Helping patients to stop smoking

Cognitive-behavioural strategies can be used for smokers who request assistance in stopping smoking. These strategies are based on social learning theory, which defines smoking cessation as a process of breaking all of the emotional and situational ties that have been established with the act of smoking. To do this, the quitting smoker needs to understand the addiction process as well as conditioned responses to it in dealing with withdrawal symptoms and craving. The health worker can help the quitting smoker by providing techniques to understand what and how smoking reinforces itself, to enhance and maintain motivation to remain abstinent, to encourage using a social support system and to plan the coping techniques that might be used. Both acts (behaviours) and thinking (cognitions) can be powerful tools in persevering to cope with craving and to manage undesirable side-effects of cessation. These include identifying the antecedents (cues to use tobacco) and the consequences of using tobacco to identify critical emotions and situations where coping is most necessary, finding activities to replace the act of lighting a cigarette, mentally preparing for craving and keeping at bay unhelpful thoughts (such as 'I'll just take one last puff'). Mental preparation is also necessary to understand and to avoid or limit the side effects of cessation.

Tobacco cessation and brief advice

Patients who are enrolled on tuberculosis (TB) treatment are often ill and are seeking ways to get better. They are more likely at that time to adopt risk-reducing health behaviours. Interventions that are neither complicated nor time-consuming are available to health service personnel to help patients undertake smoking cessation. Brief advice to patients repeated at various times throughout their TB care can increase cessation rates. All tobacco use needs to be identified and reasons for quitting enunciated. Patients are thus given a framework for considering smoking cessation. If patients then choose not to stop currently, they can be asked to reconsider at a later visit, and also be cautioned to avoid smoking in the presence of others. Smokers who want to stop can discuss strategies for avoiding craving and withdrawal, and pharmacological agents can be recommended if they are available. Because the brief advice is repeated, patients are reinforced either for having stopped or for their progress towards stopping.

Introducing brief advice in tuberculosis services

There are individual and contextual barriers to the adoption of new routines in health care. Health professionals working in tuberculosis (TB) care are unlikely to adopt smoking cessation interventions unless they understand the importance of such interventions, feel that doing them will produce results and are convinced that the interventions should be used. Health professionals need to know what they are expected to do and to feel they have the skills or tools necessary. But beyond informed, willing and ready health care providers, the health care service also needs to provide an encouraging infrastructure. Tobacco cessation has to be included in standard practice guidelines on TB case management, and information about smoking should be included in the standard monitoring process, with appropriate forms. Programme managers and technical advisors need to ask about, encourage and support the inclusion of smoking cessation interventions. It is advisable for one staff member to coordinate tobacco cessation activities to ensure that needed materials are available and to provide assistance and feedback to other staff.

Tobacco use and tobacco control

Smoking begins when tobacco is readily available and others smoke. It easily becomes something more than experimentation, as the symptoms of nicotine dependence can develop rapidly. The social and environmental cues to smoke, the personal perceptions of smoking and the physiological effects of nicotine create strong links that are difficult to break. Programmes should be put in place to help people to stop smoking, but these programmes cannot reach their potential for success if the wider social and environmental factors are not also changed through strengthened anti-tobacco social values and tobacco control legislation, as exemplified in the WHO Framework Convention on Tobacco Control.

Associations between tobacco and tuberculosis

The association between smoking and tuberculosis (TB) has been investigated since 1918. Both passive and active exposure to tobacco smoke have been shown to be associated with tuberculous infection and with the transition from being infected to developing TB disease. The association between smoking and developing TB disease (without separating the risk of transition from being exposed to being infected and that from being infected to developing TB disease) has been reported substantially. Smoking affects the clinical manifestations of TB. It has been shown that ever smokers are more likely to have cough, dyspnoea, chest radiograph appearances of upper zone involvement, cavity and miliary appearance, and positive sputum culture, but are less likely to have isolated extra-pulmonary involvement than non-smokers. Smoking has been found to be associated with both relapse of TB and TB mortality. There appears to be enough evidence to conclude that smoking is causally associated with TB disease. Patients with TB need and should receive counselling and assistance in stopping smoking.

