2022 TB programme review in Pakistan: strengthening governance, with better patient diagnosis and treatment.

BACKGROUND: In Pakistan, 84% of healthcare is provided by the private sector. We conducted an epidemiological and programme review for TB to document progress and guide further efforts. METHODS: Surveillance and data systems were assessed before analysing epidemiological data. We reviewed the programme at federal, provincial and peripheral levels and compiled national data along with WHO estimates to describe the evolution of epidemiological and programme indicators. RESULTS: In 2021, of the estimated number of TB cases, 55% of overall cases and 18% of drug-resistant cases were diagnosed and treated respectively. The contribution of the private sector in case detection increased from 30% in 2017 to 40% by 2021. For newly diagnosed pulmonary TB cases, the overall proportion of confirmed cases was 52%. In 2021, testing for rifampicin resistance among confirmed cases was 66% for new and 84% for previously treated patients. The treatment success rate exceeded 90% for drug susceptible TB. The main challenges identified were a funding gap (60% in 2021-2023), fragmented electronic systems for data collection and suboptimal coordination among provinces. CONCLUSIONS: The main challenges prevent further progress in controlling TB. By addressing these, Pakistan could improve coverage of interventions, including diagnosis and treatment. Bacteriological confirmation using recommended diagnostics also requires further optimisation.

CONTEXTE: Au Pakistan, le secteur privé assure 84% des services de santé. Une étude épidémiologique et programmatique a été réalisée sur la TB afin de recueillir des informations sur les avancées réalisées et de guider les actions à venir. MÉTHODES: Les systèmes de surveillance et de données ont été évalués préalablement à l'analyse des données épidémiologiques. Nous avons examiné le programme aux niveaux fédéral, provincial et local et compilé les données nationales ainsi que les estimations de l'OMS afin de décrire l'évolution des indicateurs épidémiologiques et du programme. RÉSULTATS: En 2021, environ 55% de l'ensemble cas de TB et 18% des cas résistants aux médicaments ont été diagnostiqués et traités respectivement. La contribution du secteur privé dans la détection des cas est passée de 30% en 2017 à 40% en 2021. La proportion totale de cas confirmés pour les nouveaux diagnostics de TB pulmonaire s'élevait à 52%. En 2021, les tests de résistance à la rifampicine parmi les cas confirmés s'élevaient à 66% pour les nouveaux patients et de 84% pour les patients déjà traités. Le taux de réussite du traitement a dépassé 90% pour la TB sensible aux médicaments. Les défis majeurs comprennent un manque de financement (60% pour la période 2021­2023), des systèmes électroniques de collecte de données fragmentés et une coordination insuffisante entre les provinces. CONCLUSIONS: Les défis majeurs entravent les avancées dans la lutte contre la TB. En les mettant en évidence, le Pakistan pourrait améliorer la portée des interventions, y compris le diagnostic et le traitement. Il est également essentiel d'optimiser la confirmation bactériologique en utilisant les diagnostics recommandés.

Community-based multi-disease prevention campaigns for controlling human immunodeficiency virus-associated tuberculosis.

Human immunodeficiency virus (HIV) infection increases the risk of tuberculosis (TB) 21-34 fold, and has fuelled the resurgence of TB in sub-Saharan Africa. The World Health Organization (WHO) recommends the Three I's for HIV/TB (infection control, intensified case finding [ICF] and isoniazid preventive therapy) and earlier initiation of antiretroviral therapy for preventing TB in persons with HIV. Current service delivery frameworks do not identify people early enough to maximally harness the preventive benefits of these interventions. Community-based campaigns were essential components of global efforts to control major public health threats such as polio, measles, guinea worm disease and smallpox. They were also successful in helping to control TB in resource-rich settings. There have been recent community-based efforts to identify persons who have TB and/or HIV. Multi-disease community-based frameworks have been rare. Based on findings from a WHO meta-analysis and a Cochrane review, integrating ICF into the recent multi-disease prevention campaign in Kenya may have had implications in controlling TB. Community-based multi-disease prevention campaigns represent a potentially powerful strategy to deliver prevention interventions, identify people with HIV and/or TB, and link those eligible to care and treatment.

First national tuberculin survey in Nepal.

SETTING: The size of the tuberculosis (TB) problem in Nepal is unknown, as no national tuberculin or TB prevalence survey has yet been performed. OBJECTIVE: To assess the prevalence of TB infection and the annual risk of TB infection (ARTI) in primary schoolchildren in the three ecological zones (mountains, hills and terai) and Kathmandu valley. DESIGN: A representative sample of primary schoolchildren were tuberculin skin tested using the Mantoux method. The data were analysed using cut-off levels to define infection and by the mirror method. RESULTS: Of 19577 children registered, 17260 (88.2%) were available for analysis. Seventy-eight per cent had a visible bacille Calmette-Guérin scar. The best estimate of the prevalence of TB infection was 7.0% (95%CI 4.2-9.7), with an ARTI of 0.86% (95%CI 0.49-1.23) using the mirror method, with a mode at 16 mm. Although the ARTI was higher in Kathmandu and the mountains compared to the hills and terai, the difference between the areas was not significant. CONCLUSION: The ARTI in Nepal is lower than previous estimates, indicating a decrease in transmission or overestimation of previous estimates. To obtain information about the trend of the ARTI in Nepal, the survey needs to be repeated in 5 to 7 years.

