Journal Article > ResearchFull Text
Int J Tuberc Lung Dis. 2005 October 1
Bonnet MMB, Sizaire V, Kebede YYK, Janin A, Doshetov D, et al.
Int J Tuberc Lung Dis. 2005 October 1
SETTING: After the collapse of the Soviet Union, countries in the region faced a dramatic increase in tuberculosis cases and the emergence of drug resistance. OBJECTIVE: To discuss the relevance of the DOTS strategy in settings with a high prevalence of drug resistance. DESIGN: Retrospective analysis of one-year treatment outcomes of short-course chemotherapy (SCC) and results of drug susceptibility testing (DST) surveys of six programmes located in the former Soviet Union: Kemerovo prison, Russia; Abkhasia, Georgia; Nagorno-Karabagh, Azerbaijan; Karakalpakstan, Uzbekistan; Dashoguz Velayat, Turkmenistan; and South Kazakhstan Oblast, Kazakhstan. Results are reported for new and previously treated smear-positive patients. RESULTS: Treatment outcomes of 3090 patients and DST results of 1383 patients were collected. Treatment success rates ranged between 87% and 61%, in Nagorno-Karabagh and Kemerovo, respectively, and failure rates between 7% and 23%. Any drug resistance ranged between 66% and 31% in the same programmes. MDR rates ranged between 28% in Karakalpakstan and Kemerovo prison and 4% in Nagorno-Karabagh. CONCLUSION: These results show the limits of SCC in settings with a high prevalence of drug resistance. They demonstrate that adapting treatment according to resistance patterns, access to reliable culture, DST and good quality second-line drugs are necessary.
Journal Article > ResearchFull Text
Int J Tuberc Lung Dis. 2007 September 1
Bonnet MMB, Ramsay AR, Gagnidze L, Githui W, Guerin PJ, et al.
Int J Tuberc Lung Dis. 2007 September 1
SETTING: Urban health clinic, Nairobi. OBJECTIVE: To evaluate the impact on tuberculosis (TB) case detection and laboratory workload of reducing the number of sputum smears examined and thresholds for diagnosing positive smears and positive cases. DESIGN: In this prospective study, three Ziehl-Neelsen stained sputum smears from consecutive pulmonary TB suspects were examined blind. The standard approach (A), > or = 2 positive smears out of 3, using a cut-off of 10 acid-fast bacilli (AFB)/100 high-power fields (HPF), was compared with approaches B, > or = 2 positive smears (> or = 4 AFB/100 HPF) out of 3, one of which is > or = 10 AFB/100 HPF; C, > or = 2 positive smears (> or = 4 AFB/100 HPF) out of 3; D, > or = 1 positive smear (> or = 10 AFB/100 HPF) out of 2; and E, > or = 1 positive smear (> or = 4 AFB/100 HPF) out of 2. The microscopy gold standard was detection of at least one positive smear (> or = 4 AFB/100 HPF) out of 3. RESULTS: Among 644 TB suspects, the alternative approaches detected from 114 (17.7%) (approach B) to 123 cases (19.1%) (approach E) compared to 105 cases (16.3%) for approach A (P < 0.005). Sensitivity ranged between 82.0% (105/128) for A and 96.1% (123/128) for E. The single positive smear approaches reduced the number of smears by 36% compared to approach A. CONCLUSION: Reducing the number of specimens and the positivity threshold to define a positive case increased the sensitivity of microscopy and reduced laboratory workload.
Journal Article > ResearchFull Text
Int J Tuberc Lung Dis. 2017 March 1; Volume 21 (Issue 3); 314-319.; DOI:10.5588/ijtld.16.0661
Huerga H, Bastard M, Kamene M, Wanjala S, Arnold A, et al.
Int J Tuberc Lung Dis. 2017 March 1; Volume 21 (Issue 3); 314-319.; DOI:10.5588/ijtld.16.0661
SETTING
In March 2006, the first multidrug-resistant tuberculosis (MDR-TB) treatment programme was implemented in Kenya.
OBJECTIVE
To describe patients' treatment outcomes and adverse events.
DESIGN
A retrospective case note review of patients started on MDR-TB treatment at two Médecins Sans Frontières-supported sites and the national referral hospital of Kenya was undertaken. Sites operated an ambulatory model of care. Patients were treated for a minimum of 24 months with at least 4-5 drugs for the intensive phase of treatment, including an injectable agent.
