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Navigating the Indian health system is a challenge for people with tuberculosis (TB) symptoms. The onus of organizing care is on the patient and their families alone. Factors like gender discrimination and opportunity costs further aggravate this. As a result, people may not complete the diagnostic and treatment pathway even though they experience poor health. Navigators can aid in the pathway’s completion. We implemented two projects in India—a public sector intervention in Bihar, with a population of 1.02 million, and a private sector intervention in Andhra Pradesh (AP), with a population of 8.45 million. Accredited Social Health Activists (ASHAs) of the public health system in Bihar and local field officers in AP facilitated the patients’ navigation through the health system. In Bihar, ASHAs accompanied community-identified presumptive TB patients to the nearest primary health center, assisted them through the diagnostic process, and supported the patients throughout the TB treatment. In AP, the field officers liaised with the private physicians, accompanied presumptive patients through the diagnosis, counseled and started treatment, and followed-up with the patients during the treatment. Both projects recorded case-based data for all of the patients, and used the yield and historical TB notifications to evaluate the intervention’s effect. Between July 2017 and December 2018, Bihar confirmed 1650 patients, which represented an increase of 94% in public notifications compared to the baseline. About 97% of them started treatment. During the same period in AP, private notifications increased by 147% compared to the baseline, and all 5765 patients started treatment. Patient navigators support the patients in the diagnostic and treatment pathways, and improve their health system experience. This novel approach of involving navigators in TB projects can improve the completion of the care cascade and reduce the loss to follow-up at various stages.

Summary box In 2019, 10.0 million people developed tuberculosis (TB) yet 2.9 million were not notified to National TB programmes (NTPs).1 This is largely due to limited accessibility to healthcare services, underdeveloped health reporting systems, insufficient human resources and poor linkages between private providers and national authorities.2 There are various global initiatives to address this challenge, including the Find.Treat.All #EndTB initiative and the End TB strategy which aims to reduce TB incidence by 90% between 2015 and 2035.3 To support innovative programmes, approaches and technologies aiming to increase the number of people detected with TB in low-and-middle income countries (LMICs), the TB REACH initiative was launched in 2010. It is led by the Stop TB Partnership …

The zoonotic origin of the SARS-CoV-2 pandemic is still unknown. Animal experiments have shown that non-human primates, cats, ferrets, hamsters, rabbits and bats can be infected by SARS-CoV-2. In addition, SARS-CoV-2 RNA has been detected in felids, mink and dogs in the field. Here, we describe an in-depth investigation of outbreaks on 16 mink farms and humans living or working on these farms, using whole genome sequencing. We conclude that the virus was initially introduced from humans and has evolved, most likely reflecting widespread circulation among mink in the beginning of the infection period several weeks prior to detection. At the moment, despite enhanced biosecurity, early warning surveillance and immediate culling of infected farms, there is ongoing transmission between mink farms with three big transmission clusters with unknown modes of transmission. We also describe the first animal to human transmissions of SARS-CoV-2 in mink farms.One sentence summarySARS-CoV-2 transmission on mink farms.

ObjectiveTo quantify the prediagnostic loss to follow-up (PDLFU) in an active case finding tuberculosis (TB) programme and identify the barriers and enablers in undergoing diagnostic evaluation.DesignExplanatory mixed-methods design.SettingA rural population of 1.02 million in the Samastipur district of Bihar, India.ParticipantsBased on their knowledge of health status of families, community health workers or CHWs (called accredited social health activist or locally) and informal providers referred people to the programme. The field coordinators (FCs) in the programme screened the referrals for TB symptoms to identify presumptive TB cases. CHWs accompanied the presumptive TB patients to free diagnostic evaluation, and a transport allowance was given to the patients. Thereafter, CHWs initiated and supported the treatment of confirmed cases. We included 13 395 community referrals received between January and December 2018. To understand the reasons of the PDLFU, we conducted in-depth interviews with patients who were evaluated (n=3), patients who were not evaluated (n=4) and focus group discussions with the CHWs (n=2) and FCs (n=1).Outcome measuresProportion and characteristics of PDLFU and association of demographic and symptom characteristics with diagnostic evaluation.ResultsA total of 11 146 presumptive TB cases were identified between January and December 2018, out of which 4912 (44.1%) underwent diagnostic evaluation. In addition to the free TB services in the public sector, the key enablers were CHW accompaniment and support. The major barriers identified were misinformation and stigma, deficient family and health provider support, transport challenges and poor services in the public health system.ConclusionFinding the missing cases will require patient-centric diagnostic services and urgent reform in the health system. A community-oriented intervention focusing on stigma, misinformation and patient support will be critical to its success.

