Search

Abstract Introduction One of the contributors to tuberculosis (TB) burden among vulnerable populations, such as sexual minority people, is the delay in case finding and notification. Given their socially excluded, hard-to-reach nature, community-led approaches need to be introduced to facilitate their screening of TB symptoms and their subsequent referral to TB healthcare providers. This article aimed to explore the existing challenges surrounding TB screening and referral, and the implementation facilitators and barriers of the proposed community-based TB screening model for sexual minority people in Dhaka, Bangladesh. Methods This study followed the quasi-experimental design using mixed methods (i.e., qualitative and quantitative) approach. The study participants who were also a part of the community-led TB screening model included sexual minority people enrolled in HIV prevention interventions. In addition to quantitative inquiry, in-depth interviews were conducted on sexual minority people, focus group discussions were also conducted on them and HIV prevention service providers, and key-informant interviews were conducted on service providers, programmatic experts and TB researchers. Data were analyzed using content, contextual and thematic approaches. Results The ‘Six Steps in Quality Intervention Development’ framework was used to guide the development of the community-based TB screening model. In Step 1 (identifying the problem), findings revealed low rates of TB screening among sexual minority people enrolled in the HIV prevention intervention. In Step 2 (identifying contextual factors for change), various individual, and programmatic factors were identified, which included low knowledge, low-risk perception, prioritization of HIV services over TB, and stigma and discrimination towards these populations. In Step 3 (deciding change mechanism), community-based screening approaches were applied, thus leading to Step 4 (delivery of change mechanism) which designed a community-based approach leveraging the peer educators of the HIV intervention. Step 5 (testing intervention) identified some barriers and ways forward for refining the intervention, such as home-based screening and use of social media. Step 6 (collecting evidence of effectiveness) revealed that the main strength was its ability to engage peer educators. Conclusion This study indicates that a community-based peer-led TB screening approach could enhance TB screening, presumptive TB case finding and referral among these populations. Therefore, this study recommends that this approach should be incorporated to complement the existing TB program.

Introduction: One of the contributors to tuberculosis (TB) burden among vulnerable populations, such as sexual minority people, is the delay in case finding and notification. Given their socially excluded, hard-to-reach nature, community-led approaches need to be introduced to facilitate their screening of TB symptoms and their subsequent referral to TB healthcare providers. This article aimed to explore the existing challenges surrounding TB screening and referral, and the implementation facilitators and barriers of the proposed community-based TB screening model for sexual minority people in Dhaka, Bangladesh. Methods: This study followed the quasi-experimental design using mixed methods (i.e., qualitative and quantitative) approach. The study participants who were also a part of the community-led TB screening model included sexual minority people enrolled in HIV prevention interventions. In addition to quantitative inquiry, in-depth interviews were conducted on sexual minority people, focus group discussions were also conducted on them and HIV prevention service providers, and key-informant interviews were conducted on service providers, programmatic experts and TB researchers. Data were analyzed using content, contextual and thematic approaches. Results: The 'Six Steps in Quality Intervention Development' framework was used to guide the development of the community-based TB screening model. In Step 1 (identifying the problem), findings revealed low rates of TB screening among sexual minority people enrolled in the HIV prevention intervention. In Step 2 (identifying contextual factors for change), various individual, and programmatic factors were identified, which included low knowledge, low-risk perception, prioritization of HIV services over TB, and stigma and discrimination towards these populations. In Step 3 (deciding change mechanism), community-based screening approaches were applied, thus leading to Step 4 (delivery of change mechanism) which designed a community-based approach leveraging the peer educators of the HIV intervention. Step 5 (testing intervention) identified some barriers and ways forward for refining the intervention, such as home-based screening and use of social media. Step 6 (collecting evidence of effectiveness) revealed that the main strength was its ability to engage peer educators. Conclusion: This study indicates that a community-based peer-led TB screening approach could enhance TB screening, presumptive TB case finding and referral among these populations. Therefore, this study recommends that this approach should be incorporated to complement the existing TB program. [ABSTRACT FROM AUTHOR]

No abstract available.

Abstract Background Decreasing the burden of Tuberculosis (TB) among PLHIV through TB screening is an effective intervention recommended by the World Health Organization (WHO). However, after over a decade of implementation in Ghana, the intervention does not realize the expected outcomes. It is also not well understood whether this lack of success is due to implementation barriers. Our study, therefore, sought to examine the factors influencing the implementation of the intervention among people living with HIV (PLHIV) attending HIV clinics at district hospitals in Ghana. Methods This was a qualitative study conducted from 6th to 31 May 2019 in three regions of Ghana. We conducted 17 in-depth interviews (IDIs – comprising two regional, six districts and nine facility TB/HIV coordinators) and eight focus group discussions (FGD – consisting of a total of 65 participants) with HIV care providers. The Consolidated Framework for Implementation Research (CFIR) guided the design of interview guides, data collection and analysis. All responses were digitally audio-recorded and transcribed verbatim for coding and analysis using the Framework Approach. Participants consented to the interview and recording. Results The main barriers to TB screening relate to the low commitment of the implementers to screen for TB and limited facility infrastructure for the screening activities. Facilitators of TB screening include (1) ease in TB screening, (2) good communication and referral channels, (3) effective goals and feedback mechanisms, (4) health workers recognizing the need for the intervention and (5) the role of chemical sellers. Conclusions Key barriers and facilitators to the intervention are revealed. The study has shown that there is a need to increase HIV care providers and institutional commitment towards TB screening interventions. In addition, cost issues need to be assessed as they are drivers of sustainability. Our study also advances the field of implementation science through CFIR to better understand the factors influencing the implementation.

