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An Effective Health System Approach to End TB: Implementing the Double X Strategy in Vietnam

Anh L. Innes, Victoria Lebrun, Gia Linh Hoang, Andres Martinez, Nhi Dinh, Thi Thuy Ha Nguyen, Tan Phat Huynh, Van Luong Quach, Thanh Binh Nguyen, Van Chinh Trieu, Nghi Do Bao Tran, Huy Minh Pham, Van Luong Dinh, Binh Hoa Nguyen, Thi Thanh Huyen Truong, Van Cu Nguyen, Viet Nhung Nguyen and Thu Hien Mai
Global Health: Science and Practice June 2024, 12(3):e2400024; https://doi.org/10.9745/GHSP-D-24-00024

Figures & Tables

Figures

  • FIGURE 1
    FIGURE 1

    The 2X Health System Strategy to Screen and Diagnose TB Disease,a Vietnam

    Abbreviations: 2X, Double X; ACF, active case-finding; CXR, chest radiography; ICF, intensified case-finding; Xpert, GeneXpert; ±, with or without.

    a Facility-based ICF and community ACF reached a range of vulnerable populations, who were evaluated (with or without symptoms) followed by CXRs, and, if TB-presumptive, Xpert testing.

  • FIGURE 2
    FIGURE 2

    Algorithms for TB Disease and TB Infection Among Household Contacts, Vietnam

    Abbreviations: CXR, chest radiography, MTB, Mycobacterium TB; TST, tuberculin skin test; QFT, QuantiFERON-TB Gold Plus; Xpert, GeneXpert; (+), positive diagnostic test result.

  • Figure

    A man scans the quick-response code to complete a TB screening questionnaire in Tay Ninh province, 2022. © 2022 Vu Ngoc Dung/FHI 360

  • FIGURE 3
    FIGURE 3

    Rates for TB-Presumptive CXR and Xpert Positivity From 2X ACF Before CAD, After CAD Piloting, and CAD Standardizationa

    Abbreviations: 2X, Double X; ACF, active case-finding; CAD, computer-aided diagnosis; CXR, chest radiography; Xpert, GeneXpert.

    a Number of CXRs interpreted for each year: 2020, N=52,868; 2021, N=19,275; and 2022, N=28,437.

  • FIGURE 4
    FIGURE 4

    Xpert Testing for Project Provinces Directly Implementing 2Xa Compared to Non-Project Provinces Receiving TA on 2X

    Abbreviations: 2X, Double X; TA, technical assistance; Xpert, GeneXpert.

    a For 2X project sites, data were analyzed from 6 provinces that implemented for the full duration from 2020 through 2022, excluding 3 provinces that phased in or out of direct implementation. Data before project implementation (2017–2019) are shown for comparison with project results (2020–2022).

Tables

  • TABLE 1.

    TB Cascade for 2X ACF and ICF Implementation, March 2020–December 2022, Vietnam

    ModelScreened With CXRs, No.TB-Presumptive CXRs, No. (%)Tested With Xpert, No.Xpert Positive, No. (%)TB Diagnosed (All Forms), No.All Forms TB Yield per 100,000 CXR, No.NNS With CXRCost to Detect 1 Person With TB Disease, US$Initiated on TB Treatment, No. (%)
    2X ACF community campaigns100,58016,197 (16.1)16,0331,393 (8.7)1,4481,440691,193 (82.4)
     Household contacts21,5292,120 (9.8)2,217138 (6.2)140650154739121 (86.4)
     Other TB vulnerable populations79,05114,077 (17.8)13,8161,255 (9.1)1,3081,655601,072 (82.0)
    2X ICF in health facilities573,94430,688 (5.3)28,6766,375 (22.2)6,4651,12689835,818 (90.0)
     Diabetes outpatients73,0255,324 (7.3)5,027724 (14.4)7301,000100446667 (91.4)
     Smokers, alcohol use disorders, elderlya6,5391,703 (26.0)1,605328 (20.4)3385,16919116304 (89.9)
     Inpatients and outpatients494,38023,661 (4.8)22,0445,323 (24.1)5,3971,0929231b4,847 (89.8)

    • Abbreviations: 2X, Double X; ACF, active case-finding; CXR, chest radiography; ICF, intensified case-finding; NNS, number needed to screen; Xpert, GeneXpert.

