Community- vs. hospital-based management of multidrug-resistant TB in Pakistan.

BACKGROUND Multidrug-resistant TB (MDR-TB) treatment takes 18-24 months and is complex, costly and isolating. We provide trial evidence on the WHO Pakistan recommendation for community-based care rather than hospital-based care.METHODS Two-arm, parallel-group, superiority trial was conducted in three programmatic management of drug-resistant TB hospitals in Punjab and Sindh Provinces, Pakistan. We enrolled 425 patients with MDR-TB aged >15 years through block randomisation in community-based care (1-week hospitalisation) or hospital-based care (2 months hospitalisation). Primary outcome was treatment success.RESULTS Among 425 patients with MDR-TB, 217 were allocated to community-based care and 208 to hospital-based care. Baseline characteristics were similar between the community and hospitalised arms, as well as in selected sites. Treatment success was 74.2% (161/217) under community-based care and 67.8% (141/208) under hospital-based care, giving a covariate-adjusted risk difference (community vs. hospital model) of 0.06 (95% CI -0.02 to 0.15; P = 0.144).CONCLUSIONS We found no clear evidence that community-based care was more or less effective than hospital-based care model. Given the other substantial advantages of community-based care over hospital based (e.g., more patient-friendly and accessible, with lower treatment costs), this supports the adoption of the community-based care model, as recommended by the WHO.

Four bridges to cross.

PIP: Dr. Mahbub ul Haq, former Minister of Finance and Planning in Pakistan, is interviewed for his perspective on follow-up steps to the Earth Summit. The Rio conference Earth Summit definitively established the link between development and environment, highlighting the fact that sustainable development is possible only with continuous growth and that development must accelerate especially in developing countries. While the Summit represents an important conceptual agreement, other hurdles must be overcome to translate increasing global concern for the environment into real action. To secure needed additional financial resources, the following are suggested: opening global markets, reducing arms spending, and taxing oil and coal internationally. Tradeable permits in carbon dioxide emissions are suggested to create a market in the environment. Finally, institutional follow-up to the Earth Summit and a World Summit in 1995 are recommended. Closing paragraphs recommend actions for poor countries to take to follow up on Agenda 21.^ieng