Community Caregivers’ Experiences and Programmatic Strategies to Improve Active Case Finding in Community Tuberculosis Care in Botswana 2016-2021

Background: The community tuberculosis care program was started to reduce the impact of TB and increase successful treatment outcomes, thus contributing to meeting WHO targets on TB. According to the Botswana Ministry of Health, community tuberculosis care was introduced with the main goal of reducing tuberculosis-related morbidity and mortality among communities through the expansion of direct observed therapy and community involvement to community settings. The community caregivers were to support tuberculosis patients throughout their treatment period until they were cured or had completed their treatment. Settings: Two major cities of Botswana, Francistown and Gaborone, with more than twenty-two health clinics offering tuberculosis care. Objective: To investigate community caregivers’ experiences and identify programmatic strategies to improve active TB case findings under the community TB care (CTBC) program in Botswana during 2016-2021. Methods: We adopted a descriptive qualitative research design, followed by convenience purposive sampling. We obtained consent and interviewed 40 participants who met the inclusion criteria, 16 out of 73 in Gaborone and 24 out of 38 from Francistown. Results: We interviewed 40 caregivers with a mean age of 43.4 years. Accepting the caregiving role was identified as the main experience by more than two thirds of the caregivers. While at least more than two-fifth felt obligated to care for the patient at home due to personal relations. More than half of the respondents found caregiving difficult or frustrating due to some challenges encountered during the caregiving role. Behavioral modifications were suggested under different subthemes as strategies to improve active case finding. [-rId13-]Conclusion: Acceptance was the major experience in CTBC. Intensification of known programmatic strategies was suggested by caregivers to improve tuberculosis active case finding in CTBC.

Role of community-based active case finding in screening tuberculosis in Yunnan province of China

Background:The barriers to access diagnosis and receive treatment,in addition to insufficient case identification and reporting,lead to tuberculosis(TB)spreads in communities,especially among hard-to-reach populations.This study evaluated a community-based active case finding(ACF)strategy for the detection of tuberculosis cases among high-risk groups and general population in China between 2013 and 2015.Methods:This retrospective cohort study conducted an ACF in ten communities of Dongchuan County,located in northeast Yunnan Province between 2013 and 2015;and compared to 136 communities that had passive case finding(PCF).The algorithm for ACF was:1)screen for TB symptoms among community enrolled residents by home visits,2)those with positive symptoms along with defined high-risk groups underwent chest X-ray(CXR),followed by sputum microscopy confirmation.TB incidence proportion and the number needed to screen(NNS)to detect one case were calculated to evaluate the ACF strategy compared to PCF,chi-square test was applied to compare the incidence proportion of TB cases'demography and the characteristics for detected cases under different strategies.Thereafter,the incidence rate ratio(IRR)and multiple Fisher's exact test were applied to compare the incidence proportion between general population and high-risk groups.Patient and diagnostic delays for ACF and PCF were compared by Wilcoxon rank sum test.Results:A total of 97521 enrolled residents were visited with the ACF cumulatively,12.3%were defined as highrisk groups or had TB symptoms.Sixty-six new TB patients were detected by ACF.There was no significant difference between the cumulative TB incidence proportion for ACF(67.7/100000 population)and the prevalence for PCF(62.6/100000 population)during 2013 to 2015,though the incidence proportion in ACF communities decreased after three rounds active screening,concurrent with the remained stable prevalence in PCF communities.The cumulative NNS were 34,39 and 29 in HIV/AIDS infected individuals,people with positive TB symptoms and history of previous TB,respectively,compared to 1478 in the general population.The median patient delay under ACF was 1 day(Interquartile range,IQR:0-27)compared to PCF with 30 days(IQR:14-61).Conclusions:This study confirmed that massive ACF was not effective in general population in a moderate TB prevalence setting.The priority should be the definition and targeting of high-risk groups in the community before the screening process is launched.The shorter time interval of ACF between TB symptoms onset and linkage to healthcare service may decrease the risk of TB community transmission.Furthermore,integrated ACF strategy in the National Project of Basic Public Health Service may have long term public health impact.

