Identifying research questions for HIV, tuberculosis, tuberculosis-HIV, malaria, and neglected tropical diseases through the World Health Organization guideline development process: a retrospective analysis, 2008-2018

OBJECTIVES

World Health Organization (WHO) guidelines for health programmes and healthcare delivery are the foundation of its technical leadership in public health and essential to decision-making globally. A key function of guideline development is to identify areas in which further evidence is needed because filling these gaps will lead to future improvements in population health. The objective of this study was to examine the knowledge gaps and research questions for addressing those gaps generated through the WHO guideline development process, with the goal of informing future strategies for improving and strengthening the guideline development process.

STUDY DESIGN

We did a systematic, retrospective analysis of research questions identified in the published guidelines.

METHODS

We analyzed guidelines published between January 1, 2008, and December 31, 2018, by the Communicable Diseases Cluster in five disease areas: tuberculosis (TB), HIV, malaria, TB-HIV, and neglected tropical diseases (NTDs). Research questions were extracted independently by two researchers. We analyzed the distribution of research questions by disease and by topic category and did a qualitative assessment of optimum practice for research question generation during the guideline development process.

RESULTS

A total of 48 guidelines were included: 26 on HIV, 1 on malaria, 11 on TB, 5 on TB/HIV, and 5 on NTDs. Overall, 36 (75%) guidelines encompassed a total of 360 explicit research questions; the remainder did not contain specific research questions. The number of research questions that focused on TB was 49, TB/HIV was 38, HIV was 250, and NTDs was 23. The number of research questions that focused on diagnosis was 43 (11.9%) of 360, prevention was 62 (17.2%), treatment was 103 (28.6%), good practice was 12 (3.3%), service delivery was 86 (23.8%), and other areas was 54 (15%). Research questions were often not formulated in a specific or actionable way and were hard to identify in the guideline. Examples of good practice identified by the review team involved the generation of specific and narrowly defined research questions, with accompanying recommendations for appropriate study design.

CONCLUSIONS

The WHO must strengthen its approach to identifying and presenting research questions during the guideline development process. Ensuring access to research questions is a key next step in adding value to the guideline development process.

Identifying factors affecting age at first semen freezing and age at first semen use in Sahiwal bulls

Aim:

The objective of the study was to evaluate the effects of non-genetic factors on reproduction traits viz. age at first semen freezing and age at first semen use of breeding bulls in Sahiwal bulls by fitting least-squares analysis.

Materials and Methods:

The information on reproduction traits of 43 Sahiwal breeding bulls belonging to 8 sets of Sahiwal breeding program at Indian Council of Agricultural Research-National Dairy Research Institute (ICAR-NDRI), Karnal (Haryana), India during 27 years (1987-2013) were analyzed using fixed linear model. The information was collected from AI records, reproduction sheets, and bull AI register maintained at different sections of Institute viz. record room of Dairy Cattle Breeding Division (DCB), Cattle Yard, Artificial Breeding Research Centre, ICAR-NDRI, Karnal.

Results:

The average age at first semen freezing and age at first semen use of Sahiwal breeding bulls was estimated as 3.17±0.01 years and 5.35±0.01 years, with the coefficient of variation 18.93% and 20%, respectively. The overall least-squares mean for age at first semen freezing and age at first semen use was estimated as 3.14±0.09 years and 5.25±0.02 years, respectively, in Sahiwal breeding bulls. Period of freezing/use had significant effects on reproductive traits (p<0.01). Season had no significant effect on any of the traits considered in this study.

Conclusion:

It can be concluded that management inputs such as nutrition, breeding, and optimum environment should be taken care of to optimize age at first semen freezing and age at first semen use for better utilization of superior germplasm.

Open access for operational research publications from low- and middle-income countries: who pays?

Open-access journal publications aim to ensure that new knowledge is widely disseminated and made freely accessible in a timely manner so that it can be used to improve people's health, particularly those in low- and middle-income countries. In this paper, we briefly explain the differences between closed- and open-access journals, including the evolving idea of the 'open-access spectrum'. We highlight the potential benefits of supporting open access for operational research, and discuss the conundrum and ways forward as regards who pays for open access.

The looming epidemic of diabetes-associated tuberculosis: learning lessons from HIV-associated tuberculosis

The prevalence of diabetes mellitus is increasing at a dramatic rate, and countries in Asia, particularly India and China, will bear the brunt of this epidemic. Persons with diabetes have a significantly increased risk of active tuberculosis (TB), which is two to three times higher than in persons without diabetes. In this article, we argue that the epidemiological interactions and the effects on clinical presentation and treatment resulting from the interaction between diabetes and TB are similar to those observed for human immunodeficiency virus (HIV) and TB. The lessons learned from approaches to reduce the dual burden of HIV and TB, and especially the modes of screening for the two diseases, can be adapted and applied to the screening, diagnosis, treatment and prevention of diabetes and TB. The new World Health Organization (WHO) and The Union Collaborative Framework for care and control of TB and diabetes has many similarities to the WHO Policy on Collaborative Activities to reduce the dual burden of TB and HIV, and aims to guide policy makers and implementers on how to move forward and combat this looming dual epidemic. The response to the growing HIV-associated TB epidemic in the 1980s and 1990s was slow and uncoordinated, despite clearly articulated warnings about the scale of the forthcoming problem. We must not make the same mistake with diabetes and TB. The Framework provides a template for action, and it is now up to donors, policy makers and implementers to apply the recommendations in the field and to 'learn by doing'.