Access to inhaled corticosteroids is key to improving quality of care for asthma in developing countries

Asthma is a worldwide public health problem affecting about 300 million people. The majority of persons living with asthma are in the developing world where there is limited access to essential drugs. The financial burden for persons living with asthma and their families, as well as for healthcare systems and governments, is very high. Inadequate treatment and the high cost of medications leads to disability, absenteeism and poverty. Despite the existence of effective asthma medications and international guidelines, and progress made in the implementation of such guidelines over the last decade, the high cost of essential asthma medications remains a major obstacle for patient access to treatment in developing countries. The International Union Against Tuberculosis and Lung Disease has evaluated this problem and created an Asthma Drug Facility (ADF) so that countries can purchase affordable, good quality essential drugs for asthma. The ADF uses pooled procurement along with other purchasing and supply strategies to obtain the lowest possible prices. Accompanied by the implementation of standardized asthma management, the increased affordability of drugs provided by the ADF should bring rapid and significant health and cost benefits for patients, their communities and governments.

Feasibility of brief tobacco cessation advice for tuberculosis patients: a study from Sudan

SETTING

Twenty-four health care centres in Sudan.

OBJECTIVE

To examine the feasibility of introducing a tobacco cessation intervention into tuberculosis (TB) treatment programmes.

DESIGN

A feasibility study of a tobacco cessation intervention for new cases of pulmonary tuberculosis (PTB) in men compared survey centres (controls) and tobacco cessation intervention centres. Feasibility was evaluated by examining 1) acceptance by health staff and 2) the impact of additional tasks on TB treatment outcomes. A secondary assessment looked at rate of stopping tobacco use among those enrolled in the intervention condition.

RESULTS

Staff members did not differ in personal use of tobacco, in enforcing rules banning the use of tobacco at health centres or in rates of recruitment into the study. A total of 513 patients (44% of those eligible) were enrolled. Differences in TB treatment success were found between patients who were enrolled and those who were not: respectively 83% and 59% were cured or completed treatment. Of identified tobacco users undergoing the cessation intervention, 66% reported abstinence at the end of their TB treatment.

CONCLUSION

Although differences existed between patients enrolled or not enrolled, the intervention was demonstrated to be feasible to implement and effective for those enrolled within routine TB services.

High success rate of TB treatment among Bhutanese refugees in Nepal

SETTING

Camps for refugees from Bhutan in south-east Nepal.

OBJECTIVES

To evaluate the outcome of treatment of tuberculosis (TB) cases in the refugee camps.

DESIGN

Cohort analysis of results of treatment of cases started on treatment from mid-July 1999 to mid-July 2004.

RESULT

A total of 1214 patients with TB were notified in the programme. Among these, 631 (52%) were new smear-positive pulmonary tuberculosis (PTB) cases, 175 (14%) new smear-negative PTB cases, 290 (24%) new extra-pulmonary TB (EPTB) cases and 118 (10%) smear-positive retreatment cases. Treatment success was achieved in 1061 (94%). The proportion of new non-smear-positive cases who died on treatment was significantly higher than the corresponding figure for new smear-positive cases (RR 7.57, 95%CI 3.74-15.32 for new smear-negative and 4.22, 95%CI 2.08-8.55 for EPTB).

CONCLUSION

High cure rates and low bacteriological failure rates can be achieved in refugee settings if there is close coordination and collaboration between the local health agencies and the National Tuberculosis Programme of the host country.

The impact of migrants on the epidemiology of tuberculosis in Beijing, China

SETTING

Tuberculosis (TB) services in the Municipality of Beijing, China.

OBJECTIVE

To evaluate the impact of migrants on the epidemiology and management of TB in Beijing.

DESIGN

Comparison of information on permanent residents and migrants from routine reports of TB cases registered in Beijing from 1993 to 2005.