The role of active case finding in reducing patient incurred catastrophic costs for tuberculosis in Nepal

Background:The World Health Organization(WHO)End TB Strategy has established a milestone to reduce the number of tuberculosis(TB)-affected households facing catastrophic costs to zero by 2020.The role of active case finding(ACF)in reducing patient costs has not been determined globally.This study therefore aimed to compare costs incurred by TB patients diagnosed through ACF and passive case finding(PCF),and to determine the prevalence and intensity of patient-incurred catastrophic costs in Nepal.Methods:The study was conducted in two districts of Nepal:Bardiya and Pyuthan(Province No.5)between June and August 2018.One hundred patients were included in this study in a 1:1 ratio(PCF:ACF,25 consecutive ACF and 25 consecutive PCF patients in each district).The WHO TB patient costing tool was applied to collect information from patients or a member of their family regarding indirect and direct medical and non-medical costs.Catastrophic costs were calculated based on the proportion of patients with total costs exceeding 20%of their annual household income.The intensity of catastrophic costs was calculated using the positive overshoot method.The chi-square and Wilcoxon-Mann-Whitney tests were used to compare proportions and costs.Meanwhile,the Mantel Haenszel test was performed to assess the association between catastrophic costs and type of diagnosis.Results:Ninety-nine patients were interviewed(50 ACF and 49 PCF).Patients diagnosed through ACF incurred lower costs during the pre-treatment period(direct medical:USD 14 vs USD 32,P=0.001;direct non-medical:USD 3 vs USD 10,P=0.004;indirect,time loss:USD 4 vs USD 13,P<0.001).The cost of the pre-treatment and intensive phases combined was also lower for direct medical(USD 15 vs USD 34,P=0.002)and non-medical(USD 30 vs USD 54,P=0.022)costs among ACF patients.The prevalence of catastrophic direct costs was lower for ACF patients for all thresholds.A lower intensity of catastrophic costs was also documented for ACF patients,although the difference was not statistically significant.Conclusions:ACF can reduce patient-incurred costs substantially,contributing to the End TB Strategy target.Other synergistic policies,such as social protection,will also need to be implemented to reduce catastrophic costs to zero among TB-affected households.

Ophthalmic findings in two cases of methanol optic neuropathy with relapsed vision disturbance

【正】Dear Sir,We hereby report two cases of methanol optic neuropathy with relapsed vision disturbance.Methanol intoxication appears after accidental or suicidal oral ingestion of industrial solvents or cleaning and antifreeze liquids or occasionally is due to fraudulent adulteration of wine or other alcoholic beverages.Its ingestion can cause severe visual disturbances and the outcomes of visual disturbances vary diffusively.Some completely or partially recovered,and some suffered

Factors Undermining the Investigation of Child Contacts of TB Patients： The Case of FCT, Abuja, Nigeria

Facility records of 320 TB （tuberculosis） patients were examined over a one-year-period; January-December 2009 to ascertain the screening of children under 6 years of age who have had contacts with sputum smear positive TB patients as stipulated in the NTBLCP （National Tuberculosis and Leprosy Control Program） guidelines. In addition, semi-structured questionnaires were administered to 28 DOTS （directly-observed treatment strategy） clinicians to elicit information to help explain findings from the analysis of the routine data. Over 60% of children less than 6 years of age who had contacts with TB patients were not investigated in the health facilities included in the survey. The level of educational attainment of DOTS providers was associated with the screening of TB patients＇ contacts （P = 0.008）. Forgetfulness by clinicians to ask for or screen children of TB patients in the facilities is the singular most important factor undermining contact investigation. The proportion of under 6 years TB contacts screened or not screened for TB in the facilities was similar according to the age and gender of TB patients, and the type of health facilities where treatment was accessed by patients （P = 0.325）. The study underscored the need for the state program to evaluate the quality of service provision as well as counseling provided to TB patients at the facilities.

A Case-Finding Clinical Decision Support System to Identify Subjects with Chronic Obstructive Pulmonary Disease Based on Public Health Data

Chronic obstructive pulmonary disease(COPD)is a serious chronic respiratory disease.Improving the ability to identify patients with COPD in primary medical institutions is important to prevent and treat the disease.With the continuous development of medical digitization,the application of big data informatization in the medical and health fields has become possible.Recently,applying innovative technologies such as big data analysis,machine learning,and artificial intelligence-assisted decision-making in the medical field has become an interdisciplinary research hotspot.Based on the identification and diagnosis of COPD in the high-risk population,this study proposes a convenient and effective clinical decision support system to help identify patients with COPD in primary health institutions.The results of the preliminary experiments show that the proposed method is convenient and effective compared with the existing methods.