We describe an active and latent tuberculosis (TB) screening programme undertaken in Manchester, UK in response to the arrival of a cohort of refugees from Afghanistan. In total, 217 adults and 347 children were offered screening, which involved a symptom questionnaire, Mantoux test or interferon gamma release assay, blood-borne virus screening and a chest X-ray in participants over the age of 11. We found a latent TB infection (LTBI) rate of 15% in adults and 1.5% in children, which is lower than global LTBI estimates. One case of active TB was detected. Screening was undertaken in the hotels where participants were temporarily housed, leading to high participant engagement levels. Attendance rates were almost doubled compared with a previous hospital-based screening programme. Hotel-based screening for TB presented several challenges, including transfer of information and results to secondary care. Understanding these challenges and learning from the programme has helped us refine our screening protocol to optimise migrant TB screening in Manchester in the future. [ABSTRACT FROM AUTHOR]

Background: Village health workers (VHWs) play an essential role because they extend the capacity of primary healthcare, particularly for developing countries. In Lesotho, VHWs are part of the primary healthcare connecting the community with clinics in their respective villages. They contribute to the prevention of the spread of tuberculosis (TB) within their catchment areas by encouraging communities to partake in TB screening. This study aimed at identifying factors associated with the utilisation of VHWs' service to undertake TB screenings in Lesotho. Methods: This study emanates from the main study that used a cross-sectional descriptive design. A total of 19 health service areas (HSAs) comprised 17 catchment areas and two clinics, each randomly selected from the District Health Management Team (DHMT) and the Lesotho Flying Doctors Service (LFDS), respectively. A total of 2928 individual household members aged 15 and above were included in the study. Data analysis included descriptive and inferential statistics. Results: There were more female than male respondents, with a majority (77%) below 65 years of age. Tuberculosis knowledge of respondents was mostly on the TB symptoms and curability of TB, but they were less knowledgeable about the causes of TB. The use of VHWs' services for TB screening was very low (23.3%). Conclusion: The study revealed that while respondents were to some extent knowledgeable about TB, their utilisation of VHWs' services for TB screening varied with education level, having worked in South Africa and the household size at α = 0.01. [ABSTRACT FROM AUTHOR]

Abstract Background Tuberculosis screening of people living with HIV (PLHIV) – an intervention to reduce the burden of TB among PLHIV – is being implemented at HIV clinics in Ghana since 2007, but TB screening coverage remains low. Facility adherence to intervention guidelines may be a factor but is missing in implementation science literature. This study assesses the level of HIV clinic adherence to the guidelines and related facility characteristics in selected district hospitals in Ghana. Methods This cross-sectional study was conducted in all 27 district hospitals with HIV clinics, X-ray and geneXpert machines in Ghana. These hospitals are in 27 districts representing about 27% of the 100 district hospitals with HIV clinics in Ghana. A data collection tool with 18-items (maximum score of 29) was developed from the TB/HIV collaborative guidelines to assess facility adherence to four interrelated components of the TB screening programme as stated in the guidelines: intensive TB case-finding among PLHIV (ITCF), Isoniazid preventive therapy initiation (IPT), TB infection control (TIC), and programme review meetings (PRM). Data were collected through record review and interviews with 27 key informants from each hospital. Adherence scores per component were summed to determine an overall adherence score per facility and summarized using medians and converted to proportions. Facility characteristics were assessed and compared across facilities with high (above median) versus low (below median) overall adherence scores, using nonparametric test statistics. Results From the 27 key interviews and facility records reviewed, the median adherence scores for ITCF, IPT, TIC, and PRM components were 85.7% (IQR: 85.5–100.0), 0% (IQR: 0–66.7), 33.3% (IQR: 33.3–50.0), and 90.0% (IQR: 70.0–90.0), respectively. The overall median adherence score was 62.1% (IQR: 58.6–65.1), and 17 clinics (63%) with overall adherence score above the median were categorized as high adherence. Compared to low adherence facilities, high adherence facilities had statistically significant lower PLHIV clinic attendees per month (256 (IQR: 60–904) vs. 900 (IQR: 609–2622); p = 0.042), and lower HIV provider workloads (28.6 (IQR: 8.6–113) vs. 90 (IQR: 66.7–263.5); p = 0.046), and most had screening guidelines (76%, p

Background: Decreasing the burden of Tuberculosis (TB) among PLHIV through TB screening is an effective intervention recommended by the World Health Organization (WHO). However, after over a decade of implementation in Ghana, the intervention does not realize the expected outcomes. It is also not well understood whether this lack of success is due to implementation barriers. Our study, therefore, sought to examine the factors influencing the implementation of the intervention among people living with HIV (PLHIV) attending HIV clinics at district hospitals in Ghana.Methods: This was a qualitative study conducted from 6th to 31 May 2019 in three regions of Ghana. We conducted 17 in-depth interviews (IDIs - comprising two regional, six districts and nine facility TB/HIV coordinators) and eight focus group discussions (FGD - consisting of a total of 65 participants) with HIV care providers. The Consolidated Framework for Implementation Research (CFIR) guided the design of interview guides, data collection and analysis. All responses were digitally audio-recorded and transcribed verbatim for coding and analysis using the Framework Approach. Participants consented to the interview and recording.Results: The main barriers to TB screening relate to the low commitment of the implementers to screen for TB and limited facility infrastructure for the screening activities. Facilitators of TB screening include (1) ease in TB screening, (2) good communication and referral channels, (3) effective goals and feedback mechanisms, (4) health workers recognizing the need for the intervention and (5) the role of chemical sellers.Conclusions: Key barriers and facilitators to the intervention are revealed. The study has shown that there is a need to increase HIV care providers and institutional commitment towards TB screening interventions. In addition, cost issues need to be assessed as they are drivers of sustainability. Our study also advances the field of implementation science through CFIR to better understand the factors influencing the implementation. [ABSTRACT FROM AUTHOR]

Background: Active tuberculosis (TB) during pregnancy has an adverse effect on maternal and neonatal outcomes. This study analysed the results of a pilot project integrating TB screening into antenatal care (ANC) visits in a high-TB-burden, low-resource setting. Methods: Data were extracted from the TB screening pilot in obstetrician-gynaecologist clinics of six tertiary care facilities in Karachi, Pakistan from April to December 2017. Data from the verbal symptom screening conducted at each ANC visit for all women and the Xpert MTB/RIF testing for all symptomatic women to investigate TB yield were analysed by assessing the numbers screened, presumptive patients and active TB diagnoses among pregnant women and neonates. Results: Symptom screening was performed on 113,078 pregnant women, 2,965 (2.6%) of whom reported at least one TB symptom. Sputum samples were collected from 2,896 (97.7%) symptomatic women. Of the 27 (0.9%) newly diagnosed bacteriologically positive TB patients, 25 (93%) initiated TB treatment. No case of vertical TB transmission was reported among 26 live births. Discussion: TB screening is feasible and should be implemented during routine ANC visits in high-TB-burden settings. There is a need to explore a multi-faceted approach with inclusion of clinical examination and chest X-rays to diagnose TB in pregnant women.