RESULTS

From 1993 to 2005, there was a steady rise in the proportion of migrants among TB cases notified in Beijing, from approximately one in 10 cases to one in three cases. The results of treatment in migrant cases of TB over the period 1997-2004 were unsatisfactory. The proportion of cases cured among permanent residents was 90.6%, compared with only 37.0% of cases among migrants.

CONCLUSION

Migrants pose a challenge to TB services in Beijing. Special attention must be given to them by the National Tuberculosis Programme to address these challenges.

An evaluation of symptom and chest radiographic screening in tuberculosis prevalence surveys

SETTING

A tuberculosis (TB) prevalence survey was performed in 2002 in two urban communities in Cape Town, South Africa. The population was 36,334 in 2001, and the TB notification rate was 341 per 100,000 population for new smear-positive TB in 2002.

OBJECTIVE

To evaluate the relative contributions of symptom and chest radiographic (CXR) screening in the detection of subjects with smear- and/or culture-positive TB in prevalence surveys.

DESIGN

Information on symptoms, CXR abnormalities, sputum smear and culture was gathered from a random cluster sample of 1170 adults (aged > or = 15 years). Smear and/or culture-positive TB was used as the gold standard.

RESULTS

Of 1170 adults, 29 had bacteriologically positive TB (smear- and/or culture-positive). The presence of any abnormalities on CXR had the highest sensitivity for detecting subjects with bacteriologically positive TB (0.97, 95%CI 0.90-1.00). Specificity for any abnormalities on CXR was 0.67 (95%CI 0.64-0.70). The specificity of any of five TB-related symptoms was 0.68 (95%CI 0.65-0.71). Individual symptoms had low sensitivities, ranging from 0.10 for fever to 0.54 for cough of > or = 2 weeks.

CONCLUSION

In this TB prevalence survey, CXR screening, but not symptom screening, was a sensitive alternative to sputum examination of all participants.

Treatment outcome of asthma after one year follow-up in health centres of several developing countries

SETTING

Seven selected out-patient clinics caring for asthma patients in Algeria, Guinea, Morocco, Syria, Turkey and Vietnam.

DESIGN

Evaluation of treatment outcomes after one year of follow-up of a cohort of asthma patients consecutively enrolled in a prospective study evaluating routine practice.

RESULTS

Among 310 asthma patients registered, the following outcomes were recorded after one year of follow-up: 95 (31%) successful, 61 (20%) under control, 35 (11%) failed, 116 (37%) defaulted and 3 (1%) transferred. Among the 167 (53.9%) patients still on treatment after one year there was a substantial increase in the proportion of patients classified as intermittent at the end of treatment (from 11% to 53%), with a decrease in all categories of persistent asthma (from 34% to 12% for mild, 45% to 28% for moderate and 10% to 8% for severe asthma).

CONCLUSIONS

While patients' quality of life can be improved if they follow regular treatment, the key challenge in providing care is to ensure that patients adhere to their treatment.

Outcome of pulmonary multidrug-resistant tuberculosis: a 6-yr follow-up study

A retrospective study was performed to determine factors associated with the outcome of pulmonary multidrug-resistant tuberculosis (MDR-TB) in Taipei, Taiwan. All patients newly diagnosed with pulmonary MDR-TB in a referral centre from 1992-1996 were enrolled and their outcome over the subsequent 6 yrs was determined. A total of 299 patients were identified, comprising 215 (71.9%) males and 84 (28.1%) females with a mean age of 47.3 yrs. The patients received a mean of 3.7 effective drugs. Out of the 299 patients, 153 (51.2%) were cured, 31 (10.4%) failed, 28 (9.4%) died and 87 (29.1%) defaulted. Of the 125 patients receiving second-line drugs with ofloxacin, 74 (59.2%) were cured. Those who received ofloxacin had a lower risk of relapse than those receiving only first-line drugs (hazard ratio (HR) 0.16, 95% confidence interval (CI) 0.03-0.81) and a lower risk of TB-related death than those receiving second-line drugs but not ofloxacin (adjusted HR 0.50, 95% CI 0.31-0.82). In conclusion, multidrug-resistant tuberculosis patients who received ofloxacin were more likely to be cured, and were less likely to die, fail or relapse. The utility of new-generation fluoroquinolones, such as moxifloxacin, in the treatment of multidrug-resistant tuberculosis needs to be evaluated. Default from treatment is a major challenge in the treatment of multidrug-resistant tuberculosis.

