Setting: Bedaquiline (BDQ) was introduced in the multidrug-resistant tuberculosis (MDR-TB) programme in Daru in remote Papua New Guinea in 2015, along with a core package of active drug-safety monitoring (aDSM). Objective: To assess interim results and safety of BDQ for the treatment of MDR-TB from 1 July 2015 to 31 December 2017. Design: A retrospective cohort analysis of routine programme data. Results: Of 277 MDR-TB patients, 77 (39%) received BDQ with a total of 8 serious adverse events including 5 (6.5%) deaths, of which 1 (1.3% QTcF prolongation, grade 3) was attributable to BDQ. Of 200 (61%) patients who did not receive BDQ, there were 17 (9%) deaths. Completeness of monitoring for the BDQ group was 90% for 5 electrocardiograms and 79% for 2 cultures. In the interim result indicator analysis at month 6 in the BDQ and non-BDQ groups, there were respectively 0% and 1% lost to follow-up; 6.5% and 8.5% who died; 94% and 91% in care; and 92% and 96% with negative culture among those monitored. Conclusion:Early experience in Daru shows BDQ is safe and feasible to implement with aDSM with good interim effectiveness supporting the rapid adoption and scale-up of the 2019 WHO MDR-TB treatment guidelines in the programme and in similar remote settings. * Among eligible patients who had 2 valid culture tests sent 30 days apart (see Figure 2 for full definitions). MDR-TB = multidrug-resistant tuberculosis; BDQ = bedaquiline.
The COVID-19 pandemic and response measures, including lockdowns and the reorientation of health services, have disrupted essential health services for other diseases, including TB, HIV and malaria. For TB, reductions in case detection due to the COVID-19 pandemic are projected to result in increased TB transmission, morbidity and mortality. Active case-finding (ACF) for TB using community-based approaches is a potential strategy to offset reductions in TB detection by obviating the need for patients to seek care at a health facility. A number of approaches can be used to conduct TB ACF safely and screen designated target populations while managing the risks of SARS-CoV-2 transmission for staff, individuals and the community. We present a framework of options for and experience of adapting TB ACF services in response to the challenges of COVID-19 in our programme in Yogyakarta, Indonesia. Key changes have included revised prioritisation of target populations focusing on household contacts, reducing case-finding throughput, implementation of additional infection control measures and precautions, and integration of COVID-19 screening among those being screened for TB. Our approach could inform other programmes seeking to adapt TB ACF services to mitigate the negative impact of COVID-19 on TB case detection.
Indonesia has the third highest tuberculosis (TB) caseload internationally. A cornerstone for strengthening health systems to respond to TB is a well-trained workforce. In a partnership between Indonesian and Australian institutions, TB training was run during 2018 to strengthen the local capacity to meet End TB strategy targets. This paper aims to report on course design, delivery, training outcomes, and reflections. Seventy-six Indonesian healthcare workers, program staff, researchers, and policy-makers were selected from over 800 applicants. The structure comprised three trainings, each with a pre-course workshop (in Indonesia) to identify learning needs, a two-week block (Australia), and a post-course workshop (Indonesia). The training content delivered was a combination of TB technical knowledge and program/project theory, design, and logic, and the training utilised multiple teaching and learning methods. An innovative element of the training was participant-designed TB workplace projects focusing on context-specific priorities. Evaluation was undertaken using participant surveys and appraisal of the projects. Participants rated the course highly, while success in project implementation varied. Reflections include the importance of involving Indonesian experts in delivery of training, the need to understand participant learning requirements and adapt the training content accordingly, and the challenge of measuring tangible training outputs.
Point-of-care ultrasound (PoCUS) is an examination often performed at the bedside that can assist in patient assessment and answer focused questions. It is increasingly used by a number of specialties to aid invasive procedures and for clinical evaluation, with the ultimate aim of improving patient management. Although there is a paucity of robust evidence supporting some applications, it is gaining popularity and has been termed the 'new stethoscope'. Good clinical governance arrangements, especially with regard to training and competency, are key to this modality developing further and safely.
Background: In East New Britain, TB care was mainly offered by the General Hospital, resulting in limited community-based care and poor treatment outcomes. In 2016, TB services were decentralised from the provincial to the district level by 1) training health workers, 2) increasing community awareness of TB, and 3) providing a weekly Clinical Outreach (TACO) service. Objective: To describe the effect of TACO on the use of TB diagnostic and treatment services from 1 January 2014 to 31 December 2017. Design: This was a retrospective study comparing 2014-2015 (pre-TACO) and 2016-2017 (TACO) cohorts. Results: There was an increase in pre-TACO to TACO cohorts in screened cases (1581 to 2195), total registered TB cases (678 to 824) and registered cases at decentralised sites (209 to 615). Unfavourable treatment outcomes were common (pre-TACO, 46.0% vs. TACO, 40.1%). In multivariable analysis, treatment at a decentralised Basic Management Unit (aOR 0.55, 95%CI 0.42-0.74) was significantly associated with fewer unfavourable outcomes, but treatment outcomes between the pre-TACO and the TACO group were not significantly different. Conclusion: Strengthening decentralisation of TB services at the district level increased TB screening and case registration, with similar treatment outcomes. * Missing data: pre-TACO, n = 1476; TACO, n = 2094. † Variables with an unknown/missing category 10% of the total sample were excluded from the χ 2 tests. ‡ Not calculated for this variable due to the large proportion of missing Xpert results. TB = tuberculosis; TACO = Training, Community Awareness and Clinical Outreach; IQR = interquartile range; BMU = Basic Management Unit; RMP = rifampicin.
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