healthcare workers’ perspective from Beira, Mozambique

Funding Information: This study was elaborated based on the work of first Miguelhete Lisboa?s doctoral program, a Funda??o Calouste Gulbenkian (FCG) scholarship holder (ID: P-135647/SBG/2014) and, used grants obtained from World Health Organization, The Special Programme for Research and Training in Tropical Diseases (WHO/TDR) and co-sponsored by the United Nations Children?s Fund, United Nations Development Programme, World Bank and WHO ? award ID number: B40151/2014. The FCG and WHO/TDR were neither involved in the design of the study and collection, analysis, interpretation of data, nor in the writing of manuscript or decision to publish. Therefore, the authors are responsible for all information. The authors acknowledge the Tutorial Commission of the doctoral program of Miguelhete Lisboa (Professors Sonia Dias and Miguel Viveiros at Instituto de Higiene e Medicina Tropical Universidade Nova de Lisboa, Portugal); people who helped in the collection and data management: Marques Nhamonga, Joaquim Lequechane and Estefano Colove; the Centro de Investiga??o Operacional da Beira directorate and all colleagues, the Beira Central Hospital directorate and all healthcare workers. Publisher Copyright: © 2020 Lisboa et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Background: Mozambique is one of the countries with the deadly implementation gaps in the tuberculosis (TB) care and services delivery. In-hospital delays in TB diagnosis and treatment, transmission and mortality still persist, in part, due to poor-quality of TB care cascade. Objective: We aimed to assess, from the healthcare workers’ (HCW) perspective, factors associated with poor-quality TB care cascade and explore local sustainable suggestions to improve in-hospital TB management. Methods: In-depth interviews and focus group discussions were conducted with different categories of HCW. Audio-recording and written notes were taken, and content analysis was performed through atlas.ti7. Results: Bottlenecks within hospital TB care cascade, lack of TB staff and task shifting, centralized and limited time of TB laboratory services, and fear of healthcare workers getting infected by TB were mentioned to be the main factors associated with implementation gaps. Interviewees believe that task shifting from nurses to hospital auxiliary workers, and from higher and well-trained to lower HCW are accepted and feasible. The expansion and use of molecular TB diagnostic tools are seen by the interviewees as a proper way to fight effectively against both sensitive and MDR TB. Ensuring provision of N95 respiratory masks is believed to be an essential requirement for effective engagement of the HCW on high-quality in-hospital TB care. For monitoring and evaluation, TB quality improvement teams in each health facility are considered to be an added value. Conclusion: Shortage of resources within the national TB control programme is one of the potential factors for poor-quality of the TB care cascade. Task shifting of TB care and services delivery, decentralization of the molecular TB diagnostic tools, and regular provision of N95 respiratory masks should contribute not just to reduce the impact of resource scarceness, but also to ensure proper TB diagnosis and treatment to both sensitive and MDR TB.publishersversionpublishe

a quasi-experimental study

Funding Information: This study was elaborated based on the work of Miguelhete Lisboa doctoral program, a Fundação Calouste Gulbenkian scholarship holder, and used grants obtained from The Special Programme for Research and Training in Tropical Diseases (TDR) and co-sponsored by the United Nations Children’s Fund (UNICEF), United Nations Development Programme (UNDP), World Bank, and World Health Organization (WHO)—award ID number: B40151/ 2014. The FCG and WHO/TDR were not involved in the design of the study and collection; analysis and interpretation of data; and writing the manuscript; therefore, the authors are responsible for all information. Publisher Copyright: © 2020 The Author(s).Background In-hospital logistic management barriers (LMB) are considered to be important risk factors for delays in TB diagnosis and treatment initiation (TB-dt), which perpetuates TB transmission and the development of TB morbidity and mortality. We assessed the contribution of hospital auxiliary workers (HAWs) and 24-h TB laboratory services using Xpert (24h-Xpert) on the delays in TB-dt and TB mortality at Beira Central Hospital, Mozambique. Methods A quasi-experimental design was used. Implementation strategy—HAWs and laboratory technicians were selected and trained, accordingly. Interventions—having trained HAW and TB laboratory technicians as expediters of TB LMB issues and assurer of 24h-Xpert, respectively. Implementation outcomes—time from hospital admission to sputum examination results, time from hospital admission to treatment initiation, proportion of same-day TB cases diagnosed, initiated TB treatment, and TB patient with unfavorable outcome after hospitalization (hospital TB mortality). A nonparametric test was used to test the differences between groups and adjusted OR (95% CI) were computed using multivariate logistic regression. Results We recruited 522 TB patients. Median (IQR) age was 34 (16) years, and 52% were from intervention site, 58% males, 60% new case of TB, 12% MDR-TB, 72% TB/HIV co-infected, and 43% on HIV treatment at admission. In the intervention hospital, 93% of patients had same-day TB-dt in comparison with a median (IQR) time of 15 (2) days in the control hospital. TB mortality in the intervention hospital was lower than that in the control hospital (13% vs 49%). TB patients admitted to the intervention hospital were nine times more likely to obtain an early laboratory diagnosis of TB, six times more likely to reduce delays in TB treatment initiation, and eight times less likely to die, when compared to those who were admitted to the control hospital, adjusting for other factors. Conclusion In-hospital delays in TB-dt and high TB mortality in Mozambique are common and probably due, in part, to LMB amenable to poor-quality TB care. Task shifting of TB logistic management services to HAWs and lower laboratory technicians, to ensure 24h-Xpert through “on-the-spot strategy,” may contribute to timely TB detection, proper treatment, and reduction of TB mortality.publishersversionpublishe

Caracterização do perfil de resistência do Mycobacterium tuberculosis isolado de pacientes da cidade de Beira, Sofala - Moçambique

