Evaluation of community-based interventions for non-communicable diseases: experiences from India and Indonesia.

This paper reports the results of formative and outcome evaluation of two ongoing community-based intervention programmes for integrated non-communicable disease (NCD) prevention and control in urban low-income settings of Ballabgarh near New Delhi, India, and in Depok, West Java Province of Indonesia. At both sites, a coalition of community members facilitated by academic institution and the World Health Organization, planned and implemented the intervention since 2004. The intervention consisted of advocacy and mediation with stakeholders, training of volunteers and school teachers, communication campaigns, risk assessment camps and reorientation of health services. The formative evaluation was based on the review of documents, and outcomes were assessed using the standardized surveys for NCD risk factors in 2003-2004 and 2006-2007. The baseline surveys showed that tobacco use, low intake of fruits and vegetable, suboptimal levels of physical activity and obesity were prevalent in both the communities. A frequent change in local administrators and lack of perceived priority for health and NCDs limited their involvement. Pre-existing engagement of community-based organizations and volunteers in health activities facilitated its implementation. The reach of the programme among the population was modest (25-32%). Health system interventions resulted in increased diagnosis and better management of NCDs at health facilities. Early outcome measures showed mixed results of change in different risk factors. The experiences gained are being used in both countries to expand and provide technical support to national efforts. This paper adds to the knowledge base on the feasibility of designing and implementing large-scale community-based interventions for integrated prevention of NCDs through modification of risk factors.

[Evaluation of diagnostic and therapeutic management in patients with bacteriologically negative pulmonary tuberculosis]. / Ocena postepowania diagnostycznego i leczniczego u chorych na czynna gruzlice ukladu oddechowego niepotwierdzona bakteriologicznie.

The study aimed at assessing the frequency and type of errors in the diagnosis and management of newly registered bacteriologically negative cases of pulmonary tuberculosis. Random sample of 560 out of 7272 such patients registered in 1993 was subject of detailed analysis of all available medical documentation. The analysis was performed by an independent team of three specialists: pulmonologist, radiologist and epidemiologist. The results of the analysis indicate insufficient utilization of modern available diagnostic methods. Apart from clinical assessment the main basis for diagnosis of tuberculosis was A-P radiography. Tomography examination was performed in 35.5% of patient only, bronchoscopic in 19.8% and cytologic examination of sputum in 15.9%. Bacteriological examinations during the first phase of diagnosis, usually in hospitals, were satisfactory. Error in diagnosis was found in 63 patients, i.e. 11.3% of cases. The treatment in patients considered as correctly diagnosed, was in the intensive phase correct, but in the continuation phase--too long.

[Analysis of diagnostic errors and recommendations of diagnostic procedures in bacteriologically negative pulmonary tuberculosis]. / Analiza blednych rozpoznan u chorych na gruzlice czynna niepotwierdzona bakteriologicznie. Zasady postepowania diagnostycznego.

The paper presents a detailed analysis of errors in the diagnosis of bacteriologically negative pulmonary tuberculosis in a random sample of 560 patients out of all such patients registered in 1993. The false diagnosis was found in 63 patients i.e. in 11.3% of the sample. Among the 63 patients with false diagnosis of tuberculosis there were 15 cases with lung cancer, 15 cases with pneumonia and/or pleuritis, 15 cases with disease of circulatory system with abnormal radiological of the lungs, 8 cases with old post-tuberculosis changes in the lung considered as relapses, 4 cases of bronchiolitis obliterans with organizing pneumonia, 3 cases of sarcoidosis and 1 case of aspergillosis in a post-tb cavity. The most serious errors were those related to failure in diagnosing (or of too late diagnosis) of lung cancer. These failures comprised 2.7% of patients in the sample. The chance to detect a lung cancer in the sample was 2900 cases in 100,000 men and 2200 cases in 100,000 women. This chance was much higher than in general population--29x for men and 100x for women. The main source of errors was false interpretation of radiological examinations and neglect to utilise other diagnostic procedures like bronchoscopy, cytology or tomography examinations. As an outcome of the analysis authors present their recommendations for diagnostic procedures in the diagnosis of bacteriologically negative pulmonary tuberculosis.

