Browsing by Author "Muyoyeta M"

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A mixed methods study on men's and women's tuberculosis care journeys in Lusaka, Zambia-Implications for gender-tailored tuberculosis health promotion and case finding strategies.
(2023) Kerkhoff AD; Mwamba C; Pry JM; Kagujje M; Nyangu S; Mateyo K; Sanjase N; Chilukutu L; Christopoulos KA; Muyoyeta M; Sharma A; Division of Epidemiology, University of California Davis, Davis, California, United States of America.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Division of HIV, Infectious Diseases and Global Medicine Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, California, United States of America.; Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Men and women with undiagnosed tuberculosis (TB) in high burden countries may have differential factors influencing their healthcare seeking behaviors and access to TB services, which can result in delayed diagnoses and increase TB-related morbidity and mortality. A convergent, parallel, mixed-methods study design was used to explore and evaluate TB care engagement among adults (≥18 years) with newly diagnosed, microbiologically-confirmed TB attending three public health facilities in Lusaka, Zambia. Quantitative structured surveys characterized the TB care pathway (time to initial care-seeking, diagnosis, and treatment initiation) and collected information on factors influencing care engagement. Multinomial multivariable logistic regression was used to determine predicted probabilities of TB health-seeking behaviors and determinants of care engagement. Qualitative in-depth interviews (IDIs; n = 20) were conducted and analyzed using a hybrid approach to identify barriers and facilitators to TB care engagement by gender. Overall, 400 TB patients completed a structured survey, of which 275 (68.8%) and 125 (31.3%) were men and women, respectively. Men were more likely to be unmarried (39.3% and 27.2%), have a higher median daily income (50 and 30 Zambian Kwacha [ZMW]), alcohol use disorder (70.9% [AUDIT-C score ≥4] and 31.2% [AUDIT-C score ≥3]), and a history of smoking (63.3% and 8.8%), while women were more likely to be religious (96.8% and 70.8%) and living with HIV (70.4% and 36.0%). After adjusting for potential confounders, the probability of delayed health-seeking ≥4 weeks after symptom onset did not differ significantly by gender (44.0% and 36.2%, p = 0.14). While the top reasons for delayed healthcare-seeking were largely similar by gender, men were more likely to report initially perceiving their symptoms as not being serious (94.8% and 78.7%, p = 0.032), while women were more likely to report not knowing the symptoms of TB before their diagnosis (89.5% and 74.4%; p = 0.007) and having a prior bad healthcare experience (26.4% and 9.9%; p = 0.036). Notably, women had a higher probability of receiving TB diagnosis ≥2 weeks after initial healthcare seeking (56.5% and 41.0%, p = 0.007). While men and women reported similar acceptability of health-information sources, they emphasized different trusted messengers. Also, men had a higher adjusted probability of stating that no one influenced their health-related decision making (37.9% and 28.3%, p = 0.001). In IDIs, men recommended TB testing sites at convenient community locations, while women endorsed an incentivized, peer-based, case-finding approach. Sensitization and TB testing strategies at bars and churches were highlighted as promising approaches to reach men and women, respectively. This mixed-methods study found important differences between men and women with TB in Zambia. These differences suggest the need for gender-tailored TB health promotion, including addressing harmful alcohol use and smoking among men, and sensitizing HCWs to prolonged delays in TB diagnosis among women, and also using gender-specific approaches as part of community-based, active case-finding strategies to improve TB diagnosis in high burden settings.
A Prospective Evaluation of the Diagnostic Accuracy of the Point-of-Care VISITECT CD4 Advanced Disease Test in 7 Countries.
(2025-Feb-04) Gils T; Hella J; Jacobs BKM; Sossen B; Mukoka M; Muyoyeta M; Nakabugo E; Van Nguyen H; Ubolyam S; Macé A; Vermeulen M; Nyangu S; Sanjase N; Sasamalo M; Dinh HT; Ngo TA; Manosuthi W; Jirajariyavej S; Denkinger CM; Nguyen NV; Avihingsanon A; Nakiyingi L; Székely R; Kerkhoff AD; MacPherson P; Meintjes G; Reither K; Ruhwald M; School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom.; German Centre for Infection Research, Heidelberg University Hospital, Heidelberg, Germany.; Viet Tiep Hospital, Hai Phong, Viet Nam.; Bamrasnaradura Infectious Diseases Institute, Nonthaburi, Thailand.; National Lung Hospital, Ha Noi, Viet Nam.; Taksin Hospital, Bangkok, Thailand.; Global Health Institute, University of Antwerp, Wilrijk, Belgium.; Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.; Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.; University of Basel, Basel, Switzerland.; Public Health Group, Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi.; Ifakara Health Institute, Dar es Salaam, Tanzania.; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.; Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, USA.; Clinical Research Unit, Swiss Tropical and Public Health Institute, Allschwil, Switzerland.; Department of Pathology, Kamuzu University of Health Sciences, Blantyre, Malawi.; HIV Netherlands Australia Thailand Research Collaboration, Thai Red Cross AIDS Research Centre and Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.; Foundation for Innovative New Diagnostics, the Global Alliance for Diagnostics, Geneva, Switzerland.; Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom.; Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Germany.; Infectious Diseases Institute, Makerere University, Kampala, Uganda.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: CD4 measurement is pivotal in the management of advanced human immunodeficiency virus (HIV) disease. VISITECT CD4 Advanced Disease (VISITECT; AccuBio, Ltd) is an instrument-free, point-of-care, semiquantitative test allowing visual identification of CD4 ≤ 200 cells/µL or >200 cells/ µL from finger-prick or venous blood. METHODS: As part of a diagnostic accuracy study of FUJIFILM SILVAMP TB LAM, people with HIV ≥18 years old were prospectively recruited in 7 countries from outpatient departments if a tuberculosis symptom was present, and from inpatient departments. Participants provided venous blood for CD4 measurement using flow cytometry (reference standard) and finger-prick blood for VISITECT (index text), performed at point-of-care. Sensitivity, specificity, and positive and negative predictive values of VISITECT to determine CD4 ≤ 200 cells/ µL were evaluated. RESULTS: Among 1604 participants, the median flow cytometry CD4 was 367 cells/µL (interquartile range, 128-626 cells/µL) and 521 (32.5%) had CD4 ≤ 200 cells/µL. VISITECT sensitivity was 92.7% (483/521; 95% confidence interval [CI], 90.1%-94.7%) and specificity was 61.4% (665/1083; 95% CI, 58.4%-64.3%). For participants with CD4 0-100, 101-200, 201-300, 301-500, and >500 cells/µL, VISITECT misclassified 4.5% (95% CI, 2.5%-7.2%), 12.5 (95% CI, 8.0%-18.2%), 74.1% (95% CI, 67.0%-80.5%), 48.0% (95% CI, 42.5%-53.6%), and 22.6% (95% CI, 19.3%-26.3%), respectively. CONCLUSIONS: VISITECT's sensitivity, but not specificity, met the World Health Organization's minimal sensitivity and specificity threshold of 80% for point-of-care CD4 tests. VISITECT's quality needs to be assessed and its accuracy optimized. VISITECT's utility as CD4 triage test should be investigated. Clinical Trials Registration. NCT04089423.