Global monitoring of collaborative TB-HIV activities.

Tuberculosis (TB) and human immunodeficiency virus (HIV) programs are increasingly working together towards providing universal access to integrated TB and HIV prevention, treatment, care and support services. To monitor progress we need to measure the delivery and impact of these services; however, the lack of investment in monitoring and evaluation and the added complexity of sharing data between two vertical programs, makes monitoring and evaluation of collaborative TB-HIV activities especially challenging. We describe the global system to record, report and analyse data on collaborative TB-HIV activities and summarize results to date. Although the data suggest that there is a steady increase in collaborative TB-HIV activities in many high-burden countries over time, we are already falling behind the globally agreed implementation milestones. This is due to a combination of slow implementation and lack of necessary tools and systems for capturing activity data. In particular, data from HIV program monitoring of TB screening, TB preventive treatments and TB infection control for people living with HIV is lacking. Much remains to be done by both programs to improve the implementation, monitoring and evaluation of collaborative TB-HIV activities and to optimize prevention, treatment and care for people infected with both TB and HIV, especially in areas at high risk of drug-resistant TB.

Factors affecting patient adherence to DOTS in urban Kathmandu, Nepal.

SETTING: The urban area of Kathmandu has a population of one million, with an annual risk of tuberculosis (TB) infection of 4%. It is estimated that up to 200 people default from treatment in Kathmandu annually, giving a defaulter rate of 10%. OBJECTIVES: To identify the socio-demographic factors, availability and accessibility of DOTS services and behavioural factors affecting patient adherence to DOTS. METHODS: Structured questionnaire of a random sample of 234 new smear-positive TB patients enrolled on treatment. Analysis of socio-demographic, psychosocial factors and availability and accessibility of DOTS services. Sub-analysis of non-adherent (missed >7 consecutive treatment days) vs. adherent patients. RESULTS: Reasons given by non-adherent patients included 61% who claimed insufficient knowledge about the need to take daily treatment, especially after they felt better. Directly observed treatment, younger age, knowledge of TB and availability of daily health education were associated with increased adherence. Daily health education and knowledge of TB and its treatment were independently associated with adherence on multivariate analysis (OR 6.27, 95%CI 2.88-13.64, P < 0.001). CONCLUSION: Daily health education delivered at DOTS centres is strongly associated with improved adherence. Adherence throughout treatment needs emphasis.

Implementing global knowledge in local practice: a WHO lung health initiative in Nepal.

Clinical practice guidelines are used widely to improve the quality of primary health care in different health systems, including those of low-income countries. Often developed at international level and adapted to national contexts to increase the feasibility of effective uptake, guideline initiatives aim to transfer global scientific knowledge into local practice. The WHO's Practical Approach to Lung Health (PAL) is an example of such an initiative and is currently being developed to improve the quality of care for youths and adults with respiratory diseases. We assessed ex-ante the feasibility of successful implementation of PAL in a pilot programme in rural Nepal, studying three components: the quality of the innovation (i.e. the guidelines), the effectiveness of the implementation strategy (i.e. training) and the receptiveness of the social system of health staff at all levels (i.e. social and organizational characteristics). We assessed the guideline innovation with the AGREE instrument for guidelines, the intended implementation strategy by critical comparison with literature on effective strategies, and the social system with both a stakeholder analysis and a descriptive analysis of the health care system at district level. This ex-ante assessment of an adaptive local implementation of international WHO guidelines showed that in July 2002 the 'implementability' of the package was challenged on the three components studied. To increase the chances of successful implementation, the national guideline development process should be improved and the implementation strategy needs to be upgraded. In order to successfully transfer global knowledge into local practice, we need to develop additional multifactorial sustained interventions that tackle other culture-specific and health system-specific barriers as well. The primary health workers are key informants for these barriers.

An outbreak of Campylobacter infection associated with the consumption of unpasteurised milk at a large festival in England.

Seventy-two laboratory confirmed cases of Campylobacter infection were identified in people who attended a large festival in England. A case-control study was undertaken to identify the vehicle of infection. Potential risk factors included the water supply to the site, and food, bottled spring water and unpasteurised milk sold at the event. Only the consumption of unpasteurised milk showed a statistical association with having a Campylobacter infection, strongly suggesting that this was the vehicle of infection.

Stimulation of mucosal mast cell growth in normal and nude rat bone marrow cultures.

Mast cells with the morphological and biochemical properties of mucosal mast cells (MMC) appear and proliferate to form the predominant cell type in rat bone marrow cultures stimulated with factors from antigen- or mitogen-activated lymphocytes. Conditioned media causing a selective proliferation of MMC were derived from mesenteric lymph node cells of Nippostrongylus brasiliensis-infected rats restimulated in vitro with specific antigen or from normal or infected rat mesenteric lymph node cells stimulated with concanavalin A. MMC growth factor is not produced by T-cell-depleted mesenteric lymph node cells or by the mesenteric lymph node cells of athymic rats. By contrast, MMC precursors are present in the bone marrow of athymic rats and are normally receptive to the growth factor produced by the lymphocytes of thymus-intact rats. The thymus dependence of MMC hyperplasia is thus based on the requirement of a thymus-independent precursor for a T-cell-derived growth promoter.