Community- vs. hospital-based management of multidrug-resistant TB in Pakistan

BACKGROUND Multidrug-resistant TB (MDR-TB) treatment takes 18-24 months and is complex, costly and isolating. We provide trial evidence on the WHO Pakistan recommendation for community-based care rather than hospital-based care.METHODS Two-arm, parallel-group, superiority trial was conducted in three programmatic management of drug-resistant TB hospitals in Punjab and Sindh Provinces, Pakistan. We enrolled 425 patients with MDR-TB aged >15 years through block randomisation in community-based care (1-week hospitalisation) or hospital-based care (2 months hospitalisation). Primary outcome was treatment success.RESULTS Among 425 patients with MDR-TB, 217 were allocated to community-based care and 208 to hospital-based care. Baseline characteristics were similar between the community and hospitalised arms, as well as in selected sites. Treatment success was 74.2% (161/217) under community-based care and 67.8% (141/208) under hospital-based care, giving a covariate-adjusted risk difference (community vs. hospital model) of 0.06 (95% CI -0.02 to 0.15; P = 0.144).CONCLUSIONS We found no clear evidence that community-based care was more or less effective than hospital-based care model. Given the other substantial advantages of community-based care over hospital based (e.g., more patient-friendly and accessible, with lower treatment costs), this supports the adoption of the community-based care model, as recommended by the WHO.

GSK3-like kinase BIN2 phosphorylates RD26 to potentiate drought signaling in Arabidopsis

Plant steroid hormones brassinosteroids (BRs) regulate plant growth and development at many different levels. Recent research has revealed that stress-responsive NAC (petunia NAM and Arabidopsis ATAF1, ATAF2, and CUC2) transcription factor RD26 is regulated by BR signaling and antagonizes BES1 in the interaction between growth and drought stress signaling. However, the upstream signaling transduction components that activate RD26 during drought are still unknown. Here, we demonstrate that the function of RD26 is modulated by GSK3-like kinase BIN2 and protein phosphatase 2C ABI1. We show that ABI1, a negative regulator in abscisic acid (ABA) signaling, dephosphorylates and destabilizes BIN2 to inhibit BIN2 kinase activity. RD26 protein is stabilized by ABA and dehydration in a BIN2-dependent manner. BIN2 directly interacts and phosphorylates RD26 in vitro and in vivo. BIN2 phosphorylation of RD26 is required for RD26 transcriptional activation on drought-responsive genes. RD26 overexpression suppressed the brassinazole (BRZ)  insensitivity of BIN2 triple mutant bin2 bil1 bil2, and BIN2 function is required for the drought tolerance of RD26 overexpression plants. Taken together, our data suggest a drought signaling mechanism in which drought stress relieves ABI1 inhibition of BIN2, allowing BIN2 activation. Sequentially, BIN2 phosphorylates and stabilizes RD26 to promote drought stress response.

Integrating a diabetes and hypertension case management package within primary health care: a mixed methods feasibility study in Bangladesh

Background

Almost three quarters of non-communicable disease (NCD) deaths, and 82% of premature NCD deaths, occur in low- and middle-income countries. Bangladesh has an estimated 7 million hypertensives and 10 million diabetics, and primary care is struggling to respond. Our aim was to develop and support implementation of a diabetes and hypertension case management package, and assess its appropriateness, feasibility and acceptability in two NCD clinics within two primary-care centres in Bangladesh.

Methods

We used a convergent mixed methods design. We first assessed the level of appropriate hypertension and cardiovascular disease patient management, based on a composite outcome indicator using data from patients’ treatment cards. Appropriate management was primarily informed by International Diabetes Federation (IDF) and World Health Organisation (WHO) guidelines. We then performed qualitative in-depth interviews with doctors and patients to explain these quantitative findings and to understand the challenges to achieving appropriate patient management in the NCD clinics.

Results

Eighty-one newly diagnosed patients were recruited. Over 3 months, 53.1% (95% CI 42.3% to 63.6%) of patients were appropriately managed. We found incomplete diagnosis (especially missing hypertension diagnosis alongside diabetes) and non-provision of follow-up appointments were the main causes of the relatively low level of appropriate management. We conducted interviews with 11 patients and 8 health professionals and found a shortage of human resources, reporting materials, available drugs and diagnostic equipment. This undermined patients’ willingness to attend clinics and doctors’ willingness to offer follow-ups. Hands-on skill-building training was valuable in increasing doctors’ competence for appropriate management, but was seen as a novel training method and faced constraints to implementation.