RESULTS
Of 169 patients, 25.6% were human immunodeficiency virus (HIV) positive and 89.3% were culture-positive at baseline. Adverse events occurred in 67.4% of patients: 45.9% had nausea/vomiting, 43.9% electrolyte disturbance, 41.8% dyspepsia and 31.6% hypothyroidism. The median time to culture conversion was 2 months. Treatment outcomes were as follows: 76.6% success, 14.5% deaths, 8.3% lost to follow-up and 0.7% treatment failure. HIV-positive individuals (adjusted odds ratio [aOR] 3.51, 95% confidence interval [CI] 1.12-11.03) and women (aOR 2.73, 95%CI 1.01-7.39) had a higher risk of unfavourable outcomes, while the risk was lower in those with culture conversion at 6 months (aOR 0.11, 95%CI 0.04-0.32).
CONCLUSION
In Kenya, where an ambulatory model of care is used for MDR-TB treatment, treatment success was high, despite high rates of HIV. Almost half of the patients experienced electrolyte disturbance and one third had hypothyroidism; this supports the view that systematic regular biochemical monitoring is needed in Kenya.
In March 2006, the first multidrug-resistant tuberculosis (MDR-TB) treatment programme was implemented in Kenya.
OBJECTIVE
To describe patients' treatment outcomes and adverse events.
DESIGN
A retrospective case note review of patients started on MDR-TB treatment at two Médecins Sans Frontières-supported sites and the national referral hospital of Kenya was undertaken. Sites operated an ambulatory model of care. Patients were treated for a minimum of 24 months with at least 4-5 drugs for the intensive phase of treatment, including an injectable agent.
RESULTS
Of 169 patients, 25.6% were human immunodeficiency virus (HIV) positive and 89.3% were culture-positive at baseline. Adverse events occurred in 67.4% of patients: 45.9% had nausea/vomiting, 43.9% electrolyte disturbance, 41.8% dyspepsia and 31.6% hypothyroidism. The median time to culture conversion was 2 months. Treatment outcomes were as follows: 76.6% success, 14.5% deaths, 8.3% lost to follow-up and 0.7% treatment failure. HIV-positive individuals (adjusted odds ratio [aOR] 3.51, 95% confidence interval [CI] 1.12-11.03) and women (aOR 2.73, 95%CI 1.01-7.39) had a higher risk of unfavourable outcomes, while the risk was lower in those with culture conversion at 6 months (aOR 0.11, 95%CI 0.04-0.32).
CONCLUSION
In Kenya, where an ambulatory model of care is used for MDR-TB treatment, treatment success was high, despite high rates of HIV. Almost half of the patients experienced electrolyte disturbance and one third had hypothyroidism; this supports the view that systematic regular biochemical monitoring is needed in Kenya.
Journal Article > ResearchFull Text
Int J Tuberc Lung Dis. 2015 February 1; Volume 19 (Issue 2); 172-178.; DOI:10.5588/ijtld.14.0421
Sinanovic E, Ramma L, Vassall A, Azevedo VD, Wilkinson LS, et al.
Int J Tuberc Lung Dis. 2015 February 1; Volume 19 (Issue 2); 172-178.; DOI:10.5588/ijtld.14.0421
SETTING
The cost of multidrug-resistant tuberculosis (MDR-TB) treatment is a major barrier to treatment scale-up in South Africa.
OBJECTIVE
To estimate and compare the cost of treatment for rifampicin-resistant tuberculosis (RR-TB) in South Africa in different models of care in different settings.
DESIGN
We estimated the costs of different models of care with varying levels of hospitalisation. These costs were used to calculate the total cost of treating all diagnosed cases of RR-TB in South Africa, and to estimate the budget impact of adopting a fully or partially decentralised model vs. a fully hospitalised model.
RESULTS
The fully hospitalised model was 42% more costly than the fully decentralised model (US$13 432 vs. US$7753 per patient). A much shorter hospital stay in the decentralised models of care (44–57 days), compared to 128 days of hospitalisation in the fully hospitalised model, was the key contributor to the reduced cost of treatment. The annual total cost of treating all diagnosed cases ranged from US$110 million in the fully decentralised model to US$190 million in the fully hospitalised model.
CONCLUSION
Following a more decentralised approach for treating RR-TB patients could potentially improve the affordability of RR-TB treatment in South Africa.
The cost of multidrug-resistant tuberculosis (MDR-TB) treatment is a major barrier to treatment scale-up in South Africa.
OBJECTIVE
To estimate and compare the cost of treatment for rifampicin-resistant tuberculosis (RR-TB) in South Africa in different models of care in different settings.
