Development of a questionnaire to determine the case detection delay of leprosy: A mixed-methods cultural validation study

Background Delay in case detection is a risk factor for developing leprosy-related impairments, leading to disability and stigma. The objective of this study was to develop a questionnaire to determine the leprosy case detection delay, defined as the period between the first signs of the disease and the moment of diagnosis, calculated in total number of months. The instrument was developed as part of the PEP4LEP project, a large-scale intervention study which determines the most effective way to implement integrated skin screening and leprosy post-exposure prophylaxis with a single-dose of rifampicin (SDR-PEP) administration in Ethiopia, Mozambique and Tanzania. Methodology/Principal findings A literature review was conducted and leprosy experts were consulted. The first draft of the questionnaire was developed in Ethiopia by exploring conceptual understanding, item relevance and operational suitability. Then, the first draft of the tool was piloted in Ethiopia, Mozambique and Tanzania. The outcome is a questionnaire comprising nine questions to determine the case detection delay and two annexes for ease of administration: a local calendar to translate the patient’s indication of time to number of months and a set of pictures of the signs of leprosy. In addition, a body map was included to locate the signs. A ‘Question-by-Question Guide’ was added to the package, to provide support in the administration of the questionnaire. The materials will be made available in English, Oromiffa (Afaan Oromo), Portuguese and Swahili via https://www.infolep.org. Conclusions/Significance It was concluded that the developed case detection delay questionnaire can be administered quickly and easily by health workers, while not inconveniencing the patient. The instrument has promising potential for use in future leprosy research. It is recommended that the tool is further validated, also in other regions or countries, to ensure cultural validity and to examine psychometric properties like test-retest reliability and interrater reliability.

Repairing boundaries along pathways to tuberculosis case detection: a qualitative synthesis of intervention designs

Background Tuberculosis case-finding interventions often involve several activities to enhance patient pathways, and it is unclear which activity defines the type of case-finding intervention. When conducting studies to identify the most effective case-finding intervention it is important to have a clear understanding of these interventions for meaningful comparisons. This review aimed to construct a systems-based logic model of all pathways to tuberculosis case detection through a synthesis of intervention designs. Methods We identified an existing systematic review on the effectiveness of interventions to increase tuberculosis case detection and updated the search from December 2016 to October 2020. We included randomized controlled trials, as these designs encourage detailed description of interventions. Taking each study in turn, intervention descriptions were read in detail. The texts were analysed qualitatively by constantly comparing emerging codes to construct patient journeys, visualized as logical chains. Actions taken as part of interventions were positioned along patient journeys to theorize the sequence of outcomes. Patient journeys formed the basis of the model, which was refined through discussion. Results Based on intervention descriptions from 17 randomized controlled trials, our model distinguishes two care-seeking pathways and four screening pathways. An open invitation to people with tuberculosis symptoms creates care-seeking pathways. On care-seeking pathways, systematic screening can be conducted at general health services, but not at specific TB care services. People invited to tuberculosis services regardless of symptoms follow tuberculosis screening pathways and may be identified with presumptive tuberculosis even if they do not seek care for tuberculosis symptoms. Tuberculosis screening pathways include screening offered to all people accessing care at general health services, screening at a mobile clinic or health facility with open invitation to a whole population or tuberculosis contacts, screening personally offered to a whole population or tuberculosis contacts at home, work or school, and screening offered to people receiving care for human immunodeficiency virus or other clinical risk-group care. Conclusion This systems-based logic model of tuberculosis case-finding pathways may support standardized terminology, consistency, transparency and improved communication among researchers, policy-makers, health workers and community members when implementing and evaluating interventions to improve tuberculosis case detection.

