Browsing by Author "Nalugwa, Talemwa"
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Item Challenges with scale-up of GeneXpert MTB/RIF® in Uganda: a health systems perspective(BMC health services research, 2020) Nalugwa, Talemwa; Shete, Priya B.; Nantale, Mariam; Farr, Katherine; Ojok, Christopher; Ochom, Emma; Mugabe, Frank; Joloba, Moses; Dowdy, David W.; Moore, David A. J.; Davis, J. Lucian; Cattamanchi, Adithya; Katamba, AchillesMany high burden countries are scaling-up GeneXpert® MTB/RIF (Xpert) testing for tuberculosis (TB) using a hub-and-spoke model. However, the effect of scale up on reducing TB has been limited. We sought to characterize variation in implementation of referral-based Xpert TB testing across Uganda, and to identify health system factors that may enhance or prevent high-quality implementation of Xpert testing services. Methods: We conducted a cross-sectional study triangulating quantitative and qualitative data sources at 23 community health centers linked to one of 15 Xpert testing sites between November 2016 and May 2017 to assess health systems infrastructure for hub-and-spoke Xpert testing. Data sources included a standardized site assessment survey, routine TB notification data, and field notes from site visits. Results: Challenges with Xpert implementation occurred at every step of the diagnostic evaluation process, leading to low overall uptake of testing. Of 2192 patients eligible for TB testing, only 574 (26%) who initiated testing were referred for Xpert testing. Of those, 54 (9.4%) were Xpert confirmed positive just under half initiated treatment within 14 days (n = 25, 46%). Gaps in required infrastructure at 23 community health centers to support the huband- spoke system included lack of refrigeration (n = 14, 61%) for sputum testing and lack of telephone/mobile communication (n = 21, 91%). Motorcycle riders responsible for transporting sputum to Xpert sites operated variable with trips once, twice, or three times a week at 10 (43%), nine (39%) and four (17%) health centers, respectively. Staff recorded Xpert results in the TB laboratory register at only one health center and called patients with positive results at only two health centers. Of the 15 Xpert testing sites, five (33%) had at least one non-functioning module. The median number of tests per day was 3.57 (IQR 2.06–4.54), and 10 (67%) sites had error/invalid rates > 5%. Conclusions: Although Xpert devices are now widely distributed throughout Uganda, health system factors across the continuum from test referral to results reporting and treatment initiation preclude effective implementation of Xpert testing for patients presenting to peripheral health centers. Support for scale up of innovative technologies should include support for communication, coordination and health systems integration.Item Design and execution of a public randomization ceremony to enhance stakeholder engagement within a cluster randomized trial to improve tuberculosis diagnosis in Uganda(Contemporary clinical trials communications, 2021) Reza, Tania F.; Nalugwa, Talemwa; Nantale, Mariam; Adams, Katherine; Fielding, Katherine; Nakaweesa, Annet; Oyuku, Denis; Nabwire, Sarah; Musinguzi, Johnson; Ojok, Christopher; Babirye, Diana; Ackerman, Sara L.; Handley, Margaret A.; Kityamuwesi, Alex; Dowdy, David W.; Moore, David A.J.; Davis, J. Lucian; Turyahabwe, Stavia; Katamba, Achilles; Cattamanch, AdithyaPublic randomization ceremonies have been proposed as a strategy to strengthen stakeholder engagement and address concerns and misconceptions associated with trial randomization. However, there are few published examples that describe how to conduct a public randomization ceremony with meaningful stakeholder engagement or how such ceremonies impact stakeholder perceptions about randomization and the randomization process. Cluster randomization for the GeneXpert Performance Evaluation for Linkage to Tuberculosis Care (XPEL-TB) trial was conducted at a public randomization ceremony attended by 70 stakeholders in Kampala, Uganda. Presentations given by the Acting Assistant Commissioner from the Uganda National Tuberculosis and Leprosy Programme and trial investigators emphasized how the trial aimed to further national TB goals, as well as how stakeholders contributed to the intervention design. The purpose and process of randomization were described using simple text and visuals. Randomization was an interactive activity that required participation of stakeholders from each trial site. A survey administered to stakeholders at the end of the ceremony suggested high comprehension of randomization (98%), trust in the randomization process (96%), and satisfaction with randomization outcomes (96%). Public