Background
Tuberculosis in displaced communities
TB & Syrian refugees in Jordan
Objectives
Methods
Study participants & data collection
Definitions
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Index case (IC) is defined as any PTB case among the Syrian refugee population treated within a NTP centre in Jordan. Cases of extra-pulmonary TB (EPTB) were excluded.
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Contact is defined as “a person who shared the same enclosed living space for one or more nights or for frequent or extended periods during the day with the IC during the 3 months before commencement of the current treatment episode” [16].
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LTBI is defined as having evidence of M. tuberculosis infection by immunologic tests (Tuberculin Skin Test (TST) > 10 mm after 48–72 h in both children and adults) in a patient in whom active TB was excluded.
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Active TB case is defined either as bacteriologically confirmed TB (whereby a biological specimen was positive by smear microscopy (Ziehl-Neelsen stain) or culture) or clinically diagnosed TB (whereby the criteria for bacteriological confirmation are not fulfilled but the following three clinical conditions are present: cough for more than three weeks; no response to non-TB antibiotics and a chest radiograph compatible with TB). PTB and EPTB cases in contacts were considered when calculating active TB prevalence in this group.
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The female caregiver category includes mothers, grandmothers and aunts, often involved in daily childcare in the Middle East.
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Previous TB history in the family is defined as having another member of the family who developed active PTB in the past two years but who is currently not living in the same household as the IC.
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Median time interval between diagnosis and screening was defined as the number of days between the diagnosis of PTB in the IC and the contact's first medical consult.
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Performance indicators were defined using the objectives for CT programs recommended by the Centre for Disease Control and Prevention (CDC) (Table 5).
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Regarding treatment outcomes, we used the following definitions [17]:
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Cured: A pulmonary TB patient with bacteriologically confirmed TB at the beginning of treatment who was smear- or culture-negative in the last month of treatment and on at least one previous occasion.
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Treatment completed: A TB patient who completed treatment without evidence of failure but with no record to show that sputum smear or culture results in the last month of treatment and on at least one previous occasion were negative, either because tests were not done or because results are unavailable.
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Not evaluated: A TB patient for whom no treatment outcome is assigned. This includes cases “transferred out” to another treatment unit as well as cases for whom the treatment outcome is unknown to the reporting unit.
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Statistical methods
Results
Screening tests
IC characteristics | Male | Female | All |
---|---|---|---|
Total | 52 | 24 | 76 |
Mean age (years) | 39.8 | 34.2 | 38 |
N (% of all IC) | N (% of all IC) | N (% of all IC) | |
Previous history | |||
Familial | 8 (10.5) | 4(5.3) | 12 (15.8) |
Personal | 9(11.8) | 2(2.6) | 11(14.5) |
Familial + Personal | 2(2.6) | 3 (3.9) | 5(6.6) |
None | 33 (43.4) | 15(19.7) | 48 (63.2) |
