Journal Article > Meta-AnalysisFull Text
Eur Respir J. 2020 March 20; Volume 55 (Issue 3); 1901467.; DOI:10.1183/13993003.01467-2019
Abidi S, Achar J, Assao Neino MM, Bang D, Benedetti A, et al.
Eur Respir J. 2020 March 20; Volume 55 (Issue 3); 1901467.; DOI:10.1183/13993003.01467-2019
We sought to compare the effectiveness of two World Health Organization (WHO)-recommended regimens for the treatment of rifampin- or multidrug-resistant (RR/MDR) tuberculosis (TB): a standardised regimen of 9-12 months (the "shorter regimen") and individualised regimens of ≥20 months ("longer regimens").
We collected individual patient data from observational studies identified through systematic reviews and a public call for data. We included patients meeting WHO eligibility criteria for the shorter regimen: not previously treated with second-line drugs, and with fluoroquinolone- and second-line injectable agent-susceptible RR/MDR-TB. We used propensity score matched, mixed effects meta-regression to calculate adjusted odds ratios and adjusted risk differences (aRDs) for failure or relapse, death within 12 months of treatment initiation and loss to follow-up.
We included 2625 out of 3378 (77.7%) individuals from nine studies of shorter regimens and 2717 out of 13 104 (20.7%) individuals from 53 studies of longer regimens. Treatment success was higher with the shorter regimen than with longer regimens (pooled proportions 80.0% versus 75.3%), due to less loss to follow-up with the former (aRD -0.15, 95% CI -0.17- -0.12). The risk difference for failure or relapse was slightly higher with the shorter regimen overall (aRD 0.02, 95% CI 0-0.05) and greater in magnitude with baseline resistance to pyrazinamide (aRD 0.12, 95% CI 0.07-0.16), prothionamide/ethionamide (aRD 0.07, 95% CI -0.01-0.16) or ethambutol (aRD 0.09, 95% CI 0.04-0.13).
In patients meeting WHO criteria for its use, the standardised shorter regimen was associated with substantially less loss to follow-up during treatment compared with individualised longer regimens and with more failure or relapse in the presence of resistance to component medications. Our findings support the need to improve access to reliable drug susceptibility testing.
We collected individual patient data from observational studies identified through systematic reviews and a public call for data. We included patients meeting WHO eligibility criteria for the shorter regimen: not previously treated with second-line drugs, and with fluoroquinolone- and second-line injectable agent-susceptible RR/MDR-TB. We used propensity score matched, mixed effects meta-regression to calculate adjusted odds ratios and adjusted risk differences (aRDs) for failure or relapse, death within 12 months of treatment initiation and loss to follow-up.
We included 2625 out of 3378 (77.7%) individuals from nine studies of shorter regimens and 2717 out of 13 104 (20.7%) individuals from 53 studies of longer regimens. Treatment success was higher with the shorter regimen than with longer regimens (pooled proportions 80.0% versus 75.3%), due to less loss to follow-up with the former (aRD -0.15, 95% CI -0.17- -0.12). The risk difference for failure or relapse was slightly higher with the shorter regimen overall (aRD 0.02, 95% CI 0-0.05) and greater in magnitude with baseline resistance to pyrazinamide (aRD 0.12, 95% CI 0.07-0.16), prothionamide/ethionamide (aRD 0.07, 95% CI -0.01-0.16) or ethambutol (aRD 0.09, 95% CI 0.04-0.13).
In patients meeting WHO criteria for its use, the standardised shorter regimen was associated with substantially less loss to follow-up during treatment compared with individualised longer regimens and with more failure or relapse in the presence of resistance to component medications. Our findings support the need to improve access to reliable drug susceptibility testing.
Journal Article > ResearchFull Text
Public Health Action. 2016 June 21; Volume 6 (Issue 2); 105-10.; DOI:10.5588/pha.15.0081
Mchunu G, van Griensven J, Hinderaker SG, Kizito W, Sikhondze W, et al.