Conclusions

A clinical guide, skill-based training and recording package can be implemented in routine primary care and can lead to appropriate management of around half of diabetic and hypertensive patients in a low-income country. However, considerable health systems challenges must be addressed before more patients can be managed appropriately.

Improving the quality of care of children in community clinics: an intervention and evaluation in Bangladesh

SETTING

Community health care providers (CHCPs) in 40 rural community clinics of Comilla district, Bangladesh, were trained using a newly developed case-management job aid based on the World Health Organization Integrated Management of Childhood Illness and a communication guide.

OBJECTIVES

To assess 1) the change in knowledge of the CHCPs after training; 2) the absolute quality of care provided by the CHCPs (determined as the proportion of children aged <5 years [under-fives] correctly diagnosed, treated and referred); and 3) the consultation behaviour of the CHCPs.

DESIGN

Change in knowledge was assessed by tests pre-and post-training. The quality of care was determined by reassessments at the clinic exit by a medical officer, without a baseline comparison. Consultation behaviour was assessed through direct observation. The study was performed during 2014-2015.

RESULTS

The mean standard knowledge score of the CH-CPs increased from 19 to 25 (P < 0.001). Of 1490 under-fives examined, 91% were correctly diagnosed, 86% were correctly treated and 99.5% received a correct referral decision. The CHCPs performed well on most of the measures of good communication, although one third did not explain the diagnosis and treatment to patients.

CONCLUSION

The training was effective in changing knowledge. The CHCPs applied the knowledge gained and provided good quality care. Following these results, the Bangladesh Ministry of Health and Family Welfare has scaled up the training nationwide. The lessons learnt should be useful for other countries.

Incremental cost-effectiveness of improving treatment results among migrant tuberculosis patients in Shanghai

SETTING

Two projects were introduced in October 2007 to improve treatment completion among rural-to-urban migrant tuberculosis (TB) patients in Shanghai. The Communicable Disease Research Consortium (COMDIS) project provided financial incentives to poor patients, whereas the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) project provided incentives to all patients and increased staff time.

OBJECTIVE

To assess the incremental cost-effectiveness of these two projects.

METHODS

Case study. Costs were assessed from a societal perspective. The primary measure of effectiveness was the treatment completion rate. The incremental cost-effectiveness ratio was calculated as the additional cost of the intervention divided by the additional percentage of patients completing treatment compared to controls.

RESULTS

Post intervention, the treatment completion rates in the COMDIS and Global Fund projects were respectively 89% and 88%, 17% and 16% higher than in the control district (76%). For one additional per cent of patients to complete treatment, the additional cost of the COMDIS intervention was US$1891, 91% lower than that of the Global Fund intervention (US$21,904).

CONCLUSION

The intervention that addressed the financial barriers of poor patients was more cost-effective than the comprehensive intervention that provided assistance to both patients and providers. Further study is needed to understand the process of interventions prior to wider scale-up.

Development and testing of models of tuberculosis contact tracing in rural southern Africa

SETTING

A regional hospital in rural Swaziland.

OBJECTIVES

To evaluate a hospital-based contact screening programme and test approaches to improve its effectiveness.

DESIGN

An evaluation and quality improvement study of tuberculosis (TB) contact tracing services.

RESULTS

Hospital-based TB contact tracing led to screening of 157 (24%) of 658 contacts; of these, 4 (2.5%) were diagnosed with TB. Of 68 contacts eligible for human immunodeficiency virus (HIV) testing and counselling, 45 (66%) were tested and 7/45 (16%) were identified as HIV-positive. Twelve (50%) of 24 screened contacts aged <5 years were provided isoniazid prophylaxis. Three enhanced models of TB contact tracing were piloted to screen contacts in the community. Although some enhanced models screened large numbers of contacts, no contacts were diagnosed with TB.

