The burden and treatment outcomes of extra-pulmonary tuberculosis in Bhutan

Setting:

All tuberculosis (TB) registration sites in Bhutan.

Design:

Cross-sectional study involving a retrospective review of TB registers and TB treatment cards.

Objectives:

To determine: 1) the number and proportion of all TB cases registered as extra-pulmonary TB (EPTB) from 2001 to 2010, 2) the age and sex of the patients and the categories and types of EPTB registered in 2010, and 3) their treatment outcomes.

Results:

The proportion of all TB cases registered as EPTB over a period of 10 years varied from 30% to 40%. In 2010, 505 patients were registered with EPTB, of whom 50% were male, 21% were children, and 96% were new EPTB cases. TB lymph node enlargement and pleural effusion were the two most common types of EPTB, accounting for 67%, followed by abdominal TB and spinal/bone/kidney disease. The overall treatment success rate was 90%, and was generally similar with respect to sex, age and different types of EPTB.

Conclusion:

Bhutan has a high proportion of patients registered as having EPTB, for whom treatment outcomes are satisfactory. Further work is needed to better understand how EPTB is diagnosed throughout the country.     

Time to unsuccessful tuberculosis treatment outcome,Cambodia, China,and Viet Nam

Objective:

To determine the frequency and characteristics of patients with unsuccessful tuberculosis (TB) treatment.

Methods:

Random selection of TB case registers among all treatment units in Cambodia, two provinces in China, and Viet Nam. The data of two calendar years were analyzed to assess unsuccessful outcomes and their time of occurrence.

Results:

Among the 33 309 TB patients, treatment was unsuccessful in respectively 10.1%, 3.0% and 9.1% of patients in Cambodia, China and Viet Nam. The risk of death was highest in Cambodia, higher among males than females, increased with age, and was more common among retreatment cases than new cases, and among patients with a high than a low sputum smear microscopy grade. Half of all deaths occurred in the first 2 months in Cambodia and within 11 weeks in China and Viet Nam. Median time to default was 3 months in Cambodia and Viet Nam, and about 2 months in China.

Conclusions:

Treatment was highly successful in the three study countries, with a low proportion of death and default. As the majority of defaulting occurs at the beginning of treatment, all countries should critically review their current policy of treatment support in this period.     

2011年泰州市区结核病诊疗情况分析

目的为了解泰州市区结核病的临床类型、年龄结构、病例分类,治疗转归等情况,为结核病防控提供依据。方法对2011年专科门诊确诊的病人进行登记、诊断、治疗、管理,所有资料数据录入Excel 2003,并应用SPSS 18.0进行流行病学分析。结果 2011年市区结核病人年登记率为62.73/10万,以45~64岁为主,占42.59%岁,男女比1.75∶1;农民占70.03%,其次为工人,占19.19%;全年涂阳结核病治愈率达88.24%,涂阴病人及未查痰病人完成疗率95.38%。结论目前泰州市市区结核病疫情仍较严重,需加强宣传,增强学生、农民等重点人群结核病防控力度,降低结核病发病。     

Short-term and long-term outcomes following DOTS-based treatment for tuberculosis patients in Burkina Faso

A cross-sectional study was initiated in Burkina Faso’s National Tuberculosis Programme to confirm successful treatment results within 3 months of completing treatment and to characterise longer-term outcomes 12–24 months after completion. The sample (n = 278) included 91 patients who had completed treatment 0–3 months earlier (‘short-term’ sample) and 187 patients who had completed treatment 12–24 months earlier (‘long-term’ sample). All sputum specimens from the short-term sample were confirmed as negative. In the long-term sample, among 154 patients with available information, 13 (8%) had died, 24 were not traced, and 117 (76%) were interviewed and had sputum examinations, of which 2 (2%) were smear-positive. Recording of successful treatment outcomes shows good validity.     