Public Health Action. 2016 June 21; Volume 6 (Issue 2); 105-10.; DOI:10.5588/pha.15.0081
SETTING
All health facilities providing tuberculosis (TB) care in Swaziland.
OBJECTIVE
To describe the impact of human immunodeficiency virus (HIV) interventions on the trend of TB treatment outcomes during 2010-2013 in Swaziland; and to describe the evolution in TB case notification, the uptake of HIV testing, antiretroviral therapy (ART) and cotrimoxazole preventive therapy (CPT), and the proportion of TB-HIV co-infected patients with adverse treatment outcomes, including mortality, loss to follow-up and treatment failure.
DESIGN
A retrospective descriptive study using aggregated national TB programme data.
RESULTS
Between 2010 and 2013, TB case notifications in Swaziland decreased by 40%, HIV testing increased from 86% to 96%, CPT uptake increased from 93% to 99% and ART uptake among TB patients increased from 35% to 75%. The TB-HIV co-infection rate remained around 70% and the proportion of TB-HIV cases with adverse outcomes decreased from 36% to 30%. Mortality remained high, at 14-16%, over the study period, and anti-tuberculosis treatment failure rates were stable over time (<5%).
CONCLUSION
Despite high CPT and ART uptake in TB-HIV patients, mortality remained high. Further studies are required to better define high-risk patient groups, understand the reasons for death and design appropriate interventions.
All health facilities providing tuberculosis (TB) care in Swaziland.
OBJECTIVE
To describe the impact of human immunodeficiency virus (HIV) interventions on the trend of TB treatment outcomes during 2010-2013 in Swaziland; and to describe the evolution in TB case notification, the uptake of HIV testing, antiretroviral therapy (ART) and cotrimoxazole preventive therapy (CPT), and the proportion of TB-HIV co-infected patients with adverse treatment outcomes, including mortality, loss to follow-up and treatment failure.
DESIGN
A retrospective descriptive study using aggregated national TB programme data.
RESULTS
Between 2010 and 2013, TB case notifications in Swaziland decreased by 40%, HIV testing increased from 86% to 96%, CPT uptake increased from 93% to 99% and ART uptake among TB patients increased from 35% to 75%. The TB-HIV co-infection rate remained around 70% and the proportion of TB-HIV cases with adverse outcomes decreased from 36% to 30%. Mortality remained high, at 14-16%, over the study period, and anti-tuberculosis treatment failure rates were stable over time (<5%).
CONCLUSION
Despite high CPT and ART uptake in TB-HIV patients, mortality remained high. Further studies are required to better define high-risk patient groups, understand the reasons for death and design appropriate interventions.
Journal Article > ResearchFull Text
Public Health Action. 2018 April 25; Volume 8 (Issue 1); DOI:10.5588/pha.17.0058
Zulu Z, Kunene S, Mkhonta N, Owiti P, Sikhondze W, et al.
Public Health Action. 2018 April 25; Volume 8 (Issue 1); DOI:10.5588/pha.17.0058
Background: To be able to eliminate malaria, accurate, timely reporting and tracking of all confirmed malaria cases is crucial. Swaziland, a country in the process of eliminating malaria, has three parallel health information systems. Design: This was a cross-sectional study using country-wide programme data from 2010 to 2015. Methods: The Malaria Surveillance Database System (MSDS) is a comprehensive malaria database, the Immediate Disease Notification System (IDNS) is meant to provide early warning and trigger case investigations to prevent onward malaria transmission and potential epidemics, and the Health Management Information Systems (HMIS) reports on all morbidity at health facility level. Discrepancies were stratified by health facility level and type. Results: Consistent over-reporting of 9-85% was noticed in the HMIS, principally at the primary health care level (clinic and/or health centre). In the IDNS, the discrepancy went from under-reporting (12%) to over-reporting (32%); this was also seen at the primary care level. At the hospital level, there was under-reporting in both the HMIS and IDNS. Conclusions: There are considerable discrepancies in the numbers of confirmed malaria cases in the HMIS and IDNS in Swaziland. This may misrepresent the malaria burden and delay case investigation, predisposing the population to potential epidemics. There is an urgent need to improve data integrity in order to guide and evaluate efforts toward elimination.
