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Bundled TB testing, on-site provider training improves disease detection, outcomes
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Although more sensitive tuberculosis tests are still necessary, a program that used better diagnostics and on-site provider training improved TB detection and treatment outcomes in settings without a medical officer, according to prospective, quasi-experimental study results.
“Optimized training of the existing workforce with available diagnostic techniques will improve TB case detection toward global targets and will require fewer resources than active case finding strategies,” Yukari C. Manabe, MD, of Johns Hopkins University School of Medicine, and colleagues wrote in Open Forum Infectious Diseases.
The researchers implemented a bundled intervention program that included better laboratory diagnostics — a combination of fluorescence microscopy and use of the Xpert MTB/RIF (Cepheid) test — and an on-site provider training program for mid-level practitioners at 10 health facilities in sub-Saharan Africa. They compared the results with two facilities that did not use the bundled program. To compensate for the lack of control facilities, the researchers compared each intervention facility with its own baseline performance from the year before the program was initiated.
Yukari C. Manabe
During the 10-month study period, 186,357 outpatients were seen at the intervention facilities; 32,866 outpatients visited the two nonintervention facilities.
The number of presumptive TB cases with a sputum examination was approximately 52% higher at the intervention facilities (OR = 12.65; 95% CI, 5.6-28.55). After they adjusted for age and gender, Manabe and colleagues found that the number of smear-positive patients started on treatment was 37.76% higher at the intervention facilities (aOR = 7.59; 95% CI, 2.19-26.33). After adjusting for HIV and TB retreatment status, the number of patients with TB who completed therapy was 29.16% higher (aOR = 4.89; 95% CI, 2.24-10.67). In addition, the number of patients lost to follow-up was about 67% lower for the intervention facilities.
In comparing the intervention facilities with their own baseline results, 64.7% of the presumptive TB cases had a sputum smear result during the intervention period vs. 3.44% the year before program initiation (OR = 51.38; 95% CI, 20.04-131.76). The presumptive TB cases identified were more likely to receive an HIV test when compared with baseline (63.4% vs. 6.7%) and were more likely to be started on treatment (87.76% vs. 31.51%), according to the researchers.
“The proportion of outpatients who were appropriately screened for TB by sputum smear increased dramatically in intervention facilities compared to control facilities and compared to a baseline historical time period,” the researchers wrote. “Significant improvement in treatment outcomes was also measured after our bundled intervention. Despite limited previous training, the existing [mid-level health practitioners] in these rural facilities were effectively trained to identify and manage patients with TB and TB-HIV coinfection in the absence of medical officers.” – by Colleen Owens
Disclosure: The researchers report no relevant financial disclosures.
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