PEPFAR support for the scaling up of collaborative TB/HIV activities

The US President's Emergency Plan for AIDS Relief (PEPFAR) has supported a comprehensive package of care in which interventions to address HIV-related tuberculosis (TB) have received increased funding and support in recent years. PEPFAR's TB/HIV programming is based on the World Health Organization's 12-point policy for collaborative TB/HIV activities, which are integrated into PEPFAR annual guidance. PEPFAR implementing partners have provided crucial support to TB/HIV collaboration, and as a result, PEPFAR-supported countries in sub-Saharan Africa have made significant gains in HIV testing and counseling of TB patients and linkages to HIV care and treatment, intensified TB case finding, and TB infection control. PEPFAR's support of TB/HIV integration has also included significant investment in health systems, including improved laboratory services and educating and enlarging the workforce. The scale-up of antiretroviral therapy along with support of programs to increase HIV counseling and testing and improve linkage and retention in HIV care may have considerable impact on TB morbidity and mortality, if used synergistically with isoniazid preventive therapy, intensified case finding, and infection control. Issues to be addressed by future programming include accelerating implementation of isoniazid preventive therapy, increasing access and ensuring appropriate use of new TB diagnostics, supporting early initiation of antiretroviral therapy for HIV-infected TB patients, and strengthening systems to monitor and evaluate program implementation.     

‘Fight TB with BCG’: Mass Vaccination Campaigns in the British Caribbean, 1951–6

Based on a wide range of primary materials, including WHO reports and Colonial Office correspondence, this article examines the UNICEF/WHO-funded mass BCG campaigns that were carried out in seven Caribbean colonies between 1951 and 1956. It explores the reasons behind them, their nature and aftermath and also compares them to those in other non-European countries and discusses them within a context of decolonisation. In doing so, it not only adds to the scholarship on TB in non-European contexts, which had tended to focus on Africa and Asia, but also to the relatively new field of Caribbean medical history and the rapidly expanding body of work on international health, which has paid scant attention to the Anglophone Caribbean and the pre-independence period.     

International Tuberculosis Laboratory Consulting

Improving tuberculosis (TB) laboratory test capacity internationally is essential to combat the increasing prevalence of drug-resistant TB in many countries throughout the world, which poses a direct public health threat to the United States. Microbiologists from the U.S. who plan to serve as consultants to assist in improving TB laboratories in resource-challenged countries should prepare for such work using available resources that are readily available from the Centers for Disease Control and Prevention, as well as the Global Laboratory Initiative of the World Health Organization (WHO). Identifying and networking with potential collaborators in various countries can help ensure success. Consultants should also become familiar with WHO-recommended TB laboratory test methods, available training programs, and tools for laboratory accreditation.     

Overcoming the global crisis: “Yes,we can”, but also for TB … ?

Tuberculosis (TB) poses formidable challenges to global health at the public health‐, scientific‐ and political level. Causing almost two million deaths every year, this ancient disease represents a continuing global crisis. The writing on the wall is that TB is resurging in more virulent and treatment‐resistant forms. Our tools to combat TB are dangerously out of date and ineffective. Besides new tools (TB drugs, vaccines, diagnostics), we also need new strategies to identify key Mycobacterium tuberculosis/human host interactions, since it is here that we can most likely find Mtb's Achilles' heel. Equally important is that we build high‐quality clinical trial capacity and biobanks for TB biomarker identification. But most important is a global commitment at all levels to roll back TB before it outwits us again.     

