Search results

Background Tuberculosis (TB) remains the most common cause of infectious disease deaths worldwide. What is perhaps less appreciated is that the caseload of tuberculosis patients in South Asia is staggering.South Asia has almost 40% of the global TB burden with 4,028,165 cases in 2015. This region also has a disproportionate share of TB deaths (681,975 deaths, 38% of the global burden). Worldwide just 12.5% of TB cases are in HIV positive individuals, but much research and investment has focused on HIV-associated TB. Only 3.5% of patients with tuberculosis in South Asia have HIV co-infection. Not surprisingly with such a huge burden of disease, this region has an estimated 184,336 multi drug resistant (MDR) cases among notified TB cases which accounts for a third of global MDR burden. Crucially, at least 70% of the estimated MDR cases remain untreated in this region and MDR treatment success ranged from only 46% for India to 88% for Sri Lanka in the 2012 cohort that received treatment. This region represents many of the drivers of the modern TB epidemic: rapid urbanization and high density populations with dramatically rising incidence of diabetes, a burgeoning and largely unregulated private sector with escalating drug resistance and high air pollution both outdoor and household. Conclusion From bacterial biochemistry to policy implementation, we suggest ways in which South Asia can seize the opportunity lead global TB elimination by demonstrating feasibility in some of the world's most densely populated cities and remotest reaches of the Himalayas. Clearly political will is essential, but we cannot defeat TB without understanding how to eliminate it in South Asia.

Objective To explore antecedents, components and influencing factors on active case-finding (ACF) policy development and implementation. Design Scoping review, searching MEDLINE, Web of Science, the Cochrane Database of Systematic Reviews and the World Health Organization (WHO) Library from January 1968 to January 2018. We excluded studies focusing on latent tuberculosis (TB) infection, passive case-finding, childhood TB and studies about effectiveness, yield, accuracy and impact without descriptions of how this evidence has/could influence ACF policy or implementation. We included any type of study written in English, and conducted frequency and thematic analyses. Results Seventy-three articles fulfilled our eligibility criteria. Most (67%) were published after 2010. The studies were conducted in all WHO regions, but primarily in Africa (22%), Europe (23%) and the Western-Pacific region (12%). Forty-one percent of the studies were classified as quantitative, followed by reviews (22%) and qualitative studies (12%). Most articles focused on ACF for tuberculosis contacts (25%) or migrants (32%). Fourteen percent of the articles described community-based screening of high-risk populations. Fifty-nine percent of studies reported influencing factors for ACF implementation; mostly linked to the health system (eg, resources) and the community/individual (eg, social determinants of health). Only two articles highlighted factors influencing ACF policy development (eg, politics). Six articles described WHO's ACF-related recommendations as important antecedent for ACF. Key components of successful ACF implementation include health system capacity, mechanisms for integration, education and collaboration for ACF. Conclusion We identified some main themes regarding the antecedents, components and influencing factors for ACF policy development and implementation. While we know much about facilitators and barriers for ACF policy implementation, we know less about how to strengthen those facilitators and how to overcome those ...

ABSTRACT Objective To explore antecedents, components and influencing factors on active case- finding (ACF) policy development and implementation. Design Scoping review, searching MEDLINE, Web of Science, the Cochrane Database of Systematic Reviews and the World Health Organization (WHO) Library from January 1968 to January 2018. We excluded studies focusing on latent tuberculosis (TB) infection, passive case- finding, childhood TB and studies about effectiveness, yield, accuracy and impact without descriptions of how this evidence has/could influence ACF policy or implementation. We included any type of study written in English, and conducted frequency and thematic analyses. Results Seventy- three articles fulfilled our eligibility criteria. Most (67%) were published after 2010. The studies were conducted in all WHO regions, but primarily in Africa (22%), Europe (23%) and the Western- Pacific region (12%). Forty- one percent of the studies were classified as quantitative, followed by reviews (22%) and qualitative studies (12%). Most articles focused on ACF for tuberculosis contacts (25%) or migrants (32%). Fourteen percent of the articles described community- based screening of high- risk populations. Fifty- nine percent of studies reported influencing factors for ACF implementation; mostly linked to the health system (eg, resources) and the community/individual (eg, social determinants of health). Only two articles highlighted factors influencing ACF policy development (eg, politics). Six articles described WHO's ACF- related recommendations as important antecedent for ACF. Key components of successful ACF implementation include health system capacity, mechanisms for integration, education and collaboration for ACF. Conclusion We identified some main themes regarding the antecedents, components and influencing factors for ACF policy development and implementation. While we know much about facilitators and barriers for ACF policy implementation, we know less about how to strengthen those facilitators and how to overcome those barriers. A major knowledge gap remains when it comes to understanding which contextual factors influence ACF policy development. Research is required to understand, inform and improve ACF policy development and implementation.

