capacity was enhanced through a competitive grant scheme providing TB researchers with financial and technical support. The Ethiopian Tuberculosis Research Advisory Committee was also supported in its functions. Regional ethics review bodies were strengthened or established where they did not exist. RESULTS: Fifty-two people were trained and conducted 13 OR projects, of which six have been published to date. In addition, eight protocols were supported through grants. Ethics review bodies were strengthened in all regions. CONCLUSION: The initiative trained participants from all regions and succeeded in the completion of all stages of the OR process. The success of the programme can be attributed to the team approach, 'learning while doing', integrated mentorship programme and strong national ownership.

Contexte : La recherche opérationnelle programmatique joue un rôle majeur dans la lutte contre la tuberculose (TB). En 2012, le ministère éthiopien de la santé a lancé une initiative de renforcement des capacités en recherche opérationnelle (OR).Objectif : Développer des capacités pérennes d'OR en Ethiopie dans le cadre d'une initiative s'étalant sur plusieurs années.Schéma : L'initiative a été élaborée en collaboration avec des experts régionaux, nationaux et internationaux. Des équipes représentant les régions d'Ethiopie ont réalisé une OR relative aux priorités nationales et régionales. Un programme de formation de mentors domestiques a été inclus afin d'exploiter l'expertise locale et d'accroitre la pérennité. La capacité existante a été renforcée grâce à un financement compétitif offrant aux chercheurs du domaine de la TB un soutien financier et technique. Le fonctionnement du comité de concertation éthiopien sur la recherche relative à la TB a également bénéficié d'un soutien. Les comités d'éthique régionaux ont été renforcés ou créés lorsqu'ils n'existaient pas.Résultats : Cinquante-deux personnes ont été formées et ont réalisé 13 projets d'OR, dont six ont été publiés à ce jour. De plus, huit protocoles ont été soutenus par des subventions. Les comités d'éthique ont été renforcés dans toutes les régions.Conclusion: L'initiative a formé des participants de toutes les régions et ceux-ci ont terminé avec succès toutes les étapes du processus d'OR. Le succès de ce programme peut être attribué à une approche sous forme de travail d'équipe, à un apprentissage sur le tas, au programme intégré de mentors et à une forte appropriation nationale.

Marco de referencia: La práctica de investigación operativa dentro del marco programático es importante en el fortalecimiento del control de la tuberculosis (TB). En el 2012, el Ministerio Federal de Salud de Etiopía puso en marcha una iniciativa encaminada a crear capacidad de investigación operativa (OR).Objetivo: Desarrollar capacidad sostenible de OR en el país mediante una iniciativa plurianual.Método: La iniciativa se formuló en cooperación con expertos regionales, nacionales e internacionales. Varios equipos, en representación de las regiones de Etiopía, llevaron a cabo proyectos de OR que respondían a las prioridades nacionales y regionales. Con el propósito de aprovechar las competencias locales y mejorar la sostenibilidad se incorporó al proyecto un programa interno de capacitación de tutores. Se reforzó la capacidad existente mediante un plan de subvenciones otorgadas por concurso y destinado a suministrar ayuda económica y técnica a los investigadores en el campo de la TB. Asimismo, se prestó apoyo al funcionamiento del Comité Asesor de la Investigación sobre TB en Etiopía. Se reforzaron los comités de ética existentes y donde no existían se crearon nuevos comités.Resultados: Se capacitó a 52 personas y se llevaron a cabo 13 proyectos de OR, de los cuales seis han publicado sus resultados hasta la fecha. Se financiaron además ocho protocolos por conducto de las subvenciones. Se reforzaron los comités de ética en todas las regiones.Conclusión: Gracias a esta iniciativa se capacitó a los participantes provenientes de todas las regiones y se logró la compleción de todas las etapas del proceso de OR. El éxito del programa se puede atribuir a la estrategia de equipo, el aprendizaje en la acción, la integración del programa de tutoría y a una decidida apropiación nacional de la iniciativa.

Documentation and treatment outcomes of smear-negative and extra-pulmonary tuberculosis in Ethiopia.