The spectrum of disease in children treated for tuberculosis in a highly endemic area

BACKGROUND

Children contribute a substantial proportion of the global tuberculosis (TB) caseload, particularly in endemic areas, where little is known about their spectrum of disease.

OBJECTIVE

To document the complete disease spectrum, with relevant age- and HIV-related differences, in children treated for TB in a highly endemic community.

METHODS

A prospective descriptive study was conducted from February 2003 to October 2004 at five primary health care clinics in Cape Town, South Africa, including all children (< 13 years of age) treated for TB.

RESULTS

In total, 439 children received anti-tuberculosis treatment. The spectrum of disease included 85 (19.4%) 'not TB', 307 (86.7%) intra-thoracic TB and 72 (20.3%) extra-thoracic TB (25 [5.7%] with co-existing intra- and extra-thoracic disease were included in both groups). In non-HIV-infected children, disseminated (miliary) disease (9/11, 81.8%) and tuberculous meningitis (TBM) (10/13, 76.9%) were predominantly documented in children < 3 years of age. In HIV-infected children, complicated Ghon focus and disseminated (miliary) disease were significantly more common (6/25, 24.0%) than in non-HIV-infected children (12/414, 2.9%) (OR 10.9, 95% CI 3.2-35.9).

CONCLUSION

This study describes the complete disease spectrum observed in children treated for TB in a highly endemic area. Children suffered significant morbidity, with most severe disease recorded in very young and/or HIV-infected children.

Ensuring the quality of asthma case management

An evaluation based on recording the number of patients and evaluating their treatment outcomes provides the information necessary to plan the provision of care, determine the analysis of the situation and revise practice if the results are not satisfactory. The standardised tools proposed for this evaluation are: a district register for new persistent asthma patients, quarterly reports of case finding and an annual report of cohort patient follow-up. The main indicators of quality of care based on register information given by the cohort analysis are the percentage of defaulters and the percentage of patients whose asthma is controlled or well controlled after 1 year of follow-up. The services involved in asthma management should be adapted to the local situation in each country. In particular, the health service structure and national guidelines must be respected, and services involved in asthma management should be implemented in stages. Operational research within the services is essential to ensure that the services provided are appropriate. This type of research involves the health personnel responsible for patient management, provides them with new knowledge and helps them to resolve problems they are confronted with on a regular basis. It also inspires critical thinking, which is crucial to both research and practice.

How to organise the care of asthma patients

Care of asthma patients must be well organised to ensure their regular follow-up. The quality of care of asthma patients is improved by a partnership between the patients and care givers to achieve the objectives of long-term treatment. Health education for the patient must be progressive, repetitive and adapted to the level of the patient. The goal of health education is treatment adherence and the ability of the patient to participate in the management and control of the condition. Health workers must listen to the patient, teach techniques (particularly drug inhalation) and give information on the disease, the objectives of the treatment, the effects of the drugs prescribed and the organisation of follow-up. A patient card with essential information should be given to the patient. It includes the assessed grade of severity, the patient's best peak expiratory flow, usual long-term treatment prescribed and the dates of the scheduled appointments. An illustration of the inhalation technique is also provided on the patient card to demonstrate how to inhale the drugs. The organisation and coordination of the care givers at different levels of the health services involved in asthma management must be organised, and essential equipment must be made available.