Background: Village health workers (VHWs) play an essential role because they extend the capacity of primary healthcare, particularly for developing countries. In Lesotho, VHWs are part of the primary healthcare connecting the community with clinics in their respective villages. They contribute to the prevention of the spread of tuberculosis (TB) within their catchment areas by encouraging communities to partake in TB screening. This study aimed at identifying factors associated with the utilisation of VHWs’ service to undertake TB screenings in Lesotho. Methods: This study emanates from the main study that used a cross-sectional descriptive design. A total of 19 health service areas (HSAs) comprised 17 catchment areas and two clinics, each randomly selected from the District Health Management Team (DHMT) and the Lesotho Flying Doctors Service (LFDS), respectively. A total of 2928 individual household members aged 15 and above were included in the study. Data analysis included descriptive and inferential statistics. Results: There were more female than male respondents, with a majority (77%) below 65 years of age. Tuberculosis knowledge of respondents was mostly on the TB symptoms and curability of TB, but they were less knowledgeable about the causes of TB. The use of VHWs’ services for TB screening was very low (23.3%). Conclusion: The study revealed that while respondents were to some extent knowledgeable about TB, their utilisation of VHWs’ services for TB screening varied with education level, having worked in South Africa and the household size at α = 0.01.

Background: In Myanmar, the use of a mobile app for tuberculosis (TB) screening and its operational effect on seeking TB health care have not been evaluated yet. Objective: This study aims to report the usability of a simple mobile app to screen TB and comply with chest X-ray (CXR) examination of presumptive cases detected by the app. Methods: A new "TB-screen" app was developed from a Google Sheet based on a previously published algorithm. The app calculates a TB risk propensity score from an individual's sociodemographic characteristics and TB clinical history and suggests whether the individual should undergo a CXR. The screening program was launched in urban slum areas soon after the COVID-19 outbreak subsided. A standard questionnaire was used to assess the app's usability rated by presumptive cases. Compliance to undergo CXR was confirmed by scanning the referral quick response (QR) code via the app. Results: Raters were 453 presumptive cases detected by the app. The mean usability rating score was 4.1 out of 5. Compliance to undergo CXR examination was 71.1% (n=322). Active TB case detection among CXR compliances was 7.5% (n=24). One standard deviation (SD) increase in the app usability score was significantly associated with a 59% increase in the odds to comply with CXR (ß=.464) after adjusting for other variables (P<.001). Conclusions: This simple mobile app got a high usability score rated by 453 users. The mobile app usability score successfully predicted compliance to undergo CXR examination. Eventually, 24 (7.5%) of 322 users who were suspected of having TB by the mobile app were detected as active TB cases by CXR. The system should be upscaled for a large trial. [ABSTRACT FROM AUTHOR]

Sputum smear microscopic examination is an effective, fast, and low-cost technique that is highly specific in areas with a high prevalence of pulmonary tuberculosis. Since manual screening needs trained pathologist in high prevalence zones, the possibility of deploying adequate technicians during the epidemic sessions would be impractical. This condition can cause overburdening and fatigue of working technicians which may tend to reduce the potential efficiency of Tuberculosis (TB) diagnosis. Hence, automation of sputum inspection is the most appropriate aspect in TB outbreak zones to maximize the detection ability. Sputum collection, smear preparing, staining, interpreting smears, and reporting of TB severity are all part of the diagnosis of tuberculosis. This study has analyzed the risk of automating TB severity grading. According to the findings of the analysis, numerous TB-positive cases do not fit into the standard TB severity grade while applying direct rule-driven strategy. The manual investigation, on the other hand, arbitrarily labels the TB grade on those cases. To counter the risk of automation, a fuzzy-based Tuberculosis Severity Level Categorizing Algorithm (TSLCA) is introduced to eliminate uncertainty in classifying the level of TB infection. TSLCA introduces the weight factors, which are dependent on the existence of maximum number of Acid-Fast Bacilli (AFB) per microscopic Field of View (FOV). The fuzzification and defuzzification operations are carried out using the triangular membership function. In addition, the α -cut approach is used to eliminate the ambiguity in TB severity grading. Several uncertain TB microscopy screening reports are tested using the proposed TSLCA. Based on the experimental results, it is observed that the TB grading by TSLCA is consistent, error-free, significant and fits exactly into the standard criterion. As a result of the proposed TSLCA, the uncertainty of grading is eliminated and the reliability of tuberculosis diagnosis is ensured when adapting automatic diagnosis. [ABSTRACT FROM AUTHOR]

Tuberculosis (TB) is a chronic lung disease that occurs due to bacterial infection and is one of the top 10 leading causes of death. Accurate and early detection of TB is very important, otherwise, it could be life-threatening. In this work, we have detected TB reliably from the chest X-ray images using image pre-processing, data augmentation, image segmentation, and deep-learning classification techniques. Several public databases were used to create a database of 3500 TB infected and 3500 normal chest X-ray images for this study. Nine different deep CNNs (ResNet18, ResNet50, ResNet101, ChexNet, InceptionV3, Vgg19, DenseNet201, SqueezeNet, and MobileNet) were used for transfer learning from their pre-trained initial weights and were trained, validated and tested for classifying TB and non-TB normal cases. Three different experiments were carried out in this work: segmentation of X-ray images using two different U-net models, classification using X-ray images and that using segmented lung images. The accuracy, precision, sensitivity, F1-score and specificity of best performing model, ChexNet in the detection of tuberculosis using X-ray images were 96.47%, 96.62%, 96.47%, 96.47%, and 96.51% respectively. However, classification using segmented lung images outperformed that with whole X-ray images; the accuracy, precision, sensitivity, F1-score and specificity of DenseNet201 were 98.6%, 98.57%, 98.56%, 98.56%, and 98.54% respectively for the segmented lung images. The paper also used a visualization technique to confirm that CNN learns dominantly from the segmented lung regions that resulted in higher detection accuracy. The proposed method with state-of-the-art performance can be useful in the computer-aided faster diagnosis of tuberculosis.