Active TB case finding in a high burden setting; comparison of community and facility-based strategies in Lusaka, Zambia.
(2020) Kagujje M; Chilukutu L; Somwe P; Mutale J; Chiyenu K; Lumpa M; Mwanza W; Muyoyeta M; Strategic Information Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Tuberculosis Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
INTRODUCTION: We conducted an implementation science study to increase TB case detection through a combination of interventions at health facility and community levels. We determined the impact of the study in terms of additional cases detected and notification rate and compared the yield of bacteriologically confirmed TB of facility based and community based case finding. METHODOLOGY: Over a period of 18 months, similar case finding activities were conducted at George health facility in Lusaka Zambia and its catchment community, an informal peri-urban settlement. Activities included awareness and demand creation activities, TB screening with digital chest x-ray or symptom screening, sputum evaluation using geneXpert MTB/RIF, TB diagnosis and linkage to treatment. RESULTS: A total of 18,194 individuals were screened of which 9,846 (54.1%) were screened at the facility and 8,348 (45.9%) were screened in the community. The total number of TB cases diagnosed during the intervention period were 1,026, compared to 759 in the pre-intervention period; an additional 267 TB cases were diagnosed. Of the 563 bacteriologically confirmed TB cases diagnosed under the study, 515/563 (91.5%) and 48/563 (8.5%) were identified at the facility and in the community respectively (P<0.0001). The TB notification rate increased from 246 per 100,000 population pre-intervention to 395 per 100,000 population in the last year of the intervention. CONCLUSIONS: Facility active case finding was more effective in detecting TB cases than community active case finding. Strengthening health systems to appropriately identify and evaluate patients for TB needs to be optimised in high burden settings. At a minimum, provider initiated TB symptom screening with completion of the TB screening and diagnostic cascade should be provided at the health facility in high burden settings. Community screening needs to be systematic and targeted at high risk groups and communities with access barriers.
Addressing Common Mental Health Disorders Among Incarcerated People Living with HIV: Insights from Implementation Science for Service Integration and Delivery.
(2020-Oct) Smith HJ; Topp SM; Hoffmann CJ; Ndlovu T; Charalambous S; Murray L; Kane J; Sikazwe I; Muyoyeta M; Herce ME; Johns Hopkins University, Baltimore, MD, USA.; Columbia University, New York, NY, USA.; Implementation Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; Implementation Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia. michael.herce@cidrz.org.; Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. michael.herce@cidrz.org.; James Cook University, Townsville, Australia.; University of the Witwatersrand Johannesburg, Johannesburg, South Africa.; The Aurum Institute, Johannesburg, South Africa.
PURPOSE: Despite evidence of disproportionate burden of HIV and mental health disorders among incarcerated people, scarce services exist to address common mental health disorders, including major depressive and anxiety disorders, post-traumatic stress disorder, and substance use disorders, among incarcerated people living with HIV (PLHIV) in sub-Saharan Africa (SSA). This paper aims to summarize current knowledge on mental health interventions of relevance to incarcerated PLHIV and apply implementation science theory to highlight strategies and approaches to deliver mental health services for PLHIV in correctional settings in SSA. RECENT FINDINGS: Scarce evidence-based mental health interventions have been rigorously evaluated among incarcerated PLHIV in SSA. Emerging evidence from low- and middle-income countries and correctional settings outside SSA point to a role for cognitive behavioral therapy-based talking and group interventions implemented using task-shifting strategies involving lay health workers and peer educators. Several mental health interventions and implementation strategies hold promise for addressing common mental health disorders among incarcerated PLHIV in SSA. However, to deliver these approaches, there must first be pragmatic efforts to build corrections health system capacity, address human rights abuses that exacerbate HIV and mental health, and re-conceptualize mental health services as integral to quality HIV service delivery and universal access to primary healthcare for all incarcerated people.
Breaking the threshold: Developing multivariable models using computer-aided chest X-ray analysis for tuberculosis triage.