[Epidemiology of tuberculosis in Poland and in the world]. / Gruzlica w Polsce i na swiecie.

The paper describes the risk of tuberculosis infection and the incidence of the disease as measures of the epidemiological situation and presents data on the epidemiological situation of tuberculosis in Poland and the world. It also describes the effectiveness of the national tuberculosis control programme in Poland. The annual risk of tuberculosis infection in Poland is estimated at 0.2% which is about 10 times higher than the lowest one in Europe (the Netherland), but there are countries in the world with the risk of 2.0% and higher. The incidence of tuberculosis in Poland (all forms) declined from 182.6/100,000 in 1965 to less than 40,0/100,000 in 1996, of which less than half were bacteriologically positive cases. The incidence of smear positive cases, the most infectious group, declined from 18.7/100,000 in 1980 to 9.7/100,000 in 1995. All cases of tuberculosis in Poland are treated with 4-drugs regimen in the intensive phase of treatment and 3-drugs in the continuation phase. The duration of treatment is 6-8 months and the cure rate is above 90%.

[Comparative study of BCG vaccines: Polish, Danish and Japanese]. / Badanie porównawcze szczepionek BCG produkcji polskiej, dunskiej i japonskiej.

In a group of 1111 school children aged 12 years from two selected town in Poland (Rzeszów and Ostroleka) a comparative study of three BCG vaccines was performed, the Polish, the Danish, and the Japanese. Tests for viability of the vaccines gave the following results: for the Polish vaccine 17680000 culturable particles in 1 mg; the Danish--12060000, and the Japanese--43540000 respectively Children eligible for vaccination were selected on the basis of prevaccination tuberculin testing with 2 TU tuberculin RT-23 with Tween 80. All the three vaccines gave high level of postvaccination tuberculin reactions measured after 10 weeks. In more than 30% of children these reactions were higher than 15 mm. The mean postvaccination reactions after the Polish vaccine was 14.2 mm (s.d.3.7), after the Danish--13.7 mm (s.d.3.9), and after the Japanese 14.9 mm(s.d.3.0). The difference between the Danish and the Japanese vaccines was statistically significant, but between the Polish and the other two vaccines was not. It was also formed that children with larger postvaccination tuberculin indurations had larger diameter of preview BCG scars.

[Evaluation of the epidemiologic situation of tuberculosis in Poland and in the world]. / Ocena sytuacji epidemiologicznej gruzlicy w Polsce i w swiecie.

The paper describes the current epidemiological situation of tuberculosis in Poland, its trends in the last 2-3 decades and its place on comparison to the global world-wide situation. The incidence of tuberculosis in Poland declined from 182.6 per 100,000 population in 1965 to 43.2 per 100,000 in 1991, but is still at least two times higher than the average for Europe. The rate of decline for the last few decades was about 5.5% annually, but last year an increase has been observed. Among newly detected cases of tuberculosis in Poland in comparison to other European countries there is a higher proportion of young adults, of severe clinical forms, and relatively lower proportion of relapses. The annual risk of tuberculosis infection, the indicator considered as a most reliable one, which ranges from 0.01 to more than 3% worldwide, in Poland as about 0.2%. The highest risk, and prevalence of tuberculosis infection is in African and Asian countries, where there is also the highest prevalence of HIV infection, and consequently an important increase in the incidence of tuberculosis. Such an increase has also been observed in the USA and in some European countries. The increase in the incidence of tuberculosis in Europe however, could not be directly connected with the HIV infection. The current epidemiological situation of tuberculosis and its worldwide perspectives seem to be closely related to: (i) existing geographical differences in the level of the risk and prevalance of tuberculosis (ii) the level and the spread of HIV infection (iii) the difference in the demographic structure of population in different parts of the world which will determine the frequency of dual (HIV/TB) infection, (iv) the effectiveness of tuberculosis control activities, and (v) the level of migratory movements of population, particularly from countries/areas with high prevalence of tuberculosis. The recently observed increase in the incidence of tuberculosis in many parts of the world including Poland indicates clearly the importance and the necessity to constantly monitor all the changes in the epidemiological situation of tuberculosis and of AIDS/HIV infection [corrected].

Tuberculosis and AIDS: European and worldwide perspectives.