PPD | |||
Positive | 10 (13.2) | 1 (1.3) | 11 (14.5) |
Negative | 2(2.6) | 1 (1.3) | 3(3.9) |
Unknown | 40 (52.6) | 22 (28.9) | 62 (81.6) |
Sputum | |||
Positive | 21 (27.6) | 11 (14.5) | 32(42.1) |
Negative | 30 (39.5) | 13 (17.1) | 43 (56.6) |
Unknown | 1 (1.3) | 0 | 1 (1.3) |
Culture | |||
Positive | 20 (26.3) | 10 (13.2) | 30 (39.5) |
Negative | 21(27.6) | 8 (10.5) | 29 (38.2) |
MOTT | 0 | 1 (1.3) | 1 (1.3) |
Unknown/Not performed | 11 (14.5) | 5 (6.6) | 16 (21.1) |
Case finding | |||
Self-referred | 18(23.7) | 10 (13.2) | 28 (36.8) |
Referred from private sector | 8 (10.5) | 3 (3.9) | 11 (14.5) |
Referred from public sector | 8 (10.5) | 3 (3.9) | 11 (14.5) |
Active case finding (IOM) | 18(23.7) | 8 (10.5) | 26(34.2) |
Outcome | |||
Cured | 16 (21.1) | 6(7.9) | 22 (28.9) |
Died | 3(3.9) | 0 | 3(3.9) |
Lost to follow-up | 2(2.6) | 0 | 2(2.6) |
Treatment completed | 20 (26.3) | 13 (17.1) | 33 (43.4) |
Under treatment | 11 (14.5) | 5 (6.6) | 16 (21.1) |
Symptoms at diagnosis | |||
Cough | 44(57.9) | 21 (27.6) | 65 (85.5) |
Sputum | 33 (43.4) | 14 (18.4) | 47(61.8) |
Fatigue | 33 (43.4) | 11 (14.5) | 44(57.9) |
Fever | 31 (40.8) | 16 (21.1) | 47 (61.8) |
Night sweats | 34(44.7) | 14 (18.4) | 48 (63.2) |
Loss of weight | 36 (47.4) | 13 (17.1) | 49 (64.5) |
Loss of appetite | 27 (35.5) | 13 (17.1) | 40 (52.6) |
Chest pain | 23 (30.3) | 8(10.5) | 31(40.8) |
Co-morbidities | |||
HIV | 0 | 0 | 0 |
Diabetes | 2 (2.6) | 4 (5.3) | 6 (7.9) |
Vaccination (BCG scar) | |||
Yes | 14 (18.4) | 7(9.2) | 21 (27.6) |
No | 5 (6.6) | 3(3.9) | 8 (10.5) |
Unknown | 33 (43.4) | 14 (18.4) | 47(61.8) |
Median number of contacts screened | 5 | 7 | 6 |
< 5 | 5 to 15 | > 15 | Not mentioned | All | |
---|---|---|---|---|---|
Gender | N (% of all contacts) | ||||
Male | 40 (8.3) | 74 (15.4) | 105(21.8) | 18(3.7) | 237 (49.3) |
Female | 36(7.5) | 60 (12.5) | 132(27.4) | 16 (3.3) | 244 (50.7) |
All | 76 (15.8) | 134 (27.9) | 237 (49.3) | 34(7.1) | 481 (100) |
Time from diagnosis to contact screening | |||||
Available data (N) | 54 | 83 | 126 | 16 | 279 |
Investigations performed before 120 days(%) | 43 (79.6) | 77 (92.8) | 109 (86.5) | 16 (100) | 245 (87.8) |
Median time interval in days | 12 | 7 | 6 | 4 | 7 |
Complementary exams performed | N (% among age group) | ||||
Nothing | 3 (3.9) | 8 (6.0) | 42 (17.7) | 6 (17.6) | 59 (12.3) |
CXR only | 12(15.8) | 36 (26.9) | 136(57.4) | 10 (29.4) | 194 (40.3) |
PPD only | 28 (36.8) | 39 (29.1) | 3 (1.3) | 2 (5.9) | 72 (15.0) |
CXR + PPD | 33 (43.4) | 51 (38.1) | 56 (23.6) | 16(47.1) | 156 (32.4) |
Total | 76 (100) | 134 (100) | 237(100) | 34 (100) | 481 (100) |
TST results | |||||
Not performed | 15 | 44 | 178 | 16 | 253 |
≤ 10 mm | 45 | 71 | 43 | 14 | 173 |
> 10 mm | 16 | 19 | 16 | 4 | 55 |
Active TB
Contacts of all IC | Contacts of Smear + IC only | |||||||
---|---|---|---|---|---|---|---|---|
All | < 5 | 5 to 15 | > 15 | All | < 5 | 5 to 15 | > 15 | |
All contacts (n) | 481 | 76 | 134 | 237 | 210 | 33 | 60 | 87 |
Active TB (%) (IC 95) | 2.1 (1.1-3.9) | 5.3 (1.7-13.7) | 0 | 2.5 (1.0-5.7) | 3.8 (1.8-7.6) | 9.1 (2.4-25.5) | 0 | 5.7 (2.1-13.4) |
PTB prevalence (%) (IC 95) | 1.6 (0.7-3.3) | 3.9 (1.0-11.8) | 0 | 2.1 (0.8-5.1) | 2.9 (1.2-6.5) | 6.1 (1.1-21.7) | 0 | 4.6 (1.5-12.0) |
EPTB prevalence (%) (IC 95) | 0.4 (0.1-1.6) | 1.3 (0.1-81) | 0 | 0.4 (0.0-2.7) | 1.0 (0.2-3.8) | 3.0 (0.2-17.5) | 0 | 1.1 (0.1-7.1) |
Contacts with TST result available (n) | 228 | 61 | 90 | 59 | 120 | 28 | 44 | 34 |
LTBI prevalence (%) (IC 95) | 24.1 (18.8-30.3) | 26.2 (16.1-39.3) | 21.1 (13.5-31.2) | 27.1 (16.7-40.5) | 37.5 (29.0-46.8) | 39.3 (22.1-59.3) | 40.9 (26.7-56.7) | 35.3 (20.3-53.5) |
LTBI
INH preventive therapy
Contacts diagnosed with LTBI | U5 s in contact with bacteriologically confirmed PTB | All contacts requiring prophylaxis | |||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
