Is knowledge retained by healthcare providers after training? A pragmatic evaluation of drug-resistant tuberculosis management in China.

OBJECTIVES: Considering the urgent need of training to improve standardised management of drug-resistant infectious disease and the lack of evidence on the impact of training, this study evaluates whether training participants' knowledge on multidrug-resistant tuberculosis (MDR-TB) is improved immediately and a year after training. SETTING AND PARTICIPANTS: The study involved 91 MDR-TB healthcare providers (HCPs), including clinical doctors, nurses and CDC staff, who attended a new MDR-TB HCP training programme in Liaoning and Jiangxi provinces, China. MAIN OUTCOME MEASURES: A phone-based assessment of participants' long-term retention of knowledge about MDR-TB management was conducted in July 2017, approximately 1 year after training. The proportion of correct responses in the long-term knowledge assessment was compared with a pretraining test and an immediate post-training test using a χ2 test. Factors influencing participants' performance in the long-term knowledge assessment were analysed using linear regression. RESULTS: Across both provinces, knowledge of definitions of drug-resistant TB, standardised MDR-TB case detection protocols and laboratory diagnosis was improved 1 year after the training by 14.5% (p=0.037), 32.4% (p<0.001) and 31% (p<0.001) relative to pretraining. However, compared with immediately after training, the knowledge of the three topics declined by 26.5% (p=0.003), 19.8% (p=0.018) and 52.7% (p<0.001) respectively in Jiangxi, while no significant decline was observed in Liaoning. Additionally, we found that obtaining a higher score in the long-term knowledge assessment was associated with longer years of clinical experience (coefficient=0.51; 95 CI% 0.02 to 0.99; p=0.041) and attending training in Liaoning (coefficient=0.50; 95% CI 0.14 to 0.85; p=0.007). CONCLUSION: Our study, the first to assess knowledge retention of MDR-TB HCPs 1 year after training, showed an overall positive long-term impact of lecture-style group training on participants' knowledge. Knowledge decline 1 year after training was observed in one province, Jiangxi, and this may be partly addressed by targeted support to HCPs with fewer years of clinical experience

Eff ect of a comprehensive programme to provide universal access to care for sputum-smear-positive multidrugresistant tuberculosis in China: a before-and-after study

Background China has a quarter of all patients with multidrug-resistant tuberculosis (MDRTB) worldwide, but less than 5% are in quality treatment programmes. In a before-and-after study we aimed to assess the eff ect of a comprehensive programme to provide universal access to diagnosis, treatment, and follow-up for MDRTB in four Chinese cities (population 18 million). Methods We designated city-level hospitals in each city to diagnose and treat MDRTB. All patients with smear-positive pulmonary tuberculosis diagnosed in Center for Disease Control (CDC) clinics and hospitals were tested for MDRTB with molecular and conventional drug susceptibility tests. Patients were treated with a 24 month treatment package for MDRTB based on WHO guidelines. Outpatients were referred to the CDC for directly observed therapy. We capped total treatment package cost at US$4644. Insurance reimbursement and project subsidies limited patients’ expenses to 10 (2011) to those from a retrospective survey of all patients with MDRTB diagnosed in the same cities during a baseline period (2006–09). Findings 243 patients were diagnosed with MDRTB or rifampicin-resistant tuberculosis during the 12 month programme period compared with 92 patients (equivalent to 24 per year) during the baseline period. 172 (71 243 individuals were enrolled in the programme. Time from specimen collection for resistance testing to treatment initiation decreased by 90 started on appropriate drug regimen increased 2·7 times (from nine [35 172), and follow-up by the CDC after initial hospitalisation increased 24 times (from one [4 163 [99 increased ten times (from two [8 programme period had negative cultures or clinical–radiographic improvement. Patients’ expenses for hospital admission after MDRTB diagnosis decreased by 78$796 to $174), reducing the ratio of patients’ expenses to annual household income from 17·6% to 3·5% (p<0·0001 for all comparisons between baseline and programme periods). However, 36 (15%) patients did not start or had to discontinue treatment in the programme period because of fi nancial diffi culties. Interpretation This comprehensive programme substantially increased access to diagnosis, quality treatment, and aff ordable treatment for MDRTB. The programme could help China to achieve universal access to MDRTB care but greater fi nancial risk protection for patients is needed

The epidemiologic impact and cost-effectiveness of new tuberculosis vaccines on multidrug-resistant tuberculosis in India and China.