Active case-finding for tuberculosis by mobile teams in Myanmar:yield and treatment outcomes

Background:Since 2005,the Myanmar National Tuberculosis Programme(NTP)has been implementing active case finding(ACF)activities involving mobile teams in hard-to-reach areas.This study revealed the contribution of mobile team activities to total tuberculosis(TB)case detection,characteristics of TB patients detected by mobile teams and their treatment outcomes.Methods:This was a descriptive study using routine programme data between October 2014 and December 2014.Mobile team activities were a one-stop service and included portable digital chest radiography(CXR)and microscopy of two sputum samples.The algorithm of the case detection included screening patients by symptoms,then by CXR followed by sputum microscopy for confirmation.Diagnosed patients were started on treatment and followed until a final outcome was ascertained.Results:A total of 9349 people with symptoms suggestive of TB were screened by CXR,with an uptake of 96.6%.Of those who were meant to undergo sputum smear microscopy,51.4%had sputum examinations.Finally,504 TB patients were identified by the mobile teams and the overall contribution to total TB case detection in the respective townships was 25.3%.Among total cases examined by microscopy,6.4%were sputum smear positive TB.Treatment success rate was high as 91.8%in study townships compared to national rate 85%(2014 cohort).Conclusions:This study confirmed the feasibility and acceptability of ACF by mobile teams in hard-to-reach contexts,especially when equipped with portable,digital CXR machines that provided immediate results.However,the follow-up process of sputum examination created a significant barrier to confirmation of the diagnosis.In order to optimize the ACF through mobile team activity,future ACF activities were needed to be strengthened one stop service including molecular diagnostics or provision of sputum cups to all presumptive TB cases prior to CXR and testing if CXR suggestive of TB.

Buruli ulcer in Nigeria:results of a pilot case study in three rural districts

Background:Buruli ulcer(BU),also known as Mycobacterium ulcerans disease,is the third most common mycobacterial disease worldwide.Although BU disease has been diagnosed among Nigerians in neighbouring West African countries,data on the burden of the disease in Nigeria itself are scanty.This study aimed to assess the magnitude and epidemiology of BU in the South South region of Nigeria.Methods:We conducted a cross-sectional survey in the Ogoja territory(comprising 31 communities).We undertook sensitisation programmes centred on BU in 10 of the communities.Participants were asked to identify community members with long-standing ulcers,who were then invited for evaluation.We also contacted traditional healers to refer their clients who had non-healing ulcers.All suspected cases had a full clinical evaluation and laboratory testing.Confirmed cases were given treatment in a referral hospital in the territory.Results:We diagnosed 41 clinical BU cases;36(87.8%)of which were confirmed by quantitative polymerase chain reaction(qPCR).These 36 PCR-confirmed cases were diagnosed in a total population of 192,169 inhabitants.Therefore,the estimated crude prevalence of BU was 18.7 per 100,000 population,varying from 6.0 to 41.4 per 100,000 in the districts surveyed.The majority(66.7%)of the cases were females.About 92%of the BU lesions were located on the patients’extremities.No differences were observed between the sexes in terms of the location of the lesions.The age of the patients ranged from four to 60 years,with a median age of 17 years.All 35(100%)patients who consented to treatment completed chemotherapy as prescribed.Of the treated cases,29(82.9%)needed and received surgery.All cases healed,but 29(82.9%)had some limitations in movement.Healing with limitations in movement occurred in 18/19(94.7%)and 8/10(80.0%)of patients with lesions>15 cm(Category III)and 6–15 cm in diameter(Category II),respectively.The median duration of treatment was 130(87–164)days for children and 98(56–134)days for adults(p=0.15).Conclusions:In Nigeria,BU is endemic but its severity is underestimated—at least in the study setting.There is a need to identify and map BU endemic regions in Nigeria.A comprehensive BU control programme is also urgently needed.