BackgroundIn Pakistan, many tuberculosis (TB) cases are not reported to the national surveillance system. An active case finding strategy in the form of conventional (simple) or innovative (infotainment) chest camps can contribute to diagnosing these missed cases.ObjectiveTo compare the yield in terms of TB patients detected at a simple chest camp (SCC) versus an infotainment chest camp (ICC) in rural areas.MethodsA cluster randomized controlled trial with 2 parallel arms was conducted in 4 districts of Pakistan from June 2012 to May 2013. Rural neighborhoods (n = 318) were randomly allocated in a ratio of 1:3 to receive either SCC or ICC. Incidence of TB (all forms and sputum smear positive [SS+]) and number needed to screen (NNS) to diagnose 1 TB case were calculated. Cluster analysis was done according to intention to treat and risk ratio (RR), and 95% confidence intervals (CIs) were calculated.FindingsA total of 3086 participants were tested at the SCC and 9029 at the ICC, of whom 38.5% were female. Mean age was 37.4 ± 15.9 years. Incidences of previously undiagnosed TB (all forms) for SCC and ICC were 23.6 (95% CI 20.04-27.4) and 22.1 (95% CI 20.3-24.1) per 100,000 population ('P' = .42), SS+ TB 22.5 (95% CI 19.3-26.1) and 21.6 (95% CI 19.8-23.6) ('P' = .67), respectively. NNS to diagnose 1 TB case were 260 (95% CI 234.3-289.6) and 258 (95% CI 233.3-287.9) for SCC and ICC, respectively ('P' = .9). RRs for all forms of TB and SS+ TB in SCC compared to ICC were 0.94 (95% CI 0.73-1.19) and 0.95 (95% CI 0.74-1.22) and 'P' values were .58 and .71, respectively.ConclusionsBoth types of chest camps are equally effective in active case finding of previously undiagnosed TB cases in rural areas in 2 provinces in Pakistan.

backgroundDespite active case-finding (ACF) identifying more presumptive and confirmed TB cases, high pre-diagnostic loss to follow-up (PDLFU) among presumptive TB cases referred for diagnostic test remains a concern. We aimed to quantify the PDLFU, and identify the barriers and enablers in undergoing a diagnostic evaluation in an ACF program implemented in 1.02 million rural population in the Samastipur district of Bihar, India.methodsDuring their routine work, Accredited Social Health Activists (ASHA, a community health worker or CHW), informal providers, and community laypersons identified people at risk of TB, and referred them to the program. A field coordinator (FC) screened them for TB symptoms at the patient’s home. The identified presumptive TB cases were accompanied by the CHW to a designated government facility for diagnostics. Those with a confirmed TB diagnosis were put on treatment by the CHW and followed-up till treatment completion. All services were provided free of cost and patients were supported throughout the care pathway, including a transport allowance. We analyzed programmatically collected data, conducted in-depth interviews with patients, and focus group discussions with the CHWs and FCs in an explanatory mixed-methods design.resultsA total of 11146 presumptive TB cases were identified from January 2018 to December 2018, out of which 4912 (44.1%) underwent a diagnostic evaluation. The key enablers were CHW accompaniment and support in addition to the free TB services in the public sector. The major barriers identified were transport challenges, deficient family and health provider support, and poor services in the public system.conclusionIf we are to find missing cases, the health system needs urgent reform, and diagnostic services need to be patient-centric. A strong patient support system engaging all stakeholders and involvement of CHWs in routine TB care is an effective solution.STRENGTHS AND LIMITATIONS OF THIS STUDYFirst such study to explore the reasons for pre-diagnostic loss to follow-upA mixed-method design including the views of both patients and community health workersUses operational data from a routine programmatic setting at an NGO siteNo record of the actual number of people screened intuitively before being referred to the program.No record of patients accessing diagnostics in private sector and those completing the diagnostic process.