CONCLUSION

Contact tracing of household members conducted in TB clinics within hospital settings is effective in high-burden, low-income settings, and can be provided using current resources. Enhanced household contact tracing models that followed up contacts in the community were not found to be effective. Additional resources would be required to provide household TB contact tracing in the community.

Improving adherence to antiretroviral therapy in sub-Saharan African HIV-positive populations: an enhanced adherence package

With the increasing access to antiretroviral therapy in sub-Saharan African HIV-positive populations, it is important to find additional simple, effective, and feasible methods of improving and maintaining adequately high levels of adherence. In this study, we undertook the development, testing, implementation, and evaluation of various adherence support interventions at four sites in Uganda. A one-group pre- and post-intervention design was employed under routine operational conditions. Various adherence support strategies were identified, adapted, and developed. These strategies which included a combination of elements such as counseling, group education, leaflets, late attendee tracing, and adherence diaries was implemented for an antiretroviral treatment cohort which had baseline levels of adherence measured preintervention. Follow-up was from August 2009 through August 2010. Mean adherence and proportions of clients achieving adherence levels of 95% and above were determined at end of follow-up. Of the 967 participants enrolled, 856 (88.5%) completed follow-up. A before-and-after comparison of outcomes demonstrated that mean adherence (95% confidence interval [CI]) improved statistically significant from baseline following implementation of the interventions (97.4% [96.9-97.9%] to 99.1% [99.0-99.3%], P=0.001). There was also a significant difference between proportions with optimal (≥ 95%) and suboptimal adherence (<95%) pre- and post-intervention (7.0% difference, 95% CI: 4.6-9.4%, P<0.001). We conclude that additional adherence strategies (including counseling, group education, leaflets, late attendee tracing, and adherence diaries) can substantially improve and maintain high levels of treatment adherence in the long term. Health systems in sub-Saharan African countries should consider integrating these elements into their treatment programs for HIV/AIDS.

Training needs, practices and barriers in the work of community reproductive health workers in Masindi district, Uganda

Community reproductive health workers play a valuable role in family planning counselling and the distribution of contraceptive methods in rural communities. However, they face stigma, misconceptions and a lack of support. Regular supervision by health workers and support from community leaders can help address these issues.

Could clinical audit improve the diagnosis of pulmonary tuberculosis in Cuba, Peru and Bolivia?

OBJECTIVES

To assess the effectiveness of clinical audit in improving the quality of diagnostic care provided to patients suspected of tuberculosis; and to understand the contextual factors which impede or facilitate its success.

METHODS

Twenty-six health centres in Cuba, Peru and Bolivia were recruited. Clinical audit was introduced to improve the diagnostic care for patients attending with suspected TB. Standards were based on the WHO and TB programme guidelines relating to the appropriate use of microscopy, culture and radiological investigations. At least two audit cycles were completed over 2 years. Improvement was determined by comparing the performance between two six-month periods pre- and post-intervention. Qualitative methods were used to ascertain facilitating and limiting contextual factors influencing change among healthcare professionals' clinical behaviour after the introduction of clinical audit.

RESULTS

We found a significant improvement in 11 of 13 criteria in Cuba, in 2 of 6 criteria in Bolivia and in 2 of 5 criteria in Peru. Twelve out of 24 of the audit criteria in all three countries reached the agreed standards. Barriers to quality improvement included conflicting objectives for clinicians and TB programmes, poor coordination within the health system and patients' attitudes towards illness.

CONCLUSIONS

Clinical audit may drive improvements in the quality of clinical care in resource-poor settings. It is likely to be more effective if integrated within and supported by the local TB programmes. We recommend developing and evaluating an integrated model of quality improvement including clinical audit.

Improving sputum microscopy services for the diagnosis of tuberculosis in Peru and Bolivia

SETTING

Sixteen primary care health centres in Peru and Bolivia.

OBJECTIVES

To assess the utilisation of microscopy services in Peru and Bolivia and determine if clinical audit, a quality improvement tool, improves the utilisation of these services.

DESIGN

We estimated the percentage of patients with suspected tuberculosis (TB) in whom sputum microscopy was effectively utilised in Peru and Bolivia over two 6-month periods before and after a clinical audit intervention that included standards setting, measuring clinical performance and feedback.