(2024-Oct) Geric C; Tavaziva G; Breuninger M; Dheda K; Esmail A; Scott A; Kagujje M; Muyoyeta M; Reither K; Khan AJ; Benedetti A; Ahmad Khan F; Tuberculosis Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; IRD Global, Singapore.; Tuberculosis Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Zambart, Lusaka, Zambia.; McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Canada; Department of Medicine, McGill University, Montreal, Canada; Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada. Electronic address: faiz.ahmadkhan@mcgill.ca.; McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Canada; Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada.; Centre for Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa.; Centre for Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom.; Division of Infectious Diseases, Department I of Internal Medicine, University of Cologne, Cologne, Germany.; McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Canada; Department of Medicine, McGill University, Montreal, Canada; Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Canada.; Swiss Tropical and Public Health Institute, Allschwill, Switzerland; University of Basel, Basel, Switzerland.; McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Canada; Department of Medicine, McGill University, Montreal, Canada; Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
OBJECTIVES: Computer-aided detection (CAD) software packages quantify tuberculosis (TB)-compatible chest X-ray (CXR) abnormality as continuous scores. In practice, a threshold value is selected for binary CXR classification. We assessed the diagnostic accuracy of an alternative approach to applying CAD for TB triage: incorporating CAD scores in multivariable modeling. METHODS: We pooled individual patient data from four studies. Separately, for two commercial CAD, we used logistic regression to model microbiologically confirmed TB. Models included CAD score, study site, age, sex, human immunodeficiency virus status, and prior TB. We compared specificity at target sensitivities ≥90% between the multivariable model and the current threshold-based approach for CAD use. RESULTS: We included 4,733/5,640 (84%) participants with complete covariate data (median age 36 years; 45% female; 22% with prior TB; 22% people living with human immunodeficiency virus). A total of 805 (17%) had TB. Multivariable models demonstrated excellent performance (areas under the receiver operating characteristic curve [95% confidence interval]: software A, 0.91 [0.90-0.93]; software B, 0.92 [0.91-0.93]). Compared with threshold scores, multivariable models increased specificity (e.g., at 90% sensitivity, threshold vs model specificity [95% confidence interval]: software A, 71% [68-74%] vs 75% [74-77%]; software B, 69% [63-75%] vs 75% [74-77%]). CONCLUSION: Using CAD scores in multivariable models outperformed the current practice of CAD-threshold-based CXR classification for TB diagnosis.
Breakthrough TB among people living with HIV on TB preventive therapy.
(2022-Dec-21) Nyangu S; Kagujje M; Mwaba I; Luhanga D; Hambwalula R; Maliko S; Mushili T; Mwamba E; Mulai M; Muyoyeta M; Centre of Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.
BACKGROUND: Zambia has an estimated TB incidence of 319/100,000 population and a HIV prevalence of 11.1%. In 2020, only 49% of new people living with HIV (PLHIV) received TB preventive therapy (TPT) in Zambia. Misconceptions about the reliability of symptom screening and drug resistance among people who develop TB while on TPT are barriers to TPT scale-up. We determined the incidence and predictors of breakthrough TB during TPT among PLHIV in Zambia. METHOD: This was a retrospective analysis of routine TPT programme data among PLHIV collected between October 2016 and October 2019 from select primary health facilities in Zambia. RESULTS: Of 48,581 PLHIV enrolled on TPT, 130 (0.3%) developed breakthrough TB during TPT. Of the 130, 90 client records were accessed. The median age of the breakthrough TB cases was 35 years; 68% were males. Overall, 96% of the breakthrough TB cases had been on antiretroviral therapy (ART) for ⩽3 months; 24% were symptomatic at the beginning of TPT, 22% were asymptomatic and others had missing data. Of the 130 breakthrough TB cases, 79% developed TB in the first month after TPT initiation. The median time to TB diagnosis was 10 days (IQR 4-16). CONCLUSION: Breakthrough TB during TPT is rare among PHLIV on ART, and very rare after the first month of TPT initiation. It should therefore not be a barrier to TPT scale-up.
Chest X-ray Analysis With Deep Learning-Based Software as a Triage Test for Pulmonary Tuberculosis: An Individual Patient Data Meta-Analysis of Diagnostic Accuracy.
(2022-Apr-28) Tavaziva G; Harris M; Abidi SK; Geric C; Breuninger M; Dheda K; Esmail A; Muyoyeta M; Reither K; Majidulla A; Khan AJ; Campbell JR; David PM; Denkinger C; Miller C; Nathavitharana R; Pai M; Benedetti A; Ahmad Khan F; Swiss Tropical and Public Health Institute, Basel, Switzerland.; IRD Global, Singapore.; World Health Organization, Geneva, Switzerland.; Département des Médicaments et Santé des Populations, Faculty of Pharmacy, Université de Montréal, Montreal, Canada.; Centre for Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa.; Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA.; McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Canada.; Division of Infectious Diseases, Department I of Internal Medicine, University of Cologne, Cologne, Germany.; Interactive Research & Development (IRD) Pakistan, Karachi, Pakistan.; Division of Tropical Medicine, Center of Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; University of Basel, Basel, Switzerland.; Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.; Faculty of Infectious and Tropical Diseases, Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom.; Departments of Medicine & Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Canada.; Zambart, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Automated radiologic analysis using computer-aided detection software (CAD) could facilitate chest X-ray (CXR) use in tuberculosis diagnosis. There is little to no evidence on the accuracy of commercially available deep learning-based CAD in different populations, including patients with smear-negative tuberculosis and people living with human immunodeficiency virus (HIV, PLWH). METHODS: We collected CXRs and individual patient data (IPD) from studies evaluating CAD in patients self-referring for tuberculosis symptoms with culture or nucleic acid amplification testing as the reference. We reanalyzed CXRs with three CAD programs (CAD4TB version (v) 6, Lunit v3.1.0.0, and qXR v2). We estimated sensitivity and specificity within each study and pooled using IPD meta-analysis. We used multivariable meta-regression to identify characteristics modifying accuracy. RESULTS: We included CXRs and IPD of 3727/3967 participants from 4/7 eligible studies. 17% (621/3727) were PLWH. 17% (645/3727) had microbiologically confirmed tuberculosis. Despite using the same threshold score for classifying CXR in every study, sensitivity and specificity varied from study to study. The software had similar unadjusted accuracy (at 90% pooled sensitivity, pooled specificities were: CAD4TBv6, 56.9% [95% confidence interval {CI}: 51.7-61.9]; Lunit, 54.1% [95% CI: 44.6-63.3]; qXRv2, 60.5% [95% CI: 51.7-68.6]). Adjusted absolute differences in pooled sensitivity between PLWH and HIV-uninfected participants were: CAD4TBv6, -13.4% [-21.1, -6.9]; Lunit, +2.2% [-3.6, +6.3]; qXRv2: -13.4% [-21.5, -6.6]; between smear-negative and smear-positive tuberculosis was: were CAD4TBv6, -12.3% [-19.5, -6.1]; Lunit, -17.2% [-24.6, -10.5]; qXRv2, -16.6% [-24.4, -9.9]. Accuracy was similar to human readers. CONCLUSIONS: For CAD CXR analysis to be implemented as a high-sensitivity tuberculosis rule-out test, users will need threshold scores identified from their own patient populations and stratified by HIV and smear status.