Childhood pulmonary tuberculosis:old wisdom and new challenges

据世界卫生组织最新报道,全球每年至少有100万儿童患结核病,其中25.3万患儿死于结核病。儿童结核病是一个严重的公共卫生问题,因临床表现缺乏特异性,痰含菌量少等使儿童结核病诊断非常困难。儿童感染结核分枝杆菌后较成人更易进展为结核病,且年龄越小越易重症化。卡介苗仍是目前唯一用于预防结核的疫苗,但有其缺陷。结核分枝杆菌耐药通常也是导致儿童结核病死亡的主要原因之一。目前我国儿童耐药结核病化学治疗的原则与成人相同,用药也基本相似,新型短程耐药化疗方案能否运用于我国耐药儿童结核病还有待商榷。随着基因测序技术的革新,生物医学分析技术的进步,大数据下的精准医疗将为儿童结核病的防治提供一场新的变革。     

The burden and outcomes of childhood tuberculosis in Cotonou,Benin

Setting:

The National Tuberculosis Programme (NTP) and the paediatric ward of the General Hospital (GH), Cotonou, Benin.

Objective:

To describe the burden of tuberculosis (TB), characteristics and outcomes among children treated in Cotonou from 2009 to 2011.

Design:

Cross-sectional cohort study consisting of a retrospective record review of all children with TB aged <15 years.

Results:

From 2009 to 2011, 182 children with TB were diagnosed and treated (4.5% of total cases), 153 (84%) by the NTP and 29 (16%) by the GH; the latter were not notified to the NTP. The incidence rate of notified TB cases was between 8 and 13 per 100 000 population, and was higher in children aged >5 years. Of 167 children tested, 29% were HIV-positive. Treatment success was 72% overall, with success rates of 86%, 62% and 74%, respectively, among sputum smear-positive, sputum smear-negative and extra-pulmonary patients. Treatment success rates were lower in children with sputum smear-negative TB (62%) and those with HIV infection (58%).

Conclusion:

The number of children being treated for TB is low, and younger children in particular are underdiagnosed. There is a need to improve the diagnosis of childhood TB, especially among younger children, and to improve treatment outcomes among HIV-TB infected children, with better follow-up and monitoring.     

The struggle of weaning: Factors determining breastfeeding duration in East Bhutan

This paper presents the qualitative part of a project in a traditional community in East Bhutan, which, among other items, investigates the effects on child health of breastfeeding, weaning and subsequent pregnancy of the mother. Quantitative data from the project have shown that children who are weaned during a subsequent pregnancy of the mother have a reduced weight gain and an increased incidence of infectious diseases during weaning, while this is not so for children weaned from non-pregnant mothers. In-depth interviews with 35 women with experience from breastfeeding were carried out in the local language in order to obtain qualitative data regarding the processes underlying the mother decisions during weaning. Breastfeeding was found to fulfil a valuable social function in addition to its biological and emotional properties. The breastfed child had an undebatable “right of access” to the mother's care, not only her breast, whenever it wanted. This child also assumed a status in the family in which both its vulnerability, its special needs and its value were clearly recognized. The mothers expressed a basic motivation to breastfeed “as long as possible”. There were, however, important limitations as to how this was manifested in the practical weaning process. If the mother was pregnant at the time of weaning, these limitations tended to be mother-centred. Most of the women had experienced tenderness of the breasts and a reduced milk production from the start of the next pregnancy. It was believed that the breast milk of a pregnant woman could “rot” and cause disease in the child. In spite of this belief, concurrent breastfeeding and pregnancy were common, but a pregnant mother whose breastfed child got ill, e.g. with diarrhoea, would immediately stop breastfeeding. The child would thereby abruptly loose the most important protection against the negative effects of the disease, when this protection was most needed. Concurrent pregnancy and lactation are common in many areas of the poor world. This has important consequences for the health of mothers and children, and has only recently been given the attention it derserves.     