DESIGN
We estimated the costs of different models of care with varying levels of hospitalisation. These costs were used to calculate the total cost of treating all diagnosed cases of RR-TB in South Africa, and to estimate the budget impact of adopting a fully or partially decentralised model vs. a fully hospitalised model.
RESULTS
The fully hospitalised model was 42% more costly than the fully decentralised model (US$13 432 vs. US$7753 per patient). A much shorter hospital stay in the decentralised models of care (44–57 days), compared to 128 days of hospitalisation in the fully hospitalised model, was the key contributor to the reduced cost of treatment. The annual total cost of treating all diagnosed cases ranged from US$110 million in the fully decentralised model to US$190 million in the fully hospitalised model.
CONCLUSION
Following a more decentralised approach for treating RR-TB patients could potentially improve the affordability of RR-TB treatment in South Africa.
Journal Article > ResearchFull Text
Int J Tuberc Lung Dis. 2015 November 1; Volume 19 (Issue 11); 1300-1304.; DOI:10.5588/ijtld.15.0015
Cox V, De Azevedo V, Stinson K, Wilkinson LS, Rangaka MX, et al.
Int J Tuberc Lung Dis. 2015 November 1; Volume 19 (Issue 11); 1300-1304.; DOI:10.5588/ijtld.15.0015
BACKGROUND
The World Health Organization recommends tuberculin skin tests (TSTs) where feasible to identify individuals most likely to benefit from isoniazid preventive therapy (IPT). The requirement for TST reading after 48–72 h by a trained nurse is a barrier to implementation and increases loss to follow-up.
METHODS
Patients with human immunodeficiency virus (HIV) infection were recruited from a primary care clinic in South Africa and trained by a lay counsellor to interpret their own TST. The TST was placed by a nurse, and the patient was asked to return 2 days later with their self-reading result, followed by blinded reading by a trained nurse (reference).
RESULTS
Of 227 patients, 210 returned for TST reading; 78% interpreted their test correctly: those interpreting it as negative were more likely to be correct (negative predictive value 93%) than those interpreting it as positive (positive predictive value 42%); 10/36 (28%) positive TST results were read as negative by the patient.
CONCLUSIONS
Patients with HIV in low-resource settings can be trained to interpret their own TST. Those interpreting it as positive should return to the clinic within 48–72 h for confirmatory reading and IPT initiation; those with a negative interpretation can return at their next scheduled visit and initiate IPT at that time if appropriate.
The World Health Organization recommends tuberculin skin tests (TSTs) where feasible to identify individuals most likely to benefit from isoniazid preventive therapy (IPT). The requirement for TST reading after 48–72 h by a trained nurse is a barrier to implementation and increases loss to follow-up.
METHODS
Patients with human immunodeficiency virus (HIV) infection were recruited from a primary care clinic in South Africa and trained by a lay counsellor to interpret their own TST. The TST was placed by a nurse, and the patient was asked to return 2 days later with their self-reading result, followed by blinded reading by a trained nurse (reference).
RESULTS
Of 227 patients, 210 returned for TST reading; 78% interpreted their test correctly: those interpreting it as negative were more likely to be correct (negative predictive value 93%) than those interpreting it as positive (positive predictive value 42%); 10/36 (28%) positive TST results were read as negative by the patient.
CONCLUSIONS
Patients with HIV in low-resource settings can be trained to interpret their own TST. Those interpreting it as positive should return to the clinic within 48–72 h for confirmatory reading and IPT initiation; those with a negative interpretation can return at their next scheduled visit and initiate IPT at that time if appropriate.
Journal Article > ResearchAbstract Only
Int J Tuberc Lung Dis. 2018 September 1; Volume 22 (Issue 9); 1023-1030.; DOI:10.5588/ijtld.17.0826
Snyman L, Venables E, Trivino Duran L, Mohr E, Azevedo VD, et al.
Int J Tuberc Lung Dis. 2018 September 1; Volume 22 (Issue 9); 1023-1030.; DOI:10.5588/ijtld.17.0826
SETTING
Early interventions for patients who interrupt their treatment for drug-resistant tuberculosis (DR-TB) are rarely reported and assessed. A novel, patient-centred intervention for patients at risk of loss to follow-up (LTFU) from DR-TB treatment was implemented in Khayelitsha, South Africa, in September 2013.
OBJECTIVE
To explore the experiences and perceptions of patients, key support persons, health care workers (HCWs) and programme managers of a patient-centred model.
DESIGN
This was a qualitative study consisting of 18 in-depth interviews with patients, key support persons, HCWs, key informants and one focus group discussion with HCWs, between July and September 2017. Data were coded and thematically analysed.