OBJECTIVE: To explore antecedents, components and influencing factors on active case-finding (ACF) policy development and implementation. DESIGN: Scoping review, searching MEDLINE, Web of Science, the Cochrane Database of Systematic Reviews and the World Health Organization (WHO) Library from January 1968 to January 2018. We excluded studies focusing on latent tuberculosis (TB) infection, passive case-finding, childhood TB and studies about effectiveness, yield, accuracy and impact without descriptions of how this evidence has/could influence ACF policy or implementation. We included any type of study written in English, and conducted frequency and thematic analyses. RESULTS: Seventy-three articles fulfilled our eligibility criteria. Most (67%) were published after 2010. The studies were conducted in all WHO regions, but primarily in Africa (22%), Europe (23%) and the Western-Pacific region (12%). Forty-one percent of the studies were classified as quantitative, followed by reviews (22%) and qualitative studies (12%). Most articles focused on ACF for tuberculosis contacts (25%) or migrants (32%). Fourteen percent of the articles described community-based screening of high-risk populations. Fifty-nine percent of studies reported influencing factors for ACF implementation; mostly linked to the health system (eg, resources) and the community/individual (eg, social determinants of health). Only two articles highlighted factors influencing ACF policy development (eg, politics). Six articles described WHO's ACF-related recommendations as important antecedent for ACF. Key components of successful ACF implementation include health system capacity, mechanisms for integration, education and collaboration for ACF. CONCLUSION: We identified some main themes regarding the antecedents, components and influencing factors for ACF policy development and implementation. While we know much about facilitators and barriers for ACF policy implementation, we know less about how to strengthen those facilitators and how to overcome ...

Objective: To explore experts' views on factors influencing national and global active case-finding (ACF) policy development and implementation, and the use of evidence in these processes. Design: This is an exploratory study based on semistructured expert interviews. Framework analysis was applied. Participants: The study involved a purposive sample of 39 experts from international, non-governmental and non-profit organisations, funders, government institutions, international societies, think tanks, universities and research institutions worldwide. Results: This study highlighted the perceived need among experts for different types of evidence for ACF policy development and implementation, and for stakeholder engagement including researchers and policymakers to foster evidence use. Interviewees stressed the influence of government, donor and non-governmental stakeholders in ACF policy development. Such key stakeholders also influence ACF policy implementation, in addition to available systems and processes in a given health system, and implementers' motivation and incentives. According to the interviewees, the World Health Organization (WHO) guidelines for systematic screening face the innate challenge of providing guidance to countries across the broad area of ACF in terms of target groups, settings and screening algorithms. The guidelines could be improved by focusing on what should be done rather than what can be done in ACF, and by providing howto examples. Leadership, integration into health systems and long-term financing are key for ACF to be sustainable. Conclusions: We provide new insights into ACF policy processes globally, particularly regarding facilitators for and barriers to ACF policy development, evidence need and use, and donor organisations' influence. According to expert participants, national and global ACF policy development and implementation can be improved by broadening stakeholder engagement. Meanwhile, using diverse evidence to inform ACF policy development and implementation could mitigate the 'power plays plus push' that might otherwise disrupt and mislead these policy processes.