RESULTS

Before the intervention, only 31% (95%CI 27-35) of TB suspects were assessed with sputum microscopy in Peru. In Bolivia, 30% (95%CI 25-35) underwent at least two sputum microscopy examinations. After clinical audit, the availability of sputum microscopy results improved by respectively 7% (95%CI 1-12, P < 0.05) and 23% (95%CI 15-30, P < 0.05) over 2 years in Peru and Bolivia.

CONCLUSIONS

Despite World Health Organization recommendations that all TB suspects should undergo sputum microscopy before treatment, results are available for further assessment for only one third. This is a potentially serious obstacle to TB case detection. Clinical audit can bring some improvement. We recommend regular monitoring of effective utilisation of microscopy services and investigations to ascertain organisational and structural issues in their uptake and use.

Clinical guidelines to diagnose smear-negative pulmonary tuberculosis in Pakistan, a country with low-HIV prevalence

OBJECTIVES

To develop and validate clinical guidelines for diagnosis of smear-negative pulmonary tuberculosis (TB) in developing countries with low-HIV prevalence.

METHODS

We developed diagnostic guidelines for smear-negative TB. Clinical diagnoses based on these guidelines were compared with sputum culture, chest X-rays and reports of an expert panel.

RESULTS

The guidelines achieved a sensitivity of 0.59 [confidence interval (CI) 0.46-0.66] and a specificity of 0.86 (CI 0.84-0.88) in diagnosing smear-negative TB. A total of 6.8% of patients who initially improved after a course of antibiotics were later confirmed to have TB. Clinicians detected an abnormal chest X-ray in 92% (CI 88-96%) and radiological signs of pulmonary TB in 98% (CI 94-100%) of cases.

CONCLUSIONS

Our experience highlights a number of dilemmas faced in developing, testing and implementing diagnostic guidelines in poorly resourced conditions. Using radiological criteria for TB and appropriate training can help in improving the diagnostic skills of primary care clinicians working in low-HIV settings with access to X-ray facilities. But a significant number of apparently smear-negative TB cases may in fact be smear positive and TB programmes should focus on improving the quality of direct acid-fast bacilli microscopy. The value of an antibiotic trial is questionable due to the relatively large number of false negatives generated by this approach.

Simplified antiviral prophylaxis with or and without artificial feeding to reduce mother-to-child transmission of HIV in low and middle income countries: modelling positive and negative impact on child survival

BACKGROUND

Antiviral prophylaxis is recommended for HIV positive mothers to prevent mother-to-child transmission of HIV. To date UNAIDS and WHO policy has been based on a study in Thailand which showed a reduction in transmission by half with short course AZT (Zidovudine) treatment together with artificial feeding. We modelled the possible positive and negative effects on child deaths in low and middle resource developing country settings of two interventions to reduce mother to child transmission (MTCT) of HIV: antenatal testing, short-course antivirals (zidovudine or nevirapine), firstly with and then without artificial feeding.

MATERIAL AND METHODS

Estimates are made of child lives likely to be saved by the programme by age ten years, balanced against increases in deaths due to more uninfected mothers choosing to use artificial feeds where these are part of the intervention. Mid-point values for variables affecting the balance of mortality gains and losses are taken from recent published data for low and middle income developing countries and a sensitivity analysis is undertaken.

RESULTS

In low income settings the use of antivirals alone would result in an estimated gain in child survival of around 0.36%, representing 360 deaths avoided from a birth cohort of 100,000 by age 10 years. Adding artificial feeding could reduce the gain to 0.03% (30 deaths avoided). In middle income settings the gain from antivirals alone would be 0.26% but as 'spill-over' of artificial feeding to uninfected women was more likely it could result in a net increase of child deaths of up to 1.08% (1,080 additional deaths). A sensitivity analysis emphasised this potential for regimens using artificial feeding if progamme participation was low, and under most circumstances in middle income settings.

CONCLUSIONS

HIV testing and use of antivirals by infected mothers, if well implemented, will be effective at a population level in reducing MTCT. However the addition of artificial feeding is potentially be a high risk strategy, especially in middle income countries.

