A quality assessment tool for tuberculosis control activities in resource limited settings.
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ABSTRACT:
SUBMITTER: McQuade Billingsley K
PROVIDER: S-EPMC3248985 | biostudies-literature | 2011 Dec
REPOSITORIES: biostudies-literature
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A quality assessment tool for tuberculosis control activities in resource limited settings.
McQuade Billingsley Katherine K Smith Nathaniel N Shirley Rhett R Achieng Loice L Keiser Philip P
Tuberculosis (Edinburgh, Scotland) 20111115
Tuberculosis (TB) is a significant problem, infecting nearly 9 million new patients per year and killing about 2 million a year. The primary means with which to affect TB globally are to decrease transmission locally, mainly by effective identification, diagnosis, and treatment of infectious TB patients. Therefore, quality assurance of TB control efforts at the local level is essential. This study describes the creation of a data extraction tool for retrospective chart review based on the Intern ...[more]
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Project description:ObjectivesThe light-emitting diode (LED) fluorescence microscopy has made acid-fast bacilli (AFB) detection faster and efficient although its optimal performance in resource-limited settings is still being studied. We assessed the optimal performances of light and fluorescence microscopy in routine conditions of a resource-limited setting and evaluated the digestion time for sputum samples for maximum yield of positive cultures.DesignCross-sectional study.SettingFacility-based involving samples of routine patients receiving tuberculosis treatment and care from the main tuberculosis case referral centre in northern Nigeria.ParticipantsThe study included 450 sputum samples from 150 new patients with clinical diagnosis of pulmonary tuberculosis.MethodsThe 450 samples were pooled into 150 specimens, examined independently with mercury vapour lamp (FM), LED CysCope (CY) and Primo Star iLED (PiLED) fluorescence microscopies, and with the Ziehl-Neelsen (ZN) microscopy to assess the performance of each technique compared with liquid culture. The cultured specimens were decontaminated with BD Mycoprep (4% NaOH-1% NLAC and 2.9% sodium citrate) for 10, 15 and 20 min before incubation in Mycobacterium growth incubator tube (MGIT) system and growth examined for acid-fast bacilli (AFB).ResultsOf the 150 specimens examined by direct microscopy: 44 (29%), 60 (40%), 49 (33%) and 64 (43%) were AFB positive by ZN, FM, CY and iLED microscopy, respectively. Digestion of sputum samples for 10, 15 and 20 min yielded mycobacterial growth in 72 (48%), 81 (54%) and 68 (45%) of the digested samples, respectively, after incubation in the MGIT system.ConclusionsIn routine laboratory conditions of a resource-limited setting, our study has demonstrated the superiority of fluorescence microscopy over the conventional ZN technique. Digestion of sputum samples for 15 min yielded more positive cultures.
| S-EPMC3948456 | biostudies-literature
Project description:BACKGROUND:The quality of care for tuberculosis (TB) is deficient in high-burden countries and urgently needs improvement. However, comprehensively identifying the required improvements is challenging. Providing high-quality TB care is an important step toward improving patients' quality of life and decreasing TB morbidity and mortality. Effective tools for assessing the quality of TB services using international standards and guidelines can identify existing gaps in services and inform improvements to ensure high-quality inpatient TB services. OBJECTIVE:This study aimed to develop evaluation instruments for defining the quality of provision of TB services. METHODS:To assess quality of services in the largest TB hospital in Armenia, we developed instruments based on the Joint Commission International Accreditation Standards for Hospitals, International Standards for TB Care, TB Laboratories Bio-Safety Standards, and the World Health Organization framework for conducting TB program reviews. A mixed methods approach was utilized, triangulating quantitative (checklists) and qualitative (in-depth interviews) results. A scoring system and strengths, weaknesses, opportunities, and treats analysis was applied to detail results for each of the 122 standards assessed. A scaling approach was used to present overall performances of inpatient services for eight patient-centered functions and five organization management functions. RESULTS:Overall, 40 in-depth interviews and 91 checklists (21 observations, 16 policy papers, 20 staff qualification documents, and 34 medical records) were developed, utilized, and analyzed to explore practices of health care professionals, assess inpatient treatment experience of patients and their family members, evaluate facility environmental conditions, and define the degree of compliance to standards. CONCLUSIONS:The effective comprehensive evaluation instruments and methods developed in this study for quality of inpatient TB services support the implementation of similar effective assessments in other countries. It may also become a platform to develop similar approaches for assessing ambulatory TB services in resource-limited countries. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID):DERR1-10.2196/13903.