People living with a human immunodeficiency virus (HIV) infection have a high risk of tuberculosis and should undergo regular screening. However, they can be difficult to reach because they are stigmatized and discriminated against.In Nepal, the nongovernmental organization Naya Goreto implemented a peer-led tuberculosis screening project in which people living with HIV volunteered to contact others in this high-risk population. Volunteers took part in a short training course, after which they attempted to contact people living with HIV through existing networks and self-help groups. Tuberculosis screening and testing were carried out in accordance with national guidelines.In Nepal, the prevalence of HIV infection is 0.3% in the general population but is much higher, at 6%, in people in Kathmandu who inject drugs. To date, the health system has not been able to implement systematic tuberculosis screening in people living with HIV.Between May 2014 and mid-September 2015, 30 volunteers screened 6642 people in 10 districts, 5430 (82%) of whom were living with HIV. Of the 6642, 6046 (91%) were tested for tuberculosis and 287 (4.3%) were diagnosed with the disease, 240 of whom were HIV-positive. Of those with tuberculosis, 270 (94%) initiated treatment.Using peers to contact people living with HIV for tuberculosis screening resulted in a high participation rate and the identification of a considerable number of HIV-positive tuberculosis patients. Follow-up during treatment was difficult in this highly mobile group and needs more attention in future interventions.Les personnes qui vivent avec le virus de l'immunodéficience humaine (VIH) courent un risque accru de contracter la tuberculose et devraient se soumettre à un dépistage régulier. Cependant, cela s'avère parfois difficile du fait de leur stigmatisation et de la discrimination à leur encontre.Au Népal, l'organisation non gouvernementale Naya Goreto a mis en place un projet de dépistage de la tuberculose par les pairs, qui a consisté à ce que des personnes vivant avec le VIH se portent bénévoles pour contacter d'autres membres de cette population à haut risque. Les bénévoles ont suivi une courte formation, après laquelle ils ont tâché de contacter des personnes vivant avec le VIH par le biais de réseaux existants et de groupes d'entraide. Le dépistage de la tuberculose ainsi que les examens ont eu lieu conformément aux directives nationales.Au Népal, la prévalence du VIH est de 0,3% dans la population générale mais elle est bien plus élevée (6%) chez les usagers de drogues injectables de Katmandou. À ce jour, le système de santé n'a pas réussi à organiser le dépistage systématique de la tuberculose chez les personnes vivant avec le VIH.De mai 2014 à mi-septembre 2015, 30 bénévoles ont examiné 6642 personnes dans 10 districts, parmi lesquelles 5430 (82%) vivaient avec le VIH. Sur ces 6642 personnes, 6046 (91%) ont été soumises à un test de la tuberculose et la maladie a été diagnostiquée chez 287 (4,3%) d'entre elles, dont 240 séropositives. Parmi les personnes atteintes de tuberculose, 270 (94%) ont commencé un traitement.Le recours à des pairs pour contacter des personnes vivant avec le VIH afin de dépister la tuberculose a permis d'obtenir un fort taux de participation et d'identifier un nombre considérable de patients séropositifs atteints de tuberculose. Le suivi pendant le traitement s'est révélé difficile dans ce groupe extrêmement mobile et nécessitera une attention accrue lors des interventions futures.Las personas que viven infectadas con el virus de la inmunodeficiencia humana (VIH) tienen un alto riesgo de sufrir tuberculosis y deberían someterse a exámenes de detección con regularidad. No obstante, pueden resultar difíciles de alcanzar, pues están estigmatizadas y discriminadas.En Nepal, la organización no gubernamental NayaGoreto implementó un proyecto de exámenes de detección de tuberculosis dirigidos por pares en el cual personas que viven con el VIH se presentaban voluntarias para ponerse en contacto con otras personas en esta población de alto riesgo. Los voluntarios realizaron un pequeño curso de formación, tras el cual intentaron contactar con personas que viven con el VIH a través de redes existentes y grupos de autoayuda. Los exámenes y pruebas de detección de tuberculosis se realizaron según las directrices nacionales.En Nepal, la prevalencia de la infección por VIH es del 0,3% en la población general, pero es mucho mayor (del 6%) en Katmandú, donde la población consume drogas por vía intravenosa. Hasta la fecha, el sistema sanitario no ha sido capaz de implementar un examen de detección de tuberculosis sistemático en personas que viven con el VIH.Entre mayo de 2014 y mediados de septiembre de 2015, 30 voluntarios hicieron exámenes de detección a 6 642 personas de 10 distritos; 5 430 (82%) de estas personas vivían con el VIH. De las 6 642, 6 046 (91%) se sometieron a pruebas de tuberculosis y 287 (4,3%) fueron diagnosticadas con la enfermedad, 240 de las cuales eran positivas en VIH. De las personas afectadas por tuberculosis, 270 (94%) iniciaron un tratamiento.Al utilizar pares para contactar con personas que viven con el VIH para someterlos a exámenes de detección de tuberculosis, se produjo una alta tasa de participación y se identificó una cantidad considerable de pacientes con tuberculosis y resultados positivos de VIH. El seguimiento durante el tratamiento fue complicado en este grupo altamente cambiante, por lo que es necesaria una mayor atención en futuras intervenciones.