[Thirty years of tuberculosis control in Cameroon: alternating "vertical" and "horizontal" health care delivery systems]

Patient-Pathway Analysis of Tuberculosis Services in Cameroon

In Cameroon, in 2019, tuberculosis (TB) treatment coverage was estimated at 53%, indicating that almost half of all people sick with TB were not diagnosed or linked to care. To inform strategies to improve access to TB services, we conducted an evaluation of the alignment between patient-initiated care-seeking behavior and spatial and institutional allocation of TB services. Data sources included the Cameroon Demographic and Health Survey (2018), the Health Facility List (2017), and routinely collected TB surveillance data. Data visualization was performed in Tableau and QGIS. The pathway analysis showed that only an estimated 9% of people attended a health facility providing TB services at initial care-seeking, with access varying from <3% to 16% across the ten regions of the country. While 72% of government and 56% of private hospitals (Level 2 facilities) provide TB services, most Cameroonians (87%) initially chose primary care (Level 1) or informal private sector sites (Level 0) without TB services. The gaps were greatest in regions with the highest prevalence of poverty, a significant determinant for TB. These results indicate that access may be improved by expanding TB services at both public and private facilities across the country, prioritizing regions with the greatest gaps.

Tuberculosis Chemotherapy Outcome in the Littoral Region of Cameroon: A Meta-analysis of Treatment Success Rate between 2014 and 2016

Background

Tuberculosis (TB) is a public health concern, especially in resource-constrained countries like Cameroon. TB drug resistance is a major obstacle to control and prevent.

Design

Data from 2014 to 2016 on the outcome of anti-TB treatment in the Littoral Region were reviewed manually and analysed using the meta-analysis concept. The treatment success rates (TSR) were the primary outcome used for this study. The heterogeneity statistics (I ²) was computed to orientate the choice of the best statistical model (binary fixed effect or random) to compute pooled value of TSR.

Results

Using an intention-to-treat analysis, the pooled proportions of HIV-uninfected TB patients successfully cured from TB were low and slightly decreased by 1% between 2014 and 2016. Regarding HIV-infected TB patients, pooled values of TSR were lower than those of their HIV-negative counterparts with values ranging from 71% (95% CI: 63%-83%; I ² = 71.16%) in 2014 to 68% (95% CI: 58%-79%; I ² = 70.97%) in 2016. In addition, no heterogeneity was found in three years (I ² = 0.0%; P value = 1). These cure rates were strongly and negatively correlated with the rates of patients lost to follow-up regardless of the year. In HIV-infected patients, the pooled values of ITT analysis-based treatment success rates were 73% (χ ² = 13.92, P value = 0.0002), 71% (χ ² = 7.26, P value = 0.007), and 68% (χ ² = 8.02, P value = 0.004), respectively. The coverage rates with cotrimoxazole (CTX) gradually increased over year ranging from 78.90% in 2014 to 94.17% in 2016, similar to the coverage rate for ARV therapy that was 60.06% in 2014 against 90% in 2016. A positive and statistically significant correlation was found between the success of the anti-TB therapy in HIV-infected patients and coverage rates with CTX and ARV.

Conclusion

An improvement in the reduction of percentage of lost to follow-up and coverage with CTX and ARV therapy could greatly increase chances to efficiently control TB in Cameroon.

A Centre for the Diagnosis and Treatment of Tuberculosis (CDT) in a resource-limited setting: a dragnet for patients with heart disease?

Background

Cardiovascular disease is a growing public health problem in sub-Saharan Africa. Cough and dyspnea are symptoms of both lung diseases and heart failure. This study aimed at determining the contribution of cardiac diseases versus pulmonary diseases in the etiological profile of patients presenting with cough and dyspnea in a Center for the Diagnosis and Treatment of Tuberculosis (CDT), in a semi-rural area in Cameroon.

Methods

This is a cross-sectional analysis of data from patients aged 18 years or more who consulted for cough and or dyspnea between December 2009 and December 2010 at the CDT of Lafe-Baleng, Bafoussam, Cameroon.

