Strategies to detect and manage latent tuberculosis infection among household contacts of pulmonary TB patients in high TB burden countries ‐ a systematic review and meta‐analysis

OBJECTIVE: To summarise latent tuberculosis infection (LTBI) management strategies among household contacts of bacteriologically confirmed pulmonary tuberculosis (TB) patients in high‐TB burden countries. METHODS: PubMed/MEDLINE (NCBI) and Scopus were searched (January 2006 to December 2021) for studies reporting primary data on LTBI management. Study selection, data management and data synthesis were protocol‐driven (PROSPERO‐CRD42021208715). Primary outcomes were the proportions of LTBI, initiating and completing tuberculosis preventive treatment (TPT). Reported factors influencing the LTBI care cascade were qualitatively synthesised. RESULTS: From 3694 unique records retrieved, 58 studies from 23 countries were included. Most identified contacts were screened (median 99%, interquartile range [IQR] 82%–100%; 46 studies). Random‐effects meta‐analysis yielded pooled proportions for: LTBI 41% (95% confidence interval [CI] 33%–49%; 21,566 tested contacts); TPT initiation 91% (95% CI 79%–97%; 129,573 eligible contacts, 34 studies); TPT completion 65% (95% CI 54%–74%; 108,679 TPT‐initiated contacts, 28 studies). Heterogeneity was significant (I (2) ≥ 95%–100%) and could not be explained in subgroup analyses. Median proportions (IQR) were: LTBI 44% (28%–59%); TPT initiation 86% (60%–100%); TPT completion 68% (44%–82%). Nine broad themes related to diagnostic testing, health system structure and functions, risk perception, documentation and adherence were considered likely to influence the LTBI care cascade. CONCLUSION: The proportions of household contacts screened, detected with LTBI and initiated on TPT, though variable was high, but the proportions completing TPT were lower indicating current strategies used for LTBI management in high TB burden countries are not sufficient

Status of Tuberculosis services in Indian Prisons

Introduction: Prisons are known to be a high risk environment for tuberculosis (TB) due to overcrowding, low levels of nutrition, poor infection control and lack of accessible healthcare services. India has nearly 1400 prisons housing 0.37 million inmates. However, information on, availability of diagnostic and treatment services for TB in the prison settings is limited. This study examined the availability of TB services in prisons of India. Simultaneously, prison inmates were screened for tuberculosis. Method: The study was conducted in 157 prisons across 300 districts between July-December 2013. Information on services available and practices followed for screening, diagnosis and treatment of TB was collected. Additionally, the inmates and prison staff were sensitised on TB using interpersonal communication materials. The inmates were screened for cough ≥2 weeks as a symptom of TB. Those identified as presumptive TB patients (PTBP) were linked with free diagnostic and treatment services. Results: Diagnostic and treatment services for TB were available in 18% and 54% of the prisons respectively. Only half of the prisons screened inmates for TB on entry, while nearly 60% practised periodic screening of inmates. District level prisons (OR, 6.0; 95% CI, 1.6-22.1), prisons with more than 500 inmates (OR, 52; 95% CI, 1.4-19.2), and prisons practising periodic screening of inmates (OR, 2.7; 95% CI, 1.0-7.2) were more likely to diagnose TB cases. 19% of the inmates screened had symptoms of TB (cough ≥2 weeks) and 8% of the PTBP were diagnosed with TB on smear microscopy. Conclusion: The TB screening, diagnostic and treatment services are sub-optimal in prisons in India and need to be strengthened urgently

Active Case Finding for Tuberculosis in India: A Syntheses of Activities and Outcomes Reported by the National Tuberculosis Elimination Programme

India launched a national community-based active TB case finding (ACF) campaign in 2017 as part of the strategic plan of the National Tuberculosis Elimination Programme (NTEP). This review evaluated the outcomes for the components of the ACF campaign against the NTEP’s minimum indicators and elicited the challenges faced in implementation. We supplemented data from completed pretested data proformas returned by ACF programme managers from nine states and two union territories (for 2017–2019) and five implementing partner agencies (2013–2020), with summary national data on the state-wise ACF outcomes for 2018–2020 published in annual reports by the NTEP. The data revealed variations in the strategies used to map and screen vulnerable populations and the diagnostic algorithms used across the states and union territories. National data were unavailable to assess whether the NTEP indicators for the minimum proportions identified with presumptive TB among those screened (5%), those with presumptive TB undergoing diagnostic tests (>95%), the minimum sputum smear positivity rate (2% to 3%), those with negative sputum smears tested with chest X-rays or CBNAAT (>95%) and those diagnosed through ACF initiated on anti-TB treatment (>95%) were fulfilled. Only 30% (10/33) of the states in 2018, 23% (7/31) in 2019 and 21% (7/34) in 2020 met the NTEP expectation that 5% of those tested through ACF would be diagnosed with TB (all forms). The number needed to screen to diagnose one person with TB (NNS) was not included among the NTEP’s programme indicators. This rough indicator of the efficiency of ACF varied considerably across the states and union territories. The median NNS in 2018 was 2080 (interquartile range or IQR 517–4068). In 2019, the NNS was 2468 (IQR 1050–7924), and in 2020, the NNS was 906 (IQR 108–6550). The data consistently revealed that the states that tested a greater proportion of those screened during ACF and used chest X-rays or CBNAAT (or both) to diagnose TB had a higher diagnostic yield with a lower NNS. Many implementation challenges, related to health systems, healthcare provision and difficulties experienced by patients, were elicited. We suggest a series of strategic interventions addressing the implementation challenges and the six gaps identified in ACF outcomes and the expected indicators that could potentially improve the efficacy and effectiveness of community-based ACF in India

Operational research within a Global Fund supported tuberculosis project in India: why, how and its contribution towards change in policy and practice

Background: The Global Fund encourages operational research (OR) in all its grants; however very few reports describe this aspect. In India, Project Axshya was supported by a Global Fund grant to improve the reach and visibility of the government Tuberculosis (TB) services among marginalised and vulnerable communities. OR was incorporated to build research capacity of professionals working with the national TB programme and to generate evidence to inform policies and practices. Objectives: To describe how Project Axshya facilitated building OR capacity within the country, helped in addressing several TB control priority research questions, documented project activities and their outcomes, and influenced policy and practice. Methods: From September 2010 to September 2016, three key OR-related activities were implemented. First, practical output-oriented modular training courses were conducted (n = 3) to build research capacity of personnel involved in the TB programme, co-facilitated by The Union, in collaboration with the national TB programme, WHO country office and CDC, Atlanta. Second, two large-scale Knowledge, Attitude and Practice (KAP) surveys were conducted at baseline and mid-project to assess the changes pertaining to TB knowledge, attitudes and practices among the general population, TB patients and health care providers over the project period. Third, studies were conducted to describe the project’s core activities and outcomes. Results: In the training courses, 44 participant teams were supported to develop research protocols on topics of national priority, resulting in 28 peer-reviewed scientific publications. The KAP surveys and description of project activities resulted in 14 peer-reviewed publications. Of the published papers at least 12 have influenced change in policy or practice. Conclusions: OR within a Global Fund supported TB project has resulted in building OR capacity, facilitating research in areas of national priority and influencing policy and practice. We believe this experience will provide guidance for undertaking OR in Global Fund projects