Global Fund financing of public-private mix approaches for delivery of tuberculosis care

Objectives To map the extent and scope of public–private mix (PPM) interventions in tuberculosis (TB) control programmes supported by the Global Fund. Methods We reviewed the Global Fund’s official documents and data to analyse the distribution, characteristics and budgets of PPM approaches within Global Fund supported TB grants in recipient countries between 2003 and 2008. We supplemented this analysis with data on contribution of PPM to TB case notifications in 14 countries reported to World Health Organization in 2009, for the preparation of the global TB control report. Results Fifty‐eight of 93 countries and multi‐country recipients of Global Fund‐supported TB grants had PPM activities in 2008. Engagement with ‘for‐profit’ private sector was more prevalent in South Asia while involvement of prison health services has been common in Eastern Europe and central Asia. In the Middle East and North Africa, involving non‐governmental organizations seemed to be the focus. Average and median spending on PPM within grants was 10% and 5% respectively, ranging from 0.03% to 69% of the total grant budget. In China, India, Nigeria and the Philippines, PPM contributed to detecting more than 25% TB cases while maintaining high treatment success rates. Conclusion In spite of evidence of cost‐effectiveness, PPM constitutes only a modest part of overall TB control activities. Scaling up PPM across countries could contribute to expanding access to TB care, increasing case detection, improving treatment outcomes and help achieve the global TB control targets.     

Patient delay determinants for patients with suspected tuberculosis in Yogyakarta province, Indonesia

Objectives Indonesia has a high incidence of tuberculosis (TB), despite the successful introduction of the directly observed treatment short‐course strategy (DOTS strategy). DOTS depends on passive case finding. It is therefore important to identify determinants of patient delay and reasons for visiting a DOTS healthcare provider when seeking care. The aim of this study was to assess these determinants in TB suspects (coughing for at least 2 weeks). Methods Cross‐sectional data were gathered with a structured questionnaire in which psychosocial determinants were based on an extended version of the theory of planned behaviour (TPB). The study was conducted in five governmental lung clinics of Yogyakarta province. In total, 194 TB suspects that registered at the lung clinics were interviewed. Results The median patient delay was 14 days (range 0–145). Ordinal regression analyses showed that visiting a private healthcare provider when first seeking health care, reporting travel distance/travel time as reason for choosing a certain healthcare provider when first seeking health care, discussing the symptoms with family and a reported short travel time, but no factors of TPB, were significantly associated with a shorter patient delay. An important factor negatively associated with visiting a DOTS clinic was the reported travel time. Conclusion Accessibility of the healthcare provider was the main determinant of patient delay, but the role of psychosocial factors cannot be fully excluded. Urban and suburban areas have relatively good access to (private) health care, hence the short delay. Thus, future studies should be focussed on extending the DOTS strategy to the private sector.     

Performance of an algorithm based on WHO recommendations for the diagnosis of smear-negative pulmonary tuberculosis in patients without HIV infection

Objective To evaluate the performance of an algorithm based on WHO recommendations for diagnosis of smear‐negative pulmonary tuberculosis in HIV‐negative patients. Methods We recruited HIV‐negative patients with clinical suspicion of tuberculosis who had had three negative sputum smears in Lima, Peru. All included subjects underwent a complete anamnesis, physical examination and chest X‐ray, and had a sputum specimen cultured in Ogawa, Middlebrook 7H9 media and MGIT®. We applied an algorithm based on WHO recommendations to classify patients as having tuberculosis or not. The diagnostic performance of the algorithm was evaluated comparing its results against the reference standard of a positive culture for M. tuberculosis in either of the media used. Results A total of 264 of the 285 patients included (92.6%) completed evaluation and follow up. Of these, 70 (26.5%) had a positive culture for M. tuberculosis. Clinical response to a broad spectrum course of antibiotics was good in 32 of these 70 patients (45.7; 95%CI 34.0–57.4%). Overall, the algorithm attained a sensitivity of 22.9% (95% CI 13.1–32.7%) and a specificity of 95.4 % (95% CI 92.4–98.3%) compared to culture results. The positive likelihood ratio was 4.93 and the negative likelihood ratio was 0.81. Conclusions The sensitivity and negative likelihood ratio of the algorithm is poor. It should be re‐evaluated, and possibly adapted to local circumstances before further use. The clinical response to an antibiotic trial is the most important component to reassess. We also suggest considering performing chest X‐ray earlier in the diagnostic work‐up.     

