3Ts of low cure rate: taxonomy, themes and theory of low cure rate in Pakistan's TB control programme and gathering a 360-degree perspective through qualitative, in-depth interviewing approach.
ABSTRACT: OBJECTIVE:WHO recommends cure of tuberculosis (TB) as the best prevention strategy; however, information about factors associated with low cure rate in patients with drug-susceptible TB is limited in Pakistan. Therefore, the purpose of this study was to explore the factors that account for low TB cure rate. METHODOLOGY:The present qualitative study recruited diverse informants through purposive sampling to explore low cure rate situation in Badin between March and June 2017. Data were collected from clinicians, paramedics, lab technicians, district field supervisors, patients and treatment supporters through indepth and face-to-face interviews. Interviews were conducted in local languages (Urdu and Sindhi) and transcribed into English. Coding structure was developed inductively and applied on textual data to draw output at the levels of taxonomy, themes and theory, as proposed by Bradley et al. FINDINGS:Thirty-seven individuals consented to participate in this study and provided detailed account of the subject under enquiry. Review of interview data collected from a variety of informants resulted in the identification of four broad factors (taxonomy) that contributed to the situation of low cure rate in one of the districts implementing the public-private mix intervention. These factors were (1) health-seeking behaviour, (2) technical capacity of the healthcare provider, (3) managerial capacity of the healthcare provider, and (4) access to healthcare facility and services. Each factor is deconstructed into key dimensions (themes) that emerged from the dialogue between the interviewer and the respondents. Moreover, dimensions were exemplified through underlying concepts that correspond to theories for low cure rate. CONCLUSION:Change in programme reporting requirement has demeaned the significance of having cure as treatment outcome. Therefore, returning the focus to achieving cure status for TB cases will be beneficial for assessing the effectiveness of TB control efforts. In parallel to the care delivery system, a mechanism for disseminating disease-related and treatment-related information should be introduced.
Project description:This research mainly aims to develop a generalized cure rate model, estimate the proportion of cured patients and their survival rate, and identify the risk factors associated with infectious diseases. The generalized cure rate model is based on bounded cumulative hazard function, which is a non-mixture model, and is developed using a two-parameter Weibull distribution as the baseline distribution, to estimate the cure rate using maximum likelihood method and real data with R and STATA software. The results showed that the cure rate of tuberculosis (TB) patients was 26.3%, which was higher than that of TB patients coinfected with human immunodeficiency virus (HIV; 23.1%). The non-parametric median survival time of TB patients was 51 months, while that of TB patients co-infected with HIV was 33 months. Moreover, no risk factors were associated with TB patients co-infected with HIV, while age was a significant risk factor for TB patients among the suspected risk factors considered. Furthermore, the bounded cumulative hazard function was extended to accommodate infectious diseases with co-infections by deriving an appropriate probability density function, determining the distribution, and using real data. Governments and related health authorities are also encouraged to take appropriate actions to combat infectious diseases with possible co-infections.
Project description:BACKGROUND:Despite the efforts of the National Tuberculosis Programme, TB cure rates in Brazil are sub-optimal. The End TB Strategy for post-2015 identifies conditional cash transfer interventions as powerful tools to improve TB control indicators, including TB cure rate. This study aims to inform the new policy by evaluating the role of the Bolsa Familia Programme (BFP), one of the largest conditional cash transfer programmes in the world, on TB cure rates in Brazil. METHODS:We undertook a retrospective cohort study, based on an unprecedented record linkage of socioeconomic and health data, to compare cases of patients newly diagnosed with TB in 2010 receiving BFP cash benefits (n=5788) with those who did not (n=1467) during TB treatment. We used Poisson regression with robust variance to estimate the relative risks for TB cure adjusted for known confounders. RESULTS:The cure rate among patients exposed to BFP during TB treatment was 82.1% (4752/5788), 5.2% higher than among those not exposed. This was confirmed after controlling for TB type, diabetes mellitus, HIV status and other relevant clinical and socioeconomic covariates (RR=1.07, 95% CI 1.04 to 1.11 for cure rates among BFP beneficiaries). This association seemed higher for patients not under directly observed treatment (RR=1.11; 95% CI 1.05 to 1.16). CONCLUSIONS:Although further research is needed, this study suggests that conditional cash transfer programmes can contribute to improve TB cure rate in Brazil.
