Thrombose veineuse profonde d'origine tuberculeuse : à propos d'un cas observé au complexe pédiatrique de Bangui (République Centrafricaine)

La tuberculose est un facteur de risque de maladies thromboemboliques. Nous rapportons le cas d'une fille de dix ans qui a présenté un premier épisode de thrombose veineuse profonde découverte devant une douleur du membre pelvien droit avec œdème et impotence fonctionnelle, confirmée par un échodoppler des vaisseaux de la cuisse. Lors de la recherche de la cause, la tuberculose pulmonaire a été diagnostiquée selon les critères de l'Union Internationale Contre la Tuberculose et les Maladies Respiratoires. La patiente a été mise sous des antituberculeux associés à l'héparine de bas poids moléculaire relayée par l'anti vitamine K. L'évolution a été favorable. Il conviendrait en l'absence de diagnostic microbiologique de la tuberculose dans les pays à ressources limitées, d'évoquer une tuberculose devant toute thrombose veineuse profonde associée à une pneumonie

Importance of Therapeutic Drug Monitoring in the Treatment of Active Tuberculosis - A Retrospective Study of 4 Cases

Background: In the treatment of active tuberculosis, therapeutic drug monitoring (TDM) is used to optimize dosing that maximizes therapeutic benefit while minimizing toxicity. In Morocco, TDM is not routinely used, yet low levels of anti-TB drugs can be associated with poorer treatment outcomes.Methods: We retrospectively checked our archives for patients with active TB for whom TDM was performed during 2014. Medical records were reviewed to abstract demographic, clinical, radiographic and microbiological data including time until smear and culture conversion. Then, we looked for cases with delay of TB conversion.Results: In total, 24 patients were identified, for whom TDM was performed, they all had low serum drug levels. Among them, 4 patients showed delayed bacteriological conversion. Conclusions: Our study cases are showing the benefit of serum dosage in the follow-up of the patients showing a delay of sputum examination conversion,both direct and culture, during their evolutions. TDM is potentially useful for the treatment of active TB, but is currently underused in Morocco

Impact of Combination Antiretroviral Therapy Initiation on Adherence to Antituberculosis Treatment

Background: Healthcare workers are often reluctant to start combination antiretroviral therapy (ART) in patients receiving tuberculosis (TB) treatment because of the fear of high pill burden; immune reconstitution inflammatory syndrome; and side-effects.Object: To quantify changes in adherence to tuberculosis treatment following ART initiation.Design: A prospective observational cohort study of ART-naive individuals with baseline CD4 count between 50 cells/mm3 and 350 cells/mm3 at start of TB treatment at a primary care clinic in Johannesburg; South Africa. Adherence to TB treatment was measured by pill count;self-report; and electronic Medication Event Monitoring System (eMEMS) before and after initiation of ART.Results: ART tended to negatively affect adherence to TB treatment; with an 8% - 10% decrease in the proportion of patients adherent according to pill count and an 18% - 22% decrease in the proportion of patients adherent according to eMEMS in the first month following ART initiation; independent of the cut-off used to define adherence (90%; 95% or 100%). Reasons for non-adherence were multi factorial; and employment was the only predictor for optimal adherence (adjusted odds ratio 4.11; 95% confidence interval 1.06-16.0).Conclusion: Adherence support in the period immediately following ART initiation could optimise treatment outcomes for people living with TB and HIV

Sputum Smear-Positive Tuberculosis among Previously Treated Individuals in the Western Cape Province; South Africa

A considerable share of South Africa's tuberculosis burden affects those people who have previously been treated for tuberculosis - many of them successfully. In a retrospective cohort study that was conducted using tuberculosis treatment register data from two communities in suburban Cape Town; it was found that the hazard rate of re-treatment for smear-positive tuberculosis was between 3- and 5.26-times higher in tuberculosis cases who had defaulted from treatment compared to successfully treated cases. But although the rate of re-treatment was substantially higher among defaulters; cases after treatment success account for the vast majority of smear-positive re-treatment cases due to the fact that far more tuberculosis cases were successfully treated than had defaulted