Objective: To analyze the resistance profile of Mycobacterium tuberculosis isolates from patients with tuberculosis in Beira, Sofala, Mozambique. Method: Descriptive cross-sectional study that analyzed secondary data from patients who had positive culture for M. tuberculosis on MGIT960-BACTECTM. For each patient, demographic data, information of Human Immunodeficiency Virus (HIV) serology, rapid molecular test - GeneXpertα-Cepheid result and first line drug susceptibility test (DST) were reviewed . All tests were performed in the Referral Laboratory of Tuberculosis in Beira, from January 2014 to March 2015. Findings: Totally of 87 isolates from Sofala province, Mozambique were analyzed. Of these, 33/87 (37.9%) isolates had any anti-TB drug resistance detected while in 54/87 (62.1%) the drug resistance was not detected. Among the 33 isolates with drug resistance: 18/33 (54,7%) were multidrug-resistant (MDR), 11/33 (33,3%) were Isoniazid (INH) mono-resistant, 2/33 (6%) Rifampicin (RIF) mono-resistant and 2/33 (6%) were Etambutol mono-resistant. Of the total isolates with resistance to INH, 5/11 (42%) were additionally resistance to streptomycin (Sm). Of the 49 patients with HIV serology known, 30 (61,2%) were confirmed HIV positive. The HIV infection was two times more frequent among patients with drug resistant compared to those without drug resistance. All isolates resistant to INH and RIF (MDR) had previous history of tuberculosis treatment. Conclusion: There is high proportion of co-infection TB/HIV among patients with any drug resistant TB MDR or monoresistance . We also observed high frequency of monoresistance to isoniazid and association of drug resistance between isoniazid and streptomycinObjetivo: Avaliar o perfil de resistência do Mycobacterium tuberculosis isolado de pacientes da cidade de Beira, Sofala, Moçambique. Método: Estudo descritivo transversal, que analisou dados secundários de pacientes que tiveram cultura positiva para M. tuberculosis MGIT960-BACTEC™. Para cada isolado foram revistos dados demográ- ficos do respetivo paciente, a sorologia para o vírus da imunodeficiência humana (HIV), o resultado do teste rápido molecular (TRM) - GeneXpertα-Cepheid e o teste de fenotípico de sensibilidade aos fármacos (TS) de primeira linha. Os testes foram realizados no Laboratório de Referência para tuberculose na cidade de Beira, Moçambique no período de Janeiro de 2014 a Março de 2015. Resultados: Foram analisadas 87 isolados de M. tuberculosis de pacientes da província de Sofala, Moçambique. Desses, 33/87 (37,9%) apresentaram algum tipo de resistência do bacilo aos fármacos anti-TB, enquanto que em 54/87 (62,1%) a resistência não foi detectada. Dos 33 isolados com resistência: 18/33 (54,7%) foram classificados como multidrogarresistentes (TB-MDR), 11/33 (33,3%) monorresistentes à isoniazida(INH), e 2/33 (6%) monorresistentes à rifampicina (RMP) e 2/33 (6%) resistentes ao Etambutol. Do total de isolados com resistência à INH, 5/11 (42%) também apresentavam resistência à estreptomicina (Sm). De 49 pacientes que fizeram sorologia para HIV, 30/49 (61,2%) tinham infecção confirmada pelo HIV, sendo esta duas vezes mais frequente entre os pacientes portadores do Mycobacterium tuberculosis resistente do que naqueles com bacilo sensível. Todos isolados resistentes a RIF e INH eram pacientes com história prévia de tratamento para TB . Conclusão: Observa-se uma alta proporção de coinfecção HIV/TB entre pacientes portador de cepas do M. tuberculosis monorresistente ou MDR. Além de alta taxa de monorresistencia à isoniazida, e a associação entre resistência concomitante à INH e S

Time delay and associated mortality from negative smear to positive Xpert MTB/RIF test among TB/HIV patients: a retrospective study

Abstract Background The GeneXpert MTB/RIF Assay (Xpert®) is known to be a feasible, effective and a hopeful tool for rapid tuberculosis (TB) diagnosis and treatment. However, little is known about the time delay caused by initial negative sputum smear microscopy (NSSM), but consecutive positive Xpert TB test (PXTBt) and its association with TB mortality in resource-constrained settings. We aimed to estimate the median time delay between initial NSSM but consecutive PXTBt and TB treatment initiation and its association with TB mortality among TB/HIV co-infected patients in Beira, Mozambique. Methods we used data from a retrospective cohort study of TB/HIV co-infected patients in six TB services in Beira city. The study included all patients that tested NSSM, followed by a PXTBt in the six health centers with TB services during the year 2015. Data were extracted from the laboratory and TB treatment registers. To assess the difference in median time delays between groups, Mann-Whitney and Kruskal-Wallis tests were computed. To analyze the associations between the time delays and TB mortality, logistic regression model was used. Results Among the 283 patients included in the study, median (IQR) age was 31 (17) years, 59.0% were males, 57.6% in the WHO clinical fourth stage of HIV. The median (IQR) values for diagnostic delay, treatment delay and total time delay was 10 (9) days, 13 (12) days and 28 (20) days, respectively. For TB/HIV co-infected patients who tested negative for smear microscopy initially, a total time delay of one month or longer was associated with high mortality (aOR = 12.40, 95% CI: 5.70–22.10). Conclusion Our study indicates that delays in TB diagnosis and treatment resulting from initial NSSM, but consecutive PXTBt are common in Beira city and are one of the main factors associated with TB mortality among TB/HIV co-infected patients. Applying GeneXpert assay as gold standard for HIV-positive patients with suspected pulmonary TB or replacing the sputum smear microscopy by Xpert assay and its availability within 24 h is urgently needed to ensure early diagnosis and treatment, and to maximize the impact of the few resources available in the country