Role of risk factors and socio-economic status in pulmonary tuberculosis: a search for the root cause in patients in a tertiary care hospital, South India

Objective To determine the frequency of underlying risk factors and the socio‐economic impact based on occupation in the development of tuberculosis. Method Retrospective analysis of 207 clinically and microbiologically diagnosed patients with pulmonary tuberculosis (PTB) admitted to Kasturba Hospital in 2005 and 2006. Demographic details and underlying risk factors were statistically evaluated. Results Diabetes mellitus (DM) (30.9%) was the most prevalent condition and significantly more common than other risk factors like smoking (16.9%), alcoholism (12.6%), HIV (10.6%), malignancy (5.8%), chronic liver diseases (3.9%), history of contact with TB (3.4%), chronic corticosteroid therapy (2.9%), chronic kidney diseases and malnourishment (1.5%). There were 82 patients (39.6%) with no underlying risk factor. Men (M:F = 3.7:1) and patients older than 40 years had a higher incidence of co‐existing conditions. PTB was significantly more common in blue‐collar (44%) and white‐collar (27.1%) workers than household workers (12.1%), students (10.6%) and retired/unemployed people (6.3%). Conclusion Pulmonary tuberculosis had a significant impact and predominated in male patients co‐existing with DM. Patients with DM and suggestive pulmonary symptoms should be screened for tuberculosis. More stringent health education and awareness programme should be implemented at the grass root level.     

Integrated tuberculosis and HIV care in a resource-limited setting: experience from the Martin Preuss centre, Malawi

Objectives To describe the development and operation of integrated tuberculosis (TB) and HIV care at the Martin Preuss Centre, a multipartner organization bringing together governmental and non‐governmental providers of HIV and TB services in Lilongwe, Malawi. Methods We used a case study approach to describe the integrated TB/HIV service and to illustrate successes and challenges faced by service providers. We quantified effective TB and HIV integration using indicators defined by the World Health Organization. Results The custom‐designed building facilitates patient flow and infection control, and other important elements include coordinated leadership; joint staff training and meetings; and data systems prompting coordinated care. Some integrated services have worked well from the outset, such as promoting HIV testing among patients with TB (96% of patients with TB had documented HIV status in 2009). Other aspects of integrated care have been more challenging, for example achieving high uptake of antiretroviral therapy among HIV‐positive TB patients and combining data from paper and electronic systems. Good TB treatment outcomes (>85% cure or completion) have been achieved among both HIV‐positive and HIV‐negative individuals. Conclusions High‐quality integrated services for TB and HIV care can be provided in a resource‐limited setting. Lessons learned may be valuable for service providers in other settings of high HIV and TB prevalence.     

TB and HIV integration: obstacles and possible solutions to implementation in South Africa

Objectives To identify key obstacles to operational integration of TB and HIV services and to suggest strategies to promote integration in the prevention, treatment and care of patients with TB and HIV. Methods This is a health systems research case study of operational integration of TB and HIV in South Africa. Peer‐reviewed and grey literature together with the experiences of the authors were used to identify key obstacles to integration in service implementation practices and community‐level care. Relevant legislation, policies and guidelines were analysed to determine whether they facilitated or undermined the integration of TB and HIV services. Results Obstacles to integration exist at contextual and epidemiological levels as well as at intervention design and implementation levels. Importantly, integration at an operational level is undermined by fundamentally different principles underpinning the design of TB and HIV programmes and national policies and legislation which mitigate against integration. Conclusion South Africa has an opportunity to effect changes that will facilitate TB/HIV integration and improve care for all those infected with TB, HIV or both conditions. An analytic approach necessary to understand the obstacles to and ensure effective strategies facilitating integration is required. This needs to be followed by mobilisation of clinical and health systems expertise, health infrastructure, commitment and experience in creative and appropriate ways for the variety of health care settings.     

前路病灶清除后路椎弓根固定治疗腰椎结核

目的探讨前后路联合Ⅰ期手术治疗腰椎结核的效果。方法采用后路椎弓根钉内固定同时前路病灶清除及椎间植骨融合治疗腰椎结核患者43例。术后随访12~33个月,平均(20±2)个月。在X线片上测量术前、术后后凸角度(Cobb角),观察植骨融合情况,应用Frankel分级评分评估神经恢复情况。结果平均手术时间(3.0±0.5)h,术中平均出血(600±50)mL。43例患者术后切口均甲级愈合,未发生感染现象,未见窦道形成。植骨块均骨性融合,局部无复发,术后X线片显示后凸畸形角度矫正10°~25,°平均(14±2)°,随访1 a以上至植骨块融合时,角度丢失0°~3°,平均(2±1)°,所有患者均未发生后凸畸形加重。15例有神经症状患者术后均有一定程度的恢复。结论前后路联合Ⅰ期手术治疗腰椎结核可以促进植骨融合和神经功能恢复,防止后凸畸形,临床疗效满意。