Assessment of Community Pharmacists' Willingness to become Tuberculosis DOTS Services Providers in Lagos State

"Background: Hospital based Directly Observed Therapy Short course (DOTS) for the treatment of tuberculosis though effective has constraints to its effectiveness e.g. restricted timings of TB clinics; long distance to travel by tuberculosis patients to TB DOTS clinics; etc. Community pharmacy based TB DOTS services under thesupervision of community pharmacists can address these constraints. Objectives: To assess community pharmacists' willingness to become Tuberculosis Directly Observed TherapyShort course (TB DOTS) service providers in Lagos state; Nigeria. Methods: A 25 item self completion questionnaire was administered to 120 community pharmacists spreadacross three; Association of Community Pharmacists zones of Ikotun; Iyana-Ipaja; as well as Festac zones in Lagos state; Nigeria respectively. These community pharmacists' zones were formed in Lagos state to ensure theease of administration and prevention of the operation of illegal premises in Lagos state and the twelve zones inLagos state are duly recognized by both the Pharmaceutical Society of Nigeria and the State Chapter of the Association of Community Pharmacists. Data was collected on a scale that ranged from 8 to 40 with an assumedneutral point of 24 and statistically analysed. Results: Community pharmacists in Lagos state Nigeria were willing to be TB DOTS services providers as shownby a mean score of 30.53+ 6.71 in 77 of the respondents. On the 5-point rating scale; ""5"" represented thehighest mean score while ""1"" represented the lowest mean score. On the 8 item scale; the lowest mean score is 8and the highest mean score is 40 with a neutral point of 24. The percentage performance was the number of respondents that scored above the critical or neutral point on the rating scale. Statistically not significant association was observed between having heard of TB DOTS services and their willingness (X2 =0.66; P=0.3485;P0.05). Association between training in the provision of TB DOTS services and the willingness observed was2statistically also not significant (X =2.08; P=0.2525; P0.05).So also for the association between number of yearsof community pharmacy practice and their willingness to be TB DOTS service providers (X2=1.18; p=0.371;P0.05). Conclusion: Community pharmacists in Lagos state Nigeria are willing to be TB DOTS services providers. Howevertheir willingness to be TB DOTS services providers is not associated with the level of training that they have hadon TB DOTS services provisions; neither is it associated with their level of awareness about TB DOTS services.Their years of community pharmacy practice experience also had no influence on their willingness to be TB DOTSservices providers."

Advances in the diagnosis, treatment and control of HIV associated tuberculosis

There has been an increase in the number of published tuberculosis/HIV (TB/HIV) research findings in recent times. The potential impact of these findings on routine care has informed this review which aims at discussing current concepts and practices underpinning TB/HIV care and control. Any HIV infected person with a cough of any duration is currently considered a TB suspect. Preliminary results also show that the diagnostic yield of same day sputum samples(front loading) is comparable to two­day samples. Laboratory diagnosis is shifting from Ziehl­Neelsen (ZN) smear microscopy and solid culture to fluorescent microscopy, molecular tests and liquid culture. Concomitant TB/HIV therapy improves survival and WHO has recommended ART for all TB/HIV patients. Unless CD4 cell counts are less than 50 cells/µl, ART can be deferred until end of intensive phase. Evidence of survival benefit at high CD4 cell counts is still lacking. New TB drugs and treatment shortening studies are underway but so far no new TB drugs has been added to the current arsenal and treatment duration still remains six months or more. WHO has recommended the 3Is (intensified TB case finding, isoniazid prophylaxis and infection control) for TB/HIV control in addition to effective therapy, Antiretroviral therapy and TB vaccines. There has been immense progress in TB/HIV research, however optimal management of HIV­Infected TB patients, will require further research and appropriate translation of emerging evidence to policy and practice