OBJECTIVE: To explore experts' views on factors influencing national and global active case-finding (ACF) policy development and implementation, and the use of evidence in these processes. DESIGN: This is an exploratory study based on semistructured expert interviews. Framework analysis was applied. PARTICIPANTS: The study involved a purposive sample of 39 experts from international, non-governmental and non-profit organisations, funders, government institutions, international societies, think tanks, universities and research institutions worldwide. RESULTS: This study highlighted the perceived need among experts for different types of evidence for ACF policy development and implementation, and for stakeholder engagement including researchers and policymakers to foster evidence use. Interviewees stressed the influence of government, donor and non-governmental stakeholders in ACF policy development. Such key stakeholders also influence ACF policy implementation, in addition to available systems and processes in a given health system, and implementers' motivation and incentives. According to the interviewees, the World Health Organization (WHO) guidelines for systematic screening face the innate challenge of providing guidance to countries across the broad area of ACF in terms of target groups, settings and screening algorithms. The guidelines could be improved by focusing on what should be done rather than what can be done in ACF, and by providing howto examples. Leadership, integration into health systems and long-term financing are key for ACF to be sustainable. CONCLUSIONS: We provide new insights into ACF policy processes globally, particularly regarding facilitators for and barriers to ACF policy development, evidence need and use, and donor organisations' influence. According to expert participants, national and global ACF policy development and implementation can be improved by broadening stakeholder engagement. Meanwhile, using diverse evidence to inform ACF policy development and implementation could ...

Background Active case-finding (ACF), also referred to as community-based tuberculosis screening, is a component of the World Health Organization's End TB Strategy. ACF has potential benefits but also harms, which need to be carefully assessed when developing and implementing ACF policies. While empirical evidence on the benefits of ACF is still weak, evidence on the harms is even weaker. This study aimed to explore experts' views on the benefits and harms of ACF for people with presumptive TB and communities. Methods This was an exploratory study. Semi-structured interviews were conducted with a purposive sample of 39 experts from international, non-governmental/non-profit organizations, funders, government institutions, international societies, think tanks, universities and research institutions worldwide. Framework analysis was applied. Results Findings elaborated perceived benefits of ACF, including reaching vulnerable populations, reducing patient costs, helping raise awareness for tuberculosis among individuals and engaging communities, and reducing tuberculosis transmission. Perceived harms included increasing stigma and discrimination, causing false-positive diagnoses, as well as triggering other unintended consequences related to screening for tuberculosis patients, such as deportation of migrants once confirmed to have tuberculosis. Most of the perceived benefits of ACF could be linked to its objective of finding and treating persons with tuberculosis early (theme 1), while ACF was also perceived as a "double-edged sword" and could cause harms, if inappropriately designed and implemented (theme 2). The analysis underlined the importance of considering the benefits and harms of ACF throughout the screening pathway. The study provides new insights into the perceived benefits and harms of ACF from the perspectives of experts in the field. Conclusion This study highlights gaps in the evidence base surrounding ACF and can stimulate further research, debate and analysis regarding the benefits and harms of ACF to inform contextual optimization of design and implementation of ACF strategies. ; publishedVersion ; Peer reviewed

BACKGROUND Active case-finding (ACF), also referred to as community-based tuberculosis screening, is a component of the World Health Organization's End TB Strategy. ACF has potential benefits but also harms, which need to be carefully assessed when developing and implementing ACF policies. While empirical evidence on the benefits of ACF is still weak, evidence on the harms is even weaker. This study aimed to explore experts' views on the benefits and harms of ACF for people with presumptive TB and communities. METHODS This was an exploratory study. Semi-structured interviews were conducted with a purposive sample of 39 experts from international, non-governmental/non-profit organizations, funders, government institutions, international societies, think tanks, universities and research institutions worldwide. Framework analysis was applied. RESULTS Findings elaborated perceived benefits of ACF, including reaching vulnerable populations, reducing patient costs, helping raise awareness for tuberculosis among individuals and engaging communities, and reducing tuberculosis transmission. Perceived harms included increasing stigma and discrimination, causing false-positive diagnoses, as well as triggering other unintended consequences related to screening for tuberculosis patients, such as deportation of migrants once confirmed to have tuberculosis. Most of the perceived benefits of ACF could be linked to its objective of finding and treating persons with tuberculosis early (theme 1), while ACF was also perceived as a "double-edged sword" and could cause harms, if inappropriately designed and implemented (theme 2). The analysis underlined the importance of considering the benefits and harms of ACF throughout the screening pathway. The study provides new insights into the perceived benefits and harms of ACF from the perspectives of experts in the field. CONCLUSION This study highlights gaps in the evidence base surrounding ACF and can stimulate further research, debate and analysis regarding the benefits and harms of ACF to inform contextual optimization of design and implementation of ACF strategies.