BACKGROUND: Smear-negative and extra-pulmonary tuberculosis (TB) comprise two thirds of TB cases reported in Ethiopia. Neither treatment outcomes nor underlying associated factors are routinely reported for these cases. OBJECTIVE: To assess treatment outcomes and associated risk factors of smear-negative and extra-pulmonary TB in comparison with smear-positive cases. DESIGN: Record review of all TB cases registered in 14 randomly selected public and private health facilities in Addis Ababa, Ethiopia, over a 1-year period. RESULTS: Percentages of smear-negative and extra-pulmonary TB were independent of human immunodeficiency virus (HIV) status, and were not evenly distributed among health facilities. Extra-pulmonary TB was overrepresented in the private sector, and smear-negative TB was more frequent in health clinics than in hospitals. Outcomes reported by clinics were more favourable than those of the hospitals; no differences were observed when comparing public and private health facilities. Only 54% of the TB registers were complete; missing information correlated with unfavourable outcomes. Younger age, but not sex or HIV status, was associated with favourable outcomes. CONCLUSION: The uneven distribution of smear-negative and extra-pulmonary TB among different health facilities requires further study and may provide important insight into diagnosis and care of these patients. Incomplete TB register information may be an underappreciated factor contributing to unfavourable outcomes.

Cadre : La tuberculose (TB) extra-pulmonaire et la TB à frottis négatif constituent deux tiers des cas déclarés en Ethiopie, mais les rapports de routine ne précisent pas les résultats du traitement ni les facteurs sous-jacents associés.Objectif : Evaluer les résultats du traitement et les facteurs de risque associés à la TB extra-pulmonaire et à frottis négatif par comparaison avec les cas à frottis positif.Schéma : Revue des dossiers de tous les cas enregistrés dans 14 structures de santé publiques et privées sélectionnées au hasard à Addis Abeba pendant une période d'une année.Résultats : Les proportions de TB à frottis négatif et extra-pulmonaire étaient indépendantes du statut à l'égard du virus de l'immunodéficience humaine (VIH) et n'étaient pas distribuées de façon égale dans les différentes structures. La TB extra-pulmonaire était surreprésentée dans le secteur privé et la TB à frottis négatif se trouvait plutôt dans les centres de santé que dans les hôpitaux. Les résultats rapportés par les centres de santé étaient plus favorables que ceux des hôpitaux ; aucune différence n'a été observée entre les structures publiques et privées. Seulement 54% des dossiers de TB étaient complets ; il y avait une corrélation entre le manque d'informations et des résultats défavorables. Un âge plus jeune était associé à un résultat favorable, mais le sexe et le statut VIH ne l'étaient pas.Conclusion : La distribution inégale de la TB à frottis négatif et extra-pulmonaire dans les différentes institutions justifie une nouvelle étude et pourrait révéler d'importantes perspectives en matière de diagnostic et de soins de ces patients. Le caractère incomplet des dossiers des patients tuberculeux pourrait être un facteur sous-estimé contribuant aux résultats défavorables.

Marco de referencia: La tuberculosis (TB) con baciloscopia negativa y la TB extrapulmonar (EPTB) representan dos tercios de los casos notificados en Etiopía. Estas notificaciones no comportan sistemáticamente datos sobre los desenlaces terapéuticos ni los factores subyacentes.Objetivo: Evaluar los desenlaces clínicos de los casos de TB con baciloscopia negativa y EPTB, determinar los factores de riesgo que se asocian con su aparición y compararlos con los casos de TB con baciloscopia positiva.Método: Se examinaron las historias clínicas de todos los casos de TB atendidos durante un período de un año en 14 establecimientos sanitarios públicos y privados de Addis Abeba, escogidos de manera aleatoria.Resultados: Los porcentajes de casos de TB con baciloscopia negativa y EPTB fueron independientes de la situación frente el virus de la inmunodeficiencia humana (VIH). La distribución de estos casos no fue homogénea en las diferentes instituciones. La EPTB se encontró sobrerrepresentada en el sector privado y la TB con baciloscopia negativa fue más frecuente en los consultorios que en los hospitales. Los desenlaces terapéuticos notificados por los consultorios fueron más favorables que los comunicados por los hospitales y no se observaron diferencias entre las instituciones del sector público y el sector privado. Solo el 54% de los registros de TB estaba completo y la información incompleta se correlacionó con los desenlaces desfavorables. La menor edad se asoció con los desenlaces favorables, pero no el sexo ni la situación frente al VIH.Conclusión: La distribución heterogénea de los casos de TB con baciloscopia negativa y EPTB en las diferentes instituciones de salud justifica futuras investigaciones que podrían revelar aspectos importantes sobre el diagnóstico y la atención de estos pacientes. La información incompleta en los registros de TB puede ser un factor que contribuye a los desenlaces clínicos desfavorables y que no se ha valorado hasta el momento.