Integrating tuberculosis and HIV services in rural Kenya: uptake and outcomes

Setting: Seventeen rural public health facilities in Western Kenya that introduced three models of integrated care for tuberculosis (TB) and human immunodeficiency virus (HIV) patients.Objective: To assess the uptake and timing of cotrimoxazole preventive therapy (CPT) and antiretroviral treatment (ART) as well as anti-tuberculosis treatment outcomes among HIV-infected TB patients before (March–October 2010) and after (March–October 2012) the introduction of integrated TB-HIV care.Design: A before-and-after cohort study using programme data.Results: Of 501 HIV-infected TB patients, 357 (71%) were initiated on CPT and 178 (39%) on ART in the period before the introduction of integrated TB-HIV care. Following the integration of services, respectively 316 (98%) and 196 (61%) of 323 HIV-infected individuals were initiated on CPT and on ART (P < 0.001). The median time to CPT and ART initiation dropped from 7 to 2 days and from 42 to 34 days during the pre- and post-integration phases, respectively. Overall TB success rates did not vary with integration or with type of model instituted.Conclusion: Integration of TB and HIV services enhanced uptake and reduced delay in instituting CPT and ART in rural health facilities. There is a need to increase impetus in these efforts.     

Promoting patient safety in Bhutan: Challenges and priority strategies for accelerating progress

Patient safety is a fundamental principle of quality health care. In Bhutan, which is a resource poor nation, improving patient safety in the health care context is a challenge. Bhutan requires sound patient safety policies and strategies to mitigate safety issues in the health care system. Drawing upon the available literature on patient safety in Bhutan and the author's own experience, this paper attempts to explore the challenges that the Bhutanese health care system is facing in terms of promoting patient safety. Based upon the challenges identified, this paper offers a roadmap to move forward—ie, suggestions on how Bhutan could promote patient safety.     

Measles and rubella immunity in the population of Bhutan, 2017

BackgroundIn 2017, measles elimination was verified in Bhutan, and the country appears to have sufficiently high vaccination coverage to achieve rubella elimination. However, a measles and rubella serosurvey was conducted to find if any hidden immunity gaps existed that could threaten Bhutan’s elimination status.MethodsA nationwide, three-stage, cluster seroprevalence survey was conducted among individuals aged 1–4, 5–17, and >20 years in 2017. Demographic information and children’s vaccination history were collected, and a blood specimen was drawn. Serum was tested for measles and rubella immunoglobulin G (IgG). Frequencies, weighted proportions, and prevalence ratios for measles and rubella seropositivity were calculated by demographic and vaccination history, taking into account the study design.ResultsOf the 1325 individuals tested, 1045 (81%, 95% CI 78%–85%) were measles IgG seropositive, and 1290 (97%, 95% CI 95%–99%) were rubella IgG seropositive. Rubella IgG seropositivity was high in all three age strata, but only 47% of those aged 5–17 years were measles IgG seropositive. Additionally, only 41% of those aged 5–17 years who had documented receipt of two doses of measles– or measles-rubella–containing vaccine were seropositive for measles IgG, but almost all these children were rubella IgG seropositive.ConclusionsAn unexpected measles immunity gap was identified among children 5–17 years of age. It is unclear why this immunity gap exists; however, it could have led to a large outbreak and threatened sustaining of measles elimination in Bhutan. Based on this finding, a mass vaccination campaign was conducted to close the immunity gap.     

晚期妊娠合并活动性肺结核的诊治

妊娠并结核病常因症状与妊娠生理反应混淆,以及临床意识不足故易误诊或延误诊断,该文针对发现的晚期妊娠合并活动性肺结核和肠结核案例进行分析,文献复习妊娠并肺结核的临床表现、诊断和治疗.     

山东省老年肺结核病人诊疗情况调查

目的了解现阶段山东省老年肺结核病人的诊疗情况,分析存在的问题。方法采用多阶段整群分层随机抽样方法选取样本,使用自制调查问卷,采取面对面方式对登记确诊的332例老年肺结核病人进行访谈式调查。结果78.6%(261人)的病人初次就诊时有咳嗽症状,33.7%(112人)的病人初次就诊单位为村卫生室,45.8%(152人)的病人初次就诊时被误诊,31.0%(103人)的病人就诊延迟,77.7%(258人)的病人在县级结核病防治机构确诊,25.8%(69人)的病人确诊延迟,91.0%(302人)的病人能定期取药,88.0%(292人)的病人能定期复查。结论老年肺结核病人初次就诊时多有咳嗽、咳痰、胸闷及气短症状,极易被误诊。半数左右的病人初次就诊选择村卫生室或乡镇卫生院,大部分病人由结核病防治机构确诊,部分病人发生就诊延迟或确诊延迟现象。     

Treatment outcomes of new adult tuberculosis patients in relation to HIV status in Zimbabwe

Setting:

All public health facilities in Chitungwiza District, Zimbabwe.