Background: Tuberculosis screening of people living with HIV (PLHIV) - an intervention to reduce the burden of TB among PLHIV - is being implemented at HIV clinics in Ghana since 2007, but TB screening coverage remains low. Facility adherence to intervention guidelines may be a factor but is missing in implementation science literature. This study assesses the level of HIV clinic adherence to the guidelines and related facility characteristics in selected district hospitals in Ghana.Methods: This cross-sectional study was conducted in all 27 district hospitals with HIV clinics, X-ray and geneXpert machines in Ghana. These hospitals are in 27 districts representing about 27% of the 100 district hospitals with HIV clinics in Ghana. A data collection tool with 18-items (maximum score of 29) was developed from the TB/HIV collaborative guidelines to assess facility adherence to four interrelated components of the TB screening programme as stated in the guidelines: intensive TB case-finding among PLHIV (ITCF), Isoniazid preventive therapy initiation (IPT), TB infection control (TIC), and programme review meetings (PRM). Data were collected through record review and interviews with 27 key informants from each hospital. Adherence scores per component were summed to determine an overall adherence score per facility and summarized using medians and converted to proportions. Facility characteristics were assessed and compared across facilities with high (above median) versus low (below median) overall adherence scores, using nonparametric test statistics.Results: From the 27 key interviews and facility records reviewed, the median adherence scores for ITCF, IPT, TIC, and PRM components were 85.7% (IQR: 85.5-100.0), 0% (IQR: 0-66.7), 33.3% (IQR: 33.3-50.0), and 90.0% (IQR: 70.0-90.0), respectively. The overall median adherence score was 62.1% (IQR: 58.6-65.1), and 17 clinics (63%) with overall adherence score above the median were categorized as high adherence. Compared to low adherence facilities, high adherence facilities had statistically significant lower PLHIV clinic attendees per month (256 (IQR: 60-904) vs. 900 (IQR: 609-2622); p = 0.042), and lower HIV provider workloads (28.6 (IQR: 8.6-113) vs. 90 (IQR: 66.7-263.5); p = 0.046), and most had screening guidelines (76%, p < 0.01) and questionnaire (80%, p < 0.01) available on-site.Conclusion: PRM had highest score while the IPT component had the lowest score. Almost a third of the facilities implemented the TB screening programme activities with a high level of adherence to the guidelines. We suggest to ensure adherence to all four components, reducing staff workloads and making TB screening questionnaires and guidelines available on-site would increase facility adherence to the intervention and ultimately achieve intervention targets. [ABSTRACT FROM AUTHOR]

Screening of high-risk groups for Tuberculosis (TB) is considered as the cornerstone for TB elimination but the measure of cost-effectiveness is also crucial in deciding the strategy for TB screening. This study aims to measure the cost-effectiveness of TB screening between the various high-risk groups in Malaysia. A decision tree model was developed to assess the cost-effectiveness of TB screening among the high-risk groups from a provider perspective using secondary data from the year 2016 to 2018. The results are presented in terms of an Incremental Cost-Effectiveness Ratio (ICER), expressed as cost per TB case detected. Deterministic and Probabilistic Sensitivity Analysis was also performed to measure the robustness of the model. TB screening among Person Living with Human Immunodeficiency Virus (PL HIV) was the most cost-effective strategy, with MYR 2,597.00 per TB case detected. This was followed by elderly, prisoners and smokers with MYR 2,868.62, MYR 3,065.24, and MYR 4,327.76 per one TB case detected, respectively. There was an incremental cost of MYR 2.49 per screening, and 3.4 TB case detection per 1,000 screening for TB screening among PL HIV in relation to TB screening among prisoners. The probability of symptomatic cases diagnosed as TB was the key driver for increasing cost-effectiveness efficacy among PL HIV. Results of the study suggest prioritization of high-risk group TB screening program by focusing on the most cost-effective strategy such as screening among PL HIV, prisoners and elderly, which has a lower cost per TB case detected.

While it is known that a substantial proportion of individuals with tuberculosis disease (TB) present subclinically, usually defined as bacteriologically-confirmed but negative on symptom screening, considerable knowledge gaps remain. Our aim was to review data from TB prevalence population surveys and generate a consistent definition and framework for subclinical TB, enabling us to estimate the proportion of TB that is subclinical, explore associations with overall burden and program indicators, and evaluate the performance of screening strategies. We extracted data from all publicly available prevalence surveys conducted since 1990. Between 36.1% and 79.7% (median, 50.4%) of prevalent bacteriologically confirmed TB was subclinical. No association was found between prevalence of subclinical and all bacteriologically confirmed TB, patient diagnostic rate, or country-level HIV prevalence (P values,.32,.4, and.34, respectively). Chest Xray detected 89% (range, 73%–98%) of bacteriologically confirmed TB, highlighting the potential of optimizing current TB case-finding policies. [ABSTRACT FROM AUTHOR]

• Tuberculosis (TB) screening is feasible during routine antenatal care visits in high-TB-burden settings. • Out of 113,078 women verbally screened at obstetrics and gynaecology clinics, 2.6% were TB-positive. • The overall yield of active TB cases among pregnant women was low (0.02%; 27/113,078). Active tuberculosis (TB) during pregnancy has an adverse effect on maternal and neonatal outcomes. This study analysed the results of a pilot project integrating TB screening into antenatal care (ANC) visits in a high-TB-burden, low-resource setting. Data were extracted from the TB screening pilot in obstetrician-gynaecologist clinics of six tertiary care facilities in Karachi, Pakistan from April to December 2017. Data from the verbal symptom screening conducted at each ANC visit for all women and the Xpert MTB/RIF testing for all symptomatic women to investigate TB yield were analysed by assessing the numbers screened, presumptive patients and active TB diagnoses among pregnant women and neonates. Symptom screening was performed on 113,078 pregnant women, 2,965 (2.6%) of whom reported at least one TB symptom. Sputum samples were collected from 2,896 (97.7%) symptomatic women. Of the 27 (0.9%) newly diagnosed bacteriologically positive TB patients, 25 (93%) initiated TB treatment. No case of vertical TB transmission was reported among 26 live births. TB screening is feasible and should be implemented during routine ANC visits in high-TB-burden settings. There is a need to explore a multi-faceted approach with inclusion of clinical examination and chest X-rays to diagnose TB in pregnant women. [ABSTRACT FROM AUTHOR]

