Improving cascade outcomes for active TB: A global systematic review and meta-analysis of TB interventions

Abstract

Background To inform policy and implementation that can enhance prevention and improve tuberculosis (TB) care cascade outcomes, this review aimed to summarize the impact of various interventions on care cascade outcomes for active TB. Methods and findings In this systematic review and meta-analysis, we retrieved English articles with comparator arms (like randomized controlled trials (RCTs) and before and after intervention studies) that evaluated TB interventions published from January 1970 to September 30, 2022, from Embase, CINAHL, PubMed, and the Cochrane library. Commentaries, qualitative studies, conference abstracts, studies without standard of care comparator arms, and studies that did not report quantitative results for TB care cascade outcomes were excluded. Data from studies with similar comparator arms were pooled in a random effects model, and outcomes were reported as odds ratio (OR) with 95% confidence interval (CI) and number of studies (k). The quality of evidence was appraised using GRADE, and the study was registered on PROSPERO (CRD42018103331). Of 21,548 deduplicated studies, 144 eligible studies were included. Of 144 studies, 128 were from low/middle-income countries, 84 were RCTs, and 25 integrated TB and HIV care. Counselling and education was significantly associated with testing (OR = 8.82, 95% CI:1.71 to 45.43; I2 = 99.9%, k = 7), diagnosis (OR = 1.44, 95% CI:1.08 to 1.92; I2 = 97.6%, k = 9), linkage to care (OR = 3.10, 95% CI = 1.97 to 4.86; I2 = 0%, k = 1), cure (OR = 2.08, 95% CI:1.11 to 3.88; I2 = 76.7%, k = 4), treatment completion (OR = 1.48, 95% CI: 1.07 to 2.03; I2 = 73.1%, k = 8), and treatment success (OR = 3.24, 95% CI: 1.88 to 5.55; I2 = 75.9%, k = 5) outcomes compared to standard-of-care. Incentives, multisector collaborations, and community-based interventions were associated with at least three TB care cascade outcomes; digital interventions and mixed interventions were associated with an increased likelihood of two cascade outcomes each. These findings remained salient when studies were limited to RCTs only. Also, our study does not cover the entire care cascade as we did not measure gaps in pre-testing, pretreatment, and post-treatment outcomes (like loss to follow-up and TB recurrence). Conclusions Among TB interventions, education and counseling, incentives, community-based interventions, and mixed interventions were associated with multiple active TB care cascade outcomes. However, cost-effectiveness and local-setting contexts should be considered when choosing such strategies due to their high heterogeneity.

Interventions to improve latent and active tuberculosis treatment completion rates in underserved groups in low incidence countries: a scoping review

“…A recent systematic review looking at interventions throughout the TB care cascade for active TB in mainly low-income and middle-income countries found that interventions that included counselling and education were significantly associated with treatment success. 56 A further systematic review assessing community-based TB interventions (such as electronic medication monitors, community health worker or family direct observation therapy) in low-income and middleincome countries found these approaches may improve treatment success while also offering convenience to patients. 57 Evidence on sex workers was limited to one single-arm study, and no studies were identified that focused on GRT populations.…”

Low treatment success rate among previously treated persons with drug-susceptible pulmonary tuberculosis in Kampala, Uganda

“…To improve TSR among previously treated persons with TB, barriers to suboptimal TSR like inadequate food, stigma, lack of social protection, frequent drug stock-outs and transportation challenges among others [25] should be addressed. The notable strategies might include strengthening health education on the importance treatment adherence and treatment completion [26] , and providing incentives like food support [27] , [28] and unconditional cash grants [29] , [30] . Strategies to assess treatment adherence like pill counts, three-day medication adherence recall, self-reported medication adherence, and pharmacy refills, which currently are not routinely used in TB care should be encouraged.…”

Active tuberculosis incidence among treatment failure experienced patients in North Wollow Zone: A multicenter historical cohort

“…TB-associated case mortality accounts for 25%-40% of global deaths and 18%-25% of admissions among PLHIV, despite treatment and detection advances. [13][14][15] In Ethiopia, 5.9% of HIV-positive patients newly enrolled in ART in 2016 had active TB (22). The country is among the top 10 TB burden countries, contributing to 87% of global TB cases (23).…”

“…The twin epidemic of TB and HIV caused 0.3 million deaths worldwide in 2017, with a lifetime risk increase from 15% to 22% (1). TB‐associated case mortality accounts for 25%–40% of global deaths and 18%–25% of admissions among PLHIV, despite treatment and detection advances 13–15 …”

“…TB‐associated case mortality accounts for 25%–40% of global deaths and 18%–25% of admissions among PLHIV, despite treatment and detection advances. 13 , 14 , 15 …”