Project description:Elevated rates of reinfection tuberculosis in various hyperendemic regions have been reported and, in particular, it has been shown that in a high-incidence setting near Cape Town, South Africa, the rate of reinfection tuberculosis (TB) disease after cure of a previous TB disease episode is about four times greater than the rate of first-time TB disease. It is not known whether this elevated rate is caused by a high reinfection rate due, for instance, to living circumstances, or a high rate of progress to disease specific to the patients, or both. In order to address that question we analysed an extensive data set from clinics attended by TB patients in the high-incidence setting near Cape Town, South Africa and found that, in fact, the (average) rate of reinfection (as opposed to the rate of reinfection disease) after cure of a previous TB disease episode is initially about 0.85 per annum. This rate diminishes rapidly over time and after about ten years this rate is similar to the rate of infection in the general population. Also, the rate of progress to disease after reinfection is initially high but declines in subsequent years down to the figure typical for the general population. These findings suggest that the first few months after cure of a TB disease episode form a critical period for controlling reinfection disease in a hyperendemic setting and that monitoring such cured patients could pre-empt a reinfection progressing to active disease.
Project description:There are few drugs with proven efficacy in cutaneous leishmaniasis (CL), and pentavalent antimonial derivatives are still the main first-line therapeutic agents worldwide, despite their recognized high toxicities. Randomized controlled clinical trials assessing the efficacy and safety of new therapeutic modalities are of high priority, and the definition of the design of such trials raises debate about the use of placebo as a comparator. To support the use of placebo as a comparator, two main points need to be addressed: 1--the cure rate without any therapeutic intervention and 2--the damage caused by CL and its impact on patients.The aim of this study was to systematically assess the spontaneous cure rate for American CL and to broaden the discussion about placebo use in CL trials.The PRISMA guidelines for systematic reviews and the Cochrane manual were followed. The sources used were the PubMed and LILACS databases. Studies were included if they reported cure rates using placebo or no treatment in American CL.Thirteen studies of a total of 352 patients were ultimately included in this review. The summarized global cure rates for all Leishmania species according to the intention-to-treat analyses performed at approximately three ("initial cure") and nine ("definitive cure") months after "no treatment" or placebo use were 26% (CI95%: 16 to 40%) and 26% (CI95%:16 to 38%), respectively. Notably, a significantly lower cure rate was observed for L. braziliensis infection (6.4%, CI95%:0.2 to 20%) than for L. mexicana infection (44%, CI95%:19 to 72%), p = 0.002. Of note, relapse occurred in 20% of patients with initial healing (CI95%:9.2 to 38.9%).These results clearly demonstrate a low spontaneous cure rate following no-treatment or placebo use, confirming that this strategy for the control group in CL studies expose patients to greater morbidity, especially for CL caused by L. braziliensis. Therefore, from this point, the crucial question to consider regarding placebo use is the seriousness of the suffering caused by this disease.
Project description:INTRODUCTION:Tuberculosis incidence is disproportionately high among people in poverty. Cash transfer programs have become an important strategy in Brazil fight inequalities as part of comprehensive poverty alleviation policies. This study was aimed at assessing the effect of being a beneficiary of a governmental cash transfer program on tuberculosis (TB) treatment cure rates. METHODS:We conducted a longitudinal database study including people ?18 years old with confirmed incident TB in Brazil in 2015. We treated missing data with multiple imputation. Poisson regression models with robust variance were carried out to assess the effect of TB determinants on cure rates. The average effect of being beneficiary of cash transfer was estimated by propensity-score matching. RESULTS:In 2015, 25,084 women and men diagnosed as new tuberculosis case, of whom 1,714 (6.8%) were beneficiaries of a national cash transfer. Among the total population with pulmonary tuberculosis several determinants were associated with cure rates. However, among the cash transfer group, this association was vanished in males, blacks, region of residence, and people not deprived of their freedom and who smoke tobacco. The average treatment effect of cash transfers on TB cure rates, based on propensity score matching, found that being beneficiary of cash transfer improved TB cure rates by 8% [Coefficient 0.08 (95% confidence interval 0.06-0.11) in subjects with pulmonary TB]. CONCLUSION:Our study suggests that, in Brazil, the effect of cash transfer on the outcome of TB treatment may be achieved by the indirect effect of other determinants. Also, these results suggest the direct effect of being beneficiary of cash transfer on improving TB cure rates.