    • a ICF smokers, those with alcohol use disorders, and those aged 60 years and older were evaluated in Dong Thap and Thai Binh provinces in 2021, and in An Giang province in 2022.

    • b CXR costs were covered by the project for ACF and all ICF populations except inpatients and outpatients with clinical indications for TB whose CXRs were covered by social health insurance. Supplement Table S2 lists full cost details for all models.

  • TABLE 2.

    CXR and Xpert Results by Demographic Characteristics for 2X ACF and ICF Participants, March 2020–December 2022, Vietnam

     CXRs, No.TB-Presumptive CXRs, No. (%)Tested With Xpert, No.Xpert Positive, No. (%)TB Diagnosed (All forms), No.All Forms TB Yield per 100,000 CXR, No.NNS With CXR
    ACF100,58016,197 (16.1)16,0331,393 (8.7)1,4481,44069
    Age, years
     <569394 (13.6)1813 (1.7)3433231
     5–144,481263 (5.9)2884 (1.4)4891,120
     15–242,968221 (7.4)21318 (8.5)18606165
     25–345,346499 (9.3)49147 (9.6)47879114
     35–4410,3671,109 (10.7)1,07399 (9.2)101974103
     45–5417,1732,419 (14.1)2,391227 (9.5)2341,36373
     55–6426,5464,521 (17)4,453393 (8.8)4211,58663
     ≥6530,8807,004 (22.7)6,918515 (7.4)5331,72658
    Sex
     Female56,2085,292 (9.4)5,284269 (5.1)282502199
     Male44,37210,905 (24.6)10,7491,124 (10.5)1,1662,62838
    ICF573,94430,688 (5.3)28,6766,375 (22.2)6,4651,12689
    Age, yearsa
     <5NANA49513 (2.6)15NANA
     5–14NANA26935 (13.0)40NANA
     15–24NANA536225 (42.0)227NANA
     25–34NANA1,249461 (36.9)464NANA
     35–44NANA2,359838 (35.5)844NANA
     45–54NANA4,3461,317 (30.3)1,331NANA
     55–64NANA7,2621,571 (21.6)1,593NANA
     ≥65NANA11,0031,658 (15.1)1,694NANA
     Age NANANA1,157257 (22.2)257NANA
    Sex
     Female279,29211,000 (3.9)10,2721,450 (14.1)1,475528189
     Male294,65219,688 (6.7)18,4044,925 (26.8)4,9901,69459

    • Abbreviations: ACF, active case-finding; CXR, chest radiography; ICF, intensified case-finding; NA, not available; NNS, number needed to screen; Xpert, GeneXpert.

    • a CXRs disaggregated by age groups were not available for ICF implementation.

  • TABLE 3.

    TB Cascade for the 2X Strategy Adapted During the COVID-19 Pandemic, March 2021–December 2022, Vietnam

    2X ModelScreened With CXRs, No.TB-Presumptive CXRs, No. (%)Tested With Xpert, No.Xpert Positive, No. (%)TB Diagnosed (All Forms), No.All Forms TB Yield per 100,000 CXR, No.NNS With CXRCost to Detect 1 Person With TB Disease, US$Initiated on TB Treatment, No. (%)
    Hybrid ACF/ICF from March 20218,6741,463 (16.9)1,57591 (5.8)961,1079071884 (87.5)
    Single X from October 2021N/AN/A8,822954 (10.8)962N/AN/A72830 (86.3)
    QR code self-screen from April 20222,5541,062 (41.6)1,048217 (20.7)2288,92711225213 (93.4)

    • Abbreviations: 2X, Double X; ACF, active case-finding; CXR, chest radiography; ICF, intensified case-finding; N/A, not applicable; NNS, number needed to screen; QR, quick response; Single X, GeneXpert-only algorithm.

