Public-private mix for control of tuberculosis and TB-HIV in Nairobi, Kenya: outcomes, opportunities and obstacles.

SETTING: Nairobi, the capital of Kenya. OBJECTIVE: To promote standardised tuberculosis (TB) care by private health providers and links with the public sector. DESIGN AND METHODS: A description of the results of interventions aimed at engaging private health providers in TB care and control in Nairobi. Participating providers are supported to provide TB care that conforms to national guidelines. The standard surveillance tools are used for programme monitoring and evaluation. RESULTS: By the end of 2006, 26 of 46 (57%) private hospitals and nursing homes were engaged. TB cases reported by private providers increased from 469 in 2002 to 1740 in 2006. The treatment success rate for smear-positive pulmonary TB treated by private providers ranged from 76% to 85% between 2002 and 2005. Of the 1740 TB patients notified by the private sector in 2006, 732 (42%) were tested for human immunodeficiency virus (HIV), of whom 372 (51%) were positive. Of the 372 HIV-positive TB patients, 227 (61%) were provided with cotrimoxazole preventive treatment (CPT) and 136 (37%) with antiretroviral treatment (ART). CONCLUSION: Private providers can be engaged to provide TB-HIV care conforming to national norms. The challenges include providing diagnostics, CPT and ART and the capacity to train and supervise these providers.

Provider-initiated HIV testing and counselling for TB patients and suspects in Nairobi, Kenya.

SETTING: Integrated tuberculosis (TB) and human immunodeficiency virus (HIV) services in a resource-constrained setting. OBJECTIVE: Pilot provider-initiated HIV testing and counselling (PITC) for TB patients and suspects. DESIGN: Through partnerships, resources were mobilised to establish and support services. After community sensitisation and staff training, PITC was introduced to TB patients and then to TB suspects from December 2003 to December 2005. RESULTS: Of 5457 TB suspects who received PITC, 89% underwent HIV testing. Although not statistically significant, TB suspects with TB disease had an HIV prevalence of 61% compared to 63% for those without. Of the 614 suspects who declined HIV testing, 402 (65%) had TB disease. Of 2283 patients referred for cotrimoxazole prophylaxis, 1951 (86%) were enrolled, and of 1727 patients assessed for antiretroviral treatment (ART), 1618 (94%) were eligible and 1441 (83%) started treatment. CONCLUSIONS: PITC represents a paradigm shift and is feasible and acceptable to TB patients and TB suspects. Clear directives are nevertheless required to change practice. When offered to TB suspects, PITC identifies large numbers of persons requiring HIV care. Community sensitisation, staff training, multitasking and access to HIV care contributed to a high acceptance of HIV testing. Kenya is using this experience to inform national response and advocate wide PITC implementation in settings faced with the TB-HIV epidemic.

National scale-up of HIV testing and provision of HIV care to tuberculosis patients in Kenya.

SETTING: Kenya, one of the 22 tuberculosis (TB) high-burden countries, whose TB burden is fuelled by the human immunodeficiency virus (HIV). OBJECTIVE: To monitor and evaluate the implementation of HIV testing and provision of HIV care to TB patients in Kenya through the establishment of a routine TB-HIV integrated surveillance system. DESIGN: A descriptive report of the status of implementation of HIV testing and provision of HIV interventions to TB patients one year after the introduction of the revised TB case recording and reporting system. RESULTS: From July 2005 to June 2006, 88% of 112835 TB patients were reported to the National Leprosy and TB Control Programme, 98773 (87.9%) of whom were reported using a revised recording and reporting system that included TB-HIV indicators. HIV testing of TB patients increased from 31.5% at the beginning of this period to 59% at the end. Of the 46428 patients tested for HIV, 25558 (55%) were found to be HIV-positive, 85% of whom were provided with cotrimoxazole preventive treatment and 28% with antiretroviral treatment. CONCLUSION: A country-wide integrated TB-HIV surveillance system in TB patients can be implemented and provides essential data to monitor and evaluate TB-HIV related interventions.

Planning for PPM-DOTS implementation in urban slums in Kenya: knowledge, attitude and practices of private health care providers in Kibera slum, Nairobi.

SETTING: Kibera, the largest slum in Nairobi, Kenya. OBJECTIVE: To determine the tuberculosis (TB) knowledge, attitude and practices (KAP) of private health care providers (PHCPs) to identify their training needs and willingness to participate in a National Leprosy and Tuberculosis Control Programme (NLTP) guided TB control effort in the slum. DESIGN AND METHODOLOGY: A cross-sectional survey. The KAP of PHCPs was assessed using an interviewer administered questionnaire. RESULTS: Of 75 PHCPs interviewed, the majority (96.0%) were paramedics; 51 (77.1%) did not consider sputum smear microscopy crucial in patients presenting with prolonged cough or when a chest X-ray was suggestive of TB; of 29 (38.7%) who indicated familiarity with the drugs used in TB treatment, 20 (58.5%) would have chosen the NLTP-recommended regimens for the treatment of the various types of TB; 16 (21.3%) PHCPs indicated that they treated TB, six (37.5%) of whom were not familiar with anti-tuberculosis drug regimens. All the PHCPs referred TB suspects to the public sector for diagnosis. CONCLUSION: This study reveals a significant gap in TB knowledge among the PHCPs in Kibera slum. However, given appropriate training and supervision, there is potential for public-private mix for DOTS implementation in this setting.