RESULTS
The model was well perceived and viewed positively by patients, care providers and programme managers. 'Normalisation' and tolerance of occasional treatment interruptions, tracing, tailored management plans and peer support were perceived to be beneficial for retaining patients in care. Although the model was resource-demanding, health workers were convinced that it 'needs to be sustained,' and proposed solutions for its standardisation.
CONCLUSION
An intervention based on early tracing of patients who interrupt treatment, peer-delivered counselling and individualised management plans by a multidisciplinary team was considered a beneficial and acceptable model to support patients at risk of LTFU from DR-TB treatment.
Early interventions for patients who interrupt their treatment for drug-resistant tuberculosis (DR-TB) are rarely reported and assessed. A novel, patient-centred intervention for patients at risk of loss to follow-up (LTFU) from DR-TB treatment was implemented in Khayelitsha, South Africa, in September 2013.
OBJECTIVE
To explore the experiences and perceptions of patients, key support persons, health care workers (HCWs) and programme managers of a patient-centred model.
DESIGN
This was a qualitative study consisting of 18 in-depth interviews with patients, key support persons, HCWs, key informants and one focus group discussion with HCWs, between July and September 2017. Data were coded and thematically analysed.
RESULTS
The model was well perceived and viewed positively by patients, care providers and programme managers. 'Normalisation' and tolerance of occasional treatment interruptions, tracing, tailored management plans and peer support were perceived to be beneficial for retaining patients in care. Although the model was resource-demanding, health workers were convinced that it 'needs to be sustained,' and proposed solutions for its standardisation.
CONCLUSION
An intervention based on early tracing of patients who interrupt treatment, peer-delivered counselling and individualised management plans by a multidisciplinary team was considered a beneficial and acceptable model to support patients at risk of LTFU from DR-TB treatment.
Journal Article > LetterFull Text
Int J Tuberc Lung Dis. 2022 August 1; Volume 26 (Issue 8); 792-794.; DOI:10.5588/ijtld.22.0168
Rekart ML, Morshed T, Mulanda WK, Klieascikova J, Sitali N, et al.
Int J Tuberc Lung Dis. 2022 August 1; Volume 26 (Issue 8); 792-794.; DOI:10.5588/ijtld.22.0168
Journal Article > LetterFull Text
Int J Tuberc Lung Dis. 2012 June 1; Volume 16 (Issue 8); 1129-1130.; DOI:10.5588/ijtld.12.0370-2
Zachariah R, Edginton ME, Srinath S
Int J Tuberc Lung Dis. 2012 June 1; Volume 16 (Issue 8); 1129-1130.; DOI:10.5588/ijtld.12.0370-2
Journal Article > ResearchFull Text
Int J Tuberc Lung Dis. 2014 April 1; Volume 18 (Issue 4); 441-448.; DOI:10.5588/ijtld.13.0742
Cox HS, Hughes J, Daniels J, Azevedo VD, McDermid C, et al.
Int J Tuberc Lung Dis. 2014 April 1; Volume 18 (Issue 4); 441-448.; DOI:10.5588/ijtld.13.0742
SETTING: Khayelitsha, South Africa, a peri-urban township with high burdens of tuberculosis (TB), drug-resistant tuberculosis (DR-TB), and human immunodeficiency virus (HIV) infection.
OBJECTIVE: To describe case detection and patient outcomes in a community-based DR-TB programme.
DESIGN: DR-TB management was integrated into primary health care in Khayelitsha from 2007 onwards. Implementation was incremental, and included training and clinician support, counselling and home visits, tuberculous infection control, a local in-patient service, and routine monitoring. Patients received treatment rapidly through their local clinic, and were only hospitalised if clinically unwell.
RESULTS: DR-TB case notification (any rifampicin resistance) increased from 28 per 100 000 population per year (2005–2007) to 55/100 000/year in 2009–2011 (72% HIV-infected). From 2008 to 2011, 754 patients received treatment (86% of those diagnosed). The median time between diagnostic sputum and treatment decreased over the years of implementation to 27 days in 2011 (P < 0.001). Treatment success was 52% in 2010, with 31% default, 13% death and 4% treatment failure. Two-year survival was 65%, with poorer survival in those with HIV (HR 2.0, 95%CI 1.4–2.8), second-line drug resistance (HR 3.3, 95%CI 2.2–4.8), and diagnosis in earlier programme years (HR 1.4, 95%CI 1.1–2.0).
