2022 TB programme review in Pakistan: strengthening governance, with better patient diagnosis and treatment.

BACKGROUND: In Pakistan, 84% of healthcare is provided by the private sector. We conducted an epidemiological and programme review for TB to document progress and guide further efforts. METHODS: Surveillance and data systems were assessed before analysing epidemiological data. We reviewed the programme at federal, provincial and peripheral levels and compiled national data along with WHO estimates to describe the evolution of epidemiological and programme indicators. RESULTS: In 2021, of the estimated number of TB cases, 55% of overall cases and 18% of drug-resistant cases were diagnosed and treated respectively. The contribution of the private sector in case detection increased from 30% in 2017 to 40% by 2021. For newly diagnosed pulmonary TB cases, the overall proportion of confirmed cases was 52%. In 2021, testing for rifampicin resistance among confirmed cases was 66% for new and 84% for previously treated patients. The treatment success rate exceeded 90% for drug susceptible TB. The main challenges identified were a funding gap (60% in 2021-2023), fragmented electronic systems for data collection and suboptimal coordination among provinces. CONCLUSIONS: The main challenges prevent further progress in controlling TB. By addressing these, Pakistan could improve coverage of interventions, including diagnosis and treatment. Bacteriological confirmation using recommended diagnostics also requires further optimisation.

CONTEXTE: Au Pakistan, le secteur privé assure 84% des services de santé. Une étude épidémiologique et programmatique a été réalisée sur la TB afin de recueillir des informations sur les avancées réalisées et de guider les actions à venir. MÉTHODES: Les systèmes de surveillance et de données ont été évalués préalablement à l'analyse des données épidémiologiques. Nous avons examiné le programme aux niveaux fédéral, provincial et local et compilé les données nationales ainsi que les estimations de l'OMS afin de décrire l'évolution des indicateurs épidémiologiques et du programme. RÉSULTATS: En 2021, environ 55% de l'ensemble cas de TB et 18% des cas résistants aux médicaments ont été diagnostiqués et traités respectivement. La contribution du secteur privé dans la détection des cas est passée de 30% en 2017 à 40% en 2021. La proportion totale de cas confirmés pour les nouveaux diagnostics de TB pulmonaire s'élevait à 52%. En 2021, les tests de résistance à la rifampicine parmi les cas confirmés s'élevaient à 66% pour les nouveaux patients et de 84% pour les patients déjà traités. Le taux de réussite du traitement a dépassé 90% pour la TB sensible aux médicaments. Les défis majeurs comprennent un manque de financement (60% pour la période 2021­2023), des systèmes électroniques de collecte de données fragmentés et une coordination insuffisante entre les provinces. CONCLUSIONS: Les défis majeurs entravent les avancées dans la lutte contre la TB. En les mettant en évidence, le Pakistan pourrait améliorer la portée des interventions, y compris le diagnostic et le traitement. Il est également essentiel d'optimiser la confirmation bactériologique en utilisant les diagnostics recommandés.

Evidence of protective effect of BCG vaccination in persons at low risk of tuberculosis in Nordic countries.

SETTING: Norway, Sweden, Denmark and Finland have low incidence rates (IRs) of tuberculosis (TB) but the use of bacille Calmette-Guérin (BCG) vaccination has varied. OBJECTIVE: To assess if different IRs among persons at low risk in the four countries could be related to the different use of BCG vaccination, and to estimate the number of adolescent BCG vaccinations needed to prevent one case of TB in Norway. DESIGN: The study period was 1996-2005. In part A, IRs for cases classified as 'born in country/national' in the EuroTB database in all four countries were calculated. In part B, the IRs among persons born in Norway and Sweden with two parents from low-incidence countries were calculated for cases registered in the respective national TB registers. In both parts, IRs and IR ratios among 0-14-year-olds and 15-29-year-olds were compared and related to different BCG vaccination policies. RESULTS AND CONCLUSIONS: Our results are consistent with a protective effect of newborn BCG vaccination in native-born 0-14-year-olds in Finland, and of adolescent BCG vaccination in 15-29-year-olds in Norway. The Norwegian BCG vaccination programme conferred 61-64% protection to 15-29-year-olds; however, 21699-25125 vaccinations were needed to prevent one case.

Isoniazid preventive therapy for people living with HIV: public health challenges and implementation issues.

