Browsing by Author "Nicholson, Tom"
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Item Open Access Closing delivery gaps in the treatment of tuberculosis infection: Lessons from implementation research in Peru(PLOS ONE) Yuen, Courtney M; Millones, Ana Karina; Puma, Daniela; Jimenez, Judith; Galea, Jerome T; Calderon, Roger; Pages, Gabriela S; Brooks, Meredith B; Lecca, Leonid; Nicholson, Tom; Becerra, Mercedes C; Keshavjee, SalmaanBackground Targeted testing and treatment of TB infection to prevent disease is a pillar of TB elimination. Despite recent global commitments to greatly expand access to preventive treatment for TB infection, there remains a lack of research on how best to expand preventive treatment programs in settings with high TB burdens. Methods We conducted implementation research in Lima, Peru, around a multifaceted intervention to deliver TB preventive treatment to close contacts of all ages, health care workers, and people in congregate settings. Key interventions included use of the interferon gamma release assay (IGRA), specialist support for generalist physicians at primary-level health facilities, and treatment support by community health workers. We applied a convergent mixed methods approach to evaluate feasibility and acceptability based on a care cascade framework. Findings During April 2019-January 2020, we enrolled 1,002 household contacts, 148 non-household contacts, 107 residents and staff of congregate settings, and 357 health care workers. Cumulative completion of the TB preventive care cascade was 34% for contacts <5 years old, 28% for contacts 5–19 years old, 18% for contacts ≥20 years old, 0% for people in congregate settings, and 4% of health care workers. IGRA testing was acceptable to adults exposed to TB. Preventive treatment was acceptable to contacts, but less acceptable to physicians, who frequently had doubts about prescribing preventive treatment for adults. Community-based treatment support was both acceptable and feasible, and periodic home-visits or calls were identified as facilitators of adherence. Conclusions We attempted to close the gap in TB preventive treatment in Peru by expanding preventive services to adult contacts and other risk groups. While suboptimal, care cascade completion for adult contacts was consistent with what has been observed in high-income settings. The major losses in the care cascade occurred in completing evaluations and having doctors prescribe preventive treatment.Item Open Access Identifying barriers and facilitators to implementation of community-based tuberculosis active case finding with mobile X-ray units in Lima, Peru: a RE-AIM evaluation(BMJ Open, 2021-07) Yuen, Courtney M; Puma, Daniela; Millones, Ana Karina; Galea, Jerome T; Tzelios, Christine; Calderon, Roger I; Brooks, Meredith B; Jimenez, Judith; Contreras, Carmen; Nichols, Tim C; Nicholson, Tom; Lecca, Leonid; Becerra, Mercedes C; Keshavjee, SalmaanObjectivesIdentify barriers and facilitators to integrating community tuberculosis screening with mobile X-ray units into a health system.MethodsReach, effectiveness, adoption, implementation and maintenance evaluation.Setting3-district region of Lima, Peru.Participants63 899 people attended the mobile units from 7 February 2019 to 6 February 2020.InterventionsParticipants were screened by chest radiography, which was scored for abnormality by computer-aided detection. People with abnormal X-rays were evaluated clinically and by GeneXpert MTB/RIF (Xpert) sputum testing. People diagnosed with tuberculosis at the mobile unit were accompanied to health facilities for treatment initiation.Primary and secondary outcome measuresReach was defined as the percentage of the population of the three-district region that attended the mobile units. Effectiveness was defined as the change in tuberculosis case notifications over a historical baseline. Key implementation fidelity indicators were the percentages of people who had chest radiography performed, were evaluated clinically, had sputum samples collected, had valid Xpert results and initiated treatment.ResultsThe intervention reached 6% of the target population and was associated with an 11% (95% CI 6 to 16) increase in quarterly case notifications, adjusting for the increasing trend in notifications over the previous 3 years. Implementation indicators for screening, sputum collection and Xpert testing procedures all exceeded 85%. Only 82% of people diagnosed with tuberculosis at the mobile units received treatment; people with negative or trace Xpert results were less likely to receive treatment. Suboptimal treatment initiation was driven by health facility doctors’ lack of familiarity with Xpert and lack of confidence in diagnoses made at the mobile unit.ConclusionMobile X-ray units were a feasible and effective strategy to extend tuberculosis diagnostic services into communities and improve early case detection. Effective deployment however requires advance coordination among stakeholders and targeted provider training to ensure that people diagnosed with tuberculosis by new modalities receive prompt treatment.Item Open Access Integrated care as a means to improve primary care delivery for adults and adolescents in the developing world: a critical analysis of Integrated Management of Adolescent and Adult Illness (IMAI)(BMC Medicine, 2014-12) Vasan, Ashwin; Ellner, Andrew; Lawn, Stephen D; Gove, Sandy; Anatole, Manzi; Gupta, Neil; Drobac, Peter; Nicholson, Tom; Seung, Kwonjune; Mabey, David C; Farmer, Paul EItem Open Access Strengthening of primary-care delivery in the developing world: IMAI and the need for integrated models of care(The Lancet Global Health, 2013-12) Vasan, Ashwin; Ellner, Andrew; Lawn, Stephen D; Gupta, Neil; Anatole, Manzi; Drobac, Peter; Nicholson, Tom; Gove, Sandy; Seung, Kwonjune; Mabey, David; Farmer, Paul