Project description:Tafenoquine has been licensed for the single-dose radical cure of Plasmodium vivax in adults; however, it is only recommended in patients with > 70% of normal glucose-6-phosphate dehydrogenase (G6PD) activity. Because this may hinder widespread use, we investigated sex-based treatment strategies in which all adult patients are tested with a qualitative G6PD rapid diagnostic test (RDT). Glucose-6-phosphate dehydrogenase normal males are prescribed tafenoquine in all three strategies, whereas G6PD normal females are prescribed either a low-dose 14-day primaquine regimen (PQ14, total dose 3.5 mg/kg) or a high-dose 7-day primaquine regimen (PQ7, total dose 7 mg/kg), or referred to a healthcare facility for quantitative G6PD testing before prescribing tafenoquine. Patients testing G6PD deficient are prescribed a weekly course of primaquine for 8 weeks. We compared the cost-effectiveness of these three strategies to usual care in four countries using a decision tree model. Usual care in Ethiopia does not include radical cure, whereas Afghanistan, Indonesia, and Vietnam prescribe PQ14 without G6PD screening. The cost per disability-adjusted life-year (DALY) averted was expressed through incremental cost-effectiveness ratios (ICERs). Compared with usual care, the ICERs for a sex-based treatment strategy with PQ7 for females from a healthcare provider perspective were $127 per DALY averted in Vietnam, $466 in Ethiopia, $1,089 in Afghanistan, and $4,443 in Indonesia. The PQ14 and referral options cost more while averting fewer DALYs than PQ7. This study provides an alternative cost-effective mode of rolling out tafenoquine in areas where initial testing with only a G6PD RDT is feasible.
Project description:OBJECTIVES:Drug-resistant tuberculosis (DR-TB) is one of the major public health threats in low-income countries such as Ethiopia. It is intertwined with larger socioeconomic and political factors that complicate its management and control. Whether directly observed therapy (DOT) is serving its purpose-better patient adherence and treatment outcome-still remains a debatable issue. To contribute to this discussion, this study explored health workers' field experiences tinkering with DOT in patients with DR-TB in Addis Ababa, Ethiopia. DESIGN:A qualitative study using in-depth interviews and focus group discussion. SETTING:Ten public healthcare facilities: eight health centres at Addis Ababa Health Bureau level and two TB-specialised hospitals at the Federal Health Bureau level in Ethiopia. PARTICIPANTS:18 healthcare providers working with DR-TB patients. RESULTS:Three findings emerged from the analysis. First, the purpose of DOT is to ensure that patients go to healthcare facilities and swallow pills under the observation of a healthcare provider. Thus, its rigid application could lead to the emergence of more DR-TB. Second, DOT should be tinkered with and its practice improved by incorporating more counselling and health education, with more flexibility towards, and attentiveness of, patient context. Third, there exists a family-like patient-provider relationship, and providers do understand their patients and empathise with them to provide better healthcare services. CONCLUSION:If rigidly implemented, DOT could lead to more DR-TB-a problem DOT was invented to resolve. Front-line healthcare providers are sensitive to the tragic experiences of DR-TB patients and empathise with them. Thus, they do not strictly implement DOT and are willing to take any blame resulting from tinkering with it. It is high time to shape the practice of DOT for DR-TB patients, with meaningful contributions from front-line healthcare providers.