Isoniazid preventive therapy (IPT) is recognised as an important component of collaborative tuberculosis (TB) and human immunodeficiency virus (HIV) activities to reduce the burden of TB in people living with HIV (PLHIV). However, there has been little in the way of IPT implementation at country level. This failure has resulted in a recent call to arms under the banner title of the 'Three I's' (infection control to prevent nosocomial transmission of TB in health care settings, intensified TB case finding and IPT). In this paper, we review the background of IPT. We then discuss the important challenges of IPT in PLHIV, namely responsibility and accountability for the implementation, identification of latent TB infection, exclusion of active TB and prevention of isoniazid resistance, length of treatment and duration of protective efficacy. We also highlight several research questions that currently remain unanswered. We finally offer practical suggestions about how to scale up IPT in the field, including the need to integrate IPT into a package of care for PLHIV, the setting up of operational projects with the philosophy of 'learning while doing', the development of flow charts for eligibility for IPT, the development and implementation of care prior to antiretroviral treatment, and finally issues around procurement, distribution, monitoring and evaluation. We support the implementation of IPT, but only if it is done in a safe and structured way. There is a definite risk that 'sloppy' IPT will be inefficient and, worse, could lead to the development of multidrug-resistant TB, and this must be avoided at all costs.

Mass screening for active case finding of pulmonary tuberculosis in the Russian Federation: how to save costs.

BACKGROUND: In Russia, mass chest X-ray (CXR) screening for tuberculosis (TB) is mandatory.OBJECTIVE: To compare the yield and the cost per TB case detected and the total cost of CXR screening, passive case finding and contact tracing among adolescents and adults in the Arkhangelsk Oblast, Russian Federation, 2013-2017.DESIGN: This was an analysis of costing strategies using aggregated data. Costing information was obtained from the Finance Department of the Arkhangelsk Clinical TB Dispensary, Arkhangelsk, and the Territorial Fund of Mandatory Medical Insurance, Arkhangelsk, Russian Federation.RESULTS: TB cases were detected using CXR screening (n = 684, 46%), contact tracing (n = 61, 4%) and passive case finding (n = 743, 46%). The number of cases detected using CXR screening, contact tracing and passive case finding was respectively 28,753 and 960/100 000. The mean costs/test were respectively US$3.54 (US$12 541/case), US$20.28 (US$2693/case) and US$11.85 (US$1235/case) using CXR screening, contact tracing and passive case finding The number of cases/100 000 in targeted groups was as follows: HIV-positive persons, 645; homeless persons, 461; and migrants, 441. The cost/TB case detected was respectively US$549, US$768 and US$803.CONCLUSION: Mass CXR screening (excluding HIV-positive, migrant and homeless populations) has low yield and high cost per TB case detected. It should be stopped and resources should instead be used to strengthen the screening of targeted high-risk groups, contacts and passive case finding.

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

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

Outcome definitions for multidrug-resistant tuberculosis treated with shorter treatment regimens.

To assess whether the revised 2013 World Health Organization (WHO) definitions for multidrug-resistant tuberculosis (MDR-TB) treatment outcomes apply to shorter treatment regimens in low- and middle-income countries and to propose modified criteria. Criteria for 'failure' and 'cure' outcomes were assessed using data on 1006 patients enrolled in an observational study on the standardised 9-11 month shorter MDR-TB regimen in Africa. Absence of conversion in the intensive phase, a WHO criteria for failure, was the worst performing criterion; reversion had low sensitivity and other criteria provided limited added value. Based on our study results, we propose new definitions for 'treatment failure' as treatment termination or the permanent discontinuation of 2 anti-tuberculosis drugs due to 1) positive culture after 6 months of treatment (except for one isolated positive culture) or 2) at least two consecutive grade 2+ positive sputum smears after 6 months of treatment if culture is not available; and for 'cure' as treatment completion without proof of failure AND two consecutive negative cultures taken 30 days apart, one of which should be after 6 months of treatment. The proposed new definitions are applicable to shorter regimens in low- and middle-income countries, and should also work for the newly recommended longer regimens. .

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

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

Revising the tuberculosis recording and reporting information system.

OBJECTIVE: The tuberculosis recording and reporting information system (TB R&R), one of the five pillars of the DOTS strategy, has undergone a revision to comply with the new elements of the Stop TB Strategy and to ensure standardisation of essential TB information. DESIGN: An expert group on TB R&R, including the main technical partners, held a series of consultations with the Stop TB Working Groups and countries. Draft revised forms were field tested by countries with the participation of technical partners. A survey was conducted by the World Health Organization (WHO) in 105 countries. RESULT: The main changes in the TB R&R are the inclusion of TB-HIV activities (the leading reason for change at the country level), smear examinations and culture for settings performing this test routinely and the management of patient drug kits. The revised forms help monitor contributions from all care providers and community workers. The package of forms is presented in three sets: 1) essential data, 2) setting with routine culture and 3) additional data. CONCLUSION: The revised R&R forms were endorsed by the WHO, the KNCV Tuberculosis Foundation, the International Union Against Tuberculosis and Lung Disease and the US Centers for Disease Control and Prevention in 2007. They are now available in English, French and Spanish, and are adopted in most countries.

Diagnosis and treatment of tuberculosis in undocumented migrants in low- or intermediate-incidence countries.