Morbidity in HIV-1-infected individuals before and after the introduction of antiretroviral therapy: a longitudinal study of a population-based cohort in Uganda

BACKGROUND

We compared morbidities in HIV-1-infected patients before and after the introduction of antiretroviral therapy (ART) in a rural Ugandan cohort followed from 1990 to 2008. ART was introduced in 2004.

METHODS

Random-effects Poisson regression models were used to estimate incidence rates of World Health Organization (WHO) stage-defining diseases in HIV-infected individuals aged 13 years or older with known seroconversion dates, and in an age-stratified sample of HIV-negative individuals.

RESULTS

The most common morbid event was bacterial pneumonia, with an incidence of 7.4/100 person-years (pyr) among 309 HIV seroconverters and 1.3/100 pyr among 348 HIV-negative participants [hazard ratio (HR) 5.64; 95% confidence interval (CI) 3.6-8.8]. Among seroconverters, the incidence of the acquisition of any WHO stage-defining disease rose from 14.4/100 pyr (95% CI 11.1-18.6) in 1990-1998 to 46.0/100 pyr (95% CI 37.7-56.0) in 1999-2003. Following the introduction of ART, the incidence among seroconverters declined to 36.4/100 pyr (95% CI 27.1-48.9) in 2004-2005 and to 28.3/100 pyr (95% CI 21.2-37.8) in 2006-2008. At the individual level, a higher rate of acquiring any WHO stage-defining disease was independently associated with lower CD4 cell count, longer duration of HIV infection and older age. In addition, individuals who had been on ART for longer than 12 months had a substantially lower rate of any WHO stage disease than those not yet on ART (adjusted HR 0.35; 95% CI 0.2-0.6).

CONCLUSION

Morbidity in HIV-positive participants decreased following the introduction of ART, and this decline was more marked with increasing duration on ART. The benefits of decreased HIV-related morbidity from ART lend support to urgent efforts to ensure universal access to early diagnosis of HIV infection and to ART, especially in rural Africa.

Health transition in Africa: practical policy proposals for primary care

Sub-Saharan Africa is undergoing health transition as increased globalization and accompanying urbanization are causing a double burden of communicable and noncommunicable diseases. Rates of communicable diseases such as HIV/AIDS, tuberculosis and malaria in Africa are the highest in the world. The impact of noncommunicable diseases is also increasing. For example, age-standardized mortality from cardiovascular disease may be up to three times higher in some African than in some European countries. As the entry point into the health service for most people, primary care plays a key role in delivering communicable disease prevention and care interventions. This role could be extended to focus on noncommunicable diseases as well, within the context of efforts to strengthen health systems by improving primary-care delivery. We put forward practical policy proposals to improve the primary-care response to the problems posed by health transition: (i) improving data on communicable and noncommunicable diseases; (ii) implementing a structured approach to the improved delivery of primary care; (iii) putting the spotlight on quality of clinical care; (iv) aligning the response to health transition with health system strengthening; and (v) capitalizing on a favourable global policy environment. Although these proposals are aimed at primary care in sub-Saharan Africa, they may well be relevant to other regions also facing the challenges of health transition. Implementing these proposals requires action by national and international alliances in mobilizing the necessary investments for improved health of people in developing countries in Africa undergoing health transition.

Recombinant NY‐ESO‐1 Cancer Antigen: Production and Purification under cGMP Conditions

The cancer-testis antigen, NY-ESO-1, has been engineered into a bacterial expression plasmid which incorporates a His6-tag. The plasmid was transfected into E. coli strain BL21 and Master and Working cell banks generated from this expression system. Three 15-litre fermentations were performed under cGMP (code of Good Manufacturing Practice) conditions and the crude NY-ESO-1 tagged protein isolated as solubilised inclusion bodies. A three-step cGMP chromatography process (immobilised metal affinity, anion exchange, and hydrophobic interaction) was utilised to purify the protein. The purified NY-ESO-1 is being used in early stage human cancer vaccine trials in Australia and the U.S.A.

Clinical efficacy and safety of the factor VIII/von Willebrand factor concentrate BIOSTATE in patients with von Willebrand's disease: a prospective multi-centre study

von Willebrand's disease (VWD) is an inherited bleeding disorder characterized by deficient levels of or dysfunctional von Willebrand factor (VWF). This phase II/III open-label, multicentre study evaluated the efficacy and safety of BIOSTATE, a high purity plasma-derived double-virus inactivated FVIII/VWF concentrate, when used in non-surgical bleeds, surgical procedures and prophylactic therapy in VWD patients for whom desmopressin treatment was deemed ineffective, inadequate or contraindicated. Twenty three patients (7 type 1, 9 type 2 and 7 type 3; 12 male, 11 female), who received FVIII/VWF concentrate as part of their VWD management, were recruited prospectively between December 2004 and May 2007 from eight centres in Australia and New Zealand. BIOSTATE dosing was based on pre-treatment FVIII:C and/or VWF:RCo plasma levels and a predetermined dosing guide. Haemostatic efficacy of BIOSTATE was rated as excellent or good for all major and minor surgery events, long-term prophylaxis, and for four of the six assessable non-surgical bleeding events. Blood transfusions were required by two major surgery patients as well as one patient with a non-surgical bleed. The median overall exposure to BIOSTATE across all groups was 8 days, greater in the prophylactic group (range 53-197) compared with major surgery (3-24), minor surgery (1-8) and non-surgical bleeds (1-10). BIOSTATE was shown to be efficacious and well tolerated when treating patients with VWD. This study also provides important insights into dosing regimens with BIOSTATE and the role of monitoring therapy with FVIII:C and VWF:RCo.