Clinical and radiographic characteristics of presumptive tuberculosis patients previously treated for tuberculosis in Zambia.
(2022) Mateyo K; Kerkhoff AD; Dunn I; Nteeni MS; Muyoyeta M; Department of Radiology, Levy Mwanawasa University Teaching Hospital, Lusaka, Zambia.; Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, California, United States of America.; Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Department of Radiology, University of British Columbia, Vancouver, Canada.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Persistent respiratory symptoms and radiographic abnormalities are common among individuals previously treated for tuberculosis (TB) and may contribute to misdiagnosis and incorrect treatment when they seek care. We sought to determine if clinical and radiographic characteristics differed among previously treated, presumptive TB patients according to their current TB disease status. METHODS: Adults (>18 years of age) seeking care at a public health facility in Lusaka, Zambia were systematically evaluated for active TB using symptom screening and chest X-ray. All patients with presumptive TB submitted a sputum sample for microbiological TB testing. Patients who reported a prior history of TB treatment were included in the present analysis. 'Confirmed TB' was defined by the detection of TB using Xpert Ultra and/or liquid culture, while 'possible TB' was defined by the receipt of TB treatment without a positive Xpert Ultra or culture result. We evaluated the positive predictive value (PPV) of clinical symptoms and radiographic features for active TB alone and in combination. RESULTS: Of 740 presumptive TB patients, 144 (19%) had been previously treated for active TB. Of these, 19 (13%) patients had confirmed TB, 14 (10%) had possible TB, and 111 (77%) had no pulmonary TB. Overall, 119 (83%) patients had ≥1 current respiratory symptom-this did not differ according to current TB disease classification (95%, 93%, 79%; p = 0.23). Sixty-one patients (56%) had radiographic abnormalities suggestive of active TB and such findings were more common among patients with confirmed or possible TB compared to those without TB (93%, 71%, vs. 47%; p = 0.002). Most patients (n = 91, 83%) had at least one radiographic abnormality-no difference by current TB classification was observed (93%, 100%, 79%; p = 0.08). The PPV of any current respiratory symptom, active TB radiographic finding, or any radiographic abnormality for TB was 13% (95%CI: 7-21%), 21% (95%CI: 12-34) and 14% (95%CI: 9-23), respectively; combining clinical and radiographic characteristics did not significantly improve the PPV for active TB. CONCLUSIONS: Among presumptive TB patients previously treated for TB, respiratory symptoms and radiographic abnormalities were common and poorly differentiated those with current active TB from those without current active TB. Reliance on clinical and radiographic characteristics alone in this patient population may result in substantial overtreatment and therefore, microbiological investigations should be used to inform TB treatment decisions whenever possible.
Community-wide Screening for Tuberculosis.
(2020-Mar-19) Kerkhoff AD; Muyoyeta M; Cattamanchi A; University of California, San Francisco, San Francisco, CA andrew.kerkhoff@ucsf.edu.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; University of California, San Francisco, San Francisco, CA.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Comparison of indoor contact time data in Zambia and Western Cape, South Africa suggests targeting of interventions to reduce Mycobacterium tuberculosis transmission should be informed by local data.