SETTING: Countries with low or intermediate tuberculosis (TB) incidence. OBJECTIVES: 1) To gather information on individuals and TB patients who are undocumented migrants and their access to TB diagnostic and treatment services; 2)to discuss interventions to strengthen diagnosis and treatment and 3) to formulate recommendations on how to ensure adequate TB prevention and control. DESIGN: Questionnaires sent to members of the Working Group (WG) on Transborder Migration and TB, managers of national TB programmes and EuroTB correspondents; literature research and development of a paper by a writing committee through consultation. RESULTS: Undocumented migrants represent 5-30% of immigrants and 5-10% of TB cases. Most countries reported full access to diagnosis and treatment, but in practice there were limitations. Most countries also reported that they could and did deport cases who were on TB treatment. A variety of activities to ensure access were reported from different countries. CONCLUSION: The WG recommends that 1) health authorities and/or health staff should ensure easy access to low-threshold facilities where undocumented migrants who are TB suspects can be diagnosed and treated without giving their names and without fear of being reported to the police or migration officials. Health authorities should remind health staff that they have an obligation of confidentiality; 2) each country should ensure that undocumented migrants with TB are not deported until completion of treatment; and 3) authorities and non-governmental sectors should raise awareness among undocumented migrants about TB, emphasising that diagnosis and treatment should be free of charge and wholly independent of migratory status.

Tuberculosis in children treated with second-line drugs under programmatic conditions in Lima, Peru.

OBJECTIVE: To characterise childhood tuberculosis (TB) treated with second-line drugs (SLDs) in Lima, Peru. DESIGN: Results for the age groups <5 and 5-14 years were compared and treatment outcomes were assessed in cases reported between 2011 and 2015 from six districts of Lima. RESULTS: Of 96 reported cases, 82 were evaluated. Among these, 59% were boys; the median age was 8 years and 32% were aged <5 years. Contact with a TB case was reported in 82% of cases; 90% were treatment-naïve, 98% had pulmonary localisation and 50% underwent the tuberculin skin test (purified protein derivative), with induration 10 mm in 88%. A positive smear was found in 40%, all in the 5-14 years age group, and 46% were culture-positive. Only 26% had confirmed multidrug-resistant TB, 90% of whom were in the 5-14 years age group. SLDs for confirmed or probable drug-resistant TB (DR-TB) were administered to all cases, with a high proportion of success (over 83%), no failures or deaths and a high proportion of loss to follow-up. CONCLUSION: The main indication for SLDs in childhood TB was the empirical treatment of DR-TB due to contact with one or more identified DR-TB patients. Bacteriological confirmation was limited; however, treatment success was adequate.

Programmatic management of patients with pre-extensively drug-resistant tuberculosis in Peru, 2011-2014.

BACKGROUND: In Peru, a treatment approach for extensively drug-resistant tuberculosis (XDR-TB) incorporating World Health Organization Group 5 drugs and patient-centred care has achieved 65% success. To extend this approach to pre-XDR-TB patients, we evaluated this population separately. OBJECTIVE: To assess programmatic management of pre-XDR-TB. METHOD: Retrospective study using the official national registry from 2011 to 2014. Cases were separately evaluated according to resistance to fluoroquinolones (FQs) (pre-XDR-F) or to second-line injectables (SLIs) (pre-XDR-I). RESULTS: Of 610 pre-XDR-TB patients, 120 (20%) had pre-XDR-F and 490 (80%) had pre-XDR-I. Pre-XDR-F cases were older (34 years vs. 28 years, P < 0.001) and a higher proportion had previously received two or more regimens (70% vs. 38%, P < 0.001). Among the 452 patients who started treatment in 2011-2013, treatment success was 43.3%, 26.5% were lost to follow-up, 12.1% died and 13.7% failed treatment. Success was higher in pre-XDR-I (48.5%) than pre-XDR-F (21.4%) patients. History of previous treatment (OR 2.23, 95%CI 1.52-3.38) and pre-XDR-F (OR 2.39, CI 1.18-4.83) were associated with unsuccessful outcomes. CONCLUSION: Programmatic management of pre-XDR-TB has not been successful, particularly in pre-XDR-F patients, with lower rates of success than those achieved in the same setting for XDR-TB. The strategy used for XDR-TB should be extended to pre-XDR-TB patients in Peru.

Rapid drug susceptibility testing and treatment outcomes for multidrug-resistant tuberculosis in Peru.