Pathways to suicidality across ethnic groups in Canadian adults: the possible role of social stress

BACKGROUND: Ethnicity is an important determinant of mental health outcomes including suicidality (i.e. suicidal ideation and suicide attempt). Understanding ethnic differences in the pathways to suicidality is important for suicide prevention efforts in ethnically diverse populations. These pathways can be conceptualized within a social stress framework. METHOD: The study examines ethnic differences in the pathways to suicidality in Canada within a social stress framework. Using data from the Canadian Community Health Survey Cycle 1.1 (CCHS 1.1) and path analysis, we examined the hypotheses that variations in (1) socio-economic status (SES), (2) sense of community belonging (SCB), (3) SES and SCB combined, and (4) SES, SCB and clinical factors combined can explain ethnic differences in suicidality. RESULTS: Francophone whites and Aboriginals were more likely to report suicidality compared to Anglophone whites whereas visible minorities and Foreign-born whites were least likely. Disadvantages in income, income and education, income and its combined effect with depression and alcohol dependence/abuse led to high rates even among the low-risk visible minority group. Indirect pathways for Asians differed from that of Blacks and South Asians, specifically through SCB. With the exception of SCB, Aboriginals were most disadvantaged, which exacerbated their risk for suicidality. However, their strong SCB buffered the risk for suicidality across pathways. Disadvantages in education, income and SCB were associated with the high risk for suicidality in Francophone whites. CONCLUSIONS: Francophone whites and Aboriginals had higher odds of suicidality compared to Anglophone whites; however, some pathways differed, indicating the need for targeted program planning and prevention efforts.     

A review of the literature on the economics of vaccination against TB

The BCG vaccine was introduced in 1921 and remains the only licensed vaccine for the prevention of TB worldwide. Despite its extensive use, the BCG vaccine lacks the ability to fully control the TB-endemic and -pandemic situations. The BCG vaccine is most effective in preventing pediatric TB, in particular, miliary TB and tuberculous meningitis. However, it has a limited effect in preventing pulmonary TB, which occurs more frequently in adults. BCG vaccination has now been implemented in more than 157 countries worldwide. For various countries, the benefits of vaccination are only limited and potentially not cost effective. The International Union Against Tuberculosis and Lung Diseases had set the criteria for discontinuation of BCG vaccination in 1994. This decision, however, was not based on economic considerations. Many developed countries have met the criteria set by the International Union Against Tuberculosis and Lung Disease and stopped universal BCG vaccination. For developing countries, the BCG vaccine is still an effective intervention in protecting young children from TB infection. A lot of effort has been spent on R&D of new TB vaccines, the first of which are expected to be available within 5-7 years from now. Novel TB vaccines are expected to be better and more effective than the current BCG vaccine and should provide a viable strategy in controlling TB morbidity and mortality. In this review, the aim is to explore economic evaluations that have been carried out for vaccination against TB worldwide. In addition to epidemiological evidence, economic evidence can play a crucial role in supporting the governments of countries in making proper public health decisions on BCG vaccination policies, in particular, to implement, continue, or discontinue.     

Diagnosis of tuberculosis: urgent need to strengthen laboratory services

Tuberculosis (TB) is of great public health concern globally, and the impact is most felt in developing countries of Asia and Africa, where 95% of cases and 98% of deaths are attributable to the disease, The disease is poverty-driven and the situation is further worsened by absence of rapid diagnostic tools to facilitate early diagnosis of the illness, thus leading to widespread of the disease. While attention is being focused on the HIV/AIDS pandemic, little is being heard of TB, especially in the areas of laboratory diagnosis despite the fact that the disease is the commonest cause of death in people living with HIV/AIDS. The importance of a diagnostic laboratory in a TB control program cannot be overemphasized. Smear microscopy, which is the cornerstone of World Health Organization (WHO) 'DOTS' strategy for the treatment of TB, has many drawbacks among which is its inability to detect latent infection and the dependency of its sensitivity on a trained and motivated microscopist. Therefore, there is a need for a more reliable, sensitive and rapid diagnostic test to facilitate early diagnosis of cases and prompt initiation of therapy for a TB control program to have a meaningful impact in the community.     

