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      Burden of tuberculosis and challenges related to screening and diagnosis in Ethiopia

      research-article
      a , c , * , b , h , d , c , f , c , g , c , c , e , c , g
      Journal of Clinical Tuberculosis and Other Mycobacterial Diseases
      Elsevier
      Tuberculosis, Screening, Diagnosis, Xpert mtb/rif assay, Maternal and child health, Ethiopia, AFB, acid fast bacilli, ANC, ant-natal care, ART, anti-retroviral therapy, DOTS, directly observed treatment, short course, eHMIS, electronic Health Management Information System, EPTB, extra pulmonary tuberculosis, FMoH, Federal Ministry of Health, HIV, human immunodeficiency virus, MDR-TB, multi-drug resistant tuberculosis, NGOs, non-governmental organizations, NTB, National TB program, PFSA, Pharmaceutical Fund and Supply Agency, PMTCT, prevention mother to child transmission, PNC, postnatal care, TB, tuberculosis, WHO, World Health Organization

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          Abstract

          Introduction

          One-third of tuberculosis (TB) cases in Ethiopia are missing from care for reasons that are not well studied. The aim of this study was to assess TB burden and identify challenges related to TB screening and diagnosis in Ethiopia.

          Methods

          A facility-based cross-sectional study was conducted in seven health facilities selected from two regions and 2 city administrations of Ethiopia using stratified random sampling procedures. The data of 1,059,065 patients were included from outpatient department, HIV clinic, diabetic, and maternal-child health clinics. Data were collected from October to December 2018 using a retrospective review of three years’ facility data (2015 to 2017) supplemented by a semi-structured interview with purposively selected health care workers and heads of the health facilities.

          Results

          A total of 1,059,065 patients visited the health facilities in three years, of these, 978,480 (92.4%) were outpatients. Of the total, 20,284 (2%) were presumptive TB cases (with 14 days or more cough), 12.2% (2483/20,284) of which had TB. For the type of TB, 604 (24.3%) were smear-positive pulmonary TB (PTB), 789 (31.8%) were smear-negative PTB, 719 (29%) were extra-pulmonary TB, and data were missing for the rest. TB screening was integrated into HIV clinic, outpatient department, diabetic clinic but not with the maternal and child clinics. High patient load, weak TB laboratory specimen referral system, and shortage of TB diagnostic tools including Xpert MTB/RIF assay and chest X-ray, were the major challenges in the screening and diagnosis of TB.

          Conclusion

          The burden of TB was high in the study setting, and frequent interruption of laboratory reagents and supplies hampered TB screening and diagnostic services. Realizing the END-TB strategy in such resource-limited settings requires sustainable TB diagnostic capacity and improved case detection mechanisms, with national TB programs strongly integrated into the general health care system.

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          Most cited references16

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          Active case finding of tuberculosis: historical perspective and future prospects.

          Despite a history of remarkable scientific achievements in microbiology and therapeutics, tuberculosis (TB) continues to pose an extraordinary threat to human health. Case finding and treatment of TB disease are the principal means of controlling transmission and reducing incidence. This review presents a historical perspective of active case finding (ACF) of TB, detailing case detection strategies that have been used over the last century. This review is divided into the following sections: mass radiography, house-to-house surveys, out-patient case detection, enhanced case finding, high-risk populations and cost-effectiveness. The report concludes with a discussion and recommendations for future case finding strategies. Understanding the strengths and weaknesses of these methods will help inform and shape ACF as a TB control policy in the twenty-first century.
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            Intensified Tuberculosis Case-Finding in HIV-Positive Adults Managed at Ethiopian Health Centers: Diagnostic Yield of Xpert MTB/RIF Compared with Smear Microscopy and Liquid Culture