يواجه المصابون بعدوى فيروس نقص المناعة البشرية (HIV) مخاطر عالية للإصابة بالسل، ويجب أن يخضعوا للفحص المنتظم. ومع ذلك، فقد يصعب الوصول إليهم بسبب مواجهتهم للشعور بالخزي والتمييز ضدهم.قامت المنظمة غير الحكومية "نايا غوريتو" بتنفيذ مشروع لفحص حالات السل النشط من خلال مقارنة الحالات المناظرة، قام من خلاله المصابون بفيروس نقص المناعة البشرية بالاتصال بالأشخاص المنتمين إلى فئات سكانية تواجه نسب خطر عالية. وشارك المتطوعون في دورة تدريبية قصيرة، يحاولون بعدها الاتصال بالمصابين بفيروس نقص المناعة البشرية من خلال الشبكات القائمة ومجموعات المساعدة الذاتية. وأُجريت فحوصات واختبارات السل وفقًا للمبادئ التوجيهية الوطنية.بلغ معدل انتشار عدوى فيروس نقص المناعة البشرية في نيبال 0.3‏‏٪ بين عموم السكان ولكن المعدل كان أعلى من ذلك بكثير في كاثماندو حيث بلغ ‏6‏%‏ بين الأشخاص الذين يتعاطون المخدرات بالحقن. حتى الآن، لم يستطع النظام الصحي تنفيذ فحص السل المنهجي للأشخاص الذين يعانون من فيروس نقص المناعة البشرية.قام 30 متطوعًا بفحص 6642 شخصًا في 10 أحياء، كان 5430 (‏‏82‏٪) منهم يعانون من فيروس نقص المناعة البشرية وذلك في الفترة ما بين أيار/مايو 2014 ومنتصف أيلول/سبتمبر 2015. ومن بين 6642 شخصًا، تم توقيع كشف السل على 6046 شخصًا (‏‏91‏‏٪) منهم، وأظهر التشخيص إصابة 287 شخصًا (‏4.3‏‏٪) بهذا المرض، منهم 240 شخصًا يعانون من فيروس نقص المناعة البشرية. وبدأ المصابون بمرض السل الذين يبلغ عددهم 270 (94‏‏‏٪) في تعاطي العلاج.أنتج استخدام النظراء للاتصال بالأشخاص الذين يعانون من فيروس نقص المناعة البشرية لفحص مرض السل عن نسبة مشاركة عالية والتعرف على عدد كبير من مرضى السل بفيروس نقص المناعة البشرية. كانت المتابعة أثناء العلاج أمرًا صعبًا وسط هذه المجموعة سريعة التغيير، وبالتالي فإن الأمر يحتاج إلى المزيد من الاهتمام في عمليات التدخل المستقبلية.人类免疫缺陷病毒 (HIV) 携带者患有结核病的风险很高，应该定期筛检。 但是，由于他们受到侮辱和歧视，所以很难与他们取得联系。.在尼泊尔，非政府组织 Naya Goreto 开展了一项同伴支持结核病筛查项目。艾滋病毒感染者自愿联系该高危人群中的其他人员。 志愿者参加了简单的培训课程，之后他们尝试通过现有关系网络和自助小组联系艾滋病毒携带者。 项目按照国家指南开展了结核病筛查和检测。.在尼泊尔，一般人群的艾滋病感染率为 0.3%，但加德满都注射毒品人群的感染率较高，为 6%。 截至目前，医疗系统尚无法在艾滋病毒携带者间开展系统性的结核病筛查。.2014 年 5 月至 2015 年 9 月中旬，30 名志愿者筛查了 10 个地区的 6642 人，其中 5430 (82%) 人携带艾滋病毒。 在这 6642 人中，6046 (91%) 人接受了结核病检查，287 (4.3%) 人诊断患有此疾病，其中 240 人为 HIV 阳性。 在患有结核病的人中，270 (94%) 人开始了治疗。.通过同伴联系艾滋病毒携带者开展结核病筛检项目的参与率很高，并且确定了相当多的 HIV 阳性结核病患者。 在这个具有高度流动性的群体间开展治疗跟进工作很有难度，并且需要在未来的干预中给予更多关注。.Люди, живущие с вирусом иммунодефицита человека (ВИЧ), подвергаются высокому риску заражения туберкулезом и должны регулярно проходить скрининговое обследование. Однако может быть сложно установить контакт с такими людьми, поскольку они являются объектами стигматизации и дискриминации.В Непале неправительственная организация Naya Goreto реализовала проект скринингового обследования на туберкулез под руководством лиц одного круга с обследуемыми, в рамках которого люди с ВИЧ на добровольной основе устанавливали контакт с другими членами этой группы населения высокого риска. Добровольцы прошли небольшой курс подготовки и затем попытались установить контакт с людьми, живущими с ВИЧ, посредством существующих социальных сетей и групп взаимопомощи. Скрининговое обследование и тестирование на туберкулез проводились в соответствии с национальными руководящими принципами.В Непале распространенность ВИЧ-инфекции составляет 0,3% от общей численности населения, но гораздо выше (6%) среди жителей Катманду, употребляющих инъекционные наркотики. До сих пор в рамках системы здравоохранения не удавалось обеспечить выполнение систематического скринингового обследования на туберкулез среди людей, живущих с ВИЧ.В период с мая 2014 года до середины сентября 2015 года 30 добровольцев провели скрининговое обследование 6642 людей в 10 районах, 5430 (82%) из них жили с ВИЧ. Из 6642 людей 6046 (91%) прошли тестирование на туберкулез, и у 287 (4,3%) он был диагностирован, у 240 из них был позитивный результат анализа на ВИЧ. 270 людей (94%) из числа тех, у кого диагностировали туберкулез, начали лечение.Привлечение лиц одного круга для установления контактов с людьми, инфицированными ВИЧ, в целях проведения скринингового обследования на туберкулез позволило добиться высокого уровня участия и идентифицировать значительное число людей с позитивным результатом анализа на ВИЧ, больных туберкулезом. Сложность проведения последующего врачебного наблюдения во время лечения в этой группе людей была обусловлена ее высокой мобильностью, и в будущих вмешательствах последующему наблюдению необходимо уделять больше внимания.