Adherence to anti-tuberculosis treatment in Tigray, Northern Ethiopia.

SETTING: Tuberculosis (TB) patients in Mekelle Zone, Tigray Region, in Ethiopia. OBJECTIVE: To investigate adherence to anti-tuberculosis treatment. DESIGN: A cross-sectional study in health facilities providing anti-tuberculosis treatment was conducted. Adherence was measured in three ways: through self-reported missed doses, by visual analogue scale whereby patients rate their own adherence and by record review. A patient was considered to be adherent if 90% or more of the prescribed medication was taken. RESULT: Of 278 TB patients included, 101 were in the intensive and 177 in the continuation phase. Respectively 67 (24.1%), 130 (46.8%) and 80 (28.8%) patients had smear-positive, smear-negative and extra-pulmonary TB. Self-report of missed doses and record review indicated adherence of respectively 273 (97.3%) and 271 (97.5%) patients. By visual analogue scale, 250 (91.6%) patients rated themselves as adherent. History of drug side effects (aOR 0.25, 95%CI 0.08-0.77) and knowledge about TB prevention (aOR 0.19, 95%CI 0.05-0.8) were independently associated with being adherent in this setting. CONCLUSION: Adherence to anti-tuberculosis treatment was high in our study. Adherence support should be given to the poor, the elderly, patients co-infected with the human immunodeficiency virus, alcohol abusers and smokers. Health education on TB prevention should be given to all TB patients regularly.

Contexte : Patients tuberculeux dans la zone de Mekelle, région du Tigray en Ethiopie.Objectif : Examiner l'adhésion au traitement antituberculeux.Schéma : Une étude transversale a été réalisée dans des centres de santé offrant un traitement antituberculeux. L'adhésion a été mesurée de trois manières : par la déclaration des doses manquées par les patients eux-mêmes, par une échelle visuelle analogue grâce à laquelle les patients notent leur propre adhésion et en étudiant les dossiers. Un patient était considéré comme adhérent s'il avait pris au moins 90% des doses prescrites.Résultats : Un total de 278 patients tuberculeux ont été inclus, 101 dans la phase intensive et 177 dans la phase de continuation. Respectivement 67 (24,1%), 130 (46,8%) et 80 (28,8%) patients avaient une tuberculose à frottis positif, à frottis négatif et extra-pulmonaire. La déclaration par les patients sur les doses manquées et la consultation des dossiers ont indiqué une adhésion de 273 patients (97,3%) et 271 patients (97,5%), respectivement. Avec l'échelle visuelle analogue, 250 (91,6%) patients se considéraient comme adhérents. Des antécédents d'effets secondaires (aOR ajusté [aOR] 0,25 ; IC95% 0,08­0,77) et des connaissances en matière de prévention de la TB (aOR 0,19 ; IC95% 0,05­0,8) étaient indépendamment associés à l'adhésion dans ce contexte.Conclusion : L'adhésion au traitement antituberculeux était élevée dans notre étude. Un soutien à l'adhésion devrait être offert aux patients pauvres, âgés, co-infectés par le virus de l'immunodéficience humaine, consommateurs excessifs d'alcool et fumeurs. Tous les patients devraient bénéficier régulièrement d'une éducation sanitaire à la prévention de la TB.

