Background:There is a lack of national data on antibiotic consumption by teaching hospitals in Islamic Republic of Iran based on the WHO access, watch and reserve categorisation. Aim:To quantify antibiotic consumption by teaching hospitals in Islamic Republic of Iran. Methods:We analysed antibiotic consumption data for March 2023 to March 2024 across all 248 teaching hospitals in the 10 regions of Islamic Republic of Iran, using the WHO-defined daily dose methodology and the access, watch and reserve categorisation. Results:Median antibiotic consumption was 299 defined daily dose per 100 admissions per day. Hospitals in Region 10 had the highest overall consumption (24.3% of total consumption), while Region 7 showed the highest use of reserve group antibiotics. Across all hospitals and regions, watch antibiotics were the most used (61%), followed by access (37%) and reserve (2%). Ceftriaxone 1 g and cefazolin 1 g were the most frequently used (11% of total consumption each), followed by meropenem 1 g injection (8.8%) and vancomycin 0.5 g (7%). Conclusion:Our findings show high reliance on watch antibiotics, extensive cephalosporin use and prevalent parenteral formulations. There is a need to assess the appropriateness of antibiotic use in Iranian teaching hospitals in order to strengthen antibiotic stewardship.

Objective:To develop a new tuberculosis transmission model, addressing the limitations of and building on the TB Impact Model and Estimates software tool, to enable decision-makers to assess the impact of various tuberculosis interventions and allocate resources more effectively. Methods:We designed a model incorporating diagnosis and treatment pathways across public and private sectors, stratified across age groups, drug susceptibility, human immunodeficiency virus status and vaccination status. We calibrated our model using country-specific data from 29 high-burden countries and determined calibration target indicators according to national epidemic profiles. We performed the model calibration using a Bayesian adaptive Markov chain Monte Carlo process. We compare modelled and actual data for Indonesia and Nigeria. Findings:Our model calibration results showed good agreement with historical tuberculosis data. In Indonesia, we demonstrate that comprehensive implementation of the Stop TB Partnership Global plan to end TB interventions, including a public-private partnership, modern diagnostics, improved treatment for drug-resistant tuberculosis and a post-exposure vaccine, could enable the country to achieve the targets of the World Health Organization (WHO) End TB Strategy by 2035. In Nigeria, implementing the National strategic plan for tuberculosis control 2021-2026 could reduce tuberculosis incidence by 27% and mortality by 37% by 2030, even without a vaccine. Conclusion:Our model provides a robust analytical foundation from which to assess the epidemiological impact of diverse interventions, prioritize investments and guide policy. The model's open-source design and alignment with WHO recommendations make it a valuable tool for guiding evidence-based investment.

Background: Routine tuberculosis (TB) programmatic indicators fail to capture long-term outcomes like TB recurrence and mortality, given limited post-treatment follow-up. Furthermore, active case finding (ACF) has expanded in India, although its impact on long-term outcomes remains unclear. We assessed the TB care cascade in central India through one-year post-treatment and examined differences by case-finding strategy. Methods: From 2020 to 2022, we conducted a prospective cohort study of adults (≥18 years old) with drug-susceptible smear-positive pulmonary TB diagnosed by ACF or passive case finding (PCF) in five districts in central India. Participants were followed from diagnosis through one-year post-treatment. Composite unfavourable outcomes comprised pretreatment loss to follow-up, unsuccessful on-treatment outcomes, and post-treatment TB recurrence or death. Poisson regression was performed, accounting for complex survey design, with multiple imputation for missing data. Findings: Among 657 participants, 47.6% experienced composite unfavourable outcomes across the care cascade. Among those who completed treatment (n=447), 23.2% experienced post-treatment TB recurrence/death. Composite outcomes did not differ by case-finding strategy (adjusted risk ratio [aRR] 0.89 [0.76-1.03]). However, ACF-detected individuals had higher unsuccessful on-treatment outcomes (aRR 1.24 [95%CI: 1.02-1.55]), but lower post-treatment recurrence or death (aRR 0.61 [95%CI:0.43-0.86]). Severe undernutrition, unhealthy alcohol use, rural residence, lower educational attainment, and lack of cellphone access were independently associated with composite unfavourable outcomes. Interpretation: Nearly half of people experienced composite unfavourable outcomes across the care cascade. One-fourth experienced post-treatment recurrence or death, underscoring the need for systematic post-treatment follow-up. More intensive interventions may be needed to retain ACF-detected individuals during TB treatment.