Translating global health research aims into action: the example of the ALPHA network

There is increasing consensus on the importance of strengthening global health research to meet health and development goals. Three key global health research aims are to ensure that research (i) addresses priority health needs, (ii) contributes to policy development, and (iii) adds value to investments in developing countries through South-South collaboration and capacity-strengthening in the South. The ALPHA network (Analysing Longitudinal Population-based HIV/AIDS data on Africa) is an illustrative example of how these global health research aims can be translated into action. The network facilitates additional collaborative HIV epidemiological research among six independent research projects in Africa studying population-based cohorts. Under the first of the earlier mentioned aims, the network addresses key epidemiology research issues in HIV/AIDS which are crucial to making progress and monitoring progress in the response against HIV/AIDS. Under the second aim, the network's scientific programme of research has contributed to strengthening the evidence base on HIV epidemiology in Africa and has informed policy development in areas such as targeted HIV prevention, social support, monitoring epidemic response and epidemic forecasting. Under the third aim, investment in the network has added value to the research investment in the individual projects through capacity development among African researchers as well as through the collaborative research outputs of the individual projects. Lessons from the network are relevant to collaborations facing similar challenges in other areas of global health research. These include the importance of establishing transparent and efficient governance for research collaborations, developing advance consensus on data sharing, ensuring effective communication for networking and demonstrating the added value of research investment in South-South collaborations.

Trends in age at first sex in Uganda: evidence from Demographic and Health Survey data and longitudinal cohorts in Masaka and Rakai

OBJECTIVES

To derive the best possible estimates of trends in age at first sex (AFS) among successive cohorts of Ugandan men and women based on all the data available from the Demographic and Health Surveys (DHS) and cohort studies in Masaka and Rakai districts.

METHODS

The datasets from the DHS, Masaka cohort and Rakai cohort were analysed separately. Survival analysis methods were used to estimate median AFS for men and women born in the 1950s-1980s and to compute hazard ratios for first sex, comparing later cohorts with earlier cohorts.

RESULTS

The DHS and Masaka data showed an increase in AFS in women in the more recent birth cohorts compared with those born before 1970, but this was less apparent in the Rakai data. Successive male cohorts in Masaka appeared first to have an increased AFS which subsequently decreased, a trend that was also apparent (but not significant) in the DHS data. Younger men in Rakai had an earlier AFS than those born before 1980.

CONCLUSIONS

Women in Uganda who were born after 1970 have, on average, had sex at a later age than those born earlier. For men, AFS has not changed consistently over the period in question. Differences between Masaka and Rakai may reflect socioeconomic differences. Most of the change in AFS occurred too late to have contributed to the initial decline in the incidence of HIV.

Community engagement in health research: two decades of experience from a research project on HIV in rural Uganda

OBJECTIVES

To describe how a research project on HIV epidemiology in rural Uganda has engaged the community over the past two decades, describing activities, opportunities and challenges that have arisen.

METHOD

The review draws on the experience of the authors as investigators involved in the project at various times since its inception in 1989, and on project documents and peer-reviewed publications.

RESULTS

The project attracts community interest, participation and support mostly through community groups. The three main areas of activity are: health care and promotion, HIV/AIDS prevention and care, and community development aimed at poverty reduction. Key opportunities arise from the long-term joint commitment of the project and the community over nearly 20 years, and the potential to accommodate research beyond HIV. Challenges arise from participation fatigue, countered by innovations for the community and investment in capacity development for staff, and from the need to balance community development expectations and the project focus on HIV research.

CONCLUSIONS

Judged by criteria of longevity, acceptance, and scientific output, community engagement in this HIV research project in rural Uganda has been successful. The experience from this project contributes to the collective documentation and analysis of case studies from various research projects in developing countries which identify good practices from multiple stakeholder perspectives.

Investigation by bioassay of the efficacy of sodium hydroxide treatment on the inactivation of mouse-adapted scrapie

Sodium hydroxide (NaOH) has been shown to reduce the infectivity of transmissible spongiform encephalopathy (TSE) agents. This study investigated the efficacy of sodium hydroxide at 0.1M, 0.25M and 0.5M concentrations for the inactivation of mouse-adapted scrapie strain ME7. Times and temperatures modelled conditions used in an industrial plasma fractionation plant for sanitisation of ultrafilters, and the sodium hydroxide component of Clean In Place sanitisation. The concentration of scrapie ME7 brain homogenate in NaOH test solutions was 1% (w/v). At the end of incubation periods, the samples were adjusted to neutral pH prior to intracerebral inoculation into mice for bioassay. The conditions of 0.1M NaOH at 60 degrees C for 2min and 0.25M NaOH at 30 degrees C for 60min were found to inactivate 3.96 and 3.93logs of scrapie, respectively. Use of 0.5M NaOH at 30 degrees C for 60 or 75min was found to inactivate >or=4.23 and 4.15logs of scrapie. This indicates that the use of these conditions in an industrial process would substantially reduce prion infectivity.

A research agenda to promote the management of childhood tuberculosis within national tuberculosis programmes

Despite causing considerable mortality and morbidity, childhood tuberculosis (TB) is a neglected aspect of national tuberculosis programmes (NTPs), particularly in developing countries. A recently published World Health Organization (WHO) document, "Guidance for national tuberculosis programmes on the management of tuberculosis in children", addresses the effective management of children within NTPs. Taking into account this document and following a literature review, research priorities are identified to promote the integration of childhood tuberculosis into NTPs. The implications of human immunodeficiency virus (HIV) infection apply to all aspects of this agenda. The major priorities are: --The prospective evaluation of the incidence of childhood TB and the monitoring of programme performance with regard to childhood TB. A lot of data are already available within many programmes that could inform this process. --Study of the criteria to suspect and diagnose childhood TB using uniform criteria as defined in the Guidance document mentioned above. Evaluate new methodologies for this purpose. --Study the pharmacokinetics and toxicity of anti-tuberculosis drugs in children and the long-term outcome of the treatment of children. --Determine how many childhood contacts of adult pulmonary TB qualify for chemoprophylaxis in different communities. Study chemoprophylaxis for drug-resistant TB and chemoprophylaxis among certain groups of adolescents. --Document at what level children enter NTPs, the availability of qualified staff and their effectiveness in performing diagnostic investigations and ensuring quality care. Study the role of families as agents for DOTS, evaluate private sector participation in childhood TB management. --Document bacille Calmette-Guérin (BCG) immunisation complications and study management strategies.