Marco de referencia: Los pacientes con diagnóstico de tuberculosis (TB) de la zona de Mekelle en la región Tigray en Etiopía.Objetivo: Evaluar el cumplimiento del tratamiento antituberculoso.Método: Se practicó un estudio transversal en los centros de atención sanitaria que suministran tratamiento antituberculoso. La medición de la observancia terapéutica se obtuvo mediante tres mecanismos, a saber la referencia de los propios pacientes sobre las dosis omitidas, una escala visual analógica en la cual los pacientes calificaban su propio cumplimiento y el examen de las historias clínicas. Se consideró que un paciente cumplía con el tratamiento cuando tomaba como mínimo 90% de los medicamentos recetados.Resultados: Se incluyeron en el estudio 278 pacientes con diagnóstico de TB, de los cuales 101 se encontraban en la fase intensiva del tratamiento y 177 en la fase de continuación. Sesenta y siete pacientes presentaron una baciloscopia positiva (24,1%) y 130 una baciloscopia negativa (46,8%); en 80 pacientes la TB fue de localización extrapulmonar (28,8%). Con base en la autorreferencia sobre las dosis omitidas se observó cumplimiento terapéutico en 273 pacientes (97,3%) y en 271 (97,5%) cuando se examinaron los registros clínicos. En la prueba de la escala visual analógica, 250 pacientes consideraron que eran cumplidos (91,6%). Los factores que se asociaron de manera independiente con la observancia del tratamiento en este entorno fueron los antecedentes de reacciones adversas a los medicamentos (OR ajustada [aOR] 0,25; IC95% 0,08­0,77) y los conocimientos en materia de prevención de la TB (aOR 0,19; IC95% 0,05­0,8).Conclusión: Se observó una alta tasa de cumplimiento del tratamiento antituberculoso. Es importante respaldar la observancia terapéutica de las personas con escasos recursos, los ancianos, los pacientes aquejados de coinfección por el virus de la inmunodeficiencia humana o abuso de alcohol y los fumadores. Se recomienda impartir educación en materia de prevención de la enfermedad de manera sistemática a todos los pacientes que reciben tratamiento antituberculoso.

Ambulatory care for multidrug-resistant tuberculosis: lessons learned in Addis Ababa, Ethiopia.

SETTING: Ethiopia is one of the high multidrug-resistant tuberculosis (MDR-TB) burden countries. Efforts by the National TB Programme to control MDR-TB include expanding ambulatory care. OBJECTIVE: To investigate the opportunities and challenges faced by treatment follow-up health centres (TFCs) when managing MDR-TB patients, with greater focus on recording, TB infection control (IC) and supervision practices. METHODS: A facility-based cross-sectional study was conducted by reviewing the records of all MDR-TB cases in all 25 TFCs in Addis Ababa, Ethiopia. The TB focal point, pharmacy and laboratory heads were also interviewed. RESULT: A total of 221 MDR-TB patients were registered; 157 (71%) patients had been referred from one of the two treatment initiating centres. While some TFCs oversaw up to 41 patients, others had just one patient. The majority of the TFCs (n = 21, 84%) followed standardised TB IC procedures. Poor documentation of patient information was observed at all sites; for example, human immunodeficiency virus and current treatment status was not indicated for respectively 86 (38%) and 41 (18%) patients. CONCLUSION: The study revealed that infection prevention practices were largely adhered to. Documentation of patient-related information was a major challenge, and regular supervision of the TFCs should be emphasised. Record keeping is critical.

Contexte : L'Ethiopie est l'un des pays durement frappés par la tuberculose multirésistante (TB-MDR). Les efforts du programme national de lutte contre la TB pour contrôler la TB-MDR incluent l'expansion des soins ambulatoires.Objectif : Etudier les opportunités et les défis affrontés par les centres de santé qui suivent le traitement des patients (TFC) dans la prise en charge de patients atteints de TB-MDR avec un accent sur la tenue des dossiers, la lutte contre l'infection tuberculeuse et les pratiques de supervision.Méthodes : Une étude transversale a été réalisée dans des centres de santé grâce à une revue des dossiers de tous les cas de TB-MDR dans les 25 TFC à Addis Ababa, Ethiopie. Le point focal TB, le chef de service de la pharmacie et du laboratoire ont également été interviewés.Résultats: Un total de 221 patients TB-MDR ont été inscrits ; 157 (71%) patients ont été transférés de l'un des deux centres de mise en route du traitement. Si certains TFC ont suivi jusqu'à 41 patients, d'autres n'ont vu qu'un patient. La majorité des TFC (n = 21, 84%) ont suivi les procédures standardisées de lutte contre l'infection TB. Dans tous les sites, on a observé une documentation insuffisante des informations relatives aux patients. Le statut à l'égard du virus de l'immunodéficience humaine et le traitement en cours n'étaient, par exemple, pas indiqués pour 86 (38%) et 41 (18%) patients, respectivement.Conclusion : L'étude a révélé que les pratiques de prévention de l'infection étaient largement observées. Le principal défi résidait en la documentation des informations relatives aux patients ; la supervision régulière des TFC devrait également être renforcée. La bonne tenue des dossiers est cruciale.