SETTING: The detection of multidrug-resistant tuberculosis (MDR-TB) using rapid drug susceptibility testing (DST) has increased steadily in recent years in Peru, from 9216 tests in 2010 to 27 021 tests in 2015. Research examining the impact of rapid DST on treatment outcomes is required. OBJECTIVE: To evaluate the association between rapid DST use (nitrate reductase assay, microscopic observation drug susceptibility assay [MODS] and GenoType® MTBDRplus) and treatment outcomes and mortality in MDR-TB patients in Peru. DESIGN: Retrospective cohort study of patients diagnosed with pulmonary MDR-TB between 2010 and 2013 (with treatment outcomes up to December 2015) using the electronic registry of the Peruvian National TB Programme. RESULTS: A total of 2671 MDR-TB patients were included; the median age was 27 years, 2.8% were co-infected with the human immunodeficiency virus. Use of rapid DST was associated with a 40% increase in the adjusted odds of treatment success (aOR 1.40, 95%CI 1.19-1.64) and a 54% reduction in mortality (aOR 0.46, 95%CI 0.33-0.64). Higher treatment success rates were driven by MODS and GenoType® MTBDRplus testing (aORs for unsuccessful outcomes respectively 0.68 and 0.66). CONCLUSION: The use of rapid DST (MODS and MTBDRplus) to diagnose MDR-TB was associated with a reduction in the odds of death and a substantial increase in the odds of treatment success.

Pre-treatment loss to follow-up among smear-positive TB patients in tertiary hospitals, Quetta, Pakistan.

Setting: Three public sector tertiary care hospitals in Quetta, Balochistan, Pakistan, with anecdotal evidence of gaps between the diagnosis and treatment of patients with tuberculosis (TB). Objectives: To assess the proportion of pre-treatment loss to follow-up (LTFU), defined as no documented evidence of treatment initiation or referral in TB registers, among smear-positive pulmonary TB patients diagnosed in 2015, and the associated sociodemographic factors. Design: A retrospective cohort study involving the review of laboratory and TB registers. Results: Of 1110 smear-positive TB patients diagnosed (58% female, median age 40 years, 5% from outside the province or the country), 235 (21.2%) were lost to follow-up before starting treatment. Pre-treatment LTFU was higher among males; in patients residing far away, in rural areas, outside the province or the country; and in those without a mobile phone number. Conclusion: About one fifth of the smear-positive TB patients were lost to follow-up before starting treatment. Strengthening the referral and feedback mechanisms and using information technology to improve the tracing of patients is urgently required. Further qualitative research is needed to understand the reasons for pre-treatment LTFU from the patient's perspective.

Contexte : Trois hôpitaux publics tertiaires à Quetta, Baloutchistan, Pakistan, avec des preuves empiriques d'un fossé entre le diagnostic et le traitement des patients tuberculeux (TB).Objectif : Evaluer la proportion de patients perdus de vue avant le traitement (pas de preuve documentée de mise en route du traitement ou de référence dans les registres TB) parmi les patients atteints de TB pulmonaire à frottis positif diagnostiqués en 2015, et identifier les facteurs sociodémographiques associés.Schéma : Etude rétrospective de cohorte impliquant une revue des registres de laboratoire et de TB.Résultats : Sur 1110 patients TB à frottis positif diagnostiqués (58% de femmes, d'âge médian 40 ans, 5% venant de l'extérieur de la province ou du pays), 235 (21,2%) ont été perdus de vue avant de démarrer le traitement. Cette perte de vue avant le traitement a été plus élevée parmi les hommes ; parmi les patients résidant loin, en zone rurale, hors de la province ou du pays ; et parmi ceux ne possédant pas de téléphone portable.Conclusion : Environ un cinquième des patients TB à frottis positif ont été perdus de vue avant la mise en route du traitement. Il est nécessaire de manière urgente de renforcer les mécanismes de référence et de retro-information et d'avoir une meilleure traçabilité des patients grâce aux techniques d'information. Une autre recherche qualitative est requise afin de comprendre les raisons de cette perte de vue avant le traitement selon la perspective des patients.

Marco de referencia: Tres hospitales de atención terciaria del sector público de Quetta, en la provincia de Balochistán del Pakistán, donde existen datos anecdóticos de un desfase entre el diagnóstico y el tratamiento de los pacientes con tuberculosis (TB).Objetivos: Evaluar la proporción de pérdidas durante el seguimiento antes de comenzar el tratamiento (falta de documentación de la iniciación del tratamiento o la remisión a otros centros en los registros de TB) de los pacientes con TB pulmonar y baciloscopia positiva diagnosticados en el 2015 y analizar los factores socioeconómicos determinantes.Métodos: Un estudio retrospectivo de cohortes a partir del examen de los registros de laboratorio y los registros de TB.Resultados: De los 1110 pacientes con baciloscopia positiva diagnosticados (58% de sexo femenino, mediana de la edad 40 años y 5% procedente de otra provincia o país), 235 (21,2%) se perdieron durante el seguimiento antes de iniciar el tratamiento. Estas pérdidas fueron mayores en los pacientes de sexo masculino; los pacientes que residían en zonas rurales remotas, fuera de la provincia o del país; y en las personas que no contaban con un número de teléfono celular.Conclusión: Cerca de un quinto de los pacientes con diagnóstico de TB y baciloscopia positiva se perdió durante el seguimiento antes de comenzar el tratamiento. Es urgente fortalecer el mecanismo de remisiones y de retroinformación de los resultados y mejorar la localización de los pacientes haciendo uso de la tecnología de la información. Se precisan nuevas investigaciones cualitativas que favorezcan la comprensión de las razones de esta pérdida durante el seguimiento desde la perspectiva de los pacientes.

