Impact of the COVID-19 pandemic on tuberculosis services

Background: In Portugal, Outpatient Tuberculosis Centres (OTBC) are responsible for the diagnosis, treatment, screening and prevention of tuberculosis (TB), and only severe or resistant cases are hospitalized. Aim: To understand how infection control norms and standards were applied and how these centres responded during the pandemic. Method: We sent an electronic questionnaire to all coordinators of OTBC. The questionnaire included questions on infection control during the COVID-19 pandemic and evaluation of the functioning of the OTBC in two periods: during the 1st National State of Emergency and after 1 year. Results: Thirty-two responses were obtained (52.5%). The infection control norms were globally applied; diagnosis, treatment, and prevention were kept, and contact screening was only affected during the 1st State of Emergency. However, half of the respondents (53.1%) believed that there were diagnostic delays during the 1st State of Emergency, rising to 68.8% after 1 year. Only 31.3% performed Directly Observed Therapy (DOT) in all patients during the 1st State of Emergency, and 59.4% after 1 year. Half the inquiries expected an increase in TB incidence in the near future. Conclusion: The pandemic affected OTBC functioning, although the services were kept open; diagnostic delay and DOT appliance were the most affected. © 2022 Sociedade Portuguesa de PneumologiaFunding text 1: No specific funding was received for this work. However, Ana Aguiar holds a PhD Grant (2020.09390.BD), co-funded by the FCT and the FSE Program. We would like to thank all of the coordinators of TB centres who have answered the questionnaire. This research initiative would not be possible without their participation. We would also like to thank Ana Isabel Ribeiro for drawing the map of Portugal's Region Health Administrations. The work is part of the scientific activities of Global Tuberculosis Network and of the WHO Collaborating Centre for TB and Lung Diseases in Tradate, Italy (ITA-80).; Funding text 2: No specific funding was received for this work. However, Ana Aguiar holds a PhD Grant (2020.09390.BD), co-funded by the FCT and the FSE Program

COVID-19 Related Hospital Re-organization and Trends in Tuberculosis Diagnosis and Admissions: Reflections From Portugal; [Reorganización hospitalaria relacionada con COVID-19 y tendencias en el diagnóstico y la hospitalización por tuberculosis: reflexiones desde Portugal]

[No abstract available]No specific funding was received for this work. However, Ana Aguiar holds a PhD Grant ( 2020.09390.BD ), cofunded by the Fundação para a Ciência e a Tecnologia (FCT) and the Fundo Social Europeu (FSE) Program

Improving the TB case management: The International Standards for Tuberculosis Care.

Tuberculosis (TB) is currently the leading cause of death from a curable infectious disease. The World Health Organization (WHO) estimates that 8.9 million new TB cases occurred in 2004 (of which 3.9 million were sputum smear positive), although only about half of the estimated number were reported by public health systems. Whilst the highest TB incidence rate is in sub-Saharan Africa (estimated to be 356 new cases per 100,000 population per yr), in most countries of the former Soviet Union the estimated incidence rate exceeds 100 new cases per 100,000 population per yr. Although the rate of increase in the TB incidence rate is decreasing, the global TB notification grew by 1% between 2003 and 2004, the last year for which data are available. This continued increase is largely the result of the striking increase in cases in sub-Saharan Africa and, to a lesser extent, in the former USSR. Whilst the worsening of the TB incidence in Africa is due to the HIVepidemic compounded by an insufficient health infrastructure, it is due to different causes in Eastern Europe, including economic decline, increased poverty, social disruption and sub-standard health services. In addition, as a result of these factors, .10% of new TB cases in the Baltic states and in some parts of Russia are multidrug-resistant (MDR-TB), i.e. resistant to at least isoniazid and rifampicin. In the European region, 445,000 new TB cases and nearly 70,000 deaths were estimated to have resulted from TB in 2004. In the Eastern part of the region, the levels of directly observed treatment, short-course (DOTS) strategy coverage and case detection are the lowest among the world regions, and the overall treatment success rate is the second lowest (75%) after Africa