In Silico identification of M. TB proteins with diagnostic potential

TB, caused by Mycobacterium tuberculosis (MTB), is one of the major global infectious diseases. For the pandemic control, early diagnosis with sensitive and specific methods is fundamental. With the advent of bioinformatics’ tools, the identification of several proteins involved in the pathogenesis of TB (TB) has been possible. In the present work, the MTB genome was explored to look for molecules with possible antigenic properties for their evaluation as part of new generation diagnostic kits based on the release of cytokines. Seven proteins from the MTB proteome and some of their combinations suited the computational test and the results suggested their potential use for the diagnosis of infection in the following population groups: Cuba, Mexico, Malaysia and sub-Saharan Africa. Our predictions were performed using public bioinformatics tools plus three computer programs, developed by our group, to facilitate information retrieval and processing.     

Collaboration between the national tuberculosis programme and a non governmental organisation in TB/HIV care at a district level: experience from Tanzania

Background

The increase in tuberculosis and HIV/AIDS patients in many countries in Africa including Tanzania, is outstripping the ability of public health services to cope. This calls for a closer collaboration between tuberculosis programmes and other stakeholders involved in HIV/AIDS care.

Objective

To determine the feasibility of establishing collaboration between the tuberculosis programme and an NGO in TB/HIV care at a district level in Tanzania.

Methods

Quantitative and qualitative study designs involving TB as well as HIV suspects and patients together with health workers, were conducted between December, 2001 and September, 2002.

Results

A total of 72 patients and 28 key informants were involved. The collaboration was in the following areas; voluntary counselling and testing for HIV, diagnosis and treatment of TB, referral and follow up of patients and suspects, home based care, psychological support and training. . Both the tuberculosis programme and NGO benefited from the collaboration. TB case detection among PLWA increased more than three folds and TB treatment was integrated in home based care of NGO. The main barriers identified in this study were; poor communication, poor referral system and lack of knowledge and skills among health staff.

Conclusion

The study has shown that it is possible for a tuberculosis programme and a non governmental organisation to collaborate in TB/HIV care. The study has also identified potential areas of collaboration and barriers that needed to be overcome in order to provide such comprehensive services at a district level.     

Laboratory diagnosis of tuberculosis in resource-poor countries: challenges and opportunities

With an estimated 9.4 million new cases globally, tuberculosis (TB) continues to be a major public health concern. Eighty percent of all cases worldwide occur in 22 high-burden, mainly resource-poor settings. This devastating impact of tuberculosis on vulnerable populations is also driven by its deadly synergy with HIV. Therefore, building capacity and enhancing universal access to rapid and accurate laboratory diagnostics are necessary to control TB and HIV-TB coinfections in resource-limited countries. The present review describes several new and established methods as well as the issues and challenges associated with implementing quality tuberculosis laboratory services in such countries. Recently, the WHO has endorsed some of these novel methods, and they have been made available at discounted prices for procurement by the public health sector of high-burden countries. In addition, international and national laboratory partners and donors are currently evaluating other new diagnostics that will allow further and more rapid testing in point-of-care settings. While some techniques are simple, others have complex requirements, and therefore, it is important to carefully determine how to link these new tests and incorporate them within a country's national diagnostic algorithm. Finally, the successful implementation of these methods is dependent on key partnerships in the international laboratory community and ensuring that adequate quality assurance programs are inherent in each country's laboratory network.     

Tuberculosis and HIV infection in Brazil -- update and overview

In Brazil, tuberculosis (TB) has become an important public health problem with approximately 90,000 cases reported annually. Compounding the TB problem is the interaction of the growing HIV/AIDS epidemic with TB, with potential implications for intranosocomial transmission to immunodeficient patients and health care workers, as well as for the emergence of multidrug-resistant strains. The increased number of reported TB cases is attributed to the deterioration in socioeconomic conditions, the decentralization and restructuring of local TB programs, and the HIV epidemic. TB is the third most common AIDS-defining event; hence, increase in TB cases could be attributed to coinfection with HIV. To this effect, the Tuberculosis and AIDS Programs created a joint committee in order to define national guidelines for the prevention, case management, and treatment of HIV-associated TB. These guidelines recommend 1) preventive therapy with Isoniazid (300 mg daily for 6 months); and 2) Rifampicin-Isoniazid-Pyrazinamide daily for 2 months plus Rifampicin-Isoniazid for the following 7 months for those with active TB. In addition to these strategies, Bacillus-Calmette Guerin vaccination is mandatory for newborns and children under age 4 years, especially for all HIV positive asymptomatic newborns of HIV-infected or AIDS mothers.     