randomization ceremonies should be considered more routinely to engage stakeholders in and address potential concerns about the fairness and impartiality of the randomization process for community-based trials.Item Experiences and intentions of Ugandan household tuberculosis contacts receiving test results via text message: an exploratory study(BMC public health, 2020) Ggita, Joseph M.; Katahoire, Anne; Meyer, Amanda J.; Nansubuga, Elizabeth; Nalugwa, Talemwa; Turimumahoro, Patricia; Ochom, Emmanuel; Ayakaka, Irene; Haberer, Jessica E.; Katamba, Achilles; Armstrong-Hough, Mari; Davis, J. LucianThe World Health Organization (WHO) recommends household contact investigation for tuberculosis (TB) in high-burden countries. However, household contacts who complete evaluation for TB during contact investigation may have difficulty accessing their test results. Use of automated short-messaging services (SMS) to deliver test results could improve TB status awareness and linkage to care. We sought to explore how household contacts experience test results delivered via SMS, and how these experiences influence follow-up intentions. Methods: We conducted semi-structured interviews with household contacts who participated in a randomized controlled trial evaluating home sputum collection and delivery of TB results via SMS (Pan-African Clinical Trials Registry #201509000877140). We asked about feelings, beliefs, decisions, and behaviors in response to the SMS results. We analyzed the content and emerging themes in relation to the Theory of Planned Behavior. Results: We interviewed and achieved thematic saturation with ten household contacts. Nine received TB-negative results and one a TB-positive result. Household contacts reported relief upon receiving SMS confirming their TB status, but also said they lacked confidence in the results delivered by SMS. Some worried that negative results were incorrect until they spoke to a lay health worker (LHW). Household contacts said their long-term intentions to request help or seek care were influenced by perceived consequences of not observing the LHW’s instructions related to the SMS and follow-up procedures; beliefs about the curability of TB; anticipated support from LHWs; and perceived barriers to responding to an SMS request for further evaluation. Conclusion: Household contacts experienced relief when they received results. However, they were less confident about results delivered via SMS than results delivered by LHWs. Delivery of results by SMS should complement continued interaction with LHWs, not replace them.Item Feasibility of a short message service (SMS) intervention to deliver tuberculosis testing results in peri-urban and rural Uganda(Journal of clinical tuberculosis and other mycobacterial diseases, 2019) Babirye, Diana; Shete, Priya B.; Farr, Katherine; Nalugwa, Talemwa; Ojok, Christopher; Nantale, Mariam; Oyuku, Denis; Ayakaka, Irene; Katamba, Achilles; Davis, J. Lucian; Nadunga, Diana; Joloba, Moses; Moore, David; Cattamanchi, AdithyaPre-treatment loss to follow-up is common for patients diagnosed with tuberculosis (TB) in highburden countries. Delivering test results by Short-Messaging-Service (SMS) is increasingly being considered as a solution, but there is limited information about its feasibility as a public health tool in low resourced settings. Objective: We sought to assess the feasibility of utilizing SMS technology to deliver TB test results during routine TB diagnostic evaluation in Uganda. Methods: We conducted a single arm interventional pilot study at four community health centers in Uganda that referred sputum samples to a district hospital for GeneXpert-MTB/RIF (Xpert) testing (Cepheid, USA). Using existing GxAlert-software (SystemOne,USA), we set up an automated SMS platform to send Xpert results to patients and referring health centers. We assessed each step of the SMS delivery cascade for consecutive patients who presented to these four community health centers between December 2015 and March 2016 and underwent Xpert testing. Results: Of 233 patients enrolled, 161 (69%) had phone numbers recorded on individual Xpert referral forms. Phone numbers were entered into Xpert device software in the correct format for 152 (94%) patients. GxAlertsoftware generated an automated SMS reporting Xpert results for 151 (99%) patients and delivered it successfully to mobile phone service providers for 145/151 (96%). Of the 123 patients reached by phone to determine receipt of test results, 114 (93%) confirmed SMS receipt. SMS-based delivery of Xpert results was verified for 114/233 (49%) patients overall. In contrast, phone calls to health centers confirmed that health centers received messages for 222/233 (95%) patients. Conclusion: Reporting Xpert results via automated SMS is technically feasible and results in approximately half of patients receiving their test results immediately. Additional research should be done to address process inefficiencies in order to maximize impact of this technology and link its successful utilization to improved patient outcomes.Item Is aggregated surveillance data a reliable method for constructing tuberculosis care cascades? A secondary data analysis from Uganda(PLOS Glob Public Health, 2021) White, Elizabeth B.; Hernandez-Ramırez, Raul U.; Kaos Majwala, Robert; Nalugwa, Talemwa; Reza, Tania; Cattamanchi, Adithya; Katamba, Achilles; Davis, J. LucianTo accelerate tuberculosis (TB) control and elimination, reliable data is needed to improve the quality of TB care. We assessed agreement between a surveillance dataset routinely collected for Uganda’s national TB program and a high-fidelity dataset collected from the same source documents for a research study from 32 health facilities in 2017 and 2019 for six measurements: 1) Smear-positive and 2) GeneXpert-positive diagnoses, 3) bacteriologically confirmed and 4) clinically diagnosed treatment initiations, and the number of people initiating TB treatment who were also 5) living with HIV or 6) taking antiretroviral therapy. We measured agreement as the average difference between the two methods, expressed as the average ratio of the surveillance counts to the research data counts, its 95% limits of agreement (LOA), and the concordance correlation coefficient. We used linear mixed models to investigate whether agreement changed over time or was associated with facility characteristics. We found good overall agreement with some variation in the expected facilitylevel agreement for the number of smear positive diagnoses (average ratio [95% LOA]: 1.04 [0.38–2.82]; CCC: 0.78), bacteriologically confirmed treatment initiations (1.07 [0.67–1.70]; 0.82), and people living with HIV (1.11 [0.51–2.41]; 0.82). Agreement was poor for Xpert positives, with surveillance data undercounting relative to research data (0.45 [0.099–2.07]; 0.36). Although surveillance data overcounted relative to research data for clinically diagnosed treatment initiations (1.52 [0.71–3.26]) and number of people taking antiretroviral therapy (1.71 [0.71–4.12]), their agreement as assessed by CCC was not poor (0.82 and 0.62, respectively). Average agreement was similar across study years for all six measurements, but facility-level agreement varied from year to year and was not explained by facility characteristics. In conclusion, the agreement of TB surveillance data with high-fidelity research data was highly variable across measurements and facilities. To advance the use of routine TB data as a quality improvement tool, future research should elucidate and address reasons for variability in its quality.Item New Manual Quantitative Polymerase Chain Reaction Assay Validated on Tongue Swabs Collected and Processed in Uganda Shows Sensitivity That Rivals Sputum-based Molecular Tuberculosis Diagnostics(Clinical Infectious Diseases, 2024-02-02) Steadman, Amy; Andama, Alfred; Ball, Alexey; Mukwatamundu, Job; Khimani, Khushboo;; Mochizuki, Tessa; Asege, Lucy; Bukirwa, Alice; Kato, John Baptist; Katumba, David; Kisakye, Esther; Mangeni, Wilson; Mwebe, Sandra; Nakaye, Martha; Nassuna, Irene; Nyawere, Justine; Nakaweesa, Annet; Cook, Catherine; Phillips, Patrick; Nalugwa, Talemwa; Bachman, Christine M; Semitala, Fred Collins; Weigl, Bernhard H; Connelly, John; Worodria, William; Cattamanchi, AdithyaBACKGROUNDSputum-based testing is a barrier to increasing access to molecular diagnostics for tuberculosis (TB). Many people with TB are unable to produce sputum, and sputum processing increases assay complexity and cost. Tongue swabs are emerging as an alternative to sputum, but performance limits are uncertain.METHODSFrom June 2022 to July 2023, we enrolled 397 consecutive adults with cough >2 weeks at 2 health centers in Kampala, Uganda. We collected demographic and clinical information, sputum for TB testing (Xpert MTB/RIF Ultra and 2 liquid cultures), and tongue swabs for same-day quantitative polymerase chain reaction (qPCR) testing. We evaluated tongue swab qPCR diagnostic accuracy versus sputum TB test results, quantified TB targets per swab, assessed the impact of serial swabbing, and compared 2 swab types (Copan FLOQSWAB and Steripack spun polyester).RESULTSAmong 397 participants, 43.1% were female, median age was 33 years, 23.5% were diagnosed with human immunodeficiency virus, and 32.0% had confirmed TB. Sputum Xpert Ultra and tongue swab qPCR results were concordant for 98.2% (95% confidence interval [CI]: 96.2-99.1) of participants. Tongue