Background Many of the countries in sub-Saharan Africa are still largely dependent on microscopy as the mainstay for diagnosis of tuberculosis (TB) including patients with previous history of TB treatment. The available guidance in management of TB retreatment cases is focused on bacteriologically confirmed TB retreatment cases leaving out those classified as retreatment ‘others’. Retreatment ‘others’ refer to all TB cases who were previously treated but with unknown outcome of that previous treatment or who have returned to treatment with bacteriologically negative pulmonary or extra-pulmonary TB. This study was conducted in 11 regional referral hospitals (RRHs) serving high burden TB districts in Uganda to determine the profile and treatment success of TB retreatment ‘others’ in comparison with the classical retreatment cases. Methods A retrospective cohort review of routinely collected National TB and Leprosy Program (NTLP) facility data from 1 January to 31 December 2010. This study uses the term classical retreatment cases to refer to a combined group of bacteriologically confirmed relapse, return after failure and return after loss to follow-up cases as a distinct group from retreatment ‘others’. Distribution of categorical characteristics were compared using Chi-squared test for difference between proportions. The log likelihood ratio test was used to assess the independent contribution of type of retreatment, human immunodeficiency virus (HIV) status, age group and sex to the models. Results Of the 6244 TB cases registered at the study sites, 733 (11.7 %) were retreatment cases. Retreatment ‘others’ constituted 45.5 % of retreatment cases. Co-infection with HIV was higher among retreatment ‘others’ (70.9 %) than classical retreatment cases (53.5 %). Treatment was successful in 410 (56.2 %) retreatment cases. Retreatment ‘others’ were associated with reduced odds of success (AOR = 0.44, 95 % CI 0.22,0.88) compared to classical cases. Lost to follow up was the commonest adverse outcome (38 % of adverse outcomes) in all retreatment cases. Type of retreatment case, HIV status, and age were independently associated with treatment success. Conclusion TB retreatment ‘others’ constitute a significant proportion of retreatment cases, with higher HIV prevalence and worse treatment success. There is need to review the diagnosis and management of retreatment ‘others’.