Ethambutol dosage for the treatment of children: literature review and recommendations

The currently recommended daily dose of ethambutol (EMB) for the treatment of tuberculosis (TB) in children varies from a maximum daily dose of 15 mg/kg body weight daily (without a range) to 15-20 mg/kg and 20 mg/ kg (range 15-25 mg/kg). Published evidence relating to the dosage, toxicity and pharmacokinetics of EMB in children and adults is reviewed and a dose of EMB for use in childhood is recommended. Using key words 'ethambutol', 'childhood', 'TB', 'pharmacokinetics', 'bioavailability' and 'toxicity', Medline searches were conducted; cross-references were sought from original papers, books and conference proceedings dating from 1961. When English summaries were available, data were extracted from papers in languages other than English. EMB has a dose-related efficacy best seen when given to adults alone or with a single other drug. Together with isoniazid (INH), a dose of 15 mg/kg EMB gave better results than 6 mg/kg, and 25 mg/kg better than 15 mg/kg. The occurrence of ocular toxicity was also dose-related; >40% of adults developed toxicity at doses of >50 mg/ kg, and 0-3% at a dose of 15 mg/kg/daily. Peak serum EMB concentrations increase in relation to dose, but are significantly lower in children receiving the same dosage. In only 2 of 3811 children (0.05%) receiving EMB doses of 15-30 mg/kg was EMB stopped due to possible ocular toxicity; children of all ages can be given EMB in daily doses of 20 mg/kg (range 15-25 mg/kg) and three times weekly intermittent doses of 30 mg/kg body weight without undue concern.

Investigation of prion removal/inactivation from chromatographic gel

BACKGROUND AND OBJECTIVES

Concerns about the potential for prions to be retained on chromatography gels during the manufacture of plasma products prompted development of an investigational strategy for detecting infectious prions bound to gels. The objective was to firstly examine methods of implanting gels intracerebrally (IC) in mice, then to examine prion cleaning from a scaled-down version of the DEAE Sepharose column used in a production process to fractionate immunoglobulins and albumin from human plasma.

MATERIALS AND METHODS

The study consisted of two parts: (i) the pathophysiological impact by IC inoculation of ground gel beads was compared to whole gel beads; (ii) the feedstreams to two DEAE Sepharose columns were spiked with scrapie ME7. One column was subjected to the protein loading and elution portions of the chromatography cycle. The other column was subjected to the full cycle of protein loading and elution, followed by regeneration with 0.5 m NaCl, 1 m NaOH and solvent/detergent washes. The gels were unpacked and bioassayed by IC implantation in mice to quantify infectivity.

RESULTS

IC inoculation of ground gel beads resulted in unacceptably high pathological impact in the mice whereas whole gel bead inoculation resulted in a reduced affect. Accordingly, the whole bead model system was used to assess prion removal/inactivation from chromatography gels at the pre- and postcleaning stage of the chromatography cycle. Infectious prions were detected on the DEAE Sepharose prior to the cleaning step; however, the gel cleaning cycle reduced infectivity by a log reduction factor (LRF) of > or = 2.75, thus reducing infectivity by bioassay to below detectable limits.

CONCLUSIONS

A model system for assessment of prion inactivation/removal from chromatography gels has been established. Spiked prion infectivity does bind to DEAE Sepharose gel; however, the cleaning cycle removed infectivity to levels below that detectable by bioassay.

Prion-removal capacity of chromatographic and ethanol precipitation steps used in the production of albumin and immunoglobulins

BACKGROUND AND OBJECTIVES

Although there is no epidemiological evidence to suggest that classical Creutzfeldt-Jakob disease (CJD) is transmitted through blood or blood products, the variant form (vCJD) has been implicated in transmission via packed red blood cells. The potential threat of the infectious agent contaminating plasma pools has led to manufacturing processes being examined for capacity to remove prions. The objective of these studies was to examine the prion-removal potential of the chromatographic purification and ethanol precipitation steps used to fractionate immunoglobulins and albumin from human plasma.

MATERIALS AND METHODS

Western blot assay was used to examine the partitioning of proteinase K-resistant scrapie prion protein (PrPsc) over DEAE Sepharose, CM Sepharose and Macro-Prep High Q chromatographic columns, utilizing microsomal scrapie 263K spiked into each scaled down feedstream and assayed after each chromatographic step. In further studies, bioassay in C57 black mice was used and spikes of 10 000 g clarified brain homogenate of scrapie ME7 were added to feedstreams before sequences of scaled down chromatographic or Cohn fractionation process steps.

RESULTS

The microsomal spiking study with Western blot detection demonstrated substantial partitioning of PrPsc away from the target proteins in all ion exchange chromatographic steps examined. The log10 reduction factors (LRF) across DEAE Sepharose and CM Sepharose columns for albumin were > or = 4.0 and > or = 3.0 respectively. The reductions across DEAE Sepharose and Macro-Prep High Q for intravenous immunoglobulin were 3.3 and > or = 4.1 respectively. Bioassay demonstrated LRFs of >or = 5.6 across the combination of DEAE Sepharose and CM Sepharose columns in the albumin process and > or = 5.4 across the combination of DEAE Sepharose and Macro-Prep High Q columns in the intravenous immunoglobulin process. Bioassay studies also demonstrated a LRF of > or = 5.6 for immunoglobulin produced by Cohn fractionation.