Managing acute attacks of asthma

Asthma patients may present to the health services with acute attacks. Assessment and management must be undertaken rapidly. The patient must be given oxygen and then assessed by measuring the peak expiratory flow rate (PEF) before and after salbutamol, and by questioning and examining the patient. Using the information gathered, the caregiver is able to assess the grade of severity of the attack and provide appropriate care according to the severity. Patients judged as having imminent respiratory arrest must be immediately transferred to intensive care after starting treatment. Patients judged as having a severe attack are given oxygen, salbutamol, systemic corticosteroids and are closely monitored. They must remain for a minimum of 6 h prior to being either hospitalised or sent home. Patients with moderate attacks are given salbutamol and oral prednisone and are kept under observation for a minimum of 2 h. If stable at least 1 h after last dose of salbutamol, they may be sent home. Patients with mild attacks are given inhaled salbutamol and kept under observation for a minimum of 2 h. If stable at least 1 h after the last dose of salbutamol, they may be sent home. Careful and correct follow-up after an attack is crucial.

Treating the patient with asthma

Treatment of patients with asthma, although straight-forward, is a challenge. The treatment is prolonged, often for life, and must be taken regularly. For low-income countries, the treatment must be efficient and feasible. Two drugs are indicated: one to reduce the inflammation and one to relieve the airflow obstruction. The treatment and its goals need to be explained to the patient with asthma and to family members, as the success of treatment is dependent on their cooperation. The medications that reduce inflammation are corticosteroids. Inhaled beclomethasone 250 microg per puff is indicated for every patient who has persistent asthma. The medication recommended for relief of airflow obstruction is inhaled salbutamol/100 microg per puff. A four-step approach to treatment is indicated, starting with the dose of medication indicated by the degree of severity of the asthma, and periodically adjusted. When the condition improves and remains stable for at least 3 months, the dose of medication may be reduced to fit the grade of severity assessed at that time. In the event the condition worsens, the treatment is increased stepwise. This approach to treatment has every promise to improve the life and health of patients with asthma.

The bacteriologic yield in children with intrathoracic tuberculosis

This report documents the bacteriologic yield in children who received treatment for intrathoracic tuberculosis in an area where it is highly endemic. A total of 307 children were included in the study, and bacteriologic confirmation was achieved in 122 (62.2%) of 196 children from whom specimens were collected. The lowest bacteriologic yield was recorded for the 69 children with uncomplicated lymph node disease (24 [34.8%] had bacteriologic confirmation). The high overall bacteriologic yield indicates the need to reassess the value of bacteriology-based approaches to diagnosis of intrathoracic tuberculosis in children, particularly in areas of endemicity where they frequently present with advanced disease.

How to diagnose asthma and determine the degree of severity of the disease

Asthma care begins with establishing the diagnosis and determining the severity of the disease. The key elements are the history of the disease and the measurements of peak expiratory flow (PEF). The characteristic of asthma is variability. A history of chest symptoms that are variable is typical of asthma. Demonstrating a variation of PEF > or = 20% establishes a definite diagnosis of asthma. This variability is demonstrated either, in patients with normal PEF when they are well, by measuring a decrease in PEF during a period when the patient has symptoms of asthma or, in patients with PEF < normal, an improvement after inhalation of salbutamol or after a period of treatment. Classifying the severity of asthma is also based on history and lung function measurement. Patients with PEF <60% or continuous symptoms are classified as severe persistent. Those with PEF 60-79% or daily symptoms (not continuous) are classified as moderate persistent. Those with symptoms more than once per week but less than daily and PEF > or = 80% are classified as mild persistent. Those with symptoms less than once per week and PEF > or = 80% are classified as intermittent. Establishing the diagnosis and assessing the severity are crucial to high quality care.

Management of asthma: the essentials of good clinical practice

Asthma is a condition that affects all countries worldwide. It is a chronic, disabling condition that diminishes the quality of life and the economic prosperity of those who live with it. The majority of persons living with asthma are from developing countries. Asthma management necessitates long-term treatment that is expensive, making it less accessible to poor people. The cost of medications is the key factor preventing people living with asthma from having access to care that has the potential to relieve their suffering, improve their quality of life and enhance their economic status. Asthma is a disease caused by environmental exposures. Genetic factors predispose certain people to developing asthma once they are exposed to the causative agents, and certain factors can trigger symptomatic episodes of asthma in those who have already developed the disease. Certain clinical characteristics differentiate asthma from other chronic lung conditions. The most important of these is that the symptoms and functional disability caused by asthma vary from one occasion to another. In those with less severe asthma, they may be present on some occasions and not others; in those with more severe asthma, their degree of severity varies from one time to another.

