Treatment outcomes and adverse drug reactions among patients with drug-resistant tuberculosis receiving all-oral,long-term regimens:First record viewing report from Pakistan

Objective:To assess the effectiveness and adverse drug reactions of all-oral regimens for patients with multidrug-resistant tuberculosis.Methods:This retrospective study was conducted at 10 Programmatic Management of Drug Resistant Tuberculosis sites in Punjab province of Pakistan.Patients receiving treatment for drug resistant tuberculosis from July 2019 to December 2020 with at least interim result i.e.6th month culture conversion or final outcomes(cured,complete,lost to follow-up,failure,death)available,were included in the study.Data was extracted from electronic data management system.For the reporting and management of adverse drug events,active tuberculosis drug safety monitoring and management was implemented across all sites.All the data was analyzed using SPSS version 22.Results:Out of 947 drug resistant tuberculosis patients included in this study,579(68%)of the patients had final outcomes available.Of these,384(67.9%)successfully completed their treatment.Out of 368(32%)patients who had their interim results available,all had their 6th month culture negative.Combining new medications was thought to result in serious adverse outcomes such as QT prolongation.However,this study did not record any severe adverse events among patients.Conclusions:All-oral regimens formulation guided by overall treatment effectiveness resulted in treatment outcomes comparable to those obtained with traditional injectable treatment.

Assessment of Retreatment Tuberculosis Cases amongst All Tuberculosis Cases Notification in District Swat 2015-2017: A Retrospective Cohort Review

Retreatment Tuberculosis (TB) has long been a neglected area in global TB control. To determine the notification of re-treatment Tuberculosis TB cases among all enrolled TB patients, we conducted a retrospective cohort review of routine program data from 2015-2017. A total of 8663 tuberculosis cases (all new and old forms) were registered at the study site. Of these, 1916 (22%) were pulmonary bacteriological confirmed;3498 (40.37%) were pulmonary clinical diagnosed and 3396 (39.20%) were clinically or bacteriological confirmed extra-pulmonary tuberculosis cases. Retreatment cases trend was found to be increased from 1% in 2015 to 1.6% in 2017. Majority of re-treatment cases were in the age group 18 - 43 years and only 7 patients were under the age of 15 years. This concludes that notification of re-treatment cases is very low among all enrolled TB patients and this could be possibly due to the fact that most of the re-treatment cases were registered as new cases or misdiagnosed. There is need and space to increase retreatment cases. Most of the re-treatment cases were usually converted to MDR-TB (Multi-Drug Resistant Tuberculosis) as noted in PMDT (Programmatic management of Drugs resistant tuberculosis) site. Therefore, proper history and diagnosis should be encouraged at the time of case notification.

Does Cash Incentive Effect TB Case Notification by Public Private Mix-General Practitioners Model in Pakistan?

Setting: Private healthcare providers including solo practitioners and laboratories enrolled with Public Private Mix General Practitioners model in Pakistan who were enrolled with the program and maintained participation during 2014 to 2016. Objective: To assess the change in case notification by private healthcare providers as well as effect on sputum smear positivity rate at private laboratories after introduction of incentives. Design: A comparative cross-sectional study based on routinely maintained National TB Control Program data collected before and after the introduction of incentives (2014 and 2016). Results: In 2016, TB case notification increased by 71% after cash incentives was introduced. Among the 618 private healthcare providers who enrolled and maintained participation in the Public Private Mix program, only 1% of the GPs contributed to 19% increase in case notification, whereas 27% GPs had reported a reduced number of cases compared to the pre-intervention period. After incentives, slide positivity rate for diagnostic declined by 1.9% and follow-up increased by 0.6%. Number of slides for diagnostic and follow-up testing increased by 82% and 72% respectively. Conclusion: Engaging the private healthcare sector, by providing cash incentives to private health care Provider’s is an effective strategy for providing a substantial increase in National TB case notification.