Journal Article > ResearchFull Text
Public Health Action. 2018 April 25; Volume 8 (Issue 1); DOI:10.5588/pha.17.0047
Dlamini SV, Kosgei RJ, Mkhonta N, Zulu Z, Makadzange K, et al.
Public Health Action. 2018 April 25; Volume 8 (Issue 1); DOI:10.5588/pha.17.0047
Objective: To assess adherence to malaria diagnosis and treatment guidelines (2010 and 2014) in all health care facilities in Swaziland between 2011 and 2015. Methods: This was a cross-sectional descriptive study involving all health care facilities that diagnosed and managed malaria cases in Swaziland. Patients' age, sex, diagnosis method and type of treatment were analysed. Results: Of 1981 records for severe and uncomplicated malaria analysed, 56% of cases were uncomplicated and 14% had severe malaria. The type of malaria was not recorded for 30% of cases. Approximately 71% of cases were confirmed by rapid diagnostic tests (RDT) alone, 3% by microscopy alone and 26% by both RDT and microscopy. Of the uncomplicated cases, 93% were treated with artemether-lumefantrine (AL) alone, 5% with quinine alone and 2% with AL and quinine. Amongst the severe cases, 11% were treated with AL alone, 44% with quinine alone and 45% with AL and quinine. For severe malaria, clinics and health centres prescribed AL alone more often than hospitals (respectively 13%, 12% and 4%, P = 0.03). Conclusion: RDTs and/or microscopy results are used at all facilities to inform treatment. Poor recording of malaria type causes difficulties in assessing the prescription of antimalarial drugs.
Journal Article > ResearchFull Text
Trop Med Int Health. 2019 September 19; Volume 24 (Issue 9); 1114-1127.; DOI:10.1111/tmi.13290
Kerschberger B, Schomaker M, Telnov A, Vambe D, Kisyeri N, et al.
Trop Med Int Health. 2019 September 19; Volume 24 (Issue 9); 1114-1127.; DOI:10.1111/tmi.13290
OBJECTIVES
This paper assesses patient- and population-level trends in TB notifications during rapid expansion of antiretroviral therapy in Eswatini which has an extremely high incidence of both TB and HIV.
METHODS
Patient- and population-level predictors and rates of HIV-associated TB were examined in the Shiselweni region in Eswatini from 2009 to 2016. Annual population-level denominators obtained from projected census data and prevalence estimates obtained from population-based surveys were combined with individual-level TB treatment data. Patient- and population-level predictors of HIV-associated TB were assessed with multivariate logistic and multivariate negative binomial regression models.
RESULTS
Of 11 328 TB cases, 71.4% were HIV co-infected and 51.8% were women. TB notifications decreased fivefold between 2009 and 2016, from 1341 to 269 cases per 100 000 person-years. The decline was sixfold in PLHIV vs. threefold in the HIV-negative population. Main patient-level predictors of HIV-associated TB were recurrent TB treatment (adjusted odds ratio [aOR] 1.40, 95% confidence interval [CI]: 1.19-1.65), negative (aOR 1.31, 1.15-1.49) and missing (aOR 1.30, 1.11-1.53) bacteriological status and diagnosis at secondary healthcare level (aOR 1.18, 1.06-1.33). Compared with 2009, the probability of TB decreased for all years from 2011 (aOR 0.69, 0.58-0.83) to 2016 (aOR 0.54, 0.43-0.69). The most pronounced population-level predictor of TB was HIV-positive status (adjusted incidence risk ratio 19.47, 14.89-25.46).