Tuberculosis in Pakistan: socio-cultural constraints and opportunities in treatment

This study explores the extent to which factors related to individuals, the care provision process, and the cultural context influence the behaviour of tuberculosis patients attending TB clinics in rural Pakistan, and examines the effects of disease on their personal lives. Thirty-six patients attending three TB treatment clinics were interviewed in depth. These patients were stratified by stage of treatment (treatment proceeding, treatment completed, default), sex and by rural/urban status. Results indicate that the majority of patients were very poor, but nonetheless initially chose to attend private practitioners. Normally their disease was correctly diagnosed as tuberculosis only after repeated visits to a succession of health care providers. Patients' knowledge about their disease was limited, and doctors gave incorrect or only very limited health education. Most patients reported dissatisfaction with care provided. Almost all patients reported problems with access to treatment, both in terms of time and money; this was particularly true of women, whose freedom to travel in Pakistan is limited. Potential causes of default appeared to be more closely linked to deficiencies in treatment provision rather than patients' unwillingness to comply. Largely because of a perception that TB was incurable, respondents were generally unwilling to disclose that they were undergoing or had undergone TB treatment. For reasons related to confidential access to treatment, this could lead to default, perpetuating the perception of incurability, and hence causing a vicious circle. For TB programmes to be successful in Pakistan, it is essential that this circle is broken; and this can only be done through provision of good quality TB care and education to improve the population's understanding that TB can be cured. In addition, patients' unwillingness to disclose to health care providers that they had already received previous treatment meant that many patients were prescribed incorrect treatment regimes, potentially leading to the emergence of drug-resistant TB. In common with other researchers' findings, no clear differences were found between those who had completed treatment and those who had defaulted from treatment. This study was performed to provide information to assist the researchers to design potential TB treatment delivery strategies, and has proved invaluable for this purpose. Strategies based on findings from the study are currently being assessed using a randomised controlled trial.

The tuberculosis emergency in Africa: opportunities and strategies for action

Tuberculosis rates are increasing dramatically in many regions of the world due to poverty, rapid population growth, ineffective Tb programmes and the HIV pandemic. Innovative approaches of treatment supervision are required to increase cure rates and hence reduce transmission. National tuberculosis programmes need to be strengthened, co-ordinated with AIDS programmes and supported by national advocacy groups.

Health planning and resource allocation in a changing Vietnam

Vietnam is rapidly changing from a centrally planned to a market economic system. Explores the existing constraints and the degree of flexibility for management in the Government health system. Analyses the potential influence of the recent changes in health sector resource allocation with budgets becoming less under the direct control of the local authority, and based on population rather than the current number of beds. These changes create new possibilities, and responsibilities, for managers actively to manage health services and preventive programmes. Health managers are ill-prepared for this challenge.

The HIV-tuberculosis time bomb: how can hospitals in developing countries cope?

The treatment of the ever-increasing number of people in developing tuberculosis as a consequence of the AIDS epidemic is becoming a new challenge in hospitals. Policies are needed that will ensure high detection anc cure rates, especially of the adult smear positive pulmonary tuberculosis case--the main cause of transmission. Decisions may be required on: case management procedures; counseling; prioritizing in-patient care; out-patient-based supervised care, where feasible; identifying human, material and financial resources to cope with the HIV-related tuberculosis epidemic.

Care for AIDS patients in developing countries: a review

As an ever increasing number of HIV-infected persons develop AIDS, treating the manifestations associated with HIV infection has become a new challenge to health sectors in developing countries. Given resource constraints of health systems before the AIDS epidemic, there is an urgent need to start examining ways in which health care can be delivered to the large number of AIDS patients, without infringing on other primary health care activities. This paper reviews current experience with AIDS patient care management in developing countries and determines some of the areas where further research is crucial. The main issues identified are: (1) that reliable data on standardized treatment schemes for AIDS patients are scarce; (2) that there is an urgent need for research on low-cost supportive treatment of AIDS patients, comparing costs and outcomes; (3) that outpatient and home-based care can be a valuable alternative to hospital-based care, but that cost-efficiency of these alternative treatment strategies should be examined more closely; and finally, that (4) the potential benefit of using HIV/AIDS patients to promote prevention of HIV transmission should be acknowledged.

Fibrous cortical defect and non-ossifying fibroma

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