swab qPCR sensitivity was 92.6% (95% CI: 86.5 to 96.0) and specificity was 99.1% (95% CI: 96.9 to 99.8) versus microbiological reference standard. A single tongue swab recovered a 7-log range of TB copies, with a decreasing recovery trend among 4 serial swabs. Swab types performed equivalently.CONCLUSIONSTongue swabs are a promising alternative to sputum for molecular diagnosis of TB, with sensitivity approaching sputum-based molecular tests. Our results provide valuable insights for developing successful tongue swab-based TB diagnostics. MEDLINE - AcademicItem Patient Perspectives and Willingness to Accept Incentives for Tuberculosis Diagnostic Evaluation in Uganda(Value in Health Regional Issues, 2021) Kadota, Jillian L.; Nabwire, Sarah; Nalugwa, Talemwa; White, Justin S.; Cattamanchi, Adithya; Katamba, Achilles; Shete, Priya B.We assessed attitudes and perceptions and willingness to accept (WTA) varying incentive structures for completing tuberculosis (TB) diagnostic evaluation among patients in Uganda. Methods:We surveyed 177 adult patients undergoing TB evaluation at 10 health centers between September 2018 and March 2019. We collected household sociodemographic information and assessed attitudes and perceptions of incentives. We surveyed patients regarding their willingness to complete TB diagnostic evaluation in exchange for incentives ranging in value from 500 Ugandan shillings (USh) to 25 000USh (~$0.15-$6.75). We compared associations between WTA and patient characteristics using ordered logistic regression. Results: Participant willingness to return to the health center to complete TB diagnostic evaluation increased proportionally with incentive amount. The median participant accepted between 2000 and 5000 USh. Cash (52%) and transportation vouchers (34%) were the most popular incentive types. Half of respondents preferred unconditional incentives; for a multiday evaluation, 84% preferred conditioning incentive receipt upon returning to the health center. In multivariate models, we found the pairwise difference between the third and lowest income quartile (aOR = 2.38, 95% CI: 1.20-4.69; P = .01), younger age, and difficulty returning to the health center to be significantly associated with WTA higher incentive thresholds. Conclusions: In Uganda, incentives such as cash transfers or transportation vouchers are an acceptable intervention for facilitating adherence to TB diagnostic evaluation. Household income is associated with preferred incentive structure and amount, especially for those at the cusp of the poverty threshold who are more likely to prefer unconditional and higher valued incentives. Targeted and context-specific socioeconomic supports for at-risk patients are needed to optimize outcomes.Item Quality of care for patients evaluated for tuberculosis in the context of Xpert MTB/RIF scale-up(Journal of clinical tuberculosis and other mycobacterial diseases, 2019) Farra, Katherine; Nalugwa, Talemwa; Ojok, Christopher; Nantale, Mariam; Nabwire, Sarah; Oyuku, Denis; Shete, Priya B.; Han, Alvina H.; Fielding, Katherine; Joloba, Moses; Mugabe, Frank; Dowdy, David W.; Mooreh, DAJ; Davis, Lucian; Katamba, Achilles; Cattamanchi, AdithyaMany high-burden countries are scaling-up Xpert MTB/RIF using a hub-and-spoke model. We evaluated the quality of care for patients undergoing TB evaluation at microscopy centers (spokes) linked to Xpert testing sites (hubs) in Uganda. Objectives: To characterize the extent to which patients were receiving care in accordance with international and national guidelines. Methods: We conducted a prospective cohort study of all adults with presumptive pulmonary TB at 24 health centers linked to Xpert testing sites. Health center staff photographed TB registers, and uploaded photos to a secure server bi-weekly. We assessed the proportion of patients (1) initiating testing; (2) completing testing; and (3) treated for confirmed TB within 14 days. Measurements and Main Results: Between January to December 2017, 6744 patients underwent evaluation for pulmonary TB. Only 1316 patients had sputum referred for Xpert testing, including 1075/3229 (33.3%) people living with HIV and 241/3515 (6.9%) without HIV. Of 119 patients confirmed to have TB by Xpert testing, 44 (36%) did not initiate treatment. There were significant losses along the entire diagnostic cascade of care, with only 5330/6744 (79.0%) patients having samples referred for sputum-based testing, 2978/5330 (55.9%) patients completing recommended testing if referred, and 313/418 (74.9%) patients initiating treatment within 14 days if confirmed to have TB. Conclusions: Although coverage of Xpert testing services across Uganda is high, the quality of care delivered to