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.

Commitment, partnerships and operational research: three priorities for 11 EMR countries to achieve TB elimination.

BACKGROUND: In 2022, 11 of 22 Member States of the WHO Eastern Mediterranean Region (EMR) had an estimated TB incidence of <20 cases per 100,000 population. We assessed preparedness for elimination and provided recommendations to pursue the process. METHODS: We surveyed 11 EMR national TB programme managers and collected information on eight TB elimination framework domains using a close-ended data collection tool. We compiled, consolidated and validated data, including a virtual consultation before triangulating data with other sources. RESULTS: Implementation was sufficient (≥74%) for 5 of 8 domains, highest for TB infection management, TB preventive treatment, laboratory service, drug management, drug-resistant TB and TB-HIV collaboration (89%, 83% and 78%, respectively). Countries ranked lowest for commitment (73%), operational research and infection control (63%), and partnership/collaborations (41%). Five countries reached >80% when consolidating the responses, reaching sufficient from all domains. Two reached <50%. CONCLUSION: Key identified obstacles to TB elimination in EMR were insufficient commitment/financing, sub-optimal partnerships/collaborations and operational research calling for 1) all-stakeholder-inclusive, sustainably funded TB elimination plans, 2) cost-effective tools to exchange strategic information and build operational research capacity, and 3) improved collaboration.

CONTEXTE: En 2022, 11 des 22 États membres de la Région de la Méditerranée orientale de l'OMS avaient une incidence de la TB estimée à moins de 20 cas pour 100 000 habitants. Nous avons évalué l'état de préparation à l'élimination et formulé des recommandations pour poursuivre le processus. MÉTHODES: Nous avons interrogé 11 responsables de programmes nationaux de lutte contre la TB dans la région de la Méditerranée orientale et recueilli des informations sur huit domaines du cadre d'élimination de la TB à l'aide d'un outil de collecte de données à questions fermées. Nous avons compilé, consolidé et validé les données, y compris lors d'une consultation virtuelle, avant de les trianguler avec d'autres sources. RÉSULTATS: La mise en œuvre était suffisante (≥74%) pour 5 des 8 domaines, les plus élevés étant la gestion de l'infection tuberculeuse, le traitement préventif de la TB, les services de laboratoire, la gestion des médicaments, la TB pharmacorésistante et la collaboration TB-VIH (89%, 83% et 78%, respectivement). Les pays se sont classés au dernier rang pour l'engagement (73%), la recherche opérationnelle et la lutte contre l'infection (63%) et le partenariat/la collaboration (41%). Cinq pays ont atteint >80% lors de la consolidation des réponses, atteignant un niveau suffisant dans tous les domaines. Deux pays ont atteint un taux de réponse inférieur à 50%. CONCLUSION: Les principaux obstacles à l'élimination de la TB dans les pays de l'Union européenne sont un engagement/un financement insuffisant, des partenariats/collaborations sous-optimaux et une recherche opérationnelle nécessitant 1) des plans d'élimination de la TB incluant toutes les parties prenantes et bénéficiant d'un financement durable, 2) des outils rentables permettant d'échanger des informations stratégiques et de renforcer les capacités de recherche opérationnelle, et 3) une meilleure collaboration.

Determinants of consultation, diagnosis and treatment delays among new smear-positive pulmonary tuberculosis patients in Morocco: a cross-sectional study.

We conducted a cross-sectional survey in 2012 in 12 selected provinces and prefectures in Morocco to determine consultation delay (patient delay), diagnosis delay and treatment delay (health system delays), and factors relating to these delays. The sample included 250 eligible and consenting newly diagnosed smearpositive pulmonary tuberculosis patients who were interviewed at the time of their registration within Diagnosis of Tuberculosis and Respiratory Diseases Reference Centers (CDTMR) or Integrated Health Centers (CSI) using a pretested and structured questionnaire. The median total delay was 46 days [inter-quartile interval (IQI) = 29-84 days]. Patient delay (median = 20; IQI = 8-47 days) was higher than health system delay (median=15; IIQ = 7-35 days). Being illiterate, thinking symptoms will disappear by themselves; having financial constraints and feeling fear of diagnosis or social isolation were associated with patient delay. Consulting first in the private sector or having 3 or more consultations before diagnosis was associated with health system delay.

Determinants of consultation, diagnosis and treatment delays among new smear-positive pulmonary tuberculosis patients in Morocco: a cross-sectional study

We conducted a cross-sectional survey in 2012 in 12 selected provinces and prefectures in Morocco to determine consultation delay [patient delay], diagnosis delay and treatment delay [health system delays], and factors relating to these delays. The sample included 250 eligible and consenting newly diagnosed smear-positive pulmonary tuberculosis patients who were interviewed at the time of their registration within Diagnosis of Tuberculosis and Respiratory Diseases Reference Centers [CDTMR] or Integrated Health Centers [CSI] using a pretested and structured questionnaire. The median total delay was 46 days [inter-quartile interval [IQI]= 29-84 days]. Patient delay [median = 20; IQI = 8-47 days] was higher than health system delay [median-15; IIQ = 7-35 days]. Being illiterate, thinking symptoms will disappear by themselves; having financial constraints and feeling fear of diagnosis or social isolation were associated with patient delay. Consulting first in the private sector or having 3 or more consultations before diagnosis was associated with health system delay

