• 10-year assessment of treatment outcome among Cambodian refugees with sputum smear-positive tuberculosis in Khao-I-Dang, Thailand.

      Sukrakanchana-Trikham, P; Puéchal, X; Rigal, J; Rieder, H L; Médecins sans Frontières Tuberculosis Programme, Khao-I-Dang, Prachinburi, Thailand. (International Union Against Tuberculosis and Lung Disease, 1992-12)
      Tuberculosis control among displaced persons is fraught with difficulties to ensure adherence of patients to treatment for a prolonged period of time. In the Khao-I-Dang camp for Cambodian refugees an approach with daily, directly observed treatment throughout the course of 6 months duration was chosen to address the problem. Of a total 929 patients with sputum smear-positive tuberculosis who were enrolled from 1981 to 1990, 5.0% died, 75.5% completed treatment and were bacteriologically cured with a day-to-day adherence of more than 98%, none failed bacteriologically, 19.2% were transferred to another camp where continuation of treatment was guaranteed, and only 0.4% absconded from treatment. These data suggest that the approach to tuberculosis control in this refugee camp was very effective in cutting the chain of transmission of tuberculosis in a highly mobile population and in reducing substantially unnecessary morbidity and mortality.
    • Advances in malaria elimination in Botswana: a dramatic shift to parasitological diagnosis, 2008-2014

      Moakofhi, K; Edwards, JK; Motlaleng, M; Namboze, J; Butt, W; Obopile, M; Mosweunyane, T; Manzi, M; Takarinda, KC; Owiti, P (International Union Against Tuberculosis and Lung Disease, 2018-04-25)
      Background: Malaria elimination requires infection detection using quality assured diagnostics and appropriate treatment regimens. Although Botswana is moving towards malaria elimination, reports of unconfirmed cases may jeopardise this effort. This study aimed to determine the proportion of cases treated for malaria that were confirmed by rapid diagnostic testing (RDT) and/or microscopy. Methods: This was a retrospective descriptive study using routine national data from the integrated disease surveillance and case-based surveillance systems from 2008 to 2014. The data were categorised into clinical and confirmed cases each year. An analysis of the data on cases registered in three districts that reported approximately 70% of all malaria cases was performed, stratified by year, type of reporting health facilities and diagnostic method. Results: During 2008-2014, 50 487 cases of malaria were reported in Botswana, and the proportion of RDT and/or blood microscopy confirmed cases improved from 6% in 2008 to 89% in 2013. The total number of malaria cases decreased by 97% in the same period, then increased by 41% in 2013. Conclusion: This study shows that malaria diagnostic tests dramatically improved malaria diagnosis and consequently reduced the malaria burden in Botswana. The study identified a need to build capacity on microscopy for species identification, parasite quantification and guiding treatment choices.
    • Adverse events among people on delamanid for rifampicin-resistant tuberculosis in a high HIV prevalence setting

      Hughes, J; Reuter, A; Chabalala, B; Isaakidis, P; Cox, H; Mohr, E (International Union Against Tuberculosis and Lung Disease, 2019-09-01)
      SETTING: Patients with rifampicin-resistant tuberculosis (RR-TB) in the township of Khayelitsha, South Africa, were offered delamanid (DLM) within a decentralised RR-TB treatment programme. OBJECTIVE: To describe adverse events (AEs) among HIV-positive and negative people receiving DLM for RR-TB in a programmatic setting. DESIGN: Patients were followed up monthly for blood, electrocardiography and clinical monitoring and AEs were assessed for severity grade, seriousness and relationship to DLM. RESULTS: Fifty-eight patients (55% male; median age 35 years, interquartile range [IQR] 28–42) started DLM; 46 (79%) were HIV-positive, median CD4 count 173 cells/mm3 (IQR 70–294). Fifty (86%) patients experienced ≥1 new or worsening AE after starting DLM, most commonly vomiting, QTcB >450 ms and/or myalgia. Serious and/or severe AEs were experienced by 22 (38%) patients; three HIV-positive patients died (not related to DLM). HIV status was not significantly associated with number (P = 0.089) or severity/seriousness (P = 0.11) of AEs during exposure to DLM. Two (3%) patients had DLM withdrawn due to AEs. CONCLUSION: AEs during RR-TB treatment, both before and during DLM exposure, were common, with relatively few serious/severe AEs considered related to DLM and no significant association with HIV status. Clinical and electrocardiography monitoring should be prioritised in the first two months after starting DLM.
    • Age-stratified tuberculosis treatment outcomes in Zimbabwe: are we paying attention to the most vulnerable?