Pattern and Magnitude of Treatment Delay among TB Patients in Five States in Southern Nigeria

Prompt diagnosis and early treatment of Tuberculosis (TB) cases is an important strategy in TB prevention and control. Thus; passive case finding of TB suspects; sputum examination for diagnosis; and prompt treatment using Directly Observed Treatment Short Course (DOTS) are key elements in the national guideline for TB control programme. The aim of this study is to determine the time interval between diagnosis of smear-positive TB cases and the commencement of treatment in DOTS facilities in southern Nigeria. The study was carried out in 20 healthcare facilities supported by TB Control Assistance Program (TB-CAP) involved in TB management in southern Nigeria; which comprised tertiary; secondary; and primary healthcare facilities including public and private facilities. Data were collected through review of clients' and facility records covering July-September 2009. Data collected were sociodemographic characteristics; sputum-smear result; date of diagnosis; and date of commencement of treatment. Data were analyzed using SPSS version 15.0 software. Of the total 2;507 TB suspects examined for Acid-Fast Bacillus (AFB); 323 were diagnosed to be Sputum-Smear-Positive (SS+ve); However; 269 new smear positive cases were commenced on treatment within the period; thus 54 (17.0) of the new SS+ve cases defaulted initially. One hundred and two (38) of them commenced TB treatment within 3 days of smear examination for diagnosis; while 59 (22) commenced 4-6 days after diagnosis. The study revealed significant delay in commencement of TB treatment for most new smear positive TB cases in southern Nigeria and underlines the need to further explore factors responsible for delay in commencement of TB treatment following diagnosis

Evaluation of directly observed treatment for tuberculosis in the Bojanala health district, North West Province of South Africa

Background: Tuberculosis (TB) remains one of the top public health problems in South Africa. Approximately 150 000 new cases and 10 000 TB-related deaths are reported in South Africa annually. In declaring TB a global emergency in 1993, the World Health Organization developed control strategies that include active case finding, laboratory support, directly observed treatment (DOT), contact tracing, and prevention of multidrug­ and extreme drug-resistant tuberculosis (MDR-TB and XDR-TB). High DOT rates reported in some countries have been discordant with 'low cure' and 'high MDR' rates. Objectives: The aim of the study was to evaluate the use of DOT for TB in the Bojanala health district, North West Province, South Africa, by estimating the proportion of DOT use (1) amongst all TB patients and (2) in the initial TB treatment regimen compared to retreatment regimens. Method: A cross-sectional, descriptive study was conducted in 2008. Data regarding implementation of DOT were collected from eight purposefully selected primary health care clinics and one prison clinic in the health district. Upon receiving their informed consent, a questionnaire was administered to patients receiving TB treatment at the selected facilities. Results: A total of 88 (of 90 selected) patients participated in the study, of whom 50 (56.8%) were on DOT and had DOT supporters. However, 35 (40%) had never heard of DOT. DOT was used mainly for patients on the retreatment regimen (87.5%), rather than for those on first-line treatment (48.6%). Conclusion: In this South African rural health district, the DOT utilisation rate for TB was 56.8%, mainly for patients on the TB retreatment regimen. Strict implementation of DOT in all patients undergoing TB treatment is a known strategy for improving TB cure rate and preventing recurrence and drug resistance

Effectiveness of home-based directly observed treatment for tuberculosis in Kweneng West subdistrict, Botswana