The academic alliance for AIDS care and prevention in Africa.

Fourteen university-based Ugandan and North American physicians in 2001 founded a unique organization at Makerere University Faculty of Medicine in Uganda, the Academic Alliance for AIDS Care and Prevention in Africa (AA), with programs in training, research, prevention, and care. Funding was obtained from Pfizer, Inc.; in 2004, the Infectious Disease Institute (IDI) was built to house the flagship training and care programs of the AA. Although HIV/AIDS was the initial priority, other infectious diseases have been added to the AA's mission, and training has been provided to date to individuals from 26 countries in Africa. These programs are now supported by the Academic Alliance Foundation (AAF), which is based in the United States.The authors describe the AA's programs to train health care workers and to offer ongoing support for health care professionals throughout Africa, as well as efforts to strengthen the health care system within Uganda. They also outline research and clinical services carried out by the IDI and research scholarship programs supported by the AAF. They state that it is too early to judge the success of the AA, and they acknowledge that the lack of trained health care providers and of an adequate care infrastructure are major challenges in Africa. They conclude that the critical challenge facing the AAF and the IDI is to diversify the funding base to sustain current program levels. They then enumerate issues that must be addressed to ensure long-term organizational strength and stability.     

Australian public health policy in 2003 - 2004

In Australia, compared with other developed countries the many and varied programs which comprise public health have continued to be funded poorly and unsystematically, particularly given the amount of publicly voiced political support.In 2003, the major public health policy developments in communicable disease control were in the fields of SARS, and vaccine funding, whilst the TGA was focused on the Pan Pharmaceutical crisis. Programs directed to health maintenance and healthy ageing were approved. The tertiary education sector was involved in the development of programs for training the public health workforce and new professional qualifications and competencies. The Abelson Report received support from overseas experts, providing a potential platform for calls to improve national funding for future Australian preventive programs; however, inconsistencies continued across all jurisdictions in their approaches to tackling national health priorities. Despite 2004 being an election year, public health policy was not visible, with the bulk of the public health funding available in the 2004/05 federal budget allocated to managing such emerging risks as avian flu. We conclude by suggesting several implications for the future.     

Early initiation of antiretroviral treatment: Challenges in the Middle East and North Africa

New World Health Organization guidelines recommend the initiation of antiretroviral treatment (ART) for asymptomatic patients with CD4+ T-cell counts of ≤ 500 cells/mm³. Substantial reduction of human immunodeficiency virus (HIV) transmission is addressed as a major public health outcome of this new approach. Middle East and North Africa (MENA), known as the area of controversies in terms of availability of comprehensive data, has shown concentrated epidemics among most of it’s at risk population groups. Serious challenges impede the applicability of new guidelines in the MENA Region. Insufficient resources restrict ART coverage to less than 14%, while only one fourth of the countries had reportable data on patients’ CD4 counts at the time of diagnosis. Clinical guidelines need to be significantly modified to reach practical utility, and surveillance systems have not yet been developed in many countries of MENA. Based on available evidence in several countries people who inject drugs and men who have sex with men are increasingly vulnerable to HIV and viral hepatitis, while their sexual partners - either female sex workers or women in monogamous relationships with high-risk men - are potential bridging populations that are not appropriately addressed by regional programs. Research to monitor the response to ART among the mentioned groups are seriously lacking, while drug resistant HIV strains and limited information on adherence patterns to treatment regimens require urgent recognition by health policymakers. Commitment to defined goals in the fight against HIV, development of innovative methods to improve registration and reporting systems, monitoring and evaluation of current programs followed by cost-effective modifications are proposed as effective steps to be acknowledged by National AIDS Programs of the countries of MENA Region.     