BACKGROUND: Vietnam has a high burden of undetected tuberculosis (TB). The Vietnamese National TB Strategic Plan highlights active case-finding (ACF) as one strategy to find people with TB who are currently unreached by the existing government health services. The IMPACT TB (Implementing proven community-based active TB case-finding intervention) project was implemented across six districts of Ho Chi Minh City, 2017–2019. We aimed to explore the facilitators and barriers for ACF implementation during the IMPACT TB project to understand how and why the intervention achieved high yields. METHODS: This was an exploratory qualitative study based on 39 semi-structured key-informant interviews with TB patients who were diagnosed through ACF, employees and volunteers who implemented ACF, and leaders from district, national, or international institutions and organizations in Vietnam. Thematic analysis was applied, using an implementation science framework by Grol and Wensing. RESULTS: We generated three main themes: (1) the studied ACF model used in Vietnam provided a conducive social and organizational context for ACF implementation with areas for improvement, including communication and awareness-raising, preparation and logistics, data systems and processes, and incentives; (2) employees and volunteers capitalized on their strengths to facilitate ACF implementation, e.g., experience, skills, and communication; and (3) employees and volunteers were in a position to address patient-level barriers to ACF implementation, e.g., stigma, discrimination, and mistrust. These themes covered a variety of facilitators and barriers, which we divided into 17 categories. All categories were mentioned by employees and volunteers, except the category of having a network that facilitates ACF implementation, which was only mentioned by volunteers. This study also highlighted examples and ideas of how to address facilitators and barriers. CONCLUSIONS: IMPACT TB provided a favorable social and organizational context for ACF ...

BACKGROUND Vietnam has a high burden of undetected tuberculosis (TB). The Vietnamese National TB Strategic Plan highlights active case-finding (ACF) as one strategy to find people with TB who are currently unreached by the existing government health services. The IMPACT TB (Implementing proven community-based active TB case-finding intervention) project was implemented across six districts of Ho Chi Minh City, 2017-2019. We aimed to explore the facilitators and barriers for ACF implementation during the IMPACT TB project to understand how and why the intervention achieved high yields. METHODS This was an exploratory qualitative study based on 39 semi-structured key-informant interviews with TB patients who were diagnosed through ACF, employees and volunteers who implemented ACF, and leaders from district, national, or international institutions and organizations in Vietnam. Thematic analysis was applied, using an implementation science framework by Grol and Wensing. RESULTS We generated three main themes: (1) the studied ACF model used in Vietnam provided a conducive social and organizational context for ACF implementation with areas for improvement, including communication and awareness-raising, preparation and logistics, data systems and processes, and incentives; (2) employees and volunteers capitalized on their strengths to facilitate ACF implementation, e.g., experience, skills, and communication; and (3) employees and volunteers were in a position to address patient-level barriers to ACF implementation, e.g., stigma, discrimination, and mistrust. These themes covered a variety of facilitators and barriers, which we divided into 17 categories. All categories were mentioned by employees and volunteers, except the category of having a network that facilitates ACF implementation, which was only mentioned by volunteers. This study also highlighted examples and ideas of how to address facilitators and barriers. CONCLUSIONS IMPACT TB provided a favorable social and organizational context for ACF implementation. Individual employees and volunteers still determined the success of the project, as they had to be able to capitalize on their own strengths and address patient-level barriers. Volunteers especially used their networks to facilitate ACF. Knowledge of both facilitators and barriers, and how to address them can inform the planning and implementation ACF in Vietnam and similar contexts across low- and middle-income countries worldwide.