The Prevalence of Mycobacterium Tuberculosis Using Gene Xpert Among Tuberculosis Suspected Patients in Gedeo Zone, Southern Ethiopia

Background Tuberculosis (TB) is a communicable disease remains a major global health problem and the leading cause of death from a single infectious agent. Even though many of the WHO recommended TB control strategy was implemented; there is still a major gap in TB case detection and treatment. This study aimed to determine the prevalence of Mycobacterium tuberculosis among presumptive TB patients in Gedeo Zone, Southern Ethiopia. Methods A cross-sectional study was conducted on 384 TB suspected patients in Gedeo Zone from February to July 2021. Data were collected using a pretested structured questionnaire. Laboratory examination was processed using Xpert-MTB/RIF assay. Data entry was made using Epi info version 7 and analyzed by SPSS version 24. Logistic regression models were used to determine the risk factors. Results Out of 384 study participants suspected with TB, M tuberculosis was isolated from 103 giving an overall prevalence of 26.8%. Males (AOR) = 1.95; 95% CI 1.56-2.65, P=0.01) were more likely to develop TB than females. Study participants who were illiterate (AOR 2.10; 95% CI 1.17-2.51, p=0.014) were more likely to develop TB than the educated one. Cigarette smokers (AOR 2.89; 95% CI 2.10-3.84, p=0.01), khat chewers (AOR 2.86; 95% CI 1.28-3.79, p=0.01), vaccination (AOR 0.52; 95% CI 0.21-0.88, p=0.02), close contact (AOR 3.42; 95% CI 2.24-4.50, p=0.01) and being positive for HIV (AOR 2.01; 95% CI 1.07-3.52, 0.01) were more likely to develop TB. Conclusion Despite implementation of national and international TB control strategies, TB still remains one of the major public health problems in the country especially in the study area. The high prevalence of MTB was reported different risk groups. Early case detection and management of TB should be given special attention to strengthen and an appropriate control and prevention methods to reduce the emergence and increasing of MTB cases.

Improved Diagnosis of Pulmonary Tuberculosis using Bleach (Sodium hypochlorite) Concentration Technique at Tertiary Care Hospital

Introduction: In the Revised National Tuberculosis Control Program (RNTCP), microscopic examination of sputum for acid-fast bacilli (AFB) is currently the backbone for the diagnosis of pulmonary tuberculosis. Studies have shown liquefaction and concentration of sputum by 5% sodium hypochlorite is useful in providing increased sensitivity and safety for the handling of specimens. Objective: To assess the utility of the 5% Sodium hypochlorite concentration method in increasing the sensitivity of smear microscopy for detection of AFB for diagnosis of pulmonary tuberculosis. Methods: The study included a total of 1000 sputum samples from 500 patients with suspected pulmonary tuberculosis. Direct smears were prepared from the sputum samples as per RNTCP guidelines. The remaining sputum was used for bleach concentration and smears prepared from the concentrated material. Both smears were stained by Ziehl-Neelsen staining and screened for acid-fast bacilli and graded according to the RNTCP guidelines. Results: A total of 158 samples (15.8%) from 89 patients were positive by a routine direct method whereas by concentration method 236 samples (23.6%) from 143 patients were found positive diagnosing additional 54 patients. The gain in sputum smear positivity of 7.8% over the routine method is highly significant (p=0.0000, χ2= 270) with a 10.8% increase in case detection. Conclusions: Improvement in the sensitivity of smears microscopy will be useful in case detection of tuberculosis especially in resource-poor countries. The increased positivity of microscopy by bleach method indicates that would prove useful if included in the RNTCP to improve case detection. Keywords: Concentration; smear positivity; sodium hypochlorite; tuberculosis.

Early TB case detection by community-based mobile X-ray screening and Xpert testing in Balochistan

SETTING: This survey was conducted at 35 sites of 20 cities in 15 districts with low programmatic TB case notifications in the past years in Balochistan.OBJECTIVE: To assess the effectiveness of the systemic community-based screening and diagnosis for early detection of TB; and 2) to describe the characteristics and understand the strengths and weaknesses of the intervention in Balochistan, and sociodemographic factors associated with it.DESIGN: This cross-sectional descriptive study was conducted using a mobile van equipped with a digital X-ray machine with computer-aided detection for TB (CAD4TB) software for screening, followed by confirmatory high sensitivity Xpert® MTB/RIF assay testing.RESULTS: A total of 236 (3.4%) TB cases was detected out of 6,899 screened. About 1,168 (17%) presumptive TB cases were identified and 1,065 (91%) sputum samples were tested on Xpert. Among those diagnosed, 166 (70%) were Mycobacterium tuberculosis-positive and 70 (30%) were with clinical suspicion. Of the sputum samples tested, 87% (923/1065) had a probability score of >70 on CAD4TB.CONCLUSION: Community-based screening with innovative activities, comprising sensitive screening and diagnostic tools, effectively improves TB case detection, which might suffice to reduce the prevalence of TB and break the chain of infection transmission in the at-risk population.