CONCLUSIONS
This high HIV-TB prevalence setting experienced a rapid decline in TB notifications, most pronounced in PLHIV. Achievements in HIV-TB programming were likely contributing factors.
This paper assesses patient- and population-level trends in TB notifications during rapid expansion of antiretroviral therapy in Eswatini which has an extremely high incidence of both TB and HIV.
METHODS
Patient- and population-level predictors and rates of HIV-associated TB were examined in the Shiselweni region in Eswatini from 2009 to 2016. Annual population-level denominators obtained from projected census data and prevalence estimates obtained from population-based surveys were combined with individual-level TB treatment data. Patient- and population-level predictors of HIV-associated TB were assessed with multivariate logistic and multivariate negative binomial regression models.
RESULTS
Of 11 328 TB cases, 71.4% were HIV co-infected and 51.8% were women. TB notifications decreased fivefold between 2009 and 2016, from 1341 to 269 cases per 100 000 person-years. The decline was sixfold in PLHIV vs. threefold in the HIV-negative population. Main patient-level predictors of HIV-associated TB were recurrent TB treatment (adjusted odds ratio [aOR] 1.40, 95% confidence interval [CI]: 1.19-1.65), negative (aOR 1.31, 1.15-1.49) and missing (aOR 1.30, 1.11-1.53) bacteriological status and diagnosis at secondary healthcare level (aOR 1.18, 1.06-1.33). Compared with 2009, the probability of TB decreased for all years from 2011 (aOR 0.69, 0.58-0.83) to 2016 (aOR 0.54, 0.43-0.69). The most pronounced population-level predictor of TB was HIV-positive status (adjusted incidence risk ratio 19.47, 14.89-25.46).
CONCLUSIONS
This high HIV-TB prevalence setting experienced a rapid decline in TB notifications, most pronounced in PLHIV. Achievements in HIV-TB programming were likely contributing factors.
Journal Article > ResearchFull Text
Low uptake of preventive interventions among malaria cases in Swaziland: towards malaria elimination
Public Health Action. 2018 April 25; Volume 8 (Issue 1); DOI:10.5588/pha.17.0016
Makadzange K, Dlamini N, Zulu Z, Dlamini SV, Kunene S, et al.
Public Health Action. 2018 April 25; Volume 8 (Issue 1); DOI:10.5588/pha.17.0016
Settings: Swaziland is striving to achieve sustainable malaria elimination. Three preventive interventions are vital for reaching this goal: 1) effective household utilisation of long-lasting insecticide nets (LLINs), 2) indoor residual spraying (IRS), and 3) provision of chemoprophylaxis for those travelling to malaria-endemic areas. Objectives: To assess the uptake of preventive intervention among confirmed malaria cases. Design: A longitudinal study using nation-wide programme data from 2010 to 2015. Data on malaria cases from health facilities were sourced from the Malaria Surveillance Database System. Results: Of a total 2568 confirmed malaria cases in Swaziland, 2034 (79%) had complete data on case investigations and were included in the analysis. Of 341 (17%) individuals who owned LLINs, 169 (8%) used them; 338 (17%) had IRS and 314 (15%) slept in sprayed structures. Of 1403 travellers to areas at high malaria risk, 59 (4%) used any form of malaria prevention, including chemoprophylaxis. Conclusion: The uptake of all three key malaria prevention interventions is low, and could threaten the progress made thus far toward malaria elimination. Efforts to improve this situation, including qualitative research to understand the reasons for low uptake, are urgently needed.
Journal Article > ResearchFull Text
Bedaquiline and delamanid result in low rates of unfavourable outcomes among TB patients in Eswatini
Int J Tuberc Lung Dis. 2020 October 1; Volume 24; DOI:10.5588/ijtld.20.0082
Vambe D, Kay AW, Furin J, Howard AA, Dlamini T, et al.