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Project description:Over the last decade, extensive scientific and policy innovations have begun to reduce the "quality chasm"--the gulf between best practices and actual implementation that exists in resource-rich medical settings. While limited data exist, this chasm is likely to be equally acute and deadly in resource-limited areas. While health systems have begun to be scaled up in impoverished areas, scale-up is just the foundation necessary to deliver effective healthcare to the poor. This perspective piece describes a vision for a global quality improvement movement in resource-limited areas. The following action items are a first step toward achieving this vision: 1) revise global health investment mechanisms to value quality; 2) enhance human resources for improving health systems quality; 3) scale up data capacity; 4) deepen community accountability and engagement initiatives; 5) implement evidence-based quality improvement programs; 6) develop an implementation science research agenda.
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Project description:There is an urgent need for simple, rapid, and affordable diagnostic tests for tuberculosis (TB) to combat the great burden of the disease in developing countries. The microscopic observation drug susceptibility assay (MODS) is a promising tool to fill this need, but it is not widely used due to concerns regarding its biosafety and efficiency. This study evaluated the automated MODS (Auto-MODS), which operates on principles similar to those of MODS but with several key modifications, making it an appealing alternative to MODS in resource-limited settings. In the operational setting of Chiang Rai, Thailand, we compared the performance of Auto-MODS with the gold standard liquid culture method in Thailand, mycobacterial growth indicator tube (MGIT) 960 plus the SD Bioline TB Ag MPT64 test, in terms of accuracy and efficiency in differentiating TB and non-TB samples as well as distinguishing TB and multidrug-resistant (MDR) TB samples. Sputum samples from clinically diagnosed TB and non-TB subjects across 17 hospitals in Chiang Rai were consecutively collected from May 2011 to September 2012. A total of 360 samples were available for evaluation, of which 221 (61.4%) were positive and 139 (38.6%) were negative for mycobacterial cultures according to MGIT 960. Of the 221 true-positive samples, Auto-MODS identified 212 as positive and 9 as negative (sensitivity, 95.9%; 95% confidence interval [CI], 92.4% to 98.1%). Of the 139 true-negative samples, Auto-MODS identified 135 as negative and 4 as positive (specificity, 97.1%; 95% CI, 92.8% to 99.2%). The median time to culture positivity was 10 days, with an interquartile range of 8 to 13 days for Auto-MODS. Auto-MODS is an effective and cost-sensitive alternative diagnostic tool for TB diagnosis in resource-limited settings.
| S-EPMC4290917 | biostudies-literature
Project description:Despite increasing availability of anti-retroviral therapy, invasive cryptococcal disease continues to be a leading cause of death among HIV-infected individuals in resource-limited settings. Screening asymptomatic HIV-infected individuals with advanced immunosuppression for serum cryptococcal antigen clearly identifies a population at high risk of cryptococcal meningitis and death. However, screening with serum cryptococcal antigen alone identifies a heterogeneous clinical population, many of whom have mild clinical symptoms, sub-clinical meningeal infection, or fungemia. Currently, there is wide variation in practice and little evidence to guide the use of anti-fungal and anti-retroviral treatment for asymptomatic cryptococcal antigenemia (ACA). Furthermore, implementing a targeted screening and treatment intervention for ACA presents numerous operational challenges for already overburdened health care systems in resource-limited settings. While such an intervention shows promise, there are critical gaps in our understanding of ACA and its implications in the outpatient setting and an urgent need for additional research in this area.
