Eliminating the category II retreatment regimen from national tuberculosis programme guidelines: the Georgian experience.

PROBLEM: The category II retreatment regimen for management of tuberculosis in previously treated patients was first introduced in the early 1990s. It consists of 8 months of total therapy with the addition of streptomycin to standard first-line medications. A review of 6500 patients on category II therapy in Georgia showed poor outcomes and high rates of streptomycin resistance. APPROACH: The National Tuberculosis Program used an evidence-based analysis of national data to convince policy-makers that category II therapy should be eliminated from national guidelines in Georgia. LOCAL SETTING: The World Health Organization tuberculosis case-notification rate in Georgia is 102 per 100,000 population. All patients receive culture and drug susceptibility testing as a standard part of tuberculosis diagnosis. In 2009, routine surveillance found multidrug-resistant tuberculosis in 10.6% of newly diagnosed patients and 32.5% of previously treated cases. RELEVANT CHANGES: Category II retreatment regimen is no longer used in Georgia. Treatment is guided by results of drug susceptibility testing--using rapid, molecular tests where possible--for all previously treated tuberculosis patients. LESSONS LEARNT: There was little resistance to policy change because the review was initiated and led by the National Tuberculosis Program. This experience can serve as a successful model for other countries to make informed decisions about the use of category II therapy.

Tungiasis in rural Haiti: a community-based response.

Tungiasis is a disease endemic to poor communities in Latin America, the Caribbean and Africa. It is caused by the female flea, Tunga penetrans, which burrows into the skin of its host to feed while producing and extruding eggs. Consequent lesions may be painful and even crippling with damage ranging from mild erythema and swelling to necrosis. Superinfection of lesions can be serious and may result in auto-amputation or death from tetanus. We describe an outbreak of tungiasis in rural Haiti and a community-based intervention used to address it. Of 177 patients assessed, 132 (47 female, 85 male, 23 children) had tungiasis lesions. Forty-four patients had clinical signs of superinfection; 15 had ectopic lesions. Community health workers cleaned and disinfected patients' feet and any parts of the body with ectopic lesions, and then extracted fleas from existing lesions. Patients with superinfections were treated with appropriate antibiotics. Over 1000 pairs of shoes were distributed in the villages. Over 400 adults were given tetanus vaccinations during follow-up visits. Patients who had been treated reported feeling better and those who had received shoes indicated they had not developed new lesions. All superinfections were resolved. We concluded that community-based care can treat tungiasis effectively.

Treatment of multidrug-resistant tuberculosis during pregnancy: long-term follow-up of 6 children with intrauterine exposure to second-line agents.

Treatment of gestational multidrug-resistant tuberculosis (MDR-TB) is controversial. We describe follow-up of 6 children exposed to second-line antituberculous agents in utero. Each child (average age, 3.7 years) underwent comprehensive clinical evaluation. One child had MDR-TB diagnosed. There was no evidence of significant late-presentation toxicity among the children. The results suggest that aggressive management of gestational MDR-TB may benefit both mother and child.

Programmes and principles in treatment of multidrug-resistant tuberculosis.

Multidrug-resistant tuberculosis (MDR-TB) presents an increasing threat to global tuberculosis control. Many crucial management issues in MDR-TB treatment remain unanswered. We reviewed the existing scientific research on MDR-TB treatment, which consists entirely of retrospective cohort studies. Although direct comparisons of these studies are impossible, some insights can be gained: MDR-TB can and should be addressed therapeutically in resource-poor settings; starting of treatment early is crucial; aggressive treatment regimens and high-end dosing are recommended given the lower potency of second-line antituberculosis drugs; and strategies to improve treatment adherence, such as directly observed therapy, should be used. Opportunities to treat MDR-TB in developing countries are now possible through the Global Fund to Fight AIDS, TB, and Malaria, and the Green Light Committee for Access to Second-line Anti-tuberculosis Drugs. As treatment of MDR-TB becomes increasingly available in resource-poor areas, where it is needed most, further clinical and operational research is urgently needed to guide clinicians in the management of this disease.

Addressing gender inequity in HIV care in rural Lesotho: the 'Male Initiative'.

BACKGROUND: Lesotho is a nation in Southern Africa with an HIV prevalence of 25%. Males are less likely to access HIV services and there is a need for strategies to improve male participation in HIV care. This paper describes the development and implementation of the Male Initiative to increase male participation in HIV services. METHODS: A combination of qualitative and quantitative methods were used to describe the components, process, organization, participation and potential impact of the Male Initiative. RESULTS: The Male Initiative was developed in partnership with local village chiefs, traditional healers and spiritual leaders. It used the traditional male meeting structure known as the Pitso-ea-banna to deliver messages about HIV care. 1311 men participated in five Male Initiative meetings over a 30 month period from June 2006-31 December, 2008. Male enrollment increased from 32% in 2006 to 36.8% in 2008, a trend which approached statistical significance (p = 0.07) and suggests potential programmatic impact that merits further study. CONCLUSION: Gender inequalities in enrollment in HIV care can be addressed through programs developed in partnership with local leaders and delivered in culturally accepted settings.