WHO recently published guidelines for identifying and treating individuals with latent tuberculosis infection (LTBI) in high- and middle-income countries with a low incidence of active tuberculosis as part of the ‘End TB Strategy’ for the post-2015 era of tuberculosis control [1]. Systematic screening for LTBI is advised for immunocompromised individuals and contacts of patients with tuberculosis, in whom the risk of progression from latent infection to active diseases is increased, and for whom prevention of progression through adequate treatment has the highest impact. For migrants from countries with a highincidence of tuberculosis and healthcare workers, LTBI screening is encouraged.

Setting District and urban health care facilities in three provinces (Manica, Sofala, Tete) in central Mozambique. Objective To assess the level of implementation of selected tuberculosis infection prevention and control (TB-IPC) measures. Design In a cross-sectional study of TB-IPC implementation in 29 health care facilities, we assessed TB clinics, laboratories, out-patient departments and medical and TB wards. Assessment included selected managerial, administrative and environmental measures and the availability and use of respiratory protective equipment (N95 respirators). Results Guidelines for diagnosis and treatment of (presumptive) TB patients were not present in all facilities. Staff instructed patients on sputum collection in 91%, but only 4% observed it. Using a pragmatic '20% rule', 52% of the rooms assessed had adequate ventilation. Potentially, this could be increased to 76%. Three quarters of the health care workers had N95 respirators. Only 36% knew how to use it correctly. Conclusion Implementation of TB-IPC measures showed wide variations within health care facilities. Relatively simple measures to improve TB-IPC include the availability of guidelines, opening doors and windows to improve ventilation, and training and support on correct N95 respirator use. However, even relatively simple measures are challenging to implement, and require careful attention in and evaluation of the implementation process.