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Project description:BackgroundThe early identification of individuals at high risk for adverse outcomes by a Comprehensive Geriatric Assessment (CGA) in resource-limited primary care settings enables tailored treatments, however, the evidence concerning its benefits are still controversial. The main objective of this study was to examine the validity and reliability of the "Multidimensional Assessment of Older People in Primary Care (AMPI-AB)", a CGA for primary care in resource-limited settings.MethodsLongitudinal study, with median follow-up time of 16 months. Older adults from a public primary care unit in São Paulo, Brazil, were consecutively admitted. Reliability was tested in a sample from a public geriatric outpatient clinic. Participants were classified by the AMPI-AB score as requiring a low, intermediate or high complexity of care. The Physical Frailty Phenotype was used to explore the AMPI-AB's concurrent validity. Predictive validity was assessed with mortality, worsening of the functional status, hospitalizations, emergency room (ER) visits and falls. The area under the ROC curve and logistic regression were calculated for binary outcomes, and a Cox proportional hazards model was used for survival analysis.ResultsOlder adults (n = 317) with a median age of 80 (74-86) years, 67% female, were consecutively admitted. At the follow-up, 7.1% of participants had died, and increased dependency on basic and instrumental activities of daily living was detected in 8.9 and 41.1% of the participants, respectively. The AMPI-AB score was accurate in detecting frailty (area under the ROC curve = 0.851), predicted mortality (HR = 1.25, 95%CI = 1.13-1.39) and increased dependency on basic (OR = 1.26, 95%CI = 1.10-1.46) and instrumental (OR = 1.22, 95%CI = 1.12-1.34) activities of daily living, hospitalizations (OR = 2.05, 95%CI = 1.04-1.26), ER visits (OR = 1.20, 95%CI = 1.10-1.31) and falls (OR = 1.10, 95%CI = 1.01-1.20), all models adjusted for sex and years of schooling. Reliability was tested in a sample of 52 older adults with a median age of 72 (85-64) years, 63.5% female. The AMPI-AB also had good interrater (ICC = 0.87, 95%CI = 0.78-0.92), test-retest (ICC = 0.86, 95%CI = 0.76-0.93) and proxy reliability (ICC = 0.84, 95%CI = 0.67-0.93). The Cronbach's alpha was 0.69, and the mean AMPI-AB administration time was 05:44 ± 02:42 min.ConclusionThe AMPI-AB is a valid and reliable tool for managing older adults in resource-limited primary care settings.
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Project description:Introduction:Under five mortality rates (UFMR) remain high for children in low- and middle-income countries (LMICs) in the developing world. Education for practitioners in these environments is a key factor to improve outcomes that will address United Nations Sustainable Development Goals 3 and 10 (good health and well being and reduced inequalities). In order to appropriately contextualize a curriculum using simulation, it is necessary to first conduct a needs assessment of the target learner population. The World Health Organization (WHO) has published a tool to assess capacity for emergency and surgical care in LMICs that is adaptable to this goal. Materials and methods:The WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was modified to assess pediatric resuscitation capacity in clinical settings in two LMICs: Uganda and Myanmar. Modifications included assessment of self-identified learning needs, current practices, and perceived epidemiology of disease burden in each clinical setting, in addition to assessment of pediatric resuscitation capacity in regard to infrastructure, procedures, equipment, and supplies. The modified tool was administered to 94 respondents from the two settings who were target learners of a proposed simulation-based curriculum in pediatric and neonatal resuscitation. Results:Infectious diseases (respiratory illnesses and diarrheal disease) were cited as the most common causes of pediatric deaths in both countries. Self-identified learning needs included knowledge and skill development in pediatric airway/breathing topics, as well as general resuscitation topics such as CPR and fluid resuscitation in shock. Equipment and supply availability varied substantially between settings, and critical shortages were identified in each setting. Current practices and procedures were often limited by equipment availability or infrastructural considerations. Discussion and conclusion:Epidemiology of disease burden reported by respondents was relatively consistent with WHO country-specific UFMR statistics in each setting. Results of the needs assessment survey were subsequently used to refine goals and objectives for the simulation curriculum and to ensure delivery of pragmatic educational content with recommendations that were contextualized for local capacity and resource availability. Effective use of the tool in two different settings increases its potential generalizability.