      Ncube, RT; Takarinda, KC; Zishiri, C; van den Boogaard, W; Mlilo, N; Chiteve, C; Siziba, N; Trinchán, F; Sandy, C (International Union Against Tuberculosis and Lung Disease, 2017-09-21)
      Setting: A high tuberculosis (TB) incidence, resource-limited urban setting in Zimbabwe. Objectives: To compare treatment outcomes among people initiated on first-line anti-tuberculosis treatment in relation to age and other explanatory factors. Design: This was a retrospective record review of routine programme data. Results: Of 2209 patients included in the study, 133 (6%) were children (aged <10 years), 132 (6%) adolescents (10-19 years), 1782 (81%) adults (20-59 years) and 162 (7%) were aged ⩾60 years, defined as elderly. The highest proportion of smear-negative pulmonary TB cases was among the elderly (40%). Unfavourable outcomes, mainly deaths, increased proportionately with age, and were highest among the elderly (adjusted relative risk 3.8, 95%CI 1.3-10.7). Having previous TB, being human immunodeficiency virus positive and not on antiretroviral treatment or cotrimoxazole preventive therapy were associated with an increased risk of unfavourable outcomes. Conclusion: The elderly had the worst outcomes among all the age groups. This may be related to immunosuppressant comorbidities or other age-related diseases mis-classified as TB, as a significant proportion were smear-negative. Older persons need better adapted TB management and more sensitive diagnostic tools, such as Xpert® MTB/RIF.
    • Ambulatory tuberculosis treatment in post-Semashko health care systems needs supportive financing mechanisms

      Kohler, S; Asadov, D A; Bründer, A; Healy, S; Khamraev, A K; Sergeeva, N; Tinnemann, P (International Union Against Tuberculosis and Lung Disease, 2014-12-01)
      The tuberculosis (TB) control strategy in the Republic of Karakalpakstan, Uzbekistan, is being changed to decentralised out-patient care for most TB patients by the Government of Uzbekistan, in collaboration with the international medical humanitarian organisation Médecins Sans Frontières. Ambulatory treatment of both drug-susceptible and drug-resistant TB from the first day of treatment has been recommended since 2011. Out-patient treatment of TB from the beginning of treatment was previously prohibited. However, the current Uzbek health financing system, which evolved from the Soviet Semashko model, offers incentives that work against the adoption of ambulatory TB treatment. Based on the 'Comprehensive TB Care for All' programme implemented in Karakalpakstan, we describe how existing policies for the allocation of health funds complicate the scale-up of ambulatory-based management of TB.
    • Antenatal care and pregnancy outcomes in a safe motherhood health voucher system in rural Kenya, 2007–2013

      Kihara, A-B; Harries, A D; Bissell, K; Kizito, W; Van Den Berg, R; Mueke, S; Mwangi, A; Sitene, J C; Gathara, D; Kosgei, R J; et al. (International Union Against Tuberculosis and Lung Disease, 2015-03-21)
    • Antibiotic use in a district hospital in Kabul, Afghanistan: are we overprescribing?

      Bajis, S; Van den Bergh, R; De Bruycker, M; Mahama, G; Van Overloop, C; Satyanarayana, S; Bernardo, R S; Esmati, S; Reid, A J (International Union Against Tuberculosis and Lung Disease, 2014-12-21)
    • Barriers and solutions to finding rifampicin-resistant tuberculosis cases in older children and adolescents

      Mohr-Holland, E; Apolisi, I; Reuter, A; de Azevedo, V; Hill, J; Matthee, S; Seddon, JA; Isaakidis, P; Furin, J; Trivino-Duran, L (International Union Against Tuberculosis and Lung Disease, 2019-12-21)
      Little is known about the barriers to post-exposure management of rifampicin-resistant tuberculosis (RR-TB) in older children and adolescents. We report on implementation lessons from a pilot programme targeting household-exposed individuals aged 6–18 years in Khayelitsha, South Africa. Barriers included misperceptions regarding risk of exposure, multiple research and implementation stakeholders, additional workload for an overburdened healthcare system, logistical issues faced by families, and insufficient human and financial resources. Solutions to these barriers are possible, but creativity and persistence are required. Our experience can guide others looking to roll-out care for children and adolescents exposed to RR-TB.
    • Bedaquiline and delamanid result in low rates of unfavourable outcomes among TB patients in Eswatini