Incidence and risk factors of tuberculosis among the elderly population in China:a prospective cohort study

Background:China is facing challenges of the shifting presentation of tuberculosis(TB)from younger to elderly due to an ageing population,longer life expectancy and reactivation disease.However,the burden of elderly TB and influence factors are not yet clear.To fill the gap,we generated a cohort study to measure the magnitude of TB incidence and associated factors among the elderly population aged 65 years and above in China.Methods:In this cohort established in 2013 through a prevalence survey conducted in selected sites,a total of 34076 elderlies without TB were enrolled into two-year follow-up.We used both active and passive case findings to find out all TB patients among them.The person-year(PY)incidence rates for both bacteriologically positive TB and active TB were calculated.Cox proportional regression model was performed to test effect of risk factors,and the population attributable fraction(PAF)of each risk factor contributing to incident TB among elderlies was calculated.Results:Over the two-year follow-up period,a total of 215 incident active TB were identified,62 of which were bacteriologically positive.The incidence rates for active TB and bacteriologically positive TB were 481.8 per 100000 PY(95%CI:417.4–546.2 per 100000 PY)and 138.9 per 100000 PY(95%CI:104.4–173.5 per 100000 PY),respectively.Incident cases detected by active case finding were significantly higher(P<0.001).Male,non-Han nationality,previously treated TB,ex/current smoker and body mass index(BMI)<18.5 presented as independent predictors for developing TB disease.For developing bacteriologically positive TB,the biggest contribution was from self-reported ex or current smoker(18.06%).And,for developing active TB,the biggest contribution was from non-Han nationality(35.40%),followed by male(26.80%)and age at 75 years and above(10.85%).Conclusions:Ageing population in China had a high TB incidence rate and risk to develop TB disease,implying that National TB Program(NTP)needs to prioritize for elderly.Active case finding should be applied capture more active TB cases among this particular population,especially for male,non-Han nationality,and those with identified risk factors.

Evaluating the yield of systematic screening for tuberculosis among three priority groups in Ho Chi Minh City,Viet Nam

Background: In order to end tuberculosis(TB),it is necessary to expand coverage of TB care services,including systematic screening initiatives.However,more evidence is needed for groups among whom systematic screening is only conditionally recommended by the World Health Organization.This study evaluated concurrent screening in multiple target groups using community health workers(CHW).Methods:: In our two-year intervention study lasting from October 2017 to September 2019,CHWs in six districts of Ho Chi Minh City,Viet Nam verbally screened three urban priority groups:(1)household TB contacts;(2)close TB contacts;and(3)residents of urban priority areas without clear documented exposure to TB including hotspots,boarding homes and urban slums.Eligible persons were referred for further screening with chest radiography and follow-on testing with the Xpert MTB/RIF assay.Symptomatic individuals with normal or without radiography results were tested on smear microscopy.We described the TB care cascade and characteristics for each priority group,and calculated yield and number needed to screen.Subsequently,we fitted a mixed-effect logistic regression to identify the association of these target groups and secondary patient covariates with TB treatment initiation.Results: We verbally screened 321020 people including 24232 household contacts,3182 social and close contacts and 293606 residents of urban priority areas.This resulted in 1138 persons treated for TB,of whom 85 were household contacts,39 were close contacts and 1014 belonged to urban priority area residents.The yield of active TB in these groups was 351,1226 and 345 per 100000,respectively,corresponding to numbers needed to screen of 285,82 and 290.The fitted model showed that close contacts[adjusted odds ratio(aOR)=2.07;95%CI:1.38–3.11;P<0.001]and urban priority area residents(aOR=2.18;95%CI:1.69–2.79;P<0.001)had a greater risk of active TB than household contacts.Conclusions: The study detected a large number of unreached persons with TB,but most of them were not among persons in contact with an index patient.Therefore,while programs should continue to optimize screening in contacts,to close the detection gap in high TB burden settings such as Viet Nam,coverage must be expanded to persons without documented exposure such as residents in hotspots,boarding homes and urban slums.

MODELING THE IMPACT OF VOLUNTARY TESTING AND TREATMENT ON TUBERCULOSIS TRANSMISSION DYNAMICS

A deterministic model for evaluating the impact of voluntary testing and treatment on the transmission dynamics of tuberculosis is formulated and analyzed. The epidemio- logical threshold, known as the reproduction number is derived and qualitatively used to investigate the existence and stability of the associated equilibrium of the model system. The disease-free equilibrium is shown to be locally-asymptotically stable when the reproductive number is less than unity, and unstable if this threshold parameter exceeds unity. It is shown, using the Centre Manifold theory, that the model undergoes the phenomenon of backward bifurcation where the stable disease-free equilibrium co- exists with a stable endemic equilibrium when the associated reproduction number is less than unity. The analysis of the reproduction number suggests that voluntary tuber- culosis testing and treatment may lead to effective control of tuberculosis. Furthermore, numerical simulations support the fact that an increase voluntary tuberculosis testing and treatment have a positive impact in controlling the spread of tuberculosis in the community.