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Project description:Background:Recommendations for haemodynamic assessment and support in sepsis and septic shock in resource-limited settings are largely lacking. Methods:A task force of six international experts in critical care medicine, all of them members of the Global Intensive Care Working Group of the European Society of Intensive Care Medicine and with extensive bedside experience in resource-limited intensive care units, reviewed the literature and provided recommendations regarding haemodynamic assessment and support, keeping aspects of efficacy and effectiveness, availability and feasibility and affordability and safety in mind. Results:We suggest using capillary refill time, skin mottling scores and skin temperature gradients; suggest a passive leg raise test to guide fluid resuscitation; recommend crystalloid solutions as the initial fluid of choice; recommend initial fluid resuscitation with 30 ml/kg in the first 3 h, but with extreme caution in settings where there is a lack of mechanical ventilation; recommend against an early start of vasopressors; suggest starting a vasopressor in patients with persistent hypotension after initial fluid resuscitation with at least 30 ml/kg, but earlier when there is lack of vasopressors and mechanical ventilation; recommend using norepinephrine (noradrenaline) as a first-line vasopressor; suggest starting an inotrope with persistence of plasma lactate >2 mmol/L or persistence of skin mottling or prolonged capillary refill time when plasma lactate cannot be measured, and only after initial fluid resuscitation; suggest the use of dobutamine as a first-line inotrope; recommend administering vasopressors through a central venous line and suggest administering vasopressors and inotropes via a central venous line using a syringe or infusion pump when available. Conclusion:Recommendations for haemodynamic assessment and support in sepsis and septic shock in resource-limited settings have been developed by a task force of six international experts in critical care medicine with extensive practical experience in resource-limited settings.
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Project description:The HIV-associated tuberculosis (TB) epidemic remains a huge challenge to public health in resource-limited settings. Reducing the nearly 0.5 million deaths that result each year has been identified as a key priority. Major progress has been made over the past 10 years in defining appropriate strategies and policy guidelines for early diagnosis and effective case management. Ascertainment of cases has been improved through a twofold strategy of provider-initiated HIV testing and counseling in TB patients and intensified TB case finding among those living with HIV. Outcomes of rifampicin-based TB treatment are greatly enhanced by concurrent co-trimoxazole prophylaxis and antiretroviral therapy (ART). ART reduces mortality across a spectrum of CD4 counts and randomized controlled trials have defined the optimum time to start ART. Good outcomes can be achieved when combining TB treatment with first-line ART, but use with second-line ART remains challenging due to pharmacokinetic drug interactions and cotoxicity. We review the frequency and spectrum of adverse drug reactions and immune reconstitution inflammatory syndrome (IRIS) resulting from combined treatment, and highlight the challenges of managing HIV-associated drug-resistant TB.
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Project description:RationaleThe spread of severe acute respiratory syndrome coronavirus-2 has suspended many non-COVID-19 related research activities. Where restarting research activities is permitted, investigators need to evaluate the risks and benefits of resuming data collection and adapt procedures to minimize risk.ObjectivesIn the context of the multicountry Household Air Pollution Intervention (HAPIN) trial conducted in rural, low-resource settings, we developed a framework to assess the risk of each trial activity and to guide protective measures. Our goal is to maximize the integrity of reseach aims while minimizing infection risk based on the latest scientific understanding of the virus.MethodsWe drew on a combination of expert consultations, risk assessment frameworks, institutional guidance and literature to develop our framework. We then systematically graded clinical, behavioral, laboratory and field environmental health research activities in four countries for both adult and child subjects using this framework. National and local government recommendations provided the minimum safety guidelines for our work.ResultsOur framework assesses risk based on staff proximity to the participant, exposure time between staff and participants, and potential viral aerosolization while performing the activity. For each activity, one of four risk levels, from minimal to unacceptable, is assigned and guidance on protective measures is provided. Those activities that can potentially aerosolize the virus are deemed the highest risk.ConclusionsBy applying a systematic, procedure-specific approach to risk assessment for each trial activity, we were able to protect our participants and research team and to uphold our ability to deliver on the research commitments we have made to our staff, participants, local communities, and funders. This framework can be tailored to other research studies conducted in similar settings during the current pandemic, as well as potential future outbreaks with similar transmission dynamics. The trial is registered with clinicaltrials.gov NCT02944682 on October 26. 2016 .
| S-EPMC8040756 | biostudies-literature