Eighty years of the Slovenian Institute of Public Health: challenges for the future

Eighty years after the first national public health institution was founded in Slovenia, the Institute of Public Health of the Republic of Slovenia (IPHRS) endeavors to meet ever-growing national demands. With the independence of Slovenia in 1991, new tasks had to be tackled, many of which were initially coupled with typical difficulties of a postcommunist country in transition. Also, increasing demands of the European Union (EU) and other international partners had to be met. The IPHRS monitors the health of the Slovenian population and its determinants and contributes to planning and implementation of population-based interventions for the better health of the whole nation. The diversity of the IPHRS activities is mirrored by the organization's internal complexity, multi-disciplinary approach, and links to various sectors. Currently, activities are organized within five centers: Center for Population Health Research; Center for Health Care Organization, Economics and Informatics; Center for Environmental Health; Center for Communicable Diseases; and Center for Health Promotion. The IPHRS is the key national institution in public health research, which is an integral part of all the areas covered by the Institute. The IPHRS also provides education programs in the field of public health. In the near future, it will be important to sustain current activities while integrating into the new program of Community action in the field of public health as well as contributing to the response to challenging public health issues in the wider context of the whole European region. Our aim is to integrate the Institute's activities in the programs relevant to public health issues of outstanding importance in this European sub-region. The IPHRS, given the geographic position and recent history, can act as an intermediate between the public health networks in EU and other countries in the sub-region.     

Building capacities in research for blood services in Africa

BackgroundCapacity building of African based blood services researchers has been identified as key in developing a sustainable programme of generation local evidence to support sound decision making. There are a number of research training programmes that have been instituted targeted at blood services in Africa. The article shares programme experiences of building research capacities for blood services in Africa.MethodologyThe Francophone Africa Transfusion Medicine Research Training network, the NIH REDS-III and NIH Fogarty South Africa programmes and T-REC (Building transfusion research capacity in Africa) have been the key research capacity programmes targeting blood services in Africa over the last decade. To understand their experiences on the implementation of the capacity building programmes, data were drawn from research outputs, publications and end of programme reports. The success, challenges and the main research outputs from their initiatives were highlighted.ResultsThe Francophone research network achievements included more than 135 trainees and in excess of 30 publications. The NIH REDS study the achievements included more than 12 research publications with South Africa junior investigators as lead authors. The NIH Fogarty program currently includes 56 short course trainees, 5 Masters and 6 PhD candidates. The four year (2011-2015, funding period) T-REC programme produced more than 20 publications, 4 PhDs, 42 in-service Diploma in Project Design and Management (DPDM), and supported bursaries for 60 Masters/undergraduate research. The main common challenges in the running of the research programmes include shortages of in-country mentoring and identified needs in high quality research grants writing.Discussion and conclusionThe key achievements for the blood services research capacity building include a mix of short courses, medium-term (epidemiology & biostats) and MS/PhD degree training. Also, having a "train the trainers' programme to develop in-country mentors has been instrumental. Overall, the key recommendations for blood services research capacity building include the need for research collaborations with high-income countries which can jump-start research,and for more in-country grant-writing capacity building, which would help sustainability.     