      Vambe, D; Kay, AW; Furin, J; Howard, AA; Dlamini, T; Shabangu, A; Hassen, F; Masuku, S; Maha, O; Wawa, C; et al. (International Union Against Tuberculosis and Lung Disease, 2020-10-01)
      SETTING: Since 2015, Eswatini has been scaling up bedaquiline (BDQ) and delamanid (DLM) based drug-resistant TB treatment regimens under programmatic conditions. OBJECTIVE: Identification of factors associated with treatment outcomes in patients receiving BDQ and/or DLM either as a new treatment initiation or drug substitution. DESIGN: This is a retrospective cohort study of patients receiving BDQ and/or DLM in Eswatini between March 2015 and October 2018. We describe factors associated with unfavourable treatment outcomes (death, lost to follow-up, treatment failure and amplification of resistance) and culture conversion using multivariable flexible parametric survival and competing-risks regression analyses. RESULTS: Of 352 patients receiving BDQ and/or DLM, 7.8% and 21.2% had an unfavourable treatment outcome at 6 and 24 months, respectively. Predictors were age ≥ 60 years (adjusted hazard ratio aHR 4.49, 95%CI 1.61–12.57) vs. age 20–39 years, and a treatment regimen combining both drugs (aHR 4.49, 95%CI 1.61–12.57) vs. BDQ only. The probability of culture conversion was increased for two health facilities and patients with a poly resistance profile (adjusted sub-hazard ratio 2.01, 95%CI 1.13–3.59) vs. multidrug resistance. CONCLUSION: Single use of BDQ or DLM was associated with low rates of unfavourable outcomes, suggesting that these medications may be effectively adopted at scale under routine programmatic conditions. Combined use of BDQ and DLM was a risk factor for unfavourable outcomes and should prompt for collection of more data on the combined use of these medications.
    • Beyond 'cure' and 'treatment success': quality of life of patients with multidrug-resistant tuberculosis

      Laxmeshwar, C; Stewart, A G; Dalal, A; Kumar, A M V; Kalaiselvi, S; Das, M; Gawde, N; Thi, S S; Isaakidis, P (International Union Against Tuberculosis and Lung Disease, 2019-01-01)
      Two drug-resistant tuberculosis (DR-TB) sites (MSF Clinic, Jupiter Hospital) in Mumbai, India.
    • Bringing care to the community: expanding access to health care in rural Malawi through mobile health clinics

      Geoffroy, E; Harries, A D; Bissell, K; Schell, E; Bvumbwe, A; Tayler-Smith, K; Kizito, W (International Union Against Tuberculosis and Lung Disease, 2014-12-21)
    • Building the capacity of public health programmes to become data rich, information rich and action rich

      Harries, AD; Khogali, M; Kumar, AMV; Satyanarayana, S; Takarinda, KC; Karpati, A; Olliaro, P; Zachariah, R (International Union Against Tuberculosis and Lung Disease, 2018-06-21)
      Good quality, timely data are the cornerstone of health systems, but in many countries these data are not used for evidence-informed decision making and/or for improving public health. The SORT IT (Structured Operational Research and Training Initiative) model has, over 8 years, trained health workers in low- and middle-income countries to use data to answer important public health questions by taking research projects through to completion and publication in national or international journals. The D2P (data to policy) training initiative is relatively new, and it teaches health workers how to apply 'decision analysis' and develop policy briefs for policy makers: this includes description of a problem and the available evidence, quantitative comparisons of policy options that take into account predicted health and economic impacts, and political and feasibility assessments. Policies adopted from evidence-based information generated through the SORT IT and D2P approaches can be evaluated to assess their impact, and the cycle repeated to identify and resolve new public health problems. Ministries of Health could benefit from this twin-training approach to make themselves 'data rich, information rich and action rich', and thereby use routinely collected data in a synergistic manner to improve public health policy making and health care delivery.
    • The Burden of Road Traffic Injuries in an Emergency Department in Addis Ababa, Ethiopia

      Getachew, S; Ali, E; Tayler-Smith, K; Hedt-Gauthier, B; Silkondez, W; Abebe, D; Deressa, W; Enquessilase, F; Edwards, J K (International Union Against Tuberculosis and Lung Disease, 2016-06-21)
      The emergency department (ED) of Zewditu Memorial Hospital, Addis Ababa, Ethiopia.
    • Case management of malaria in Swaziland, 2011-2015: on track for elimination?