To the Editors: Tuberculosis (TB) remains a serious public health problem in many low- and middle-income countries in Africa, Asia and the former Soviet Union [1]. Mozambique is one of them. Despite the fact that in this country, detection of patients with TB has drastically increased during the past decade due to improved notification (from nearly 20,000 new TB cases notified in 1998 to nearly 40,000 in 2008), less than half of the cases of TB estimated to emerge annually are currently being detected. As in other southern African countries, the HIV epidemic is fuelling the TB epidemic in Mozambique, with 60% of patients with TB being co-infected with HIV [1]. Drug-resistant TB is thought to be a major problem, although the latest information available on the magnitude of resistance to anti-TB drugs is from 1998, when the first national drug resistance survey (DRS) was conducted. At that time, multidrug-resistant (MDR)-TB (defined as TB resistant to at least isoniazid and rifampicin, the two main first-line drugs in the treatment of TB) was found among 3.5 and 3.3% of new and previously treated TB cases, respectively [2]. Since then, there has been no further investigation of the magnitude of drug resistance in the country. Based on the latest available data, >3,500 MDR-TB cases are estimated to have emerged in Mozambique in 2008 [3]. Detecting and treating patients with MDR-TB is feasible but substantially more complex and costly than treating patients with fully susceptible Mycobacterium tuberculosis strains. Knowing the …

Objective Healthcare Workers (HCWs) have a higher frequency of TB exposure than the general population and have therefore an occupational TB risk that infection prevention and control (IPC) measures aim to reduce. HCWs are crucial in the implementation of these measures. The objective of the study was to investigate Mozambican HCWs' perceptions of their occupational TB risk and the measures they report using to reduce this risk. In addition, we explored the challenges HCWs encounter while using these TBIPC measures. Methods Focus group discussion. Analysis according content method. Participants Four categories of HCWs: auxiliary workers, medical (doctors and clinical officers), nurses and TB program staff. Results HCWs are aware of their occupational TB risk and use various measures to reduce their risk of infection. HCWs find it challenging to employ measures that minimize such risks and a lack of clear guidelines contributes to these challenges. HCWs' and patient behavior further complicate the use of TBIPC measures. Conclusion HCWs in Mozambique perceive a high occupational risk of TB infection. They report several challenges using measures to reduce this risk such as shortage of material, lack of clear guidelines, insufficient motivation and inadequate training. Robust training with motivational approaches, alongside supervision and support for HCWs could improve implementation of TBIPC measures. Healthcare management should address the areas for improvement that are beyond the individual HCW's control.

The inability to detect all individuals with active tuberculosis has led to a growing interest in new approaches to improve case detection. Policy makers and program staff face important challenges measuring effectiveness of newly introduced interventions and reviewing feasibility of scaling-up successful approaches. While robust research will continue to be needed to document impact and influence policy, it may not always be feasible for all interventions and programmatic evidence is also critical to understand what can be expected in routine settings. The effects of interventions on early and improved tuberculosis detection can be documented through well-designed program evaluations. We present a pragmatic framework for evaluating and measuring the effect of improved case detection strategies using systematically collected intervention data in combination with routine tuberculosis notification data applying historical and contemporary controls. Standardized process evaluation and systematic documentation of program implementation design, cost and context will contribute to explaining observed levels of success and may help to identify conditions needed for success. Findings can then guide decisions on scale-up and replication in different target populations and settings.