(2016-Feb-09) McCreesh N; Looker C; Dodd PJ; Plumb ID; Shanaube K; Muyoyeta M; Godfrey-Faussett P; Corbett EL; Ayles H; White RG; TB Modelling Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK. clare_looker@hotmail.com.; Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK. faussettp@unaids.org.; ZAMBART Project, School of Medicine, University of Zambia, Lusaka, Zambia. Monde.Muyoyeta@cidrz.org.; TB Modelling Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK. idplumb@gmail.com.; ZAMBART Project, School of Medicine, University of Zambia, Lusaka, Zambia. helen@zambart.org.zm.; Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK. p.j.dodd@sheffield.ac.uk.; TB Modelling Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK. p.j.dodd@sheffield.ac.uk.; Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK. lizcorbett04@gmail.com.; HIV and TB Theme, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi. lizcorbett04@gmail.com.; TB Modelling Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK. richard.white@lshtm.ac.uk.; TB Modelling Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK. nicky.mccreesh@lshtm.ac.uk.; TB Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. Monde.Muyoyeta@cidrz.org.; ZAMBART Project, School of Medicine, University of Zambia, Lusaka, Zambia. kshanaube@zambart.org.zm.; Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK. helen@zambart.org.zm.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: In high incidence settings, the majority of Mycobacterium tuberculosis (M.tb) transmission occurs outside the household. Little is known about where people's indoor contacts occur outside the household, and how this differs between different settings. We estimate the number of contact hours that occur between adults and adult/youths and children in different building types in urban areas in Western Cape, South Africa, and Zambia. METHODS: Data were collected from 3206 adults using a cross-sectional survey, on buildings visited in a 24-h period, including building function, visit duration, and number of adults/youths and children (5-12 years) present. The mean numbers of contact hours per day by building function were calculated. RESULTS: Adults in Western Cape were more likely to visit workplaces, and less likely to visit shops and churches than adults in Zambia. Adults in Western Cape spent longer per visit in other homes and workplaces than adults in Zambia. More adults/youths were present at visits to shops and churches in Western Cape than in Zambia, and fewer at homes and hairdressers. More children were present at visits to shops in Western Cape than in Zambia, and fewer at schools and hairdressers. Overall numbers of adult/youth indoor contact hours were the same at both sites (35.4 and 37.6 h in Western Cape and Zambia respectively, p = 0.4). Child contact hours were higher in Zambia (16.0 vs 13.7 h, p = 0.03). Adult/youth and child contact hours were highest in workplaces in Western Cape and churches in Zambia. Compared to Zambia, adult contact hours in Western Cape were higher in workplaces (15.2 vs 8.0 h, p = 0.004), and lower in churches (3.7 vs 8.6 h, p = 0.002). Child contact hours were higher in other peoples' homes (2.8 vs 1.6 h, p = 0.03) and workplaces (4.9 vs 2.1 h, p = 0.003), and lower in churches (2.5 vs 6.2, p = 0.004) and schools (0.4 vs 1.5, p = 0.01). CONCLUSIONS: Patterns of indoor contact between adults and adults/youths and children differ between different sites in high M.tb incidence areas. Targeting public buildings with interventions to reduce M.tb transmission (e.g. increasing ventilation or UV irradiation) should be informed by local data.
Coordinating the prevention, treatment, and care continuum for HIV-associated tuberculosis in prisons: a health systems strengthening approach.
(2018-Nov) Herce ME; Muyoyeta M; Topp SM; Henostroza G; Reid SE; Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, School of Medicine, Birmingham, Alabama, USA.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; College of Public Health, Medical and Veterinary Sciences, James Cook University, Queensland, Australia.; Division of Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
PURPOSE OF REVIEW: To advance a re-conceptualized prevention, treatment, and care continuum (PTCC) for HIV-associated tuberculosis (TB) in prisons, and to make recommendations for strengthening prison health systems and reducing HIV-associated TB morbidity and mortality throughout the cycle of pretrial detention, incarceration, and release. RECENT FINDINGS: Despite evidence of increased HIV-associated TB burden in prisons compared to the general population, prisoners face entrenched barriers to accessing anti-TB therapy, antiretroviral therapy, and evidence-based HIV and TB prevention. New approaches, suitable for the complexities of healthcare delivery in prisons, have emerged that may address these barriers, and include: novel TB diagnostics, universal test and treat for HIV, medication-assisted treatment for opioid dependence, comprehensive transitional case management, and peer navigation, among others. SUMMARY: Realizing ambitious international HIV and TB targets in prisons will only be possible by first addressing the root causes of the TB/HIV syndemic, which are deeply intertwined with human rights violations and weaknesses in prison health systems, and, second, fundamentally re-organizing HIV and TB services around a coordinated PTCC. Taking these steps can help ensure universal access to comprehensive, good-quality, free and voluntary TB/HIV prevention, treatment, and care, and advance efforts to strengthen health resourcing, staffing, information management, and primary care access within prisons.
Costs and cost-effectiveness of a comprehensive tuberculosis case finding strategy in Zambia.
(2021) Jo Y; Kagujje M; Johnson K; Dowdy D; Hangoma P; Chiliukutu L; Muyoyeta M; Sohn H; Centre For Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; School of Public Health, University of Zambia, Lusaka, Zambia.; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.; University of North Carolina School of Global Public Health, Chapel Hill, North Carolina, United States of America.
INTRODUCTION: Active-case finding (ACF) programs have an important role in addressing case detection gaps and halting tuberculosis (TB) transmission. Evidence is limited on the cost-effectiveness of ACF interventions, particularly on how their value is impacted by different operational, epidemiological and patient care-seeking patterns. METHODS: We evaluated the costs and cost-effectiveness of a combined facility and community-based ACF intervention in Zambia that utilized mobile chest X-ray with computer-aided reading/interpretation software and laboratory-based Xpert MTB/RIF testing. Programmatic costs (in 2018 US dollars) were assessed from the health system perspective using prospectively collected cost and operational data. Cost-effectiveness of the ACF intervention was assessed as the incremental cost per TB death averted over a five-year time horizon using a multi-stage Markov state-transition model reflecting patient symptom-associated care-seeking and TB care under ACF compared to passive care. RESULTS: Over 18 months of field operations, the ACF intervention costed $435 to diagnose and initiate treatment for one person with TB. After accounting for patient symptom-associated care-seeking patterns in Zambia, we estimate that this one-time ACF intervention would incrementally diagnose 407 (7,207 versus 6,800) TB patients and avert 502 (611 versus 1,113) TB-associated deaths compared to the status quo (passive case finding), at an incremental cost of $2,284 per death averted over the next five-year period. HIV/TB mortality rate, patient symptom-associated care-seeking probabilities in the absence of ACF, and the costs of ACF patient screening were key drivers of cost-effectiveness. CONCLUSIONS: A one-time comprehensive ACF intervention simultaneously operating in public health clinics and corresponding catchment communities can have important medium-term impact on case-finding and be cost-effective in Zambia. The value of such interventions increases if targeted to populations with high HIV/TB mortality, substantial barriers (both behavioral and physical) to care-seeking exist, and when ACF interventions can optimize screening by achieving operational efficiency.
Coverage of clinic-based TB screening in South Africa may be low in key risk groups.