Tuberculosis in children exposed at home to multidrug-resistant tuberculosis.

BACKGROUND: The tuberculosis burden in children exposed at home to multidrug-resistant tuberculosis (MDR-TB) is unquantified. With limited access to MDR-TB treatment, likely millions of children share the experience of chronic exposure to an infectious patient. METHODS: We conducted a retrospective cohort study of child and adult household contacts of patients treated for MDR-TB in Lima, Peru, in 1996 to 2003. The primary outcome was TB disease. We estimated prevalence of TB disease when the index case began MDR-TB treatment and incidence of TB disease over the subsequent 4 years. RESULTS: Among 1299 child contacts, 67 were treated for TB. TB prevalence was 1771 (confidence interval [CI]: 1052-2489) per 100,000 children. In 4362 child-years of follow-up, TB incidence rates per 100,000 child-years were: 2079 (CI: 1302-2855) in year 1; 315 (CI: 6-624) in year 2; 634 (CI: 195-1072) in year 3; and 530 (CI: 66-994) in year 4. TB disease rates in children aged >1 year were not significantly different from those observed in adults. Children accounted for 20% of TB cases. Seven (87.5%) of 8 children tested had MDR-TB. Child contacts had TB disease rates approximately 30 times higher than children in the general population. CONCLUSIONS: Children were at high risk for TB disease when the index case started MDR-TB treatment and during the following year. These results highlight the need for implementing contact investigations and establishing systems for prompt referral and treatment of pediatric household contacts of MDR-TB patients, regardless of the age of the child.

Lay health workers and HIV care in rural Lesotho: a report from the field.

Lay health workers (LHWs) are individuals who participate in a variety of health services, even though they have no formal professional training. They have been used in a variety of settings, especially where health care needs outstrip available human resources. Lesotho faces a severe human resource shortage as it attempts to manage its HIV pandemic, with more than 25% of the population infected with HIV. This article reports on a program that provided HIV services in seven rural clinics in Lesotho. LHWs played an important role in the provision of HIV services that ranged from translation, adherence counseling, voluntary counseling and testing (VCT) for HIV and patient triage, to medication distribution and laboratory specimen processing. Training the LHWs was part of the clinic physicians' responsibilities and thus required no additional funding beyond regular clinic operations. This lent sustainability to the training of the LHWs. This paper describes the recruitment, training, activities, and perceptions of the LHW work between June 2006 and December 2008. LHWs participated successfully in the care of thousands of people with HIV in Lesotho and their experience can serve as a model for other countries facing the disease.

Community-based therapy for children with multidrug-resistant tuberculosis.

OBJECTIVES: The goals were to describe the management of multidrug-resistant tuberculosis among children, to examine the tolerability of second-line antituberculosis agents among children, and to report the outcomes of children treated for multidrug-resistant tuberculosis in poor urban communities in Lima, Peru, a city with high tuberculosis prevalence. METHODS: A retrospective analysis of data for 38 children <15 years of age with multidrug-resistant tuberculosis, either documented with drug sensitivity testing of the child's tuberculosis isolate or suspected on the basis of the presence of clinical symptoms for a child with a household contact with documented multidrug-resistant tuberculosis, was performed. All 38 children initiated a supervised individualized treatment regimen for multidrug-resistant tuberculosis between July 1999 and July 2003. Each child received 18 to 24 months of therapy with > or =5 first- or second-line drugs to which their Mycobacterium tuberculosis strain was presumed to be sensitive. RESULTS: Forty-five percent of the children had malnutrition or anemia at the time of diagnosis, 29% had severe radiographic findings (defined as bilateral or cavitary disease), and 13% had extrapulmonary disease. Forty-five percent of the children were hospitalized initially because of the severity of illness. Adverse events were observed for 42% of the children, but no events required suspension of therapy for >5 days. Ninety-five percent of the children (36 of 38 children) achieved cures or probable cures, 1 child (2.5%) died, and 1 child (2.5%) defaulted from therapy. CONCLUSIONS: Multidrug-resistant tuberculosis disease among children can be treated successfully in resource-poor settings. Treatment is well tolerated by children, and severe adverse events with second-line agents are rare.