Background: There is a high risk of occupational exposure to tuberculosis among healthcare workers in endemic countries. Regular screening for tuberculosis among healthcare workers is not carried out in Nepal. Infection control measures are also not routinely implemented. The aim of this study was to determine the prevalence of active tuberculosis among staff/students at Patan Hospital.Methods: Participants were given a self-administered questionnaire and invited to undergo chest radiography. Cases were scored and reviewed based on predetermined criteria, and presumptive tuberculosis cases were invited to undergo sputum smear and culture. Participants were categorized according to the extent of patient contact and asked about history of tuberculosis medication. Results: Among 560 participants, 76.8% had direct contact with patients. Fifty-eight (10.4%) gave history of cough >2 weeks. Based on symptom history and chest radiography, 20.0% (n=112) cases were reviewed, and 12.5% (n=14) of those reviewed had sputum tested for acid-fast bacilli. One participant had culture-positive tuberculosis. Fifty participants (8.9%) reported tuberculosis in the past, among which 42.0% (n=21) occurred after employment at Patan Hospital and 42.0% before joining Patan Hospital. Security staff, radiology technicians and ward cleaning staff had the highest proportion of cases with a history of tuberculosis.History of tuberculosis medication had no relation with age, sex, education, body mass index and smoking.The incidence rate of tuberculosis at Patan Hospital was 3.6 per 1000 person-years.Conclusions: Overall incidence of tuberculosis among healthcare workers is noteworthy. However, this study suggests when symptomatic tuberculosis occurs in healthcare worker at Patan Hospital, it is diagnosed and there is not a large pool of undiagnosed tuberculosis.

BACKGROUND Tuberculosis (TB) remains a major cause of avoidable deaths. Economic migrants represent a vulnerable population due to their exposure to medical and social risk factors. These factors expose them to higher risks for TB incidence and poor treatment outcomes. METHODS This cross-sectional study evaluated WHO-defined TB treatment outcomes among economic migrants in an urban district of Ho Chi Minh City, Viet Nam. We measured the association of a patient's government-defined residency status with treatment success and loss to follow-up categories at baseline and performed a comparative interrupted time series (ITS) analysis to assess the impact of community-based adherence support on treatment outcomes. Key measures of interest of the ITS were the differences in step change (β) and post-intervention trend (β). RESULTS Short-term, inter-province migrants experienced lower treatment success (aRR = 0.95 [95% CI: 0.92-0.99], p = 0.010) and higher loss to follow-up (aOR = 1.98 [95% CI: 1.44-2.72], p 55 years of age (aRR = 0.93 [95% CI: 0.89-0.96], p < 0.001), relapse patients (aRR = 0.89 [95% CI: 0.84-0.94], p < 0.001), and retreatment patients (aRR = 0.62 [95% CI: 0.52-0.75], p < 0.001) had lower treatment success rates. TB/HIV co-infection was also associated with lower treatment success (aRR = 0.77 [95% CI: 0.73-0.82], p < 0.001) and higher loss to follow-up (aOR = 2.18 [95% CI: 1.55-3.06], p < 0.001). The provision of treatment adherence support increased treatment success (IRR(β) = 1.07 [95% CI: 1.00, 1.15], p = 0.041) and reduced loss to follow-up (IRR(β) = 0.17 [95% CI: 0.04, 0.69], p = 0.013) in the intervention districts. Loss to follow-up continued to decline throughout the post-implementation period (IRR(β) = 0.90 [95% CI: 0.83, 0.98], p = 0.019). CONCLUSIONS Economic migrants, particularly those crossing provincial borders, have higher risk of poor treatment outcomes and should be prioritized for tailored adherence support. In light of accelerating urbanization in many regions of Asia, implementation trials are needed to inform evidence-based design of strategies for this vulnerable population.