Implementation of asthma guidelines in health centres of several developing countries

SETTING

Nine selected out-patient clinics caring for asthma patients in Algeria, Guinea, Ivory Coast, Kenya, Mali, Morocco, Syria, Turkey and Vietnam.

DESIGN

Prospective enrolment of consecutive patients considered by the practitioner to have asthma with evaluation of adherence of the practitioner with recommended standard case management, including proportion of patients confirmed to have asthma, proportion in whom severity was correctly graded and proportion in whom treatment with inhaled corticosteroids corresponded to severity grade.

RESULTS

Of 499 consecutive patients, 456 (91%) were enrolled and evaluated. The diagnosis was confirmed in 263 (58%). Agreement between the practitioner and the guidelines in assigning grade of severity was moderate overall (kappa = 0.42). It was higher for assignment of grade using symptoms (K = 0.51), but poor for assignment of grade using peak expiratory flow (PEF) rate (kappa = 0.29), with practitioners tending to underestimate the severity. Agreement between the practitioners' assessment of severity and treatment with inhaled corticosteroids was poor (kappa = 0.18), with underutilisation of inhaled corticosteroids.

CONCLUSIONS

Practitioners caring for asthma patients in this study tended to underutilise the PEF rate in assessing their patients and underutilised treatment of patients with inhaled corticosteroids.

Should tuberculosis treatment and control be addressed differently in HIV-infected and -uninfected individuals?

Infection with HIV drives the tuberculosis epidemic, especially in sub-Saharan Africa, where up to 75% of individuals with tuberculosis are co-infected with HIV. This article reviews the epidemiological link between the conditions, how tuberculosis diagnosis and treatment differ between HIV-infected versus -uninfected individuals and the span of additional measures required to prevent and control HIV-related tuberculosis. Tuberculosis chemotherapy using standard short-course regimens is highly effective in both groups, and treatment follows the same principles. It differs in certain aspects, such as when antiretroviral treatment should be started in HIV-infected individuals with tuberculosis and consideration of drug-drug interactions between the rifamycins and certain antiretroviral drugs. Control of HIV-related tuberculosis requires, fundamentally, control of HIV transmission. Meanwhile, it is necessary to make concentrated efforts to intensify high-quality tuberculosis services employing the directly observed treatment, short-course (DOTS) strategy, carry out extensive research towards an evidence-based model for the expanded scope of collaborative tuberculosis and HIV/AIDS interventions, and ensure efficient implementation of the findings and recommended policies. The challenge is gigantic, and both robust within-country and international leadership and competent management capabilities will be required, in addition to substantial human and financial resources.

Management of tuberculosis in children in low-income countries

Children become infected when they are exposed to infectious adults with smear-positive tuberculosis (TB). Most children become infected, but few progress to disease (TB). Children at greatest risk of developing disease are those younger than 5 years of age, HIV-infected and severely malnourished. TB is diagnosed in a child when the child has been exposed to an infectious case, has symptoms and a radiological picture suggestive of TB. Children are treated by the DOTS strategy, and can be treated with 6- or 8-month regimens. HIV-infected children are treated with the same regimens. Children under 5 years of age exposed to an infectious case or infected with TB (tuberculin skin test positive) who are asymptomatic must receive preventive chemotherapy (isoniazid for 6 months). Babies born to mothers with active TB must be managed carefully, as they could have congenital TB, and if they do not have TB they will need preventive chemotherapy for 6 months. BCG is indicated in all children soon after birth, except for those with symptomatic HIV infection. The main aim of any TB programme is to prevent the spread of TB, and also the spread to children, which is best achieved by early detection and treatment of adults with smear-positive TB.