Browsing by Author "Handel, Andreas"
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Item Effectiveness of WHO’s pragmatic screening algorithm for child contacts of tuberculosis cases in resource-constrained settings: a prospective cohort study in Uganda(Lancet Respir Med, 2017) Martinez, Leonardo; Shen, Ye; Handel, Andreas; Chakraburty, Srijita; Stein, Catherine M; Malone, LaShaunda L; Boom, Henry; Quinn, Frederick D; Joloba, Moses L; Whalen, Christopher C; Zalwango, SarahBackground Tuberculosis is a leading cause of global childhood mortality; however, interventions to detect undiagnosed tuberculosis in children are underused. Child contact tracing has been widely recommended but poorly implemented in resource-constrained settings. WHO has proposed a pragmatic screening approach for managing child contacts. We assessed the effectiveness of this screening approach and alternative symptom-based algorithms in identifying secondary tuberculosis in a prospectively followed cohort of Ugandan child contacts. Methods We identified index patients aged at least 18 years with microbiologically confirmed pulmonary tuberculosis at Old Mulago Hospital (Kampala, Uganda) between Oct 1, 1995, and Dec 31, 2008. Households of index patients were visited by fieldworkers within 2 weeks of diagnosis. Coprevalent and incident tuberculosis were assessed in household contacts through clinical, radiographical, and microbiological examinations for 2 years. Disease rates were compared among children younger than 16 years with and without symptoms included in the WHO pragmatic guideline (presence of haemoptysis, fever, chronic cough, weight loss, night sweats, and poor appetite). Symptoms could be of any duration, except cough (>21 days) and fever (>14 days). A modified WHO decision-tree designed to detect high-risk asymptomatic child contacts was also assessed, in which all asymptomatic contacts were classified as high risk (children younger than 3 years or immunocompromised [HIV-infected]) or low risk (aged 3 years or older and immunocompetent [HIV-negative]). We also assessed a more restrictive algorithm (ie, assessing only children with presence of chronic cough and one other tuberculosis-related symptom). Findings Of 1718 household child contacts, 126 (7%) had coprevalent tuberculosis and 24 (1%) developed incident tuberculosis, diagnosed over the 2-year study period. Of these 150 cases of tuberculosis, 95 (63%) were microbiologically confirmed with a positive sputum culture. Using the WHO approach, 364 (21%) of 1718 child contacts had at least one tuberculosis-related symptom and 85 (23%) were identified as having coprevalent tuberculosis, 67% of all coprevalent cases detected (diagnostic odds ratio 9·8, 95% CI 6·8–14·5; p<0·0001). 1354 (79%) of 1718 child contacts had no symptoms, of whom 41 (3%) had coprevalent tuberculosis. The WHO approach was effective in contacts younger than 5 years: 70 (33%) of 211 symptomatic contacts had coprevalent disease compared with 23 (6%) of 367 asymptomatic contacts (p<0·0001). This approach was also effective in contacts aged 5 years and older: 15 (10%) of 153 symptomatic contacts had coprevalent disease compared with 18 (2%) of 987 asymptomatic contacts (p<0·0001). More coprevalent disease was detected in child contacts recommended for screening when the study population was restricted by HIV-serostatus (11 [48%] of 23 symptomatic HIV-seropositive child contacts vs two [7%] of 31 asymptomatic HIV-seropositive child contacts) or to only cultureconfirmed cases (47 [13%] culture confirmed cases of 364 symptomatic child contacts vs 29 [2%] culture confirmed cases of 1354 asymptomatic child contacts). In the modified algorithm, high-risk asymptomatic child contacts were at increased risk for coprevalent disease versus low-risk asymptomatic contacts (14 [6%] of 224 vs 27 [2%] of 1130; p=0·0021). The presence of tuberculosis infection did not predict incident disease in either symptomatic or asymptomatic child contacts: in symptomatic contacts, eight (5%) of 169 infected contacts and six (5%) of 111 uninfected contacts developed incident tuberculosis (p=0·80).Item Four Degrees of Separation: Social Contacts and Health Providers Influence the Steps to Final Diagnosis of Active Tuberculosis Patients in Urban Uganda(BMC infectious diseases, 2015) Sekandi, Juliet N.; Zalwango, Sarah; Martinez, Leonardo; Handel, Andreas; Kakaire, Robert; Nkwata, Allan K.; Ezeamama, Amara E.; Kiwanuka, Noah; Whalen, Christopher C.Delay in tuberculosis (TB) diagnosis adversely affects patients’ outcomes and prolongs transmission in the community. The influence of