Funding: Stop TB Partnership/UNOPS – TB REACH project (grant number: 5–31); European Union, Horizon 2020 – IMPACT TB project (grant number: 733174). ; This study compared the yield of tuberculosis (TB) active case finding (ACF) interventions applied under TB REACH funding. Between June 2017 to November 2018, Birat Nepal Medical Trust identified presumptive cases using simple verbal screening from three interventions: door-to-door screening of social contacts of known index cases, TB camps in remote areas, and screening for hospital out-patient department (OPD) attendees. Symptomatic individuals were then tested using smear microscopy or GeneXpert MTB/RIF as first diagnostic test. Yield rates were compared for each intervention and diagnostic method. We evaluated additional cases notified from ACF interventions by comparing case notifications of the intervention and control districts using standard TB REACH methodology. The project identified 1092 TB cases. The highest yield was obtained from OPD screening at hospitals (n = 566/1092; 52%). The proportion of positive tests using GeneXpert (5.5%, n = 859/15,637) was significantly higher than from microscopy testing 2% (n = 120/6309). (OR = 1.4; 95%CI = 1.12–1.72; p = 0.0026). The project achieved 29% additionality in case notifications in the intervention districts demonstrating that GeneXpert achieved substantially higher case-finding yields. Therefore, to increase national case notification for TB, Nepal should integrate OPD screening using GeneXpert testing in every district hospital and scale up of community-based ACF of TB patient contacts nationally. ; Publisher PDF ; Peer reviewed

Background: To achieve the WHO End TB Strategy targets, it is necessary to detect and treat more people with active TB early. Scale–up of active case finding (ACF) may be one strategy to achieve that goal. Given human resource constraints in the health systems of most high TB burden countries, volunteer community health workers (CHW) have been widely used to economically scale up TB ACF. However, more evidence is needed on the most cost-effective compensation models for these CHWs and their potential impact on case finding to inform optimal scale-up policies. Methods: We conducted a two-year, controlled intervention study in 12 districts of Ho Chi Minh City, Viet Nam. We engaged CHWs as salaried employees (3 districts) or incentivized volunteers (3 districts) to conduct ACF among contacts of people with TB and urban priority groups. Eligible persons were asked to attend health services for radiographic screening and rapid molecular diagnosis or smear microscopy. Individuals diagnosed with TB were linked to appropriate care. Six districts providing routine NTP care served as control area. We evaluated additional cases notified and conducted comparative interrupted time series (ITS) analyses to assess the impact of ACF by human resource model on TB case notifications. Results: We verbally screened 321,020 persons in the community, of whom 70,439 were eligible for testing and 1138 of them started TB treatment. ACF activities resulted in a + 15.9% [95% CI: + 15.0%, + 16.7%] rise in All Forms TB notifications in the intervention areas compared to control areas. The ITS analyses detected significant positive post-intervention trend differences in All Forms TB notification rates between the intervention and control areas (p = 0.001), as well as between the employee and volunteer human resource models (p = 0.021). Conclusions: Both salaried and volunteer CHW human resource models demonstrated additionality in case notifications compared to routine case finding by the government TB program. The salaried employee CHW model achieved a greater impact on notifications and should be prioritized for scale-up, given sufficient resources.

BACKGROUND: To achieve the WHO End TB Strategy targets, it is necessary to detect and treat more people with active TB early. Scale–up of active case finding (ACF) may be one strategy to achieve that goal. Given human resource constraints in the health systems of most high TB burden countries, volunteer community health workers (CHW) have been widely used to economically scale up TB ACF. However, more evidence is needed on the most cost-effective compensation models for these CHWs and their potential impact on case finding to inform optimal scale-up policies. METHODS: We conducted a two-year, controlled intervention study in 12 districts of Ho Chi Minh City, Viet Nam. We engaged CHWs as salaried employees (3 districts) or incentivized volunteers (3 districts) to conduct ACF among contacts of people with TB and urban priority groups. Eligible persons were asked to attend health services for radiographic screening and rapid molecular diagnosis or smear microscopy. Individuals diagnosed with TB were linked to appropriate care. Six districts providing routine NTP care served as control area. We evaluated additional cases notified and conducted comparative interrupted time series (ITS) analyses to assess the impact of ACF by human resource model on TB case notifications. RESULTS: We verbally screened 321,020 persons in the community, of whom 70,439 were eligible for testing and 1138 of them started TB treatment. ACF activities resulted in a + 15.9% [95% CI: + 15.0%, + 16.7%] rise in All Forms TB notifications in the intervention areas compared to control areas. The ITS analyses detected significant positive post-intervention trend differences in All Forms TB notification rates between the intervention and control areas (p = 0.001), as well as between the employee and volunteer human resource models (p = 0.021). CONCLUSIONS: Both salaried and volunteer CHW human resource models demonstrated additionality in case notifications compared to routine case finding by the government TB program. The salaried employee CHW ...