The association of access to medical care with regular source of care and sociodemographic characteristics in patients with HIV and tuberculosis

PURPOSE: To examine satisfaction with access to health care in two populations, one with HIV and one with TB, and examine the effect of having a regular doctor and sociodemographic characteristics. DESIGN: Cross-Sectional survey. PATIENTS: A sample of HIV inpatients hospitalized at seven Los Angeles sites (N = 217) and TB outpatients chosen randomly from the Los Angeles County TB Registry Census (N = 313). ANALYSIS: We performed bivariate and multivariate regression analyses of satisfaction with access to care on gender, race/ethnicity, age, education, income, insurance, and having a regular doctor. MAIN OUTCOME MEASURES: A six-item scale of satisfaction with access to care (range 0-100; Cronbach's alpha 0.87). RESULTS: The mean satisfaction with access score for the HIV sample was significantly lower than the TB sample (53.5 vs. 61.2, p<0.001). The HIV sample multivariate analysis (including all the variables) showed that increasing age (p<0.021 and having a regular doctor (p<0.002) were associated with better access, and that low income (p<0.005) was associated with poor access. In the TB sample analysis, only increasing age was associated with better satisfaction with access to care (p< 0.01). CONCLUSION: HIV patients receiving care in the private sector reported less satisfaction with access to care compared to TB patients receiving care in the public health sector. The traditional factors of socio-economic status and having a regular doctor were associated with satisfaction with access-to-care in the HIV sample but not the TB sample. Our findings suggest that certain characteristics of the TB public health programs may explain these differences and suggests that, perhaps, the existence of a similar public health program for vulnerable low-income populations with HIV would improve their satisfaction with access, as well.     

Building global health through a center-without-walls: the Vanderbilt Institute for Global Health

The Institute for Global Health at Vanderbilt enables the expansion and coordination of global health research, service, and training, reflecting the university's commitment to improve health services and outcomes in resource-limited settings. Global health encompasses both prevention via public health and treatment via medical care, all nested within a broader community-development context. This has fostered university-wide collaborations to address education, business/economics, engineering, nursing, and language training, among others. The institute is a natural facilitator for team building and has been especially helpful in organizing institutional responses to global health solicitations from the National Institutes of Health (NIH), Centers for Disease Control (CDC), and other funding agencies. This center-without-walls philosophy nurtures noncompetitive partnerships among and within departments and schools. With extramural support from the NIH and from endowment and developmental investments from the school of medicine, the institute funds new pilot projects to nurture global educational and research exchanges related to health and development. Vanderbilt's newest programs are a CDC-supported HIV/AIDS service initiative in Africa and an overseas research training program for health science graduate students and clinical fellows. New opportunities are available for Vanderbilt students, staff, and faculty to work abroad in partnership with international health projects through a number of Tennessee institutions now networked with the institute. A center-without-walls may be a model for institutions contemplating strategic investments to better organize service and teaching opportunities abroad, and to achieve greater successes in leveraging extramural support for overseas and domestic work focused on tropical medicine and global health.     

Early detection of Pre-XDR TB with line probe assay in a high TB burden country

BackgroundWorldwide, tuberculosis (TB) is one of the top 10 causes of death. Drug resistant tuberculosis has lately become a major public health problem that threatens progress made in Tuberculosis (TB) care and control worldwide. The aim of this study was to determine the prevalence of Pre-extensive drug resistant TB among MDR TB in North Central of Nigeria.MethodsThis study was conducted from October, 2018 to August, 2019 with 150 samples. In Nigeria, guidelines for DR-TB as recommended by WHO is followed. All the samples from the patients who gave their consent were transported to a zonal reference TB laboratory (ZRL).ResultsMean age was 38.6 ± 13.4 years with peak age at 35–44. Out of these 103 samples processed with LPA, 101(98%) were rifampicin resistant and 2 were rifampicin sensitive, 99(96%) were INH resistant and 4 (4%) were INH sensitive, 5(5%) were fluoroquinolone resistant, 98(95%) were fluoroquinolone sensitive, 12 (12%) were Aminoglycoside + Capreomycin resistant, 91(83%) were Aminoglycoside + Capreomycin sensitive.ConclusionMultidrug resistant TB and its severe forms (Pre-extensive & extensively drug resistant TB) can be detected early with rapid tool- Line Probe Assay rapid and prevented timely by early initiation on treatment.