BACKGROUND: Chronic TB empyema is a serious complication of TB that often requires surgery because drug penetration into fibrotic pleural tissue is poor. We compared uniportal video-assisted thoracic surgery (VATS) and thoracotomy for pleural decortication. METHODS: We retrospectively analysed 112 patients with chronic TB empyema who underwent surgical treatment between 2020 and 2024. Thoracic morphometric changes were assessed using pre- and postoperative computed tomography, and factors associated with postoperative thoracic expansion were explored. RESULTS: Of the 112 patients, 65 underwent thoracotomy and 47 uniportal VATS. The overall excellent/good outcome rate was 91.9%, based on postoperative lung re-expansion, residual empyema cavity and residual fibrous pleural plaque. Compared with thoracotomy, uniportal VATS was associated with less intraoperative blood loss (151.8 ± 127 vs. 278 ± 231 mL, P < 0.001) and a shorter postoperative hospital stay (8.2 ± 3.7 vs. 9.9 ± 3.1 days, P = 0.002). Both groups showed significant postoperative improvement in thoracic morphometric measurements. Older age was associated with poorer postoperative thoracic expansion. CONCLUSION: In this retrospective single-centre cohort, uniportal VATS was associated with more favourable perioperative outcomes than thoracotomy, with comparable short-term radiographic recovery.
BACKGROUND:TB incidence in prison populations exceeds surrounding communities by factors of up to 100. Early case detection in correctional systems is constrained by gaps in health care worker training and inconsistent application of diagnostic algorithms. Structured clinical mentorship may strengthen diagnostic performance, although evidence from Kenyan correctional settings remains limited. METHODS:We conducted a retrospective evaluation across 20 prison health facilities in Kenya, comparing TB indicators during 4-month pre- and post-intervention periods following a 3-month clinical mentorship programme. Facility-level outcomes included TB screening coverage, testing coverage, diagnostic modality use, and TB detection among presumptive cases. Analyses were stratified by baseline facility TB detection capacity (≥1 vs. 0 confirmed cases pre-intervention). RESULTS:Among inmates, TB diagnostic yield was higher in the post-intervention period than in the pre-intervention period (2.6% vs. 5.4%; risk ratio [RR] 2.05, 95% confidence interval: 1.33-3.17), and screening coverage also increased (58.5% vs. 70.3%; RR 1.20; P < 0.001). Diagnostic practices shifted toward WHO-recommended modalities. These changes were concentrated in facilities with baseline detection capacity. CONCLUSION:Clinical mentorship was associated with higher TB diagnostic yield, greater screening coverage, and increased use of WHO-recommended diagnostics during the post-intervention period. Gains were concentrated in facilities with baseline detection capacity.
BACKGROUND:Despite advances in TB care, approximately 2.4 million people with TB remain undiagnosed or unreported each year. A key contributor to these 'missed millions' is that major diagnostic gaps persist especially among underserved populations. Developing diagnostic algorithms that are accessible and integrated into health care systems where they are intended to be used is essential to meet WHO End TB targets. METHODS:Start4All a multi-country, cross-sectional diagnostic accuracy study (in Bangladesh, Brazil, Cameroon, Kenya, Malawi, Nigeria, and Viet Nam) aims to assess and model algorithms using combinations of WHO-endorsed, and experimental TB screening and diagnostic tests across the lowest levels of care and the community, compared to a sputum culture reference standard. Evaluated tools include C-reactive protein tests, computer-aided detection-interpreted chest X-rays, pooled Xpert® MTB/RIF Ultra (Xpert Ultra) testing, and a third generation lipoarabinomannan (LF-LAM) assay. DISCUSSION:Start4All will generate high-quality evidence to guide policy decisions on the adoption and the integration of non-sputum and laboratory independent tools to accelerate early TB detection and close the treatment gap. CONCLUSION:A feature of Start4All is its implementation within national TB programmes across seven high-burden countries to ensure that findings are directly translatable to policy and operational decision making. Harmonised protocols, standardised microbiological reference testing, and unified data management systems will enable cross-country comparison and strengthen the external validity of results.