Enhancing Childhood TB Notifications by Strengthening Linkages with Large Hospitals in Pakistan<br/>—Childhood TB in Large Hospitals, Pakistan

To improve childhood Tuberculosis management, the National Tuberculosis Program implemented a package of interventions Hospital DOTS linkages (HDL) in 2015 in 144 tertiary and secondary care hospitals across Pakistan. This included systematic engagement of hospital administration and all specialist doctors, staff training and regular facility-based review meetings. HDL was associated with 35% increase in childhood TB notifications in 2015 (versus 2014) in HDL sites as compared to 16% increase in non-HDL sites. The increase was seen across provinces, age-groups and sexes, but did not correlate with presence of Xpert MTB/RIF&reg;?or “screeners” (health workers deployed to screen children for TB).

Did “Screeners” Increase Pediatric Tuberculosis Case Notification in Sindh, Pakistan?

To identify missing childhood Tuberculosis (TB) cases, “screeners” (hospital-based health workers trained to screen accompanying contacts of TB patients for symptoms) were introduced in eight tertiary care hospitals of Sindh, Pakistan in 2013. There was a 55% increase in childhood TB notifications in 2014 compared to 2012 in facilities with screeners (n = 8) compared to 40% increase in facilities without screeners (n = 22). This apparent association disappeared when stratified by presence of “trained pediatrician” whose introduction was associated with a massive increase in notifications while transfer was associated with a marked decrease. In conclusion, screeners were not associated with increase in pediatric TB case notifications.

Assessing Tuberculosis among Smokers: Secondary Analysis of an Active Case Finding Project

Background: Previous case-control studies and a small number of cohort studies in high-risk populations have found an association between smoking and tuberculosis, but limited studies are available in the general population that predicts association of smoking and TB. Objectives: To investigate the association between smoking and tuberculosis in a cohort of a general population. Methods: Four districts of Punjab province (Lahore, Rawalpindi, Faisalabad and Islamabad) were randomly selected. In routine, household contact investigation is practiced by the National TB Control Programme. For two years from July 2013-June 2015, all people who were living within 50 metres from the household of smear positive TB patients were screened for tuberculosis. Those found presumptive TB were investigated through smear microscopy and those found smear negative;the Xpert MTB/RIF test was done. All the diagnosed TB patients were referred to nearest basic health unit for further treatment and care. Results: A total of 783,043 contacts were screened for tuberculosis, of whom 19,815 (2.53%) were smokers. Smoking was common among men, in diabetic & teenage, elderly age population and in household contact of smear positive TB patients. Smoking was associated with an increased risk of tuberculosis (odds ratio [OR], 2.43;95% confidence interval, 2.27 - 2.60) in household contact of smear positive TB patients. The association was stronger among those greater than 45 years of age (OR, 11.09) than those between 25 - 44 years of age (OR, 5.83) and diabetic persons (OR, 2.0). Conclusions: Smoking was associated with a twofold increased risk of active tuberculosis in a cohort of general population.

Prevalence of Human Immune Deficiency among Registered Tuberculosis Patients across Pakistan during 2013-2015<br/>—Prevalence of TB-HIV Co-Infection in Pakistan

The problem of Tuberculosis (TB) and Human Immune Deficiency Virus (HIV) co-infection becomes vital when it is seen in the context of under developed countries like Pakistan. Pakistan ranks 5th high burden countries for drug-susceptible and 6th among drug-resistant TB patients [1]. Objectives of the study were to assess the prevalence of TB-HIV Co-infection at the designated Sentinel Sites across Pakistan. A cross-sectional study is based on retrospective record review of routinely maintained TB program data at all 17 designated sentinel sites of TB Control Program from 2013-15. Among the screened TB patients 145 (0.66%) were found HIV reactive. The prevalence of HIV was higher (1.02%) in extra-pulmonary and male TB patients (1.23 %) as compared to pulmonary (0.55%) and female patients (0.09%). Scale up TB surveillance activities, integrating TB-HIV care services, active case finding among key affected populations will have a positive impact on TB-HIV co-infection and disease control.