Accelerating development of new shorter TB treatment regimens in anticipation of a resurgence of multi-drug resistant TB due to the COVID-19 pandemic

The WHO 2020 global TB Report estimates that in 2019 there were an estimated 500,000 cases of multi-drug resistant TB (MDR-TB) of which only 186,772 MDR-TB cases were diagnosed, and positive treatment outcomes were achieved in 57% of them. These data highlight the need for accelerating and improving MDR-TB screening, diagnostic, treatment and patient follow-up services. The last decade has seen three new TB drugs being licensed; bedaquiline, delamanid and pretomanid, and combinations these new, existing and repurposed drugs are leading to improved cure rates. The all oral six month WHO regimen for MDR-TB is more tolerable, has higher treatment success rates and lower mortality. However, the unprecedented ongoing COVID-19 pandemic is having major direct and indirect negative impacts on health services overall, including national TB programs and TB services. This adds further to longstanding challenges for tackling MDR-TB such as cost, rollout of diagnostics and drugs, and implementation of latest WHO guidelines for MDR-TB. In light of COVID-19 disruption of TB services, it is anticipated the numbers of MDR-TB cases will rise in 2021 and 2022 and will affect treatment outcomes further. Investing more in development of new TB drugs and shorter MDR-TB treatment regimens is required in anticipation of emerging drug resistance to new TB drug regimens. There is an urgent need for protecting current investments in TB services, sustaining gains being made in TB control and accelerating roll out of TB diagnostic and treatment services

Bronchoalveolar lavage causes decrease in PaO2, increase in (A-a) gradient value and bronchoconstriction in asthmatics.

7siAbstract The aims of this study were to (1) record the changes of (arterial oxygen partial pressure) PaO2, (arterial carbon dioxide partial pressure) PaCO2, (percentage saturation of haemoglobin with oxygen in arterial blood) SaO2 and alveolar-arterial (A-a) oxygen gradiant resulting from bronchoalveolar lavage (BAL) in asthmatic and normal subjects; (2) measure changes in forced expiratory volume in 1 s (FEV1), vital capacity forced (FVC) associated with BAL; and (3) assess possible predictive factors for the degree of hypoxaemia and impairment of spirometry resulting from BAL. Bronchoscopy and BAL (150 ml) were performed in 24 asthmatics and 15 healthy subjects. Serial arterial blood samples (radial artery) were obtained in all subjects: T1 and before T2 after local anaesthesia; T3 at end of bronchoscopy; T4 after BAL and 5 min, 15 min, 1 h, 2 h, 8 h and 24 h (T5-T10) after the procedure, FEV1 and FVC were measured immediately before and 5 min afer bronchoscopy. Baseline PaO2 was lower in asthmatics (10.2 +/- 0.8 kPa) than in healthy subjects (10.8 +/- 0.8). Both groups showed a significant decrease in PaO2, and a significant widening in (A-a) oxygen tension gradiant at T3-9, with respect to T1 (P < 0.05). PaO2 reached a significantly lower value in asthmatics (7.1 +/- 0.6 kPa) than in HS (7.7 +/- 0.5; P < 0.05). In asthmatics, FEV1, FVC and the ratio FEV1/FVC decreased significantly after BAL (P < 0.001). In healthy subjects, FEV1 and FVC decreased significantly (P < 0.001), whereas FEV1/FVC did not. The fall in FEV1 after BAL was significantly greater in asthmatics (32.4 +/- 10.0%) than in healthy subjects (17.7 +/- 4.6; P < 0.001). Severity of asthma, basline FEV1 or initial PaO2 did not predict the degree of hypoxaemia or the fall of FEV1. It is concluded that BAL causes more severe hypoxaemia and a greater decrease in FEV1 in asthmatics compared to healthy subjects, strongly supporting the recommendation of special caution and careful monitoring when BAL is undertaken in asthmatics.nonemixedSPANEVELLO A; MIGLIORI GB; SATTA A; SHARARA A; BALLARDINI L; IND PW; NERI M.Spanevello, Antonio; Migliori, Gb; Satta, A; Sharara, A; Ballardini, L; Ind, Pw; Neri, M