Infection control in hospitals managing drug-resistant tuberculosis in Pakistan: how are we doing?

Setting: Ten hospitals managing drug-resistant tuberculosis (TB) in Pakistan. Objective: To assess the implementation of TB infection control (IC) practices and reasons for non-adherence to guidelines. Design: This was a descriptive study conducted between April and October 2016 with three components: 1) non-participant observation of service delivery areas (SDAs) (n = 82) in hospitals (n = 10) using structured checklists; 2) exit interviews with 100 patients (10 per hospital); and 3) interviews with 100 health-care workers (HCWs, 10/hospital). Results: Of the 82 SDAs, posters were displayed in 34 (41%), mechanical ventilation was implemented in 79% and functional ultraviolet germicidal irradiation (UVGI) was available in only 26%. Patient interviews showed 50-65% adherence to triage and use of personal protective measures. Key reasons for non-adherence were lack of adequate supplies, discomfort using N-95 masks, a lack of knowledge or training, perceived non-cooperation by patients, poor maintenance of mechanical ventilators and UVGI due to unstable electricity supply, a lack of clarity in roles (no-one designated in charge) and staff shortages and subsequent workloads. Adherence to natural ventilation usage was poor for reasons related to climate and privacy. Conclusion: Implementation of TBIC measures in hospitals was suboptimal. Urgent measures need to be put in place, including retraining of HCWs, addressing weaknesses in mask and poster supplies and constant supervision and monitoring.

Contexte : Dix hôpitaux prenant en charge la tuberculose (TB) pharmacorésistante au Pakistan.Objectif : Evaluer la mise en œuvre des pratiques de lutte contre l'infection TB (CITB) et les raisons de la non-adhésion aux directives.Schéma : Étude descriptive réalisée entre avril et octobre 2016 avec trois composants : 1) observation non participative des zones de prestations de service (SDA) (n = 82) dans des hôpitaux (n = 10) grâce à des checklists structurées ; 2) entretiens de sortie avec 100 patients (10 par hôpital) ; 3) entretiens avec 100 prestataires de soins de santé (HCW, 10 par hôpital).Résultats : Parmi 82 SDA, des affiches ont été déployées dans 34 (41%) d'entre elles, une ventilation mécanique a été mise en œuvre dans 79% et un système fonctionnel d'irradiation par ultraviolets germicides (UVGI) a été disponible dans seulement 26%. Les entretiens avec les patients ont mis en évidence 50­65% d'adhérence au triage et à l'utilisation de mesures de protection personnelles. Les raisons majeures de la non-adhésion ont été le manque de fournitures appropriées, l'inconfort d'utilisation des masques N-95, le manque de connaissance ou de formation, la perception d'une non-coopération par les patients, la maintenance médiocre des ventilateurs mécaniques et de l'UVGI à cause de l'instabilité de l'alimentation électrique et le manque de clarification des responsabilités (aucune personne désignée responsable), et la pénurie de personnel avec surcharge de travail du personnel présent. L'adhésion à la ventilation naturelle a été médiocre en raison du climat et pour des problèmes de confidentialité.Conclusion : La mise en œuvre de mesures de CITB dans les hôpitaux a été sous-optimale. Des mesures urgentes sont requises, notamment la formation continue des HCW, la lutte contre les problèmes de fourniture de masques et d'affiches et une supervision et un suivi constants.

