A Population-Based Cohort Study of Mycobacterium tuberculosis Beijing Strains: An Emerging Public Health Threat in an Immigrant-Receiving Country?

Mycobacterium tuberculosis Beijing strains are frequently associated with tuberculosis outbreaks and drug resistance. However, contradictory evidence and limited study generalizability make it difficult to foresee if the emergence of Beijing strains in high-income immigrant-receiving countries poses an increased public health threat. The purpose of this study was to determine if Beijing strains are associated with high risk disease presentations relative to other strains within Canada.This was a retrospective population-based study of culture-confirmed active TB cases in a major immigrant-receiving province of Canada in 1991 through 2007. Of 1,852 eligible cases, 1,826 (99%) were successfully genotyped. Demographic, clinical, and mycobacteriologic surveillance data were combined with molecular diagnostic data. The main outcome measures were site of disease, lung cavitation, sputum smear positivity, bacillary load, and first-line antituberculosis drug resistance.A total of 350 (19%) patients had Beijing strains; 298 (85%) of these were born in the Western Pacific. Compared to non-Beijing strains, Beijing strains were significantly more likely to be associated with polyresistance (aOR 1.8; 95% CI 1.0-3.3; p = 0.046) and multidrug-resistance (aOR 3.4; 1.0-11.3; p = 0.049). Conversely, Beijing strains were no more likely than non-Beijing strains to be associated with respiratory disease (aOR 1.3; 1.0-1.8; p = 0.053), high bacillary load (aOR 1.2; 0.6-2.7), lung cavitation (aOR 1.0; 0.7-1.5), immediately life-threatening forms of tuberculosis (aOR 0.8; 0.5-1.6), and monoresistance (aOR 0.9; 0.6-1.3). In subgroup analyses, Beijing strains only had a significant association with multidrug-resistant tuberculosis (aOR 6.1; 1.2-30.4), and an association of borderline significance with polyresistant tuberculosis (aOR 1.8; 1.0-3.5; p = 0.062), among individuals born in the Western Pacific.Other than an increased risk of polyresistant or multidrug-resistant tuberculosis, Beijing strains appear to pose no more of a public health threat than non-Beijing strains within a high-income immigrant-receiving country

The Effectiveness and Acceptability of Six-Month Isoniazid Preventive Therapy amongst People Living with HIV in KwaZulu-Natal, South Africa

Tuberculosis (TB) preventive therapy is an integral part of global strategies to end TB. Isoniazid preventive therapy (IPT) is currently the only regimen recommended globally for low-resource settings with high burdens of TB and TB-HIV. In South Africa, where the incidence of TB and TB-HIV are among the highest in the world, health districts were quick to facilitate access to six-month IPT in the absence of active TB symptoms for all people living with HIV, amid numerous unknowns. My doctoral thesis responds to some of these unknowns; specifically, the effectiveness of IPT to reduce TB incidence and its acceptability in communities where latent TB infection was previously unfamiliar. The research occurred within a community-based participatory research framework including regular meetings with grassroots community advisory teams in three communities of uMgungundlovu District, KwaZulu-Natal. IPT effectiveness was evaluated utilising a retrospective cohort design, comparing TB incidence across two years among people receiving IPT alone, antiretroviral therapy (ART) alone, or IPT+ART to those without intervention. Acceptability was evaluated utilising the ethnographic method, including extensive field work, eight group interviews to learn about perspectives of TB infection, disease and IPT, and nine individual interviews with people accepting, discontinuing or declining IPT to learn about IPT experiences and decision making. Among those who completed the regimen, IPT significantly reduced the two-year TB incidence by 100% among women (97.5%CI=78-100%), with a less certain effect among men: IR=0.46, 95%CI=0-85%. IPT also appeared to provide additional prevention for people on ART. Nevertheless, IPT was interpreted by some as dangerous when the costs related to pill collection or consumption exacerbated poverty, the stigma associated with HIV and ART were conflated with its use, or it was seen as toxic. Clinical expectations of IPT initiation and adherence may also conflict with expectations of women in Zulu culture. Some women may initiate IPT to please the healthcare provider, rather than from a belief in preventive benefits. Taken together, findings suggest that IPT can reduce the risk of TB among people living with HIV, but may not be a high priority when economic and social needs compete

The role of agency in the implementation of Isoniazid Preventive Therapy (IPT): Lessons from <i>oMakoti</i> in uMgungundlovu District, South Africa

