How health systems in sub-Saharan Africa can benefit from tuberculosis and other infectious disease programmes.

Weak and dysfunctional health systems in low-income countries, particularly in sub-Saharan Africa, are recognised as major obstacles to attaining the health-related Millennium Development Goals by 2015. Some progress is being made towards achieving the targets of Millennium Development Goal 6 for tuberculosis (TB), HIV/AIDS and malaria, with the achievements largely resulting from clearly defined strategies and intervention delivery systems combined with large amounts of external funding. This article is divided into four main sections. The first highlights the crucial elements that are needed in low-income countries in sub-Saharan Africa to deliver good quality health care through general health systems. The second discusses the main characteristics of infectious disease and TB control programmes. The third illustrates how TB control and other infectious disease programmes can help to strengthen these components, particularly in human resources; infrastructure; procurement and distribution; monitoring, evaluation and supervision; leadership and stewardship. The fourth and final section looks at progress made to date at the international level in terms of policy and guidelines, with some specific suggestions about this might be moved forward at the national level. For TB and other infectious disease programmes to drive broad improvements in health care systems and patient care, the lessons that have been learnt must be consciously applied to the broader health system, and sufficient financial input and the engagement of all players are essential

Important co-morbidity in patients with diabetes mellitus in three clinics in Western Kenya

SETTING: Diabetes clinics in three hospitals in Western Kenya: Moi Teaching and Referral Hospital and two associated district hospitals. OBJECTIVE: To determine the proportion of diabetes patients with a history of tuberculosis (  TB), human immunodeficiency virus (HIV  ) infection and tobacco smoking. DESIGN: A descriptive study using routinely collected data from patient records in the three diabetes clinics. RESULTS: Of 1376 patients analyzed, 750 (55%) were female. The mean age of the patients in the clinics was 53.5 years (95%CI 52.2–54.8), with an average duration of diabetes of 8.1 years (95%CI 7.6–8.7). Of all patients, 5.6% reported a history of TB, similar to the frequency about 20 years earlier (1990) in Tanzania. Only 30% of the patients reported knowing their HIV status; 6% were HIV-positive. A history of tobacco smoking was reported by 3.8% of the patients. CONCLUSION: The HIV epidemic does not seem to have significantly changed the relationship between TB and diabetes mellitus (DM) in this cohort of diabetes patients. The frequency of HIV and TB in this special population was comparable to that in the general population, and only a small proportion of patients reported a history of tobacco smoking

Severe malnutrition in children presenting to health facilities in an urban slum in Bangladesh

SETTING: An urban slum in Kamrangirchar, Bangladesh. OBJECTIVES: Among children aged 6–59 months seeking medical care from the two Médecins Sans Frontières-supported primary health centres, to determine 1) the prevalence of severe acute malnutrition (SAM) and severe chronic malnutrition (SCM), and 2) the extent of overlap between SAM and SCM. DESIGN: In a retrospective record review, data were analysed from out-patient registers on age, sex, height, weight and mid-upper arm circumference (MUAC) of children attending for medical care from April to September 2011. SAM was defined as weight for height < −3 Z scores of the median and/or MUAC <115 mm. SCM was defined as height for age < −3 Z scores of the median. World Health Organization growth standards were used as reference. RESULTS: Data were complete in the records of 7318 (98%) children, of whom 322 (4%) had SAM and 1698 (23%) had SCM. Among the 322 children with SAM, 162 (50%) also had SCM. CONCLUSION: In an urban Bangladesh slum, SAM and SCM co-exist, with a predominance of SCM. The current national guidelines for severe malnutrition, which focus on identification and management only for SAM, urgently need to be expanded to include SCM if substantial childhood morbidity and mortality are to be reduced

Language in tuberculosis services: can we change to patient-centred terminology and stop the paradigm of blaming the patients?

The words 'defaulter', 'suspect' and 'control' have been part of the language of tuberculosis (TB) services for many decades, and they continue to be used in international guidelines and in published literature. From a patient perspective, it is our opinion that these terms are at best inappropriate, coercive and disempowering, and at worst they could be perceived as judgmental and criminalising, tending to place the blame of the disease or responsibility for adverse treatment outcomes on one side-that of the patients. In this article, which brings together a wide range of authors and institutions from Africa, Asia, Latin America, Europe and the Pacific, we discuss the use of the words 'defaulter', 'suspect' and 'control' and argue why it is detrimental to continue using them in the context of TB. We propose that 'defaulter' be replaced with 'person lost to follow-up'; that 'TB suspect' be replaced by 'person with presumptive TB' or 'person to be evaluated for TB'; and that the term 'control' be replaced with 'prevention and care' or simply deleted. These terms are non-judgmental and patient-centred. We appeal to the global Stop TB Partnership to lead discussions on this issue and to make concrete steps towards changing the current paradigm

Treatment Outcomes of Patients With Multidrug-Resistant and Extensively Drug-Resistant Tuberculosis According to Drug Susceptibility Testing to First- and Second-line Drugs: An Individual Patient Data Meta-analysis

The clinical validity of drug susceptibility testing (DST) for pyrazinamide, ethambutol, and second-line antituberculosis drugs is uncertain. In an individual patient data meta-analysis of 8955 patients with confirmed multidrug-resistant tuberculosis, DST results for these drugs were associated with treatment outcome

Integration of TB and ART services fails to improve TB treatment outcomes: Comparison of ART/TB primary healthcare services in Cape Town, South Africa

BACKGROUND: The combined tuberculosis (TB) and HIV epidemics in South Africa (SA) have created enormous operational challenges for a health service that has traditionally run vertical programmes for TB treatment and antiretroviral therapy (ART) in separate facilities. This is particularly problematic for TB/HIV co-infected patients who need to access both services. OBJECTIVE: To determine whether integrated TB facilities had better TB treatment outcomes than single-service facilities in Cape Town, SA. METHODS: TB treatment outcomes were determined for newly registered, adult TB patients (aged > or = 18 years) at 13 integrated ART/TB primary healthcare (PHC) facilities and four single-service PHC facilities from 1 January 2009 to 30 June 2010. A chi2 test adjusted for a cluster sample design was used to compare outcomes by type of facility. RESULTS: Of 13,542 newly registered patients, 10,030 received TB treatment in integrated facilities and 3,512 in single-service facilities. There was no difference in baseline characteristics between the two groups with HIV status determined for 9,351 (93.2%) and 3,227 (91.9%) patients, of whom 6 649 (66.3%) and 2,213 (63%) were HIV-positive in integrated facilities and single-service facilities, respectively. The median CD4+ count of HIV-positive patients was 152 cells/microl (interquartile range (IQR) 71-277) for integrated facilities and 148 cells/microl (IQR 67-260) for single-service facilities. There was no statistical difference in the TB treatment outcome profile between integrated and single-service facilities for all TB patients (p = 0.56) or for the sub-set of HIV-positive TB patients (p = 0.58) CONCLUSION: This study did not demonstrate improved TB treatment outcomes in integrated PHC facilities and showed that the provision of ART in the same facility as TB services was not associated with lower TB death and default rates