Individuals exposed to a person with infectious multidrug-resistant or rifampicin-resistant (MDR-RR) tuberculosis are at risk of developing tuberculosis disease. Historically, insufficient empirical evidence for preventive treatment in this group has permitted inadequate guidance for clinical decision making. However, several high-quality studies have been published detailing preventive treatment options for these contacts at high risk. In this Review, we discuss the management of individuals exposed to patients with infectious MDR-RR tuberculosis. We pay particular attention to the entire spectrum of clinical care for this population, including baseline assessment, possible preventive treatments, follow-up, and shared decision making. We discuss the available evidence, the rationales for different management strategies, and the interactions with (and implications of) secondary comorbidities such as HIV or malnutrition.

Objectives A ‘7-1-7’ timeliness metric, developed for hastening the response to infectious disease outbreaks/pandemics, was adapted to improve screening and managing household contacts (HHCs) of pulmonary tuberculosis (TB) patients. The feasibility, enablers, challenges and utility of implementing this modified metric through TB Champions (TB survivors) for HHC management were assessed.Design This was an explanatory mixed-methods study with a cohort design (quantitative) followed by a descriptive design with focus group discussions (qualitative).Setting The study was conducted within routine programmatic settings in public health facilities in six districts from three states of India.Participants In total, 595 drug-susceptible index pulmonary TB patients registered for treatment in the selected health facilities, and their listed 2108 HHCs were included in the study between December 2022 and August 2023. All 17 TB Champions involved in implementation participated in the focus group discussions.Primary outcome measures The primary outcome measures were the percentage of eligible participants receiving the desired service within the ‘7-1-7’ timeliness metric and challenges in achieving the timeliness metrics.Results In 89% of 595 index patients, their HHCs were line-listed within 7 days of initiating anti-TB treatment (‘First-7’). In 90% of 2108 HHCs, screening outcomes were ascertained within 1 day of line-listing (‘Next-1’). In 42% of 2073 HHCs eligible for further evaluation, anti-TB treatment, TB preventive treatment (TPT) or a decision to not receive medication were made within 7 days of screening (‘Second-7’). Barriers to TPT uptake included lack of money and daily wage losses for travelling to clinics, reluctance of asymptomatic contacts to take medication and fear of adverse events. TB Champions felt timeliness metrics improved performance in the systematic and timely management of HHCs.Conclusions TB Champions found ‘7-1-7’ timeliness metrics were feasible and useful, and national TB programmes should consider their operationalisation.

Background:Tuberculosis (TB) remains one of the deadliest infectious diseases globally. Despite the World Health Organization's (WHO) End TB Strategy targets for 2035, progress has been hindered by structural, financial, and implementation barriers, including recent cuts in global funding. Strategic use of mathematical modelling is useful for prioritizing high-impact interventions and optimizing limited resources. A new global TB infection transmission model was developed to address limitations in existing tools with respect to these applications. Methods:The model includes enhanced features such as age-specific mixing, explicit representation of asymptomatic TB, stratification by drug resistance, HIV status, and new vaccine status, and inclusion of both public and private care pathways. It was calibrated to country-specific data using Bayesian adaptive Markov Chain Monte Carlo (MCMC) methods. The model was used to assess the impact of national strategic plans and the Global Plan to End TB, using a Target Population (TP) component to map interventions to WHO guidelines. Results:Model calibration showed good agreement with historical TB data from 29 high-burden countries, with case studies for Indonesia and Nigeria presented here. In Indonesia, comprehensive implementation of Global Plan interventions - including public-private mix efforts, modern diagnostics, improved treatment for drug-resistant TB, and a post-exposure vaccine - could enable the country to achieve End TB targets by 2035. In Nigeria, implementing its National Strategic Plan could reduce TB incidence by 27% and mortality by 37% by 2030, even without a vaccine. The model highlighted the additional efforts that are needed to meet the End-TB goals. Conclusions:The enhanced TB model provides a flexible, policy-relevant framework for assessing the epidemiological impact of TB interventions at both national and global levels. Its open-source design and alignment with WHO recommendations make it a valuable tool for guiding evidence-based investments amid tightening global health budgets.