patients undergoing TB evaluation remains poor. Further research is needed to identify health system interventions to facilitate uptake of Xpert testing and high-quality care.Item Readiness to implement on-site molecular testing for tuberculosis in community health centers in Uganda(Implementation Science Communications, 2022) Nalugwa, Talemwa; Handley, Margaret; Shete, Priya; Ojok, Christopher; Nantale, Mariam; Reza, Tania; Katamba, Achilles; Cattamanchi, Adithya; Ackerman, SaraNewer molecular testing platforms are now available for deployment at lower-level community health centers. There are limited data on facility- and health worker-level factors that would promote successful adoption of such platforms for rapid tuberculosis (TB) testing and treatment initiation. Our study aimed to assess readiness to implement onsite molecular testing at community health centers in Uganda, a high TB burden country in sub-Saharan Africa. Methods: To understand implementation readiness, we conducted a qualitative assessment guided by the Consolidated Framework for Implementation Research (CFIR) at 6 community health centers in central and eastern Uganda between February and April 2018. We conducted 23 in-depth, semi-structured interviews with health workers involved in TB care at each health center to assess TB-related work practices and readiness to adopt onsite molecular testing using the GeneXpert Edge platform. Interviews were transcribed verbatim and coded for thematic analysis. Results: Participants (N=23) included 6 nurses/nursing assistants, 6 clinicians, 6 laboratory directors/technicians, 1 medical officer, 2 health center directors, and 2 other health workers involved in TB care. Health workers described general enthusiasm that on-site molecular testing could lead to greater efficiencies in TB diagnosis and treatment, including faster turn- around time for TB test results, lack of need for trained laboratory technicians to interpret results, and reduced need to transport sputum specimens to higher level facilities. However, health workers also expressed concerns about implementation feasibility. These included uncertainty about TB infection risk, safety risks from disposal of hazardous waste, a lack of local capacity to provide timely troubleshooting and maintenance services, and concerns about the security of GeneXpert devices and accessories. Health workers also expressed the need for backup batteries to support testing or charging when wall power is unstable. Conclusion: Our study generated a nuanced understanding of modifiable contextual barriers and led to direct revisions of implementation strategies for onsite molecular testing. The findings highlight that novel diagnostics should be implemented along with health system co-interventions that address contextual barriers to their effective uptake. Pre-implementation assessment of stakeholder perspectives, collaborative work processes, and institutional contexts is essential when introducing innovative technology in complex health care settings.Item Where will it end? Pathways to care and catastrophic costs following negative TB evaluation in Uganda(PLoS ONE, 2021) Samuels, Thomas H. A.; Shete, Priya B.; Ojok, Chris; Nalugwa, Talemwa; Farr, Katherine; Turyahabwe, Stavia; Katamba, Achilles; Cattamanchi, Adithya; Moore, David A. J.Catastrophic costs incurred by tuberculosis (TB) patients have received considerable attention, however little is known about costs and pathways to care after a negative TB evaluation. Materials and methods We conducted a cross-sectional study of 70 patients with a negative TB evaluation at four community health centres in rural and peri-urban Uganda. Patients were traced 9 months post-evaluation using contact information from TB registers. We collected information on healthcare visits and implemented locally-validated costing questionnaires to assess the financial impact of their symptoms post-evaluation. Results Of 70 participants, 57 (81%) were traced and 53 completed the survey. 31/53 (58%) surveyed participants returned to healthcare facilities post-evaluation, making a median of 2 visits each (interquartile range [IQR] 1–3). 11.3% (95%CI 4.3–23.0%) of surveyed patients and 16.1% (95%CI 5.5–33.7%) of those returning to healthcare facilities incurred catastrophic costs (i.e., spent >20% annual household income). Indirect costs related to lost work represented 80% (IQR 32–100%) of total participant costs. Conclusions Patients with TB symptoms who experience financial catastrophe after negative TB evaluation may represent a larger absolute number of patients than those suffering from costs due to TB. They may not be captured by existing definitions of non-TB catastrophic health expenditure.