Background: Tuberculosis (TB) and HIV are major public health problems in Botswana. In the face of growing TB notification rates, a low cure rate, human resource constraints and poor accessibility to health facilities, Botswana Ministry of Health decided to offer home-based directly observed treatment (DOT) using community volunteers. Objectives: The aim of this study was to assess the outcomes of home-based directly observed treatment (HB-DOT) versus facility-based, directly observed treatment (FB-DOT) in the Kweneng West subdistrict in Botswana and to explore the acceptability of HB-DOT among TB patients, community volunteers and health workers. Method: A quantitative, observational study using routinely collected TB data from 405 TB patients was conducted and combined with 20 qualitative in-depth interviews. Results: The overall cure rate for smear-positive pulmonary TB patients was 78.5. Treatment outcomes were not statistically different between FB-DOT and HB-DOT. Contact tracing was significantly better in FB-DOT patients. Interviews revealed advantages and disadvantages for both FB and HB options and that flexibility in the choice or mix of options was important. A number of suggestions were made by the interviewees to improve the HB-DOT programme. Conclusion: HB-DOT is at least as good as FB-DOT in terms of the treatment outcomes, but attention must be given to contact tracing. HB-DOT offers some patients the flexibility they need to adhere to TB treatment and community volunteers may be strengthened by ongoing training and support from health workers, financial incentives and provision of basic equipment

Assessment of the Health System to Support Tuberculosis and AIDS Care. A Study of Three Rural Health Districts of Burkina Faso

There is increasing evidence demonstrating the importance of healthcare systems for improvement of chronic illness care. The aims of this study were to develop a comprehensive assessment of the health services capacity to provide tuberculosis (TB) and human immunodeficiency virus (HIV) care but also to enhance patient empowerment; social network and community support. A cross-sectional study was conducted from 1 to 31 of August 2007 in 3 districts of Burkina Faso. We used a step-by-step model and the assessment of chronic illness care (ACIC) scale to assess capacities of 24 first line health centres (FLHC) and 3 district hospitals (DH) for providing TB and HIV/AIDS care. Data for the step-by-step model were extracted from medical records of 75 TB and 66 HIV patients. The ACIC scale was completed by health professionals; 6 medical doctors and 18 nurses; working at the DH level and at the FLHC level; respectively. The biological test for confirmation was free of charge for all the TB patients but only for 10.6(7/66) HIV cases. Up to the time of the survey; 5 TB (6.6) and 18 HIV+ patients (27.3) have been hospitalised for care at least once; 64 TB (85.3) had been declared cured and 38 HIV (54.5) were under antiretroviral treatment. Health care process organisation for TB and HIV care had distinct areas of weaknesses. From a maximum ACIC score of 11; the overall score for TB care ranged between 1.9 and 4.9 with a median of 3.7 and for HIV care between 2.1 and 6.7 with a median of 4.1. This study provides an illustration of assessing the HIV and TB care combining data from the routine information system and from the chronic illness care assessment tool; to encompass both disease control and patient health perspective. It provides to health managers arguments for clear conclusions and sufficient data for action

Management of TB in the Private Sector in Khartoum; Sudan: Quality and Impact on TB Control

Introduction: Sudan has a large and growing private health sector. No survey was done in Sudan to show the extent of the use of private health care services by the population. Also precise data on tuberculosis (TB) diagnosis and treatment in the private sector are not available. Material and methods A facility-based cross-sectional survey was carried out during February2007-June 2007 in Khartoum state; whereby consented private physicians working in the all private clinics (n=110) were interviewed. Results This study showed that a large private sector exist in the country and deliver care to TB patients and reported the non-adherence of this sector to National Tuberculosis Program (NTP) guidelines. 59.1of the interviewed physicians correctly mentioned the TB treatment regimens; only 8(12.3) physicians that reported management of TB patients actually prescribed these regimens to their patients. Similarly; only 10(15.4) physicians requested sputum smear examination for TB diagnosis. Conclusion A considerable proportion of cases is inadequately managed by the private sector and is not notified to NTP. The information delivered by this study can be used to develop a workable Public-private mix (PPM) model with the private sector