<div><p>Introduction</p><p>In response to revisions in global and national policy in 2011, six-month isoniazid preventive therapy (IPT) became freely available as a preventive measure for people living with HIV in the uMgungundlovu District of KwaZulu-Natal province, South Africa. Given a difference in uptake and completion by sex, we sought to explore the reasons why Zulu women were more likely to accept and complete IPT compared to men in an effort to inform future implementation.</p><p>Methods</p><p>Utilising a community-based participatory research approach and ethnographic methods, we undertook 17 individual and group interviews, and met regularly with grassroots community advisory teams in three Zulu communities located in uMgungundlovu District between March 2012–December 2016.</p><p>Findings & discussion</p><p>Three categories described women’s willingness to initiate IPT: women are caregivers, women are obedient, and appearance is important. The findings suggest that the success of IPT implementation amongst clinic-utilising women of uMgungundlovu is related to the cultural gender norms of <i>uMakoti</i>, isiZulu for “the bride” or “the wife.” We invoke the cultural concept of <i>inhlonipho</i>, meaning “to show respect,” to discuss how the cultural values of <i>uMakoti</i> may conflict with biomedical expectations of adherence. Such conflict can result in misinterpretations by healthcare providers or patients, and lead some patients to fear the repercussions of asking questions or contemplating discontinuation with the provider, preferring instead to appear obedient. We propose a shift in emphasis from adherence-focussed strategies, characteristic of the current biomedical approach, to practices that promote patient agency in an effort to offer IPT more appropriately.</p><p>Implications</p><p>Building on existing tools, namely the harm reduction model and the use of mini-ethnography, we provide guidance on how to support women to participate as agents in the decision to initiate or continue IPT, decisions which may also impact the health and choices of the family.</p></div

Understanding the gaps in DR-TB care cascade in Nigeria: A sequential mixed-method study

Background: Despite the availability of free drug-resistant tuberculosis (DR-TB) care in Nigeria since 2011, the country continues to tackle low case notification and treatment rates. In 2018, 11% of an estimated 21,000 cases were diagnosed and 9% placed on treatment. These low rates are nevertheless a marked improvement from 2015 when only 3.4% were diagnosed and 2.3% placed on treatment of an estimated 29,000 cases. This study describes the Nigerian DR-TB care cascade from 2013 to 2017 and considers factors influencing gaps in care. Methods: Our study utilized a mixed-method design. For the quantitative component, we utilized the national diagnosis and treatment databases, as well as the World Health Organization's estimates for prevalence to construct a 5-year care cascade: numbers of patients at each level of DR-TB care, including incident cases, individuals who accessed testing, were diagnosed, initiated treated and completed treatment in Nigeria between 2013 and 2017. Using retrospective data for patients diagnosed in 2015, we performed the Fisher's exact test to determine the association between patient (age and gender) and provider/patient (region- north or south) variables, permitting a closer look at the gaps in care revealed across the 5 years. Barriers to care were explored using framework thematic analysis of 57 qualitative interviews and focus group discussions with patients, including 5 cases not initiated on treatment from the 2015 cohort, treatment supporters, community members, healthcare workers and program managers in 2017. Results: A 5-year analysis of cascade of care data shows significant, but inadequate, increases in overall numbers of cases accessing care. On average, between 2013 and 2017, 80% of estimated cases did not access testing; 75% of those who tested were not diagnosed; 36% of those diagnosed were not initiated on treatment and 23% of these did not finish treatment. In 2015, children and patients in Northern Nigeria had odds of 0.3 [95% CI 0.1–0.7] and 0.4 [0.3–0.5] of completing treatment once diagnosed; while males were shown to have a 1.34 [95% CI 1.0–1.7] times greater chance of completing treatment after diagnosis

More than Just Great Quotes: An Introduction to the Canadian Tri-Council’s Qualitative Requirements

Although at times misunderstood by the general research community, qualitative research has developed out of diverse, rich and complex philosophical traditions and theoretical paradigms. In the most recent Canadian Tri-Council policy statement on the ethical conduct of research involving humans, a chapter was devoted to a summary of methods and methodological requirements that characterize robust qualitative research, despite the diversity of approaches. To dispel common misperceptions about qualitative research and introduce the unfamiliar reader to these requirements, the work of a qualitative study on isoniazid preventive therapy for prophylaxis of tuberculosis published in AIDS is critiqued alongside each of the Tri-Council’s nine requirements.Peer Reviewe

More than Just Great Quotes: An Introduction to the Canadian Tri-Council’s Qualitative Requirements

Although at times misunderstood by the general research community, qualitative research has developed out of diverse, rich and complex philosophical traditions and theoretical paradigms. In the most recent Canadian Tri-Council policy statement on the ethical conduct of research involving humans, a chapter was devoted to a summary of methods and methodological requirements that characterize robust qualitative research, despite the diversity of approaches. To dispel common misperceptions about qualitative research and introduce the unfamiliar reader to these requirements, the work of a qualitative study on isoniazid preventive therapy for prophylaxis of tuberculosis published in AIDS is critiqued alongside each of the Tri-Council’s nine requirements