      Dlamini, SV; Kosgei, RJ; Mkhonta, N; Zulu, Z; Makadzange, K; Zhou, S; Owiti, P; Sikhondze, W; Namboze, J; Reid, A; et al. (International Union Against Tuberculosis and Lung Disease, 2018-04-25)
      Objective: To assess adherence to malaria diagnosis and treatment guidelines (2010 and 2014) in all health care facilities in Swaziland between 2011 and 2015. Methods: This was a cross-sectional descriptive study involving all health care facilities that diagnosed and managed malaria cases in Swaziland. Patients' age, sex, diagnosis method and type of treatment were analysed. Results: Of 1981 records for severe and uncomplicated malaria analysed, 56% of cases were uncomplicated and 14% had severe malaria. The type of malaria was not recorded for 30% of cases. Approximately 71% of cases were confirmed by rapid diagnostic tests (RDT) alone, 3% by microscopy alone and 26% by both RDT and microscopy. Of the uncomplicated cases, 93% were treated with artemether-lumefantrine (AL) alone, 5% with quinine alone and 2% with AL and quinine. Amongst the severe cases, 11% were treated with AL alone, 44% with quinine alone and 45% with AL and quinine. For severe malaria, clinics and health centres prescribed AL alone more often than hospitals (respectively 13%, 12% and 4%, P = 0.03). Conclusion: RDTs and/or microscopy results are used at all facilities to inform treatment. Poor recording of malaria type causes difficulties in assessing the prescription of antimalarial drugs.
    • Changing distribution and abundance of the malaria vector Anopheles merus in Mpumalanga Province, South Africa

      Mbokazi, F; Coetzee, M; Brooke, B; Govere, J; Reid, A; Owiti, P; Kosgei, R; Zhou, S; Magagula, R; Kok, G; et al. (International Union Against Tuberculosis and Lung Disease, 2018-04-25)
      Background: The malaria vector Anopheles merus occurs in the Mpumalanga Province of South Africa. As its contribution to malaria transmission in South Africa has yet to be ascertained, an intensification of surveillance is necessary to provide baseline information on this species. The aim of this study was therefore to map An. merus breeding sites in the Ehlanzeni District of Mpumalanga Province and to assess qualitative trends in the distribution and relative abundance of this species over a 9-year period. Methods: The study was carried out during the period 2005-2014 in the four high-risk municipalities of Ehlanzeni District. Fifty-two breeding sites were chosen from all water bodies that produced anopheline mosquitoes. The study data were extracted from historical entomological records that are captured monthly. Results: Of the 15 058 Anopheles mosquitoes collected, 64% were An. merus. The abundance and distribution of An. merus increased throughout the four municipalities in Ehlanzeni District during the study period. Conclusion: The expanded distribution and increased abundance of An. merus in the Ehlanzeni District may contribute significantly to locally acquired malaria in Mpumalanga Province, likely necessitating the incorporation of additional vector control methods specifically directed against populations of this species.
    • Childhood immunization in Bungoma County, Kenya, from 2008 to 2011: need for improved uptake

      Mbuthia, G W; Harries, A D; Obala, A A; Nyamogoba, H D N; Simiyu, C; Edginton, M E; Khogali, M; Hedt-Gauthier, B L; Otsyla, B K (International Union Against Tuberculosis and Lung Disease, 2014-03)
      Uptake of immunisations in children aged 1–2 years in Bungoma County, Kenya, was determined as part of the 6-monthly Health and Demographic Surveillance System surveys. A total of 2699 children were assessed between 2008 and 2011. During this time period, full immunisation declined significantly from 84% to 58%,and measles vaccine declined uptake from 89% to 60%(P<0.001). Each year there was a significant fall-off for the third doses of the oral polio and pentavalent vaccines(P<0.001). These findings are of concern, as low immunisation coverage may lead to vaccine-preventable disease outbreaks. Further investigations into the reasons for declining immunisation trends are required.
    • Childhood tuberculosis in Mauritania, 2010-2015: diagnosis and outcomes in Nouakchott and the rest of the country