To examine the possible influence of AIDS and HIV infection on the epidemiology of tuberculosis in Europe and worldwide in the coming decades an analysis of the available data on the two diseases and on the transmission of the two infections in relation to the demographic structure of the population was conducted, including projections for up to the year 2025. Globally, the effects of the AIDS pandemic on the tuberculosis situation will probably be very serious, adding some 1.5 million new cases of tuberculosis annually by the year 2025 as a result of HIV infection. However, this effect for Europe in the year 2025 may be in the range of 15,000 additional cases only. The main factor determining the scale of aggravation of Tb is the age structure of the population infected, or at risk of being infected, with tubercle bacilli and HIV. Although the influence of HIV infection on tuberculosis in Europe may not be very high due to the fact that HIV infection involves mainly younger age groups it may, however, substantially postpone the elimination of tuberculosis from Europe. Therefore it seems necessary to monitor constantly all the changes in the epidemiological situation of both tuberculosis and AIDS/HIV.

[Tuberculosis in Poland and in the world--actual state and expectations after the year 2000]. / Gruzlica w Polsce i na swiecie--stan aktualny i przewidywany po roku 2000.

Decreased trends of tuberculosis incidence have been observed in Poland. A rate of decreased incidence has been hesitated from about 1% to above 12% per year. In 1989 year 16,185 (42.8%/100,000) cases with active pulmonary tuberculosis have been registered and about half of them have been bacteriologically supported. Analyzed epidemiological parameters for tuberculosis are twice higher in Poland than in Europe. Using relation between an incidence of active tuberculosis bacteriologically supported and annual risk of infection it was documented that an annual risk of tubercule bacillus infection was 10-times higher in Poland in comparison with other countries characterized by the lowest incidence of tuberculosis (Norway, Holland).

[Effectiveness of nifedipine in the treatment of arterial hypertension in various types of diabetes mellitus]. / Skutecznosc nifedypiny w leczeniu nadcisnienia tetniczego wystepujacego w róznych postaciach cukrzycy.

Selection of indications and the general tactics of nifedipine monotherapy of hypertension in diabetic subjects is not clearly established, as yet. It refers specifically to different forms and phases of diabetes mellitus. This was the reason to carry out a respective study. In 4 groups of hypertension: 1) in diabetics without vascular complications, 2) in diabetic nephropathy, 3) in diabetics type II without nephropathy, and 4) in comparative group of subjects without diabetes mellitus, a 6-week controlled, open trial was performed. Before, during and after nifedipine (3 X 10-20 mg p.d.), the following parameters were monitored: 1) systolic, diastolic and mean blood pressures, 2) glycaemic indices of diabetes control, 3) serum cholesterol: total, HDL, LDL, triglycerides, 4) daily albuminuria and GFR, 5) adverse reactions to nifedipine. It could be concluded that nifedipine therapy was relatively most effective and safe in hypertensive diabetics type II without nephropathy. It was less effective in diabetics type I without nephropathy and failed in diabetics type I with nephropathy.

[Monotherapy with acebutolol in hypertensive diabetic patients]. / Monoterapia nadcisnienia tetniczego za pomoca acebutololu u chorych na cukrzyce.

Monotherapy of hypertension with acebutolol in diabetics in daily dose of 200-400 mg for 6 weeks induced only non-significant and practically not acceptable hypotensive effect in groups of patients with hypertension and diabetes type I or type II without nephropathy. No therapeutical effect was observed in hypertension in diabetics type I with nephropathy. Administration of acebutolol to hypertensive diabetic patients with nephropathy resulted in tendency to increase in albuminuria. Values of creatinine clearance did not change at the same time. Also no effect of acebutolol on glycemic or lipid indices was observed. The lack of clear hypotensive effect under studied conditions of acebutolol in diabetic patients contrasted with its significant action in comparative group of hypertensive non-diabetic subjects.

Tuberculosis control in refugee settlements.

Tuberculosis and its management in refugees and other displaced persons in temporary settlements poses a challenge to organisations coordinating and providing care in refugee emergencies. This paper offers a consensus of the co-sponsoring agencies on practical recommendations for implementing measures aimed at both interrupting transmission of tuberculosis and treatment of individual patients.