Do Instructional Videos on Sputum Submission Result in Increased Tuberculosis Case Detection? A Randomized Controlled Trial

Abstract

ObjectiveWe examined the effect of an instructional video about the production of diagnostic sputum on case detection of tuberculosis (TB), and evaluated the acceptance of the video.Trial DesignRandomized controlled trial.MethodsWe prepared a culturally adapted instructional video for sputum submission. We analyzed 200 presumptive TB cases coughing for more than two weeks who attended the outpatient department of the governmental Municipal Hospital in Mwananyamala (Dar es Salaam, Tanzania). They were randomly assigned to either receive instructions on sputum submission using the video before submission (intervention group, n = 100) or standard of care (control group, n = 100). Sputum samples were examined for volume, quality and presence of acid-fast bacilli by experienced laboratory technicians blinded to study groups.ResultsMedian age was 39.1 years (interquartile range 37.0–50.0); 94 (47%) were females, 106 (53%) were males, and 49 (24.5%) were HIV-infected. We found that the instructional video intervention was associated with detection of a higher proportion of microscopically confirmed cases (56%, 95% confidence interval [95% CI] 45.7–65.9%, sputum smear positive patients in the intervention group versus 23%, 95% CI 15.2–32.5%, in the control group, p <0.0001), an increase in volume of specimen defined as a volume ≥3ml (78%, 95% CI 68.6–85.7%, versus 45%, 95% CI 35.0–55.3%, p <0.0001), and specimens less likely to be salivary (14%, 95% CI 7.9–22.4%, versus 39%, 95% CI 29.4–49.3%, p = 0.0001). Older age, but not the HIV status or sex, modified the effectiveness of the intervention by improving it positively. When asked how well the video instructions were understood, the majority of patients in the intervention group reported to have understood the video instructions well (97%). Most of the patients thought the video would be useful in the cultural setting of Tanzania (92%).ConclusionsSputum submission instructional videos increased the yield of tuberculosis cases through better quality of sputum samples. If confirmed in larger studies, instructional videos may have a substantial effect on the case yield using sputum microscopy and also molecular tests. This low-cost strategy should be considered as part of the efforts to control TB in resource-limited settings.Trial RegistrationPan African Clinical Trials Registry PACTR201504001098231

Extrapulmonary tuberculosis in HIV-infected patients in rural Tanzania: The prospective Kilombero and Ulanga antiretroviral cohort

“…While the majority of positive samples (86.3%) originated from sputum, the rate of positive samples from extrapulmonary sites was very low with 5% (25/500). Poor sensitivity of Xpert 1 MTB/RIF has been demonstrated in PLHIV with HIV previously [5] and is partly due to challenges in proper sampling [36] and the paucibacillary nature of disease in PLHIV and in extrapulmonary sites [37,38]. In one study overall sensitivity and specificity of Xpert 1 MTB/ RIF compared to culture was 81.3% and 99.8%, respectively in patients with EPTB.…”

Does mobile phone instructional video demonstrating sputum expectoration improve the sputum sample quality and quantity in presumptive pulmonary TB cases? Protocol for a prospective pragmatic non-randomised controlled trial in Karnataka state, India

“…The sputum sample would be considered as ‘adequate' if it is at least 2 mL and at least half of the sputum is thick/non-salivary (ie, mucoid, purulent, blood-stained or combination of these) 3. Quality of the sputum will be categorised as mucoid (containing mucus, thicker than normal and either yellow or green colour), purulent (containing dead tissue, usually in large amount with foul smell, yellow or green colour), blood-stained (containing varying amounts of blood) or as salivary (transparent and watery specimen with bubbles) 20. To minimise the bias in categorising the sputum quality, RNTCP laboratory technician will use standard photographs for each category to assess the sputum quality.…”

Remembering the basics: interventions to improve sputum collection for tuberculosis diagnosis

“…One study found a substantial increase in diagnostic performance for participants who viewed an instructional video. 8 Implementation of a videographic intervention would allow presentation of other educational material as well. 9 Cultural factors might require consideration: Khan and colleagues 10 showed differences in the effectiveness of an instructional intervention depending on the sex of the participant with presumptive tuberculosis.…”

“…9 Cultural factors might require consideration: Khan and colleagues 10 showed differences in the effectiveness of an instructional intervention depending on the sex of the participant with presumptive tuberculosis. Regardless of these considerations, an instructional intervention is an attractive strategy that would probably incur few additional costs 8,10 and have minimal effect on healthcare workers' time. 8,10,11 Good quality evidence is required to influence policy, and this should be borne in mind when considering the studies included in the meta-analysis by Datta and colleagues, which were of variable quality.…”

“…Regardless of these considerations, an instructional intervention is an attractive strategy that would probably incur few additional costs 8,10 and have minimal effect on healthcare workers' time. 8,10,11 Good quality evidence is required to influence policy, and this should be borne in mind when considering the studies included in the meta-analysis by Datta and colleagues, which were of variable quality. Some studies included a comparator or uninstructed group that was not well defined and was probably difficult to control; the absence of blinding is inherent to the nature of the intervention.…”