(2016-Mar-21) McCreesh N; Faghmous I; Looker C; Dodd PJ; Plumb ID; Shanaube K; Muyoyeta M; Godfrey-Faussett P; Ayles H; White RG; TB Modelling Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine (LSHTM), London, UK.; ZAMBART Project, School of Medicine, University of Zambia, Lusaka, Zambia ; TB Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Department of Clinical Research, LSHTM, London, UK.; ZAMBART Project, School of Medicine, University of Zambia, Lusaka, Zambia ; Department of Clinical Research, LSHTM, London, UK.; TB Modelling Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine (LSHTM), London, UK ; Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK.; ZAMBART Project, School of Medicine, University of Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
The South African Ministry of Health has proposed screening all clinic attendees for tuberculosis (TB). Amongst other factors, male sex and bar attendance are associated with higher TB risk. We show that 45% of adults surveyed in Western Cape attended a clinic within 6 months, and therefore potentially a relatively high proportion of the population could be reached through clinic-based screening. However, fewer than 20% of all men aged 18-25 years, or men aged 26-45 who attend bars, attended a clinic. The population-level impact of clinic-based screening may be reduced by low coverage among key risk groups.
Cross-sectional assessment of tuberculosis and HIV prevalence in 13 correctional facilities in Zambia.
(2021-Sep-27) Kagujje M; Somwe P; Hatwiinda S; Bwalya J; Zgambo T; Thornicroft M; Bozzani FM; Moonga C; Muyoyeta M; Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK.; Tuberculosis Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Tuberculosis Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia mkagujje@gmail.com.; Health directorate, Zambia Correctional Service, Lusaka, Zambia.; Strategic Information Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
OBJECTIVE: To determine the prevalence of tuberculosis (TB) and HIV in 13 Zambian correctional facilities. METHODS: Cross-sectional study. SETTING: 13 correctional facilities in seven of the 10 provinces in Zambia. PARTICIPANTS: All incarcerated individuals were eligible for TB and HIV screening and testing. Of the total study population of 9695 individuals, which represent 46.2% of total correctional population at the beginning of the study, 8267 and 8160 were screened for TB and HIV, respectively. INTERVENTIONS: TB and HIV screening and testing was done between July 2018 and February 2019. PRIMARY OUTCOME MEASURES: All forms of TB, bacteriologically confirmed TB, drug-resistant TB, HIV. RESULTS: Prevalence of all forms of TB and bacteriologically confirmed TB was 1599 (1340-1894) per 100 000 population and 1056 (847-1301) per 100 000 population, respectively. Among those with bacteriologically confirmed TB, 4.6% (1.3%-11.4%) had drug-resistant TB.There was no statistically significant difference in the prevalence of all forms of TB, bacteriologically confirmed TB and drug resistant TB between adults and juveniles: (p=0.82), (p=0.23), (p=0.68) respectively. Of the bacteriologically confirmed TB cases, 28.7% were asymptomatic. The prevalence of HIV was 14.3% (13.6%-15.1%). The prevalence of HIV among females was 1.8 times the prevalence of HIV among males (p=0.01). CONCLUSION: Compared with the study in 2011 which screened inmates representing 30% of the country's inmate population, then the prevalence of all forms of TB and HIV in correctional facilities has reduced by about 75% and 37.6%, respectively. However, compared with the general population, the prevalence of all forms of TB and HIV was 3.5 and 1.3 times higher, respectively. TB/HIV programmes in correctional facilities need further strengthening to include aspects of juvenile-specific TB programming and gender responsive HIV programming.
Designing community-based strategies to reach non-household contacts of people with tuberculosis in Lusaka, Zambia: a rapid qualitative study among key stakeholders.
(2024) Kerkhoff AD; Foloko M; Kundu-Ng'andu E; Nyirenda H; Jabbie Z; Syulikwa M; Mwamba C; Kagujje M; Muyoyeta M; Sharma A; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, United States.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: In high-burden settings, most tuberculosis (TB) transmission likely occurs outside the home. Our qualitative study in Zambia explored the acceptability and preferences for designing TB active case finding (ACF) strategies to reach non-household contacts of people with TB. METHODS: We conducted 56 in-depth interviews with persons with TB ( RESULTS: All participants felt that TB was an important issue in their community and that new detection strategies were needed. A "social-network strategy" was perceived as acceptable and feasible, where participants noted it was a caring act and could facilitate early diagnosis. For a "venue-based strategy," most participants suspected TB transmission occurred at bars/taverns due to heavy alcohol use and prolonged time spent in crowded spaces; churches and betting halls were also commonly mentioned locations. Nearly all owners/leaders and patrons/attendees of bars, churches, and betting halls expressed acceptance of a venue-based strategy. They also indicated an interest in participating, citing many benefits, including increased TB knowledge/awareness, early diagnosis, convenience, and possibly reduced transmission, and recommended that the strategy incorporate sensitization, consent, volunteerism, and respectful, confidential, private services. For both strategies, most participants preferred the use of and being approached by trained peer TB survivors to facilitate ACF, given their prior TB patient experience and trust among community members. CONCLUSION: Stakeholders found social-network and venue-based TB-ACF strategies highly acceptable, recognizing their potential benefits for individuals and the broader community. Future research should evaluate the feasibility and effectiveness of TB ACF strategies for reaching non-household contacts.
Diagnosed with TB in the era of COVID-19: patient perspectives in Zambia.