Results

A total of 1196 patients were received for various complaints during the study period; 348 (29.1%) of them presented with cough and or dyspnea, and were included in the study. 186 patients (53.4%; 95% CI: 48.2-58.6) had a pure cardiac disease, while 122 patients (35.1%; 95% CI: 30.2-40.2) had a pulmonary disease. The prevalence of hypertension was 50.9%, and hypertensive heart disease was the most frequent cardiac disease with a prevalence rate of 37.6%. Heart failure was diagnosed in 222 patients, representing 63.8% (95% CI: 58.9-68.9) of patients with cough and or dyspnea, and 18.6% (95% CI: 16.5-21.0) of all the patients received at the CDT of Lafe-Baleng during the study period. Compared to patients with a pulmonary disease, patients with cardiac disease were older (p < 0.001) and more likely to present with dyspnea (p < 0.001) and to have hypertension (p < 0.001).

Conclusion

We found a high prevalence of heart failure in this Centre for the Diagnosis and Treatment of Tuberculosis thus, a veritable dragnet for patients with heart disease. Our findings emphasize the urgent need to increase the access to cardiovascular care and to continuously raise the awareness of the communities on cardiovascular diseases in Cameroon.

Strong decrease in streptomycin-resistance and absence of XDR 12 years after the Reorganization of the National Tuberculosis Control Program in the Central Region of Cameroon

Background

In the 1990s, resistance rates of 15% for streptomycin-resistance and 0.6% for multidrug-resistance (MDR) were reported from the Central Region of Cameroon. This work assesses drug resistant tuberculosis in this region 12 years after reorganization of the National Tuberculosis Control Program (NTCP).

Methods

This cross-sectional study was conducted from April 2010 to March 2011 in Jamot Hospital in Yaoundé, Cameroon. Only patients with smear positive pulmonary tuberculosis were included. Sputa were cultured and subsequently underwent drug susceptibility testing (DST). All consenting individuals were tested for their HIV status.

Results

A total of 665 smear positive pulmonary tuberculosis patients were enrolled. The HIV prevalence was 28.5% (95%CI [25.2–32.1]). Of the 582 sputa that grew Mycobacterium tuberculosis complex species, DST results were obtained for 576. The overall resistance rate was 10.9% (63/576). The overall resistance rates for single drug resistance were: isoniazid-resistance 4.7% (27/576), streptomycin-resistance 3.3% (19/576), rifampicin-resistance 0.2% (1/576), kanamycin-resistance 0.2% (1/576) and ofloxacin-resistance 0.2% (1/576). The MDR rate was 1.1% (6/576) and no extensively drug resistant tuberculosis (XDR) was detected.

Conclusions

The data show that reorganization of the NTCP resulted in a strong decrease in streptomycin-resistance and suggest that it prevented the emergence of XDR in the Central Region of Cameroon.

The interface between the national tuberculosis control programme and district hospitals in Cameroon: missed opportunities for strengthening the local health system -a multiple case study

BACKGROUND

Tuberculosis remains a major public health problem in sub-Saharan Africa. District hospitals (DHs) play a central role in district-based health systems, and their relation with vertical programmes is very important. Studies on the impact of vertical programmes on DHs are rare. This study aims to fill this gap. Its purpose is to analyse the interaction between the National Tuberculosis Control Programme (NTCP) and DHs in Cameroon, especially its effects on the human resources, routine health information system (HIS) and technical capacity at the hospital level.

METHODS

We used a multiple case study methodology. From the Adamaoua Region, we selected two DHs, one public and one faith-based. We collected qualitative and quantitative data through document reviews, semi-structured interviews with district and regional staff, and observations in the two DHs.

RESULTS

The NTCP trained and supervised staff, designed and provided tuberculosis data collection and reporting tools, and provided anti-tuberculosis drugs, reagents and microscopes to DHs. However, these interventions were limited to the hospital units designated as Tuberculosis Diagnostic and Treatment Centres and to staff dedicated to tuberculosis control activities. The NTCP installed a parallel HIS that bypassed the District Health Services. The DH that performs well in terms of general hospital care and that is well managed was successful in tuberculosis control. Based on the available resources, the two hospitals adapt the organisation of tuberculosis control to their settings. The management teams in charge of the District Health Services are not involved in tuberculosis control. In our study, we identified several opportunities to strengthen the local health system that have been missed by the NTCP and the health system managers.

CONCLUSION

Well-managed DHs perform better in terms of tuberculosis control than DHs that are not well managed. The analysis of the effects of the NTCP on the human resources, HIS and technical capacity of DHs indicates that the NTCP supports, rather than strengthens, the local health system. Moreover, there is potential for this support to be enhanced. Positive synergies between the NTCP and district health systems can be achieved if opportunities to strengthen the district health system are seized. The question remains, however, of why managers do not take advantage of the opportunities to strengthen the health system.