Marco de referencia: Etiopía es uno de los países con alta carga de morbilidad por tuberculosis multidrogorresistente (TB-MDR). Entre las iniciativas del programa nacional contra la TB, encaminadas a luchar contra este tipo de TB, se encuentra la ampliación de la prestación de atención ambulatoria.Objetivo: Investigar las oportunidades que encuentran y los obstáculos que afrontan los centros donde se practica el seguimiento terapéutico de los pacientes con TB-MDR, con un interés especial en las prácticas de registro, iniciación del control de la infección tuberculosa y supervisión del tratamiento.Métodos: Se llevó a cabo un estudio transversal de los centros de atención sanitaria (TFC) mediante el examen de las historias clínicas de todos los casos de TB-MDR en los 25 centros de seguimiento terapéutico de Addis Abeba, Etiopía. Se practicaron además entrevistas en el centro de coordinación de la TB, en las farmacias y a los directores de laboratorio.Resultados: Se registraron 221 pacientes con diagnóstico de TB-MDR. Ciento cincuenta y siete pacientes habían sido transferidos de uno de los dos centros de iniciación del tratamiento antituberculoso (TIC) de la ciudad. Algunos de los TFC supervisaban 41 pacientes, pero otros practicaban el seguimiento de un solo paciente. En la mayoría de los TFC se cumplía con los procedimientos normalizados de control de la infección tuberculosa (n = 251, 84%). En todos los centros se observó una documentación deficiente de la información sobre los pacientes; por ejemplo, en 86 casos no se indicó su situación frente al virus de la inmunodeficiencia humana (38%) y en 41 casos no existía información sobre el estado del tratamiento antituberculoso en el momento de la recogida de los datos (18%).Conclusión: El presente estudio reveló una alta tasa de cumplimiento de las prácticas de prevención de la infección tuberculosa en los centros participantes. Un escollo importante que se observó fue la deficiencia en la documentación de la información sobre los pacientes. Se debe reforzar la supervisión periódica de los TFC y es primordial mantener al día los registros clínicos.

Poor symptomatic tuberculosis screening practices in a quarter of health centres in Amhara Region, Ethiopia.

SETTING: In 2011, Ethiopia introduced a strategy of symptomatic tuberculosis (TB) screening for patients attending out-patient services to increase identification of presumptive TB. OBJECTIVE: To assess implementation and factors affecting symptomatic TB screening at out-patient departments in health centres in the Amhara Region, Ethiopia. DESIGN: Using a cross-sectional study design, 86 randomly selected public health centres providing DOTS were included in the study. Data were captured by reviewing TB registers and interviewing key informants at out-patient services. RESULTS: Of 86 health centres, 24 (28%) had poor symptomatic TB screening practices, defined as screening <80% of attending out-patients. Having an actively functioning multidisciplinary health centre team to assess TB services (aOR 2.29, 95%CI 2.23-30.80) and partner support for TB activities (aOR 4.84, 95%CI 1.05-22.40) were associated with higher TB screening rates, whereas availability of antiretroviral therapy was negatively associated. In all health centres combined, 1.6% of out-patient department attendees were identified as having presumptive TB. CONCLUSION: A quarter of health centres had poor symptomatic TB screening practices in the out-patient services in this study. Strengthening multidisciplinary teams and expanding partner support are recommended to improve TB screening practices at out-patient services in Ethiopia.