BACKGROUND: Despite recent advances through the development pipeline, how novel tuberculosis (TB) vaccines might affect rifampicin-resistant and multidrug-resistant tuberculosis (RR/MDR-TB) is unknown. We investigated the epidemiologic impact, cost-effectiveness, and budget impact of hypothetical novel prophylactic prevention of disease TB vaccines on RR/MDR-TB in China and India. METHODS: We constructed a deterministic, compartmental, age-, drug-resistance- and treatment history-stratified dynamic transmission model of tuberculosis. We introduced novel vaccines from 2027, with post- (PSI) or both pre- and post-infection (P&PI) efficacy, conferring 10 years of protection, with 50% efficacy. We measured vaccine cost-effectiveness over 2027-2050 as USD/DALY averted-against 1-times GDP/capita, and two healthcare opportunity cost-based (HCOC), thresholds. We carried out scenario analyses. RESULTS: By 2050, the P&PI vaccine reduced RR/MDR-TB incidence rate by 71% (UI: 69-72) and 72% (UI: 70-74), and the PSI vaccine by 31% (UI: 30-32) and 44% (UI: 42-47) in China and India, respectively. In India, we found both USD 10 P&PI and PSI vaccines cost-effective at the 1-times GDP and upper HCOC thresholds and P&PI vaccines cost-effective at the lower HCOC threshold. In China, both vaccines were cost-effective at the 1-times GDP threshold. P&PI vaccine remained cost-effective at the lower HCOC threshold with 49% probability and PSI vaccines at the upper HCOC threshold with 21% probability. The P&PI vaccine was predicted to avert 0.9 million (UI: 0.8-1.1) and 1.1 million (UI: 0.9-1.4) second-line therapy regimens in China and India between 2027 and 2050, respectively. CONCLUSIONS: Novel TB vaccination is likely to substantially reduce the future burden of RR/MDR-TB, while averting the need for second-line therapy. Vaccination may be cost-effective depending on vaccine characteristics and setting

Correction to: The epidemiologic impact and cost-effectiveness of new tuberculosis vaccines on multidrug-resistant tuberculosis in India and China.

The original article contained errors in the Abstract which have all since been corrected

Comparing yield and relative costs of WHO TB screening algorithms in selected risk groups among people aged 65 years and over in China, 2013.

To calculate the yield and cost per diagnosed tuberculosis (TB) case for three World Health Organization screening algorithms and one using the Chinese National TB program (NTP) TB suspect definitions, using data from a TB prevalence survey of people aged 65 years and over in China, 2013.This was an analytic study using data from the above survey. Risk groups were defined and the prevalence of new TB cases in each group calculated. Costs of each screening component were used to give indicative costs per case detected. Yield, number needed to screen (NNS) and cost per case were used to assess the algorithms.The prevalence survey identified 172 new TB cases in 34,250 participants. Prevalence varied greatly in different groups, from 131/100,000 to 4651/ 100,000. Two groups were chosen to compare the algorithms. The medium-risk group (living in a rural area: men, or previous TB case, or close contact or a BMI <18.5, or tobacco user) had appreciably higher cost per case (USD 221, 298 and 963) in the three algorithms than the high-risk group (all previous TB cases, all close contacts). (USD 72, 108 and 309) but detected two to four times more TB cases in the population. Using a Chest x-ray as the initial screening tool in the medium risk group cost the most (USD 963), and detected 67% of all the new cases. Using the NTP definition of TB suspects made little difference.To "End TB", many more TB cases have to be identified. Screening only the highest risk groups identified under 14% of the undetected cases,. To "End TB", medium risk groups will need to be screened. Using a CXR for initial screening results in a much higher yield, at what should be an acceptable cost

The Global Fund in China: Multidrug-resistant tuberculosis nationwide programmatic scale-up and challenges to transition to full country ownership

China has the world's second largest burden of multidrug-resistant tuberculosis (MDR-TB;resistance to at least isoniazid and rifampicin), with an estimated 57,000 cases (range,48,000±67,000) among notified pulmonary TB patients in 2015. During October 1, 2006±June 30, 2014, China expanded MDR-TB care through a partnership with the Global Fundto Fight AIDS, Tuberculosis, and Malaria (Global Fund). We analyzed data on site expansion,patient enrolment, treatment outcomes, cost per patient, and overall programmeexpenditure. China expanded MDR-TB diagnostic and treatment services from 2 prefecturesin 2006 to 92 prefectures, covering 921 of the country's 3,000 counties by June 2014.A total of 130,910 patients were tested for MDR-TB, resulting in 13,744 laboratory-confirmedcases, and 9,183 patients started on MDR-TB treatment. Treatment success was48.4% (2011 cohort). The partnership between China and the Global Fund resulted in enormousgains. However, changes to health system TB delivery and financing coincided withthe completion of the Global Fund Programme, and could potentially impact TB and MDRTBcontrol. Transition to full country financial ownership is proving difficult, with a decline inenrollment and insufficient financial coverage. [...

The location of 10 sample counties in the TB prevalence survey in China in 2013.

<p>The location of 10 sample counties in the TB prevalence survey in China in 2013.</p

Cost of each component of active TB case-finding in this study in China in 2013.

<p>Cost of each component of active TB case-finding in this study in China in 2013.</p

Algorithms to screen the population for TB aged 65 or over in the different high risk group in this study, based on the WHO recommendations.

<p>Algorithms to screen the population for TB aged 65 or over in the different high risk group in this study, based on the WHO recommendations.</p