CONCLUSIONS

Using rodent-adapted scrapie as a model, the studies indicated that ion exchange chromatography, as well as Cohn immunoglobulin fractionation have the potential to effectively reduce the load of TSE agents should they be present in plasma pools.

Targets for global tuberculosis control

The United Nations Millennium Development Goals (MDGs) have added to the suite of targets and indicators used to evaluate progress in tuberculosis (TB) control. This paper reviews the history of target setting for TB control and lays out the complete set of indicators and targets that will guide TB control through to 2015, the target year for all MDGs.

Tuberculosis deaths in countries with high HIV prevalence: what is their use as an indicator in tuberculosis programme monitoring and epidemiological surveillance?

Although the reduction of tuberculosis deaths is one of the aims of tuberculosis control, it has not always been a priority for National Tuberculosis Programmes (NTPs). The usual explanation is that death as a treatment outcome not associated with ongoing tuberculosis transmission is not relevant to the public health objective of cutting the cycle of disease transmission. However, death as an adverse outcome for tuberculosis patients and their families is an important indicator in NTP monitoring. Global health targets agreed as part of the Millennium Development Goals include the reduction of tuberculosis deaths. Tuberculosis deaths as an indicator of the impact of tuberculosis control measures are therefore important in the epidemiological surveillance of progress towards these targets. These considerations are particularly important in countries with high human immunodeficiency virus (HIV) prevalence where HIV has exacerbated the tuberculosis epidemic and is now the single best predictor of tuberculosis incidence. Tuberculosis deaths are also closely linked to HIV prevalence. Routine NTP data on tuberculosis cohort deaths are important in programme monitoring, and improvements in recording and reporting of deaths would help to overcome limitations in their accuracy. As routine NTP data on tuberculosis cohort deaths are insufficient as an indicator in epidemiological surveillance regarding the impact of NTPs on tuberculosis mortality, measuring progress towards targets for reduced tuberculosis deaths depends on improved national vital registration systems for a more accurate determination of tuberculosis mortality.

HIV-related tuberculosis: how well are we doing with current control efforts?

SETTING

The top 25 human immunodeficiency virus (HIV) prevalence countries.

OBJECTIVE

To review the current status of implementation of interventions to control HIV-related tuberculosis (TB).

DESIGN

Using data on national TB and HIV programme activities from the most recent national survey results published by international public health agencies, we reviewed the status of implementation of selected key interventions to control HIV-related TB.

RESULTS

Regarding implementation of the DOTS strategy for TB control, only four of the top 25 HIV prevalence countries reported achieving the target for treatment outcomes. Nearly all countries reported low levels of national programme performance in implementing key HIV prevention and care measures.

CONCLUSIONS

The generally low performance of national TB and HIV programmes in the top 25 HIV prevalence countries is unlikely to make a significant impact on control of HIV-related TB. Controlling HIV-related tuberculosis requires increased investment in full implementation of the DOTS strategy and the key HIV prevention measures. In settings fully implementing these basic interventions, collaboration between TB and HIV programmes is necessary to scale up implementation of additional prioritised interventions to control HIV-related TB (e.g., antiretroviral therapy, intensified TB case finding and isoniazid and cotrimoxazole preventive therapies) that are of demonstrated feasibility, effectiveness and cost-effectiveness.

European framework to decrease the burden of TB/HIV

Tuberculosis (TB) in Europe is declining in countries in western and central Europe, but the burden is still high and increasing in eastern Europe. HIV/AIDS is increasing dramatically in eastern Europe. HIV-related tuberculosis (TB/HIV) morbidity and mortality are expected to accelerate significantly in the future. This framework aims to guide European countries in developing their national plan for reducing TB/HIV morbidity and mortality. It results from an extensive consultation process undertaken by the World Health Organization Regional Office for Europe and by those responsible for HIV/AIDS and TB programmes and their partners. It builds on strategies developed globally and in Europe for TB control and for HIV/AIDS prevention and care. This framework sets out the rationale for effective collaboration between HIV/AIDS and tuberculosis national programmes. It identifies five strategic components (political commitment, collaborative prevention, intensified case-finding, coordinated treatment and strengthened surveillance) and eight key operations (central coordination, policy development, surveillance, training, supply management, service delivery, health promotion and research).

Decentralisation of tuberculosis treatment from the main hospitals to the peripheral health units and in the community within Machakos district, Kenya

SETTING

A rural district, Machakos, in Kenya, facing decreasing national resources for health and an increasing tuberculosis (TB) caseload fuelled by the human immunodeficiency virus (HIV).

OBJECTIVE

To evaluate the impact on district TB programme performance of decentralising TB treatment by providing ambulatory care in the hospital and peripheral health units and in the community.

METHODS

A comparative study of district TB programme performance before and after the decentralisation of TB services at the end of 1997. To facilitate ambulatory care, ethambutol replaced streptomycin in the new treatment regimen.