BACKGROUND: TB preventive treatment (TPT) is central to reducing TB incidence among high-risk populations. This paper presents learnings from a large-scale TPT implementation under a Global Fund-supported project in India. METHODS: The project targeted household contacts (HHCs) of people with pulmonary TB (PTB) across 208 districts in 23 states. Data on symptom-based screening, TPT initiation, adherence, and completion were analysed to inform scale-up strategies. RESULTS: Of 3,097,831 HHCs identified from 851,974 people with PTB, 91% were symptom-screened, and among those screened 28% underwent chest X-ray and 54% initiated TPT, with an 84% completion rate. Integration with active case finding, portable digital chest X-rays, and short-course regimens (3HP) improved coverage. Decentralised service delivery through Health and Wellness Centres and engagement of community health workers enhanced treatment access and follow-up. Teleconsultations, digital tracking, and incentive mechanisms supported adherence. Challenges included early discontinuation due to adverse drug reactions, regional diagnostic disparities, and limited private sector engagement. CONCLUSION: Large-scale TPT delivery is feasible in high-burden settings when integrated with routine health system platforms and community-based approaches. Key operational insights included chest X-ray screening, and scale-up of shorter regimens, supporting India’s TB elimination goals.
BACKGROUND: Patient-centred communication (PCC) is critical for delivering high-quality TB care. The 4-Habits Coding Scheme (4-HCS) is a tool designed to assess 23 communication behaviours from a patient-centred perspective. METHODS: We aimed to cross-culturally adapt and validate the 4-HCS into Chinese and evaluate PCC skills among TB health care workers (HCWs) in primary health care (PHC) settings in Western China. RESULTS: The Chinese version of the 4-HCS demonstrated robust reliability, face validity, and construct validity, and construct validity, and a total of 2,807 HCWs were included in the study. Community-level TB HCWs (3.872 ± 0.842) had better PCC skills than village-level HCWs (3.748 ± 0.860). The Habit 4 (Invest in the End) dimension which required more TB treatment knowledge had the lowest scores across four dimensions at both levels. Factors associated with higher 4-HCS scores included positive working attitudes, high working satisfaction, more years of TB working experience, and being from the community level (all P < 0.05). CONCLUSION: The Chinese version of the 4-HCS is a reliable and valid tool for assessing PCC skills among TB HCWs in PHC settings. Future research should expand to diverse regions and incorporate objective assessments to further validate the tool and explore its broader applicability.
Despite being preventable and curable, TB remains a major infectious killer. Effective control requires prevention, early diagnosis, proper treatment, and the ability to address socio-economic risk factors. With limited resources, countries must prioritise interventions amid evolving epidemiology, technologies, and health system demands. To support this, the WHO's policy brief, 'Priority-setting in tuberculosis programme planning', outlines structured and participatory decision-making approaches. It frames priority-setting as an ongoing governance function, not a one-time response to scarcity, helping align resources with population needs, promote equity, and strengthen integration of TB services within primary health care and universal health coverage.
BACKGROUND:Nurse case management (NCM) models have improved outcomes in chronic disease and HIV, but evidence in multidrug-resistant TB (MDR-TB) is limited. We therefore evaluated whether NCM could improve MDR-TB outcomes. METHODS:This pragmatic, cluster-randomised trial was conducted at 10 district hospitals in KwaZulu-Natal and Eastern Cape, South Africa. RESULTS:Between 13 November 2014 and 5 September 2019, 2,844 were enrolled. A total of 2,134 were analysed (1,093 NCM, 1,041 usual care). Among 1,236 men (57.9%) and 898 women (42.1%), mean age was 37.4 years (standard deviation 12.2). Treatment success occurred in 706 (64.5%) of NCM group and 645 (61.9%) in usual care (P = 0.62). Treatment failure occurred in 28 (2.6%) of NCM group and 47 (4.5%) of usual care. NCM did not improve the proportion of successful treatment (adjusted odds ratio [aOR] = 0.79, P = 0.17, and 95% confidence interval [CI]: 0.56, 1.12). In secondary analysis, NCM reduced the odds of treatment failure by 44% (aOR 0.56, 95% CI: 0.31-0.99), which improved to 49% (aOR 0.51, 95% CI: 0.26-0.99) in sensitivity analysis. Differences for other outcomes were not significant. CONCLUSION:NCM did not improve MDR-TB treatment success. Yet, NCM was associated with reduced odds of treatment failure. The intervention alone was insufficient to overcome barriers associated with loss to follow-up, or delayed presentation.