Rationale:Tuberculosis (TB) remains a global health crisis, disproportionately affecting low- and middle-income countries. Strategic resource allocation is essential to achieving the WHO End TB targets. Existing TB costing tools have limitations in conducting global analyses, prompting the development of a novel model tailored to address these gaps. Methods:We developed a new, open-source TB costing model that simulates detailed TB care cascades comprising steps of screening, diagnosis, treatment, and prevention for those eligible - according to WHO guidelines for 20 distinct population groups. These include 10 groups each from patient-initiated and provider-initiated pathways, capturing variations in pulmonary status, age, HIV/ART status, and drug sensitivity. The model captures the cost of a large-scale vaccine. We demonstrate the model's functionality through a case study that informed the Global Fund's Investment Case for its 8th replenishment (2027-2029). Results:In the case study, the model was first used to estimate the cost of implementing the TB Global Plan 2023 - 2030. This scenario incorporated intervention targets, normative standards of care, and the availability of new TB tools. An optimization routine applied to 29 high-burden countries estimated maximal TB impact under constrained funding scenarios. The results were also used to assess the potential impact and contribution of innovation within the Global Fund's 8th replenishment. Discussion:This new TB costing model offers improved representation of TB care complexity across diverse populations, with enhanced transparency, flexibility, and policy relevance. Its application in global TB strategy analysis highlights its value in informing investment cases and prioritizing interventions for maximal impact under resource constraints.

Background IOM piloted the use of Ag RDTs for COVID-19 in Iraq, in collaboration with FIND, the Global Alliance for Diagnostics, to facilitate access to testing and understand barriers and opportunities for testing in a displacement context. The purpose was to (i) evaluate the performance metrics of the Sure Status COVID-19 Antigen Card Test in this population; (ii) compare Ag RDT results across high- and low-probability cases, vaccination status, and symptom severity; and (iii) report participant perspectives on Ag RDT use for COVID-19 and other diseases. Methods Secondary analysis was conducted using de-identified cross-sectional data collected from November 2022-March 2023 in four IDP camps in the Kurdistan region of Iraq. Data was collected during the recording, reporting, and monitoring processes of the pilot project using Ag RDTs for COVID-19 among displaced populations. Descriptive statistics and bivariate analyses were conducted in Stata (version 17). Results The observed performance metrics of the Sure Status Ag RDT were as follows: sensitivity = 72.73% (95% CI: 69.56–75.80%); specificity = 99.74% (95% CI: 99.39–100%), PPV = 92.31% (95% CI: 92.31–94.15%), and NPV = 98.85% (95% CI: 98.11–99.58%). Ag RDT uptake was higher among women and symptomatic individuals, and preference for Ag RDTs was especially strong among illiterate respondents. The overall positivity of Ag RDTs and PCR results in this population remained lower than national averages. Concerningly, 23.39% of respondents declined an Ag RDT because they did not believe in COVID-19. Conclusions This pilot program was among the first to explore Ag RDT use in Iraqi Kurdistan. Over 99% of respondents reported satisfaction with their Ag RDT experience, and over 90% wanted to see Ag RDTs available for other diseases. These findings can inform implementation of RDTs and screening protocols for other infectious diseases, and patient perspectives on Ag RDTs for testing and screening of COVID-19 among displaced populations can inform health programming within Iraq and globally.