FINDINGS

The number of patients registered in the control period (1996) was 1141, of whom almost 100% were admitted during the intensive phase of TB treatment, and in the intervention period (1998 and 1999), it was 3244, of whom only 153 (4.7%) required admission in the intensive phase. Of 3244 TB patients (all forms) registered in the intervention period, the number (%) choosing the different options for directly observed treatment (DOT) supervision were: hospital clinic 1618 (49.9%), peripheral health unit 904 (27.9%), community volunteer 569 (17.5%) and hospitalisation 153 (4.7%). The options were found to be acceptable to patients, their families and health staff. The treatment outcomes among new sputum smear-positive pulmonary TB patients were similar in the intervention and control cohorts, with treatment success rates of 88% vs. 85% and death rates of 4% vs. 6%, respectively. Treatment completion was significantly higher among new sputum smear-negative and extra-pulmonary TB patients in the intervention than in the control cohort (79% vs. 48%, respectively).

CONCLUSION

The decentralisation of the intensive phase of TB treatment resulted in maintenance of good TB programme performance, while Machakos hospital closed its TB wards. A separate paper describes the cost-effectiveness of this approach. The National Tuberculosis Control Programme plans to adopt this approach as national policy.

Implementation of the DOTS strategy for tuberculosis control in rural Kiboga District, Uganda, offering patients the option of treatment supervision in the community, 1998-1999

SETTING

Kiboga District, a rural district in central Uganda.

OBJECTIVE

As part of routine tuberculosis control programme operations, to measure the effectiveness and acceptability of community-based tuberculosis (TB) care using the directly observed treatment, short-course (DOTS) strategy for TB control. The implementation of the DOTS strategy with active participation of local communities in providing the option of treatment supervision in the community is known in Uganda as community-based DOTS (CB-DOTS).

DESIGN

Effectiveness was measured by comparing TB case-finding and treatment outcomes before and after the introduction of CB-DOTS in 1998. Acceptability was measured by administering a knowledge, attitudes and beliefs questionnaire to community members, health care workers and TB patients before and after the intervention.

RESULTS

A total of 540 TB patients were registered in the control period (1995-1997) before the introduction of CB-DOTS, and 450 were registered in the intervention period (1998-1999) after the implementation of CB-DOTS. Following the implementation of CB-DOTS, treatment success among new smear-positive pulmonary TB cases increased from 56% to 74% (RR 1.3, 95%CI 1.2-1.5, P < 0.001) and treatment interruption decreased from 23% to 1% (RR 16.5, 95%CI 6.1-44.7, P < 0.001). There was no significant difference in the proportion of deaths before and after the implementation of CB-DOTS (15% vs. 14% for new smear-positive pulmonary, and 38% vs. 29% for new smear-negative and extra-pulmonary TB cases). The acceptability of CB-DOTS was very high among those interviewed, mainly because CB-DOTS improved access to TB care, decreased costs and enabled patients to stay with their families.

CONCLUSIONS

In enabling patients to choose TB treatment supervision in the community, CB-DOTS provided a highly effective and acceptable additional option to conventional TB care. Efforts are underway to address the high case fatality rates in both study groups before and after the introduction of CB-DOTS. CB-DOTS is an example of shared responsibility between health services and communities in tackling a major public health priority.

Integration of tuberculosis treatment in a community-based home care programme for persons living with HIV/AIDS in Ndola, Zambia

SETTING

Two small urban townships (compounds) in Ndola, Zambia, served by an HIV/AIDS home care programme.

OBJECTIVE

To evaluate the implementation of the directly observed treatment, short-course (DOTS) strategy as part of an existing HIV/AIDS home care programme, by comparing TB treatment outcomes in an intervention population (Chipulukusu compound), where implementation of the DOTS strategy is an integral part of the HIV/AIDS home care programme, and in a control population (Twapia compound) with district TB services but as yet without coverage by the HIV/AIDS home care programme.

DESIGN

Prospective evaluation of all new sputum smear-positive TB patients registered in Chipulukusu and Twapia compounds between 1 February 1998 and 30 September 1999, with documentation of 2-month sputum smear conversion and 8-month treatment outcomes.

RESULTS

There were 72 new sputum smear-positive pulmonary TB cases in Chipulukusu and 96 in Twapia registered during the study period. In comparing treatment outcomes in Chipulukusu and Twapia, there was no significant difference in treatment success (cure plus treatment completion) (61% vs. 48.9%) or in deaths (22% vs. 19%). However, cure rate was significantly higher in Chipulukusu than in Twapia (54.2% vs. 20.8%) and treatment interruption was significantly lower in Chipulukusu than in Twapia (8.3% vs. 22.9%).

CONCLUSION

Integration of the DOTS strategy for TB control with an existing HIV/AIDS home care programme led to improved TB programme performance in a compound with a small population (about 20000). There is scope to scale up this approach so that the entire population of all the compounds in Ndola served by the HIV/AIDS home care programme can benefit from improved TB control.

Cost and cost-effectiveness of community-based care for tuberculosis in Cape Town, South Africa

SETTING

Guguletu and Nyanga areas of Cape Town, South Africa.

OBJECTIVE

To evaluate the affordability and cost-effectiveness of community involvement in tuberculosis (TB) care.

DESIGN

A cost-effectiveness analysis comparing treatment for new smear-positive pulmonary and retreatment TB patients in two similar townships, one providing clinic-based-care with community-based observation options available for its TB patients (Guguletu) and one providing clinic-based care only, with no community-based observation of treatment (Nyanga). Costs were assessed from a societal perspective in 1997 US dollars, and cost-effectiveness was calculated as the cost per patient successfully treated.