Nous avons conduit en 2012 une étude transversale dans une sélection de 12 provinces/préfectures au Maroc pour déterminer les délais de consultation [délai patient], de diagnostic et de mise sous traitement [délai système de santé]chez les nouveaux cas de tuberculose pulmonaire à microscopie positive et les facteurs en relation avec ces délais. L’échantillon comprenait 250 patients, éligibles et consentants, qui ont été interviewés lors de leur enregistrement aux Centres de Diagnostic de la Tuberculose et des Maladies Respiratoires [CDTMR] ou aux Centres de Santé Intégrés [CSI], en utilisant un questionnaire structuré et prétesté. Le délai total médian est de 46 jours [intervalle interquartile [IIQ]: 29-84 jours]. Le délai patient [médiane : 20 jours ; IIQ : 8-47] est supérieur au délai système de santé [médiane : 15 jours ; IIQ : 7-35]. Etre analphabète, croire à la disparition spontanée des symptômes, avoir des contraintes économiques ou peur du diagnostic et de l’isolement social sont associés au délai patient. Consulter en premier dans le secteur privé ou faire trois consultations au moins avant le diagnostic sont associés au délai système de santé

Qualitative study of perceived causes of tuberculosis treatment default among health care workers in Morocco.

SETTING: In Morocco, tuberculosis (TB) treatment default is increasing in some urban areas. OBJECTIVE: To provide a detailed description of factors that contribute to patient default and solutions from the point of view of health care professionals who participate in TB care. DESIGN: In-depth interviews were conducted with 62 physicians and nurses at nine regional public pulmonary clinics and local health clinics. RESULTS: Participants had a median of 24 years of experience in health care. Treatment default was seen as a result of multilevel factors related to the patient (lack of means, being a migrant worker, distance to treatment site, poor understanding of treatment, drug use, mental illness), medical team (high patient load, low motivation, lack of resources for tracking defaulters), treatment organization (poor communication between treatment sites, no systematic strategy for patient education or tracking, incomplete record keeping), and health care system and society. Tailored recommendations for low- and higher-cost interventions are provided. CONCLUSIONS: Interventions to enhance TB treatment completion should take into account the local context and multilevel factors that contribute to default. Qualitative studies involving health care workers directly involved in TB care can be powerful tools to identify contributing factors and define strategies to help reduce treatment default.

[Radiographic anomalies and obstructive sleep apnea syndrome]. / Anomalies téléradiographiques et syndrome d'apnées obstructives du sommeil.

BACKGROUND: The purpose of this study was to identify the particular cranio-facial pattern observed in patients with obstructive sleep apnea syndrome and to search for possible correlations between morphological anomalies and disease severity. MATERIAL AND METHODS: The study group included 49 dentate patients, mean age 47.7 years suffering from obstructive sleep apnea syndrome. Most of the patients were overweight. RESULTS: Typical features observed in these patients were a short craniospinal field, a retro-maxillary, a retro-mandibula, antero-inferior vertical excess of the face, and class II malocclusion. No correlation between severity of obstructive sleep apnea syndrome and craniofacial morphology could be identified. DISCUSSION: These results are in agreement with data in the literature. The absence of a morphological correlation appears to be related to the type of patients studied (overweight). Indeed, two categories of sleep apnea patients have been identified: obese patients who have few or no anomalies of the facial skeleton and thin patients with characteristic open bite class II malocclusion.

[The management of anterior transversal mandibular deficiencies by distraction osteogenesis. Preliminary results and report of 3 cases]. / Prise en charge des déficits transversaux antérieurs de la mandibule par ostéodistraction symphysaire. Résultats préliminaires à propos de trois cas cliniques.

During the last ten years, osteodistraction genesis appeared as being a treatment of some maxillo-facial transversal deficiencies. A new technique have been develop in Lille Maxillo-Facial Department (Pr Ferri, France). This new technique is used in cases of mandibular hyposymphysis, which induce most of the time a mandibular incisor crowding. This distraction osteogenesis performed after sagittal osteotomy of the mandibular symphysis and associated with orthodontic treatment is a solution to avoid teeth extractions. Other treatments could be used to solve anterior mandibular teeth crowding but they have disadvantages: teeth slicing, teeth extraction or orthodontic teeth tilting. This new technique is performed with intra oral-device, small enough to be placed under mandibular periosteum. Three patients have been treated by this technique, they got a stable result. In these three cases, alveolar and basal bone is present. So for us, symphysis osteogenesis distraction appears to be an alternative treatments to mandibular incisor crowding.

[Growth: responses to pathology. Preliminary study]. / Croissance: les expériences naturelles de la pathologie. Etude préliminaire.

Many pathologies involve face. Among them, many have craniofacial growth consequences. The authors' aims are to analyze some of these pathologies, where clinical observations emphasize the role of the different craniofacial growth patterns. Despite a complex relation between the malformative part and the deformative one, untreated observations provide a better understanding of some craniofacial growth defects. Syndromes can be classified in 4 categories, involving the primitive causes of the clinical finding: 1. organic abnormalities of one or many functional matrix, 2. localized abnormalities of the anatomical structures, 3. general abnormalities of the conjunctive tissue, 4. mixed syndromes. Many observations will presented.