Int J Tuberc Lung Dis. 2020 October 1; Volume 24; DOI:10.5588/ijtld.20.0082
SETTING: Since 2015, Eswatini has been scaling up bedaquiline (BDQ) and delamanid (DLM) based drug-resistant TB treatment regimens under programmatic conditions.
OBJECTIVE: Identification of factors associated with treatment outcomes in patients receiving BDQ and/or DLM either as a new treatment initiation or drug substitution.
DESIGN: This is a retrospective cohort study of patients receiving BDQ and/or DLM in Eswatini between March 2015 and October 2018. We describe factors associated with unfavourable treatment outcomes (death, lost to follow-up, treatment failure and amplification of resistance) and culture conversion using multivariable flexible parametric survival and competing-risks regression analyses.
RESULTS: Of 352 patients receiving BDQ and/or DLM, 7.8% and 21.2% had an unfavourable treatment outcome at 6 and 24 months, respectively. Predictors were age ≥ 60 years (adjusted hazard ratio aHR 4.49, 95%CI 1.61–12.57) vs. age 20–39 years, and a treatment regimen combining both drugs (aHR 4.49, 95%CI 1.61–12.57) vs. BDQ only. The probability of culture conversion was increased for two health facilities and patients with a poly resistance profile (adjusted sub-hazard ratio 2.01, 95%CI 1.13–3.59) vs. multidrug resistance.
CONCLUSION: Single use of BDQ or DLM was associated with low rates of unfavourable outcomes, suggesting that these medications may be effectively adopted at scale under routine programmatic conditions. Combined use of BDQ and DLM was a risk factor for unfavourable outcomes and should prompt for collection of more data on the combined use of these medications.
OBJECTIVE: Identification of factors associated with treatment outcomes in patients receiving BDQ and/or DLM either as a new treatment initiation or drug substitution.
DESIGN: This is a retrospective cohort study of patients receiving BDQ and/or DLM in Eswatini between March 2015 and October 2018. We describe factors associated with unfavourable treatment outcomes (death, lost to follow-up, treatment failure and amplification of resistance) and culture conversion using multivariable flexible parametric survival and competing-risks regression analyses.
RESULTS: Of 352 patients receiving BDQ and/or DLM, 7.8% and 21.2% had an unfavourable treatment outcome at 6 and 24 months, respectively. Predictors were age ≥ 60 years (adjusted hazard ratio aHR 4.49, 95%CI 1.61–12.57) vs. age 20–39 years, and a treatment regimen combining both drugs (aHR 4.49, 95%CI 1.61–12.57) vs. BDQ only. The probability of culture conversion was increased for two health facilities and patients with a poly resistance profile (adjusted sub-hazard ratio 2.01, 95%CI 1.13–3.59) vs. multidrug resistance.
CONCLUSION: Single use of BDQ or DLM was associated with low rates of unfavourable outcomes, suggesting that these medications may be effectively adopted at scale under routine programmatic conditions. Combined use of BDQ and DLM was a risk factor for unfavourable outcomes and should prompt for collection of more data on the combined use of these medications.
Journal Article > ResearchFull Text
Public Health Action. 2015 June 21; Volume 5 (Issue 2); 140-146.; DOI:10.5588/pha.15.0001
Sikhondze W, Dlamini T, Khumalo D, Maphalala G, Dlamini SV, et al.
Public Health Action. 2015 June 21; Volume 5 (Issue 2); 140-146.; DOI:10.5588/pha.15.0001
SETTING
All 19 public health laboratories in Swaziland that had Xpert(®) MTB/RIF machines installed as part of a countrywide roll-out between June 2011 and June 2014.
OBJECTIVE
To evaluate the utilisation and functionality of Xpert from 2011 to mid-2014.
DESIGN
Descriptive study of Xpert implementation using routinely collected data.