RESULTS

TB treatment in Guguletu was more cost-effective than TB treatment in Nyanga for both new and retreatment patients (dollars 726 vs. dollars 1201 and dollars 1419 vs. dollars 2058, respectively). This reflected both lower costs (dollars 495 vs. dollars 769 per patient treated for new cases; dollars 823 vs. dollars 1070 per patient treated for retreatment cases) and better treatment outcomes (successful treatment rate 68% vs. 64% and 58% vs. 52% for new and retreatment patients, respectively). Within Guguletu, community-based care was more than twice as cost-effective as clinic-based care (dollars 392 vs. dollars 1302 per patient successfully treated for new patients, and dollars 766 vs. dollars 2008 for retreatment patients), for similar reasons (e.g., for new cases, dollars 314 vs. dollars 703 per patient treated, successful treatment rate 80% vs. 54%).

CONCLUSION

Community involvement in TB care can improve the affordability and cost-effectiveness of TB treatment in urban South Africa. Expansion in the Western Cape and in similar areas of the country is worthy of serious consideration by planners and policy-makers.

Decentralisation of tuberculosis services in an urban setting, Lilongwe, Malawi

SETTING

Lilongwe, the capital of Malawi, one of the countries in the world badly affected by the human immunodeficiency virus/acquired immune-deficiency syndrome (HIV/AIDS) epidemic.

OBJECTIVE

In the face of a rising burden of tuberculosis (TB) fuelled by HIV, to evaluate the impact on the Lilongwe district tuberculosis programme performance of decentralisation of TB services, including extending the range of options for supervision of directly observed treatment (DOT) during the initial phase of treatment, and using a fully oral, intermittent regimen.

DESIGN

Prospective assessment under programme conditions of 1) duration of hospital stay, 2) bed occupancy and 3) 8-month treatment outcomes in a cohort of patients registered before (1997) and after (1998) the introduction of decentralisation of TB services.

RESULTS

The number of new patients (all forms) registered in Lilongwe district was 3144 in 1997 and 3761 in 1998. There were significant differences (P < 0.05) between all outcomes that were compared. In 1998, bed occupancy dropped by 38%; among smear-positive patients, the average length of hospital stay fell from 58 days in 1997 to 16, the cure rate was higher (64% vs. 56%), default rate was lower (5% vs. 19%), and treatment completion rate was lower (2% vs. 4%); among smear-negative patients, the treatment completion rate was higher (50% vs. 33%), default rate was lower (23% vs. 55%), and death rate was higher (17% vs. 4%). This death rate is attributable to improved follow-up and reporting of outcomes, rather than to increased deaths.

CONCLUSION

Programme implementation of decentralised TB services in Lilongwe, including an extended range of supervision options for DOT and the use of an ambulatory treatment regimen, achieved reduced hospital stay and bed occupancy and good treatment outcomes.

Evaluation of community contribution to tuberculosis control in Cape Town, South Africa

SETTING

Low income, high density, urban settlements in Cape Town, South Africa.

OBJECTIVES

To evaluate community treatment supervision as part of tuberculosis (TB) programme implementation.

DESIGN

A non-randomised prospective study was conducted under programme conditions from January 1998 to December 1999, comparing TB programme performance in an area with (Guguletu), and an area without (Nyanga) the option of TB treatment supervision by community health workers.

RESULTS

Data were collected for 2873 adult TB patients. For smear-positive TB patients, treatment cure rates were higher in the intervention area (Guguletu) than in the control area (Nyanga) (58% vs. 50%, P = 0.0378) and for retreatment cases (47% vs. 35%, P = 0.0791), treatment success rates were similar.

CONCLUSIONS

Community health worker support contributed to better TB control programme performance than an approach based exclusively on health facilities. Clear government policy and support for lay health worker programmes in TB control is needed.

Contribution of traditional healers to a rural tuberculosis control programme in Hlabisa, South Africa

SETTING

The rural health district of Hlabisa, KwaZulu-Natal, South Africa.

OBJECTIVES

To assess the acceptability and effectiveness of traditional healers as supervisors of tuberculosis (TB) treatment in an existing directly observed treatment, short-course (DOTS) programme.

DESIGN

An observational study comparing treatment outcomes among new TB patients in the three intervention sub-districts offered the additional option of traditional healers for directly observed treatment (DOT) supervision with those in the remainder of the district offered the standard range of options for DOT supervision (health facility, community health worker and lay persons). A comparison was also made of treatment outcomes between different options for DOT supervision.

RESULTS

A total of 3461 TB patients were registered in Hlabisa District from April 1999 to December 2000, of whom 2823 were discharged from hospital to the ambulatory DOT programme. Treatment outcomes were known for 1816 patients in Hlabisa District (275 patients in the intervention area and 1541 patients in the control area). There was no significant difference (P < 0.5) in treatment outcome in the intervention and control areas (77% vs. 75%). Among 275 patients with known outcomes in the intervention area, 48 patients were supervised by traditional healers and 227 patients supervised by people other than traditional healers. Treatment completion was not significantly higher among patients supervised by traditional healers than among patients supervised by other categories of DOT supervisor (88% vs. 75%, P = 0.3841). Interviews with 41 of 51 traditional healer patients who had completed treatment revealed high levels of satisfaction with the care received.

CONCLUSIONS

Traditional healers make an effective contribution to TB programme performance in this pilot scheme in Hlabisa district. Further evaluation will be necessary as this approach is scaled up.

Childhood tuberculosis in Malawi: nationwide case-finding and treatment outcomes

SETTING

All 43 non-private hospitals (three central, 22 [corrected] district and 18 [corrected] mission) in Malawi that register and treat adult and paediatric TB cases.

OBJECTIVE

To assess the rate, pattern and treatment outcome of childhood TB case notifications in Malawi in 1998.

DESIGN

Retrospective data collection using TB registers, treatment cards and information from health centre registers. Information was collected on number of cases, types of TB and treatment outcomes using standardised definitions.