Marco de referencia: Diez hospitales que se ocupan del tratamiento de la tuberculosis (TB) multirresistente en el Pakistán.Objetivo: Evaluar la aplicación de las prácticas de control de la infección TB (CITB) y determinar las razones del incumplimiento de las normas.Método: De abril a octubre del 2016 se realizó un estudio descriptivo que comportó los siguientes elementos: 1) personas no vinculadas evaluaron las zonas de prestación de servicios (n = 82) en los hospitales (n = 10), con listas de verificación estructuradas; 2) se realizaron entrevistas de salida a 100 pacientes (10 por cada hospital) y 3) entrevistas a 100 profesionales de salud (HCW; 10 por cada hospital).Resultados: De las 82 zonas de prestación de servicios evaluadas, en 34 había afiches expuestos (41%), el 79% contaba con sistemas de ventilación mecánica y solo en el 26% existía un dispositivo funcional de radiación ultravioleta germicida (UVGI). Las entrevistas a los pacientes revelaron un cumplimiento de 50% a 65% con la selección de los pacientes y las medidas de protección personal. Las principales explicaciones del incumplimiento fueron la insuficiencia de suministros, la incomodidad de utilización de las mascarillas N-95, la carencia de conocimientos o capacitación adecuada, la percepción de una falta de cooperación por parte de los pacientes, un mantenimiento deficiente de los ventiladores mecánicos y los dispositivos de UVGI debido a la inestabilidad del suministro eléctrico y la poca claridad con respecto a las funciones (falta de designación de una persona encargada), la escasez de personal y la consecuente sobrecarga de trabajo. El cumplimiento de las normas de ventilación natural era deficiente por causa de las condiciones climáticas y aspectos relacionados con el respeto de la intimidad.Conclusión: La aplicación de las medidas de CITB en los hospitales es deficiente. Se precisa de manera urgente instaurar medidas como la actualización de la formación de los HCW, la corrección de las deficiencias en el abastecimiento de mascarillas y afiches y la práctica constante de la supervisión y la vigilancia.

Gastric specimens for diagnosing tuberculosis in adults unable to expectorate in Rawalpindi, Pakistan.

Setting: Adult pulmonary tuberculosis (TB) patients unable to expectorate quality sputum represent a diagnostic challenge. A private hospital in Pakistan routinely performs gastric aspiration in adults with difficulties expectorating. Objective: To assess the usefulness of gastric specimens (GS) in diagnosing pulmonary TB (PTB) and drug-resistant TB in adult presumptive TB patients unable to expectorate, and to compare the diagnostic yield and sensitivity of smear, culture and the Xpert® MTB/RIF assay. Design: This was a comparative cross-sectional study based on retrospective record review. Results: Of 900, 885 and 877 GS tested by smear, Xpert and culture, respectively, interpretable results were obtained for respectively 900 (100%), 859 (97.1%) and 754 (86.0%), with a diagnostic yield of respectively 23.6%, 30.3% and 24.9%. The yield was significantly higher for Xpert in previously treated patients. There were 313 patients with definite TB, defined as positive on Xpert and/or culture. The 82.8% sensitivity of Xpert was significantly higher than that of smear (61.0%) and culture (67.8%). Conclusion: GS obtained by aspiration under routine programme conditions is useful for detecting TB and drug-resistant TB in adult patients unable to expectorate. Xpert, with its rapid testing, high proportion of interpretable results and better sensitivity, can substantially improve the diagnosis of bacteriologically confirmed TB and rifampicin resistance.

Contexte: Les patients adultes atteints de tuberculose pulmonaire (TB) incapables d'expectorer des crachats de qualité posent un problème en matière de diagnostic. Un hôpital privé du Pakistan réalise en routine l'aspiration gastrique chez les adultes qui ont du mal à expectorer.Objectif: Evaluer l'utilité des échantillons gastriques (GS) chez des patients adultes présumés atteints de TB incapables d'expectorer, pour le diagnostic de la TB pulmonaire et pharmacorésistante et pour comparer le rendement diagnostique et la sensibilité du frottis, de la culture et du test Xpert® MTB/RIF.Schéma: Etude comparative transversale basée sur une revue rétrospective des dossiers.Résultats: Un total de 900, 885 et 877 GA ont été testés respectivement par frottis, Xpert et culture et des résultats interprétables ont été obtenus chez 900 (100%), 859 (97,1%) et 754 (86,0%) patients avec un rendement diagnostique respectivement de 23,6%, 30,3% et 24,9%. Le rendement a été significativement plus élevé pour l'Xpert chez les patients déjà traités. Il y avait 313 patients avec une TB, définie comme la positivité de l'Xpert et/ou de la culture. La sensibilité de l'Xpert de 82,8% a été significativement plus élevée que le frottis (61,0%) et la culture (67,8%).Conclusion: Le GS aspiré sous des conditions de routine de programme est utile pour détecter la TB et la TB pharmacorésistante chez des patients adultes incapables d'expectorer. L'Xpert avec un test rapide, la proportion élevée de résultats interprétables et une meilleure sensibilité, peuvent substantiellement améliorer le diagnostic de la TB confirmée par bactériologie et la résistance à la rifampicine.