Success of the Control of Tuberculosis in Nigeria: a Review

Tuberculosis (TB) has emerged as the single leading cause of death from any single infectious agent and has continued to be a major public health problem all over the world. Of the over 14 million cases worldwide reported by World Health Organisation (WHO) in 2008; Nigeria ranked fifth in terms of incidence. Depending on the prevailing social factors such as socio-economic status of the people; malnutrition; crowded living conditions; incidence of HIV/AIDS; level of development of health infrastructures; quality of available control programmes; degree of drug resistance to anti-tuberculous agents; etc; prevalence; patterns of presentation; and outcomes of treatment from TB can vary from one country to another and from one region of a country to the other. Attempts to deal with the problems of the disease led to the development of Directly Observed Treatment Short Course (DOTS) by WHO in 1995; and more recently the Stop TB strategy in 2006. In Nigeria; the DOTS programme has been implemented in all States and local government areas in the country and 3;000 DOTS centres have been operating across the country since 2006. This article reviewed the available information on the success of the control of TB in Nigeria has observed a significant improvement in TB detection and treatment. However; neither the set target for the detection rate nor the cure rate have been achieved nationally as several challenges have militated against the effective implementation of the DOTS programme

What are the Reasons for Patients not Adhering to their Anti-TB Treatment in a South African District Hospital?

Introduction :TB is a major health problem in South Africa; with increasing numbers of patients notified; inadequate successful treatment rates and an emerging problem with resistant strains. This study was conducted at a District Hospital in KwaZulu-Natal where the successful treatment rate was as low as 23. The aim of this study was to identify key factors at the hospital that may affect adherence to TB treatment and to recommend interventions that could improve adherence. Methods:The study design was a case control study using prospectively collected data. Information was collected over an 8-month period; when the patients started their anti-TB treatment; according to the known factors that influence TB adherence. The patients were then followed up to determine those who did not adhere to their treatment; and those who successfully completed treatment. The two groups involved; therefore; were the controls (those who did adhere) and the cases (those who did not adhere). The data previously collected were then compared for significant associations with the controls and cases. Results :Data were obtained from 159 TB patients; 105 (66) were adherent and 54 (34) non-adherent. The following variables showed a significant association (p 0.05) with non-adherence: higher level of education; distance from the hospital; time taken to travel; the method of transport; satisfaction with the hospital; food security; income; the smoking of tobacco and/or marijuana; the patients' perspective and beliefs; HIV testing and status; functional status; social support; the relationship with the TB nurse; depression score; and self-rating of confidence. A stepwise logistic regression was performed; and only two variables remained significantly associated: travel time (OR7.9; 95CI 1.4-44.1) and the relationship with the TB nurse (OR2.6; 95CI 1.3-5.1). Conclusions: The most important recommendation is to improve the relationship between patients and TB nurses through training in communication skills. A more holistic assessment of patients would help identify issues such as depression; and a more patient-centred approach would help to understand and address patient's concerns; beliefs and expectations. It may also be important to ensure that management and administrative systems support a more patient-centred approach. It may be important to encourage the recruitment of family physicians who are trained in communication skills and a patient-centred approach; to work in the rural areas; where they can mentor and teach other colleagues and staff. More needs to be done in terms of helping patients to access facilities through transport; or in making services more available at the community level through DOTS (Directly Observed Treatment) supporters and adequate home-based carer support

Case report: Pulmonary hydatid disease

A.N.

History of TB in the Sudan

Introduction: Medical history in Sudan is far from being complete. There are no reliable records.Attempt to write on the projects and development of history of TB in the Sudan is a difficult task.Objective:To study and trace the progress of TB in Sudan during the last century through their historical development.Design: A retrospective study.Methods:Data were collected from the annual reports of the Sudan Medical Services.Libraries and a number of previous studies were consulted.Results: The route of entry of TB in the Sudan is mainly from the North.The South was virgin from TB up to 1930s. Northern Sudanese tribes have a high susceptibility and incidence of TB during 1925-1932 (3.7/1000). The south and the Nuba Mountains were almost free from infection or disease. The infectivity rate was highest in North 4.3while Khartoum showed 3. In the South;Rumbek district; no TB cases were reported before the age of puberty up to 1930.Prevalence of tuberculosis in 1959/1960 was 26.0and the detection rate was only 30.Conclusion: Northern Sudanese contracted tuberculosis while serving in the Egyptian army and cities. The Southern and Western tribes who were almost free from TB infection became highly susceptible to both infection and disease. The infectivity rate remains static during the last 50 years