Contexte : En 2011, l'Ethiopie a introduit une stratégie de dépistage de la tuberculose (TB) basé sur les symptômes parmi les patients venant en consultation externe afin d'augmenter l'identification de patients suspects de TB.Objectif : Evaluer la mise en œuvre et les facteurs affectant le dépistage symptomatique de la TB en consultation externe dans des centres de santé de la région d'Amhara, Ethiopie.Schéma : Grâce à une étude transversale, 86 centres de santé publics, choisis au hasard et offrant des services DOTS, ont été inclus dans cette étude. Les données ont été recueillies grâce à une revue des registres et à des entretiens avec les personnes clé des services de consultations externes.Résultats : Vingt-huit pour cent des centres de santé (24/86) avaient une pratique médiocre du dépistage symptomatique de la TB, définie comme un dépistage de <80% des consultants externes. Les facteurs associés à un dépistage plus exhaustif comprenaient le fait d'avoir un centre de santé actif et bien fonctionnel, une équipe multidisciplinaire discutant des services liés à la TB (aOR 2,29, IC95% 2,23­30,80) et un soutien d'un partenaire pour les activités liées à la TB (aOR 4,84, IC95% 1,05­22,40) ; par contre, la disponibilité du traitement antirétroviral y était négativement associée. Dans tous les centres de santé combinés, 1,6% des consultants externes ont été identifiés comme suspects de TB.Conclusion : Dans cette étude, un quart des centres de santé avait une pratique de dépistage de la TB médiocre dans ses services de consultation. Il est recommandé de renforcer les équipes multidisciplinaires et d'étendre le soutien par un partenaire afin d'améliorer la pratique du dépistage de la TB dans les services de consultation externe en Ethiopie.

Marco de referencia: En el 2011 se introdujo en Etiopía una estrategia de detección sistemática de la tuberculosis (TB) sintomática en los pacientes que acuden a los servicios ambulatorios, con el objeto de mejorar el reconocimiento de los casos con presunción clínica de TB.Objetivo: Evaluar la aplicación de la estrategia de detección sistemática y los factores que influyen sobre sus resultados en los servicios ambulatorios de los establecimientos de salud en la región de Amhara en Etiopía.Método: En un examen transversal se seleccionaron de manera aleatoria, con el fin de participar en el estudio, 86 centros de atención sanitaria que prestan servicios de DOTS. Los datos se obtuvieron a partir del examen de los registros clínicos y mediante entrevistas a los informantes clave en los servicios ambulatorios.Resultados: Se observó que en 28% (24 de 86) de los centros sanitarios las prácticas de detección sistemática de la TB sintomática eran deficientes, pues alcanzaban <80% de los pacientes ambulatorios. Los siguientes factores se asociaron con una tasa más alta de detección: un equipo multidisciplinario operativo que examine los servicios relacionados con la TB en el centro (ORa 2,29; IC95% 2,23­30,80) y el respaldo de los organismos asociados a las actividades relacionadas con la TB (ORa 4,84; IC95% 1,05­22,40); la oferta de tratamiento antirretrovírico ofreció una relación inversa con la detección de la TB. En general, se estableció el diagnostico presuntivo de TB en 1,6% de los pacientes ambulatorios que acudieron a todos los centros.Conclusión: En un cuarto de los establecimientos sanitarios examinados en el presente estudio las prácticas de detección sistemática de la TB en los servicios ambulatorios eran deficientes. Se recomienda fortalecer los equipos multidisciplinarios y ampliar el respaldo de los asociados con el propósito de mejorar la detección de la TB en Etiopía.

Free tuberculosis diagnosis and treatment are not enough: patient cost evidence from three continents.

SETTING: The National Tuberculosis Programs of Ghana, Viet Nam and the Dominican Republic. OBJECTIVE: To assess the direct and indirect costs of tuberculosis (TB) diagnosis and treatment for patients and households. DESIGN: Each country translated and adapted a structured questionnaire, the Tool to Estimate Patients' Costs. A random sample of new adult patients treated for at least 1 month was interviewed in all three countries. RESULTS: Across the countries, 27-70% of patients stopped working and experienced reduced income, 5-37% sold property and 17-47% borrowed money due to TB. Hospitalisation costs (US$42-118) and additional food items formed the largest part of direct costs during treatment. Average total patient costs (US$538-1268) were equivalent to approximately 1 year of individual income. CONCLUSION: We observed similar patterns and challenges of TB-related costs for patients across the three countries. We advocate for global, united action for TB patients to be included under social protection schemes and for national TB programmes to improve equitable access to care.