Objective:

To determine, in new tuberculosis (TB) patients registered in 2009, 1) the proportion of persons human immunodeficiency virus (HIV) tested, stratified by age, sex and type of TB, and 2) treatment outcomes in relation to type of TB and HIV status.

Design:

Retrospective cohort study.

Results:

Of 1800 TB patients, 1100 (61%) were tested, of whom 877 (80%) were HIV-positive and 75 (9%) were documented as receiving antiretroviral treatment (ART). HIV testing and HIV positivity were similar between patients with different types of TB. Overall, the treatment success rate was 70%, and 17% had transferred out. Being HIV-positive on ART was associated with better treatment success and lower transfer out; age ≥55 years was associated with poor treatment success and higher death rates. Defaulting was more common in those who did not undergo smear testing or in extra-pulmonary TB patients, while deaths were higher in males.

Conclusion:

In a Zimbabwe district, less than two thirds of TB patients were tested. Better treatment success was observed in patients documented as HIV-positive and on ART. Important lessons for improved TB control include increasing HIV testing uptake for better access to ART, more comprehensive recording practices on ART and better reporting on true outcomes of transfer-out patients.     

肺结核规范治疗及管理现状调查

目的调查贵州省遵义市肺结核治疗、督导、管理现状及影响因素,为该市肺结核规范督导、治疗提出改进措施。方法应用定量研究与定性研究相结合的方法,对肺结核患者进行问卷调查和深入访谈。结果该市肺结核发病率从2002年的149.93/10万上升至2007年的223.64/10万,选择到肺结核防治机构治疗的农村患者和城市患者分别占76.6%和72.7%;未进行督导管理的分别占31.7%和29.1%。结论应强化对该市肺结核的规范治疗。政府重视、改善基层医务人员待遇、提高基层医务人员素质、加强宣传教育、严格落实直接面视下短期督导治疗(DOTS)策略等是提高肺结核的规范治疗率主要措施。     

2006-2015年新疆肺结核患者发现情况分析

目的 分析2006-2015年新疆肺结核患者发现情况,为进一步做好新疆结核病控制工作提供科学依据。 方法 利用中国疾病预防控制信息系统的 “结核病信息管理系统”(以下简称“结核病专报”)和《2006-2015年新疆结核病控制工作季度录入表》 (登记的肺结核患者全部来源于结防机构统计),并结合专题调查收集的数据,对2006-2015年新疆非结核病防治机构通过“传染病报告信息管理系统”(以下简称“网络直报”)报告的299 338例肺结核患者的转诊、追踪情况;新疆结核病防治机构接诊的999 482例肺结核可疑症状者的就诊情况;新疆结核病防治机构发现的281 867例活动性肺结核患者登记情况等数据进行分析。 结果 2006-2015年新疆非结核病防治机构通过“网络直报”报告的肺结核患者的转诊到位率平均为32.6％(97 675/299 338);肺结核患者追踪到位率平均为66.6%(121 843/183 047);非结核病防治机构通过“网络直报”系统报告的肺结核患者的总体到位率从2006年的61.3％(13 180/21 501)提高至2015年的90.0%(41 409/45 986)。2006-2015年新疆各级结核病防治机构共接诊肺结核可疑症状者999 486例,年均初诊患者占人口比率469.6(1/10万)。2006-2015年,新疆各级结核病防治机构共发现活动性肺结核患者281 867例,其中,涂阳肺结核患者115 067例,涂阴患者166 635例,未查痰患者165例。2006-2015年间初治患者占涂阳患者的构成比从2006年的82.0%(13 949/17 017)逐渐下降至74.7%(5 718/7 658);涂阴患者占活动性患者构成比从2006年的43.1%(25 005/32 666)逐渐上升至2015年的76.5%(12 903/29 920)。 结论 通过各级结核病防治机构的努力,新疆维吾尔自治区结核患者的发现水平不断提高,非结防机构报告疑似患者总体到位率不断提高,结核病服务质量不断提升,新疆结核病防治工作成效显著。     