(2020-Dec-21) Mwamba C; Kerkhoff AD; Kagujje M; Lungu P; Muyoyeta M; Sharma A; Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA.; National Tuberculosis and Leprosy Control Programme, Lusaka.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
INTRODUCTION: Delayed TB diagnosis and treatment perpetuate the high burden of TB-related morbidity and mortality in resource-constrained settings. We explored the potential of COVID-19 to further compromise TB care engagement in Zambia. METHODS: From April to May 2020, we purposefully selected 17 adults newly diagnosed with TB from three public health facilities in Lusaka, Zambia, for in-depth phone interviews. We conducted thematic analyses using a hybrid approach. RESULTS: The majority of participants were highly concerned about the impact of lockdowns on their financial security. Most were not worried about being diagnosed with COVID-19 when seeking care for their illness because they felt unwell prior to the outbreak; however, they were very worried about contracting COVID-19 during clinic visits. COVID-19 was perceived as a greater threat than TB as it is highly transmittable and there is no treatment for it, which provoked fear of social isolation and of death among participants in case they contracted it. Nonetheless, participants reported willingness to continue with TB medication and the clinic visits required to improve their health. CONCLUSION: The COVID-19 pandemic did not appear to deter care-seeking for TB by patients. However, messaging on TB in the era of COVID-19 must encourage timely care-seeking by informing people of infection control measures taken at health facilities.
Diagnostic accuracy of a novel point-of-care urine lipoarabinomannan assay for the detection of tuberculosis among adult outpatients in Zambia: a prospective cross-sectional study.
(2021-Nov) Muyoyeta M; Kerkhoff AD; Chilukutu L; Moreau E; Schumacher SG; Ruhwald M; These authors contributed equally to this work.; Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia.; Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, USA.; Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia Mondemuy@gmail.com.; Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: A novel, rapid, point-of-care urine-based lipoarabinomannan assay (Fujifilm SILVAMP TB LAM ("FujiLAM")) has previously demonstrated substantially higher sensitivity for tuberculosis (TB) compared with the commercially available Determine TB LAM assay using biobanked specimens. However, FujiLAM has not been prospectively evaluated using fresh urine specimens. Therefore, we determined the diagnostic accuracy of FujiLAM among HIV-positive and HIV-negative outpatients with presumptive TB in Zambia. METHODS: Adult (≥18 years old) presumptive TB patients presenting to two outpatient public health facilities in Lusaka were included. All patients submitted sputa samples for smear microscopy, Xpert MTB/RIF and mycobacterial culture, and urine samples for the FujiLAM assay. Microbiologically confirmed TB was defined by the detection of RESULTS: 151 adults with paired sputum microbiological tests and urine FujiLAM results were included; 45% were HIV-positive. Overall, 34 out of 151 (23%) patients had culture-confirmed pulmonary TB. The overall sensitivity and specificity of FujiLAM was 77% (95% CI 59-89%) and 92% (95% CI 86-96%), respectively. FujiLAM's sensitivity among HIV-positive patients was 75% (95% CI 43-95%) compared with 75% (95% CI 51-91%) among HIV-negative patients. The sensitivity of FujiLAM in patients with smear-positive, confirmed pulmonary TB was 87% (95% CI 60-98%) compared with 68% (95% CI 43-87%) among patients with smear-negative, confirmed pulmonary TB. CONCLUSIONS: FujiLAM demonstrated high sensitivity for the detection of TB among both HIV-positive and HIV-negative adults, and also demonstrated good specificity despite the lack of systematic extrapulmonary sampling to inform a comprehensive microbiological reference standard.
Diagnostic yield as an important metric for the evaluation of novel tuberculosis tests: rationale and guidance for future research.
(2024-Jul) Broger T; Marx FM; Theron G; Marais BJ; Nicol MP; Kerkhoff AD; Nathavitharana R; Huerga H; Gupta-Wright A; Kohli M; Nichols BE; Muyoyeta M; Meintjes G; Ruhwald M; Peeling RW; Pai NP; Pollock NR; Pai M; Cattamanchi A; Dowdy DW; Dewan P; Denkinger CM; Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia.; Boston Children's Hospital, Boston, MA, USA.; The University of Sydney Infectious Diseases Institute, Sydney, NSW, Australia; Children's Hospital at Westmead, Sydney, NSW, Australia.; Bill & Melinda Gates Foundation, Seattle, WA, USA.; Department of Epidemiology, Epicentre, Paris, France.; McGill International TB Centre, McGill University, Montreal, QC, Canada.; Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA; Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of California Irvine, Irvine, CA, USA.; Department of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany; DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Faculty of Science, Stellenbosch University, Stellenbosch, South Africa.; London School of Hygiene & Tropical Medicine, London, UK.; DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.; Department of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany; German Center for Infection Research, Heidelberg University Hospital, Heidelberg, Germany. Electronic address: claudia.denkinger@uni-heidelberg.de.; Department of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany.; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.; Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.; Division of HIV, Infectious Diseases, and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA; Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA.; Division of Infection and Immunity, School of Biomedical Sciences, University of Western Australia, Perth, WA, Australia.; Department of Medicine, Centre for Outcomes Research & Evaluation, McGill University, Montreal, QC, Canada.; FIND, Geneva, Switzerland.; Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Better access to tuberculosis testing is a key priority for fighting tuberculosis, the leading cause of infectious disease deaths in people. Despite the roll-out of molecular WHO-recommended rapid diagnostics to replace sputum smear microscopy over the past decade, a large diagnostic gap remains. Of the estimated 10·6 million people who developed tuberculosis globally in 2022, more than 3·1 million were not diagnosed. An exclusive focus on improving tuberculosis test accuracy alone will not be sufficient to close the diagnostic gap for tuberculosis. Diagnostic yield, which we define as the proportion of people in whom a diagnostic test identifies tuberculosis among all people we attempt to test for tuberculosis, is an important metric not adequately explored. Diagnostic yield is particularly relevant for subpopulations unable to produce sputum such as young children, people living with HIV, and people with subclinical tuberculosis. As more accessible non-sputum specimens (eg, urine, oral swabs, saliva, capillary blood, and breath) are being explored for point-of-care tuberculosis testing, the concept of yield will be of growing importance. Using the example of urine lipoarabinomannan testing, we illustrate how even tests with limited sensitivity can diagnose more people with tuberculosis if they enable increased diagnostic yield. Using tongue swab-based molecular tuberculosis testing as another example, we provide definitions and guidance for the design and conduct of pragmatic studies that assess diagnostic yield. Lastly, we show how diagnostic yield and other important test characteristics, such as cost and implementation feasibility, are essential for increased effective population coverage, which is required for optimal clinical care and transmission impact. We are calling for diagnostic yield to be incorporated into tuberculosis test evaluation processes, including the WHO Grading of Recommendations, Assessment, Development, and Evaluations process, providing a crucial real-life implementation metric that complements traditional accuracy measures.