Abstract Background The neutrophil to lymphocyte ratio (NL ratio) has been reported to be a predictive biomarker of tuberculosis (TB). We assessed the association between the NL ratio and the incidence of active TB cases within 1 year after TB screening among HIV-infected individuals in Thailand. Methods A day care center that supports HIV-infected individuals in northernmost Thailand performed TB screening and follow-up visits. We compared the baseline characteristics between the TB screening positive group and the TB screening negative group. The threshold value of NL ratio was determined by cubic-spline curves and NL ratios were categorized as high or low NL ratio. We assessed the association between NL ratio and progression to active TB within 1-year using the Cox-proportional hazard model. Results Of the 1064 HIV-infected individuals who screened negative for TB at baseline, 5.6% (N = 60) eventually developed TB and 26 died after TB diagnosis. A high NL ratio was associated with a higher risk of TB (adjusted hazard ratio (aHR) 2.19, 95% CI: 1.23–3.90), after adjusting for age, sex, ethnicity, CD4 counts, and other risk factors. A high NL ratio in HIV-infected individuals with normal chest X-ray predicted TB development risk. In particular, a high NL ratio with TB symptoms could predict the highest risk of TB development (aHR 2.58, 95%CI: 1.07–6.23). Conclusions Our results showed that high NL ratio increased the risk of TB. NL ratio combined with TB symptoms could increase the accuracy of TB screening among HIV-infected individuals.

Abstract Background Every year around 4 million people with tuberculosis (TB) are not detected. Thus may not get the medical care that they need and deserve from their respective health systems. Ethiopia is included in the 12 countries who contribute 75% of the globally estimated “missed” cases. This study assessed if there are missed Pulmonary TB (PTB) cases among inpatients of a large referral hospital in Ethiopia. Method A cross sectional survey was conducted in the general medical wards of the large referral hospital from June to August 2015. Inpatients not diagnosed with TB were screened for TB symptoms and requested to submit a morning sputum sample for smear microscopy and molecular testing by GeneXpert MTB/RIF assay. The results of the symptom screening, smear and GeneXpert testing were analyzed as the main outcome characteristics for “missed” PTB cases. Result Over the 3-month period, 300 inpatients were evaluated for TB. The patients median age was 38 years (IQR 26–51.5), 41% were female, median reported duration of sickness before admission was 30 days (IQR 14–240), and median body mass index (BMI) was 21.5 (IQR 20–22.67). HIV status was documented for 198/300 (66%) of patients, 37 (18.7%) were found to be HIV positive, with a median CD4 count of 176 (IQR 52–400). All 300 inpatients submitted a sputum sample and 10 (3.3%) were found to be GeneXpert MTB positive, with 4/10 also being smear positive. All GeneXpert positive inpatients reported having a cough of > 2 weeks duration. Eight had at least 3 common symptoms of TB (i.e. cough, fever, weight loss or night sweat). Co-morbidity with Diabetes Mellitus (DM) and HIV was found in 1/10 and 4/10 cases respectively. Conclusion Bacteriological confirmed TB cases were found to have been “missed” amongst the general medical ward inpatients in the hospital. The identified TB cases all reported typical signs and symptoms of TB. Basic clinical practices were not being followed (i.e. history taking/documentation and requesting of appropriate laboratory tests) by the attending health care workers (HCWs) in the hospital. The index of suspicion for TB disease needs to improve and the use of more sensitive technologies, such as GeneXpert could assist the diagnosis of TB. However, the findings of the study need to be investigated in other hospital settings in Ethiopia.

Background: Interferon gamma release assays (IGRAs) have been shown to be highly dynamic tests when used in serial testing for TB infection. However, there is little information demonstrating a clear association between TB exposure and IGRA responses over time, particularly in high TB incidence settings. Objectives: To assess whether QuantiFERON-TB Gold In-Tube (QFT) responses are associated with occupational TB exposures in a cohort of young health care trainees in India. Methods: All medical and nursing students at Mahatma Gandhi Institute of Medical Sciences were approached. Participants were followed up for 18 months; QFT was performed 4 times, once every 6 months. Various modeling approaches were used to define IFN-gamma trajectories and correlations with TB exposure. Results: Among 270 medical and nursing trainees, high rates of conversions (6.3–20.9%) and reversions (20.0–26.2%) were found depending on the definitions used. Stable converters were more likely to have had TB exposure in hospital pre-study. Recent occupational exposures were not consistently associated with QFT responses over time. Conclusion: IFN-gamma responses and rates of change could not be explained by occupational exposure investigated. High conversion and subsequent reversion rates suggest many health care workers (HCWs) would revert in the absence of treatment, either by clearing the infection naturally or due to fluctuations in the underlying immunological response and/or poor assay reproducibility. QFT may not be an ideal diagnostic test for repeated screening of HCWs in a high TB incidence setting.

Highlights • E-DETECT TB, a European collaboration, collects screening data on active and latent TB for better evidence in future screening guidelines. • E-DETECT TB aims to address the present lack of evidence concerning coverage, impact and cost-effectiveness in migrant TB screening. • Through collaborative efforts, country-level screening is collated by using agreed key variables in a joint database. • The project has successfully overcome considerable administrative, practical and legal challenges. Abstract Background and aim Screening for active and latent TB among migrants in low TB incidence countries may constitute an important contribution to TB elimination. E-DETECT TB, a European multi-county collaboration, aims to address the present lack of evidence on effectiveness of migrant TB screening by collating data in an international database and perform cross-country pooled and comparative analyses of screening coverage, results and linkage to care. Method A database was established using migrant TB screening data from participating countries' national screening programs, national screening pilots and local research projects. All partner countries contributed to a common agreed protocol with standardized variables, pooling available numerator and denominator screening data from participating countries and sites. Results All collaborating members drafted and agreed upon a data sharing accord as well as a protocol that clearly defined responsibilities and data governance principles. The database has been created and data transfer is ongoing. Conclusion By persistence and focus the project has overcome considerable administrative, practical and legal challenges. This international collaboration provides greater power of analysis of harmonized data and thereby a unique opportunity to contribute migrant TB screening evidence. E-DETECT TB has started to invite other countries to contribute data to the database. [ABSTRACT FROM AUTHOR]