social contacts on steps taken by active pulmonary TB patients to seek a diagnosis has not been well examined. Methods: A retrospective study design was use to enroll TB patients on treatment for 3 months or less and aged ≥18 years from 3 public clinics in Kampala, Uganda, from March to July 2014. Social network analysis was used to collect information about social contacts and health providers visited by patients to measure the number of steps and time between onset of symptoms and final diagnosis of TB. Results: Of 294 TB patients, 58 % were male and median age was 30 (IQR: 24–38) years. The median number of steps was 4 (IQR: 3, 7) corresponding to 70 (IQR: 28,140) days to diagnosis. New patients had more steps and time to diagnosis compared retreatment patients (5 vs. 3, P < 0.0001; 84 vs. 46 days P < 0.0001). Fifty-eight percent of patients first contacted persons in their social network. The first step to initiate seeking care accounted for 41 % of the patients’ time to diagnosis while visits to non-TB providers and TB providers (without a TB diagnosis) accounted for 34 % and 11 % respectively. New TB patients vs. retreatment (HR: 0.66, 95 % CI; 1.11, 1.99), those who first contacted a non-TB health provider vs. contacting social network (HR: 0.72 95 % CI; 0.55, 0.95) and HIV seronegative vs. seropositive patients (HR: 0.70, 95 % CI; 0.53, 0.92) had a significantly lower likelihood of a timely final diagnosis. Conclusions: There were four degrees of separation between the onset of symptoms in a TB patient and a final diagnosis. Both social and provider networks of patients influenced the diagnostic pathways. Most delays occurred in the first step which represents decisions to seek help, and through interactions with non-TB health providers. TB control programs should strengthen education and active screening in the community and in health care settings to ensure timely diagnosis of TB.Item A prospective validation of a Clinical Algorithm to detect Tuberculosis in child contacts(American Thoracic Society, 2018) Zalwango, Sarah; Malone, LaShaunda; Stein, Catherine; Quinn, Frederick; Chakraburty, Srijita; Shen, Ye; Handel, Andreas; Martinez, LeonardoOver 60% of pediatric tuberculosis cases are undetected by healthcare services in low-income settings (1). Untreated children with tuberculosis have fatality rates of .20%, reaching above 40% in children ,5 years old (2). Specific, effective, and validated interventions to increase case detection in children are urgently needed.Item Validation of a Pictorial Survey Tool to Measure Time Use in an African Urban Setting(Sage publication, 2019) Schwartz, Lauren M.; Mutanga, Jane; Kakaire, Robert; Davis-Olwell, Paula; Handel, Andreas; Sekandi, Juliet; Halloran, Elizabeth M.; Kiwanuka, Noah.; Zalwango, Sarah.; Whalen, Christopher C.Disease often depends on how a host interacts with his or her environment. This interaction is important for respiratory infectious diseases, where built environments may promote transmission. To learn about time use, or the amount of time people spend in a day doing various activities,in sub-Saharan Africa may be difficult because of low literacy and different cultural perceptions of time. We developed a culturally appropriate survey tool to measure time use called the mweso game. Method: Three cross sectional studies were performed among adults in Kampala, Uganda, to evaluate criterion and construct validity and to assess reliability of the mweso game. The mweso game was compared to actual elapsed time, a detailed 24-hr recall survey, and between three different recall periods. In all analyses, the mean number of beads, or hours, was calculated; Pearson correlation coefficients and Cronbach’s a were estimated. Results: Criterion validity for the use of beads to measure time was fair; mean values tended to be accurate, but there was variability in estimates of time across participants. When comparing the mweso game to the 24-hr recall survey, construct validity was very good. For most of the settings, the difference between measurements was less than one hour; there was good to excellent correlation for most settings. Reliability and internal consistency were best for time use at home and work. Conclusions: We have developed the mweso game as an instrument to measure time use in the context of low literacy and different cultural perceptions of time. The mweso game was valid and reliable, especially for measuring time use at home and work. With further validation, it may prove useful in measuring time use and in studying its relation to transmission of respiratory infectious diseases.