Marco de referencia: El diagnóstico de la tuberculosis (TB) pulmonar se dificulta en los pacientes adultos que no pueden suministrar muestras de esputo de buena calidad. En un hospital privado del Pakistán se practica de manera sistemática la aspiración gástrica en los adultos con dificultad para expectorar.Objetivo: Evaluar la utilidad del aspirado gástrico (GS) para el diagnóstico de la TB pulmonar farmacorresistente, en los pacientes con presunción de TB que tienen dificultad para expectorar y comparar el rendimiento diagnóstico y la sensibilidad de la baciloscopia, el cultivo y la prueba Xpert® MTB/RIF.Método: Un estudio transversal comparativo a partir del examen retrospectivo de las historias clínicas.Resultados: Se examinaron 900 muestras de GS mediante baciloscopia, 885 con la prueba Xpert y 877 por cultivo; se obtuvieron resultados interpretables en 900 (100%), 859 (97,1%) y 754 muestras (86,0%), con un rendimiento diagnóstico de 23,6%, 30,3% y 24,9%, respectivamente. El rendimiento fue significativamente superior con la prueba Xpert en los pacientes con antecedente de tratamiento. El diagnóstico definitivo de TB, definido como un resultado positivo de la prueba Xpert, el cultivo o ambos, se estableció en 313 pacientes. La prueba Xpert exhibió una sensibilidad de 82,8%, que fue significativamente más alta que la sensibilidad de la baciloscopia (61,0%) y la del cultivo (67,8%).Conclusión: El examen de las muestras de GS en el marco del programa corriente es útil para detectar la TB y la TB farmacorresistente en los pacientes adultos que no pueden expectorar. La prueba Xpert que ofrece un diagnóstico rápido, alta proporción de resultados interpretables y mejor sensibilidad puede mejorar notablemente el diagnóstico con confirmación bacteriológica de la TB y la resistencia a rifampicina.

Tuberculosis control in conflict-affected East Timor, 1996-2004.

SETTING: East Timor has undergone major political changes in the past 10 years. Tuberculosis (TB) control has flourished, despite chronic low tension conflict, a brief but intense period of high-level conflict and post-conflict reconstruction. OBJECTIVE: To assess TB control in East Timor from 1996 to 2004. DESIGN: Data were collected from a variety of sources. Key TB programme indicators were analysed with reference to WHO targets to assess the performance of the three TB control programmes that operated during the study period. RESULTS: Before 1999, a non-governmental TB control programme was established in several districts in parallel with the government TB programme, and showed optimistic results. External donor funds, technical assistance and local control strategies were key components. In 1999, conflict led to complete disruption of both programmes. In 2000, a National Tuberculosis Control Programme (NTP) was established from the non-governmental programme in collaboration with other partners. The smear-positive TB case notification rate of 108 per 100000 population is the highest in the region and reflects high population coverage. The cure rate of 81% is close to reaching the WHO target. CONCLUSION: High-quality TB control has been introduced in conflict-affected East Timor. Further research is needed to examine Timorese approaches to inform other, similar settings.

Did FIDELIS projects contribute to the detection of new smear-positive pulmonary tuberculosis cases in China?

Setting: The first phase of the Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB (FIDELIS) projects in China started in 2003. Objective: To determine whether the FIDELIS projects contributed to the increased case detection rate for new smear-positive pulmonary tuberculosis (PTB) in China. Methods: We compared the case notification rates (CNRs) in the intervention year with those of the previous year in the FIDELIS areas, then compared the difference between the CNRs of the intervention year and the previous year in the FIDELIS areas with those in the non-FI-DELIS areas within the province. Results: There was an increase in the CNR in the intervention year compared with the previous year for all the project sites. The differences between the CNR in the intervention year and the previous year ranged from 6.4 to 31.1 per 100 000 population in the FIDELIS areas and from 2.9 to 20.4/100 000 in the non-FIDELIS areas. Differences-in-differences analysis shows that the differences in the CNRs in the FIDELIS areas were not statistically significantly different from those in the non-FIDELIS areas (P = 0.393). Conclusion: The FIDELIS projects may have contributed to the increase in case detection of new smear-positive PTB in China, but the level of evidence is low.

Objectif : Déterminer si les projets de la « Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB ¼ (FIDELIS), commencés en 2003, ont contribué à une augmentation de la détection des cas de tuberculose pulmonaire (TBP) à frottis positif en Chine.Méthodes : Nous avons comparé le taux de notification des cas (CNR) pendant l'année d'intervention avec celui de l'année précédente dans les zones FIDELIS. Nous avons également comparé la différence du CNR de l'année d'intervention et de l'année précédente dans les zones FIDELIS et les zones non FIDELIS à l'intérieur de la province.Résultats : Il y a eu une augmentation du CNR pendant l'année d'intervention comparée à l'année précédente dans tous les sites du projet. Cette différence de CNR entre l'année d'intervention et l'année précédente allait de 6,4 à 31,1 par 100 000 habitants dans les zones FIDELIS et de 2,9 à 20,4/100 000 dans les zones non FIDELIS. L'analyse des écarts dans les différences a montré que les différences de CNR dans les zones FIDELIS n'étaient pas statistiquement significatives par rapport à aux zones non FIDELIS (P = 0,393).Conclusions : Les projets FIDELIS pourraient avoir contribué à l'augmentation de la détection des cas nouveaux de TBP à frottis positif en Chine, mais le niveau de preuves reste faible.