Background: Every year around 4 million people with tuberculosis (TB) are not detected. Thus may not get the medical care that they need and deserve from their respective health systems. Ethiopia is included in the 12 countries who contribute 75% of the globally estimated "missed" cases. This study assessed if there are missed Pulmonary TB (PTB) cases among inpatients of a large referral hospital in Ethiopia.Method: A cross sectional survey was conducted in the general medical wards of the large referral hospital from June to August 2015. Inpatients not diagnosed with TB were screened for TB symptoms and requested to submit a morning sputum sample for smear microscopy and molecular testing by GeneXpert MTB/RIF assay. The results of the symptom screening, smear and GeneXpert testing were analyzed as the main outcome characteristics for "missed" PTB cases.Result: Over the 3-month period, 300 inpatients were evaluated for TB. The patients median age was 38 years (IQR 26-51.5), 41% were female, median reported duration of sickness before admission was 30 days (IQR 14-240), and median body mass index (BMI) was 21.5 (IQR 20-22.67). HIV status was documented for 198/300 (66%) of patients, 37 (18.7%) were found to be HIV positive, with a median CD4 count of 176 (IQR 52-400). All 300 inpatients submitted a sputum sample and 10 (3.3%) were found to be GeneXpert MTB positive, with 4/10 also being smear positive. All GeneXpert positive inpatients reported having a cough of > 2 weeks duration. Eight had at least 3 common symptoms of TB (i.e. cough, fever, weight loss or night sweat). Co-morbidity with Diabetes Mellitus (DM) and HIV was found in 1/10 and 4/10 cases respectively.Conclusion: Bacteriological confirmed TB cases were found to have been "missed" amongst the general medical ward inpatients in the hospital. The identified TB cases all reported typical signs and symptoms of TB. Basic clinical practices were not being followed (i.e. history taking/documentation and requesting of appropriate laboratory tests) by the attending health care workers (HCWs) in the hospital. The index of suspicion for TB disease needs to improve and the use of more sensitive technologies, such as GeneXpert could assist the diagnosis of TB. However, the findings of the study need to be investigated in other hospital settings in Ethiopia. [ABSTRACT FROM AUTHOR]

Abstract Early screening is recommended in children exposed to a contagious case of tuberculosis (TB), to prevent rapid progression to active TB. The aim of this study was to evaluate the percentage of potentially preventable cases of pediatric TB stemming from inadequate screening. The data gathered on children aged 0 to 10 years, who were evaluated by the Paris Center for TB Control (CLAT75) between January 2009 and December 2013, were extracted and retrospectively analyzed. French National Guidelines for screening were used as reference. During the study period, 1232 children 0–10 years were screened, because of a known exposure to an index case, including 124 (10%) with criteria for latent tuberculosis infection (LTBI) and 26 (2%) with active TB. Twelve additional cases of TB were reported, diagnosed based on symptoms or systematic exams. As a whole, 68% of pediatric TB cases were diagnosed at screening around an adult index case, highlighting the quality of the screening network. Among the 38 TB cases, 19 (50%) had a missed opportunity for potential prevention, due to the absence of screening despite a known contaminant (n = 2) or to screening not in compliance with current recommendations (n = 17). Delayed first evaluation was the most frequent error of the screening procedures. In conclusion, despite the quality of the screening network set up in Paris, half of the pediatric TB cases in this study did not undergo the recommended screening procedures. A significant reduction in the number of pediatric TB cases can be expected through the optimization of screening networks. [ABSTRACT FROM AUTHOR]

Objectives We assessed the effect of an active case finding (ACF) project on tuberculosis (TB) case notification and the yields from a household and neigbourhood intervention (screening contacts of historical index TB patients diagnosed >24 months ago) and a community intervention (screening attendants of health education sessions/mobile clinics). Design Cross-sectional analysis of project records, township TB registers and annual TB reports. Results In the household and neigbourhood intervention , of 56,709 people screened, 1,076 were presumptive TB and 74 patients were treated for active TB with a screening yield of 0.1% and a yield from presumptive cases of 6.9%. In the community intervention, of 162,881 people screened, 4,497 were presumptive TB and 984 were treated for active TB with a screening yield of 0.6% and yield from presumptive cases of 21.9%. Of active TB cases, 94% were new, 89% were pulmonary, 44% were bacteriologically-confirmed and 5% had HIV. Case notification rates per 100,000 in project townships increased from 142 during baseline (2011-2013) to 148 during intervention (2014-2016) periods. Conclusions The yield from household and neigbourhood intervention was lower than community intervention. This finding highlights reconsidering the strategy of screening of contacts from historical index cases. Strategies to reach high-risk groups should be explored for future ACF interventions to increase yield of TB. [ABSTRACT FROM AUTHOR]

Objectives Intense migrations from tuberculosis endemic areas to Gulf countries create special risks for people in the region. The purpose of this study was to provide data that could justify implementing universal, regular TB screening in UAE. Design This prospective, cross-sectional study used interferon-γ release assay (IGRA) to screen for TB among Emirati citizens between August-2016 and May-2017; expatriates were not included in this study. Participants were recruited from Emiratis attending Tawam Hospital Polyclinics for problems unrelated to TB risk assessment. IGRA was requested for all enrolled participants. A risk-assessment questionnaire was completed by all participants. In addition, a retrospective review of IGRA results (January-2011 to April-2016) was conducted to compare prevalence of positive IGRA in the ‘prospective sample’ with that in ‘patients screened in the past’. Results Four hundred fifty-five participants (69% females) were enrolled in this study. Participants’ age (mean ± SD) was 42 ± 16y. The majority of participants had traveled to or had helpers from TB-endemic areas. Two hundred forty (53%) participants had IGRA test. Forty-five (18.8%) participants had positive IGRA, similar to the retrospective results of 12.4% to 23.5%. Conclusions The prevalence of positive-IGRA in this study is high. [ABSTRACT FROM AUTHOR]