BACKGROUND:India accounts for about one-quarter of people contracting tuberculosis (TB) disease annually and nearly one-third of TB deaths globally. Many Indians do not navigate all care cascade stages to receive TB treatment and achieve recurrence-free survival. Guided by a population/exposure/comparison/outcomes (PECO) framework, we report findings of a systematic review to identify factors contributing to unfavorable outcomes across each care cascade gap for TB disease in India. METHODS AND FINDINGS:We defined care cascade gaps as comprising people with confirmed or presumptive TB who did not: start the TB diagnostic workup (Gap 1), complete the workup (Gap 2), start treatment (Gap 3), achieve treatment success (Gap 4), or achieve TB recurrence-free survival (Gap 5). Three systematic searches of PubMed, Embase, and Web of Science from January 1, 2000 to August 14, 2023 were conducted. We identified articles evaluating factors associated with unfavorable outcomes for each gap (reported as adjusted odds, relative risk, or hazard ratios) and, among people experiencing unfavorable outcomes, reasons for these outcomes (reported as proportions), with specific quality or risk of bias criteria for each gap. Findings were organized into person-, family-, and society-, or health system-related factors, using a social-ecological framework. Factors associated with unfavorable outcomes across multiple cascade stages included: male sex, older age, poverty-related factors, lower symptom severity or duration, undernutrition, alcohol use, smoking, and distrust of (or dissatisfaction with) health services. People previously treated for TB were more likely to seek care and engage in the diagnostic workup (Gaps 1 and 2) but more likely to suffer pretreatment loss to follow-up (Gap 3) and unfavorable treatment outcomes (Gap 4), especially those who were lost to follow-up during their prior treatment. For individual care cascade gaps, multiple studies highlighted lack of TB knowledge and structural barriers (e.g., transportation challenges) as contributing to lack of care-seeking for TB symptoms (Gap 1, 14 studies); lack of access to diagnostics (e.g., X-ray), non-identification of eligible people for testing, and failure of providers to communicate concern for TB as contributing to non-completion of the diagnostic workup (Gap 2, 17 studies); stigma, poor recording of patient contact information by providers, and early death from diagnostic delays as contributing to pretreatment loss to follow-up (Gap 3, 15 studies); and lack of TB knowledge, stigma, depression, and medication adverse effects as contributing to unfavorable treatment outcomes (Gap 4, 86 studies). Medication nonadherence contributed to unfavorable treatment outcomes (Gap 4) and TB recurrence (Gap 5, 14 studies). Limitations include lack of meta-analyses due to the heterogeneity of findings and limited generalizability to some Indian regions, given the country's diverse population. CONCLUSIONS:This systematic review illuminates common patterns of risk that shape outcomes for Indians with TB, while highlighting knowledge gaps-particularly regarding TB care for children or in the private sector-to guide future research. Findings may inform targeting of support services to people with TB who have higher risk of poor outcomes and inform multicomponent interventions to close gaps in the care cascade.

Although screening of household contacts (HHCs) of TB patients and provision of TB preventive therapy (TPT) is a key intervention to end the TB epidemic, their implementation globally is dismal. We assessed whether introducing a ‘7-1-7’ timeliness metric was workable for implementing HHC screening among index patients with pulmonary TB diagnosed by private providers in Chennai, India, between November 2022 and March 2023.This was an explanatory mixed-methods study (quantitative-cohort and qualitative-descriptive).There were 263 index patients with 556 HHCs. In 90% of index patients, HHCs were line-listed within 7 days of anti-TB treatment initiation. Screening outcomes were ascertained in 48% of HHCs within 1 day of line-listing. Start of anti-TB treatment, TPT or a decision to receive neither was achieved in 57% of HHC within 7 days of screening. Overall, 24% of screened HHCs in the ‘7-1-7’ period started TPT compared with 16% in a historical control ( P < 0.01). Barriers to achieving ‘7-1-7’ included HHC reluctance for evaluation or TPT, refusal of private providers to prescribe TPT and reliance on facility-based screening of HHCs instead of home visits by health workers for screening.Introduction of a timeliness metric is a workable intervention that adds structure to HHC screening and timely management.