Influence des parcours de soins sur le debut du traitement antituberculeux a Conakry (Guinee)

Les parcours de soins sont souvent complexes et peuvent induire des retards de traitement; avec des effets particulierement deleteres en cas de tuberculose. Nous avons cherche a identifier de facon retrospective; les parcours de soins des patients avant le diagnostic de tuberculose et l'influence de ces parcours sur les delais de traitement a Conakry-Guinee.Nous avons interroge 112 nouveaux patients a leur enregistrement pour tuberculose pulmonaire a bacilloscopie positive. Ont ete distingues les parcours conventionnels (recours aux seules structures sanitaires) et mixtes (associant structures sanitaires; automedication et medecine traditionnelle). L'influence des caracteristiques des patients sur le type de parcours a ete testee en analyses uni et multivariees et les delais de mise sous traitement ont ete compares pour les deux types de parcours. Deux patients sur trois ont suivi un parcours mixte. Ce type de parcours n'etait lie; en analyse multivariee; qu'au niveau de scolarisation (p=0;02). Les delais moyens de traitement etaient similaires (respectivement 13;4 et 12;8 semaines pour les parcours conventionnels etmixtes; p=0;68). La proportion de parcours comportant plus de trois recours aux structures sanitaires etait significativement plus elevee pour les parcours conventionnels que pour les parcours mixtes (72vs 30; p0;001). Les principales raisons invoquees pour l'utilisation tardive des structures sanitaires etaient l'ignorance des signes de la tuberculose (26) et le cout eleve des soins (12). Les parcours des patients sont multiples et peuvent induire des retards a la mise sous traitement antituberculeux. Une sensibilisation de la population et des soignants est necessaire

Perceptions of Tuberculosis and Treatment Seeking Behaviour in Ilala and Kinondoni Municipalities in Tanzania

This study was carried out in Ilala and Kinondoni Municipalities in Tanzania to explore the perceptions of Tuberculosis (TB); and treatment seeking behaviour; among patients attending healthcare facilities. The study was conducted in four randomly selected health facilities providing directly observed treatment (DOT). Exit interviews were administered to 69 randomly selected TB patients. The mean age of the respondents was 33.2 years (range= 11-72 years). Forty-six (66.7) of the patients had primary school education. Fifty-nine (84.1) patients had good knowledge on the transmission of TB. Majority (75) of the respondents were of the opinion that the incidence of TB was on the increase and this was mainly associated with HIV/AIDS epidemic. All respondents knew that TB was a curable disease if one complies with the treatment. Sixty-four (60) respondents had good knowledge on the correct duration of tuberculosis treatment. The median duration before seeking treatment from a health facility was 1.5 months. The majority of the patients 47 (68) visited public health facilities for treatment as their ?rst action. Overall; 83.8(57/68) respondents said females comply better with treatment than male patients. The majority of the respondents lived within a walking distance to a healthcare facility. Only 18.8(13/69) had to spend an average of US$ 0.2-0.3 as travel costs to the healthcare facility. Most of the respondents (57.8) said they were well attended by service providers. Half (21/42) and 59.3(16/27) of the males and females; respectively; mentioned good patient-service provider relationship as an important reason for satisfaction of the service (?2 =0.57; df=1; P0.005). Twenty-nine (42) of respondents were of the opinion that female TB patients conformed better to treatment than males and a similar number thought that both of them equally conformed to treatment. Findings from this study indicate that a large population in urban settings are aware that health facilities play a major role in TB treatment. In conclusion; there is a need to further explore how this information could potentially be used to enhance early seeking of appropriate services among TB patients in the era of rapid urbanization. Strategies in the control of TB and other diseases should focus on advocacy in seeking appropriate care