RESULTS
Of 48 829 Xpert tests conducted, 93% were successful: 14% detected Mycobacterium tuberculosis and 12% showed rifampicin resistance. The most common cause of unsuccessful tests was an 'Error' result (62%). Similar findings were obtained in government-supported and partner-supported laboratories. Annual utilisation of Xpert improved from 51% of maximum capacity in 2011 and 2012 to 74% in 2013 and 2014. A monitoring and supervision exercise of all Xpert testing sites in 2014 showed a generally good performance, with over 50% of laboratories achieving a ⩾80% score on most components. However, poor scores were obtained with equipment use and maintenance (6% achieving a score of ⩾80%), internal audit (19% achieving a score of ⩾80%) and process control (25% achieving a score of ⩾80%).
CONCLUSION
Countrywide roll-out of Xpert in Swaziland has been successful, although operational issues have been identified and need to be resolved.
All 19 public health laboratories in Swaziland that had Xpert(®) MTB/RIF machines installed as part of a countrywide roll-out between June 2011 and June 2014.
OBJECTIVE
To evaluate the utilisation and functionality of Xpert from 2011 to mid-2014.
DESIGN
Descriptive study of Xpert implementation using routinely collected data.
RESULTS
Of 48 829 Xpert tests conducted, 93% were successful: 14% detected Mycobacterium tuberculosis and 12% showed rifampicin resistance. The most common cause of unsuccessful tests was an 'Error' result (62%). Similar findings were obtained in government-supported and partner-supported laboratories. Annual utilisation of Xpert improved from 51% of maximum capacity in 2011 and 2012 to 74% in 2013 and 2014. A monitoring and supervision exercise of all Xpert testing sites in 2014 showed a generally good performance, with over 50% of laboratories achieving a ⩾80% score on most components. However, poor scores were obtained with equipment use and maintenance (6% achieving a score of ⩾80%), internal audit (19% achieving a score of ⩾80%) and process control (25% achieving a score of ⩾80%).
CONCLUSION
Countrywide roll-out of Xpert in Swaziland has been successful, although operational issues have been identified and need to be resolved.
Journal Article > ResearchFull Text
Public Health Action. 2018 April 25; Volume 8 (Issue 1); DOI:10.5588/pha.17.0043
Dlamini N, Zulu Z, Kunene S, Geoffroy E, Ntshalintshali N, et al.
Public Health Action. 2018 April 25; Volume 8 (Issue 1); DOI:10.5588/pha.17.0043
Background: Swaziland is one of the southern African countries that aim to eliminate malaria by 2020. In 2010, the country introduced an Immediate Disease Notification System (IDNS) for immediate reporting of notifiable diseases, including malaria. Health facilities are to report malaria cases within 24 h through a toll-free telephone number (977), triggering an alert for case investigation at the patient's household within 48 h. We assessed the completeness of reporting in the IDNS, the subsequent case investigation, and whether it was done within the stipulated timelines. Methods: A cross-sectional study using routine country-wide data. Results: Of 1991 malaria cases notified between July 2011 and June 2015, 76% were reported in the IDNS, of which 68% were investigated-a shortfall of 24% in reporting and 32% in case investigations. Of the 76% of cases reported through the IDNS, 62% were reported within 24 h and 20% were investigated within 48 h. These shortcomings were most pronounced in hospitals and private facilities. Investigated cases (n = 1346) were classified as follows: 60% imported, 35% local and 5% undetermined. Conclusion: The utilisation of the IDNS for case reporting to trigger investigation is crucial for active surveillance. There is a need to address the reporting and investigation gaps identified to ensure that malaria cases receive appropriate interventions.
Journal Article > Short ReportFull Text
Public Health Action. 2017 September 21; Volume 7 (Issue 3); DOI:10.5588/pha.17.0054
Vambe D, Dlamini T, Furin J, Gracia-Edwards C, Keus K, et al.
Public Health Action. 2017 September 21; Volume 7 (Issue 3); DOI:10.5588/pha.17.0054