Do community-based active case-finding interventions have indirect impacts on wider TB case detection and determinants of subsequent TB testing behaviour? A systematic review

Community-based active case-finding (ACF) may have important impacts on routine TB case-detection and subsequent patient-initiated diagnosis pathways, contributing “indirectly” to infectious diseases prevention and care. We investigated the impact of ACF beyond directly diagnosed patients for TB, using routine case-notification rate (CNR) ratios as a measure of indirect effect. We systematically searched for publications 01-Jan-1980 to 13-Apr-2020 reporting on community-based ACF interventions compared to a comparison group, together with review of linked manuscripts reporting knowledge, attitudes, and practices (KAP) outcomes or qualitative data on TB testing behaviour. We calculated CNR ratios of routine case-notifications (i.e. excluding cases identified directly through ACF) and compared proxy behavioural outcomes for both ACF and comparator communities. Full text manuscripts from 988 of 23,883 abstracts were screened for inclusion; 36 were eligible. Of these, 12 reported routine notification rates separately from ACF intervention-attributed rates, and one reported any proxy behavioural outcomes. Two further studies were identified from screening 1121 abstracts for linked KAP/qualitative manuscripts. 8/12 case-notification studies were considered at critical or serious risk of bias. 8/11 non-randomised studies reported bacteriologically-confirmed CNR ratios between 0.47 (95% CI:0.41–0.53) and 0.96 (95% CI:0.94–0.97), with 7/11 reporting all-form CNR ratios between 0.96 (95% CI:0.88–1.05) and 1.09 (95% CI:1.02–1.16). One high-quality randomised-controlled trial reported a ratio of 1.14 (95% CI 0.91–1.43). KAP/qualitative manuscripts provided insufficient evidence to establish the impact of ACF on subsequent TB testing behaviour. ACF interventions with routine CNR ratios >1 suggest an indirect effect on wider TB case-detection, potentially due to impact on subsequent TB testing behaviour through follow-up after a negative ACF test or increased TB knowledge. However, data on this type of impact are rarely collected. Evaluation of routine case-notification, testing and proxy behavioural outcomes in intervention and comparator communities should be included as standard methodology in future ACF campaign study designs.

An Evaluation of Childhood Tuberculosis Program in Chegutu District, Zimbabwe, 2020: A Descriptive Cross-Sectional Study

Background Childhood tuberculosis (TB) is a major global public health concern contributing to significant child morbidity and mortality. A records review of the TB notification for Chegutu District Health Information System 2 (DHIS2) showed a low childhood TB case detection rate. For 2018 and 2019, childhood TB notifications were 4% and 7% respectively against the national 12% case detection rate. We evaluated the performance of the childhood TB program in Chegutu. Methods We conducted a descriptive cross-sectional study. Sixty-six health workers (HW) participated in the study. Interviewer-administered questionnaires and checklists were used to collect data on reasons for low TB case detection, HW childhood TB knowledge, program inputs, processes and outputs. Strengths, Weaknesses, Opportunities and Threats analysis was used to assess the childhood TB processes. We analyzed the data using Epi Info 7TM to generate frequencies, proportions and means. A Likert scale was used to assess health worker knowledge. Results The majority 51/66(77%) of HW were nurses and 51/66(67%) of respondents were females. Reasons for the low childhood TB case detection were lack of HW confidence in collecting gastric aspirates 55/66(83%) and HW’s negative attitudes towards gastric aspirate collection 23/66(35%). HW 24/66 (37%) had a fair childhood TB notification knowledge. The district had only one functional X-ray machine for 34 health facilities. Only 6/18 motorcycles were functional with inadequate fuel supply. No desk guide for the management of TB in children for HW (2018) was available in 34 health facilities. Ethambutol 400mg was out of stock and adult 800mg tablets were used. Funds allocated for motor vehicle and motorcycles service ($1612USD/year) were inadequate. The district failed to perform planned quarterly TB review meetings, contact tracing and childhood TB training due to funding and COVID-19 lockdown restrictions. Conclusion The childhood TB program failed to meet its targets due to inadequate inputs and suboptimal HW childhood TB knowledge. Case detection and notification can be improved through on-job training, mentorship, support and supervision and adequate resources.