BACKGROUND: TB is a leading cause of morbidity and mortality, and TB treatment shortening is a focus of TB therapeutic trials. Clofazimine (CFZ) has been proposed as part of a shorter TB regimen but the drug causes skin hyperpigmentation. Patient preferences around shorter regimens with CFZ should be documented. METHODS: We performed an exploratory, qualitative sub-study using in-depth interviews among purposively selected participants in the CLO-FAST trial (NCT04311502). Participants were asked about their experience with their assigned treatment regimen and about preferences for treatment. Data were analysed by trained qualitative researchers using the theoretical framework of acceptability. RESULTS: Twenty-three participants from India, Malawi, and Zimbabwe were selected from 89 participants randomised to two study arms in the parent trial. Most participants expressed preference for shorter regimen even if it led to skin hyperpigmentation. Preferences for a longer regimen may have been influenced by anticipated concerns around inadvertent disclosure and by a belief that longer regimens were more potent. CONCLUSION: Preference assessment can be successfully built into therapeutic TB trials. Most participants preferred shorter treatment but concerns about potency and skin discolouration were expressed. Additional work is needed to describe therapeutic preferences among people with TB.
BACKGROUND:Distinguishing TB infection (TBI) from TB disease remains difficult because routine tests, including tuberculin skin test and interferon-gamma release assay (IGRA), cannot separate these states. We assessed a flow cytometry-based assay that measures T-cell cytokine responses after stimulation with Mycobacterium tuberculosis. METHODS:We enrolled 118 IGRA-positive participants, including individuals with TB/TBI. Individuals were grouped by age and disease category into paediatric/adult TB, TBI, and immunocompromised TBI. Peripheral blood lymphocytes were stimulated with ESAT-6/CFP-10 antigens under CD4+-focused (TB1) or combined CD4+/CD8+ (TB2) conditions. Intracellular IL-10, IL-2, and tumour necrosis factor-α (TNF-α) were quantified by flow cytometry. Cytokine levels were compared using Mann-Whitney U tests. RESULTS:Among children, most cytokine responses overlapped between TBI and TB, except TNF-α in CD8+ T cells after TB2 stimulation, which was higher in TB. In adults, IL-10 in CD4+ T cells was elevated in TBI after TB1 and TB2 stimulation, whereas IL-2 in CD4+ T cells was higher in TB after TB2 stimulation. TNF-α did not differentiate groups in adults. CONCLUSION:Flow-cytometric cytokine profiling may help distinguish TBI from TB, with age-specific markers. TNF-α in CD8+ T cells appears informative in children, while IL-10 and IL-2 in CD4+ T cells show promise in adults. Further validation is needed.
BACKGROUND: TB remains a major public health challenge in the Kyrgyz Republic due to continued transmission and drug resistance. Despite an overall decline in incidence, gaps persist in case notification, procurement processes, and patient-centred care. METHODS: This study reports on the first community-led monitoring (CLM) initiative for TB services, implemented by TB People Kyrgyzstan in partnership with KNCV KG from 2019 to 2024. Programmatic data were combined with structured interviews of people with TB, community monitors, and health workers to identify barriers to diagnosis, treatment, and access to medicines. RESULTS: Estimated TB incidence declined over the study period, yet under-notification remained substantial, with 56.5% of cases not notified in 2024. Procurement was generally stable; however, regulatory and customs delays limited access to new medicines. Patients reported stigma, transport costs, and limited psychosocial support as key barriers, while health workers highlighted shortages of trained staff in rural areas. CONCLUSION: CLM complemented national surveillance by amplifying community perspectives and identifying actionable priorities. Expanding access to rapid diagnostics, strengthening procurement coordination, investing in the TB workforce, and sustaining community engagement are essential to accelerate progress towards End TB targets. This approach supports equity, improvement, and resilience.