RESULTS

There were 22,982 cases of TB registered in Malawi in 1998, of whom 2,739 (11.9%) were children. Children accounted for 1.3% of all case notifications with smear-positive pulmonary TB (PTB), 21.3% with smear-negative PTB and 15.9% with extra-pulmonary TB (EPTB). Estimated rates of TB in children were 78/ 100,000 in those aged less than one year, 83/100,000 in those aged 1-4 years and 33/100,000 in those aged 5-14 years. A significantly higher proportion of TB cases was diagnosed in central hospitals. Only 45% of children completed treatment. There were high rates of death (17%), default (13%) and unknown treatment outcomes (21%). Treatment outcomes were worse in younger children and in children with smear-negative PTB. Treatment completion was best (76%) and death rates lowest (11%) for the 127 children with smear-positive PTB.

CONCLUSION

Childhood TB is common in Malawi and treatment outcomes are poor. Research should be directed towards improved diagnosis and follow-up of children with TB, and the National TB Programme should support appropriate management of childhood contacts of smear positive PTB cases.

Tuberculosis case fatality rates in high HIV prevalence populations in sub-Saharan Africa

BACKGROUND

Tuberculosis is a leading cause worldwide of morbidity and mortality among HIV-infected people. The HIV era has seen a dramatic increase of the tuberculosis case fatality rate (CFR) in high HIV prevalence populations. Providing care for HIV-infected people must include measures to tackle this high tuberculosis CFR.

AIMS

To analyse the extent of the increased tuberculosis CFR in high HIV prevalence populations in sub-Saharan Africa, the reasons for this increase and the causes of death, in order to identify possible ways of tackling this problem.

METHODS

References were obtained by searching the MEDLINE on 'tuberculosis', 'HIV infection', and 'mortality' (MesH or textword). In addition, available data from National Tuberculosis Programme reports were reviewed.

FINDINGS

Tuberculosis CFR is closely linked to HIV prevalence. Limited autopsy data suggest that death from HIV-related diseases other than tuberculosis is probably the main reason for the increased CFR in HIV-infected tuberculosis patients. Among HIV-infected tuberculosis patients, the higher tuberculosis CFR in sputum smear-negative and extrapulmonary than in sputum smear-positive tuberculosis cases can also be attributed to misdiagnosis of HIV-related diseases as tuberculosis. The adverse effect of the HIV/AIDS epidemic on general health service performance probably accounts for the higher tuberculosis CFR among HIV-negative tuberculosis patients in high prevalence populations than that in low HIV-prevalence populations.

CONCLUSION

Tackling the problem of the increased tuberculosis CFR in high HIV prevalence populations requires collaboration between tuberculosis control and HIV/AIDS programmes in implementing measures such as improved health services, tuberculosis and HIV control services, preventive treatment for HIV-related diseases and anti-HIV treatment.

A randomized, double blind study in young healthy adults comparing cell mediated and humoral immune responses induced by influenza ISCOM vaccines and conventional vaccines

Although current influenza vaccines have been shown to reduce influenza-related morbidity and mortality, there is a desire to develop more efficacious products. Vaccines which can induce CD8(+) cytotoxic T cell (CTL) responses in addition to strong antibody responses may be more effective in preventing disease since it has been demonstrated that CTL contribute to protective immunity, even against drift variants of influenza A viruses. The immunogenicity of two types of experimental influenza vaccines, which were based on immune stimulating complexes (ISCOM), were evaluated and compared with a conventional non-adjuvanted inactivated split virion vaccine, after immunization of human volunteers. In this randomized, double blind study, it was shown that the ISCOM vaccines altered the kinetics of the serum antibody response, resulting in more rapid titer rises against the vaccine strains. This accelerated antibody response coincided with enhanced in vitro proliferative T cell responses, which were observed shortly after vaccination. In addition, CTL responses were observed in a higher proportion of the vaccinees receiving an ISCOM vaccine, than in vaccinees receiving the conventional influenza vaccine.

Mortality rates and recurrent rates of tuberculosis in patients with smear-negative pulmonary tuberculosis and tuberculous pleural effusion who have completed treatment

SETTING

Queen Elizabeth Central Hospital, Blantyre, and Zomba Central Hospital, Zomba, Malawi.

OBJECTIVE

To follow-up human immunodeficiency virus (HIV) seropositive and HIV-seronegative patients with smear-negative pulmonary tuberculosis (PTB) and pleural TB who had completed treatment with two different regimens in Blantyre and Zomba, and to assess rates of mortality and recurrent TB.

DESIGN

Patients with smear-negative and pleural TB who had completed 8 months ambulatory treatment in Blantyre or 12 months standard treatment in Zomba and who were smear and culture negative for acid-fast bacilli at the completion of treatment were actively followed every 4 months for a total of 20 months.

RESULTS

Of 248 patients, 150 with smear-negative PTB and 98 with pleural TB, who completed treatment and were enrolled, 205 (83%) were HIV-positive. At 20 months, 145 (58%) patients were alive, 85 (34%) had died and 18 (7%) had transferred out of the district. The mortality rate was 25.7 per 100 person-years, with increased rates strongly associated with HIV infection and age >45 years. Forty-nine patients developed recurrent TB. The recurrence rate of TB was 16.1 per 100 person-years, with increased rates strongly associated with HIV infection, having smear-negative PTB and having received 'standard treatment'.

CONCLUSION

High rates of mortality and recurrent TB were found in patients with smear-negative PTB and pleural effusion during 20 months of follow-up. TB programmes in sub-Saharan Africa must consider appropriate interventions, such as co-trimoxazole and secondary isoniazid prophylaxis, to reduce these adverse outcomes.