A qualitative assessment of challenges to tuberculosis management and prevention in Northern Ethiopia.

OBJECTIVE: To elicit Ethiopian health care providers' understanding of challenges to effectively preventing, diagnosing and treating tuberculosis (TB). DESIGN: Qualitative data were collected via in-depth interviews and focus group discussions with 73 providers, including physicians, nurses, pharmacists and laboratory technicians, in five hospitals in the Northern Ethiopian regions of Amhara and Tigray. There was no intervention. RESULTS: Focus groups and interviews shared a number of prominent common themes. Respondents identified numerous challenges associated with active case identification, infection control practices, diagnostics, including the absence of TB culture and drug susceptibility testing capacity, and the lack of infrastructure for diagnosing and treating multidrug-resistant TB. Pharmacists noted a need for improved procurement practices and pediatric dosages for TB medications. Providers shared concerns regarding isoniazid preventive therapy, health workforce challenges and the risk of contracting TB in the workplace. CONCLUSIONS: Health care providers in the Northern Ethiopian regions of Tigray and Amhara identified many challenges to effectively preventing, diagnosing and treating TB. These challenges are complicated by severe resource constraints and challenges in attracting and retaining providers in government hospitals in centers outside Addis Ababa.

Arginine as an adjuvant to chemotherapy improves clinical outcome in active tuberculosis.

Nitric oxide (NO) is involved in the host defence against tuberculosis (TB). Patients with TB exhibit increased catabolism and reduced energy intake. Thus the hypothesis for this study was that restoring a relative deficiency in the amino acid arginine, the substrate for mycobactericidal NO production, would improve the clinical outcome of TB by increasing NO production. In a randomised double-blind study, patients with smear-positive TB (n = 120) were given arginine or placebo for 4 weeks in addition to conventional chemotherapy. Primary outcomes were sputum conversion, weight gain, and clinical symptoms after week 8. Secondary outcomes were sedimentation rate and levels of NO metabolites, arginine, citrulline, and tumour necrosis factor-a. Compared with the human immunodeficiency virus (HIV)-/TB+ placebo group, the HIV-/TB+ patients in the arginine group showed significant improvement, defined as increased weight gain, higher sputum conversion rate and faster reduction of symptoms, such as cough. The arginine level increased after week 2 in the HIV-/TB+ arginine group (100.2 microM (range 90.5-109.9) versus 142.1 microM (range 114.1-170.1)) compared with the HIV-/TB+ placebo group (105.5 microM (range 93.7-117.3) versus 95.7 microM (range 82.4-108.9)). HIV seroprevalence was 52.5%. No clinical improvement or increase in serum arginine was detected in arginine supplemented HIV+/TB+ patients compared with placebo. Arginine is beneficial as an adjuvant treatment in human immunodeficiency virus-negative patients with active tuberculosis, most likely mediated by increased production of nitric oxide.