CONCLUSION: Community-based DR-TB management is feasible, and contributes to improved case detection, reduced treatment delay and improved survival. Treatment outcomes remain poor, highlighting the poor efficacy, tolerability and lengthy duration of current treatment.
OBJECTIVE: To describe case detection and patient outcomes in a community-based DR-TB programme.
DESIGN: DR-TB management was integrated into primary health care in Khayelitsha from 2007 onwards. Implementation was incremental, and included training and clinician support, counselling and home visits, tuberculous infection control, a local in-patient service, and routine monitoring. Patients received treatment rapidly through their local clinic, and were only hospitalised if clinically unwell.
RESULTS: DR-TB case notification (any rifampicin resistance) increased from 28 per 100 000 population per year (2005–2007) to 55/100 000/year in 2009–2011 (72% HIV-infected). From 2008 to 2011, 754 patients received treatment (86% of those diagnosed). The median time between diagnostic sputum and treatment decreased over the years of implementation to 27 days in 2011 (P < 0.001). Treatment success was 52% in 2010, with 31% default, 13% death and 4% treatment failure. Two-year survival was 65%, with poorer survival in those with HIV (HR 2.0, 95%CI 1.4–2.8), second-line drug resistance (HR 3.3, 95%CI 2.2–4.8), and diagnosis in earlier programme years (HR 1.4, 95%CI 1.1–2.0).
CONCLUSION: Community-based DR-TB management is feasible, and contributes to improved case detection, reduced treatment delay and improved survival. Treatment outcomes remain poor, highlighting the poor efficacy, tolerability and lengthy duration of current treatment.
Journal Article > ResearchFull Text
Int J Tuberc Lung Dis. 2014 February 1; Volume 18 (Issue 2); 160-167.; DOI:10.5588/ijtld.13.0369
Sanchez-Padilla E, Marquer C, Kalon S, Qayyum S, Hayrapetyan A, et al.
Int J Tuberc Lung Dis. 2014 February 1; Volume 18 (Issue 2); 160-167.; DOI:10.5588/ijtld.13.0369
SETTING
Armenia, a country with a high prevalence of drug-resistant tuberculosis (DR-TB).
OBJECTIVE
To identify factors related to default from DR-TB treatment in Yerevan.
DESIGN
Using a retrospective cohort design, we compared defaulters with patients who were cured, completed or failed treatment. Patients who initiated DR-TB treatment from 2005 to 2011 were included in the study. A qualitative survey was conducted including semi-structured interviews with defaulters and focus group discussions with care providers.
RESULTS
Of 381 patients, 193 had achieved treatment success, 24 had died, 51 had failed treatment and 97 had defaulted. The number of drugs to which the patient was resistant at admission (aRR 1.16, 95%CI 1.05–1.27), the rate of treatment interruption based on patient's decision (aRR 1.03, 95%CI 1.02–1.05), the rate of side effects (aRR 1.18, 95%CI 1.09–1.27), and absence of culture conversion during the intensive phase (aRR 0.47, 95%CI 0.31–0.71) were independently associated with default from treatment. In the qualitative study, poor treatment tolerance, a perception that treatment was inefficient, lack of information, incorrect perception of being cured, working factors and behavioural problems were factors related to treatment default.
CONCLUSION
In addition to economic reasons, poor tolerance of and poor response to treatment were the main factors associated with treatment default.
Armenia, a country with a high prevalence of drug-resistant tuberculosis (DR-TB).
OBJECTIVE
To identify factors related to default from DR-TB treatment in Yerevan.
DESIGN
Using a retrospective cohort design, we compared defaulters with patients who were cured, completed or failed treatment. Patients who initiated DR-TB treatment from 2005 to 2011 were included in the study. A qualitative survey was conducted including semi-structured interviews with defaulters and focus group discussions with care providers.
RESULTS
Of 381 patients, 193 had achieved treatment success, 24 had died, 51 had failed treatment and 97 had defaulted. The number of drugs to which the patient was resistant at admission (aRR 1.16, 95%CI 1.05–1.27), the rate of treatment interruption based on patient's decision (aRR 1.03, 95%CI 1.02–1.05), the rate of side effects (aRR 1.18, 95%CI 1.09–1.27), and absence of culture conversion during the intensive phase (aRR 0.47, 95%CI 0.31–0.71) were independently associated with default from treatment. In the qualitative study, poor treatment tolerance, a perception that treatment was inefficient, lack of information, incorrect perception of being cured, working factors and behavioural problems were factors related to treatment default.
CONCLUSION
In addition to economic reasons, poor tolerance of and poor response to treatment were the main factors associated with treatment default.