Community-based multi-disease prevention campaigns for controlling human immunodeficiency virus-associated tuberculosis.

Human immunodeficiency virus (HIV) infection increases the risk of tuberculosis (TB) 21-34 fold, and has fuelled the resurgence of TB in sub-Saharan Africa. The World Health Organization (WHO) recommends the Three I's for HIV/TB (infection control, intensified case finding [ICF] and isoniazid preventive therapy) and earlier initiation of antiretroviral therapy for preventing TB in persons with HIV. Current service delivery frameworks do not identify people early enough to maximally harness the preventive benefits of these interventions. Community-based campaigns were essential components of global efforts to control major public health threats such as polio, measles, guinea worm disease and smallpox. They were also successful in helping to control TB in resource-rich settings. There have been recent community-based efforts to identify persons who have TB and/or HIV. Multi-disease community-based frameworks have been rare. Based on findings from a WHO meta-analysis and a Cochrane review, integrating ICF into the recent multi-disease prevention campaign in Kenya may have had implications in controlling TB. Community-based multi-disease prevention campaigns represent a potentially powerful strategy to deliver prevention interventions, identify people with HIV and/or TB, and link those eligible to care and treatment.

Integration of HIV testing in tuberculosis drug resistance surveillance in Kazakhstan and Kenya.

In Kenya and Kazakhstan, integration of human immunodeficiency virus (HIV) testing results into the routine surveillance of multidrug-resistant tuberculosis (MDR-TB) proved feasible and useful. The integration process improved overall data quality and data validation capacity, and integrated data are a useful addition to routine cohort and treatment outcome data. Besides their importance for individual patient care, they provide trends on the association of MDR-TB and HIV in the routine programme setting. They also form a useful epidemiological basis for more specific studies, such as on nosocomial outbreaks. Whether the system itself is sensitive enough to monitor possible outbreaks needs further investigation.

Predictors for neoplastic progression in patients with Barrett's Esophagus: a prospective cohort study.

OBJECTIVES: Patients with Barrett's esophagus (BE) have an increased risk of developing esophageal adenocarcinoma (EAC). As the absolute risk remains low, there is a need for predictors of neoplastic progression to tailor more individualized surveillance programs. The aim of this study was to identify such predictors of progression to high-grade dysplasia (HGD) and EAC in patients with BE after 4 years of surveillance and to develop a prediction model based on these factors. METHODS: We included 713 patients with BE (≥ 2 cm) with no dysplasia (ND) or low-grade dysplasia (LGD) in a multicenter, prospective cohort study. Data on age, gender, body mass index (BMI), reflux symptoms, tobacco and alcohol use, medication use, upper gastrointestinal (GI) endoscopy findings, and histology were prospectively collected. As part of this study, patients with ND underwent surveillance every 2 years, whereas those with LGD were followed on a yearly basis. Log linear regression analysis was performed to identify risk factors associated with the development of HGD or EAC during surveillance. RESULTS: After 4 years of follow-up, 26/713 (3.4%) patients developed HGD or EAC, with the remaining 687 patients remaining stable with ND or LGD. Multivariable analysis showed that a known duration of BE of ≥ 10 years (risk ratio (RR) 3.2; 95% confidence interval (CI) 1.3-7.8), length of BE (RR 1.11 per cm increase in length; 95% CI 1.01-1.2), esophagitis (RR 3.5; 95% CI 1.3-9.5), and LGD (RR 9.7; 95% CI 4.4-21.5) were significant predictors of progression to HGD or EAC. In a prediction model, we found that the annual risk of developing HGD or EAC in BE varied between 0.3% and up to 40%. Patients with ND and no other risk factors had the lowest risk of developing HGD or EAC (<1%), whereas those with LGD and at least one other risk factor had the highest risk of neoplastic progression (18-40%). CONCLUSIONS: In patients with BE, the risk of developing HGD or EAC is predominantly determined by the presence of LGD, a known duration of BE of ≥10 years, longer length of BE, and presence of esophagitis. One or combinations of these risk factors are able to identify patients with a low or high risk of neoplastic progression and could therefore be used to individualize surveillance intervals in BE.