Risk factors associated with malaria infection identified through reactive case detection in Zanzibar, 2012–2019

Background Over the past two decades, Zanzibar substantially reduced malaria burden. As malaria decreases, sustainable improvements in control interventions may increasingly depend on accurate knowledge of malaria risk factors to further target interventions. This study aimed to investigate the risk factors associated with malaria infection in Zanzibar. Methods Surveillance data from Zanzibar’s Malaria Case Notification system from August 2012 and December 2019 were analyzed. This system collects data on malaria cases passively detected and reported by all health facilities (index cases), and household-based reactive case detection (RCD) activities linked to those primary cases. All members of households of the index cases were screened for malaria using a malaria rapid diagnostic test (RDT). Individuals with a positive RDT were treated with artemisinin-based combination therapy. Univariate and multivariate logistic regression analyses were done to investigate the association between RDT positivity among the household members and explanatory factors with adjustment for seasonality and clustering at Shehia level. Results A total of 30,647 cases were reported of whom household RCD was completed for 21,443 (63%) index case households and 85,318 household members tested for malaria. The findings show that younger age (p-value for trend [Ptrend] < 0.001), history of fever in the last 2 weeks (odds ratio [OR] = 35.7; 95% CI 32.3–39.5), travel outside Zanzibar in the last 30 days (OR = 2.5; 95% CI 2.3–2.8) and living in Unguja (OR = 1.2; 95% CI 1.0–1.5) were independently associated with increased odds of RDT positivity. In contrast, male gender (OR=0.8; 95% CI 0.7–0.9), sleeping under an LLIN the previous night (OR = 0.9; 95% CI 0.7–0.9), having higher household net access (Ptrend < 0.001), and living in a household that received IRS in the last 12 months (OR = 0.8; 95% CI 0.7–0.9) were independently associated with reduced odds of RDT positivity. A significant effect modification of combining IRS and LLIN was also noted (OR = 0.7; 95% CI 0.6–0.8). Conclusions The findings suggest that vector control remains an important malaria prevention intervention: they underscore the need to maintain universal access to LLINs, the persistent promotion of LLIN use, and application of IRS. Additionally, enhanced behavioural change and preventive strategies targeting children aged 5–14 years and travellers are needed.

Knowledge, Attitude, and Practices Regarding Childhood Tuberculosis Detection and Management Among Health Care Providers in Cambodia: A Cross-Sectional Study

Background The World Health Organization (WHO) estimated that 29% of global tuberculosis (TB) and almost 47% of childhood TB cases were not reported to national TB programs in 2019. In Cambodia, most childhood TB cases were reported from health facilities supported by the Global Fund to Fight AIDS, Tuberculosis, and Malaria in 2019. This study aimed to compare the healthcare providers' KAP on childhood TB case detection in ODs with high and low childhood TB case detection in Cambodia. Methods We conducted a cross-sectional study between November and December 2020 among healthcare providers in 10 purposively selected operational districts (ODs) with high childhood TB case detection and 10 ODs with low childhood TB case detection. A total of 110 healthcare providers from referral hospitals and 220 from health centers were interviewed. We collected information on socio-demographic characteristics, training, and KAP on childhood TB. Pearson's Chi-square or Fisher's exact and Student's t-tests were performed to explore the differences in KAP of healthcare providers from ODs with low vs. high childhood TB detection. Results Of the 330 respondents, 193 were from ODs with high childhood TB case detection, and 66.67% were from health centers. A significantly higher proportion (46.11%) of respondents from ODs with high childhood TB case detection received training on childhood TB within the past two years than those from low childhood TB case detection ODs (34.31%) (p=0.03). Key knowledge on childhood TB was not significantly different among respondents from ODs with high and low childhood TB case detection. A significantly higher proportion of respondents from ODs with high childhood TB case detection had a good attitude (98.96% v.s. 97.08%, p=0.002) and performed good practices (58.55% v.s. 45.26%, p=0.02) on contact investigation in the community than those from low childhood TB case detection ODs. Conclusions Healthcare providers from ODs with high childhood TB detection had better attitudes and practices towards childhood TB. The attitudes and practices need to be improved among healthcare providers in ODs with low case detection. Further investment in training and experience sharing on childhood TB case detection among healthcare providers is needed to improve childhood TB case detection.