Applicability of the shorter 'Bangladesh regimen' in high multidrug-resistant tuberculosis settings

In spite of the recent introduction of two new drugs (delamanid and bedaquiline) and a few repurposed compounds to treat multidrug-resistant and extensively drug-resistant tuberculosis (MDR- and XDR-TB), clinicians are facing increasing problems in designing effective regimens in severe cases. Recently a 9 to 12-month regimen (known as the 'Bangladesh regimen') proved to be effective in treating MDR-TB cases. It included an initial phase of 4 to 6 months of kanamycin, moxifloxacin, prothionamide, clofazimine, pyrazinamide, high-dose isoniazid, and ethambutol, followed by 5 months of moxifloxacin, clofazimine, pyrazinamide, and ethambutol. However, recent evidence from Europe and Latin America identified prevalences of resistance to the first-line drugs in this regimen (ethambutol and pyrazinamide) exceeding 60%, and of prothionamide exceeding 50%. Furthermore, the proportions of resistance to the two most important pillars of the regimen - quinolones and kanamycin - were higher than 40%. Overall, only 14 out of 348 adult patients (4.0%) were susceptible to all of the drugs composing the regimen, and were therefore potentially suitable for the 'shorter regimen'. A shorter, cheaper, and well-tolerated MDR-TB regimen is likely to impact the number of patients treated and improve adherence if prescribed to the right patients through the systematic use of rapid MTBDRsl testing

Psychosocial support interventions to improve treatment outcomes for people living with tuberculosis: a mixed methods systematic review and meta-analysis

BACKGROUND: People with tuberculosis (TB) face multi-dimensional barriers when accessing and engaging with care. There is evidence that providing psychosocial support within people-centered models of care can improve TB outcomes, however, there is limited consensus on what works. It remains important for such interventions to be rigorously assessed, and mixed methods systematic reviews are one way of synthesising data for policy makers to be able to access such evidence. Mixed methods reviews take a complexity perspective, with qualitative data being used to contextualise the quantitative findings and giving an insight into how interventions are contingent on variations in design and context. METHODS: Five electronic databases were searched from January 1 2015 to 14 January 2023 for randomised controlled trials, quasi-experimental trials, cohort studies and qualitative studies of interventions providing psychosocial support (material and/or psychological-based support) to adults with any clinical form of active TB. Studies with inpatient treatment as the standard of care were excluded. Quantitative studies reporting pre-specified standard TB outcomes were eligible. In line with established mixed methods review methodology, a convergent parallel-results synthesis design was followed: quantitative and qualitative syntheses were distinct and carried out using appropriate methods. A convergent coding matrix was then used to integrate the results. The protocol was registered on PROSPERO (CRD42021235211). FINDINGS: Twenty-three studies of interventions were included (12 quantitative, 10 qualitative, and 1 mixed methods study). Most studies were conducted in low-and middle-income countries with a high-burden of TB. Three explanatory and contextual middle-range theories from the integration of qualitative and quantitative data were developed: effective interventions provide multi-dimensional support; psychological-based support is transformative but there is insufficient evidence that it improves treatment outcomes on its own; intervention delivery shapes a logic of care. INTERPRETATION: This review takes a complexity perspective to provide actionable and timely insight to inform the design and implementation of locally-appropriate and people-centered psychosocial support interventions within national TB programmes. FUNDING: There was no funding source for this study

Strengthening tuberculosis control to advance towards elimination: The 2018 Rev. Port. Pneumol. (RPP) TB Series

n/