Background Antiretroviral therapy (ART) is lifesaving for HIV-infected tuberculosis (TB) patients. ART-use by these patients lag behind compared to HIV-testing and co-trimoxazole preventive therapy. TB programmes provide the data on ART-use by HIV-infected TB patients, however often the HIV services provide the ART. We evaluated whether the data on ART-use in the TB register were complete and correct. The timing of ART initiation was evaluated to assess whether reporting on ART-use could have happened with the TB case finding reporting. We collected data on TB treatment, HIV testing and ART for adult TB cases in 2007 from three TB clinics in Manica Province, Mozambique. These data on use of ART from TB registers were compared with those from the HIV services. Findings Of 628 patients included, 504 (81%) were tested and of these 356 (71%) were HIV-infected. Of the co-infected patients, 81% registered with the HIV services in the same facility. The TB register was correct on ART-use in 73% of co-infected cases and complete in 74%. Information on ART-use could have been reported with the TB case finding reports in 56% of co-infected patients. Conclusion The TB register is reasonably correct and complete on ART-use. However, the HIV patient record seems a much better source to provide this information. Reporting on ART-use at the end of the quarter in which TB treatment starts provides the programme with timely but incomplete information. A more complete but less timely picture is available after a year.

Background Tuberculosis (TB) presents a serious problem in Mozambique. HIV prevalence among TB patients is estimated at 47%. A delay in having their first CD4+ cell count could lead to a missed opportunity for ART initiation due to a CD4+ cell increase above the cut-off caused by TB treatment. The objective is to describe CD4+ cell response during TB treatment and quantify the effect of TB treatment and ART on this response. Methods All new HIV + adult TB cases in 2007 from three TB clinics in Mozambique were included. Data on TB diagnosis and treatment and HIV parameters were collected. A general mixed model was used for CD4+ cell count response. Results 338 HIV + patients were notified and 252 (75%) were included in the analysis. Using TB medication was not independently associated with the CD4+ count response (19 cells/mm3; 95% CI: -40 to 79; p = 0.529). ART-use was associated with statistically significantly higher CD4+ cells compared to no ART-use (81 cells/mm3; 95% confidence interval (CI): 12 to 151; p = 0.022). Conclusion In this study, no independent effect of TB treatment on CD4+ cell count was found. HIV-infected TB patients on ART had a significantly higher CD4+ cell count than those not receiving ART. CD4+ cell counts for patients not on ART at TB treatment start, remained below the cut off for initiating ART during the first three months of TB treatment; therefore some delay in getting the first CD4+ cell count would not lead to missing the opportunity to start ART.

Background The Xpert MTB/RIF assay has garnered significant interest as a sensitive and rapid diagnostic tool to improve detection of sensitive and drug resistant tuberculosis. However, most existing literature has described the performance of MTB/RIF testing only in study conditions; little information is available on its use in routine case finding. TB REACH is a multi-country initiative focusing on innovative ways to improve case notification. Methods We selected a convenience sample of nine TB REACH projects for inclusion to cover a range of implementers, regions and approaches. Standard quarterly reports and machine data from the first 12 months of MTB/RIF implementation in each project were utilized to analyze patient yields, rifampicin resistance, and failed tests. Data was collected from September 2011 to March 2013. A questionnaire was implemented and semi-structured interviews with project staff were conducted to gather information on user experiences and challenges. Results All projects used MTB/RIF testing for people with suspected TB, as opposed to testing for drug resistance among already diagnosed patients. The projects placed 65 machines (196 modules) in a variety of facilities and employed numerous case-finding strategies and testing algorithms. The projects consumed 47,973 MTB/RIF tests. Of valid tests, 7,195 (16.8%) were positive for MTB. A total of 982 rifampicin resistant results were found (13.6% of positive tests). Of all tests conducted, 10.6% failed. The need for continuous power supply was noted by all projects and most used locally procured solutions. There was considerable heterogeneity in how results were reported and recorded, reflecting the lack of standardized guidance in some countries. Conclusions The findings of this study begin to fill the gaps among guidelines, research findings, and real-world implementation of MTB/RIF testing. Testing with Xpert MTB/RIF detected a large number of people with TB that routine services failed to detect. The study demonstrates the versatility and impact of the technology, but also outlines various surmountable barriers to implementation. The study is not representative of all early implementer experiences with MTB/RIF testing but rather provides an overview of the shared issues as well as the many different approaches to programmatic MTB/RIF implementation.