Objectives: To assess the magnitude of active TB disease and latent TB infection (LTBI) in young adults of college age.Participants: Individuals who were aged 18–24 years in 2011 were used as a proxy for college students.Methods: Active TB cases reported to the 2011 US National TB Surveillance System (NTSS) were included. LTBI prevalence was calculated from the 2011–2012 National Health and Nutrition Examination Survey. The 2011 American Community Survey was used to calculate population denominators. Analyses were stratified by nativity.Results: Active TB disease incidence among persons aged 18–24 years was 2.82/100,000, 18.8/100,000 among foreign-born individuals and 0.9/100,000 among US-born individuals. In 2011, 878 TB cases were reported; 629 (71.6%) were foreign-born. LTBI prevalence among persons of 18–24 years was 2.5%: 8.7% and 1.3% among foreign-born and US-born, respectively.Conclusion: Active screening and treatment programs for foreign-born young adults could identify TB cases earlier and provide an opportunity for prevention efforts. [ABSTRACT FROM PUBLISHER]

There is a high prevalence of latent tuberculosis infection (LTBI) and risk of re- activation among refugees. This study describes LTBI prevalence, treatment initiation, and completion rates in refugee patients seen at one urban Connecticut hospital. This retrospective chart review includes 248 adult refugee patients screened between January 2009 and April 2012. Demographics, tuberculin skin test (TST) results, treatment initiation and completion rates, and treatment-related variables were collected. Ninety-eight percent of adult refugees received TST screening and 44.0% were diagnosed with LTBI. Of these, 95.5% initiated treatment, and of those, 48.2% completed treatment. Early treatment discontinuation was high, with 29.5% of patients diagnosed with LTBI defaulting after the first clinic visit. Despite near-universal screening within this refugee population, LTBI treatment initiation and completion rates remain low. Greater efforts should be made to ensure LTBI treatment initiation and completion among refugees through early case management and shorter treatment duration. [ABSTRACT FROM AUTHOR]

Background The use of biologic agents has become an important option in treating patients with rheumatoid arthritis. However, these drugs have been associated with an increased risk of tuberculosis ( TB) reactivation. Local guidelines for TB screening prior to the use of biologic agents were developed to address this issue. Aim This study is a survey describing the compliance of Filipino rheumatologists to these guidelines. Method Eighty-seven rheumatologists in the Philippines were given the questionnaire and responses from 61 rheumatologists were included in the analysis. Results All respondents agree that patients should be screened prior to giving the biologic agents. Local guidelines recommend screening with tuberculin skin test ( TST) and chest radiograph. However, cut-off values considered for a positive TST and timing of initiation of biologic agents after starting TB prophylaxis and treatment varied among respondents. In addition, screening of close household contacts were only performed by 41 (69.5%) respondents. There were 11 respondents who reported 16 patients developing TB during or after receiving biologic agents, despite adherence to the guidelines. Conclusion This survey describes the compliance rate of Filipino rheumatologists in applying current local recommendations for TB screening prior to initiating biologic agents. The incidence of new TB cases despite the current guidelines emphasizes the importance of compliance and the need to revise the guidelines based on updated existing literature. [ABSTRACT FROM AUTHOR]

Symptom-based tuberculosis screening identifies less than one-third of eligible HIV-infected patients as candidates for isoniazid preventive therapy (IPT). We evaluated whether testing for C-reactive protein (CRP) improves patient selection for IPT.We measured CRP levels (normal <10 mg/L) using a point-of-care (POC) assay on stored serum samples from HIV-infected Ugandan adults initiating antiretroviral therapy. We assessed diagnostic accuracy in reference to baseline tuberculosis status adjudicated by an expert committee and calculated net reclassification improvement to quantify the incremental discriminatory benefit of POC-CRP in determining IPT eligibility compared to the World Health Organization (WHO) symptom screen.Of 201 patients (median CD4 cell count, 137 cells/μL; interquartile range, 83-206), 5 (2.5%) had tuberculosis. Compared to the WHO symptom screen, POC-CRP had similar sensitivity (100% vs. 80%, P = 0.30) but greater specificity (21% vs. 87%, P < 0.0001) for tuberculosis. If based on the WHO symptom screen, no patients with tuberculosis but only 42 of 196 patients without tuberculosis would have been considered IPT eligible. If POC-CRP were used instead, 1 patient with tuberculosis (reclassification of cases, -20%; P = 0.32) and 129 patients without tuberculosis (reclassification of noncases, +66%; P < 0.001) would have been reclassified as IPT eligible, a net reclassification improvement of 46% (P = 0.03). In addition, POC-CRP testing would have reduced the proportion of patients without active tuberculosis requiring confirmatory tuberculosis testing (87% vs. 21%, P < 0.0001).POC-CRP testing increased more than 4-fold the proportion of HIV-infected adults immediately identified as IPT eligible and decreased the proportion of patients requiring referral for further tuberculosis diagnostic testing. POC-CRP testing could substantially improve implementation of tuberculosis screening guidelines. [ABSTRACT FROM AUTHOR]

Abstract: Background: Interferon gamma release assays (IGRAs) have been shown to be highly dynamic tests when used in serial testing for TB infection. However, there is little information demonstrating a clear association between TB exposure and IGRA responses over time, particularly in high TB incidence settings. Objectives: To assess whether QuantiFERON-TB Gold In-Tube (QFT) responses are associated with occupational TB exposures in a cohort of young health care trainees in India. Methods: All medical and nursing students at Mahatma Gandhi Institute of Medical Sciences were approached. Participants were followed up for 18months; QFT was performed 4 times, once every 6months. Various modeling approaches were used to define IFN-gamma trajectories and correlations with TB exposure. Results: Among 270 medical and nursing trainees, high rates of conversions (6.3–20.9%) and reversions (20.0–26.2%) were found depending on the definitions used. Stable converters were more likely to have had TB exposure in hospital pre-study. Recent occupational exposures were not consistently associated with QFT responses over time. Conclusion: IFN-gamma responses and rates of change could not be explained by occupational exposure investigated. High conversion and subsequent reversion rates suggest many health care workers (HCWs) would revert in the absence of treatment, either by clearing the infection naturally or due to fluctuations in the underlying immunological response and/or poor assay reproducibility. QFT may not be an ideal diagnostic test for repeated screening of HCWs in a high TB incidence setting. [Copyright &y& Elsevier]