Marco de referencia: La primera fase de ejecución del Fondo para la Expansión Innovadora de DOTS mediante Iniciativas Locales para Detener la Tuberculosis (FIDELIS, por su acrónimo en inglés), en la China, comenzó en 2003.Objetivo: Determinar si los proyectos de la iniciativa FIDELIS contribuían a aumentar la detección de casos nuevos de tuberculosis pulmonar (TBP) con baciloscopia positiva en la China.Métodos: Se comparó la tasa de notificación de casos (CNR) durante el año de la intervención, con la tasa del año anterior en las zonas vinculadas con el proyecto FIDELIS, y se examinó además la diferencia de la CNR durante el año de la intervención y el año anterior en zonas de la provincia que no participaron en el proyecto.Resultados: Durante el año de la intervención, se observó un aumento de la CNR con respecto al año anterior en todos los centros del proyecto. Las diferencias de la CNR en ambos períodos en las zonas que participaron en el proyecto FIDELIS oscilaron entre 6,4 y 31,1 por 100 000 habitantes; en las zonas donde no hubo intervención las diferencias de la tasa de notificación oscilaron entre 2,9 y 20,4/100 000. Al comparar estos resultados, no se puso en evidencia una diferencia significativa en las CNR al comparar las zonas que practicaron la intervención y las zonas fuera del proyecto FIDELIS (P = 0,393).Conclusión: Es posible que los proyectos FIDELIS hayan contribuido a mejorar la tasa de detección de casos nuevos de TBP con baciloscopia positiva en la China, pero la fuerza demostrativa de las pruebas científicas es escasa.

Multidrug-resistant tuberculosis in Norway: a nationwide study, 1995-2014.

SETTING: The management of multidrug-resistant tuberculosis (MDR-TB) is strictly regulated in Norway. However, nationwide studies of the epidemic are lacking. OBJECTIVE: To describe the MDR-TB epidemic in Norway over two decades. DESIGN: Retrospective analysis of data on MDR-TB cases in Norway, 1995-2014, obtained from the national registry, patient records and the reference laboratory, with genotyping and cluster analysis data. Data for non-MDR-TB cases were collected from the national registry. RESULTS: Of 4427 TB cases, 89 (2.0%) had MDR-TB, 7% of whom had extensively drug-resistant TB (XDR-TB) and 24% pre-XDR-TB. Of the 89 MDR-TB cases, 96% were immigrants, mainly from the Horn of Africa or the former Soviet Union (FSU); 37% had smear-positive TB; and 4% were human immunodeficiency virus co-infected. Of the 19% infected in Norway, the majority belonged to a Delhi/Central Asian lineage cluster in a local Somali community. Among the MDR-TB cases, smear-positive TB and FSU origin were independent risk factors for XDR/pre-XDR-TB. Treatment was successful in 66%; 17% were lost to follow-up, with illicit drug use and adolescence being independent risk factors. Forty-four per cent of patients treated with linezolid discontinued treatment due to adverse effects. CONCLUSION: MDR-TB is rare in Norway and is predominantly seen in immigrants from the Horn of Africa and FSU. Domestic transmission outside immigrant populations is minimal.

Long-term risk of tuberculosis among immigrants in Norway.

BACKGROUND: Two-thirds of the tuberculosis (TB) cases in Norway were discovered among immigrants. Some cases were discovered at arrival, but many develop the disease several years post-migration. Knowledge about how long after migration to Norway TB were discovered will enable us to better target preventive measures including preventive therapy. This study examines the long-term risk of TB among immigrants in Norway. METHODS: All non-Nordic immigrants who arrived in Norway between 1986 and 2002, as registered by the Norwegian Directorate of Immigration, were followed-up. Their TB status was determined from the National Tuberculosis Registry. Observation period for TB cases was calculated from the date of arrival in Norway to TB registration. For persons without TB, it was calculated from the date of arrival in Norway to the date of emigration from Norway, date of death, or until end of follow-up (December 31, 2002). RESULTS: For immigrants from Africa and Asia, the TB rates were 190 and 80 per 100,000 person-years (PY), respectively, at 7 years post-migration. For immigrants from Somalia, Pakistan, Vietnam, and the former Yugoslavia, the rates were 520, 160, 210, and 40 per 100 000 PY respectively, at 7 years post-migration. These rates were 7 to 90 times higher than the crude TB incidence for Norway. This increased risk applies to both genders, pulmonary and extra-pulmonary sites. CONCLUSION: These results indicate the need for health personnel to be aware that immigrants remain at high risk of TB many years post-migration. Screening for TB on arrival should be strengthened, and preventive therapy for those with recent TB infection should be considered.