  • TABLE 4.

    TB Infection Cascade Results Before and After Changing the TST Induration Threshold, Vietnam

    TB InfectionaDiagnostic Tests, No.TB Infection Test Results, No. (%)Positive TB Infection Test Results, No. (%)Eligible for TPT After Excluding TB Disease, No.Initiated on TPT, No. (%)
    March 2020–October 2021: TST threshold ≥10 mm
    ACF community campaigns25,37825,320 (99.8)3,190 (12.6)3,1011,674 (54.0)
    November 2021–December 2022: TST threshold ≥5 mm
    ACF community campaigns7,3347,174 (97.8)1,936 (26.4)1,8851,497 (79.4)

    • Abbreviations: ACF, active case-finding; QFT, QuantiFERON-TB Gold Plus; TPT, TB preventive treatment; TST, tuberculin skin testing.

    • ↵a TB infection was diagnosed using TST; in a subset of individuals (2,887 [8.8%]) who received both TST and QFT for quality assurance, a positive TST or QFT result yielded a diagnosis of TB infection. COVID-19 pandemic restrictions decreased the number undergoing TB infection evaluation in 2022.

  • TABLE 5.

    TB Cascade Before and After CAD Integration Into 2X ICF Facility Implementation, Vietnam

    Evaluated With CXRs, No.TB-Presumptive CXRs, No. (%) Tested With Xpert, No. (%)TB Diagnosed (All Forms), No. (%)All Forms TB Yield/ 100,000 CXR, No.Initiated on TB Treatment, No. (%)
    Before CAD: April–December 2021
    CAD facilities (n=7)12,3511,322 (10.7)1,320 (99.8)437 (33.1)3,538424 (97.0)
    After CAD: April–December 2022
    CAD facilities (n=7)19,2893,884 (19.9)3,352 (85.9)896 (26.7)4,645816 (91.1)
    Non-CAD facilities (n=23)81,2457,269 (8.9)7,029 (96.4)1,915 (27.2)2,3571,729 (90.3)

    • Abbreviations: CAD, computer-aided diagnosis; CXR, chest radiograph; ICF, intensified case-finding; Xpert, GeneXpert.

  • TABLE 6.

    All Forms TB Notifications per Year in 2X Provinces,a Vietnam, 2017–2022

    All Forms TB Notified, No.Rate of All Forms TB Notified per 100,000 Population
    201714,854127.24
    201814,755125.88
    201914,753125.38
    202014,688124.39
    202110,69090.25
    202215,207128.04

    • Abbreviation: 2X, Double X.

    • ↵a Annual TB notifications at the provincial level from the National TB Program’s Vietnam TB Information Management Electronic System were used to calculate notification rates per 100,000 population, using the total TB notifications for each province by year among the provinces’ total annual populations. Estimates of subnational populations in Vietnam for 2015–2030 were obtained from the U.S. President’s Emergency Plan for AIDS Relief’s U.S. Census Bureau.43 Data were analyzed for the 6 2X provinces that implemented for the full duration from 2020–2022; data from pre-project implementation (2017–2019) are shown to compare trends.

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An Effective Health System Approach to End TB: Implementing the Double X Strategy in Vietnam
Anh L. Innes, Victoria Lebrun, Gia Linh Hoang, Andres Martinez, Nhi Dinh, Thi Thuy Ha Nguyen, Tan Phat Huynh, Van Luong Quach, Thanh Binh Nguyen, Van Chinh Trieu, Nghi Do Bao Tran, Huy Minh Pham, Van Luong Dinh, Binh Hoa Nguyen, Thi Thanh Huyen Truong, Van Cu Nguyen, Viet Nhung Nguyen, Thu Hien Mai
Global Health: Science and Practice Jun 2024, 12 (3) e2400024; DOI: 10.9745/GHSP-D-24-00024
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