Short CommunicationInvolving community partners in the management of tuberculosis among drug users
Introduction
In Portugal, the incidence of tuberculosis (TB) remains the highest in Western Europe, despite the decrease from 66.4 to 25.3 per 100,000 individuals from 1985 to 2008.1 The strong association between TB and drug use is well known, and 15% of TB patients diagnosed in 2008 were active drug users.1
The major challenges faced by the healthcare system when dealing with drug users with TB are late diagnosis, low compliance with treatment, and treatment abandonment.1 These problems were found in Vila Nova de Gaia at the end of 2003, with almost half of drug users with TB showing low compliance and one-third dropping out of treatment. An intervention based on the joint efforts of multiple local partners and stakeholders was designed to improve early identification and treatment of drug users with TB.
The intervention was implemented in the city of Vila Nova de Gaia (population 290,000) in Porto Metropolitan Area. In the last decade, this area has constantly demonstrated the highest incidence of TB in Portugal (54.1/100,000 inhabitants in 2004; 1.7 times higher than the national incidence of TB).1
There are no reliable data on the number of drug users in Vila Nova de Gaia. In Portugal, the estimated prevalence of injecting drug users aged 15–64 years ranges between 4.3 and 6.4 per 1000 inhabitants.2 Assuming these national rates, the expected number of injecting drug users in Vila Nova de Gaia can be estimated to be between 1247 and 1856.
The key partners in the intervention were the outpatient TB clinic (a chest disease centre – CDP), drug users’ support centres, shelters and street teams that care for and support drug users in the community, the local public health department and the local hospital. Five of the seven eligible institutions for harm reduction and treatment (one public and four private) agreed to take part.
Before the intervention, the general strategy was as follows. Drug users were referred to the CDP with a diagnosis of TB, generally after discharge from hospital. Treatment was not compulsory, and the measures to improve compliance were: provision of information about the disease and necessary treatment to the patient and family, psychosocial support, full treatment, transport and breakfast free of charge.
Although drug users are mentioned in the national TB programme as a risk group for TB that should be screened, there is no active screening policy for this group.
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Design and implementation of the intervention
In 2004, a consulting board with representatives from all involved institutions was created to provide advice on policies and promote networking. Regular meetings of the involved staff were held to standardize TB screening and TB treatment compliance methods according to national guidelines.3
During 2004, the key partners were trained in TB treatment and screening, counselling, negotiation skills and referral. All key partners identified injecting drug users in their population. The first part
Data
Screening and treatment records for all drug users visiting the CDP between 2001 and 2007 were reviewed. Data were gathered regarding diagnoses of active and latent TB, treatment compliance and treatment abandonment for before (2001–2003) and after (2005–2007) the intervention. Odds ratios (OR) and 95% confidence intervals (CI) were used to measure the strength of associations.
Study definitions
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Active TB: diagnosis based on culture and identification of Mycobacterium tuberculosis or clinical and radiological criteria.
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Latent TB: asymptomatic individuals with normal chest radiography and positive TST (TST > 5 mm in immunocompromised persons, TST > 10 mm in immunocompetent persons).
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Treatment success: cure (i.e., negative cultures) or completion of treatment without bacteriological evidence of cure.
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Treatment abandonment: cases in which treatment was interrupted for more than 2 months.
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Results
Between 2001 and 2003, 125 drug users were observed in the CDP. 52 drug users were screened for TB (100% male, mean age 32 years); 73 were referred to the CDP because of complaints or following discharge from hospital with a diagnosis of TB. From 2005 to 2007, 465 drug users were screened (86% male, mean age 36 years); 30 were referred to the CDP because of complaints or following discharge from hospital with a diagnosis of TB. The percentage of drug users screened without any symptoms
Discussion
TB and drug abuse are major public health issues in Portugal, and there is a need to improve case identification and cure rates. Community involvement with the creation of multi-institutional networks can be viewed as an effective alternative to conventional management. Four years after the inception of a programme designed to involve multiple stakeholders in a comprehensive approach to this health problem, the number of screened drug users had increased, therapy was available to a higher
Study limitations
This study has some potential weakness. First, the before-and-after nature of the analysis in the absence of a controlled trial setting may have led to specific biases. Although the precise contribution of each action is impossible to determine, the findings suggest that such a programmatic approach can be a strategic element to improve treatment compliance among TB patients that use drugs.
Ethical approval
Screening was offered as part of the National Programme Guidelines published by the National Health Department and published in the Portuguese official journal of legal acts. It was approved by the CDP de Vila Nova de Gaia body.
Funding
None declared.
Competing interests
None declared.
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From contact investigation to tuberculosis screening of drug users and homeless persons in Rotterdam
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