      Aw, B; Ade, S; Hinderaker, SG; Dlamini, N; Takarinda, KC; Chiaa, K; Feil, A; Traoré, A; Reid, T (International Union Against Tuberculosis and Lung Disease, 2017-09-21)
      Setting: The National Tuberculosis Programme, Mauritania. Objective: To compare the diagnosis and treatment outcomes of childhood tuberculosis (TB) cases (aged <15 years) registered between 2010 and 2015 inside and outside Nouakchott, the capital city. Design: This was a retrospective comparative cohort study. Results: A total of 948 children with TB were registered. The registration rate was 10 times higher in Nouakchott. The proportion of children among all TB cases was higher inside than outside Nouakchott (7.5% vs. 4.6%, P < 0.01). Under-fives represented 225 (24%) of all childhood TB cases, of whom 204 (91%) were registered in Nouakchott. Extra-pulmonary TB was more common in Nouakchott, while smear-negative TB was less common. Treatment success was similar inside and outside Nouakchott (national rate 61%). The principal unsuccessful outcomes were loss to follow-up outside Nouakchott (21% vs. 11%, P < 0.01) while transfers out were more common in the city (25% vs. 14%, P = 0.01). Being aged <5 years (OR 1.2, 95%CI 1.1-1.5) was associated with an unsuccessful outcome. Conclusion: This study indicates problems in the diagnosis and treatment of childhood TB in Mauritania, especially outside the city of Nouakchott. We suggest strengthening clinical diagnosis and management, improving communications between TB treatment centres and health services and pressing the TB world to develop more accurate and easy-to-use diagnostic tools for children.
    • Clinical perspectives on treatment of rifampicin-resistant/multidrug-resistant TB

      Cox, V; McKenna, L; Acquah, R; Reuter, A; Wasserman, S; Vambe, D; Ustero, P; Udwadia, Z; Trivino-Duran, L; Tommasi, M; et al. (International Union Against Tuberculosis and Lung Disease, 2020-11-01)
      Rapid diagnostics, newer drugs, repurposed medications, and shorter regimens have radically altered the landscape for treating rifampicin-resistant TB (RR-TB) and multidrug-resistant TB (MDR-TB). There are multiple ongoing clinical trials aiming to build a robust evidence base to guide RR/MDR-TB treatment, and both observational studies and programmatic data have contributed to advancing the treatment field. In December 2019, the WHO issued their second ‘Rapid Communication´ related to RR-TB management. This reiterated their prior recommendation that a majority of people with RR/MDR-TB receive all-oral treatment regimens, and now allow for specific shorter duration regimens to be used programmatically as well. Many TB programs need clinical advice as they seek to roll out such regimens in their specific setting. In this Perspective, we highlight our early experiences and lessons learned from working with National TB Programs, adult and pediatric clinicians and civil society, in optimizing treatment of RR/MDR-TB, using shorter, highly-effective, oral regimens for the majority of people with RR/MDR-TB.
    • Closing the gap: decentralising mental health care to primary care centres in one rural district of Rwanda

      Nyirandagijimana, B; Edwards, JK; Venables, E; Ali, E; Rusangwa, C; Mukasakindi, H; Borg, R; Fabien, M; Tharcisse, M; Nshimyiryo, A; et al. (International Union Against Tuberculosis and Lung Disease, 2017-09-21)
      Setting: Programmes that integrate mental health care into primary care settings could reduce the global burden of mental disorders by increasing treatment availability in resource-limited settings, including Rwanda. Objective: We describe patient demographics, service use and retention of patients in care at health centres (HC) participating in an innovative primary care integration programme, compared to patients using existing district hospital-based specialised out-patient care. Design: This was a retrospective cohort study using routinely collected data from six health centres and one district hospital from October 2014 to March 2015. Results: Of 709 patients, 607 were cared for at HCs; HCs accounted for 88% of the total visits for mental disorders. Patients with psychosis used HC services more frequently, while patients with affective disorders were seen more frequently at the district hospital. Of the 68% of patients who returned to care within 90 days of their first visit, 76% had a third visit within a further 90 days. There were no significant differences in follow-up rates between clinical settings. Conclusion: This study suggests that a programme of mentorship for primary care nurses can facilitate the decentralisation of out-patient mental health care from specialised district hospital mental health services to HCs in rural Rwanda.
    • Cohort analysis of antenatal care and delivery outcomes in pregnancy: a basis for improving maternal health

      Harries, A D; Jahn, A; Ben-Smith, A; Gadabu, O J; Douglas, G P; Seita, A; Khader, A; Zachariah, R (International Union Against Tuberculosis and Lung Disease, 2014-06-21)