Early user perspectives on using computer-aided detection software for interpreting chest X-ray images to enhance access and quality of care for persons with tuberculosis.
(2023-Dec-21) Creswell J; Vo LNQ; Qin ZZ; Muyoyeta M; Tovar M; Wong EB; Ahmed S; Vijayan S; John S; Maniar R; Rahman T; MacPherson P; Banu S; Codlin AJ; Department of Global Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institutet, Stockholm, Sweden.; Stop TB Partnership, Geneva, Switzerland.; Friends for International TB Relief (FIT), Hanoi, Vietnam.; Division of Infectious Diseases, Heersink School of Medicine, University of Alabama Birmingham, Birmingham, AL, USA.; Africa Health Research Institute, KwaZulu-Natal, South Africa.; PATH India, Mumbai, India.; Socios En Salud Sucursal Peru, Lima, Peru.; Interactive Research and Development (IRD) Pakistan, Karachi, Pakistan.; London School of Hygiene & Tropical Medicine, London, UK.; Janna Health Foundation, Yola, Nigeria.; International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.; Stop TB Partnership, Geneva, Switzerland. jacobc@stoptb.org.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; School of Health & Wellbeing, University of Glasgow, Glasgow, UK.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Despite 30 years as a public health emergency, tuberculosis (TB) remains one of the world's deadliest diseases. Most deaths are among persons with TB who are not reached with diagnosis and treatment. Thus, timely screening and accurate detection of TB, particularly using sensitive tools such as chest radiography, is crucial for reducing the global burden of this disease. However, lack of qualified human resources represents a common limiting factor in many high TB-burden countries. Artificial intelligence (AI) has emerged as a powerful complement in many facets of life, including for the interpretation of chest X-ray images. However, while AI may serve as a viable alternative to human radiographers and radiologists, there is a high likelihood that those suffering from TB will not reap the benefits of this technological advance without appropriate, clinically effective use and cost-conscious deployment. The World Health Organization recommended the use of AI for TB screening in 2021, and early adopters of the technology have been using the technology in many ways. In this manuscript, we present a compilation of early user experiences from nine high TB-burden countries focused on practical considerations and best practices related to deployment, threshold and use case selection, and scale-up. While we offer technical and operational guidance on the use of AI for interpreting chest X-ray images for TB detection, our aim remains to maximize the benefit that programs, implementers, and ultimately TB-affected individuals can derive from this innovative technology.
Engagement of private health care facilities in TB management in Lusaka district of Zambia: lessons learned and achievements.
(2024-Mar-14) Hambwalula R; Kagujje M; Mwaba I; Musonda D; Singini D; Mutti L; Sanjase N; Kaumba PC; Ziko LM; Zimba KM; Kasese-Chanda P; Muyoyeta M; Division of Health, United States Agency for International Development, Lusaka, Zambia.; TB department, Centre of Infectious Disease Research in Zambia, Plot # 34620 Off Alick Nkhata Road, Mass Media, P.O. Box 34681, Lusaka, 10101, Zambia. Mary.Kagujje@cidrz.org.; Lusaka District Health Office, Ministry of Health, Great East Road, Lusaka, Zambia.; TB department, Centre of Infectious Disease Research in Zambia, Plot # 34620 Off Alick Nkhata Road, Mass Media, P.O. Box 34681, Lusaka, 10101, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Globally, at least 3 million TB patients are missed every year. In Zambia, the TB treatment coverage increased from 66% in 2020 to 92% in 2022. Involvement of all levels of health care service delivery is critical to finding all the missing TB patients. METHODS: A survey was undertaken in 15 private facilities in Lusaka district of Zambia using a structured tool administered by project team and a district health team member. Data collected during the survey was analysed and results were used to determine the type of TB services that were offered as well as barriers and enablers to TB service provision. This was followed by a set of interventions that included; training and mentorship on active case finding and systematic TB screening, increased diagnostic capacity, provision of national recording and reporting tools and provision of TB medication through linkage with the National TB program (NTP). We report findings from the baseline survey and changes in presumptive TB identification and notification following interventions. RESULTS: Major barriers to TB service delivery were the high cost of TB diagnostic testing and treatment in facilities where services were not supported by the National TB program; the mean cost was 33 (SD 33) and 93 (SD 148) for GeneXpert testing and a full course of treatment respectively. Pre-intervention, presumptive TB identification appeared to increase monthly by 4 (P = 0.000, CI=[3.00-5.00]). The monthly trends of presumptive TB identification during the intervention period increased by 5.32 (P = 0.000, [CI 4.31-6.33. Pre-intervention, the notification of TB appeared to decrease every month by -4.0 (P = 0.114, CI=[-9.00-0.10]) followed by an immediate increase in notifications of 13.94 TB patients (P = 0.001, CI [6.51, 21.36] in the first month on intervention. The monthly trends of notification during the intervention period changed by 0.34 (P = 0.000 [CI 0.19-0.48]). Private facility contribution to TB notification increased from 3 to 7%. CONCLUSION: Engagement and inclusion of private health facilities in TB service provision through a systems strengthening approach can increase contribution to TB notification by private health facilities.