            Background Detection of active tuberculosis (TB) before antiretroviral therapy (ART) initiation is important, but optimal diagnostic methods for use in resource-limited settings are lacking. We assessed the prevalence of TB, evaluated the diagnostic yield of Xpert MTB/RIF in comparison with smear microscopy and culture, and the impact of Xpert results on clinical management in HIV-positive adults eligible for ART at health centers in a region of Ethiopia. Methods Participants were prospectively recruited and followed up at 5 health centers. Trained nurses collected data on socio-demographic characteristics, medical history and symptoms, and performed physical examination. Two paired morning sputum samples were obtained, and lymph node aspirates in case of lymphadenopathy. Diagnostic yield of Xpert MTB/RIF in sputum was compared with smear microscopy and liquid culture. Results TB was diagnosed in 145/812 participants (17.9%), with bacteriological confirmation in 137 (16.9%). Among bacteriologically confirmed cases, 31 were smear-positive (22.6%), 96 were Xpert-positive (70.1%), and 123 were culture-positive (89.8%). Xpert MTB/RIF increased the TB detection rate by 64 cases (47.4%) compared with smear microscopy. The overall sensitivity of Xpert MTB/RIF was 66.4%, and was not significantly lower when testing one compared with two samples. While Xpert MTB/RIF was 46.7% sensitive among patients with CD4 cell counts >200 cells/mm3, this increased to 82.9% in those with CD4 cell counts ≤100 cells/mm3. Compared with Xpert-positive TB patients, Xpert-negative cases had less advanced HIV and TB disease characteristics. Conclusions Previously undiagnosed TB is common among HIV-positive individuals managed in Ethiopian health centers. Xpert MTB/RIF increased TB case detection, especially in patients with advanced immunosuppression. An algorithm based on the use of a single morning sputum sample for individuals with negative sputum smear microscopy could be considered for intensified case finding in patients eligible for ART. However, technical and cost-effectiveness issues relevant for low-income countries warrant further study.
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              Laboratory medicine in low-income and middle-income countries: progress and challenges

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                Author and article information

                Contributors
                Journal
                J Clin Tuberc Other Mycobact Dis
                J Clin Tuberc Other Mycobact Dis
                Journal of Clinical Tuberculosis and Other Mycobacterial Diseases
                Elsevier
                2405-5794
                05 March 2020
                May 2020
                05 March 2020
                : 19
                : 100158
                Affiliations
                [a ]Department of Public Health, College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia
                [b ]School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
                [c ]Centre for Innovative Drug Development and Therapeutic Trials for Africa, College of Health Sciences, Addis Ababa University, P.O. Box 1362, Dire Dawa, Ethiopia
                [d ]Muhimbili Research Centre, National Institute for Medical Research, Dares Saalem, Tanzania
                [e ]Global Health and Infection Department, Brighton and Sussex Medical School, Brighton, United Kingdom
                [f ]Department of Internal Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
                [g ]Ohio State Global One Health initiative, Office of International Affairs, The Ohio State University, Addis Ababa, Ethiopia
                [h ]School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
                Author notes
                [* ]Corresponding author at: Department of Public Health, College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia. hus.aliya@ 123456gmail.com
                Article
                S2405-5794(20)30016-4 100158
                10.1016/j.jctube.2020.100158
                7113623
                32258437
                467bc1d1-d1e3-43e5-aba0-9863a595c389
                © 2020 The Authors

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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                Categories
                Article

                tuberculosis,screening,diagnosis,xpert mtb/rif assay,maternal and child health,ethiopia,afb, acid fast bacilli,anc, ant-natal care,art, anti-retroviral therapy, dots, directly observed treatment, short course,ehmis, electronic health management information system,eptb, extra pulmonary tuberculosis,fmoh, federal ministry of health,hiv, human immunodeficiency virus,mdr-tb, multi-drug resistant tuberculosis,ngos, non-governmental organizations,ntb, national tb program,pfsa, pharmaceutical fund and supply agency,pmtct, prevention mother to child transmission,pnc, postnatal care,tb, tuberculosis,who, world health organization

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