Background: There is a paucity of data on Healthcare Providers (HCPs) caring for people living with HIV in Jordan. Objective: We aimed to understand HCPs’ knowledge, attitude, stigma, and practices, to assess the gaps in HIV care in Jordan. Methods: We conducted recorded in-depth interviews with all five HCPs working at the only HIV Service Center in Jordan, using semi-structured questions in 2021. Content analysis was performed. Results: Several organizational challenges were identified. Only one had received HIV training. All were uncertain of updated recommendations with little knowledge of international guidelines, vertical transmission, contraception, sexually transmitted infections (STIs), non-communicable diseases (NCDs), and prophylaxis. Four HCPs perform counseling, focusing on easing anxieties, risk modification, and the importance of treatment adherence. However, their counseling on contraception, risk of transmission, STIs, and NCDs is inadequate, and they have little-to-no experience with prophylaxis. Most had a positive attitude towards people living with HIV, especially HCPs working at the center the longest, encouraging marriage and reproduction. Most do not approve of mandatory testing, or of breaching patient confidentiality. They repetitively described risky behavior as ‘immoral behavior’, empathizing more with patients who caught HIV through blood transfusion or birth, and demonstrating embedded stigmatized beliefs. They reported people living with HIV experience anticipated stigma and stigma by their general community including by other HCPs. Conclusion: This is the first study on HCPs caring for people living with HIV in Jordan. It highlights the suboptimal knowledge, practices, and stigma which improve with greater participatory exposure to HIV care. HCPs had an overall positive attitude, more evident in HCPs working at the clinic the longest.

BACKGROUND:Tuberculosis knowledge, practices, and perceived stigma and discrimination among patients with tuberculosis are key factors for the management of the disease. OBJECTIVES:The objectives of the study were to assess knowledge, practices, perceived stigma and discrimination, perceived family and health workers support, perceived level of satisfaction with healthcare services, delay in diagnosis/treatment and reasons for delay among patients with tuberculosis in Jordan. METHODS:A cross-sectional study was conducted among patients who were under treatment for tuberculosis in Jordan in 2021. RESULTS:This study included a total of 452 patients with tuberculosis. About 91.4% of patients had low to moderate overall tuberculosis-related knowledge score and 8.6% had high knowledge score. Almost two-thirds of patients (67.5%) had perceived a low level of stigma, 61 (13.5%) perceived a moderate level of stigma, and 86 (19.0%) perceived a high level of stigma. The majority (84.5%) of patients with tuberculosis thought that there was a delay in diagnosis and/or treatment of tuberculosis. CONCLUSION:Our study showed gaps in tuberculosis knowledge and practices, high perceived stigma and discrimination, and perceived delay in diagnosis and treatment initiation,. Efforts within the national tuberculosis control program should be made to increase public awareness about the symptoms of tuberculosis and the importance of seeking early care.

BACKGROUND: The study assessed whether a “7-1-7” timeliness metric for screening and TB preventive therapy (TPT) could be implemented for household contacts (HHCs) of index patients with bacteriologically confirmed pulmonary TB under routine programmatic settings in Kenya.METHODS: A longitudinal cohort study conducted among index patients and their HHCs in 12 health facilities, Kiambu County, Kenya.RESULTS: Between January and June 2023, 95% of 508 index patients had their HHCs line-listed within 7 days of initiating anti-TB treatment (“First 7”). In 68% of 1,115 HHCs, screening outcomes were ascertained within 1 day of line-listing (“Next 1”). In 65% of 1,105 HHCs eligible for further evaluation, anti-TB treatment, TPT or a decision for no drugs was made within 7 days of screening (“Second 7”). Altogether, 62% of screened HHCs started TPT during the “7-1-7” period compared with 58% in a historical cohort. Main barriers to TPT uptake were HHCs not consulting clinicians, HHCs being unwilling to initiate TPT and drug shortages. Healthcare workers felt that a timeliness metric was valuable for streamlining HHC management and proposed “3-5-7” as a workable alternative.CONCLUSIONS: The national TB programme must generate awareness about TPT, ensure uninterrupted drug supplies and assess whether the “3-5-7” metric can be operationalised.