< 5 | 5-15 | > 15 | All | Any TST | TST - | < 5 | All | ||||||||
N | Under INH (%) | N | Under INH (%) | N | Under INH (%) | N | Under INH (%) | N | Under INH (%) | N | Under INH (%) | N | Under INH (%) | N | Under INH (%) |
16 | 15 (93,8) | 19 | 19 (100) | 16 | 14 (87,7) | 55 | 52 (94,5) | 31 | 16 (51,6) | 21 | 6 (28,6) | 36 | 21 (58,3) | 76 | 58 (76,6) |
Risk factors for LTBI
All N = 221 OR (CI95) | < 5y N = 57 OR (CI95) | 5-15y N = 90 OR (CI95) | 0-15y N = 147 OR (CI95) | > 15y N = 56 OR (CI95) | |
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IC characteristics | |||||
Gender (female) | 1.61(0.87-2.97) | 2.48(0.76-8.07) | 1.68(0.60-4.66) | 1.91(0.89-4.12) | 0.37(0.11-1.27) |
Personal History | 0.69(0.30-1.59) | 0.81(0.22-3.00) | 0.21(0.03-1.68) | 0.52(0.25-1.42) | 1.31(0.28-6.02) |
Family History | 4.94(2.58-9.48) | 3.81(1.11-13.09) | 21.71(5.55-85.00) | 9.66(3.95-23.64) | 0.61(0.18-2.10) |
Smear + | 6.33(298-13.41) | 4.24(1.23-14.64) | 31.15(3.93-247.08) | 8.7(3.33-22.73) | 3.32(0.91-12.05) |
Culture + | 6.99(3.29-14.84) | 3.81(1.11-13.09) | 26.07(3.29-206.30) | 7.47(2.87-19.46) | 3.32(0.91-12.05) |
Contact characteristics | |||||
Gender(Female) | 0.92(0.50-1.69) | 1.05(0.33-3.33) | 1.16(0.42-3.21) | 1.10(0.62-1.96) | 0.47(0.14-1.51) |
Age | |||||
< 5y | 1.25(0.63-2.47) | – | – | – | – |
5-15y | 0.71(0.37-1.33) | – | – | – | – |
0-15y | 0.84(0.45-1060) | – | – | – | – |
> 15 | 1.29(0.65-2.56) | – | – | – | – |
Relationship (IC is ...) | |||||
Father | – | 1.29(0.39-4.32) | 2.96(1.00-8.74) | 2.1(0.94-4.68) | – |
Mother | – | 1.88(0.51-6.94) | 1.05(0.33-3.33) | 1.32(0.56-3.11) | – |
Brother/sister | – | 0 | 0 | 0 | – |
Female caregiver | – | 3.11(0.94-10.27) | 2.83(1.00-8.00) | 2.97(1.36-6.48) | – |
Husband/Wife | – | – | – | – | 0.48(0.14-1.70) |
Son/Daughter | – | – | – | – | 0.57(0.09-3.76) |
Father/Mother | – | – | – | – | 1.06(0.30-3.69) |
All N = 221 OR (CI95) | <5y N = 57 OR (CI95) | 5-15y N = 90 OR (CI95) | 0-15y N = 147 OR (CI95) | |
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IC characteristics | ||||
Family History | 4.38(1.96-9.82) | 3.24(0.76-13.82) | 9.49(2.14-42.17) | 6.35(2.39-16.90) |
Smear + | 6.01(2.44-14.79) | 9.69(0.87-107.7) | 16.89(1.37-208.1) | 7.1(1.94-25.96) |
Relationship | ||||
Female caregiver | – | 1.65(0.42-6.44) | 2.84(0.67-12.12) | 2.00(0.78-5.16) |
Discussion
Prevalence of active TB
Risk factors for LTBI
Performance indicators
Key Indicator | Objective | Jordan |
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Proportion of infectious patients with at least one contact listed | 90% | 93.4% |
Proportion of contacts who are evaluated for TB and LTBI | 90% | 87.7% |
Proportion of contacts of contact investigations concluded within 3-4 months after the diagnosis of the index patient | 80% | 87.8% |
Proportion of infected contacts who begin preventive therapy for LTBI | 85% | 94.5% |
Limitations
Conclusions and recommendations
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Assessment of risk factors (including malnutrition, HIV infection and BCG vaccination) for active TB and LTBI in refugee populations with higher TB incidence.
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Cost effectiveness of contact screening programs in refugee populations.
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Symptom-based CT programs assessment in displacement settings, including evaluation of physicians’ clinical evaluation accuracy.
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INH preventive therapy indications and efficiency in displacement situations.
Acknowledgements
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Pandora Kodrou for her assistance in statistical calculations
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Zeina Kaladji and Raed Qarajeh, involved in data collection in Jordan