BACKGROUND:Multidrug-resistant TB (MDR-TB) in children remains a major public health challenge. Although treatment is free of direct charge in many countries, it can impose substantial indirect and non-medical costs on affected households. Evidence on the economic burden of childhood MDR-TB on families remains limited. METHODS:A cross-sectional household survey was conducted in the Western Cape, South Africa, among 45 households with a child <15 years who initiated MDR-TB treatment between 2018 and 2021. Socio-economic status, costs of accessing care, and health-related quality of life (HRQoL) were assessed and linked to health service utilisation data to estimate household-level costs. RESULTS:The median total cost per household was ZAR 7,443 (US$504) per episode of care (interquartile range: ZAR 4,119-13,207), with indirect costs accounting for the largest share of household costs. Twenty-three (51.1%) of households incurred catastrophic health expenditure, defined as >20% of annual household income. Costs increased with hospital-based care, longer treatment duration, and more frequent caregiver visits. The HRQoL of children was generally high, though not uniformly distributed. CONCLUSION:Childhood MDR-TB places substantial financial burden on already vulnerable households. Economic evaluations and care models should incorporate household costs and consider strategies to reduce the indirect burden of treatment on families.
BACKGROUND: Clinicians, public health workers, and researchers must link multiple laboratory results to individual patient records to identify emerging drug-resistant TB. OBJECTIVE: Determine the proportion of individuals with rifampicin-resistant TB (RR-TB) who developed fluoroquinolone resistance using different data matching methods. DESIGN: Data from the National Health Laboratory Service (NHLS) from the Western Cape Province, South Africa (January 2008 to June 2015), were used to identify patients with RR-TB who developed fluoroquinolone resistance after initial susceptibility. We used four methods to link patient results: A) exact match on NHLS patient number; B) exact match on surname, first name, and date of birth; C) custom algorithm (Stellenbosch University) using approximate matches for patient-identifying variables; and D) custom iterative approximate linkage developed for this study. We manually reviewed matches identified by each method. RESULTS: We identified 30,381 laboratory results showing rifampicin and fluoroquinolone susceptibility. Estimates of resistance development were 4% using methods A and B, and 8% using methods C and D. Across methods, 688 unique patients who developed fluoroquinolone resistance were identified, 598 of which were correct by manual review. Method D identified 587 (98%) of these correctly matched patients, the largest proportion across these methods. CONCLUSION: Customised approximate linkage approaches maximised correct patient matches.
BACKGROUND:In Peru, TB remains a leading public health concern, yet knowledge about its transmission among women of reproductive age is poorly characterised. We sought to determine multilevel factors associated with comprehensive TB knowledge in this population. METHODS:We analysed data from 29,889 women aged 15-49 years across 25 departments using Peru's 2024 Demographic and Health Survey. Comprehensive TB knowledge was defined as correct identification of airborne transmission and rejection of at least three of five common myths. Three-level logistic regression, spatial autocorrelation, and concentration index analyses were used to examine individual, household, and contextual determinants. RESULTS:Weighted prevalence of comprehensive TB knowledge was 27.5% (95% confidence interval: 26.3-28.6). Education exhibited a dose-response gradient (odds ratio 4.7 for higher vs. no education; 95% confidence interval: 3.30-6.57). The intraclass correlation coefficient was 22.2%, indicating substantial contextual variation. Spatial analysis showed significant clustering (Moran's I = 0.077, P < 0.001), and the concentration index of 0.115 confirmed pro-rich inequality in knowledge distribution. CONCLUSION:Approximately one in four Peruvian women possess comprehensive TB knowledge, with pronounced socio-economic and geographic inequities. These findings support targeted educational interventions for women with limited schooling in economically disadvantaged communities.