Timing of antiretroviral therapy and effects on tuberculosis treatment outcomes in HIV-co-infected patients in Malawi

Setting:

Queen Elizabeth Central Hospital, Blantyre, Malawi.

Objectives:

To determine 1) the proportion of human immunodeficiency virus (HIV) infected tuberculosis (TB) patients started on antiretroviral therapy (ART), 2) the timing of ART and 3) the effect of the timing on TB treatment outcomes.

Design:

A retrospective record review of HIV-infected TB patients registered from January to December 2009.

Results:

A total of 3376 TB patients were registered, of whom 2665 (79%) were HIV-tested and 2042 (77%) were HIV-infected. A total of 1190 HIV-infected TB patients who were not on ART at the time of starting TB treatment were studied. Of 688 (58%) who started ART, 61% started therapy within 2 months of anti-tuberculosis treatment and 39% started later (≥2 months). Treatment success for patients with TB who started ART within 2 months was higher than for those starting ART later (RR 1.6, 95%CI 1.4–1.8), and death rates were lower (RR 0.25, 95%CI 0.19–0.35).

Conclusion:

Under routine programme conditions in Malawi, a higher proportion of HIV-infected TB patients who started ART did so within 2 months of starting TB treatment, and early ART intervention was associated with better treatment outcomes. This confirms recommendations that co-infected TB patients should start ART early.     

影响云南少数民族自治州肺结核治疗成功的非治疗因素分析

[目的]分析云南省少数民族自治州影响肺结核治疗转归的非治疗因素。[方法]通过"中国疾病预防控制信息系统结核病信息管理系统"得到2008年至2011年云南省8个少数民族自治州登记的活动性肺结核33,876例数据,以"疗程结束原因"为因变量,其他变量为自变量,非条件Logistic回归模型计算得出影响因素。[结果]影响云南省少数民族自治州肺结核治疗成功的保护性因素为:少数民族(P0.01,OR=1.468);危险因素有:年龄41~60岁(P0.01,OR=0.717)、年龄≥61岁(P0.01,OR=0.426)、外地户籍(P0.01,OR=0.610)、复治病人(P0.01,OR=0.481)、非涂阳病人(P0.01,OR=0.808)、症状出现到首诊天数≥61天(P0.01,OR=0.799)。[结论]提高少数民族地区肺结核治疗成功率应针对治疗成功率低的人群,同时加大结核病就诊延迟危害的宣传力度。     

An assessment of fiscal space for health in Bhutan

Several factors are expected to put a strain on health financing in Bhutan. In a predominantly public‐financed healthcare, ensuring that the health system gains sufficient fiscal space to ensure the sustainability of its financing is a critical policy concern. This fiscal space assessment bases its analysis on national surveys and statistics, international databases and review of official documents and reports. Assuming that the government health spending will continue to respond in the same way to growth as in the period 2002–2012, Bhutan can expect to see a robust increase in government investments in health. If elasticity of health expenditure with respect to GDP does not change significantly, projections indicate that per‐capita government spending for health could more than double in the period 2012 to 2019. This increase from Ngultrum 2632 in 2012 to Ngultrum 6724 in 2019 could correspond to government health spending from 2.65% of GDP to 3.98% of GDP in the respective years. The country, however, needs to closely monitor and ensure that government investment in healthcare keeps pace with the growth of the national economy. Along with this, supplementary resources for healthcare could be explored through earmarked taxes and by generating efficiency gains. Copyright © 2015 John Wiley & Sons, Ltd.