Introduction: The National AIDS Program in Jordan has faced numerous challenges, including insufficient funding, limited resources, and complexities brought on by refugee influxes. The absence of a reliable HIV/AIDS surveillance system further complicates tracking and responding to the epidemic. This study aimed to evaluate the performance and functionality of the National AIDS Program and the HIV/AIDS surveillance system. Methods: A qualitative study was conducted to evaluate the National AIDS Program and the HIV/AIDS Surveillance System in Jordan. The study involved 14 key informants specialized in HIV/AIDS Surveillance Systems. Interviews were guided by an interview guide based on the Updated Centers for Disease Control and Prevention Guidelines for Evaluating Public Health Surveillance Systems. Data analysis was performed through directed content analysis. Results: The Voluntary Counseling and Testing Center in Jordan confronts multiple challenges, including poor infrastructure, limited accessibility, and inadequate facilities. Additionally, there is a lack of effective coordination between the Voluntary Counseling and Testing center and the Chest Diseases and Migrant Health Directorate, particularly regarding testing for Tuberculosis. HIV screening in Jordan is hindered by various factors, including disease sensitivity. Voluntary Counseling and Testing lacks HIV/AIDS specialists AND staff adequate training and fails to adhere to updated treatment guidelines. Persistent deficiencies in human resources, equipment, and training continue to plague the HIV/AIDS Surveillance System. Key informants expressed dissatisfaction with the data’s usefulness, citing concerns over poor data quality. The data were seldom used for prioritizing resources, identifying at-risk individuals, assessing HIV/AIDS risk factors, or evaluating prevention and control measures. Conclusion: The National AIDS Program and HIV/AIDS Surveillance System activities in Jordan are unstructured, poorly coordinated, and inefficient. Many gaps related to National AIDS Program and HIV/AIDS Surveillance System performance and data were identified. Recommendations include developing an electronic surveillance system for data collection, notification, and reporting, and building the capacities of HIV/AIDS healthcare providers in screening, diagnosis, and management.

Objectives: Evaluate and determine the gaps in the National Tuberculosis Program and Tuberculosis Surveillance System in Jordan. Methods: A concurrent embedded mixed quantitative/qualitative methods study was conducted to assess the National Tuberculosis Program and Tuberculosis Surveillance System in Jordan. A semi-structured questionnaire was developed based on the Updated CDC Guideline for Evaluating Public Health Surveillance System to collect necessary information from service providers and other stakeholders. Results: The National Tuberculosis Program and Tuberculosis Surveillance System encounter various gaps and challenges across several critical domains, including infrastructure, human resources, National Tuberculosis Program functions, surveillance system performance, coordination, case findings, and data collection and notification. Regrettably, not all of the Tuberculosis Surveillance System’s objectives were successfully achieved in the past. Coordination of tuberculosis services has been repeatedly reported as inadequate. This deficiency manifests in the delay in diagnosing tuberculosis patients and, in some instances, misdiagnoses. The root cause is often traced back to insufficient knowledge of tuberculosis case definitions among healthcare providers at peripheral tuberculosis clinics. Additionally, a structured approach to active case finding is conspicuously absent. Furthermore, the tuberculosis management guidelines remain unfamiliar to many healthcare providers in tuberculosis centers, leaving them inadequately equipped to handle tuberculosis cases effectively. The utilization and analysis of the system’s data are also far from optimal. A glaring concern is the delay in tuberculosis case notifications received from the stakeholders involved in the Tuberculosis Surveillance System. Conclusions: Our study showed different gaps in the National Tuberculosis Program and Tuberculosis Surveillance Systems across several areas. The structure of National Tuberculosis Program and the clinical expertise of human resources do not support tuberculosis elimination. An electronic data collection and notification system is essential to facilitate tuberculosis case detection, reporting, and follow-up. Decision-makers should push the tuberculosis epidemic on the national health agenda. Jordan should focus on allocating national and international resources for tuberculosis control programs.

Many patients with tuberculosis (TB) have comorbidities, risk determinants and disability that co-exist at diagnosis, during and after TB treatment. We conducted an observational cohort study in 11 health facilities in China to assess under routine program conditions (i) the burden of these problems at the start and end of TB treatment and (ii) whether referral mechanisms for further care were functional. There were 603 patients registered with drug-susceptible TB who started TB treatment: 84% were symptomatic, 14% had diabetes, 14% had high blood pressure, 19% smoked cigarettes, 10% drank excess alcohol and in 45% the 6 min walking test (6MWT) was abnormal. Five patients were identified with mental health disorders. There were 586 (97%) patients who successfully completed TB treatment six months later. Of these, 18% were still symptomatic, 12% had diabetes (the remainder with diabetes failed to complete treatment), 5% had high blood pressure, 5% smoked cigarettes, 1% drank excess alcohol and 25% had an abnormal 6MWT. Referral mechanisms for the care of comorbidities and determinants worked well except for mental health and pulmonary rehabilitation for disability. There is need for more programmatic-related studies in other countries to build the evidence base for care of TB-related conditions and disability.