Objectives: Health and social characteristics place prisoners at high risk for progression from latent tuberculosis infection (LTBI) to tuberculosis (TB), but completion of LTBI therapy is low with many patients lost to follow-up after release. Despite decreases in active TB, demographic characteristics of active cases have remained relatively unchanged. This study investigated whether characteristics have changed in inmates diagnosed with LTBI in San Francisco, CA, USA. Study design: Cross-sectional. Methods: Data from baseline interviews of randomized trials conducted in 1998-1999 and 2004-2007 were compared. Results: In both time periods, most subjects with LTBI (>60%) were Latinos, while the proportion in both the jail and San Francisco remained at 15-20%. Overall, the prisoners interviewed in 2004-2007 were less likely to have been on medication for LTBI previously, and expressed more likelihood of finishing their medication compared with those interviewed in 1998-1999. In 2004-2007, the foreign-born subjects were more likely to prefer English to Spanish, to have been in stable housing and to have been employed before jail compared with 1998-1999, while no such changes were seen between the two time periods for US-born subjects. Conclusions: The pool of TB-infected individuals coming from a jail is not static, and understanding the changes over time is of importance for targeted programmes. Given the high infection rate and the predominance of foreign-born individuals who may have received bacillus Calmette-Guérin vaccination, screening with interferon-gamma release assay may be beneficial to identify those with true infection. [ABSTRACT FROM AUTHOR]

Recent immigrants from developing countries (<2 years since immigration) are at very high risk of active TB disease due to reactivation of latent infections acquired in the country of origin. In industrialized low-incidence TB countries targeted testing programs for high risk groups could allow the detection of latently infected persons who would likely benefit from a course of preventive treatment. In this study we evaluated the tuberculin skin test (TST) and interferon-γ enzyme-linked immunosorbent assay (QuantiFERON TB-gold in tube, QFT-IT) strategies for TB infection screening programs in recent immigrants from highly endemic countries. This is a prospective cross-sectional study. Paired tests performed in 1,130 immigrants attending an outpatient ward, between 2005 and 2007 for any health problem were evaluated by intention-to-treat (ITT) and per-protocol (PP) analysis for efficiency and efficacy of screening program. Positive TST and QFT-IT were observed in 36.04 versus 29.82% (ITT) and in 45.27 versus 30.22% (PP) respectively. A higher drop-out rate was observed for TST (20.35 vs. 1.33%) ( p < 0.0001). Second level assessment was accepted by half of the TST positive patients. Overall agreement rate between 887 paired tests was fair ( k = 0.38). Higher k values were observed for higher TB prevalence rate in the country of origin ( k = 0.43), for TST induration diameters >20 mM ( k = 0.47), in subjects aged 40–50 years ( k = 0.41) and in unvaccinated persons ( k = 0.40). In a multiple logistic regression model continent of origin, class of TB prevalence in the country of origin and contacts with TB patients were found to be significantly associated with the probability of TST and QFT-IT positive result. Low education levels were associated only to an increased risk of TST positive results. The drawback of the TST screening strategy in recent immigrants from highly endemic countries is due to low sensitivity/specificity of the test and to high drop-out rate with an overall significant lowering in strategy efficacy/efficiency. The higher QFT-IT specificity prevents unnecessary overload of the health care system and, although more expensive, might represent a cost-effective alternative to TST in targeted screening programs directed to high risk populations. [ABSTRACT FROM AUTHOR]

Detecting and managing Mycobacterium tuberculosis (TB) infection in a health-science center population is a clinical dilemma. Tuberculin skin tests are still the preferred method for detecting present or past infection of TB. The authors discuss the performance of whole blood interferon gamma release assay test commercially known as QuantiFERON-TB Gold Test (QFT-G) as an additional tool for a TB surveillance program for the students and employees at an academic medical center. QFT-G was successfully implemented as a confirmatory test for screening of TB infection. [ABSTRACT FROM AUTHOR]

Infliximab is an anti-TNFα chimeric monoclonal antibody, commonly used in the treatment of moderate to severe psoriasis. TNFα is a pro-inflammatory cytokine which play a key role in host defense from infections by intracellular bacteria, such as Listeria monocytogenes, Histoplasma Capsulatum and especially Mycobacterium Tuberculosis. Infliximab therapy increases the risk of tuberculosis due mainly to the reactivation of latent TB infection (LTBI) and, therefore, it is mandatory to screen patients for LTBI prior to starting a treatment with anti-TNFα agents. We report the case of a psoriatic patient, who, despite a negative screening for infection by M. tuberculosis including both tuberculin skin test (TST) and chest X-ray, developed after 4 months of infliximab treatment, a severe pulmonary, lymphnodal and intestinal tuberculosis during infliximab treatment. [ABSTRACT FROM AUTHOR]

Background. QuantiFERON-TB Gold In-Tube test (QFT-GIT) can be used as an alternative to tuberculin skin testing (TST) for the targeted testing of latent tuberculosis. Due to many shortcomings with TST, QFT-GIT usage is increasing. QFT-GIT implementation in the inpatient setting remains unclear.Methods. We retrospectively identified patients admitted to a tertiary care academic center who received either a TST or a QFT-GIT in the 18 months prior to and after QFT-GIT implementation in March 2012. Risk factors associated with indeterminate results were evaluated.Results. The proportion of inpatients receiving a test for tuberculosis infection doubled following QFT-GIT implementation (1.4% vs 2.9%). After QFT-GIT became available, 75% of tested people received a QFT-GIT and 25% received a TST. We found indeterminate test results in 19.8%. Independent predictors of indeterminate results were female sex (adjusted odds ratio [AOR], 1.64), lymphopenia (AOR, 2.21), hypoalbuminemia (AOR, 6.81) and sample collection by nonphlebotomists (AOR, 3.0, vs phlebotomists). Of patients who had indeterminate results, 42% had a subsequent indeterminate result on repeat testing. All indeterminate results were due to a low mitogen response.Conclusions. QFT-GIT testing in the inpatient setting is associated with a high proportion of indeterminate results that is associated with host factors and preanalytical errors. Careful selection of patients to be tested and training on sample processing for QFT-GIT testing should be considered to decrease indeterminate results. [ABSTRACT FROM PUBLISHER]