Tuberculosis re-treatment outcomes within the public service in Nairobi, Kenya.

OBJECTIVES: This study was undertaken to describe treatment outcomes in patients started on a re-treatment drug regimen, assess the quality of follow up procedures and the adequacy of the currently advocated re-treatment drug regimen in Nairobi, Kenya. DESIGN: A retrospective study. SETTING: Mbagathi District Hospital (MDH), Nairobi, a public hospital that serves as the Tuberculosis (Tb) referral centre for Nairobi. MATERIALS AND METHODS: The Tb register at the MDH was used to identify patients who were on the re-treatment regimen for Tb. Case records for these patients were then retrieved. From these sources, information on age, sex, HIV status, previous and current tuberculosis disease and drug regimens, adherence to treatment and treatment outcomes, was obtained. Descriptive statistics was used to analyse the data. RESULTS: Of the total of 4702 patients registered at the MDH between 1996 and 1997, 593 (12.6%) were patients with either recurrent Tb, returning to treatment after default or had failed initial treatment. Of the 593 patients, case records were unavailable for 168 and 17 were children below the age of ten in whom the diagnosis of Tb was uncertain making a total of 185 patients who were excluded from the study. Of the remaining 408 patients, 77 (18.9%) were cured, 61 (15.0%) completed treatment without confirmation of cure, two (0.5%) defaulted, six (1.5%) died and 262 (64.2%) had no outcome information. There were no treatment failures. Treatment success defined as cure or treatment completion was achieved in 94.5% of the 146 patients in whom outcome data were available. HIV positive patients had a statistically significant poorer success rate (34/40, 85%) when compared with HIV negative patients (104/106, 94%), p=0.004. Mycobacterium tuberculosis culture and drug susceptibility testing, was not done. CONCLUSION: The high number of patients with no treatment outcome information at the MDH is worrying, as these patients may harbour drug resistant bacilli and reflects an inadequate follow up service for Tb re-treatment in Nairobi. However, where treatment outcomes could be assessed, the currently advocated re-treatment regimen achieved a high success rate. These observations point to an urgent need to improve Tb documentation and follow up procedures within the public service in Nairobi in order to forestall the emergence and spread of drug resistant Tb.

Altitude: a determinant for tuberculosis in Kenya?

OBJECTIVE: To determine to what extent tuberculosis incidence is associated with altitude. METHODS: Notification rates were obtained from all 41 districts in Kenya in the period 1988-1990; the mean altitude of each district was estimated. Data on indicators of socio-economic status such as literacy rate and infant mortality rate were obtained from the 1989 census, as well as data on other potential confounders such as urbanisation and median household size. RESULTS: The notification rate of new smear-positive tuberculosis was 32/100000 overall, varying between districts from 5 to 222/100000. Notification rates steeply reduced with increasing altitude (r = -0.71; 95% confidence interval [CI] -0.51 to -0.83). At altitudes of 1000 m or more the notification rates were less than 30% of those in districts at altitudes below 500 m, also after adjustment for confounding. CONCLUSION: Tuberculosis incidence in Kenya decreases strongly with increasing altitude. If the association is not due to unknown confounding factors, a range of potential biological explanations needs to be explored.

[Development of the spatial organization of the myocardium]. / Entwicklung der räumlichen Anordnung des Myokardiums.

The spatial organization of cardiac muscle was studied in the developmental stages of the rat. In the 10-day embryo the heart loop has formed and the different cardiac segments can be distinguished by the presence of intersegmental constrictions of the myocardial wall. The intersegmental myocardium looks already well organized, whereas the free segmental walls still lack a lengthwise orientation of the myocytes. On the 15th embryonic day the intersegmental zones are still the best organized, the free ventricular walls still showing areas of unorganized myocytes. Early differentiation thus seems to be concentrated in the intersegmental myocardium. This differentiation could serve contraction, as well as impulse conduction. Development of the endomysial collagen skeleton was seen in later stages. On the 13th embryonic day, collagen fibres were only seen in the septum transversum and around the venous sinus. Collagen development appeared to progress subepicardially from the venous towards the arterial pole. On the 16th day collagen fibres were found within the ventricular myocardium, but mainly in the intersegmental zones. The free ventricular walls were invested with collagen only on the 17th embryonic day, but the subendocardial myocardium, which is trabeculated and traversed by endocardial sinusoids, was relatively poor in collagen. Thus, a comparison can be made between the development of collagen and that of the coronary vascular system, which arises from epicardial as well as endocardial contributions. Further morphometric studies showed that the collagen content of ventricular myocardium gradually rises until the end of the 4th postnatal week.