Project description:Mycobacterium tuberculosis (Mtb) is extremely recalcitrant to antimicrobial chemotherapy requiring 6 months to treat drug-sensitive tuberculosis (TB). Despite this, 4-10% of cured patients will develop recurrent disease within 12 months after completing therapy. Reasons for relapse in cured TB patients remains speculative, attributed to both pathogen and host factors. Populations of dormant bacilli are hypothesized to cause relapse in initially cured TB patients however, development of tests to convincingly demonstrate their presence at the end of anti-TB treatment has been challenging. Previous studies have indicated the utility of culture filtrate supplemented media (CFSM) to detect differentially culturable tubercle bacilli (DCTB). Here, we show that 3/22 of clinically cured patients retained DCTB in induced sputum and bronchoalveolar lavage fluid (BALF), with one DCTB positive patient relapsing within the first year of completing therapy. We also show a correlation of DCTB status with "unresolved" end of treatment FDG PET-CT imaging. Additionally, 19 end of treatment induced sputum samples from patients not undergoing bronchoscopy were assessed for DCTB, identifying a further relapse case with DCTB. We further show that induced sputum is a less reliable source for the DCTB assay at the end of treatment, limiting the utility of this assay in a clinical setting. We next investigated the host proteome at the site of disease (BALF) using multiplexed proteomic analysis and compared these to active TB cases to identify host-specific factors indicative of cure. Distinct signatures stratified active from cured TB patients into distinct groups, with a DCTB positive, subsequently relapsing, end of treatment patient showing a proteomic signature closer to active TB disease than cure. This exploratory study offers evidence of live Mtb, undetectable with conventional culture methods, at the end of clinically successful treatment and putative host protein biomarkers of active disease and cure. These findings have implications for the assessment of true sterilizing cure in TB patients and opens new avenues for targeted approaches to monitor treatment response.
Project description:BACKGROUND:Currently, there is no available standardized taxonomy of defined communication techniques and aids used by healthcare providers during patient consultations. It is challenging to identify communication techniques that contribute to effective healthcare provider and patient consultations and to replicate communication interventions in research. OBJECTIVE:The aim of this paper is to describe a protocol for the development and pilot of a taxonomy of communication techniques and aids used by healthcare providers during patient consultations. METHODS:A systematic review will be completed to identify eligible studies. Extracted techniques and aids will be organized into a preliminary taxonomy by a multidisciplinary team. The preliminary taxonomy will be piloted by two groups: research assistants trained in taxonomy application and healthcare providers and healthcare professional students not trained in taxonomy use. The pilot will use custom developed video footage of health provider and patient interactions. Interrater validity and interview feedback will be used to inform a Delphi panel of multidisciplinary healthcare providers and patient experts when they convene to finalize the preliminary taxonomy. RESULTS:This study was funded in November 2017 by the Monash University Interdisciplinary Research Seed Funding Scheme. Data collection commenced in March 2018, and data analysis is in progress. We expect the results to be published in 2021. CONCLUSIONS:This is the first known attempt to develop a defined and standardized taxonomy of communication techniques and aids used by healthcare providers in patient consultations. The findings will be used to inform future research by providing a detailed taxonomy of healthcare providers' communication techniques and standardized definitions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID):DERR1-10.2196/16801.
Project description:BACKGROUND:The World Health Organization estimated that 1.12 million children developed tuberculosis (TB) in 2018, and at least 200,000 children died from TB. Implementation of effective child contact management is an important strategy to prevent childhood TB but these practices often are not prioritized or implemented, particularly in low- and middle-income countries. This study aimed to explore attitudes of healthcare providers toward TB prevention and perceived facilitators and challenges to child contact management in Lesotho, a high TB burden country. Qualitative data were collected via group and individual in-depth interviews with 12 healthcare providers at five health facilities in one district and analyzed using a thematic framework. RESULTS:Healthcare providers in our study were interested and committed to improve child TB contact management and identified facilitators and challenges to a successful childhood TB prevention program. Facilitators included: provider understanding of the importance of TB prevention and enhanced provider training on child TB contact management, with a particular focus on ruling out TB in children and addressing side effects. Challenges identified by providers were at multiple levels -- structural, clinic, and individual and included:  access to care,  supply-chain issues,  identification and screening of child contacts, and  adherence to isoniazid preventive therapy. CONCLUSIONS:Given the significant burden of TB morbidity and mortality in young children and the recent requirement by the WHO to report IPT initiation in child contacts, prioritization of child TB contact management is imperative and should include enhanced provider training on childhood TB and mentorship as well as strategies to eliminate challenges. Strategies that enable more efficient child TB contact management delivery include creating standardized tools that facilitate the implementation, tracking, and monitoring of child TB contact management coupled with guidance and mentorship from the district health management team. To tackle access to care challenges, we propose delivering intensive community health education, conducting community screening more efficiently using standardized tools, and facilitating access to services in the community.